A 35-year-old previously healthy man is involved in a motor vehicle accident and thrown off his motorcycle, resulting in multiple profusely bleeding lacerations on his extremities. He is rushed to the emergency department with the help of blue lights. Upon arrival, he receives 2 units of cross-matched blood, which causes no reaction in the blood bank. However, ten minutes after the transfusion, the patient experiences severe urticaria. What syndrome could be contributing to the patient’s symptoms?
MRCP2-2731
As the medical registrar on-call you are called to see a 24-year-old female in the Emergency Department (ED). The young female presented to the ED with a fever and productive cough of green sputum. When you arrive she looks unwell and although alert is a difficult historian.
Concerned, you immediately assess her from head to toe: Airway patient, able to speak in sentences Breathing Sats 91% on room air, Resp Rate 24 / min, coarse creps bilaterally on auscultation Circulation Heart rate 105 beats per minute, blood pressure 95/60 mmHg Disability Glasgow coma scale 15/15, capillary blood glucose 5.8 Exposure Multiple boils noted distributed widely across the patient’s body
You inquire about the history of the boils identified on examination. The patient is unsure how long she has had them for, however, mentions that her sister recently was prescribed antibiotics by their family GP for similar lesions.
You start the patient on high flow oxygen, gain IV access taking blood cultures and give a fluid bolus. An urgent portable chest X-ray is requested which appears to show bilateral consolidation with multiple cavitating lesions.
Panton-Valentine Leukocidin is a pore-forming toxin which is produced by staphylococcus aureus. It has an affinity for white blood cells and the endothelium. Clinically PVL will often present with a necrotising pneumonia, characterised by severe bilateral pneumonia with cavitations on X-ray. Often patients presenting will have a history of boils or necrotic skin lesions. As the staphylococcus is easily transmitted there may be a recent family history of similar infections / boils.
Although all of the answers in this stem could be associated with cavitating pneumonia, the severity of the clinical presentation and history of boils in the family points towards a PVL-pneumonia.
MRCP2-2732
A 23-year-old office worker presents to the clinic with complaints of swollen and tender finger joints that have been present for a few weeks. She has no significant medical history except for a recent viral illness. She denies any recent travel and reports that some of her colleagues at work have also been sick with a similar illness. On examination, there is swelling and tenderness in the metacarpophalangeal and proximal interphalangeal joints of both hands. What is the probable diagnosis?
MRCP2-2733
A 67-year-old American man is seen in the HIV Clinic. He has a CD4 count of 120 × 106/L and was started on prophylactic co-trimoxazole 2 weeks ago. Unfortunately, this resulted in a severe rash and deranged liver function tests and was discontinued. He has glucose-6-phosphate dehydrogenase (G6PD) deficiency and is a type 2 diabetic. His only current medication is metformin 500 mg bd. What is the most appropriate prophylaxis for Pneumocystis jirovecii pneumonia (PCP)?
MRCP2-2734
A 22-year-old woman arrives at the emergency department complaining of feeling exhausted, coughing, having fevers and feeling generally lethargic for the past five days. She becomes emotional during the consultation as she has never experienced this before.
Upon examination, she displays tenderness over both trapezius muscles, her temperature is 38.6 ºC and her throat is red without any pus collections.
A rapid point of care test confirms that she is positive for influenza.
What would be your next course of action?
MRCP2-2735
A 55-year-old man presents to his GP with a case of multi-dermatomal shingles and is subsequently diagnosed with HIV. His CD4 count is 480 cells/μL. What are the appropriate immunisation recommendations for this patient?
MRCP2-2736
A 28-year-old IV drug user presents with a two week history of non-productive cough, fatigue, shortness of breath and fever. On examination, he has a respiratory rate of 28, a heart rate of 90 and was hypoxic on exercise.
His blood test results were as follows: – Haemoglobin: 110 g/L (135-180) – White cell count: 3 ×109/L (4-11) – Neutrophils: 2.5 ×109/L (1.5-7.4) – Lymphocytes: 0.4 ×109/L (1.1-4.0)
Chest x-ray was normal. Which investigation would be diagnostic?
MRCP2-2737
A 50-year-old patient is admitted to the acute medical unit with a 10-day history of a dry cough and progressive shortness of breath, particularly on exertion. He also complains of intermittent fevers and a general loss of appetite. His past medical history includes HIV and he is non-compliant with his regular medications.
His observations are as follows: Temperature 38.3ºC Heart rate 112 beats/min Blood pressure 123/84 mmHg Respiratory rate 25 breaths/min Oxygen saturations 94% on air, 83% on exertion
On examination, he appears pale and cachectic. There are audible crackles bilaterally. His heart rate is regular and heart sounds are normal. He has a soft and non-tender abdomen.
Laboratory tests:
CD4 count < 200/mm³
Which of the following complications is most commonly associated with the likely underlying diagnosis?
MRCP2-2738
A 43-year-old man presents to the Emergency department with a one month history of dry cough, shortness of breath, and a six-month history of weight loss. He is a non-smoker. Two months ago, he was discharged from the hospital after being treated for pneumonia caused by Streptococcus pneumoniae. His past medical history includes a case of shingles treated by his GP a year ago. On examination, he appears breathless but is able to complete sentences. His temperature is 37.5°C, blood pressure is 110/76 mmHg, and O2 saturations are 97% at rest but drop to 92% on exercise. Blood tests reveal elevated CRP levels. What is the most likely investigation to confirm the diagnosis?
MRCP2-2739
A 28-year-old woman has just come back from a trip to Kenya and is now experiencing a fever (39.8°C), sore throat, lymphadenopathy, and a macular rash that has spread throughout her body.