Archives: MRCP Part 2

MRCP2-2933

A 23-year-old woman with lupus and antiphospholipid syndrome presented to the Rheumatology clinic complaining of sharp chest pain on her right side. The pain had started three days prior to her visit and was accompanied by shortness of breath. She also reported a vesicular rash that had appeared over the affected area one day ago. The patient weighs 65 kg and is currently taking Methotrexate 20 mg once weekly, Prednisolone 30 mg once a day, Aspirin 75 mg once a day, and Folic Acid 5 mg once a day. Upon admission to the rheumatology ward, a CTPA was performed which showed no pulmonary emboli, but widespread bilateral changes of subsolid nodules and ground-glass opacification. The patient’s shortness of breath continued to worsen and her vital signs were taken: temperature 39.1 °C, blood pressure 107/55, heart rate 122, and oxygen saturation 88% on air. What is the most appropriate treatment for her likely diagnosis?

MRCP2-2934

A 28-year-old woman presents to the Emergency Department with a 3-week history of fatigue, fever and muscle pain after returning from a trip to Costa Rica. She also reports occasional episodes of vomiting and diarrhea. She has no significant medical history and has been generally healthy.
Upon examination, she is febrile with a temperature of 38.5 °C. Her heart rate is 110 bpm and regular, with a blood pressure of 118/72 mmHg. Lung and heart sounds are normal. Her abdomen is soft and non-tender, with no palpable organomegaly. She has enlarged cervical and inguinal lymph nodes. She also has bilateral conjunctivitis and mild periorbital edema.
Electrocardiogram (ECG): sinus tachycardia, PR interval 200 ms.
Which of the following vectors is most likely responsible for transmitting the causative organism?

MRCP2-2916

A 37-year-old woman of African descent has been diagnosed with HIV and her last CD4+ count was 33 cells/mm3. Two weeks after starting on HAART (TDF/FTC/3TC), she presents with a progressively worsening headache and fever. She also has a staggering gait and dementia. On examination, she appears very ill, wasted, and anaemic with a haemoglobin of 90 g/L, and is irritable. Her Glasgow coma score (GCS) is 13/15, (E3,V4,M6). She has widespread crepitations and a respiratory rate of 24 breaths/minute.

The lumbar puncture results show a serum cryptococcal antigen ratio of 1:512, CSF cryptococcal antigen ratio of 1:2048, positive CSF culture, and an opening pressure of 30 cmH2O. The patient is started on liposomal amphotericin B (1.5 mg/kg per day) and flucytosine (100 mg/kg/d in 4 divided doses).

After two weeks of treatment, the results show a serum cryptococcal antigen ratio of 1:512, CSF cryptococcal antigen ratio of 1:512, positive CSF culture, and an opening pressure of 26 cmH2O. What would be the next step of management for this patient?

MRCP2-2917

A 23-year-old woman presents with symptoms of vulval itching, dyspareunia, and a greenish malodorous vaginal discharge that have been present for two weeks. She has a medical history of type 1 diabetes mellitus and has engaged in unprotected sexual intercourse multiple times in recent weeks.

During the examination, the cervix appears erythematous with petechial lesions. The pH of the discharge is 7.0, and the genital wet prep reveals a high number of white blood cells and a protozoan organism.

What is the most appropriate management for this patient?

MRCP2-2922

A 43-year-old woman presents to the emergency department with a 5-day history of high fevers and myalgia. She has recently returned to the US from the Democratic Republic of the Congo. Her medical history includes uterine fibroids and iron deficiency anemia, which she manages with regular ferrous sulfate.

Her vital signs are as follows:
– Temperature: 39.2ºC
– Heart rate: 120 bpm
– Blood pressure: 110/70 mmHg
– Respiratory rate: 16 breaths/min
– Oxygen saturation: 98% on room air

Upon examination, she is diaphoretic and reports a headache. Her lung sounds are clear and her heart sounds are regular. Her abdomen is soft and non-tender. However, she has multiple enlarged and tender lymph nodes in her axillae and groin.

What is the most likely infectious agent responsible for her symptoms?

MRCP2-2923

A 54-year-old male presents with a persistent cough, fatigue, fever, and shortness of breath. He has been feeling unwell for the past 6 months with recurrent colds that he cannot seem to shake off. During this time, he has lost around one and a half stone in weight due to a poor appetite. His medical history only includes asthma. He has been a widower for 7 years and enjoys traveling the world for wildlife photography. His last trip was to Africa 2 years ago.

