Archives: MRCP Part 2

MRCP2-4766

A 35-year-old Turkish man with suspected deep vein thrombosis (DVT) is referred to the Emergency Department by his General Practitioner (GP). He recently returned to the United Kingdom after a 1-year break in Turkey. During his stay in Turkey, he was admitted to the hospital with diarrhoea and abdominal pain, accompanied by multiple painful lesions in his mouth. After discharge, he presented again to the Emergency Department with an acute red and painful eye, which was treated as suspected conjunctivitis. A few months later, he developed mouth and scrotal lesions, as well as swollen and painful ankle and wrist joints, which resolved after a few weeks. He has no past medical history. On examination, he is pyrexial with a temperature of 38 °C, and investigations reveal a popliteal deep vein thrombosis (DVT) and abnormal blood results. Given the likely diagnosis, what is the best management option for this patient?

MRCP2-4738

A 55-year-old patient presents with a six-month history of polyarthralgia in her hands. Upon conducting blood tests, it is revealed that she is rheumatoid factor positive, anti-CCP antibody positive, and anti-nuclear antibody positive with a high titre. An ultrasound scan confirms active synovitis in the metacarpophalangeal joints of her hands bilaterally. What would be the drug regimen recommended for this patient?

MRCP2-4740

A 50-year-old woman has been referred to Rheumatology clinic due to experiencing widespread aches and pains felt throughout her body. What is the underlying cause of her pain?

MRCP2-4742

A 70-year-old male from the Dominican Republic presents with constant bilateral anterior thigh pain and lower limb weakness. He reports being an active man prior to these symptoms, but is now wheelchair and bed-bound. What is the best course of treatment for his condition?

MRCP2-4743

A 35-year-old woman with rheumatoid arthritis presents with feelings of malaise. She has been experiencing lethargy for the past two days and has developed a severe sore throat over the last 24 hours. The patient has been taking the following medications for the past six months: paracetamol 1g QDS, naproxen 500 mg PRN, methotrexate 15 mg once weekly, folic acid 5mg once weekly, and prednisolone 5mg OD. Upon examination, she is septic with the following vital signs: respiratory rate 26/min, heart rate 120/min, blood pressure 100/67 mmHg, and temperature 37.9ºC. She is able to tolerate oral fluids and small amounts of food. Adequate fluid resuscitation and antibiotics are initiated. What should be done regarding her regular medications?

MRCP2-4744

A 29-year-old male presents after recently returning from Bangladesh with 2 weeks of daily spiking fever, a new rash on his foot and pain on bending his knees or closing his hands. He also reports lumps and bumps on his neck that he thinks are new. He denies any cough or weight loss. He has no other past medical history and is unaware of any unwell family members.

On examination, his temperature is 39.2 degrees. You note a maculopapular rash on his left sole and face. His knees and wrists are swollen and tender. His chest and cardiovascular examination are unremarkable, his abdomen is soft. However, you note a 12cm splenomegaly.

His serum tests demonstrate:

Hb 127 g/l
Platelets 450 * 109/l
WBC 17.0 * 109/l
Neuts 11.0 * 109/l

Na+ 138 mmol/l
K+ 3.5 mmol/l
Urea 7.8 mmol/l
Creatinine 70 µmol/l

CRP 30 mg/l
Ferritin 2000 µg/l
ALP 250 u/l
ALT 160 u/l
ANA negative
dsDNA negative

His chest radiograph appears unremarkable with no focal consolidation. A first induced sputum is negative for acid-fast bacilli. What is the most likely diagnosis?

MRCP2-4745

A 72-year-old woman presents to the rheumatology clinic for a follow-up on her osteoporosis treatment. She was diagnosed with osteoporosis five years ago after experiencing a left Colles fracture from a fall. Alendronic acid was initiated as treatment. During the visit, the patient complains of persistent back pain for the past few weeks. She denies any recent falls or injuries.

The patient has a medical history of rheumatoid arthritis, which was diagnosed when she was 28 years old. She received prolonged corticosteroid treatment and various disease modifying drugs. Methotrexate (10 mg weekly) was eventually used to control her arthritis, and she has not required corticosteroid treatment for many years. The patient has no family history of osteoporosis or fragility fractures and does not smoke or drink alcohol.

On examination, the patient has mid-line point tenderness around the T12 – L1 level of her spine. Neurological examination of the lower limbs is normal. A thoracolumbar spine x-ray shows anterior height loss of the T12 vertebrae, but is otherwise unremarkable.

The patient’s height is 150 cm and weight is 55 kg. Her femoral neck BMD was T – 3.2 five years ago and is now T – 2.4. Her FRAX 10-year probability of major osteoporotic fracture is 27% and hip fracture is 8.7%.

What is the most appropriate management plan for this patient’s osteoporosis?

MRCP2-4746

A 67-year-old man presents to his General Practitioner with bilateral shoulder aches and pains that have been ongoing for 3 months. He reports stiffness in the mornings that takes up to two hours to resolve after waking. The patient denies any symptoms of headache, jaw claudication, or visual disturbance. He has no symptoms of dry eyes or mouth, no skin or hair changes, no weight loss, and no fevers.

The patient has a past medical history of hypertension and chronic obstructive pulmonary disease. He takes ramipril, simvastatin, and inhaled salbutamol as required. He is an ex-smoker who drinks 25 units of alcohol per week. The patient recently retired after working as a train driver.

On examination, there are no inflamed joints except for slight tenderness across the shoulder girdle. There is no evidence of scalp tenderness. The cardiovascular and respiratory examination is unremarkable.

The General Practitioner orders several investigations, including haemoglobin, white cell count, neutrophils, platelets, urea, creatinine, sodium, potassium, erythrocyte sedimentation rate, rheumatoid factor, creatinine kinase, calcium, alkaline phosphatase, thyroid stimulating hormone, and protein electrophoresis.

What is the appropriate next management step for this patient?

MRCP2-4747

A 25-year-old woman presents with a 2-month history of intermittent fever accompanied by chest pain, which is worse after eating. She has recently also noticed pain in the joints of her hands and feet.
She is febrile, with a temperature of 38.5 °C. Her pulse is 92/min and her blood pressure is 120/80 mmHg. The positive findings on examination are enlarged cervical lymph nodes, hepatomegaly and synovitis of the metacarpophalangeal (MCP) and ankle joints.
Investigations reveal the following:

Haemoglobin (Hb) 110 g/l 120–160 g/l
White cell count (WCC) 18 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 480 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 90 mm/hour 1–20 mm/hour
C-reactive protein (CRP) 200 mg/l < 10 mg/l
Alanine aminotransferase (ALT) 60 IU/l 5–30 IU/l
Alkaline phosphatase (ALP) 200 IU/l 30–130 IU/l
Ferritin 4000 μg/l 20–250 µg/l
Abdominal ultrasound Hepatosplenomegaly
Stool culture and blood culture –
ANA, RF, ANCA, anti CCP All –
Computed tomography (CT) chest Cardiomegaly
Which of the following is most likely diagnosis?

MRCP2-4748

A 30-year-old female patient visits her primary care physician with complaints of fever, pain, and swelling in her knees, wrists, and hands for the past week. She has no significant medical history. During the examination, her blood pressure is 110/70 mmHg, and her heart rate is 94 bpm. A purplish rash is observed throughout her body. Palpation of the metacarpophalangeal and interphalangeal joints reveals swelling and tenderness, but no deformities. What is the most probable diagnosis?