MRCP(UK) and MRCP(I) Part II 200 Cases

MRCP(UK) and MRCP(I) Part I 200 Cases

Case Histories, Data Interpretation, & Photographic Materials

Osama Shukir Muhammed Amin

MBChB, MD, MRCP, FRCP(Edin), FRCP(Glasg), FRCP(Ire), FRCP(Lond), FACP, FAHA, FCCP(USA), FRSA

Senior Consultant Neurologist

Formerly, Clinical Associate Professor

International Medical University

Kuala Lumpur, Malaysia

Copyright Notice:

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the copyright owner in writing:

Email: [email protected]

First Edition: 2022

ISBN: 978-1-4716-9710-4

Disclaimer:

This book was written depending on reliable sources. However, while every effort has been made to ensure its accuracy, no responsibility for loss, damage, or injury occasioned on any person acting or refraining from action as a result of information contained herein can be accepted by the author or publisher.

Published and distributed by Lulu Press, Inc. Northern Carolina, USA

Copyright ©2023. Osama Shukir Muhammed Amin.

Cover image: Photo©Osama Shukir Muhammed Amin

Dedication

My family

Sarah, Awan, and Naz

Acknowledgments

I would like to sincerely thank my dear patients; their clinical scenarios were used to formulate and generate these questions.

Special gratitude goes to my wife, Sarah, for her endless support and encouragement, and of course, her extreme patience.

Preface

Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert., Sir William Osler (b. 1849, d. 1919)

The methods of postgraduate teaching, training, and accreditation have evolved considerably during the past decade. The strike of the COVID-19 crisis was a huge blow to this remarkable progression yet has taught us many endless lessons. I always say, Even the best-informed trainee cannot answer all the questions. The purpose of this book is to self-assess. 100, 1000, or 10000 questions will never cover the entire curriculum/syllabus. Medicine is a huge ocean, and once you dive in, you have to swim to stay alive. 

In writing this book, I tried my best to guide you on how you approach part II written examinations, how to skim the data, and how to conclude your answer. The subjects I have chosen apply the rule of the common is common. I formulated the scenarios and their explanation in a way that, I hope, will inform you of the core feature of decision-making. It’s an art. I have tried to focus on some important updates in medicine that have been emerging during the past decade; novel diseases, novel investigations, and newly approved medications. COVID-19 (and its SARS-CoV-2) and women’s health will be encountered many times. Remember, the goal is to find and fill in the gaps in your knowledge. 

Undoubtedly, if you are well-prepared, you will pass the examination very easily. No need to panic when you hear about your colleagues’ past [bad] experiences. Lack of preparation is the single most common reason for failure. Remember, practice makes perfect. Read, practice, and self-assess; that’s it!

Good luck with your career and exams!

Osama S. M. Amin

January 2023

Chapter One - Cardiovascular Medicine

1) A 65-year-old retired police officer has been experiencing intermittent central/substernal chest pain over the past five months. The patient says that his chest pain occurs when he walks two blocks on the flat level and against the hill as well as when doing the stairs. It is relieved by resting for about ten minutes. His blood pressure has always been high. He does not take his oral anti-diabetic medication regularly. The patient smokes two packets of cigarettes per day and has been doing so for the past 30 years. In addition, he drinks three units of alcohol at weekends only. Past surgical history reveals a right-sided total hip replacement two years ago. There is no family history of note. His daily medications are valsartan 160 mg once per day and metformin 1000 mg two times daily. Examination reveals a BMI of 28 kg/m², a regular pulse rate of 90 beats/minute, and a blood pressure of 170/105 mmHg. The neck is supple, and the abdomen is benign. His chest shows features of chronic obstructive airway disease. The left knee is swollen and painful on movement; there is crepitus. A 12-lead resting ECG that was done by his general practitioner last week shows voltage criteria of marked left ventricular hypertrophy. You have ordered some blood tests to be done.

What would you do to uncover the cause of his chest pain?

a. Treadmill exercise ECG testing

b. Coronary angiography

c. Cardiac electrophysiological studies

d. Myocardial perfusion imaging

e. Repeat his 12-lead resting ECG after one week

Objective: Review the diagnostic approach of coronary artery disease/chronic stable angina.

A common theme in the MRCP examinations is the diagnostic approach to ischemic heart disease. This man displays several risk factors for coronary artery disease (CAD), and his chest pain appears ischemic. His 12-lead resting ECG is already abnormal (but does not reflect myocardial ischemia); repeating the same test now would add nothing. Can we proceed with formal exercise stress ECG testing? The answer is no, for the following reasons:

1. Patients who are unable to exercise sufficiently due to leg claudication, lower limbs arthritis, deconditioning, or associated pulmonary disease. A diagnostic test that fails to achieve 85-90% of the patient’s predicted maximal heart rate is considered inadequate to rule out ischemic heart disease if the test is otherwise negative (i.e., absence of chest discomfort or ECG findings).

