A 23 year-old male with no significant medical history presents with a 3 hour history of chest pain and difficulty breathing. The pain is sharp and located on the right side, worsening with deep inspiration.
The patient has no significant medical history. Upon examination, he is tachypneic with a respiratory rate of 28 breaths per minute. His oxygen saturation is 96% on room air. His pulse rate is 98 bpm with a blood pressure of 134/80 mmHg. A 12-lead ECG shows sinus tachycardia with a rate of 100 beats per minute.
A chest X-ray shows a right-sided pneumothorax measuring 1.5 cm at the level of the hilum.
What is the most appropriate initial management?
MRCP2-4168
A 25-year-old male non-smoker visits your respiratory clinic with complaints of more frequent episodes of wheezing and shortness of breath. He has a history of asthma and takes salbutamol after exercising and beclometasone 200 mcg inhaler bd. What would be the most suitable course of action for management?
MRCP2-4160
A 45-year-old Afro-Caribbean male presents with sudden onset palpitations and feeling generally unwell for 2 hours. An admission ECG in the emergency department demonstrates ventricular tachycardia. His heart rate is 80 beats/ minute with a blood pressure of 140/75 mmHg. The patient is chemically cardioverted back to sinus rhythm with a single intravenous bolus of amiodarone. The patient was commenced on haemodialysis 9 months ago after developing end-stage renal failure over a course of 16 months with no conclusive underlying cause found for the deteriorating renal function. He also complains of a new dry cough over the past 18 months, weight loss of at least one and a half stone and general malaise, which he attributes to his deteriorating kidneys.
On examination, the patient has normal heart sounds with no additional murmurs. Auscultation of his chest demonstrates biapical find inspiratory crackles with no wheeze. Abdominal examination reveals a mild 2 cm hepatomegaly with no splenomegaly. An arteriovenous fistula is noted in the left brachiocephalic region. No skin rashes are noted. An admission chest X-ray demonstrates no clear consolidation, reticular opacities in both apices and prominent bilateral hilar, with no cardiomegaly or tramlining.
Bilirubin 17 µmol/l ALP 55 u/l ALT 70 u/l CRP 12 mg/l ACE (angiotensin converting enzyme) negative
Pulmonary function tests: FVC 60% predicted FEV1 92% predicted
A bronchoalveolar lavage is performed, demonstrating lymphocytosis of 25%, CD4:CD8 ratio of 5:1, a transbronchial biopsy demonstrates non-caseating granulomas.
What is the underlying diagnosis?
MRCP2-4164
What is the probable cause of the symptoms and findings in a 69-year-old man with a history of well-controlled rheumatoid arthritis who presents with pain and swelling in his wrists and ankles, chronic cough, shortness of breath on exertion, weight loss, and fingernail clubbing, and has a chest X-ray showing a discrete opacification at the periphery of the right middle lobe, and laboratory results showing elevated serum uric acid and CRP levels?
MRCP2-4158
A 45-year-old man presented to the Pulmonary Clinic with a 4-year history of worsening shortness of breath and persistent cough. He has had multiple courses of antibiotics in the past few years. He smoked a pack a day for 20 years. Upon respiratory examination, his chest was hyperinflated and he had a mild wheeze throughout.
Lung function tests: FEV1 60% predicted FVC 75% predicted TLCO 65% predicted KCO 70% predicted RV:TLC No bronchodilator reversibility Increased
Which diagnostic test would be most beneficial in providing a definitive diagnosis?
MRCP2-4161
A 25-year-old woman from New York with no significant medical history is on a backpacking trip in Nepal. She is a non-smoker. After trekking above 4000 m, she complains of a headache, nausea, and vomiting. She also feels fatigued and has trouble sleeping. As the expedition medic, you note her respiratory rate is 20/min and her pulse is 95/min. Her chest is clear on auscultation. No investigations are available as the nearest hospital is over 50 km away.
What is the most likely diagnosis?
MRCP2-4159
A 29-year-old woman came to the Respiratory Outpatients Department complaining of a persistent cough and shortness of breath that had been worsening over the past 3 years. Despite taking numerous courses of antibiotics, her symptoms persisted. Although she had quit smoking 4 years ago, she had previously smoked 5 cigarettes a day for 5 years. Upon respiratory examination, her chest was hyper-inflated, and a mild wheeze was heard throughout. Lung function tests revealed an FEV1 of 50% predicted, FVC of 80% predicted, TLCO of 68% predicted, KCO of 71% predicted, and an increased RV:TLC ratio. What is the most likely diagnosis?
MRCP2-4170
A 65-year-old man presents to his primary care physician three weeks after experiencing an infective exacerbation of COPD. He is currently feeling well but is worried that this is his second exacerbation this winter. He is currently taking fostair, tiotropium, and salbutamol as needed. He has a mild cough but has attended his recent COPD review.
Upon examination, his chest is clear with no wheezing or crepitations. His JVP is not raised, and there is no edema. His oxygen saturation is 94% in air, and he has a respiratory rate of 22 breaths per minute. He is currently able to do his gardening and walk his dog up to half a mile each day without experiencing breathlessness at night. He has been discharged from chest physio and is performing well.
FEV1 (% predicted) is 40%, and FVC (% predicted) is 80%. A chest x-ray reveals several bullae and a hyperexpanded chest with no consolidation. An ECG shows sinus rhythm and a right bundle branch block.
What additional intervention should be considered for this patient’s current management?
MRCP2-4167
What is the most precise statement regarding the management of adult respiratory distress syndrome (ARDS) in a patient with severe sepsis?
MRCP2-4165
A 16-year-old girl with stable cystic fibrosis presents to the Emergency Department with a cough productive of purulent sputum tinged with blood, and significantly worse shortness of breath over the past 48 hrs. Her CF is currently well managed and she is Pseudomonas negative. On examination she is pyrexial 38.1°C, BP is 95/55 mmHg; heart rate is 85/min and regular, respiratory rate is 32. There are coarse crackles at the right base, and you also notice a couple of cold sores at the corner of her mouth. O2 saturation on air is 92%. Her BMI is 23.