Archives: MRCP Part 2

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?

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?

MRCP2-4508

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?

MRCP2-4513

A 60-year-old man with a 40 pack/year history comes to the clinic complaining of cough and haemoptysis. Upon examination, a chest x-ray reveals a cavitating mass in the right hilar region. Further tests, including bronchoscopy and biopsy, confirm the diagnosis of bronchial carcinoma. Additionally, the patient’s calcium levels are found to be 3.89, and the parathyroid hormone related peptide (PTHrH) is elevated. Based on these findings, what is the most probable histological diagnosis?

MRCP2-4507

A 48-year-old hotel cleaner presents with a fever of 39°C, malaise and myalgia followed by the development of a dry and non-productive cough. Other non-specific symptoms include headache, anorexia, nausea and non-specific abdominal pain. Positive findings on general examination include tachycardia, tachypnoea and bibasal crackles on auscultation of the chest. The CXR shows early bibasal consolidation. Blood investigations show hyponatraemia and deranged LFTs, and urine testing shows the presence of protein and blood.

What is the most appropriate initial antibiotic regimen for this patient?

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?

MRCP2-4501

A 49-year-old patient presents with a two-day history of worsening breathlessness and productive cough with purulent sputum. The patient has been smoking 20 cigarettes a day since the age of 18 and was recently diagnosed with chronic obstructive pulmonary disease by their general practitioner. This is the patient’s first hospital admission. On examination, the patient is alert and oriented but cyanosed with a respiratory rate of 26 breaths per minute. The patient’s temperature is 37.8°C, pulse is 100/minute, and blood pressure is 150/100 mmHg. Bilaterally reduced air entry is noted on chest auscultation, and the chest radiograph shows hyperinflated lung fields with a normal heart size and no pneumonic consolidation. Arterial blood gases on admission with 24% oxygen by nasal cannulae reveal a pH of 7.34, pO2 of 6.5 kPa, pCO2 of 6.8 kPa, and standard bicarbonate of 27 mmol/L. Nebulised bronchodilators are administered, and the FIO2 is increased to 28%. Repeat arterial blood gases after 30 minutes show a pH of 7.30, pO2 of 7.0 kPa, pCO2 of 8.5 kPa, and standard bicarbonate of 28 mmol/L. What is the next step in management for this patient?

MRCP2-4502

A 38-year-old woman presents to the Emergency department with a two-week history of palpitations and breathlessness. She has a past medical history of diabetes mellitus, which is well controlled on metformin 850 mg bd, and longstanding hypertension for which she has been on therapy for several years. Her current medications include captopril 50 mg bd, furosemide 40 mg od, and nifedipine 20 mg bd. She recently consulted her GP with symptoms of breathlessness, and he increased the dose of furosemide to 80 mg od.

On examination, the patient is overweight and appears distressed. She is afebrile, with a pulse of 120, regular, and a blood pressure of 145/95 mmHg. Heart sounds 1 and 2 are normal with no added sounds or murmurs. Respiratory rate is 28/minute, and the chest is clear to auscultation. The rest of the examination is normal.

Investigations:
– Hb: 134 g/L (normal range: 115-165)
– WBC: 8.9 ×109/L (normal range: 4-11)
– Platelets: 199 ×109/L (normal range: 150-400)
– Sodium: 139 mmol/L (normal range: 137-144)
– Potassium: 4.4 mmol/L (normal range: 3.5-4.9)
– Urea: 5.8 mmol/L (normal range: 2.5-7.5)
– Creatinine: 110 µmol/L (normal range: 60-110)
– Glucose: 5.9 mmol/L (normal range: 3.0-6.0)
– Arterial blood gases on air:
– pH: 7.6 (normal range: 7.36-7.44)
– O2 saturation: 99%
– PaO2: 112 mmHg/15 kPa (normal range: 75-100)
– PaCO2: 13.7 mmHg/1.8 kPa (normal range: 35-45)
– Standard bicarbonate: 20 mmol/L (normal range: 20-28)
– Base excess: -7.0 mmol/L (normal range: ±2)

What is the appropriate treatment for this patient?

MRCP2-4503

A 57-year-old man presents to the clinic for evaluation. He reports excessive daytime sleepiness, causing him to fall asleep multiple times during the day and lose his job as a taxi driver. He has a history of hypertension treated with Ramipril and is otherwise healthy. His wife reports that he snores throughout the night and frequently stops breathing. On examination, his BP is 158/88 mmHg, his pulse is 78 bpm, and his BMI is 38 kg/m2 with a collar size of 18.5.

Lab results show Hb of 135 g/l, WCC of 6.9 x109/l, PLT of 188 x109/l, Na+ of 137 mmol/l, K+ of 4.3 mmol/l, creatinine of 108 micromol/l, and fasting glucose of 8.1 mmol/l. A sleep study reveals over 10 hypoxic episodes associated with apnea during the overnight period.

What is the most effective long-term intervention for this patient?