Philip Kelly MRCP 2 book 1

Theserieswould have beenimpossiblewithout thehelpofthe following:Dr Aain,SpecialistRegistrar,Cardiology,The London ChestHospital;Dr P McCoubrie,ConsultantRadiologist,Bristol; DrY Ho,Brom

RenalMedicine

Haematology Neurology Ophthalmology

JamesWilkinsonMRCP(UK)MBBS BSc(Hons)

BritishHeartFoundation Research Fellow andSpecialist RegistrarinCardiology,Wolfson Institute for BiomedicalResearch,UniversityCollegeLondon,London

RespiratoryMedicine

SusannahLeaver MBBS BmedSci(Hons) MRCP(UK)

SpecialistRegistrarinRespiratory Medicine, SouthWestThamesRotation.

enough contribute

be usedinthesevolumes Theserieswould have beenimpossiblewithout

thehelpofthe following:Dr A)ain,SpecialistRegistrar,Cardiology,The

London ChestHospital;Dr P McCoubrie,ConsultantRadiologist,Bristol;

DrY Ho,BromptomHospital;Dr E Behr,CardiologySpecialistRegistrar,

St.George's Hospital;Dr NHughes, Consultant Radiologist, FrimleyPark

Hospital;Dr RKnight, Consultant Respiratory Physician, FrimleyPark

Hospital;Dr MichaelArdern-Jones,Specialist RegistrarDermatology,

Oxford RadcliffeNHS Trust;DrTimHo,Consultant RespiratoryPhysician,

FrimleyParkHospitaland DrHeatherleffcrson,Specialist RegistrarinNephrologyforproofreadingthe respiratorysection.

PhilipKelly

TheMRCP(UK) Part2written examination consists oftwo3-hour papers,each withupto 100multiplechoice questions;theyareeitheronefrom

five(bestof5) or'n' from many,wheretwoanswersarechosen fromten.

Eachquestion will haveaclinicalscenario andmightcontain

investigationstointerpret; manymightalsocontain animage.There is apass-mark agreedbytheexaminersbutacandidate's performanceisalso

assessedinrelationtoother candidates

Thisthree bookseriesprovidespractice questionswithextensive

explanationstoaid candidatespreparingforthe examination.Theauthors

areall clinicianswritingsectionsin their chosen fields andassuch have

been chosenfortheir clearunderstandingoftherequired knowledgebaseforthis importantexam.Thebreadth of knowledgeforthisexam is vast

andtheyhaveattemptedto coverthe'syllabus'ascompletelyaspossible.Greatcarehas beentakentoexplainareasthatcausedifficultyas

thoroughlyaspossible.Noapologyismade where the format of thequestions differsslightlyfromtheexam.These booksare notmerely

practice papers buteducationalaidsand whereatopiccanbe bestexplained bydiversionfromthe strictformat ofthe exam,forthesake ofunderstanding,this has been done

Thisbookcoverscardiologyand respiratory medicineandisbest taken

-in concertwithitscolleagues withintheseries-as asupplementto a

White cellcount (WCC)

FactorsII, V, VII,VIII, IX, X, XI, XII

vonWillebrandfactor

95 107mmol/L20-28mmol/L12-16mmol/L2.5 7.5mmol/L

60-1 10pmol/L

2.2-2.6mmol/L

0.8-1.4mmol/L

Fastingplasma glucose

3.0-6.0mmol/L

3.8-6.4%

60-180U/L

278-305mosmol/kg

lipidsand lipoproteins

(targets vary,dependingoncardiovascularrisk)

Cholesterol < 5.2mmol/L

F1DL cholesterol > 1 55 mmol/LFastingtriglyceride 0.45-1.69 mmol,

Bloodgases (sealevel,breathingair)

Plasmavasoactiveintestinalpeptide(VIP)

Plasmapancreaticpolypeptide

0.9-5.4pmol/L

<27pmol/L

0.9-4.6pmol/L

< 10mg/L6.0-13.0g/L0.8-3.0g/L

Plasma carbamazepine

Plasmadigoxin(atleast6hpost-dose)

Bloodgentamicin(peak)

65-172pmol/L40-80umol/L

< 2.5mg/mmol

< 3.5 mg/mmol

A&E Accident andEmergency (Department)

