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?
MRCP2-4467
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?
MRCP2-4468
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?
MRCP2-4469
A 29-year-old woman presents to the Respiratory Clinic for evaluation. She has been diagnosed with asthma by her GP based on peak flow testing for the past three years. Despite increasing her therapy to manage symptoms of wheezing, shortness of breath during exercise, and nocturnal coughing, she is still experiencing uncontrolled symptoms. She has a history of paroxysmal AF but is not currently taking any prophylactic medication. Her current asthma medications include inhaled beclometasone 400 mg twice daily and orally administered montelukast 10 mg (which initially provided relief). On examination, her blood pressure is 115/85 mmHg, and her pulse is regular at 75 bpm. Bilateral wheezing is present on auscultation. Her peak flow is 390 litres/minute (predicted 500 litres/minute). What is the most appropriate next step?
MRCP2-4470
A 65-year-old male patient presents to respiratory outpatients referred by his GP due to increasing breathlessness. The referral letter notes that he has had two courses of antibiotics for chest infections in the past year and a 40 pack year smoking history. The patient reports a productive cough with occasional streaks of blood but no weight loss. His medical history includes treatment for cardiac failure with enalapril, bisoprolol, and furosemide, recurrent urinary tract infections treated with long-term nitrofurantoin, and osteoarthritis treated with paracetamol and meptazinol. On examination, there are bilateral scattered coarse crepitations and finger clubbing.
Spirometry results in clinic are as follows:
Forced vital capacity (FVC) 2.10L (76% predicted) Forced expiratory volume in 1 second (FEV1) 1.25L (54% predicted) FEV1/FVC ratio 0.59
What is the probable diagnosis?
MRCP2-4449
A 57-year-old man presents to the Emergency Department with a two-week history of increasing shortness of breath and frank haemoptysis for the past few days. He had recently returned from a trip to Turkey. On admission, he was short of breath at rest and unable to complete full sentences. He also reported increasing orthopnoea for the past few weeks. He had a medical history of diabetes, hypertension, hypercholesterolaemia, and gout, as well as a long history of recurrent epistaxis, rhinitis, and sinusitis. He was taking several medications, including mometasone nasal spray, allopurinol, ramipril, amlodipine, simvastatin, metformin, and gliclazide. He smoked 20 cigarettes per day and did not drink alcohol.
Upon examination, he appeared very unwell and was in obvious respiratory distress. His respiratory rate was 28/min, his oxygen saturations were 90% on air, his blood pressure was 108/72 mmHg, his heart rate was 129, and his temperature was 37.9 degrees Celsius. His cardiovascular system had normal heart sounds with a JVP of 3cm, while his respiratory system showed the use of accessory muscles with bibasal fine crackles. Examination of the gastrointestinal and neurological systems was unremarkable.
Initial investigations revealed low Hb, high platelets and WBC, high ESR, low Na+, high K+, high urea, high creatinine, high CRP, and normal glucose. Chest x-ray showed bilateral patchy infiltration, while ECG showed normal sinus rhythm. Urinalysis showed blood and protein, but negative leuc/nit and glucose. ABG on 15 l/min oxygen showed high PaO2, low PaCO2, low HCO3, and high pH.
Further investigations revealed nil growth in urine MCS and blood culture, normal systolic function and valvular appearances, and no vegetations seen in transoesophageal echocardiogram. C3 and C4 were abnormal, ANA and dsDNA were negative, cANCA was positive, pANCA was negative, and rheumatoid factor was negative.
Given the likely underlying diagnosis, what is the best next step while awaiting haemodialysis?
MRCP2-4450
A 33-year-old construction worker presents to the emergency department with pleuritic left-sided chest pain. He is a current smoker of 10 cigarettes/day. He reports feeling sick for the past 2 weeks with a cough and fever. The chest pain started gradually over the last 3 days and has been slowly worsening. A chest x-ray reveals left-sided consolidation and an effusion. The patient is started on penicillin antibiotics. A pleural aspirate is performed under ultrasound guidance, which shows a simple effusion with the following results:
Appearance: Serous pH: 7.25 Protein: 50 g/l LDH: 420 IU/l Glucose: 3.5 mmol/l Gram stain: No organisms or malignant cells seen Culture: No growth
What is the next best course of action?
