MRCP Deck 1 Apr 2023 Flashcards
A 23YO F is 5 months pregnant. She reports that she has always had light-brown discolourations, freckling and lumps on her skin but these have worsened in pregnancy. O/E she has multiple light brown pigmented areas on her skin, a number of friable cutaneous skin lesions and axillary freckling. What is the most likely diagnosis?
A) Acanthosis nigricans
B) MEN1
C) MEN2
D) NF1
E) NF2
NF1 - results from deletion of the NF1 gene which leads to an increase in CNS tumours. NF1 is associated with less CNS tumours than NF2 but is associated with a mixture of skin features which often increase during puberty and pregnancy.
A 62 YO F presents with chronic pain following L nephrectomy for renal carcinoma. She has bony pain from metastatic disease and it is planned to start her on meptazinol.
Which of the following is the correct advice with respect to potential constipation?
A) Increase PO fluids only
B) Start regular ispaghula husk
C) Start regular lactulose
D) Start regular macrogol
E) Start regular senna
Senna is the initial preferred intervention for preventing opiate induced constipation. Lactulose and movicol can be added to Senna if needed.
What is the most appropriate management option for a patient in florid pulmonary oedema due to papillary muscle rupture and subsequent MR following an MI?
A) Beta blockers, nitroprusside and diureses
B) Diuresis with furosemide
C) Diuresis and nitroprusside
D) Emergency surgical replacement/repair
E) Thrombolysis
The key definitive management is emergency surgery - often valve replacement. Medical management (A) carries a poor prognosis.
A neutropenic patient has a cough and low grade fever, sparse crepitations and his CXR shows diffuse pulmonary shadowing. No improvement with abx. Sputum shows hyphae but is culture -ve. BC, Aspergillus precipitins and Aspergillus skinprick are all -ve. What is the diagnosis?
A) ABPA
B Aspergilloma
C) Invasive aspergillosis
D) Pneumocystis pneumonia
E) Systemic candidiasis
Invasive aspergillosis often presents with a fever, cough with copious amounts of sputum and pleuritic chest pain. It often shows cavitation and non-specific consolidation on CXR with the characteristic halo sign on HRCT. Precipitin and skinprick tests are often negative since the patient is unable to mount an immune response.
Which of the following cytotoxic agents cause cardiomyopathy as a dose dependent effect?
A) Bleomycin
B) Cytarabine
C) Doxorubicin
D) Methotrexate
E) Paclitaxel
Doxorubicin causes a cumulative, dose-dependent decline in L ventricular ejection fraction with a higher incidence of myocardial dysfunction
Which respiratory condition is most commonly associated with SLE and presents with an unproductive cough and dyspnoea?
A) Asthma
B) Bronchiectasis
C) Bronchiolitis obliterans
D) Fungal infection
E) TB
Bronchiolitis obliterans = fibrous scarring of small airways - associated with RA or SLE. Presents as a dry cough and dyspnoea - CXR may be normal or show reticulonodular shadowing. Poor response to steroids and poor prognosis
Which of the following is associated with confusion, vomiting and causes a yellowish tinge to vision?
A) Amlodipine
B) Aspirin
C) Atorvastatin
D) Digoxin
E) Ramipril
Digoxin is associated with disorientation, vomiting, mental confusion, amnesia and depression. It is also associated with a yellow visual field discolouration called xanthopsia.
A patient presents with hyperventilation and tachycardia. His ABG shows a respiratory alkalosis. Which drug is he likely to have overdosed on?
A) Benzodiazepine
B) TCA
C) Cocaine
D) Paracetamol
E) Theophylline
Both theophylline and salicylates are associated with acute respiratory alkalosis. Seizures are common in theophylline overdose which are usually managed with benzodiazepines.
A patient is found to have reduced factor VIII activity, but at the >5% level. He is due to undergo an extraction of wisdom teeth. What is the most important initial intervention with respect to his management?
A) He should be given desmopressin periprocedure
B) He should be given FFP periprocedure
C) No intervention is needed
D) He should be given Factor VIII periprocedure
E) He should be given cryoprecipitate periprocedure
Mild haemophilia (>5%) means the patient is only at significant risk of bleeding associated with trauma or surgery such as tooth extraction. Desmopressin should boost factor VIII activity enough to avoid exogenous administration
Which of the following statements is the most accurate for a patient with Graves disease and bilateral thyroid eye disease that has relapsed twice after medical treatment?
A) Systemic steroids are of no value in managing the eye disease
B) Subtotal thyroidectomy is the best treatment option for her
C) Stopping smoking will make no difference now that she has established thyroid eye disease
D) Radioiodine treatment is the best treatment option for her
E) Total thyroidectomy is the best treatment option for her
Thyroid eye disease may be worsened by radio iodine treatment. Patients with Graves’ hyperthyroidism and active moderate-to-severe or sight-threatening ophthalmopathy should be treated with medications or surgery. even she has related twice with medical treatment, surgery would be the best course of action
An 11-week pregnant woman presents to hospital with hyperemesis gravidarumm. TFTs are completed and she is found to have an elevated T4 and a low TSH. She has no goitre, thyroid antibodies are negative and she has no symptoms of hyperthyroidism. What is the best management step?
A) Radioiodine
B) Immediate surgical referral
C) Propylthiouracil
D) Carbimazole
E) Observe and wait for normalisation
Transient hyperthyroidism of hyperemesis gravidarum can be caused by high levels of hCG - a known stimulator of TSH receptors. Signs and symptoms of hypermetabolism are mild/absent. Most cases often resolve spontaneously in 2-10 weeks.
A 62 y/o M has a 2M history of fatigue, exertion dyspnoea and abdominal pain. He also has severe pain in his hands (no swellings) and progressive numbness of his feet. O/E red spots are noted on the extensor surfaces of his lower limbs. An XR of the chest shows cardiomegaly. What diagnosis is best suggested by these findings?
