MRCP Deck 4 June 2023

Question 1

Which of the following genetic translocations is most likely to be seen in a patient with APML?
A) t(8;14)
B) t(8;21)
C) t(9;22)
D) t(11;14)
E) t(15;17)

Answer 1

t(15;17)

t(11;14) - mantle lymphoma
t(9;22) - AML
t(8;21) - Burkitt lymphoma

Question 1

What is the definition of functional residual capacity (FRC)?
A) The volume of air present in the lungs at the end of passive expiration
B) The additional amount of air that can be expired from the lungs by determined effort after normal expiration
C) The volume of air left in the lungs after fully exhaling
D) The amount of air that can be forcibly exhaled from the lungs after taking the deepest breath possible
E) The maximal amount of additional air that can be drawn into the lungs by determined effort after normal inspiration

Answer 1

The volume of air present in the lungs at the end of passive expiration.

The volume of air left in the lungs after fully exhaling = residual volume.

The additional amount of air that can be expired from the lungs by determined effort after normal expiration = expiratory reserve volume.

The amount of air that can be forcibly exhaled from the lungs after taking the deepest breath possible = forced vital capacity.

The maximal amount of additional air that can be drawn into the lungs by determined effort after normal inspiration = inspiratory reserve volume.

Question 2

What is the appropriate treatment for a patient with long QT syndrome who has experienced syncopal episodes but no previous cardiac arrests?
A) Amiodarone
B) High left stellate ganglionectomy
C) ICD
D) Metoprolol
E) Permanent pacing

Answer 2

If a cardiac arrest has not occurred, b-blockers should be trialled in an attempt to abort the syncopal episodes.

Ganglionectomy is considered in patients who do not respond to b-blockers. ICD is reserved for patients who do not respond to either option or who present with non-fatal cardiac arrest.

Question 3

What is the primary MOA of metformin?
A) Increases glucose uptake in fat
B) Increases glucose-dependent insulin release
C) Increases glucose-independent insulin release
D) Reduces hepatic glucose output
E) Slows gastric emptying

Answer 3

Reduces hepatic glucose output

Question 4

In HOCM, which of the following is the most likely inherited genetic defect?
A) Troponin I
B) Troponin C
C) Troponin T
D) Myosin-binding protein C
E) Alpha actin

Answer 4

Myosin-binding protein C and beta-myosin heavy chain mutations comprise of the majority of HOCM mutations.

Question 5

What is the underlying pathophysiology of Graves eye disease?
A) Deposition of extra-orbital fat
B) Deposition of glycosaminoglycans
C) Deposition of immunoglobulins
D) Oedema secondary to immunoglobulins
E) Oedema secondary to carbimazole

Answer 5

Deposition of glycosaminoglycans - Graves orbitopathy involves inflammatory infiltration of fat and extra-ocular muscles by lymphocytes, plasma cells and mast cells, followed by deposition of water and glycosaminoglycans which drive progressive exophthalmos.

Question 6

What is the treatment of a patient with known Graves disease presenting with worsening diplopia, loss of colour vision and bilateral exophthalmos?
A) Bendroflumethiazide
B) PO selenium
C) Orbital radiotherapy
D) IV methylprednisolone
E) Rituximab

Answer 6

IV methylprednisolone should be administered due to the sight-threatening symptoms of optic nerve compression.

Question 7

What is the primary MOA of terlipressin?
A) Increased DBP
B) Increased renal salt and water retention
C) Positive inotropic effects
D) Reduced intestinal motility
E) Reduced hepatic portal pressure

Answer 7

Terlipressin inhibits portal hypertension

Question 8

What is the MOA of flecainide?
A) CCB
B) Muscarinic receptor antagonist
C) K channel blocker
D) Na channel blocker
E) Na+/K+ ATPase inhibtitor

Answer 8

Na channel blocker

Amiodarone = K channel blocker

Question 9

Which antibodies are found in Hashimoto’s thyroiditis?
A) ANA
B) ASMA
C) Anti-TPO Ab
D) Blocking anti-TSHr Ab
E) Stimulating anti-TSHr Ab

Answer 9

Anti-TPO Ab and anti-thyroglobulin Ab are both associated with Hashimoto’s thyroiditis.

Question 10

Which of the following medications should not be used in conjunction with theophylline?
A) Azithromycin
B) Ciprofloxacin
C) Co-amoxiclav
D) Cephalexin
E) Doxycycline

Answer 10

Ciprofloxacin is a CYP1A2 and CYP3A4 inhibitor and hence causes an increased exposure to theophylline leading to symptoms of toxicity (nausea, vomiting, hypokalaemia).

Question 11

Which of the following can precipitate a scleroderma renal crisis?
A) Amlodipine
B) Omeprazole
C) Prednisolone
D) Ramipril
E) Valsartan

Answer 11

Prednisolone

ACEi are protective and are the intervention of choice for BP control.

Question 12

What is the most appropriate management for a patient presenting with acute GPA?
A) IV belimumab
B) IV methylprednisolone and cyclophosphamide
C) PO methotrexate
D) Plasma exchange
E) IV rituximab

Answer 12

IV methylprednisolone and cyclophosphamide

Corticosteroids form the backbone of treatment with the addition of either cyclophosphamide or rituximab.

Question 13

What is the most likely composition of renal stones in a patient with Crohns disease who has had multiple small bowel resections?
A) Calcium citrate
B) Calcium oxalate
C) Cystine
D) Magnesium ammonium phosphate
E) Uric acid

Answer 13

Small bowel resections –> short bowel syndrome –> increased intestinal absorption of oxalate –> increased oxalate into urine –> calcium oxalate stones

Question 14

Which of the following is the inheritance pattern of Von-Hippel Lindau?
A) AD
B) AR
C) Sex-linked dominant
D) Sex-linked recessive
E) Spontaneous mutation only

Answer 14

AD

Although 2 copies of the VHL gene must be altered to trigger tumour and cyst formation - a mutation of the second copy commonly occurs during a persons lifetime - often in the brain, retina and kidneys - which is why the tumours are most commonly found in these tissues.

Question 15

What is the most appropriate management in a patient with ankylosing spondylitis which has failed to be controlled by 2 different NSAIDs?
A) Apremilast
B) Etanercept
C) Methotrexate
D) Rituximab
E) Toclizumab

Answer 15

After 2 NSAIDs, treatment with anti-TNFa is the most appropriate next step. The evidence is strongest for etanercept and adalimumab.

Question 16

A 72M is reviewed regarding his hypertension. His PMHx includes T2DM and diverticulosis. He is of African-Caribbean origin and he currently takes amlodipine 10mg and metformin. What would be the most appropriate antihypertensive to add?
A) ACEi
B) A-blocker
C) ARB
D) B-blocker
E) Thiazide diuretic

Answer 16

For patients of black African or African–Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor.

