Archives: MRCP Part 2

MRCP2-2636

You are requested to assess a 75-year-old woman who is currently admitted to an orthopaedic ward. The patient was admitted three weeks ago with a transtrochanteric fracture of her left hip and was readmitted two days ago due to increased pain in the hip and a fever. A joint aspiration confirmed an infection in the hip prosthesis, which was surgically excised, and the patient was started on intravenous clindamycin. This morning, the orthopaedic team noticed that the patient’s level of consciousness has decreased, and she has been experiencing profuse diarrhea since yesterday. The patient has no significant medical history except for osteoporosis, and she was fully conscious until yesterday. On examination, the patient appears frail, drowsy, and apathetic with a Glasgow Coma Scale (GCS) score of 12/15. She is clinically dehydrated, and her heart sounds are normal, with a weak, thready pulse of over 100 beats per minute. The ward’s blood pressure monitor records her blood pressure as 75/50, and her temperature is 35.7°C. What is the likely cause of the patient’s decreased level of consciousness?

MRCP2-2637

A 32-year-old woman returned from a 2-week vacation in Thailand 14 days ago. She presents with a 72-hour history of fever, body aches, headache, dry cough, and diarrhea.

Upon examination, she is febrile and has hepatosplenomegaly but no other significant findings.

Lab results show:
– Hemoglobin (Hb): 110 g/L (normal range: 120-160 g/L)
– Platelets (PLT): 170 x 10^9/L (normal range: 150-400 x 10^9/L)
– White cell count (WCC): 2.5 x 10^9/L (normal range: 4.0-11.0 x 10^9/L)
– Alanine aminotransferase (ALT): 150 IU/L (normal range: 5-30 IU/L)
– Gamma-glutamyl transferase (γGT): 130 IU/L (normal range: 5-30 IU/L)
– Alkaline phosphatase (ALP): 280 IU/L (normal range: 30-130 IU/L)
– Bilirubin: 18 µmol/L (normal range: 2-17 µmol/L)
– Albumin: 30 g/L (normal range: 35-55 g/L)

Malaria test is negative, and blood cultures reveal the presence of Gram-negative rods.

What is the most likely infectious agent responsible for her symptoms?

MRCP2-2638

A 67-year-old man with a history of chronic lymphocytic leukemia (CLL) presents to the Hematology Clinic complaining of increasing fatigue over the past 6 months. He is normally active, playing golf three times a week, but has not been able to play recently and has started napping in the afternoons. On examination, he has marked lymphadenopathy, mild upper abdominal tenderness, and a palpable spleen and liver. His recent blood work shows a WBC count of 30.4 * 109/l with a lymphocyte count of 23.1 * 109/l, up from 15.3 * 109/l two months ago. The decision is made to start the patient on FCR chemotherapy. What prophylactic medication is most important to start?

MRCP2-2639

A 42-year-old male patient comes to you complaining of fatigue and fever. He recently returned from a vacation in Costa Maya, Mexico, two weeks ago. He denies having any cough, diarrhea, or vomiting, and has not been in contact with any known infectious individuals. During the examination, his blood pressure is 140/98, and his heart rate is 52 beats per minute. You suspect that he may have Salmonella typhi. Which oral antibiotic would be the most appropriate to start treatment?

MRCP2-2640

A 28-year-old Caucasian man with poorly controlled HIV (recent CD4 count of 113 cells/mm3) and a negative Mantoux test presents for routine testing after his father (whom he lives with) was diagnosed with active pulmonary disease. He shows no features of active disease and on examination, his chest is clear with no overt lymphadenopathy. His vital signs are stable with a blood pressure of 132/91 mmHg, heart rate of 85 beats per minute, respiratory rate of 14 breaths per minute, oxygen saturation of 96% on air, and temperature of 36.8°C.

What is the recommended next step?

MRCP2-2611

A 68-year-old woman presents with a febrile illness lasting one week. She was prescribed amoxicillin for cough and right-sided pleuritic pain but did not finish the course. She developed a severe headache and increased confusion one day ago. She has a history of diabetes mellitus managed with metformin and sitagliptin. On examination, she has herpes labialis, a BP of 100/80 mmHg, and a regular pulse of 88. She is pyrexial with a temperature of 38.8 °C. Her GCS is 13, and there is neck stiffness and meningism. Fundi are not visible. Basal crackles are heard at the right lung base. What is the most likely cause of the lung findings in this 68-year-old woman?

