Archives: MRCP Part 2

MRCP2-2779

A 35-year-old woman presents to the emergency department with confusion, headache, and fever. She has no significant medical history and is not taking any regular medications. She recently returned from a trip on the Trans-Siberian Railway where she did some hiking with friends. She had a brief flu-like illness towards the end of the trip, which resolved on its own. On examination, she has nuchal rigidity and is photophobic. Blood tests show elevated white blood cell count and C-reactive protein levels. A lumbar puncture is performed, and the CSF analysis reveals lymphocytic pleocytosis, low glucose, and elevated protein levels. Specific IgM antibodies against a flavivirus are detected in the CSF. What is the next appropriate step in management?

MRCP2-2780

A 67 year-old man with type 2 diabetes mellitus and alcoholism presents with fever, headache, and neck stiffness. He has a history of previous anaphylactic reaction to penicillin.

During examination, his temperature is 37.9ºC, respiratory rate is 20 breaths/min, and heart rate is 105 beats per minute. The patient’s nutritional state and dental hygiene are poor. The chest is clear to auscultation, and the abdomen is soft and non-tender. The Glasgow coma scale score is 15, the patient is uncomfortable during pen-torch pupillary examination, and neck flexion is limited by pain.

The CSF examination reveals 560 white cells per mm³ (85% polymorphs), 8 red cells per mm³, protein of 0.9g/L, glucose of 3.3mmol/L (serum glucose 9.2mmol/L), and a Gram stain of Gram-negative coccobacilli.

What is the appropriate antimicrobial agent to initiate?

MRCP2-2781

A 20-year-old from Cameroon has recently moved to the UK to pursue nursing. She has been experiencing diarrhoea for the past month and noticed a brief rash on her torso. Her GP ordered a blood test which revealed a significant eosinophilia. She has not lost weight and is worried about gaining weight since moving to the UK. She has no history of allergies or medication. Her brother had an eye worm last year. A stool sample was sent for ova cysts and parasites and microscopy and culture. The results showed multiple Strongyloides stercoralis larvae on charcoal culture. She was started on a seven-day course of Ivermectin. However, four days later, she was brought to the Emergency Department with a GCS of 6. What is the diagnosis?

MRCP2-2782

A 45-year-old man presents with bloody diarrhoea. He is HIV positive with a CD4 count of 140 cells/µL. He had traveled to Zimbabwe 9 months ago. For the past 2 weeks, he has been experiencing anorexia and mild abdominal discomfort, which has progressed to severe abdominal cramps and bloody diarrhoea. His vital signs include a temperature of 37.8ºC, blood pressure of 100/60, and a pulse of 111/min. Upon examination, he appears unwell, emaciated, and has generalised tenderness in his abdomen. There is no guarding or peritonitis. What is the most likely causative organism?

MRCP2-2783

A 28-year-old male presents to the emergency department with a 5-day history of fevers, myalgia, and headaches. He has no significant medical history and is a non-smoker. On examination, he appears dyspnoeic with oxygen saturations of 92% and a respiratory rate of 24/minute. Heart sounds are normal, and the abdomen is soft with no organomegaly. A chest x-ray shows subtle bilateral interstitial infiltrates.

His blood tests reveal a high white blood cell count, elevated liver enzymes, and a slightly low oxygen level. He works on a dairy farm with his father, who recently had pneumonia but tested negative for COVID19. The patient has had limited social contacts to protect his father from COVID19.

What is the most likely cause of his symptoms?

MRCP2-2784

A 55-year-old man presents to the emergency department with a rash and ulceration on his lower limbs. He has a past medical history of untreated hepatitis C virus. He is not on any regular medications. He is homeless. He is an intravenous drug user.

On examination, there is a purpuric rash on his lower limbs with ulceration of the digits. There is no clinical evidence of synovitis.

