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

A 55-year-old lady with severe asthma attends with two days of shortness of breath and chest tightness. She has a history of multiple exacerbations and was intubated three months ago for a severe exacerbation. She usually takes Montelukast, Beclometasone and Salbutamol.
On arrival, she is cyanosed and saturating at 92% in the air. There is accessory muscle use and she is not able to vocalise beyond groans. Her respiratory rate is 22/min and there is a quiet wheeze heard bilaterally in the chest. She has failed to respond to nebulisers, steroids and magnesium sulfate. She is planned for intubation and initiation of aminophylline.

What recording is essential when administering aminophylline?

2. A 30-year-old labourer presents with diffuse colicky abdominal pain and night sweats. He also has had a high-grade fever up to 102F associated with rigors and chills, and a dry cough. With antibiotics, these symptoms improved but recurred after 3 days and were accompanied now by frontal headache, body aches and lethargy.

On examination, his temperature is 103 F, pulse 110/min, BP 110/60 mmHg and respiratory rate 20/min. He is lethargic and easily irritable. There is no neck stiffness and he has a clear lung field on auscultation. Cardiac auscultation shows a soft pansystolic murmur at the apex. The abdomen is tender to palpation in the upper quadrants without any guarding or rigidity. There are no focal neurological signs.

On investigations, his Hb is 8.5 g/dL, MCV 85 fl, MCHC 30 pg, TLC 7.5 x 10^9/L with 63% neutrophils, platelets 116 x 10^9/L, ESR 75 mm fall at end of first hour.

Blood glucose is 6.2 mmol/L, Sodium 130 mmol/L, potassium 4.0 mmol/L, bicarbonate 20 mmol/L, creatinine 490 µmol/L, Bilirubin 12 µmol/L, ALT 50 IU/L, LDH 495 IU/L, Amylase 60 IU/L, creatinine kinase 50 IU/L, albumin 28 g/L, total protein 65 g/L, calcium 1.7 mmol/L, phosphate 1.19 mmol/L.

Urine dipstick test : blood +, protein +++

Urine microscopy: granular and hyaline casts seen / HPF

Chest & abdominal x-rays are normal

CT Head – Normal

What is the most likely diagnosis?

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.

3. 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 52-year-old taxi driver, with a 55 pack-year smoking history, presents with increasingly
breathless on exertion. Oxygen saturations are 98% on room air. Examination reveals tracheal
tug, reduced cricosternal distance and a barrel chest. He has reduced cardiac dullness and symmetrically reduced air entry. CXR reveals hyperinflation and spirometry reveals moderate airway obstruction. The patient walks 300 m on an incremental walk test before becoming breathless. Oxygen saturation is normal in room air.
What pathological change best explains why he is breathless on exertion?

5. 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?

6. A 75-year-old man presents with chronic cough and breathlessness that has been increasing over the past 12 months. He is a lifelong non-smoker. On examination, he has clubbing of the fingers and crackles over the lower half of both lungs.

A chest X-ray shows an interstitial pattern mainly in the lower lobes with a suggestion of honeycombing. Lung function tests show an FVC of 75% of predicted with an FEV1/FVC ratio of 0.86; carbon monoxide transfer is 45% of predicted.

A high-resolution CT of the chest shows symmetrical bilateral reticular opacities with honeycombing, predominantly in the bases of the lungs. Laboratory tests for connective tissue disease are negative.

Which treatment has been shown to be of long-term benefit for his lung disease?

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.

7. What is the appropriate next step of treatment?

8. 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?

9. 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 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?

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.

11. 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 56-year-old gentleman was admitted to the Emergency Department with a two-week history of progressively increasing shortness of breath, with frank haemoptysis for the last couple of days. By the point of admission, he was short of breath on minimal exertion and at rest and was unable to complete full sentences. He also complained of increasing orthopnoea for the last few weeks. He had a long history of recurrent epistaxis, rhinitis and sinusitis, as well as a past medical history of diabetes, hypertension, hypercholesterolaemia and gout. His medication regimen comprised of Mometasone nasal spray, Allopurinol 100mg OD, Ramipril 2.5 mg OD, Amlodipine 5mg OD, Simvastatin 40mg OD, Metformin 500mg TDS and Gliclazide 80mg OD. He smoked 20 cigarettes per day and did not consume alcohol.
On examination, he appeared very unwell with obvious respiratory distress. His respiratory rate was 28/min, oxygen saturation was 90% on room air, BP was 108/72 mmHg, heart rate 130/min and the temperature was 37.9 C. Examination of his cardiovascular system revealed normal heart sounds with a JVP of 3 cm. Examination of the respiratory system revealed the use of accessory muscles with bibasal fine crackles. Examination of the gastrointestinal and neurological systems was unremarkable.
Initial investigations revealed the following:

Chest x-ray: bilateral patchy infiltration
ECG: heart rate 130 bpm and sinus rhythm.
Urinalysis: Blood ++++, Protein +++, Leuc/Nitrites – negative, Glucose – negative
ABG on 15 L/min oxygen:

He was commenced on an IV infusion of normal saline, as well as Co-amoxiclav 625mg TDS, and quickly transferred to the Intensive Care Unit. He was cathetrized. A decision was made to institute immediate haemodialysis, for which preparations were being made.

Further investigations revealed the following:
Urine MCS: nil grown
Blood culture – interim results: nil grown

Transoesophageal echocardiogram: normal systolic function, valvular appearances and no vegetations seen

Given the likely underlying diagnosis, which of the following interventions is the next best step whilst awaiting haemodialysis?

A 45-year-old woman has a recent diagnosis of adenocarcinoma of the lung made at bronchoscopy 1 week ago. She presents to the emergency department acutely short of breath
with a non-productive cough. She has an ache in the centre of her chest that is made worse by
breathing in. She is apyrexial. Oxygen saturations are 91 % on 40 % oxygen. Respiratory rate is
30 breaths/min. Blood pressure (BP) is 100/65 mmHg and pulse is 110 beats/min.
Examination reveals decreased expansion of the right side with dullness to percussion
throughout the right side. Her trachea is deviated to the right and the apex beat is not
palpable. Breath sounds are reduced on the right. What is the most likely diagnosis?

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 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.

15. What is the most likely diagnosis?

A 52-year-old man has attended the emergency department with severe palpitations and breathlessness. He describes them as intermittent, lasting between 20 seconds and one minute, and self-resolving.
His past medical history includes myocardial infarction requiring stents, left ventricular systolic dysfunction, and type 2 diabetes mellitus. Electrolytes results are shown below:

16. Na+  142 mmol/L, K+ 3.8 mmol/L, Bicarbonate 24 mmol/L, Calcium 2.36 mmol/L, Phosphate 0.92 mmol/L, Mg 0.96 mmol/L

The most recent ECG is shown below.Whist in the department he describes a sudden recurrence of these palpitations. He denies chest pain and dizziness. HR 210 bpm, BP 125/75 mmHg, SaO2 98%, RR 32/minute, Temp 37 C.

17. A 25-year-old woman has recently been diagnosed with Marfan’s syndrome. She undergoes an echocardiogram which demonstrates severe aortic regurgitation, significant aortic root dilatation and a left ventricular ejection fraction of 70%. She is asymptomatic and has no family history of aortic dissection. What is the most appropriate management of her cardiac problem?

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:

18. 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?

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:

20. 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?