Archives: MRCP Part 2

MRCP2-2748

A 28-year-old male patient presents to the Emergency department with a three-day history of fever, myalgia, and abdominal pain. He had recently traveled through Cote d’Ivoire but had not been in contact with anyone known to have a viral haemorrhagic fever. He had been taking malaria prophylaxis with good concordance. On examination, he appeared unwell, dehydrated, and feverish. His chest examination was unremarkable, but he was diffusely tender in his abdomen without any rebound guarding or organomegaly. There were no signs of haemorrhage or rash. His neurological examination was unremarkable, and laboratory reports showed some abnormalities. His haemoglobin was 120 g/L, WCC was 3.5 ×109/L, platelets were 501 ×109/L, neutrophils were 2.4 ×109/L, and lymphocytes were 0.8 ×109/L. His sodium was 134 mmol/L, urea was 7.5 mmol/L, potassium was 3.6 mmol/L, and creatinine was 86 µmol/L. His urine dip showed protein 1+ and nothing else. What is the next appropriate step in managing this patient?

MRCP2-2749

A 28-year-old woman seeks your guidance after hearing about the recent Zika virus outbreak. She and her partner are planning to have a baby, but she just returned from a business trip to Brazil last week. She has not shown any signs of fever or concerning symptoms during her travels or since returning to the UK. What advice should you offer her?

MRCP2-2750

A 49-year-old man presents to the emergency department with a headache and confusion. His partner reports that he has been experiencing these symptoms for the past few days, along with a fever and swollen glands in his neck. While waiting to be transferred to the medical ward, he had a seizure. The patient has a history of HIV and was previously hospitalized for severe pneumonia due to non-compliance with his anti-retroviral treatment.

A CT scan of the head revealed multiple ring-enhancing lesions. The infectious diseases team ordered additional blood tests, which showed abnormal results. The patient’s hemoglobin, platelet count, and white blood cell count were all low, while his urea and creatinine levels were high. His CRP level was also elevated, indicating inflammation. Toxoplasmosis serology was positive, but Cryptococcal serology and β-d-Glucan and Galactomannan levels were normal.

What is the most appropriate treatment for this patient?

MRCP2-2751

A 65-year-old farmer presents with a six month history of recurrent night sweats and fever. He has lost approximately 5 kg in weight and complains of fatigue. On examination, he is afebrile. Heart sounds are normal and his chest is clear. A spleen tip is palpable 4 cm below the left costal margin. The remainder of the examination is unremarkable apart from a faint palpable purpuric rash around both ankles.

Investigations show:

Haemoglobin 121 g/L (130-180)

WBC 7.5 ×109/L (4-11)

Neutrophils 5.5 ×109/L (1.5-7)

Lymphocytes 2.0 ×109/L (1.5-4)

Monocytes 0.05 ×109/L (0-0.8)

Eosinophils 0.01 ×109/L (0.04-0.4)

Basophils 0.01 ×109/L (0-0.1)

Platelets 110 ×109/L (150-400)

Serum sodium 137 mmol/L (137-144)

Serum potassium 4.1 mmol/L (3.5-4.9)

Serum urea 9.3 mmol/L (2.5-7.5)

Serum creatinine 170 µmol/L (60-110)

Serum bilirubin 12 µmol/L (1-22)

Serum aspartate transaminase 98 U/L (1-31)

Serum alkaline phosphatase 101 U/L (45-105)

Serum albumin 35 g/L (37-49)

Urinalysis Protein +

Urine microscopy Red cells seen; no bacteria

Urine culture Negative

What is the diagnosis?

MRCP2-2752

A 32-year-old office worker presents with a three month history of recurrent episodes of disorientation and confusion. Her colleagues have found her staring blankly at her computer screen on several occasions, apparently with no idea of what she was doing. Her mood has been very low, with frequent emotional outbursts, and she has considered quitting her job because of difficulties with concentration and memory. Her partner feels her condition is significantly worsening.

On physical examination, there are recurrent, asymmetrical jerks in all four limbs. Which investigation would be most useful in reaching a diagnosis?

MRCP2-2753

A 70-year-old male with a long history of intravenous drug use presents with fevers, rigors, and back pain. Upon admission, three sets of blood cultures are taken and grow positive for gram-positive cocci in clusters, indicating a possible Staphylococcus aureus bacteraemia. The patient is started on intravenous vancomycin, but half an hour into the infusion, he develops flushing and erythema over his neck, face, and trunk. Despite denying significant distress or discomfort, his vital signs are monitored and recorded as blood pressure 125/70 mmHg, heart rate 85/min, temperature of 36.8ºC, respiratory rate of 18/min, and oxygen saturation of 98% on room air. What is the most appropriate management for this patient?

MRCP2-2754

A 55-year-old woman presents with a history of fever, chills, and painful urination for the past two days. She has been given aggressive fluid resuscitation.
Her vital signs show a heart rate of 120 beats per minute, respiratory rate of 30 breaths per minute, systolic blood pressure of 80 mmHg, and temperature of 39°C.
The results of her laboratory tests reveal a C reactive protein (CRP) level of 150 mg/dL (<10), a white cell count of 22 ×109/L (3.2-12), and neutrophils of 16 ×109/L (1.9-7.7).
Which of her vital signs indicates that she is in septic shock?

MRCP2-2755

A 24-year-old man presents to the HIV clinic for the first time after being diagnosed with positive HIV serology during an opportunistic screening at a local GUM clinic. He is feeling anxious about managing his disease and is eager to start treatment. He has no symptoms and has no significant medical history.

During his consultation, the diagnosis was discussed with him, and the role of antiretroviral treatment was explained.

Blood tests:
Hb 136 g/l
Platelets 390 * 109/l
WBC 7.8 * 109/l
Na+ 142 mmol/l
K+ 4.2 mmol/l
Urea 4.8 mmol/l
Creatinine 68 µmol/l
HIV viral load 210 copies/ml
CD4 count 920 cells/mm3

What is the most appropriate management plan to offer?

MRCP2-2728

A 30-year-old woman comes back from a vacation in Thailand and presents with diarrhea. She has no medical history and is not taking any regular medication except for the oral contraceptive pill. She has a peanut allergy but no other allergies. The patient has been experiencing diarrhea for three days with mild abdominal cramps that started five days after returning from her trip. There is a small amount of blood in her stool. Her vital signs are normal, and she does not have any postural symptoms. Stool samples are sent to the microbiology lab for analysis. What is the most appropriate treatment?

MRCP2-2729

A 39-year-old Mexican man presents to the Emergency Department with a 1-month history of dizziness and unsteady gait. He had been visiting his family, who were concerned about his strange behavior, depression, and fatigue. He also complained of back pain and constipation. He works on a cattle ranch in Mexico, does not smoke, and does not use drugs. On examination, he is febrile, confused, and has hepatosplenomegaly and an unsteady gait. His blood work shows low white cell count, low platelets, high LDH, high ALT, high ALP, high bilirubin, and high ESR. Blood cultures and imaging studies are normal, and he tests negative for HIV. What is the most likely diagnosis?