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

An 87-year-old man is admitted to the hospital with a severe exacerbation of his COPD. He is breathless on rest and although alert and orientated, is starting to become drowsy. His observation reveals a temperature of 37.8ºC, a heart rate of 80 beats per minute, blood pressure of 115/75 mmHg, respiratory rate of 28 breaths per minute and oxygen saturation of 84% on a 28% Venturi mask.
An arterial blood gas is performed and reveals a PaO2 of 9.0 kPa, PCO2 of 11.4kPa, HCO3 of 31 mmol/l and a pH of 7.29.
A decision is made to commence him on non-invasive ventilation – which of the following is the most appropriate management for this patient?

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:

A 24-year-old female presents to the clinic complaining of several episodes of palpitations. She states that during the episodes it feels like her heart skips a bit. She denies pre-syncope or syncope. She has one episode every few days. She drinks approximately 28 units of alcohol per week and several cups of coffee per day.
You arrange a 7-day cardiac Holter monitor. The results are as follows:

3. PR interval 100 ms, QRS duration 110 ms, Events: 24 single ectopics with normal P wave morphology and a QRS of 110 ms

What is the most appropriate initial management plan?

4. 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?

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 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 patient, with recent MI and PCI, follow up in cardiology clinic. He is taking his medications regularly and is asymptomatic now. His pulse rate is 55/min but otherwise clinical examination is unremarkable. An ECG is done and shows accelerated idioventricular rhythm (AIVR) with a rate of 55 beats per minute.
What is the next management step?

8. 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 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?

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?

11. A 79-year-old man presents with severe central chest pain which started around 90 minutes ago. He is known to have ischaemic heart disease and had a coronary artery bypass graft (CABG) five years ago. On arrival at the Emergency Department, he is clammy and vomiting. An ECG is taken:

What is the most accurate description of what is shown on this ECG?

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?

A 30-year-old man presents to the emergency department with a four-day history of subjective fevers, shortness of breath, non-productive cough and malaise. On arrival at the emergency department, his observations revealed a temperature of 38.5ºC, heart rate 120/min, blood pressure 90/60 mmHg, respiratory rate 35/min and oxygen saturation of 80% on room air. An arterial blood gas revealed severe type 1 respiratory failure and the patient was intubated and placed on mechanical ventilation.
A post-intubation chest x-ray revealed bilateral pulmonary infiltrates and within the limits of a portable chest x-ray, a normal-sized cardiac silhouette.
Intravenous 1g ceftriaxone, 500mg azithromycin and 200mg hydrocortisone were given in the emergency department for severe community-acquired pneumonia prior to transfer to the intensive care unit (ICU). The patient remained on invasive mechanical ventilation for the first 24 hours. During this time, he underwent computed tomography pulmonary angiography (CTPA) and bronchoalveolar lavage. He made good progress and was extubated to high flow nasal cannulae after 24 hours. He is haemodynamically stable. He is stepped down to the high dependency unit (HDU), where you review the patient.
You speak with the patient’s wife to obtain a collateral history. The patient has no known past medical, surgical, drug or family history of note. He works as a full-time chef and there have been no known sick contacts. He drinks 1-2 cans of standard strength beer per night and occasionally binge drinks at the weekends. He recently started smoking cigarettes to cope with increased stress at work and there is no history of illicit drug use. There has been no recent travel history.
On examination in the HDU, the temperature was 37.5ºC, heart rate 90/min, blood pressure 100/60 mmHg and respiratory rate 26/min. He is on high flow oxygen via nasal cannulae, with a flow rate of 30 litres per minute, the fraction of inspired oxygen is 30% and has an oxygen saturation of 95%. There are fine inspiratory crepitations audible in the lower posterior chest bilaterally which do not change with coughing. The jugular venous pressure was not elevated and there was no pedal oedema.
Current medications are IV Ceftriaxone, Azithromycin and PRN Paracetamol.
You review the latest available results for this patient:

Which of the following would be the most appropriate ongoing management for this patient?

A 62-year-old man sees his GP with complaints of leg pain. Over the last few months, he notices a crampy uncomfortable feeling in the back of both of his calves when he walks to the shops. The discomfort can be so bad that he has to stop and rest for a few minutes after which he notices that his symptoms are improved. On occasions, he also gets the symptoms when he is shopping in the supermarket. He attributes this to overexerting himself, and tries to rest on his shopping trolley while walking but does not seem to help. He has a 40-pack year smoking history and takes amlodipine for his blood pressure, and paracetamol and ibuprofen for lower back pain that has troubled him for years.
Physical examination reveals mild atrophy of his thigh and calf muscles bilaterally, in addition to shiny pale skin with significant hair loss throughout his lower limbs. His pedal pulses are bilaterally impalpable, and popliteal pulses are faint. Power in both lower limbs is normal throughout all movements, and he has normal patellar reflexes bilaterally and absent ankle reflexes. His Babinski reflex is downgoing on the left side and equivocal on the right side. A recently obtained ankle-brachial pressure index test yielded a result of 0.70 on the right side and 0.95 on the left side. X-rays of his lumbar spine show evidence of joint space narrowing and osteophytes.
Which one of the following is the next best step in the management of this patient?

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 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?

17. 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 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 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?

A 60-year-old man with metastatic small cell lung cancer is admitted with shortness of breath, cough and purulent sputum.
His chest x-ray shows right lower lobe pneumonia with partial collapse of the right lung. He has a bulky primary tumour at the right hilum and extensive hilar lymphadenopathy.
He is treated with IV antibiotics, fluids and oxygen. His symptoms improve over the next 5 days and his breathing is comfortable on 2 litres of oxygen via nasal cannulae. His pain is controlled on 20 mg long-acting Morphine sulphate twice daily. The decision is made to discharge him to a hospice for end-of-life care. However, due to the proximity of his lung tumour to major vessels, he is at risk of a major terminal bleed.
Which medication should the hospice be advised to give in the event of a major bleed?