MRCP2-2612

A 42-year-old woman presented to the clinic complaining of breathlessness, wheezing, and fatigue that had been ongoing for the past 6 months. She had recently returned to the United Kingdom after spending 8 months in rural areas of Zanzibar, where she swam in lakes and walked around barefoot. During her trip, she experienced vague abdominal discomfort for 2 months, which resolved after taking a prescribed tablet. On examination, her pulse was 80 bpm, and her respiratory rate was 20 breaths/min at rest, increasing to 28 breaths/min on walking 40 m. She appeared pale, and auscultation of the chest revealed scattered wheezing. Further investigations showed a low haemoglobin level, low mean corpuscular volume, and elevated platelet count. What is the most likely diagnosis?

MRCP2-2613

A 49-year-old male presents to the emergency department with joint pains and rash developing over 48 hours. He describes feeling weak and tired with headaches, myalgia, and lumbar back pain.

Examination reveals painful tender distal inter-phalangeal (DIP) joints and tender wrists in a symmetric distribution. He tells you the pain is worse in the morning and improves throughout the day. He has an erythematous maculopapular rash involving his torso and upper limbs with multiple insect bites. During your assessment, he develops a fever of 39.7°C. His chest is clear on auscultation. There is no palpable lymphadenopathy. He denies any nausea, vomiting, or diarrhoea.

His medical history includes asthma, obstructive sleep apnoea, and depression. He tells you he returned from a family holiday in Mexico 5 days earlier.

Blood tests:

Hb 148g/L Male: (135-180)
Female: (115 – 160)
Platelets 98* 109/L (150 – 400)
WBC 7.8* 109/L (4.0 – 11.0)
Neuts 6.8* 109/L (2.0 – 7.0)
Lymphs 0.2* 109/L (1.0 – 3.5)
Mono 0.6* 109/L (0.2 – 0.8)
Eosin 0.2* 109/L (0.0 – 0.4)
Urea 6.8 mmol/L (2.0 – 7.0)
Creatinine 128 µmol/L (55 – 120)
CRP 24 mg/L (< 5) What is the most likely cause of this man’s presentation?

MRCP2-2614

A 30-year-old man presents with a 2-week history of pus and blood mixed in his stool with severe rectal pain, especially on defaecation. He is HIV positive and is on antiretroviral therapy. He had several episodes of unprotected receptive anal sex with new partners in the preceding 6 months.

On examination, his temperature is 37.8 °C, and pulse rate is 95 beats/min. The abdomen is soft with some mild lower abdominal discomfort. Per rectal examination is very painful and reveals some blood mixed in with stool. There are large, tender inguinal lymph nodes. Proctoscopy is attempted but is too painful.

Investigations:
Investigation Result Normal Values
CD4+ 410 × 106/l 430 – 1690 × 106/l
HIV viral load Undetectable (lower detection limit 40 copies/ml)

What is the most likely diagnosis?

MRCP2-2615

A 35-year-old woman presents with a 2-week history of increasing breathlessness, dry cough and joint swelling. She has a painful left ear and when she breathes in she has sharp stabbing pains on the right side of her chest. She is also concerned about a rash that has started on both her arms and legs which burns her but is not itchy. She smokes 20 cigarettes a day and her mother died of lung cancer at the age of 43 years.

On examination, she is febrile, with a temperature of 38.2 °C, respiration rate 20/min on exertion and her saturation is 94% on room air. She has symmetrical, mucocutaneous lesions, with concentric colour changes in most lesions. She has an erythematous left ear and occipital lymphadenopathy. She has coarse inspiratory crackles in the right lung mid-zone.

Investigations reveal the following:

Haemoglobin (Hb) 93 g/l 115–155 g/l

White cell count (WCC) 16.2 × 109/l 4.0–11.0 × 109/l

Mean corpuscular volume (MCV) 84.6 fl 76–98 fl

Sodium (Na+) 131 mmol/l 135–145 mmol/l

Urea 6.3 mmol/l 2.5–6.5 mmol/l

Creatinine (Cr) 93 µmol/l 50–120 µmol/l

Alanine aminotransferase (ALT) 135 IU/l 5–30 IU/l

What is the most likely diagnosis?