MRCP 2 April/July 2010 Discussion

[JAK 2 Mutation]

Friends

Here we can share information and strategies most talked about regarding MRCP-2 written attempts.

I am planning to appear in April 2010 diet (as a dry run) so starting with the following:

1. Sanjay Sharma
2. Onexamination part 2 subscription
3. Pastest part 2 online subscription
4. ACES for PACES (will try to cover if got time)

Anyone with a better advice please ?

Thanks

[JAK 2 Mutation]

Here I'm copying some valuable advices I've found by passers of part 2 in this forum:

RNA, on Sun Aug 23, 2009 wrote:

"hi all i got 70.72% with the grace of ALLAH in my first attempt and my advice to all is that do sharma really well and i mean really well and go thruogh karla clinical chapters to get the overview of topics like nephrology, respiration etc and do imptant topics from davidson and passmedicine is must but dont go for the question go through the answers really well and make ur own questions while u go thru the answers and i think onexamination is enough and go thru a good atlas and plz no echos or audiograms are in exam so dont waste much time on them just know it but dont master it rite now last but not least sharma has 10 questions in its answers so make ur own question wen u read those answers and sharma does have mistakes and plz plz if u wanna skip davidson go ahead cos OHCM(oxford handbook)is perfect for this exam it has all the answers i did oxford at the end but had a base of current,uptodate,harrison and davidson but i knew what to pic from OHCM peace one thing more run thru dialysis complications from karla and davidson its realy big in part 2 expect atleast 3 questions"

Also:

"let me tell u the trick of this exam that is do electrolytes from karla and OHCM and learn those charts really well in OHCM i mean the hyper and hypocalcemia etc and hyperkalemia from karla nephro read karla for an overview and respiration and the diferential of eosinophilia and OHCM and important topics from davidson if u have time do sharma the most important book read differential of eosinophilia dat chart in the last questions and know it by heart .read sharma realy well and make questions with in its each answer, infact sharma have a few mistakes like renopulmonary syndromes it adds polyarteitis nodosa in one answer which infact very very realy involves lung and dats one of the differentiating factor from microscopic polyangitis and like nobody said in the other forum dat treatment of ABPA is steroids and dan u add on itraconozole if to cut down on steroids or the treatment of warfarin overdose but overall its a good concept affirming book and plz do one thing before u start sharma again go to a photocopier and photocopy the lab data page in the end so u dont have to keep turning the book again and again and photocopy the page 4 of sharma which has all the system base question given and do sharma chapter wise from page 4 dat is do differrent systems question from page 4 system wise and make extra copies of page 4 and highlight those questions which u think need revision and do onexamination really well and passmedicine is a must but focus on the answers and while doing those answers make ur own questions and if u have time go through pastest questions which infact has so many mistakes in its answers but the make uyou focus on the important points in a topic but to be frank for me passmedicine and onexamination was enough but i did nephro, respiration, git, derma and toxicology from pasttest too but didnt have enough time to do the rest of chapters but do derma from pastest and passmedicine they are must with dermanet newzealand for explanation go thrugh alot of images from forbes and other image books, peace and wish u best of luck bro"

Later:

"i suggest to u the electrolytes bcoz if u know those tables from OHCM by heart and the hypokalemia one from karla nephro bro u will interpret almost all questions and practice these tables while interpreting questions in onexamination or pastest and one thing more do dialysis from karla and complication table from davidson they usually hav 2-3 questions about it like v had selemevar to give for which most guys on this forum stoped alfacalcidol and the other question wid dialysis induced peritonitis one had to give intraperitoneal vanc and genta and not to remove the line so i hope u get my point its not how much u study this exam is how u study and wat u focus on and do hypogonodism and infertility from karla coz v had alot of question abt it .try to do pastest too coz bof make u notice ur weaknesses.almost everyone answered the question about kartegeners syndrome wrong coz every1 thought it was sweat test infact it was nasal mucosal biopsy coz there was dextro cardia on the ct so plz be alert in the exam and pay attention to details coz this is the only exam dat wants you to fall for the bait.and wen you do nephro n hypokalemia from karla u will know wat i mean but plz add bicarbonate values to dat table to make it even more easier to interprete data on the exam peace and best of luck my brother dna and did u photocopy page 4 of sharma"

May Allah bless him for this help. Hope we can get guidance from his valuable advices.

