MRCP Deck 2 May 2023 Flashcards
A 24M frequently engages in unprotected sex with multiple partners. He had a mildly raised Venereal Disease Research Laboratory (VDRL) test at 1:8. He did however have a negative EIA and TPPA test. You suspect it could be a false positive test result. Which of the following would be useful at determining a cause?
A) HIV test
B) RF
C) Electrophoresis
D) Varicella serology
E) Mycoplasma serology
The VDRL test is very sensitive for syphilis infections and titres can be used to track treatment and progression. It is, however, prone to many false positives (a positive VDRL in the absence of a positive EIA/TPPA). False positives are usually due to a reaction of antibodies to the cardiolipin-lecithin-cholesterol reagent in the RPR/VDRL tests. SLE, HIV, antiphospholipid syndrome and TB infection are classic causes of this.
False positive VDRL/RPR: ‘SomeTimes Mistakes Happen’ (SLE, TB, malaria, HIV)
Example of test results:
-Positive non-treponemal test + positive treponemal test = active syphilis infection
-Positive non-treponemal test + negative treponemal test = consistent with a false-positive syphilis result
-Negative non-treponemal test + positive treponemal test = successfully treated syphilis
A 19M undergoes primary immunisation against hepatitis B. Following the full course of vaccines, his post immunisation bloods show Anti-HBs< 10 mIU/ml. What is the most appropriate course of action?
A) Give one further dose of Hep B
B) HIV test
C) Test for current or past Hep B infection and repeat full course
D) Give 2 further doses of Hep B vaccine
E) Give a course of HBIg and one further dose of Hep B vaccine
An antibody level below 10mIU/ml is classified as a non-response to vaccine, and testing for markers of current or past infection is good clinical practice. In non-responders, a repeat course of vaccine is recommended, followed by retesting one to two months after the second course. Those who still have anti-HBs levels below 10mIU/ml, and who have no markers of current or past infection, will require HBIG for protection if exposed to the virus.
A 55M with a history of IHD presents with palpitations for the past 10 days. He has a pulse of 130 bpm which is irregularly irregular. He has had one previous episode of atrial fibrillation 3 months ago which was terminated by elective cardioversion following warfarinisation. What term best describes his arrhythmia?
A) Persistent AF
B) Atrial flutter
C) Permanent AF
D) Paroxysmal AF
E) Secondary AF
-First detected episode
-Recurrent episodes = 2 or more episodes of AF. If episodes of AF terminate spontaneously then the term paroxysmal AF is used. Such episodes last less than 7 days (typically < 24 hours). If the arrhythmia is not self-terminating then the term persistent AF is used. Such episodes usually last greater than 7 days
-Permanent AF = continuous atrial fibrillation which cannot be cardioverted. Treatment goals are therefore rate control and anticoagulation if appropriate.
Which of the following may cause a decompensation in chronic liver disease?
A) High fibre diet
B) Low protein diet
C) Constipation
D) Diarrhoea
E) High carbohydrate diet
Constipation is a common cause of liver decompensation due to the accumulation of toxic products within the body. Some patients with liver decompensation and hepatic encephalopathy are treated with enemas to reduce the uptake of toxic products.
Other common causes include infection, electrolyte imbalances, dehydration, upper GI bleeds or increased alcohol intake.
What is the best treatment for a patient presenting in haemolytic crisis secondary to hereditary spherocytosis?
A) Eculizumab
B) Folic acid
C) IVIG
D) Splenectomy
E) Steroids
Patients with HS have chronic low-grade haemolysis and therefore an increased red cell turnover. Since folic acid is essential for haematopoiesis, all patients with HS should continue on lifelong folic acid replacement. This is even more essential in a haemolytic crisis. Importantly this remains the case even when folic acid levels are normal.
Indications for splenectomy in HS include severe symptomatic anaemia, transfusion dependence, or gallstone disease.
Which of the following is characteristic of atrial myxoma?
A) It originates from the R atrium
B) Fragments of tumour break off and metastasise
C) Echo is diagnostic in most cases
D) The clinical signs can mimic MR
E) Recurrence is frequent, even after surgical removal
Atrial myxomas are benign tumours of the heart that are more common in men. They consist of a triad of: embolism, intracardiac obstruction and constitutional symptoms. 2D echo is usually sufficient to make the diagnosis.
It usually originates from the L atrium and clinical signs mimic MS rather than MR.
Which of the options is a specific requirement for MDR-TB compared to other variants of TB?
A) A combination of at least 4 drugs are recommended
B) Directly observed therapy is recommended
C) There is usually no requirement for fluroquinolones
D) Treatment is required for at least 6M
E) Treatment failure is defined as 2 positive blood cultures after 2 months of therapy
It is difficult to confirm adequate adherence to therapy, and eradication of TB is essential. As such, as much as possible, DOT should be instigated.
Which of the following is expected to be seen on a biopsy of a granuloma in sarcoidosis?
A) Asteroid bodies
B) B lymphocytes
C) T lymphocytes
D) Caseation
E) Heinz bodies
Asteroid bodies are found in sarcoid granulomas and are thought to comprise lipids arranged into bilayer membranes.
Which of the following medications is most likely to precipitate hepatic encephalopathy in a patient with advanced alcoholic liver disease?
A) Amlodipine
B) Diazepam
C) Folic acid
D) Thiamine
E) Vitamin E
Patients with liver disease are more susceptible to the effects of various sedative medications on the CNS: benzodiazepines, opioids, barbiturates and chlorpromazine.
Which of the following is the most appropriate definitive treatment for a hyperthyroid solitary toxic nodule?
A) Radioactive iodine therapy
B) Carbimazole
C) Surgical excision
D) Propranolol
E) High dose carbimazole therapy with thyroxine therapy
Toxic thyroid nodules are particularly amenable to treatment with radioactive iodine treatment and if the nodule is shrinking 3M post treatment then no further assessment is required. Surgical excision is used second line or in women who are lactating or are pregnant (radioactive iodine is not appropriate).
What are two common complications of seborrhoeic dermatitis?
A) Alopecia and otitis externa
B) Blepharitis and otitis externa
C) Photosensitivity and alopecia
D) Photosensitivity and blepharitis
E) Blepharitis and alopecia
Otitis externa and blepharitis are common complications of seborrhoeic dermatitis.
A 14-year-old boy is admitted with palpitations and is noted to have a long QT interval. His only past medical history is deafness. What is the likely diagnosis?
A) Leriche syndrome
B) WPW syndrome
C) Jerville-Lange-Nielson syndrome
D) Romano-Ward syndrome
E) Osler-Wender-Rendu syndrome
Jervell-Lange-Nielsen syndrome is associated with profound deafness and a prolonged QT interval.
Romano-Ward syndrome is also associated with a prolonged QT interval but no deafness.
Which feature would be the strongest indication for referral of a hyperparathyroid patient for consideration of parathyroid surgery?
A) Co-existing T2DM
B) Post-menopausal patient
C) Persistent hypercalcaemia over 4Y
D) Vitamin D deficiency
E) 45 years of age
Treatment of hyperparathyroidism:
-The definitive management is total parathyroidectomy
-Conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage
-Patients not suitable for surgery may be treated with cinacalcet (‘mimics’ the action of calcium on tissues by allosteric activation of the calcium-sensing receptor)
NICE guidelines clearly stipulate the circumstances under which parathyroidectomy should be considered in primary hyperparathyroidism. These are listed below:
-<50 years.
-Cca that is >0.25 mmol/L above the upper end of the reference range.
-eGFR <60 mL/min/1.73 m2 a
-Renal stones
-Osteoporosis/osteoporotic fracture.
-Symptomatic disease
What follow up is required for a patient found to have pleural plaques on CT with no abnormalities noted on their blood tests?
