A 23-year-old woman presents at 16 weeks of pregnancy with complaints of myalgia, sore throat, and coryza. She has a fever of 38.1 and works at a nursing home that is currently closed due to an influenza A outbreak. Upon further questioning, she reveals that she has been experiencing morning sickness for the past 8 weeks and is unable to take oral medication. On examination, her chest is clear, but she has an erythematous oropharynx without exudate. A chest X-ray shows no abnormalities. Besides notifying the obstetrics team, what would be your approach to managing this patient?
MRCP2-2627
A 29-year-old man presents to the Medical Admissions Unit with a 2-day history of abdominal distension, right upper quadrant pain, and itching. The pain started as a dull ache but became constant and severe over several hours.
The patient has a history of left lower limb DVT at age 20 but takes no regular medications, is a non-smoker, and drinks 2-3 units of alcohol per week. He denies intravenous drug use.
On examination, the patient appears jaundiced with pale conjunctiva and is visibly uncomfortable. His abdomen is moderately distended with marked tenderness in the right upper quadrant. The liver and spleen are palpable 2 cm below the costal margin, and shifting dullness is present on percussion of the abdomen.
Blood tests reveal anemia, elevated bilirubin, ALP, ALT, and γGT, and low albumin. The patient’s abdominal ultrasound scan is consistent with hepatic vein thrombosis, and he is started on low molecular weight heparin. After a review by the Haematologists, the patient is diagnosed with paroxysmal nocturnal hemoglobinuria and advised to start treatment with eculizumab.
Based on the proposed treatment strategy, which vaccinations should be offered to this 29-year-old patient?
MRCP2-2628
A 50-year-old male has been on HAART for four years. He presents to your clinic with a concern about breast swelling and tenderness, but is asymptomatic otherwise. Can you identify which medication in his regimen may be the cause of these symptoms?
MRCP2-2629
A 45-year-old man presents with fever, dry cough, headache, abdominal pain, and diarrhea. He had been experiencing intermittent fevers and night sweats for the past two weeks. In the last three days, he developed abdominal pain, watery diarrhea, and a dry cough. He also noted constipation prior to this, having only had one bowel movement in three days despite eating a large amount of fruit from market stalls in South Korea where he recently traveled for business.
Upon examination, the patient was jaundiced, had a rash on his chest, and had tender hepatomegaly. His vital signs were as follows: temperature of 40.1ºC, heart rate of 38/min, regular rhythm, and blood pressure of 130/90 mmHg. An ECG showed sinus bradycardia.
What diagnostic tests would you order to determine the patient’s diagnosis?
MRCP2-2630
A 65-year-old woman complains of lower abdominal pain, dysuria, and frequent urination. Upon urine dip, nitrites and leukocytes were detected. She has a medical history of recurrent C.difficile infection and has undergone two tapering courses of vancomycin treatment.
The microbiology report reveals the presence of Vancomycin Resistant Enterococcus (VRE) in her urine culture. What would be your approach to managing this patient?
MRCP2-2631
A 50-year-old man comes to the clinic complaining of sudden scrotal swelling and dysuria. Upon examination, there is noticeable redness, swelling, and tenderness on one side of the scrotum. The patient denies any recent injuries but has had recurring urinary tract infections.
What is the best immediate course of treatment?
MRCP2-2632
A 46-year-old man presents to the dermatology clinic with erythema migrans on his left calf, which he noticed within the last 24 hours. He is concerned about the possibility of having contracted Lyme disease during his recent walking holiday in the Scottish highlands. The patient denies any other symptoms and has a past medical history of hypertension treated with ramipril.
On examination, a circular erythematous rash 15 cm in diameter is observed on the patient’s left leg, with an appearance typical for erythema migrans. The rash has expanded significantly in the past 24 hours. No other significant rashes are identified, and examination of the nervous, cardiovascular, respiratory, and abdominal systems is unremarkable. There is no palpable lymphadenopathy.
What is the appropriate management for this patient’s erythema migrans?
MRCP2-2633
A 99-year-old woman is admitted with a fever and confusion and is initially treated with broad spectrum antibiotics. Despite five days of treatment, her temperature remains at 38.9°C and her condition appears to have worsened. She has no significant medical history. A urine culture confirms the presence of an extended spectrum B-lactamase (ESBL) producing Escherichia coli (E. coli), confirming a diagnosis of urinary tract infection (UTI).
Given the failure of the initial treatment, what antibiotic is most likely to be effective?
MRCP2-2634
A 42-year-old HIV positive patient attends a routine outpatient appointment. Two years ago, he was diagnosed with HIV disease after presenting with Pneumocystis jirovecii pneumonia (PCP) and a CD4 T-lymphocyte count of 40 cells/mm3. He was started on combination antiretroviral therapy and responded well, with an increase in his CD4 count (210 cells/mm3) and achieving an undetectable HIV viral load in the peripheral blood. However, one year ago, his CD4 count started to fall and HIV RNA became detectable in peripheral blood. An HIV viral resistance test confirmed resistance to all of his antiretroviral drugs, and he admitted to only taking his therapy intermittently. Despite the risks, he decided not to have any further antiviral therapy. His CD4 count was 20 cells/mm3 with a very high HIV viral load of 120,000 copies/ml. Seven months ago, he presented with malaise, weight loss (8 kg), fevers, and night sweats, and was diagnosed with Mycobacterium avium intracellulare (MAI) and started on therapy with ethambutol and rifabutin. He subsequently agreed to re-start antiretroviral therapy. During his clinic consultation, he reports a steady deterioration in his visual acuity over the past four weeks. His current medications include stavudine (d4T), didanosine (ddI), nevirapine, ethambutol, and rifabutin. On examination, fundoscopy is normal. His last CD4 count, taken one month ago, was 30 cells/mm3, with an HIV viral load of 2500 copies/ml. What is the most likely cause of his reduction in visual acuity?
MRCP2-2635
A 30-year-old man presents to the emergency department with three days of headache, fever, diarrhoea and malaise. He has recently returned from Angola, where he was studying the behavior of chimpanzees. He has no past medical history and is on no regular medications. He works as a primatologist for a research institute.
His observations are heart rate 124 beats per minute, respiratory rate 21/minute, blood pressure 85/54 mmHg, oxygen saturations 96% on room and air and temperature 39.3ºC.
Clinical examination reveals an unwell man. His capillary refill time is four seconds and his skin turgor is increased. He is oozing blood from his mucous membranes. Chest auscultation is normal. Heart sounds are normal with no murmurs. His abdomen is soft, diffusely tender but not peritonitic.
Intravenous access is obtained and intravenous fluids and empirical broad-spectrum antibiotics are administered. It is noted that he is oozing blood from his cannulae sites.