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

An 84-year-old nun presented to A&E 2 weeks after discharge from the hospital under the care of the cardiologists. Her presenting
complaint is one of feeling faint and dizzy and intermittently short of breath. She mentions that during her last admission she was started on digoxin because she had an irregular heart rate that was racing away. On discharge, she claims that she had no problems and only developed this dizziness in the past couple of days. Her drug history includes atenolol 100mg once daily. Her ECG today shows a rate of approximately 40 beats per minute with no association between P waves and QRS complexes. What is the next step in her management?

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.

2. 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?

A 66-year-old man is admitted with a 2-hour history of central chest pain radiating to the left arm and is associated with nausea and vomiting. He has a past medical history of hypertension, dyslipidemia and diet-controlled diabetes. He takes Amlodipine and Atorvastatin.
On examination, he is afebrile, his blood pressure is 145/90 mmHg and heart rate is 110 beats per minute. His saturations are 96% on room air. Cardiovascular and respiratory examinations are unremarkable.
An ECG shows T wave inversion in leads I, V4, V5 and V6. Cardiac biomarkers are raised. CBC with differential, renal functions and electrolytes are normal. He has been managed for NSTEMI acutely, and 3 days later he undergoes coronary angiography with stenting of the left circumflex artery. On systems reviews, prior to discharge, he comments that he has noticed a rash on his legs and has not been passing much urine despite drinking plenty of water. On examination, he has a bluish lacey discolouration over his legs. He has no palpable bladder. CBC shows eosinophilia and RFTs are slightly deranged.

3. What is the most likely diagnosis?

4. A patient with a background of COPD presents to the emergency department with a simple pneumothorax 2.4 cm in size. What is the most suitable management option?

A 73-year-old ex-smoker with a history of COPD presents to the emergency room by ambulance. He has an FEV1 of 40% of predicted. He does not use home oxygen. His pulse is 120/min and regular, blood pressure 110/60 mmHg, respiratory rate 12/min, and Glasgow Coma Scale score reduced to 12. He is breathing 10 L of oxygen via a mask.
Arterial blood gases (ABGs) demonstrate pH 7.21, PaO2 103 mmHg, PaCO2 90 mmHg, HCO3 – 35 mmol/L (RR 23–33). Your approach to treatment should be:

6. A 25-year-old woman presents to ED with three days of acute shortness of breath. She initially had a dry cough and sore throat. She is usually fit and well and is fully vaccinated. She is taking the combined oral contraceptive pill. On examination, she had bibasal crepitations with dullness to percussion at the bases. Her observations show a respiratory rate of 25 breaths per minute, heart rate of 105 beats per minute and saturations of 96% maintained on a 60% venturi mask. Her JVP is seen at 5 cm above her sternal angle and there are no murmurs.

Na+ 132 mmol/L, K+ 4.9 mmol/L, Urea 5.8 mmol/L, Creatinine 90 mcmol/L, Troponin 18000 ng/ml (normal value < 20). ECG show ST elevation in V-V4. What is your most likely diagnosis?

A 55-year-old woman is admitted with an infective exacerbation of bronchiectasis. Multiple sputum cultures in the community have grown 7. Pseudomonas aeruginosa and her GP had started oral ciprofloxacin. However, despite 4 days of this, she has developed worsening breathlessness, hypoxia, and fever and is now requiring oxygen.
Widespread coarse crepitations are heard and her chest x-ray demonstrates bilateral infiltrates.
What is the most appropriate course of action?

A 62-year-old man presents to his GP with several months of exertional chest pain which subsides with rest. He is using Atorvastatin for dyslipidemia. The GP starts Bisoprolol.
Several weeks later, the patient complains of the persistence of symptoms.
Regarding drug therapy for this patient, what should be added next?

A 56-year-old gentleman presents with shortness of breath and haemoptysis which has worsened over ten days. He is currently coughing up an estimated 200 ml of fresh red blood every day. He has night sweats and feels cold and sweaty at times. He has not lost any weight and was well prior to this.
He has mild COPD and takes Foster inhaler twice a day with no exacerbations in the past 5 years. He moved to the UK 15 years ago but lived 10 years in Louisiana as a mining operator extracting minerals with exposure to bats and birds during this time. He drinks 10 units of alcohol a week and was born in Syria where he received a BCG vaccine as a child. He has not been around any ill contacts and lives with his wife and two children. There is no recent foreign travel and he keeps no pets.
On examination, he has crepitations in the right side mid and upper zones. He has palpable lymph nodes in his axillae and neck but his abdomen is non-tender with no hepatosplenomegaly. He is breathing rapidly and appears cachectic. His observations show temperature 38.3ºC, respiratory rate 28/min, heart rate 98/min, saturation 88% in air. An arterial blood gas has not been done.