A) Dermatomyositis
B) Polyarteritis nodosa
C) Polymyalgia rheumatica
D) Rheumatoid arthritis
E) Sarcoidosis
Polyarteritis nodosa (PAN) is a necrotising vasculitis that causes aneurysms of medium sized arteries. Abdominal pain due to mesenteric vasculitis infarction of a viscus. dyspnoea due to pulmonary infiltrates and cardiomegaly, arthralgia, neuropathy and purpuric spots can all occur in this condition.
Which of the following would cause a rise in the carbon monoxide transfer factor (TLCO)?
A) Emphysema
B) Pulmonary haemorrhage
C) Pulmonary embolism
D) Pneumonia
E) Pulmonary fibrosis
Transfer factor = rate at which gas diffuses from alveoli into the blood. Alveolar haemorrhage causes the TLCO to increase due to the enhanced uptake of CO by intra-alveolar haemoglobin.
Raised TLCO = asthma, haemorrhage, L>R shunts, polycythaemia, male gender, exercise
A patient is found to have a renal angiomyolipoma. What is the most likely underlying diagnosis?
A) Neurofibromatosis
B) Budd-Chiari syndrome
C) Hereditary haemorrhagic telangiectasia
D) Von Hippel-Lindau syndrome
E) Tuberous sclerosis
10% of patients with renal angiomyolipomas are found to have underlying tuberous sclerosis whilst most patients with TS are likely to have severe renal angiomyolipomas. TS is an AD condition with neurocutaneous features (similar to neurofibromatosis).
Which of the following is not associated with an increased risk of developing torsades de pointes?
A) TCA
B) SAH
C) Hypercalcaemia
D) Romano-Ward syndrome
E) Hypothermia
Hypercalaemia is associated with QT interval shortening (hypocalcaemia is associated with QT prolongation).
Which antibiotics should be prescribed to cover for a human bite?
A) Amoxicillin
B) Co-amoxiclav
C) Doxycycline
D) Metronidazole
E) Metronidazole with clarithromycin
Human bites, like animal bites, should be treated with co-amoxiclav. Doxycycline + metronidazole is recommended if the patient is penicillin allergic.
A 57F with PMR taking 10mg prednisolone for the past 5M has a DEXA scan which shows a T-score of -1.5SD. What is the most suitable management?
A) No treatment
B) Vitamin D + calcium supplementation + repeat DEXA in 6M
C) Vitamin D + calcium supplementation
D) Vitamin D + calcium supplementation + hormone replacement
E) Vitamin D + calcium supplementation + oral bisphosphonate
Patients with a T score of <-1.5 SD is an indication for a bisphosphonate. This should be co-prescribed with calcium and vitamin D.
A 25 year old man has a renal biopsy due to worsening renal function. This reveals linear IgG deposits along the basement membrane. What is the most likely diagnosis?
A) SLE
B) IgA nephropathy
C) Minimal change disease
D) Post-streptococcal GN
E) Goodpastures syndrome
Goodpastures syndrome = IgG deposits on renal biopsy with anti-GBM antibodies.
If the mean is 4.6 with an SD of 0.3. Which of the following statements is correct?
A) 95% of the values lie between 4.5 and 4.75
B) 95.4% of the values lie between 4.3 and 4.9
C) 99.7% of the values lie between 4.0 and 5.2
D) 68.3% of the values lie between 4.5 and 4.75
E) 68.3% of the values lie between 4.3 and 4.9
68.3% of values of a normally distributed variable lie with 1 SD of the mean. 95.4% of values lie within 2 SD of the mean. 99.7% of values lie within 3 SD of the mean. Within 1.96 SD of the mean lie 95% of the sample values.
A patient has recently been switched from sodium valproate to lithium. She has presented with bilateral pitting oedema to her knees with her urine protein creatinine ratio of 450mg/mmol and hypoalbuminaemia. What is the most likely underlying pathology?
A) Lithium induced CKD
B) FSGS
C) Minimal change disease
D) Membranous nephropathy
E) IgA nephropathy
Minimal change disease is the most common cause of nephrotic syndrome in children and is the most common form of lithium induced nephrotic syndrome. Lithium can also cause FSGS but is les common than lithium-induced minimal change disease.
A 28 YO F wiht Sjogrens syndrome and SLE has recently began to suffer with lethargy and bony pain. She currently takes hydroxychloroquine and low dose steroids. Her bloods show K 3.1, Bicarb 16, Cr 138 and CCa 2.1. What is the most likely diagnosis?
A) Osteomalacia
B) Renal tubular acidosis type 1
C) Renal tubular acidosis type 2
D) Renal tubular acidosis type 4
E) Secondary hyperparathyroidism
RTA type 1 is associated with metabolic acidosis, hypokalaemia and hypocalciuria. It commonly coincides with Sjogrens and SLE.
RTA type 2 is associated with multiple tubular disorders/Fanconi syndrome. It involves impaired retention of bicarbonate in the proximal tubules with resulting systemic acidosis. Hypokalaemia is present.
RTA type 4 (most common) is associated with a reduced response to aldosterone, leading to hyperkalaemic metabolic acidosis in patients with mild chronic renal insufficiency.
A 57 YO M with advanced cirrhosis presents confused, drowsy and unwell. His BP is 105/65 with a CVP of 14. Urinary catheterisation shows a residual volume of 35ml and he is anuric for the next 2hr. Urine Na is low. USS shows no evidence of obstruction and an empty bladder. Despite IVF, no improvement in urine output is seen. Cr 385, U 8.1. What is the most likely diagnosis?
A) Acute GI haemorrhage
B) ATN secondary to sepsis
C) Hepato-renal syndrome
D) Pre-kidney hypovolaemia
E) SBP
Hepato-renal syndrome is a feature of advanced cirrhosis. Urinary Na is useful in differentiating between causes of renal dysfunction. Pre-renal disease is likely if urinary Na <20; intrinsic kidney disease is likely if urinary Na >40; very low urinary Na is a strong indicator of hepatorenal disease. Mx = volume challenge, relief of tense ascites and treatment of any infection. Dialysis may be considered as a last resort.
