Archives: MRCP Part 2

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?

MRCP2-4387

A 26-year-old asthmatic patient arrives at the emergency department with complaints of increased shortness of breath, wheezing, and a productive cough for several days. Upon examination, the patient has a respiratory rate of 40 breaths per minute and oxygen saturations (SpO2) of 88% on high flow oxygen. The patient’s blood pressure is 160/70 mmHg and pulse rate is 100 beats per minute. The peak expiratory flow rate is 35% of predicted, and the patient is unable to complete sentences. However, the PaCO2 is within the normal range. What feature of acute life-threatening asthma is present in this patient?

MRCP2-4361

A 67-year-old retired farmer presents with a 3-week history of increasing shortness of breath, non-specific non-pleuritic chest pain and weight loss. His medical history includes previous angina and hypertension. He is known to keep racing pigeons in a barn on his property and is an active smoker with a 35 pack year history. On examination, bilateral clubbing and tar staining are noted. Respiratory examination revealed a respiratory rate of 20 breaths per minute, sats 93% on air, reduced bilateral chest expansion and reduced air entry in both bases associated with dullness to percussion.

A chest radiograph demonstrates moderate right >left bilateral pleural effusions and patchy opacities across both lung fields in a non-lobar distribution. CT thorax with high-resolution slices demonstrates bilateral pleural effusion, thickened pleura with no lung parenchyma abnormalities.

Lung function testing demonstrates FEV1 1.8ls, FVC 60% of predicted.

What is the most appropriate next investigation?

MRCP2-4362

A 60-year-old man presents with a four-week history of pleuritic chest pain, shortness of breath, and dry cough. He has also experienced a weight loss of nearly 10 kg in the past six months. The patient had a myocardial infarction 20 years ago but has not experienced any exertional chest pain since. He lives alone and has not seen his general practitioner in two years, but has recently visited twice for mild recurrent pain in his left knee. He is an ex-smoker of 15 cigarettes per day and quit smoking 10 years ago. He takes only aspirin. On examination, his chest has reduced expansion, a dull percussion note, and decreased breath sounds on the right. A chest x-ray confirms a right-sided pleural effusion. Analysis of a pleural aspirate reveals a pleural fluid protein content of 42 g/L and pleural fluid glucose of 2.0 mmol/L. What is the likely diagnosis?

MRCP2-4363

A 72-year-old man visited his GP complaining of a persistent cough. He has been smoking 10 cigarettes a day since he was 16 years old. The GP ordered a chest x-ray which showed calcification on both hemidiaphragms and clear lung fields, leading to a referral to the outpatients’ department. The patient had worked in a shipyard for eight years fifty years ago. He had no significant medical history, except for occasional heartburn and nocturia. He lived alone and raised pigeons. On examination, his pulse was 74 beats per minute, blood pressure was 155/75 mmHg, and there were no respiratory abnormalities detected. Which statement below is accurate?