Archives: MRCP Part 2

MRCP2-1798

A 40-year-old man returns from a significant period abroad working for a tech company in Japan. He reports chronic diarrhoea over the past few months with associated weight loss, fatigue, and now lower limb oedema. Upon examination, he appears pale and has stomatitis and glossitis. His BMI is only 21 and he admits to having lost 5 kg in weight in 2 months. Further investigations reveal megaloblastic anaemia, low albumin levels, positive D-xylose malabsorption test, and elevated faecal fat excretion. Anti-endomysial antibodies are negative. What is the most likely diagnosis for this patient?

MRCP2-1799

A 43-year-old woman with a history of small bowel diverticulae and anaemia presents with pins and needles in her hands and feet, weight loss, and offensive-smelling stool. She is a non-smoker and non-drinker who eats red meat. On examination, she has normal leg power and tone, exaggerated knee jerks, absent ankle jerks, absent joint position and vibration sense below her ankles, and extensor plantar responses. Her blood tests show macrocytosis, hypersegmented neutrophils, low haemoglobin, high bilirubin, and low serum B12 and folate levels. The Schilling test reveals poor absorption of oral vitamin B12. What is the most likely diagnosis?

MRCP2-1800

A 32-year-old woman presents to the Emergency Department with symptoms of a GI upset and increasing dull abdominal pain. She is worried because she has become jaundiced. She has a history of occasional cocaine use in college but denies any illicit drug use currently. Prior to her recent trip to Mexico, she received a vaccination against hepatitis A. On examination, she has tenderness in the right upper quadrant. Which infection is the most likely diagnosis?

Investigations:
– Haemoglobin (Hb): 130 g/l (normal value: 115-155 g/l)
– White cell count (WCC): 11.3 × 109/l (normal value: 4-11 × 109/l)
– Platelets (PLT): 201 × 109/l (normal value: 150-400 × 109/l)
– Sodium (Na+): 138 mmol/l (normal value: 135-145 mmol/l)
– Potassium (K+): 3.4 mmol/l (normal value: 3.5-5.0 mmol/l)
– Creatinine (Cr): 112 µmol/l (normal value: 50-120 µmol/l)
– Alanine aminotransferase (ALT): 1821 IU/l (normal value: 5-30 IU/l)
– Alkaline phosphatase (ALP): 203 IU/l (normal value: 30-130 IU/l)
– Albumin: 35 g/l (normal value: 35-55 g/l)
– Prothrombin time (PT): 13.2 s (normal value: 10.6-14.9 s)

MRCP2-1780

A 35-year-old woman presents to her family doctor with yellowing of the skin and eyes. She has a history of Ulcerative Colitis for the past 15 years, which is managed with Sulfasalazine. She reports feeling increasingly fatigued and itchy over the past few months. Her urine has also become darker. The following results were obtained from her blood tests:

Haemoglobin (Hb): 120 g/l (normal range: 135 – 175 g/l)
White cell count (WCC): 5.8 × 109/l (normal range: 4.0 – 11.0 × 109/l)
Platelets (PLT): 190 × 109/l (normal range: 150 – 400 × 109/l)
Sodium (Na+): 140 mmol/l (normal range: 135 – 145 mmol/l)
Potassium (K+): 4.2 mmol/l (normal range: 3.5 – 5.0 mmol/l)
Creatinine (Cr): 90 μmol/l (normal range: 50 – 120 µmol/l)
Alkaline phosphatase (ALP): 400 u/l (normal range: 30 – 150 u/l)
Alanine aminotransferase (ALT): 85 u/l (normal range: 7 – 55 u/l)
Bilirubin: 100 μmol/l (normal range: 1 – 22 μmol/l)

What would be the preferred investigation in this case?

MRCP2-1781

A 32-year-old woman presents to the Emergency Department with a four-week history of increasing frequency of diarrhoea, up to eight times per day. She has noticed blood in her stools over the past few days. She reports a weight loss of 5 kg over the past few months and intermittent night sweats. On examination, her blood pressure is 120/80 mmHg, pulse is 90 bpm and regular. Abdominal examination reveals mild tenderness in the left lower quadrant. Stool cultures taken by her General Practitioner have been negative. Which investigation would be most helpful in establishing a diagnosis?

MRCP2-1782

A 57-year-old woman presents with jaundice, vomiting, and back pain. She has been experiencing a gradual decline in health over the past four months and has been losing weight. The patient reports passing pale stools and dark urine, and has no history of gallstones. On physical examination, she appears deeply jaundiced and dehydrated, with tenderness in the right upper quadrant of the abdomen and a palpable liver edge 3 cm below the costal margin. Blood tests reveal elevated levels of bilirubin, alkaline phosphatase, ALT, and AST, as well as decreased albumin levels and an elevated INR. What is the most appropriate initial imaging study to determine the cause of her jaundice?

MRCP2-1783

A 65-year-old man has been referred to the Endocrine Clinic with a history of increasing hat size and problems with his glasses fitting. He also complains of flushing and sweating.

Routine blood testing at the initial clinic appointment confirms an elevated random blood glucose and an elevated IGF-1. Because of a suspected diagnosis of acromegaly, an oral glucose tolerance test with growth hormone is performed as well as a gadolinium-enhanced magnetic resonance image (MRI) of the pituitary. He attends for review after the tests have been performed.

The results of the oral glucose tolerance test are as follows:

Time (min) Growth hormone (GH) (mU)
0 10
30 11 (elevated)
60 12
90 11
120 10
180 9

The gadolinium-enhanced MRI of the pituitary is reported as not showing an adenoma, although the pituitary appears slightly enlarged overall.

What would be the next best step in managing his case?

MRCP2-1784

A 55-year-old man presents with visual hallucinations, profuse sweating, and tremors while on the ward. He was admitted three days ago for diarrhea, which has since resolved. The patient has a history of alcohol and intravenous drug abuse. His vital signs include a pulse of 120 beats per minute, blood pressure of 190/90 mmHg, and temperature of 37.8ºC. On examination, he appears agitated, sweaty, and inattentive with multiple spider naevi on his trunk and jaundiced sclerae. Mild ascites is present, and the abdomen is non-tender. The chest is clear on auscultation, and a liver flap cannot be elicited. What is the most likely diagnosis?

MRCP2-1785

You are on call and have been referred a 45-year-old woman with abdominal pain and increasing abdominal girth. Her symptoms have been progressing over several months. There is no history of jaundice. She has a past history of pulmonary embolism for which she was treated with warfarin six years ago.

On examination, she has mildly jaundiced sclerae. She is alert and orientated, there is no encephalopathy. Abdominal examination reveals ascites and hepatosplenomegaly.

You arrange an abdominal ultrasound scan with Dopplers which demonstrates and confirms hepatosplenomegaly and moderate ascites.

What is the most likely underlying diagnosis?

MRCP2-1786

A 63-year-old man presents to the Gastroenterology Clinic with a 9-month history of abdominal discomfort, bloating, loose stools that are difficult to flush away, and weight loss of one stone. He also reports a general deterioration in his health over the last few years with malaise, arthralgia, and depression. Recently, he has been experiencing problems with co-ordination and has become more unsteady on his feet. On examination, he is thin with areas of abnormal cutaneous pigmentation and scattered lymphadenopathy. There is no jaundice or finger clubbing. Neurological examination reveals evidence of cerebellar ataxia. Investigations show abnormal results for Hb, WCC, PLT, ESR, Cr, MCV, Na+, K+, Ca2+, bilirubin, ALT, ALP, γGT, and glucose. What is the most likely diagnosis for this patient?