ABPA Allergicbronchopulmonaryaspergillosis

ACE Angiotensin-convertingenzyme

ADH Antidiuretichormone

AF Atrial fibrillation

AICD Automaticimplantablecardioverter/defibrillator

AIHA Autoimmunehaemolyticanaemia

ALL Acutelymphoblasticleukaemia

ALP Alkalinephosphatase

ALT Alanineaminotranferase

AML Acutemyeloblasts(/myelocytic/myeloid)leukaemiaANA Antinuclearantibody

ANCA Anti-neutrophilcytoplasmic antibody

Anti-Ach R Anti-acetylcholinereceptor

APKD Adultpolycystic kidneydisease

APTT Activatedpartialthromboplastintime

ASD Atrialseptal defect

ASOT Antistreptolysin-Otitre

vincristine(Oncovin®),prednisolone (chemotherapy)

CNS Centralnervous system

CO, Carbondioxide

C-OPD Chronicobstructivepulmonarydisease

CPAP Continuouspositiveairwaypressure(ventilation)

DCT DirectCoombs'test

DEXA Dual-energyX-rayabsorptiometry

DIC Disseminated intravascular coagulation

DIP Distalinterphalangeal(joint)

DKA Diabetic ketoacidosis

DM Diabetes niellitus

DMARD Disease-modifyingantirheumatic drug

DVT Deepveinthrombosis

EBV Epstein-Barrvirus

ECT Electroconvulsive therapy

EEC Electroencepha1ogram

ElISA Enzyme-linkedimmunosorbent assay

ENA Extractableantinuclear antibody

GFR Glomerularfiltrationrate

GORD Gastro-oesophagealrefluxdisease

HELLP Haemolysis,elevated liver functiontests,lowplatelets

HEV Hepatitis Evirus

HHT 1lereditaryhaemorrhagic telangiectasia

HIV Humanimmunodeficiencyvirus

HLA Humanleucocyteantigen

HNPCC Hereditarynon-polyposiscolorectal cancer

HONK Hyperosmolarnon-ketoticstale

HSP Henoch-Schbnleinpurpura

HTLV-1 HumanT-cellleukaemiavirus1

ICU/ITU IntensiveCare Unit/IntensiveTherapyUnit

INR Internationalnormalisedratio

IPD Intermittentperitoneal dialysis

IPSID Immunoproliferativesmall-intestinal disease

UP Immunethrombocytopaenia

IUGR Intrauterinegrowthretardation

IVC Inferiorvena cava

IVP Intravenouspyelography

IVU Intravenousurography

)VP Jugular venous pulse/pressure

Kco Transfercoefficient

MCP Metacarpophalangeal(joint)

MCU Micturatingcystourography

MDMA 3,4-methylenedioxymelhamphetamine (Ecstasy)

MEN Multipleendocrineneoplasia

MODS Multiple-organ dysfunction syndrome

MPO Myeloperoxidase

MRA Magneticresonanceangiogram

MRI Magnetic resonance imaging

MSU Mid-streamurine(sample)

MTP Metatarsopha1angea1(joint)

NHL Non-Hodgkin'slymphoma

NICE NationalInstituteforClinicalExcellence

NIV Non-invasiveventilation

NSAID Non-steroidalanti-inflammatorydrug

OA Ostroarthritis

PA Perniciousanaemia/pulmonaryartery

PBC Primarybiliarycirrhosis

PCOS Polycysticovarysyndrome

PCP Pneumocystiscariniipneumonia

PCV Packed cell volume

PDA Patentductusarteriosus

PEE(R) Peak expiratory flow(rate)

PIP Proximalinlerphalangeal(joint)

RDW Red celldistribution width

REM Rapiceyemovement

RSD Reflexsympathetic dystrophy

RSV Respiratorysyncytialvirus

RTA Renal tubularacidosis/road trafficaccident

RV Right ventricle/residualvolume

RVOT Rightventricular outflowtract

SCD Sicklecelldisease

SIADH SyndromeofinappropriateADH secretion

SLE Systemiclupuserythematosus

Spo Oxygensaturation,measured by pulse oximetry

SSRI Serotoninreuptakeinhibitor

TB Tuberculosis

TCC Transitional cellcarcinoma

TIA Transientischaemic attack

TLC Totallungcapacity

Tlco Transfer factorofthelungforcarbonmonoxide(= Dlco)

TNF Tumour necrosisfactor

TOE Transoesophagealechocardiogram

tPA Tissue-typeplasminogenactivator

TPN Totalparenteralnutrition

TRUS Transrectal ultrasound

IT Thrombintime

UP Thromboticthrombocytopaenicpurpura

U&Es Ureaandelectrolytes

A38-year-oldmanpresentedtoA&Ewithretrosternalchestpain, which hehadhadfor7hours.

