Archives: MRCP Part 2

MRCP2-0395

A 36-year-old woman arrives at the Emergency Department complaining of sudden chest pain and difficulty breathing that started while she was watching TV four hours ago. She describes the pain as severe, located in the center of her chest, and not radiating. She denies coughing or coughing up blood. She has no significant medical history except for taking oral contraceptives.

Upon examination, the patient is overweight, has a heart rate of 114 beats per minute, and a blood pressure of 101/63 mmHg. Her respiratory rate is 22, and her oxygen saturation is 94% on room air. Her jugular venous pressure is 5 cm, but there is no swelling in her extremities. Scattered crepitations are heard upon chest auscultation. Her heart sounds are dual, with no audible murmurs. A portable chest x-ray shows clear lung fields.

Shortly after, the patient’s blood pressure drops to 90/59 mmHg. A bedside echocardiogram reveals elevated right ventricular filling pressures with evidence of strain. What is the most appropriate course of action?

MRCP2-0396

You review a 70-year-old patient in cardiology outpatient clinic. He has a left ventricular ejection fraction of 15% on maximal medical therapy. On reviewing his ECG you note a QRS duration of 135ms without evidence of left bundle branch block. Upon taking a history you note the patient is breathless at rest and struggles to walk around his bungalow.

Which implantable device would be appropriate to consider?

MRCP2-0397

A 56 year-old man with a history of ischaemic heart disease and Crohn’s disease presents with colonic enterocutaneous fistulae. He undergoes surgery and a temporary ileostomy is created for bowel dysfunction and healing promotion. However, two days after the operation, he experiences palpitations and the surgical team seeks your assistance.

Upon examination, his pulse rate is 220 bpm and blood pressure is 135/90 mmHg. Oxygen saturation is 96% on 2L nasal oxygen. A clear chest is observed during auscultation. A 12-lead ECG shows a wide-complex tachycardia with a polymorphic waveform.

The morning blood tests reveal the following results: Hb 129 g/l, platelets 643 * 109/l, WBC 13.8 * 109/l, Na+ 129 mmol/l, K+ 3.3 mmol/l, phosphate 0.63 mmol/l, Mg++ 0.59 mmol/l, urea 8.1 mmol/l, creatinine 97 µmol/l, bilirubin 15 µmol/l, ALP 143 u/l, ALT 53 u/l, and albumin 31 g/l.

What is the most appropriate initial management for this patient?

MRCP2-0398

A 58-year-old, previously healthy man experiences an infero-posterior myocardial infarction (MI) and undergoes primary angioplasty. He initially stabilizes, but the nursing staff expresses concerns about his condition the following day. On examination, his blood pressure is 85/60 mmHg, his pulse is 50 bpm and regular, and his JVP is elevated at 6 cm. A creatinine level taken that morning is elevated at 140 µmol/l. Despite administering 2 mg of atropine, there is no significant improvement in his pulse or BP. A CVP line is inserted, which measures a CVP of 10. What is the most appropriate next intervention?

MRCP2-0399

A 19-year-old male complains of gradually worsening shortness of breath over the past year. He denies cough, wheeze or chest pain and has no significant medical history. During examination, a loud second heart sound is noted and an ECG reveals right bundle branch block (RBBB) with left axis deviation (LAD).

What is the probable diagnosis?

MRCP2-0400

A 55-year-old man arrives at the Emergency Department (ED) with severe crushing chest pain, which was later confirmed as a heart attack. He developed atrial fibrillation (AF) two days after the heart attack and was given digitalis, but was not fully anticoagulated at that time. On the sixth day after the heart attack, he collided with a bed and a wall while walking to the bathroom and appeared to be blind, although he denied it and tried to describe objects around his bed. His pupillary reflexes were normal. What is the most accurate description of the lesion that occurred?

MRCP2-0380

A 24-year-old Afro-Caribbean female presents with a four-month history of fatigue, transient fever lasting hours, 12kg weight loss and non-specific bilateral headaches. She has presented to the Emergency Department four times in the past 3 months with non-specific abdominal pains that are worse after eating and also blue-lighted into her local hyperacute stroke unit as a thrombolysis patient after sudden onset loss of monocular blindness in her left eye, which resolved before any treatment was given. She has no other past medical history, does not smoke and drinks minimally.

