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

A 65-year-old gentleman presents with a three-day history of a productive cough. He complains that over the last two days he has been progressively shorter of breath, He complains of feeling very weak and lethargic and on further questioning reports fevers with rigors. His wife brought him to the emergency department as she was concerned as he appeared to be deteriorating rapidly.
Observations are: heart rate 125 beats per minute, respiratory rate 32 breaths per minute, S_{1. a}O₂ 90% on room air, temperature 38.9ºC, blood pressure is 130/85 mmHg. He appears distressed but is not confused.
Initial investigations show:
CBC –

KFTs –

Chest x-ray shows left lower zone consolidation.
From the above information, what is his CURB-65 score?

A 55-year-old woman is admitted with an infective exacerbation of bronchiectasis. Multiple sputum cultures in the community have grown 2. 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 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 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?

5. 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?

6. 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 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?

8. 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 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:

• 9. 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 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?

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 64-year-old female was admitted to the hospital with a moderate-large sized embolic stroke. She had a history of diabetes and newly diagnosed atrial fibrillation (AF). Her blood pressure on admission was 165/90 mmHg with a heart rate of 95 beats per minute.
An MRI brain was performed 24 hours after admission which showed a moderate to a large area of infarction involving the anterior 2/3rd of the left middle cerebral artery territory without haemorrhagic transformation.
With regards to the management of her AF and stroke prevention, the most appropriate decision would be to commence which of the following?

13. 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?

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?

15. 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 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 38-year-old gentleman attends A&E at 9 p.m. during a busy medical take. He complains of chest pain which has intermittently been present since the morning. On further questioning, his pain is central in location with no radiation and some associated nausea. His father suffered from an MI at the age of 65 and his grandfather suffered from peripheral vascular disease. His troponin-I is 0.05 (significant >0.1) and ECG shows no ischaemic changes. This gentleman asks you what happens next, what should you tell him?

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?

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?

20. A 33-year-old man presents with a chronic productive cough which has been affecting him for several years. He has no other past medical history apart from recurrent otitis media as a child. He takes no regular medications. He has never smoked and has no history of passive smoking and works as a solicitor. He has no pets at home and has no mould that he is aware of. On examination, there is finger clubbing, he appears underweight, and there are coarse late-inspiratory crepitations and a mild wheeze. Also, his heart sounds are louder on the right side, and his apex beat is also only present on the right. What further investigation would most likely confirm the diagnosis?