Archives: MRCP Part 2

MRCP2-2824

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?

MRCP2-2828

A 57 year-old man presents to his GP with a 10 day history of watery diarrhoea, associated with fresh red blood and abdominal cramps. He has lost 5kg in weight and has difficulty swallowing food or fluids due to pain. He also experiences an intermittent sensation of needing to defecate but being unable to. The patient was diagnosed with HIV 8 years ago but has not been attending follow-up or taking his medications. On examination, he has dry mucous membranes with reduced skin turgor and generalised abdominal tenderness. His observations are as follows: respiratory rate- 18 breaths per minute, heart rate- 110 beats per minute, blood pressure- 104/60 mmHg, and temperature 37.7ºC. What is the most likely pathogen responsible for his symptoms?

MRCP2-2829

A 47-year-old Indian woman presented with a 3-week history of cough, intermittent fever, night sweats and fatigue. Four weeks ago, she had travelled to India for 3 months to visit her family. She denied any contacts with tuberculosis or haemoptysis.
Upon examination, her temperature was 38.1 °C and pulse rate was 92 bpm. There was reduced chest expansion on the left, and the left base was dull to percussion, with bronchial breathing above. There was 3-cm, tender hepatomegaly, with an irregular border.
Investigations reveal the following:

Bilirubin 22 µmol/l 2–17 µmol/l
Alanine aminotransferase (ALT) 31 IU/l 5–30 IU/l
Alkaline phosphatase (ALP) 142 IU/l 30–130 IU/l
Blood cultures No growth
Sputum cultures No growth
CT chest, abdomen, pelvis Multi-loculated, left-sided pleural effusion, 12 × 7 cm hepatic collection
Pleural biopsy No acid-fast bacilli
The pleural effusion was drained.
What is the best course of action for further treatment?

MRCP2-2830

A 36-year-old farmer presents to the acute medical unit with a 2-week history of fever and dry cough. He reports feeling increasingly lethargic with body aches and headaches. There is mild tenderness in the right upper quadrant, but his abdomen remains soft with no palpable organomegaly. On auscultation, scattered crackles are heard. Laboratory tests reveal elevated WBC count and CRP levels. Based on this presentation, what is the most probable causative organism?

MRCP2-2801

A 45-year-old man visits a sexual health clinic with a painless ulcer on the glans of his penis and inguinal lymphadenopathy. He had unprotected vaginal intercourse with a female partner within the last two weeks. He is prescribed doxycycline but returns the next day with a fever and rash. He is concerned about an allergy to doxycycline and consents to monitoring blood tests. What is the best course of action given the likely diagnosis?

MRCP2-2802

A 28 year-old man who has been on a hiking expedition in the mountains of South America presents to the local clinic with a 4 day history of fever, headache and a widespread maculopapular rash. He has been trekking through dense forests, crossing rivers and has reported being bitten by various insects. Upon examination, a black necrotic eschar is observed on his arm. A malaria RDT is negative.

What would be the most suitable course of action for management?

MRCP2-2803

A 22-year-old male presents with a two-week history of increasing pain and swelling in his right knee. He has also been experiencing discomfort in his heels when walking and irritation in both eyes. He denies any genital symptoms but reports having had unprotected insertive anal and oral sex with six casual male partners in the past year. His last sexual contact was three weeks ago. He has no significant medical history and is not taking any medication, but his brother has a history of ankylosing spondylitis. On examination, there is tenderness in the right knee joint with reduced range of motion and a positive patellar tap. The right conjunctiva is injected, but pupil and visual acuity are normal. The medial anterior border of the calcaneus is tender bilaterally, and there are no skin lesions. Knee joint aspiration reveals 60,000 leukocytes/uL, and no organisms are seen. What test is most likely to identify the cause of his symptoms?