Question 17

A 30M has fine, fair hair and long arms. He has visible kyphosis and mild learning difficulties. He has had seizures in the past. He has previously been reviewed by ophthalmology due to downward dislocation of his lens and severe myopia. He has also been reviewed in haematology clinic with recurrent DVT. What is the most likely diagnosis?
A) Charcot-Marie-Tooth disease
B) Ehlers-Danlos syndrome
C) Fragile X
D) Homocystinurie
E) Marfan syndrome

Answer 17

Tall, long fingered, downward lens dislocation, learning difficulties, DVT - homocystinuria.

Marfan’s syndrome and homocystinuria can be difficult to differentiate clinically. However, Marfan’s syndrome is typically associated with upwards lens dislocation, unlike the downwards dislocation of the lens in this vignette. The heart is rarely affected in homocystinuria, whereas aortic regurgitation is common in Marfan’s. The recurrent thrombosis noted in this case is also more typical of homocystinuria. Marfan’s syndrome is inherited in an autosomal dominant fashion where homocystinuria is inherited in an autosomal recessive fashion.

Question 18

A 17M presents with 2W of abdominal pain, diarrhoea and repeated episodes of flushing. Examination reveals urticarial skin lesions on the trunk. What test is most likely to reveal the diagnosis?
A) CXR
B) Urinary catecholamines
C) Serum amylase
D) Urinary HIAA
E) Urinary histamine

Answer 18

Given the history of diarrhoea and flushing a diagnosis of carcinoid syndrome should be considered, which would be investigated with urinary 5-HIAA levels. This does not explain the urticarial skin lesions. In a young person a diagnosis of systemic mastocytosis should be considered (average age of patients with a carcinoid tumour = 61).

Urinary histamine is used to diagnose systemic mastocytosis

Question 19

A 17M presents with 2W of abdominal pain, diarrhoea and repeated episodes of flushing. Examination reveals urticarial skin lesions on the trunk. What test is most likely to reveal the diagnosis?
A) CXR
B) Urinary catecholamines
C) Serum amylase
D) Urinary HIAA
E) Urinary histamine

Answer 19

Given the history of diarrhoea and flushing a diagnosis of carcinoid syndrome should be considered, which would be investigated with urinary 5-HIAA levels. This does not explain the urticarial skin lesions. In a young person a diagnosis of systemic mastocytosis should be considered (average age of patients with a carcinoid tumour = 61).

Urinary histamine is used to diagnose systemic mastocytosis

Question 20

A 55M who was admitted following a stroke 2W ago is reviewed. Yesterday he started to have a temperature and become more confused. A septic screen has shown radiological evidence of pneumonia. O/E his: RR 36/min, HR112/min, O2 sats 95% on RA and BP 102/66 mmHg. What is the most appropriate antibiotic to use?
A) Teicoplanin
B) Cefuroxime
C) Amoxicillin
D) Imipenem
E) Tazocin

Answer 20

Hospital-acquired pneumonia

-Within 5 days of admission: co-amoxiclav or cefuroxime
-More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)

Question 21

A 55M who was admitted following a stroke 2W ago is reviewed. Yesterday he started to have a temperature and become more confused. A septic screen has shown radiological evidence of pneumonia. O/E his: RR 36/min, HR112/min, O2 sats 95% on RA and BP 102/66 mmHg. What is the most appropriate antibiotic to use?
A) Teicoplanin
B) Cefuroxime
C) Amoxicillin
D) Imipenem
E) Tazocin

Answer 21

Hospital-acquired pneumonia

-Within 5 days of admission: co-amoxiclav or cefuroxime
-More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)

Question 22

LMWH has the greatest inhibitory effect on which one of the following proteins involved in the coagulation cascade?
A) Factor IXa
B) Factor XIa
C) Factor Xa
D) Thrombin
E) Factor XIIa

Answer 22

Heparins generally act by activating antithrombin III. Unfractionated heparin forms a complex which inhibits thrombin, factors Xa, IXa, XIa and XIIa. LMWH however only increases the action of antithrombin III on factor Xa.

Question 23

What is the minimum time period to wait before increasing the dose of metformin from 500mg OD to BD?
A) 3D
B) 5D
C) 1W
D) 2W
E) 4W

Answer 23

Metformin should be titrated slowly, leave at least 1 week before increasing dose.

The BNF states that 500mg should be taken once daily, with breakfast, for at least 1 week. It can then be increased to 500mg twice daily, with breakfast and evening meals, again for 1 week. Subsequently, it can be increased to three times a day (with breakfast, lunch and evening meal), for another 1 week. It can then be titrated upwards once more to a total of 2g daily.

Question 24

Which of the following is the most likely explanation for a poor response to Hep B vaccine? A) Anti-retroviral therapy B) HIV positivity C) Inadequate dosing of vaccine D) Previous Hep C infection E) Vaccination with Hep A

Answer 24

HIV positivity

Question 25

What is the first line anti-hypertensive for a 45YO patient on lithium therapy? A) Amlodipine B) Doxazosin C) Indapamide D) Ramipril E) Valsartan

Answer 25

Amlodipine Ramipril enhances tubular reabsorption of lithium and should hence be avoided.

Question 26

What treatment should be given to a patient with acute pericarditis with a background of well-controlled asthma? A) Clopidogrel, aspirin and fondaparinux B) Naproxen C) Colchicine D) PCI E) Prednisolone

Answer 26

Naproxen Colchicine, either alone or in combination with NSAIDs should be given to patients with recurrent pericarditis or with symptoms >14 days.

Question 27

What treatment option is most appropriate in a patient with PMR unable to wean off prednisolone? A) Bevacizumab B) Golimumab C) Infliximab D) Rituximab E) Toclizumab

Answer 27

Toclizumab is an anti-IL6 antibody which has been found to be an effective initial therapy for GCA and as an adjunct to prednisolone.

Question 28

Which of the following medications are most likely to cause gum hypertrophy? A) Amlodipine B) Dapagliflozin C) Indapamide D) Ramipril E) Sitagliptin

Answer 28

Amlodipine, and other CCBs, are a recognised cause of gum hypertrophy.

Question 29

Which artery supplies the most blood to the greater curvature of the stomach? A) Gastroduodenal B) Left gastroepiploic C) Left gastric D) Right gastric E) Short gastric

Answer 29

The left gastroepiploic artery is the largest branch of the splenic artery and supplies several ascending branches to the greater curvature. The left gastric artery supplies the lesser curvature whilst the gastroduodenal artery supplies the pylorus.

Question 30

In tennis elbow, tendonitis affecting which muscle causes pain? A) Biceps B) Extensor carpi radialis brevis C) Flexor carpi radialis D) Flexor carpi ulnaris E) Flexor digitorum superficialis

Answer 30

Tennis elbow is related to tendonitis affecting the common extensor tendon with most of the pain and restriction of movement related to inflammation of the extensor carpi radialis brevis.

Question 31

What is the best option for treatment in a patient with primary sclerosis cholangitis? A) Cholestyramine B) Mycophenolate C) Penicillamine D) Colchicine E) Ursodeoxycholic acid

Answer 31

Ursodeoxycholic acid has been shown to improve LFTs in patients with early PSC.