A) None
B) Palliative chemotherapy
C) Radiotherapy
D) Surgery
E) Repeat CT in 6 months
Pleural plaques are benign and do not undergo malignant change. They, therefore don’t require any follow-up.
On what chromosome is the most likely mutation of a patient with ADPKD?
A) 3
B) 16
C) 4
D) 12
E) 6
The majority of patients with ADPKD have a mutation on chromosome 16, with the remaining 15% having a mutation on chromosome 4.
The screening investigation for relatives is abdominal ultrasound:
-2 cysts, unilateral or bilateral, if < 30YO
-2 cysts in both kidneys if 30-59 YO
-4 cysts in both kidneys if > 60 YO
Tolvaptan MAY be used to treat depending on if the patient meets the criteria.
What is the mechanism of action of amphotericin B?
A) Inhibits DNA polymerase
B) Converted to 5-fluoruracil
C) Binds with ergosterol
D) Inhibits synthesis of B-glucan
E) Interacts with microtubules to disrupt the mitotic spindle
Amphotericin B binds with ergosterol, a component of fungal cell membranes, forming pores that cause lysis of the cell wall and subsequent fungal cell death
A 65M presents with a sudden, painless loss of vision in his right eye upon waking up this morning. PMHx is notable for DM and HTN. Fundoscopic examination of the left eye reveals no abnormalities but of the right eye reveals multiple retinal haemorrhages. What is the most likely diagnosis?
A) Amaurosis fugax
B) Central retinal artery occlusion
C) Central retinal vein occlusion
D) Hypertensive retinopathy
E) Optic neuritis
Central retinal vein occlusion - sudden painless loss of vision, severe retinal haemorrhages on fundoscopy
-Amaurosis fugax = temporary vision loss that resolves in a few minutes. It is caused by atheroembolism from the carotid arteries.
-Central retinal artery occlusion = acute painless vision loss, loss of relative afferent pupillary defect, and on fundoscopy, a cherry-red macula and a white/pale retina.
-Optic neuritis = sudden loss of vision associated with severe pain and an afferent pupillary defect.
In terms of the cell cycle, which one of the following phases determine the length of the cell cycle:
A) M
B) M0
C) G1
D) S
E) G2
G1 is where the cells increase in size and determines the length of the cell cycle.
A patient wakes up an hour ago with right-sided weakness and difficulty speaking. A CT head does not show any signs of intracranial haemorrhage and a CT angiogram reveals a clot in the first branch (M1) of the left middle cerebral artery (MCA). Which of the following interventions is most likely to be of benefit in this patient?
A) Thrombolysis
B) Mechanical clot retrieval
C) Treatment dose heparin
D) Mechanical clot retrieval and thrombolysis
E) DAPT
Thrombolysis is contra-indicated in patients with wake-up strokes but mechanical clot retrieval can be performed in patients who have a confirmed occlusion of the proximal anterior circulation.
Contraindications to thrombolysis: >4.5hrs since symptoms due to risk of haemorrhagic transformation, presence of an intracranial neoplasm, recent major bleeding e.g. from the gastrointestinal tract.
A nurse at the local hospital undergoes vaccination against Hep B. 3 months after completion of the primary course:
Anti-HBs: 10 - 100 mIU/ml
(An antibody level of >100 mIU/ml indicates a good immune response with protective immunity)
What is the most appropriate course of action?
A) Repeat course (3 doses)
B) Repeat anti-HbS level in 3M
C) Give HbIG and one further dose of vaccine
D) Give one further dose of vaccine
E) Do a HIV test
Testing for anti-HBs is only recommended for those at risk of occupational exposure and patients with CKD. Anti-HBs levels should be checked 1-4 months after primary immunisation.
> 100 = adequate respone, booster in 5Y
10-100 = one additional vaccine dose should be given
<10 = Test for current or past infection. Give further vaccine course (i.e. 3 doses again) with testing following. If still fails to respond then HBIG would be required for protection if exposed to the virus.
What is the most appropriate initial management for a patient with suspected cord compression secondary to advanced, non-small cell lung cancer?
A) Broad-spec antibiotics
B) High dose PO dexamethasone
C) IV mannitol
D) Urgent MRI spine
E) Urgent referral for radiotherapy
Spinal cord compression is an oncological emergency and so dexamethasone should be given whilst arranging investigations, ideally a whole MRI spine within 24hours of presentation.
What organism is most likely to be responsible in causing IE in a patient with a recent dental extraction and poor dentition?
A) Eikenella corodens
B) MRSA
C) S. aureus
D) Streptococcus sanguinis
E) Streptococcus bovis
Patients with very poor dental hygiene may develop endocarditis secondary to Viridans streptococci e.g. Streptococcus sanguinis
The two most notable viridans streptococci are Streptococcus mitis and Streptococcus sanguinis - they are both commonly found in the mouth and in particular dental plaque so endocarditis caused by these organisms is linked with poor dental hygiene or following a dental procedure.
A 36F presents with skin lesions on her upper limbs. She has recently been on extensive travels throughout the world. OE she has an annular granulomatous rash with an asymmetrical distribution, 3 lesions on her left arm, and 1 lesion on her right arm. The lesions are hypopigmented and have well defined raised borders. They are associated with hair loss and decreased sensation. What is the most likely diagnosis?
A) Bullous pemphigoid
B) Cutaneous leishmaniasis
C) Lyme disease
D) Necrotising fasciitis
E) Tuberculoid leprosy
Tuberculoid leprosy is suggested by a limited number of skin lesions, hypaesthesia, and hair loss. Mycobacterium leprae are scanty in tuberculoid leprosy lesions. It is a relatively benign form of leprosy and one of the least contagious.
Cutaneous leishmaniasis is characterised by an initial small red papule that enlarges in size and develops a central ulceration that can exude pus or dry with a crusted scab.
A 67M with a history of HTN presents with a 24hr history of dyspnoea and palpitations. He also complains of mild chest discomfort. OE, you note an irregularly irregular pulse (115bpm), BP 95 / 70 mmHg and RR 20 breaths/min. Nil regular medication. An ECG shows absent P waves with QRS complexes irregularly irregular intervals. What is the most appropriate management?
A) Digoxin
B) B-blocker
C) IV adenosine
D) DCCV
E) Clopidogrel
BP of 95/70 mmHg in a patient with a history of HTN, who is currently not taking any BP medication is quite concerning. It suggests that he is hemodynamically unstable. New-onset AF within 48hrs should be treated with DC cardioversion if unstable or either DC cardioversion or pharmacological cardioversion.
If the AF is definitely of less than 48 hours onset patients should be heparinised. If the patient has been in AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion. Following electrical cardioversion patients should be anticoagulated for at least 4 weeks.
Which of the following cytotoxic chemotherapy agents are most likely to be responsible for low magnesium levels?
A) Docetaxel
B) Vincristine
C) Cisplatin
D) Cyclophosphamide
E) Cytarabine
Cisplatin is associated with hypomagnesaemia.
-Docetaxel (ovarian cancer) = neutropenia
-Vincristine (haematological malignancies and breast cancer) = peripheral neuropathy and paralytic ileus
-Cyclophosphamide (ovarian cancer) = haemorrhagic cystitis, myelosuppression and transitional cell carcinoma.
-Cytarabine (haematological malignancies) = myelosuppression and ataxia.
A 42M presents a two-month history of steatorrhoea, abdominal discomfort, and diarrhoea. 3 years ago, he required colonic resection following ischaemic colitis, leaving him with short bowel syndrome. He also reports paraesthesia and feeling unsteady on his feet. The endoscopic appearance of the small bowel is unremarkable. Biopsy samples show non-specific eosinophilia. Colonoscopy is also unremarkable. Abdominal examination is unremarkable, and his weight has remained stable. What investigation is most likely to be diagnostic?
