Archives: MRCP Part 2

MRCP2-2740

A 68-year-old woman was admitted to the hospital with a tender, hot, right calf. She had a history of congestive cardiac failure and chronic edema of her left leg. The admitting doctor considered deep vein thrombosis or cellulitis as possible diagnoses and started the patient on low molecular weight heparin while scheduling a Doppler ultrasound scan of the affected leg.

During the night, the nursing staff requested a review of the patient by the senior house officer, as they felt that she was unwell. Upon examination, the SHO noted that the patient was confused, had a fever of 39.0°C, a blood pressure of 85/60 mmHg, a pulse of 120 beats per minute and regular, and a respiratory rate of 32 breaths per minute. The area of erythema on the right lower leg had extended to the mid-thigh.

Given the patient’s acute illness, which of the following is the appropriate course of action?

MRCP2-2741

A 28-year-old pregnant woman presents to the acute medical unit with flu-like symptoms and jaundiced sclera at 26 weeks gestation. She recently returned from a two-week trip to visit family in Bangladesh and had received the hepatitis A vaccine prior to travel. On examination, she has a jaundiced sclera, a blood pressure of 108/60 mmHg, a temperature of 38.1ºC, and a pulse of 96/min. She experiences slight tenderness in the right upper quadrant of her abdomen. Blood tests reveal elevated levels of bilirubin, ALP, ALT, γGT, and CRP, as well as decreased albumin levels. What is the most likely diagnosis?

MRCP2-2742

A 29 week pregnant woman presents to her GP with a rash that has developed over the past 12 hours. Upon examination, lesions indicative of chickenpox are observed. The patient’s vital signs are stable and she appears to be in good health.

What course of action would be advised for management of this condition?

MRCP2-2717

A 25-year-old carpenter arrives at the Emergency department with a hot and erythematous patch on the back of his hand. The erythema rapidly spreads up his arm and he begins to feel unwell. Urgent debridement in theatre is scheduled. What antibiotics should be administered, assuming no allergies?

MRCP2-2718

A 50-year-old man presents with a fever, pain, and erythema across his abdomen. He had undergone an elective repair of an umbilical hernia 10 days ago and was discharged home. He has a history of type 2 diabetes mellitus and a high body mass index of 31 kg/m² (normal range 18.5 – 24.9kg/m²).

He had been feeling well until the morning of presentation when he noticed a small area of erythema and tenderness around the incision site near his umbilicus. Throughout the day, the erythema grew and became more painful, prompting his wife to bring him to the Emergency Department.

On examination, he appeared unwell with the following vital signs:
temperature 38.6ºC
respiratory rate 23 breaths/min
oxygen saturation 97% on air
heart rate 125 bpm
blood pressure 88/61 mmHg

He complained of severe abdominal pain and nausea, with one episode of vomiting. There was a large area of erythema across the lower half of his abdomen which was extremely tender to palpation. Examination of the erythematous area also revealed impaired sensation to light touch.

His blood results showed:
WBC 17 * 109/L (4.0 – 11.0)
CRP 460 mg/L (< 5) What is the most likely cause of this patient’s infection?

MRCP2-2722

A 35-year-old woman is undergoing her second round of chemotherapy for breast cancer. She is experiencing two days of vomiting and watery diarrhoea, accompanied by occasional chills and weakness. She has not traveled abroad and has not been in contact with anyone who is ill. Her husband is a farmer, and they recently attended a farm foods show that featured local cheese and meats in the area.

During the examination, the woman’s abdomen is soft, with mild tenderness in the right iliac fossa. She has dry mucosa and muscle aches throughout her body.

Hb 110 g/l Na+ 138 mmol/l
Platelets 348 * 109/l K+ 3.9 mmol/l
WBC 2.4 * 109/l Urea 4.3 mmol/l
Neuts 0.7 * 109/l Creatinine 76 µmol/l
Lymphs 1.4 * 109/l CRP 96 mg/l

The stool specimen reveals a gram-positive bacillus. What is the likely causative organism in this case?

MRCP2-2723

A 54-year-old male with acute lymphoblastic leukaemia is on his third cycle of chemotherapy. He is admitted to the ward after developing a temperature of 38.7ºC before his fourth cycle. He feels well in himself but has ongoing trouble with diarrhoea and mucositis. Currently, his stools are type four on the Bristol stool chart and his mouth ulcers are being treated with a lidocaine/nystatin topical solution. He denies any cough, sore throat or urinary symptoms.

During examination, his abdomen is soft and non-tender with normal bowel sounds. His chest is clear with air entry heard throughout. He has no murmurs, joint effusions or areas of cellulitis. His mouth contains multiple ulcers with areas of straw colored exudate overlying them.

Hb 110 g/l
Platelets 60 * 109/l
WBC 1.1 * 109/l
Neuts 0.5 * 109/l

Blood culture (1st) Staphylococcus epidermidis
Blood culture (2nd) no growth
Chest X-ray clear lung fields, normal cardiac contour
Nasopharyngeal PCR negative
Urine dip negative for leucocytes and nitrites

What investigation would be the most effective in identifying the cause of the fever?

MRCP2-2724

A 42-year-old man with poorly controlled type 1 diabetes mellitus presents with a nodular lesion on the left-side of his face around the angle of the jaw. Two months ago he had a tooth extraction at the dentist. The nodule is around 2 cm in diameter, raised and purple-red in colour. On examination a sinus tract is seen in the middle of the nodule which is draining a blood-stained fluid.

Microscopy of the discharge shows microscopic yellow granules.

What is the most likely causative organism?

MRCP2-2725

A 65 year old male who is a malnourished alcoholic presents with a chronic cough for the past 6 weeks associated with a low grade fever. The cough is productive of purulent sputum.

Six months previously he had been diagnosed with early stage non-Hodgkin’s lymphoma, which had responded well to chemotherapy (doxorubicin, bleomycin, vinblastine, and prednisolone).

On examination his temperature is 37.8ºC, blood pressure 140/80 mmHg, and his pulse is 96/minute and regular. Auscultation of the chest reveals absence of breath sounds over the left middle lung field. Chest x-ray confirms left upper lobar consolidation.

The following investigations were ordered:

Hb 12 g/dl
Platelets 180 * 10^9/l
WBC 7 * 10^9/l
MCV 85 fl
Na+ 140 mmol/l
K+ 5 mmol/l
Creatinine 90 µmol/l
Urea 5 mmol/l
CRP 50 mg/l

Sputum stains partially acid fast bacilli with branching rods

What is the most appropriate initial treatment plan for this patient?

MRCP2-2726

A 52-year-old businessman who frequently travels to the Gambia and is usually diligent with his malaria prophylaxis presents with general malaise and relapsing/remitting fevers occurring every third day. He returned from the Gambia a week ago and did not take his malaria prophylaxis as he has never contracted the disease before. He has no significant medical history and takes no regular medication. The thick and thin films reveal malarial parasites, which are confirmed as Plasmodium vivax by the Malaria Reference Laboratory. What is the most appropriate management in accordance with current UK guidelines?