Any comments ?

[rose99999]

Dear JAK 2,
Thank you very much for inviting to this forum, for part 2 preparation, and I think it will really prove helpful. I am also planning to appear in part 2 in April. The information that I have gathered so far is that Sharma seems to be a very important book for part 2, also we have to practice a lot of questions, and pastest and onexamination seem a good choice. There is mention of passmedicine in the previous forums but I could not find any MRCP 2 account on passmedicine website. If there was it would have been very helpful. There is some mention of a lot of mistakes on pastest website for MRCP 2 questions, I dont know whether it is true or not. To kick start the preparation I am starting from pastest. Give your suggestions please.

[giroop2003]

hi JAK-2 thanks for starting new forum, i felt april is too near, I heard from my seniors here that pastest and onexamination with some ref,

[giroop2003]

in sharma which one you mean, is the cd or sharmas course or books, can any you clarify

[giroop2003]

hi rose passmedicine part-1 notes is very imp for mrcp-2

[JAK 2 Mutation]

Thanks rose, giroop and others for the excellent response and complements.

The book's name is Rapid review of clinical medicine for MRCP part 2 by Sanjay Sharma, 2nd edition.

Passmedicine website has BOFs for part 1 only but their explanations/guidelines are (said to be) valid for part 2 as well. Some people have emphasized on it alot.

Yes April is too near, I havent applied for the exam as yet, sent an email to RCP to confirm if they'll accept application online and fees through a banker's draft (they usually do but i wanted to re-confirm) since last date is near and just awaiting their response so shall decide in a few days if I am appearing for April but I want to give it a try though for this I'd have to go to Jeddah to appear, it will actually reflect on whats deficient in terms of preparation and I do not want to lose the pace I am maintaining after part 1 exam.

Good luck all

[giroop2003]

Hi, JAK-2, Thanks for clarification I may not take April but I will join for discussion, If any body wants to have daily discussion for at least one topic or any thing imp ideas or notes, it will great help if they share in this forum

[Rose99999]

Hi every body,
From pastest and onexamination, which one do you think is better. For april exam I thing practising a lot of questions, try can be given. After exam, one can read sharma, which can be useful for paces as well. What are your suggestions.

[giroop2003]

Hi, Rose in Qatar everybody is advising Pastest, if time permits can go to onexamination

[mrcpin]

First of all i want to congratulate you all for passing the exam and special thanks to JAK2 Mutation for again putting the show and trying to pave a way for others i told you he is such a gentleman soon you all will feel the same.
I am still in Euphoria trying to come out of it soon i will be glad to join this although i am not sure for April yet will actively participate.
we should decide to start unite by unite like gastro endo respo etc first read from OHCM or from passmedicine notes than we will but Bofs from sharmapastest and onexam and will start discussing about them .
or if you guys have any different idea we can add that too.
i wish you all very best in this endeavor and the good thing about is now its not looking endless .
You all have all the confidence in world now as you are pumped up with your resent achievement and thinking you can move the mountains right so i request you all dont break the momentum let your pendulum swing with its full flow i mean even if you are not appearing for april plz just join this group to maintain your rhythm so that you can be ready for july when the time comes.
Hope to see you all often........

[JAK 2 Mutation]

Thanks mrcpin for complements. I wish you a great success in part 2 as well in the first attempt the way you did in part 1, you are brilliant mashAllah.

The best thing in part 2 is that we no more have to read Easterbrook or any clinical sciences stuff......in particular "Statistics"...... which is the major cause of gastroparesis for me

[guest 579]

hi, congrats to all who have passed the exam.JKA2 u r doing a great job.are u in UK or abroad.u have suggested the reading and revision material but what about radilogy,ecg and atlas?

[Fydologyst]

Great forum... Sadly though knew about it only after part 1...

Anyway... thought wanna share my research..Here r some of the past experiences in other pages from those who could make it..

]1.Guest Posted: Fri Sep 05, 2008 6:39 am Post subject: Part 2 written july
Hi! Tot I'll share. Took mrcp 2a 3rd time this july. Usually missed passing mark by 1 mark. This time I passed.

Thought paper 1 easy. Similar topics & questions to Pastest online which I did every question & also tried repeatedly in the exam format.
Paper 2 was just ok. I was too tired. Don't think I scored that well but ok.
Paper 3 was just right.

