Archives: MRCP Part 2

MRCP2-2788

A 49-year-old woman originally from South Africa has lived in the UK for 17 years and works as a librarian. She was diagnosed with HIV 18 months ago after discovering her husband had been having an affair. Her lowest CD4 count was 211 /mm3. She has been well on her Anti-Retroviral Therapy (ART) until 3 weeks ago when she was seen in HIV clinic with a 4-week history of a cough and weight loss of 3 kilogrammes. Today, she has been brought into the hospital by the Police. She was found naked wandering in her street, accosting passers-by and asking them to help her remove a device planted under her skin by the CIA to monitor her thoughts. What is the reason for her admission?

MRCP2-2789

You are asked to evaluate a 65-year-old Indian male who recently returned from a six month trip to the north east of India. He presents with a productive cough lasting for three weeks, with brown sputum production. He also reports experiencing daily fevers and excessive sweating at night. The patient denies any weight loss or TB contacts. He admits to feeling relatively well despite these symptoms and did not seek medical attention until a family member noticed blood in his sputum and brought him to the hospital.

Upon examination, the patient appears comfortable with evidence of a right lower zone pneumonia, which is confirmed on chest radiograph. You order several investigations, including sputum for routine culture and acid fast bacilli. The results are as follows:

Hb 115 g/l Na+ 140 mmol/l
Platelets 320 * 109/l K+ 4.0 mmol/l
WBC 12.5 * 109/l Urea 7.5 mmol/l
Neuts 7.5 * 109/l Creatinine 105 µmol/l
Lymphs 1.0 * 109/l CRP 40 mg/l
Eosin 1.0 * 109/l
Sputum MC&S Negative
Sputum TB PCR Negative

What is the most appropriate treatment plan for this patient?

MRCP2-2790

A 20 year-old University student presented to her General Practitioner with a four month history of intermittent diarrhoea and anorexia. She had lost approximately 9 kg of weight over a similar period. The patient had no previous abdominal symptoms and no significant past medical history. The symptoms had started several weeks after her return from a gap year expedition to Ghana. On close questioning the patient did recall a short-lived intensely itchy erythematous rash on one of her feet while she was in Africa. This had spontaneously resolved and not subsequently recurred.

Initial investigations are listed below:

Hb 12.5 g/dl
Platelets 200 * 109/l
WBC 11.2 * 109/l
Neutrophils 5.5 * 109/l
Lymphocytes 2.3 * 109/l
Monocytes 0.9 * 109/l
Eosinophils 2.5 * 109/l
Basophils 0.1 * 109/l

Na+ 137 mmol/l
K+ 4.1 mmol/l
Urea 4.1 mmol/l
Creatinine 80 µmol/l

Stool microscopy: Strongyloides stercoralis larvae
Strongyloides stercoralis filariform larvae IgG: positive

Under supervision from Infectious Disease department the patient was treated with Ivermectin.

What is the most effective way to evaluate the eradication of Strongyloides stercoralis six months after the completion of the treatment course?

MRCP2-2791

A 24-year-old medical student presents to the emergency department after accidentally cutting herself while cooking, resulting in significant blood loss. Routine blood tests are ordered and the results show:

– Hb: 145 g/L (Male: 135-180, Female: 115-160)
– Platelets: 235 * 109/L (150-400)
– WBC: 7.2 * 109/L (4.0-11.0)
– Eosinophils: 0.91 * 109/L (0.0-0.4)

The patient recently returned from her elective in Malawi, where she spent six weeks with two friends. She reports taking all recommended vaccines before travel and completing the course of malaria prophylaxis as advised. However, she frequently walked barefoot around the banks of the lake and recalls one episode where her foot became itchy and developed a serpiginous rash, advancing up the foot over several hours before resolving. She did not seek medical help.

What is the first-line treatment recommended for this condition?

