Archives: MRCP Part 2

MRCP2-4486

A 49-year-old male presents to the respiratory clinic with his partner, concerned about his recent weight loss of 5 kgs over the past three months. He reports a persistent productive cough and is producing approximately half a cup of phlegm daily. The patient denies fevers or night sweats, and his systems review is unremarkable.

After a chest X-ray, multiple cavitating lesions are found, and sputum microscopy, sensitivities, and culture (MC&S) are negative. An HIV test is also negative. The patient is referred for a bronchoscopy and bronchoalveolar lavage (BAL) to aid in diagnosis. Several weeks later, the microbiology registrar on call informs you that the patient’s sputum has cultured a non-tuberculous mycobacterium (Mycobacterium intracellulare).

The patient returns to the clinic, and his symptoms persist. What is the most appropriate management plan for this 49-year-old individual?

MRCP2-4487

A 62 year-old male patient with known chronic obstructive pulmonary disease presents for routine review at respiratory outpatients. He is currently taking inhaled tiotropium and salmeterol/fluticasone at optimal doses. You note he has had two exacerbations in the previous 12 months requiring oral steroids and antibiotics. A recent high resolution CT showed severe emphysema affecting all lobes.

His ABGs in clinic today is a follows:

pH 7.38
pO2 7.91 kPa
pCO2 6.7 kPa
HCO3 30.1 mmol/L
Sats 88%

His blood tests today show:

Hb 16.2 g/dL
Platelets 260 x 10 9 /L
WCC 6.9 x 10 9 /L

What would be the best approach to further optimize his management?

MRCP2-4490

A 25-year-old man presents with severe tightness in his chest and difficulty breathing. Upon examination, he is found to be very wheezy, with a high respiratory rate, but is still able to speak in full sentences. He has a history of asthma, which is usually well-controlled and only requires occasional use of a salbutamol inhaler. The onset of his symptoms occurred during a thunderstorm, leading to a suspicion of thunderstorm asthma. What is believed to be the underlying cause of this condition?

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?

MRCP2-4495

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?

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?

MRCP2-4484

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?

MRCP2-4491

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?

MRCP2-4475

A 72-year-old man with a history of metastatic pancreatic cancer complains of sudden onset dyspnea and chest pain that sounds like pleurisy. Upon examination, his heart rate is 118 bpm and his oxygen saturation is 84% on 2 L of oxygen. Clear lung fields are heard upon auscultation. Determine his Wells score.

MRCP2-4474

A 75-year-old man with a history of type 2 diabetes mellitus and alcohol misuse comes in with a fever and productive cough. He denies any weight loss or coughing up blood. He was born and raised in the United States and has never traveled abroad. He has never been a smoker. During the examination, he has crackles in his left upper lobe but is otherwise stable. A chest X-ray shows consolidation that is cavitating in his left upper lobe. What is the probable diagnosis?