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bmjonexamination question bank mrcp part 1
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1. A 24-year-old Indian deck hand is admitted as an emergency following acollapse shortly after his ship docked. According to the ships' medical officer,
he had been suffering from a sore throat over the past two days which
diagnosed as a viral infection. He is usually fit and well and takes no regular
medication.On examination, he is pyrexial (temperature 38.9°C), his BP is
100/60, and pulse 61 and regular. He has marked cervical lymphadenopathy
and pharyngitis with a grey/white membrane overlying the tonsils.Which of the
following is the most likely diagnosis?
a. Cytomegalovirus infection
b. Epstein Barr Virus infection
c. Streptococcus pyogenes
d. Pertussis infection
e. Diphtheria infection
Answer: E
Explanation: Key learning points
Infectious Diseases
● Patients with diphtheria classically present with severe pharyngitis and the
presence of a pseudomembrane over the tonsils.
Explanation
The answer is diphtheria infection. The clues here include the gentleman's ethnic
background (uptake of the diphtheria vaccination is less in India than in the UK),
severe pharyngitis with lymphadenopathy and the presence of a greyish
pseudomembrane over the tonsillar bed.
The relative bradycardia, potentially due to diphtheria exotoxin, is a further pointer to
the diagnosis. Definitive diagnosis is via culture of blood or tonsillar exudate, but
prior to this, the patient should be treated with antibiotics (usually a macrolide or
penicillin). Airway support may also be required in severe cases, and the patient
should be monitored closely.
CMV rarely causes isolated pharyngitis, and EBV would be less likely given the
markedly raised CRP and the presence of a pseudomembrane on the tonsils.
Pertussis infection is characterised by a marked cough, which is not described here.
Streptococcal throat infection is a reasonable alternative diagnosis, although
formation of a pseudomembrane would be unusual in this context.
,2. A 3-year-old child is admitted to hospital due to loose bowel motions with no fresh
or altered blood, fever, and vomiting. Escherichia coli subtype O157:H7 is cultured
from his stool. With adequate resuscitation, he makes an uneventful recovery and is
discharged home after seven days.
He presents again 10 days from initial presentation with bloody diarrhoea and
collapse. His renal function tests are severely deranged, his clotting screen is normal
but blood film examination shows severe thrombocytopenia with evidence of
microangiopathic anaemia. Coombs' test and C-reactive protein are both negative.
Which is the most probable underlying complication?
A. Disseminated intravascular coagulation (DIC)
B. Septicaemia
C. Autoimmune haemolytic anaemia (AIHA)
D. Thrombotic thrombocytopenic purpura (TTP)
E. Haemolytic uraemic syndrome (HUS) due to VTEC E. coli
Answer: E
Explanation: Key learning points
Haematology
● Haemolytic uraemic syndrome bears resemblance to TTP except for
prominent renal impairment and a lack of neurological signs. It should be
diagnosed quickly and managed with dialysis and plasma exchange.
Explanation
The initial presentation with diarrhoea with culture positive E. coli O157-H7 should
lead one to consider HUS as the complication. Negative Coombs' test is against
AIHA, whereas TTP would show several red cell fragments and neurological
complications.
DIC is excluded by the normal clotting screen and septicaemia is improbable seeing
the normal inflammatory markers.
HUS due to VTEC E. coli is the most probable diagnosis.
Haemolytic uraemic syndrome (HUS) is a triad of:
, ● microangiopathic haemolytic anaemia (Coombs' test negative)
● thrombocytopenia, and
● acute renal failure.
Typical HUS is most commonly associated with Escherichia coli with somatic (O)
antigen 157 and flagella (H) antigen 7, hence the designation O157:H7. It produces
a toxin called Shiga toxin or verotoxin. General management includes appropriate
fluid and electrolyte management, antihypertensive therapy and dialysis where
required.
Reference:
Patient.info. Haemolytic Uraemic Syndrome
3. ollowing your morning surgery, you receive a telephone call from the lab at the
local hospital regarding an 82-year-old patient of yours whom you admitted from her
nursing home with headache, photophobia and neck stiffness.
When you saw her, her temperature was 39.0°C, pulse rate 115 beats/min and there
were no skin rashes or focal neurological signs. Her Glasgow coma scale was 15/15.
Following admission, CSF was obtained and Gram stain showed Gram-negative
coccobacilli, subsequent culture confirms a Haemophilus influenzae meningitis.
What chemoprophylaxis should be offered to the nurses at her home?
A. No chemoprophylaxis needed
B. Azithromycin
C. Rifampicin
D. Ceftriaxone
E. Chloramphenicol
Answer: E
Key learning points
Infectious Diseases
● Close contacts of Haemophilus influenzae meningitis should receive
rifampicin
Explanation
, The decision to give chemoprophylaxis to contacts of patients with confirmed
meningitis is usually made by Public Health England or the appropriate public health
agency. However, it is important to be aware of the basic principles.
With regard to Haemophilus influenzae, prophylaxis is recommended for three main
groups:
● Household contacts: any non-immunised contact, under 4 years of age,
should receive the Hib vaccine. Rifampicin should also be given once daily (at
20 mg/kg), for four days (unless the patient is less than 4 and has been fully
immunised). Nurses, in this case, would likely qualify as household contacts,
but this should be discussed with the HPU.
● The index case should be immunised, irrespective of age.
● Room contacts of children in playgrounds, nurseries or creches. Any
unimmunised children less than 4 years of age should be vaccinated.
Chemoprophylaxis should be offered when two or more cases of Hib disease
have occurred within 120 days.
Recommendations from the Department of Health and Public Health England state:
"Rifampicin at a dose of 20 mg/kg (maximum 600 mg) once a day for four days for
adults and children older than three months is the prophylaxis of choice for
eliminating carriage in the index case and among household contacts (STRONGLY
RECOMMENDED) because it is highly effective (eradication rate of 92-97%) and Hib
resistance to rifampicin is extremely rare (<0.1%) in the UK".
Ciprofloxacin is an acceptable alternative.
Reference:
Public Health England. Haemophilus influenzae type b (Hib): revised
recommendations for the prevention of secondary cases.
4. you are called to see a man in the Emergency department who has been in a road
traffic accident. His memory of events is poor but he thinks he banged his head. His
main complaint now is of extreme pain in his right eye.
On examination he has reduced visual acuity (counting fingers only), proptosis and
complete ophthalmoplegia of his right eye. You notice that the eye is injected,
chemotic and on closer inspection appears to be pulsating.
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