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

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 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:

2. 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 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?

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?

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?

6. 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?

7. 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 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 67-year-old woman is complaining of a six-hour history of chest pain and dizziness in the high-dependency unit. She underwent a mitral valve replacement five days ago and had some temporary trans-venous pacing wires removed earlier today.
On examination, she has oxygen saturation of 93% on 2 litres via nasal cannula, has a heart rate of 110/min, a blood pressure of 76/43mmHg, has a temperature of 37.9ºC, and is responsive to voice. She feels cool peripherally. An ECG is performed at the bedside which shows sinus rhythm with QRS complexes of alternating amplitude.
Blood tests from this morning show: Hb 89 g/L, WBC 13.1 x 10^9/L, Platelets 121 x 10^9/L, Na= 143 mmol/L, K= 3.1 mmol/L, Urea 18.2 mmol/L, Creatinine 151 mcmol/L, CRP 282 mg/L, Mg 0.83 mmol/L.

9. What is the most appropriate management given 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.

10. 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 36-year-old woman is investigated for lethargy, fever, cough and weight loss. She has been treated by her GP with five courses of antibiotics over the past six months for a combination of chest and sinus infections. Her symptoms, however, have continued unabated. Clinical examination is unremarkable other than some scattered crackles in the right base. She is apyrexial. Urine dipstick: blood ++, protein +.
Lung function tests and blood tests show the following:

Her chest x-ray is shown here:

What is the likely diagnosis?

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

13. 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?

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 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?

16. 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?

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?

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 58-year-old female presents to the hospital with 3 days of breathlessness, cough and fevers. She has a history of asthma but has had no prior admissions. At presentation she is diaphoretic with warm peripheries. She has a pulse of 140 beats/min and sinus rhythm, blood pressure of 70/40 mmHg, and temperature of 38.4°C. A chest X-ray shows consolidation involving the right lower and middle lobes. Electrocardiography demonstrates ST depression in leads V3–V5 with
T wave inversion. The Troponin level is elevated. Arterial blood gases demonstrate a pH of 7.29, PaO2 50 mmHg, and PaCO2 30 mmHg. Serum biochemistry reveals Na 130 mmol/L, K 4.9 mmol/L, urea 11.4 mmol/L (Normal Range 2.1–9.0), creatinine 120 micromol/L (NR 40–90), and HCO3 – 14 mmol/L (NR 23–33). You assess that she is in shock. From your findings you should institute the following treatment based on the probable cause of her shock:

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.

20. 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?