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

A 56-year-old man presents to the emergency department with a three-day history of sharp chest pain. He denies any shortness of breath. His pain is worse on deep inspiration and has not improved with paracetamol. He has no other symptoms. He has a past medical history of COPD and uses regular combination inhalers with salbutamol inhalers when he becomes short of breath. He has not recently had an exacerbation and he has never been admitted to ICU or had invasive ventilation. On examination, vital parameters are within normal range. The chest is clear on auscultation. A chest X-ray demonstrates a < 1cm right-sided pneumothorax. He is treated with high flow oxygen. What is the benefit of oxygen in the treatment of a pneumothorax?

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 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?

4. A 65-year-old  is admitted with pyrexia of unknown origin. He has past history of IHD and PCI. On examination, his pulse is 98/min, temperature 38.3ºC and blood pressure 105/65 mmHg. A petechial rash is noted on his hands and legs. On cardiac auscultation, a systolic murmur is noted. Lung auscultation is unremarkable. His 3-year-old echocardiogram showed no valvular disease. A chest x-ray is normal and the urine dipstick shows blood ++.

A presumptive diagnosis of infective endocarditis is made and empirical treatment with IV Amoxicillin and Gentamicin is given. Two days later blood cultures show a coagulase-negative staphylococcus. What is the most appropriate action with respect to antibiotic therapy?

A 22-year-old student was referred by his general practitioner with a 4-week history of increasing cough and breathlessness. The cough was generally non-productive but he had coughed up a small amount of blood on 3 occasions. His past medical history consisted only of asthma which was well controlled with a Salbutamol inhaler. There was no family history of venous thromboembolism. His recent travel history included a trip to Sierra Leone 3 months ago. He was a non-smoker and drank 20 units of alcohol per week.
On examination, his temperature was 37.6 C, heart rate 80/minute, blood pressure 125/90 mmHg, respiratory rate 22 breaths per minute and oxygen saturation 92% on room air. He was able to talk in full sentences. A few bibasal crackles were evident on auscultation of the chest. His JVP was not elevated and heart sounds were normal.
Investigations:

5. Hb 14.5 g/dl

WBC 8 x 10^9/L (Neuts 3.5 x 10^9/L, Lymphs 1.6 x 10^9/L, Eosins 1.3 x 10^9/L)

Platelets 325 x 10^9/L

Chest x-ray: Bilateral lower zone haziness
ECG: Normal sinus rhythm
What is the most appropriate treatment for the underlying condition?

6. 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 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 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:

8. 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.

9. 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 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 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:

12. 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:

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 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.

15. What is the appropriate next step of treatment?

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?

17. 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?

18. 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?

A 56-year-old man is being reviewed in the sleep clinic. He was initially referred by his GP for early morning headaches, somnolence during the day and a report of loud snoring by his wife. He underwent sleep polygraphy which showed 28 apnoeas and hypopneas per hour.
Previous medical history includes hypertension and hyperlipidaemia. His BMI is 33 kg/m². He is a non-smoker and drinks 6 units of alcohol a week. In the last month, he has lost 3 kg in weight. But states that his symptoms have shown little improvement so far.
What would be the next step in his management?

20. A 16-year-old girl has been brought by her mother with symptoms of fatigue. Her mother has noticed that ‘she is becoming pale’. Her menarche set in about 2 years ago and her menstrual bleed has become heavier recently. There is no history of bleeding elsewhere or bruising. Her father is working overseas and is not available. However, they give a history of recurrent anemia in his youth. She has no siblings. On examination she is pale and abdominal palpation reveals 2-cm splenomegaly.

Her labs are as follows:

Hb                                                                   6.7 g/dL

TLC                                                                 8.1 x 10⁹/L

Platelets                                                          370 x 10⁹/L

Reticulocytes                                                  10%

Direct Coomb’s test                                      Negative

Urea                                                                4.2 mmol/L

Na⁺                                                                 141 mmol/L

K⁺                                                                                 4.9 mmol/L

Bilirubin                                                          38 µmol/L

AST                                                                  69 U/L

Alkaline phosphatase                                   119 U/L

Haptoglobins                                              Not detected

Urinary hemosiderin                                       Absent

What is the next most appropriate investigation?