Archives: MRCP Part 2

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?

MRCP2-2727

A 25-year-old patient presents to the clinic with a six-month history of malaise, anorexia, and weight loss. Additionally, he reports experiencing diarrhea for the past four weeks. Upon examination, the patient appears cachectic and has white frond-like patches on both lateral margins of his tongue. Scraping off the patches proves to be unsuccessful. What is the organism responsible for this abnormality on the patient’s tongue?

MRCP2-2703

A 30-year-old man with a history of IV heroin use is brought to the Emergency Department with severe muscle spasms and abdominal pain. He reports difficulty finding clean needles and injection sites in recent weeks. On examination, there is an abscess in his right groin and he exhibits bilateral hyperreflexia and increased tone. When asked to swallow water, he begins to choke. Laboratory results show a low hemoglobin level, elevated white cell count and CRP, and abnormal liver function tests. What is the most suitable course of action at this point?

MRCP2-2704

A 72-year-old woman presents to the emergency department with a 3-week history of severe headaches that have been progressively worsening. She reports that over the past few days, she has noticed swelling in her face and arms. She has a history of smoking 20 cigarettes per day for the past 50 years and has recently developed a cough with blood-tinged sputum.
Upon examination, her blood pressure is 160/95 mmHg, pulse is 88/min and regular, and she appears to be in distress. She has a flushed face and dilated veins in her upper body.
Lab results show a hemoglobin level of 112 g/l, a white cell count of 8.9 × 109/l, and a platelet count of 175 × 109/l. Her sodium level is 138 mmol/l, potassium level is 4.2 mmol/l, and creatinine level is 118 μmol/l. Her corrected calcium level is 2.68 mmol/l, alkaline phosphatase level is 130 u/l, and alanine aminotransferase level is 70 u/l. A chest X-ray reveals a left hilar mass consistent with bronchogenic carcinoma.
What is the most effective treatment for her superior vena cava obstruction?

MRCP2-2705

A 56-year-old man is in the process of being weaned off ventilatory support after spending two weeks in the intensive care unit with single organ failure. However, his blood pressure has suddenly dropped to 80/40 mmHg over the last four hours, and he is experiencing a sinus tachycardia of 120 beats per minute. Additionally, his oxygen saturation has decreased to 86% on FiO2 0.6, and he has become confused. His peripheries are cool, and air entry is reduced at the right base. To make matters worse, his temperature is only 34.6°C. What should be the first course of action in this situation?

MRCP2-2706

An 81-year-old man presents with a three week history of increasing breathlessness. He denies any cough or sputum production. He reports feeling unwell for several days, but attributes it to a recent urinary tract infection for which he received a course of antibiotics. Despite the antibiotics, he feels increasingly unwell and fatigued. He also reports episodes of feeling hot, but has not taken his temperature. He has a past medical history of benign prostatic hypertrophy and hypertension, and takes finasteride and atenolol. He lives alone in warden-controlled accommodation and is visited twice weekly by his daughter. On examination, he appears pale with a temperature of 37.8°C, blood pressure of 130/65 mmHg, and pulse of 72 beats per minute. A systolic murmur is heard at the lower left sternal edge and at the apex. Investigations reveal anemia, leukocytosis, thrombocytosis, elevated ESR and CRP, and hematuria with proteinuria. Chest radiograph is unremarkable. TTE shows thickened aortic valve leaflets with mild aortic regurgitation, and a transoesophageal echocardiogram is scheduled for two days’ time. What is the best course of management in the meantime?