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

An 80-year-old woman was a passenger in a car that collided with a lamppost in the city
centre. She was initially complaining of pain in her right hip and ribs but has become
increasingly drowsy since the paramedics administered 2 mg of morphine. She is brought
to the emergency department by ambulance.
Urgent X-rays reveal a pelvic fracture and a single right-sided rib fracture. Having, initially been drowsy but responsive she is now unresponsive. Oxygen saturation is 87 % on 2 L/min oxygen via nasal cannulae.
She is apyrexial. BP is 110/66 mmHg, pulse is 65 beats/min. There are no new findings on
examination.

1. An urgent CT brain reveals only small vessel disease. Arterial blood gas: pH 7.22, PaO2 65 mmHg, PaCO2 75 mmHg, HCO3 − 26 mmol/L.

What is the most likely cause of her deteriorating conscious level?

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:

2. 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?

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?

4. A patient with a background of COPD presents to the emergency department with a simple pneumothorax 2.4 cm in size. What is the most suitable management option?

5. 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 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?

7. 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?

8. 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?

9. 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?

10. A 56-year-old woman presents to the clinic for review following investigations and MDT discussion. She has chronic exertional dyspnoea and following a restrictive pattern detected on spirometry and changes on high-resolution CT scanning she has been diagnosed with idiopathic pulmonary fibrosis. What medication can be used to modify disease progression?

11. 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?

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 61-year-old man comes to his GP complaining of cough and dyspnoea on exertion. He has had the cough for over 2 years, but it has gotten worse recently along with increasing shortness of breath. He has no haemoptysis, chest pain or leg swelling. The patient has a 60 pack-year smoking history and drinks a moderate amount of alcohol. His temperature is 37.2ºC, blood pressure is 140/80 mmHg, his pulse is 80/min, and respirations are 20/min.
Chest x-ray shows prominent bronchovascular markings and mild diaphragmatic flattening.
Pulmonary function test results are as follows:

Carbon monoxide diffusion capacity is 100% of the predicted value.
Which of the following is the most likely cause of this patient’s symptoms?

14. A 42-year-old male, with HIV, is found to have a tuberculin skin test of 8 mm induration. He has no symptoms and has not had a BCG vaccination. He has no history of contact with tuberculosis patients. Chest X-ray is normal. What is the most appropriate for him?

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?

16. 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 54-year-old lady is brought into the emergency department with a Glasgow Coma Scale of 5. She was found by a friend this morning unconscious and purple with no response. She had been unwell the previous days with an exacerbation of her COPD in which she was developing severe pleuritic chest pain. She had recurrent exacerbations of her COPD and had been hospitalised three times this year with one admission to ITU for intubation and ventilation.
In addition, she had hypertension, hypothyroidism and chronic regional pain syndrome. Her medications include fostair, ventolin, gabapentin, codeine, paracetamol, amlodipine, ramipril, levothyroxine and morphine sulfate. She had taken extra doses of oral morphine to control her pleuritic pain. She has started a rescue pack of amoxicillin and prednisolone one day prior
On examination, she does not open her eyes which have 2 mm pupils bilaterally that are reactive. She groans to pain but there is no motor response. Her chest has some wheeze across and her respiratory rate is 9 breaths per minute. She is saturating at 88% on 4 litres of oxygen via nasal cannulae and there is no accessory muscle use. She has mild pitting oedema and is centrally cyanosed. She has a capillary refill of two seconds and there are no murmurs.

17. Hb 16.1 g/L, WBC 9.0 x 10^9/L (neutrophils 7.7 x 10^9/L, Lymphos 1.0 x 10^9/L), Platelets 309 x 10^9/L

ABGs(on arrival) – pH 7.25, pO2 59 mmHg, pCO2 56 mmHg, HCO3 31 mmol/L

Chest x-ray – poor inspiration, no overt consolidation

ECG – Sinus Rhythm

What is your first step in management?

A 55-year-old woman is admitted with an infective exacerbation of bronchiectasis. Multiple sputum cultures in the community have grown 18. 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 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_{19. 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?

20. 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?