Archives: MRCP Part 2

MRCP2-1777

A 65-year-old retired politician with a history of non-insulin-dependent diabetes, inferior myocardial infarction, hypertension, and mild chronic obstructive airway disease was admitted to the Coronary Care Unit 6 days ago with a non ST elevation myocardial infarction (NSTEMI). He developed atrial fibrillation and was started on intravenous digoxin. He now complains of severe abdominal pain that is worse after meals and radiates to his back. On examination, he appears pale and unwell with xanthelasma, a heart rate of 120 beats/min, blood pressure of 100/60 mmHg, and a soft systolic murmur at the apex. Investigations show abnormal results for Hb, WCC, INR, K+, Cr, HCO3-, and CRP. The most useful next investigation would be:

a) Abdominal ultrasound
b) CT scan of the abdomen
c) Upper gastrointestinal endoscopy
d) Colonoscopy
e) Serum lipase levels

MRCP2-1778

A 69-year-old man with a history of heavy alcohol use presents to the Emergency Department with complaints of weight loss, fevers, and malaise over the past four months. He also reports a dry cough with occasional blood-stained sputum. On examination, he has a moderate amount of ascites and is febrile at 37.5°C. His lab results show elevated levels of alkaline phosphatase, γ-glutamyl transpeptidase, and aspartate aminotransferase, as well as a low hemoglobin and high mean corpuscular volume. An ascitic tap reveals low levels of total protein and albumin. A plain abdominal film shows adrenal calcification. Which investigation is most likely to provide a diagnosis?

MRCP2-1779

A 32-year-old man presents to the Gastroenterology Clinic with complaints of abdominal pain, bloating, and diarrhea for the past few months. He has a history of type I diabetes, for which she takes a basal bolus insulin regimen.. On examination, his blood pressure is 120/80 mmHg, pulse is 75 bpm and regular, and BMI is 22 kg/m2. Laboratory investigations reveal a hemoglobin level of 110 g/l, WCC of 7.5 × 109/l, PLT of 200 × 109/l, Na+ of 140 mmol/l, K+ of 4.0 mmol/l, Cr of 80 µmol/l, albumin of 30 g/l, ALT of 25 IU/l, bilirubin of 10 µmol/l, ALP of 100 IU/l, and Ca of 2.4 mmol/l. The anti-tissue transglutaminase antibody (IgA) test is negative. What is the most appropriate next step in management?

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?