MRCP Deck 2 June 2023 Flashcards
1
Q
A 50 y/o diabetic right-handed lady presents with left shoulder pain. She describes a stiff shoulder often more painful at night and has difficulty dressing or doing up her bra. There is no point tenderness and you notice weakness in external rotation. What is the most likely cause of her shoulder pain?
A) Acromioclavicular degeneration
B) Subacromial impingement
C) Rotator cuff tear
D) Calcific tendinopathy
E) Adhesive capsulitis
A
Adhesive capsulitis presents as a painful stiff shoulder with restriction of active and passive range of motion in abduction, internal and external rotation. However external rotation often shows the most marked restriction and is the first movement to show impairment. The stem describes difficulty dressing and doing up her bra as well as weakness of external rotation suggesting a globally impaired range of motion. Patients often report difficulty sleeping on the affected side. Other indications that the answer is adhesive capsulitis, include coexisting diabetes, female gender and symptoms in the non-dominant hand, all of which are common findings in this condition
2
Q
Which of the following is the first line management in BPH?
A) Alpha 1 antagonist
B) 5a reductase inhibitor
C) Non-urgent referral for TURP
D) Empirical treatment with ciprofloxacin for 2W
E) Urgent urology referral
A
Alpha-1 antagonists (tamsulosin, alfuzosin)
decrease smooth muscle tone of the prostate and bladder and are first-line in patients with benign prostatic hyperplasia.
5 alpha-reductase inhibitors (finasteride)
block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH - indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression.
3
Q
A 78F with a history of recurrent VT has routine blood tests 3 months after starting amiodarone therapy which indicates hypothyroidism. How should her thyroid dysfunction be managed?
A) Continue amiodaron and add folic acid
B) Stop amiodarone and start thyroxine
C) Stop amiodarone and start carbimazone and thyroxine
D) Stop amiodarone and repeat bloods in 4W
E) Continue amiodarone and start thryoxine
A
Patients who develop hypothyroidism whilst taking amiodarone can continue to take the drug if this is desirable. Given that this patient has a history of ventricular tachycardia it would be unwise to withdraw amiodarone abruptly.
4
Q
A defect in which immunoglobulin would account for the poor B-cell activation?
A) IgA
B) IgD
C) IgG
D) IgE
E) IgM
A
IgD is correct. Its role in the immune system is poorly understood, however, it is known that IgD is involved in the activation of B-cells. It is also known to bind to other immune cells, such as mast cells, aiding in the respiratory immune response.
5
Q
What are Lewy bodies made up of?
A) a-synuclein
B) B-amyloid
C) DNA inclusion bodies
D) Lipofuscin
E) Tau protein
A
A-synuclein
6
Q
Which pulse is associated with a PDA?
A) Collapsing
B) Jerky
C) Slow rising
D) Dichrotic
E) Thready
A
Collapsing
7
Q
In a patient with band keratopathy, which of the following investigations is likely to ascertain the underlying cause?
A) Cholesterol
B) Ferritin
C) U&E
D) Gamma GT
E) Calcium
A
Band keratopathy is caused by calcium deposition in the Bowman layer of the cornea.
8
Q
Which circumstance most strongly indicates a need for repeated oral administration of activated charcoal following a mixed overdose?
A) If a bleeding disorder develops
B) If it is given within 12h of ingestion of the poison
C) In cases of heavy-metal poisoning
D) In cases where gastric lavage is contra-indicated
E) In cases where the drug circulates through the enterohepatic circulation
A
Multiple doses of activated charcoal aid in the elimination of some drugs that are prone to enterohepatic circulation.
9
Q
Which of the following is an enzyme inhibitor?
A) Carbamazepine
B) Erythromycin
C) Glimepiride
D) Phenytoin
E) Rifampicin
A
Erythromycin
10
Q
Which feature would be most beneficial in making a diagnosis of Marfan’s disease?
A) Arachnodactyly
B) Early diastolic murmur
C) High arched palate
D) Joint hypermobility
E) Mid-systolic click
A
Early diastolic murmur indicates aortic valve incompetence secondary to aortic root dilatation, a major feature of Marfan syndrome. The other features are all examples of minor criterion.
11
Q
How does metformin cause diarrhoea?
A) Autonomic neuropathy
B) Osmotic diarrhoea
C) Secretory diarrhoea
D) Bile acid malabsorption
E) Steatorrhoea
A
Metformin and other biguanide medications are a cause of bile acid malabsorption.
12
Q
What is the most common mode of inheritance of Alport syndrome?
A) AD
B) AR
C) X-linked D
D) X-linked R
E) Mitochondrial
A
X-linked dominant.
It is due to a defect in the gene which codes for type IV collagen resulting in an abnormal glomerular-basement membrane (GBM).
13
Q
Which of the findings is the most likely to be reported upon flow cytometry of a blood sample from a patient with paroxysmal nocturnal haemaglobinuria?
A) C3-ve cells
B) CD55-ve cells
C) CD59-ve cells
D) C5 to C9-ve cells
E) C55 and CD59-ve cells
A
Flow cytometry for CD59 and CD55 is the gold standard test for paroxysmal nocturnal haemoglobinuria.
14
Q
A 24M presents with palpitations and pre-syncope. He has no past medical history. An ECG demonstrates T wave inversion and an epsilon wave in leads V1-V3. Given the likely diagnosis, what is the expected pathological finding in this condition?
A) Apical biventricular ballooning
B) Asymmetric hypertrophy of the left ventricle with septal thickening
C) Non-caseating granulomata
D) No gross anatomic findings
E) Asymmetric hypertrophy of the left ventricle with septal thickening
A
Arrhythmogenic right ventricular cardiomyopathy is characterised by right ventricular myocardium replaced by fatty and fibrofatty tissue.
15
Q
Where is the site of action of bendroflumethiazide?
A) Proximal collecting duct
B) Ascending loop of Henle
C) Descending loop of Henle
D) Proximal part of DCT
E) Distal part of DCT
A
Thiazides/thiazide-like drugs (e.g. indapamide) - inhibits sodium reabsorption by blocking the Na+-Cl− symporter at the beginning of the distal convoluted tubule. Potassium is lost as a result of more sodium reaching the collecting ducts.
16
Q
Which one of the following vaccines uses a protein that attaches to the polysaccharide outer coat to make the pathogen more immunogenic?
A) Rabies
B) Yellow fever
C) Oral polio
D) Meningococcus
E) Measles
A
Meningococcus is a conjugate vaccine.
All of the others are live attenuated vaccines except for rabies which is an inactivated vaccine.
17
Q
Which one of the following markers is most useful for monitoring the progression of patients with COPD?
A) FEV1/FVC ratio
B) Lifestyle questionnaire
C) O2 sats
D) FEV1
E) Number of exacerbations per year
A
The severity of COPD is categorised using the FEV1.
18
Q
Which one of the following is a contraindication to the use of a triptan in the management of migraine?
A) Concurrent pifotzen use
B) >55 years old
C) History of epilepsy
D) Previous intracranial tumour
E) History of IHD
A
Cardiovascular disease is a contraindication to triptan use.
19
Q
A 72M is admitted to the local hospice for symptom control. His main problem at the moment is intractable hiccups. What is the most appropriate management?
A) Chlorpromazine
B) Codeine phosphate
C) Diazepam
D) Methadone
E) Phenytoin
A
Hiccups in palliative care - chlorpromazine or haloperidol.
20
Q
What proteins is a patient with coeliac disease and dermatitis herpetiformis most likely to test positive for?
A) Anti-CCP
B) HLA-B27
C) HLA-DR3
D) HLA-DR4
E) RF
A
Dermatitis herpetiformis is associated with HLA-DR3.
HLA-DQ2/DQ8 = coeliac disease
HLA-DR4 is associated with type 1 diabetes mellitus and RA, and not with coeliac or dermatitis herpetiformis.
21
Q
What additional health benefits might the COCP provide?
A) Decreased risk of breast cancer
B) Decreased risk of cervical cancer
C) Decreased risk of endometrial cancer
D) Decreased risk of STI
E) Decreased risk of stroke and IHD
A
-Increased risk of breast and cervical cancer
-Protective against ovarian and endometrial cancer
-Increased risk of VTE
-Increased risk of stroke and IHD
22
Q
A CT head report describes a hypodense collection around the convexity of the brain that is not limited to suture lines. What is the most likely radiological diagnosis?
A) SAH
B) Extradural haematoma
C) Acute subdural haematoma
D) Chronic subdural haematoma
E) Intracerebral haematoma
A
On CT imaging, a chronic subdural haematoma will appear as a hypodense (dark), crescentic collection around the convexity of the brain.
On CT imaging, acute haematomas appear bright (hyperdense) whereas chronic haematomas appear dark (hypodense). Extradural haematomas are limited by suture lines whereas subdural haematomas are not. Subarachnoid haemorrhage are typically seen as hyperdensity within the basal cisterns and sulci of the subarachnoid space.
23
Q
What cells are primarily responsible for producing interferon-gamma?
A) Fibroblasts
B) Leucocytes
C) Mast cells
D) Monocytes
E) Natural killer cells
A
Interferon-gamma is produced primarily by natural killer cells and T helper cells.
24
Q
Which of the following organisms are most likely to be responsible in the pathogenesis of colorectal cancer?