What is the likely diagnosis?

10. A 65-year-old man comes to the respiratory clinic. He is a current smoker with a 60 pack-year history. He has been suffering from a worsening cough and haemoptysis for the last month and has had a weight loss of 3 kg over one month. On examination he looks cachectic, his fingers are clubbed and tar-stained. His wrists are tender. His chest shows reduced expansion on the right side with reduced breath sounds and dullness. What is the wrist tenderness likely to indicate?

An 80-year-old woman was a passenger in a car that collided with a lamppost in the city
centre. She was initially complaining of pain in her right hip and ribs but has become
increasingly drowsy since the paramedics administered 2 mg of morphine. She is brought
to the emergency department by ambulance.
Urgent X-rays reveal a pelvic fracture and a single right-sided rib fracture. Having, initially been drowsy but responsive she is now unresponsive. Oxygen saturation is 87 % on 2 L/min oxygen via nasal cannulae.
She is apyrexial. BP is 110/66 mmHg, pulse is 65 beats/min. There are no new findings on
examination.

11. An urgent CT brain reveals only small vessel disease. Arterial blood gas: pH 7.22, PaO2 65 mmHg, PaCO2 75 mmHg, HCO3 − 26 mmol/L.

What is the most likely cause of her deteriorating conscious level?

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:

12. 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?

13. A 65-year-old  is admitted with pyrexia of unknown origin. He has past history of IHD and PCI. On examination, his pulse is 98/min, temperature 38.3ºC and blood pressure 105/65 mmHg. A petechial rash is noted on his hands and legs. On cardiac auscultation, a systolic murmur is noted. Lung auscultation is unremarkable. His 3-year-old echocardiogram showed no valvular disease. A chest x-ray is normal and the urine dipstick shows blood ++.

A presumptive diagnosis of infective endocarditis is made and empirical treatment with IV Amoxicillin and Gentamicin is given. Two days later blood cultures show a coagulase-negative staphylococcus. What is the most appropriate action with respect to antibiotic therapy?

14. A 50-year-old gentleman presents to the clinic with shortness of breath and a dry cough. He has noticed his symptoms getting progressively worse over months. He has a past medical history of hypertension and depression. He takes only ramipril and has no allergies. On examination, he has bilateral inspiratory crackles at both lung bases. A chest X-ray demonstrates extensive pleural plaques. He worked as an electrician 20 years ago and believes that he may have had asbestos exposure. A diagnosis of asbestosis with extensive pleural plaques is suspected. What are his pulmonary function tests likely to show?

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:

• 15. 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

16. A 73-year-old man presents with dyspnoea. A chest x-ray is performed. What is the main finding in the chest x-ray?

A 25-year-old man is reviewed prior to discharge. He was admitted to the hospital one day ago with a small pneumothorax. As it was <1 cm in size he was treated with high flow oxygen and he was admitted for observations over 24 hours. His symptoms have resolved and a repeat chest x-Ray shows complete resolution of the pneumothorax. What advice should he be given before discharge?

18. For a 61-year-old male patient with severe COPD (FEV1 32% of predicted and PaO2 53 mmHg), which of the following has been shown to prolong his life expectancy?

19. A 35-year-old female presents with breathlessness on exertion. She is a non-smoker and has two budgies at home. She had severe pneumonia about 4 years ago and required intubation in intensive care for 5 days. She recovered but has reported ongoing dyspnoea and on examination has an inspiratory wheeze. This has not improved despite her GP starting inhaled steroids for asthma. Her chest X-ray was unremarkable, peak flow was reduced and eosinophil count was normal. What is the most likely diagnosis?

A 67-year-old man was admitted from A&E 3 days after suffering a myocardial infarction. He was complaining of increasing shortness of breath. On observation was tachypnoeic at rest whilst sitting up. On examination, his jugular venous pressure was raised, respiratory rate was 30 breaths per minute and his heart rate was 120/minute.
On auscultation, you hear a systolic murmur but no other findings. An erect chest X-ray was normal. Which of the
following complications of MI is most likely to be the cause of this gentleman’s shortness of breath?