Single Best Answers for MRCP-2 (Take this FREE Mock Test)

A 32-year-old man has presented to the hospital with a 4-day history of fatigue, palpitations, and nausea. He recently had severe diarrhoea. There is no vomiting or syncope.
Examination shows no apparent cardiovascular or neurological abnormality. The ECG borderline prolonged PR, small T waves in the limb leads, flattened T waves in the chest leads and U waves.

1. What electrolyte abnormality will you anticipate in his blood results?

A 68-year-old man has been referred to the hospital. He complains of intermittent palpitations, occurring once a week and self-resolve within seconds. There are no associated symptoms.
An ECG which was performed by the GP was reported as showing atrioventricular dissociation.
Currently, he feels well. On examination, his pulse rate is 64/min, BP 145/70 mmHg, Resp rate 14/min, Temperature 37.2 C, Sats on room air 94%. His ECG revealed Mobitz II AV block.

2. What is the appropriate next step of treatment?

3. An 89-year-old lady presents acutely short of breath and distressed. She has a background of previous myocardial infarction (MI) and hypertension. She is now coughing up white sputum. Examination reveals bilateral coarse crepitations throughout the lung fields. She has a raised jugular venous pressure and peripheral oedema. Observations are a respiratory rate of 35/min, oxygen saturation of 92% on 15 litres of oxygen per minute, blood pressure 135/90 mmHg, and heart rate of 100/min. Chest X-ray reveals widespread interstitial shadowing. Intravenous furosemide has been given but the patient fails to improve. Which of the following would be useful in treating this patient?

A 46-year-old woman with a long history of asthma presents with gradually progressive cough and breathlessness, and with fever and mild weight loss. There is no history of rhinosinusitis, rash, or focal neurological symptoms. On examination, there is a bilateral wheeze. Oxygen sats on room air is 92%. A chest X-ray shows diffuse alveolar infiltrates, predominantly peripheral. A high-resolution CT scan of the chest confirms alveolar infiltrates and mediastinal lymphadenopathy. Blood eosinophils are 5.4 × 10^9/mL (normal <0.4 × 109/mL). Serum precipitins for Aspergillus are negative. What is the most likely diagnosis?

A 62-year-old man is referred to the respiratory clinic by his GP. Having previously been well controlled, he has had four exacerbations of chronic obstructive pulmonary disease in the last 12 months. His forced expiratory volume in one second (FEV1) is 44% of the predicted normal. His inhaled medications include a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid. He quit smoking five years previously. His six-minute walk distance is 100 m.
On examination, he is a barrel-shaped chest and there is mild wheeze heard bilaterally. The jugular venous pulse is not raised and there is no peripheral oedema.
What is the most appropriate next step in management?

A 78-year-old man is seen in the respiratory clinic due to poor control of his chronic obstructive pulmonary disease (COPD). Despite being prescribed inhaled salbutamol as required, he remains breathless on minimal exertion, limiting his ability to carry out daily activities. These symptoms are consistently present with no diurnal variation.
He has a 50 pack-year smoking history. His past medical history includes hypertension for which he takes Ramipril. He has no allergies. Recent blood tests show the following:

6. Hb 14 g/dl

WBC 6 x 10^9/L (Neuts 4.1 x 19^9/L, Lymphs 1.7 x 10^9/L, Mono 0.4 x 10^9/L, Eosin 0.1 x 10^9/L)

Platelets 300 x 10^9/L

Which of the following treatment options would be most appropriate to initiate?

7. A 75-year-old gentleman is referred by his GP to a consultant cardiologist for management of his newly diagnosed atrial fibrillation (AF). Palpitations and occasional shortness of breath are the only symptoms he experiences. He has no past history of cardiovascular disease but has suffered a transient ischaemic event in the past. On examination, he is found to have an irregular heart rate ranging between 70 and 90 beats per minute. ECG confirms AF. Which of the following is the most appropriate next stage in his management?

A 44-year-old is referred to a respiratory clinic with 2 months of exertional shortness of breath. He has a past medical history of HIV. He is well controlled on Truvada. He had an unprovoked pulmonary embolism three years ago and was treated with six months of warfarin. He smoked 15 cigarettes daily for the last 20 years. He recently completed his first mountaineering expedition and successfully reached the summit of Kilimanjaro.
On examination, there is a loud P2. The jugular venous pulse is raised and there is peripheral oedema. Chest auscultation is unremarkable and there are no murmurs.
A transthoracic echocardiogram is arranged, which demonstrates a mean pulmonary arterial pressure (PAPm) of 38 mmHg and mitral regurgitation with a regurgitant fraction of 14%.
An HRCT chest is normal. V/Q scanning demonstrates mismatched perfusion defects. The patient is referred for a right heart catheter, which confirms a PAPm of 38 mmHg and also demonstrates a pulmonary arterial wedge pressure (PAWP) of 11 mmHg.
Given the likely diagnosis, what is the probable underlying aetiology?

