A 60-year-old man has recently returned from a trip to India and is experiencing bloody diarrhoea and fevers for the past two weeks. He noticed rose coloured spots on his abdomen yesterday. He has no significant medical history except for a prosthetic aortic valve. His blood tests show elevated inflammatory markers and stool microbiology has identified a gram-negative bacillus as a non-typhoidal Salmonella. Sensitivities are pending. What is the most appropriate initial empiric management?
MRCP2-2817
You are consulted to evaluate a 55-year-old Indian man who has presented to the Emergency Department (ED) from Heathrow airport. He reports a 3-week history of a productive cough with brown sputum, fevers, and drenching night sweats. His wife is concerned about the color of his sputum, which has been brown/red since the onset of his illness. The patient denies weight loss or hemoptysis. He is a non-smoker and had been in good health, except for a recent episode of diarrhea. He is a resident of a rural community in northeast India and is visiting family in London. On examination, he appears relatively well, with a heart rate of 95 beats per minute and respiratory rate of 20 breaths per minute. He has a productive cough with dark brown sputum, and auscultation reveals coarse crepitations at the right base with some bronchial breathing. The remainder of his physical examination is unremarkable.
You order routine microscopy sensitivity and culture (MC&S) and acid-fast bacilli (AFB) and tuberculosis PCR on his sputum, which are negative. His chest X-ray shows right lower zone consolidation. Laboratory investigations reveal a hemoglobin level of 110 g/L, platelets of 500 * 10^9/L, white blood cell count of 16.0 * 10^9/L with neutrophils of 10.0 * 10^9/L, lymphocytes of 2.0 * 10^9/L, eosinophils of 2.0 * 10^9/L, sodium of 138 mmol/L, potassium of 4.5 mmol/L, urea of 6.0 mmol/L, creatinine of 99 µmol/L, and CRP of 55 mg/L.
What is the most likely diagnosis?
MRCP2-2818
A 60-year-old man is currently being treated in the ICU. He was admitted 10 days ago after experiencing a seizure at home. Due to his confusion and agitation, he was unable to provide a clear medical history, but his family reported that he had been feeling unwell for about two weeks prior to the seizure. The patient had initially presented with a fever, myalgia, anorexia, and intense itching on his left arm. As time passed, he became increasingly confused and agitated. The patient had recently returned to the UK after visiting his native India six months prior, during which time he was bitten by a dog in his family’s village. Although the wound was minor and healed without incident, his wife recalled the incident. The patient’s medical history was otherwise unremarkable, with the exception of hypertension, tablet-controlled type 2 diabetes, and gout.
Upon admission, the patient was highly agitated and disoriented, with hypersalivation and a refusal to eat or drink. Due to his agitation, a thorough examination was not possible, but no focal neurological symptoms were noted. After sedation, it was observed that striking a large muscle group with a tendon hammer led to a few seconds of mounding of the muscle.
The patient’s CSF protein level was 457 g/dL, with no abnormalities noted in the CSF microscopy. Rabies virus neutralizing antibodies were not detected in the CSF, but were detected in the serum.
At present, the patient is receiving end-of-life care and is sedated with midazolam delivered by a syringe driver. His family wishes to be present at his bedside.
What personal protective equipment should healthcare workers and family members use when in contact with the patient?
MRCP2-2821
A 35-year-old woman presents to the clinic with complaints of fatigue, fevers, right upper quadrant pain, and diarrhea. She admits to occasional use of cocaine. On examination, she appears thin and has tender hepatosplenomegaly and lymphadenopathy. Her partner accompanies her and expresses concern. The following investigations are conducted:
What is the most likely diagnosis for this patient?
MRCP2-2822
A 35-year-old woman presents to the Gastroenterology Clinic with a 3-week history of profuse watery diarrhoea. She has been experiencing intermittent cramping abdominal pain and episodes of nausea, but denies vomiting. Her appetite is reduced and she is now feeling extremely fatigued. There is no recent travel or change in diet. She has no significant medical history or regular medications. On examination, her temperature is 36.5 °C. She appears pale and thin, but not jaundiced. Her heart rate is 98 bpm and regular and her blood pressure is 100/70 mmHg. She has generalised abdominal tenderness but no guarding or palpable masses. There are visible needle marks in her right antecubital fossa. What is the most likely organism responsible for this patient’s symptoms?
