Archives: MRCP Part 2

MRCP2-0321

An 80-year-old woman was admitted to the hospital with acute coronary syndrome and was discharged on day six after making a good recovery.

Her medication on discharge included atenolol 50 mg daily, enalapril 10 mg daily, isosorbide mononitrate 30 mg daily, atorvastatin 20 mg daily, and aspirin 75 mg daily.

During admission, investigations showed that her serum urea was 12.4 mmol/L (2.5-7.5) and serum creatinine was 250 µmol/L (60-110).

However, she was re-admitted one week after discharge with deteriorating dyspnoea. Further investigations revealed that her serum urea was 28.9 mmol/L (2.5-7.5), serum creatinine was 600 µmol/L (60-110), serum bicarbonate was 18 mmol/L (20-28), and serum potassium was 6.0 mmol/L (3.5-4.9). The ECG showed T wave inversion in leads II, III, and V5-6.

If the patient is clinically fluid overloaded, what is the best course of management?

MRCP2-0322

A 35-year-old individual with a history of IV drug abuse is brought to the ED in cardiac arrest. They have been intubated and ventilated by the ambulance crew. CPR is ongoing, but medical personnel are unable to gain IV access to administer adrenaline.
What is the most suitable alternative route to administer adrenaline in this case?

MRCP2-0323

A 65-year-old man presents with a two-week history of fever, weakness, and night sweats. During the initial examination, an early diastolic murmur was detected. Blood cultures grew S. bovis three times, indicating infective endocarditis. Vegetations on the aortic valve were observed on both transthoracic and transoesophageal echocardiograms, but no aortic root abscess was found. Before discharge, which investigation should be arranged?

MRCP2-0324

A 58-year-old former user of intravenous drugs is in cardiac arrest and you are part of the cardiac arrest team called urgently to the Emergency department to assist. Upon arrival, the patient is already intubated and receiving chest compressions from the nurse. Despite two shocks for VF, the patient remains unresponsive. The paramedics and Emergency department team have made several attempts to gain venous access but have been unsuccessful. Adrenaline is now indicated for the next cycle. What is the recommended next step to administer adrenaline?

MRCP2-0325

A 40-year-old woman has been diagnosed with systemic sclerosis and is now experiencing headaches and blurred vision. She has a history of asthma. During examination, her blood pressure is found to be 230/120 mmHg, and there are bilateral papilloedema and fundal haemorrhages. What medication should be prescribed immediately?

MRCP2-0326

You are the Senior House Officer (SHO) in the Cardiology Clinic and wish to start an elderly male patient, who has recently been diagnosed with hypertension, on an agent in addition to his angiotensin-converting enzyme (ACE) inhibitor. He is a type II diabetic who is currently diet-controlled. His blood pressure is 155/90 mmHg.

Which of the following is the most suitable next medication?

MRCP2-0327

A 45 year old man has been referred to the endocrinology clinic for investigation and management of his persistently raised blood pressure. Despite being on ramipril 5mg once daily for four weeks, his blood pressure remains elevated between 170/100 mmHg and 180/110 mmHg. During the consultation, the patient mentions experiencing headaches for the past year, along with increased stool frequency and looser stools. He also reports flushing episodes and feeling that his clothes are looser than they were a year ago. The patient’s family history includes his mother having a breast lump removed and his father having a pancreatic mass removed. On examination, the patient is tall with a wide arm span, and has a minor tachycardia of 95 bpm and a quiet systolic flow murmur. A 24h urinary catecholamine test arranged by the GP showed raised levels of total urine catecholamines at 210 mcg/24hr. A CT of the abdomen and pelvis was reported as normal, except for a few incidental simple renal cysts. Urinalysis in clinic today showed no leucocytes or blood, but did show glucose. Which test is most likely to determine the cause of the patient’s hypertension?

MRCP2-0328

A 55-year-old man with a 3 year history of hypertension is referred for further evaluation due to his blood pressure being difficult to control. The following results were obtained prior to commencing medications:

Na+ 146 mmol/l
K+ 3.5 mmol/l
Creatinine 120 µmol/l
Renin 98 (7-50 IU/mL ambulatory)
Aldosterone 1000 (N: 80-800 ng/dL ambulatory)
Renin:Aldosterone Ratio 10.8 (< 500)
Plasma Metanephrines 0.40 (<0.50 nmol/L) These results are most consistent with which of the following:

MRCP2-0329

A 42-year-old Caucasian man presents to your clinic with a blood pressure reading of 145/95 mmHg. He reports not regularly monitoring his blood pressure at home and is currently asymptomatic. Upon examination, his cardiovascular and fundoscopic findings are unremarkable, and his 12-lead ECG shows no evidence of left ventricular hypertrophy. He is currently taking a regimen of 10 mg amlodipine, 10 mg ramipril, 1.5 mg indapamide, and 25 mg spironolactone. What would be the most appropriate next step in treating this patient?

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?