_Jjotw Telegram chamnel: = 2 PANE https://.me/DrThobanMohammed E.MAIL: Thoban.mrcp.up.to.date@gmail.com Hello Doctor .. MRCP & Medicine Lovers Now on your hand. Passmedicine question hank 2019 tor MRC part @ which contains the lastest guidelines so as to be updated in internal medicine which reflected in an excellent Knowledge, practices & skilles . Hope all to enjoy this materials Always Medicine is Medicine Dicass dont hesitate to comtnct me Chrongh man > Keihan send tk pou alll moantectinls wihiich meqmtined) Ror hONSP mt 3 To Best luck for all. De Thoban CldiedenyA 54 year old female is admitted with a severe pneumonia following a holiday in Turkey. Bloods reveal both hyponatraemia and deranged liver function tests. A chest x-ray shows patchy alveolar infiltrates with consolidation in the right lower lobe. Which one of the following investigations is most likely to confirm the probable diagnosis? Sputum culture Urinary antigen Blood cultures Bone marrow aspirate Lumbar puncture“Sputum culture od cultures my Bone marrow aspirate ! Lumbar punctureA 28-year-old man who has recently returned from Nigeria presents with a painful ulcer on his genitals. On examination, you note a ‘lem x 1cm ulcerated lesion with a ragged border. You also note tender lymphadenopathy in the groin What is the most likely causative organism? Herpes simplex virus Chlamydia trachomatis Treponema pallidum Haemophitus ducreyi Klebsiella granulomatisHerpes simplex virus ‘Chlamydia trachomatis id llidum Klebsiella granulomatis ap Chancroid causes painful genital ulcers Ser a eee ee eae The painful genital ulcer with a ragged border associated with tender inguinal lymphadenopathy points to chancroid. Chancroid is caused by Haemophilus ducreyi. Herpes simplex virus also causes painful genital ulcers, but they are generally smaller and multiple and primary attacks are often associated with fever. The other organisms are causes of painless genital ulcers: C. trachomatis causes lymphogranuloma venereum; T. pallidum causes syphilis; K. granulomatis causes granuloma inguinale.A 28-year-old lady is reviewed in a follow-up appointment at the sexual health clinic. Twelve months ago she was diagnosed with syphilis and was given intramuscular r to the follow-up appointment benzathine penicillin. Blood tests were taken a week p and the serology results are shown below: TPHA positive VDRL negative What is the most likely explanation for the serology results shown above? She has been re-infected and has developed syphilis She is HIV positive She is pregnant She has been successfully treated for syphilis She has been suboptimally treated for syphilisShe has been re-infected and has developed syphilis [ee positive id She is pregnant | se tcbeenscesy end erie : She has been suboptimally treated for syphilis 16% a ey 9 A a Q 8 tg Following treatment for syphilis: TPHA remains positive, VDRL becomes negative Important forme Less important VDRL becomes negative following treatment of syphilis, TPHA remains positive despite successful treatment of syphilis. Her serology is consistent with previous syphilis infection, for example after successful treatment. Therefore 4 is the correct answer. Options 1 and 5 suggest active infection with syphilis, in which case the VDRL would be positive. Options 2 and 3 are causes of a false-positive VDRL test, which would not explain the negative VDRL but positive TPHA in the question.A 65-year-old diabetic male patient presents with back pain and dysuria. MRI Pelvis shows evidence of prostatitis. He has a prolenged course of antibiotics to treat his prostatitis, however, at a follow-up visit he has been shown to be colonised with MRSA (methicillin- resistant Staphylacoccus aureus) Which of the following antibiotics is most likely to have contributed to this? Ciprofloxacin Trimethoprim Gentamicin Tobramycin Nitrofurantoinoi Gentamicin Tobramycin rr Nitrofurantoin erry Ciprofloxacin promotes acquisition of MRSA. Important forme Less important Although ciprofloxacin is not a beta-lactam antibiotic, its use is strongly linked to the acquisition of MRSA as with all quinolone antibiotics. The other choices are unlikely to lead to MRSA infection or colonisation.A young black African male recently moved from Zimbabwe presents with a skin lesion on his hand. On examination you note an ulceration with a black centre (eschar) with surrounding oedema, he says it is not painful. What is an important microbe to consider? Mycobacterium ulcerans Bacillus anthracis Strongyloides stercoralis Chikungunya virus Mycobacterium lepraeferium ulcerans Strongyloides stercoralis Chikungunya virus Mycobacterium leprae 16% Painless black eschar - anthrax Important forme Less important Classical description of a cutaneous manifestation of anthrax, caused by Bacillus anthracis. Zimbabwe had the largest known outbreak of more than 10,000 cases in the late 80's (Central African Journal of Medicine, 1996) Mycobacterium ulcerans usually presents