MRCP2-2823
A 47-year-old man presents to the emergency department with fever and dry cough for the last week. He also complains of myalgia and headaches which have been affecting his work as a construction worker. These headaches are variable in location, but usually worse behind his eyes. He is a non-smoker and has no significant past medical history of note.
On examination, he has coarse crackles in his left lung base. His abdomen is soft and non-tender. There is no rash. Heart sounds are normal, with no murmurs heard.
Initial investigations are done and a chest x-ray is requested.
A 36-year-old woman presents to a gastroenterology clinic referred by her primary care physician. She has been experiencing ongoing gastrointestinal symptoms after being diagnosed with giardiasis and receiving appropriate first-line treatment. The patient reports a 3-month history of variable bowel habits, including periods of normal motions and frequent diarrhea. She has lost approximately 7 kg in weight during the course of her illness. The patient denies experiencing fever or bloody diarrhea but reports unusual episodes of burping with an unpleasant taste, described as tasting like ‘rotten eggs’.
The patient had a stool microscopy test after her initial symptoms, which showed evidence of infection with Giardia lamblia. She had not traveled overseas recently but was employed as a nursery nurse, which was suspected to be the source of her infection. Her employer moved her to a different job role that did not involve direct contact with children after she disclosed her condition.
The patient was treated with a 5-day course of metronidazole following the diagnosis of giardiasis, which resulted in some improvement but not full resolution of her symptoms. She had no significant past medical history except for a salpingectomy performed 5 years ago due to an ectopic pregnancy. She had never experienced problematic gastrointestinal symptoms before and took no regular medications or had any known drug allergies.
Upon examination, the patient’s abdomen was unremarkable, and she appeared to be in generally good physical condition. A urinary pregnancy test was negative. The decision was made to prescribe the patient a single dose of tinidazole as a second-line treatment for giardiasis. What advice should be given to the patient alongside this treatment?
MRCP2-2825
A 55-year-old woman presents to the Emergency Department with palpitations and a productive cough of green sputum. She reports feeling feverish and lethargic. Upon examination, she has bronchial breathing at her right base, a respiratory rate of 25/min, and sats of 95% on room air. Her heart sounds are normal, but she has an irregularly irregular heartbeat with a heart rate of 120/min and blood pressure of 90/40 mmHg. An ECG reveals atrial fibrillation with a fast ventricular rate. Despite having no prior history of atrial fibrillation, what is the initial treatment that should be administered for her condition?
MRCP2-2826
A 29-year-old patient has presented with upper limb weakness. He is extremely anxious and tells you that this morning he noticed that he had a dry mouth and found it difficult to swallow. His friends also commented that his voice sounded different to normal. Several hours later he began to notice weakness in both of his arms. He has not noticed any weakness in his lower limbs. He has no relevant past medical history or family history of note.
He smokes 10 cigarettes a day, drinks approximately 30 units of alcohol per week and occasionally injects heroin.
His Glasgow Coma Score is 15/15. Neurological examination reveals power 3/5 in the upper limbs, 5/5 in the lower limbs. Biceps and supinator reflexes are absent. Knee and ankle reflexes are normal. His pupils are dilated and sluggish in reaction to light. He is unable to abduct either eye. You notice needle track marks on the patient’s forearm and an erythematous wound in the patient’s right antecubital fossa.
What immediate treatment would you provide to the patient?
MRCP2-2827
A 50 year old man presents to his General Practitioner with complaints of persistent fatigue and lethargy for the past few months. He reports experiencing recurrent minor infections, leading to him rarely feeling well for any significant length of time. His medical history includes obesity, hypertension, impaired fasting glucose tolerance, and osteoarthritis of the knees. He is currently taking ramipril, bendroflumethiazide, and paracetamol as required. The patient is an ex-smoker who rarely drinks alcohol and has recently retired from his job as a salesperson for luxury yachts, which involved extensive travel around the world. On examination, the patient is significantly overweight with a BMI of 36 kg/m². His GP orders some basic blood tests, which show a similar full blood count differential to a test taken 6 months prior. What is the most appropriate next line investigation?