Archives: MRCP Part 2

MRCP2-4364

A 38-year-old man presents to the Emergency department with a one week history of a non-productive cough and increasing breathlessness. He reports his breathing is much worse on exertion. His past medical history includes migraines and childhood asthma (but he has not used any inhaler in almost 30 years). He works in the pharmaceutical industry and often travels to India and Africa with work.

Examination reveals mild pyrexia of 37.8°C. Investigations are as follows: Hb 134 g/L (130-180), WBC 3.3 ×109/L (1.5-7), Plt 177 ×109/L (150-400), CRP 78 mg/L (<10), pH 7.35 (7.35-7.45), pO2 6.5 kPa (11.3-12.6), pCO2 5.8 kPa (4.7-6.0), LDH 310 U/L (10-250), CXR shows bilateral patchy infiltrates. What would be the most appropriate initial treatment regimen given the likely diagnosis?

MRCP2-4365

A 65-year-old man presents with a productive cough that has been ongoing for three days. He has been experiencing increasing shortness of breath over the past two days and reports feeling weak and lethargic. He also has a fever and rigors. His wife brought him to the emergency department as she is concerned about his rapid deterioration.

Upon examination, his heart rate is 125 beats per minute, respiratory rate is 32 breaths per minute, Sa02 is 90% on room air, temperature is 38.9º, and blood pressure is 130/84 mmHg. Although he appears distressed, he is not confused.

Initial investigations reveal a Hb of 134 g/l, platelets of 550 * 109/l, and WBC of 18 * 109/l. His electrolyte levels are within normal range, with Na+ at 141 mmol/l and K+ at 3.7 mmol/l. His urea level is 9.2 mmol/l and creatinine is 130 µmol/l. A chest x-ray shows left lower zone consolidation.

What is his CURB-65 score based on the given information?

MRCP2-4366

A 68-year-old man presents to the emergency department with a 24-hour history of shortness of breath. Additionally, he complains of a worsening cough with green sputum. He has a 25 pack-year smoking history and drinks 12 units of alcohol a week. He has a past medical history of COPD, for which he takes inhaled corticosteroids, formoterol and salbutamol.

Upon auscultation of his chest, there are crackles at the left base, no wheezes. He has a respiratory rate of 22 breaths per minute, a heart rate of 100 bpm, BP is 120/70 mmHg, SpO2 is 92% on 4L through a 28% Venturi mask, and he is afebrile.

A chest X-ray shows left lower zone consolidation.

An arterial blood gas shows the following:

HCO3 27 (22-26 meq/L)
pH 7.38 (7.35 – 7.45)
pCO2 6.1 (4.5 – 6.0 kPa)
pO2 9.9 (10 – 14 kPa)

You have prescribed appropriate IV fluids and administered IV co-amoxiclav and clarithromycin.

What is the most suitable additional treatment?

MRCP2-4367

A 28-year-old non-smoking Chinese woman arrives at the emergency department complaining of sudden left pleuritic chest pain and shortness of breath. She reports a gradual decline in her exercise tolerance over the past year. A chest x-ray reveals a large pneumothorax that is successfully aspirated. A follow-up chest x-ray shows resolution of the pneumothorax but reticulonodular changes in the bases bilaterally. A CT scan of the chest shows cystic changes in the lung bases with a minimal left-sided pleural effusion. What is the most likely diagnosis?

MRCP2-4368

A 60-year-old woman presents to the emergency department following a choking incident. She reports feeling short of breath and has a temperature of 37.8°C. Although she smokes 20 cigarettes per day, she has no prior history of respiratory issues, but did experience a stroke six months ago. Her general practitioner prescribed oral co-amoxiclav. A chest x-ray reveals a homogenous opacity at the right base, with the right hilum pulled downwards. What is the recommended next step in investigation?

MRCP2-4369

A 52-year-old woman presents to the chest clinic with a history of recurrent chest infections and occasional wheezing. She reports experiencing frequent flushing attacks and suspects she may be going through menopause. She has a history of smoking 10 packs of cigarettes per year.

Upon examination, a chest x-ray was ordered by her GP and the results indicate right upper lobe collapse. No masses were identified in the remaining lung fields and the heart appears normal. What is the probable diagnosis?

MRCP2-4370

A 70-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 has been experiencing a dull pain on the right side of her chest for the past month, which is partially relieved with ‘low dose’ co-codamol prescribed by her GP. She is a smoker, consuming 15 cigarettes a day, and her husband, who was a retired plumber, recently passed away due to a chest problem.

Upon examination, the patient appears cachectic and dyspnoeic. Chest examination reveals reduced expansion, vocal fremitus, breath sounds, and dull percussion note throughout the right lung. A chest x-ray shows a medium-sized pleural effusion on the right side, with thickening of the pleura in the right hemithorax.

What is the most likely diagnosis?

MRCP2-4371

A 45-year-old patient presents with a persistent cough and difficulty breathing during physical activity for the past few weeks. He has no personal medical history, but his mother was diagnosed with breast cancer at a young age. He has a history of smoking for 15 pack-years. During examination, he has a chest that appears to be hyper-expanded and bi-basal wheezing can be heard upon auscultation.

The spirometry results are as follows:
Investigation Result
FEV1 60% predicted
FVC 78% predicted
Residual volume (RV) 120% predicted
TLCO 70% predicted
KCO 68% predicted

What is the most likely diagnosis based on the above results?

MRCP2-4372

A 72-year-old woman in the ICU is extubated eight hours after a Hartmann’s procedure. The nurse calls you one hour later to evaluate the patient as she has developed stridor. She has a medical history of chronic asthma. What is a known risk factor for post-extubation stridor (PES)?

MRCP2-4373

A 30-year-old woman with cystic fibrosis attends the respiratory clinic with her partner. They are considering starting a family but have concerns about the impact of her asthma on pregnancy. She has had a few exacerbations in the past year but is currently well-controlled on inhaled corticosteroids. She works as a teacher. During her last exacerbation, a blood gas analysis showed a pH of 7.35 and a PaO2 of 70 mmHg on room air.
Investigations:

Haemoglobin 135 g/l 115–155 g/l
White cell count (WCC) 8.5 × 109/l 4–11 × 109/l
Platelets 250 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine 80 µmol/l 50–120 µmol/l
FEV1 85% of that predicted

What advice should be given to the couple regarding pregnancy?