as a painless nodule and progresses to an ulcer without an eschar. Strongyloides stercoralis is an helminth which is contracted through contact with soil containing the larvae and most commonly in the tropics and subtropics. Usually asymptomatic and raised eosinophils maybe the only indication. Chikungunya virus is contracted through infected mosquitos. Commonly present with myalgia, arthralgia and fevers. Mycobacterium leprae causes leprosy characterised by damages to peripheral nerves, skin and muscle.A 30-year-old man presents to the genito-urinary medicine clinic. He has been handed a slip from an ex-girlfriend stating she has tested positive for Chlamydia. He last slept with her 2 months ago. He has no symptoms of note, in particular no dysuria or discharge. What is the most appropriate management? Reassure symptoms would have presented by naw Offer antibiotic therapy Offer Chlamydia testing and antibiotic treatment immediately without waiting for the results Offer Chlamydia testing and antibiotic treatment if positive Notify public health| reas symptoms would have presented by now Offer antibiotic therapy 10% ep nt immediately without waiting for Offer Chlamydia testing and antibiotic treatment if positive 21% Notify public health cs Treatment is given on the basis of exposure to infection rather than proven infectionA 52-year-old man with a history of alcohol dependence is admitted with fever and feeling generally unwell. An admission chest x-ray shows consolidation in the right upper lobe with early cavitation. What is the most likely causative organism? Streptococcus pneumoniae Legionella pneumophilia Staphylococcus aureus Klebsiella pneumoniae Mycoplasma pneumoniae‘Streptococcus pneumoniae Legionella pneumophilia caccus aureus Mycoplasma pneumoniaeA 35-year-old male patient presents to the emergency department with fever and hypotension. He had returned 2 days previously from a business trip from India, which lasted 3 weeks. The patient had not sought any pre-travel advice and had not taken any malaria prophylaxis. The patient was pale and looked lethargic. His temperature was 38.5°C, oxygen saturations were 92% on air, blood pressure was 80/60 mmHg and heart rate was 135/min at initial presentation. A malaria rapid diagnostic kit had revealed a probable falciparum malaria. Which of the following options is most appropriate? Oral quinine IV quinine IV artesunate Doxycycline ClindamycinOral quinine IV quinine aD [a © Doxycycline a2 2 Clindamycin Quinine is no longer recommended as a first-line treatment for complicated/severe falciparum malaria Important forme Less. Whilst all the above options are potential antimalarial treatments, according to the UK malaria treatment guidelines 2016 Jiournal of Infection) IV artesunate is the first line treatment where available for complicated or severe malaria. The patient is shocked and this therefore suggests complicated malaria. Several trials have demonstrated benefit of IV artesunate over IV quinine for complicated falciparum malaria.A 24-year-old man with no past medical history is diagnosed with syphilis and the treatment is administered. An hour later he starts to develop a rash and you are called to review him. His heart rate is 120 beats per minute and his blood pressure is 96/62 mmHg. On auscultation of his chest, you notice a wheeze throughout. What is the most appropriate initial management? Give oral chlorphenamine Give an intravenous fluid bolus Reassure and discharge Give intramuscular adrenaline Monitor his observations every 30 minutesGive oral chlorphenamine Give an intravenous fluid bolus €D discharge frig Monitor his observations every 30 minutes ap The Jarisch-Herxheimer reaction, unlike an anaphylactic reaction, will not present with hypotension and wheeze Important forme Less imeortant The scenario is describing an anaphylactic reaction following the treatment for syphilis, probably due to an unknown penicillin allergy. He, therefore, requires treatment with intramuscular adrenaline in the first instance. The other options are therefore incorrect. It is important to distinguish anaphylactic reactions from the Jarisch-Herxheimer reaction, which can result in fever, tachycardia and rash following syphilis treatment. A Jarisch- Herxheimer reaction would not cause a wheeze and is unlikely to cause hypotension.