On examination, cranial nerve examination and fundoscopy are both unremarkable. Upper and lower limb neurology are intact with downgoing plantars. Her heart sounds demonstrates a gallop rhythm, an early diastolic murmur and a mild radial-radial delay. Chest auscultation is clear. She appears very warm and measures 38.4ºC in your clinic with facial flushing. Blood tests are as follows:

Hb 94 g/l
Platelets 245 * 109/l
WBC 18.4 * 109/l
Eosinophil 0.1 * 109/l
ESR 121 mm/hr

Na+ 141 mmol/l
K+ 4.0 mmol/l
Urea 5.2 mmol/l
Creatinine 68 µmol/l
CRP 56 mg/l

Complement levels were reported as normal and an antibody screen including ANCA and ANA was negative. Urine dip is negative. Chest X-ray demonstrates focal consolidation. Her heart rate is 95 and regular, her blood pressure is 185/110 mmHg.

What is the underlying diagnosis that unifies all of these symptoms?

MRCP2-0381

A 57-year-old man presents with a feeling of tightness in his chest and jaw, accompanied by increasing breathlessness, clamminess, and vomiting. He has a history of refractory hypertension but was feeling well prior to this episode. On examination, he has a loud pansystolic murmur, raised JVP with cannon V waves, and a palpable, pulsatile liver. His blood pressure is 190/110 mmHg, heart rate 90/min, and oxygen saturation is 92%. Laboratory results show elevated troponin levels and ST depression in leads V1-V3 on ECG, as well as an enlarged cardiac shadow on chest X-ray. What is the most likely diagnosis?

MRCP2-0382

An 85 year old gentleman attends a heart failure follow up clinic with poorly controlled symptoms. He has a medical history of NSTEMI and kidney stones. The patient is able to move around his house but experiences breathlessness when walking to the nearby shops, which are approximately 100m away.

During his recent visit to the GP, spironolactone was added to his regular medications due to persistent hypokalaemia. The patient’s potassium levels have since returned to normal. His latest echocardiogram shows an ejection fraction of 25%, and his ECG indicates sinus rhythm. The patient’s most recent BNP level was 1000 pg/ml.

Currently, the patient is taking senna, ramipril 10mg, aspirin 75mg, frusemide 40mg bd, simvastatin 40mg, and spironolactone 50mg. At the clinic, his oxygen saturation is 94% on room air, blood pressure is 126/66 mmHg, and heart rate is 84/min.

What additional medication would be beneficial for this patient?

MRCP2-0383

A 59-year-old man was admitted with a stroke following a month’s history of recurrent fevers, anorexia and weight loss. On examination, he had a right-sided hemiparesis and facial droop. Cardiovascular examination revealed splinter haemorrhages in 5 of his fingers across both hands, and a soft diastolic murmur heard loudest in expiration over the aortic area.

A trans-thoracic echocardiogram showed an oscillating vegetation on an aortic leaflet, in the path of regurgitant jets. Two blood cultures were positive for Streptococcus spp. He was diagnosed with infective endocarditis and started on intravenous benzylpenicillin 1.2g every 4 hours and gentamicin 1 mg/kg twice daily therapy.

He was reviewed after 5 days on antibiotic therapy with the following results.

Na+ 139 mmol/l
K+ 4.7 mmol/l
Urea 14.2 mmol/l
Creatinine 178 µmol/l
Serum bilirubin 16 µmol/l
Serum alkaline phosphatase 115 IU/l
Serum aspartate aminotransferase 18 IU/l
C Reactive protein 89 mg/l
Haemoglobin 138 g/l
White cell count 13.6 x 10^9/L
INR 1.1
Blood cultures Streptococcus Bovis
Penicillin Minimum Inhibitory Concentration (MIC) 0.6 mg/L (high)
ECG Prolonged PR interval (not present on admission ECG)

What is the next most important step in management?