Onexaminationhe lookedcomfortablebutwastachycardicandpyrexial;

hisphysicalexaminationwasotherwise normal.Histroponin T ismildly

elevated.His ECG isshownbelow:

* iiM <i m m* Mil II •».•» [ ul i •« (•» a | •»•»

1 What b themostlikely diagnosis?

ÿ A ST-elevationmyocardialinfarct

CARDIOLOGY QUESTIONS

Case2

You arcreferreda45-year-oldmanwithchest pain, which he describesas

adull epigastric/lower chestache thatcame onwhen heranfora bus,shortly afteralarge meal, andlastedabout20 minutesbefore easingoff

He isobeseandknowntohaveCORD.

Physicalexaminationisnormal.HisinitialECCshowssomeflatteningofhisTwavesin the lateral leads buthismost recentECCisnormal The

troponinT, taken6hoursafterthepatient saidthe pain started,isnormal

1 Which of thefollowingwould hemostappropriate?

D A Reassurehim,prescribea protonpumpinhibitor and discharge himto

hisCP

ÿ B Reassurehim,prescribehimaGTN spray,dischargehimand arrange

forhimto comebackfor an exercise lest in 6 weeks

ÿ C Givehimthrombolytic therapyandadmit himtotheCoronaryCare

Unit (CCU)

ÿ D Reassurehim,dischargehimandtell himlo seehisGPif hehasany

furthersymptoms

D E Admithim,treathimasif he hadacutecoronarysyndromeand repeat

histroponinin 12 hours

A 70-year-oldladyhasanout-of-hospitalcardiacarrest;when theparamedicsarrive on scenesheisin VF They successfully cardioverther, resuscitateheron-sceneand transfer herto A&E Onarrivalsheisstable

andinsinusrhythm.Thefollowingdaysheiswellandthereis noevidence

ofan Ml orofanyother precipitatingcause.

Shehadaninferior Mloneyear ago, forwhich shereceivedthrombolysis

Anangiogram,doneprivately6monthsago,showedunobstructed

coronarieswith plaquedisease, inferiorhypokinesiaand an ejection

fraction of30%.Sheisonramipril,aspirin anda statinand has beenasymptomaticwithnormalexercisetolerance

1 Which of thefollowingdescribes how she should be best managed?

ÿ A Put onoralamiodarone anddischarge

ÿ B Do an exercise testanddischargeif itisnormal

ÿ C Havean automaticimplantablecardioverterdefibrillator(AICD)

inserted priortodischarge

ÿ D Reassure anddischarge

ÿ E Put on ap-blocker andnitrateanddischarge withanexercisetest

booked for 6weeks'time

CARDIOLOGY- QUESTIONS

Case 4

A seniorhouse officerpresentstheirclerkingofayoungmantheyhave

seenin clinic, thepatientpresentedwitha6-monthhistoryof worseningshortnessofbreathonexertion, occasionaldizzy spellsandblackouts

Onexaminationtheseniorhouse officer found the patienttohavealoud

ejectionsystolicmurmur attheleftsternaledge.Thepulseand bloodpressurewereboth normaland the remainder ofthe cardiovascular

examination wasnormal.Inthenotesyounoticethereis apictureofthe

patientas achild(shown below).Theseniorhouseofficer hasrequestedan

echo and hasarrangedforthe patienttobeseen as afollowup intwo

weekswiththe results Thesenior house officer asks youwhat themostlikely diagnosisis,to putintheirclinic lettertotheCP.

BelowistheECCfrom leads VI-3 (theECCrecordingfromallotherleads,

notshown,is normal)ofa young man presentingwithahistoryofblackouts.He is on nomedication,takesnodrugsoralcohol andhasno

family historyofnote Hisphysicalexaminationis normal

VI

V 2

V3

::

CARDIOLOGY- QUESTIONS

Case 6

The surgeonsadmittedan18-year-oldmanwith left iliac fossa pain.Hehadahistoryofrecurrentsinusitis butnoothermedicalproblems

Onexaminationtherewere nomurmurs,his bloodpressure andpulse

werenormal andhehad reboundtendernessandguardingin hisleftiliacfossa.Belowishis chestX-ray:

Image providedby Dr PMcCoubrie, Consultant Radiologist,Southmead Hospital, Bristol

1 What does his chest X-ray show?

A70-year-oldmanhasablackoutandcollapseswithoutwarning whileplayingbowls.Bythetimehereaches hospitalheisfine.Hehasnopastmedicalhistory,is on nodrugsandhas normalexercisetolerance.

