Archives: MRCP Part 2

MRCP2-2804

A 25-year-old second generation British Pakistani presents to the Tuberculosis (TB) Specialist Nurse for contact tracing. Her father has recently been diagnosed with active TB after presenting to the respiratory clinic with a 2-month history of cough, fever, and night sweats.

The patient reports feeling well and denies any respiratory symptoms. She has no significant medical history and is a non-smoker. She works full-time and lives with her family. She received all her childhood vaccinations.

Upon examination, she is afebrile with a respiratory rate of 14/min and oxygen saturation of 98% on room air. There is no lymphadenopathy, her chest is clear, and her abdomen is soft and non-tender.

The Mantoux test is performed and read after 72 hours, revealing a 6mm area of induration within a 15mm area of erythema. An interferon-gamma release assay (IGRA) is ordered. What does a positive IGRA result indicate?

MRCP2-2805

A 43-year-old woman presents to the emergency department with a dry cough. Over the last six days, she has been experiencing a worsening dry cough, shortness of breath that is worse on exertion, and she has felt feverish. She has a medical history of recently diagnosed HIV, but no other medical problems. She has been compliant with antiretroviral treatment and PCP prophylaxis for the past two months.

Fundoscopy reveals white branches alongside blood vessels. She denies any eye pain or changes in vision.

Observations:
Saturations 94%
Respiratory rate 19/min
Blood pressure 130/72 mmHg
Heart rate 88/min
Temperature 38.2°C

Blood tests:
Hb 120 g/l
Platelets 399 * 109/l
WBC 10.5 * 109/l
Na+ 139 mmol/l
K+ 4.1 mmol/l
Urea 5.3 mmol/l
Creatinine 72 µmol/l
HIV viral load 11,800 copies/ml
CD4 count 68 cells/mm3

A chest X-ray shows bilateral interstitial infiltrates. A broncho-alveolar lavage is scheduled, but no organisms are found on microscopy, including with silver staining. PCR studies are pending.

What is the most appropriate treatment?

MRCP2-2806

A 56-year-old man presents to the emergency department with two days of pain and a rash on his left thigh. He has recently had the chickenpox for the first time and was given a course of aciclovir, which he has now completed. The lesions have now healed. He has type 2 diabetes and is on metformin. He smokes ten cigarettes daily.

His observations are heart rate 121 beats per minute, respiratory rate 24/minute, blood pressure 85/45 mmHg, oxygen saturations 97% on air and temperature 39.4ºC.

On examination, he appears unwell. He is diaphoretic and anxious. There is a tense erythematous area on his left thigh, which is severely painful. His pulse is bounding and there is a flow murmur heard in the aortic area.

Blood tests:

Hb 121 g/L Male: (135-180)
Female: (115 – 160)
Platelets 580 * 109/L (150 – 400)
WBC 25.2 * 109/L (4.0 – 11.0)
Na+ 137 mmol/L (135 – 145)
K+ 4.1 mmol/L (3.5 – 5.0)
Urea 11.4 mmol/L (2.0 – 7.0)
Creatinine 176 µmol/L (55 – 120)
CRP 380 mg/L (< 5)
Bilirubin 25 µmol/L (3 – 17)
ALP 88 u/L (30 – 100)
ALT 89 u/L (3 – 40)
γGT 45 u/L (8 – 60)
Albumin 29 g/L (35 – 50)

Despite aggressive fluid resuscitation, his blood pressure remains 86/51 mmHg.

What is the most important treatment for the likely diagnosis?

MRCP2-2807

A 79-year-old man is being reviewed during ward rounds. He was admitted due to ulcerative colitis flare and diarrhea, and is currently being treated with oral and rectal mesalazine. Although his bowel has improved, he has developed a rash on his left antecubital fossa and has a temperature of 38.2ºC. Upon examination, his chest is clear and his abdomen is soft, but the left antecubital fossa is tender and has a warm erythematous rash. Stool results show no growth, and both abdominal and chest X-rays are clear. However, a MRSA swab from his nose has tested positive. What is the most appropriate course of treatment?

