MRCP Deck 5 July 2023 Flashcards
Where does aqueous humour drain to?
A) Bruch’s membrane
B) Canal of Schlemm
C) Choroid plexus
D) Eustachian tube
E) Sylvian fissure
Aqueous humour flows from the ciliary body into the anterior chamber. At the front of the eye, it flows out through the trabecular meshwork and into the canal of Schlemm.
The choroid plexus produces most of the CSF of the CNS.
Which of the following is seen most frequently after TIPS?
A) Acute liver failure
B) Biliary fistula
C) Cardiac failure
D) Haemolytic anaemia
E) Hepatic encephalopathy
HE is the most common complication following TIPS placement.
Which of the following investigations is most useful to confirm a diagnosis of mumps within 36hrs of symptoms?
A) Monospot testing
B) Serum CMV IgM
C) Serum measles IgG
D) Oral fluid measles IgM
E) Oral fluid measles RNA
In early measles, detection of measles viral RNA in oral fluids is the investigation of choice. It is detected by RT-PCR and remains positive for up to 3 days after the presentation of the rash.
Oral fluid measles IgM is the most sensitive test for measles 3 days following the presentation of notes.
For a patient with HNF1-alpha MODY uncontrolled on gliclazide (HbA1c 63), what would be the next most appropriate addition?
A) Dapagliflozin
B) Long-acting insulin
C) Metformin
D) Pioglitazone
E) Sitagliptin
Long-acting insulin
Although sulfonylurea’s in MODY can be beneficial for many years, eventually B-cell failure progresses and initiation of insulin is necessary.
What is the MOA of cyclophosphamide?
A) CTLA-4 inhibition
B) DNA alkylation
C) Inhibition of IL-2 production
D) Inhibition of microtubule disassembly
E) Thymidylate synthetase inhibition
DNA alklyation
The immunosuppressive effect of cyclophosphamide is based on its inhibitory effect on B cells, CD4+ T cells and CD8+ T cells. Acrolein - a toxic metabolite, is the cause of haemorrhagic cystitis.
What is the treatment of choice in a patient recently diagnosed with Alport syndrome. His 24hr urinary protein is raised at 1.8g.
A) Amlodipine
B) Prednisolone
C) Ramipril
D) Reassurance
E) Spironolactone
ACEi are the intervention of choice to reduce proteinuria and slow renal progression in patients with Alport syndrome. Corticosteroids have no impact in slowing disease progression.
Which of the following would you expect to find on pleural fluid testing related to rheumatoid arthritis?
A) Blood staining
B) pH 7.1
C) Pleural fluid glucose 4.5mmol/L
D) Pleural LDH/serum LDH 0.4
E) Pleural fluid protein/serum protein 0.3
A pH <7.2 is a strong pointer towards a pleural effusion related to rheumatoid arthritis. Causes of a pH<7.3 include connective tissue disease, malignancy, empyema, TB and oesophageal rupture.
Pleural fluid protein/serum protein 0.3 indicates the the fluid is a transudate which is more likely to be associated with cardiac failure, liver failure and renal impairment. Elevated pleural LDH is associated with rheumatoid arthritis.
A patient present with a TIA. What is the most important contributor to risk of future stroke?
A) BP 152/92
B) Cr 132
C) T2DM
D) Duration of expressive dysphasia >80mins
E) Presence of expressive dysphasia
The events associated with the highest risk of future stroke according to the ABCD2 score are related to the duration of symptoms (>60mins) and both limb weakness and speech disturbance.
Which of the following is the biggest pointer to obesity hypoventilation syndrome?
A) BMI 37
B) Hb 140
C) Nocturnal snoring
D) Serum bicarb 32mmol/L
E) SBP 148
An elevated bicarb is associated with consistent CO2 retention and renal compensation and is a strong pointer to OHS. A serum HCO3- <27 has a 97% negative predictive value and is hence a good initial investigation before moving onto an ABG. An overnight sleep study is the best way to confirm the diagnosis, with weight loss and CPAP as optimal intervention.