2. Patients with certain ECG changes at rest that may influence the interpretation of the exercise test. These abnormalities include pre-excitation (Wolff-Parkinson-White) syndrome, a paced ventricular rhythm, >1 mm ST depression at rest, complete left bundle branch block, digoxin therapy, and finally ECG criteria of left ventricular hypertrophy (even in the presence of <1 mm baseline ST depression). On the other hand, patients with right bundle branch block or those with <1 mm of ST depression at rest are candidates for diagnostic exercise ECG testing in the appropriate clinical setting.

Pharmacologic stress testing with radionuclide myocardial perfusion imaging or echocardiography is convenient in patients who cannot exercise using a treadmill or a bicycle; exercise testing with radionuclide myocardial perfusion imaging or echocardiography should be performed in patients with resting ECG abnormalities, and an imaging study should be performed to localize ischemia or assess myocardial viability. Exercise ECG testing is most useful in patients with an intermediate pretest probability (variably defined as 25-75% or 10-90%). Positive tests in these patients are more likely to be genuinely positive due to the predictive accuracy of the test. The test is less useful in patients with a high (our patient) or low pretest probability. Men over the age of 50 years and women over the age of 60 years who have had a history of typical angina pectoris demonstrate very high pretest probabilities, depending on the CAD-based symptoms alone (87% and 91%, respectively). Exercise testing is not indicated to secure the diagnosis in these patients. On the other hand, a relatively high false-positive rate may be encountered in patients with pretest probabilities of CAD below 25% (e.g., men under the age of 40 years or women under the age of 50 years with atypical chest pain).

Correct Answer: b (coronary angiography)

2) A 69-year-old retired high school teacher visits the Emergency Department after having had central chest pain for the last six hours. The pain is partially responsive to many sublingual nitroglycerin tablets. The patient’s daughter says that her father’s pain increased gradually while he was reading the newspaper. He developed three short-lived anginal attacks within the past 24 hours. The man has chronic stable angina, hypertension, hypercholesterolemia, and type II diabetes. He smokes about ten cigarettes per day but does not drink alcohol. The patient’s father died of myocardial infarction at the age of 71 years. The patient’s doctor prescribed bisoprolol, aspirin, and isosorbide dinitrate for his heart problem two months ago. The precordial examination is unhelpful, and his blood pressure is 150/95 mmHg. A 12-lead resting ECG shows deep symmetrical T-wave inversion in the precordial leads, from V1 to V6. There is no Q-wave. Serum troponin-I is minimally raised. The plain chest X-ray is unremarkable. You run a battery of routine blood tests which turn out to be within their normal reference range. In the Emergency Department, you give morphine, aspirin, clopidogrel, heparin, metoprolol, abciximab, and nitroglycerin infusion.

Which one of the following is the best next step?

a. Intravenous alteplase

b. Modified exercise ECG stress testing

c. Coronary angiography and revascularization

d. Intra-arterial lepirudin

e. Emergency coronary artery bypass grafting

Objective: Review the management of acute coronary syndromes/non-ST-segment elevation myocardial infarction.

This patient has developed non-ST-segment elevation myocardial infarction (NSTEMI). His TIMI score is 5 (out of 7); this would put him in the high-risk category. NSTEMI with intermediate (TIMI score of 3-4) or high (TIMI score of 5-7) risk benefits from early coronary intervention once the patient is stabilized on optimal medical therapy. High-risk patients should also receive clopidogrel and GPIIb/IIIa inhibitors (e.g., abciximab). Direct thrombin inhibitors (e.g., lepirudin) are suitable alternatives to unfractionated heparin when the latter is contraindicated (e.g., history of heparin-induced thrombocytopenia). Thrombolytic therapy has no place in NSTEMI. ACE inhibitors can be used when indicated (e.g., to control blood pressure, treat congestive heart failure, etc.). Stress ECG testing can add prognostic significance but is usually deferred until the patient stabilizes after at least one month. Correct Answer: c (coronary angiography and revascularization)

3) A 31-year-old woman visits the physician’s office because of poor exercise tolerance. She was diagnosed with NYHA functional class III idiopathic dilated cardiomyopathy seven months ago after developing breathlessness, orthopnea, raised JVP, bi-basal crackles, and leg edema. Currently, she receives enalapril 10 mg twice daily, carvedilol 12.5 mg twice daily, spironolactone 25 mg once daily, and frusemide 40 mg once daily. She is compliant with her regimen, and she denies the ingestion of any other medication or doing drugs. On a specific inquiry about her current complaint, she answered, I feel weak when I walk on the flat after some time, doing the stairs, scrubbing or mopping the floor, or dusting the furniture. Examination reveals mildly raised JVP, trace leg edema, clear lung bases, and no gallop rhythm. A 12-lead resting ECG shows wide-spread non-specific ST-T segment changes and a QRS complex duration of 170 msec. Her up-to-date ejection fraction is 31%. The blood pressure is 100/60 mmHg, and the pulse rate is 62 beats/minute which is regular in rhythm and volume.