A) Streptococcus bovis
B) Staphylococcus epidermidis
C) Coxiella burnetii
D) Streptococcus mitis
e) Staphylococcus aureus
A
Studies have shown an increased risk of colorectal cancer is patients with streptococcus bovis endocarditis.
25
What is the MOA of fleicanide?
A) Alpha blocker
B) Beta blocker
C) Calcium channel blocker
D) Potassium channel blocker
E) Sodium channel blocker
Sodium channel blocker
26
Which of the following is a recognised complication of bronchial carcinoma?
A) IgA nephropathy
B) Membranoproliferative glomerulonephritis
C) Membranous glomerulonephritis
D) Minimal change glomerulonephritis
E) Post-streptococcal glomerulonephritis
Membranous glomerulonephritis
27
Which of the following medications is most likely to cause a seizure as a side-effect?
A) Diazepam
B) Amiodarone
C) Clomethiazole
D) IV benzylpenicillin
E) Chlordiazepoxide
High dose IV penicillin can provoke seizures, as can other antibiotics including quinolones (ciprofloxacin).
28
Where may compression of the trigeminal nerve, secondary to an acoustic neuroma, be most likely to be occurring?
A) Brainstem
B) Cavernous sinus
C) Cerebellopontine angle
D) Skull base
E) Trigeminal ganglion
Lesions at the cerebellopontine angle resulting in fifth nerve damage include acoustic neuroma, meningioma and secondary tumour deposits.
28
What is the most appropriate intervention for tics in a patient with Tourette syndrome?
A) Diazepam
B) Risperidone
C) Ropinorole
D) Sodium valproate
E) Carbamazepine
Risperidone
29
Which of the following contributes the most to increased pulse pressure as a person ages?
A) Decreased aortic compliance
B) Increased aortic compliance
C) Increased peripheral vascular resistance
D) Decreased peripheral vascular resistance
E) Decreased left ventricular wall compliance
Decreased aortic compliance with increased age means the aorta is less able to absorb the pulse wave that comes from left ventricular contraction, increasing pulse pressure.
Peripheral vascular resistance increases with age and increases the general BP rather than the pulse pressure.
30
A 23M with rheumatoid arthritis is planning to start a family. Which of the following drugs would be safest to prescribe?
A) Cyclophosphamide
B) Hydroxychloroquine
C) Leflunomide
D) Methotrexate
E) Sulfasalazine
Hydroxychloroquine is considered safe pre-conception, in pregnancy and in breast-feeding women and in men hoping to start a family.
31
Which of the following is most likely to cause blue vision as a side effect?
A) Digoxin
B) Metformin
C) Prazosin
D) Ramipril
E) Sildenafil
Sildenafil is a phosphodiesterase V inhibitor used in the treatment of erectile dysfunction which can cause blue visual discolouration as a side effect.
Digoxin leads to a yellow discolouration of vision as a side effect.
32
Which of the following murmurs is most associated with angiodysplasia?
A) AR
B) AS
C) MR
D) MS
E) TR
The association of angiodysplasia leading to colonic bleeding and aortic stenosis is known as Heyde's syndrome.
33
Which intervention would be most appropriate for a patient with ABPA not controlled on 40mg PO prednisolone?
A) Further oral steroids
B) Nebulised budesonide
C) PO clarithryomycin
D) PO itraconazole
E) Regular nebulised salbutamol
The addition of PO itraconazole to established corticosteroid therapy in ABPA has been found to be beneficial.
34
A patient who has overdosed on bisoprolol presents with a HR of 30bpm, BP 80/60 with no ischaemic changes on ECG. She has failed to respond 3mg of atropine. Which of the following is the next most obvious step?
A) IM adrenaline
B) Glucagon infusion
C) IV calcium gluconate
D) IV NaCl
E) Transvenous pacing
Glucagon infusions can be trialled whilst transcutaneous pacing is being set up.
IM adrenaline would be a last resort option in patients who have failed to respond following glucagon infusion and transcutaneous pacing (different to transvenous pacing).
35
Which of the HIV peptides is thought to play a role in the initial step for HIV entry into cells?
A) CCR5
B) CXCR4
C) GP41
D) P55
E) P160
Gp120 fuses to the CD4 receptor which allows GP41 to penetrate the cell membrane.
CCR5 and CXCR4 are co-receptors on the WBC that is used by HIV to allow entry into the cell.
36
In a patient with homocysteinuria, which of the following enzymes is most likely to be deficient?
A) Cystathione beta synthase
B) Cystinosin
C) Homogentisate oxidase
D) Malonyl decarboxylase
E) Phenylalanine hydroxyls
Cystathione beta synthase
Phenylalanine hydroxyls deficiency leads to the development of phenylketonuria.
37
Which of the following vaccines should be avoided in a patient with an egg allergy?
A) Hepatitis A
B) Influenza
C) MMR
D) Typhoid
E) Varicella
Conventional influenza vaccine is produced using eggs and should be avoided in a patient with an egg allergy.
38
Which of the following is known to stimulate the release of pancreatic enzymes?
A) CCK
B) Gastrin
C) GLP-1
D) Secretin
E) VIP
CCK stimulates the acinar cells to release pancreatic enzymes.
39
To which venous structure to oesophageal varices drain to?
A) Azygous vein
B) Hepatic vein
C) IVC
D) Splenic vein
E) SVC
Oesophageal varices drain into the azygous vein which drain into the SVC.
40
What are the driving restrictions in place for a patient with an ICD implanted following VT?
A) He should no longer drive a bus
B) He may continue to drive a car with no break
C) He should not drive any vehicle for one year after the procedure
D) He may drive a bus after 6M
E) He may drive a car after 1M
Patients with an ICD implanted after VT associated with incapacity are no longer permitted to drive a public service or heavy goods vehicle.
He is not permitted to drive a car until 6M after the procedure.
41
Which of the following correctly describes the way to measure the QT interval?
A) Beginning of the Q wave to the end of the T wave
B) End of the Q wave to the end of the T wave
C) End of the Q wave to the beginning of the T wave
D) End of the Q wave to the mid-point of the T wave
E) Mid-point of the Q wave to the beginning of the T wave
Beginning of the Q wave to the end of the T wave
42
A 22 year old patient with testicular feminisation presents to the clinic for review. What would you expect the patients phenotype to be?
A) Female with clitoromegaly
B) Female with normal genitalia but with no pubic or axillary hair
C) Female with normal genitalia and short stature
D) Male with testicular size and body hair
E) Male with small testicular size and sparse body hair
Patients with androgen insensitivity syndrome have no pubic or axillary hair, and scanty hair on the rest of the body. Patients with AIS are infertile.
43
Which of the following immunoglobulin isotope has the highest concentration in serum?
A) IgA
B) IgD
C) IgE
D) IgG
E) IgM
IgG
44
Which radiological feature would be most suggestive or rheumatoid arthritis?
A) Decreased joint space
B) Lipping at the joint margins
C) Periarticular osteoporosis
D) Punched out erosions in junta-articular bone
E) Sunchondral sclerosis
Periarticular osteoporosis is a characteristic finding in patients with rheumatoid arthritis on XR.
Punched out erosions in juxta-articular bone are seen in gouty arthritis.
45
Which of the following is the underlying pathophysiology of hepatorenal syndrome?
A) Renal afferent arteriolar vasodilation
B) Renal efferent arteriolar vasodilation
C) Splanchnic vasoconstriction
D) Splanchnic vasodilation
E) Systemic vasodilation
Splanchnic vasodilation lies at the heart of the hepatorenal syndrome.
46
Which of the following is considered essential before starting chemotherapy?
A) Benzbromarone
B) Colchicine
C) GCSF
D) Ibuprofen
E) Rasburicase
Rasburicase is a recombinant urate oxidase, which, as part of a pre-treatment including rehydration has been shown to reduce the risk of rate nephropathy after induction chemotherapy.
46
Which of the following is the mechanism that drives gentamicin toxicity?
A) Acute glomerulonephritis
B) Acute interstitial nephritis
C) Afferent arteriolar hypotension
D) Distal tubular dysfunction
E) Proximal tubular dysfunction
Proximal tubular dysfunction
47
For which one of the following would drug concentrations be most helpful in the context of a suspected drug overdose?
A) Chlorpromazine
B) Diazepam
C) Imipramine
D) Morphine
E) Paraquat
Paraquat concentration can aid in assessing prognosis and clinical decision-making regarding treatment.
47
Consumption of which vitamin may reduce a patients risk of developing colon cancer?
A) Vitamin A
B) Vitamin B12
C) Vitamin C
D) Vitamin D
E) E
Vitamin D
48
A patient presents following a STEMI. What is the most appropriate intervention whilst awaiting PCI?
A) Aspirin, clopidogrel, LMWH
B) Aspirin, clopidogrel, fondaparinaux
C) Aspirin, clopidogrel, unfractionated heparin
D) Aspirin and prasugrel
E) Aspirin, ticagrelor, abciximab
Aspirin and prasugrel
48
Which of the following is most likely to cause erythema nodosum as a side effect?
A) Metformin
B) Omeprazole
C) Ramipril
D) Sitagliptin
E) Simvastatin
Omeprazole
49
Which of the following is most likely to gain symptom relief for a patient with SVC compression?
A) CT guided tumour biopsy and targeted chemotherapy
B) Endovascular stunting
C) IV corticosteroids
D) Surgical debulking
E) Urgent radiotherapy
Endovascular stenting allows rapid symptom relief.
Surgical debunking would not be appropriate due to technical difficulties and limited life expectancy.