A 62M has a rising creatinine following angiography. He feels nauseous and develops HTN with increasing SOB. BP 155/90, HR 85/min, B/L basal crackles consistent with pulmonary oedema. You suspect he may have cholesterol emboli. Which of the following features would be most commonly seen?
A) Low C3 and C4
B) Eosinophili
C) Erythema ab igne
D) Microcytic anaemia
E) Neutropenia
Leucocytosis with eosinophilia is common in 80% of patients with cholesterol emboli. The eosinophilia represents a foreign body-type response to cholesterol deposition. Progression to CKD is common.
Low C3 and C4 may be seen in septic emboli (e.g. IE) but not cholesterol emboli.
A young african woman is diagnosed as having SLE. What is the characteristic epidemiological feature of this condition?
A) First degree relatives have a 25% chance of developing the disease
B) It’s 2x as common in women than men
C) It’s associated with HLA-DR2 and -DR3 in white ethnicity
D) The age of onset is usually >40years
E) The highest incidence is amongst white women
There is an increased frequency of HLA-DR2 and -DR3 in white Europeans with SLE
A 32 F 2-days post partum has suffered two seizures and has been complaining of a severe headache over the previous 24hrs. She received an epidural during delivery. O/E she is drowsy with a BP of 134/87. She has bilateral papilloedema and a temperature of 37.4. What is the most likely diagnosis?
A) Bacterial meningitis
B) Cerebral venous thrombosis
C) Epidural abscess
D) Pre-eclampsia toxaemia
E) SAH
Pregnancy and post-partum are both procoagulable states with LP and epidurals also both increasing the risk of cerebral venous thrombosis. The above symptoms are all most consistent with this diagnosis.
A 25M presents with 1W history of fever and myalgia. He travelled to Chile 8W ago and on return, had a swollen R eyelid for a few weeks. ECG shows non-specific T wave changes in all leads. What is the most likely diagnosis?
A) Echinococcosis
B) Falciparum malaria
C) Schistosomiasis
D) Toxoplasmosis
E) Trypanosomiasis
Trypanosoma cruzi causes Chagas disease (common in S America) and is spread by reduvid bugs. They are transmitted by scratching infected faeces of the bug into skin abrasions caused by the bug during blood sucking. In acute trypanosomiasis the patient presents with fever, myalgia, hepatosplenomegaly and myocarditis. Chronically, in small proportion there may be delayed ventricular dilatation with heart failure. Unilateral periorbital oedema and swelling of the eyelid can result from a bug bite around the eyes (Romana’s sign).
How many repeats of the abnormal triplet sequence would typically be found in a patient with Huntington’s disease?
A) 1-7
B) 7-11
C) 12-33
D) 34-37
E) >37
HD is an AD neurodegenerative disorder due to a mutation in CAG trinucleotide in the huntingtin gene on chromosome 4. Normally this triplet sequence contains from about 11-34 repeats - when the number rises >37, HD occurs.
A 63M presents with a grand mal seizure along with two days of fatigue and drowsiness. He recently underwent chemotherapy for small-cell carcinoma of the bronchus a few months ago. He has an Na of 120 and is diagnosed with SIADH. His fluid intake is restricted but this further falls to 119 with an increased drowsiness. What is the most appropriate management for him?
A) Continue fluid restriction
B) Start dexamethasone
C) Give normal saline 0.9%
D) Give demeclocycline
E) Give hypertonic saline
Severe symptomatic hyponatraemia should be treated with IV hypertonic saline (3%) as an initial bolus of 300ml with repeat sodium measurements every 20 mins.
Anaesthetic recovery time was recorded for 100 patients. Mean and median times for the procedure were 40 and 65 minutes respectively; the SD was 50 and range 95 (20-115 mins). What is the best way of summarising this data for a paper to a medical journal?
A) mean = 40, SD = 50
B) mean = 40, standard error = 5
C) mean = 40, range 20-115
D) median = 65, SD = 50
E) median = 65, range = 20-115
This sample population is very skewed as the mean and median times are so disparate. They are both concentrated towards the lower end of the range which is wide. Hence the best way to summarise this skewed data is to use the median and the range as this is a better way to demonstrate an average and the variance in such an asymmetrical population.
A 53F with long-standing diabetes and gastric dysmotility asks for advice regarding cisapride. Which of the following statements is most accurate regarding cisapride?
A) Decreases PT in patients receiving warfarin
B) Delays gastric emptying time
C) Exacerbation of symptoms of heartburn
D) Relaxation of colonic musculature
E) QT prolongation on the ECG
Cisapride is a pro kinetic drug that reduces gastric emptying time and interacts with anticoagulants and increases prothrombin time and bleeding risk. It increases the motility of the entire GI tract. QT abnormalities are reported with therapy and has unfortunately been associated with fatal arrhythmias - leading to restricted use.
Which of the following agents are most likely to interact with lithium to cause lithium toxicity?
A) Amlodipine
B) Bisoprolol
C) Hydrochlorthiazide
D) Ramipril
E) Valsartan
Thiazides carry the greatest risk of lithium toxicity when the medications are co-prescribed, leading to a rapid rise in lithium levels due to a decrease in lithium excretion
A 45F is admitted with end-stage carcinoma of the breast. She has failed various treatments and you are considering treating her with docetaxel. What is the mode of action of docetaxel?
A) Binding to microtubules
B) Disrupting DNA
C) Inhibiting mitochondrial energy production
D) Inhibiting RNA production
E) Inhibiting ribosome production
Docetaxel reversibly binds to microtubules with high affinity, leading to a decrease in the availability of free tubulin, thus preventing mitotic cell activity. Microtubules also accumulate within the cell, increasing the rate of apoptosis.
Which one of the following features of haemachromatosis may be reversible with treatment?
A) Cardiomyopathy
B) Hypogonadotrophic hypogonadism
C) Diabetes mellitus
D) Arthropathy
E) Liver cirrhosis
Cardiomyopathy and skin pigmentation are reversible with treatment. Haemachromatosis is an AR disorder resulting in iron accumulation.
Which test results indicate Wilsons disease?
