Archives: MRCP Part 2

MRCP2-0497

A 70-year-old man has been urgently referred to clinic by his GP due to worsening breathlessness. The patient has been experiencing increasing exertional dyspnoea for around three months. Prior to the onset of his symptoms, he had no restrictions on his exercise capacity and would regularly play a round of golf once or twice a week. At the time of his clinic review, he becomes breathless just getting onto the examination couch. He has also had two recent episodes of severe dizziness while rushing to do his shopping. Although he did not collapse on either occasion, he felt light-headed and had to sit down. On both occasions, he felt as though he was going to faint.

During examination, the patient is comfortable at rest. His pulse is regular and beats at 90 beats per minute. A parasternal thrill is palpable over the chest wall. A loud ejection systolic murmur is audible in the second right intercostal space and radiates up into the carotid arteries.

A transthoracic echocardiogram reveals a peak aortic valve gradient of 100 mmHg with normal left ventricular systolic function. There are no other valvular abnormalities. What is the next indicated treatment for this gentleman?

MRCP2-0498

A 35-year-old woman presents to the Emergency Department (ED) with complaints of palpitations. She reports occasional palpitations in the past year, but this episode has been ongoing for about 30 minutes. She also reports worsening shortness of breath. She was diagnosed with WPW syndrome a year ago when she presented with similar symptoms.

Upon examination, she appears anxious. Her pulse is 120 bpm and her BP is 90/60 mmHg. Crackles are heard on auscultation at both lung bases.

The following investigations are conducted:
– Urea and electrolytes (U&Es): Normal
– Full blood count (FBC): Normal
– Chest X-ray (CXR): Normal
– Electrocardiogram (ECG): Narrow complex regular tachycardia with heart rate of 140 bpm

What is the next appropriate immediate step in her management?

MRCP2-0499

A 70-year-old man is brought to the Emergency Department (ED) in a collapsed state. He had collapsed in a grocery store while shopping with his wife. He received two direct current (DC) shocks on his way to the hospital in the ambulance.

Looking through his medical history, he has a past diagnosis of bipolar disorder and is currently taking lithium and valproic acid. He was admitted last month for the treatment of a urinary tract infection (UTI) and was started on ciprofloxacin. His admission electrocardiogram (ECG) at the time showed a sinus rhythm of 78 beats per minute (bpm), normal axis, and a QTc of 450 milliseconds.

On examination, he complains of feeling unwell. His blood pressure (BP) is 110/70 mmHg. His pulse is > 130 beats per minute (bpm) and he has an oxygen saturation of 92% on 40% oxygen. An ECG reveals torsades de pointes.

Arterial blood gas analysis reveals that he is hypomagnesaemic.

What immediate interventions would you consider for this patient?

MRCP2-0500

A 75-year-old woman presents to your Cardiology Clinic for routine check-up. She has a history of stable heart failure (NYHA II) caused by ischaemic cardiomyopathy and chronic atrial fibrillation (AF) for which she is taking warfarin. Her recent ECHO showed biatrial dilation. She is currently on digoxin 125 μg once a day, furosemide 40 mg once a day, ramipril 2.5 mg once a day and bisoprolol 2.5 mg. During examination, her resting pulse is 63 bpm with a BP of 130/80 mmHg. Her INR today was 2.5. She is curious if there are any advantages to being cardioverted to normal sinus rhythm. What would be your advice to her?

MRCP2-0490

A 72-year-old man with heart failure due to ischemic heart disease presented at the outpatient clinic. He was on perindopril 2 mg, bisoprolol 1.25 mg, and had recently had his furosemide dose increased from 40 mg to 80 mg. During the consultation, he reported experiencing dizziness, especially when standing up after sitting down. There were no signs of cardiac failure during the examination. His serum urea and electrolytes results were as follows: Serum urea 13.3 mmol/L (2.5-7.5) and serum creatinine 221 µmol/L (60-110). What is the next step in his management?