Onexaminationhe looks well; thereis anejectionsystolicmurmurwithaquiet second heart sound.Hispulsevolumeisreduced.Thereare noothersigns.His ECCshows left bundle branch blockand sinusrhythm.Allhisbloodtests arenormal

1 Which of thefollowingis the mostappropriatenextstep?

ÿ A Ensurehe hasaninpatientechocardiogrampriortodischarge

CD B Givehimthrombolysisforhisnew anteriorMl

CD C Arrangeanexercisetest

CD D Arrangeanoutpatient echo and follow-up

ÿ E Arrangeanoutpatient Holtertest

CARDIOLOGY- QUESTIONS

Case8

A26-year-oldpatientisreferredtoyoubyA&Ehavingcollapsed;she hashadincreasingbreathlessnessandfatigueover the last week Apart from a

transientrashwhileshe was awayonholiday,which sheputdowntoheat

rash, shehas nopastmedicalhistoryandisnotonanymedication.Shetakesno alcohol, tobacco ordrugs.Sheisavery fitcross-country runner,

previousmedicalandECC2years ago were normal, asrequiredbytheAthleticsAssociation

Shefeelsvery unwell,dizzy and hasdifficultystanding;herbloodpressure

is80/40mmHg.Apartfromthis and abradycardia,her examinationis

otherwisenormal Belowisher ECG:

a

•i 1

1 Which of the followingdescribeshow sheshould best bemanaged?

ÿ A Insertionof adual-chamber pacemaker

ÿ B Medicaltherapy

ÿ C Doaninvasiveelectrophysiologicalstudy withaviewtodefinitive

A23-year-oldladywhoisknowntosuffer fromrecurrentsupraventricular

tachycardia(SVT)presentswithpalpitationsandanSVT

Shecarriesher restingECGwithher,whichisshown below.Herrecent

andthereis noevidence ofpulmonaryoedema She hasnoothermedical

Image providedby Or I Wilkinson, Cardiology Research Fellow, University College London, London

1 Howshould she bestbe managed?

ÿ A Intravenousadenosine

ÿ C Intravenousverapamil

CARDIOLOGY- QUESTIONS

Case 1 0

A53-year-oldman ontheCoronaryCareUnit (CCU)suddenly develops

cardiogenicshock5daysafterhis initialinferior ST-elevation Ml,lorwhich

hereceivedthrombolysis

The salient featuresonexaminationare:pulse120bpm,BP75/50mmHg,

pansystolicmurmur, floridpulmonary oedema.A rightheart catheterisinsertedtohelp guidemanagementand the following readingsarenoted:

Centralvenoussaturation 55%

Pulmonaryarterysaturations 80%

1 Which of thefollowingdescribes thediagnosisand best management

(assumeyourclinical diagnosishas been confirmedwithanurgent

echo)?

ÿ A Ischaemicmitral regurgitationduetoruptured papillary muscle

needingurgentintra-aorticballoon pumpandreferral for surgery

ÿ B Rightventricularruptureneedingurgentsurgery

D C Ischaemic ventricularseptaldefect needingurgent intra-aortic

balloon pumpand referralfor surgery

ÿ D Ischaemic ventricular septal defect needingmedical therapy with

inotropes

ÿ E Ischaemic ventricular septal defectneedingurgent intra-aortic

balloon pumpandurgentinterventionalradiology

At 2o'clock in the morninga72-year-oldladypresents totheDistrictGeneralHospitalwhereyou are oncall She hascentralcrushingchest

painof3hours'duration andbreathlessness.Shehas recentlybeen

diagnosedwithdiabetes mellitus(started ondietcontrol)andsmokes five

cigarettesaday.She isotherwise fit,fullyindependentandison nomedicaltreatment.

