Archives: MRCP Part 2

MRCP2-4756

A 49-year-old woman visits her doctor complaining of joint swelling, morning stiffness, weight loss, myalgia, and general malaise. She is concerned that she may have hyperthyroidism because her mother and grandmother both had thyroidectomy at a young age.

During the examination, the doctor notes a mild erythema around the patient’s nose, but not in the nasolabial folds. There is no proximal myalgia, and cardiovascular and respiratory examination is normal. No goitre is present.

Blood tests reveal an elevated ESR, prompting an autoimmune profile. The results show a positive rheumatoid factor, negative anti-CCP, ANA at 1:320, negative ANCA, positive anti-DsDNA, normal C3/C4 levels, and positive anti-RNP. The patient’s TSH level is 4.5 miU/l, and T4 is 12 pmol/l.

Based on the above information, what is the most likely diagnosis?

MRCP2-4757

A 36-year-old man visits his primary care physician complaining of right elbow pain that has been bothering him for the past 2 days and worsens with movement. He reports no stiffness or involvement of other joints. The patient has no significant medical history and is typically healthy, regularly participating in sports.

During the physical examination, the physician notes tenderness over the right elbow, particularly on the lateral side. There are no skin changes or effusion present.

Which additional finding on examination would most strongly suggest the probable diagnosis?

MRCP2-4758

A 36-year-old male electrician is referred to the medical assessment unit by his GP due to reduced oxygen saturations. He has had mild asthma since childhood but no other medical history of note. His medications are a salbutamol inhaler when required and co-codamol for long standing back pain. On examination he is found to have an early diastolic murmur but no other abnormalities are detected. He goes on to have a chest x-ray which demonstrates apical interstitial shadowing. He undergoes pulmonary function tests which are as follows:

FEV1 1.9L (Predicted 2.1-3.1)
FVC 2.2 (Predicted 3.0-4.4)
TLC 4.5 (Predicted 5.0-7.5)
Transfer factor (DLCO) Low

What is the most likely diagnosis?

MRCP2-4759

As the medical doctor in charge of an acute medical admissions unit, you receive a 55-year old female patient with a history of hypertension, pulmonary fibrosis, and recent diagnosis of Raynaud’s phenomenon. She complains of feeling generally unwell and reports experiencing dysphagia for the past few months, which is currently being investigated by the gastroenterology team at your hospital. The patient is currently taking amlodipine 5mg od.

Upon assessment, her vital signs are as follows: temperature 36.4°C, pulse 88/min, blood pressure 172/88 mmHg, respiratory rate 14/min, and sats 100% on room air. Her chest is clear, and her abdomen is soft and non-tender. Blood tests reveal an acute kidney injury with the following results: sodium 141 mmol/l, potassium 4.6 mmol/l, urea 27 mmol/l, creatinine 320 µmol/l (her GP notes state she had a normal renal function from a routine blood test 1 month ago).

What is the most appropriate course of treatment for this patient at this stage?

MRCP2-4760

A 26-year-old woman presents to her GP with a persistent cough for the past 4 days. She has been experiencing knee pain and has started taking ibuprofen and undergoing physiotherapy for her knee. While recovering, she began exercising at the gym and noticed that she felt breathless and had tightness in her chest. This was followed by a non-productive cough that is worse at night. She sleeps with two pillows and denies any ankle swelling. She has a history of childhood breathing problems for which she took inhalers, but these have since resolved. She admits to smoking 20 cigarettes a day for the past decade and takes no regular medication. She has not traveled abroad or had any contact with sick individuals.

Upon examination, she has a dry cough and is able to speak in full sentences. She has a clear chest with mild wheezing heard in the left lower base. Her peak flow is 220, and she saturates at 98% in air with a respiratory rate of 21 breaths per minute.

Sodium: 139 mmol/l
Potassium: 4.2 mmol/l
Urea: 5.1 mmol/l
Creatinine: 68 µmol/l

Hemoglobin: 110 g/l
Platelets: 390 * 109/l
White blood cells: 10.0 * 109/l

Chest x-ray shows clear lung fields with good chest expansion and no active lung lesion.

What is the probable diagnosis?

MRCP2-4761

A 67-year-old man presents to the hospital with acute pain in his left hip after a fall. His medical history includes Paget’s disease and depression, for which he takes venlafaxine. As a child, he was treated for acute lymphocytic leukaemia. The orthopaedic team has requested advice as the CT scan shows demineralisation in the femur and pelvis. A DEXA scan confirms osteoporosis. Blood tests reveal a calcium level of 2.0 mmol/L (2.1-2.6), phosphate level of 0.9 mmol/L (0.8-1.4), magnesium level of 0.9 mmol/L (0.7-1.0), TSH level of 8.9 mU/L (0.5-5.5), free T4 level of 3 pmol/L (9.0 – 18), free testosterone level of 82 ng/dL (in ages >50 years: 193 – 740), and ALP level of 202 U/L (60-306). What factors in this man’s medical history and blood tests could contribute to his development of osteoporosis?

MRCP2-4762

A 56-year-old woman is currently being treated for back pain with 1g of paracetamol four times a day and the maximum dose of 2.4g of ibuprofen daily. Despite tolerating the medication well, she continues to experience persistent pain. What is the most effective solution to enhance her pain management?

MRCP2-4763

An 82-year-old woman is being seen in an oncology clinic for cancer of unknown primary with bone metastases. She has a history of deep vein thrombosis and chronic kidney disease. Routine blood tests show low hemoglobin, platelets, and white blood cells, as well as elevated CRP and adjusted calcium levels. Her vitamin D levels are also low. What treatment is recommended for bone protection in this patient?

MRCP2-4764

A 72-year-old woman with a history of metastatic breast cancer, hypertension, and chronic kidney disease presents to the oncology clinic. She is currently taking doxorubicin, cyclophosphamide, amlodipine, and ramipril. She denies smoking or drinking alcohol and lives with her husband. On examination, she has evidence of bilateral mastectomies. Laboratory results show elevated urea, creatinine, and CRP, as well as bony metastatic disease in the vertebral column on a recent CT scan. Given her clinical history, what is the most appropriate medication to prevent pathological fractures?

MRCP2-4765

A 39-year-old woman presents with a dry cough, recurrent sinusitis, and weight loss over the past few weeks. Despite multiple courses of antibiotics, her symptoms have not improved. On admission, she has a temperature of 37°C, pedal edema, and a blood pressure of 178/98 mm Hg. A urine dipstick reveals 3+ blood and 3+ protein. She also has bloody nasal discharge. Recent tests show elevated levels of ESR, CRP, and creatinine, as well as a positive ANCA (cytoplasmic pattern) and anti-proteinase 3 antibody. CXR, ultrasound abdomen and pelvis are normal.

What is the next step in the management of this patient?