Archives: MRCP Part 2

MRCP2-4476

A 25-year-old woman from New York, with no significant medical history, traveled to Nepal for a hiking trip in the Himalayas. She is a non-smoker. After reaching an altitude of 4000 m, she developed a severe headache, accompanied by nausea and vomiting. She also felt fatigued and complained of difficulty sleeping. Her respiratory rate was 20/min and her pulse was 95/min. The rest of the physical examination was unremarkable. No medical tests are available as the nearest hospital is over 150 km away. By the next morning, she was disoriented and had difficulty walking steadily, and by the following day, she was lethargic and confused.

What would be the appropriate course of treatment for this woman?

MRCP2-4478

A 21-year-old male presented to the hospital with symptoms of nausea and vomiting that had been ongoing for two days. He had a history of asthma since the age of 4 and had been admitted to the hospital a year ago due to acute severe asthma. He was also being treated for obesity and weighed over 220 kg. He lived with his parents and was currently unemployed. He was a non-smoker and was taking beclomethasone, salmeterol, and sustained release theophylline for his asthma, which had been well controlled for the past nine months. However, he had developed increasing wheezing, breathlessness, fever, and a cough with purulent sputum five days ago. He had seen his general practitioner, who prescribed him a course of tablets, but his symptoms continued to worsen. On examination, he was agitated and breathless at rest, with a peak expiratory flow rate of 190 L/min. He had a temperature of 37.8°C, a pulse of 120 beats per minute, and a blood pressure of 120/88 mmHg. What was the most likely treatment prescribed by his general practitioner?

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?

MRCP2-4468

A 68-year-old man presents with a 5 day history of coughing up green sputum, increased breathlessness, wheezing, fever, and right-sided pleuritic chest pain. He has a medical history of chronic obstructive pulmonary disease, hypertension, and diabetes. He has a smoking history of 40 pack years but quit 2 years ago.

Upon examination, he appears unwell, flushed, and breathless at rest. Heart sounds are normal, but he has right basal crackles with bronchial breathing and wheezing. There is no leg edema or tenderness. His vital signs show a pulse of 120 beats per minute, blood pressure of 120/70 mmHg, SaO2 = 89% on 24% oxygen, respiratory rate of 32 breaths per minute, and T=38.5oC.

An electrocardiogram reveals sinus tachycardia, and a chest X-ray confirms right basal consolidation. Blood tests show Hb 13.1 g/dl, platelets 180 * 109/l, WBC 15.4 * 109/l, Na+ 135 mmol/l, K+ 4.9 mmol/l, urea 10 mmol/l, creatinine 120 µmol/l, and CRP 180 mg/l. Arterial blood gas shows pH 7.28, pCO2 5.0 kPa, pO2 8.5 kPa, and HCO3- 15 mEq/l.

What is the optimal management plan for this patient?

MRCP2-4482

A 67 year old woman presents to the emergency department with a 4 day history of worsening shortness of breath and cough. She has a history of COPD and is being treated for an infective exacerbation. She also has a past medical history of hypertension, type 2 diabetes mellitus, hypercholesterolaemia, hypothyroidism, osteoarthritis and depression.

Despite nebulisers, steroids and antibiotics, she remains acutely breathless and her oxygen saturations are only 84% on air. Blood gas analysis shows:

pH 7.22
pCO2 10.3 kPa
pO2 7.1 kPa
BE -4.5 mmol/l
HCO3- 36 mEq/l

The decision is made to try NIV and she is transferred to the NIV unit. Initial settings on NIV are IPAP 8 cm H2O and EPAP 4 cm H2O. However, she remains tachypnoeic and has oxygen saturations of 87%. Her repeat blood gas after 1 hour is as follows:

pH 7.26
pCO2 9.8 kPa
pO2 9.5 kPa
BE -3.8 mmol/l
HCO3- 35 mEq/l

What adjustments would you make to the NIV settings?

