Archives: MRCP Part 2

MRCP2-4500

A 30-year-old man with a history of asthma presents to the Emergency Department with an acute exacerbation of his condition. He typically manages his asthma well with inhaled fluticasone twice daily and salbutamol inhaler as needed. However, he reports progressively worsening shortness of breath over the past few days, requiring multiple doses of salbutamol per day. On examination, he is visibly distressed with a respiratory rate of 26 breaths per minute and unable to complete sentences in one breath. Bilateral expiratory polyphonic wheezes and poor air entry are noted. Arterial blood gases on air reveal a PaCO2 of 3.6 kPa/27 mmHg, PaO2 of 10 kPa/75 mmHg, pH of 7.45, and standard bicarbonate of 24 mmol/L. The casualty officer initiates high flow oxygen and continuous nebulised salbutamol, as well as administering 200 mg of hydrocortisone IV and one dose of nebulised ipratropium bromide. However, there is no improvement after 30 minutes of treatment. What would be the most appropriate next step in management?

MRCP2-4484

A 28-year-old woman with severe asthma presents to the Emergency department. She is currently on high dose salmeterol/fluticasone and montelukast but reports worsening symptoms since developing a cold 24 hours ago. She has been admitted to the ICU twice before. On examination, her blood pressure is 120/80 mmHg and her pulse rate is 90 beats per minute. Auscultation reveals quiet breath sounds with polyphonic wheeze, and her respiratory rate is 28/min. Despite receiving back-to-back salbutamol nebulisers, ipratropium nebulisers, and IV hydrocortisone, her PEFR only improves minimally from 100 to 120 (300 predicted). Her oxygen saturation is 93% on 60% oxygen delivered via mask. The anaesthetist is called for possible intubation.

What is the most appropriate next step?

MRCP2-4492

A 65-year-old man has been admitted for an infective exacerbation of COPD. He presented with a productive cough, fever, shortness of breath, and chest tightness. Despite receiving back-to-back nebulisers, IV hydrocortisone, and IV antibiotics, he remains in type two respiratory failure with acidosis. Non-invasive ventilation (NIV) with IPAP of 10cmH2O and EPAP of 4cmH2O was initiated and later increased to IPAP of 16cmH2O. The nursing staff inquires about the administration of nebulisers, which were prescribed every three hours.

What is the appropriate approach to nebuliser treatment while the patient is receiving NIV?

MRCP2-4493

A 72-year-old ex-miner presents to the Respiratory Clinic with a 5-month history of intermittent dyspnoea and dry cough. These episodes last for several days and are accompanied by fever, malaise, and chest tightness. He reports recovering from the most recent episode 3 weeks ago.

The patient has no significant medical history and reports feeling well between episodes. He does have a long-standing shortness of breath on exertion, which has been stable for the past 7 years, and estimates his exercise tolerance at 200 yards. He worked as a miner until the early 1980s and then retrained as a plumber, working until his retirement in the early 2000s. He now enjoys keeping pigeons in his back garden and is a non-smoker.

On examination, his respiratory rate is 14/min, and his oxygen saturations are 95% on room air. The patient has clubbed fingers, and bibasal crackles are heard on chest auscultation. Heart sounds are dual with no added sounds.

A high-resolution CT (HRCT) scan of the thorax shows subpleural bibasal reticular opacities with some evidence of honeycombing but no appreciable ground-glass opacification.

What is the most likely cause of the patient’s symptoms?

MRCP2-4496

A 67-year-old patient is being reviewed after being admitted with an infective exacerbation of COPD. The patient presented with shortness of breath, tight-chestedness, and feeling generally unwell. Medical treatment was initiated, including IV piperacillin with tazobactam, IV hydrocortisone, IV fluids, nebulized salbutamol, and nebulized ipratropium bromide. However, the patient’s hypercapnia and acidosis failed to improve. Non-invasive ventilation (NIV) was then initiated, starting with IPAP of 10 cm H2O and EPAP of 4 cm H2O. The patient has managed to have the IPAP increased to 14 cm H2O, but is struggling to tolerate this and is feeling increasingly anxious. The patient has only had NIV for three hours so far.

Arterial blood gas results:
On admission Current
pH 7.11 7.23
pCO2 14.7 12.1
pO2 8.4 10.7

What is the most appropriate method to help settle the patient?

MRCP2-4491

A patient who was seen in rapid access chest clinic at the age of 60 undergoes a CT thorax. The report states that there is a mass arising from the left main bronchus, 1.5 cm from the carina and not directly involving the carina. The mass is causing almost complete obstruction of the left main bronchus and is likely to represent a primary lung tumour. Additionally, there are several left hilar lymph nodes, the largest measuring 2 cm. What is the TNM staging of this lung tumour?

MRCP2-4494

A 65-year-old patient is seen in oncology clinic and has been diagnosed with mesothelioma after a pleural biopsy. He has a medical history of hypothyroidism, pseudogout, and depression. He is worried about the financial consequences and plans to seek compensation. As a plumber for his entire career, he wants to know when he was most likely exposed to asbestos that led to his mesothelioma. How long ago did his exposure to asbestos occur?

MRCP2-4483

A 29-year-old man presents to the acute medical team after being referred by A&E. He is a Swedish PhD student studying at the local university. He reports a 6-week history of fevers and a non-productive cough. He also mentions a reduction in exercise tolerance and pains in his knees, ankles, and wrists. He has noticed some painful red swellings on his legs, which he had experienced several years ago but resolved without medical treatment. He denies any bowel symptoms or weight loss but admits to having bilateral tender red nodules on his shins. On examination, he is afebrile and cardiovascularly stable. His blood results show elevated platelets and non-specific inflammation. His chest x-ray and CT chest reveal bilateral hilar lymphadenopathy with small pulmonary infiltrates. A bronchoscopy is normal, and transbronchial biopsies of the hilar lymph nodes show non-caseating granulomas. What is the most appropriate treatment for this patient?

MRCP2-4498

A 54-year-old woman comes to the respiratory clinic for evaluation. She had a persistent cough for which her GP prescribed a week-long course of amoxicillin. However, as the cough did not improve within ten days, she returned to her GP who ordered a chest X-ray. The results prompted a referral to the respiratory clinic, even though all of her symptoms had resolved by then. The patient has a medical history of idiopathic intracranial hypertension, polycystic ovaries, and type 2 diabetes mellitus. She takes only metformin and has no known allergies. She has never smoked and has no significant occupational exposure. She drinks approximately one glass of wine per day. On examination, she is obese, but her chest is clear upon auscultation. The chest X-ray shows bilateral hilar lymphadenopathy.

Hemoglobin: 127 g/l
Platelets: 417 * 109/l
White blood cells: 6.2 * 109/l
ESR: 43 mm/hr
Sodium: 138 mmol/
Potassium: 3.7 mmol/l
Urea: 4.8 mmol/l
Creatinine: 82 µmol/l
Corrected calcium: 2.1 mmol/l

What would be the most appropriate course of action for this patient?

MRCP2-4495

A 35-year-old woman has just started a new job as a hairdresser. She reports experiencing more frequent episodes of shortness of breath, coughing, and wheezing during the workweek. However, she notices that her symptoms improve over the weekends and during a recent vacation to Hawaii. When examined on a Monday morning, there is no wheezing present, and her peak flow is 450 (480 predicted).

What is the most appropriate initial step to take in this situation?