Archives: MRCP Part 2

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?

MRCP2-4286

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?

MRCP2-4281

A 22-year-old Asian medical student presented to the emergency department with a month-long history of fever, night sweats, and a cough productive of purulent sputum.

On examination, the patient was found to be febrile with a pulse of 110 beats per minute and a respiratory rate of 22 breaths per minute. Coarse crackles were heard over the right lung apex, and a chest x-ray showed right upper lobar consolidation with a single cavitating lesion. Further investigations revealed a positive sputum sample for acid-alcohol fast bacilli.

The patient was started on anti-tuberculous therapy, and within seven days, his fever had settled, and his inflammatory markers were improving. Contact tracing revealed that he lived with his parents and two sisters. His older sister, who had lived in the United Kingdom all her life, subsequently had a strongly positive Mantoux test. She otherwise feels well and has no symptoms of anorexia, weight loss, fever, night sweats, or cough, and her chest radiograph is normal.

What is the most appropriate management for the patient’s sister?

MRCP2-4279

A 67-year-old man with a significant smoking history is referred to the rapid access chest clinic with a six month history of weight loss, a cough and two episodes of haemoptysis. He was previously fit and well.

On further questioning, he reports a troublesome cough, mild left sided chest pain which he describes as an ache, increasing fatigue and spending a few hours of the day in bed or on the sofa. However, he is still able to complete most of his activities of daily living with some assistance from his wife.

Based on the WHO classification, what is his performance status?

MRCP2-4261

A 50-year-old HIV-positive American woman presents with fever, cough, and fatigue following her recent holiday. Despite receiving oral co-amoxiclav, her symptoms persist and a normal chest radiograph is obtained. Upon undergoing a bronchoscopy, Histoplasma capsulatum is identified in her bronchial washings. What is the most effective treatment to alleviate her symptoms?

MRCP2-4273

A 32-year-old male presents to the emergency department with a 1-day history of dyspnoea, dry cough, and palpitations. On examination, his temperature is 37.3ºC, respiratory rate is 28 breaths per minute, and oxygen saturation is 94% on room air. Blood pressure is 125/80 mmHg with a heart rate of 100 bpm. Reduced air entry in the right lower zone is noted on auscultation, and a chest radiograph confirms a right pneumothorax. A thoracostomy tube is immediately placed on the right side.

During the morning ward round, 3 days later, it is observed that there is an air leak of 50cc while checking the chest drain. A repeat chest radiograph shows that the right pneumothorax is still present.

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

MRCP2-4262

A 50-year-old computer software firm owner presents with increasing breathlessness over the past few months. He has previously been fit and well and had installed a home gym, swimming pool and hot tub/steam room to use for personal training around 18 months ago. He is a non-smoker and has a previous history of asthma as a child. Examination reveals crackles and high-pitched wheeze throughout the lung fields. His blood pressure is 115/75 mmHg, with pulse 70 and regular. There is no ankle swelling.
What is the most appropriate course of action for this patient?

MRCP2-4271

A 68-year-old man with a history of COPD presents to the clinic with complaints of persistent breathlessness during physical activity. He denies any significant coughing. Upon pulmonary function testing, his SpO2 is at 90%, FVC is at 2.8L, FEV1 is at 1.47 (40% predicted), and FEV1/FVC ratio is at 53%. His medical records indicate that there has been significant diurnal variation (>20%) in his peak flows. Currently, he is taking a short-acting beta-2 agonist and a combination inhaler containing a long-acting beta-2 agonist and corticosteroid. What would be the most appropriate additional medication to prescribe for this patient?