Archives: MRCP Part 2

MRCP2-4143

A 57-year-old smoker was referred to the respiratory outpatient clinic by his GP with a history of progressively worsening shortness of breath. His symptoms started several months ago with shortness of breath on extreme exertion but he gradually developed shortness of breath with minimal activity. He also complained of increasing tiredness and a non-productive cough had lost approximately 3 pounds in 6 months. He denied the presence of sputum production, haemoptysis or chest pain, and also denied the presence of both orthopnoea and paroxysmal nocturnal dyspnoea. He had a past medical history comprising ankylosing spondylosis diagnosed 30 years ago as well as hypertension and hypercholesterolaemia. His drug history comprised naproxen 500mg BD, lansoprazole 30 mg OD, felodipine M/R 2.5mg OD and atorvastatin 20 mg OD. He stated that he had been trialled with a course of methotrexate a few years ago for his ankylosing spondylosis and was subsequently stopped.

Examination revealed the presence of a well male with a blood pressure of 146/86 mmHg, heart rate 74 bpm and respiratory rate of 18/min. His oxygen saturations were 93% on air. There was no BCG scar seen on examination of his arm. Examination of his respiratory system revealed the presence of bilateral fine upper zone crackles but nil else and no respiratory distress. Examination of his cardiovascular system revealed no abnormalities including a normal JVP and the absence of pedal oedema, and examination of his gastrointestinal system was likewise unremarkable.

Initial investigations revealed the following:

Hb 166 g/l
Platelets 341 * 109/l
WBC 6.3 * 109/l
ESR 34 mm/hr
CRP 26 mg/l

Chest x-ray: Bilateral apical fibrosis

Pulmonary function testing
FEV1 2.4 l (predicted value 2.3)
FVC 2.6 l (predicted value 4.8)
FEV1/FVC ratio 92%
TLCO transfer factor 86% of predicted value

What is the most likely diagnosis?

MRCP2-4144

A 67-year-old man who is visiting from Chile presents to the emergency department with worsening shortness of breath over the past two days. He has a history of rheumatoid arthritis, hypertension, and ischemic heart disease. He used to work in coal and silica extraction but retired due to health issues. He has lost 5 stone in weight over the past year and has a productive cough with black sputum, which he reports as normal for him. On examination, he is in respiratory distress with use of accessory muscles, has crepitations throughout the mid and upper zones, and is drowsy with peripheral cyanosis. His ABG shows a pH of 7.31, PaO2 of 7.92 kPa, and PaCO2 of 6.44 kPa. His chest X-ray shows upper zone reticulonodular changes with a large cavity on the right apex, and a high-resolution CT scan shows ground glass opacities in the upper zones with a modular appearance and centroacinar emphysema in the lower zone. His blood work shows a Hb of 110 g/l, platelets of 310* 109/l, WBC of 12.3 * 109/l, and CRP of 156 mg/l. What is the likely diagnosis?

MRCP2-4145

What is the most appropriate course of action for the continued treatment of this patient?

MRCP2-4146

A 67-year-old woman slips on an icy road and sustains a neck of femur fracture. She has a medical history of hypertension, type 2 diabetes, and a 40-year pack-year smoking history. After being hospitalized for six days, she experiences shortness of breath and haemoptysis. Her vital signs are as follows:

– Blood pressure: 135/70 mmHg
– Pulse: 110 bpm
– Temperature: 36.4 deg C
– Respiratory rate: 24/min
– Oxygen saturation: 89% on air

A subsequent CTPA reveals a right segmental pulmonary embolus and a 4mm solid nodule in her right upper lobe. What is the most appropriate approach to managing her nodule?

MRCP2-4147

A 22-year-old woman presents to her family doctor with recurring episodes of shortness of breath and a dry cough. She has a history of asthma and is currently on treatment with Seretide 25/100 (salmeterol and fluticasone) using a metered dose inhaler with a spacer, which provides relief for most of the day. However, she experiences wheezing and breathlessness while running or cycling. She also has a medical history of allergic rhinitis and takes loratadine and various nasal sprays for it.

During the examination, the chest appeared normal, and peak expiratory flow readings were 78% predicted.

What would be the most appropriate course of action in this scenario?

MRCP2-4148

A 50-year-old man presents to the Emergency Department with sudden onset chest pain and associated shortness of breath. The chest pain is on the left hand side only and there is no history of cough, fever chills or recent fatigue. The patient is an ex-smoker and has a background of well-controlled chronic obstructive pulmonary disease (COPD).

On examination the patient is tachycardia and tachypnoeic but otherwise the examination is normal.

Routine haematology and biochemistry are unremarkable but a chest x-ray shows a left sided pneumothorax which is measured to be approximately 2.5 cms.

What is the best management option for this patient?

MRCP2-4149

A 58-year-old man was admitted to the hospital with a productive cough. Chest x-ray revealed left basal pneumonia. He was treated with intravenous antibiotics and discharged after successful weaning off oxygen. What follow-up, if any, should be recommended for this patient?

MRCP2-4150

A 68-year-old man presents to the emergency department with severe shortness of breath. He has a medical history of COPD, type 2 diabetes mellitus and hypertension. Upon examination, he appears very breathless and drowsy, with bilateral crackles and wheeze audible on auscultation. Despite treatment with nebulisers, steroids, antibiotics and fluids, he remains in type 2 respiratory failure with acidosis.

Arterial blood gas on admission:
pH 7.32
pO2 7.3kPa
pCO2 8.1kPa
HCO3- 25 mmol/L

Arterial blood gas at two hours:
pH 7.30
pO2 8.2kPa
pCO2 9.6kPa
HCO3- 26mmol/L

He is started on non-invasive ventilation with a bi-level positive airway pressure. What initial settings would be most appropriate for IPAP and EPAP?

MRCP2-4151

A 75-year-old patient presents with exertional dyspnoea and bilateral pulmonary oedema on chest x-ray. The patient has a past medical history of type 2 diabetes mellitus, hypertension, hypercholesterolaemia, and a previous NSTEMI in 2010. An echocardiogram shows moderate to severe LV dysfunction and a pulmonary arterial pressure of 83 mmHg (normal <25 mmHg). What diagnostic investigation should be done next?

MRCP2-4152

A 23-year-old man presents to the emergency department with a worsening cough and shortness of breath over the past few days. He has no significant past medical history except for a known allergy to bee stings and is not on any regular medication. Although he does not smoke himself, he works in an environment where others are often smoking around him.

Upon examination, he appears to be in respiratory distress, with tachypnoea, tachycardia and low-grade pyrexia. His peripheral oxygen saturations are 87% on air. Blood tests are conducted:

Hb 112 g/L Male: (135-180)
Female: (115 – 160)
Platelets 185 * 109/L (150 – 400)
WBC 13.3 * 109/L (22% eosinophils) (4.0 – 11.0)
Urea 6.9 mmol/L (2.0 – 7.0)
Creatinine 87 µmol/L (55 – 120)

A chest X-ray is also performed, which reveals patchy mixed alveolar-interstitial infiltrates. The medical team is consulted to review the patient, and a bronchoalveolar lavage is conducted, which shows no signs of infection but 56% eosinophils.

What is the most appropriate initial intervention given the likely diagnosis?