Archives: MRCP Part 2

MRCP2-0304

A 50-year-old woman presents to the emergency department after a road traffic accident where she sustains multiple injuries including an open fracture of her left tibia and fibula. The following day she has an open reduction and internal fixation of the left tibia and fibula and remains in hospital for physiotherapy. She is quite immobile during this period and then develops subsequent painful swelling and erythema of the left calf. Subsequent ultrasonography confirms a left-sided above knee deep vein thrombosis.

Before treatment starts, she develops sudden onset weakness in her right leg and right arm, dysarthric speech and a reduction in conscious level. Subsequent CT scanning confirms the presence of a left-sided infarct in the middle cerebral artery territory. Doppler investigation of the carotids shows a 20% stenosis on the left side and 10% on the right side. The 24-hour tape shows average heart rate 52 bpm with 1.5s pauses maximum, sinus bradycardia.

What feature from further investigations would best explain this woman’s presentation, given that she is now 50 years old?

MRCP2-0305

A 35-year-old pregnant patient is referred to the cardiology clinic with a history of regular fast palpitations. The gestational age is 27 weeks. There is no history of collapse and the patient is usually fit and well.

You examine the patient. Pulse is 105 and regular and the blood pressure is 105/80 mmHg. Venous pressure is not elevated. Heart sounds are normal and a resting 12 lead ECG shows sinus rhythm only.

What is an expected physiological change during a normal pregnancy?

MRCP2-0306

A 68-year-old man presents with lethargy, weight loss, and anorexia that have been progressively worsening over the past six months. He has lost a total of 10 kg in weight. On examination, his blood pressure is 152/76 mmHg, pulse is 82 and regular. The patient appears pale, and there are splinter haemorrhages on his fingers. A systolic murmur is heard at the lower left sternal edge on auscultation of his heart. An abdominal examination reveals a mass in the right iliac fossa. Laboratory investigations show a haemoglobin level of 100 g/L (135-177), a white cell count of 9.2 ×109/L (4-11), platelets of 205 ×109/L (150-400), an ESR of 80 mm/hr (<10), a sodium level of 140 mmol/L (135-146), a potassium level of 4.2 mmol/L (3.5-5), and a creatinine level of 130 µmol/L (79-118). Which of the following organisms is most likely responsible for the patient's endocarditis?

MRCP2-0307

A 58-year-old man with a history of angina underwent angioplasty and bare metal stent implantation for single vessel coronary artery disease. After being discharged, he was symptom-free for three months, but then began experiencing the same exertional chest discomfort as before. He visited the cardiology outpatient clinic and underwent an exercise tolerance test, during which he experienced 3 mm of ST segment depression after four minutes of a standard Bruce protocol. What is the most probable reason for the return of his symptoms?

MRCP2-0308

A 20-year-old left-handed woman presented to the hospital with sudden onset of right-sided weakness and difficulty speaking. She had no significant medical history. The patient was a college student studying psychology and had recently returned from a summer trip volunteering with Habitat for Humanity. She did not smoke and consumed approximately six units of alcohol per week.

During the examination, the patient had a regular pulse of 80 beats per minute and a blood pressure of 120/70 mmHg. The heart exam revealed a soft systolic murmur in the second left intercostal space and wide fixed splitting of the second heart sound. The lungs were clear on auscultation. Neurological examination showed expressive and receptive dysphasia, weakness of the right arm and leg with increased tone, and hyperreflexia on the right with an extensor right plantar response. The left lower leg appeared swollen and erythematous.