50
A patient has an absent corneal reflex in the left eye when stimulated but an intact consensual response in the left eye when the right eye is stimulated. Which of the following nerves is likely to be damaged?
A) III
B) IV
C) V
D) VI
E) VII
The examination indicates the afferent pathway for the left eye corneal reflex is damaged but the efferent pathway is intact. The nasociliary branch of the ophthalmic branch of the 5th cranial nerve is responsible for sensing the stimulus on the cornea.
51
Which of the following genetic conditions would be most associated with a risk of developing breast cancer?
A) Ataxia-telangiectasia
B) Chediak-Higashi syndrome
C) CF
D) Huntingtons disease
E) Von-hippel Lindau
Ataxia-telangiectasia
52
A 64F presents with unexplained IDA with UGI endoscopy showing one duodenal ulcer with no active bleeding. What is the most appropriate next step?
A) Capsule endoscopy
B) Colonoscopy
C) Omeprazole and review of symptoms in 3M
D) Omeprazole and repeat UGI endoscopy in 3M
Colonoscopy.
Capsule endoscopy would only be indicated after normal upper and lower GI endoscopies.
53
What is the poorest prognostic factor in a patient with B-cell ALL?
A) Abnormal LFTs
B) Age of 21
C) Anaemia
D) Mediastinal mass
E) 9:22 translocation
The Philadelphia translocation (9:22) is associated with the poorest outcome.
54
A patient is on 40mg prednisolone for SLE. Her creatinine is 132 (50-120). She presents with joint pains, night sweats and thrombocytopenia (platelet count 40x10(9)). Which of the following is the best way to treat her thrombocytopenia?
A) Ciclosporin A
B) Eltrombopag
C) Hydroxychloroquine
D) Increased prednisolone
E) Platelet transfusion
Azathioprine, Ciclosporin A and hydroxychloroquine can all be effective in treating cytopenias in SLE but hydroxychloroquine is particularly effective in treating joint pains and has less of an impact on renal function.
She is already on a relatively high dose of prednisolone so increasing it would not be appropriate.
55
A patient with ulcerative pan colitis was not being managed despite treatment with IV hydrocortisone. Which of the following options about treatment options is correct?
A) Ciclosporin is indicated to induce remission
B) CMV is a common cause of non-repsonsive colitis
C) Methotrexate is indicated to induce remission
D) NDAIS are a useful adjunct to therapy
E) Surgery is contra-indicated
The options for treating acute severe UC not responding to IV steroids include IC cyclosporin or infliximab (medical), or subtotal colectomy (surgical).
56
Which of the following has the strongest evidence of reducing the risk of colon cancer?
A) Aspirin
B) HRT
C) Ramipril
D) Simvastatin
E) Vitamin A
Aspirin
57
Which of the following is the least likely diagnosis to be confirmed with bronchoscopy with transbronchial lung biopsy?
A) Cryptogenic organising pneumonia
B) EAA
C) Idiopathic pulmonary fibrosis
D) Lymphangitis carcinomatosa
E) Sarcoidosis
IPF can be patchy disease and transbronchial bronchoscopy may reveal established fibrosis with no particular aetiology. If a biopsy is required, then a surgical biopsy guided by HRCT will produce better specimens.
58
Which of the following is second line treatment for bipolar disorder in a patient who does not respond to lithium?
A) Carbamazepine
B) Citalopram
C) Lamotrigine
D) Sodium valproate
E) Topiramate
Valproate is second like therapy for those who don't respond to lithium.
Lamotrigine is for patients in whom lithium and valproate are contraindicated. Carbamazepine is third or fourth line treatment.
59
Which of the following is most commonly associated with erythema multiforme?
A) Coeliac disease
B) Herpes simplex infection
C) Rheumatoid arthritis
D) Sarcoidosis
E) Tuberculosis
HSV infection. It can also follow mycoplasma infection and can be associated with a variety of other viral infections (including HIV and hepatic viruses).
60
Which of the following anti-hypertensives may help reduce difficulties with urinary incontinence?
A) Amlodipine
B) Atenolol
C) Doxazosin
D) Valsartan
E) Verapamil
Alpha blockers, such as doxazosin, may be useful in patients with spinal cord injury who have incontinence due to autonomous bladder activity.
61
Increased incidence of which cancer is associated with acromegaly?
A) Breast cancer
B) Colorectal cancer
C) Endometrial cancer
D) Lung cancer
E) Oesophageal cancer
Colorectal cancer
62
What is the relationship between standard deviation and variance?
A) SD = mean x variance
B) SD = mean - variance
C) SD = variance
D) SD = variance squared
E) SD = square root of variance
SD = square root of variance
Variance is a measure of the spread of scores away from the mean.
63
What is the treatment for schistosomiasis?
A) Albendazole
B) Trimethoprim
C) Prednisolone
D) Doxycycline
E) Praziquantel
Praziquantel
64
Which of the following conditions may a botox injection be found to be beneficial?
A) Diverticular disease
B) Haemorrhoids
C) Crohns
D) IBS
E) Achalasia
Botulinum toxin is used therapeutically in achalasia, often in cases where the patient is not suitable for surgical intervention (for example in some elderly patients).
65
What is the mechanism of action of varenicline?
A) Norepinephrine and dopamine reuptake inhibitor and nicotinic receptor antagonist
B) Dopamine agonist
C) Dopamine antagonist
D) SSRI
E) Nicotinic receptor partial agonist
A nicotinic receptor partial agonist.
Bupropion is a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist.
66
A 64M is admitted with chest pain radiating through to his back. Pulse 90 regular, BP 140/90. A CXR shows mediastinal widening. A CT shows dissection of the descending aorta. What is the most suitable initial management?
A) Observe only
B) IV labetalol
C) IV sodium nitroprusside
D) Emergency surgery
E) Oral verapamil
Aortic dissection
-Type A - ascending aorta - control BP (IV labetalol) + surgery
-Type B - descending aorta - control BP(IV labetalol)
67
A patient has a past medical history of colorectal cancer and presents with peripheral oedema, frothy urine and deranged urea and creatinine consistent with nephrotic syndrome. What is the most likely underlying diagnosis?
A) Amyloidosis
B) FSGS
C) Membranoproliferative glomerulonephritis
D) Membranous nephropathy
E) Minimal change disease
Given the patient's background of colorectal carcinoma, the most likely underlying cause is membranous nephropathy, as this is the option most frequently associated with malignancy.
Biopsy would show subepithelial immune complex deposits and management typically involves the use of ACE inhibitors and immunosuppression.
68
Which of the following would be the most likely ECG finding of organophosphate poisoning?
A) Atrial flutter
B) Sinus bradycardia
C) VF
D) VT
E) QTc interval shortening
The most common feature is bradycardia due to overwhelming cholinergic activity.
69
Which one of the following is least associated with thymomas?
A) SIADH
B) Myasthenia gravis
C) Red cell aplasia
D) Dermatomyositis
E) Motor neurone disease
Motor neurone disease
69
Which one of the following is least associated with thymomas?
A) SIADH
B) Myasthenia gravis
C) Red cell aplasia
D) Dermatomyositis
E) Motor neurone disease
Motor neurone disease
70
During which stage of the cell cycle does vincristine act?
A) Anaphase
B) Cytokinesis
C) Metaphase
D) Prophase
E) Telophase
Metaphase is when chromosomes align at the middle at of the cell and then begin to separate. Vincristine disrupts this process by binding to the tubulin protein, preventing the formation of microtubules and preventing the initiation of chromosome separation. The cell will then undergo apoptosis.
71
Which of the following medications should be avoided in a patient who is breast-feeding?
A) Aspirin
B) Erythromycin
C) Warfarin
D) Thyroxine
E) Heparin
Aspirin should be avoided due to the risk of Reye syndrome.
72
Which of the following medications should be avoided in a patient who is breast-feeding?
A) Aspirin
B) Erythromycin
C) Warfarin
D) Thyroxine
E) Heparin
Aspirin should be avoided due to the risk of Reye syndrome.
73
\which of the following is the most appropriate prophylaxis treatment for close contacts of a patient diagnosed with meningococcus meningitis?
A) Amoxicillin
B) Ciprofloxacin
C) Penicillin V
D) Ceftriaxone
E) No intervention needed
Ciprofloxacin
74
Which of the following medications would pose the greatest hazard during desensitisation treatment?
A) Amlodipine
B) Beclometasone
C) Losartan
D) Ramipril
E) Salmeterol
The use of ACEi during desensitisation therapy may result in prolonged and severe systemic allergic reactions.
75
A 40M with learning difficulties is noted to have a small stature and large head circumference, with a large jaw and ears and pale irises. What is the most likely diagnosis?
A) Down syndrome
B) Tuberous sclerosis
C) Prader-Willi
D) Fragile X
E) Lesch-Nyhan syndrome
Fragile X syndrome is the most common hereditary cause of mental disability. Patients often have a shorter than average height and a larger than average head circumference.
76
Which of the following medications is likely to have the greatest impact in reducing proteinuria in a patient with minimal change disease?
A) Ciclosporin
B) Cyclophosphamide
C) Diltiazem
D) Prednisolone
E) Ramipril
Corticosteroids are the treatment for minimal change disease that has been confirmed in a patient with proteinuria and on renal biopsy.
77
Which of the following is characteristic of a patient with diabetes?