What is the MOA of timolol in acute angle closure glaucoma?
A) Arteriolar constriction in the conjunctiva
B) Carbonic anhydrase inhibition
C) Constriction of the iris
D) Reduced formation of aqueous humour
E) Reduced formation of vitreous humour
B-blockers lead to a reduction in intra-ocular pressure by reducing the production of aqueous humour.
Pilocarpine is a muscarinic receptor agonist which causes constriction of the iris.
What is the treatment option for a patient with mumps orchitis?
A) Aciclovir
B) Flucloxacillin
C) Ganciclovir
D) Ibuprofen
E) Ofloxacin
Ibuprofen - supportive therapy is the intervention of choice for a mumps infection. Paracetamol an ibuprofen are particularly useful in treating the pain related to mumps orchitis.
What is the best method in controlling bone pain secondary to metastatic prostate cancer for a patient on morphine, paracetamol and ibuprofen?
A) External beam radiation therapy
B) Increased PO morphine
C) IV zoledronate
D) Strontium-89 therapy
E) Transfer to fentanyl patch
IV ibandronate and IV zoledronate are both potential options to control bone pain from metastatic prostate cancer. Denosumab can also be used.
External beam radiotherapy can be used in patients who have failed to respond to systemic therapy.
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What is most likely to happen to a patient’s INR on warfarin if they were to start taking carbamazepine?
A) Fall in INR over 3-4W
B) Fall in INR over 2-3D
C) No change in INR
D) Rise in INR over 3-4W
E) Rise in INR over 2-3D
Fall in INR over 3-4W
Carbamazepine is a potent P450 enzyme inducer. It also exhibits auto induction which builds up over a number of weeks (this leads to a need to increase the dose for treating epilepsy after 3W).
What is the most effective intervention for achalasia?
A) Amlodipine
B) Botulinum toxin
C) Isosorbide dinitrate
D) Nissen’s fundoplication
E) Pneumatic dilatation
Pneumatic dilatation is the initial treatment of choice for achalasia. Where patients fail to get benefit from dilatation, surgery (Heller’s myotomy) is the next intervention of choice.
Nissen’s fundoplication is for the management of a hiatus hernia.
What is the treatment of erysipelas near to the nose or eye?
A) PO clarithromycin
B) PO flucloxacillin
C) PO co-amoxiclav
D) PO vancomycin
E) Topical Fucidin ointment
High dose PO co-amoxiclav is the intervention of choice for erysipelas close to the nose or eye.
High dose PO flucloxacillin is recommended is erysipelas is not close to the eye or nose.
What is the most appropriate long-term management for a patient with haemachromatosis?
A) Desferrioxamine
B) Metformin
C) Penicillamine
D) Phlebotomy
E) Zinc acetate
Phlebotomy is the intervention of choice with weekly phlebotomy initially to remove 400-500ml of blood.
Desferrioxamine is a chelating agent used in the treatment of thalassemia major.
What is the MOA for clindamycin?
A) Binds to dihydrofolate reductase
B) Binds to the 50S subunit of the bacterial ribosome
C) Forms nitroso radicals to inhibit nucleic acid synthesis
D) Inhibits bacterial cell wall synthesis by attaching to specific binding proteins
E) Inhibits bacterial cell wall synthesis by binding to the D-Ala-D-Ala terminal of the growing peptide chain
Binds to the 50S subunit of the bacterial ribosome - it has bacteriostatic activity against a wide range of Gram+ve aerobes and anaerobic bacteria. It binds to the 50S subunit in a similar way to macrolides and inhibits the early stage of protein synthesis.
Which of the following cells is likely to give long-lasting immunity to hepatitis B following the vaccine?
