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

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?

2. 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 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.

3. 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.

4. 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?

5. 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 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 44-year-old is referred to a respiratory clinic with 2 months of exertional shortness of breath. He has a past medical history of HIV. He is well controlled on Truvada. He had an unprovoked pulmonary embolism three years ago and was treated with six months of warfarin. He smoked 15 cigarettes daily for the last 20 years. He recently completed his first mountaineering expedition and successfully reached the summit of Kilimanjaro.
On examination, there is a loud P2. The jugular venous pulse is raised and there is peripheral oedema. Chest auscultation is unremarkable and there are no murmurs.
A transthoracic echocardiogram is arranged, which demonstrates a mean pulmonary arterial pressure (PAPm) of 38 mmHg and mitral regurgitation with a regurgitant fraction of 14%.
An HRCT chest is normal. V/Q scanning demonstrates mismatched perfusion defects. The patient is referred for a right heart catheter, which confirms a PAPm of 38 mmHg and also demonstrates a pulmonary arterial wedge pressure (PAWP) of 11 mmHg.
Given the likely diagnosis, what is the probable underlying aetiology?

8. A 60-year-old man with hypertension presents with uncontrolled blood pressure despite being on Amlodipine and Enalapril. He has no symptoms of postural hypotension, and his latest ambulatory blood pressure readings show an average blood pressure of 160/94 mmHg. His lab work shows:

Na+ 137 mmol/L, K+ 4.2 mmol/L, Urea 4.5 mmol/L, Creatinine 85 mcmol/L

What medication you would prescribe as a next step to manage his hypertension?

9. 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?

10. 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?

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?

12. 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 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?

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.

14. What is the most appropriate management given the likely diagnosis?

15. 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?

16. 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 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 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:

18. 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?

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:

19. 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.

20. 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?