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

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 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 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:

3. 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?

4. 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?

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 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.

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

A 30-year-old man presents to the emergency department with a four-day history of subjective fevers, shortness of breath, non-productive cough and malaise. On arrival at the emergency department, his observations revealed a temperature of 38.5ºC, heart rate 120/min, blood pressure 90/60 mmHg, respiratory rate 35/min and oxygen saturation of 80% on room air. An arterial blood gas revealed severe type 1 respiratory failure and the patient was intubated and placed on mechanical ventilation.
A post-intubation chest x-ray revealed bilateral pulmonary infiltrates and within the limits of a portable chest x-ray, a normal-sized cardiac silhouette.
Intravenous 1g ceftriaxone, 500mg azithromycin and 200mg hydrocortisone were given in the emergency department for severe community-acquired pneumonia prior to transfer to the intensive care unit (ICU). The patient remained on invasive mechanical ventilation for the first 24 hours. During this time, he underwent computed tomography pulmonary angiography (CTPA) and bronchoalveolar lavage. He made good progress and was extubated to high flow nasal cannulae after 24 hours. He is haemodynamically stable. He is stepped down to the high dependency unit (HDU), where you review the patient.
You speak with the patient’s wife to obtain a collateral history. The patient has no known past medical, surgical, drug or family history of note. He works as a full-time chef and there have been no known sick contacts. He drinks 1-2 cans of standard strength beer per night and occasionally binge drinks at the weekends. He recently started smoking cigarettes to cope with increased stress at work and there is no history of illicit drug use. There has been no recent travel history.
On examination in the HDU, the temperature was 37.5ºC, heart rate 90/min, blood pressure 100/60 mmHg and respiratory rate 26/min. He is on high flow oxygen via nasal cannulae, with a flow rate of 30 litres per minute, the fraction of inspired oxygen is 30% and has an oxygen saturation of 95%. There are fine inspiratory crepitations audible in the lower posterior chest bilaterally which do not change with coughing. The jugular venous pressure was not elevated and there was no pedal oedema.
Current medications are IV Ceftriaxone, Azithromycin and PRN Paracetamol.
You review the latest available results for this patient:

Which of the following would be the most appropriate ongoing management for this patient?

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?

An 84-year-old nun presented to A&E 2 weeks after discharge from the hospital under the care of the cardiologists. Her presenting
complaint is one of feeling faint and dizzy and intermittently short of breath. She mentions that during her last admission she was started on digoxin because she had an irregular heart rate that was racing away. On discharge, she claims that she had no problems and only developed this dizziness in the past couple of days. Her drug history includes atenolol 100mg once daily. Her ECG today shows a rate of approximately 40 beats per minute with no association between P waves and QRS complexes. What is the next step in her management?

A 56-year-old man presents to the emergency department with a three-day history of sharp chest pain. He denies any shortness of breath. His pain is worse on deep inspiration and has not improved with paracetamol. He has no other symptoms. He has a past medical history of COPD and uses regular combination inhalers with salbutamol inhalers when he becomes short of breath. He has not recently had an exacerbation and he has never been admitted to ICU or had invasive ventilation. On examination, vital parameters are within normal range. The chest is clear on auscultation. A chest X-ray demonstrates a < 1cm right-sided pneumothorax. He is treated with high flow oxygen. What is the benefit of oxygen in the treatment of a pneumothorax?

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:

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

13. 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 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:

• 14. 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 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 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 66-year-old man is admitted with a 2-hour history of central chest pain radiating to the left arm and is associated with nausea and vomiting. He has a past medical history of hypertension, dyslipidemia and diet-controlled diabetes. He takes Amlodipine and Atorvastatin.
On examination, he is afebrile, his blood pressure is 145/90 mmHg and heart rate is 110 beats per minute. His saturations are 96% on room air. Cardiovascular and respiratory examinations are unremarkable.
An ECG shows T wave inversion in leads I, V4, V5 and V6. Cardiac biomarkers are raised. CBC with differential, renal functions and electrolytes are normal. He has been managed for NSTEMI acutely, and 3 days later he undergoes coronary angiography with stenting of the left circumflex artery. On systems reviews, prior to discharge, he comments that he has noticed a rash on his legs and has not been passing much urine despite drinking plenty of water. On examination, he has a bluish lacey discolouration over his legs. He has no palpable bladder. CBC shows eosinophilia and RFTs are slightly deranged.

17. What is the most likely diagnosis?

18. 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?

19. 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?

20. 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?