A 55-year-old male presents with a three-month history of unintentional weight loss (13kg over 3 months) and a chronic non-productive cough. He has just returned from a months holiday in Thailand. He denies haemoptysis or chest pain. He is a lifelong smoker. He has no past medical history except a period of generalised limb weakness three years ago when he was referred to outpatient neurology clinic and diagnosed with Lambert-Eaton myasthenic syndrome following investigations. His blood tests are unremarkable. However, his chest x-ray demonstrates a rounded opacity in his left midzone, about 4 cm from his left main bronchus.
What is the most likely diagnosis?
MRCP2-4251
An 80-year-old man was admitted to the hospital due to an exacerbation of his long-standing chronic obstructive airways disease. The patient’s regular treatment for COPD included home oxygen, home bronchodilator nebulisers, and high-dose inhaled steroids. His exercise tolerance was very limited, and he became profoundly breathless after mobilizing only short distances around his house. The patient had expressed a wish that he would not want non-invasive ventilation or intubation in the future and stated that control of his symptoms was his priority, following an admission to the intensive care unit for respiratory support the previous winter.
Upon admission, the patient was treated with prednisolone, nebulised bronchodilators, and antibiotics. His symptoms gradually improved over the next week until he returned to his baseline of dyspnoea on minimal physical exertion. However, he again requested if there were any other treatments that could ameliorate his symptoms.
Recent investigations showed that his forced vital capacity was 115% predicted, forced expiratory volume (1s) was 34% predicted, and FEV1/FVC was 30% predicted. His haemoglobin was 170 g/dL, white cell count was 15.8 * 109/l, platelets were 167 * 109/l, urea was 6.7 mmol/L, creatinine was 98 micromol/L, sodium was 140 mmol/L, potassium was 4.1 mmol/L, and packed cell volume was 0.42.
What is the best treatment choice for relieving dyspnoea in this patient?
MRCP2-4252
A 63-year-old man presents to the hospital with a 4-day history of dyspnoea, pleuritic chest pain and several episodes of haemoptysis. Prior to this, he had been experiencing constant rhinorrhoea for several months, with some nasal crusting, several large epistaxis and constant pain below his eyes. He had also noticed some double vision and swelling of his right eye. Upon examination, he had low-grade pyrexia and was normotensive. There was some nasal mucosal ulceration and right-sided proptosis. Cardiovascular examination was unremarkable. He had localised areas of crepitations throughout both lung fields. His abdomen was soft and non-tender, with no masses. There were no focal neurological signs or skin lesions. The investigation results showed multiple large cavitating nodules throughout both lung fields on chest X-ray. What would be the most useful investigation in pointing to the diagnosis if positive?
MRCP2-4246
A 60-year-old man visits his doctor after his spouse complains about his loud snoring and occasional cessation of breathing during sleep. He also experiences daytime sleepiness while watching TV or reading. The patient had tonsillectomies and adenoidectomy in childhood. During examination, his height is 1.80m and weight is 100kg. Despite losing 15kg in the past six months, his symptoms persist. The doctor refers him for a sleep study which indicates moderate sleep apnoea. What is the initial management option that should be recommended?
MRCP2-4250
A 67-year-old woman comes to the emergency department complaining of difficulty breathing. A CT pulmonary angiogram is performed, ruling out a pulmonary embolism, but revealing a solid nodule measuring 4.5 mm in the midzone of her right lung.
What is the recommended course of action for addressing this nodule?
MRCP2-4256
A 68-year-old man arrives at the Emergency department with a four-day history of increasing breathlessness, productive cough, and fever. Upon examination, his vital signs are as follows: HR 132 (irregular), BP 89/61 mmHg, RR 29, and temperature 38.7°C. He appears slightly disoriented. The laboratory results show Hb 111 g/L (130-180), WBC 22.5 ×109/L (4-11), Platelets 567 ×109/L (150-400), Na+ 136 mmol/L (137-144), K+ 4.5 mmol/L (3.5-4.9), Urea 8.9 mmol/L (2.5-7.5), Creatinine 114 μmol/L (60-110), and CRP 345 mg/L (<10). A chest x-ray reveals right lower lobe consolidation. Based on current guidelines, what is the appropriate empirical antibiotic regimen to initiate?
MRCP2-4249
A 62-year-old man is referred to the respiratory clinic by his GP due to four exacerbations of chronic obstructive pulmonary disease in the past year, despite previously being well controlled. His FEV1 is 46% of predicted normal and he is currently on a long-acting muscarinic antagonist, a long-acting beta-2 agonist, and an inhaled corticosteroid. He quit smoking five years ago and his six-minute walk distance is 110m. Upon examination, he has a barrel chest and mild wheezing bilaterally, but no raised jugular venous pulse or peripheral edema.
What is the most appropriate next step in managing this patient?
MRCP2-4253
A 32-year-old man presents with increasing shortness of breath and cough over the past two weeks during the holiday season. He has occasional joint pains and sinusitis episodes in the past year, but no significant family history. He smokes 10 cigarettes per day and recently acquired a dog with his partner. On examination, he is dyspnoeic and tachycardic with bilateral coarse crackles and oxygen saturation of 92% on 10 L oxygen. His lab results show elevated urea, creatinine, and CRP, as well as positive c-ANCA and negative anti-GBM antibodies and p-ANCA. Chest x-ray reveals bilateral infiltrates, denser at the bases. He deteriorates and requires intubation and renal replacement therapy.
What is the most likely diagnosis, and what treatment should be initiated?
MRCP2-4255
A 65-year-old woman presented to the rapid access lung cancer clinic following an abnormal chest x-ray. She had been feeling unwell for the past six weeks with lethargy, intermittent fever, and myalgia. She also experienced breathlessness on exertion and difficulty climbing steep hills. She had a 40 pack/year smoking history and no pets at home. On examination, she had a temperature of 38.4°C, elevated blood pressure, and tenderness of her right carotid artery. A repeat chest x-ray showed alveolar shadowing in the right upper lobe. Her blood tests showed anemia, leukocytosis, elevated ESR, and positive ANA and cANCA. A Heaf test showed a Grade 2 reaction. What is the most likely diagnosis?
MRCP2-4254
A 29-year-old man presented with increasing shortness of breath and cough over the past two weeks during the holiday season. He had no significant medical history but reported occasional joint pains and a couple of episodes of sinusitis in the past year. He smoked 10 cigarettes per day and recently acquired a dog with his partner. On examination, he was dyspnoeic and tachycardic, with oxygen saturations of 92% on 10L oxygen. Chest examination revealed coarse crackles bilaterally. Laboratory investigations showed abnormal levels of Hb, Na+, WBC, K+, platelets, urea, CRP, and creatinine. Urinalysis showed protein and blood, but nitrates and leucocytes were negative. Chest x-ray revealed bilateral infiltrates, more dense at the bases. What investigation would confirm the most likely diagnosis for this patient?