Archives: MRCP Part 2

MRCP2-4319

A 35-year-old woman presents to the Emergency Department with a persistent dry cough and low-grade fever for the past three days. She reports difficulty sleeping due to the cough. She smokes five cigarettes per day, drinks occasionally, and works as a teacher. Her blood pressure is 118/80 mmHg, and her pulse is 82 bpm and regular. She is afebrile. Upon examination, her chest is clear.
The following investigations are conducted:
Haemoglobin (Hb): 142 g/l (normal range: 120-160 g/l)
White cell count (WCC): 8.0 × 109/l (normal range: 4.0-11.0 × 109/l)
Platelets (PLT): 195 × 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): 95 µmol/l (normal range: 50-120 µmol/l)

What is the most appropriate course of action for managing this patient?

MRCP2-4320

A 35-year-old patient with a history of asthma is brought to the Emergency Department after experiencing a severe asthma attack. Upon arrival, the patient is visibly cyanotic, with a respiratory rate of 10 breaths/min and a heart rate of 50 bpm. High-flow oxygen is administered through a non-rebreather mask. Suddenly, the patient experiences respiratory arrest, but still has a radial pulse of 55 bpm. During intubation attempts, the patient begins to vomit.

What is the most immediate course of action in this situation?

MRCP2-4321

As the pediatric SHO, you are admitting a 5-year-old asthma patient with an exacerbation of his asthma with a cough and severe wheeze that has been worsening over the past two days. He is normally on regular, short-acting β-agonist only and his predicted peak flow is 300 l/min. You are concerned that he may need review by the intensive care team.

On examination in the Emergency Department, his blood pressure (BP) is 100/60 mmHg, with pulse 120/min and regular. He has severe bilateral wheeze and his respiratory rate is 32/min.

Investigations:

PaO2 9.8 kPa 10.5–13.5 kPa
PaCO2 4.2 kPa 4.6–6.0 kPa
pH 7.38 7.35–7.45
PEFR 120 l/min (300 predicted)

Which of the findings is most concerning?

MRCP2-4322

A 35-year-old construction worker is admitted with a fracture of his left femur, which he sustained on the job. He is put on traction in the ward and he is scheduled for theatre two days later. On the eve of the procedure he is seen by the house officer because of an episode of chest pain. Clinical examination is unremarkable except for a rash on his chest. His MRI and X-ray are reported as normal, and the patient is prescribed some pain medication.

The following morning the patient is taken to theatre as planned. While in the anaesthetic room he is noted to have a respiratory rate of 20/min and oxygen saturations of 90% on room air. His heart rate is 110 beats/min regular and his blood pressure is 95/70 mmHg. His heart sounds are normal and there are crackles on auscultation of his chest bilaterally. His jugular venous pressure is raised to 6 cm. There is no peripheral edema.

His ECG shows right axis deviation with prominent R waves on leads V1–V2.

What would be the appropriate next step in this patient’s management?

MRCP2-4323

A 68-year-old man presents to the clinic with complaints of insomnia, daytime sleepiness, and early morning headaches. He has a medical history of cholecystectomy and gout, and takes no regular medications. Examination is unremarkable. Laboratory results show a hemoglobin level of 161 g/l, white cell count of 6.4 × 109/l, platelets of 94 × 109/l, mean corpuscular volume of 101 fl, thyroid-stimulating hormone level of 1.2 mu/l, and glucose level of 8.2 mmol/l. What is the optimal long-term management plan for this patient?

MRCP2-4324

A 26-year-old male patient arrives at the Emergency department complaining of pleuritic chest pain that started two hours ago. He reports no difficulty in breathing and his oxygen saturation level is at 96% without supplemental oxygen. A chest x-ray is ordered and a CT1 notices a small apical pneumothorax measuring 1.8 cm. Based on current guidelines, what is the recommended intervention for this patient?

MRCP2-4326

A 32-year-old man presents to the Emergency Department with sudden-onset right-sided pleuritic chest pain. Her past medical history includes frequent shoulder dislocations. He is not taking any medications.

Upon examination, he is tall with long arms and appears short of breath and diaphoretic. Vital signs show a heart rate of 100 bpm, blood pressure of 120/70 mmHg, respiratory rate of 20 breaths per minute, and oxygen saturations of 97% on room air. There is decreased breath sounds on the right side and a ‘pop’ on auscultation. A chest X-ray reveals a 3-cm pneumothorax on the right.

What is the most appropriate course of action for this patient?

MRCP2-4327

A 25-year-old male presents to the Emergency department complaining of chest pain and difficulty breathing. Upon examination, a significant right-sided pneumothorax is identified and promptly treated with chest tube drainage. Interestingly, this patient had a similar episode six months prior, which was also treated successfully with chest tube drainage. He has no history of smoking or any other significant medical conditions. After 24 hours, his lung has fully re-expanded and he is in stable condition. What is the next appropriate step in managing this patient?

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.

What is the most appropriate next step?

MRCP2-4329

A 49-year-old man, admitted for a routine hernia surgery, was found to have a pneumothorax on his pre-operative chest X-ray. He has a past medical history of chronic bronchitis and a smoking history of 45 pack-years. The chest X-ray reveals a 2.5 cm unilateral pneumothorax. Although he is not experiencing shortness of breath, he is experiencing chest discomfort.
What would be the optimal approach to manage this clinical situation?