Her ECG isshown below:

t tY t' "r i

I) -/iisi »•/»«

1 Which of thefollowingisthemostappropriatestatement?

ÿ A Putheron aheparininfusionwhileyou callacardiologist(whoison

call fromhome)atyour localinterventioncentre,whichismorethan

CARDIOLOGY- QUESTIONS

Case 12

A26-year-oldladypresentswithsudden-onset pulmonary oedema,forwhichshe hastobeintubatedandventilated Apartfrom normally

deliveringahealthy baby7weeks agoshe hasnopastmedicalhistory and

is on nomedication Shehasneversmokedanddrinksapproximately8 unitsofalcoholperweek,althoughshedidnotdrinkduringher

pregnancy Sheis on nomedicationandthereisnofamily history of heartdisease

Herecho showspoorleftventricularfunctionwithanejectionfractionof25% A stillimageisshownbelow:

Image providedby Or A lain, Cardiology Research Fellow, London Chest Hospital, London

1 Whatis themostlikely diagnosis?

A37-year-oldpatientwith schizophreniacollapsesonthepsychiatric

ward.BasicCPRisstartedby the nurses; when thearrest team arrive,theinitialrhythmisfoundtobeVFandheiscardiovertedbacktosinusrhythm

and transferredtoCCU.While heis onthe ward he becomes unwelland

arrestsagain,needingcardioversion(recordedrhythmstrip shownbelow).

Image provided by Dr I Wilkinson, Cardiology Research Fellow, University College London, London

1 What does hisECGshow?

Q B Torsadesde pointes

ÿ D AFwithbundle branchblock

ÿ E Sinusrhythm withmultipleectopics

HisrestingECG isshownbelow.Hisechocardiogramisnormal andtherewas notroponinrise.Apart fromsmoking,hehasnorisk factors for

ischaemic heartdiseaseorsignificantpastmedical history.He wasfit andactivepriortothis admission.Allhis electrolytesarenormal.He is on numerousantipsychoticmedications

CARDIOLOGY - QUESTIONS

2 Which of thefollowingismostcorrect?

ÿ A Hehascongenital long QT syndrome

ÿ B HehasacquiredlongQTsyndromeduetohisneurolepticmedication

ÿ C He has WPWsyndrome

D D HehasBrugada syndrome

ÿ E Hehasright ventricular outflowtract (RVOT)dysplasiacausing VT

A24-year-oldmancollapseswithoutwarning while rowing;bythetimehegets to A&Eheisinsinusrhythmandwell.Heisdischargedfrom A&Ewith

adiagnosisof vasovagalsyncope.His CP notesthat hiscousincollapsed

withoutpriorsymptoms at asimilarage whileplayingfootball, andwas

deadonthe side of thepitch bythetimetheambulance arrived

TheGPordersanechocardiogramandthe2Dimageisshown below.You aretoldintheechoreportthat thereare noabnormalgradientsorvalvularregurgitationoncolour Doppler

Image providedby Dr A Jain, Cardiology Research Fellow, London Chest Hospital, London

1 Which ofthefollowingstatementsismost accurate?

ÿ A Hisechocardiogramshowsasymmetricalseptal hypertrophy.The

diagnosisishypertrophic cardiomyopathy.Heshould be considered

foran AICD insertion

ÿ B Hisechocardiogramshowsasymmetricalseptal hypertrophy.The

diagnosisishypertrophic cardiomyopathy.Heshould beputon a

CARDIOLOGY- QUESTIONS

Case15

You arereferredan84-year-oldpatientinA&Ewhois inpulmonary

oedema thatstartedsuddenlyat 4am,waking herfromhersleep.Shehas

neverhadchest pain Sheisnormallyfit andindependent.However,she

hasrecentlybeengettingincreasinglybreathless walkingtotheshopsandnowneedstosleepwithfourpillows.Shehas been hypertensive for

20years,but this hasbeencontrolledbyherCPwithathiazidediureticand,morerecently,an ACEinhibitoraswell Sheis notdiabeticandhas

neversmoked

HerBPis120/80mmHg,theJVPisraised and shehas pittingoedema of

her ankles.Herchest X-ray confirmsyourclinicalfindingsofpulmonary

oedema.HerECGisshownbelow:

sim* ii 'J V J 11

n «/mci I eW.V I I ! I ,

—jV /vJV~ Vÿ"

Image providedby Dr I Wilkinson, Cardiology Research Fellow, University College London, London

1 Whichofthefollowingstatementsis mostaccurate?

ÿ A Her ECGshowsleftbundlebranch blockand she shouldreceive

A26-year-oldmanpresentswithahistoryofbreathlessness andfaints.

