MRCP UK Part 2 practice questions

The current ECG shows right bundle branch block with left anterior fascicular block, while the previous tracing documented left bundle branch block. This represents alternating bundle branch block, evidence of advanced disease affecting all three fascicles and a high risk of progression to complete atrioventricular block. Permanent pacing is indicated even without symptoms; isolated stable bifascicular block alone would not necessarily require pacing.

Sources: European Society of Cardiology guidance on cardiac pacing; NICE technology appraisal TA88, Dual-chamber pacemakers for symptomatic bradycardia; British Heart Rhythm Society pacing standards.

Correct answer: Proceed through a robust best-interests process without mandatory court referral if consensus remains.

Clinically assisted nutrition and hydration are medical treatments and may be withdrawn when no longer in the patient's best interests.

The assessment must be rigorous and include specialist diagnosis, prognosis, prior wishes and consultation with those close to him.

Current UK law does not require court authorisation in every prolonged-disorder-of-consciousness case when guidance is followed and there is agreement.

Court involvement remains appropriate when there is disagreement, uncertainty or a novel legal issue.

His wife is an important consultee but cannot sign a binding refusal merely as next of kin.

Withdrawal should occur only after formal multidisciplinary documentation and detailed palliative planning.

The legal and ethical distinction is between stopping a burdensome treatment and intending the patient's death.

The display shows coarse ventricular fibrillation, a shockable cardiac-arrest rhythm. An unsynchronised biphasic shock should be delivered without delay at the manufacturer's recommended energy, followed immediately by 2 minutes of cardiopulmonary resuscitation without pausing for a pulse check. Adrenaline and amiodarone are introduced later in the shockable-rhythm algorithm rather than before the first shock.

Sources: Resuscitation Council UK, Adult advanced life support guidelines; British National Formulary, adrenaline and amiodarone in cardiac arrest.

The patient consented to receive medically actionable additional findings, and the pathogenic result has been diagnostically confirmed. The family history and previous borderline QT prolongation further increase its potential clinical relevance. She should be informed with appropriate counselling and referred promptly to an inherited-cardiac service for ECG phenotyping, risk assessment and management. Citalopram and clarithromycin can prolong repolarisation, so medication review and avoidance of avoidable QT-prolonging combinations are important. The finding should not be ignored merely because it does not explain the neurological phenotype. Her adult children may each be at risk, but disclosure and cascade testing should ordinarily proceed through discussion with her rather than bypassing her. Immediate unsupervised cessation of every medicine is unnecessary and may cause harm. Repeat genome sequencing is not needed when the finding has already been confirmed using an appropriate diagnostic method.

The combined posterior-column and corticospinal signs, macrocytosis, low vitamin B12 and raised methylmalonic acid establish neurological vitamin B12 deficiency with subacute combined degeneration. MRI commonly shows symmetric posterior-column signal change. Neurological involvement requires intensive intramuscular hydroxocobalamin on alternate days until no further improvement occurs, followed by an appropriate maintenance regimen determined by the cause. A three-monthly schedule from the outset is inadequate loading. Oral therapy is less suitable for severe neurological disease and possible malabsorption. Folate alone can improve the haematological abnormality while allowing neurological injury to progress. Treatment should not await intrinsic-factor antibody results. Recovery may be incomplete if therapy is delayed, and potassium and reticulocyte responses may require monitoring early in treatment.