Archives: MRCP Part 2

MRCP2-2757

A 67-year-old man presents to the respiratory clinic with a three-month history of a productive cough and steady weight loss of 10 kg. He has noticed streaks of blood in his sputum over the past week and complains of night sweats. He has a history of bronchial asthma and has required hospital admission on several occasions. His current therapy includes salbutamol and beclomethasone inhalers and prednisolone 5 mg once daily. His chest x-ray shows right apical consolidation and a sputum sample is positive for acid-alcohol fast bacilli, leading to a presumptive diagnosis of pulmonary tuberculosis. He is started on antituberculous therapy but presents to the Emergency department five days later with breathlessness and wheeze. On examination, he has widespread expiratory wheezes and a PEFR of 110 L/min. His chest x-ray does not show any significant change. What is the most appropriate step in his management?

MRCP2-2758

A 29-year-old man presents with fever, headache, abdominal pain, and a rash on the chest 2 weeks after returning from a trip to South America.

On examination, his temperature is 38.2ºC. He has a rash on his chest consisting of rose-colored blanching papules. His respiratory rate is 20 breaths/min and his heart rate is 58 beats per minute. His chest is clear to auscultation. The abdomen is diffusely tender, and there is mild splenomegaly.

Initial blood results show:

Hb 128 g/l
Platelets 184 * 109/l
WBC 3.9 * 109/l
Na+ 131 mmol/l
K+ 3.3 mmol/l
Urea 7.2 mmol/l
Creatinine 141 µmol/l
Bilirubin 46 µmol/l
ALP 147 u/l
ALT 96 u/l
Albumin 38 g/l
CRP 52 mg/l

What is the most appropriate initial antimicrobial therapy?

MRCP2-2759

A Commonwealth diplomat is traveling to Uganda to monitor the elections. He has received his vaccinations in advance. He has a history of schizophrenia but has recovered and is capable of working. He is concerned about malaria and seeks your advice on how to avoid mosquito bites. He also wants to know the most effective medication for malaria prophylaxis. What medication would you suggest for him?

MRCP2-2760

A 35-year-old woman comes to the clinic with a rash on her upper thighs. She reports that she noticed the rash three days ago and it is both itchy and red. Additionally, she has been experiencing itchy hands. The patient lives with her partner and 3-year-old son and works as a care assistant in a nursing home. During the examination, the healthcare provider observes a dry erythematous papular rash on the medial aspect of both thighs. What is the recommended treatment for the most probable diagnosis?

MRCP2-2761

A 27-year-old woman visits the clinic about 6 weeks after returning from a hiking trip in South America. She admits to having swam in local rivers and lakes. She has a history of fever, fatigue, muscle pain, loss of appetite, and vague abdominal discomfort.

During the examination, an urticarial rash is observed, and she has a temperature of 38.3 °C. There is evidence of generalized lymphadenopathy and hepatosplenomegaly.

The following investigations are conducted:

Haemoglobin (Hb) 122 g/l 135–175 g/l
White cell count (WCC) 8.5 × 109/l (marked eosinophilia) 4.0–11.0 × 109/l
Platelets (PLT) 190 × 109/l 150–400 × 109/l
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 125 µmol/l 50–120 µmol/l
Alanine aminotransferase (ALT) 140 IU/l 5–30 IU/l
Chest X-ray (CXR) Generalized increase in vascular / interstitial markings, lymphadenopathy

What is the most likely diagnosis?

MRCP2-2762

A 25-year-old man presents to the emergency department with a fever and a rash after returning from a backpacking trip in rural Thailand. He has been experiencing general malaise for the past few days, along with a frontal headache and a rash that appeared last night. Upon examination, he has tender cervical lymphadenopathy and a maculopapular rash on his trunk. Additionally, there is a small painless erythematous lesion on his lower calf with a necrotic center.

Based on these symptoms, what is the most likely diagnosis?

MRCP2-2763

A 20-year-old male presents to the general medical take with large grey lesions around his perineum and in his mouth which started two days ago. He reports that he has a more general rash on his trunk and the palms and soles of his feet. He generally feels unwell with malaise and fever. He has never had anything like this before but mentions that he did see a small ulcer on his scrotum a month ago that didn’t hurt and healed on its own.

On examination, he has a symmetrical, widespread, maculopapular rash on his trunk, limbs and the palms and soles of his feet. This is different from the large greyish lesions that you see in his mouth and perineum. He has general lymphadenopathy that is minimally tender on palpation. His chest is clear on auscultation, there are no added heart sounds and his abdomen is soft and non-tender.

Investigations show:
Haemoglobin 13g/dl
WCC 11 x 10^9/l
Platelets 352 x 10^9/l
CRP 89
Sodium 145 mmol/l
Potassium 3.8 mmol/l
Urea 4 mmol/l
Creatinine 82 umol/l

What is the most likely diagnosis?

MRCP2-2764

A 27-year-old homosexual man presented to the hospital with a fever, dry cough, and dyspnea. Upon examination, oropharyngeal candidiasis was noted. Further testing revealed that he was HIV antibody positive and had Pneumocystis jirovecii in his bronchoalveolar lavage, which was treated with intravenous co-trimoxazole. He was subsequently started on highly active antiretroviral therapy (HAART).
After four weeks, he returned to the clinic complaining of weakness and generalized aching. He was taking AZT, 3TC, nelfinavir, co-trimoxazole for Pneumocystis jirovecii prophylaxis, and fluconazole.
Investigations showed that his serum creatine kinase was 6700 IU/L (24-195) and myoglobin was found in his urine. What is the underlying cause of his symptoms?

MRCP2-2765

A 42 year-old woman presented to the medical clinic with progressive leg swelling over the past 2 years. She had a history of malaria as a child and had recently moved to the United States from Nigeria. On examination, non-pitting leg swelling was observed bilaterally with thickening of the skin. Her vital signs were within normal limits and laboratory investigations were unremarkable except for a slightly elevated bilirubin level. What is the probable organism responsible for her symptoms?

MRCP2-2766

A 69-year-old male was admitted to the ward with right leg cellulitis. He was septic on admission and the sepsis 6 bundle was completed in one hour. He is treated with IV flucloxacillin initially and was switched to oral flucloxacillin on day 2. On day 3 of admission you receive a call from the duty microbiologist with the following results:

Anaerobic blood culture bottle Positive for Staphylococcus aureus
Aerobic blood culture bottle Positive for Staphylococcus aureus

What would be your plan of action for managing this patient?