A) H LDL, L HDL, H Triglycerides
B) H LDL, H HDL, N Triglycerides
C) H LDL, L HDL, N Triglycerides
D) N LDL, H HDL, H Triglycerides
E) N LDL, L HDL, H Triglycerides
N LDL, L HDL, H Triglycerides
78
Which one of the following drugs causes shortening of the QT interval?
A) Digoxin
B) Sotalol
C) Amiodarone
D) TCAs
E) Chloroquine
Digoxin causes shortening of the QT interval whilst the other four drugs cause QT prolongation.
79
A 59F is admitted with a productive cough and pyrexia. She is usually fit and well but is undergoing investigation for dysphagia. This has been present for the past 3M and affects both food and drink. CXR shows an air-fluid level behind a normal-sized heart. What is the most likely diagnosis?
A) Massive pericardial effusion
B) TB
C) Achalasia
D) Pharyngeal pouch
E) Hiatus hernia
A retrocardiac air-fluid level is sometimes seen in patients with achalasia.
80
A 72M is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of the following is it most important to co-prescribe for the first three weeks of treatment?
A) Tamoxifen
B) Lansoprazole
C) Allopurinol
D) Cyproterone acetate
E) Tamsulosin
Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin analogues due to the risk of tumour flare. This phenomenon is secondary to initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels.
The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.
81
A 30F presents with a 3-day history of vulval discomfort associated with frothy, green vaginal discharge which smells offensive. An examination reveals a 'strawberry cervix'. Examination of a sample of the discharge shows a pH of 5.5 and motile trophozoites. She has no past medical history. What antimicrobial course is most suitable for the GP to prescribe?
A) IV ceftriaxone
B) IV metronidazole
C) PO doxycycline
D) PO fluconazole
E) PO metronidazole
Trichomonas vaginalis - treat with 5-7 days oral metronidazole
82
A diagnosis of tricuspid regurgitation is suspected. Which one of the following additional features would be most supportive of this diagnosis?
A) Split first heart sound
B) Early diastolic murmur
C) Left parasternal heave
D) Wide pulse pressure
E) Cannon a waves
Left parasternal heave is a feature of tricuspid regurgitation.
83
Which one of the following cardiac conditions is most associated with a louder murmur following the Valsalva manoeuvre?
A) MS
B) MR
C) AS
D) HOCM
E) VSD
HOCM
-ejection systolic murmur: due to left ventricular outflow tract obstruction. Increases with Valsalva manoeuvre and decreases on squatting
-pansystolic murmur: due to systolic anterior motion of the mitral valve → mitral regurgitation
84
A 34F attends the clinic with a 4-week history of perianal itching. Her young daughter has also been suffering from the same symptoms. The family has no recent significant travel history. What organism is implicated?
A) Ascaris lumbricoides
B) Enterobius vermicularis
C) Echinococcus multilocularis
D) Schistosoma mansoni
E) Wuchereria bancrofti
The history is highly suggestive of a threadworm infection which is caused by the organism Enterobius vermicularis. CKS recommend a combination of anthelmintic with hygiene measures for all members of the household.
85
Which of the following features about carcinoid tumours are true?
A) Fibrosis of the heart valves is a recognised feature
B) 50% of patients die within 2M of diagnosis
C) Octreotide is not useful at controlling the diarrhoea
D) Presentation only occurs after metastasis
E) They most commonly involve the colon
Fibrosis of the heart valves is a recognised feature. It is the valves on the R side of the heart that are most frequently affected.
Carcinoid tumours may arise from either the GI tract or from the bronchi. The majority of tumours arise from the jejunum or the ileum.
86
Which of the following conditions is associated with an increased risk of gallstones?
A) Gastritis
B) Coeliac disease
C) Crohns disease
D) UC
E) High HDL levels
Crohns disease
87
Which of the following would increase aldosterone secretion?
A) Hypokalaemia
B) Hyponatraemia
C) Hypervolaemia
D) MAP 110 mmHg
E) Taking NSAIDs
Hyponatramia - aldosterone stimulates Na+ reabsorption through exchange of the Na/K pump in the distal tubules and collecting ducts. Reduced Na levels will stimulate the release of renin and hence aldosterone, stimulating the reabsorption of sodium.
88
A patient is taking codeine sulphate 60mg four times a day for pain however this is still poorly controlled. The decision is made to convert this to oral morphine. What is the equivalent dose of oral morphine daily?
A) 6mg
B) 20mg
C) 24mg
D) 80mg
E) 120mg
Codeine to morphine - divide by 10
89
A 60M is diagnosed as having angina pectoris. Which one of the following drugs is most likely to improve his long-term prognosis?
A) Aspirin
B) Atenolol
C) ISMN
D) Ramipril
E) Nicorandil
Strong evidence exists supporting the use of aspirin in stable angina. The benefit of ACE inhibitors and beta-blockers are significant in patients who've had a myocardial infarction but modest in those with stable angina.
90
What is the most appropriate test to check for latent tuberculosis?
A) Mantoux test
B) Heaf test
C) Sputum culture
D) IGRA
E) CXR
The Mantoux test is the main technique used to screen for latent tuberculosis. In recent years the interferon-gamma blood test has also been introduced. It is used in a number of specific situations such as:
-the Mantoux test is positive or equivocal
-people where a tuberculin test may be falsely negative
91
With respect to the coagulopathy associated with liver disease, which clotting factor is characteristically increased?
A) Factor VIII
B) Factor II
C) Factor IX
D) Factor VII
E) Factor XII
In liver failure all clotting factors are low, except for factor VIII which is paradoxically supra-normal. This is because factor VIII is synthesised in endothelial cells throughout the body, unlike the other clotting factors which are synthesised purely in hepatic endothelial cells.
92
Which one of the following features would best indicate severe aortic stenosis?
A) Valvular gradient of 35mmHg
B) Quiet first heart sound
C) Loudness of ejection systolic murmur
D) Fourth heart sound
E) Development of an opening snap
Aortic stenosis - S4 is a marker of severity
93
Where are the fastest conduction velocities in the heart?
A) AV node
B) Bachmann's bundle
C) Bundle of His
D) Myocardium
E) Purkinje fibres
Purkinje fibres are of large diameter and achieve velocities of 2-4 m/s, the fastest conduction in the heart. This rapid conduction allows coordinated ventricular contraction.
AV node has the slowest conduction velocity in the heart (0.05 m/s). This conduction delay between the atria and the ventricles facilitates the completion of the ventricular filling from the atrial kick before the ventricular contraction begins.
94
Which one of the following causes of thrombophilia is associated with resistance to heparin?
A) Protein S deficiency
B) Antithrombin III deficiency
C) Protein C deficiency
D) Lupus anticoagulant
E) Activated Protein C resistance
Heparin works by binding to antithrombin III, enhancing its anticoagulant effect by inhibiting the formation of thrombin and other clotting factors. Patients with antithrombin III deficiency may therefore by resistant to heparin treatment.
95
A 29M is on a hiking expedition up Mount Everest. Upon reaching around 5000m, he starts to feel unwell, complaining to his team members of headache. He appears to have poor coordination and slurred speech. Given the likely occurrence, what is the most appropriate treatment?
A) Descent and acetazolamide
B) Descent and dexamethasone
C) Descent and mannitol
D) Descent and nifedipine
E) Descent and oxygen
Management of high altitude cerebral oedema (HACE) is with descent + dexamethasone.
Descent with acetazolamide is incorrect. This would be appropriate for high altitude pulmonary oedema (HAPE), which would present with classic pulmonary oedema features. Acetazolamide may also be used for acute mountain sickness (AMS), which is generally self-limiting.
96
Which of the following would favour a diagnosis of vascular dementia over Alzheimers disease?
A) Social disinhibition and irritability
B) Frequent seizures
C) Slow, insidious onset
D) Early loss of insight
E) Disrupted sleep-wake cycle
Seizures are more common in patients with vascular dementia due to neuronal irritability in places where there is vascular compromise.
97
Which of the following results would qualify a patient who has taken a paracetamol overdose for a super-urgent liver transplant?
A) Cr 230 INR 2.8
B) AST 1650 ALT 1800
C) pH 7.28
D) Bilirubin 150
E) Grade 1 encephalopathy
The Kings criteria are used to determine which patients would benefit the most for liver transplantation:
pH <7.3
OR
INR >6.5 + Cr >300 + grade 3/4 hepatic encephalopathy
98
Which of the following arteries is likely to be responsible for a large pontine bleed?
A) Anterior cerebral
B) Basilar
C) Middle cerebral
D) Posterior communicating
E) Posterior temporal
The pons is part of the brainstem that is supplied by small pontine branches of the basilar artery. These are a well recognised site of intracerebral haemorrhage related to poorly controlled HTN and arterio-venous malformations.
99
Which of the following is the most likely complication of a patient with PCP?
A) Meningitis
B) Hepatosplenomegaly
C) Meningitis
D) Pancreatitis
E) Pneumothorax
Pneumothorax. Hepatosplenomegaly is a complication but is not as common as pneumothoraces.
100
Which of the following tumours are most associated with FAP?
A) Endometrial cancer
B) Glioblastoma
C) Ovarian cancer
D) Lung cancer
E) Medulloblastoma
Medulloblastoma.
HNPCC is more associated with glioblastomas, ovarian and endometrial cancer.
101
A 45M is admitted following a methanol overdose. His BP is 102/60, HR 95, RR 28, GCS 5, Bicarb 12, pH 7.2 and methanol level 730mg/l. Which of the following is the most appropriate intervention?
