Archives: MRCP Part 2

MRCP2-0817

A 32-year-old woman, with a history of ulcerative colitis, presents with a four-day history of profuse bloody diarrhoea. She reports having to use the bathroom up to 15 times each day and describes passing both bloody stool and frank blood.

Upon examination, she appears pale. Her heart rate is 92 beats per minute, respiratory rate 18 breaths per minute, blood pressure 130/80 mmHg. Her chest is clear to auscultation and her abdomen is soft but diffusely tender. Despite her diarrhoea, the patient appears relatively well and is able to walk.

The patient is diagnosed with a flare-up of her ulcerative colitis and is given intravenous fluids and steroids after obtaining intravenous access.

Upon admission, her blood tests show:

Hb 98 g/l
Platelets 500 * 109/l
WBC 18.2 * 109/l
ESR 80 mm/h

What is the appropriate venous thromboembolism prophylaxis for this patient during her hospital stay?

MRCP2-0818

A 27-year-old female with a history of cerebral palsy is admitted for an elective intrathecal pump refill. Unfortunately, the procedure was unsuccessful and the pump could not be re-sited. Later that evening, the patient complains of severe pain in her lower limbs and feels generally unwell.

Based on the following blood results, which drug is the patient experiencing withdrawal from?

Hb 145 g/l
Platelets 525 * 109/l
WBC 14.1 * 109/l
Neuts 8.4 * 109/l
Creatine kinase 8445 Units/litre (normal range 24-170)
CRP 44 mg/l
Na+ 138 mmol/l
K+ 5.6 mmol/l
Urea 12.8 mmol/l
Creatinine 156 µmol/l

MRCP2-0819

You are working as the duty physician at a high school athletics meet and are collecting samples to look for drugs of abuse.

Which of the following initial tests is most useful to look for testosterone abuse?

MRCP2-0820

A 38-year-old man presents to the endocrinology clinic concerned about the long-term effects of his previous anabolic steroid use. He had been a competitive bodybuilder for 10 years and had recently stopped using steroids. During his steroid use, he experienced severe acne, gastrointestinal issues, male pattern baldness, erectile dysfunction, and scrotal discomfort. He denies symptoms associated with heart or liver disease but admits to past recreational drug use, including cocaine. On examination, he has moderate pitting edema and mild bilateral gynecomastia. His lab results show elevated HbA1C and LDL cholesterol levels, low HDL cholesterol levels, and elevated prolactin levels. His luteinizing hormone and follicle-stimulating hormone levels are low. A transthoracic echocardiogram is normal. Which of the patient’s unwanted effects will be irreversible after stopping steroid use?

MRCP2-0821

A 28-year-old man presents to his GP with generalised itchiness that has been ongoing for several weeks. Despite trying various over-the-counter creams, the itchiness has persisted and is now affecting his sleep. He has become fatigued and has been late to work as a fitness instructor multiple times. He denies alcohol use and is a former smoker. His GP decides to perform some blood tests to investigate further.

Upon examination, the patient appears well-built and has scleral icterus. There are numerous scratch marks on his torso, and he has mild gynaecomastia. His abdomen is soft with no palpable masses, and there are no spider naevi. His ankles are soft with no oedema, and he has no rashes. His mother has ulcerative colitis with liver complications, but he has no significant past medical history.

Hb: 180 g/l
Platelets: 459 * 109/l
WBC: 9.8 * 109/l
Neuts: 7.2 * 109/l
Lymphs: 1.2 * 109/l
Na+: 145 mmol/l
K+: 3.0 mmol/l
Urea: 4.5 mmol/l
Creatinine: 95 µmol/l
Bilirubin: 45 µmol/l
ALP: 189 u/l
ALT: 61 u/l
γGT: 213 u/l
Albumin: 45 g/l
Anti smooth muscle antibody: negative
Anti liver kidney antibody: negative

Based on these results, what is the most likely cause of the patient’s deranged bloods?

MRCP2-0822

A 49-year-old man has been referred to the endocrinology clinic due to polydipsia and polyuria. He has a medical history of hypertension and bipolar disorder, but cannot recall which medication he is taking for the latter. His GP conducted blood tests and found elevated blood glucose, with an HbA1c level of 62 mmol/mol (normal range: 42-48). What is the probable medication responsible for this result?

MRCP2-0801

A 28-year-old male from Eastern Europe presents to the Emergency Department with 72 hours of severe ‘burning and sharp’ electrical pains in his arms and legs. He is well known to the department, having been treated for alcohol withdrawal a number of times in the past and is a known intravenous drug user. He reports no weakness, dysarthria or hallucinations. He reports drinking about 8 pints of beer in the past 24 hours, which he says is normal for him, and has used intravenous heroin daily for the past 3 weeks.

On examination, both upper and lower limbs are rigid and mildly bradykinetic. A bilateral resting tremor is noted in both hands. Reflexes and sensation are normal. Examination of cranial nerves and eye movements are unremarkable.

His initial blood tests return and are as follows:

Hb 162 g/l
Platelets 280 * 109/l
WBC 5.8 * 109/l
Vitamin B12 198 ng/l
Folate 480 (>317 nmol/l)

Na+ 141 mmol/l
K+ 4.2 mmol/l
Urea 6.2 mmol/l
Creatinine 87 µmol/l
CRP 8 mg/l
HIV negative

Which investigation is most likely to yield the underlying diagnosis?

MRCP2-0802

A 16-year-old girl with a history of epilepsy and self-harm presents to the emergency department with a Glasgow coma score of 13 (E3 V4 M6) and a respiratory rate of 8/min. Upon examination, her pulse is regular at 56/min, blood pressure is 110/60 mmHg, and her chest is clear. Although there are no signs of injury, an empty packet of diazepam was found in her handbag. A nurse in the emergency department takes an arterial blood gas while the patient is breathing room air, revealing the following results:

pH 7.39
pO2 10.1 kPa
pCO2 5.6 kPa
BE 0.8 mEq/l

What is the most appropriate initial management for this patient?

MRCP2-0803

A 67-year-old man is admitted to the Cardiology Unit with fast atrial fibrillation and cardiac failure. He has ischaemic heart disease and long-standing atrial fibrillation for which he takes a range of medications. You understand that over the past few months he has been experiencing increasing heartburn and has been buying over the counter antacids.
On examination, his blood pressure is 120/80 mmHg, his pulse is 130 beats per minute (bpm) (atrial fibrillation), and there are bibasal crackles on auscultation of the chest. His digoxin level is 0.4 ng/ml (therapeutic range is 0.6 – 1.2 ng/ml).
What is the most probable reason for his low digoxin level?

MRCP2-0804

A 67-year-old female presents to respiratory outpatients with an 8-week history of gradually worsening shortness of breath. Her exercise tolerance has reduced to 50 yards from several miles; she reports chronic lower back pain but no other symptoms. Her past medical history includes type 2 diabetes mellitus, psoriasis, recurrent urinary tract infections and ischaemic heart disease. She currently takes metformin 500 mg BD, bisoprolol 2.5 mg OD, aspirin 75 mg OD, atorvastatin 40 mg ON, ramipril 2.5 mg and nitrofurantoin 50 mg ON with no change in the last 6 months. She has never smoked, has no pets and works as a secretary.

On examination, the patient is breathless on minimal exertion. Observations are normal, there is no clubbing and she has fine end-inspiratory crepitations at both bases. A CT chest shows ground glass changes with minimal honey combing at both bases. What is the most likely cause of her underlying respiratory condition?