Onexamination theonly findingis along,soft,earlydiastolicmurmur at

the upperleftsternaledge.Hehadcorrectivesurgery fortetralogyofFallot

as achild His ECG is shown below:

- ÿ

Image provided by Or I Wilkinson Cardiology Research Fellow, University College London, London

1 Whichofthefollowingstatementsismostaccurate?

ÿ A His ECG isnormal;hehasaflowmurmurfrom previoussurgery.He is

over-anxiousas aresultofhispreviousproblemsand should bereassured

O B His ECGshowsrightbundle branch block; hismurmur islikelytobe

duetopulmonary regurgitation but thisisrelativelybenignand hecan

be reassured and doesnotneedregular follow-up

ÿ C His ECGshowsrightbundle branch block and heprobablyhas

recurrentsmallpulmonaryemboli causinghissymptomsandECG

changes

CD D HisECGshowsrightbundle branchblock;hismurmurislikelytobe

CARDIOLOGY- QUESTIONS

Case17

A45-year-oldbuilderisadmittedwithpulmonary oedema; hegivesa

history ofworsening exercise tolerance overthepast 6months.Hedoes

notsmoke andhasnopastmedicalhistory

Noevidence of ischaemic heart diseaseisfoundandhe hasaninpatientangiogram,which shows normal coronaryarteries Heisapyrexial andallbloodtestsincludingCRP arenormal.HissubsequentchestX-ray isnormal.Oncehispulmonary oedema has resolvedandheiswell,hegoesdown for anechocardiogram, whichisshownbelow (the lesion shown is

demonstratedtobesevere,bymeasurements not shown).

Image providedby Dr A lain Cardiology Research Fellow, LondonChesl Hospital, London

1 Whatisthebestnextstepinhis management?

CD A Hehasaventricularseptaldefectandshould havean intra-aortic

balloonpumpinserted andbereferredforurgentsurgery

Q B Hehas mitral regurgitationand should haveatransoesophageal

A56-year-oldmanwithanMlisadmittedto CCU on aFridayafternoon,

afterreceivingthrombolysis,withtPA,intheA&E department You arecalledto seehimlater(at 2 am)because heisbreathless,hasalowurine outputandlow BP(80/55mmHg).Hedenieshavingchestpain butissittingupright,verybreathless,lookingpale,sweatyandveryunwell.His ECG isshown below:

Image providedby Dr I Wilkinson, Cardiology Research Fellow, University College London, London

HischestX-rayisshown below:

CARDIOLOGY- QUESTIONS

1 Which of thefollowingstatementsismostappropriate?

0 A Hehascardiogenicshockand shouldreceiveasecond dose of

thrombolysis before intubation andtransferto ICUforventilationand

furthermanagement

0 B Hehascardiogenicshock;ifpossible,aSwan-Ganzcatheter should

beinsertedtooptimisehishaemodynamics.Heshould haveanurgentecho(if available)andyou should considerinsertionofanintra-aortic

balloonpump,transferring him urgentlyto aninterventioncentre

providedyoucan gelhimstableenough

O C Hehascardiogenic shock; ifpossible,aSwan-Ganz catheter should

be insertedtooptimise hishaemodynamics.He should havean urgentecho(if available)and youshould considerinsertionofanintra-aortic

balloon pumpandtransferring himtoICU,stabilisinghimforatleast

48hours before youconsidertransferringhimto an intervention

centre

O D Hehascardiogenic shock; heshouldhavean urgentecho(if available)

and youshouldstarthimon ahigh-dose,furosemide infusion, afteran

initialbolus ofatleast200mg,to treathispulmonary oedema andhelpraisehisurineoutput

0 E Hehascardiogenicshock;ifpossible,aSwan-Ganzcatheter should

be insertedtooptimisehishaemodynamics.Heshouldhavean urgentecho(if available)and youshouldstarthimoninotropesand

non-invasive ventilation, andgetthecardiologiststo reviewhim

urgentlyonMondaymorning

A74-year-oldladyis admittedwithchestpainradiatingtoherleftarmand

generally feelingunwell

Herchestisclear, oxygensaturations100% onairandBP 130/84mmHg.HerECGisshown below:

Image providedby Dr J Wilkinson, CardiologyResearch Fellow, University College London, London