What would you do to improve her exercise tolerance?

a. Give amiodarone

b. Start digoxin

c. Arrange for resynchronization therapy

d. Refer for cardiac transplantation

e. Increase frusemide dose

Objective: Recognize the indications and benefits of cardiac resynchronization therapy in congestive heart failure.

Biventricular pacing (cardiac resynchronization therapy) improves the cardiac pump and contractile functions and helps prevent ventricular remodeling (ventricular dyssynchrony exacerbates left ventricular dysfunction). This form of therapy is used in highly selected patients with:

1. Advanced heart failure (NYHA functional class III or IV)

2. Severe left ventricular dysfunction (ejection fraction <35%)

3. Intraventricular conduction delay (QRS complex duration >120 msec)

This patient’s medical treatment (ACE inhibitor, beta-blocker, aldosterone antagonist, and loop diuretic) has resulted in some degree of symptomatic improvement; however, she is a candidate for resynchronization therapy for a better response to achieve. Digoxin may reduce hospitalization rate and may produce some symptomatic improvement even in patients with sinus rhythm; however, it offers no survival benefit. Digoxin will not produce any substantial improvement in this woman.

The question did not address any form of cardiac arrhythmia; amiodarone use is not justified. Cardiac transplantation is an option in refractory heart failure. Although her JVP is mildly elevated, her chest has no basal crackles, and her legs demonstrated trace leg edema, the volume status is reasonably well-controlled and there is no need to increase the diuretic dose.

Correct Answer: c (arrange for resynchronization therapy)

4) A 68-year-old man visits the physician’s office for his annual check-up. He has long-standing hypertension and type II diabetes mellitus. He says that he has difficulty doing the stairs and shopping and has noticed that he has no power when he walks every morning. He lives alone in a two-story house. He is an ex-smoker but drinks a glass of wine every night. He thinks that his condition is deteriorating despite being compliant with his daily atenolol of 50 as well as aspirin. The patient’s physique is thin. The blood pressure is 170/110 mmHg, and the pulse rate is 74 beats/minute.

- Blood tests show HbA1c 10.3%, serum LDL cholesterol 160 mg/dL, blood urea 42 mg/dL, and Hb 13 g/dL

- Transthoracic echocardiography reveals concentric left ventricular hypertrophy, mild diastolic dysfunction, and an ejection fraction of 41%

Which one of the following you would not choose as part of this man’s management?

a. Add enalapril

b. Increase the dose of atenolol

c. Add rosuvastatin

d. Add frusemide

e. Prescribe glimepiride

Objective: Review the clinical presentation of left ventricular systolic dysfunction and its drug therapy.

This man demonstrates poorly controlled systemic hypertension and hyperglycemia (note the high HbA1c) and has developed heart failure (ejection fraction of 41%). The blood pressure and cardiac function should be well-controlled. Atenolol, a beta-blocker, is a cardiac depressant and should be stopped gradually while anti-failure measures (ACE inhibitors or ARBs, diuretics, digoxin, spironolactone, and certain beta-blockers) are being introduced. The question did not address any specific anti-diabetic medication he takes, and you should conclude that his diabetes is being managed by diet alone (which has not achieved a target HbA1c of <7%). Therefore, glimepiride can be introduced to this thin man to lower his hyperglycemia. Diabetes mellitus is a coronary artery disease equivalent, and his LDL cholesterol should be kept below 100 mg/dL by drug therapy (statins). Type II diabetic patients should have their urine tested annually for proteins in addition to retinal examination. Note that thiazolidinediones (TZDs) are contraindicated in heart failure. Correct Answer: b (increase the dose of atenolol).

5) A 22-year-old college student has been referred to your Emergency Department by a general practitioner’s office as a probable case of myocardial infarction. The patient says that he visited his physician because of precordial pricking pain and tenderness. A 12-lead resting ECG was done and ST-segment elevations in leads V1-3, as well as a right bundle branch block, were detected. The patient’s two older brothers died suddenly in their 3rd decade. The patient is frightened and desperate for help. He denies retrosternal chest pain or shortness of breath. There are no palpitations. He does not smoke but drinks beer at weekends. Examination shows blood pressure of 125/78 mmHg and a regular heart rate of 94 beats/minute. The neck is supple, the chest is normal, and the abdomen is benign. You repeat the 12-lead resting ECG and you confirm the general practitioner’s ECG findings. His blood tests are Hb 15 g/dL, blood urea 36 mg/dL, serum potassium 4.2 mEq/L, and fasting plasma glucose 92 mg/dL. Serum troponin-I and MB-CK enzyme are within their normal reference range. The chest X-ray film is unremarkable.

