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

1. 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?

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?

3. 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?

4. A 50-year-old gentleman presents to the clinic with shortness of breath and a dry cough. He has noticed his symptoms getting progressively worse over months. He has a past medical history of hypertension and depression. He takes only ramipril and has no allergies. On examination, he has bilateral inspiratory crackles at both lung bases. A chest X-ray demonstrates extensive pleural plaques. He worked as an electrician 20 years ago and believes that he may have had asbestos exposure. A diagnosis of asbestosis with extensive pleural plaques is suspected. What are his pulmonary function tests likely to show?

A 67-year-old man was admitted from A&E 3 days after suffering a myocardial infarction. He was complaining of increasing shortness of breath. On observation was tachypnoeic at rest whilst sitting up. On examination, his jugular venous pressure was raised, respiratory rate was 30 breaths per minute and his heart rate was 120/minute.
On auscultation, you hear a systolic murmur but no other findings. An erect chest X-ray was normal. Which of the
following complications of MI is most likely to be the cause of this gentleman’s shortness of breath?

6. 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 27-year-old man is reviewed in the asthma clinic. Despite therapy with high dose Salmeterol/Fluticasone, Montelukast and oral Theophylline, he has suffered a 4th exacerbation in the past year and is now unable to reduce his dose of oral Prednisone below 10 mg without a significant increase in shortness of breath and wheeze. On examination, his blood pressure is 125/80 mmHg, pulse is 80/minute and regular. Chest auscultation reveals a quiet wheeze. His peak flow is 429 ml/min, (550 predicted). Eosinophils are elevated at 3.9 x 10^9/L. IgE is within the normal range.
Which of the following is the most appropriate next intervention?

8. 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?

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?

10. 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 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 68-year-old man has been referred to the hospital. He complains of intermittent palpitations, occurring once a week and self-resolve within seconds. There are no associated symptoms.
An ECG which was performed by the GP was reported as showing atrioventricular dissociation.
Currently, he feels well. On examination, his pulse rate is 64/min, BP 145/70 mmHg, Resp rate 14/min, Temperature 37.2 C, Sats on room air 94%. His ECG revealed Mobitz II AV block.

12. What is the appropriate next step of treatment?

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:

• 13. 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?

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.

15. 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 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.

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

17. 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:

18. A 16-year-old girl has been brought by her mother with symptoms of fatigue. Her mother has noticed that ‘she is becoming pale’. Her menarche set in about 2 years ago and her menstrual bleed has become heavier recently. There is no history of bleeding elsewhere or bruising. Her father is working overseas and is not available. However, they give a history of recurrent anemia in his youth. She has no siblings. On examination she is pale and abdominal palpation reveals 2-cm splenomegaly.

Her labs are as follows:

Hb                                                                   6.7 g/dL

TLC                                                                 8.1 x 10⁹/L

Platelets                                                          370 x 10⁹/L

Reticulocytes                                                  10%

Direct Coomb’s test                                      Negative

Urea                                                                4.2 mmol/L

Na⁺                                                                 141 mmol/L

K⁺                                                                                 4.9 mmol/L

Bilirubin                                                          38 µmol/L

AST                                                                  69 U/L

Alkaline phosphatase                                   119 U/L

Haptoglobins                                              Not detected

Urinary hemosiderin                                       Absent

What is the next most appropriate investigation?

19. A 60-year-old man with hypertension presents with uncontrolled blood pressure despite being on Amlodipine and Enalapril. He has no symptoms of postural hypotension, and his latest ambulatory blood pressure readings show an average blood pressure of 160/94 mmHg. His lab work shows:

Na+ 137 mmol/L, K+ 4.2 mmol/L, Urea 4.5 mmol/L, Creatinine 85 mcmol/L

What medication you would prescribe as a next step to manage his hypertension?

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?