Archives: MRCP Part 2

MRCP2-2685

A 35-year-old woman with a history of chronic alcohol abuse, type 2 diabetes, and latent tuberculosis presents to the Emergency Department with complaints of tingling in her feet for the past four weeks. She has been taking Metformin and Isoniazid monotherapy for two months. On examination, she appears unkempt and smells strongly of alcohol. Neurological examination reveals absent ankle reflexes and diminished sensation in her lower limbs. The remainder of her examination is normal.

Investigations reveal normal fasting plasma glucose and HbA1C levels, but low serum B12 and folate levels. Her hemoglobin, white cell count, platelets, serum sodium, serum potassium, serum urea, and serum creatinine levels are within normal limits.

What is the most likely cause of her neurological symptoms?

MRCP2-2657

A 14-year-old boy is referred to a tertiary immunology service due to recurrent infections since infancy, including sinusitis, otitis media, and pneumonia. He had a prolonged admission to the pediatric intensive care unit with respiratory failure requiring intubation, where he was diagnosed with Pneumocystis jirovecii pneumonia. HIV testing was negative. He also experiences chronic diarrhea, and no cause has been found. Clinical examination revealed stomatitis and gingivitis, but no organomegaly or lymphadenopathy. Blood tests showed low white blood cell count, low lymphocyte count, and low immunoglobulin A levels. What is the likely diagnosis?

MRCP2-2658

Sarah is a 19-year-old woman presenting with diarrhoea. The diarrhoea has been ongoing for the past 7 days and her stool is described as a type 6-7 stool on the Bristol stool charts. She did not note any blood or mucous accompanying her diarrhoea. There is accompanying crampy abdominal pains and she noted a fever of 38.2ºC yesterday. She did not note any accompanying weight loss but has been feeling tired over this period.

The abdominal examination was unremarkable. She is not sexually active at present.

She has been hospitalized approximately 5-6 times in the last 3 years with recurrent infections. From her previous medical notes, her last admission related to a chest infection. She had a dry cough and shortness of breath during this time. Oxygen saturation measured on admission was 96% but quickly decreased to 89% on exertion with bilateral opacification noted on chest X-rays.

Stool cultures had been taken and on Ziehl-Neelsen staining, red oocysts are visible within the stool culture. Blood tests taken reveals:

Hb 150 g/L Male: (135-180)
Female: (115 – 160)
Platelets 250 * 109/L (150 – 400)
WBC 4.5 * 109/L (4.0 – 11.0)
Neuts 1.1 * 109/L (2.0 – 7.0)
Lymphs 2.5 * 109/L (1.0 – 3.5)
Mono 0.6 * 109/L (0.2 – 0.8)
Eosin 0.3 * 109/L (0.0 – 0.4)

Immunoglobulin studies were carried out and this revealed reduced levels of IgG and IgA but IgM levels were normal.

What is the most likely unifying diagnosis for her symptoms?

MRCP2-2659

A 36-year-old man presents to the emergency department with fever and shivering, occurring approximately every two days. He has returned from India three weeks ago, having spent four months travelling. While he was in India, he was treated for malaria with chloroquine. He has no other past medical history and does not take any regular medications.

Observations:
Heart rate 88 beats/min
Blood pressure 120/77 mmHg
Respiratory rate 18 breaths/min
Oxygen saturations 98% on room air
Temperature 38.6ºC

On examination, the patient is diaphoretic. There is palpable splenomegaly.

What is the most likely organism responsible for the patient’s malaria?

MRCP2-2660

You are asked to assess a 65-year-old alcoholic who has developed several abscesses. While the patient is started on broad-spectrum antibiotics, a sample of pus is sent to the lab for analysis. The lab report indicates the presence of Gram-positive bacteria in atypical clusters, with positive results for catalase and coagulase tests. What is the responsible pathogen for the formation of these boils?

MRCP2-2661

A 32-year-old man presents with the sudden onset of fever, pharyngitis, myalgia, and diarrhea. He recently traveled through Sierra Leone two weeks ago and has no significant medical history. On examination, he appears unwell with a temperature of 38°C. There are no signs of hemorrhage or rash, and his chest, abdominal, and neurological exams are normal. The FBC shows mild thrombocytopenia, but otherwise unremarkable. Biochemically, he has mild dehydration, and liver function tests are normal. What is the most likely diagnosis?

MRCP2-2662

A 35-year-old male presented to the Emergency Department with a decreasing level of consciousness. He had just returned from a business trip in Asia. He was completely healthy during his travels, but he started to develop a fever two days after his return. The fever was associated with a severe frontal headache and photophobia. These symptoms persisted for the last two days and he started to become sleepier.

On examination: blood pressure 110/70 mmHg, pulse rate 115/min, temperature 39.5ºC, respiratory rate 28/min. He had evidence of neck stiffness. Blood investigations showed:

Hb 120 g/l
Platelets 135* 109/l
WBC 12* 109/l

What is the most likely diagnosis?

MRCP2-2663

A 26-year-old female patient complains of a sudden severe headache and fever. During the examination, she shows signs of nuchal rigidity and has a body temperature of 38°C. Upon further inquiry, she discloses that she has been treated twice before for similar symptoms and has been diagnosed with a complement deficiency. What is the most probable finding on the Gram stain of her cerebrospinal fluid (CSF)?

MRCP2-2664

A 46-year-old man presents to the general outpatient clinic after returning from a hiking trip in the Scottish Highlands. He reports feeling unwell with muscle aches, fatigue, and a mild headache. During the examination, a red papule with a clear patch of skin and a red ring is observed on the posterior aspect of his calf. The area is non-tender, and there is no warmth. The rest of the examination is normal.

What is the best initial course of action?

MRCP2-2665

A 38-year-old man presents to the Emergency Department with sudden onset of shortness of breath and pleuritic chest pain on the right side. He has a history of HIV and his latest CD4 count is 190/mm³. According to the last clinic letter, he may not be adhering to his anti-retroviral medication due to persistent diarrhea. Upon examination, there are decreased breath sounds on the right side with scattered fine crepitations in both lung fields. Oxygen saturation is 93% on room air. A chest x-ray shows a 1 cm pneumothorax on the right side at the hilum. What is the suspected pulmonary infection?