A) Low caeruloplasmin, low serum copper, increased 24hr urinary copper excretion
B) High caeruloplasmin, low serum copper, increased 24hr urinary copper excretion
C) Low caeruloplasmin, high serum copper, increased 24hr urinary copper excretion
D) High caeruloplasmin, High serum copper, increased 24hr urinary copper excretion
E) High caeruloplasmin, High serum copper, decreased 24hr urinary copper excretion
Low caeruloplasmin, low serum copper, increased 24hr urinary copper excretion - the diagnosis is confirmed by genetic analysis of the ATP7B gene
Which anti-rheumatic drug should be avoided in patients who have a background of asthma and hypersensitivity to aspirin and NSAIDs causing urticaria and angioedema?
A) Infliximab
B) Leflunomide
C) Methotrexate
D) Rituximab
E) Sulfasalazine
Patients who are allergic to aspirin may also react to sulfasalazine. Aspirin hypersensitivity often co-exists with sensitivity to non-steroidal anti-inflammatories and asthma.
A 25-year-old female has type I diabetes. Her HbA1c is 58 mmol/L. Her blood pressure is 126/68 mmHg. Her BMI is 28 kg/m². She is not keen to increase her total insulin dose. Which of the following adjuncts could you consider to help improve her glycaemic control?
A) Add metformin
B) Switch to mixed insulin regime
C) Add sitagliptin
D) Add exanatide
E) Enrol in supported weight loss programme
NICE recommends that adding metformin should be considered in type I diabetics with a BMI > 25 - weight loss is likely to be beneficial but there is greater evidence for benefit with the use of metformin. A mixed insulin regime might be used if a multiple injection basal-bolus regime was not suited to the patient’s lifestyle but is not usually chosen for better glycaemic control.
A 57-year-old male complains of having very vivid dreams. He reports a 6-week history of having frequent nightmares with extremely disturbing and vivid imagery. You find that he was started on a new medication 6 weeks ago.
Which medication was he likely to have been started on?
A) Nitrate
B) Bisoprolol
C) Amlodipine
D) Verapamil
E) Nicorandil
Beta-blockers can cause sleep disturbance.
A 26M presents 2 weeks following a witnessed seizure which self-resolved. He has no past medical history and has never had a seizure before. CTH NAD, MRI NAD, EEG NAD. Which advice should he be given concerning driving restrictions?
A) The patient is able to drive immediately
B) The patient is unable to drive for at least 6M irrespective of whether AED are started or not
C) The patient is unable to drive for at least 12M irrespective of whether AED are started or not
D) It is at the discretion of the neurologist as to whether this patient can resume driving
E) The patient is unable to drive until they can prove compliance with AEDs
Patients cannot drive for 6 months following a first unprovoked or isolated seizure if brain imaging and EEG normal. The minimum interval for which the patient is unable to drive would be extended to 12 months were there evidence for a structural abnormality (e.g. a space-occupying lesion) on imaging which could have caused his seizure, or if there were evidence for epileptiform activity on his EEG.
64-year-old man presents to the emergency department via ambulance. Four hours earlier, he noticed some speech difficulties. He has a past medical history of hypertension, atrial fibrillation and hypercholesterolaemia and is on regular atorvastatin and ramipril. On examination, he has an expressive dysphasia. There is right-sided hemiplegia, sensory loss and homonymous hemianopia. Urgent CT head and CT angiography excluded intracranial haemorrhage and confirmed occlusion of the proximal anterior circulation. What is the most appropriate management?
A) Apixaban
B) Aspirin 300mg
C) IV thrombolysis
D) IV thrombolysis + mechanical thrombectomy
E) Mechanical thrombectomy
Thrombectomy should be offered as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have an acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA).
Which one of the following statements regarding macular degeneration is true?
A) Drusen are characteristic of wet macular degeneration
B) Photodynamic therapy is useful in dry macular degeneration
C) Asian ethnicity is a risk factor
D) Male sex is a risk factor
E) Wet macular degeneration carries the worst prognosis
Age-related macular degeneration is the most common cause of blindness in the UK. It is characterised by degeneration of retinal photoreceptors that results in the formation of drusen (seen on fundoscopy). It is more common with advancing age and is more common in females. Classically there are two forms of macular degeneration - dry/atrophic macular degeneration (90% of cases, characterised by drusen) and wet/exudative/neovascular macular denegeration (choroidal neovascularisation, carries the worst prognosis)
For a patient with paroxysmal AF, which part of the electrocardiogram trace should a direct current cardioversion be delivered on for this patient given their arrhythmia?
A) P wave
B) PR interval
C) R wave
D) T wave
E) Unsynchronised shock
DC cardioversion for a haemodynamically stable, symptomatic patient with paroxysmal AF is an effective treatment provided the patient has been on anticoagulation for at least 4 weeks. The current should be synchronised with the R wave.
Which other abnormality of the blood would be most consistent with Polycythaemia vera?
A) Raised ALP
B) Hypokalaemia
C) Thrombocytopaenia
D) Raised ferritin
E) Neutrophilia
Polycythaemia vera is a myeloproliferative disorder caused by clonal proliferation of a marrow stem cell leading to an increase in red cell volume, often accompanied by overproduction of neutrophils and platelets.
Through what mechanism does alcohol intoxication lead to hypoglycaemia?
A) Alcohol causing increased insulin secretion
B) Increased glycogenolysis
C) Increased pancreatic exocrine activity
D) Low levels of carbohydrate content in alcohol decreasing blood sugar levels
E) Promotion of gluconeogenesis
Alcohol results in exaggerated insulin secretion causing hypoglycaemia. The mechanism is thought to be due to the effect of alcohol on the pancreatic microcirculation leading to a redistribution of pancreatic blood flow from the exocrine into the endocrine parts and thus increased insulin secretion.
Which one of the following cytotoxic agents acts by inhibiting dihydrofolate reductase and thymidylate synthesis?
A) Methotrexate
B) Vincristine
C) Bleomycin
D) Cyclophosphamide
E) Doxorubicin
Methotrexate - inhibits dihydrofolate reductase and thymidylate synthesis
What chromosome is the CFTR gene located on?
