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?
MRCP2-4460
A 72-year-old woman presents to the emergency department after being referred by her out-of-hours GP service due to worsening shortness of breath and cough. She reports that the shortness of breath has been increasing in severity over the past 3 weeks and is occasionally accompanied by a non-productive cough.
The patient has a significant cardiac history, including two myocardial infarctions treated with percutaneous coronary intervention, an aortic heart valve replacement, and mild mitral regurgitation. She also has hypertension, which is managed with amlodipine and ramipril, hypercholesterolaemia treated with atorvastatin, and mild COPD for which she takes salbutamol and ipratropium bromide. The patient previously worked as a librarian, has smoked 10 cigarettes per day for the past 20 years, and drinks an average of 5 units of alcohol per week.
Upon examination, the patient has dull percussion and reduced breath sounds over the left mid and lower bases of the lung. An urgent chest x-ray reveals a left-sided pleural effusion. A pleural aspirate is taken and shows a protein content of 45 g/L, glucose of 2.4mmol/L, and a pH of 7.32.
What is the most likely 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?
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?
MRCP2-4465
A 52 year-old man is referred by his GP to the respiratory outpatient clinic. He has had multiple sinusitis episodes in the past three years and is currently being referred to plastic surgery due to partial collapse of the bridge of his nose. A recent chest X-ray revealed five nodules and his blood tests showed a urea level of 11.6 mmol/l and a creatinine level of 198 µmol/l.
What is the most suitable initial treatment for this condition?
MRCP2-4452
A 64-year-old man presents with a 6-week history of anorexia, malaise and breathlessness which he relates to rapidly worsening asthma. He takes NSAIDs for osteoarthritis of his knees, paroxetine and also inhalers for mild asthma. He was on lithium carbonate 2–5 years ago. Examination reveals mild peripheral oedema, bilateral pleural effusions and a skin rash. He is hypertensive at 210/100 mmHg. Investigations show abnormal results for haemoglobin, eosinophils, corrected calcium, phosphate, urea, creatinine, potassium, and urinalysis. The likely diagnosis is:
MRCP2-4458
A 45-year-old man presents to the emergency department with worsening respiratory symptoms over the past 3 days. What is the probable causative agent of his illness?
MRCP2-4459
A 52-year-old woman presents to the Medical Admissions Unit with a 2-week history of fever, breathlessness, lethargy, and fatigue. She has a history of poorly controlled asthma, resulting in multiple visits to the Emergency Department over the past 2 years. Despite being started on reducing dose oral prednisolone during her last admission, she was unable to decrease her dose below 10 mg per day due to recurrent breathlessness and wheezing. Four months ago, she was started on montelukast 10mg per day as a steroid-sparing therapy, which allowed her to reduce her prednisolone to 5mg per day and remain well. She has a past medical history of sinusitis and nasal polyposis, for which she has undergone several surgeries. Her current medications include Seretide 500/50 1 puff twice daily, montelukast 10 mg once daily, prednisolone 5mg once daily, and salbutamol via MDI as required. On examination, she has an elevated JVP, bibasal crackles, and diffuse polyphonic wheeze. Her initial investigations reveal abnormal levels of various blood components and urine dipstick results of blood +++ and protein ++. What is the most likely finding on renal biopsy?
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?
MRCP2-4461
A 92-year-old man is admitted to the hospital with a severe exacerbation of his COPD. He is experiencing breathlessness at rest and is starting to feel drowsy, although he remains alert and oriented. Upon observation, his temperature is 37.9ºC, heart rate is 82 beats per minute, blood pressure is 116/74 mmHg, respiratory rate is 28 breaths per minute, and oxygen saturations are at 84% on a 28% Venturi mask.
An arterial blood gas test is conducted, revealing a PaO2 of 9.0 kPa, PCO2 of 11.4kPa, HCO3 of 31 mmol/l, and a pH of 7.29.
Given the patient’s condition, it is decided to initiate non-invasive ventilation. What is the most appropriate management for this patient?