Other than what I learnt during my various subspecs postings, what I did:
Did ALL pastest online questions.
Did ALL pastest mcq books & picture tests.
Read sanjay sharma & kalra.

Another one
2..
bilal 74: Tue Aug 26, 2008 9:49 pm Post subject:
Dear doctors,,,,
Simply ,if any one want to pass part2 written,should not bother himself by many resources:
the following are fair enough:

1.123 doc.
2.sanjay sharma.
3.passmedicine,which is for part 1..

[Fydologyst]

So, it seems that all agreed on how important is Sanjay as well as passmedicine (which was my favourite for the 1st)...

[Fydology]

One more who summarized ( or actually added) everyone else experince...

guest6

Posted: Fri Sep 12, 2008 2:24 pm Post subject:
this is my summary of what I have learned from posts on this forum

MRCP2 ADVICE

Time management during exam is important

1) onexamination - repeat 4 times or more do past papers and all pictures - the questions and explanations, at the end make notes of all clues

2) Sanjay Sharma textbook - read the book from cover to cover 3 times and make notes.
3) Kalra or OHCM..Kumar..Harrison to complete your knowledge about common diseases
4) Data interpretation
5) X-Ray, CT, ECG

Guidelines summaries
Pastest, Passmedicine

Cotran and Robbins small book if possible


and yet another one... with extensive advice!!

guest6

Posted: Tue Jan 13, 2009 11:33 am Post subject:

Keep on looking but there is no simple answer to what to read for CTs and echos, etc., if you are looking for a perfect preparation. But sharma gives you enough audiograms, echos and spirometry to prepare for the exam.

There are quite a few cardiac data interpretation questions in onexamination website, but if you want more you can read questions/explanations given in the 'the complete data interpretation for the MRCP' by Steve Hughes. This book is very good, I would recommend it strongly for the exam for endocrinology, rheumatology, basically all systems for data interpretaiton.

Look up important dermatology images in google.

Radiology: again google is a great source. Look them up one by one. In December exam, there were two bone tumour x-rays, so don't forget tumours. Sharma CD has quite a few x-rays.

There are plenty of ECG's in MCQs and in Sharma. Learn them.

Bone scans: look them on google. There are just a few that you need to know.

In the end, the most important are Sharma and MCQs, and do the above as much as you can.

If you remember that there will always be questions you won't be able to answer in the exam (actually, plenty, but you don't need to answer all the questions to pass) it will help you keep calm in the exam, which will in turn make it easier to retrieve information from your brain.

I did the above and I passed, first attempt.

[Geust 211]

Dear colleagues,
congrats for passing, my gift to you.... I have a collection of BOF for part 2 , mail me at ahmad347atyahoodotcom i will send to you

[Guest]

hi, is there anyone who appeared in part 1 from karachi

[Guest]

yah i appeared from karachi do you need any help?

[mrcpian]

Dear Doctors,
Here are some pastest Bofs please check them i will post others as well


152. A 53-year-old man is referred by his general practitioner with a tremor affecting his left wrist and hand. This has been present for the past 8 months and is present intermittently but seems to worsen with stress or anxiety. He also reports feeling generally fatigued and low in mood. He has noticed a subtle decrease in dexterity and lack of co-ordination with activities such as playing golf. On examination, he is noted to have a simple oscillating tremor of the left hand, which is present at rest. The same tremor is noticed with the arms outstretched. Assessment of tone reveals cogwheeling in the distal left upper limb. Examination of his gait demonstrates small steps with reduced arm swing of the left upper limb with postural instability on tests of retropulsion.

