Archives: MRCP Part 2

MRCP2-0341

A 45-year-old man, who was previously healthy and physically fit, presented to the Emergency department with left-sided weakness that lasted for two hours. However, the weakness resolved by the time he arrived at the hospital. A CT scan of his head was normal, with no signs of haemorrhage or infarction.

The patient is a non-smoker, has no history of hypertension or hypercholesterolaemia, and there is no family history of cerebrovascular disease. During the examination, a soft diastolic murmur was heard in the aortic area, and the patient had a fever of 38.2°C. Upon further questioning, he reported feeling lethargic and experiencing rigors for the past two weeks.

A transthoracic echocardiogram and transoesophageal echocardiogram revealed a suspicious mobile mass on the aortic valve with moderate aortic regurgitation. Blood cultures showed that the patient was infected with Staphylococcus aureus, which was sensitive to flucloxacillin. The patient was started on appropriate antibiotic therapy for infective endocarditis after consulting with the microbiologist.

However, two weeks later, the patient still had a daily fever that reached 38.5°C. What is the next most appropriate step?

MRCP2-0342

A 20-year-old female presented to her general practitioner complaining of general malaise, lethargy, and fatigue. She couldn’t pinpoint when the symptoms started but felt they had been gradually developing over several months. The GP referred her to a cardiologist after finding some physical abnormalities.

The cardiac catheterization results are as follows:

– Superior vena cava: 77% oxygen saturation, no pressure recorded
– Right atrium (mean): 79% oxygen saturation, 7 mmHg pressure
– Right ventricle: 78% oxygen saturation, no pressure recorded
– Pulmonary artery: 87% oxygen saturation, 52/17 mmHg pressure
– Pulmonary capillary wedge pressure: 16 mmHg
– Left ventricle: 96% oxygen saturation, 120/11 mmHg pressure
– Aorta: 97% oxygen saturation, 130/60 mmHg pressure

What is the diagnosis?

MRCP2-0343

A 23-year-old male presents to the cardiology clinic with recurrent episodes of loss of consciousness, which tend to occur in the late morning or late afternoon. These episodes have been increasing in frequency over the past six months and now occur several times a week. Prior to the episodes, the patient experiences tremors and sweating, and eating chocolate has sometimes prevented or relieved the symptoms. The patient has also noticed these problems occurring during exercise. After the episodes, there is no confusion, disorientation, or residual weakness. On examination, the patient has a BMI of 25 kg/m2 and reports gaining 3 kg in the past three months. The patient has a pulse rate of 70/min−1, blood pressure is 126/78 mmHg lying and 130/80 mmHg standing, and heart sounds S1 and S2 are audible with no added sounds or murmurs. The patient is clinically euthyroid, and there is no evidence of clinical neurological deficit.

Initial investigations show:
– Haemoglobin 140 g/L (115-165)
– WCC 5.0 ×109/L (4-11)
– Platelet count 180 ×109/L (140-400)
– Serum sodium 142 mmol/L (137-144)
– Serum potassium 4.0 mmol/L (3.5-4.9)
– Serum urea 5.5 mmol/L (2.5-7.5)
– Serum creatinine 80 μmol/L (60-110)
– Serum corrected calcium 2.4 mmol/L (2.2-2.6)
– Serum phosphate 1.0 mmol/L (0.8-1.4)
– Glucose 5.0 mmol/L (3.0-6.0)
– TSH 2.0 mU/L (0.4-5)
– Free T4 18.0 pmol/L (10-22)
– Free T3 5.5 pmol/L (5-10)

The ECG shows sinus rhythm, and the chest x-ray reveals a normal cardiac silhouette and clear lung fields. What is the most appropriate investigation for this patient?

MRCP2-0344

A 48-year-old woman presented with sudden onset chest pain and difficulty breathing. She had a history of hypertension, atrial fibrillation, and was a smoker of 20 cigarettes per day. Recently, she had gone through a difficult separation from her husband and was living alone with occasional visits from a friend. She had a family history of heart disease and had been experiencing a cold that was resolving. Her medications included aspirin 75mg once daily and bisoprolol 5mg once daily. Upon arrival, her ECG showed ST elevation in the anterior chest leads, and she was immediately taken to the angiography suite. The angiogram revealed mild coronary atherosclerosis but an akinetic left ventricle. Her troponin T levels were significantly elevated at 7800 ng/L (normal < 14). What is the most likely diagnosis?

MRCP2-0345

An Emergency Department receives a patient who is 72 years old and complains of crushing central chest pain that started 30 minutes ago. The ECG reveals tall R waves in V1-2. What is the probable coronary territory that is affected?

MRCP2-0346

A 55-year-old man presents to the clinic with abnormal blood tests. He has a medical history of hypertension, type two diabetes, obesity, and depression. The patient was prescribed atorvastatin two months ago due to elevated cholesterol levels identified during a routine QRISK assessment. A blood test was performed three months after starting the medication, which revealed an increase in alanine aminotransferase from 28 iU/L to 94 iU/L. All other blood tests were within normal ranges, except for cholesterol, which improved from 5.4mmol/L to 4.9mmol/L. How should the patient’s atorvastatin treatment be managed?

MRCP2-0347

An 80-year-old man comes to the emergency department with a case of epistaxis. He has a medical history of atrial fibrillation and takes warfarin daily.

During the examination, the epistaxis has stopped, and his vital signs are normal. However, his INR level is 5.8 (<1.1). What is the suitable course of action considering the patient’s clinical situation?

MRCP2-0348

A 32-year-old woman visits the haematology clinic after experiencing shortness of breath three days ago. She had gone to the emergency department where a CT pulmonary angiogram scan revealed a pulmonary embolus. She was discharged with low molecular weight heparin injections at treatment dose and advised to attend the anticoagulation clinic to begin warfarin. The patient has no medical history or allergies and only takes Microgynon as an oral contraceptive.

The patient is not pregnant and consents to starting warfarin. What should be done with her heparin while initiating warfarin treatment?

MRCP2-0349

A 65-year-old woman arrives at the emergency department complaining of breathlessness. She has been experiencing increasing shortness of breath for the past two weeks, with a significant decrease in her ability to exercise. She now finds that even walking a few steps leaves her feeling breathless, whereas previously she could walk to her local shops and back without issue. She is unable to lie down as it exacerbates her symptoms. Her medical history includes hypertension, a previous heart attack, and asthma.

Upon examination, her JVP is elevated, and there are bilateral crepitations on auscultation. Air entry is reduced in both lung bases, and percussion is dull. Her chest X-ray reveals evidence of pulmonary edema and bilateral pleural effusions. What is the most appropriate course of action?

MRCP2-0330

An 83-year-old man visits his doctor to discuss his medication. He reports experiencing shortness of breath with minimal exertion and having to sleep upright in his armchair. His current medication includes lisinopril, metoprolol, spironolactone, furosemide, aspirin, simvastatin, nifedipine, and metformin.

During the physical examination, the patient’s heart rate is 69 beats per minute with a regular rhythm, and his blood pressure is 118/100 mmHg. His peripheries are cool, and his carotid pulse is difficult to palpate. The doctor notes a sustained apical impulse palpable in the 5th intercostal space in the mid-clavicular line. Additionally, the patient has a palpable thrill in the second intercostal space at the right sternal border, where the doctor hears a loud crescendo-decrescendo murmur that radiates into the neck. The patient has a quiet S1, an inaudible S2, and a loud S4. The doctor also observes 1+ peripheral edema.

Which of the following physical examination findings are most indicative of severe aortic stenosis?