Archives: MRCP Part 2

MRCP2-4265

A 36-year-old man visits his primary care physician complaining of difficulty breathing and a productive cough with yellow sputum. He typically experiences a dry cough only. This marks his third episode this year, and he has undergone four rounds of antibiotics and steroids. He has only smoked once or twice during his university days and works in a factory that produces computer components.

The patient was fully vaccinated as a child and was healthy until three years ago. He has no other medical history.

During the examination, the patient displays scattered wheezing but no crepitations. His chest is resonant and hyperinflated, and his respiratory rate is 28 breaths per minute with 94% saturation in air. There is no clubbing or cyanosis. The patient is awaiting lung function testing.

Hb 140g/l Na+ 138 mmol/l
Platelets 340 * 109/l K+ 4.7 mmol/l
WBC 14.1 * 109/l Urea 6.2 mmol/l
Neuts 12 * 109/l Creatinine 89 µmol/l
Lymphs 3.2 * 109/l CRP 50 mg/l
Eosin 1.0 * 109/l

The chest x-ray reveals hyperinflated lung fields, a flattened hemidiaphragm, and no consolidation.

What other test would be beneficial for the patient?

MRCP2-4266

You are tasked with reviewing the results of a long term oxygen therapy (LTOT) assessment for a 72-year-old male with a history of COPD. He has been experiencing dyspnoea at rest.

Results of the LTOT assessment are as follows:

ABG on air:

PaO2 7.2 kPa
PCO2 5.2 kPa
pH 7.40
HCO3 26

ABG after 1 litre of O2 via a nasal cannula:

PaO2 9.4 kPa
PCO2 6.4 kPa
pH 7.34
HCO3 26

The patient reports feeling less short of breath at the end of the trial.

You determine that further medical optimization and reassessment of arterial blood gas in 4 weeks is necessary.

After 4 weeks, the patient returns to the clinic with stable COPD and optimized medical management with salbutamol, ipratropium, and carbocysteine.

A repeat LTOT assessment is as follows:

ABG on air:

PaO2 6.8 kPa
PCO2 5.1 kPa
pH 7.41
HCO3 26

ABG after 1 litre of O2 via a nasal cannula:

PaO2 9.6 kPa
PCO2 6.7 kPa
pH 7.31
HCO3 26

What is your plan for managing this patient?

MRCP2-4267

A 70-year-old man with a history of chronic kidney disease, hypertension, and type 2 diabetes arrives at the Emergency Department complaining of cough and shortness of breath with minimal exertion. Upon examination, he displays bilateral inspiratory crepitations and pitting edema up to his sacrum. A chest X-ray reveals a moderate effusion on the right side and a smaller one on the left.

What is the most appropriate single course of action?

MRCP2-4268

You schedule a long term oxygen therapy (LTOT) assessment for a 68-year-old man with a history of COPD. He reports experiencing dyspnoea at rest.

The LTOT assessment reveals the following results:

ABG on room air:

– PaO2: 7.1 kPa
– PCO2: 5.1 kPa
– pH: 7.41
– HCO3: 26 mmol/l

ABG after administering 1 litre of O2 via a nasal cannula:

– PaO2: 9.3 kPa
– PCO2: 6.5 kPa
– pH: 7.33
– HCO3: 26 mmol/l

The patient reports feeling less short of breath at the end of the trial. How would you proceed with managing this patient?

MRCP2-4269

A 72-year-old active smoker with a 35 pack year history presents with his second non-infective exacerbation of COPD in 3 months. He was diagnosed with COPD three years ago and had been relatively well controlled using salbutamol as required prior to these two admissions. Three days after his admission, he reports that he is close to his baseline and would like to go home. His repeat pulmonary function tests reveal a forced expiratory volume in 1 second of 48%.

On reviewing his peak flow diary you note a significant (> 20%) diurnal variation in his peak flow.

What would be the most effective approach to optimize his COPD management?

MRCP2-4270

A 57-year-old male presents with symptoms and signs consistent with exacerbation of chronic obstructive pulmonary disease (COPD). This is his fifth exacerbation in the last two months. His most recent FEV 1 is 38%. He is currently taking salbutamol as required once daily regimen.

After reviewing his peak flow diary, you observe a significant (> 20%) diurnal variation in his peak flow.

What medication should be added to his regular COPD control next?

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?

MRCP2-4272

An 82-year-old man presents to the respiratory clinic with poorly controlled COPD despite being prescribed inhaled salbutamol. He reports consistent breathlessness on minimal exertion, which is limiting his daily activities. There is no diurnal variation in his symptoms. He has a significant smoking history of 50 pack years and a past medical history of hypertension treated with ramipril. Recent blood tests show normal hemoglobin, platelets, and white blood cell count with a slightly elevated neutrophil count. The lymphocyte and eosinophil counts are within normal limits.

What would be the most appropriate initial management 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?

MRCP2-4274

A 68-year-old man with a history of ischaemic heart disease, left ventricular hypertrophy, hypertension, and type 2 diabetes presents to the Acute Medical Assessment Unit with progressive shortness of breath. He has been a heavy smoker for the past 50 years. His blood tests show a slightly elevated white blood cell count and C-reactive protein level, but are otherwise unremarkable. A chest x-ray reveals bilateral pleural effusions, cardiomyopathy, and pleural plaques. The patient responds well to intravenous diuresis, but a significant residual pleural effusion remains on the right side. What further investigation should be performed for this patient?