Archives: MRCP Part 2

MRCP2-1013

A 22-year-old female patient visits the clinic for evaluation. She was prescribed bisoprolol by her GP after experiencing palpitations and has now developed a rash on her elbows, knees, navel, and genital area. The rash has been itchy but not painful, and she has not experienced any further palpitations. She had eczema as a young child, but it disappeared before she turned five. She is not aware of any allergies. Upon examination, she has a well-defined erythematous rash on the extensor surfaces of her elbows, knees, umbilicus, and groin. What is the most probable diagnosis?

MRCP2-1014

A 27-year-old Caucasian male presents with his first ever witnessed generalised seizure, lasting for 4 minutes and terminated by benzodiazepines administered by paramedics. He has no past medical history of head injuries but has a history of recurrent epistaxis since childhood and is currently being treated for a left calf deep vein thrombosis. A thrombophilia screen has been negative. Family history is unavailable.

On examination, the patient is confused postictally and uncooperative with the examination. His blood tests and arterial blood gas are within normal limits except for an elevated CRP. A CT head reveals an arterio-venous fistula in his right parietal lobe. The patient remains an inpatient while discussed for management with neurosurgeons and returns to baseline with no focal neurological deficits. However, at 48 hours after admission, he develops sudden onset left face, arm and leg weakness and loss of sensation, with flaccid tone, downgoing plantars. A repeat CT head confirms a right middle cerebral artery ischaemic stroke.

What is the underlying diagnosis that unifies these symptoms?

MRCP2-1015

A 42 year old Indian man who recently moved to the UK presents to the Emergency Department with complaints of numbness in his left foot. He has a medical history of type 2 diabetes mellitus, hypertension, and gastro-oesophageal reflux disease. His most recent HbA1c is 6.4%. During examination, he exhibits reduced sensation in the left heel and plantar area of the foot, as well as six hypoesthesic, hypopigmented patches on both legs. What is the most appropriate course of action?

MRCP2-1016

A 28-year-old man presents to the clinic with a severely itchy rash on his forearms and buttocks. The rash began as papules and vesicles a month ago and quickly crusted over when scratched. He has tried various creams and emollients, including over-the-counter hydrocortisone cream, with no relief. He also reports intermittent abdominal bloating, nausea, and diarrhea, which he has self-diagnosed as irritable bowel syndrome (IBS). His family history includes hypothyroidism and diabetes in his mother. On examination, there are multiple crops of vesicles and papules with evidence of excoriation, erythema, and crusting. Blood tests reveal low ferritin levels, among other things. What is the most appropriate initial treatment for this likely diagnosis?

MRCP2-1017

A 67-year-old man presents with blistering lesions on his skin. He reports he has suffered from mouth ulcers recently for which his GP prescribed chlorhexidine mouthwash. However, this has not been of any benefit and the ulcers are now affecting his ability to eat and drink. He reports over the last few days, large blisters have appeared across his torso and back.

His past medical history includes hypertension and angina. He currently takes ramipril, simvastatin and GTN spray when needed.

On examination, you find his mouth is erythematous with multiple superficial blisters; some have ulcerated and the patient reports they have been slow to heal. He has flaccid bullae across his torso and upper back, which appear to be filled with clear fluid. The bullae are fragile, with a thin outer layer. There are some areas where the blisters have ruptured, leaving exposed eroded skin, with some crusting around the edges.

Dermatology comes to review and they perform a punch biopsy, but advise you to start treatment whilst the results are awaited.

What is the most appropriate first-line treatment for this likely diagnosis in a 67-year-old man?

MRCP2-1018

A 54-year-old male presented to the dermatology clinic with a persistent rash that had been bothering him for four months. He complained of an extremely itchy blistering rash on his popliteal fossa and buttocks. Despite being prescribed levocetirizine 5 mg OD, Eumovate BD, and Diprobase QDS, his symptoms had worsened. The patient had a medical history of refractory eczema, gout, angina, hypertension, and type 2 diabetes for which he was taking allopurinol 100mg OD, aspirin 75mg OD, simvastatin 40 mg OD, ramipril 5mg OD, and metformin M/R 1g BD. His eczema was in remission after being treated with azathioprine six months ago. He also had a history of irritable bowel syndrome diagnosed several years ago. On examination, he had multiple bullae and papules on the extensor surface of his knees and buttocks with excoriation. What is the most likely diagnosis?

MRCP2-1019

A 55-year-old woman presents with a painful burning rash two weeks after starting chemotherapy. She reports a tingling sensation that began four days ago, which has now progressed to swelling and redness of both her hands. This is affecting her ability to perform daily tasks at home. She has also noticed the appearance of a blister in the last 24 hours. In addition to fatigue and nausea, she has a history of left breast cancer treated with wide local excision, axillary node clearance, adjuvant radiotherapy, chemotherapy with docetaxel, and endocrine therapy. What is the most appropriate course of action?

MRCP2-1020

A 25-year-old female presents to her primary care physician with a complaint of a rash behind her knee that has been present for two days. She has a medical history of asthma and eczema and is currently taking Symbicort and using emollients. She does not smoke or drink and recently returned from a camping trip where she went hiking in a forested area.

During the examination, a bull’s eye lesion is observed just above her right popliteal fossa. She is otherwise in good health and has no fever.

What is the most appropriate initial course of action?

MRCP2-1021

A 76-year-old man with learning difficulties presents with an acute exacerbation of congestive cardiac failure. He is currently taking bumetanide 2 mg TDS, carvedilol 25 mg OD, perindopril 4 mg BD, and spironolactone 100 mg OD. During examination, severe raised plaques of psoriasis are observed on his chest, elbows, knees, and scalp. The patient reveals that he has been using topical creams for years but has not seen any improvement and did not seek medical advice due to embarrassment. What is the recommended treatment for his psoriasis?

MRCP2-1022

A 68-year-old man presents with a four week history of skin rash. He reports that the rash appeared suddenly and has been progressing over the past four weeks.

The patient has a medical history of type 2 diabetes mellitus and is obese with a BMI of 38 kg/m². He also consumes alcohol excessively. A cirrhosis diagnosis was confirmed by an ultrasound scan conducted four years ago.

Upon examination, the patient has over 60 raised, oval-shaped lesions with tan pigmentation on his chest and back. The lesions range from 5 mm to 25mm in diameter and have a warty texture with a stuck-on appearance.

What would be the most appropriate next step for this patient?