A) Ethanol infusion
B) IV abx
C) Haemodialysis
D) IV fluid rehydration
E) NG activated charcoal
Methanol levels >500mg/l are treated as severe poisoning with harm-dialysis indicated to extensively remove the circulating methanol.
Indications for haemodialysis:
->30ml methanol ingested
-serum methanol >20mg/dl (200mg/l)
-observation of visual complications
-no improvement of acidosis despite repeated IV sodium bicarbonate
Ethanol or fomepizol are indicated for mild-moderate poisoning severity.
102
What is the best treatment for postpartum thyrotoxicosis?
A) Carbimazole
B) Levothyroxine
C) Propranolol
D) Propylthiouracil
E) Radioiodine
Propranolol for symptomatic relief. Postpartum thyroiditis is transient in nature and hence anti-thyroid medications is not recommended.
103
A 65M with metastatic prostate cancer receiving chemotherapy presents to the emergency department with intolerable diffuse back pain. Despite taking regular MR morphine, the pain does not seem to be settling down. What is the most appropriate next step in managing his pain?
A) Dexamethasone
B) Radiotherapy
C) Surgery
D) Lidocaine patch
E) Bisphosphonates
Bisphosphonate are is used as a treatment when analgesic medications such as opioids are no longer effective in the treatment of bone cancer pain.
Radiotherapy can be delivered to the area of the bone affected by cancer. It can take up to 6-weeks before you feel the full effect of radiotherapy, meaning that bisphosphonates work quicker.
104
What is the mechanism of action of dabigatran?
A) Activates anti-thrombin III
B) P2Y12 inhibitor
C) Glycoprotein IIb/IIIa inhibitor
D) Direct thrombin inhibitor
E) Direct factor Xa inhibitor
Dabigatran is a direct thrombin inhibitor.
105
What is the first-line management of pityriasis versicolor?
A) Imidazole cream
B) Ketoconazole shampoo
C) PO itraconazole
D) Selenium sulphide shampoo
E) Take skin scrapings
Ketoconazole shampoo is used to treat pityriasis versicolor.
A topical cream such as imidazole would be less appropriate in this scenario, given the widespread nature of the rash. If a much smaller area was affected, cream would be more suitable.
106
A 45M is started on ciclosporin following a renal transplant. Which one of the following adverse effects is most likely to occur?
A) Depression
B) Increased risk of IHD
C) Pulmonary fibrosis
D) Optic neuritis
E) Nephrotoxicity
Ciclosporin may cause nephrotoxicity.
107
Which one of the following is the most common complication of ERCP?
A) Significant bleeding
B) Cholangitis
C) Infection
D) Acute pancreatitis
E) Intolerance to sedation
Acute pancreatitis due to irritation of the pancreatic duct by the X-ray contrast material or cannula is the most common complication of ERCP.
107
Which one of the following is the most common complication of ERCP?
A) Significant bleeding
B) Cholangitis
C) Infection
D) Acute pancreatitis
E) Intolerance to sedation
Acute pancreatitis due to irritation of the pancreatic duct by the X-ray contrast material or cannula is the most common complication of ERCP.
108
A 78F presents with persistent diarrhoea. Her symptoms started around three months ago and she is now passing frequent 'mucous' like stools. There is no visible blood in the stool and her weight is stable. Her K is 3.1. What is the most likely diagnosis?
A) Diverticular disease
B) Angiodysplasia
C) Tubular adenoma
D) Colon cancer
E) Villous adenoma
Villous adenomas are colonic polyps with the potential for malignant transformation. They characteristically secrete large amounts of mucous, potentially resulting in electrolyte disturbances.
Diarrhoea + hypokalaemia → villous adenoma
109
Which of the following drugs would most likely provoke a haemolytic crisis in G6PD deficiency?
A) Trimethoprim
B) Ibuprofen
C) Ciprofloxacin
D) Chloroquine
E) Sodium valproate
Ciprofloxacin is contraindicated in G6PD deficiency.
Other drugs with a high risk include primaquine, sulfonamides, methylene blue, dapsone & doxorubicin.
110
A follow-up study is performed looking at the height of 100 adults who were given steroids during childhood. The average height of the adults is 169cm, with a standard deviation of 16cm. What is the standard error of the mean?
A) Cannot be calculated
B) 1.69
C) 0.16
D) 1.6
E) 1.3
1.6
Standard error of the mean = standard deviation / square root (number of patients)
Therefore the SEM gets smaller as the sample size (n) increases.
111
A 69M who takes warfarin for AF asks for advice. He is due to have a tooth extraction at the dentist. The last INR was taken two weeks ago and reported as 2.8 with his target INR being 2.0-3.0. What is the most appropriate advice RE his warfarin?
A) Admit to hospital and switch to S/C LMWH prior to extraction
B) Switch to aspirin prior to extraction
C) Check INR 72hrs before procedure, proceed if INR <4.0
D) Check INR 72hrs before procedure, proceed if INR <2.5
E) Admit to hospital and switch to IV heparin
Dentistry in warfarinised patients - check INR 72 hours before procedure, proceed if INR < 4.0. If a patient has a history of an unstable INR then it should be checked within 24 hours of the dental procedure.
112
Which of the following antibodies are most closely associated with polymyositis?
A) Anti-Jo1
B) Anti-Ro
C) Anti-La
D) Anti-smooth muscle
E) Anti-SRP
Anti-Jo1 are the most myositis specific but only present in 20% of the population.
113
Which of the following would have the greatest effect on long-term prognosis in a patient undergoing surgical repair of a thoracic aneurysm with a history of Marfan's?
A) Aspirin
B) Atorvastatin
C) Bisoprolol
D) Indapamide
E) Ramipril
The strongest evidence with respect to BP control following thoracic aneurysms is B-blockade.
114
What is C3 nephritic factor?
A) Anti-C3a antibody
B) Anti-C3b antibody
C) Anti-C3bBb antibody
D) 3a
E) 3bBb
Anti-C3bBb antibody
115
What is the most likely cause of elevated uric acid in a patient who has just commenced induction chemotherapy for AML?
A) Lipid breakdown
B) Nephrotoxic chemotherapy
C) Nucleic acid breakdown
D) Peptide breakdown
E) Pre-renal failure
In patients with haematological malignancies, massive cell death occurs soon after induction chemotherapy has begun. Breakdown of nucleic acids lead to a large rise in purines which are degraded to uric acid. Patients are pre-treated with fluid loading, allopurinol and given pre-combinant urate oxidase to reduce the risk of urate nephropathy.
116
Where would the lesion be if a patient was found to have a central scotoma?
A) Occipital cortex
B) Optic chiasm
C) Optic nerve
D) Parietal radiation
E) Temporal radiation
Central scotomas are features of optic nerve lesions. Examples of causes include: MS, vascular lesions and optic nerve gliomas. Bilateral scotomas are seen with methanol poisoning.
117
Which antibodies are seen in a patient with heparin-induced thrombocytopenia?
A) Anti-cardiolipin antibodies
B) Anti-CCP antibodies
C) ANA
D) Anti-PF4 antibodies
E) Anti-thrombin antibodies
Anti-PF4 antibodies
118
What is the treatment option for a patient with Klebsiella pneumonia?
A) Co-amoxiclav
B) Doxycycline
C) Metronidazole
D) Tazocin
E) Vancomycin
Tazocin is a powerful option in treating Klebsiella pneumonia.
119
A blueish discolouration of the skin is typically seen with which drug?
A) Amiodarone
B) Sotalol
C) Disopyramide
D) Fleicanide
E) Verapamil
Amiodarone
120
Which of the following is the best intervention for essential thrombocytosis?
A) Anagrelide
B) Hydroxyurea
C) Imetelstat
D) Interferon alpha
E) Phosphorus P32
Hydroxyurea is the initial therapy for ET (anagrelide has been found inferior).
121
Which part of the antibody binds to a receptor on the phagocyte surface?
A) Antigen binding site
B) Fab portion
C) Fc portion
D) Hinge region
E) Hypervariable region
Fc portion
The antigen binding site recognises the offending bacterium.
122
Which of the following is most attributed to chloroquine toxicity?
A) Acute blindness
B) Hyperglycaemia
C) Hyperkalaemia
D) Increased PR interval on ECG
E) QRS prolongation on ECG
QRS prolongation on ECG
123
In a patient with coarctation of the aorta, which of the following cardiac abnormalities is most likely to be seen?
A) Bicuspid aortic valve
B) Intracranial aneurysms
C) Mitral stenosis
D) Pulmonary stenosis
E) VSD
Bicuspid aortic valves exist in up to 60% of patients with coarctation of the aorta.
124
In a patient with coarctation of the aorta, which of the following cardiac abnormalities is most likely to be seen?
A) Bicuspid aortic valve
B) Intracranial aneurysms
C) Mitral stenosis
D) Pulmonary stenosis
E) VSD
Bicuspid aortic valves exist in up to 60% of patients with coarctation of the aorta.
125
Which of the following is the best method to differentiate cerebral toxoplasma from other diagnoses?
A) Brain biopsy
B) CSF PCR
C) IgG toxoplasma antibody titre
D) MRI
E) PET scanning
CSR PCR is the best way to rapidly confirm the diagnosis.
126
Which of the following medications is most associated with acute pancreatitis?