A) CT abdomen
B) CT colonoscopy
C) Faecal calprotectin
D) Hydrogen breath test
E) Serum lipase
Small bowel overgrowth syndrome (SBOS) is where excessive microbes colonise the bowel. As in this case, anatomic disorders can predispose to SBOS due to intestinal stasis. In the majority of cases, it presents as bloating and steatorrhoea. In patients with vitamin B12 deficiency, neurological symptoms can also co-exist. The diagnosis can be established with a positive hydrogen breath test. The mucosal histology is variable, and may include modest villous blunting accompanied by increased lamina propria and epithelial inflammation. It is often normal.
What cancer is a male patient positive for the BRCA gene more likely to have?
A) Colon
B) Lung
C) Prostate
D) Retinoblastoma
E) Brain
Prostate cancer in males is strongly associated with the BRCA genes.
A 38F presents to ED with poorly-defined symptoms of headache and drowsiness. She has a PMHx of asthma and is known to be HIV-positive. An urgent CT head scan demonstrates a single brain lesion with homogenous enhancement. A subsequent thallium SPECT scan is conducted and has a positive result. Given the findings, what is the most likely diagnosis?
A) Encephalitis
B) Lymphoma
C) PML
D) Toxoplasmosis
E) Tb
The most likely finding here is primary CNS lymphoma, given the neurological symptoms in an HIV-positive patient and the single brain lesion with homogenous enhancement.
Treatment generally involves steroids, chemotherapy and possible surgical intervention.
Toxoplasmosis presents similarly but with multiple ring-enhancing lesions and is Thallium SPECT negative.
A 56M presents with falls. He feels he is getting progressively weaker and has difficulties walking up the stairs. He is hypertensive and has suffered with chronic smokers cough for years. O/E he has weakness of hip flexion, particularly knee flexion. He is unable to keep his fingers flexed against force, the right being weaker than the left. There are no sensory abnormalities and reflexes are preserved. Serum CK is normal.
A) Cervical cord compression
B) Inclusion body myositis (IBM)
C) Limb-girdle muscular dystrophy
D) MND
E) Polymyositis
IBM is an idiopathic inflammatory myopathy. The pattern of muscle weakness (quadriceps and long finger flexors) and asymmetry of signs is characteristic. IBM is the most common acquired myopathy in people >50 and occurs more often in men.
Limb-girdle muscular dystrophy usually presents with slowly progressive proximal arm/leg weakness. It is rare.
A patient presents with bradycardia and profound hypotension. It is thought to be due to b-blocker overdose. Which of the following agents is most suitable in initial treatment?
A) Adrenaline
B) Glucagon
C) Insulin
D) Neostigmine
E) Pyridostigmine
The initial treatment of b-blocker overdose is atropine but the preferred treatment of patients with profound bradycardia and hypotension is IV bolus of glucagon followed by IV glucagon infusion.
Adrenaline and isoprenaline can be given if glucagon is not available.
Following a stroke/TIA, what driving restrictions apply?
A) Must not drive a heavy goods vehicle for at least 2 years
B) Must not drive for 1M
C) Must not drive for 3M
D) Must not drive until neurological signs are resolved
E) No driving necessary
Strokes and TIA have driving restrictions for 1M from the date of attack. If the significant neurological deficits that interfere with the ability to drive persists the the restriction is likely to be prolonged.
Which of the following abnormalities would be expected to be seen in a patient with refeeding syndrome?
A) Raised LH and FSH
B) Elevated circulating cortisol
C) Low resting growth hormone level
D) Increased levels of GnRH
E) Normal oestrogen levels
Circulating cortisol have been shown to be elevated in anorexia.
An unwell patient is found to have P. falciparum species seen, 12% parasitaemia on malarial films. What treatment should be commenced?
A) Chloroquine
B) Artesunate and exchange transfusion
C) Artesunate
D) Doxycycline
E) Quinine and doxycycline
Patients with severe malaria should be treated with IV artesunate, and in cases where parasitaemia >10% is seen, consideration should be given to the performance of exchange transfusions.
54M with T2DM is found to have new vessel formation at the optic disc. Visual acuity in both eyes is not affected (6/9). Blood pressure is155/84 mmHg. HbA1c: 68 mmol/mol (8.4%) What is the most important intervention in this patient?
A) Follow up ophthalmoscopy in 3M
B) Add aspirin
C) BP control
D) Tight glycemic control
E) Laser therapy
This patient has proliferative diabetic retinopathy and urgent referral to an ophthalmologist for panretinal photocoagulation is indicated. Intravitreal VEGF inhibitors can also be used alongside laser therapy.
A 65M has been started on amiodarone. He has been told he must first take higher doses and then continue on a lower maintenance dose long-term. What is the reasoning behind this initial dose regime?
A) Extensive hepatic P450 breakdown of amiodarone
B) Fast metabolism of amiodarone due to extensive protein binding
C) Slow absorption of amiodarone via the enteral route
D) Slow metabolism of amiodarone due to extensive protein binding
E) Slow renal excretion of amiodarone
Slow metabolism of amiodarone due to extensive lipid binding is the correct answer. Lipid-bound drugs generally have longer half-lives as they are extensively distributed in tissues, primarily adipocytes. A longer half-life means that loading doses are required. The time taken to achieve stable systemic drug concentration correlates with the half-life of that drug. A long half-life means a drug is cleared more slowly. If the patient were to start taking a drug at the maintenance dose it would take much longer to reach therapeutic concentrations.
A 20F Nigerian presents with chest pain. She reports a long history of fatigue and joint pains. Examination reveals a pericardial rub and bilateral pitting oedema. Observations show only that she has a low grade pyrexia 37.7ºC and BP 170/100 mmHg. Urinalysis shows haematuria and nephrotic-range proteinuria. ECG shows saddle-shaped ST-elevation in all leads. Bloods: Urea 8.2 mmol/l, Creatinine 212 µmol/l, eGFR 33ml/m/m². Which of the following histopathological findings is most likely on renal biopsy?
A) Focal proliferative glomerulonephritis
B) Membranous glomerulonephritis
C) Diffuse proliferative glomerulonephritis
D) FSGS
E) Mesangial proliferative glomerulonephritis
The presence of hypertension, kidney injury, proteinuria and haematuria point towards a nephritic picture of kidney insult.
The multisystem presentation of fever, arthralgia, pericarditis and nephritis associated with the epidemiological clues (a young black female) suggests SLE.
The most common histological pattern seen in lupus nephritis is diffuse proliferative glomerulonephritis.
Class IV (diffuse proliferative glomerulonephritis) is the most common and severe of the glomerulonephritides. Renal biopsy characteristically shows:
-glomeruli shows endothelial and mesangial proliferation, ‘wire-loop’ appearance
-if severe, the capillary wall may be thickened secondary to immune complex deposition
-electron microscopy shows subendothelial immune complex deposits
-granular appearance on immunofluorescence
Which of the following medications are most associated with constipation?
A) Verapamil
B) Sitagliptin
C) Metformin
D) Ramipril
E) Atorvastatin
Verapamil, like other calcium channel blockers, is a common pharmacological cause of constipation.
Which of the following advice should be given to a patient on carbamazepine who wants to start breastfeeding?
A) Breast-feeding should be avoided whilst taking carbamazepine
B) Increase the dose of carbamazepine
C) No changes required
D) Switch carbamazepine to lamotrigine
E) Switch carbamazepine to levetiracetem
Breast feeding is acceptable with nearly all anti-epileptic drugs.
Which foramen does the maxillary nerve go through?
