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

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 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?

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?

4. 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?

5. A 42-year-old male has been admitted with a week history of fever, anorexia and headache not responding to over-the-counter paracetamol. 4 days back he also developed a dry cough and mild dyspnea, and developed generalized skin rash 2 days back. He was prescribed Tab Co-Amoxiclav from a private clinic 3 days ago. He has a 10-pack-year smoking history. His past medical history is unremarkable.

On admission, he was fully alert. His temperature was 102.4 F, Pulse 90/min, BP 110/65 mmHg. His chest auscultation reveal bilateral vesicular breathing without any wheeze but several fine crepitations were audible at the right lung base. He has a fine maculopapular rash over his trunk and arms; several target lesions were noted. The general examination was otherwise normal. His co-amoxiclav has been stopped. The following day, he complains of myalgias and dull aching pain central chest.

His investigations are as follows:

Hb                                                                   13 g/dL

ESR                                                                70 mm fall at 1st hour

TLC                                                                 10 x 10^9 / L

Sodium                                                           142 mmol/L

Potassium                                                      4.4 mmol/L

Urea                                                                9 mmol/L

Creatinine                                                      90 µmol/L

Aspartate transaminase                                 90 U/L

Alkaline phosphatase                                      150 U/L

Bilirubin                                                           12 µmol/L

Blood & sputum culture                                 Negative

Cold agglutinins                                                 Positive

Chest X-Ray                                    Patchy consolidation right base

ABGs –                                       pO₂ – 8.9 kPa, pCO₂ – 4.5 kPa

ECG                                           sinus tachycardia, widespread T-wave flattening and inversion

Echocardiography – Normal valves and chambers with slightly reduced contractility of Left ventricle

What is the most likely diagnosis?

6. 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?

7. A 72-year-old woman is brought to ER after she had an episode of loss of consciousness. She gives a history of increasing shortness of breath on exertion. Her past medical history includes a right total hip replacement following a fractured neck of femur about 4 years ago. Otherwise, she is on no regular medication. There are no drug allergies.

On examination, her pulse was 80/min, blood pressure 105/90 mmHg, and respiratory rate 16 breaths/minute. You found the pulse to be slowly rising. There was an ejection systolic murmur heard loudest in the aortic area, and radiating to the carotid arteries.

Her ECG shows sinus rhythm and left ventricular hypertrophy criteria. The chest x-ray appears normal.

A transthoracic echocardiogram shows an Aortic valve area of 0.9 cm^2 (normal 3-4 cm^2) and transvalvular gradient 55 mmHg. Aortic valve replacement is considered for severe aortic stenosis. What other investigation is needed to be done before the procedure?

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 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?

10. 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 64-year-old female was admitted to the hospital with a moderate-large sized embolic stroke. She had a history of diabetes and newly diagnosed atrial fibrillation (AF). Her blood pressure on admission was 165/90 mmHg with a heart rate of 95 beats per minute.
An MRI brain was performed 24 hours after admission which showed a moderate to a large area of infarction involving the anterior 2/3rd of the left middle cerebral artery territory without haemorrhagic transformation.
With regards to the management of her AF and stroke prevention, the most appropriate decision would be to commence which of the following?

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?

13. 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?

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 53-year-old obese patient (body mass index = 43) complains of morning headaches and daytime sleepiness. His wife reports that he snores very loudly. He has a history of systemic hypertension, and myocardial infarction 3 years ago with no residual cardiac dysfunction. He is a non-smoker. An overnight oximetry study shows significant hypoxemia with 20 % of the night spent with oxygen saturation below 90% and an oxygen desaturation index (3%) of 38/hour. Arterial blood gases show a pH of 7.38, PaCO2 of 56 mmHg, PaO2 of 67 mmHg and bicarbonate of 32 mmol/L.
Which is the most likely diagnosis?

A 60-year-old man with metastatic small cell lung cancer is admitted with shortness of breath, cough and purulent sputum.
His chest x-ray shows right lower lobe pneumonia with partial collapse of the right lung. He has a bulky primary tumour at the right hilum and extensive hilar lymphadenopathy.
He is treated with IV antibiotics, fluids and oxygen. His symptoms improve over the next 5 days and his breathing is comfortable on 2 litres of oxygen via nasal cannulae. His pain is controlled on 20 mg long-acting Morphine sulphate twice daily. The decision is made to discharge him to a hospice for end-of-life care. However, due to the proximity of his lung tumour to major vessels, he is at risk of a major terminal bleed.
Which medication should the hospice be advised to give in the event of a major bleed?

17. 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 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 68-year-old man is being treated in a medical ward for an empyema. A chest drain was inserted under ultrasound guidance at the time of admission and antibiotics were started. Over the past few days, there have been significant volumes drained and the patient has been improving clinically. On the daily morning ward round, his chest drain is reviewed which is on suction. There is minimal drain output over the past 24 hours, and it is noted that the chest drain is bubbling. This bubbling is more significant when the patient is asked to cough.
What does this indicate?

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?