Archives: MRCP Part 2

MRCP2-4259

A 54-year-old man with decompensated chronic liver disease presents to the Respiratory Clinic with worsening exertional dyspnoea, easy fatigability, and increasing abdominal distension. Despite being compliant with medications, his symptoms have been gradually worsening over the past few weeks. On examination, his blood pressure is 100/60 mmHg and his heart rate is 74 bpm. Pulse oximetry reveals an oxygen saturation (SpO2) of 91% in the recumbent position and 84% in the upright position. The respiratory examination was normal and the abdominal examination was significant for the presence of ascites. What is the most definitive management for this patient?

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?

MRCP2-4258

A 27-year-old man presents to the emergency department with a chief complaint of exertional dyspnea that has been ongoing for four hours. He reports feeling short of breath when climbing three flights of stairs, accompanied by mild chest discomfort. Symptoms improve with rest but recur upon continued exertion. Upon examination, the patient appears well with a pulse of 80 beats per minute and blood pressure of 120/65 mmHg. Auscultation of the chest reveals a loud clicking sound at the lower left sternal border that is synchronized with the patient’s heartbeat. What is the most likely diagnosis?

MRCP2-4257

A 30-year-old man is being assessed before being discharged from the hospital. He was admitted one day ago due to a small pneumothorax, which was treated with high flow oxygen as it was less than 1 cm in size. He was kept under observation for 24 hours and his symptoms have now disappeared. A follow-up chest x-ray shows that the pneumothorax has completely resolved. What instructions should he be given before leaving the hospital?

MRCP2-4248

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?

MRCP2-4241

A 35-year-old man presents with sudden onset of right-sided chest pain that occurred while lifting weights at the gym 24 hours ago. He has no significant medical history and is not taking any medications. The pain has improved since onset and he has not taken any painkillers in the past 6 hours. On examination, his blood pressure is 122/78 mmHg, pulse rate is 76 beats per minute and regular, and his oxygen saturation on room air is 98%. Chest auscultation reveals normal breath sounds bilaterally. A chest X-ray shows a small right-sided pneumothorax with a rim measuring less than 1 cm. Which of the following is the most appropriate next step in management?

MRCP2-4243

A 65-year-old man presents to the Emergency Department with pleuritic chest pain. This has developed since earlier that morning. Previous medical history includes hypertension, bronchiectasis, hyperlipidaemia and atrial fibrillation.

His blood tests show:

– Hb 178 g/L Male: (135-180) Female: (115 – 160)
– Platelets 360 * 109/L (150 – 400)
– WBC 10.4 * 109/L (4.0 – 11.0)

His observations show:

– Heart rate 78/min
– Blood pressure 136/89 mmHg
– Respiratory rate 16/min
– Saturations 94% on room air

A chest x-ray shows no consolidation and a less than 1 cm pneumothorax on the left-hand side.

What is the most appropriate management for this patient?

MRCP2-4240

A 72-year-old retired bus driver presents to the respiratory fast-track clinic with a two-month history of right-sided chest pain and cough. He was prescribed amoxicillin by his GP, which provided some relief, but he has since developed shortness of breath while walking around his house. The patient has a 30 pack-year smoking history.

Upon examination, the patient has reduced air entry and dullness to percussion on the right lung base. His oxygen saturation is 96% on air. A chest x-ray confirms the presence of a right pleural effusion, and a pleural ultrasound reveals a moderate-sized simple effusion. A pleural aspirate is performed, with the following results:

– Appearance: Serosanguineous
– pH: 7.32
– Protein: 45 g/l
– LDH: 450 IU/l
– Glucose: 4.0mmol/l
– Gram stain: No organisms or malignant cells seen
– Culture: No growth

Based on the patient’s clinical presentation and test results, what is the most appropriate next step in investigating this case?

MRCP2-4245

A 27-year-old female patient has come for a follow-up on her asthma management. She reports that her asthma control has deteriorated lately and she is using her Ventolin inhaler once or twice a week. She confirms that she is not taking any other medication for asthma control. She denies any recent sickness, but she does mention that her symptoms worsen in colder temperatures and during physical activity. What would be the most appropriate course of action to take next?

MRCP2-4242

A 56-year-old man presents to the emergency department with sudden onset chest pain and difficulty breathing. He denies any other symptoms such as fever or cough. The patient has a history of chronic obstructive pulmonary disease and is currently taking Spiriva (budesonide and formoterol) and salbutamol as needed.

Upon examination, the patient appears to be short of breath and unable to complete full sentences. There is reduced air entry on the left side of his chest, which is hyper-resonant to percussion. The patient’s heart sounds are normal, and there is no evidence of pitting edema in his calves.

The patient’s vital signs are as follows:
– Temperature: 36.1ºC
– Heart rate: 100 bpm
– Blood pressure: 125/82 mmHg
– Respiratory rate: 24 breaths/min
– Oxygen saturations: 93% on 6L via facemask

A chest x-ray reveals a 1.5cm left-sided pneumothorax. What is the most appropriate course of action for this patient?