A) Jugular foramen
B) Foramen ovale
C) Superior orbital fissure
D) Optic canal
E) Foramen rotundum
Foramen rotundum
A 34M is investigated following an unexplained collapse whilst at work. A resting ECG shows convex ST elevation in V1-V3 with a partial right bundle branch block pattern. What is the most likely diagnosis?
A) Polymorphic VT
B) HOCM
C) Arrythmogenic right ventricular cardiomyopathy
D) Brugada syndrome
E) Normal variant
Brugada syndrome is a form of inherited CV disease which may present with sudden cardiac death. It is an autosomal dominant disease and is more common in Asians.
ECG changes
-convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave
-partial right bundle branch block
The ECG changes may be more apparent following the administration of flecainide or ajmaline (investigation of choice)
A research facility is trying to develop a new test to screen for breast cancer compared to current standards which include mammography. From preliminary data, the new screening test appears to be better at picking up early cancers. When comparing both these tests, however, there appears to be no obvious difference between survival rates. What is this an example of?
A) Lead-look bias
B) Lead-time bias
C) Publication bias
D) Recall bias
E) Work up bias
Lead-time bias - occurs when two tests for a disease are compared, the new test diagnoses the disease earlier, but there is no effect on the outcome of the disease
A fit and well 24M presents with palpitations in the early hours of the morning after consuming a large amount of alcohol. He denied any chest pain or breathlessness. His pulse was 120 bpm and irregularly irregular. His BP was 124/70 mmHg. ECG showed AF with a ventricular rate of 118. What is the most appropriate initial management?
A) Oral bisoprolol
B) IV metoprolol
C) Oral flecainide
D) ECV
E) IVF
This patient has atrial fibrillation with a fast ventricular rate but is otherwise stable and shows no signs of decompensation. This is likely to have been precipitated by his heavy alcohol consumption and it is reasonable to rehydrate him with IVF and see whether this reverts him to sinus rhythm before attempting pharmacological or electrical cardioversion.
An 80M presents with recurrent episodes of hallucinations. He describes seeing faces smaller than normal or other objects out of proportion. He finds these episodes distressing although he says he knows they’re not real. PMHx of macular degeneration and an episode of depression 20 years ago following the death of his wife. Neurological examination is unremarkable. What is the most likely diagnosis?
A) Schizophrenia
B) Charles-Bonnet syndrome
C) Psychotic depression
D) Cerebral tumour
E) Alzheimers disease
Charles-Bonnet syndrome is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment. Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.
A 41M is diagnosed with idiopathic pulmonary arterial hypertension. He undergoes vasodilator testing with intravenous epoprostenol to which he has a positive response. What is the most appropriate first-line treatment for his condition?
A) Sildenafil
B) Trepostinil
C) Bosentan
D) ISMN
E) Nifedipine
Patients who test positive to vasodilator testing are typically treated with calcium channel blockers such as nifedipine, diltiazem and increasingly amlodipine.
If there is a negative response to acute vasodilator testing (the majority) –>
-prostacyclin analogues: treprostinil, iloprost
-endothelin receptor antagonists: bosentan, ambrisentan
-phosphodiesterase inhibitors: sildenafil
What would you expect the normal anatomical dead space to be in a healthy adult male?
A) 50ml
B) 150ml
C) 250ml
D) 350ml
E) 450ml
150ml
A cocaine user presents to ED with multiple superficial lacerations. She says she can feel something crawling under her skin and was trying to see what was there. What is this symptom known as?
A) Auditory hallucination
B) Visual hallucination
C) Haptic hallucination
D) Primary delusion of infestation
E) Illusion
Haptic hallucinations are experiences of sensations of being touched/strangled/feeling of insects beneath skin. These can often occur in cocaine users. Haptic hallucinations also occur in alcohol withdrawal and schizophrenia.
Which of the following prednisolone doses matches most closely with the physiological production of glucocorticoid in a 75kg male?
A) 1mg
B) 2mg
C) 7.5mg
D) 15mg
E) 20mg
7.5mg
Which of the following factors increases the risk of developing hydralazine-induced lupus?
A) White ethnicity
B) dsDNA +ve
C) Family Hx of SLE
D) HLA-B6 genotype
E) Rapid acetylator status
SLE is more common in Afro-caribbeans whilst drug-induced SLE is more common in those of white ethnicity, men and women affected equally. the reaction is dose and concentration-dependent.
Slow acetylator status increases the risk of developing drug-induced SLE due the slower metabolism leading to elevated concentrations in the blood. Drug-induced lupus is more common in those with HLA-DR4 genotype.
For a patient with discrete small cell lung cancer, which of the following systemic therapies is most appropriate to use alongside radiotherapy?
A) Cisplatin and etoposide
B) Carboplatin and etoposide
C) Carboplatin and paclitaxel
D) Topotecan and ifosfamide
E) Vinorelbine and cisplatin
Cisplatin and etoposide is standard therapy for small cell lung cancer, but carboplatin is frequently used in patients who can’t tolerate it or have a contra-indication to it.
Which of the following is accurate regarding the pharmacological interaction between lithium and anti-hypertensive agents?
A) Acetazolamide decreases lithium concentrations
B) ACEi leads to decreased lithium concentration
C) Bendroflumethiazide decreases lithium concentration
D) CCB lessen the risk of lithium neurotoxicity
E) Methyldopa leads to decreased lithium neurotoxicity
Osmotic diuretics and carbonic anhydrase inhibitors such as acetazolamide lead to increased renal excretion of sodium and lithium.
Which of the following tissues are most commonly affected in SLE?
A) Joints
B) Skin
C) Kidneys
D) Lungs
E) Heart and blood vessels
Joints (80%). 75% of patients have skin manifestations.
Which of the following blood results is most consistent with haemachromatosis?
A) ALP 178 (45-105)
B) Ferritin 324 (15-300)
C) Serum iron 25 (12-30)
D) TIBC 43 (45-75)
E) Transferrin saturation 78% (20-50)
Haemachromatosis is caused by a mutation in the gene HFE which results in iron accumulation in different organs. Findings suggestive of iron accumulation:
-Ferritin >500
-Serum iron >30
-Transferrin saturation >60%
-TIBC <20
What is the treatment for Ramsay Hunt syndrome?
A) Corticosteroids only
B) IV aciclovir
C) PO aciclovir and corticosteroids
D) PO aciclovir
E) Reassurance
Full recovery is more likely if antiviral treatment is started within 72 hours of the onset of symptoms. First-line treatment includes aciclovir 800 mg orally five times daily for 7 days and prednisone 60 mg orally daily for 5 days.
Steroids are helpful due to their strong anti-inflammatory action. This is thought to reduce oedema in the affected nerves and result in shorter disease duration.
What feature on examination most strongly suggests that the mitral valve leaflets are still mobile?
A) Loud S1
B) Loud diastolic murmur
C) Opening snap
D) Quiet S1
E) Quiet diastolic murmur
In mitral stenosis, an opening snap indicates the leaflets still have some mobility.
An opening snap is pathognomonic of mitral valve stenosis. It is a high-pitched early diastolic sound (just after S2) due to the sudden contraction of the valve leaflets after their initial opening. A clear opening snap suggests that the valve is pliable and would therefore be suitable for balloon mitral valvuloplasty.
Features of severe MS
length of murmur increases
opening snap becomes closer to S2.
A 54M with a history of depression presents for review. He was started on fluoxetine 8W ago and is now requesting to stop his medication as he feels so well. What should be recommended regarding his treatment?
A) It should be stopped straight away
B) It should be continued for another 6W
C) It should be continued for another 3M
D) It should be continued for another 6M
E) It should be continued for another 12M
Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine).
What is the causative organism of granuloma inguinale?