Question 32

A patient has myasthenia gravis which is not controlled on PO prednisolone and pyridostigmine. What is the most appropriate next treatment option? A) Azathioprine B) Cyclophosphamide C) Methotrexate D) Rituximab E) Thymectomy

Answer 32

Typical steroid sparing agents (e.g. azathioprine, mycophenolate, cyclosporine) can be used second line in MG. Thymectomies are reserved for patients who have MG resistant to medical therapies and where an obvious thymoma are detected.

Question 33

Which of these medications should be avoided in pregnancy? A) Amoxicillin B) Cefalexin C) Ciprofloxacin D) Nitrofurantoin E) Trimethoprim

Answer 33

Ciprofloxacin - quinolones are not recommended in pregnancy due to the risk of tendon rupture in animal models. Trimethoprim is a second line option for UTI treatment in pregnancy and, during the first trimester, should be prescribed in conjunction with folic acid.

Question 34

Which of the following is the most appropriate treatment option for a patient with acromegaly? A) Cabergoline B) Lanreotide C) Metyrapone D) Pegvisomant E) Trans-sphenoidal surgery

Answer 34

Lanreotide is a long-acting analogue of somatostatin, like octreotide. They are used to reduce pre-operative mortality. Pegvisomant is a GH antagonist that blocks the peripheral synthesis of IGF-1 - it is third line therapy in patients who fail to gain control of symptoms on somatostatin analogues combined with dopamine agonists.

Question 35

Which of the following is the most appropriate treatment option for a patient with acromegaly? A) Cabergoline B) Lanreotide C) Metyrapone D) Pegvisomant E) Trans-sphenoidal surgery

Answer 35

Lanreotide is a long-acting analogue of somatostatin, like octreotide. They are used to reduce pre-operative mortality. Pegvisomant is a GH antagonist that blocks the peripheral synthesis of IGF-1 - it is third line therapy in patients who fail to gain control of symptoms on somatostatin analogues combined with dopamine agonists.

Question 36

A patient has presented with new-onset Graves disease and is 28W pregnant. Which of the following is the most appropriate intervention? A) Carbimazole B) Carbimazole and thyroxine C) Propranolol D) Propylthiouracil E) Propylthiouracil and thyroxine

Answer 36

Carbimazole is safe to give later on in pregnancy, propylthiouracil used later in pregnancy is associated with increased risk of hepatic dysfunction. Propylthiouracil is preferred in early pregnancy.

Question 37

Which of the following features of rheumatoid arthritis stratifies aggressive joint disease? A) Acute onsent B) Anti-CCP positivity C) CRP 89 D) ESR 62 E) RF +ve

Answer 37

Anti-CCP is predictive of significantly more radiological damage, independent of RF status

Question 38

Which of the following is the most appropriate intervention for a patient presenting with symptomatic pulmonary disease secondary to sarcoidosis? A) Azathioprine B) High dose fluticasone C) Infliximab D) Mycophenolate mofetil E) PO prednisolone

Answer 38

Oral corticosteroids are the mainstay of initial therapy for sarcoidosis, although treatment is only indicated for patients with symptomatic pulmonary disease or have hypercalcaemia.

Question 39

What is the most appropriate initial intervention for a patient with carpal tunnel syndrome? A) Acupuncture B) Gabapentin C) Local corticosteroid injection at the wrist D) Regular NSAIDs E) Surgical carpal tunnel release

Answer 39

Local corticosteroid injection at the wrist are the most appropriate initial intervention. NSAIDs have been shown to be no better than placebo.

Question 40

Which of the following medications can be used to treat early NASH on a background of obesity, HTN and T1DM? A) Atorvastatin B) Fenofibrate C) Liraglutide D) Metformin E) Pioglitazone

Answer 40

Liraglutide is licensed for the treatment of obesity where HTN and T2DM are present.

Question 41

What is the MOA of exenetide? A) Alpha glucosidase inhibitor B) DPPIV inhibitor C) GLP-1 agonist D) PPAR-gamma activator E) SGLT-2 inhibitor

Answer 41

GLP-1 agonist Empagliflozin = SGLT2 inhibitor

Question 41

What is the best intervention for a pregnant patient who has been exposed to two people who have just been diagnosed with Hepatitis A? A) Advice on avoidance of paracetamol B) Hepatitis A IgM testing C) Hepatitis A vaccination D) Weekly LFTs E) Reassurance

Answer 41

Hepatitis A vaccination. PEP may reduce the risk of infection occurring, especially given serious sequelae are more common in pregnancy.

Question 42

What is the most appropriate treatment for Yersinia diarrhoea infection? A) Amoxicillin B) Cephalexin C) Gentamicin D) Loperamide E) Ofloxacin

Answer 42

Yersinia is sensitive to treatment with quinolones, co-trimoxazole and tetracyclines. Ofloxacin and gentamicin could both be options (ofloxacin preferred in renal impairment).

Question 43

A 33F is admitted due to R-sided weakness. She has a past history of DVT following the birth of her daughter. She has also had two miscarriages. A CT head confirms an ischaemic stroke in the left MCA territory. What is the likely finding on echocardiography? A) Normal B) Dilated cardiomyopathy C) Bicuspid aortic valve D) ASD E) VSD

Answer 43

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. Hence it is likely the echo will show a normal result.

Question 44

What is the best screening test for hereditary angioedema between attacks? A) Immunoglobulins B) Mast cell tryptase C) C1 esterase inhibitor D) C2 E) C4

Answer 44

C4 is the most reliable screening test for hereditary angioedema. C1-INH can be tested during an acute attack of hereditary angioedema and are often low. However, this is not a valid screening tool for hereditary angioedema and so shouldn't be performed between episodes.

Question 45

Which one of the following adverse effects is most strongly associated with cabergoline? A) Optic neuritis B) Transient rise in LFTs C) Pulmonary fibrosis D) Renal failure E) Thrombocytopenia

Answer 45

Pulmonary fibrosis

Question 46

Which one of the following conditions would contraindicate the prescription of bupropion? A) History of SVT B) Previous acute pancreatitis C) Epilepsy D) Depression E) Hypertension

Answer 46

Bupropion should not be used in a patient with epilepsy as it reduces seizure threshold.

Question 47

Which one of the following conditions would contraindicate the prescription of bupropion? A) History of SVT B) Previous acute pancreatitis C) Epilepsy D) Depression E) Hypertension

Answer 47

Bupropion should not be used in a patient with epilepsy as it reduces seizure threshold.

Question 48

A patient has been titrated up to 75mg OD amitriptyline for neuropathic pain that is still not well controlled. What is the next most appropriate management strategy to manage her pain? A) Stop amitriptyline and start duloxetine B) Continue amitriptyline at current dose and re-review in 2W C) Continue amitriptyline at current dose and start duloxetine D) Increase amitriptyline in gradual increments over 6W E) Refer to pain clinic for increasing dose of amitriptyline

Answer 48

The NICE guidelines advise that when a first-line medication is not effective then that medication should be stopped and another first-line medication should be tried. Neuropathic medications should be given as monotherapy outside of specialist pain clinics. When prescribing amitriptyline it should be trialled for a period of 6-8 weeks with at least 2 weeks at the maximum dose.