A 27-year-old man is reviewed in the asthma clinic. Despite therapy with high dose Salmeterol/Fluticasone, Montelukast and oral Theophylline, he has suffered a 4th exacerbation in the past year and is now unable to reduce his dose of oral Prednisone below 10 mg without a significant increase in shortness of breath and wheeze. On examination, his blood pressure is 125/80 mmHg, pulse is 80/minute and regular. Chest auscultation reveals a quiet wheeze. His peak flow is 429 ml/min, (550 predicted). Eosinophils are elevated at 3.9 x 10^9/L. IgE is within the normal range.
Which of the following is the most appropriate next intervention?

A 68-year-old man is being treated in a medical ward for an empyema. A chest drain was inserted under ultrasound guidance at the time of admission and antibiotics were started. Over the past few days, there have been significant volumes drained and the patient has been improving clinically. On the daily morning ward round, his chest drain is reviewed which is on suction. There is minimal drain output over the past 24 hours, and it is noted that the chest drain is bubbling. This bubbling is more significant when the patient is asked to cough.
What does this indicate?

A 53-year-old obese patient (body mass index = 43) complains of morning headaches and daytime sleepiness. His wife reports that he snores very loudly. He has a history of systemic hypertension, and myocardial infarction 3 years ago with no residual cardiac dysfunction. He is a non-smoker. An overnight oximetry study shows significant hypoxemia with 20 % of the night spent with oxygen saturation below 90% and an oxygen desaturation index (3%) of 38/hour. Arterial blood gases show a pH of 7.38, PaCO2 of 56 mmHg, PaO2 of 67 mmHg and bicarbonate of 32 mmol/L.
Which is the most likely diagnosis?

A 50-year-old man is admitted to the respiratory ward with left lower lobe pneumonia. He has a history of chronic obstructive pulmonary disease, hypertension, and dyslipidemia and is a current smoker.
He is treated with steroids, nebulisers and antibiotics. After 5 days, he continues to be hypoxic with saturations of 86% on air, ongoing left basal crepitations and wheeze.
A CT scan of the chest is performed which shows emphysematous changes and resolving left basal consolidation. There is also a 7 mm lung nodule in the right upper lobe with surrounding ground-glass change.
Over the next 3 days, his saturations improve to 93% on air and his symptoms resolve. He is discharged home.
What imaging does he require to follow up for his pulmonary nodule?

13. A 45-year-old man presents to ER with shortness of breath, heavy chest pain and syncope. The chest pain and shortness of breath have been worsening over the last week. He is currently undergoing adjunct chemotherapy for a non-resectable soft tissue sarcoma. He has known metastasis in his thorax and mediastinum.

On physical examination, he is alert with his pulse rate being 110/min and regular, Blood pressure 95/55mmHg,  Respiratory rate 26/min, and Temperature 36.7ºC. JVP is raised at 5 cm. On precordial examination, there are no thrills, and he has quiet S1 and S2.

Lab tests show:
Hb 9.0 g/dl, Platelets 100 x 10^9/L, WBC 12.4 x 10^9/L

Sodium – 132 mmol/L, Potassium 3.2 mmol/L, Bicarb 19 mmol/L, Urea 8 mmol/L, Creatinine 144 mcmol/L.

What is the more specific ECG finding associated with this diagnosis?

A 42-year-old with a past medical history of asthma was reviewed by you in the clinic. Asthma was diagnosed in childhood. In adulthood, he has had multiple admissions to the hospital with asthma exacerbations in the summer months and never required intubation and ventilation for these.
He reports a nocturnal cough up to three times per week. There are associated rhinorrhoea and dry eyes that have been present since the weather became a bit warmer. Currently, he is using a salbutamol inhaler every other day for wheeze and mild dyspnoea. He works in construction and finds that his symptoms are worse when he is outside. Three weeks ago he was admitted to the hospital with an exacerbation of his asthma, where he was treated with salbutamol nebulisers and a short course of prednisolone.
Other past medical history includes eczema, allergic rhinitis and idiopathic generalised epilepsy. He has not had a seizure for many years. Drug history reveals:

• 14. Salbutamol metered dose inhaler when required
• Salmeterol 50 micrograms/fluticasone propionate 500 micrograms – two puffs twice daily
• Levetiracetam 500mg twice daily

On examination, vital signs are all normal. Auscultation of the chest reveals some mild end expiratory wheeze in the upper posterior zones bilaterally. The jugular venous pressure is not elevated, heart sounds were dual with no murmurs and there was no pedal oedema.

Hb 13.9 g/dl

WBC 7 x 10^9/L (Neutr 4 x 10^9/L, Lymphos 1.5 x 10^9/L, Eosinophils 0.5 x 10^9/L)

Platelets 290,000

Sodium 140 mmol/L, Potassium 3.6 mmol/L, Urea 4 mmol/L, Creatinine 60 mcmol/L, C-reactive protein 2 mg/L

Aspergillus precipitins – Negative

IgE – 500 UI/ml (reference range 150 – 300 UI/ml)

Chest x-ray – Appears normal

A 30-year-old pregnant woman (24 weeks) is admitted to the acute medical unit with sudden onset shortness of breath and pleuritic chest pain. She has no past medical history other than eczema and this is her first pregnancy.
On examination, auscultation of her chest reveals only a mild wheeze with oxygen saturation of 94% on room air and a respiratory rate of 25/min. Her heart sounds are normal, with a heart rate of 97 bpm and blood pressure is 105/60 mmHg. An ECG shows sinus rhythm.
The FY1 doctor on the ward has requested a D-dimer to try and ‘speed up the diagnosis, which comes back positive.
What is the next appropriate investigation?