Which of the following therapeutic strategies is most appropriate in this case?
Entacapone 200 mg three times daily
Amantadine 100 mg twice daily
Propranolol 80 mg twice daily
Co-Careldopa 100 mg three times daily Your answer
Cabergoline 1 mg daily Correct answer
The clinical scenario is suggestive of Parkinson’s disease (PD). Onset is typically asymmetrical, with the most common initial finding being resting tremor in an upper extremity. Over time, patients notice symptoms related to progressive bradykinesia, rigidity, and gait difficulty. Other initial symptoms of PD may be nonspecific and include fatigue and depression. The three cardinal signs of PD are resting tremor, rigidity, and bradykinesia. Of these cardinal features, two of three are required to make the clinical diagnosis. The goal of medical management of PD is to provide control of signs and symptoms for as long as possible while minimising adverse effects. Medications usually provide good symptomatic control for 4–6 years. After this, disability progresses despite best medical management, and many patients develop long-term motor complications including fluctuations and dyskinesia. Levodopa, coupled with a peripheral decarboxylase inhibitor (PDI), remains the mainstay of symptomatic treatment for PD. It provides the greatest antiparkinsonian benefit with the fewest adverse effects. Dopamine agonists provide symptomatic benefit comparable to levodopa/PDI in early disease. Concerns exist that levodopa/PDI might accelerate disease progression or contribute to the development of motor fluctuations and dyskinesia. There is increasing evidence for use of dopamine agonists such as cabergoline, pramipexole, and ropinirole as first-line therapy as these carry a much lower risk of dyskinesias. Dopamine agonists are also used as add-on therapies to levodopa. The younger the patient, the more emphasis placed on long-term considerations to guide early treatment. Young patients have a longer life expectancy and are more likely to develop motor fluctuations and dyskinesia. For older patients, less emphasis is placed on long-term considerations; the focus is on providing adequate symptomatic benefit in the near term with as few adverse effects as possible.
153. A 19-year-old secretary presents with a 1-year history of progressive slowness of walking and tremor in his arms. He was sacked from his job after his line manager complained of an increasing number of mistakes at work, a general lack of motivation, and irritable nature. In his family history, his mother is alive and well, his father committed suicide in his early forties, and he has one younger sister who is alive and well. On examination, he is noted to be in an unkempt state with decreased facial expression. His Mini-Mental State Examination score was 22 out of 30. Tone was increased in the limbs with decreased speed and amplitude of repetitive fine finger movements. An action tremor was also noted.
Which one of the following tests is most likely to establish the diagnosis in this case?
A levodopa challenge test
Molecular genetic analysis in the gene coding for superoxide dismutase 1
Molecular genetic analysis for CAG repeats chromosome 4p16.3 Correct answer
Molecular genetic analysis to identify a mutation in the gene coding for dystrophin
Free serum copper, total serum copper, and serum caeruloplasmin Your answer
This patient presents with the Westphal variant of Huntington’s disease (HD) which manifests as presentation in youth with associated Parkinsonian symptoms. The family history of suicide is of relevance and may be associated with behavioural features of the disease or retained insight during emergence of neurological symptoms. HD is inherited in an autosomal dominant pattern with complete penetrance. The gene for HD is on the short arm of chromosome 4, which contains CAG repeats (coding for glutamine). Healthy subjects have 11–34 repeats, while patients with HD have more than 40. Paternal inheritance is associated with anticipation (increasingly earlier age of onset in subsequent generations).
154. A 67-year-old carpenter was reviewed in an out-patient clinic complaining of weakness in his arms and ‘twitching’ of his thighs. His symptoms started 8 months ago when he noticed difficulties shelving heavy objects in his garage. Three weeks ago, he noticed weakness affecting his left hand. His children have noticed that his speech has become slurred and that he is uncharacteristically tearful. He has lost 5 kg in weight in the past year. He has smoked ten cigarettes a day for the past 25 years and drinks 5 pints of cider a week.
On examination, cranial-nerve examination was unremarkable. Fasciculation was noted over both scapular regions with wasting of the small muscles of the right hand. Power was reduced in all muscle groups of the right upper limb. Examination of the lower limbs demonstrated fasciculation over the quadriceps bilaterally with difficulty rising from a low chair. Reflexes were symmetrically brisk with bilateral extensor plantars. Examination of co-ordination and sensation was grossly normal.
Which one of the following investigations is most likely to confirm the suspected diagnosis?
Cerebrospinal fluid cytology
Anti-Hu antibody
Magnetic resonance imaging cervical spine
Nerve-conduction studies and electromyography Your answer
Quadriceps muscle biopsy
The clinical scenario is suggestive of MND with mixed upper- and lower motor neurone symptoms in the limbs. MND presents with proximal of distal asymmetrical weakness of the limbs, or with bulbar dysfunction. Deficits are often accompanied by leg cramps and fasciculation in the proximal limb muscles. Nerve-conduction studies and electromyography are helpful in confirming the diagnosis and in excluding other potentially treatable conditions, notably multifocal motor neuropathy. Imaging of the brain and cervical cord is important in excluding an underlying inflammatory process and cervical myelopathy. A lumbar puncture is useful for excluding an inflammatory or malignant process.
155. A 27-year-old office worker presents with a 3-year history of epigastric pain, especially 30 minutes after eating. This is associated with nausea and belching. She also describes constipation with occasional explosive diarrhoea. The stools are normally hard with mucus and she needs to strain with every motion. Abdominal pain is relieved after defecation but abdominal bloating persists. She wakes up an hour earlier each morning to finish her breakfast in order to prevent vomiting. She has missed work on a few occasions and feels that her weight has fluctuated. Past medical history includes scarlet fever. She is not on any regular medications except intermittent laxatives over the counter. Abdominal examination is normal. Rectal examination reveals an anal fissure.