Question 49

What is the mechanism of action of azathioprine? A) Inhibits purine synthesis B) Inhibits inosine monophosphate dehydrogenase C) Mercaptopurine antagonist D) Thiopurine methyltransferase inhibitor E) Causes cross-linking in DNA

Answer 49

Azathioprine is metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis. A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.

Question 50

What is the first line antibiotic in the treatment of Shigella dysentery? A) Flucloxacillin B) Vancomycin C) Ciprofloxacin D) Metronidazole E) Ampicillin

Answer 50

Shigella infection is usually self-limiting and does not require antibiotic treatment. Antibiotics (e.g. ciprofloxacin) are indicated for people with severe disease, who are immunocompromised or with bloody diarrhoea.

Question 51

Which of the following would cause a normal anion gap metabolic acidosis? A) DKA B) Salicylate poisoning C) Renal tubular acidosis D) Methanol poisoning E) Sepsis

Answer 51

Renal tubular acidosis causes a normal anion gap. Diarrhoea is also a cause of normal anion gap acidosis. The remaining 4 choices would give a raised anion gap. Diabetic ketoacidosis - ketones Salicylate and methanol - exogenous acid poisons Sepsis - lactate

Question 52

What is the most likely adverse effect associated with cisplatin-based chemotherapy? A) AF B) Dilated cardiomyopathy C) HUS D) Pulmonary fibrosis E) Transitional cell carcinoma of the bladder

Answer 52

Rhythm disturbances are common in patients treated with cisplatin-based chemotherapy, with AF seen in approximately 1 in 25. Pulmonary fibrosis is seen in patients with bleomycin based chemotherapy. TCC is seen with increased risk in people with cyclophosphamide based therapy.

Question 53

What treatment should be offered to patients with pemphigus vulgaris that has not responded to PO prednisolone and azathioprine? A) Change azathioprine to cyclophosphamide B) Change azathioprine to methotrexate C) IVIG D) IV rituximab E) Plasma exchange

Answer 53

When rituximab is added to traditional therapies (prednisolone + steroid sparing agent), remission can be achieved in 80% of patients. IVIG IS an alternative to rituximab but it is slower to improve symptoms.

Question 54

What is the mode of inheritance of hereditary hypophosphataemic rickets? A) AR B) AD C) Mitochondrial D) X-linked dominant E) X-linked recessive

Answer 54

X-linked dominant X-linked dominant means the disease will present in women but not as severely as in men (who only have one X chromosome)

Question 55

A patient suffering from HFrEF post anterior MI is currently taking DAPT, ramipril, bisoprolol, atorvastatin and furosemide. Which medication should be added for long term improvement? A) Digoxin B) Eplerenone C) Increase furosemide D) Valsartan E) Switch ramipril to valsartan sacubitril

Answer 55

Eplerenone is an aldosterone receptor antagonist - it is indicated as an adjunct to therapy in patients with LVF<40% and following an MI.

Question 56

Which antibodies are most likely to be found in a patient with mixed connective tissue disease? A) Anti-Jo1 B) Anti-Ro C) Anti-Scl70 D) Anti-smooth muscle E) Anti-U1 RNP

Answer 56

Anti-U1 RNP

Question 57

You have a strong suspicion a patient is suffering from Lyme disease but there is no rash. What is the next most important step? A) Amoxicillin B) Clarithromycin C) Doxycycline D) Lyme serology E) Prednisolone

Answer 57

If there is a high suspicion of Lyme disease, even if no rash (erythema migrans) is present, patients should be treated with doxycycline without waiting for the results of Lyme serology.

Question 58

What is the most appropriate intervention for pneumocystis prophylaxis in a HIV positive patient with previous PCP pneumonia and a CD4 count of 140? A) Dapsone B) Dapsone + trimethoprim C) Pentamidine D) Pyrimethamine E) Trimethoprim-sulfamethoxazole

Answer 58

For patients with a CD4 count of <200 and previous episode of PCP, they are at a significant risk of a future episode. Prophylaxis with trimethoprim-sulfamethoxazole is recommended.

Question 59

What is the most appropriate next step for a patient familial hypercholesterolaemia treated with atorvastatin and ezetimibe with a fasting cholesterol at 7.2. A) Evolocumab B) Fenofibrate C) Low-fat diet D) Niacin E) Reassurance

Answer 59

Evolocumab is a PCSK9 inhibitor which prevents degradation of LDL receptors on the surface of liver cells. This allows more LDL cholesterol to be removed from the peripheral blood.

Question 60

What is the MOA of acyclovir? A) DNA gyrase inhibitor B) DNA polymerase inhibitor C) Fusion inhibitor D) Reverse transcriptase inhibitor E) RNA polymerase inhibitor

Answer 60

DNA polymerase inhibitor

Question 61

Which of the following medications is most likely to dilated cardiomyopathy? A) Atelozizumab B) Cisplatin C) Imatinib D) Nivolumab E) Trastuzumab

Answer 61

Trastuzumab is a HER2 receptor antagonist commonly used in the treatment of breast cancer. HER2 agonism is thought to protect against the development of dilated cardiomyopathy. Baseline cardiac function and echo is required before commencing therapy with cardiac function reviewed every 3M.

Question 62

What is the most appropriate intervention for a patient with ARDS secondary to acute pancreatitis? A) CPAP B) Inotropic support C) IV labetolol D) IV furosemide E) IV methylprednisolone

Answer 62

CPAP is the initial intervention of choice, followed by intubation and ventilation in patients who deteriorate further.

Question 63

What is the strongest indicator for surgery in a patient with infective endocarditis? A) Crackles at both lung bases on auscultation B) Episodes of complete heart block C) Failure of CRP to fall after 3D of antibiotics D) Symptomatic anaemia E) Vegetations >10mm

Answer 63

Episodes of complete heart block imply paravalvular extension of infection and implies high mortality/morbidity with medical management alone. Early surgical intervention is recommended.

Question 64

Which antibiotic therapy should be given to a patient who is penicillin allergic and has been bitten by a dog that morning? A) Ciprofloxacin and erythromycin B) Clarithromycin C) Clindamycin D) Metronidazole and doxycycline E) No antibiotic therapy needed

Answer 64

Metronidazole and doxycycline

Question 65

Which of the following is the most prominent side effect associated with mycophenolate mofetil? A) Cystitis B) Hepatic fibrosis C) Hirsutism D) Pulmonary fibrosis E) Tremor

Answer 65

Tremor

Question 66

What is the most appropriate intervention for a patient with normal pressure hydrocephalus? A) Acetazolamide B) Bendroflumethiazide C) Prednisolone D) Shunt insertion E) Therapeutic LP

Answer 66

Therapeutic LP's can predict response to shunting and medical therapies such as acetazolamide so is the initial intervention of choice.

