A 28-year-old man presents to the asthma clinic for follow-up. Despite being on fluticasone 250 mcg and salmeterol 50 mcg (seretide 250) twice daily, he continues to experience shortness of breath, especially at night and during physical activity. He works in an office, does not have any pets, and is a non-smoker. Other than asthma, he has no significant medical history.
During the examination, his blood pressure is 124/76, his pulse is regular at 70 beats per minute. Bilateral air entry is good, but occasional wheezing can be heard. His peak expiratory flow rate (PEFR) is 480, compared to a predicted value of 590.
What is the most appropriate next step?
MRCP2-4511
A 65-year-old patient with a history of bronchiectasis presents with the growth of fully sensitive Pseudomonas aeruginosa in their sputum for the first time. The patient reports a worsening of their shortness of breath. What would be the most appropriate first-line antibiotic treatment option?
MRCP2-4512
An 88-year-old man presents to the Emergency department with sudden onset of chest pain and difficulty breathing. He reports noticing swelling in his left leg a week ago but did not seek medical attention. He has a history of hypertension and takes bendroflumethiazide. He has never smoked. On examination, he is dyspnoeic at rest with a respiratory rate of 28 breaths per minute, blood pressure of 90/60 mmHg, pulse of 110 beats per minute, and oxygen saturations of 86% on room air. A loud second heart sound is heard over the right second intercostal space. Arterial blood gas analysis on air shows a pH of 7.35, PaO2 of 7.0 kPa, PaCO2 of 3.8 kPa, and standard HCO3 of 24 mmol/L. A CT pulmonary angiogram reveals a large saddle embolism in the pulmonary trunk. What is the most appropriate management?
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?
MRCP2-4514
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?
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.
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?