Investigation results:
Haemoglobin (Hb 13.1 g/dl
White blood count (WBC) 6.0 × 109/l
Platelets 180× 109/l
Mean cell volume (MCV) 87 fL
International normalised ratio (INR) 1.0
Na+ 136 mmol/l
K+ 3.9 mmol/l
Urea 3.7 mmol/l
Creatinine 70 μmol/l
Albumin 39 glL
Liver function test normal
Anti-endomysial antibody negative
Thyroid function test normal
Gastroscopy normal
Flexible sigmoidoscopy and biopsy normal
Abdominal and pelvic ultrasouns scan normal

What is the most likely diagnosis to account for her symptoms?
Overlap irritable bowel syndrome and functional dyspepsia Correct answer
Diarrhoea pre-dominant irritable bowel syndrome
Sphincter of Oddi dysfunction
Malabsorption sydrome and non-ulcer dyspepsia
Globus hystericus Your answer
This lady has signs of irritable bowel syndrome, especially in light of all the normal investigation results. It is the result of complex interactions between psychosocial factors, disordered bowel motility and altered intestinal sensations. This disorder is commonly associated with functional dyspepsia and patients are more likely to get chronic fatigue syndrome and globus hystericus. Diagnostic criteria have been developed, most notably the ‘Rome criteria’. These include symptoms of abdominal pain relieved by defecation that is associated with a change in stool frequency and consistency, abdominal bloating and passing mucus per rectum.
156. A 40-year-old woman with a long history of reflux disease attends for an upper gastrointestinal endoscopy due to worsening symptoms. She finds it difficult to sleep at night as she describes acid regurgitation into her mouth. On examination, she is overweight. There is no lymphadenopathy or abdominal masses.
On endoscopy, the below appearance is seen (Figure 7) and several biopsies are taken of the salmon-pink mucosa.

Figure 7: endoscopic appearance

Which of the following is least likely to be seen on histology of the samples taken?
Intestinal metaplasia
Presence of goblet cell
Low-grade dysplastic mucosa
Metaplastic mucosa with Paneth cells
Presence of cuboidal mucosal phenotype Your answer
The endoscopic appearance shows Barrett’s oesophagus, which is characterised by replacement of the squamous oesophageal mucosa by intestinal columnar-lined epithelium. It is associated with gastro-oesophageal reflux disease in 10% of patients. Barrett’s oesophagus is a pre-malignant condition and can result in adenocarcinoma of oesophagus in approximately 10% of cases overall. Current surveillance practice includes endoscopy every 2 years in general, but annually in high-risk patients and in the presence of low-grade dysplasia. Quadrantic biopsies should be taken of the oesophageal mucosa at 2-centimetre intervals. A presumed diagnosis should always be confirmed histologically and possible features present include columnar intestinal type mucosa, metaplastic mucosa that exhibits paneth cells, goblet cells and a brush border.
157. A 30-year-old man who has a history of manic depression is referred from the psychiatric department. He is found to have abnormal liver function tests. On examination, he is very irritable, dysarthric and ataxic.

