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

A 32-year-old man has presented to the hospital with a 4-day history of fatigue, palpitations, and nausea. He recently had severe diarrhoea. There is no vomiting or syncope.
Examination shows no apparent cardiovascular or neurological abnormality. The ECG borderline prolonged PR, small T waves in the limb leads, flattened T waves in the chest leads and U waves.

1. What electrolyte abnormality will you anticipate in his blood results?

2. 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?

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?

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?

5. 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 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:

• 6. 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

7. 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?

8. 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:

9. 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 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 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 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 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 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?

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:

15. 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?

16. 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?

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 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 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 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:

20. 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.