Archives: MRCP Part 2

MRCP2-4440

A 76-year-old man with Chronic Obstructive Pulmonary Disease presents to the Respiratory clinic with complaints of decreased exercise tolerance and shortness of breath at rest. He experiences infrequent exacerbations and does not have a productive cough. His oxygen saturations on air are 90%, and his FEV1 is 27% predicted. The patient has a medical history of osteoarthritis, ischaemic heart disease, and chronic kidney disease. He takes Paracetamol, Ramipril, Aspirin, inhaled long-acting beta-agonist with inhaled corticosteroid, and inhaled long-acting muscarinic agonist. He has previously undergone pulmonary rehabilitation and does not smoke.

Investigations reveal a Hb of 19.8 g/dL, WCC of 6.0 *10^9/l, Platelets of 180 *10^9/l, and MCV of 88fL. Echocardiogram shows no abnormalities, and CT Chest reveals widespread mild bullous disease throughout upper and lower lung fields. Arterial blood gas on air shows a pH of 7.40, pCO2 of 5.1 kPa, pO2 of 7.5 kPa, and HCO3 of 25 mmol/l.

What is the most appropriate treatment for this patient?

MRCP2-4441

A 25 year-old patient presents to the Acute Medical Unit with a 4-week history of increasing cough and breathlessness. The cough was generally non-productive but he had coughed up a small amount of blood on 3 occasions. His past medical history consisted only of asthma which was well controlled with a salbutamol inhaler. There was no family history of venous thromboembolism. His recent travel history included a trip to Sierra Leone 3 months ago. He was a non-smoker and drank 20 units of alcohol per week.

On examination, his temperature was 37.6oC, heart rate 80 beats per minute, blood pressure 124/88 mmHg, respiratory rate 22 breaths per minute and oxygen saturations 92% on room air. He was able to talk in full sentences. A few bibasal crackles were evident on auscultation of the chest. His JVP was not elevated and heart sounds were normal.

What is the most appropriate treatment for the underlying condition?

MRCP2-4442

A 57-year-old man presents to the emergency department with abdominal pain. He has a history of type 2 diabetes and a BMI of 39 kg/m². He takes regular metformin and glibenclamide and has had previous episodes of pancreatitis. On examination, he reports central abdominal pain radiating to his back, similar to previous episodes. He has never smoked and worked as a bank manager for 36 years before retiring early.

During the examination, the patient’s chest is clear, and his respiratory rate is 15/min. There is guarding in the epigastric areas, but bowel sounds are present. The surgical registrar requests an arterial blood gas, and the results are as follows:

pH 7.38
pCO2 7.8 kPa
pO2 8.4 kPa
HCO3 31 mmol/L
Base excess +4.2
Glucose 5.3 mmol/L
Lactate 2.50mmol/L

What is the probable cause of these findings?

MRCP2-4443

A 57-year-old man presents with worsening shortness of breath and haemoptysis over the past ten days. He is currently coughing up an estimated 200 ml of fresh red blood daily. He experiences night sweats and feels cold and sweaty at times. He has not lost any weight and was previously healthy.

The patient has mild COPD and takes fostair twice a day with no exacerbations in the past 5 years. He moved to the UK 15 years ago but lived 10 years in Louisiana as a mining operator extracting minerals with exposure to bats and birds during this time. He drinks 10 units of alcohol a week and was born in Syria where he received a BCG vaccine as a child. He has not been around any ill contacts and lives with his wife and two children. There is no recent foreign travel and he keeps no pets.

On examination, he has crepitations in the right side mid and upper zones. He has palpable lymph nodes in his axillae and neck but his abdomen is non-tender with no hepatosplenomegaly. He is breathing rapidly and appears cachectic. His observations show temperature 38.3ºC, respiratory rate 28/min, heart rate 98/min, saturations 88% in air. An arterial blood gas has not been done.

Hb 110 g/l Na+ 139 mmol/l
Platelets 450 * 109/l K+ 3.4 mmol/l
WBC 13 * 109/l Urea 4.1 mmol/l
Neuts 9.8 * 109/l Creatinine 78 µmol/l
Lymphs 0.78 * 109/l CRP 130 mg/l
Eosin 0.1 * 109/l
HIV serology negative

Sputum culture no acid-fast bacilli or other growth seen
Chest x-ray bilateral hilar lymphadenopathy with patchy right upper zone consolidation
Beta-D-glucan strongly positive

What is the 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?

MRCP2-4445

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?

MRCP2-4446

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?

MRCP2-4447

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.

The following investigations were conducted:

– Haemoglobin 14.2 g/dl
– WCC 7.1 x10^9/l
– Platelets 420 x10^9/l
– ESR 65 mm/hr
– Na+ 139 mmol/l
– K+ 4.3 mmol/l
– Urea 13.2 mmol/l
– Creatinine 171 µmol/l
– Corrected calcium 2.26 mmol/l
– ANCA Positive, with perinuclear staining pattern
– PR3 antibodies Negative
– MPO antibodies Positive
– Urine dipstick +++ blood, +++ protein
– Urine microscopy Red cell casts
– Chest radiograph Clear

What is the most likely diagnosis?

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?

MRCP2-4423

A 54-year-old woman complains of deteriorating exercise capacity despite an increase in her asthma medication by her GP. Her salbutamol inhaler also fails to provide any relief. She has no other medical history. During examination, her lung fields are clear on auscultation, but an early diastolic murmur is present. Enlarged proximal pulmonary arteries are evident on her chest X-ray. What diagnostic test is most likely to provide an accurate diagnosis?