Archives: MRCP Part 2

MRCP2-4397

A 62-year-old Nepalese woman who recently moved to the United Kingdom presents to her GP with a known multinodular goitre that has been untreated. Her daughter, who acts as a translator, reports that her mother has been experiencing a sensation of tightness in her neck, as if she is being strangled. This sensation is worse in the mornings and her daughter has noticed that her mother’s face appears puffy. The patient denies any weight loss, fevers, or night sweats. On examination, a large multinodular goitre is observed, measuring 15-20 cm in width and occupying a significant portion of the neck. Although there is no audible stridor, several neck veins are visible. When asked to stretch her hands up high, the patient complains of worsening tightness. Chest sounds are quiet and clear, but dull percussion is noted under the top third of the sternum. Laboratory results reveal a TSH of 0.07 mU/L (normal range 0.05-5.0), T4 of 10 pmol/L (normal range 9-50), and T3 of 4.0 pmol/L (normal range 3.5-7.8). D-dimer is 0.15 (normal range 0-0.25), and a chest x-ray shows a widened mediastinum with no focal lung lesion. What is the likely cause of the patient’s new symptoms?

MRCP2-4398

A 78-year-old woman presents to the Emergency Department with a 4-day history of shortness of breath and a cough productive of yellow sputum. There are no other symptoms of note and she has a history of hypertension. She takes medication for this condition. She has never smoked.
On examination, her Glasgow Coma Scale score is 15/15. She has a respiratory rate of 28 breaths per minute, and oxygen saturations of 93% on air. Her heart sounds are normal, with a heart rate of 110 bpm and a blood pressure of 140/80 mmHg. On chest auscultation, there are fine crackles at the right lung base.
Investigations:
s
Haemoglobin (Hb) 140 g/l 120 – 160 g/l
White cell count (WCC) 12.0 × 109/l 4.0 – 11.0 × 109/l
Neutrophils 8.5 × 109/l 1.5 – 7.0 × 109/l
Urea 5.0 mmol/l 2.5 – 6.5 mmol/l
Creatinine (Cr) 110 μmol/l 50 – 120 µmol/l

Which factor in this patient’s presentation is the most significant predictor of outcome?

MRCP2-4399

An 80-year-old woman presents to the rapid access chest clinic with a four-month history of progressive breathlessness, lethargy, anorexia, and a one stone weight loss. She is a housewife and smokes 15 cigarettes a day. Her husband, a retired plumber, recently passed away from a ‘chest problem’. The patient reports experiencing a dull right-sided chest pain for the last month, which is partially relieved with ‘low dose’ co-codamol prescribed by her GP. On examination, she appears dyspnoeic and cachectic. Examination of her chest reveals reduced vocal fremitus, percussion note, and breath sounds throughout the right lung. A chest x-ray shows a medium-sized right-sided pleural effusion, with thickening of the pleura in the right hemithorax. What investigation is most likely to lead to a diagnosis?

MRCP2-4374

A 28-year-old male patient complains of haemoptysis. He has been experiencing a productive cough since childhood and has a history of recurrent sinusitis. Additionally, he has been diagnosed with infertility. Upon investigation, his immunoglobulins were found to be normal, as was his sweat sodium level. Skin prick tests for grass pollen, house dust mite, and aspergillus were negative. What is the probable diagnosis?

MRCP2-4381

An 87-year-old man presents with a three-month history of increasing shortness of breath. He lives with his wife and is typically independent, but he is currently recovering from a hospitalization six months ago for pneumonia. He has lost 10kg in weight since before the admission, but denies any fevers or night sweats. He reports a constant dry cough and tightness in his chest at times. He takes ramipril for hypertension and has a history of childhood tuberculosis, but has never smoked.

On examination, he appears frail and has bilateral crepitations in the left mid and upper zones and right middle and lower zones. His respiratory rate is 24 breaths/min and his saturation is 92% at rest, dropping to 86% on standing with purple lips. He has a palpable heave and bilateral ankle swelling. His B-natriuretic peptide is within normal limits, but his CRP is elevated. His FEV1 is 87% predicted and his FVC is 75% predicted. His ECG shows right bundle branch block with a sinus rate of 70/min. His chest X-ray reveals reticular shadows bilaterally with reduced chest expansion.

An arterial blood gas in air shows a pH of 7.35, PaO2 of 7.9 kPa, PaCO2 of 6.8 kPa, and HCO3 of 28 mmol/l.

