Archives: MRCP Part 2

MRCP2-4518

A 56-year-old male presents to the respiratory clinic with a dry cough and progressive shortness of breath. He has no significant medical history or exposure to environmental triggers and is a non-smoker who does not take any medications. Upon examination, bibasal inspiratory crackles and clubbing are noted, but there are no signs of cardiac failure. His current oxygen saturation level is 94% on air, and his last appointment revealed a known FVC of 70%. Pulmonary function testing shows a restrictive pattern, and a high resolution CT scan reveals bilateral lung volume loss with >5% honeycombing extensively at the bases and subpleural areas with evidence of peripheral traction bronchiectasis, extensively at the lung bases. Blood investigations for connective tissue disease have been negative. The patient has already been referred for pulmonary rehabilitation but is interested in knowing if any medication can potentially alter the course of his disease. What medication can be used to reduce functional decline in this patient population?

MRCP2-4519

A 48-year-old woman presents with a one-year history of joint pain and an intermittent purpuric rash. For the last 4 months, she feels more fatigued than usual with malaise, fever and intermittent abdominal pain. She had an appendectomy 9 years ago. Besides that, there is no past medical history of significance.

On clinical examination, the only abnormality is a purpuric rash involving her calves and thighs.

The results of initial investigations showed a normal full blood count, but impaired renal function with a plasma creatinine of 160 µmol/l.

Another set of investigations were ordered to reach a diagnosis:

Na+ 135 mmol/l
K+ 4 mmol/l
Creatinine 165 µmol/l
Urea 11 mmol/l
CRP 50 mg/l
ESR 70 mm/hr
Urine analysis Protein +,RBCs ++
Rheumatoid factor negative
C3 and C4 levels normal
cANCA positive
pANCA positive
ANA negative

Renal biopsy showed focal necrosis, crescent formation, and absence of immunoglobulin deposits on immunofluorescence.

What is the most likely diagnosis?

MRCP2-4520

A 47-year-old man presents to the emergency department with progressive shortness of breath. He is a Saudi Arabian national who arrived in the UK for a business trip three days ago. Over the past two days, he has experienced a dry cough, runny nose, myalgia, and fever. He denies any history of productive cough, haemoptysis, or gastrointestinal symptoms. The patient has type 2 diabetes mellitus and hypertension, which are controlled with metformin and captopril. He denies any contact with domestic animals or unwell contacts.

On examination, the patient appears unwell and diaphoretic. His respiratory rate is mildly elevated, and his oxygen saturation is low. Chest x-ray shows no focal consolidation or mass lesions. Nasopharyngeal swab RT-PCR detects MERS-CoV RNA.

What is the appropriate medical management for this patient’s condition?

MRCP2-4521

A 55-year-old male presents to the respiratory clinic with a three-month history of weight loss, drenching night sweats, and a productive cough. He reports producing approximately 1 cup of green sputum daily and has lost 4 kgs during this time. He has a 40-year history of smoking 20 cigarettes a day and last traveled abroad 2 years ago to visit family in North America.

The GP has conducted routine blood tests, which are unremarkable, and a negative HIV test. Several sputum samples have been sent for routine microscopy, culture & sensitivities (MC&S), growing only normal respiratory flora. After a normal chest X-ray, a high-resolution CT (HRCT) scan is performed, revealing right middle lobe and left lower lobe bronchiectasis with multiple nodules in both lungs.

What other initial investigations would you conduct to aid in reaching a diagnosis?

MRCP2-4522

A 78-year-old man presents to clinic with shortness of breath. This has been progressing over the last 12 months and is associated with a non-productive cough. He is still able to complete his usual day-to-day tasks but struggles with more exertional activities such as walking uphill.

He finished chemotherapy for non-Hodgkin’s lymphoma three years ago. He has no other relevant medical history.

His current medications include allopurinol, bisoprolol, aspirin, simvastatin, paracetamol and codeine.

On examination, he has finger clubbing and diffuse fine crackles on chest auscultation.

