A 79-year-old man with a history of chronic obstructive airways disease (COPD) is being discharged from the hospital after being admitted for an infective exacerbation. He has completed a seven-day course of prednisolone and is no longer on antibiotics. However, his room air Sa02 remains at 91%, indicating hypoxia. The patient’s blood work shows a hemoglobin level of 134 g/l, platelet count of 350 * 109/l, and a white blood cell count of 10.2 * 109/l. Arterial blood gas analysis reveals a Pa02 of 7.8 kPa, PaCO2 of 6.5 kPa, and HCO3- of 30 mmol/L. The patient’s wife inquires about the possibility of having oxygen at home. What additional tests are necessary to determine if this patient would benefit from long-term oxygen therapy?
MRCP2-4313
A 26-year-old woman with a history of cystic fibrosis presents to the endocrinology clinic for evaluation. She has been experiencing weight loss and her recent fasting plasma glucose level was measured at 8.1 mmol/l. She has had three hospital admissions in the past year due to exacerbations of her CF. On physical examination, her blood pressure is 122/81 mmHg, pulse is regular at 71 beats per minute, and coarse crackles and scattered wheezing are heard on chest auscultation. Her abdomen is soft and non-tender, and her body mass index is 19.5 kg/m². What is the optimal approach to managing her diabetes?
MRCP2-4307
A 53-year-old man with no prior medical history presents to the Emergency Department with a dry cough, shortness of breath, abdominal discomfort, nausea, vomiting, diarrhea, and headache. He recently returned from a convention in Spain. On examination, he has bi-basal crackles, is pyrexial, and has a blood pressure of 123/67 mmHg, a pulse of 92/min, and a respiratory rate of 22/min. Investigations reveal a high white cell count, low sodium and potassium levels, elevated creatinine and C-reactive protein levels, and protein and blood in his urine. What is the likely diagnosis?
MRCP2-4315
A 26-year-old pregnant woman who is 28 weeks along suddenly experiences shortness of breath and slight left-sided chest pains. She has no cough or haemoptysis and no history of long flights or leg swelling. On examination, she appears anxious with a blood pressure of 110/60 mmHg, pulse rate of 92/min, and respiratory rate of 26/min. Her abdomen is distended, and fetal movements are seen. Investigations reveal a low probability of pulmonary embolism (PE) on a V/Q scan, but her D-dimer levels are elevated. What would be the most appropriate step in her immediate management?
MRCP2-4312
A 50-year-old woman presents with an increasing cough and shortness of breath that has been worsening over the past year. She has experienced multiple chest infections in the last six months. Although she used to smoke 10 cigarettes a day, she quit eight years ago. She has no known allergies and works as a hairdresser. A chest x-ray came back normal. Pulmonary function testing revealed an FEV1 of 1.60 L (53% predicted), FVC of 2.86 L (78% predicted), total lung capacity of 4.83 L (110% predicted), TLCO of 6.63% (93% predicted), and KCO of 1.36 (120% predicted). What is the most likely diagnosis?
MRCP2-4316
A 16-year-old male is brought to the resuscitation area of the emergency department with an acute exacerbation of asthma. This is his second hospital visit this winter. He has widespread wheezing, poor air entry, and appears fatigued. He struggles to complete full sentences. Upon checking his arterial blood gases, the results are as follows:
pH 7.4 PaO2 9.3 kPa PaCO2 3.3 kPa HCO3- 26 mmol/L
The patient is given 100% oxygen, high dose steroids, back to back salbutamol nebulisers, and an intravenous magnesium sulphate infusion. After an hour, his arterial blood gases are checked again and the results are:
An 80-year-old woman presents with worsening breathlessness and a productive cough. She has a history of exertional dyspnoea for two years, which has recently become more severe. She was a heavy smoker until three months ago and currently takes Beclasone, salmeterol, and Ventolin. On examination, she is obese with a BMI of 32 kg/m2, cyanosed, and pale. She has no clubbing or lymphadenopathy, but her chest is hyperinflated with expiratory wheezes and she has bilateral swollen ankles. After treatment with nebulised bronchodilators, oxygen therapy, prednisolone, antibiotics, and diuretics, she improves and is discharged home. Six weeks later, her arterial blood gas analysis shows a PaO2 of 6.9 kPa and a PaCO2 of 6.8 kPa, and her pulmonary function testing reveals an FEV1 of 0.9 l and an FVC of 4.2 l. What is the primary indication for long-term domiciliary oxygen therapy in this patient?