What is the best step for the time being?

a. Thrombolytic therapy

b. Coronary angiogram

c. Aspirin

d. Reassurance and discharge

e. Abciximab

Objective: Review Brugada syndrome and its characteristic ECG findings.

This young man has no risk factors for coronary artery disease. Precordial pricking pain is not cardiac in origin. The presence of asymptomatic ST-segment elevation and RBBB in leads V1-3 in a person with a strong family history of sudden death is highly suggestive of Brugada syndrome. Reassurance and explanation are all that are required for the time being and the patient should be advised about the placement of a cardioverter-defibrillator. The other question’s stems are applied in the treatment of acute coronary syndromes. The vast majority of cases of sudden cardiac arrest (SCA) and sudden cardiac death (SCD) due to ventricular fibrillation (VF) are associated with structural heart disease, particularly coronary heart disease (CAD). SCA in the normal heart is an uncommon occurrence, accounting for 5% of cases only. Some causes of SCA in patients with apparently normal hearts have been identified, and these include Brugada syndrome, long QT syndrome, pre-excitation syndrome, and commotio cordis (Latin, agitation of the heart). Brugada syndrome is associated with a peculiar pattern on ECG, consisting of pseudo-RBBB and persistent ST-segment elevation in leads V1-3. Three different patterns of ST-elevation have been described:

- In the classic Brugada type 1’s ECG, the elevated ST segment (≥ 2 mm) descends with an upward convexity to an inverted T-wave. This is referred to as the coved type Brugada pattern.

- The type 2 and type 3 patterns have a saddleback ST-T wave configuration, in which the elevated ST segment descends toward the baseline, then rises again to an upright or biphasic T wave. The ST segment is elevated ≥ 1 mm in type 2 and <1 mm in type 3.

Correct Answer: d (reassurance and discharge)

6) A 32-year-old man visits the physician’s office for a scheduled annual visit. He was diagnosed with hypertrophic cardiomyopathy two years ago, after a self-referral because of the sudden death of three family members. He denies syncope, palpitations, exertional breathlessness, or chest pain. However, he admits to having precordial thumping beats every now and then. A 24-hour Holter monitoring fails to demonstrate sustained or non-sustained ventricular tachycardia. Echocardiography shows marked left ventricular hypertrophy but no significant left ventricular outflow obstruction. Exercise ECG testing using a treadmill was inconclusive but the developed hypotension during submaximal exercise. He takes bisoprolol 5 mg once daily. The man does not smoke or participate in competitive sports.

What is the best action you should do concerning this man’s illness?

a. Add disopyramide

b. Send for radiofrequency catheter ablation

c. Repeat exercise ECG testing

d. Do coronary angiography

e. Advise for placing a cardioverter-defibrillator

Objective: Review the management of hypertrophic cardiomyopathy and its risk of sudden death.

Patients without symptoms should be evaluated by echocardiography, Holter monitoring, and exercise testing; asymptomatic patients generally have a good prognosis. Although this man is asymptomatic, he has marked left ventricular hypertrophy, hypotension upon exercise (reflecting an abnormal vascular response), and a strong family history of sudden death. These would put him in the high-risk category of sudden cardiac death. The normal blood pressure response to maximum treadmill exercise testing includes at least a 20 mmHg increase in the systolic blood pressure from rest to peak exercise. However, 20-40% of patients with hypertrophic cardiomyopathy fail to augment their baseline blood pressure during exercise; in some of these patients, the blood pressure falls below baseline values during or immediately following exercise. The best approach for this man is to continue his oral beta-blocker and to place a cardioverter-defibrillator. Patients should avoid vasodilators, digoxin, and heavy unaccustomed exercises. Needless to say, regular follow-up should be encouraged.

Correct Answer: e (advise for placing a cardioverter-defibrillator)

7) A 12-year-old girl presents with short-lived palpitations associated with presyncope. You hear a pansystolic murmur at the left lower sternal border that increases with inspiration. The mother says that her daughter’s murmur was detected by a pediatrician several years ago. The child’s mother has bipolar disorder and her father died at the age of 30 years because of a drug overdose. A 12-lead resting ECG shows P-pulmonale and right bundle branch block. Echocardiographic examination fails to show any vegetation.

Which one of the following with respect to this girl’s illness is the incorrect statement?

a. Severe cases may show the wall-to-wall heart sign on the chest film

b. The tricuspid valve is sail-like in shape

c. Stenosis doesn’t develop in this girl’s tricuspid valve

d. The anterior leaflet of the tricuspid valve is the largest and is usually attached to the tricuspid valve annulus

e. The right ventricle proper is small and, in some cases, consists of a right ventricular outflow