A) Atorvastatin
B) Bisoprolol
C) Furosemide
D) Lisinopril
E) Spironolactone
Furosemide
127
Which of the following anti-hypertensives exacerbates psoriasis?
A) Amlodipine
B) Bisoprolol
C) Doxazosin
D) Indapamide
E) Valsartan
Bisoprolol
128
Which of the following a1-antitrypsin genotypes is most associated with severe lung disease?
A) MM
B) MS
C) MZ
D) SS
E) ZZ
ZZ
129
Which of the following medications is known to worsen myasthenia graves?
A) Atenolol
B) Bendroflumethiazide
C) Indapamide
D) Ramipril
E) Valsartan
Atenolol
CCBs worsen symptoms as well.
130
A 40M presents with difficulty breathing and swallowing and is found to have an enlarged thymus gland on CT. What would you do next?
A) Arrange a biopsy of the thymus
B) Arrange an FNA of the thymus
C) Await results of antibody testing
D) Refer to oncologists for radiotherapy
E) Refer to surgeons for thymus excision
Management of a thymoma is surgical excision, particularly if the patient is symptomatic.
Thymomas contained within the thymic capsule are benign but those which have extended beyond it tend to be malignant. Biopsy can breach the capsule and risk the tumour seeding elsewhere.
131
In a patient with infective endocarditis and a prosthetic heart valve, which of the following would be the strongest indicator for surgical referral?
A) Elevated creatinine
B) Fevers after 3D antibiotics
C) Mild cardiac failure
D) Prolonged PR interval
E) S. Aureus on blood culture
Prolonged PR interval raises the possibility of an aortic root abscess which will not resolve with antibiotics alone.
Persistent fevers for 5 days of more is an indication for surgery.
132
Which of the following would be the most reliable indicator of poor prognosis in a patient with acute liver failure over 48hrs following a paracetamol overdose?
A) ALT >4x ULN
B) Creatinine 122
C) Elevated bilirubin
D) Glucose 9.1
E) INR 2.2
INR>2 at or before 48 hours or >3.5 at or before 72 hours is indicative of a poor outlook in paracetamol overdose. Peak elevations occur at 72-96 hours. Where INR>6.5, liver transplantation should be considered.
132
Which of the following would be the most reliable indicator of poor prognosis in a patient with acute liver failure over 48hrs following a paracetamol overdose?
A) ALT >4x ULN
B) Creatinine 122
C) Elevated bilirubin
D) Glucose 9.1
E) INR 2.2
INR>2 at or before 48 hours or >3.5 at or before 72 hours is indicative of a poor outlook in paracetamol overdose. Peak elevations occur at 72-96 hours. Where INR>6.5, liver transplantation should be considered.
133
Which of the following would be considered to be a good prognostic indicator in a patient with IE?
A) Abnormal creatinine
B) Presence of cardiac failure
C) PR prolongation on ECG
D) S. epidermis on blood culture
E) S. viridans on blood culture
Streptococcal valve infection is associated with good outcomes compared to other causative organisms involved in IE.
134
Which of the following would be considered to be a good prognostic indicator in a patient with IE?
A) Abnormal creatinine
B) Presence of cardiac failure
C) PR prolongation on ECG
D) S. epidermis on blood culture
E) S. viridans on blood culture
Streptococcal valve infection is associated with good outcomes compared to other causative organisms involved in IE.
135
Production of which cytokine is primarily reduced by ciclosporin use?
A) IL-1
B) IL-2
C) IL-6
D) IL-10
E) IL-13
IL-2
136
Which of the following would best fit with a malignant pleural effusion when pleural fluid is being analysed?
A) BNP 80 (<100)
B) Elevated eosinophils
C) Mesothelial cells
D) pH 7.28
E) Pleural fluid amylase
The pH of normal pleural fluid is 7.6. pH below 7.3 represents a substantial accumulation of hydrogen ions and may represent a malignant process.
137
Which of the following is the most likely side effect of cyclophosphamide?
A) Gingival hyperplasia
B) Haemorrhagic cystitis
C) Hirsutism
D) Thrombocytopenia
E) Weight gain
Thrombocytopenia, neutropenia and anaemia are the most common side effects of cyclophosphamide therapy so regular monitoring of FBC is required.
138
Which cells are mainly responsible for the production of TNF-a?
A) Eosinophils
B) Macrophages
C) Mast cells
D) Regulator B cells
E) T-helper cells
Macrophages
139
A 45F presents complaining of visual disturbance. Examination reveals a left congruous homonymous hemianopia. Where is the lesion most likely to be?
A) Optic chiasm
B) L occipital cortex
C) R optic tract
D) R occipital cortex
E) L optic tract
-Incongruous defects = optic tract lesion
-Congruous defects = optic radiation lesion or occipital cortex
A congruous defect simply means complete or symmetrical visual field loss and conversely an incongruous defect is incomplete or asymmetric.
140
An intercalating medical student conducts a case-control study for her dissertation, examining the life-long exposure to marijuana in groups of patients with and without COPD. What form of bias is this study type most at risk of?
A) Detection bias
B) Observer bias
C) Publication bias
D) Recall bias
E) Response bias
Case-control studies are particularly susceptible to recall bias, as those with COPD may relate their condition to their previous marijuana use and are therefore more likely to remember whether or not they have used marijuana in the past (and the extent of their previous use) than the patients in the control group who do not have COPD.
141
A patient's sample is grouped as B RhD negative. You manage to procure some Group B red cells from the fridge but there is no Group B FFP available. FFP from a donor of which blood group would be best to give?
A) A RhD negative
B) A RhD positive
C) AB RhD negative
D) AB RhD positive
E) O RhD positive
The universal donor of fresh frozen plasma is AB RhD negative blood.
This patient's blood group is B RhD negative, meaning her red cells possess B antigens only and she naturally produces anti-A antigens in her plasma. Therefore, she needs to receive red cells with only B antigen or no antigens at all but needs to receive FFP that does not have anti-B in it. Group O donors naturally produce anti-A and anti-B, Group A donors naturally produce only anti-B, so she can only receive FFP from groups B or AB.
142
What type of receptor does levothyroxine act on?
A) G-protein coupled receptor
B) Gap junction receptor
C) Ligand-gated ion channel
D) Nuclear receptor
E) Tyrosine kinase receptor
Levothyroxine acts via nuclear receptors.
143
What is the first line treatment of a patient with idiopathic pulmonary hypertension where acute vasodilator testing shows a negative response?
A) B-blockers
B) CCB
C) Diuretics
D) Endothelin receptor agonists
E) Endothelin receptor antagonists
Endothelin receptor antagonist, prostacyclin analogues, or phosphodiesterase inhibitors are the first-line treatment for patients with idiopathic pulmonary arterial hypertension (IPAH) who have a negative response to acute vasodilator testing. Endothelin-1 is a potent vasoconstrictor that is activated in IPAH. Hence, endothelin receptor antagonists are a mainstay of treatment in IPAH.
144
Which one of the following conditions is associated with retinitis pigmentosa?
A) ADPKD
B) Tuberous sclerosis
C) Von-Hippel-Lindau syndrome
D) Alports syndrome
E) Medullary sponge kidney
Alport's syndrome
145
What is the minimum steroid intake a patient should be taking before they are offered osteoporosis prophylaxis?
A) >10mg OD for 6M
B) >7.5mg for 6W
C) >5mg for 6W
D) >7.5mg for 3M
E) >10mg for 6W
The risk of osteoporosis is thought to rise significantly once a patient is taking the equivalent of prednisolone 7.5mg a day for 3 or more months. It is important to note that we should manage patients in an anticipatory, i.e. if it likely that the patient will have to take steroids for at least 3 months then we should start bone protection straight away.
146
Which one of the following factors is most likely to invalidate the use of the MDRD equation to calculate a patients eGFR?
A) Diuretic use
B) Pregnancy
C) T2DM
D) BP 180/110
E) Female gender
GFR tends to increase during pregnancy although the eGFR may not reflect this.
147
A 40M presents with a 4D history of vertigo. This followed a viral URTI in the past week. He is generally fit and well. His symptoms are associated with some nausea but there is no hearing loss or tinnitus. O/E, fine horizontal nystagmus is noted. What is the most likely diagnosis?
A) Vestibular neuronitis
B) Viral labyrinthitis
C) TIA
D) Acoustic neuroma
E) Meniere's disease
The absence of hearing loss suggests a diagnosis of vestibular neuronitis rather than viral labyrinthitis.
148
Dobutamine is an example of:
A) A1 agonist
B) A2 agonist
C) B1 antagonist
D) B2 antagonist
E) B1 agonist
Alpha-1 agonists
phenylephrine
Alpha-2 agonists
clonidine
Beta-1 agonists
dobutamine
Beta-2 agonists
salbutamol
149
Which of the following findings would support a diagnosis of chronic myeloid leukaemia (CML) rather than myelofibrosis?
A) t(15;17) translocation
B) t(8;21) translocation
C) Low leukocyte alkaline phosphatase score
D) High leukocyte alkaline phosphatase score
E) Massive splenomegaly
LAP is found within mature white blood cells (WBCs).
Low LAP levels are found in conditions associated with immature/undeveloped WBCs (e.g. CML), whereas pathologies associated with mature WBCs (such as myelofibrosis) cause high LAP levels.
150
A 74F presents with headache and neck stiffness. Following an LP the patient was started on IV ceftriaxone. CSF culture grows Listeria monocytogenes. What is the most appropriate treatment?