A) Klebsiella granulomatis
B) Chlamydia
C) HSV
D) Treponema pallidum
E) Haemophilus ducreyi
Granuloma inguinale - Klebsiella granulomatis
Chancroid = caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.
Lymphogranuloma venereum (LGV) = Chlamydia trachomatis. Typically infection comprises of three stages
-stage 1: small painless pustule which later forms an ulcer
-stage 2: painful inguinal lymphadenopathy
-stage 3: proctocolitis
What is the mechanism of action of procyclidine?
A) Anti-muscarinic
B) Dopamine receptor agonist
C) Decarboxylase inhibitor
D) Dopamine receptor antagonist
E) MAO-B inhibitor
Procyclidine - antimuscarinic
In the Gell and Coombs classification of hypersensitivity reactions Grave’s disease is an example of a:
A) Type I reaction
B) Type II reaction
C) Type III reaction
D) Type IV reaction
E) Type V reaction
Type V = Antibodies that recognise and bind to the cell surface receptors.
This either stimulating them or blocking ligand binding
-Graves’ disease
-Myasthenia gravis
The first-line treatment in remnant hyperlipidaemia (dysbetalipoproteinaemia) is:
A) Ursodeoxycholic acid
B) Vitamin A
C) Statins
D) Fish oil
E) Fibrates
Fibrates are first line treatment
A 63M is noted to have a pleural effusion on CXR. Which one of the following would typically cause a transudate?
A) Pancreatitis
B) Pneumonia
C) Yellow-nail syndrome
D) Hypothyroidism
E) Dresslers syndrome
Transudate (< 30g/L protein)
-heart failure
-hypoalbuminaemia
-liver disease
-nephrotic syndrome
-malabsorption
-hypothyroidism
-Meigs’ syndrome
Exudate (> 30g/L protein)
-infection
-pneumonia
-tuberculosis
-subphrenic abscess
-connective tissue disease
-rheumatoid arthritis
-systemic lupus erythmatosus
-neoplasia
-lung cancer
-mesothelioma
-metastases
-pancreatitis
-pulmonary embolism
-Dressler’s syndrome
-yellow nail syndrome
What does the power of the study equate to?
A) 1/p value
B) SD/square root of sample size
C) 1-probability of making Type II error
D) 1-probability of making Type I error
E) 1/probability of making Type I error
Power = 1 - the probability of a type II error
What is the main advantage of using capecitabine instead of fluorouracil?
A) Current data shows increased survival
B) Less cardiotoxic
C) PO administration
D) Less nausea
E) Not really excreted so can be used in patients with CKD
Capecitabine is an orally administered prodrug which is enzymatically converted to 5-fluorouracil in the tumour.
How does C. difficile spread?
A) Aerosol via ingestion of spores
B) Aerosol via ingestion of toxins
C) Faeco-oral via ingestion of spores
D) Faeco-oral via ingestion of toxins
E) Needle-stick injury
Clostridioides difficile: spreads via the faecal-oral route by ingestion of spores. Toxin A and B are responsible for the clinical manifestations of Clostridioides difficile infection but not its transmission.
Which part of the ECG does the S4 heart sound coincide with?
A) P wave
B) QRS complex
C) ST segment
D) T wave
E) U wave
The S4 heart sound is caused by atrial contraction against a stiff ventricle, occurring just before the S1 sound. It may be heard in aortic stenosis, hypertrophic cardiomyopathy or hypertension. As such, it coincides with the P wave, which represents atrial depolarisation.
What is the mechanism of action of timolol for use in primary open-angle glaucoma?
A) Increased uveoscleral outflow
B) Pupil constriction
C) Pupil dilation
D) Reduces aqueous production
E) Reduces aqueous production and increases uveoscleral outflow
Timolol is a beta-blocker which decreases intraocular pressure by reducing production of aqueous humour.
Prostaglandin analogues (latanoprost) are first-line agents in primary open-angle glaucoma and work by increasing uveoscleral outflow, but they do not reduce aqueous production. Miotics (pilocarpine) work on the muscarinic receptor causing pupil constriction and therefore increase uveoscleral outflow.
Which one of the following best describes the characteristics of a negatively skewed distribution?
A) Median < mean < mode
B) Mean < median < mode
C) Mode < mean < median
D) Median < mode < mean
E) Mean < mode < median
Skewed distributions
alphabetical order: mean - median - mode
‘>’ for positive, ‘<’ for negative
Which of the following analyses is most useful when comparing different treatment therapies?
A) Completer analysis
B) Intention to treat analysis
C) Per-protocol analysis
D) Screened and randomised analysis
E) Sensitivity analysis
Intention to treat analysis involves looking at all the people taking part in a trial based on the group they were allocated to regardless of whether or not they actually took the proposed treatment. Intention to treat analysis are often used to assess clinical effectiveness as they mirror actual clinical practice and is hence a robust way of monitoring the effectiveness of therapy.
Which of the following antibiotics is the best choice to treat typhoid fever in a patient who is 25W pregnant?
A) Ceftriaxone
B) Chloramphenicol
C) Ciprofloxacin
D) Co-trimoxazole
E) Ofloxacin
All these antibiotics can be used to treat typhoid fever. Ceftriaxone has the best safety profile in pregnancy.
Quinolones are not recommended in pregnancy.
A 75M presents with pedal oedema and ++ protein in his urine. He has a PMHx of SqCC of the lung which was resected. What is the most likely diagnosis?
A) IgA nephropathy
B) Membranous nephropathy
C) Minimal change disease
D) FSGS
E) Membranoproliferative glomerulonephritis
Membranous nephropathy is often idiopathic but can be triggered by malignancy of the bowel and bronchus, SLE, penicillamine therapy and hep B infection. There is a strong association with HLA-DR3. M>F. Thickening of the capillary BM due to immune complex deposition is the main feature of membranous nephropathy. 1/3 of patients develop CKD within 10-20Y.
A man presents with short stature, short 5th metacarpals, subcutaneous calcification, intellectual impairment and hypocalcaemia. Given the likely diagnosis, where is the most likely defect?
A) A G-protein linked to PTHr
B) A serine kinase receptor
C) A tyrosine kinase receptor
D) A tyrosine phosphatase receptor
E) An ion channel linked to the PTHr
This patient has pseudohypoparathyroidism, related to a loss-of-function mutation affecting the G-protein linked receptor for PTH.
Which of the following investigative findings on urine examination would be most consistent with acute tubular necrosis?
A) Visible haematuria
B) Myoglobin casts
C) Red cell casts
D) Urine osmolality 300mosmol/kg
E) Urine sodium 20mmol/l
Urine osmolality decreases in ATN, reflecting reduced tubal function and filtration rate. This is in contrast to pre-kidney disease with urine osmolality is high due to poor urine output and high creatinine.
Which of the following potential consequences are associated with the presence of maternal thyroid autoantibodies?
A) Higher risk of spontaneous abortion
B) Increased risk of neonatal hypothyroidism
C) Increased risk of pregnancy-induced hypertension
D) Increased risk of macrosomia
E) Increased risk of transient neonatal thyrotoxicosis
The presence of maternal thyroid autoantibodies is strongly associated with miscarriage and pre-term delivery.
Which of the following investigations would confirm a PDA?
A) CXR
B) 12 lead ECG
C) 2D Echo
D) Carotid doppler study
E) TOE with bubble study
-Incomplete RBBB may be seen on ECG
-Echo may demonstrate the defect and show right ventricular dilatation and hypertrophy and pulmonary artery dilatation but PFOs may be missed on 2D echo
-The precise size and location of the defect can be shown on TOE.
A 2D echo cannot exclude a PFO unless a bubble study and Valsalva are performed as a PFO is a potential space that is only open during Valsalva conditions.
Which hormone is chiefly responsible for epiphyseal fusion and cessation of growth?
