Archives: MRCP Part 2

MRCP2-4416

A 70-year-old man is referred to the hospital by his GP with a suspected case of pneumonia. He is able to converse appropriately in complete sentences.

His vital signs are as follows: heart rate of 98, blood pressure of 110/79 mmHg, respiratory rate of 27, and a temperature of 38.2°C.

The results of his laboratory tests are as follows: hemoglobin level of 125 g/L (normal range: 130-180), white blood cell count of 18.7 ×109/L (normal range: 4-11), neutrophil count of 16.1 ×109/L (normal range: 1.5-7.0), platelet count of 479 ×109/L (normal range: 150-400), sodium level of 123 mmol/L (normal range: 137-144), potassium level of 3.8 mmol/L (normal range: 3.5-4.9), urea level of 8.1 mmol/L (normal range: 2.5-7.5), creatinine level of 115 μmol/L (normal range: 60-110), and CRP level of 210 mg/L (normal range: <10). Based on the above information, what is his predicted mortality rate according to the current BTS guidelines?

MRCP2-4417

A 63-year-old man comes to the clinic complaining of increasing shortness of breath when he exerts himself. His symptoms have been getting worse over the past three months, and he is now worried because he can’t walk through the park without stopping to catch his breath. He has also noticed a new, raised lesion on his chin. He has had a few unexplained fevers in the past week and has mild joint pain. He assumed the latter was arthritis, but he has never had it before. He has a medical history of hypertension, glaucoma, and was hospitalized for pneumonia within the last year.

During the examination, a 1 cm wide, raised lesion on his chin is observed, which is purple in color with some telangiectasia. He does not currently have a fever, and all of his vital signs are within normal limits. There is no finger clubbing. Bilateral cervical lymphadenopathy is present, and auscultation reveals bibasal fine inspiratory crackles that do not shift with coughing. A chest X-ray is ordered. What is the most likely result of the X-ray?

MRCP2-4422

A 55-year-old man is admitted to the respiratory team with a left lower lobe pneumonia. He has a medical history of chronic obstructive pulmonary disease and is a current smoker. Additionally, he has hypertension and high cholesterol.

The patient is treated with antibiotics, nebulisers, and steroids. However, after 5 days, he remains hypoxic with saturations of 86% on air, and he continues to experience left basal crepitations and wheezing.

A CT scan of the chest is performed, revealing emphysematous changes and resolving left basal consolidation. Furthermore, a 7mm lung nodule is detected in the right upper lobe with surrounding ground glass change.

Over the next 3 days, the patient’s saturations improve to 93% on air, and his symptoms subside. He is subsequently discharged home.

What type of imaging is necessary to monitor the pulmonary nodule?

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?

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?

MRCP2-4426

A 40-year-old man presents with a chronic productive cough that has been affecting him for several years. He has a history of recurrent otitis media as a child but takes no regular medications. He has never smoked, has no history of passive smoking, and works as a lawyer. He has no pets at home and is not aware of any mold. On examination, there is finger clubbing, he appears underweight, and there are coarse late-inspiratory crepitations and a mild wheeze. Additionally, his heart sounds are louder on the right side, and his apex beat is only present on the right. What further investigation would most likely confirm the diagnosis?

MRCP2-4427

A 50-year-old presents to a respiratory clinic with a history of exertional shortness of breath for the past 2 months. The patient has a medical history of HIV and is currently on Truvada. Three years ago, the patient had an unprovoked pulmonary embolism and was treated with warfarin for six months. The patient has been smoking 15 cigarettes daily for the past 20 years. Recently, the patient successfully completed their first mountaineering expedition and reached the summit of Kilimanjaro.

During the examination, the patient was found to have a loud P2, raised jugular venous pulse, and peripheral edema. Chest auscultation was unremarkable, and there were no murmurs.

Further investigations were carried out, including a transthoracic echocardiogram, which showed a mean pulmonary arterial pressure (PAPm) of 38 mmHg and mitral regurgitation with a regurgitant fraction of 14%. An HRCT chest was normal, but V/Q scanning demonstrated mismatched perfusion defects. The patient was referred for a right heart catheter, which confirmed a PAPm of 38 mmHg and a pulmonary arterial wedge pressure (PAWP) of 11 mmHg.

What is the most likely underlying cause of the patient’s symptoms and findings?

MRCP2-4428

A 40-year-old woman arrives at the Emergency Department complaining of a dry cough, fever, and fatigue that have persisted for three weeks. She has no medical history and does not take any regular medications. She has not traveled abroad recently. During the clinical examination, inspiratory crepitations are detected in the left upper and right lower zones. Her oxygen saturation is 91% on room air. A chest x-ray reveals bilateral peripheral pulmonary infiltrates.

The following blood test results are obtained:

– Hemoglobin (Hb): 110 g/L
– Mean corpuscular volume (MCV): 78 fL
– White blood cell count (WCC): 13 x 10^9/L
– Neutrophils: 8 x 10^9/L
– Lymphocytes: 1 x 10^9/L
– Eosinophils: 3.1 x 10^9/L
– Platelets: 560 x 10^9/L
– C-reactive protein (CRP): 115mg/l

What is the most appropriate treatment for the likely diagnosis?

MRCP2-4429

A 54-year-old man presents to the hospital with a fever and cough. He has been feeling unwell for a week, coughing up rusty sputum with occasional traces of blood. He has a history of smoking ten cigarettes per day but no other significant medical history. A chest X-ray reveals consolidation in the lower lobe of the right lung with a pleural effusion. The aspirate shows a low pH, indicating the possibility of empyema, and a chest drain is requested with the guidance of ultrasound. What is a predictive factor for the success or failure of the drainage procedure?

MRCP2-4430

A 55-year-old man presents to the respiratory outpatient clinic with a gradual onset of shortness of breath. He has a medical history of hypercholesterolemia and chronic obstructive pulmonary disease. Despite being on regular atorvastatin, salbutamol, and symbicort, he still smokes 5 cigarettes daily and has a 40 pack-year history. He lives with his wife and can only tolerate exercise for approximately 30 yards.

During the clinical examination, the patient’s chest is barrel-shaped, and there is hyper-resonance to percussion bilaterally. Auscultation reveals moderate harsh-sounding wheeze, and his fingertips are stained with nicotine. However, there is no clubbing, no peripheral edema, and the jugular venous pulse is not raised. The heart sounds are normal, and the pulse is regular.

Lung function tests show that the patient’s FEV1 is 35% (predicted), FVC is 68% (predicted), and FEV1/FVC is 51.4%. Blood tests reveal that his Hb is 154 g/L, platelets are 211 * 109/L, WBC is 7.2 * 109/L, Na+ is 133 mmol/L, K+ is 4.4 mmol/L, urea is 5.3 mmol/L, creatinine is 99 µmol/L, bilirubin is 14 µmol/L, ALP is 91 u/L, ALT is 34 u/L, γGT is 66 u/L, D-dimer is 333 ng/ml, albumin is 36 g/L, CRP is 4 mg/L, and BNP is 88 pg/ml.

A plain radiography of the chest shows generalized increased lucency bilaterally but clear lung fields. Based on the patient’s clinical history, what is the appropriate next step in management?