A) Add IV amoxicillin
B) Change to IV amoxicillin + gentamicin
C) Add IV ciprofloxacin
D) Add IV co-amoxiclav
E) Continue IV ceftriaxone as monotherapy
Listeria meningitis should be treated with IV amoxicillin/ampicillin and gentamicin.
151
Which of the following should not be co-prescribed with methotrexate due to the risk of methotrexate toxicity?
A) Chlorpheniramine
B) Hydroxychloroquine
C) Montelukast
D) Nitrofurantoin
E) Trimethoprim
Trimethoprim and Co-trimoxazole should not be co-prescribed with methotrexate as they are all folate antagonists and can lead to pancytopenia.
152
A 35F is admitted to hospital with hypovolaemic shock. CT abdomen reveals a haemorrhagic lesion in the right kidney. Following surgery and biopsy this is shown to be an angiomyolipoma. What is the most likely underlying diagnosis?
A) Neurofibromatosis
B) Budd-Chiari syndrome
C) Hereditary haemorrhage telangiectasia
D) Von-Hippel-Lindau syndrome
E) Tuberous sclerosis
Around 1 in 10 people who are diagnosed with a renal angiomyolipoma have underlying tuberous sclerosis. Conversely, most patients with tuberous sclerosis will have several renal angiomyolipomata affecting both kidneys.
153
A 27F with chronic LIF pain and alternating bowel habit is diagnosed with IBS. Initial treatment is tried with a combination of antispasmodics, laxatives and anti-motility agents. Unfortunately after 6M there has been no significant improvement in her symptoms. According to recent NICE guidelines, what is the most appropriate next step?
A) Low-dose TCA
B) CBT
C) Refer to sigmoidoscopy
D) Trial of probiotics
E) SSRI
NICE recommend considering psychological interventions after 12 months. Tricyclic antidepressants should be used in preference to selective serotonin reuptake inhibitors.
154
What is the main mode of action of dobutamine?
A) A1 receptor agonist
B) A2 receptor agonist
C) B1 receptor agonist
D) B2 receptor agonist
E) D2 receptor agonist
B1 receptor agonist - it is effective in cardiac shock as it increases cardiac activity and output.
155
Which of the following is the most appropriate anti-emetic to use in a patient with PD?
A) Droperidol
B) Lorazepam
C) Metoclopramide
D) Ondansetron
E) Prochlorperazine
Ondansetron
156
Which of the following indicates a poor prognosis in a patient with chronic liver disease?
A) Spider naevi
B) Caput medusae
C) Elevated transaminases
D) Low platelets
E) Palmar erythema
Caput medusae imply significant shunting of blood - increased risk of GI bleeding, hepatic decompensation and elevated mortality.
157
Which of the following should a female of child-bearing age be warned about regarding radio iodine treatment?
A) Avoiding pregnancy for 3M after treatment
B) No contact with children for 3M
C) Not going out to places of entertainment for 3W
D) Sub-fertility post treatment
E) Teratogenicity if she is pregnant during treatment
Teratogenicity if she is pregnant during treatment.
Patients should avoid pregnancy for 6M after treatment. Males are recommended not to father children for 4M after treatment. People should not have contact with children for 3W following treatment and not go to places of entertainment for 1W following treatment.
158
What percentage of young adults have a T-score between -2 and +2?
A) 2.5%
B) 5%
C) 66%
D) 95%
E) 99.7%
95%
99.7% of adults have a T-score between -3 and +3.
159
Where is actin found in cardiac muscle cell?
A) Free within the cytoplasm
B) As a component of the thick filaments
C) As a component of the thin filaments
D) Within cardiac myocyte mitochondria
E) Within the intercalated discs
As a component of the thin filaments. Thick filaments are composed of myosin.
160
Where is actin found in cardiac muscle cell?
A) Free within the cytoplasm
B) As a component of the thick filaments
C) As a component of the thin filaments
D) Within cardiac myocyte mitochondria
E) Within the intercalated discs
As a component of the thin filaments. Thick filaments are composed of myosin.
161
Which of the following is the most appropriate intervention for acute pseudogout?
A) Allopurinol
B) Colchicine
C) Naproxen
D) Prednisolone
E) Rasburicase
Acute flares of pseudogout respond to intervention with colchicine.
162
What is the most appropriate antibiotic intervention for a patient with Staphylococcus pneumonia?
A) IV ceftriaxone
B) IV co-amoxiclav
C) IV flucloxacillin
D) IV gentamicin
E) PO clarithromycin
IV flucloxacillin
163
Which of the following antibiotic is most likely to precipitate an acute attack of gout?
A) Ethambutol
B) Isoniazid
C) Pyrazinamide
D) Rifampicin
E) Telmisartan
Pyrazinamide reduced uric acid secretion by 80% and hence increase serum uric acid levels, increasing the risk of gout.
164
When is the risk of febrile neutropenia thought to be highest?
A) 3 days into treatment
B) 6 days into treatment
C) 10 days into treatment
D) 14 days into treatment
E) 21 days into treatment
10 days into treatment
165
Which of the following can be used to monitor rivaroxaban compliance?
A) APTT
B) Bleeding time
C) Factor VIII
D) Fibrinogen
E) PT
Prothrombin time
166
If all the below factors are present, which of the following represents the poorest prognostic factor?
A) Anti-CCP positivity
B) Joint erosions on hand XR
C) Osteopaenia on hand XR
D) RF negativity
E) Response to corticosteroids
In patients who are RF negative, anti-CCP positivity stratifies more rapid progression and aggressive disease.
167
Which of the following is the most appropriate treatment of a heel ulcer infection positive for candida?
A) Amphotericin B
B) Fluconazole
C) Clotrimazole
D) Hydrocortisone and clotrimazole
E) Terbinafine
Fluconaole
Topical clotrimazole would not be appropriate here. Terbinafine is used primarily in fungal nail infections.
168
Which of the following is a direct branch off the left subclavian artery?
A) Axillary artery
B) Basilar artery
C) Left common carotid artery
D) Mammary artery
E) Vertebral artery
Vertebral artery.
The left common carotid arises directly from the aorta (the right common shares an origin with the right subclavian).
169
Which of the following would be the most appropriate treatment for a patient with a severe flare of UC uncontrolled with steroids?
A) Azathioprine
B) Ciclosporin
C) Infliximab
D) Colectomy
E) Tacrolimus
Ciclosporin is an effective salvage therapy or patients with severe refractory colitis with a rapid onset of action. It reduces the colectomy rate in the short term but has controversial use over an extended period and hence is often swapped for azathioprine for extended use. Ciclosporin is given to patients who do not respond to steroids after 72 hours - if further deterioration, surgery may be considered.
170
What is the MOA of metformin?
A) ATP-sensitive K+ potassium channel activator
B) Glucagon-like peptide 1agonist
C) Indirect AMP kinase activator
D) PPAR-gamma agonist
E) Sodium-glucose cotransporter 2 inhibitor
Indirect AMP kinase activator
171
What is the MOA of Nintedanib?
A) Anti-eosinophil monoclonal antibody
B) IL-1 antagonist
C) IL-6 antagonist
D) IL-18 antagonist
E) Tyrosine kinase inhibitor
Tyrosine kinase inhibitor licensed to treat idiopathic pulmonary fibrosis.
171
What is the MOA of Nintedanib?
A) Anti-eosinophil monoclonal antibody
B) IL-1 antagonist
C) IL-6 antagonist
D) IL-18 antagonist
E) Tyrosine kinase inhibitor
Tyrosine kinase inhibitor licensed to treat idiopathic pulmonary fibrosis.
172
Which of these medications should not be taken at the same time as calcium carbonate tablets?
A) Bisoprolol
B) Amlodipine
C) Gliclazide
D) Levothyroxine
E) Simvastatin
Levothyroxine's effect can be reduced by concomitant use of calcium carbonate, therefore they should be taken at least 4 hours apart.
173
Which of the following medications is indicated in a patient with lupus nephropathy?
A) Cyclosporin
B) Cyclophosphamide
C) Methotrexate
D) Mycophenolate
E) Tacrolimus
Mycophenolate is indicated as initial treatment of choice. Cyclophosphamide is considered second line treatment.
174
Which of the following cytokines is associated with acute gout?
A) IL-1
B) IL-2
C) IL-6
D) IL-10
E) IL-13
It is thought that acute episodes of gout are triggered by IL-1, hence IL-1 inhibitors (e.g. canakinumab) can be used in treatment of acute gout.
174
Which of the following cytokines is associated with acute gout?
A) IL-1
B) IL-2
C) IL-6
D) IL-10
E) IL-13
It is thought that acute episodes of gout are triggered by IL-1, hence IL-1 inhibitors (e.g. canakinumab) can be used in treatment of acute gout.
175
What is the MOA of magnesium in an acute asthma attack?
A) B1 agonist
B) B2 agonist
C) Decreased histamine release
D) ACh release
E) Smooth muscle constriction
Decreased histamine release, it inhibits ACh release and inhibits smooth muscle constriction.
176
What is the MOA of ropinorole?
A) COMT inhibitor
B) Dopa decarboxylase inhibitor
C) Dopamine-receptor agonist
D) Dopamine transport inhibitor
E) Dopamine antagonist
Dopamine receptor agonist
Levodopa is synthetic dopamine. Carbidopa is a dopa decarboxylase inhibitor which can be given with levodopa to prevent peripheral breakdown. Entacapone is a COMT inhibitor.
