Archives: MRCP Part 2

MRCP2-2559

A 42-year-old man presents with a 1 day history of fever. He returned to the UK 10 days ago after visiting his family in northern Uganda. He has been resident in the UK for the last 18 years and returns home on average once a year. He does not routinely take malaria prophylaxis.

On examination his temperature is 39.4ºC, pulse is 86 beats per minute, his blood pressure is 115/78 mmHg and his oxygen saturations are 98% on air. The remainder of the physical examination is normal. A thick and thin blood film are sent to the lab which confirms Plasmodium falciparum malaria. The report reads 2.1% parasitaemia with the presence of schizonts.

What would be the most appropriate initial management approach?

MRCP2-2560

A 27-year-old woman presents to the Emergency department some 2 weeks after returning from her honeymoon in Bali. Since returning she has suffered from intermittent abdominal bloating and diarrhoea and feels she has lost a little weight. Physical examination reveals a blood pressure of 118/82 mmHg, and her pulse is 70 and regular. There is mild abdominal distension and her body mass index is 22 kg/m².

Investigations:

Hb 110 g/l Na+ 138 mmol/l
Platelets 210 * 109/l K+ 4.0 mmol/l
WBC 11.2 * 109/l Urea 6.9 mmol/l
Neuts 8.1 * 109/l Creatinine 89 µmol/l
Lymphs 1.5 * 109/l CRP 82 mg/l
Albumin 34 g/l

What is the most appropriate course of action for this patient?

MRCP2-2561

A 33-year-old woman presents to the emergency department with severe generalised headache, a stiff and painful neck, photophobia, and fever. She moved to the UK from India 8 years ago and works as a nurse in the hospital. Her husband reports she has been confused and drowsy since that morning. She has no significant medical history except for a caseating granuloma found in her groin lymph nodes 4 years ago, which was not followed up.

Investigations reveal a clear chest x-ray, but blood tests show elevated white cells and CRP levels. Her CSF appears turbid with high protein and white cell counts, low glucose, and high lactate levels. Gram stain and PCR results are pending.

What is the most appropriate treatment plan for this patient?

MRCP2-2562

A 75-year-old man presents from a nursing home with a one-day history of fevers, drowsiness and vomiting. He has been unwell, not eating for the past 3 days according to his carer. Recently he has been exhibiting behavioural changes, crying and agitation when lights are turned on in the room, and holding his neck. He has a background of Alzheimer’s dementia, hypertension, congestive cardiac failure(CCF) and chronic kidney disease.

On examination, he is febrile with a temperature of 38.1oC. Heart rate 112 bpm, respiratory rate 20 breaths per minute and oxygen saturations of 94% on air. On auscultation, there are bibasal crepitations and cardiovascular examination is consistent with mild CCF. There is neck stiffness and photophobia on cranial nerve examination, pupils equal and reactive to light. Kernig’s sign is positive.

Investigations:

Na+ 129 mmol/l
K+ 4.8 mmol/l
Urea 10.9 mmol/l
Creatinine 123 µmol/l
Serum glucose 5.9mmol/l
C Reactive protein 95 mg/l
Haemoglobin 126 g/l
White cell count 16.4 x 10^9/L
INR 1.2

Cerebro-spinal fluid (CSF) analysis:

Opening pressure 25 cmH20
Protein 1.8 g/L
Glucose 2.6 mmol/l
White cell count >1000 per mm³
Gram Stain Gram-positive rods seen
Colour Cloudy, turbid

What is the likely causative organism?

MRCP2-2563

A 20-year-old man visits the Sexual Health clinic for a routine check-up. He identifies as homosexual and admits to engaging in unprotected sexual activity with multiple partners over the past three months. He does not have a regular partner at the moment. He reports feeling generally healthy, aside from a recent cold he had six weeks ago.

During his visit, he undergoes an HIV test which comes back positive. Further investigations reveal a CD4 count of 0.67×10^9/L (normal range: 0.3 – 1.4), a CD8 count of 1.35×10^9/L (normal range: 0.2 – 0.9), and a viral load of 24,378 (with less than 20 being undetectable).

What is the appropriate course of action for managing this patient?

MRCP2-2564

A 31-year-old woman presents to the infectious diseases clinic for an urgent review. She had been to the emergency department the previous weekend with constitutional symptoms and was found to have positive blood cultures. On review, she reports a 3-week history of intermittent fever, malaise, and reduced appetite, with occasional excessive sweating. She denies joint pains and other symptoms. She had recently returned from a trip to Turkey where she consumed unpasteurized dairy products. On examination, she has hepatosplenomegaly. Investigations show low white cell count, elevated alkaline phosphatase, and positive blood cultures for Brucella species. The patient strongly prefers outpatient treatment. What is the appropriate treatment regimen?

MRCP2-2565

A 19-year-old backpacker returns from a two-month trip to central and southeast Asia, where he stayed in hostels and on farms. He presents to the emergency department four weeks after his return with symptoms of myalgia, weakness, and a fever that has been ongoing for eight weeks. Blood tests reveal abnormal results, including elevated bilirubin, alanine aminotransferase, and alkaline phosphatase levels, as well as low platelet count. After six weeks of incubation, blood cultures grow coccobacilli. What is the most likely diagnosis?

MRCP2-2566

A 50-year-old male with type 2 diabetes presents with a one-day history of swelling, heat, and exquisite pain in his big toe and foot. He also reports feeling unwell with a fever and reduced appetite. He has a history of stage 2 chronic kidney disease. On examination, there is erythema and swelling of the affected area, but no skin breaks or joint immobility. Blood tests show neutrophilia, a C-Reactive Protein of 200, and a White Blood Count of 12.4. He has a temperature of 38.4°C and a heart rate of 120 BPM. What is the recommended initial treatment for his probable diagnosis?

MRCP2-2567

You are evaluating a 32-year-old woman with HIV in your clinic. Her CD4 count is 90 cells/μL. During the review of systems, she reports experiencing unusual vaginal bleeding. She had a regular Pap smear 2 years ago. What steps would you take next to address this issue?

MRCP2-2536

A 25-year-old medical student presented to hospital four weeks after returning from a two month elective period in Africa. She gave a ten day history of a non-productive cough and a fever. She had seen her general practitioner the previous day and had been started on a course of amoxicillin.

She had spent her elective in Tanzania, but had also spent time travelling in Uganda and Rwanda. She developed a febrile illness with diarrhoea two weeks before returning to the United Kingdom and was seen by a doctor in Uganda and prescribed a course of metronidazole for presumed amoebiasis and her symptoms settled within three days. There was no other past history of note.

On examination she was febrile (38.7°C) and an urticarial rash was visible over the trunk. There was no palpable lymphadenopathy. Her pulse was 95 beats per minute in sinus rhythm and blood pressure 120/70 mmHg. Her chest was clear. Her abdomen was soft and slightly tender in the right hypochondrium, where the tip of the liver could be palpated.

Investigations showed:
Haemoglobin 130 g/L (120-160)
White cell count 8.5 ×109/L (4.0-11.0)
Neutrophils 4.8 ×109/L (1.5-7.0)
Lymphocytes 2.0 ×109/L (1.5-4.0)
Monocytes 0.2 ×109/L (<0.8)
Eosinophils 1.3 ×109/L (0.04-0.4)
Basophils 0.1 ×109/L (<0.1)
Platelets 300 ×109/L (150-400)

Chest x ray: Normal –
Amoebic serology: Negative –

What is the most likely diagnosis?