Question 67

Which antibiotic would be indicated for a patient with an infected diabetic foot ulcer? A) IV co-amoxiclav B) IV flucloxacillin C) PO doxycycline D) PO clindamycin E) PO ciprofloxacin

Answer 67

IV co-amoxiclav PO clindamycin would be indicated in a patient with penicillin allergy.

Question 68

Which of the following medications may cause a reduction in disinhibition and inappropriate behaviour in fronton-temporal dementia? A) Carbamazepine B) Donepezil C) Chlorpromazine D) Lorazepam E) Paroxetine

Answer 68

Studies have shown SSRIs (e.g. fluoxetine, paroxetine) have shown a reduction in disinhibition and inappropriate behaviour in FTD.

Question 69

What is the most appropriate treatment option for a patient with ankylosing spondylitis with pain not controlled on regular ibuprofen? A) Azathioprine B) Golimumab C) Methotrexate D) Naproxen E) Prednisolone

Answer 69

Patients should be trialled on more potent NSAIDS (e.g. naproxen) if their pain is not being managed by ibuprofen alone. After this point, the next step is to move to a TNF-modulating biological. For example, golimumab may be institute after trial of 2 different NSAIDs at therapeutic doses.

Question 70

What treatment should be given to a patient with neutropenic sepsis (strep. pyogenes) on a background of carbimazole for Graves disease. Antibiotics have been given and carbimazole stopped. A) Deferipone B) Switch to propylthiouracil C) G-CSF D) Observation E) Prednisolone

Answer 70

In patients with significant bacterial sepsis and neutropenia, G-CSF carries significant benefits.

Question 71

Which of the following cytokines is mainly produced by Th2 cells? A) FGF-21 B) IFN gamma C) IL-2 D) IL-4 E) TNF-beta

Answer 71

IL-4 drives differentiation of T-helper cells to Th2 cells.

Question 72

What is the treatment of torsades de pointes? A) Amiodarone B) Calcium C) Magnesium D) Metoprolol E) Verapamil

Answer 72

IV magnesium

Question 73

What is the appropriate intervention for a patient with diarrhoea secondary to severe exocrine pancreatic insufficiency? A) Cholestyramine B) Codeine phosphate C) Creon D) Loperamide E) Metformin

Answer 73

Pancreatic enzyme replacement with creon capsules. Cholestyramine is useful in patient with bile acid diarrhoea, which can be seen in malabsorption related to active Crohns disease or due to small bowel resection.

Question 74

Which of the following HLA types are most associated with Takayusu's arteritis? A) HLA-B52 B) HLA-B51 C) HLA-DR4 D) HLA-DR2 E) HLA-B27

Answer 74

HLA-B51

Question 75

What is the most appropriate treatment option for a patient with hypothyroidism secondary to lithium use? A) Start prednisolone B) Start thyroxine C) Stop lithium D) Start metformin E) Stop olanzapine

Answer 75

Start thyroxine Lithium is thought to inhibit thyroid hormone release and may inhibit proteolytic digestion of thyroglobulin. It normally responds to treatment with thyroxine and lithium treatment can often continue.

Question 76

What is the most appropriate treatment for a patient with Tourette syndrome? A) Haloperidol B) Risperidone C) Penicillamine D) Sertraline E) Zinc

Answer 76

Low dose risperidone (off-label) is first-line treatment.

Question 77

Which of the following medications can be used to treat thyroid eye disease secondary to Graves where high-dose PO prednisolone has not been beneficial? A) Alemtuzumab B) Bendroflumethiazide C) Furosemide D) Octreotide E) Rituximab

Answer 77

Rituximab is an anti-C20 monoclonal antibody and can be very useful in patients with severe eye disease when used early. Ciclosporin can also be used.

Question 78

Which of the following is the first-line treatment for diabetic peripheral neuropathy? A) Capsaicin B) Codeine phosphate C) Lamotrigine D) Pregabalin E) Tramadol

Answer 78

Amitriptyline, pregabalin, duloxetine or gabapentin can all be considered as first-line treatment.

Question 79

What is the commonest cause of transfusion associated morbidity? A) ABO incompatibility B) Rhesus incompatibility C) TACO D) TRALI E) Transfusion-related septicaemia

Answer 79

TACO

Question 80

Where in the cell does RNA splicing occur? A) Cell membrane B) Cytoplasm C) ER D) Golgi body E) Nucleus

Answer 80

Nucleus Splicing is the editing of pre-RNA into mRNA.

Question 81

What is the treatment for a patient with AIHA secondary to CLL? A) Alemtuzumab B) Chlorambucil C) Cyclophosphamide D) Prednisolone E) Rituximab

Answer 81

Prednisolone - in patents who fail to respond, rituximab is the second choice.

Question 82

What is the management of multi-focal atrial tachycardia? A) Adenosine B) Digoxin C) Verapamil D) Atenolol E) DC cardioversion

Answer 82

MAT may be defined as a irregular cardiac rhythm caused by at least three different sites in the atria (demonstrated by morphologically distinctive P waves). It is more common in elderly patients with chronic lung disease, for example COPD. Management is with rate-limiting CCBs are often used first-line.

Question 83

What is the most appropriate treatment for restless legs syndrome? A) SSRI B) Low-dose TCA C) Dopamine agonist D) 5-HT3 antagonist E) Dopamine antagonist

Answer 83

Restless leg syndrome - management includes dopamine agonists such as ropinirole

Question 84

Which type of cells do high levels of gastrin act on? A) Gastric parietal cells B) Chief cells C) D cells D) G cells E) Goblet cells

Answer 84

Gastrin hormone is secreted from the G cells in the antrum of the stomach and increases acid secretion from gastric parietal cells.

Question 85

What is the MOA of enoxaparin? A) Activates antithrombin III and forms a complex that inhibits factor Xa B) Activates antithrombin III and forms a complex that inhibits factor Xa, IXa, XIa and XIIa C) Directly inhibits factor Xa D) Directly inhibits thrombin E) Inhibits production of thromboxane A2

Answer 85

Activates antithrombin III and forms a complex that inhibits factor Xa. Antithrombin III inactivates thrombin, factor Xa and factor IXa. All heparins act to potentiate the effect of antithrombin III. When LMWH binds to ATIII, it produces a conformational change of ATIII, which accelerates its inhibition of factor Xa.

Question 86

What antibodies are most specific for dermatomyositis? A) Anti-Jo1 B) Anti-Mi2 C) Anti-Ro D) Anti-phospholipase A2 E) ANA

Answer 86

Dermatomysotis: ANA most common, anti-Mi-2 most specific

Question 87

Which of the following medications would be most likely to contribute towards serotonin syndrome? A) Diazepam B) Ibuprofen C) Meptazinol D) Paracetamol E) Tramadol

Answer 87

Tramadol has serotoninergic effects.

Question 88

Which of the following bacteria are most likely to contaminate platelet transfusions? A) E. aerogenes B) E. coli C) K. pneumoniae D) S. epidermidis E) S. pneumoniae

Answer 88

Staphylococcus infections are most likely to be seen in platelet transfusions.

