A 85-year-old male presents with his fourth admission of right lower zone community-acquired pneumonia in 6 months. A CT thorax demonstrates a 2.5cm mass in right lower lobar bronchus with no regional lymph nodes. Bronchoscopy reveals non-small cell lung Ca 3.5cm from the carina, CT staging reveals no other metastases. A final staging diagnosis of T1b N0 M0 is made, at stage 1A. The patient undergoes lung function testing as follows:
FVC 2.1l FEV1 1.6l/s TLCO 40% of predicted
What is the most appropriate treatment?
MRCP2-4342
A 45-year-old woman complains of excessive daytime sleepiness, which is affecting her job performance. She also reports morning headaches and her partner complains of loud snoring. She is a moderate smoker and drinks about six glasses of wine per night. Her exercise tolerance is limited to walking short distances before feeling breathless. Upon examination, her BMI is 35 kg/m2. An arterial blood gas taken at 10 pm shows: PaO2 9.5 kPa 10.5–13.5 kPa PaCO2 8.0 kPa 4.6–6.0 kPa A repeat arterial blood gas the next morning shows: PaO2 9.9 kPa 10.5–13.5 kPa PaCO2 8.2 kPa 4.6–6.0 kPa What is the most likely diagnosis for this patient?
MRCP2-4335
A 20-year-old male visits his doctor complaining of a persistent cough and fever for the past 2 weeks. He initially thought it was just a cold, but his symptoms have been getting worse. He is worried because he supports his elderly parents financially, who recently returned from a trip to China. Upon further questioning, he reveals that he has lost his appetite and experiences night sweats that soak his bed sheets. Based on his medical history and physical examination, the doctor suspects tuberculosis and urgently refers him to a Chest Clinic for confirmation. Tests confirm the diagnosis, and the patient is started on standard treatment for pulmonary tuberculosis. However, when he returns to the doctor several weeks later, he reports a decline in his vision since his diagnosis. What is the most likely cause of this side effect?
MRCP2-4338
A 23-year-old man presents to rheumatology clinic with chronic lower back pain and early morning stiffness. He has a history of asthma and regularly uses steroid inhalers, experiencing multiple exacerbations annually. He is scheduled to see a respiratory physician for better management of his symptoms. During clinical examination, Schober’s sign is observed. Pelvic X-rays reveal sacroiliitis, leading to a diagnosis of ankylosing spondylitis. The patient expresses concern about using NSAIDs to manage his symptoms. What factor may indicate NSAID-sensitive asthma?
MRCP2-4333
A 22-year-old male presents to the hospital with sudden onset of sharp chest pain and difficulty breathing on the left side. Upon examination, he appears mildly breathless at rest with a regular pulse of 100 beats per minute and blood pressure of 125/60 mmHg. A chest x-ray reveals a left pneumothorax with a visible 4 cm rim of air around the left lung. His oxygen saturation on air is 98%. What is the best course of action for management?
MRCP2-4343
A 42-year-old woman presents to the endocrine clinic with a 2-year history of constant fatigue. She works as a nurse and has had difficulty staying awake during her shifts. She also experiences difficulty concentrating during the day and has frequent morning headaches. Her husband reports that she is restless at night and snores loudly, occasionally having episodes of choking. She has also noticed a decrease in her libido. She is a smoker of 20 cigarettes per day and drinks 2 glasses of wine every night. She takes an inhaler for asthma and has had a chronic cough with sputum for several years.
During the examination, she was found to be clinically obese with a BMI of 33 and had early pitting ankle edema. Her heart sounds were normal, but there was some scattered wheezing in the chest. What would be the most practical investigation to establish the diagnosis?
MRCP2-4337
A 32-year-old woman comes to the Emergency Department complaining of feeling unwell for the past few days. She reports having had a cold for the last four days. She has a dry cough, headache, fever, malaise, and muscle pains. Upon examination, she appears unwell with a blood pressure of 120/70 mmHg, pulse of 88 beats per minute, and a respiratory rate of 20 breaths per minute. Her oxygen saturation is 96% on air. Crackles are heard in both lung fields upon auscultation. Her cardiovascular and abdominal examinations are normal. The following investigations are conducted: s Haemoglobin (Hb) 120 g/l 135 – 175 g/l White cell count (WCC) 11.5 × 109/l 4.0 – 11.0 × 109/l Platelets (PLT) 320 × 109/l 150 – 400 × 109/l Sodium (Na+) 133 mmol/l 135 – 145 mmol/l Potassium (K+) 3.8 mmol/l 3.5 – 5.0 mmol/l Creatinine (Cr) 98 µmol/l 50 – 120 µmol/l Mean corpuscular volume (MCV) 92 fl 80 – 100 fl C-reactive protein (CRP) 92 mg/l < 10 mg/l Blood film Fragmented red cells, reticulocytosis Coombs’ test + What would be the appropriate treatment for this patient?
MRCP2-4341
A 65-year-old man is admitted with an infective exacerbation of COPD. He normally has a productive cough but has been bringing up large quantities of sputum and estimates about 1 cup of yellow sputum with streaks of blood being produced a day.
He takes steroid nose drops and had endoscopic surgery for recurrent sinusitis 5 years ago. He lives alone independently and drives a car. He can usually walk 50-100 metres on the flat.
He arrives to the emergency department in extremis. There is accessory muscle use and widespread coarse crepitations in both lungs. His heart sounds are normal with no signs of cardiac failure. He is started on antibiotics, steroids, aminophylline and back to back nebulisers. He continues to produce lots of phlegm and the nurses suction to clear a yellow mucoid substance from his mouth. He responds to commands, his eyes open to voice. and he is talking in normal words but his thoughts are incoherent. He is started on non invasive ventilation and tolerates the mask. He continues to cough producing a 20ml plug of sputum with dried clot whilst given his first nebuliser. The respiratory registrar decides that NIV should be stopped.
What is the contraindication to non invasive ventilation in this case?
MRCP2-4344
A 56-year-old accountant has been referred by his doctor due to complaints of constant fatigue. He has a history of depression and is currently taking antidepressant medication as prescribed by his GP. Recently, he had to resign from his job as he found it difficult to drive long distances and almost got into a car accident due to sudden swerving. He has gained 3 stone in weight over the past three years, which he attributes to his depression. During his check-up, his blood pressure was found to be high at 170/100 mmHg. What investigation is most likely to provide an explanation for his symptoms?
MRCP2-4328
A 65-year-old man presents to the Emergency Department with a 1-day history of increasing shortness of breath. He also complains of sharp chest pain over the right side of his chest. His past medical history includes chronic obstructive pulmonary disease (COPD), for which he takes high-dose fluticasone and salmeterol (combined).
On examination, he has a respiratory rate of 24 breaths per minute, with oxygen saturations of 82% on room air. There is reduced air entry on the right side of his chest and there is hyperresonance to percussion.
A chest X-ray demonstrates a 1.8-cm right-sided pneumothorax. Needle aspiration is completed and the pneumothorax has reduced to 1.3 cm.