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?

MRCP2-2867

A 32-year-old man presents to the emergency department with a three-day history of fever, muscle ache, retro-orbital headache, and a rash. He recently returned from a trip to Honduras. He has no significant medical history and takes no regular medications.

Observations:
Heart rate: 101 beats/min
Oxygen saturations: 97% on room air
Respiratory rate: 20 breaths/min
Temperature: 38.5ºC
Blood pressure: 124/82 mmHg

On examination, the patient’s face appears flushed, and he has a maculopapular rash covering most of his body. There is no splenomegaly or synovitis.

Blood tests:
Hb: 121 g/L (Male: 135-180, Female: 115-160)
Platelets: 89 * 109/L (150-400)
WBC: 4.4 * 109/L (4.0-11.0)
Na+: 137 mmol/L (135-145)
K+: 4.2 mmol/L (3.5-5.0)
Urea: 5.2 mmol/L (2.0-7.0)
Creatinine: 88 µmol/L (55-120)
CRP: 22 mg/L (<5)
Bilirubin: 14 µmol/L (3-17)
ALP: 111 u/L (30-100)
ALT: 143 u/L (3-40)
Albumin: 34 g/L (35-50)

What is the most likely diagnosis?

MRCP2-2868

A 40 year-old Brazilian accountant presented to the medical outpatient clinic with progressive leg swelling over the last 18 months. His mobility had become increasingly restricted due to both the swelling and shortness of breath on exertion. His father and paternal grandfather had both died from ischaemic heart disease in their 60s. His past medical history was unremarkable. He had smoked 15 cigarettes a day for 15 years and drank 15 units of alcohol per week.

On examination, his temperature was 36.5ºC, blood pressure was 95/50 mmHg and heart rate was 75 beats per minute. His JVP was elevated to the angle of the jaw. His chest was clear on auscultation, but a third heart sound and pan-systolic murmur were audible on auscultation of the precordium. Bilateral pitting oedema to mid-thigh level was present.

Investigations:

Haemoglobin 131 g/L (130-180)
White cell count 6.9 x 109/L (4.0-11.0)
Neutrophil count 3.1 x 109/L (2.0-7.5)
Lymphocyte count 1.9 x 109/L (1.3-3.5)
Eosinophil count 1.1 X 109/L (0.1-0.4)
Platelets 260 x 109/L (150-400)

Sodium 132 mmol/L (135-145)
Potassium 3.6 mmol/L (3.5-5.0)
Urea 8.0 mmol/L (2.5-7.5)
Creatinine 101 mol/L (20-90)
Fasting plasma glucose 7.2 mmol/L (3.0-6.0)

Echocardiogram Moderately impaired left ventricular systolic function
Dilated left ventricle with moderate mitral regurgitation

What is the most appropriate treatment for the underlying condition?

MRCP2-2869

A 28-year-old nurse presents to the emergency department after experiencing a needle-stick injury while caring for a patient in the intensive care unit. The nurse followed correct first aid procedure and was wearing gloves, but the needle had been visibly blood stained and had not been placed in an appropriate sharps bin. The patient who had been the needle-stick donor was being treated for rabies encephalitis, which he had contracted following a dog bite in Pakistan. The nurse is unsure if she has had previous vaccination against rabies. What is the appropriate management of the needle-stick injury to prevent transmission of rabies?

MRCP2-2870

A 35-year-old man presented to the Medical Admission Unit with a chief complaint of watery diarrhea that has been ongoing for the past few weeks. He denied the presence of blood or mucous in his stool but reported transient pain on swallowing and a weight loss of 2 stones over the last year. He had no history of respiratory symptoms or abdominal pain, and his past medical history was unremarkable. However, he did consume 20 cans of standard strength lager per week, smoked 20 cigarettes per day, and had no fixed abode.

Upon examination, the patient appeared unkempt and disheveled with a BMI of 17.1 kg/m². His cardiovascular and respiratory examinations were unremarkable, except for an oxygen saturation of 94% on room air. His heart rate was 92/min, blood pressure 112/62 mmHg, and temperature 36.7ºC. Abdominal examination was also unremarkable, but multiple aphthous ulcers were present in his oral cavity. Examination of the neck revealed multiple small palpable cervical lymph nodes, and fundoscopy revealed the presence of white patches. Skin examination revealed multiple pearly pink umbilicated nodules.

Initial investigations revealed a Hb of 122 g/l, platelets of 189 * 109/l, and WBC of 3.6 * 109/l. Chest x-ray and ECG were normal, and urinalysis showed no abnormalities. Stool MCS had normal interim results, pending further analysis.

What is the single investigation that is most likely to lead to the underlying diagnosis?

MRCP2-2871

A 30-year-old man presents to the genitourinary medicine clinic with a painless ulcer on his penis that has been present for a week. He is HIV positive and sexually active with one regular male partner. Despite having an undetectable viral load, they do not use condoms. He had gonorrhoeae in the past, which was treated with antibiotics. On examination, he has a single shallow ulcer with surrounding erythema. Syphilis serology shows a positive EIA and TPPA, but a negative RPR. What is the best immediate management option?

MRCP2-2872

A 27-year-old man presents to the walk-in travellers clinic after returning from a trip to Brazil 5 days ago. He complains of fever, headache, and myalgia for the past day. Despite taking regular malaria prophylaxis while away, he has multiple mosquito bites on his arms and legs. On examination, he has a heart rate of 110 beats per minute, a blood pressure of 102/72 mmHg, and a temperature of 38.1 ºC with dry mucous membranes. Blood tests reveal a positive PCR for dengue virus, and he is admitted for treatment. Although his fever and headache subside, he develops mild ankle edema. What is true regarding his discharge?