177
What is the MOA of ropinorole?
A) COMT inhibitor
B) Dopa decarboxylase inhibitor
C) Dopamine-receptor agonist
D) Dopamine transport inhibitor
E) Dopamine antagonist
Dopamine receptor agonist
Levodopa is synthetic dopamine. Carbidopa is a dopa decarboxylase inhibitor which can be given with levodopa to prevent peripheral breakdown. Entacapone is a COMT inhibitor.
178
What is the MOA of bleomycin?
A) Single strand scission
B) DNA cross-linking
C) DNA substitution
D) Inhibition of RNA polymerase
E) DNA alkylation
Single strand scission
179
Which of the following would be most helpful in confirming a suspected diagnosis of NF1?
A) CT brain
B) Cutaneous lesion of buttock
C) EEG
D) Slit lamp examination of the eye
E) Genetic testing with protein truncation assay
The presence of Lisch nodules on the eye on slit lamp examination allows one to make a positive clinical diagnosis without further investigation.
180
Ischaemic optic atrophy is most likely to be associated with which of the following diseases?
A) Rheumatoid arthritis
B) Stills disease
C) Seronegative arthrtitis
D) SLE
E) GPA
Ischaemic optic neuropathy is a prominent ophthalmic manifestation of GCA and GPA.
181
Which of the following is adjacent to the L kidney and not separated by the visceral peritoneum?
A) Jejunum
B) Pancreas
C) Spleen
D) Splenic flexure
E) Stomach
The middle portion of the L kidney is adjacent to the pancreas and not separated by the peritoneum.
The peritoneum separates the L kidney from the spleen.
182
In a patient with AS, angiodysplasia and persistent iron deficiency anaemia, which of the following is the most likely cause of bleeding?
A) Anti-thrombin III deficiency
B) Factor VIII deficiency
C) Factor IX deficiency
D) Protein S deficiency
E) vWF multiuser deficiency
Sheer stress leads to an increased activity of vWF and is thought, in AS to lead to increased cleavage of vWF multimeters. This leads to increased bleeding risk in patients with AS and why IDA often resolves after valve replacement.
183
Which of the following is the biggest contra-indication to smoking?
A) Continued smoking
B) FEV1 1.8L
C) Previous inferior MI
D) 0.8cm hilar lymph node
E) 2x pneumonia in past year
FEV1 <2L = contra-indication to pneumonectomy and <1.5L = contraindication to lobectomy.
184
Which of the following features would represent a good prognosis in a patient with AML?
A) Karnofsky score 70%
B) 3q26 karyotype abnormality
C) IDH1 mutation
D) MDR1 positive phenotype
E) Prior history of myelodysplasia
Karnofsky scores >60% indicate a good prognosis.
MDR1 negative phenotypes indicate a favourable prognosis whilst positive phenotypes indicate drug resistance.
185
Infective endocarditis with Streptococcus gallolyticus is most likely due to?
A) CLD
B) Dental extraction
C) Colon cancer
D) Diverticular disease
E) Skin infection
Streptococcus gallolyticus was previously known as Streptococcus bovis which was associated with colon cancer.
186
What is the MOA of pioglitazone?
A) Increases glucose-sensitive insulin release
B) Inhibits DPPIV
C) Increases insulin sensitivity in muscle and fat
D) Inhibits SGLT2
E) Reduces hepatic glucose output
Pioglitazone is a PPAR gamma agonist which increases insulin sensitivity in muscle and fat - it leads to improved glucose utilisation in muscle and increased capacity of peripheral fat cells to store energy. It is the increased peripheral fat storage capacity that leads to weight gain.
Metformin reduces hepatic glucose output.
GLP1 agonists increase glucose-sensitive insulin release.
187
Fundosopy reveals bilateral optic disc cupping and visual field mapping reveals bilateral arcuate scotomas. What is the most likely diagnosis?
A) Bilateral glaucoma
B) Central retinal artery occlusion
C) Occipital lobe infarction
D) Parietal lobe infarction
E) Temporal lobe infarction
Arcuate scotomas suggest a diagnosis of glaucoma.
188
Which of the following supplies blood to the lesser curve of the stomach?
A) Common hepatic artery
B) Gastroduodenal artery
C) Left gastric artery
D) Left gastro-omental artery
E) Short gastric arteries
The lesser curve of the stomach is supplied by the L and R gastric arteries- the L gastric artery being a branch of the coeliac trunk.
The gastroduodenal artery is a branch off the hepatic artery which supplies blood to the proximal part of the duodenum, pylorus and indirectly to the pancreas head.
189
Which treatment should be offered to a patient with Mycoplasma pneumonia who is unable to tolerate erythromycin?
A) Amoxicillin
B) Co-amoxiclav
C) Doxycycline
D) Trimethoprim
E) Rifampicin
Doxycycline
Rifampicin can be used as an alternative treatment for Legionella pneumophilia.
190
Which antibody is most likely to be found in a patient with bullous pemphigoid?
A) Anti-desmoplakin antibodies
B) Anti-DSG1 antibodies
C) ANA
D) Anti-TTG antobodies
E) C3 deposition on skin biopsy
C3 deposition on skin biopsy at the dermo-epidermal junction.
Anti-DSG1 antibodies are found in pemphigus vulgarisms. Anti-desmoplakin antibodies are found SJS syndrome.
191
Which antibody is most likely to be found in a patient with bullous pemphigoid?
A) Anti-desmoplakin antibodies
B) Anti-DSG1 antibodies
C) ANA
D) Anti-TTG antibodies
E) C3 deposition on skin biopsy
C3 deposition on skin biopsy at the dermo-epidermal junction.
Anti-DSG1 antibodies are found in pemphigus vulgarisms. Anti-desmoplakin antibodies are found SJS syndrome.
192
The PK of which of the following is impacted by renal impairment?
A) Amlodipine
B) Linagliptin
C) Omeprazole
D) Simvastatin
E) Warfarin
Warfarin is highly protein bound and hence changes in acid base balance in renal failure can lead to rapid increases in INR hence patients with renal impairment should have their INR monitored closely and dose reduced.
193
Which of the following drives delayed hypoglycaemia associated with alcohol consumption?
A) Increased cortisol
B) Increased glucagon
C) Increased glycogenolysis
d) Increased glycogenesis
E) Reduced gluconeogenesis
Reduced gluconeogenesis
194
How long should a patient be anticoagulated with warfarin for following DC cardioversion for AF?
A) 48hrs
B) 1W
C) 2W
D) 4W
E) 6W
4W
195
What disease presentation does the BCG vaccine provide the most protection against?
A) Primary TB infection
B) Pulmonary TB in adults
C) Reactivation of TB
D) TB lymphadenitis
E) TB meningitis in children
TB meningitis in children.
All infants aged 0-12 months who have a parent or grandparent born in a country with an incidence of TB greater than 40 per 100,000 people should receive the BCG. All infants living in areas of the UK with incidence > 40/100,000 are also offered the BCG.
196
Which one of the following would result from the use of a combined oestrogen-progestogen preparation compared to an oestrogen-only preparation?
A) Decreased risk of VTE
B) Increased risk of stroke
C) Increased risk of breast cancer
D) Increased risk of endometrial cancer
E) Better control of symptoms
HRT: adding a progestogen increases the risk of breast cancer.
This is the rationale behind giving women who've had a hysterectomy oestrogen-only treatment. The BNF states that the stroke risk is the same regardless of whether the HRT preparation contains progesterone.
Oestrogen by itself should not be given as HRT to women with a womb which is reduced by the addition of a progestogen but not eliminated completely. The risk of VTE is also increased by the addition of progesterone.
197
What is the most appropriate investigation for phaeochromocytomas?
A) MRI adrenals
B) Phenoxybenzamine suppression test
C) 24hr urinary collection of metanephrines
D) 24hr urinary collection of vanillylmandelic acid
E) 24hr urinary collection of catecholamines
Phaeochromocytoma: do 24 hr urinary metanephrines, not catecholamines.
Phaeochromocytoma is a rare catecholamine secreting tumour.
198
What is the most appropriate investigation for phaeochromocytomas?
A) MRI adrenals
B) Phenoxybenzamine suppression test
C) 24hr urinary collection of metanephrines
D) 24hr urinary collection of vanillylmandelic acid
E) 24hr urinary collection of catecholamines
Phaeochromocytoma: do 24 hr urinary metanephrines, not catecholamines.
Phaeochromocytoma is a rare catecholamine secreting tumour.
199
What would you expect to see on a skin biopsy in a patient with dermatitis herpetiformis?
A) IgA deposition in the dermis
B) IgA deposition in the epidermis
C) IgA deposition in the SC fat
D) IgG deposition in the dermis
E) IgG deposition in the epidermis
IgA deposition in the dermis would be expected. A skin biopsy is the gold standard investigation.
200
What is the most appropriate management for a patient with otitis externa?
A) Topical corticosteroid + aminoglycoside
B) Topical corticosteroid
C) Refer to eNT
D) Topical corticosteroid and clotrimazole
E) PO flucloxacillin
The first line management is either a topical antibiotic or a combined topical antibiotic and steroid. If the tympanic membrane is perforated aminoglycosides are traditionally not used. Oral antibiotics (flucloxacillin) if the infection is spreading. If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.
Malignant otitis externa is more common in elderly diabetics. In this condition, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. Intravenous antibiotics may be required.
