Archives: MRCP Part 2

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?

MRCP2-4529

A 35-year-old South American woman presents to her primary care physician with a persistent cough. She reports experiencing fever, night sweats, and weight loss for the past 10 months. She also mentions that her sputum has been occasionally blood-stained. Her medical history is unremarkable, but she has been a smoker for the past 10 years. On examination, her BMI is 18, and she has a temperature of 38°C. There are non-specific wheezes and occasional crackles on auscultation. What would be the most appropriate initial investigation in this case?

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?

MRCP2-4504

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?

MRCP2-4505

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?

MRCP2-4508

A 55-year-old male patient with a 35 pack-year smoking history visits his GP complaining of constant daytime sleepiness, which is affecting his ability to work. Upon examination, he measures 178 cm in height, weighs 118 kg, and has a neck circumference of 42 cm. Following sleep studies, he is diagnosed with moderate to severe obstructive sleep apnoea (OSA) due to hypnoea/apnoea episodes. What is the best course of treatment?

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?

MRCP2-4515

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?