Archives: MRCP Part 2

MRCP2-4530

An 85-year-old man presents to the hospital with an infective exacerbation of COPD. He complains of increasing shortness of breath, dry cough, and an episode of rigors. Despite being started on salbutamol and ipratropium nebulisers and steroids, he fails to improve clinically. Non-invasive ventilation is offered and he tolerates it well, but 36 hours later, he starts to become more breathless. On examination, he has crackles and wheeze on the right hemithorax, and the left hemithorax has reduced air entry throughout. There are no added sounds, no JVP or leg oedema that can be seen, but there is accessory muscle use. He is tired and feels ‘absolutely awful’. The non-invasive ventilation is currently set at IPAP 26 cm H2O and EPAP 6 cm H2O. A repeat chest x-ray is pending.

What is the likely cause of this deterioration?

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?

MRCP2-4528

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?

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?

MRCP2-4509

A 62-year-old man with a 35 pack per year smoking history visits his doctor complaining of fatigue and difficulty concentrating, which is affecting his ability to work. His wife reports that he frequently falls asleep in front of the TV. During the examination, his heart rate is 86 bpm and his blood pressure is 140/92 mmHg. He has a normal cardiovascular exam, and mild expiratory wheezing is heard upon auscultation of the lungs, with oxygen saturation at 92%. He is 178 cm tall, weighs 118 kg, and has a neck circumference of 43 cm. What is the most appropriate treatment option?

MRCP2-4514

A 66-year-old man with a history of alcohol excess and CABG surgery presents to the hospital with acute, severe epigastric pain and vomiting. On examination, he has pyrexia, tachycardia, and hypotension, as well as upper abdominal tenderness with rebound and guarding. His initial blood gas reveals respiratory alkalosis and metabolic acidosis. He is treated with oxygen, fluids, antibiotics, and analgesia but deteriorates 24 hours later with increasing breathlessness and hypoxia. His repeat blood gas shows respiratory acidosis. What is the most likely cause of this deterioration?

MRCP2-4516

A 65-year-old man has been experiencing progressive dyspnoea for the past 2 years and has recently been diagnosed with idiopathic pulmonary fibrosis. His latest FVC reading shows that it is 55% of predicted. What is the typical life expectancy for a patient with this condition after being diagnosed?

MRCP2-4504

A 65-year-old man presents to the Respiratory Clinic for evaluation of his chronic obstructive pulmonary disease (COPD) symptoms. He has been referred by his primary care physician due to increasing shortness of breath. Despite his diagnosis, he continues to smoke ten cigarettes per day. He reports a history of childhood asthma and a positive response to oral steroids in the past. His most recent forced expiratory volume in 1 second (FEV1) is 40% of predicted, and he can only walk 50 m to the local bus stop. He currently takes a salbutamol inhaler as needed and carbocisteine. On examination, his blood pressure is 135/82 mmHg, pulse is 78 bpm and regular, and he has signs of right heart failure. What is the most appropriate intervention to decrease the risk of future exacerbations?

MRCP2-4515

A 57-year-old woman comes to the emergency department with chest pain and persistent cold symptoms for the past few weeks. The pain is located behind the breastbone, feels dull, has an intensity of around 3/10, and does not spread to other areas. Upon further questioning, the patient reports coughing up white phlegm with small traces of blood, which has worsened over the last two weeks.

The patient has been working with a group of geologists in the Mississippi river basin for the past two years. She has never smoked, does not own any pets, and has not traveled anywhere else.

During the examination, the patient has a fever of 38ºC, and there are crackling sounds in both lungs with increased vocal resonance and dullness when tapped at the bottom.

Troponin levels are at 3 ng/L (<14), and a chest x-ray shows airspace shadowing with consolidation affecting multiple lung segments. What is the most appropriate course of action?

MRCP2-4505

A 25-year-old man with a history of cystic fibrosis presents to the Respiratory Clinic for follow-up. He was hospitalized for a significant exacerbation 3 months ago and has been experiencing gradual weight loss since then. During the examination, you hear coarse crackles and wheezing in both lung fields. His blood pressure is 130/80 mmHg, and his heart rate is regular at 70/min. His fasting plasma glucose is 8.5 mmol/l, and his HbA1c is 53 mmol/mol. What is the most appropriate approach to managing his blood sugar?