Archives: MRCP Part 2

MRCP2-2839

Sarah is a 42-year-old female presenting with a new fever. She works as a teacher and noted fevers up to 39.6ºC over the past 72 hours with a dry cough. She has also been struggling to manage her classroom due to the ongoing headache and worsening muscle aches that have accompanied the fever. The headache was significant but was not associated with any neck stiffness or photophobia.

Sarah does not note any other symptoms. She has not been in contact with anyone unwell and she has not been travelling out of the country recently.

Physical examination was otherwise unremarkable with only mild crackles heard on auscultation on her chest. No insect bites were noted. No lymphadenopathy was palpable.

Blood tests are as follow:

Hb 140 g/L Male: (135-180)
Female: (115 – 160)
Platelets 150 * 109/L (150 – 400)
WBC 7.0 * 109/L (4.0 – 11.0)
Na+ 142 mmol/L (135 – 145)
K+ 4.1 mmol/L (3.5 – 5.0)
Urea 5.5 mmol/L (2.0 – 7.0)
Creatinine 100 µmol/L (55 – 120)
Bilirubin 10 µmol/L (3 – 17)
ALP 80 u/L (30 – 100)
ALT 90 u/L (3 – 40)
AST 80 u/L (5-40)
Albumin 40 g/L (35 – 50)

What is the likely organism causing the likely diagnosis?

MRCP2-2840

A 68-year-old man was referred by his doctor for investigation of his 6-month history of lower limb peripheral neuropathy. Upon examination, he had a mixed sensory-motor peripheral neuropathy affecting his feet and a positive Romberg’s test. He had scarring on his lower legs from childhood sores when he lived in Jamaica, but has been living in the UK for 40 years. His investigations revealed a positive Treponemal EIA and Treponema pallidum particle agglutination, but a negative Rapid plasma reagin (RPR). What is the most likely explanation for his syphilis serology?

MRCP2-2841

A 17-year-old boy from Iran presents to the emergency department with dyspnoea, dry cough, and fevers. On arrival, his oxygen saturations are 91% with a respiratory rate of 27/minute. His blood pressure is 110/70 mmHg and heart rate 89/minute. There are widespread crackles on auscultation.

What is the most probable underlying diagnosis that unifies his symptoms?

MRCP2-2842

A 24-year-old man presents to the emergency department upon returning to the UK after a year-long trip to South America. He expresses concern about a dog bite he received in Brazil three months ago. During a rain-forest expedition, a dog from the village he was staying in bit him on the left hand, leaving an open wound. The patient received first aid and a course of oral antibiotics, and the wound healed over two weeks. However, he only recently learned about the risk of rabies exposure from fellow travelers.

The patient denies any acute medical problems and reports no neurological or other symptoms. He has no significant medical history and takes no regular medications. He admits to not researching his travel health needs before leaving the UK and not receiving any vaccinations prior to his trip.

Upon examination, the patient’s wound shows fully healed scars consistent with bite marks across the palm and dorsal surface of the wrist. The limb has normal neurological and vascular examination, and the patient reports normal hand function.

What is the appropriate statement regarding rabies post-exposure prophylaxis for this patient?

MRCP2-2843

A 38-year-old male from India presents with worsening headache and vomiting. He has a history of HIV but has not been seen by a doctor in the last 5 years. His CD4 count from his last appointment was 400.

During examination, there were no localizing signs, but fundoscopy revealed papiloedema.

The following investigations were conducted:

– Haemoglobin: 115 g/L (115-165)
– White cell count: 9.4 × 109/L (4.0-11.0)
– Platelet count: 220 × 109/L (150-400)
– Erythrocyte sedimentation rate: 50 mm/1st h (<30)
– Serum urea: 7.0 mmol/L (2.5-7.0)
– Serum creatinine: 105 mol/L (60-110)
– Serum alanine aminotransferase: 17 U/L (5-35)
– Serum aspartate aminotransferase: 26 U/L (1-31)
– Cryptococcal antigen test: Negative
– CD4 Count: 65 cells/mm3
– CT Head: 5cm ring enhancing lesion in right temporal lesion with surrounding oedema

What is the most appropriate management for this patient?

