Archives: MRCP Part 2

MRCP2-2890

A 70-year-old man visits the tuberculosis clinic with complaints of worsening lower back pain over the past 6 months. Despite taking analgesics, the pain has become unbearable and has affected his mobility. He lives with his wife on their farm and has been independent until now. His medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and benign prostatic hypertrophy. He had tuberculosis at the age of 24, but he cannot recall the treatment he received. An MRI of his spine reveals L4/5 discitis, and a biopsy is scheduled. The biopsy culture grows acid-fast bacilli. What is the recommended treatment regimen?

MRCP2-2891

A 44-year-old man presents to the Emergency Department with a 4-day history of a chesty cough, myalgia, fever, arthralgia, and rigors. He initially thought it was just a cold and did not seek medical attention. However, his symptoms have worsened, and he has become increasingly breathless, only able to walk to the toilet before becoming short of breath. His wife brought him to the hospital out of concern.

The patient has no significant medical history, takes no regular medications, and has never smoked. On examination, his temperature is 39.2 °C, respiratory rate 32, heart rate 127, blood pressure 107/82, and oxygen saturations 92% on air. A chest X-ray shows bilateral interstitial infiltration. His blood tests reveal a haemoglobin level of 145g/l, WCC of 13.2 x 10^9/l, and platelets of 378 x 10^9/l. His electrolyte levels are within normal limits, with a sodium of 142 mmol/l, potassium of 4.8 mmol/l, urea of 6.9 mmol/l, and creatinine of 75 mol/l. An Influenza PCR test confirms Influenza B.

What is the most appropriate management for this patient?

MRCP2-2892

A 87-year-old woman presents to the emergency room with a 2-week history of increased shortness of breath and decreased mobility. She reports that her shortness of breath is worse at night and she has been waking up gasping for breath. Additionally, she has fallen twice in the past week, which is unusual for her. Her medical history includes hypertension and type 2 diabetes, and she lives independently with her husband while her daughter helps with shopping. On examination, coarse crackles are heard bi-basally in her chest, and a pan-systolic murmur is loudest over the apex. Investigations reveal bilateral blunting of the costophrenic angles and upper lobe diversion on CXR, as well as severe mitral regurgitation with a large mobile structure on valve leaflet on echocardiogram. Blood cultures show Methicillin-sensitive Staphylococcus aureus. Her haemoglobin is 11g/dl, WCC is 6 x 10^9/l, and platelets are 178 x 10^9/l, while her sodium is 139 mmol/l, potassium is 4.2 mmol/l, urea is 8 mmol/l, and creatinine is 92 mol/l. What is the most appropriate treatment option for this patient?

MRCP2-2893

A 32-year-old man from the United Kingdom is pursuing a PhD in nutrition. He previously conducted research on rice varieties while based in China. Two months ago, he experienced an itch while in a rice paddy, which later developed into a rash that lasted for five days. Currently, he is presenting with confusion, and his girlfriend reports that he has been experiencing severe headaches, particularly in the morning, along with nausea and vomiting. His condition has progressed, and he is now experiencing difficulty using his left hand, slurred speech, impaired memory, and judgment.

During the examination, the patient appears confused and disoriented, with a Glasgow coma scale of 13/15. He exhibits sudden head and eye movements, lip smacking, and jerky muscle movements. Laboratory results show eosinophilia, with a count of 600/uL, and both haemagglutination and ELISA tests indicate the presence of Schistosoma antibodies, which remain positive upon repeat testing. A CT scan reveals oedema and multifocal small contrast-enhanced lesions in the cerebellum, occipital, and frontal lobes.

What is the appropriate management for this patient?

MRCP2-2894

A 32-year-old woman known to be HIV positive presents with a 4-day history of worsening shortness of breath, high fevers and a cough producing green phlegm. Her last CD4 count 3 months ago was 200 × 106/l and she has not started any treatment, despite being advised to do so on multiple occasions.