MRCP2-2792

An 80-year-old male was brought to the emergency department from a nursing home due to a gradual decrease in his level of consciousness over the past few days. According to his caregiver, he had been experiencing a burning sensation while urinating accompanied by a low-grade fever for the last week. The following were the results of his blood tests:

Na+ 132 mmol/l
K+ 3.8 mmol/l
Urea 12 mmol/l
Creatinine 135 µmol/l

The urine dipstick revealed an increase in leukocytes and nitrites. The urine culture showed the presence of extended-spectrum B-lactamase (ESBL) – producing Escherichia coli.

What is the recommended first-line treatment?

MRCP2-2793

A 50-year-old man presents to the Emergency department with a two-week history of fever, chills, and malaise. During the physical examination, bilateral conjunctival hemorrhages, splenomegaly, and a pansystolic murmur consistent with mitral regurgitation are noted. The possibility of infective endocarditis is being considered, and no antibiotics have been administered yet. What is the best way to draw blood samples to increase the likelihood of obtaining positive cultures?

MRCP2-2794

A 36 year old known HIV positive patient complains of a gradual decline in his vision. He reports that this has been happening for a few weeks. Reviewing his medical history, it is evident that he has been non-adherent to his antiretroviral therapy. His latest CD4 count is 177 cells/mm3. What would be the primary approach to managing this patient’s most probable diagnosis?

MRCP2-2795

A 26-year-old man presents to the outpatient infectious diseases clinic after being referred by his GP. He recently immigrated from Pakistan with his extended family and was advised to get checked up after his mother, who lives in the same house, was diagnosed with respiratory tuberculosis. The patient reports feeling well, having recovered from a cold a few weeks ago with symptoms of nasal congestion, sore throat, and a cough lasting a few days. He denies any further symptoms, weight loss, fever, cough, or night sweats. He is unsure of his immunization history. On examination, he appears well with unremarkable cardiovascular, respiratory, gastrointestinal, and neurological systems. His initial investigations reveal a negative blood film and culture, a positive Quantaferon blood test, and a positive Mantoux test. His chest x-ray appears normal. What is the next best management step?

MRCP2-2796

A 49 year-old civil servant presents to the Acute Medical Unit with progressive cognitive impairment and severe lethargy over the past 3 weeks. He has also been intermittently agitated and experiencing disturbed sleep during the night. He recently returned from a trip to Zimbabwe. He has a history of well-controlled type II diabetes, smoking 10 cigarettes a day, and drinking 14 units of alcohol per week. On examination, he has confused speech and right-sided posterior cervical lymphadenopathy. His vital signs are within normal limits. Laboratory investigations reveal a mild neutrophilic leukocytosis and elevated creatinine. CT head is unremarkable. What is the most appropriate next investigation?

MRCP2-2797

A 36 year-old woman presented to the medical outpatient clinic with an 8 month history of deteriorating vision. She also complained of a pruritic rash intermittently affecting her forearms and neck. She had recently migrated to the UK from Guinea, where she had lived since birth. She had suffered from malaria as a child but had been fit and well since. She did not smoke and drank 6-10 units of alcohol per week.

On examination, her temperature was 36.7ºC, pulse was 68 beats per minute and blood pressure was 124/80 mmHg. Her chest was clear on auscultation and heart sounds were normal. Fundoscopy was not possible due to clouding of both corneas. There was evidence of a mottled rash over the forearms and neck with a leopard print appearance.

Investigations:

Haemoglobin 141 g/L (130-180)
White cell count 6.7 x 9/L (4.0-11.0)
Neutrophil count 3.0 x 9/L (2.0-7.5)
Lymphocyte count 1.7 x 9/L (1.3-3.5)
Eosinophil count 0.6 X 9/L (0.1-0.4)
Platelets 260 x 9/L (150-400)

Sodium 138 mmol/L (135-145)
Potassium 4.3 mmol/L (3.5-5.0)
Urea 7.2 mmol/L (2.5-7.5)
Creatinine 61 umol/L (25-95)
Fasting plasma glucose 5.0 mmol/L (3.0-6.0)

Based on the likely diagnosis, what is the most appropriate treatment?