Question 89

What is the MOA of digoxin? A) Intracellular Ca depletion B) Intracellular K accumulation C) Intracellular Na accumulation D) Phosphodiesterase-4 inhibition E) Phosphodiesterase-5 inhibition

Answer 89

Increases intracellular sodium accumulation

Question 90

At which stage of the cell cycle does vincristine act? A) Anaphase B) Early prophase C) Metaphase D) Prometaphase E) Telophase

Answer 90

Vincristine causes arrest of cell division in metaphase. A number of oncology drugs act during metaphase because this is the point in mitosis when chromosomes are duplicated.

Question 91

Which of the following is the most appropriate antibiotic intervention for Legionnaires disease? A) Cefalexin B) Co-trimoxazole C) Co-amoxiclav D) Doxycycline E) Levofloxacin

Answer 91

Both quinolones and macrolides are effective in treating Legionella pneumonia - levofloxacin may be associated with a reduction in mortality.

Question 92

Which visual defect is associated with full scatter pan-retinal photocoagulation? A) Bitemporal inferior quadrantopia B) Central scotoma C) Homonymous hemianopia D) Night blindness E) Tunnel vision

Answer 92

Full scatter pan-retinal photocoagulation is associated with reduced peripheral vision (tunnel vision), reduced colour vision and impaired contrast sensitivity. Night blindness is seen in patients with glaucoma or with macular degeneration.

Question 93

What is the most appropriate treatment of diphtheria? A) Azithromycin B) Cefalexin C) Ciprofloxacin D) Co-amoxiclav E) Gentamicin

Answer 93

A range of macrolides and penicillins are appropriate in management, making azithromycin the most appropriate answer.

Question 94

In a patient with stable T2DM on metformin, how often does their HbA1c need to be monitored? A) 2M B) 3M C) 4M D) 6M E) 1Y

Answer 94

Every 6M

Question 95

Which of the following antibiotics should be used to manage a Campylobacter infection? A) Azithromycin B) Ciprofloxacin C) Co-amoxiclav D) Loperamide E) Metronidazole

Answer 95

Macrolides, including azithromycin and erythromycin are potential treatment options.

Question 96

Which of the following cancers is increased by the use of COCP? A) Cervical cancer B) Endometrial cancer C) Nasopharyngeal cancer D) Oesophageal cancer E) Ovarian cancer

Answer 96

Cervical cancer It decreases the risk of endometrial cancer.

Question 97

Which of the following is a poor prognostic factor in a patient with idiopathic pulmonary hypertension? A) Peripheral oedema B) AF C) Abnormal ALT D) Increased ventricular compliance E) Symptomatic hypotension

Answer 97

Development of AF - implies worsening clinical decompensation as a result of atrial dilatation. Elevated proBNP is also a signal of right ventricular dysfunction which is associated with poor prognosis.

Question 98

What is the largest constituent of bile? A) Bile salts B) Bilirubin C) Cholesterol D) Fatty acids E) Lecithin

Answer 98

Bile salts

Question 99

What is the treatment of choice for a nail infection with Trichophyton rubrum? A) PO terbinafine 12W B) PO itraconazole 4W C) Topical intraconazole 2W D) Topical amorolfine 6W E) PO itraconazole 1W

Answer 99

PO terbinafine 12W -If limited involvement (≤50% nail affected, ≤ 2 nails affected, more superficial white onychomycosis): topical treatment with amorolfine 5% nail lacquer; 6 months for fingernails and 9 - 12 months for toenails -If more extensive involvement due to a dermatophyte infection: oral terbinafine; 6 weeks - 3 months therapy for fingernail infections whilst toenails should be treated for 3 - 6M -If more extensive involvement due to a Candida infection: oral itraconazole

Question 100

Which of the following is the most likely reason for an obscured R heart border on CXR? A) L upper lobe consolidation B) L lower lobe consolidation C) R upper lobe consolidation D) R middle lobe consolidation E) R lower lobe consolidation

Answer 100

Loss of R heart border is consistent with R middle lobe consolidation

Question 101

Which of the following is the most suggestive of ankylosing spondylitis? A) Age 23 B) Male sex C) Back pain improved by exercise, not by rest D) Episodes of diarrhoea E) Improvement due to ibuprofen

Answer 101

Back pain improved by exercise, not by rest. Clinical criteria: -Low back pain for >3M, improved by exercise, not improved by rest -Limitation of lumbar spine motion in the saggital and frontal planes -Limitation of chest expansion relative to age and sex

Question 102

What is the appropriate management for a patient with urine positive for Schistosoma haematobium? A) Doxycycline B) Mebendazole C) Metronidazole D) Praziquantel E) Tinidazole

Answer 102

Praziquantel increases membrane permeability of schistosomal cells to calcium, leading to paralysis of worms, so they are then destroyed by the host immune response and eliminated. Mebendazole may be used as prophylaxis but not as therapy.

Question 103

What is the best way to confirm the underlying diagnosis ankylosing spondylitis? A) Anti-CCP testing B) HLA-B27 testing C) MRI of lumbosacral spine and pelvis D) Plain XR of lumbar spine E) RF antibody testing

Answer 103

MRI of lumbosacral spine and pelvis is preferred to guide early diagnosis. Plain XR is relatively insensitive.

Question 104

Which of the following ECG changes is the strongest indication for PPM insertion? A) LBBB B) 5x pauses of 2 secs at night on 24hr tape C) Periods of Mobitz Type 1 block at night on 24hr tape D) Periods of 38bpm at night on 24hr tape E) RBBB and left anterior fascicular block

Answer 104

Bifascicular block predisposes to complete heart block and is an indication for progression to a permanent pacemaker. Pauses up to 3 seconds are considered unremarkable and do not require pacing.

Question 105

Where is the ostium of the coronary sinus? A) L atrium B) L ventricle C) R atrium D) R ventricle E) SVC

Answer 105

R atrium

Question 106

Which of the following is the biggest risk to a patient with Schistosoma mansoni infection? A) Bladder carcinoma B) CKD C) Hepatic fibrosis D) Hydronephrosis E) Renal stones

Answer 106

Hepatic fibrosis Bladder carcinoma is known to be associated with Schistosoma haematobium.

Question 107

What would you see on an ECG in a patient with hypokalaemia? A) Broad P waves B) J waves C) ST elevation D) Peaked T waves E) U waves

Answer 107

U waves are small deflections classically seen in leads V2 and V3, usually in the same direction as the T wave

Question 108

Which immunosuppressant should be given alongside IV methylprednisolone for anti-GBM disease? A) Adalimumab B) Azathioprine C) Cyclophosphamide D) Golimumab E) Methotrexate

Answer 108

Cyclophosphamide and IV methylprednisolone is the initial immunosuppressant of choice.

