Archives: MRCP Part 2

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?

MRCP2-2900

A 25-year-old man returns home with diarrhoea, having worked on a volunteer project in South America. He also complains of abdominal bloating, that his stools are difficult to flush away and of excessive flatulence. He has lost his appetite over the past few weeks and has lost 4 kg in weight.

On examination, he has mild pyrexia (37.5 °C) and looks bloated. Investigations reveal the following:

Haemoglobin (Hb) – 130 g/l (normal value: 130-170 g/l)
White cell count (WCC) – 8.5 × 109/l (normal value: 4.0–11.0 × 109/l)
Platelets (PLT) – 280 × 109/l (normal value: 150–400 × 109/l)
Sodium (Na+) – 142 mmol/l (normal value: 135–145 mmol/l)
Potassium (K+) – 4.6 mmol/l (normal value: 3.5–5.0 mmol/l)
Creatinine (Cr) – 95 μmol/l (normal value: 50–120 µmol/l)
Albumin – 42 g/l (normal value: 35–55 g/l)
Stool sample – No cysts or ovae seen

What is the most appropriate treatment for him?

MRCP2-2877

A 49-year-old man presents to the emergency department with a headache, confusion, and slurred speech. He recently returned from a camping trip in Germany where he removed a tick from his leg. He was treated with doxycycline for fevers, muscle aches, and fatigue but has since developed worsening symptoms. A CT head scan was normal, but a lumbar puncture showed elevated mononuclear white blood cells and protein in the cerebrospinal fluid. Blood tests for infectious diseases were negative. What is the most appropriate management for this patient’s likely diagnosis?

MRCP2-2878

A 28-year-old woman returns from a backpacking trip through Southeast Asia and reports feeling under the weather with a high temperature. During the examination, you observe a tick bite eschar and a rash surrounding it on her right forearm.

What is the most probable organism responsible for her symptoms?

MRCP2-2882

As the medical basic specialist trainee on call, you are requested to attend to a middle-aged man who has been admitted with a severe chest infection. The ward nurse reports that he has experienced an allergic reaction within five minutes of receiving vancomycin i.v infusion.

Upon arrival, you conduct a thorough examination of the patient who is running a fever and appears to be in poor health. He is receiving oxygen through nasal prongs and reports no new symptoms since admission, except for a sudden warmth and flushing during his vancomycin drip. On examination, you detect crepitations in his left base.

Despite experiencing generalised erythema, the patient is stable, and his airways are not immediately at risk. His blood pressure is 105/67 mmHg, pulse rate is 99b/min, and oxygen saturation on 4L oxygen is 95% (all readings are consistent with previous measurements). He confirms that he has never taken vancomycin before but is allergic to penicillin and ciprofloxacin.

What is the next course of action in managing this likely diagnosis?

MRCP2-2883

A 15-year-old boy presents to the Emergency department at 9 pm with complaints of headache, fever, and diarrhea. He had an episode of watery diarrhea at 6 pm and has since become increasingly unwell. He has no significant medical history and was feeling well the previous day. There is no recent travel history, and his family members have been healthy. On examination, he has a fever of 39.5°C, a blood pressure of 80/50 mmHg, and a heart rate of 110 per minute. He complains of a headache and mild photophobia, but there is no nuchal rigidity. His chest is clear, and his abdomen is soft and non-tender. Investigations reveal a hemoglobin level of 130 g/L, a WBC count of 18.5 ×109/L, and a platelet count of 200 ×109/L. His serum electrolytes, liver function tests, and lactate dehydrogenase levels are within normal limits. What is the likely diagnosis?

MRCP2-2884

A 35-year-old woman presented with a 24-hour history of high fever, vomiting, diarrhea, and severe muscle pain. Four days ago, she finished a 5-day course of oral ciprofloxacin for a urinary tract infection. She also takes the oral contraceptive pill, and her last menstrual period ended the previous week.

During the examination, her temperature was 40.2 °C, heart rate 140 bpm, and BP 80/50 mmHg. There was no nuchal rigidity or photophobia. She had a widespread macular erythrodermic rash on her chest and legs, and significant tenderness in her thigh muscles. She also had diffuse abdominal tenderness. Neurological examination showed no abnormalities.

Investigations:
Investigation Result
Blood cultures No growth in two samples after 48 hours
Urine cultures No growth

What is the most likely diagnosis?

MRCP2-2885

A 26-year-old HIV-positive male presents to his GP with new-onset headache and weakness on the left side of his body. Upon examination, his temperature is 38ºC, blood pressure is 115/70 mmHg, respirations are 14/min, and pulse is 73/min. Neurological assessment reveals reduced strength, hyperreflexia in the left upper and lower limb, and upgoing plantars. A CT scan of the head shows multiple ring-enhancing lesions.

What would be the most appropriate course of action for managing this patient?