MRCP2-0491

A 32-year-old man presents to the Cardiology Clinic referred by his primary care physician. He has been experiencing progressive difficulty breathing for the past six months, and even minimal exertion now causes shortness of breath. He denies any chest pain, palpitations, or cough. He has no significant medical history and is not taking any medications. Despite seeing his primary care physician for the past few months, no abnormalities were detected in his full blood count, liver function tests, electrolytes, or chest X-ray.
During the examination, his blood pressure is 130/70 mmHg, his pulse is 90 bpm and regular. His jugular venous pressure is elevated to 6 cm, and there is a parasternal heave. The apex beat is in the 5th intercostal space at the mid-clavicular line. There is an increased pulmonary component of the second heart sound and tricuspid regurgitation. Blood tests and biochemistry are all within normal limits.
A chest X-ray reveals enlarged central pulmonary arteries and clear lung fields. An electrocardiogram shows right axis deviation, tall R waves in V1–V2, and right ventricular strain pattern.
An echocardiogram demonstrates tricuspid regurgitation, right ventricular enlargement, a reduction in left ventricular cavity size, and abnormal septal configuration consistent with right ventricular pressure overload.
Acute vasodilator testing yields a positive response.
What is the appropriate first-line medication for treating this condition?

MRCP2-0492

A 32-year-old woman with a history of being a keen half marathon runner in her 20’s before having her family presents to the Cardiology Clinic with increasing shortness of breath. She has returned to work after the birth of her second child, but is breathless climbing the stairs or even on running only a few yards to catch the bus. On examination, she has a loud second heart sound, bilateral pitting lower limb oedema, and an unremarkable chest X-ray. Investigations reveal an elevated estimated pulmonary artery pressure, no signs of right/left shunt/atrial septal defect, and no evidence of pulmonary emboli. Acute vasoreactivity testing is positive. Her blood pressure is 125/72 mmHg, pulse is 62 bpm and regular, BMI is 22 kg/m2, and other investigation results are within normal values except for a slightly elevated creatinine level.

Based on this information, what is the most appropriate first line therapy for her?

MRCP2-0493

A 65-year-old man who suffered an anterior myocardial infarction two years earlier presents with a second episode of sustained ventricular tachycardia at 180 bpm associated with pre-syncope despite being maintained on amiodarone and the maximum tolerated dose of bisoprolol.

On examination, his BP is 135/72 mmHg, pulse is 80 and regular. There is no evidence of decompensated cardiac failure.

Investigations show:

– Haemoglobin 135 g/L (135-177)
– White cell count 8.4 ×109/L (4-11)
– Platelets 290 ×109/L (150-400)
– Sodium 136 mmol/L (135-146)
– Potassium 4.8 mmol/L (3.5-5)
– Creatinine 123 µmol/L (79-118)

Other investigations reveal:

– 12 lead ECG – persistent ST elevation, QRS duration 150 ms
– 72 hour Holter monitor – short runs of VT seen on two separate occasions
– Echocardiogram – poor LV function (ejection fraction <30%) with left ventricular apical aneurysm. What is the most appropriate intervention?

MRCP2-0494

A 50-year-old man presents to the Emergency Department after ingesting multiple aspirin tablets 3 hours ago. He is experiencing symptoms of salicylism, including tinnitus, hyperventilation, and sweating. What is the best approach to increase the elimination of salicylate in this patient?

MRCP2-0495

A 67-year-old man with a history of occasional chest tightness presents to the Emergency Department (ED) of a District General Hospital (DGH) with central chest pain that started five hours ago while walking uphill. The severe pains radiated to his neck, jaw, and left arm and lasted for about an hour. He still has some dull chest pains but these are not very severe.

On examination, he is alert and distressed with a BP of 110/84 mmHg and a pulse of 76 bpm and regular. Investigations reveal elevated WCC, Cr, and Hb levels. His ECG shows normal sinus rhythm with inferior ST depression, and his CXR is unremarkable. You administer diamorphine, fondaparinux, and aspirin.

Which one of the following additional medications would you immediately start this patient on?