Archives: MRCP Part 2

MRCP2-4298

A 67-year-old man presents with two episodes of mild haemoptysis in the past 4 months. He has also lost 6 kilograms of weight in the past 4 months. He is a smoker with a 55 pack years history and a social drinker. He is actively mobile and has no significant past medical history.

On clinical examination, there are no abnormalities except for clubbing.

A contrast-enhanced CT chest reveals a 4 cm mass in the right upper lobe periphery close to the chest wall and enlarged right hilar (2 cm) and subcarinal (2 cm) lymph nodes. A positron emission tomography (PET) scan is performed, which shows a standard uptake value (SUV) max of 20 for the lung mass. The ipsilateral hilar and subcarinal lymph nodes are also found to be FDG (fluorodeoxyglucose) avid. There is no evidence of distant metastasis.

What is the next appropriate step in managing this patient?

MRCP2-4300

A 35-year-old construction worker presents to the Pulmonary Clinic for evaluation. He has been previously diagnosed with asthma by his primary care physician and is currently being treated with high-dose fluticasone/salmeterol and salbutamol, but his symptoms have not improved. Upon examination, his blood pressure is 120/70 mmHg, with a regular pulse of 75/min. Coarse crackles and scattered wheezing are heard during chest auscultation. Respiratory function tests reveal an obstructive pattern. A thoracic HRCT scan shows centrally dilated thickened airways with signet rings. Which test would be the most helpful in confirming the suspected diagnosis?

MRCP2-4292

The following arterial blood gases (ABGs) were taken from an unconscious 50-year-old woman in the Emergency department on FiO2 of 21%:
pH 7.36 (7.36-7.44)
pO2 13.0 kPa (11.3-12.6)
pCO2 3.7 kPa (4.7-6.0)
HCO3− 15 mmol/L (20-28)

What is the correct interpretation of the ABG result?

MRCP2-4290

A 57-year-old woman with a history of asthma attends her respiratory clinic appointment. She has been hospitalized twice in the past year due to exacerbations and also has hypothyroidism and angina. Her current medications include tiotropium, fluticasone, levothyroxine, simvastatin, aspirin, and GTN spray. During her last appointment, she was prescribed theophylline at a standard dose and completed a course of ciprofloxacin for a mild exacerbation. She is a smoker and has allergies to pollen.

Upon examination, she presents with a dry cough but is able to speak in full sentences. Her chest shows scattered wheezing throughout.

Lab results show a Na+ level of 145 mmol/l, K+ level of 3.9 mmol/l, urea level of 4.2 mmol/l, creatinine level of 56 µmol/l, and a theophylline level of 6 mcg/ml (normal range 10-20). Additionally, her chest x-ray shows hyperexpanded lung fields and her TSH level is 5.2 mU/l.

What could be the possible reason for her subtherapeutic theophylline level?

MRCP2-4296

A 70-year-old man comes to the medical clinic for a check-up. He has been diagnosed with COPD for five years and is currently taking a combination budesonide and formoterol fumarate inhaler and salbutamol inhaler as needed. He reports experiencing frequent coughing episodes and a decrease in his exercise tolerance.

The patient’s medical history includes macular degeneration, osteoarthritis, mild memory impairment, and diverticulosis. He has noticed that he can no longer walk the full distance to the local shop, which is approximately one mile away, and has to stop halfway to catch his breath.

What diagnostic test would be most beneficial in assessing the severity of his COPD?

MRCP2-4293

A 65-year-old homeless man is brought in for routine medical assessment. He has experienced a considerable weight loss in recent months and is now experiencing worsening shortness of breath. He used to be a heavy smoker. During the examination, reduced air entry is noted in the lower right chest, and percussion reveals dullness. A chest X-ray shows a significant pleural effusion on the right side. A pleural aspiration is carried out.
What is the most specific indicator of probable underlying malignancy if present in this case?

MRCP2-4291

A 42-year-old woman with a history of asthma and frequent use of oral corticosteroids is seeking information on available vaccinations. Which vaccination would be recommended for her?

MRCP2-4297

A 60-year-old retiree is admitted to the Medical Unit with a 2-day history of wheeze and exacerbation of COPD during peak flu season. She has had this diagnosis for six years, since moving from her home in the Midwest to the East Coast. She also has a history of seasonal allergies since moving to the East Coast, and her son has developed asthma too. She has no other past medical history and is a non-smoker.

Investigations:

Haemoglobin 120 g/l 115–155 g/l
White cell count (WCC) 8 × 109/l 4–11 × 109/l
Eosinophils 0.5 × 109/l 0–0.4 × 109/l
Platelets 300 × 109/l 150–400 × 109/l

Her lung fields on the chest X-ray show minor patchy shadowing.

Which additional test would you choose to perform to best rule out other causes, besides COPD, of her wheeze and current exacerbation?

MRCP2-4295

A 28-year-old teacher with breast cancer presents to the emergency department complaining of chest pain, cough, and difficulty breathing. She recently completed her last round of chemotherapy and is not currently on any treatment. She has no known allergies and no significant medical history.

Upon examination, the patient is visibly struggling to breathe and has a fever of 38.5°C. Pulse oximetry reveals her oxygen saturation to be 92%. Chest examination shows dullness on percussion in the left lower lung region, increased vocal resonance, and crackles on auscultation. To confirm the suspected diagnosis, a transbronchial biopsy is performed. The specimen stains positive for Gomori methenamine silver and haematoxylin & eosin stains, and galactomannan testing is positive.

What is the most likely diagnosis?

MRCP2-4294

A 26-year-old man presents to the Emergency department after being found unconscious by his girlfriend. He has a history of anxiety and depression and is currently taking benzodiazepines and tricyclic antidepressants. According to his girlfriend, he ingested 50mg of diazepam and 500mg of amitriptyline, and left a suicide note and an empty bottle of vodka next to his body. He also has a history of well-controlled asthma with high dose inhaled corticosteroids.

On examination, the patient is drowsy with a Glasgow coma score of 7. His vital signs are as follows: temperature of 34.8°C, pulse of 120 beats per minute, and blood pressure of 80/50 mmHg. Bronchial breath sounds are heard over the right upper zone, and a chest x-ray reveals right upper lobe consolidation.

Arterial blood gases on 15 L of oxygen per minute via a reservoir bag mask show a pH of 7.2, PaCO2 of 9.5 kPa, PaO2 of 12.0 kPa, and HCO3 of 27.3 mmol/L.

What is the most appropriate management for this patient?