MRCP2-4301
A 20-year-old Caucasian male presents with a two-day history of epigastric pain accompanied by nausea and vomiting. He was admitted under the surgical team for management of acute pancreatitis due to an elevated serum amylase level. The surgical team has requested a medical consult as the patient reports a worsening productive cough.
During your assessment, the patient reports that this is his third presentation with acute pancreatitis. He does not consume alcohol, and an ultrasound of the abdomen did not reveal any gallstones. The cough has been present for several months, initially dry but now productive of green sputum with no haemoptysis. He denies fever, chills, chest pain, and dyspnoea. Three weeks ago, he received a course of oral antibiotics from his General Practitioner after presenting with nasal congestion and mild facial pain. He states having had multiple courses of antibiotics in the past for similar presentations.
There is no significant past medical history or family history.
The patient takes no regular medications and has been receiving simple analgesia and intravenous crystalloid fluids under the surgical team’s care. He is a lifelong non-smoker and works full time in administration.
On examination, the patient’s height was 178cm with a weight of 58kg, heart rate 90/minute, blood pressure 100/60 mmHg, temperature 37.2ºC, respiratory rate 16/min, and oxygen saturation 94% on room air. Respiratory examination revealed early clubbing, no cervical lymphadenopathy, a central trachea, normal chest expansion, mild coarse inspiratory crepitations that improved somewhat after coughing at both posterior bases. Abdominal examination revealed mild epigastric tenderness but no signs of peritonism. Remaining clinical examination was unremarkable.
Sputum microscopy and culture results revealed Pseudomonas aeruginosa.
What is the most appropriate management for this patient?
MRCP2-4303
A 63-year-old man with metastatic small cell lung cancer is admitted with shortness of breath, cough, and purulent sputum. His chest x-ray reveals a right lower lobe pneumonia with partial collapse of the right lung. The right hilum has a bulky primary tumor and extensive hilar lymphadenopathy. He receives IV antibiotics, fluids, and oxygen, and his symptoms improve over the next five days. He is comfortable on 2 liters of oxygen via nasal cannulae and his pain is controlled on 20mg long-acting morphine sulfate twice daily. The decision is made to discharge him to a hospice for end-of-life care. However, due to the proximity of his lung tumor to major vessels, he is at risk of a major terminal bleed. What medication should the hospice be advised to administer in the event of a major bleed?
MRCP2-4302
A 65-year-old man presents to the emergency department with a two month history of productive cough. He reports feeling increasingly worse over the past week and experiencing feverish symptoms. He mentions that he often coughs up large amounts of mucous, but this time it is much worse and he suspects an infection. The patient discloses that he is regularly under the care of the respiratory team for a lung condition, but cannot provide further details. He is a non-smoker.
Upon examination, the patient appears sweaty and has a temperature of 38.2ºC. His heart rate is 103/min and his capillary refill time is 3 seconds. Blood pressure is 102/54 mmHg. Coarse crackles are heard bilaterally and on the right mid-zone. Heart sounds are normal with no added sounds.
A chest x-ray reveals increasing bronchovascular markings with bilateral consolidation.
Reviewing the patient’s medications, it is noted that he is on salbutamol and ipratropium nebulisers, carbocisteine, aspirin, and ramipril. The patient also mentions that he has been taking ciprofloxacin for 14 days as prescribed by the respiratory team due to an organism isolated in his sputum. Upon further investigation, it is discovered that the patient has previously grown Pseudomonas aeruginosa.
Given the patient’s penicillin allergy, what antibiotic would be appropriate to prescribe in this setting?
Answer: Appropriate treatment of Pseudomonas positive bronchiectasis failing to respond to ciprofloxacin includes IV tazocin, ceftazidime, aztreonam or meropenem. Given the patient’s penicillin allergy, the safest choice is meropenem. Nebulised colomycin has a place in the treatment of these patients, but not in the acute setting.