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?

MRCP2-4285

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?

MRCP2-4286

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

MRCP2-4287

A 31-year-old man has presented to the hospital with severe difficulty breathing.

Upon initial assessment by paramedics, his respiratory rate was 30/min, oxygen saturations were 70% on room air, his pulse was 118/min, his blood pressure was 125/70 mmHg, and his temperature was 38.5ºC.

Upon examination in the emergency department, the patient is sitting upright on the bed and leaning forward. There is evidence of drooling and a vomit bowl filled with saliva is beside him. Audible stridor can be heard from the edge of the bed. Oxygen has been administered and his saturations have improved to 92% on 15L.

A neck x-ray was performed due to concerns of a foreign body and revealed a ‘thumb sign’.

What is the most appropriate course of action for management?

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?

MRCP2-4261

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?

MRCP2-4262

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?

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?