During examination, his temperature is 38.2ºC, heart rate is 102/min and regular, blood pressure is 110/70 mmHg, and saturations are 92% air. Fine bibasal crackles are heard on chest auscultation, and his arterial blood gas shows a type 1 respiratory failure. Bilateral pulmonary infiltrates are seen on his chest x-ray. He is treated with intravenous antibiotics, but his condition worsens after two days of admission, and he requires continuous positive airway pressure (CPAP). The beta glucan test and urinary antigens are negative. The patient reports experiencing blurred vision, flashing lights, and spots in his right eye.

What is the most likely diagnosis?

MRCP2-2924

A 16-year-old male presents to the infectious disease department with a fever, sore throat, and swollen lymph nodes. He has been feeling unwell for the past three days and noticed some yellowing of his eyes. Upon routine blood testing, the following results were obtained:

– Bilirubin: 55 µmol/l
– ALP: 54 u/l
– ALT: 402 u/l
– AST: 188 u/l
– γGT: 17 u/l
– Albumin: 43 g/l

The patient denies any history of travel or sexual activity and has never used intravenous drugs. What is the most likely causative organism?

MRCP2-2925

A 16 year old girl arrives at the emergency department with her worried mother. She was born and raised in England, but her parents come from a rural rice farming community in China. She recently returned from a trip to China where she had close contact with dogs, sheep, and pigs on her family’s farm. She had been taking Mefloquine for malaria prevention during her travels.

Yesterday, she complained of a fever and headache, and today she is confused and disoriented. She has no history of medical problems, has received all of her UK immunizations, and is a successful student and active member of her college’s canoe club. She has no known allergies.

During the examination, she is febrile at 38.9°C but stable in terms of her blood pressure and heart rate. She appears confused and has difficulty walking. It is challenging to examine her cranial nerves, but there are no obvious abnormalities. She has normal strength but increased tone in her arms, which is more pronounced on the left side, and hyperreflexia on both sides. During the consultation, she has several involuntary writhing movements in her upper limbs.

A CT scan reveals hypodensity in the thalami and basal ganglia bilaterally, with more pronounced effects on the left side. A lumbar puncture shows lymphocytic cerebrospinal fluid with elevated protein levels.

What is the most probable diagnosis?

MRCP2-2926

A 49-year-old farmer presents with a three-day history of headache, fever, and vomiting. He has been undergoing chemotherapy for mantle cell lymphoma and completed his fourth cycle three days ago. Despite his treatment, he has continued to work on his dairy farm. He has no significant medical history, does not smoke or drink. On examination, the patient is lethargic and has a fever of 38.6 degrees. There are no rashes on his skin, but he displays neck stiffness and photophobia. A neurological examination is not possible, but there is no obvious facial asymmetry, and the patient is moving all four limbs. Both plantars are downgoing.

Blood tests reveal:

– Hb 98 g/l
– Platelets 78 * 109/l
– WBC 0.9 * 109/l
– Neutrophils 0.3 * 109/l
– Na+ 146 mmol/l
– K+ 4.3 mmol/l
– Urea 8 mmol/l
– Creatinine 99 µmol/l
– CRP 170 mg/l

A lumbar puncture is performed, and the cerebrospinal fluid examination shows:

– WCC 200 x 106/litre (70% neutrophil 25% lymphocytes)
– RBC 4 x 106/litre
– Glucose 1.7 mmol/l (normal 3.3-4.4 mmol/l)
– Microscopy No organisms on gram stain
– Appearance cloudy

The patient is immediately started on intravenous ceftriaxone for suspected bacterial meningitis. After 48 hours, blood and cerebrospinal fluid cultures are still pending, and the patient’s clinical state has not changed. What is an appropriate additional therapy?

MRCP2-2927

A 35-year-old woman presents to the Emergency Department. She has just returned from her trip to Thailand and is worried about the risk of contracting rabies. She had a minor bite from a stray dog while on her trip, but she immediately cleaned the wound. She has no past medical history and takes no regular medications. On examination, all of her vital signs are within normal limits and the wound has healed.
What is the best course of action to manage this patient’s risk of rabies?