Question 109

Which one of the following cells secretes the majority of tumour necrosis factor in humans? A) Neutrophils B) Macrophages C) Natural killer cells D) Helper T cells E) Killer T cells

Answer 109

Macrophages

Question 110

What is the usual target INR for a patient with a mechanical mitral valve? A) 2.0 B) 2.5 C) 3.0 D) 3.5 E) 4.0

Answer 110

Mitral - 3.5 Aortic - 3.0

Question 111

What is the most appropriate management for a patient presenting with a TIA on a background of AF that has been treated with 300mg aspirin? A) Start digoxin B) Switch to aspirin 300mg OD and dipyridamole 200mg BD long term C) Wait 2W from the date of the last event and then switch from aspirin to DOAC D) Switch to aspirin 75mg long term E) Start DOAC

Answer 111

In patients who've had an ischaemic stroke, the guidelines recommend waiting two weeks before anticoagulation is commenced to reduce the risk of haemorrhagic transformation. However, NICE recommend for TIA patients: 'in the absence of cerebral infarction or haemorrhage, anticoagulation therapy should begin as soon as possible.'

Question 112

What pulse abnormality is most associated with a patent ductus arteriosus? A) Collapsing pulse B) Bisferiens pulse C) Pulsus paradoxus D) Jerky pulse E) Pulsus alternans

Answer 112

Patent ductus arteriosus - large volume, bounding, collapsing pulse.

Question 113

What is the MOA of pilocarpine? A) Muscarinic receptor antagonist B) Muscarinic receptor agonist C) Nicotinic receptor antagonist D) Nicotinic receptor agonist E) Alpha receptor antagonist

Answer 113

Pilocarpine is a muscarinic agonist that causes pupillary constriction and contraction of the ciliary muscles, which opens up the trabecular meshwork allowing greater drainage of aqueous humour and reduces intraocular pressure.

Question 114

Which one of the following is the most common underlying mechanism causing prolongation of the QT segment? A) Opening of Ca channels B) Blockage of Na channels C) Opening of Na channels D) Blockage of K channels E) Opening of K channels

Answer 114

Long QT syndrome - usually due to loss-of-function/blockage of K+ channels

Question 115

A 30M presents one week after returning from Tanzania. He has a high fever (38.9) which started abruptly, headache and generalised severe joint pain preventing him from walking. You note his finger looks swollen. There is no rash. He has been taking his anti-malarial pills. His blood results are normal. A) Septic arthritis B) Malaria C) Dengue D) Chikgunya E) Zika

Answer 115

Severe joint pain and high fever point to chikungunya after return from Africa. The absence of a rash makes chikungunya more likely than dengue. In addition, a feature which points to chikungunya is the severe joint pain which is often debilitating and normal blood results (with dengue in some cases there are low platelets). Zika is not as common in Africa and tends to produce milder symptoms including low-grade fever (most cases are in South America).

Question 116

Which one of the following unwanted effects is most likely to occur in patients taking gliclazide? A) Peripheral neuropathy B) Cholestasis C) Peripheral neuropathy D) SIADH E) Weight gain

Question 117

Which one of the following unwanted effects is most likely to occur in patients taking gliclazide? A) Peripheral neuropathy B) Cholestasis C) Peripheral neuropathy D) SIADH E) Weight gain

Answer 117

All of the above side-effects may be seen in patients taking sulfonylureas but weight gain is the most common.

Question 118

What treatment option would be recommended for a patient with focal seizures that has failed to be controlled with levetiracetam? A) Carbamazepine B) Lamotrigine B) Phenytoin D) Sodium valproate E) Ethosuximide

Answer 118

Focal seizures not responding to first-line drug - try lamotrigine or levetiracetam (i.e. the first-line drug not already tried) and if neither help then carbamazepine.

Question 119

How is functional residual capacity calculated? A) Expiratory reserve volume + residual volume B) Expiratory reserve volume + tidal volume + inspiratory reserve volume C) Inspiratory reserve volume + residual volume D) Residual volume + expiratory reserve volume + tidal volume + inspiratory reserve volume E) Tidal volume + inspiratory reserve volume

Answer 119

Functional residual capacity = Expiratory reserve volume + Residual volume This is the volume of air remaining in the lungs at the end-expiratory position. This is increased in COPD because the lungs are more compliant and outward recoil of the chest is disturbed. ERV + tidal volume (TV) + inspiratory reserve volume (IRV) refers to the vital capacity (VC). This the maximum air that one can expel after maximum inhalation.

Question 120

What is the organism implicated in Rocky Mountain spotted fever? A) Coxiella burnetti B) Rickettsia typhi C) Rickettsia prowazekii D) Rickettsia rickettsii E) Ehrlichia

Answer 120

Rickettsia ricketsii is the causative organism for rocky mountain spotted fever. Rickettsiae are Gram-negative obligate intracellular parasites. Types of rickettsiae cause a variety of diseases that are typically characterised by fever, headache and rash. A notable exception is Q fever (cause by Coxiella burnetti which causes pneumonia but no rash. The Weil-Felix reaction is positive except in Q fever. Rickettsial diseases are all treated with tetracyclines.

Question 121

Which one of the following may decrease the accuracy of a 13C-urea breath test? A) Use of Gaviscon stopping 10 days ago B) Use of ranitidine stopping 4W ago C) Course of amoxicillin stopping 3W ago D) Use of lansoprazole stopping 6W ago E) Current COCP use

Answer 121

Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks.

Question 122

What is the most appropriate initial management step in the treatment of Pagets disease? A) Risedronate B) Calcitonin C) Prednisolone D) Vitamin D E) Teriparatide

Answer 122

In symptomatic Paget's disease, treatment is with a nitrogen-containing bisphosphonate such as alendronate, risedronate, or zoledronic acid. In patients who cannot tolerate these, calcitonin is second-line therapy.

Question 123

What is the most appropriate initial management step in the treatment of Pagets disease? A) Risedronate B) Calcitonin C) Prednisolone D) Vitamin D E) Teriparatide

Answer 123

In symptomatic Paget's disease, treatment is with a nitrogen-containing bisphosphonate such as alendronate, risedronate, or zoledronic acid. In patients who cannot tolerate these, calcitonin is second-line therapy.

Question 124

Which of the following is most commonly associated with CF? A) Absence of vas deferens B) Hypersensitivity to aspirin C) Antibodies to endomysium D) IgA deficiency E) Apical impulse to the right of sternum

Answer 124

98% of men with CF have congenital absence of the vas deferens, resulting in azoospermia and infertility.

Question 125

What is the MOA of bupropion? A) Acetylaldehyde dehydrogenase inhibitor B) MAO-b inhibitor C) Dopamine agonist D) SSRI E) Noradrenaline-dopamine reuptake inhibitor

Answer 125

Noradrenaline-dopamine reuptake inhibitor

Question 126

Which of the following is the most appropriate treatment of a pregnant patient who has tested positive for Chlamydia? A) Amoxicillin B) Azithromycin C) Erythromycin D) Ofloxacin E) Trimethoprim

Answer 126

A single dose of 1g azithromycin

Question 127

What is the MOA of adalimumab? A) Anti-CD20 B) Anti-IL6 C) Calcineurin inhibitor D) CTLA4 Ig E) Anti-TNF

Answer 127

Anti-TNF used primarily in RA and IBD. Abatacept is a CTLA4 Ig

Question 128

What is the MOA of flecainide? A) Calcium channel inhibition B) Fast sodium channel inhibition C) Muscarinic receptor inhibition D) Na+/K+ receptor inhibition E) Potassium channel inhibition

Answer 128

Fast sodium channel inhibition. Amiodarone blocks potassium channels.

