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?
MRCP2-4431
A 65-year-old man visits his primary care physician with complaints of frequent wheezy exacerbations. He has a medical history of chronic obstructive pulmonary disease and is an ex-smoker with a 35 pack-year history. He takes salbutamol as needed and denies any history of asthma or atopy. He does not consume alcohol.
During the examination, the patient appears comfortable at rest, and a mild expiratory wheeze is audible in the midzones. The jugular venous pulse is not elevated, and there is no peripheral edema.
The patient’s blood tests reveal normal levels of Hb, platelets, WBC, Neuts, Lymphs, Mono, Na+, K+, Urea, and Creatinine. Previous investigations did not show significant variation in FEV1 over time or substantial diurnal variation in peak expiratory flow.
What medication should be added to the patient’s regimen?
MRCP2-4403
A 75-year-old man presents to the respiratory outpatient clinic with complaints of shortness of breath during exertion. He has no significant medical history and is not on any regular medications. He has never smoked or consumed alcohol. The patient worked at a paper mill for 51 years.
Upon examination, the patient appears mildly dyspnoeic at rest, and bibasal inspiratory crackles are audible on auscultation. The patient’s fingers are clubbed, but cardiovascular examination is unremarkable.
A high-resolution CT scan of the chest reveals honeycomb lung, traction bronchiectasis, and parenchymal bands, with no pleural involvement.
What treatment is likely to be recommended for this probable diagnosis?
MRCP2-4409
An 80-year-old man presents to the emergency department with hemoptysis. He has a past medical history of hepatitis C. He declined anti-viral therapy.
On examination, he has a saddle nose deformity. There is a non-blanching rash on his lower limbs.
Plain radiography of the chest demonstrates bilateral infiltrates.
What test is most likely to be positive given the probable diagnosis?
MRCP2-4410
A 38-year-old woman with a history of tuberous sclerosis presents to the respiratory clinic with worsening dyspnea. Her primary care physician ordered a chest x-ray which revealed significant alterations. What is the complication that has arisen?
MRCP2-4411
A 68-year-old man is referred to the hospital by his GP due to a 6-day history of productive cough and shortness of breath. He is able to speak in full sentences without difficulty.
His vital signs are as follows: heart rate of 98 beats per minute, blood pressure of 110/79 mmHg, respiratory rate of 27 breaths per minute, and a temperature of 38.2°C.
Laboratory investigations reveal a hemoglobin level of 125 g/L (normal range: 130-180), a white blood cell count of 18.7 ×109/L (normal range: 4-11), neutrophils of 16.1 ×109/L (normal range: 1.5-7.0), platelets of 479 ×109/L (normal range: 150-400), sodium of 123 mmol/L (normal range: 137-144), potassium of 3.8 mmol/L (normal range: 3.5-4.9), urea of 8.1 mmol/L (normal range: 2.5-7.5), creatinine of 115 μmol/L (normal range: 60-110), and a CRP level of 210 mg/L (normal range: <10).
Based on the severity index CURB-65, what is the severity of pneumonia demonstrated by this patient?