Given the likely diagnosis, which of the following spirometry results would you expect?

MRCP2-4523

A 70 year-old man has been referred to the chest clinic by his General Practitioner (GP). The patient reports a 2-year history of cough and increasing shortness of breath. The GP had prescribed several courses of antibiotics and steroids, but the symptoms persisted. The patient is a non-smoker, does not consume alcohol, and is not taking any regular medications. The cough produces purulent sputum with occasional streaks of blood. The patient experiences lethargy but denies weight loss or fever. The patient’s family is healthy, and the only significant medical history is an episode of childhood pneumonia.

During respiratory examination, bilateral crackles were heard, but no other added sounds were noted. The patient was not clubbed.

A chest x-ray, ordered by the GP, revealed minor bilateral atelectasis and opacities.

What is the most suitable diagnostic test?

MRCP2-4524

A 23-year-old agricultural student presents to the respiratory clinic with a persistent cough, shortness of breath, fatigue, and a recent weight loss of 2 kg over the past 6 weeks. Upon examination, bilateral wheezing and crackles are detected. Despite two courses of antibiotics and a salbutamol inhaler prescribed by his GP, there has been no significant improvement in his condition. However, a short course of oral prednisolone provided some relief. The patient denies experiencing any fever, coughing up blood, traveling abroad, or being exposed to tuberculosis. Additionally, he has never smoked.

A chest radiograph reveals fine nodular shadowing in the mid to upper zones of both lungs. Lung function tests show a forced vital capacity (FVC) of 70% and an FEV1/FVC ratio of 85% predicted. Blood tests indicate a CRP level of 3 mg/l and an ESR of 45mm/hr.

What is the most probable diagnosis for this patient?

MRCP2-4526

A 13-year-old girl with a known nut allergy was brought to the Emergency department after accidentally eating a peanut butter sandwich.

Upon examination, she displayed audible wheezing and appeared to be struggling to breathe. Her blood pressure was 80/60 mmHg, oxygen saturation was 88% on room air, and her respiratory rate was 28 breaths per minute. Her pulse was weak.

What is the best course of immediate action for this patient?

MRCP2-4527

A 72-year-old man is receiving treatment for an empyema in a medical ward. Following the insertion of a chest drain under ultrasound guidance and the initiation of antibiotics, there has been a marked improvement in his clinical condition.

During the daily morning ward round, the medical team reviews the chest drain and notes that it is on suction. However, there has been minimal drainage output over the past 24 hours, and bubbling is observed when the patient coughs.

What is the significance of this bubbling?

MRCP2-4528

A 77-year-old female presents to the Emergency Department with confusion, nausea and vomiting. She has been generally unwell with fatigue, weakness and fevers for 3 weeks. On examination her respiratory rate is 25/min, oxygen saturations are 97% on 4 litres of oxygen, blood pressure 105/70 mmHg, pulse 118/min and temperature is 36.4oC. Her airway is patent and crepitations are present at both bases. There are crusting lesions beneath both nostrils, the pulse is thready and regular, heart sounds are normal and her abdomen is soft non-tender. Electrocardiogram shows a sinus tachycardia and urine dip showed 3+ blood and protein. Arterial blood gas on 4 litres of oxygen is as follows:

pH 7.35
pO2 7.79 kPa
pCO2 3.52 kPa
Bicarbonate 17 mmol/l
Base Excess -6.9 mmol/l
Lactate 4.5 mmol/l

Venous blood analysis is as follows:

Hb 118 g/l Na+ 129 mmol/l
Platelets 511 * 109/l K+ 6.2 mmol/l
WBC 19.1 * 109/l Urea 42.1 mmol/l
Neuts 17.2 * 109/l Creatinine 497 µmol/l
Lymphs 1.8 * 109/l CRP 241 mg/l
Eosin 0.04 * 109/l

The patient was resuscitated with fluids and antibiotics although the full septic screen was negative and renal function remained poor. ANA and cANCA pattern were positive with PR3 antibodies found and the renal team were involved. What is the most likely underlying diagnosis?