A 72-year-old man visits his GP with complaints of excessive daytime sleepiness, which has become so disruptive that he has been put on probation at work. He reports frequent morning headaches and experiences breathlessness when walking to the shops. He used to smoke 20 cigarettes a day for 20 years and drinks a pint of beer every evening at the pub. Additionally, he is clinically obese.
Upon referral to the hospital, an arterial blood test is conducted in the evening, revealing a PaO2 of 9.9 kPa and a PaCO2 of 4.4 kPa. The following morning, the arterial blood gas is repeated, showing a PaO2 of 10.0 kPa and a PaCO2 of 9.1 kPa.
What is the most probable diagnosis?
MRCP2-4447
A 55 year-old businessman presents to the neurology clinic with complaints of weakness and numbness affecting his left hand. He noticed a month ago that his little finger was often getting caught when he tried to put his hand in his pocket. Since then, he has experienced progressive difficulty using his left hand, accompanied by an unpleasant tingling sensation. In the last two weeks, he has also noticed difficulty walking and has tripped over on several occasions. When driving, he finds that his right foot often becomes stuck behind the accelerator pedal, and he struggles to lift it out.
Upon examination, there is diminished sensation over the little finger and medial side of the ring finger, as well as the medial side of the palm. There is weakness of finger abduction and adduction, but thumb abduction is normal. On examination of the legs, there is diminished sensation over the lateral aspect of the right calf, as well as the dorsum of the right foot. When asked to walk on his heels, he finds it difficult to do so and trips over the right foot.
A 30-year-old construction worker comes to the clinic complaining of cough, fever, headache, and shortness of breath that started 12 hours ago. During the examination, his heart rate is 114 bpm, respiratory rate is 26, and temperature is 37.8°C. His oxygen saturation is 92%, which drops to 88% when he walks across the ward. A chest x-ray shows a diffuse interstitial micronodular pattern. What is the probable diagnosis?
MRCP2-4433
A 65-year-old man with a history of rheumatoid arthritis well controlled on methotrexate presents with gradual pain and swelling in his wrists and ankles.
The pain is described as a dull ache that is intermittent, often worse in the evenings. There is associated swelling which can sometimes feel warm. He has tried regular paracetamol but this has had limited effect.
He also describes a chronic cough and shortness of breath on exertion for the past 6 months that he has not mentioned to his GP. There has been no haemoptysis and he denies any fevers. His wife has noticed that he has been losing weight recently.
He has a past medical history of rheumatoid arthritis, hypertension, hypercholesterolaemia and type 2 diabetes mellitus. He currently takes methotrexate weekly, folic acid 5mg weekly, ramipril 5mg, simvastatin 20mg at night, metformin 500mg three times a day and paracetamol 1g four times daily.
He is a retired accountant and a current smoker with a 50 pack year smoking history. He drinks approximately 30 units of beer a week. He denies any recent foreign travel.
On examination, he is cachectic and short of breath on exertion. His pulse is 80/min and regular, blood pressure 140/93 mmHg, oxygen saturations of 93% on air. He has marked fingernail clubbing. Examination of his wrists reveals slightly swollen and tender joints. Swan neck and ulnar deviation deformities are noted in both hands. Other than his wrists, no other joint abnormalities are detected. Examination of the peripheral nervous system is normal.
Examination of his chest is normal with no focal consolidation.
A tall 24-year-old male presents to the Emergency Department with sudden onset of chest pain and shortness of breath. The chest pain is sharp in nature and worsens on inspiration. He has no relevant medical or family history and is not taking any medications. He smokes 6 cigarettes per week for the past 5 years. Upon examination, he is tachycardic at 110 beats per minute and tachypnoeic. Blood pressure and temperature are within normal limits. Respiratory examination reveals reduced air entry on the left side, while other systems are normal. The ECG shows sinus tachycardia, and blood analysis is unremarkable. A chest radiograph reveals a left-sided pneumothorax measuring 1.7 cm at the left of the hilum. How would you manage this patient?
MRCP2-4446
A 75-year-old man presents to the oncology clinic with a two-week history of shortness of breath. He was diagnosed with mesothelioma two years ago. He has been experiencing difficulty walking long distances without becoming short of breath and had trouble making it from the car park, 200 yards away, to the clinic. He denies having a cough or fever but has been feeling more fatigued lately. His saturations are 95% while breathing room air, and his blood pressure, heart rate, respiratory rate, and temperature are all within normal limits.
Upon performing a chest X-ray, a right-sided pleural effusion is discovered, and he is admitted to the hospital. A chest drain is inserted, and three liters of blood-stained fluid are drained in two hours. He begins to cough and becomes increasingly short of breath. He denies any chest pain. On examination, he is uncomfortable and breathing 4L of oxygen via a non-rebreather mask. Bilateral crepitations are present in his chest.
What is the probable diagnosis?
MRCP2-4439
A 62-year-old male with known myasthenia gravis reports a recent increase in fatigue and decreased ability to exercise. During the examination, he presents with a weak voice, difficulty completing sentences, and a slightly slumped posture. What is the primary investigation needed during this acute phase?
MRCP2-4448
A 30-year-old female with a history of sinusitis and asthma for four years presents with a fever, ankle swelling, and new onset dyspnea. She also reports blood streaks in her sputum for the past two weeks. On examination, she has widespread wheeze and bi-basal crepitations in her chest. Her oxygen saturation improves with treatment. She has a raised JVP, pitting edema up to her knees, and a heart rate of 112 beats per minute. Blood tests show a low hemoglobin level, high white cell count and eosinophil count, and elevated platelet count and CRP. Her serum sodium and potassium levels are abnormal, and her creatinine and urea levels are high. Blood cultures show coagulase-negative staphylococci, and ANCA positive immunostaining is awaited. A urine dip test is positive for protein and blood, and a chest X-ray shows bi-basal non-specific shadowing. What is the most likely diagnosis?
MRCP2-4444
A 42-year-old man is referred to the Respiratory Clinic. He has had a long history of asthma since childhood and is maintained on combination inhaler therapy with fluticasone 250 μg/salmeterol 50 mg BD. On the advice of his doctor he moved away from the city to the suburbs and was well. Around 2 years ago he began keeping a cat and since then has noticed a gradual deterioration in his asthma control, with increased coughing up of mucous plugs. He has been started on high-dose oral corticosteroids by his GP, although he feels his symptoms have not significantly improved.
On examination in the clinic there was clear evidence of bilateral wheeze. His peak flow was measured at 400 l/min.
Investigations reveal the following: s Immunoglobulin E (IgE) 900 ng/ml Peripheral blood Eosinophil count 0.4 × 109/l 0.04–0.4 × 109/l IgG Precipitins to Cat Skin prick + to Cat Chest X-ray (CXR) Normal
Which of the following represents the optimal next step in this patient?
MRCP2-4424
A 22-year-old woman presents to the respiratory clinic for evaluation. She is an avid runner but has been experiencing increasing difficulty with wheezing and shortness of breath shortly after beginning exercise. Despite using a salbutamol inhaler before exercise, she has not seen any improvement. She has never smoked and does not take any regular medications.
During the examination, her blood pressure is 105/70, pulse is regular at 62 beats per minute, and her chest is clear. Her abdomen is soft and non-tender, and her BMI is 22. Her peak flow is 510, which is only slightly below the predicted value of 525.
What is the most appropriate next step in managing this patient’s symptoms?