A) 3
B) 7
C) 11
D) 14
E) 15
In the UK 80% of CF cases are due to delta F508 on the long arm of chromosome 7. It is an AR disorder.
Which of the following is also proven to have a causal link with asbestos exposure?
A) Bronchiectasis
B) T2DM
C) Bronchial carcinoma
D) BCC of the skin
E) IHD
Asbestos is well known to increase the risk of mesothelioma, but also increases the risk of bronchial carcinoma, laryngeal cancer and ovarian cancer.
A 23-year-old woman has been under investigation for fatigue and anaemia for several months. She attends her GP with a rash. On examination, there is a purplish reticulated rash, which is non-blanching, across her limbs and torso. The presence of this rash increases the likelihood of which of the following differential diagnoses?
A) Coeliac disease
B) Borrelia burgdorferi
C) Sarcoidosis
D) Infectious mononucleosis
E) SLE
The rash description is classic for livedo reticularis. SLE has an association with livedo reticularis and fits well with the initial presentation.
A 75F presents with increasing pain and swelling in both ankles, with stiffness and decreased mobility, worsening in the last few months. O/E she also has painful finger joints with nodules at the PIP and DIP. Over the past 2W she has had increasing difficulty passing urine and dysuria. What is the most likely cause of her joint symptoms?
A) Behcets syndrome
B) OA
C) Osteoporosis
D) Reactive arthritis
E) Rheumatoid arthritis
The nodules at the PIP and DIP are Bouchards nodes and Heberdens nodes respectively and signify OA of the hands and ankles. The 2W history of dysuria and difficulties passing urine are unrelated.
Which of the following statements best describes the pharmacological effects of nicorandil?
A) Headache occurs in 2-4% of patients
B) It inhibits ATP-dependent K channels
C) It increases ventricular filling pressures
D) It reverses the hypotensive effect of sildenafil
E) Oral ulceration is a recognised adverse effect
Nicorandil is an activator of ATP dependent K channels - its pharmacological actions are to relax smooth muscle in veins and increase venous capacitance, leading to reduced ventricular filling pressures and dilatation of the coronary arterioles. Headache is the most common unwanted effect (35%). Other adverse effects include oral ulceration, flushing and GI disturbance.
A 67F presents with 10W history of pain affecting the cervical spine, both shoulders, lumbar spine and both hips. Early morning stiffness lasts until lunchtime and she feels very tired. She has lost 5kg of weight in 12 weeks, has a low-grade pyrexia (37.4), B/L knee effusions and R carpal tunnel syndrome. Ix = normocytic anaemia, raised ESR, raised CRP, weakly positive RF, serum immunoglobulins and protein electrophoresis show a polyclonal increase in gammaglobulins and elevated a1 and a2 globulins. What is the most likely diagnosis?
A) Paraneoplastic syndrome
B) PMR
C) Polymyositis
D) Rheumatoid arthritis
E) Temporal arteritis
PMR usually affects elderly white females - symmetrical arthritis with a polyclonal increase in globulins (marker of inflammation). Early morning stiffness, particularly of the hip and shoulder girdle with associated fatigue can last 2-3 hours each morning. Transient synovitis can occur and carpal tunnel may be associated in up to 15% of cases
A 20M is referred due to hypogonadism and infertility. He went through normal puberty and there is no significant family history. O/E he is tall with gynaecomastia and small testes. He has a normal sense of smell. Which condition would be high on your list of differentials?
A) Fragile X synrome
B) Kallmann syndrome
C) Klinefelter syndrome
D) Marfan syndrome
E) XYY syndrome
Klinefelter syndrome occurs due to the presence of an additional X chromosome. It is the most common cause of male hypogonadism and infertility. Affected men tend to be tall and have an increased risk of mild intellectual impairment. They may also have an increased risk of osteoporotic fracture due to low testosterone.
Which cardiac lesion is most likely to be prone to IE?
A) Aortic regurg
B) ASD
C) Pulmonary valve regurg
D) Tricuspid regurg
E) Tricuspid stenosis
Aortic regurgitation. Endocarditis commonly affects LHS>RHS. IE most commonly affects mitral>aortic>aortic+mitral>tricuspid>pulmonary - if the valve is already abnormal then the likelihood of infection is greater.
What is the best diagnostic test for CJD?
A) CT brain
B) EEG
C) LP
D) MRI
E) SPECT scan
LP has 95.8% diagnostic sensitivity and 100% specificity. The gold standard used to be MRI brain but this has been superseded by LP results.
The risk of complications in the control arm is 2.4% an the risk of complications in the treatment arm is 1.8%. What is the absolute risk reduction associated with the new treatment?
A) 0.6%
B) 1.8%
C) 2.4%
D) 25%
E) 33%
The absolute risk reduction is the difference in risk between the control and the intervention groups - 0.6%
Which of the following is the best advice for a patient in the post-radioiodine period?
A) It is safe to try and conceive after 3M
B) She should not have close contact with young children and pregnant women for 10D post treatment
C) There is no need to monitor her TSH level
D) She will never need further doses of radioiodine
E) She can be in close contact with children within 1 day
Although the amount of radioiodine during treatment is small, it is recommended to wait approx 2 weeks before having close contact with children and pregnant women. It is recommended to wait at least 6M before attempting to conceive.
When considering dietary protein, which of the following best describes the site of amino acid absorption?
A) The caecum
B) The proximal stomach
C) The jejunum
D) The distal stomach
E) The duodenum
Most absorption occurs in the jejunum after degradation in the duodenum by pancreatic proteases.
Which of the following pathological changes is a characteristic feature of the Wernicke-Korsakoff syndrome?
A) Cerebellar atrophy
B) Dilatation of the IIIrd venricle
C) Neuronal loss in the mamillary bodies
D) Demyelination in the pons medulla
E) Microvascular lesions in the cortex
The pathological changes are symmetrical lesions in the walls of the third ventricle and periaqueductal grey matter, with subsequent atrophy of the mamillary bodies.
What is the most appropriate way to confirm H. Pylori eradication?