A) GH
B) Testosterone
C) Oestrogen
D) Thyroxine
E) Somatostatin
The growth spurt at puberty is brought about by the secretion of androgens in males and oestrogen in females; however it is oestrogens that ultimately terminate growth by causing the epiphyses in the long bones to fuse.
Which of the following diuretics is most likely to be responsible for a K 3.4, acidosis and serum bicarb 15mmol?
A) Acetazolamide
B) Amiloride
C) Bumetanide
D) Furosemide
E) Metolazone
Acetazolamide inhibits proximal tubular bicarbonate reabsorption in a similar fashion to Type 2 RTA.
TWhat is the best treatment option for a patient with a large right-sided pneumothorax, midline shift and hypotension?
A) Chest drain insertion
B) Chest drain insertion under radiographic control
C) Needle aspiration in left mid-axillary line
D) Repeat CXR after a few hours
E) Needle aspiration of the right pleural space
The most appropriate management would be needle decompression in either the 2nd ICS mid clavicular line or 5th ICS mid axillary line followed later by chest drain insertion.
Which HLA gene is most strongly associated with coeliac disease?
A) HLA-DQ2
B) HLA-B27
C) HLA-DQ4
D) HLA-DR4
E) HLA-C13
Coeliac disease has a strong association with HLA-DQ2 (present in 95% of patients).
Which one of the following is not a recognised feature of methaemoglobinaemia?
A) Chocolate cyanosis
B) Dyspnoea
C) Anxiety
D) Acidosis
E) Reduced pO2 but normal sats on pulse oximetry
Normal pO2 but decreased oxygen saturation is characteristic of methaemoglobinaemia.
Which one of the following is not a recognised feature of methaemoglobinaemia?
A) Chocolate cyanosis
B) Dyspnoea
C) Anxiety
D) Acidosis
E) Reduced pO2 but normal sats on pulse oximetry
Normal pO2 but decreased oxygen saturation is characteristic of methaemoglobinaemia.
Which one of the following features would be most consistent with a diagnosis of Bell’s palsy?
A) Vesicular rash around the ear
B) Hyperacusis
C) Sensory loss over distribution of the facial nerve
D) Pins and needles in R arm
E) Rhinorrhoea
A vesicular rash around the ear would suggest a diagnosis of Ramsey Hunt syndrome. Hyperacusis is seen in around a third of patients.
Patients may also notice
-post-auricular pain
-altered taste
-dry eyes
-hyperacusis
What is the most appropriate treatment of a severely symptomatic patient with a Na of 109 mmol/l?
A) Bolus of hypertonic saline
B) Bolus of normal saline
C) Infusion of loop diuretic
D) Infusion of hypertonic saline over 8h
E) Infusion of normal saline over 8h
Severe hyponatraemia is treated with boluses of hypertonic saline until symptoms have resolved.
Infusions of hypertonic saline over 8 hours may be useful in moderate hyponatraemia however due to the severity of the hyponatraemia, this is not a sufficient rate in this case.
Why is the COCP contra-indicated in a patient with migraines with aura?
A) Theoretical risk of ischaemic stroke
B) Significantly increased risk of ischaemic stroke
C) Increased frequency of migraines
D) Migraine is an independent RF of VTE
E) Increased severity of migraines
Significantly increased risk of ischaemic stroke
Migraine during pregnancy:
-paracetamol 1g = first-line
-NSAIDs can be used second-line in the first and second trimester
-avoid aspirin and opioids such as codeine during pregnancy
A 24F presents due to a rash on her neck and forehead. She returned from a holiday in Cyprus 1 week ago and had her hair dyed 2 days ago. On examination there is a weepy, vesicular rash around her hairline although the scalp itself is not badly affected. What is the most likely diagnosis?
A) Cutaneous leishmaniasis
B) Irritant contact dermatitis
C) Allergic contact dermatitis
D) Syphilis
E) Photocontact dermatitis
Allergic contact dermatitis
-2 main types of contact dermatitis:
-irritant contact dermatitis: common - non-allergic reaction due to weak acids or alkalis (e.g. detergents). Often seen on the hands. Erythema is typical, crusting and vesicles are rare
-allergic contact dermatitis: type IV hypersensitivity reaction. Uncommon - often seen on the head following hair dyes. Presents as an acute weeping eczema which predominately affects the margins of the hairline rather than the hairy scalp itself. Topical treatment with a potent steroid is indicated
A 24M has a cardiac arrest and the defibrillator indicates PEA. The patient was given 1mg of IV medication and chest compressions were continued. What type of receptor does this drug act on?
A) G-protein coupled receptor
B) Enzyme-linked receptor
C) Internal receptors
D) Ion channel-linked receptors
E) Voltage-sensitive ion channel
The drug which has been administered is adrenaline. Adrenaline binds to G protein-coupled receptors. G protein-coupled receptors, (seven-transmembrane domain receptors) are in the cell membrane and bind to extracellular molecules and transmit signals intracellularly. When a ligand binds to the G-protein coupled receptor, it causes a conformational change in the receptor. This then causes an associated G protein to become activated by exchanging GDP for GTP. The two principal signalling pathways involved in G protein-coupled receptors intracellularly are cyclic AMP (cAMP) pathway and the phosphatidylinositol pathway.
What treatment should be commenced in a patient who has been acutely treated for Plasmodium vivax infection?
A) ACT
B) Artesunate
C) Atovaquone and proguanil
D) Chloroquine
E) Primaquine
Non-falciparum malaria Plasmodium vivax and Plasmodium ovale can produce liver hypnozoites as part of their infection cycle. These hypnozoites can evade initial treatment by remaining dormant in the liver, before continuing the infection cycle after treatment has been stopped resulting in a relapse infection. Primaquine destroys these liver hypnozoites and therefore is used post-acute/initial therapy.
Chloroquine is used in first-line treatment for Plasmodium vivax and Plasmodium ovale, but must they again must be followed by primaquine.
What diagnostic test is recommended for a patient presenting first-line with HIV?
A) CD4
B) HIV-NAAT
C) HIV-1/2 Ab/Ag Immunoassay
D) P24
E) Western blot
HIV-1/2 Ab/Ag Immunoassay (fourth generation) should be used to screen individuals for HIV as it will detect HIV-1 and HIV-2 antibodies (Ab) and antigens (Ag) with high sensitivity within a short window period (approximately 10 days after infection).
If the initial screening results are not reactive or indeterminate and acute HIV infection is suspected then HIV-1 NAAT or p24 testing should be considered.
Which side-effect is most common following tetracycline treatment?
A) Headache
B) Red rash on face and neck
C) Dizziness
D) Dry lips and tongue
E) Ringing in ears
Tetracyclines are often prescribed for acne and can cause a photosensitive skin rash. This appears as a red rash on areas of skin exposed to the sun. Other skin reactions to tetracyclines include exfoliative dermatitis and Stevens-Johnson syndrome.
A 72M is admitted with chest pain. He is noted to be pale, have a HR of 40/min and a BP of 90/60 mmHg. Which one of the coronary arteries is most likely to be affected?
A) Posterior descending
B) LAD
C) Right coronary
D) Anterior interventricular
E) Left circumflex
This patient has developed complete heart block secondary to a right coronary artery (RCA) infarction. The atrioventricular node is supplied by the posterior interventricular artery, which in the majority of patients is a branch of the right coronary artery. In the remainder of patients the posterior interventricular artery is supplied by the left circumflex artery.
Which of the following medications are most likely to contribute towards hypercalcaemia?
A) Amlodipine
B) Enalapril
C) Bendroflumethiazide
D) Clopidogrel
E) Atorvastatin
Thiazides are recognised to cause hypercalcaemia but may also cause hypokalaemia, hypomagnesaemia, hyponatraemia and hypochloraemic alkalosis.