MRCP2-2808

A 67-year-old man presents to the emergency department with complaints of fever, a new rash, and severe leg pain that started a day ago. He has a medical history of type 2 diabetes and peripheral vascular disease and takes metformin and clopidogrel. He is a heavy smoker and lives alone.

Upon examination, he appears unwell, clammy, and diaphoretic. There is an erythema extending from his right calf to his right thigh, which is warm to touch and diffusely tender in the thigh region. The degree of tenderness seems disproportionate to the severity of the rash. Cardiovascular, respiratory, and abdominal examinations are unremarkable.

His blood tests show low hemoglobin, high platelets and white blood cells, and elevated levels of urea, creatinine, CRP, lactate, and creatine kinase. Despite antibiotics and aggressive fluid resuscitation, he remains hypotensive.

What combination of organisms is likely responsible for his condition, given the likely diagnosis?

MRCP2-2809

A 67-year-old man presents to the emergency department with three days of fever, leg pain and rash. He has a medical history of type 2 diabetes, peripheral vascular disease and hypertension. He is on regular medications including clopidogrel, amlodipine, metformin, gliclazide and insulin. He is independent and a retired carpenter.

What is the initial pharmacological management that should be considered for this patient based on his clinical presentation and laboratory results?

MRCP2-2810

A 32-year-old male presents to the emergency department with complaints of red eyes, fever, myalgia, and headache for the past 10 days. He has no significant medical history and is not taking any regular medications. He recently returned from a vacation with friends where they went kayaking and swimming in a freshwater lake. They had to cut their trip short due to concerns about exposure to raw sewage in the lake.

During examination, bilateral erythema of the conjunctiva is observed. Cardiovascular and respiratory examinations are normal. Mild right upper quadrant tenderness and hepatomegaly are noted during abdominal examination. There is no photophobia or nuchal rigidity.

Urinalysis is normal, and chest radiography shows clear lung fields. Blood tests reveal elevated levels of CRP, bilirubin, ALP, ALT, and γGT, along with leukocytosis and elevated creatinine.

What is the most appropriate diagnostic test to confirm the suspected diagnosis based on the patient’s clinical presentation?

MRCP2-2811

A 37-year-old man from Ghana visits a gastroenterology clinic. He works as a teacher and frequently travels to neighboring countries for educational conferences.

He has been experiencing diarrhea, abdominal bloating, and cramping for the past five months, with up to 7 episodes a day. There is no visible blood in his stool. He had tuberculosis as a child and was treated for it.

A stool sample is sent to the lab, and Modified Ziehl-Neelsen stain reveals multiple red staining round objects measuring 5 microns in diameter.

What is the most appropriate treatment for this patient?

MRCP2-2812

A 26-year-old recent immigrant from Albania arrives at the emergency department complaining of malaise, headache, and fever. He also reports experiencing bilateral pain and swelling at the angle of his jaw, which worsens when he talks or chews. Upon examination, the patient’s temperature is 38.4ºC, pulse is 90/min, and palpable, tender parotid glands are noted bilaterally.

What is the most probable complication that this patient will develop, given the likely diagnosis?

MRCP2-2813

A 25-year-old man presents to the emergency department with fever, cough, and shortness of breath. He has been experiencing a non-productive cough for the past two weeks and has been feeling unwell with muscle aches and malaise before that. He visited his GP and was prescribed amoxicillin, but it did not help, and now he feels more breathless and unwell. He has not traveled outside of the UK in the last year and has no medical history or regular medications. His cough comes in paroxysms, which worries him.

During the examination, a few bilateral crepitations are present, but otherwise, the examination is normal. His vital signs indicate fever and mild hypoxia. Blood tests reveal mild anemia and elevated inflammatory markers. A chest X-ray shows bilateral consolidation, but he responds well to IV co-amoxiclav and clarithromycin over a few days.

What is the most probable causative organism?