A) 13C urea breath test
B) Endoscopy and biopsy for sensitivities
C) Endoscopy and urease test
D) Faecal H. pylori antigen
E) H. pylori serology
Confirmation of H. Pylori eradication occurs 4W post completion of antibiotics and whilst off PPIs for 2W. Non-invasive tests should be used unless the patient has complex peptic ulcer disease or a MALToma. The most specific and sensitive non-invasive test is the 13C urea breath test.
What are you most likely to hear on auscultation of a patient with LBBB and a previous MI?
A) Ejection systolic murmur
B) Fixed split second heart sound
C) Pan-systolic murmur
D) Quiet 2nd heart sound
E) Reverse split 2nd heart sound
Causes of a reverse split 2nd heart sound include: aortic stenosis, HOCM and IHD with LBB
Which of the following is the underlying cause of thyroid eye disease?
A) Apoptosis of fibroblasts
B) Glycosaminoglycan (GAG) deposition
C) Iatrogenic hypothyroidism
D) Inflammatory optic neuritis
E) IgG deposition
Fibroblasts are stimulated by anti-TSH receptors and activated T cells and lead to GAG deposition. GAG is hydrophilic so draws in water from surrounding tissues and leads to significant oedema. Visual changes result from pressure being placed on the optic nerve.
A 64Y/O smoker has a 12hr history of weakness in his legs and inability to pass urine. He is hypertensive with flaccid paralysis of the lower limbs. Pain and temperature sensation are impaired to T7 but joint position is unaffected in the lower limbs. What is the most likely diagnosis?
A) Acute transverse myelitis
B) Anterior spinal artery occlusion
C) Cauda equina syndrome
D) Cervical spondylosis with acute decompensation
E) Spinal tumour
Branches of the anterior spinal artery supply the anterior 2/3 of the spinal cord, with the posterior spinal arteries supplying the posterior third. There are segments of the cord in the watershed area between the branches T2-T4 which are vulnerable to ischaemia. It can present with sudden back pain with B/L flaccid weakness and dissociated sensory loss with impaired pinprick and temperature sensation below the level of the infarct. Proprioception and vibration sense are typically spared as they are conducted in the posterior columns.
Cauda equina could cause weakness in both legs but the sensory level at T7 localises the lesion to the spinal cord and not the more distal cauda equina.
A 55F presents with abdominal pain on BG of weight loss and night sweats. O/E there is significant splenomegaly and mild hepatomegaly but no clinical enlargement of the peripheral lymph nodes. FBC: RBC 89, WCC 5.4x10(9), platelets 470m MCV 85, reticulocytes 2.4%. Blood film shows elliptocytes, occasional myelocytes and nucleated RBC. Serum LDH 1256. What is the most likely diagnosis?
A) CML
B) Essential thrombocythaemia
C) Megaloblastic anaemia
D) Myelofibrosis
E) Non-Hodgkins lymphoma
Significant splenomegaly + mild hepatomegaly, normochromic anaemia and a relatively normal WCC. Blood film shows early WBC and RBC precursors (leukoerythroblastic blood picture). The significantly enlarged spleen and normal WCC strongly suggests myelofibrosis.
CML is the other differential for a significantly enlarged spleen but this would have a very elevated WCC.
A 71F is admitted for collapse shortly after complaining of a severe headache. She has a history of HTN with a BP 195/110. Her pupils are pinpoint, but just reactive to high-intensity light. She is comatose and gazing forward but there is no movement of the eyes on head turning. Tone is increased with plantars upgoing. What is the most likely cause of her stroke?
A) Lacunar haemorrhage
B) Lateral medullary syndrome
C) Pontine haemorrhage
D) Left middle cerebral artery infarct
E) Thalamic haemorrhage
The features that point towards a pontine haemorrhage are the loss of the dolls eye reflex (confirms a nuclear rather than supranuclear palsy) and B/L pinpoint pupils which are often features of pontine lesions.
Lateral medullary syndrome is associated with altered facial sensation ipsilaterally and altered limb sensation contralaterally. Thalamic haemorrhage is associated with contralateral sensory loss and ataxia.
A 64M on peritoneal dialysis due to T2DM is admitted with a NOF. Serum Ca 2.91, phosphate 2.2, PTH 0.4. He takes alfacalcidol and calcium carbonate TDS. What would a bone biopsy show?
A) Adynamic bone disease
B) Aluminium deposition at the osteoid bon interface
C) An increase in plasma cells
D) Osteitis fibrosa cystica
E) Osteoporosis
Adynamic bone disease is most prevalent in diabetic patients and those on peritoneal dialysis, and is associated with a higher risk of NOF. There is a tendency towards hypercalcaemia as the bone loses its capacity to buffer serum calcium. It can be caused by overtreatment with alfacalcidol. Histologically it is characterised by a reduction in both bone formation and resorption with thin osteoid seams, little active mineralisation and few osteoclasts.
A 24F with a history of anorexia is found to have sores and blisters over the legs and bony prominences which did not heal, thinning hair and a sore mouth. She is underweight with fine lanugo hair over her body and glossitis. Which nutrient deficiency is likely to have caused her symptoms?
A) Copper
B) Folic acid
C) Vitamin A
D) Vitamin C
E) Zinc
Zinc deficiency is common in AN patients and causes poor wound healing, hair loss and glossitis. Zinc is common in red meat and shellfish and may be present in some cereals and pulses - it is important to replace as it impairs an individuals ability to gain weight.
Vitamin C deficiency can present similarly but is uncommon in AN due to its abundance in fresh fruit and vegetables.
Which of the following is most likely to prevent curative surgery for lung carcinoma?
A) FEV1 of 1.6L
B) Hypercalcaemia
C) Local invasion by primary tumour through the chest wall
D) Malignant pleural effusions
E) Mediastinal lymph nodes enlarged on CT
Malignant pleural effusions usually imply widely disseminated disease and any treatment is often palliative.