MRCP2-4467

A 25-year-old man is admitted to the specialist burns unit with severe burns following a house fire. He is haemodynamically stable and receives IV fluids and oxygen, although does not require intubation. Three days after his admission, he develops acute-onset shortness of breath. The only past medical history reported was hay-fever as a child and his mother has relapsing-remitting multiple sclerosis. He smoked 1-2 roll-up cigarettes per week and did not drink any alcohol.

His observations include a respiratory rate of 28 breaths per minute, oxygen saturations of 91% on 12L of oxygen, a heart rate of 112 beats per minute and blood pressure of 114/78 mmHg. His temperature was 36.9ºC. Examination revealed widespread crackles over both lung fields.

What is the most likely diagnosis?

MRCP2-4477

A 28 year old asthmatic woman has been hospitalized after intentionally overdosing on her regular theophylline medication. What is a potential complication of theophylline toxicity?

MRCP2-4466

A 28-year-old man presents to his GP with shortness of breath. This has been occurring for the past 6 months and is sometimes accompanied by wheezing, particularly later on during the day. He does not have any past medical history and occasionally takes over-the-counter antihistamines for hay-fever. His only recent travel history is a holiday to Spain, where he found he was less short of breath and he was less wheezy. His only family history of note is his mother who died of a heart attack aged 65. He works as a car mechanic and smokes 5 roll-up cigarettes per day and drinks on average 5-6 units of alcohol per week.

What investigation would be most helpful in determining the diagnosis of this 28-year-old man?

MRCP2-4479

A 35 year old man returns from a camping trip in the Amazon rainforest with weight loss, fever, dry cough, and nocturnal wheezing. He remembers being bitten by multiple mosquitoes. His chest X-ray shows pulmonary infiltrates. The following are his blood test results:

– Hemoglobin (Hb): 14 g/dl
– Platelets: 400 * 109/l
– White blood cells (WBC): 15 * 109/l
– Neutrophils: 8.0 * 10^9/l (reference range 2.0-7.5 * 10^9/l)
– Eosinophils: 1.5 * 10^9/l (reference range 0.04-0.44 * 10^9/l)

– Serum IgG: 100 mg/dl (reference range 80 – 350 mg/dl)
– Serum IgM: 180 mg/dl (reference range 45 – 250 mg/dl)
– Serum IgE: 5.0 mg/dl (reference range 0.002 – 0.2 mg/dl)

What is the most effective treatment for the likely diagnosis?

MRCP2-4481

A 60-year-old man presents to the respiratory clinic with worsening haemoptysis over the past 4 months. He is also concerned as he has noticed a loss of 7kg in the past 3 months. He previously completed a course of tuberculosis (TB) treatment 15 years ago, and he is currently a smoker, with a 45 pack year history.

On examination he is cachectic. Temperature is 36.8ºC, heart rate 80 bpm, respiratory rate 18 breaths per minute. There are decreased breath sounds and dullness to percussion over the right upper lobe, and conjunctival pallor. His fingers are clubbed. The rest of his examination is unremarkable.

Investigations:

Na+ 131 mmol/l
K+ 4.3 mmol/l
Urea 6.1 mmol/l
Creatinine 102 µmol/l
Serum corrected calcium 2.35 mmol/l
Serum bilirubin 21 µmol/l
Serum alkaline phosphatase 85 IU/l
Serum aspartate aminotransferase 16 IU/l
C Reactive protein (CRP) 15 mg/l
Haemoglobin 110 g/l
Mean Corpuscle Volume 77 fL
White cell count 11.2 x 10^9/L
Neutrophils 7.5 x 10^9/L
Eosinophils 1.9 x 10^9/L
Lymphocytes 1.1 x 10^9/L
Basophils 0.0 x 10^9/L
Platelets 490 x 10^9/L
INR 1.0

Chest x-ray: Intracavitary mass in the right upper zone

What is the next most useful diagnostic test?