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

1. 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?

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 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?

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?

5. 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 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 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?

A 55-year-old woman is admitted with an infective exacerbation of bronchiectasis. Multiple sputum cultures in the community have grown 8. Pseudomonas aeruginosa and her GP had started oral ciprofloxacin. However, despite 4 days of this, she has developed worsening breathlessness, hypoxia, and fever and is now requiring oxygen.
Widespread coarse crepitations are heard and her chest x-ray demonstrates bilateral infiltrates.
What is the most appropriate course of action?

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:

• 9. 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

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 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:

11. 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.

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?

13. 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 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:

14. 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?

15. 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 56-year-old gentleman presents with shortness of breath and haemoptysis which has worsened over ten days. He is currently coughing up an estimated 200 ml of fresh red blood every day. He has night sweats and feels cold and sweaty at times. He has not lost any weight and was well prior to this.
He has mild COPD and takes Foster inhaler twice a day with no exacerbations in the past 5 years. He moved to the UK 15 years ago but lived 10 years in Louisiana as a mining operator extracting minerals with exposure to bats and birds during this time. He drinks 10 units of alcohol a week and was born in Syria where he received a BCG vaccine as a child. He has not been around any ill contacts and lives with his wife and two children. There is no recent foreign travel and he keeps no pets.
On examination, he has crepitations in the right side mid and upper zones. He has palpable lymph nodes in his axillae and neck but his abdomen is non-tender with no hepatosplenomegaly. He is breathing rapidly and appears cachectic. His observations show temperature 38.3ºC, respiratory rate 28/min, heart rate 98/min, saturation 88% in air. An arterial blood gas has not been done.

What is the likely diagnosis?

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 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:

20. 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?