1 Which of thefollowingstatementsismostappropriate?

ÿ A Shehasaninferior ST-elevationMlwith completeheartblockand

needstobe takentothe angiosuiteforinsertionof atemporarypacingwire

ÿ B Shehasaninferior ST-elevationMlwithasinusbradycardiaand

should be giventhrombolysisandintravenousatropine

ÿ C Shehas an inferior ST-elevationMlwith completeheartblock and

CARDIOLOGY- QUESTIONS

Case20

The surgeonsadmitan 18-year-oldmanwithsuspectedappendicitis.He isknowntohavelong-standingcongenitalheart disease andhas beenon

warfarin for many years Inviewof this,thesurgicalnursesdoan ECC on

admission,whichshowshimtobeinsinusrhythm.He is anintelligent

youngmanandknows his condition well; hetells youhe has hadaprocedure calleda 'Fontanoperation', wherethevena cava is

anastomoseddirectlytothepulmonaryartery tobypassthepulmonary

valve,and that heisregularlyseen at atertiarycongenital heart disease

unit.Thesurgicalhouse officer hascalledyoubecause the patientis

complainingofpalpitations

HisECG isshown below.He is nothaemodynamicallycompromised;

1 Which of thefollowingis themostappropriatenextstep?

ÿ A Arrangetocardioverthim;his arrhythmiais new-onsetand he is

alreadyanticoagulated

D B Puthimondigoxintocontrolhisrate

BP120/85mmHg.His INR is 2.3.

CARDIOLOGY -QUESTIONS

Case 21

Theorthopaedichouse officer asksyouto see a74-year-oldpatient who

has become unwellwithpalpitations.He isknowntohavepreviouslyhad

anMlbut hasrecentlybeen fit andactive He is awaitinganelectiveknee

k Ill J/,« •« V.-, V « V V •

'

' •• 'f'1' r* t i

1 Which of thefollowingis thecorrectdiagnosis?

ÿ A Monomorphicventriculartachycardia

ÿ B Polymorphicventricular tachycardia

ÿ C Fast AFwithunderlyingbundle branchblock

ÿ D Sinustachycardia withunderlyingbundle branch block

ÿ E Torsades de pointes

2 The patientlooksunwelland hasabloodpressureof85/50mmHg.How

shouldhe bemanaged?

ÿ A Puthimon anamiodarone infusion

ÿ B Youshouldarrangeasemi-electiveTOEandcardioversion

ÿ C SynchronisedDCcardioversion

ÿ D Heshould be givenintravenousdigoxinandaheparininfusion

ÿ E Heshould beloadedwithanoral p-blockerandput on amonitor

25

CARDIOLOGY- QUESTIONS

Case22

Thesurgicalhouseofficercalls you.He isseeinga60-year-oldladyin his

pre-clerkingclinic;she is due to have acholecystectomy.Thepatienthasbeencomplainingofpalpitationsforthe last2daysbutthis hasnot

affectedherexercisetolerance much.The houseofficerhas doneanECG,

which shows hertobe inAFwitha rateof140bpm.Herbloodpressureis

133/75mmHg.Sheisknowntobemildly hypertensive,forwhich sheis on

bendroflumethiazide, but hasnoothermedicalproblemsandhasnever

hadan ECG before The houseofficeris keen to cardiovert herandis

alreadysetting thisup

1 Whichstatementbestdescribes how she should bemanaged?

ÿ A Becausesheis on adiuretic you needlocheck herpotassium before

she can have ananaestheticfor her cardioversion

ÿ B Sheshould beanticoagulatedwithwarfarin, haveherratecontrolled

withmedication,haveanechocardiogramand bebroughtbackforan

eleclivecardioversionin 6-8weeks

ÿ C Sheshould beput on intravenousheparinandamiodaroneand

admittedtoCCU

ÿ D Sheshould be given aspirinand aÿ-blocker

D E Sheshould have carotidsinusmassageand, failing this,intravenous

adenosine

You areaskedto see a34-year-oldladywho hasjust arrived intheUK

6weeks ago Sheis 6monthspregnantandhas become increasingly

breathlesson exertion overthe last5months She is now unable to walk up

asingle flightofstairswithouthavingto stopthree times

ThereferringSHOcanhearasoft murmur,whichshe thinksisdiastolic

The leftventricular functionisnormalonecho

Her ECG is shownbelow:

i "i 1 1, •" , " 1 1 1 1

-J-\*}y— —-r—r--y— y ~y— fS ULO-'JU

.L — — La_ j J

JUiJUJLLi l J,Uun

1 What is themostlikelydiagnosis?