A 32M presents with gradual onset B/L UL weakness especially affecting the hands and wrists. His only PMHx includes a rear shunt car accident a few months earlier. There is normal vibration and position sense in both UL with pain and temperature sensation lost over the shoulders and upper arms. There is distal power weakness affecting both hands and wrists. Which of the following is the most likely diagnosis?
A) Cervical myelopathy
B) Intramedullary spinal cord tumour
C) MS
D) Transverse myelitis
E) Syringomyelia
The gradual onset of dissociated sensory loss in a shawl-like distribution over the shoulders, coupled with distal weakness affecting both hands fits best with syringomyelia. It may also begin after an episode of trauma such as a traffic accident.
A 20M with epilepsy presents to ED with a 3 day history of cough and increasing SOB. He has foul smelling sputum. He had a generalised T-C seizure one week ago. O/E his temperature is 40 degrees, he has R sided creps and CXR shows right middle lobe infiltration. What is the most likely cause?
A) Mycoplasma pneumonia
B) Chemical pneumonitis
C) Pneumonia due to Gram -ve aerobes
D) Pneumonia due to Gram +ve aerobes
E) Pneumonia due to anaerobes
Anaerobic pleuropulmonary infections include aspiration pneumonia, necrotising pneumonitis, lung abscess and empyema. It is likely this patient aspirated following his seizure which has led to an anaerobic pneumonia. Patients will often mention a revolting taste and smell of their sputum.
Which of the following medications is most likely to cause significant warfarin resistance?
A) Amlodipine
B) Azathioprine
C) COCP
D) Mesalazine
E) Prednisolone
It is a recognised effect that azathioprine causes warfarin resistance but the exact mechanism is unclear ?induction of hepatic enzymes enhancing warfarin clearance.
A 50M chronic alcoholic presents with a persistent skin rash on his hands, arms, neck and face. The rash is red-brown in colour, symmetrical and scaly. He also complains of a poor appetite, nausea and diarrhoea. Which vitamin deficiency is most likely to have caused his symptoms?
A) Niacin
B) Thiamine
C) Vitamin B6
D) Folic acid
E) Zinc
Niacin (B3) deficiency is characterised by dermatitis, diarrhoea and dementia, a condition known as pellagra.
A 71M presents with severe pain around his right eye and vomiting. O/E the right eye is red and decreased visual acuity is noted. Which one of the following options is the most appropriate initial treatment?
A) Topical pilocarpine and PO steroids
B) Topical pilocarpine and topical steroids
C) Topical steroids
D) Topical pilocarpine and IV acetazolamide
E) Topical steroids and IV acetazolamide
Glaucoma is a disorder characterised by optic neuropathy as a result of raised IOP. In acute angle-closure glaucoma (AACG) there is a rise in IOP secondary to an impairment of aqueous outflow.
Features: severe ocular pain, headache, decreased visual acuity, worse with mydriasis
hard and red-eye, haloes around lights, semi-dilated non-reacting pupil. Emergency medical treatment is required to lower the IOP with more definitive surgical treatment given once the acute attack has settled. Medical treatment includes IV acetyzolamide and a combination of eye drops - a direct parasynthomimetic (pilocarpine), a b-blocker (timolol), and an alpha-2-agonist (apraclonidine). Definitive treatment is with laser peripheral iridotomy.
Which one of the following factors indicates a poor prognosis in patients with multiple sclerosis?
A) Relapsing-remitting disease
B) Presence of sensory symptoms
C) Young age of onset
D) Male sex
E) Long interval between first 2 relapses
Good prognosis features
-Female sex
-Age: young age of onset (i.e. 20s or 30s)
-Relapsing-remitting disease
-Sensory symptoms only
-Long interval between first two relapses
complete recovery between relapses
A typical patient carries a better prognosis than an atypical presentation.
A 12M presents with a purpuric rash on the extensor surfaces of his lower legs. He has a history of abdominal pain and an urticarial rash and has blood ++ in his urine. What would be the likely finding on renal biopsy?
A) Linear IgG deposits
B) No change
C) Sclerosis within the glomerulus
D) Mesangial hypercellularity
E) Basement membrane thickening
Henoch-Schonlein purpura (HSP) is an IgA mediated small vessel vasculitis. There is a degree of overlap with IgA nephropathy (Berger’s disease) but is usually seen in children following an infection. It is characterised by mesangial hypercellularity.
A 65M presents with 2W worsening shortness of breath, worse at night-time. Hx of well controlled HTN and childhood rheumatic fever. O/E you note a pulsation of the patients nail bed with a BP 170/56. What would you be most likely to hear on auscultation?
A) Continuous machinery murmur
B) Early diastolic murmur
C) Ejection systolic murmur
D) Late systolic murmur
E) Pan systolic murmur
Aortic regurgitation can present with symptoms including dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea. He is at risk of aortic regurgitation due to his history of rheumatic fever. Further signs are the wide pulse pressure (114mg) and nail-bed pulsation (Quincke’s sign).
Aortic regurgitation is associated with an early diastolic murmur, loudest on expiration.
A 34F with no past medical history presents following a fainting episode. She has had several recently and also has gradually worsening exertional breathlessness, which limits her from walking up a flight of stairs. An ECG and 24-hour tape have revealed right axis deviation. O/E she has normal heart and breath sounds, with mild peripheral oedema and a right ventricular heave. What test will be most important in deciding how this patient is managed?
A) CTCA
B) CTPA
C) HRCT
D) TTE
E) Vasodilator testing
Vasodilator testing is the cornerstone test in determining the management of pulmonary artery hypertension (PAH).
It usually affects 30-60YO women between and presents with exertional breathlessness and signs of right heart failure (e.g. right axis deviation suggests right ventricular hypertrophy, and peripheral oedema suggests right heart failure). The test involves giving vasodilator agents (e.g. nitric oxide, epoprostenol) and looking for a reduction in pulmonary arterial pressure (usually, a 10mmHg drop is classified as positive). 10-15% of PAH patients will be positive in this test, which suggests a likely benefit from calcium channel blockers in managing the condition. Those with a negative test are treated with prostacyclin analogs, endothelin receptor antagonists or phosphodiesterase inhibitors.