What is the MOA of adenosine?
A) A-blocker
B) B-blocker
C) G-protein coupled receptor agonist
D) Potassium channel blocker
E) Sodium channel blocker
G-protein coupled receptor agonist
Which of the following is most likely to be associated with episodes of facial angioedema?
A) Amlodipine
B) Aspirin
C) Bendroflumethiazide
D) Ramipril
E) Moxonidine
ACEi are associated with angioneurotic oedema and is a common side effect.
Which of the following antibodies are most likely to be positive in polymyositis?
A) Anti-smooth muscle
B) Anti-nuclear
C) Anti-dsDNA
D) Anti-SRP
E) pANCA
ANAs are positive in 1/3 of patients with polymyositis. Anti-Jo antibodies are also commonly seen.
Which of the following vaccinations should a patient with COPD get annually?
A) Clostridium tetani
B) H. influenzae type B
C) Meningococcus C
D) Influenza virus
E) Streptococcus pneumoniae
Influenza vaccine
A 25F presents complaining of various physical symptoms over the past 2 years. Examination is entirely normal. How would you best describe her condition?
A) Personality disorder
B) Somatisation disorder
C) Hypochondriacal disorder
D) Dissociative disorder
E) Depersonalisation
Somatisation disorder is characterised by multiple, changing physical symptoms. It requires the presence of:
-2 or more years of multiple, variable complaints
-Persistent refusal to accept the advice of several doctors
-Impairment of functioning due to symptoms and resultant behaviour
Hypochondriacal disorder is the preoccupation of having a serious disease.
A 67F with iron deficient anaemia is found to have an AS murmur radiating to both carotids. Upper GI endoscopy and colonoscopy are normal. What is the most appropriate next line investigation?
A) Barium enema
B) Bone marrow examination
C) Repeat colonoscopy
D) Repeat upper GI endoscopy
E) Selective mesenteric angiography
The most likely diagnosis is angiodysplasia - the most common vascular lesion of the GI tract. The condition may be asymptomatic or cause GI bleeding. The most commonly affected site is the large bowel. Angiodysplasia is associated with aortic stenosis.
Identification of colonic angiodysplasia is only 80% by colonoscopy, hence it is advisable to repeat colonoscopy.
Which of the following is the strongest pointer to T1DM?
A) Anti-GAD Ab
B) Age
C) BMI
D) Nocturia
E) Ketonuria
Ketonuria is indicative of insulinopenia and hence a strong indicator of T1DM.
Single autoantibody positivity (anti-GAD Ab) is not necessarily indicative of a diagnosis. 2 or 3 antibody positivity is much more indicative.
How is the NNT calculated over the duration of a study?
A) Number of months divided by the absolute risk reduction
B) Ratio of absolute to relative risk reduction
C) Ratio of relative to absolute risk reduction
D) Reciprocal of absolute risk reduction
E) Reciprocal of relative risk reduction
The NNT is calculated by 1/ARR
ARR = standard treatment events - new treatment events
RRR = ARR/evetns in control group
Which gene is likely implicated in a patient with a family history of breast cancer, ovarian cancer and melanoma?
A) BRCA1
B) BRCA2
C) APC
D) NF1
E) Rb
A family history of breast and ovarian cancer suggests a mutation in the BRCA genes. The family history of melanoma favours a mutation in BRCA2.
Which of the following is likely to precipitate digoxin toxicity?
A) Prolongation of PR interval on ECG
B) Cca 1.8
C) K 3.3
D) Na 110
E) Prolongation of the QTc interval on ECG
Digoxin is used for the treatment of chronic heart failure and AF. It inhibits Na+-K- ATPase pump in myocardial cells leading to increased contractility. In hypokalemia, it becomes easier for digoxin to bind to ATPase, leading to toxicity. Furosemide and other diuretics can lower potassium levels, resulting in digoxin toxicity.
Hypernatraemia, hypercalcaemia and hypothyroidism can all precipitate digoxin toxicity.
Digoxin toxicity may be associated with the prolongation of the PR interval, but it does not indicate the cause of the toxicity
Which one of the following features is least recognised in long-term lithium use?
A) Alopecia
B) Diarrhoea
C) Fine tremor
D) Goitre
E) Diarrhoea
All the above side-effects, with the exception of alopecia, may be seen in patients taking lithium
A 45F presents with a 2M history of left-hand weakness. O/E, there is mild weakness of the L upper and lower limbs with a R-sided facial weakness which spares the forehead. Where is the lesion?
A) Right cerebrum
B) Left cerebrum
C) Right pons
D) Left pons
E) Cervical spinal cord
The pons is above the level of decussation of the corticospinal tracts so a pontine lesion would cause a contralateral limb weakness. The facial motor nucleus is located in the pons and supplies the ipsilateral facial muscles. Therefore the answer is the right pons.
A patient presents sudden onset weakness of her right lower leg while preparing breakfast. O/E she also has decreased touch sensation on the same side. She has a PMHx of hypercholesterolaemia, hypertension and T2DM. CT scan showed an area of hypo-attenuation in the brain. Which artery is the most likely to be occluded in this patient?
A) Posterior cerebral artery
B) Middle cerebral artery
C) Anterior cerebral artery
D) Basilar artery
E) PICA
Contralateral hemiparesis and sensory loss with the lower extremity being more affected than the upper = anterior cerebral artery
Which of the following would likely worsen the prognosis of CLL?
A) Increased serum beta-2-microglobulin
B) Being female
C) Developing CLL at younger age
D) Deletion of 17p13 region
E) Deletion of 13q14 region
CLL prognosis can vary from 2 to 20 years. Fluorescence in situ hybridization tests (FISH) panel tests, flow cytometry and lab markers are used in order to gather information on prognosis.
Deletion of 17p13 is the strongest independent prognostic factor for CLL. The disease progresses more rapidly and tends to be refractory to many conventional treatments.
The most common genetic aberration in CLL is deletion of 13q. It is associated with a more indolent course of the disease improving the prognosis.
A 55M presents complaining of visual disturbance. Examination reveals a right congruous homonymous hemianopia with macula sparing. Where is the lesion most likely to be?
A) R optic nerve
B) R optic radiation
C) L optic tract
D) L occipital cortex
E) Optic chiasm
Incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex
A congruous defect means complete or symmetrical visual field loss and conversely an incongruous defect is incomplete or asymmetric.
Homonymous hemianopia
-incongruous defects: lesion of optic tract
-congruous defects: lesion of optic radiation or occipital cortex
-macula sparing: lesion of occipital cortex
A 45M is on maximum dose ramipril for HTN but is still found to be hypertensive. What medication should be added?
A) Bisoprolol
B) Doxazosin
C) Indapamide
D) Spironolactone
E) Verapamil
Indapamide
Verapamil is a rate-limiting CCB and is not used for the management of hypertension.
A patient is found to have mild lymphocytosis and their Toxoplasmosis serology is positive. What would be the most appropriate next step?
A) Amphotericin
B) Metronidazole
C) Pyrimethamine
D) Spiramycin
E) Supportive care
Supportive care with fluids and analgesia -most infections caused by Toxoplasma gondii are self-limiting, and treatment is not necessary for immunocompetent people. Exceptions include patients with eye involvement (toxoplasma chorioretinitis) and those who are immunosuppressed (AIDS).
If treatment is required (e.g. toxoplasmic encephalitis related to AIDS) then a combination of pyrimethamine and sulfadiazine is usually given for several weeks.
A 72M has exertional chest pain and a positive exercise tolerance test. He is discharged on a combination of aspirin 75mg od, simvastatin 40mg on, atenolol 50mg od and a GTN spray prn. O/E his pulse is 72 bpm and a BP 130/80 mmHg. He is still regularly using his GTN spray. What is the most appropriate next step in management?