His blood tests are as below:
Na+ 133 mmol/l
K+ 4.5 mmol/l
Urea 14.0 mmol/l
Creatinine 220 µmol/l
Bilirubin 45 µmol/l
Alanine aminotransferase (ALT) 70 U/l (5–35)
Alkaline phosphatase (ALP) 401 U/l (30–150)
Gamma GT (GGT) 89
Albumin 33 glL

Given the likeliest diagnosis, what therapy is he likely to require?
Desferrioximine
Penicillamine Correct answer
Venesection
Genetic analysis
N–acetylcystiene Your answer
A young man with basal ganglia signs and deranged liver function tests is likely to have Wilson’s disease, also referred to as hepatolenticular degeneration. It is an autosomal recessive disorder of the copper metabolism resulting in its accumulation in liver, kidneys, cornea and brain. Those affected become symptomatic in childhood and early adulthood. Chronic hepatitis may lead to cirrhosis and its complications. Neurological or psychiatric disease is the presenting feature in about 40% of cases. Many of these patients have Kayser–Fleischer rings, a physical sign pathognomonic of Wilson’s disease. It is associated with renal tubular acidosis type II. Although serum copper and caeruloplasmin can be low, specificity is poor. The 24-hour urinary copper excretion is rarely less than 100µg and comparison can be made following penicillamine challenge. A liver biopsy can be diagnostic. Treatment of choice is penicillamine, which is a copper chelating agent, or an alternative for those who develop adverse reactions is trientine. Desferrioximine and venesection are both treatment for iron overload. A genetic test has been difficult to develop due to a number of mutations in the gene.
158. A 34-year-old woman presents with a 4-month history of diarrhoea and intermittent fresh rectal bleeding. She works as a shopkeeper and smokes ten cigarettes per day. Her brother suffers from colitis. Blood tests show microcytic anaemia and a raised C-reactive protein. Colonoscopy shows inflammation in the recto-sigmoid colon and a normal terminal ileum. Histology suggests indeterminate colitis. She turns up to clinic very keen to know the exact diagnosis.

Which of the following will favour a diagnosis of Crohn’s disease?
Anti-endomysial antibodies Your answer
Detection of perinuclear anti-cytoplasmic antibodies (pANCA)
Dilated colon on plain abdominal radiography
Anti-Saccharomyces cerevisiae antibodies (ASCA) Correct answer
Arthritis
The diagnosis of inflammatory bowel disease is mainly based on clinical history, inflammatory markers, colonoscopy and histology results. In around 10% of patients, it is impossible to distinguish ulcerative from Crohn’s colitis and this is termed as indeterminate colitis. Serological markers may have a greater role in the future, as ulcerative colitis is strongly associated with perinuclear anti-cytoplasmic antibodies (pANCA) whereas the presence of anti-Saccharomyces cerevisiae antibodies favour Crohn’s disease. In a study where inflammatory bowel disease patients are compared with control, a positive ASCA and a negative pANCA serology had a 49% sensitivity and 96% positive predictive value for Crohn’s disease.
159. A 51-year-old Chinese gentleman presents to you with hepatitis B. He is teetotal.
You perform a series of investigations and the results are as below:
Hepatitis B surface Antigen positive
Hepatitis B e Antigen negative
HBV DNA level 500,000 copies/ml
Alanine aminotransferase (ALT) 96 U/l (5–35)
Liver biopsy Moderate hepatitis with bridging fibrosis

Which of the following is the most appropriate management?
Close monitoring of liver function test
Repeat biopsy in 2 years
Start pegylated interferon Your answer
Start pegylated interferon and ribavirin
Start lamivudine
The prevalence of e antigen negative chronic hepatitis B is rising as in this case. This highlights the importance of liver biopsy. Treatment is recommended based upon the advanced histologic features on his liver biopsy. Pegylated interferon should be started first and if there is lack of response, consider adefovir or lamivudine. Adefovir is preferred over lamivudine due to its low resistance rate. The indication for hepatitis B treatment is based on three factors: abnormal alanine aminotransferase on at least one occasion, liver biopsy showing fibrosis and hepatitis B viraemia > 105 copies/ml
160. A 55-year-old male is referred by general practitioner for evaluation of syncope, which occurred during his brisk morning walk. The patient is known to have hypercholesterolaemia and is taking simvastatin 20 mg od. He is a lifelong non-smoker and has no family history of coronary artery disease. He weighs 72 kg and his height is 170 cm. His blood pressure (BP) is 110/90 mmHg, carotid pulse is slow rising and apex beat is palpable in 5th intercostals space. The first heart sound is normal, the second heart sound is soft; there is an ejection systolic murmur at the second right intercostal space, radiating to both carotids.