MRCP2-2844

A 36-year-old man presents to respiratory clinic with a chronic cough, occasional haemoptysis, night sweats, and significant unintentional weight loss. He discloses that he spent five years in a Moscow prison for drugs offences and currently lives in shared accommodation while working on a building site. On examination, he appears cachexic with tobacco stained fingernails, reduced air entry in the upper zones bilaterally, and palpable lymphadenopathy in the anterior cervical chain. Investigations reveal patchy shadowing in both upper lobes with evidence of cavity formation on the right side, acid-fast bacilli in sputum microscopy, and resistance to rifampicin and isoniazid. What is the most appropriate treatment regimen for this patient?

MRCP2-2845

A 28-year-old woman presents to the emergency department with drowsiness. She had been experiencing headaches, nausea, and fevers over the past day. About a week ago, she had a period of feeling unwell with fever, headache, and myalgia, but it resolved on its own. She recently returned from a camping trip in Poland with friends. Her medical history includes only asthma, which she manages with salbutamol as needed.

Upon examination, the patient has a Glasgow Coma Scale (GCS) of 14 with neck stiffness but no focal neurology. Her lungs are clear, and her abdomen is soft and non-tender. There is no rash.

After a lumbar puncture, mildly elevated white blood cells are found. An HIV test comes back negative. The patient is started on ceftriaxone, dexamethasone, and aciclovir.

Although the CSF culture and PCR are negative, a sample sent to the infectious disease laboratory comes back positive for flavivirus antibodies. What is the most appropriate management for this likely diagnosis?

MRCP2-2846

A 16-year-old boy who has recently arrived in the UK from Rwanda is admitted to the hospital with complaints of headache and fever for the past four days. According to his friend, he is very lethargic with a dry cough and generalised myalgia. The patient also reports passing some dark urine this morning. He has no significant medical history. On examination, his pulse is 110/min, temperature 38.1ºC, oxygen saturations 98% on room air, and blood pressure 110/68 mmHg. His sclera are jaundiced, and there is enlargement of the liver and spleen. Blood tests reveal the following results:

Na+ 142 mmol/l
K+ 4.8 mmol/l
Urea 12.3 mmol/l
Creatinine 144 µmol/l

What is the most probable diagnosis?

MRCP2-2847

A 50-year-old female presents with a two-month history of headache and generalised malaise. She describes her headaches as a tight band-like sensation that is present almost throughout the day and causes significant difficulty in sleeping at night. She also mentions occasional episodes of vomiting along with low-grade fever and weight loss of about 7 kg over the same duration of time. She suffers from generalised anxiety disorder and takes 0.5mg alprazolam TDS. She returned from Dubai 10 months ago where she had been spending her holidays with her family.

On examination, she has a fever of 37.5°C and a pulse of 105 bpm. She appears slightly disoriented with a tendency to speak out of context but is otherwise cooperative.

There is diplopia on right-sided gaze and mild neck stiffness, but the remaining clinical examination is essentially unremarkable.

Lab reports reveal:

Hb 115 g/l
Platelets 340 * 109/l
WBC 9.0 * 109/l

Na+ 137 mmol/l
K+ 4.2 mmol/l
Urea 5.9 mmol/l
Creatinine 102 µmol/l
Glucose 7.0 mmol/l
ESR 87 mm/hr

MRI shows meningeal enhancement but no evidence of any parenchymal lesions.

CSF examination reveals:

Opening Pressure Normal
Appearance Turbid
Protein 3.2g/L (0.2 0.4 g/L)
Glucose 2.7 mmol/l
Lymphocytes 371/mm³
Neutrophils 42/mm³
ZN staining No acid-fast bacilli detected

What is the most appropriate treatment option for this 50-year-old female?

MRCP2-2848

A 32-year-old woman visits the Sexual Health Clinic after returning from a vacation in Thailand. She confesses to engaging in unprotected sexual activity during her trip. Upon examination, she presents with a painful, deep ulcer on the labia with soft, irregular edges. She also has painful lymph nodes in the groin area. What is the most suitable treatment option for this patient?