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

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?

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

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?

A 24-year-old female presents to the clinic complaining of several episodes of palpitations. She states that during the episodes it feels like her heart skips a bit. She denies pre-syncope or syncope. She has one episode every few days. She drinks approximately 28 units of alcohol per week and several cups of coffee per day.
You arrange a 7-day cardiac Holter monitor. The results are as follows:

4. PR interval 100 ms, QRS duration 110 ms, Events: 24 single ectopics with normal P wave morphology and a QRS of 110 ms

What is the most appropriate initial management plan?

5. For a 61-year-old male patient with severe COPD (FEV1 32% of predicted and PaO2 53 mmHg), which of the following has been shown to prolong his life expectancy?

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:

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. 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 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?

A 42-year-old with a past medical history of asthma was reviewed by you in the clinic. Asthma was diagnosed in childhood. In adulthood, he has had multiple admissions to the hospital with asthma exacerbations in the summer months and never required intubation and ventilation for these.
He reports a nocturnal cough up to three times per week. There are associated rhinorrhoea and dry eyes that have been present since the weather became a bit warmer. Currently, he is using a salbutamol inhaler every other day for wheeze and mild dyspnoea. He works in construction and finds that his symptoms are worse when he is outside. Three weeks ago he was admitted to the hospital with an exacerbation of his asthma, where he was treated with salbutamol nebulisers and a short course of prednisolone.
Other past medical history includes eczema, allergic rhinitis and idiopathic generalised epilepsy. He has not had a seizure for many years. Drug history reveals:

• 10. Salbutamol metered dose inhaler when required
• Salmeterol 50 micrograms/fluticasone propionate 500 micrograms – two puffs twice daily
• Levetiracetam 500mg twice daily

On examination, vital signs are all normal. Auscultation of the chest reveals some mild end expiratory wheeze in the upper posterior zones bilaterally. The jugular venous pressure is not elevated, heart sounds were dual with no murmurs and there was no pedal oedema.

Hb 13.9 g/dl

WBC 7 x 10^9/L (Neutr 4 x 10^9/L, Lymphos 1.5 x 10^9/L, Eosinophils 0.5 x 10^9/L)

Platelets 290,000

Sodium 140 mmol/L, Potassium 3.6 mmol/L, Urea 4 mmol/L, Creatinine 60 mcmol/L, C-reactive protein 2 mg/L

Aspergillus precipitins – Negative

IgE – 500 UI/ml (reference range 150 – 300 UI/ml)

Chest x-ray – Appears normal

11. A 75-year-old gentleman is referred by his GP to a consultant cardiologist for management of his newly diagnosed atrial fibrillation (AF). Palpitations and occasional shortness of breath are the only symptoms he experiences. He has no past history of cardiovascular disease but has suffered a transient ischaemic event in the past. On examination, he is found to have an irregular heart rate ranging between 70 and 90 beats per minute. ECG confirms AF. Which of the following is the most appropriate next stage in his management?

12. 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 65-year-old gentleman presents with a three-day history of a productive cough. He complains that over the last two days he has been progressively shorter of breath, He complains of feeling very weak and lethargic and on further questioning reports fevers with rigors. His wife brought him to the emergency department as she was concerned as he appeared to be deteriorating rapidly.
Observations are: heart rate 125 beats per minute, respiratory rate 32 breaths per minute, S_{13. a}O₂ 90% on room air, temperature 38.9ºC, blood pressure is 130/85 mmHg. He appears distressed but is not confused.
Initial investigations show:
CBC –

KFTs –

Chest x-ray shows left lower zone consolidation.
From the above information, what is his CURB-65 score?

A 56-year-old gentleman was admitted to the Emergency Department with a two-week history of progressively increasing shortness of breath, with frank haemoptysis for the last couple of days. By the point of admission, he was short of breath on minimal exertion and at rest and was unable to complete full sentences. He also complained of increasing orthopnoea for the last few weeks. He had a long history of recurrent epistaxis, rhinitis and sinusitis, as well as a past medical history of diabetes, hypertension, hypercholesterolaemia and gout. His medication regimen comprised of Mometasone nasal spray, Allopurinol 100mg OD, Ramipril 2.5 mg OD, Amlodipine 5mg OD, Simvastatin 40mg OD, Metformin 500mg TDS and Gliclazide 80mg OD. He smoked 20 cigarettes per day and did not consume alcohol.
On examination, he appeared very unwell with obvious respiratory distress. His respiratory rate was 28/min, oxygen saturation was 90% on room air, BP was 108/72 mmHg, heart rate 130/min and the temperature was 37.9 C. Examination of his cardiovascular system revealed normal heart sounds with a JVP of 3 cm. Examination of the respiratory system revealed the use of accessory muscles with bibasal fine crackles. Examination of the gastrointestinal and neurological systems was unremarkable.
Initial investigations revealed the following:

Chest x-ray: bilateral patchy infiltration
ECG: heart rate 130 bpm and sinus rhythm.
Urinalysis: Blood ++++, Protein +++, Leuc/Nitrites – negative, Glucose – negative
ABG on 15 L/min oxygen:

He was commenced on an IV infusion of normal saline, as well as Co-amoxiclav 625mg TDS, and quickly transferred to the Intensive Care Unit. He was cathetrized. A decision was made to institute immediate haemodialysis, for which preparations were being made.

Further investigations revealed the following:
Urine MCS: nil grown
Blood culture – interim results: nil grown

Transoesophageal echocardiogram: normal systolic function, valvular appearances and no vegetations seen

Given the likely underlying diagnosis, which of the following interventions is the next best step whilst awaiting haemodialysis?

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 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?

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.

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

18. 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?

19. 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?

20. 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?