Archives: MRCP Part 2

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?

MRCP2-4286

A COPD patient arrives at the ER with a 2.2 cm simple pneumothorax. What is the best course of action for management?

MRCP2-4277

A 23-year-old male is being evaluated on the trauma ward 6 days after a car accident. He sustained multiple injuries, the most significant of which were a subdural hematoma, left-sided pneumothorax, and a tibial fracture. The patient was intubated initially, had a chest tube inserted, and underwent open reduction and internal fixation of the tibial fracture. The subdural hematoma was managed conservatively.

The patient was successfully extubated 2 days ago and has had his oxygen requirements gradually decreased. During today’s ward round, the patient reports that his breathing is improving, but he still experiences dyspnea on exertion and requires 2L via nasal cannula. The chest tube is swinging and has intermittent bubbling. There is good air entry heard throughout the chest.

What is the most appropriate action to take?

MRCP2-4284

A 57-year-old lady presents to the Emergency Department with complaints of palpitations and shortness of breath. She has a history of mild chronic obstructive pulmonary disease (COPD) and is currently taking salbutamol, ipratropium bromide, and beclomethasone inhalers. On examination, she is dyspnoeic with a blood pressure of 154/88 mmHg and a pulse rate of >100/min (AF). Her echocardiography 6 months ago showed normal ventricular function and no structural abnormality. The admission arterial blood gases (ABG) reveal a pH of 7.35, pa(O2) of 8.1 kPa, pa(CO2) of 6.2 kPa, and bicarbonate (HCO3-) of 28 mmol/l. After starting the patient on 28% oxygen and nebulisers (salbutamol 5 mg and ipratropium 0.5 mg) and repeating the blood gases after 30 minutes, the pH is 7.36, pa(O2) is 9.6 kPa, pa(CO2) is 5.8 kPa, and bicarbonate (HCO3-) is 29 mmol/l. However, the patient still reports palpitations. A 12-lead electrocardiogram (ECG) reveals multi-focal atrial tachycardia (MAT) with a rate of 118/min, and her blood pressure has fallen to 110/70 mmHg. How would you control this arrhythmia?

MRCP2-4278

A 28-year-old man presents to the emergency department with shortness of breath. He has no regular medications and denies using any recreational, herbal, or over-the-counter drugs. His medical history includes a wisdom tooth extraction 2 days ago.

Observations show a heart rate of 130 beats per minute, respiratory rate of 26 breaths per minute, blood pressure of 120/80 mmHg, temperature of 37.5 ºC, and SpO2 of 90%. Upon auscultation, his chest is clear.

The medical team starts the patient on 15L O2 via a non-rebreather mask.

Blood gas analysis results are as follows:

pH 7.26 (7.35 – 7.45)
PaO2 70.2 kPa (10.3 – 13.3 kPa)
PaCO2 3.1 kPa (4.7 – 6 kPa)
HCO3 18 mmol/L (22 – 28 mmol/L)
SaO2 46% (94 – 98%)
Lactate 3.5 mmol/L (<1.0) What is the most probable diagnosis?

MRCP2-4275

A 58-year-old man presents with fever, chest pain, and difficulty breathing. A chest x-ray reveals a significant pleural effusion on the left side.

Thoracic ultrasound confirms the presence of a large volume pleural effusion and a suitable site is marked for drainage. A chest tube is inserted without any complications and the drainage reveals purulent fluid. The patient’s condition improves post-procedure and vital signs remain stable.

After 24 hours, the pleural effusion shows significant improvement on x-ray and minimal fluid is draining. However, there is bubbling in the underwater seal which has been present since the insertion of the chest tube. Despite this, the patient’s condition continues to improve and the chest tube is still functioning properly.

What is the most likely diagnosis?

MRCP2-4288

A 30-year-old office worker presents with a productive cough of yellow sputum, mild wheeze, and mild dyspnoea that has been ongoing for a week. He has a smoking history of 1.5 packs per year but has been otherwise healthy. Upon examination, his blood pressure is 120/90 mmHg, heart rate is 80 beats/minute, and oxygen saturation is 98% on room air. There is a mild wheeze on auscultation, but his chest is otherwise clear.

Lab results show a hemoglobin level of 140 g/l, platelet count of 350 * 109/l, and a white blood cell count of 13 * 109/l. A chest x-ray reveals no abnormalities.

What is the appropriate management for this patient?

MRCP2-4289

A 50-year-old woman comes to the clinic with a cough that has been getting worse for four months. She has been coughing up blood and has difficulty breathing when she exerts herself. She has lost over 8 kg and has a reduced appetite. She started smoking when she was a teenager and currently smokes 15 cigarettes a day. She has been diagnosed with small cell lung cancer and her staging CT shows T1a N2 M0. At her follow-up appointment in the oncology clinic, what should be considered as the first-line treatment option?

MRCP2-4285

A 57 year-old male presents with a 3 hour history of chest pain and breathlessness. The pain is left-sided and is dull in nature, worsening on exertion.

His medical history includes hypertension and hyperlipidemia. He has a 30-pack-year smoking history.

A recent cardiology clinic note shows an echocardiogram with an ejection fraction of 45%.

On examination, he is normotensive with a blood pressure of 120/80 mmHg. His oxygen saturations are 96% on room air.

An ECG reveals sinus rhythm with no significant ST-T changes.

A chest radiograph is unremarkable.

What is the most appropriate initial management?

MRCP2-4283

A 50-year-old man presents with a 4 day history of cough, feeling hot and facial pains. He is generally healthy but currently takes sertraline for anxiety and depression. He reports a cough that produces pale yellow sputum. He also experiences difficulty breathing through his nose and facial pain, especially when coughing while leaning forward.

During the examination, he is alert, with a pulse rate of 84/min, a temperature of 37.3º, and a respiratory rate of 16/min. His blood pressure is 122/74 mmHg. Chest auscultation reveals no abnormalities. He experiences tenderness over the maxilla.

What is the most appropriate next step in managing this patient?