Archives: MRCP Part 2

MRCP2-2873

A 44-year-old Ghanaian woman was traveling from Ghana to San Francisco, USA when she began exhibiting confused and inappropriate behavior on the plane. She was heard talking loudly to herself, complaining of a headache, and seemed to be hearing voices. She also experienced one episode of incontinence during the flight. Upon arrival in London, she was taken to the nearest hospital for further evaluation.

Upon examination, the patient was found to be drowsy and slow to respond to questions. Her vital signs were as follows: temperature of 37.3ºC, heart rate of 98 bpm, blood pressure of 138/92 mmHg, respiratory rate of 16, and oxygen saturations of 100% on air. Her pupils were 3 mm bilaterally, equal and reactive. She had mild photophobia and a supple neck. Her abbreviated mental test score was 6/10.

Further investigations revealed the following results:

– C Reactive protein: 24 mg/l
– Haemoglobin: 128 g/l
– White cell count: 11.6 x 10^9/L
– HIV antibody serology: positive
– HIV viral load: 19000 copies/ml
– CD4+ T lymphocyte count: 35 cells/mm³
– Na+: 136 mmol/l
– K+: 4.9 mmol/l
– Urea: 7.2 mmol/l
– Creatinine: 108 µmol/l
– Corrected calcium: 2.32 mmol/l
– Plasma glucose: 5.8 mmol/l

Imaging studies showed clear lung fields on chest X-ray and hypodense lesions involving the medial temporal regions on CT head scan. The lesions enhanced with contrast.

Cerebro-spinal fluid (CSF) analysis revealed an opening pressure of 20 cmH2O, protein of 1.2 g/L, white cell count of 50 per mm³ (predominantly mononuclear cells), red cell count of 5 per mm³, glucose of 4.8 mmol/l, and no organisms seen on gram stain.

What is the most appropriate next step in management?

MRCP2-2874

A 25-year-old man is experiencing increasing shortness of breath on exertion after being unwell for over two weeks with intermittent fevers and chills. Over the past two days, he has developed breathlessness on minimal exertion with a cough that produces blood-stained sputum. He has no prior hospital admissions but admits to regular use of recreational drugs and occasionally injecting intravenously. On examination, he is febrile with a pansystolic murmur audible at the lower left sternal edge and multiple opacities throughout both lung fields on chest radiograph. What is the most effective antimicrobial regimen for treating this patient?

MRCP2-2875

The Medical Emergency Team (MET) is called to the Surgical Unit to assist with an acutely unwell patient. This patient is a 22-year-old female who underwent open surgery for perforated appendicitis 3 days ago. The Surgical Registrar informs you that faecal contamination of the abdomen was noted during the operation and that a peritoneal washout was performed.

The patient began to complain of worsening abdominal pain 24 hours after the surgery. She became febrile in the early hours of the morning, and blood cultures were taken. Since then, she has become progressively more unwell. An urgent abdominal ultrasound was performed mid-afternoon, but the nurses were so concerned about her condition when she arrived back on the ward that a MET call was put out.

Upon examination, the patient is responsive to voice. She is febrile at 38.9ºC, her pulse is 131 bpm, and her blood pressure is 72/53 mmHg. Her peripheries are warm and clammy. Palpation of the abdomen reveals localised tenderness and guarding in the right iliac fossa. The surgical wound appears clean with minimal surrounding erythema.

As you prepare to place a large bore IV cannula, the Surgical FY1 passes you some results that have recently been phoned through:

Abdominal ultrasound Anechoic fluid collection in the right iliac fossa
Blood culture Gram-positive cocci both bottles – further information to follow

Which of the following organisms is most likely to be isolated from the blood culture?

MRCP2-2876

A 30-year-old woman presents to her GP after returning from Nigeria 2 weeks ago. She complains of fever and joint pain, making it difficult to walk. She denies any rash or headaches but has been feeling very drowsy and lethargic in the past week. She spent a week in Nigeria, visiting both urban and rural areas, and has been taking her malaria prophylaxis tablets. She reports no sexual activity in the past year. Despite negative malaria screens, she returns to the emergency department 2 months later after experiencing a seizure. She is confused, disorientated, and irritable, with tremors in her hand. Her sister reports weight loss, loss of appetite, and strange behavior in the past month. On examination, she exhibits hypertonia and hyperreflexia. Further investigations reveal abnormal blood test results, including elevated CRP and ESR levels, low hemoglobin, and lymphocytopenia. What is the likely causative organism?

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?

MRCP2-2879

You see Mr Johnson, a 36-year-old man-who-has-sex-with-men (MSM) in clinic. He was diagnosed with HIV 4 years ago, commencing combination antiretroviral therapy (cART). Following a number of alterations to his cART due to side effects he responded well to a combination of tenofovir, emtricitabine and ritonavir boosted atazanavir. His plasma viral load (pVL) of HIV RNA has remained undetectable and his adherence has been good.

In clinic today Mr Johnson reports 4 weeks of drenching night sweats, a dry cough and some subjective weight loss, going up a belt buckle during this time period. On examination you note that he appears pale and auscultation of the chest elicits crepitations in the left upper zone. Your perform a chest X-ray which demonstrates a cavitating lesion in the left upper lobe. You arrange induced sputum samples which confirm a diagnosis of pulmonary tuberculosis.

You explain your diagnosis to Mr Johnson and the need to urgently commence him on anti-tuberculosis chemotherapy. Whilst he is happy to commence treatment, he is adamant that he does not want to risk his viral control and states that he is not willing to consider altering his cART regimen at present.

What is the most appropriate management step to treat Mr Johnson?

MRCP2-2880

A 28-year-old man arrives at the emergency department complaining of severe nausea, vomiting, and diarrhea. He recently attended a gathering where 15 out of 20 attendees have experienced similar symptoms. Upon examination, he seems dehydrated but his vital signs are stable. He has no medical history and his physical exam is unremarkable. The suspected diagnosis is norovirus. What test should be performed?

MRCP2-2881

A 45-year-old male from Bolivia presents with an 8-month history of progressive fatigue, dyspnoea and intermittent chest pains. He is a chronic smoker and during a recent severe episode of breathlessness had consulted his GP who prescribed amoxicillin and prednisolone to combine with his regular inhaler therapy. Shortly after this he experienced a febrile episode which had lasted 7 days before resolving. His breathlessness also worsened during this period.

On examination, he has a temperature of 37.2 degrees, a heart rate of 98 beats per minute, a blood pressure of 110/70 mmHg and a respiratory rate of 24/min. His jugular venous pressure was raised, there was lower limb oedema to the mid shin and a pansystolic murmur heard best in inspiration in the left parasternal region. An ECG showed a prolonged PR interval.

What is the most likely underlying diagnosis?

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?