Archives: MRCP Part 2

MRCP2-1066

A 25-year-old female presents with acute illness. She has been experiencing weight loss, tiredness, and lethargy for the past three months, which has worsened over the last week. Her general practitioner had diagnosed her with hypothyroidism six weeks ago, with a Free T4 level of 8.8 pmol/L (10-22) and a Plasma TSH level of 5.5 mU/L (0.4-5). She had started taking thyroxine 50 µg daily but has deteriorated over the last two weeks. Her mother and maternal grandmother have also been diagnosed with hypothyroidism and take thyroxine. She is a non-smoker, does not drink alcohol, and takes the oral contraceptive pill.

On examination, she appears unwell and mildly dehydrated, with a temperature of 37.5°C and a BMI of 21.3 kg/m2. Her blood pressure is 72/44 mmHg, with a pulse of 100 beats per minute. Cardiovascular examination is otherwise normal, and there are no abnormalities on respiratory or abdominal examination. Brief neurological examination is normal, and both plantars are flexor.

The investigations requested by the house officer are currently unavailable. In the meantime, what is the most appropriate immediate management for this patient?

MRCP2-1067

A 35-year-old man presents to the Emergency Department two weeks after being discharged following surgery for a ruptured appendix. He experienced significant blood loss during the procedure and required a blood transfusion. He has been feeling increasingly fatigued with episodes of dizziness and near-fainting. On examination, he appears pale and his blood pressure is 100/70 mmHg with a 15 mmHg drop on standing. His pulse is 90 bpm and regular. His BMI is 25 kg/m2.

Investigations:
Haemoglobin (Hb): 105 g/l (normal range: 130-170 g/l)
White cell count (WCC): 7.5 × 109/l (normal range: 4-11 × 109/l)
Platelets (PLT): 180 × 109/l (normal range: 150-400 × 109/l)
Sodium (Na+): 132 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+): 5.2 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine (Cr): 100 µmol/l (normal range: 50-120 µmol/l)

What is the underlying pathology causing this patient’s symptoms?

MRCP2-1040

A 57-year-old man with extensive small bowel stricturing Crohn’s disease underwent a large small bowel resection. It was complicated by an anastomotic breakdown which required a further resection and jejunostomy formation. He was referred to a local intestinal failure unit and, after a period of assessment, was discharged home on parenteral nutrition. He gained weight and made good progress, although an intermittently high-output stoma persisted. When reviewed in clinic after a year on home parenteral nutrition, he complained of hair loss, a skin rash, and impairment of taste. Examination revealed a superficial scaling erythematous patchy rash that was most prominent in intertriginous areas and periorally. What is the most probable nutrient deficiency?

MRCP2-1041

A 35-year-old man presents to the cardiology clinic with bilateral foot pain that has been ongoing for 7 months. Initially, the pain only occurred at the end of his daily commute but has since progressed to being provoked by short distances and occasionally occurring at rest. He also experiences pain in his right wrist. He has no significant medical history but is a current smoker with a 20 pack year history. On examination, his feet are smooth and hairless, and there is difficulty feeling the right dorsalis pedis with cold and dusky toes. Urgent angiography reveals distal stenosis in both limbs with collateral formation. Blood tests are unremarkable except for an elevated CRP. What is the most likely diagnosis?

MRCP2-1042

An 83-year-old man presents to dermatology clinic for evaluation of a new skin lesion on his right thigh. He has a history of metastatic melanoma and was treated with vemurafenib after a metastatic lesion was identified in his liver. The patient reports feeling well but is concerned about the new lesion, which he noticed less than two months ago. On examination, an 11 mm erythematous papule with minimally everted edges and slight scaling is noted. A biopsy of the lesion is taken. What is the most likely diagnosis based on histological examination of the biopsy specimen?

MRCP2-1043

A 15-year-old girl presents to the GP with her parents for a follow-up on her constipation. She has been taking regular movicol and has seen improvement with a soft motion every 1-2 days. During the visit, her parents mention a rash on her face. The patient has a history of autism and learning difficulties.

Upon examination, the GP notes raised papules on the patient’s nose and cheeks with a warty appearance, measuring 1-2 mm. The rash does not extend to her back or chest. The patient also has two patches of hypopigmentation on her lower back, measuring 3cm x 2cm and 1 cm x 5cm, respectively. Additionally, there are three hyperpigmented patches on her abdomen that have not resolved despite using over-the-counter treatments for acne.

The patient’s blood work shows normal levels for Hb, Na+, platelets, K+, WBC, Neuts, Lymphs, and Creatinine. However, her Bilirubin levels are at 5 µmol/l, ALP at 100 u/l, and γGT at 78 u/l. Her Albumin levels are at 35 g/l, and her ALT levels are at 24 u/l.

What treatment would you recommend for the patient’s facial lesions?

MRCP2-1044

A 55-year-old male patient with a history of severe psoriasis has previously undergone treatment with topical corticosteroids, vitamin D analogue therapy and phototherapy with little success.

During examination, the patient displays multiple well-defined, hardened erythematous plaques with white scale overlaying the majority of the trunk and forearms.

The following blood tests were conducted:

– Hb 135 g/l
– Platelets 405 * 109/l
– WBC 8.2 * 109/l
– Bilirubin 12 µmol/l
– ALP 70 u/l
– ALT 27 u/l
– Albumin 35 g/l
– Na+ 140 mmol/l
– K+ 5.1 mmol/l
– Urea 8.2 mmol/l
– Creatinine 112 µmol/l

What is the most suitable treatment option?

MRCP2-1045

A 22-year-old man presents to the dermatology clinic with a severe worsening of his eczema symptoms. Despite using emollients and moderate to severe strength topical steroids, he has experienced a severe flare that did not respond to a one-week trial of oral prednisolone. He is currently experiencing severe pruritus and skin irritation, with evidence of scratch marks on the flexural surfaces of his arms and legs. What non-steroidal treatment options may be effective in controlling his flare?

MRCP2-1046

A 25-year-old woman presents to the endocrine clinic for follow-up. She has a medical history of hypertension that is controlled with ramipril and indapamide. During her birth, the midwives noticed clitoromegaly, and she was later diagnosed with 11-beta hydroxylase deficiency. What lab result is expected to be significantly elevated?

MRCP2-1047

A 32-year-old woman is seen for a follow-up appointment 6 months after giving birth. She was diagnosed with gestational diabetes during her pregnancy, but her blood sugar levels have not improved since delivery and she has now been diagnosed with type 2 diabetes mellitus. Despite being only slightly overweight with a body mass index of 27.1 kg/m², you are concerned about the possibility of missing a diagnosis of maturity onset diabetes of the young (MODY) or type 1 diabetes. What clinical feature would be most indicative of MODY?