MRCP2-4451
A 25-year-old woman presents to Accident and Emergency with acute shortness of breath. She is unable to provide a clinical history due to her breathing difficulties. Her current medications include Cetirizine 10mg orally once daily and Clobetasone butyrate (Eumovate) topically.
Upon examination, bilateral widespread polyphonic wheezes are heard. Her pulse rate is 102 beats per minute, blood pressure is 128/75 mmHg, and respiration rate is 33. Oxygen saturations are 96% on 4L/min via face mask. A dry flaking rash is observed in her elbow flexures with signs of excoriation.
Blood tests reveal a Hb of 11.2 g/dl, platelets of 204*10^9/l, WBC of 10.3 *10^9/l, eosinophil of 0.56 *10^9/l, CRP of 65, Na+ of 135 mmol/l, K+ of 4.4 mmol/l, urea of 7.6 mmol/l, and creatinine of 101 µmol/l. Chest x-ray is clear, and peak expiratory flow is 200 L/min (expected 402).
The patient is treated with nebulised salbutamol and ipratropium bromide, oral prednisolone 40mg, and oxygen 4L/min. Upon re-examination 30 minutes later on the Admissions Unit, symmetrical quiet breath sounds and quiet bilateral wheezes are heard. Her pulse rate is 80 beats per minute, blood pressure is 103/68 mmHg, and respiratory rate is 18 with oxygen saturations of 94% on 6L/min via face mask. Peak expiratory flow is 120 L/min.
A repeat arterial blood gas on 6L/min oxygen via face mask reveals a pH of 7.33, pCO2 of 6.2kPa, pO2 of 13 kPa, HCO3 of 20 mmol/l, and lactate of 2.2 mmol/l. What is the most appropriate next step in management?
MRCP2-4463
A 28-year-old woman presents to the Allergy Clinic. She reports being a long-term sufferer of allergic rhinitis, eczema, and asthma. These conditions have recently worsened, and she has developed a persistent nighttime cough despite using her steroid inhaler regularly. She has also experienced weight loss and fatigue. Additionally, she has had to visit her primary care physician multiple times for sinusitis and inner ear issues. She reports using her regular inhaler twice daily and her rescue inhaler as needed, as well as applying emollients daily for her skin. She also notes that she cannot take aspirin due to its exacerbating effect on her asthma. Which test is most likely to provide a definitive diagnosis?
MRCP2-4464
A 65-year-old caucasian female presents to the respiratory clinic with a chronic cough that has persisted for 6 months. She was referred by her GP after complaining of the cough, which is productive but without any haemoptysis. The patient’s husband has noticed that she has lost weight unintentionally and has gone down a dress size. Prior to the onset of the cough, the patient was reasonably fit and walked half an hour every day. She has never smoked and has no underlying respiratory pathology. She denies any history of fever or night sweats and recently traveled to Italy for a summer holiday where she visited a famous bird sanctuary.
Upon reviewing her chest radiograph, an increased opacity in the right upper lung field was observed. Further investigations were performed, including a high resolution CT (HRCT) scan, which revealed a cavity in the right upper lobe with associated tree-in-bud appearances in the surrounding lung. There was no associated lymphadenopathy. The following results were obtained: Hb 140g/l, Platelets 400 * 109/l, WBC 11.0 * 109/l, Neuts 6.6 * 109/l, Lymphs 2.0 * 109/l, Eosin 0.01 * 109/l, Na+ 138 mmol/l, K+ 5.0 mmol/l, Urea 3.0 mmol/l, Creatinine 89 µmol/l, CRP 18 mg/l, Sputum MC&S Normal Flora, and Sputum Acid Fast Bacilli (AFB) Positive x 3. Based on this presentation, what is the most likely causative organism?