MRCP Part 1 Cardiology and Respiratory 2 — Questions and Answers
Question 1: A 28-year-old woman presents with syncope during exercise. Echocardiography shows asymmetric septal hypertrophy with systolic anterior motion of the mitral valve. What is the most likely diagnosis?
- Hypertrophic cardiomyopathy (Correct answer)
- Dilated cardiomyopathy
- Aortic stenosis
- Pulmonary hypertension
Correct answer: Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy (HCM) characteristically shows asymmetric septal hypertrophy (ASH) and systolic anterior motion (SAM) of the mitral valve on echocardiography. Exertional syncope is a concerning feature suggesting left ventricular outflow tract obstruction.
Question 2: A 65-year-old smoker has an FEV1 of 45% predicted after bronchodilator. According to GOLD classification, what is the severity of his COPD?
- GOLD 3 — Severe (Correct answer)
- GOLD 1 — Mild
- GOLD 2 — Moderate
- GOLD 4 — Very Severe
Correct answer: GOLD 3 — Severe
GOLD classification is based on post-bronchodilator FEV1: GOLD 1 (mild) >=80%, GOLD 2 (moderate) 50-79%, GOLD 3 (severe) 30-49%, GOLD 4 (very severe) <30%. An FEV1 of 45% predicted falls into GOLD 3 (severe).
Question 3: Which ECG finding is most characteristic of hyperkalaemia?
- Tall tented T waves (Correct answer)
- Prolonged QT interval
- ST depression
- Delta waves
Correct answer: Tall tented T waves
Tall, peaked (tented) T waves are the earliest ECG change in hyperkalaemia, typically appearing when potassium exceeds 5.5-6.0 mmol/L. Progressive hyperkalaemia leads to widened QRS, loss of P waves, and eventually a sine wave pattern preceding cardiac arrest.
Question 4: A patient with known asthma presents with acute breathlessness. Arterial blood gas shows pH 7.35, PaCO2 5.5 kPa, PaO2 8.0 kPa. What does the PaCO2 suggest about the severity of this exacerbation?
- Life-threatening — indicates tiring and impending respiratory failure (Correct answer)
- Mild — normal CO2 is reassuring
- Moderate — requires nebulised salbutamol only
- Resolving — the patient is improving
Correct answer: Life-threatening — indicates tiring and impending respiratory failure
In acute asthma, patients typically hyperventilate, producing a low PaCO2. A normal or rising PaCO2 (5.5 kPa) in acute asthma is a sinister sign indicating respiratory muscle fatigue and inability to maintain the hyperventilatory response. This is classified as a feature of life-threatening asthma by BTS/SIGN guidelines.
Question 5: A 50-year-old man presents with progressive exertional breathlessness and fine bibasal inspiratory crackles. HRCT shows honeycombing and traction bronchiectasis predominantly in the lower lobes. What is the most likely diagnosis?
- Idiopathic pulmonary fibrosis (usual interstitial pneumonia pattern) (Correct answer)
- Cryptogenic organising pneumonia
- Hypersensitivity pneumonitis
- Pulmonary alveolar proteinosis
Correct answer: Idiopathic pulmonary fibrosis (usual interstitial pneumonia pattern)
The combination of progressive breathlessness, bibasal crackles, and HRCT showing honeycombing with traction bronchiectasis in a subpleural, basal distribution is the classic pattern of usual interstitial pneumonia (UIP), the hallmark of idiopathic pulmonary fibrosis (IPF).
Question 6: A patient with a mechanical mitral valve replacement presents with a new regurgitant murmur, fever, and splinter haemorrhages. Blood cultures grow Staphylococcus epidermidis. What is the most appropriate empirical antibiotic regimen whilst awaiting sensitivities?
- Vancomycin, gentamicin, and rifampicin (Correct answer)
- Amoxicillin and gentamicin
- Flucloxacillin monotherapy
- Co-amoxiclav and metronidazole
Correct answer: Vancomycin, gentamicin, and rifampicin
Prosthetic valve endocarditis (PVE) with coagulase-negative staphylococci requires vancomycin (covering MRSE), gentamicin (synergistic bactericidal activity), and rifampicin (penetrates biofilm on prosthetic material). This is recommended by ESC and NICE guidelines for PVE.
MRCP Part 1 Cardiology and Respiratory 2
A 28-year-old woman presents with syncope during exercise.
Echocardiography shows asymmetric septal hypertrophy with systolic anterior motion of the mitral valve.
What is the most likely diagnosis?