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

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?

2. 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 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 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?

5. 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 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:

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?

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?

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?

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?

A 55-year-old lady with severe asthma attends with two days of shortness of breath and chest tightness. She has a history of multiple exacerbations and was intubated three months ago for a severe exacerbation. She usually takes Montelukast, Beclometasone and Salbutamol.
On arrival, she is cyanosed and saturating at 92% in the air. There is accessory muscle use and she is not able to vocalise beyond groans. Her respiratory rate is 22/min and there is a quiet wheeze heard bilaterally in the chest. She has failed to respond to nebulisers, steroids and magnesium sulfate. She is planned for intubation and initiation of aminophylline.

What recording is essential when administering aminophylline?

A 53-year-old female patient presents to the outpatient clinic for her asthma review.
She has been admitted to the hospital three times in the last year with asthma exacerbations. Admission duration was 2-3 days in hospital but never required intubation or intensive care admission. This is on a background of multiple admissions to hospitals in previous years.
On review, she reports wheeze associated with dyspnoea on most days and this is usually triggered by exertion. There is a non-productive cough most mornings which settles throughout the course of the day. There is no history of allergic rhinitis, eczema or other medical problems. She is a life-long non-smoker.
Current asthma therapy is high dose inhaled fluticasone propionate plus salmeterol 2 puffs twice daily, prednisolone 10mg once daily and inhaled salbutamol as required. She has been taking regular prednisolone 10mg for the last eighteen months.
On examination, observations revealed a respiratory rate of 14/min, oxygen saturation of 98% on room air, heart rate 80/min regular, blood pressure 130/70 mmHg and a temperature of 36.8ºC. There is no clubbing, cervical lymphadenopathy or elevation of the jugular venous pressure. Auscultation of the chest revealed dual heart sounds with no murmurs and some mild expiratory wheeze in the upper zones. The calves were soft and non-tender, with no pedal oedema.
You had reviewed this patient during her most recent exacerbation and had arranged some outpatient tests, the results of which are shown below:

13. 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?

14. 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?

15. A 68-year-old male has presented with episodic palpitations for several months which occurs almost every other week. He gives h/o one episode of exertional syncope about a week ago. His past medical history includes a Myocardial infarction about 15 years back for which he received thrombolysis. He is using Bisoprolol, Aspirin, Atorvastatin and Ramipril. Physical examination is normal. ECG done which shows RBBB, LAD and First degree AV block.

What is the next management step?

16. 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?

17. A 25-year-old woman presents to ED with three days of acute shortness of breath. She initially had a dry cough and sore throat. She is usually fit and well and is fully vaccinated. She is taking the combined oral contraceptive pill. On examination, she had bibasal crepitations with dullness to percussion at the bases. Her observations show a respiratory rate of 25 breaths per minute, heart rate of 105 beats per minute and saturations of 96% maintained on a 60% venturi mask. Her JVP is seen at 5 cm above her sternal angle and there are no murmurs.

Na+ 132 mmol/L, K+ 4.9 mmol/L, Urea 5.8 mmol/L, Creatinine 90 mcmol/L, Troponin 18000 ng/ml (normal value < 20). ECG show ST elevation in V-V4. What is your most likely diagnosis?

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.

18. What is the appropriate next step of treatment?

19. 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?

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?