A) Add nifedipine MR 30mg OD
B) Add ISMN 30mg BD
C) Increase atenolol to 100mg OD
D) Add nicorandil 10mg BD
E) Add verapamil 80mg TDS
When treating angina, if there is a poor response to the first-line drug (e.g. a beta-blocker), the dose should be titrated up before adding another drug. The BNF recommends an atenolol dose of 100mg daily in 1 or 2 doses for angina. The starting dose of isosorbide mononitrate is 10mg bd.
NICE recommend using either a B-blocker or a CCB first-line based on ‘comorbidities, contraindications and the person’s preference’
-if a CCB is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used
-if used in combination with a B-blocker then use a longer-acting dihydropyridine CCB (e.g. amlodipine, modified-release nifedipine)
-B-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
If there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a B-blocker add a CCB and vice versa
Which of the following investigations are first-line for acromegaly?
A) GH levels
B) Faecal elastase
C) MRI pituitary gland
D) OGTT
E) Serum IGF-1 levels
Serum IGF-1 levels are now the first-line test for acromegaly. The OGTT test is recommended to confirm the diagnosis if IGF-1 levels are raised.
Growth hormone (GH) levels vary during the day and are therefore not diagnostic.
Which of the following investigations are first-line for acromegaly?
A) GH levels
B) Faecal elastase
C) MRI pituitary gland
D) OGTT
E) Serum IGF-1 levels
Serum IGF-1 levels are now the first-line test for acromegaly. The OGTT test is recommended to confirm the diagnosis if IGF-1 levels are raised.
Growth hormone (GH) levels vary during the day and are therefore not diagnostic.
Which of the following complications is a patient on anastrozole for breast cancer treatment most likely to develop?
A) Increased likelihood of cancer recurrence
B) Reduced serum HDL levels
C) MI
D) VTE
E) Osteoporotic fracture
Aromatase inhibitors (e.g. anastrozole) may cause osteoporosis. Aromatase inhibitors block the synthesis of oestrogen in peripheral tissues, which is the primary source of oestrogen in postmenopausal women. This has a detrimental effect on BMD and increased risk of #. Measurement of BMD is essential before commencing treatment and at regular intervals thereafter, with strong consideration for bisphosphonate prophylaxis.
VTE is also not linked to anastrozole treatment, it is however linked to SERM treatment. This is more of a risk in postmenopausal women who are prescribed oestrogen (rather than oestrogen-depleting drugs), such as those receiving hormone replacement therapy.
A 55Mpresents with a fever and yellow skin and eyes. He has recently had an illness characterized by fever, chills, headache, and myalgia after returning from Angola. He seemed to recover from the illness and was well for a period of 48 hours before deteriorating. He has a past medical history of rheumatoid arthritis and is on tocilizumab. O/E, there is bleeding from his eyes and mucus membranes and he is visibly jaundiced. The temperature is 38.5ºC. What is the likely diagnosis?
A) Ebola
B) Lassa fever
C) Malaria
D) Typhoid
E) Yellow fever
The patient presents with a flu-like illness after returning from Nigeria, followed by a brief period of remission with subsequent recrudescence of fever and the development of jaundice and haemorrhage from the eyes and mucus membranes. This presentation is typical of yellow fever (and the brief period of remission is characteristic). Tocilizumab treatment for rheumatoid arthritis means the yellow fever vaccine is contraindicated and would put the patient at increased risk of developing the illness.
Which of the following RF may pre-dispose a patient to Charles-Bonnet syndrome?
A) Caucasian
B) Male
C) Occupational history of working in sewers
D) Peripheral visual impairment
E) Hypertension
Charles-Bonnet syndrome is characterised by visual hallucinations associated with eye disease. Peripheral visual impairment is a risk factor.
In nephrogenic diabetes insipidus, what is the most likely mutation?
A) Aquaporin 2 channels
B) Epithelial sodium channels
C) Na/Cl pumps
D) Na/K/Cl pumps
E) Vasopressin receptors
Nephrogenic diabetes insipidus may be caused genetic mutations:
-the more common form affects the vasopression (ADH) receptor
-the less common form results from a mutation in the gene that encodes the aquaporin 2 channel
In nephrogenic DI, the kidney is unable to respond to circulating antidiuretic hormone (ADH) from the posterior pituitary, causing an inability to reabsorb water within the collecting tubules.
Which one of the following immunoglobulins is involved in the activation of B-cells?
A) IgD
B) IgM
C) IgG
D) IgA
E) IgE
IgD is involved in the activation of B-cells.
In a patient with metastatic colon cancer, what organism is most likely to cause IE?
A) Streptococcus gallolyticus
B) Brucella
C) Coxiella burnetti
D) Staphylococcus epidermidis
E) Streptococcus viridans
Streptococcus bovis
-associated with colorectal cancer
-the subtype Streptococcus gallolyticus is most linked with colorectal cancer
Which of the following investigation findings would support a diagnosis of idiopathic pulmonary fibrosis?
A) Reticular changes on CT worse at the bases
B) Obstructive picture on spirometry
C) Extensive ground glass opacities on CT
D) Increased transfer factor on spirometry
E) Lymphocytosis on BAL
On CT imaging the changes are often seen are honeycombing, reticular opacities, traction bronchiectasis, and architectural distortion. Ground-glass opacities are less of a feature of idiopathic pulmonary fibrosis. The changes are usually more pronounced at the bases.
What part of the nephron is the majority of glucose reabsorbed?
A) Glomerulus
B) DCT
C) PCT
D) Descending loop of Henle
E) Ascending loop of Henle
Glucose is usually almost fully reabsorbed in the proximal convoluted tubules (PCT) by secondary active, sodium-coupled transporters (SGLT2).
Looser’s zones x-ray are most characteristically associated with which one of the following conditions?
A) Hypoparathyroidism
B) Primary hyperparathyroidism
C) Osteomalacia
D) Pagets disease
E) Osteoporosis
Osteomalacia
In a patient with CF, chronic infection with what organism would be a contraindication to lung transplant?
A) Aspergillus fumigatus
B) Burkholderia cepacia
C) Mycobacterium abscessus
D) Pseudomonas aeruginosa
E) Scedosporium apiospermum
Chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation.
How should a patient who is unsure of their vaccination status be managed if they received a bite from a bat?
A) Prophylactic antibiotics
B) Rabies Ig
C) Rabies vaccination and Ig
D) Reassurance
E) Tetanus Ig
Rabies is the particular worry after a bat bite. High-risk non-immune patients should be treated with the rabies vaccination and immunoglobulin. If the patient has previously been vaccinated, then only a repeat course of the vaccination is needed with no need to administer immunoglobulin.
A 25M presents with multiple painful penile ulcers with ragged edges and inguinal lymphadenopathy. He admits to unprotected sexual intercourse. Gram-stain of ulcer swabs shown gram-negative rods. Which of the following is the most likely diagnosis?
A) Chancroid
B) Syphilis
C) HSV
D) Chlamydia
E) Lymphogranuloma venereum
Chancroid is caused by Haemophilus ducreyi and presents as a tender ulcer with a ragged edge that readily bleeds on contact. Multiple ulcers can occur and there is often associated lymphadenopathy.
LGV is incorrect due to the painful nature of the ulcers and Gram-ve rods. LGV is caused by Chlamydia trachomatis.
Which of the following regular medications would you prescribe to a patient with an egg-allergy that causes them to break out in hives?
A) Ranitidine
B) Prednisolone
C) Topical hydrocortisone
D) Chlorpheniramine
E) Topical lidocaine
Chlorpheniramine can be used to reduce the duration and severity of hives.
