A 68-year-old man presents for review after undergoing coronary angiography. The results show that he has dual vessel disease and requires CABG. He has a history of hypertension, which is managed with ramipril and felodipine, and peripheral vascular disease. He also takes simvastatin 40 mg and aspirin 75 mg. His blood pressure is 148/84 mmHg, pulse is 74 and regular. A right carotid bruit is detected, and a pre-operative carotid duplex is requested to assess the situation. There is no history of prior stroke or TIA. The investigations reveal a 65% stenosis in the left carotid and a 75% stenosis in the right carotid. What is the appropriate course of action?
MRCP2-0375
A 72-year-old man presents to the hospital with chest pain, nausea, and vomiting. He has a history of hypertension, chronic obstructive pulmonary disease, and a previous myocardial infarction three years ago. Despite two exacerbations of his COPD in the past 18 months, he has never required hospitalization or ventilation. His regular medications include bendroflumethiazide, inhaled tiotropium, and inhaled salbutamol. The initial diagnosis is non-ST elevation myocardial infarction, and he is treated with aspirin, clopidogrel, fondaparinux, ramipril, and atorvastatin. He is discharged with a plan for outpatient stress echocardiogram. His recent pulmonary function tests show a forced vital capacity of 105% predicted, forced expiratory volume of 67% predicted, and FVC/FEV1 of 64% predicted. Transthoracic echocardiogram reveals mild-moderate systolic impairment of lateral left ventricle and normal right ventricular function. What is the most appropriate plan for beta-blockade therapy for this patient?
MRCP2-0376
A 16-year-old boy visits his GP with complaints of experiencing shortness of breath during physical activity. His mother accompanies him and reports that his exercise capacity has been gradually decreasing, and he is no longer able to participate in Saturday morning football games. Upon examination, the GP refers the patient to a cardiologist. The cardiologist performs a cardiac catheterization and obtains the following pressure and oxygen saturation data:
Anatomical site: Oxygen saturation (%), Pressure (mmHg), End systolic/End diastolic – Superior vena cava: 74, – – Right atrium (mean): 75, 7 – Right ventricle: 87, 50/12 – Pulmonary capillary wedge pressure: -, 16 – Left ventricle: 96, 140/12 – Aorta: 97, 110/60
What is the diagnosis?
MRCP2-0377
A 70-year-old man presents to the emergency department with dizziness. He has a history of hypertension and takes amlodipine. He denies smoking or drinking alcohol. There is no chest pain, palpitations, or shortness of breath.
The patient’s vital signs are as follows:
– Heart rate: 50 beats per minute – Blood pressure: 130/86 mmHg – Respiratory rate: 18/minute – Oxygen saturations: 97% on room air – Temperature: 37.2C
Upon examination, the patient is currently asymptomatic. His heart rate is irregular, and there are no murmurs. Chest auscultation is normal, and his jugular venous pulse is not elevated. The Glasgow coma scale is 15/15.
An ECG shows intermittently non-conducted P waves associated with a prolonged PR interval that is constant and not progressive. The QRS is broad, and there are no signs of ischemia.
Bedside echocardiography reveals an approximately normal ejection fraction.
What is the most appropriate management for this patient’s likely diagnosis?
MRCP2-0378
A 65-year-old man visits his GP 3 weeks after receiving a permanent pacemaker (PPM) for symptomatic first-degree heart block. He reports feeling worse since the procedure and experiencing a decrease in exercise tolerance.
Upon conducting an ECG, it is revealed that the patient has a paced rhythm on VVI at 70/min. There are no pacing spikes in between beats, and each spike is followed by a QRS complex. Additionally, the patient has regular p waves at a rate of 35/min that are not associated with the QRS complexes.
What is the most appropriate course of action?
MRCP2-0379
A 19-year-old male presents to the clinic with complaints of blurred vision that has been gradually worsening over the past few years. He has a medical history of recurrent deep vein thromboses and mild learning difficulties. During the examination, you observe an increased arm span to body height ratio and the presence of scoliosis. The ophthalmologist notes a downward lens dislocation.
What is the probable diagnosis?
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:
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.