What is the most likely diagnosis?

MRCP2-4382

A 56-year-old woman with alcohol-related hepatic cirrhosis and portal hypertension presents to gastroenterology clinic for a follow-up after undergoing a transjugular intrahepatic portosystemic shunt (TIPS) insertion two months ago. She reports feeling breathless and experiencing reduced exercise tolerance over the past month. However, she denies any pain, confusion, or nausea. On examination, she exhibits signs of chronic liver disease, including palmar erythema, Dupuytren’s contracture, spider naevi, and leukonychia. Her chest is clear, and there are no abnormalities on cardiac auscultation except for a loud P2 sound. What is the most likely cause of her breathlessness?

MRCP2-4383

A 50-year-old retired coal miner with simple silicosis came to the clinic complaining of shortness of breath. He had retired early and was receiving a coal workers’ pension. He had been experiencing shortness of breath for the past three months. Interestingly, he had recently started keeping budgerigars as pets for the last three months. Upon auscultation, basal crepitations were heard, and a CXR revealed fine nodular shadowing in the apices. What is the probable diagnosis?

MRCP2-4384

A 67-year-old man presents to the respiratory clinic for a follow-up appointment regarding his COPD. During his last visit, his medications were increased to include regular inhaled Spiriva (tiotropium bromide), Symbicort (budesonide and formoterol), and salbutamol as needed. He reports experiencing shortness of breath at rest and during physical activity, which is limiting his daily activities. He has had two exacerbations in the past year and has been an ex-smoker for six months.

Upon examination, the patient is tachypnoeic with oxygen saturation levels of 92% on air. Bilateral wheezing is audible during auscultation, and his heart sounds are normal. The patient’s calves are soft and non-tender, with no signs of oedema.

Arterial blood gas results are as follows:

pH 7.35 (7.35 – 7.45)
PaO2 8.2 kPa (11 – 13)
PaCO2 5.1 kPa (4.7 – 6.0)
Haemoglobin 135 g/L (135 – 180)

FEV1 is less than 50% predicted.

What would be the most appropriate addition to this patient’s long-term management plan?

MRCP2-4385

A typically healthy 31-year-old black woman presents with a persistent fever and fatigue for the past few weeks. During the examination, she has a temperature of 38.2ºC, blood pressure of 115/70 mmHg, pulse of 75/min, and respirations of 18/min. Upon further examination, multiple non-tender cervical and axillary lymph nodes are found, and lung auscultation reveals fine crackles throughout bilaterally. A chest x-ray shows hilar lymphadenopathy with diffuse interstitial infiltrates, and a subsequent lymph node biopsy confirms non-caseating granulomas.

What is the most appropriate treatment for this patient?

MRCP2-4386

A 63-year-old man presents to the Emergency Department with sudden onset of left-sided chest pain and breathlessness. The pain came on suddenly while he was sitting in an armchair in front of the television and was described as sharp. The pain was followed almost immediately by a sensation of breathlessness.

His general health had been good, though he reported that he was usually breathless only on exertion, particularly walking up hills and walking up the stairs in his house. For several years he has had a productive cough in the morning, producing clear or white sputum which he attributes to a smoker’s cough. He had never noticed any blood in his sputum. His appetite was good and his weight has been steady.

He is a retired plumber who lived with his wife and two cats. He was a smoker of 20 cigarettes a day and had been since the age of 16 years; he drank approximately twelve units of alcohol per week. There was no family history of note and he had no known allergies. His regular prescribed medications included salmeterol 50 mg BD, tiotropium 18 mg OD, and Combivent PRN.

Investigations showed:

Haemoglobin 148 g/L (130-180)

White cell count 9.7 ×109/L (4-11)

Platelets 197 ×109/L (150-400)

Troponin T <0.03 U/L (<0.03) The ECG showed sinus rhythm, with a large P wave, but was otherwise unremarkable. The chest radiograph showed hyperinflated lung fields with a small apical left pneumothorax with a 3 cm margin between the lung surface and the chest wall. His oxygen saturations by pulse oximetry were 88% on room air. He was given 24% oxygen in the Emergency department, but remained dyspnoeic with oxygen saturations of 91% on 24% oxygen. What is the next step in managing this 63-year-old man with sudden onset of left-sided chest pain and breathlessness?