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

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:

1. 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.

2. 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?

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 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 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.

5. 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?

6. 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?

7. A 25-year-old man presents to the emergency department complaining of breathlessness and pleuritic chest pain, which started suddenly 12 hours ago. He has no relevant past medical history and is a non-smoker. His chest x-ray shows a pneumothorax with a 2cm rim. What is the correct management in this situation?

8. 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 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.

9. What is the appropriate next step of treatment?

10. 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 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?

12. 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 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?

14. 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?

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?

16. A 40-year-old male patient, a known case of Acute lymphoblastic leukaemia, has been referred to you from an oncology hospital with malaise, tiredness and nausea. The only pertinent history available at present is that he has been treated with chemotherapy and had developed a prolonged fever that required intravenous treatment. On examination, he is normotensive with no remarkable finding on physical examination.

His labs are as follows:

Sodium                                                 137 mmol/L

Potassium                                             2.4 mmol/L

Urea                                                      5.0 mmol/L

Bicarbonate                                          26 mmol/L

Chloride                                                110 mmol/L

Urine dipstick                                       Negative

What is the most likely diagnosis?

A 61-year-old man comes to his GP complaining of cough and dyspnoea on exertion. He has had the cough for over 2 years, but it has gotten worse recently along with increasing shortness of breath. He has no haemoptysis, chest pain or leg swelling. The patient has a 60 pack-year smoking history and drinks a moderate amount of alcohol. His temperature is 37.2ºC, blood pressure is 140/80 mmHg, his pulse is 80/min, and respirations are 20/min.
Chest x-ray shows prominent bronchovascular markings and mild diaphragmatic flattening.
Pulmonary function test results are as follows:

Carbon monoxide diffusion capacity is 100% of the predicted value.
Which of the following is the most likely cause of this patient’s symptoms?

18. A 56-year-old woman presents to the clinic for review following investigations and MDT discussion. She has chronic exertional dyspnoea and following a restrictive pattern detected on spirometry and changes on high-resolution CT scanning she has been diagnosed with idiopathic pulmonary fibrosis. What medication can be used to modify disease progression?

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?

20. A 45-year-old teacher was referred to the cardiologists after having been admitted with shortness of breath. Her past medical history consists of inflammatory bowel disease but no cardiac problems. On examination, her apex was located in the anterior axillary line in the sixth intercostal space. There were no peripheral signs of cardiovascular disease but on auscultation a fourth heart sound was audible. There were no murmurs. A bedside 2D echo showed a dilated heart with an ejection fraction of 20–25%. The likely cause of her dilated cardiomyopathy is: