Archives: MRCP Part 2

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?

MRCP2-0384

A 68-year-old man with a history of hypertension presents to the Cardiology Department with an incidental finding of a diastolic murmur during a routine check-up. He denies any symptoms of chest pain, shortness of breath, or irregular heartbeat. He is currently taking amlodipine and lisinopril for his hypertension and has no other medical history of note.

During the examination, the patient appears comfortable at rest with a blood pressure of 145/70 mmHg and a heart rate of 80 bpm. Upon palpation, there is a heaving precordium, and a diastolic murmur is heard at the left sternal edge, present for half of diastole. An electrocardiogram reveals sinus rhythm with evidence of left ventricular hypertrophy.

Further testing with an echocardiogram shows a normal-sized left ventricle with good function, but moderate aortic regurgitation and no other significant valve pathology.

What should be included in the management plan for this patient?

MRCP2-0360

As a Cardiology Senior House Officer (SHO) in the Outpatient Department, you encounter a 65-year-old woman during her annual review. She had a mechanical valve replacement four years ago for severe aortic stenosis (AS) and has been well until three weeks ago. She presents with weight loss, poor appetite, and breathlessness that started after attending a general surgical appointment for rectal bleeding. On examination, you note conjunctival pallor, splinter haemorrhages on both hands, and a soft metallic second heart sound. There is also an ejection systolic murmur at the second right intercostal space and right sternal edge, as well as an early diastolic murmur at the lower left sternal edge accentuated by forced expiration. You diagnose her with infective endocarditis on the metallic valve prosthesis and arrange for urgent admission. The most important investigation to guide further management of the infective endocarditis is awaited trans-oesophageal echocardiogram.

MRCP2-0361

An 80-year-old man arrives at the Emergency department complaining of dizziness. He reports no chest pain or difficulty breathing. The patient is currently taking 10 mg of felodipine for hypertension. After examination, his electrolyte levels are found to be normal. An ECG reveals complete heart block, and thyroid function tests come back normal. An Echo shows severe left ventricular impairment. What is the recommended course of action for this patient?

MRCP2-0362

A 37-year-old woman presents with a 3-month history of increasing swelling in her abdomen and lower limbs. She has a medical history of myasthenia gravis, which was associated with a thymic mass. She underwent a thymectomy 5 years ago, and after positive margins were noted, she received radiotherapy. She has no other medical history. On examination, her heart sounds are normal, and her chest is clear. Her JVP is located at 6 cm above the angle of Louis. Abdominal examination reveals a pulsatile liver and smooth hepatomegaly. A chest x-ray shows minimal pleural and pericardial calcification. What is the definitive treatment for this patient?

MRCP2-0363

A 67-year-old woman visits the Cardiology Clinic for a check-up after experiencing an inferior STEMI six weeks ago and receiving a stent. She is currently taking 80 mg atorvastatin, 75 mg aspirin, 75 mg clopidogrel, and 2.5 mg bisoprolol. After reading an article online, she asks for your opinion on whether vitamin E is beneficial for individuals who have had a previous heart attack. What advice would you give to this patient regarding vitamin E?

MRCP2-0364

A 56-year-old man is being evaluated on the cardiac ward 3 days after being admitted for an acute coronary syndrome event. He had previously suffered from an inferior myocardial infarction 5 years ago, which was treated with stenting. He is currently taking aspirin, atorvastatin, ramipril, bisoprolol, and indapamide. Upon examination, there are no notable findings, and he is considered fit for discharge.

What is the most suitable choice for anti-platelet therapy upon discharge?

MRCP2-0365

A 70-year-old male presents with sudden onset dyspnoea. He has a history of smoking 20 cigarettes per day and has noticed increasing exertional dyspnoea over the past year. On examination, he is short of breath at rest, obese, has an irregular pulse of 125 beats per minute, blood pressure of 122/82 mmHg, a third heart sound, and bibasal crackles on chest examination. His lab results show elevated urea, glucose, and free T4 levels, and low TSH levels. His ECG shows atrial fibrillation, and his chest x-ray reveals Kerley B lines with interstitial oedema. What is the most likely cause of this patient’s presentation?