16. A 42-year-old man is referred due to increasing shortness of breath and frequent chest infections. He is a smoker and smokes a packet per day. When he was a child he used a salbutamol inhaler but stopped this around the age of 6-7 years. He also had a whooping cough as a child. Pulmonary function tests performed by his GP show the following:

FEV1 – 3.6 L (predicted 3.8 L)

FVC 4.3 L (predicted 4.5 L)

FEV1/FVC – 84% (normal > 75%)

On auscultation of his chest scattered crepitations are noted. His oxygen saturations are 96% on room air. A CT chest is requested:

What is the most likely diagnosis?

17. A 60-year-old man with a new diagnosis of idiopathic pulmonary fibrosis is reviewed in the respiratory clinic following initial baseline investigations. He has been suffering from progressive shortness of breath for nine months with a non-productive cough. His GP has tried to give him inhalers and antibiotics but this has not helped. He has a past medical history of hypertension, depression and gout. He is concerned about his new diagnosis, especially about his prognosis. What test is most useful in determining prognosis?

A 70-year-old gentleman presents for review. He has had COPD for five years and is on regular bronchodilator treatment with Budesonide/Formoterol inhaler and Salbutamol inhaler as needed. He has found that he suffers from regular coughing bouts and his exercise tolerance has reduced.
His past medical history includes macular degeneration, osteoarthritis, mild memory impairment and diverticulosis.
What investigation would be most useful to help determine the severity of his COPD?

19. A 42-year-old male has been admitted with a week history of fever, anorexia and headache not responding to over-the-counter paracetamol. 4 days back he also developed a dry cough and mild dyspnea, and developed generalized skin rash 2 days back. He was prescribed Tab Co-Amoxiclav from a private clinic 3 days ago. He has a 10-pack-year smoking history. His past medical history is unremarkable.

On admission, he was fully alert. His temperature was 102.4 F, Pulse 90/min, BP 110/65 mmHg. His chest auscultation reveal bilateral vesicular breathing without any wheeze but several fine crepitations were audible at the right lung base. He has a fine maculopapular rash over his trunk and arms; several target lesions were noted. The general examination was otherwise normal. His co-amoxiclav has been stopped. The following day, he complains of myalgias and dull aching pain central chest.

His investigations are as follows:

Hb                                                                   13 g/dL

ESR                                                                70 mm fall at 1st hour

TLC                                                                 10 x 10^9 / L

Sodium                                                           142 mmol/L

Potassium                                                      4.4 mmol/L

Urea                                                                9 mmol/L

Creatinine                                                      90 µmol/L

Aspartate transaminase                                 90 U/L

Alkaline phosphatase                                      150 U/L

Bilirubin                                                           12 µmol/L

Blood & sputum culture                                 Negative

Cold agglutinins                                                 Positive

Chest X-Ray                                    Patchy consolidation right base

ABGs –                                       pO₂ – 8.9 kPa, pCO₂ – 4.5 kPa

ECG                                           sinus tachycardia, widespread T-wave flattening and inversion

Echocardiography – Normal valves and chambers with slightly reduced contractility of Left ventricle

What is the most likely diagnosis?

A 54-year-old lady is brought into the emergency department with a Glasgow Coma Scale of 5. She was found by a friend this morning unconscious and purple with no response. She had been unwell the previous days with an exacerbation of her COPD in which she was developing severe pleuritic chest pain. She had recurrent exacerbations of her COPD and had been hospitalised three times this year with one admission to ITU for intubation and ventilation.
In addition, she had hypertension, hypothyroidism and chronic regional pain syndrome. Her medications include fostair, ventolin, gabapentin, codeine, paracetamol, amlodipine, ramipril, levothyroxine and morphine sulfate. She had taken extra doses of oral morphine to control her pleuritic pain. She has started a rescue pack of amoxicillin and prednisolone one day prior
On examination, she does not open her eyes which have 2 mm pupils bilaterally that are reactive. She groans to pain but there is no motor response. Her chest has some wheeze across and her respiratory rate is 9 breaths per minute. She is saturating at 88% on 4 litres of oxygen via nasal cannulae and there is no accessory muscle use. She has mild pitting oedema and is centrally cyanosed. She has a capillary refill of two seconds and there are no murmurs.

20. Hb 16.1 g/L, WBC 9.0 x 10^9/L (neutrophils 7.7 x 10^9/L, Lymphos 1.0 x 10^9/L), Platelets 309 x 10^9/L

ABGs(on arrival) – pH 7.25, pO2 59 mmHg, pCO2 56 mmHg, HCO3 31 mmol/L

Chest x-ray – poor inspiration, no overt consolidation

ECG – Sinus Rhythm

What is your first step in management?