A patient diagnosed with chronic primary hyperparathyroidism was treated by parathyroidectomy and you are seeing him in clinic as a follow-up. His PTH and phosphate are now both in range but his calcium is found to be 1.7. What is the most likely explanation for this?
A) Osteomalacia
B) Hungry bone syndrome
C) Rickets
D) Scurvy
E) Parathyroid adenoma
Hungry bone syndrome rare condition that occurs as a result of a sudden drop in previously high parathyroid hormone levels. It is a significant complication of parathyroidectomy’s and causes hypocalcaemia.
On auscultation it is noted that the pulmonary component of the second heart sound occurs before the aortic. Which one of the following is associated with this finding?
A) Pulmonary stenosis
B) LBBB
C) RBBB
D) ASD
E) Deep inspiration
S2 is caused by the closure of the aortic valve (A2) closely followed by that of the pulmonary valve (P2).
Loud S2
-Hypertension: systemic (loud A2) or pulmonary (loud P2)
Soft S2
-Aortic stenosis
Fixed split S2
-Atrial septal defect
Widely split S2
-Deep inspiration
-RBBB
-Pulmonary stenosis
Reversed (paradoxical) split S2
-LBBB
-Severe aortic stenosis
-WPW type B (causes early P2)
-Patent ductus arteriosus
A 45F has blood tests taken and a urine sample dipped at a screening appointment for a clinical trial she has signed up for. All her results are normal except for an eGFR of 62 and +proteinuria. What is the most accurate description of these results?
A) CKD1
B) CKD2
C) CKD3a
D) CKD3b
E) No CKD
1 Greater than 90 ml/min, with some sign of kidney damage on other tests (if all the kidney tests* are normal, there is no CKD)
2 60-90 ml/min with some sign of kidney damage (if kidney tests* are normal, there is no CKD)
3a 45-59 ml/min
3b 30-44 ml/min
4 15-29 ml/min
5 Less than 15 ml/min - dialysis or a kidney transplant may be needed
A 72M is reviewed for management of chronic heart failure, established on bisoprolol, ramipril and eplerenone. He has ongoing symptoms of breathlessness and swelling of the legs. Obs are within range, ECG shows NSR and TTE shows LVEF of 30% with no evidence of valvular disease. What alteration to the patient’s medication is most appropriate?
A) Add hydralazine
B) Add spironolactone
C) Stop bisoprolol and start carvedilol
D) Stop ramipril and start ivabradine
E) Stop ramipril and start sacubitril-valsartan
Sacubitril-valsartan would be the most appropriate to commence as the patient has an LVEF <35%, is symptomatic and already established on an ACE-i and beta-blocker. This drug combines the neprilysin-inhibitor sacubitril with the angiotensin receptor blocker (ARB) valsartan. As sacubitril-valsartan contains an ARB it should only be commenced following a wash-out period of any ACEi or ARB a patient is already established on (in this case the patient’s ramipril should be stopped).
Hydralazine may be considered as an alternative third agent in the management of chronic heart failure. However, it must be used in combination with nitrates.
Spironolactone is an aldosterone antagonist used as a second-line agent . This patient has already been established on eplerenone (aldosterone antagonist), and remains symptomatic therefore another class of drug must be commenced.
Ivabradine is another third-line agent that can be used, however, the patient must have a resting heart rate of at least 75/min to be commenced on this drug.
OVERVIEW (with reduced EF)
1st line - ACEi + b-blocker
2nd line - aldosterone antagonist
3rd line - ivabradine, sacubitril valsartan, hydralazine in combo with nitrate, digoxin, cardiac resynchronisation therapy
A 37Fpatient presents with 5D of altered personality, visual and auditory hallucinations. On palpation, a mass is felt in the left iliac fossa. USS abdomen suggests a left ovarian tumour. What is the most likely diagnosis?
A) Meningitis
B) Anti-NMDA receptor encephalitis
C) Rabies
D) Japanese encephalitis
E) Mania
Anti-NMDA receptor encephalitis is a paraneoplastic syndrome which presents with prominent psychiatric features.
Which of the following organisms are common causes of peritonitis secondary to peritoneal dialysis?
A) Coag -ve Staph
B) Coag +ve Staph
C) E. coli
D) Gram -ve cocci
E) Group A strep
Coagulase-negative Staphylococcus species e.g. Staphylococcus epidermidis and Staphylococcus capitis peritonitis remains a common complication of peritoneal dialysis. S. Aureus would be the next most common organism.
A 65M presents with haematemesis. He has a past medical history of AF on warfarin. O/E HR 110, BP 94/58, there is dried blood around his mouth. Hb 101, INR 5.4. What is the most appropriate management of his anticoagulation?
A) Stop warfarin for x2 doses
B) Stop warfarin indefinitely
C) Stop warfarin and give IV vit K 3mg
D) Stop warfarin and give PO vit K 3mg
E) Stop warfarin and give IV vit K 5mg and PCC
The patient presents with major bleeding (haematemesis, anaemia, tachycardia, hypotension). The management of major bleeding on warfarin is to stop warfarin and give intravenous vitamin K 5mg and prothrombin complex concentrate.
If INR>8 and minor bleeding - stop warfarin and give IV vit K 3mg.
If INR>8 and no bleeding - stop warfarin and give PO vitamin K 3mg.
If INR 5.0-8.0 and no bleeding - stop warfarin for two doses.
Following a diagnosis of tetanus, what is the most appropriate antibiotic therapy to give with human tetanus immunoglobulin?
A) IV clarithromycin
B) IV benzylpenicillin
C) IV gentamicin
D) IV metronidazole
E) IV ciprofloxacin
IV metronidazole
Which factor would be most associated with a poor prognosis for patients with paracetamol overdose?
A) Hepatic encephalopathy
B) Previous paracetamol overdoses
C) INR 1.3
D) Arterial pH 7.03
E) AST 750 units/L
The single most important prognostic indicator in paracetamol overdoses is acidosis. Other indicators of reduced prognosis include a creatinine >300, and increased prothrombin time.