Investigations reveal:
Total cholesterol 6.4 mmol/l
Low-density lipoprotein (LDL) 3.8 mmol/l
High-density lipoprotein (HDL) 1.05 mmol/l
Electrocardiogram (ECG) reveals left ventricular hypertrophy.
Chest X-ray is unremarkable.
Echocardiogram reveals mean aortic valve area of 0.5 cm2 and peak transvalvular gradient of 80 mmHg.

What is the next best step in this patient’s management?
Percutaneous aortic balloon valvulotomy
Aortic valve replacement Your answer
Treadmill stress test
Coronary angiography Correct answer
Start an ACE inhibitor
This patient has severe symptomatic (syncope) aortic stenosis (AS) as shown by the mean aortic valve area of 0.5 cm2 and mean peak transvalvular gradient of 80 mmHg.
All symptomatic patients with severe AS should undergo aortic valve replacement, as prognosis without surgery is poor. Coronary artery disease (CAD) is common in patients with AS and this patient’s age, sex and hypercholesterolaemia puts him at risk of CAD. Therefore he should undergo cardiac angiography to assess the need of revascularisation at the time of surgery in the form of coronary artery bypass grafting. Hence option D is the best answer.
Percutaneous balloon valvulotomy (option A) has high restenosis rate and is only performed as bridge to surgery in unstable patients.
With regard to his hypercholesterolaemia, there is room for better lipid lowering, hence either his simvastatin should be increased or he should be swapped to a more powerful statin.
A stress test (option C) is a relative contraindication in severe AS.
161. You are called by an obstetrician for evaluation of a 39-year-old Thai female in her 39th week of gestation. She is planned to undergo Caesarean section because of fetal distress. On examination she appears an averagely built lady with body mass index of 27, heart rate of 95 beats/min, blood pressure (BP) 132/78 mmHg and respiratory rate of 18/min. She has no jugular venous distension; her apex beat is in 5th intercostals space, midclavicular line, has a mid-systolic click and a late systolic murmur at apex radiating towards axilla. The rest of her physical examination is unremarkable except for gravid uterus.
She has no past medical history of note except for a history of skin wheals and pruritis following ingestion of amoxicillin. The symptoms resolved after treatment with chlorpheniramine maleate.

Which of the following is the best regimen for endocarditis prophylaxis in this patient?
Ampicillin 2 g intravenous (iv) 30 min before operation
Vancomycin 1 g iv 60 min before operation
Clindamycin 600 mg iv 30 min before operation
Erythromycin 500 mg iv 30 min before procedure Your answer
No prophylaxis required Correct answer
Mitral valve prolapse with murmur or with thickened valve leaflets carries an intermediate risk for infective endocarditis and is one of the cardiac lesions in which prophylaxis is recommended, however Caesarean section carries low risk for bacteraemia and does not require endocarditis prophylaxis. Similarly, vaginal delivery, uterine dilatation and curettage, therapeutic abortion or insertion or removal of intrauterine contraception device does not require endocarditis prophylaxis.
In general, recent NICE guidance, (Heart 2008;94:930-931; doi:10.1136/hrt.2008.147090) suggests that antibiotic prophylaxis is not required for most genitourinary procedures.
162. A 27-year-old female in 12th week of pregnancy is referred for evaluation of progressively worsening exercise intolerance, fatigue and dyspnoea. On physical examination she has a respiratory rate of 20/min, blood pressure 120/90 mmHg and pulse rate of 91/min. She has jugular venous distension, left parasternal heave, loud pulmonary component of the second heart sound, a pan-systolic murmur at the left sternal border and pedal oedema up to the knees.

Investigations reveal:
White cell count 8 × 109/l
Haemoglobin 16.7 g/dl
Platelets 150 × 109/l
Electrocardiogram (ECG) Right atrial and right ventricular hypertrophy
Lung perfusion scintigraphy No perfusion defects
Pulmonary function test Mild restrictive defect and moderate decrease in diffusion capacity of carbon monooxide
Echocardiography: Severe pulmonary hypertension with right ventricular systolic pressure of 80 mmHg and tricuspid regurgitation

Intravenous injection of microbubbles does not show any intracardiac shunting.

