Archives: MRCP Part 2

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?

MRCP2-4494

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?

MRCP2-4495

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?

MRCP2-4496

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?

MRCP2-4497

A 32-year-old with asthma uses a salbutamol inhaler PRN and a budesonide 200 μg inhaler BD but still experiences nighttime coughing and uses the salbutamol inhaler at least ten times per week. The physician believes the asthma is not well controlled and needs treatment escalation. What would be the recommended course of action according to NICE guidelines?

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?

MRCP2-4499

A 67-year old male with metastatic small cell lung cancer presents with an acutely swollen leg. An ultrasound scan reveals a femoral vein venous thrombosis. Later, he experiences tachypnea and drops his oxygen saturation level to 88% on air. On auscultation, there is wheezing bilaterally and reduced air on the left with hyper-resonant percussion note. An urgent CT thorax is requested, which shows a large 5 cm pneumothorax, bilateral segmental PEs, and a left-sided 4x3x2 cm lung cancer. Considering the risk of bleeding following insertion of a chest drain to treat the pneumothorax, what decision should be made regarding his anticoagulation for PE?

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?

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.