A) APCs
B) Eosinophils
C) Macrophages
D) T cells
E) B cells
T cells are primarily responsible for immune memory and long term protection from vaccination
What is the inheritance pattern of Kallmann’s syndrome?
A) AD
B) AR
C) X-linked dominant
D) X-linked recessive
E) Y-linked
X-linked recessive
What is the most appropriate intervention for a patient with restless legs syndrome?
A) Codeine phosphate
B) Diazepam
C) Gabapentin
D) Paracetamol
E) Risperidone
Both gabapentin and pregabalin have demonstrated effectiveness in restless legs syndrome.
What is the next most appropriate intervention for a patient with dermatomyositis failing to respond to prednisolone?
A) Azathioprine
B) Ciclosporin
C) Cyclophosphamide
D) IVIG
E) Methotrexate
Azathioprine is used in patients failing to respond to prednisolone.
In patients with coexisting lung disease, such as pulmonary fibrosis, cyclophosphamide or cyclosporin may be more beneficial.
What is the MOA of baclofen?
A) Enhances aspartate release
B) Enhances dopamine release
C) GABA-A receptor agonist
D) GABA-A receptor antagonist
E) Inhibits glutamate release
Baclofen is a GABA-B agonist which causes inhibition of glutamate and aspartate.
Which of the following is the main treatment for ethylene glycol (anti-freeze) poisoning?
A) Activated charcoal via NGT
B) Ethyl alcohol
C) Fomepizol
D) Naloxone
E) Sodium bicarbonate
Fomepizol is the main treatment for ethylene glycol poisoning - it is a competitive inhibitor of alcohol dehydrogenase to block the formation of toxic metabolites of ethylene glycol.
In a patient with a flare of UC, which of the following is the most important risk marker for colectomy?
A) Bowels opening 6x/day
B) Creatinine 144
C) CRP 209
D) Maximal colonic diameter 6.5cm
E) WCC 15.4
Maximal colonic diameter 6.5cm is an indicator for progression to surgery.
Subtotal colectomy and ileostomy are recommended in all patients with acute severe UC who have not responded within 7 days to rescue therapy, including ciclosporin and infliximab, or who have deteriorations before that time (toxic megacolon, severe haemorrhage, perforation).
What is the most appropriate treatment option for a female patient with juvenile myoclonic epilepsy?
A) Lamotrigine
B) Levetiracetam
C) Phenytoin
D) Sodium valproate
E) Pregabalin
Levetiracetam, lamotrigine and sodium valproate can all be used for JME. Sodium valproate should be avoided in females of childbearing age, lamotrigine can augment symptoms, so levetiracetam may be preferred.
In a positively skewed data set, which of the following will be found in the data?
A) Median < Mean
B) Median > Mean
C) Median < Mode
D) Mean < Mode
E) Median = Mode
In a positively skewed distribution, there is a positive tail which means the mean > median and mode
Which of the following best fits the direct action of Vitamin D?
A) Decreased osteoblast maturation
B) Decreased osteoclast maturation
C) Increased osteoblast apoptosis
D) Increased phosphate absorption from the gut
E) Increased phosphate excretion via the kidneys
Vitamin D increases calcium and phosphate absorption from the gut, it also suppresses PTH, regulates osteoblast function and facilitates PTH induced osteoclast activation and bone resorption.
Vitamin D also has important effects on immune-inflammation, including maintaining the balance between T-helper 1 and 2 activity. It decreases the T-helper 1 response and reduces inflammation and upregulates the T-helper 2 activity which is anti-inflammatory.
What is the appropriate treatment option for a pregnant lady with rosacea?
A) PO isotretinoin
B) PO oxytetracycline
C) Topical azelaic acid
D) Topical bromonidine
E) Topical metronidazole
Topical metronidazole is the treatment of choice in pregnant patients. Azelaic acid may also be used but is associated with increased photosensitivity.
In patients who aren’t pregnant, topical ivermectin is often prescribed. If topical ivermectin fails, a combination of this and PO doxycycline may be used.