Question 129

Which of the following investigations is most useful in establishing a diagnosis of polymyositis? A) Anti-Jo Ab testing B) Anti-Mi2 Ab testing C) Anti-VGCC Ab testing D) Muscle biopsy E) TFTs

Answer 129

EMG helps establish a diagnosis of polymyositis and typical inflammatory muscle changes are confirmed with muscle biopsy. Only 20% of patients with polymyositis are positive for Anti-Jo Ab. Anti-Mi2 Ab are specific for dermatomyositis.

Question 130

Which of the following conditions moves the oxygen dissociation curve to the right (ie. increased oxygen delivery to tissues)? A) CO2 retention B) Decreased 2,3 DPG C) Increased pH D) Decreased H+ ion levels in blood E) Hypothermia

Answer 130

CO2 retention

Question 131

Which of the following acute treatments would be most effective for cluster headaches? A) High-flow O2 therapy B) Intranasal lidocaine C) Metoclopramide D) Benzodiazepine nasal spray E) Verapamil

Answer 131

High-flow O2 therapy is very effective for acute headaches, given for a period of 15-mins via a tight-fitting mask. Verapamil is first-choice in prophylaxis.

Question 132

Which of the following medications should be given to a patient presenting with Ramsay-Hunt syndrome? A) Acyclovir B) Aspirin C) Clopidogrel D) Prednisolone E) Valacyclovir

Answer 132

Prednisolone. Eye care with topical ocular lubrication is also important. There is little evidence on the use of acyclovir added to prednisolone therapy.

Question 133

In a patient with C1-inhibitor deficiency, which of the following is thought to cause the episodes of angio-oedema? A) Decreased Factor XIII B) C3 deficiency C) C4 deficiency D) Elevated levels of bradykinin E) Elevated peripheral blood eosinophils

Answer 133

Elevated levels of bradykinin

Question 134

In a patient who has completed her family, what is the best treatment option for a solitary toxic thyroid nodule? A) Long-term carbimazole monotherapy B) Long-term carbimazole and thyroxine in combination C) Partial thyroidectomy D) Total thyroidectomy E) Treatment-dose radioiodine

Answer 134

Treatment-dose radioiodine. Partial thyroidectomy may be considered if the patient refuses radioiodine or if it is unsuitable.

Question 135

What is the expected blood volume in ml/kg in a healthy 25 year old man? A) 55 B) 65 C) 75 D) 85 E) 95

Answer 135

75. 65ml/kg is expected in a woman, 85ml/kg is expected in a neonate.

Question 136

Which of the following is the most important consequence of IV quinine therapy? A) Hyperkalaemia B) Hypercalcaemia C) Hypoglycaemia D) Hypokalaemia E) Hyponatraemia

Answer 136

Malaria promotes hypoglycaemia and quinine promotes insulin release. Both factors drive dangerously low blood sugar in those prescribed quinine therapy.

Question 137

What is the rationale between using combinations of chemotherapy drugs over a single agent? A) Combination therapy can be given over shorter period of time B) Combination therapy decreases the chance of drug resistance developing C) Combination therapy is less likely to result in long-term toxicity D) Fewer side effects occur in combination therapy E) Metastases are less common in combination therapy

Answer 137

Combination therapy decreases the chance of drug resistance developing

Question 138

What is the best treatment for a 32YO F who has been found to have latent TB? A) No treatment needed B) 2M course quadruple therapy C) 3M course isoniazid D) 3M course isoniazid and rifampicin E) 6M course rifampicin

Answer 138

In patients 16-35YO, a 3M course isoniazid and rifampicin is recommended.

Question 139

Which of the following genetic abnormalities is associated with a worse prognosis in CLL? A) Del(11q) B) Del(13q) C) Del(17p) D) EGR2 mutation E) Trisomy 12

Answer 139

Del(17p) and p53 mutations both drive more aggressive CLL presentations.

Question 140

Which of the following is most likely to cause an infection in a patient with a dog bite? A) Bacteroides B) Corynebacterium C) Enterococcus D) Moraxella E) Pasteurella

Answer 140

Pasteurella is a Gram-ve coccobacillus found in 50% of dog bites.

Question 141

Which of the following drives the initial generation of an action potential within muscle cells? A) Ca efflux B) Cl efflux C) K influx D) Na influx E) Na efflux

Answer 141

ACh binds to ACh cation channel receptors >> Na diffuses into the muscle fibre leading to depolarisation >> depolarisation causes a wave of action potential >> K slowly effluxes through the open K channels down the diffusion gradient >> Ca then diffuses in to cause muscle contraction

Question 142

Which of the following immunoglobulin subtypes is RF likely to be composed of? A) IgA B) IgD C) IgE D) IgG E) IgM

Answer 142

RF are IgM antibodies directed against IgG

Question 143

Which of the following medications can be given to a patient with diabetes insipidus that has failed to respond to solute and protein reduction and discontinuation of lithium therapy? A) Acetazolamide B) Desmopressin C) Furosemide D) Hydrochlorthiazide E) Naproxen

Answer 143

Thiazides (e.g. hydrochlorthiazide) are the initial intervention of choice.

Question 144

What is the MOA of baclofen? A) Beta-3 agonist B) GABA-agonist C) GABA-antagonist D) Muscarinic agonist E) Muscarinic antagonist

Answer 144

GABA B receptor agonist GABA-antagonists are stimulants and are used to reverse the effects of sedative drugs - e.g. flumazenil

Question 145

Which of the following is the first choice anti-hypertensive in a patient taking lithium? A) Amlodipine B) Bendroflumethiazide C) Indapamide D) Ramipril E) Valsartan

Answer 145

Amlodipine - CCBs are least likely to increase serum lithium.

Question 146

Which of the following is the best treatment for pyoderma gangrenosum forming at an ileostomy site? A) Intralesional triamcinolone B) IV methylprednisolone C) PO colchicine D) IV infliximab E) Topical 5-FU

Answer 146

Systemic anti-TNF alpha treatment is effective in controlling symptoms of Crohns disease and resolving ulceration associated with pyoderma gangrenosum.

Question 147

What is the site of action of eplerenone in the kidney? A) Descending limb of loop of Henle B) Proximal portion of DCT C) Distal portion of DCT D) PCT E) Ascending limb of loop of Henle

Answer 147

Distal portion of DCT - this is where the Na/K exchange pump occurs. Thiazide diuretics work in the proximal portion where the Na/Cl transporter is found.

Question 148

Which of the following anti-TB medications are most likely to cause joint pains as a S/E? A) Ethambutol B) Isoniazid C) Pyrazinamide D) Pyridoxine E) Rifampicin

Answer 148

Pyrazinamide