Archives: MRCP Part 2

MRCP2-0356

A 36-year-old female of Asian descent, with no significant medical history, presents after experiencing a syncopal event while gardening. She has been experiencing fever, joint pain, and multiple episodes of vertigo for the past 6 months. Upon examination, a diminished radial pulse is noted in her right arm and a systolic blood pressure difference of 12 mmHg is observed in her upper extremities. A bruit is heard along the right upper extremity, and Dopplers reveal a stenotic area along the subclavian, which is later confirmed by Magnetic Resonance Angiography (MRA). The patient is diagnosed with subclavian steal syndrome. Laboratory tests show a normocytic normochromic anemia, elevated CRP and ESR, negative ANA and ANCA, and all other laboratory tests are within normal range. What is the most likely diagnosis?

MRCP2-0357

There is a diurnal variation in the manifestation of myocardial ischemia. What physiological mechanism is accountable for this phenomenon?

MRCP2-0358

A 72-year-old man is referred to hospital by his GP. He had been receiving treatment for essential hypertension with bendroflumethiazide 2.5 mg and amiloride 10 mg daily. However, during a routine check of his renal function, the following results were obtained: serum sodium 134 mmol/L (137-144), serum potassium 5.9 mmol/L (3.5-4.9), serum urea 7.0 mmol/L (2.5-7.5), and serum creatinine 100 µmol/L (60-110). At the outpatient clinic, his blood pressure is 134/86 mmHg, and a 12-lead electrocardiogram is normal. The GP’s letter indicates that the amiloride was discontinued the day before. What is the most appropriate course of action?

MRCP2-0359

A 70-year-old female presents with left chest pain accompanied by sweating in her hands and nausea. She has a medical history of T2 diabetes mellitus, hypertension, and hypercholesterolemia. Her regular medications include metformin 850mg BD, gliclazide 40mg OD, ramipril 10mg, amlodipine 5mg, and atorvastatin 40mg ON. During examination, a pansystolic murmur is heard, and her heart sounds are normal. Her ECG shows ST depression in V2 to V5. Since her admission 4 hours ago, her BMs have ranged between 6 and 14 mmol/L. What is the appropriate management of her diabetic medications?

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?