Which of the following is the biggest cause of mortality in patients with rheumatoid arthritis?
A) Alzheimers dementia
B) Colon cancer
C) Diabetes mellitus
D) Major adverse cardiovascular events
E) Suicide
There is nearly a 2-fold increase in adverse CV events in patients with RA compared to controls. The risk of infectious diseases and pneumonia is also increased.
Which of the following is a recognised cause of acute pancreatitis?
A) Amlodipine
B) Empagliflozin
C) Indapamide
D) Ramipril
E) Sodium valproate
Sodium valproate is a well-recognised cause of acute pancreatitis.
How does NSAID use contribute to renal impairment?
A) Angiotensin II inhibition
B) COX inhibition
C) Endothelin-1 inhibition
D) Plasmin inhibition
E) Renin inhibition
NSAIDs act as COX inhibitors which causes reduced levels of prostaglandins which are crucial to maintaining adequate levels of perfusion via arteriolar dilatation.
Which of the following is an immediate precursor to bilirubin?
A) Biliverdin
B) Haem
C) Stercobilin
D) Urobilinogen
E) Ursodeoxycholic acid
Biliverdin is the direct precursor of bilirubin, formed from the breakdown of haem.
Which of the following medications should be used to treat serotonin syndrome?
A) Bromocriptine
B) Chlorpromazine
C) Cyproheptadine
D) Dantrolene
E) Propranolol
Cyproheptadine is a H1 receptor agonist with non-specific serotonin antagonist properties.
Which defect underlies Alport syndrome?
A) Aquaporin-2
B) CFTR
C) Epithelial sodium channel
D) Polycystin 1
E) Type IV collagen
The condition is caused by a defect in Type IV collagen synthesis, leading to BM dysfunction and progressive glomerular disease.
Which coronary artery is most likely to be occluded in a patient presenting with a STEMI in leads II, III and aVF?
A) Distal L circumflex
B) Distal R coronary
C) LAD
D) Proximal L circumflex
E) Proximal R coronary
Distal R coronary - given the changes are confined to the interior leads. Proximal R coronary would lead to more widespread changes (i.e. STEMI in leads V1-V3 as well as leads II, III and aVF).
In a patient with suspected CLL, what would be the most useful investigation?
A) BM biopsy
B) DAT
C) Immunoglobulin electrophoresis
D) Immunophenotyping
E) Lymph node biopsy
Peripheral blood flow cytometry to perform immunophenotyping is the best initial test to confirm CLL. A positive test shows circulating clonal B lymphocytes which express particular antigens. Intervention is reserved for after the development of symptoms.
An elderly gentleman is referred for B/L central scotomas, raised intraocular pressure and B/L optic-disc cupping noted at routine appointment. Which of the following is the most appropriate initial intervention?
A) Argon laser trabeculoplasty
B) PO acetazolamide
C) Topical pilocarpine
D) Topical timolol
E) Trabeculectomy
This presentation is consistent with chronic open angle glaucoma. Topical B-blockers (e.g. timolol) are first-line intervention by reducing the production of aqueous humour.
Acetazolamide given orally is often poorly tolerated and pilocarpine is also poorly tolerated due to S/E.
Contraction of which muscle is cause of ankle clonus?
A) Extensor digitorum longus
B) Fibularis brevis
C) Gastrocnemius
D) Peroneus longus
E) Tibialis anterior
The gastrocnemius is responsible for plantar flexion of the foot and is the muscle that contracts when a patient suffers with ankle clonus.
Which of the following tumours is the most commonly seen in MEN1?
A) Gastrinoma
B) Glucagonoma
C) Insulinoma
D) Somatostatinoma
E) VIPoma
In 70% of patients with MEN1, pancreatic endocrine tumours are seen. Of which, 60% are gastrinomas. Insulinomas are much rarer and seen in 30% of patients.