‘A 28-year-old man who has recently emigrated from Nigeria presents with a penile ulcer. It initially started as a papule which later progressed to become a painful ulcer with an undermined ragged edge. Examination of the testes was unremarkable but tender inguinal lymphadenopathy was noted. What is the most likely diagnosis? Chancroid Lymphogranuloma venereum Syphilis Herpes simplex infection Granuloma inguinaleiis — ‘Herpes simplex infection ; Granuloma inguinale 08 8 ‘A diagnosis of chancroid is more likely than lymphogranuloma venereum as the ulcer is painful. Whilst herpes simplex is obviously more common the description of the ulcer is very characteristic of chancroid. Painful inguinal lymphadenopathy is present in around 50% of patients.A 29-year-old HIV positive man is admitted with right-sided hemiplegia. For the past four days he has been complaining of headache and flu-like symptoms. CT scan shows multiple ring enhancing lesions. A diagnosis of cerebral toxoplasmosis is suspected. What is the most suitable management? Artemether and lumefantrine Co-trimoxazole Supportive treatment Pyrimethamine and sulphadiazine Metronidazole and gentamicinA 29-year-old HIV positive man is admitted with right-sided hemiplegia. For the past four days he has been complaining of headache and flu-like symptoms. CT scan shows multiple ring enhancing lesions. A diagnosis of cerebral toxoplasmosis is suspected. What is the most suitable management? Artemether and lumefantrine Co-trimoxazole Supportive treatment Metronidazole and gentamicinA 35-year-old male patient presents to the emergency department with fever. He had returned 2 days previously from India on a business trip which lasted 3 weeks. The pati had not sought any pre-travel advice and had not taken any malaria prophylaxis. A malaria rapid diagnostic kit had revealed non-falciparum parasites, The patient received initial treatment for P. vivax malaria and was subsequently discharged. Which of the following is the most important next step in management? GOPD deficiency testing prior to administration of primaquine Lifelong quinine for malaria prophylaxis Mefloquine for 6 weeks No further treatment necessary Regular blood films to look for persistent parasitaemia| co nce rting orton minkbtrationrok primageine Lifelong quinine for malaria prophylaxis 0 | wetoaie to Sve _ No further treatment necessary reg Regular blood films to look for persistent parasitaemia Hypnozoite eradication is important to prevent relapsed P. vivax and P. ovale malaria Important for me Less important It is important to note that hypnozoites may persist in the liver with non-falciparum malaria, even after treatment. This could lead to relapsed malaria months or even years later. Primaquine is an important drug which can be used for eradication of hypnozoites. Primaquine should not be given to people with glucose-6- phosphate dehydrogenase (G6PD) deficiency due te the risk of haemolysis.A 25-year-old female primary school teacher presents to the emergency department with a rash and fever. She states that there have been a number of cases of slap cheek (parvovirus B19) infection at the school. Of the choices given, what is the most important consideration? Skin swab Arterial blood gas Pregnancy test Stool culture Sputum cultureSkin swab or rial bload gas @ Stool culture Sputum culture Parvovirus is a common cause of fetal hydrops during pregnancy and can be treated with fetal transfusion Important for me Less important ‘Erythema infectiosum’, ‘fifth disease’ and ‘slap cheek’ are the same condition which are all possible manifestations of parvovirus B19 infection. It is associated with fetal abnormalities and commonly causes a characteristic rash in children and in adults in can additionally cause arthralgia. Infection in a pregnant woman can lead to fetal hydrops and spontaneous miscarriage, particularly in the first trimester. This can be managed with the use of fetal blood transfusion. In patients with sick-cell disease, aplastic crisis may be precipitated by parvovirus. Immunecompromised individuals are also at risk.A 73-year-old man presents with worsening cellulitis. The nurse takes his observations which are the following a respiratory rate of 28/min, heart rate 110/min, blood pressure 100/70 mmHg and a temperature of 39.5°C. Blood cultures are taken and later reported as growing a gram positive, catalase and coagulase positive cocci. Which is the most likely organism? Streptococcus pyogenes Streptococcus viridans Staphylococcus aureus Clostridium difficile Staphylococcus epidermidisStreptococcus pyogenes 17% Streptococcus viridans stridium difficile ES Staphylococcus epidermidis er Staphylococcus aureus is a gram+ve bacterium, catalase +ve, coagulase +ve organism Important forme Leis mportant Answers 1, 2, 3, 5 are all gram positive cocci, 4 is a rod and so incorrect. Streptococcus viridans and Streptococcus pyogenes are both catalase negative. Staphylococcus epidermidis is catalase positive but coagulase negative. This therefore leaves Staphylococcus aureus as the answer.A 64-year-old man is admitted to the emergency department as his wife is concerned that he is becoming confused following a recent bad chest infection. She reports that he has not improved after a course of amoxicillin. On examination, his respiratory rate is 30/min, blood pressure 88/60 mmHg, heart rate 120/min. Crackles are noted on the right side of his chest. What is the most appropriate fluid therapy to give? 20 ml/kg stat 30 ml/kg stat 500ml stat 20 ml/kg aver 1 hour 10 ml/kg over 1 hour20 mi/kg stat stat 20 mi/kg