Archives: MRCP Part 2

MRCP2-4454

A 29-year-old female presents to the Emergency Department with increasing shortness of breath, wheezing, and a cough. She has a history of well-controlled asthma and perennial rhinitis. She takes beclomethasone (200 micrograms inhaled twice a day) and rarely uses salbutamol. She has never smoked.

On examination, her respiratory rate is 24, pulse is 98 bpm, and she has widespread wheeze on chest auscultation. Her oxygen saturation on air is 93%, and she appears anxious and disoriented. Blood tests reveal a raised white cell count of 11 x 109/L, and her chest x-ray is normal.

The patient is started on nebulized salbutamol and ipratropium bromide and given an oral dose of prednisolone. An arterial blood gas is taken 5 minutes after starting 40% oxygen, with the following results:

pH 7.36
PaO2 16.0 kPa
PaCO2 5.98 kPa
Bicarbonate 19 mmol/l

What is the most appropriate next step?

MRCP2-4455

A 65-year-old man presents to his GP with complaints of cough and dyspnoea on exertion. He reports having the cough for over 2 years, but it has worsened recently along with increasing shortness of breath. He denies any haemoptysis, chest pain or leg swelling. The patient has a smoking history of 60 pack-years and drinks a moderate amount of alcohol. His vital signs are stable with a temperature of 37.2ºC, blood pressure of 140/80 mmHg, pulse of 80/min, and respirations of 20/min.

On chest x-ray, there are prominent bronchovascular markings and mild diaphragmatic flattening. Pulmonary function tests reveal a forced expiratory volume in 1 second of 67% of predicted, forced vital capacity of 95% of predicted, and an FEV1/FVC ratio of 0.65. Carbon monoxide diffusion capacity is 100% of predicted value.

What is the most likely cause of this patient’s symptoms?

MRCP2-4456

A 67-year-old patient presents to a cardiology clinic with a medical history of long-standing atrial fibrillation, hypertension, and ischaemic heart disease. The patient reports experiencing progressive shortness of breath and a dry cough over the past year. Current medications include aspirin, amiodarone, ramipril, doxazosin, and gliclazide.

During the examination, the patient appears comfortable when lying flat but experiences dyspnea when mobilizing. Minimal ankle edema is present, and the patient’s heart rate is 78 beats per minute. Fine bibasal crepitations are heard during chest auscultation, and oxygen saturations on air are at 92%.

An echocardiogram reveals a left ventricular ejection fraction of 45%, a mildly hypertrophied left ventricle, and well-established right ventricular hypertrophy. Pulmonary artery pressures are elevated at 32 mmHg (normal: < 25 mmHg). A chest x-ray shows non-specific changes on both bases. What is the next appropriate investigation for this 67-year-old patient?

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?

MRCP2-4460

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?

MRCP2-4461

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?

MRCP2-4462

A 65-year-old man was brought to the hospital by ambulance after experiencing an out-of-hospital cardiac arrest. He was successfully resuscitated after 2 cycles of resuscitation and has been in the intensive care unit for the past 3 days, intubated and on a ventilator.

During morning rounds, it is observed that he requires a higher fraction of inspired oxygen to maintain normal oxygen levels and is producing a significant amount of secretions. A sputum sample is collected and sent for microscopy, culture, and sensitivity (MC&S). The results of the MC&S show the presence of Bacteroides fragilis.

What is the most likely interpretation of these findings?

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?