Which of the following is most appropriate management step in this patient?
Warfarin, bosentan and induction of labour at 32 weeks of pregnancy
Heparin, bosentan and Caesarean section at 32 weeks of pregnancy
Warfarin, furosemide and Caesarean section at 32 weeks of pregnancy
Heparin, furosemide and Caesarean section at 32 weeks of pregnancy Your answer
Point out the risks to her own health of continuing with the pregnancy Correct answer
This patient has primary pulmonary hypertension (PPH). Severe pulmonary hypertension in pregnancy has high mortality approaching 50%, therefore this patient should be advised about this risk versus considering a termination. Patients who opt against termination of pregnancy should be closely followed up and managed with anticoagulation, oxygen and pulmonary vasodilator therapy like prostacyclin. Bosentan is teratogenic and should not be used in pregnancy. The patients should be advised for contraception in future, but oral contraceptive pills should not be used for possible increased risk of thrombo-embolism.
163. A 75-year-old male presents to the emergency department with a history of sudden onset of chest pain one hour ago. The pain is sharp, severe, radiates to the back and is associated with sweating. He is known to have had hypertension for the past 8 years and is taking indapamide 1.5 mg/day. Physical examination reveals blood pressure of 145/75 mmHg, heart rate of 92/min and respiratory rate of 22/min. Heart sounds are normal and lung fields are clear to auscultation. Electrocardiogram (ECG) shows sinus tachycardia and left ventricular hypertrophy by voltage criteria. Chest X-ray reveals a widened mediastinum. An urgent magnetic resonance angiography reveals dissection of the aorta distal to the left subclavian artery.

Which of the following is the most appropriate next step in management of this patient?
Begin intravenous labetolol Correct answer
Begin intravenous sodium nitroprusside
Begin intravenous hydralazine
Begin intravenous labetolol and sodium nitroprusside
Urgent referral for surgery Your answer
Aortic dissection is classified as type A if it involves the ascending aorta regardless of the site of primary tear, and type B if it does not. This patient has type B aortic dissection. Patients with type A aortic dissection should have emergency surgery because of the high risk of mortality and complication such as aortic regurgitation, myocardial infarction and cardiac tamponade. Most patients with type B dissection should be treated medically unless they have complications such as persistent leak, rupture or compromised blood flow to renal, mesenteric or limb circulation.
Beta-blockers are the mainstay of medical therapy, as they reduce the rate of left ventricular ejection and shear on the aortic wall. The aim is to reduce blood pressure to 100–120 mmHg and the pulse to near 60 mmHg. Sodium nitroprusside can be added if blood pressure is not controlled with beta-blockers but should not be used alone as it may increase rate of left ventricular ejection. Hydralazine should be avoided for the same reason.
164. A 70-year-old man was admitted to the emergency department with central chest pains, which had started three hours earlier. The pain was crushing in nature, radiating to both arms and associated with nausea and vomiting. He has a past medical history of angina, hypertension and type II diabetes. He is on the following medications: glyceryl trinitrate (GTN) spray prn, amlodipine 10 mg od, atorvastatin 40 mg nocte, metformin 500 mg tds and aspirin 75 mg od.
On examination, he was sweaty with a blood pressure of 155/95 mmHg, pulse of 98/min and regular. His respiratory rate was 24/min and his chest was clinically clear. His jugular venous pulse was just visible, first and second heart sounds were heard with no added murmurs.
The following results are obtained:

Electrocardiogram (ECG) ST elevation of 3 mm in V1–V4, with reciprocal ST depression in the inferior leads.
Haemoglobin 15.8 g/dl
Mean cell volume 88.6 fl
Platelets 240 × 109 /l
White cell count 14.1 × 109 /l
Sodium 141 mmol/l
Potassium 3.8 mmol/l
Urea 7.1 mmol/l
Creatinine 121 μmol/l


A bolus infusion of tenecteplase was given together with diamorphine and metoclopramide. The patient was pain free and haemodynamically stable for 2 h when he suddenly developed recurrent chest pain. His blood pressure become unrecordable and he went into profound shock with electromechanical dissociation. Resuscitative measures were started but the patient died within a few minutes.

What is the most likely complication?
Ventricular free wall rupture Correct answer
Extension of the infarct
Acute mitral regurgitation
Ruptured ventricular septum Your answer
Pulmonary embolism
Autopsy studies reveal that ventricular free wall rupture occurs about 10 times more frequently than postinfarction ventricular septal rupture, occurring in about 11% of patients following acute myocardial infarction. Ventricular rupture and cardiogenic shock are now the leading causes of death following acute myocardial infarction, and together account for over two-thirds of early deaths in patients suffering their first acute infarction.