over 1 hour 10 mi/kg over 1 hour This patient has a number of features of red flag sepsis, including the confusion, low bloed pressure and raised respiratory rate. The sepsis 6 should be started. In the NICE guidelines on sepsis the following recommendations are made with regards to fluid resuscitation: If patients over 16 years need intravenous fluid resuscitation, use crystalloids that contain sodium in the range 130-154 mmol(itre with a bolus of 500 ml over less than 15 minutes.A 25-year-old male patient is admitted to the emergency department following an assault in prison. On examination, the patient has suffered a bite which has broken the skin. Hepatitis B surface antibody is shown to be more than 100 mIU/ml and he admits to. previous vaccination against hepatitis B. Which of the following is the most appropriate next step in management? Hepatitis B immunoglobulin Antiretrovirals for post-exposure prophylaxis for HIV Antibiotics and tetanus booster Hepatitis B vaccination Hepatitis C vaccination[Beem on Antiretrovirals for post-exposure prophylaxis for HIV [9% ] Hepatitis B vaccination Hepatitis C vaccination @Q Post-exposure prophylaxis for HIV is not recemmended following human bites Importantforme Less important The hepatitis B surface antibody levels suggest adequate immunity and therefore negates the need for further hepatitis B vaccination er hepatitis 8 immunoglobulin. Post-exposure prophylaxis for HIV is not recommended follawing human bites. Estimated risk of HIV transmission fram a bite from a known HIV-positive individual not on anti- retroviral treatment is <1 in 10,000. (BASHH guidelines, UK guideline for the use of HIV Post-Exposure Prophylaxis Following Sexual Exposure, 2015) There is no current hepatitis C vaccination.A 22-year-old female presents with an offensive vaginal discharge. History and examination findings are consistent with a diagnosis of bacterial vaginosis. What is the most appropriate initial management? Oral azithromycin Topical hydrocortisone Oral metronidazole Clotrimazole pessary Advice regarding hygiene and cotton underwearical hydrocortisone | Clotrimazole pessary = regarding hygiene and cotton underwearAn 18-year-old male student presents to the emergency department with fever, headache and photophobia. On examination, he is pyrexial at 39°C and has observable neck stiffness. There is no evidence of rash and other than a recent ear infection, there is no other relevant past medical history Which of the following is the most appropriate intravenous treatment option? Benzylpenicil Ceftriaxone Ceftriaxone and dexamethasone Cefalexin AmoxicillinBenzylpenicillin Amoxicillin cs Cefalexin Q oe Dexamethasone improves outcomes in the treatment of bacterial meningitis. Important forme Less impotent The clinical picture is of possible bacterial meningitis. In this context ceftriaxone is clearly the correct antibiotic choice. It is important to note the use of dexamethasone when treating potential meningitis. Dexamethasone has been shown to improve outcomes with particular relevance to pneumococcal meningitis. It has shown in particular te prevent long-term hearing loss. Until the cause of the meningitis is known then dexamethasone should be initiated. The recent ear infection is a risk factor for pneumococcal meningitis. See British Infection Association guidelines on management of meningitis for further information.A 28-year-old man from Zimbabwe presents to the emergency department with a 2 week history of fever, cough, headache, vomiting and neck stiffness. He is known to be HIV positive and is on treatment. His most recent CD4 count was 450 cells/mm? On examination he has no focal neurological signs but appears drowsy and confused. You suspect meningitis and perform and lumbar puncture The results show: Opening pressure 25mm H20 Appearance cloudy, White cells 200 cells/mm? Cells 90% lymphocytes CSF protein 3a/t CSF glucose 1.1 mmol/L Blood glucose = 6.8 mm/L What is the most likely diagnosis? Meningococcal meningitis TB meningitis Cryptococcal meningitis Partially treated bacterial meningitis Herpes simplex meningitisMeningococcal meningitis > Cryptococcal meningitis [econ treated bacterial meningitis Herpes simplex meningitis The lymphocytic CSF with high protein and low glucose in this case could be due to both cryptococcal and TB meningitis, however the insidious onset of symptoms, very high protein and low glucose compared to the plasma glucose (<1/3 of plasma) points more towards TB meningitis. Also this man has a relatively high CD4 count.and only a mildly raised opening pressure which makes cryptococcal meningitis more unlikely. TB and HIV co-infection are common, especially in sub-Saharan Africa and should always be considered.Which one of the following is the most commen cause of visceral larva migrans? Cryptococcus neoformans Strongyloides stercoralis Visceral leishmaniasis Toxocara canis GiardiasisCryptococcus neoformans Visceral leishmaniasis