Archives: MRCP Part 2

MRCP2-4235

A 48-year-old man is referred to the hospital due to increasing shortness of breath. He has a history of HIV and is under the care of local GUM consultants but is not currently on any antiretroviral treatment. He reports experiencing worsening shortness of breath for the past two weeks, with breathlessness occurring even with minimal exercise. He also has a non-productive cough and has been feeling lethargic for the past week. Upon examination, he is afebrile, has a blood pressure of 120/89 mmHg, and a slightly elevated heart rate of 110 bpm. His respiratory rate is 18 at rest, and his oxygen saturation is 98% on air. However, when he mobilizes to the toilet, he becomes very tachypnoeic, and his saturations drop to 90%. Blood tests reveal a low hemoglobin level of 110 g/l, normal platelet count of 201 * 109/l, and a slightly elevated white blood cell count of 9.6 * 109/l with neutrophils at 4.5 * 109/l. His electrolyte levels are within normal range, with a slightly elevated CRP level of 70 mg/l. His liver function tests show a slightly elevated bilirubin level of 5 µmol/l, normal ALP level of 89 u/l, and slightly elevated ALT level of 43 u/l, with a low albumin level of 34 g/l. An ABG test shows a pH of 7.35, pO2 of 7.7, pCO2 of 4.6, HCO3- of 21, BE of -3, and lactate level of 2.2. His chest x-ray reveals fine bilateral reticular nodular shadowing. What is the most appropriate treatment for this patient?

MRCP2-4236

A 68-year-old retired plumber presents with a gradual onset of shortness of breath over the past two years. He denies any cough or chest pain. He has a significant smoking history of 50 pack-years and consumes 40 units of alcohol per week. Despite his symptoms, he reports a good appetite and has maintained a stable weight with a BMI of 24.

The spirometry results reveal a decreased FEV1 of 2.7 L (predicted 3.3 L) and FVC of 2.9 L (predicted 4.2 L). The PEF is slightly reduced at 500 l/min (predicted 550 l/min). The TLC is also decreased at 4.1 L (predicted 7.2 L). The TLco is 7.8 mmol/min/kPa (predicted 8.0 mmol/min/kPa) and the Kco is elevated at 2.0 mmol/min/kPa/l (predicted 1.4 mmol/min/kPa/l).

What is the likely diagnosis for this patient?

MRCP2-4237

A 35-year-old construction worker presents with a 2-month history of wheezing and shortness of breath associated with working on construction sites and resolving about 8 h after stopping work.

On examination, his BP is 130/80 mmHg, pulse is 78/min and regular and oxygen saturation is 96% on air. He has fine inspiratory crackles and a dry cough. You suspect he is suffering from occupational asthma.

What is the most likely finding on his chest X-ray?

MRCP2-4238

You are requested to assess a 65-year-old man who has a medical history of chronic obstructive pulmonary disease (COPD) and is scheduled for surgery to repair a significant inguinal hernia. After conducting a thorough examination and taking a detailed medical history, you order some tests before proceeding with the operation. What factor is most closely linked to a higher risk of perioperative complications?

MRCP2-4239

A 50-year-old construction worker is brought to the hospital with comminuted fractures of the right femur and tibia. No other injuries are observed. After undergoing surgical fixation, he displays signs of aggression and confusion. His vital signs include a temperature of 37.6°C, a pulse rate of 110 beats per minute, a blood pressure of 130/80 mmHg, and a respiratory rate of 25 breaths per minute. He is receiving 45% oxygen, and his SpO2 is at 90%. What is the most probable cause of his symptoms?

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?

MRCP2-4241

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?

MRCP2-4242

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?

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?

MRCP2-4244

A 63-year-old man presents with pleuritic chest pain on the right side. He reports a chronic cough that he attributes to his smoking habit but denies experiencing shortness of breath. His medical history includes bronchitis, and he uses a salbutamol inhaler as needed. He smokes five cigarettes per day and does not consume alcohol. A chest x-ray reveals a right-sided pneumothorax measuring approximately 0.5cm at the hilum level and right basal atelectasis on a background of chronic lung changes. What is the most appropriate initial management for this patient?