Blood tests:

Hb 121 g/L Male: (135-180)
Female: (115 – 160)
Platelets 422 * 109/L (150 – 400)
WBC 5.2 * 109/L (4.0 – 11.0)
Na+ 138 mmol/L (135 – 145)
K+ 4.2 mmol/L (3.5 – 5.0)
Urea 5.2 mmol/L (2.0 – 7.0)
Creatinine 141 µmol/L (55 – 120)
CRP 55 mg/L (< 5)
Rheumatoid factor 654 IU/ml (0-20)
Complement (C3) 0.81 g/L (0.75 – 1.65)
Complement (C4) .02 g/L (0.16 to 0.48)
Antinuclear antibody negative (negative)
ESR 101 mm/Hr (0-20)
IgA 10.2 g/L (6.60 – 15.90)
IgG 24.1 g/L (6-16)
IgM 4.2 g/L (0.53-2.47)

Urinalysis:

Leucocytes negative
Nitrites negative
Blood +++
Protein ++
Glucose negative

What is the likely diagnosis?

MRCP2-2785

A 40-year-old man presents to the medical assessment unit after being referred by his general practitioner. He complains of experiencing episodic swellings of the soft tissue near various joints for the past two months. The swellings are occasionally pruritic and hot. He has no medical history and is not taking any regular medications. He recently returned from spending six months in Equatorial Guinea.

During the examination, a non-pitting swelling of 2 x 3 cm is observed on his dorsal forearm. The swelling is hot but not erythematous.

Based on the blood test results below, what is the likely diagnosis?

Hb 136 g/L Male: (135-180)
Female: (115 – 160)
Platelets 189 * 109/L (150 – 400)
WBC 14.2 * 109/L (4.0 – 11.0)
Neuts 6.5 * 109/L (2.0 – 7.0)
Lymphs 2.2 * 109/L (1.0 – 3.5)
Mono 0.3 * 109/L (0.2 – 0.8)
Eosin 5.2 * 109/L (0.0 – 0.4)

MRCP2-2786

A 32-year-old man presents to the emergency department with two weeks of fevers, malaise, myalgia, arthralgia and low back pain. He has no significant past medical history. He does not take any medications. He works as a software engineer. There is no recent travel.

Observations:

Heart rate 94 beats per minute
Blood pressure 121/88 mmHg
Respiratory rate 19/minute
Oxygen saturation 96% on room air
Temperature 38.2ºC

On examination, there is focal tenderness at the left sacroiliac joint. Cardiovascular, respiratory and abdominal examinations are unremarkable. He is diaphoretic and an associated foul smell is noted. There is no joint swelling.

Urinalysis is unremarkable.

Plain radiography of the chest is normal.

Blood tests:

Hb 138 g/L Male: (135-180)
Female: (115 – 160)
Platelets 189 * 109/L (150 – 400)
WBC 3.4 * 109/L (4.0 – 11.0)
Na+ 138 mmol/L (135 – 145)
K+ 4.2 mmol/L (3.5 – 5.0)
Urea 4.2 mmol/L (2.0 – 7.0)
Creatinine 89 µmol/L (55 – 120)
CRP 45 mg/L (< 5)
Bilirubin 12 µmol/L (3 – 17)
ALP 89 u/L (30 – 100)
ALT 35 u/L (3 – 40)
γGT 44 u/L (8 – 60)
Albumin 36 g/L (35 – 50)

What is the likely diagnosis?

MRCP2-2787

A 20-year-old female patient presents with a recent onset of skin lesions and joint pain. She had previously treated herself for vaginal thrush with a clotrimazole pessary, which has now resolved. The patient has a medical history of SLE and takes hydroxychloroquine. On examination, the patient has vesicles on her arms and legs, with some scabbing and necrosis. She also has tenderness, erythema, and reduced range of motion in her left elbow and right wrist, as well as a swollen, hot, and tender right knee joint with reduced range of motion. Blood tests reveal elevated white cell count, CRP, and ESR, as well as low C4 levels. X-ray of the right knee confirms effusion, and synovial tap shows high levels of leucocytes and polymorphs. What would be the most appropriate treatment plan for this patient?

MRCP2-2756

A group of politicians, all in their 50s, were attacked with an aerosol spray as they left a meeting. They presented to the Emergency department with symptoms of profuse tearing, eye pain, and corneal injuries. They also complained of shortness of breath, cough, and wheeze, and developed fever, nausea, and diarrhea within two hours of admission. One of the most severely affected patients had arterial blood gases showing hypoxemia and respiratory acidosis. Two of the patients eventually died despite maximal supportive care, while the other two required intubation and ventilation and had prolonged hospital stays. What was the likely substance present in the aerosol that caused this syndrome?