MRCP2-1673
What is a gastrointestinal characteristic that distinguishes an acute graft versus host reaction from a chronic one?
Archives: MRCP Part 2
MRCP2-1674
A 42-year-old man presents to the Emergency Department with worsening fatigue, loss of appetite, and abdominal pain. On examination, there is tenderness in the epigastrium and right upper quadrant of the abdomen. Laboratory tests reveal:
Alanine aminotransferase (ALT) 420 u/l 7–55 u/l
Bilirubin 85 μmol/l 1–22 μmol/l
Albumin 27 g/l 35–55 g/l
Prothrombin time (PT) and Activated partial thromboplastin time (APTT) Prolonged
Haemoglobin (Hb) 101 g/l 135–175 g/l
White cell count (WCC) 13.2 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 75 × 109/l 150–400 × 109/l
What is the most likely diagnosis based on these findings?
MRCP2-1675
A 19-year-old girl is brought in by ambulance from the farm where she lives with her parents. She gives little history but her parents say she has been off college unwell for the last few days.
She has no past medical history and takes only the oral contraceptive pill.
On examination, she has a temperature of 37.6°C, pulse is 102 bpm and blood pressure is 110/54 mmHg. She is jaundiced with the liver edge palpable 2 cm below the costal margin and there is tenderness in the right upper quadrant.
Her blood tests show:
– Haemoglobin 112g/L (130 – 180)
– Platelets 214 ×109/L (150 – 400)
– White cell count 7.4 ×109/L (4 – 11)
– Sodium 135 mmol/L (137 – 144)
– Potassium 5.2 mmol/L (3.5 – 4.9)
– Urea 11.4mmol/L (2.5 – 7.5)
– Creatinine 156 µmol/L (60 – 110)
– Bilirubin 76 µmol/L (1 – 22)
– Alkaline phosphatase 240 IU/L (45 – 105)
– ALT 10,578 IU/L (5 – 35)
– AST 11,254 IU/L (1 – 31)
– Albumin 38 g/L (37 – 49)
– INR 1.5 (<1.4)
A paracetamol level is taken and is 75 mg/L.
What is the most appropriate treatment?
MRCP2-1676
A 25-year-old female presents to the emergency department with severe abdominal pain that has developed over the last few hours. The pain is central, severe, and stabbing in nature, accompanied by vomiting. She is in hysterics and extremely agitated and confused. Her medical history includes asthma and depression. Two days ago, she saw her GP for dysuria and was prescribed trimethoprim.
She is a student studying chemistry at university and has recently been out late several nights drinking excess alcohol to celebrate passing her exams. On examination, she is unwell, extremely clammy, distressed with generalised abdominal tenderness, and weakness in both legs with areflexia. Heart sounds and chest are clear. Observations show a blood pressure of 190/100 mmHg, heart rate of 126/min, regular, and temperature of 37.9ºC.
Which investigation is most likely to provide a diagnosis?
MRCP2-1677
A 67-year-old man with his first exacerbation of COPD is admitted to the respiratory ward. He is started on doxycycline and prednisolone and starts to improve well. On day 3, he complains of feeling nauseous and begins to vomit. He develops central abdominal pain that is constant. He has two episodes of watery diarrhoea.
What is the cause of his deterioration?
MRCP2-1678
A 36-year-old female presents to the emergency department with severe upper abdominal pain that has been ongoing for 6 hours and radiates to her back. She reports feeling nauseous and vomiting, but denies experiencing any diarrhea or fever.
Her medical history includes a laparoscopic appendicectomy for appendicitis when she was 20 years old and a normal vaginal delivery 4 years ago. She does not smoke but drinks one glass of wine approximately three times per week.
Upon examination, she appears unwell, and there is tenderness in her epigastric region. Her blood work shows a hemoglobin level of 135 g/L, platelet count of 402 * 109/L, white blood cell count of 14 * 109/L, and neutrophil count of 13.5 * 109/L. Her lipase level is 1200 U/L, and her total cholesterol is 5.4 mmol/L, with an HDL level of 1.2 mmol/L, LDL level of 4 mmol/L, and triglyceride level of 2 mmol/L.
What is the most likely underlying cause of her symptoms?
MRCP2-1679
A 55-year-old man presents to the emergency department with haematemesis and collapses after vomiting ‘one pint’ of blood. He is brought in by ambulance and has had blood tests sent. He has been resuscitated with IV fluids and is now stable with normal vital signs. His blood tests show haemoglobins of 89 g/L, platelets of 112*109, creatinine of 84µmol/l and a pro-thrombin time of 13 seconds. Urgent endoscopy has been arranged and he has been started on terlipressin. What other medications should be administered?
MRCP2-1680
A 67-year-old retired man with a history of diet-controlled diabetes and mild COPD is brought in by ambulance with 3 episodes of black stool followed by collapse. He describes a 2 day history of intermittent abdominal pain. His regular medications are Seretide inhaler and paracetamol/ibuprofen when required for knee osteoarthritis.
On examination, he has conjunctival pallor and epigastric tenderness. Rectal examination confirms the presence of melaena.
His observations are as follows:
Temperature 36.4
Respiratory 28/min
Saturations 96% on air
Heart rate 126 bpm
Blood pressure 78/44 mmHg
Hb 67 g/l Na+ 140 mmol/l Bilirubin 12 µmol/l
Platelets 88* 109/l K+ 3.9 mmol/l ALP 100 u/l
WBC 12.0* 109/l Urea 13.3 mmol/l ALT 28 u/l
Neuts 6.0* 109/l Creatinine 63 µmol/l Albumin 38 g/l
Lymphs 1.0* 109/l INR 1.2
Eosin 0.3* 109/l APTT 26 Fibrinogen 4.0 g/l
What urgent medical treatment should be initiated before endoscopy?
MRCP2-1681
A 65-year-old man with a known history of alcohol dependency presents with a 4-hour history of haematemesis and abdominal discomfort. He has no history of upper GI bleed but does report several previous episodes of passing black stools. He has hypertension and a family history of coronary artery disease. A previous abdominal ultrasound has shown hepatic cirrhosis.
Today, he appears unwell. He continues to vomit small amounts of blood. On examination, his blood pressure is 130/90 mmHg and pulse rate is 80 beats per minute. His chest is clear and his abdomen is soft, though he has some epigastric tenderness. Rectal examination reveals melaena.
An intravenous cannula is inserted and blood is taken.
Blood tests show:
Hb 100 g/l
Platelets 170 * 109/l
WBC 7.0 * 109/l
Fibrinogen 2.5 g/L
APTT 32 seconds
PT 13 seconds
Na+ 140 mmol/l
K+ 4.5 mmol/l
Urea 12 mmol/l
Creatinine 95 µmol/l
What should be administered prior to endoscopy?
MRCP2-1660
A 38-year-old female presents with 5 days of feeling generally unwell and recent dysuria. Her urine has a foul odor and is dark in color. She has a history of type 1 diabetes and has been on subcutaneous insulin for a long time. Upon admission, her pH was 7.24, bicarbonate was 8 mmol/l, and blood glucose was 32 mmol/l. Her urine dip showed 2+ leukocytes, 2+ nitrites, and 4+ ketones. She was started on treatment for diabetic ketoacidosis with intravenous fluids and fixed rate insulin, as well as intravenous antibiotics for a urinary source of sepsis. You are asked to review her blood sugars 4 hours after treatment initiation. What is the goal in managing hyperglycemia in a patient with diabetic ketoacidosis?