Archives: MRCP Part 2

MRCP2-2798

A 37-year-old man presents to the clinic with an increase in the frequency of his bowel movements over the past four days. He has a history of ulcerative colitis and is currently taking azathioprine 200 mg OD and mesalazine 2.4mg BD. He has not had a flare-up in two years and has been managing his condition well. He reports passing up to 10 watery stools a day, experiencing faecal urgency, and having nocturnal episodes. He also complains of cramping pain in his left iliac fossa. There is no blood or mucous in his stools. On examination, he has a fever of 38.2 degrees Celsius, a blood pressure of 120/75 mmHg, and a heart rate of 100/min. He is underweight with a BMI of 18.5 and is dehydrated. His abdomen is soft, but he is tender in the left iliac fossa. He refuses a PR examination. Respiratory and cardiovascular examinations are normal.

His blood tests reveal:

– Hb 110 g/l
– Platelets 189 * 109/l
– WBC 3.8 * 109/l
– Neutrophils 0.89 * 109/l
– INR 1.1 (0.9-1.2)
– Na+ 136 mmol/l
– K+ 4.9 mmol/l
– Urea 8.0 mmol/l
– Creatinine 100 µmol/l
– Magnesium 0.79 mmol/L (0.7-1.0)
– Calcium 2.4 mmol/L (2.1-2.58)
– CRP 78 mg/l
– Bilirubin 5 µmol/l
– ALP 78 u/l
– ALT 28 u/l
– Albumin 33 g/l

He is started on IV hydrocortisone 100mg QDS and IV fluids. Stool specimens are sent and are reported as negative for C. difficile toxin. The next day, he undergoes a flexible sigmoidoscopy which reveals widespread left-sided colitis. The biopsy results show the presence of inclusion bodies in the colonic mucosa. What is the appropriate treatment for this patient?

MRCP2-2799

A 47 year old man presents at the Infectious Diseases clinic for a follow-up appointment. He has been HIV-positive for the past 13 years and has been doing well on his current treatment regimen of emtricitabine, atazanavir, and tenofovir. However, he has recently been experiencing difficulty swallowing and altered taste. He has also noticed a white coating in his mouth that cannot be removed by brushing. He denies any illicit drug use and reports being compliant with his medications. He has also stopped having unprotected sex. The only recent change in his medication regimen is that he was started on a new medication by his GP for non-specific symptoms. His CD4 count was 526 four months ago but has now dropped to 210. What medication is the GP likely to have prescribed?

MRCP2-2800

A 23 year old male presents to the Genitourinary Medicine clinic where you are currently working. He has been notified to attend the clinic due to recent sexual contact with someone who has been diagnosed with gonorrhoeae. Despite this, he reports no symptoms. What would be the most appropriate course of action in this scenario?

MRCP2-2772

A 65-year-old man comes to the clinic complaining of confusion that has been going on for two months. He has no history of cardiovascular or peripheral vascular disease and denies having a fever or meningism. Upon examination, he is found to have an ataxic gait and reduced coordination.

What is the most suitable test to aid in the diagnosis of tertiary syphilis?

MRCP2-2773

A 32-year-old expectant mother came to the clinic for a consultation. She is preparing to relocate to Africa and is currently 16 weeks pregnant. She wishes to check her immunization records before her trip.
Which vaccine is deemed safe during pregnancy?

MRCP2-2774

A 65-year-old man with COPD is prescribed doxycycline for a flare-up. What is the mechanism of action of doxycycline?

MRCP2-2775

A 50-year-old man receiving chemotherapy informs the nursing staff that he has been feeling ill for the past 48 hours. He is currently undergoing treatment for metastatic lung cancer and has been receiving chemotherapy through a peripherally inserted central catheter (PICC). Upon assessment, his temperature is recorded as 38.2ºC, but his other vital signs are stable. The nurses observe that his line site appears normal, his chest is clear, and his abdomen is soft and non-tender. What would be the most appropriate course of action in managing his condition?

MRCP2-2776

A 53-year-old man is seen in follow-up 72 hours after being admitted to the hospital with neutropaenic sepsis. He reported a temperature of 38.5ºC and was advised to attend the emergency department by the chemotherapy helpline. He was promptly admitted under the care of the medical team.

The patient has a history of metastatic colorectal cancer and received chemotherapy 12 days ago. He was started on piperacillin with tazobactam on admission and his temperature settled within 24 hours. Investigations, including blood cultures, a chest X-ray, urine testing, and a thorough examination did not reveal any source of infection. His initial neutrophil count was 0.3* 109/l. Recent blood tests show a neutrophil count of 0.6* 109/l. He has not experienced any symptoms since his temperature settled and his vital parameters have been normal.

What is the most appropriate course of action?

MRCP2-2777

A 72-year-old man presents to the emergency department with a fever, headache, and myalgia that started a day ago. He has a medical history of hypertension, type 2 diabetes, congestive heart failure, and bilateral hip replacement. He takes amlodipine, ramipril, aspirin, atorvastatin, gliclazide, calcium carbonate with colecalciferol (Adcal-D3), and paracetamol. He denies any allergies but is concerned about having influenza after visiting a friend in the hospital who was diagnosed with influenza A.

Upon examination, the patient appears sweaty and has a hot temperature. His chest is clear upon auscultation, and he is placed in a side room for observation while viral throat swabs are requested. His vital signs are as follows: oxygen saturation of 96% on room air, respiratory rate of 18/min, blood pressure of 129/93 mmHg, heart rate of 77/min, and a temperature of 38.1°C.

What is the most appropriate course of treatment?

MRCP2-2778

A 25-year-old woman presents to the emergency department with left-sided weakness and difficulty in finding words. She also complains of a headache and nausea for the last three days. She has no past medical history and does not smoke nor does she drink alcohol. She recently moved from Kenya to the US.

On examination, she has marked weakness in upper and lower left limbs and is unable to walk without assistance. Her responses to questions are slow and limited.

Blood tests:
Hb 129 g/l
Platelets 316 * 109/l
WBC 8.9 * 109/l
Na+ 141 mmol/l
K+ 4.7 mmol/l
Urea 5.1 mmol/l
Creatinine 71 µmol/l
HIV-1 serology positive
HIV-2 serology negative
HIV viral load pending
CD4 count pending
Toxoplasmosis serology pending
Cryptococcal antigen pending

A CT scan of her head demonstrates multiple ring-enhancing lesions and mass effect. Dexamethasone is started immediately. What is the most appropriate next step?