Archives: MRCP Part 2

MRCP2-4405

A 56-year-old man presents with a confirmed right adenocarcinoma of the bronchus. He reports weight loss over the past few months and a persistent cough, but is still able to work and care for his family. The following investigations were conducted:

Haemoglobin (Hb): 130 g/l (normal range: 115-155 g/l)
White cell count (WCC): 6.2 × 109/l (normal range: 4.0-11.0 × 109/l)
Platelets (PLT): 180 × 109/l (normal range: 150-400 × 109/l)
Sodium (Na+): 142 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+): 4.2 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine (Cr): 110 μmol/l (normal range: 50-120 μmol/l)

Which of the following tests would be most useful in determining his eligibility for surgery?

MRCP2-4406

A 50-year-old male presents to the emergency department with a worsening cough and breathlessness that has been going on for the past four weeks. He reports a productive cough with haemoptysis and admits to fevers and weight loss over this time.

His medical history includes type 2 diabetes mellitus. He currently smokes 20 cigarettes per day and drinks approximately 60 units per week.

Upon examination, an unkempt, cachectic man is observed with bronchial breath sounds in the right upper zone.

The chest X-Ray shows right upper lobe consolidation with a ‘bulging fissure sign’. What is the most likely causative organism?

MRCP2-4407

A 65-year-old man with a recent diagnosis of idiopathic pulmonary fibrosis is seen in respiratory clinic for follow-up after initial baseline investigations. He has been experiencing worsening shortness of breath for the past nine months along with a non-productive cough. Despite attempts by his GP to treat him with inhalers and antibiotics, his symptoms have not improved. The patient has a medical history of hypertension, depression, and gout, and is understandably anxious about his prognosis. What is the most effective test for determining prognosis in this case?

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?

MRCP2-4408

A 29-year-old female patient presents to your clinic with a persistent cough that worsens at night, wheezing, and difficulty breathing for the past two months. She has been producing brownish mucous plugs and has recently experienced fatigue during normal activities. Additionally, she has had episodes of haemoptysis in the last two weeks. The patient has a family history of atopy and had asthma in the past, which she has outgrown. On examination, she appears slightly dyspnoeic at rest, with an expiratory wheeze being the only significant finding. Her respiratory function tests reveal a Forced Expiratory Volume of 1.40 L, Forced Vital Capacity of 2.90 L, and Peak Expiratory Flow Rate of 200 L/min. The chest radiograph shows dilated bronchioles with a shadow in the mid-lung zones. What is the most likely diagnosis?

MRCP2-4402

A 12-year-old patient is referred to the respiratory outpatient clinic with recurrent chest infections associated with purulent sputum. His family life is chaotic and his parents frequently did not bring him to routine hospital appointments.

On examination, there are bilateral coarse crackles heard on chest auscultation, which clear on coughing. He is of thin body habitus. The nails are normal.

A chest x-ray shows evidence of bronchiectasis. A sputum sample grows Burkholderia cepacia. Genetic testing reveals that he is homozygous for the delta F508 mutation.

What is an appropriate treatment option for this likely diagnosis?

MRCP2-4414

A young couple, Mr and Mrs Y, seek your advice. Mrs Y is currently six weeks pregnant. Mr Y’s sister and her partner had a child with cystic fibrosis. After being screened, Mr Y was found to carry the DF508 mutation for cystic fibrosis. Mrs Y is hesitant to undergo testing. Given that the gene frequency for this mutation in the general population is 1/20, what is the likelihood of their child having cystic fibrosis?

MRCP2-4413

A 54-year-old man comes to the respiratory clinic complaining of a dry cough and shortness of breath that have been progressively worsening over several months. He has a medical history of hypertension and depression, takes only ramipril, and has no allergies. During the examination, bilateral inspiratory crackles are heard at both lung bases. A chest X-ray reveals extensive pleural plaques. The patient worked as an electrician 20 years ago and suspects that he may have been exposed to asbestos. Asbestosis with extensive pleural plaques is suspected. What are the expected results of his pulmonary function tests?

MRCP2-4412

A 32-year-old man weighing 225 kg was referred for investigation of breathlessness before his gastropexy operation. He reported feeling short of breath after walking just 100 yards and also complained of a non-productive cough upon waking each morning. The patient had a medical history of type 2 diabetes mellitus and childhood asthma and rhinitis. He smoked 20 cigarettes per day and consumed at least 10 units of alcohol every evening. He lived with his father who had kept pigeons for the past five years. Full pulmonary function tests were conducted, and the results are shown below. Based on this information, what is the most likely cause of his breathlessness?

Actual % predicted
FVC (l) 3.72 61
FEV1(l) 3.05 64
FRC (l) 1.42 34
RV (l) 1.01 45
TLC (l) 4.94 60
DLCO (ml/m/mm Hg) 29.13 61
DLCO/VA 4.95 94

MRCP2-4404

A 58-year-old man presents with confusion, fever, and decreased oral intake. He has a medical history of type 2 diabetes mellitus, hypertension, osteoarthritis, and gout. Blood cultures reveal E. coli infection, and despite antibiotic treatment, he develops respiratory failure. The patient is intubated and placed on mechanical ventilation with an FiO2 of 70%, tidal volume of 370 ml, and respiratory rate of 14/min.

The current arterial blood gases are:

pH 7.45
pO2 7.86 kPa
pCO2 3.99 kPa
HCO3 21 mmol/l

What is the most appropriate next step in managing this patient?