Upon examination, her O2 saturation is 92% on breathing room air, temperature 39.2°C, pulse 118 beats/min, and crackles are audible in both midzones. A chest X-ray reveals diffuse interstitial shadowing bilaterally. Arterial blood gas (on air) shows p(O2) 10.2 kPa, p(CO2) 3.8 kPa, bicarbonate 23 mmol/l, and O2 saturation 91%.

What is the most appropriate initial course of treatment?

MRCP2-2895

A 23-year-old man is brought to the Emergency Department by his friend. He has been complaining of worsening headache and neck stiffness over the past few days and is now drowsy and confused.
Upon examination, he has signs of meningism, a fever of 39.5 °C, blood pressure 110/70 mmHg, and pulse 100 bpm. There is a purpuric rash.
The following investigations are obtained:

Haemoglobin (Hb) 135 g/l 130–170 g/l
White cell count (WCC) 14.5 × 109/l 4.0–11.0 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 120 μmol/l 60–110 µmol/l
Lumbar puncture Decreased CSF glucose, increased protein,
neutrophils, gram-negative diplococci
IV benzylpenicillin is initiated, and there is initial improvement. However, 72 hours later, he develops a new fever of 39.5 °C, with an increased eosinophil count in the peripheral blood.
What is the most crucial step in management?

MRCP2-2896

A 28-year-old man, who spent 4 months on a construction project in India, comes to the clinic for follow-up. He experienced a severe bout of diarrhea with blood during his time in the country and now reports intermittent sweats and pain in his lower right chest. Upon examination, he has hepatic tenderness and a temperature of 37.8 °C. Further investigations reveal abnormal results, including a low hemoglobin level and elevated liver enzymes. A CT scan shows a single abscess in the right liver lobe measuring 6 cm in diameter. You consult with an interventional radiologist for their opinion. What is the most appropriate initial medical treatment for this patient?

MRCP2-2897

A 35-year-old woman presented with a 3-month history of swelling and discomfort affecting her lower limbs, more severe on the left than on the right. She also experienced general malaise and had occasional fevers. She had recently returned from a trip to Thailand, where she had been volunteering in rural areas surrounded by rice paddies.

Upon examination, both legs showed non-pitting edema up to the knee, which did not improve with leg elevation. The patient also had painful bilateral inguinal lymphadenopathy.

The following investigations were conducted:

– Haemoglobin: 128 g/l (normal range: 135-175 g/l)
– White cell count (WCC): 9.2 × 109/l (normal range: 4-11 × 109/l)
– Eosinophils: 1.5 × 109/l (normal range: 0.04-0.4 × 109/l)
– Chest X-ray: Bilateral pulmonary infiltrates
– Ultrasound of the groin: Bilateral inguinal lymphadenopathy with lymphatic obstruction

What is the most suitable treatment for this patient’s condition?

MRCP2-2898

A 32-year-old woman who has recently returned from Thailand presents with bloody stools and mucous. She has also been experiencing increasing abdominal pain and vomiting. Her blood pressure is 100/70 mmHg and her pulse is 110 bpm and regular.
Investigations:
s
Haemoglobin (Hb) 118 g/l 135 – 175 g/l
White cell count (WCC) 14.8 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 280 × 109/l 150 – 400 × 109/l
Urea 9.2 mmol/l 2.5 – 6.5 mmol/l
Erythrocyte sedimentation rate (ESR) 45 mm/h 1 – 20 mm/h
Sodium (Na+) 142 mmol/l 135 – 145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 80 μmol/l 50 – 120 µmol/l
C-reactive protein (CRP) 60 mg/l < 10 mg/l
What is the most appropriate initial treatment?

MRCP2-2899

A 25-year-old woman presents to the Emergency Department for review. She returned from a trip to Thailand a few days ago, during which she had unprotected sexual intercourse with a number of men. She had an onset of multiple vesicles which has now formed into multiple ulcers and she has developed burning and tingling over her vulva. On examination she is pyrexial 38.2°C, her BP is 120/80 mmHg; pulse is 80/min and regular. There are multiple small, shallow, painful ulcers over the vulva and tender inguinal lymphadenopathy. The ulcers are swabbed and she is referred to the GUM clinic.
Which of the following is the most appropriate next step?