GiardiasisA 31-year-old woman presents to the Emergency Department complaining of a headache. She has had ‘flu’ like symptoms for the past three days with the headache developing gradually yesterday. The headache is described as being ‘all aver’ and is worse on looking at bright light or when bending her neck. Gn examination her temperature is 38.2°, pulse 96 / min and blood pressure 116/78 mmHg. There is neck stiffness present but no focal neurological signs. On close inspection you notice a number of petechiae on her torso. She has been cannulated and bloods (including cultures) have been taken. What is the most appropriate next step? IV cefotaxime Arrange a CT head Perform a lumbar puncture IV dexamethasone Intramuscular benzypenicillinje a CT head Perform a lumbar puncture IV dexamethasone Intramuscular benzypenicillin This patient has meningecoccal meningitis. They need appropriate intravenous antibiotics immediately. With the advent of modern PCR diagnostic techniques there is no justification for delaying potentially lifesaving treatment by performing a lumbar puncture in patients with suspected meningococcal meningitis.A 24-year-old woman who is 18 weeks pregnant presents to the Emergency Department. Earlier on in the morning she came into contact with a child who has chickenpox. She is unsure if she had the condition herself as a child. What is the most appropriate action? Advise her to present within 24 hours of the rash developing for consideration of IV aciclovir Reassure her that there is no risk of fetal complications at this point in pregnancy Give varicella immunoglobulin ‘Check varicella antibodies Prescribe oral aciclovirvise her to present within 24 hours of the rash developing for consideration of aciclovir Reassure her that there is no risk of fetal complications at this point in pregnancy Give varicella immunoglobulin > Peescaue piace Q2 Chickenpox exposure in pregnancy - first step is to check antibodies — Important forme Less important If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodiesA 35-year-old man is reviewed in clinic having been diagnosed with HIV two years ago and is stable on anti-retroviral therapy. He has a new regular partner and is concerned about transmitting the disease to him. What factor is most likely to increase the risk of transmission? Circumcision Low CD4 count Co-infection with genital warts Diabetes Mucosal ulcerationCircumcision Co-infection with genital warts > oe > Diabetes The correct answer is mucosal ulceration. Ulceration | its barrier protection to HIV infection. A low CD4 count is not associated with increased transmission rate, but an increased HIV viral load. Genito-urinary infection can increase transmission rates but genital warts has not been shown to do so. Diabetes would increase the rates of bacterial and fungal infections but not viral ones. Circumcision is protective to HIV transmission. Source: ‘UK Guideline for the Use of HIV Post-Exposure Prophylaxis Following Sexual Exposure (PEPSE) 2015." BASHH. N.p., 2015.An 18-year-old man is bitten by a frantic dog whilst taking a gap year in Ecuador. He is worried about rabies and phones for advice. He was not immunised against prior to travelling te Ecuador. What is the most appropriate advice after thorough cleansing of the wound? Give human rabies immunoglobulin + full course of vaccination Give human rabies immunoglobulin + oral penicillin for the next 2 weeks Advise low risk but take oral co-amoxiclav for the dog bite Give human rabies immunoglobulin Give full course of vaccinationof vaccination feo bies immunoglobulin + oral penicillin for the next 2 weeks fd Advise low risk but take oral co-amoxiclav for the dog bite % Give human rabies immunoglobulin Give full course of vaccination 1% Rabies - following possible exposure give immunglobulin + vaccination” & Important forme Less meortantA 64-year-old woman presents to the Emergency Department with a cough, fever, diarthoea and myalgia. The cough is non-productive and and has been getting gradually worse since she returned from holiday in Spain one week ago. Her husband is concerned because over the past 24 hours she has become more drowsy and febrile. He initially thought she had the ‘flu but her symptoms have got progressively worse. She is normally fit and well but drinks around 20 units of alcohol per week. On examination pulse is 76/min, blood pressure 104/62 mmHg, oxygen saturations are 94% on room chest. and temperature is 38.4°C. Bilateral coarse crackles are heard in the Initial blood tests show the following: Hb 13.6 o/dl Platelets 311 * 109/1 WBC 14.2 = 10/1 Nat 131 mmol/! Ke 4.3 mmol/l Urea 9.2 mmol/l Creatinine 91 umol/l Bilirubin 12 wmol/l ALP 31u/l ALT 64u/! A chest x-ray shows patchy consolidation in the left lower zone with an associated pleural effusion. What is the most likely causative organism? Streptococcus pneumoniae Mycoplasma pneumoniae Legionella pneumophita Klebsiella pneumoniae Staphylococcus aureus