The following investigations were conducted: haemoglobin 140 g/L (130-180), white cell count 8.0 ×109/L (4-11), platelets 350 ×109/L (150-400), serum sodium 138 mmol/L (137-144), serum potassium 4.0 mmol/L (3.5-4.9), serum urea 5.0 mmol/L (2.5-7.5), serum creatinine 90 µmol/L (60-110), anti dsDNA negative, ANA negative, VDRL negative, lupus anticoagulant negative, protein C 95 U/dL (80-125), protein S 105 U/dL (80-120), antithrombin III 90 U/dL (80-120), and D-dimer 10 mg/L (<0.5). The ECG showed right ventricular hypertrophy, right bundle branch block, and partial right axis deviation. The chest x-ray revealed prominent pulmonary arteries and pulmonary plethora. What is the most likely diagnosis for this patient?

MRCP2-0309

A 75-year-old male presented with three episodes of transient loss of consciousness, but no chest pain. He had recently been discharged from the hospital after experiencing an anterior myocardial infarction. Upon examination, his pulse was regular at 80 beats per minute and his blood pressure was 136/82 mmHg. His apex beat was diffuse and displaced to the anterior axillary line in the sixth intercostal space. Neurological examination was normal. The ECG showed occasional ventricular extrasystoles, deep anterior Q waves, and ST segment elevation throughout the anterior leads. What would be the most appropriate initial course of action?

MRCP2-0310

A 32-year-old woman who is 20 weeks pregnant presents to the Cardiology Department with complaints of heart palpitations. She has no significant medical history and is not taking any medications. On examination, her BP is 120/80 mmHg, her pulse is 80 bpm and regular, and there is a systolic murmur with a fixed splitting of the second heart sound. An ECG shows left-axis deviation with an RBBB, and an ECHO reveals an ostium primum ASD. What are the potential risks to the pregnancy, if any?

MRCP2-0311

A 55-year-old male presents to the outpatient clinic for a routine check up. He has a five year history of type 2 diabetes mellitus and is currently diet controlled. He takes no other medication.

Examination reveals that he is obese with a BMI of 32 kg/m2, his blood pressure is 170/90 mmHg and he has a pulse of 75 beats per minute regular.

A check of his joint management record shows that the previous week his blood pressure was 160/90 mmHg and 170/95 mmHg. He has no evidence of any end organ damage and his pinprick sensation using a monofilament is normal.

Investigations show:

– Serum sodium 137 mmol/L (137-144)
– Serum potassium 4.2 mmol/L (3.5-4.9)
– Serum urea 6 mmol/L (2.5-7.5)
– Serum creatinine 105 µmol/L (60-110)
– Serum bicarbonate 25 mmol/L (20-28)
– Cholesterol 5.6 mmol/L (<5.2)
– Urine albumin 200 μmol/dL
– HbA1c 7.2% (5 – 6.8%)

Which of the following drugs is not supported by evidence for reducing the risk of developing a cardiac event in this man?

MRCP2-0312

A 67-year-old man presents to the Emergency Department with complaints of lethargy, fever, and loss of appetite. He had undergone a prosthetic aortic valve replacement a year ago for progressive aortic stenosis and has been in good health since then. However, his symptoms have been persistent for the past two weeks. Laboratory tests reveal a CRP level of 215 mg/l, while the chest x-ray and urine dip are normal. A transoesophageal echocardiogram is performed, which shows a large vegetative lesion around the prosthetic aortic valve, raising suspicion of infective endocarditis. What is the most appropriate antibiotic therapy to initiate while awaiting blood culture results?

MRCP2-0313

A 68-year-old with a history of ischaemic heart disease (primary percutaneous intervention for a STEMI four years ago) is admitted with a pyrexia of unknown origin. During examination, a systolic murmur is noted, but chest auscultation is unremarkable. His pulse is 96/min, temperature 38.2ºC, and blood pressure 104/66 mmHg. Three years ago, his post-myocardial infarction echocardiogram showed no valvular disease. However, a petechial rash is noted on his hands and legs, and urine dipstick shows blood ++. The presumptive diagnosis is infective endocarditis, and he is given empirical treatment with IV amoxicillin and gentamicin. Two days later, blood cultures reveal a coagulase-negative staphylococcus. What is the most appropriate course of action regarding antibiotic therapy?