MRCP final few days...

Question 1

Which one of the following medications are most likely to be responsible for a raised prolactin?
A) Omeprazole
B) Fluoxetine
C) Metoclopramide
D) Cimetidine
E) Amitriptyline

Answer 1

Causes of raised prolactin - the p’s
-pregnancy
-prolactinoma
-physiological
-polycystic ovarian syndrome
-primary hypothyroidism
-phenothiazines, metoclopramide, domperidone

Question 2

What is the most appropriate treatment for TTP?
A) Eculizumab
B) FFP
C) IV ciprofloxacin
D) IV corticosteroids
E) Plasma exchange

Answer 2

Plasma exchange with FFP is the best treatment option. A single infusion of FFP is less effective than plasma exchange.

Question 3

What is the most common mode of inheritance of Alport Syndrome?
A) AD
B) AR
C) Mitochondrial
D) Sporadic mutation
E) X-linked dominant

Answer 3

Alport’s syndrome - X-linked dominant (in the majority).

It is an oculo-renal syndrome characterised by a triad of clinical findings consisting of haemorrhagic nephritis, sensorineural hearing loss and characteristic ocular findings. It is most commonly inherited in an X-linked dominant fashion but can be inherited in an autosomal recessive manner too.

It is due to a defect in the gene which codes for type IV collagen resulting in an abnormal glomerular-basement membrane (GBM).

A favourite question is an Alport’s patient with a failing renal transplant. This may be caused by the presence of anti-GBM antibodies leading to a Goodpasture’s syndrome like picture.

Question 4

A 32F presents with fatigue and constipation. She has a history of menorrhagia, Wolff-Parkinson-White syndrome, and primary hypothyroidism. Her TFTs were satisfactory 6M ago. Her drug history includes levothyroxine 100 micrograms (once daily at 7am), amiodarone 200mg (once daily at 7am), and ferrous fumarate 210mg (once daily at 7am). Her current TFTs show hypothyroidism. How will you manage this situation?
A) Advise the patient to take iron tablets at least 4hrs apart from levothyroxine
B) Counsel the patient on the consequences of poor compliance
C) Discontinue amiodarone
D) Increase levothyroxine dose
E) Decrease levothyroxine dose

Answer 4

Iron / calcium carbonate tablets can reduce the absorption of levothyroxine - should be given 4 hours apart.

Question 5

Which one of the following urine tests would best indicate lead toxicity?
A) Haemaglobinuria
B) Coproporphyrin
C) Porphobilinogen
D) Uroporphyrin
E) Ham’s test

Answer 5

Lead toxicity, also known as plumbism, interferes with heme synthesis and results in increased urinary excretion of coproporphyrin III. This is a common diagnostic test for lead poisoning.

Question 6

A 69M with terminal lung cancer currently takes MST 60mg bd for pain. He has become unable to take oral medications and a decision is made to set-up a syringe driver. What dose of diamorphine should be prescribed for the syringe driver, to cover a 24-hour period?
A) 60mg
B) 40mg
C) 120mg
D) 30mg
E) 20mg

Answer 6

To convert from oral morphine to diamorphine the total daily morphine dose (60 * 2 = 120mg) should be divided by 3 (120 / 3 = 40mg).

Question 7

A 70M presents with a 10D history of increasing SOB and ankle swelling. He has a PMHx of HTN, T2DM, ischaemic heart disease and systolic heart failure. He started a new medication 10 days ago. Which of the below drugs is most likely to have caused his new symptoms?
A) Bendroflumethiazide
B) Pioglitazone
C) Paracetamol
D) Dapagliflozin
E) Rivaroxaban

Answer 7

Glitazones are a class of anti-hypoglycaemics which can cause retention of fluid resulting in decompensation of pre-existing heart failure.

Question 8

In sarcoidosis, which of the following features would be associated with a good prognosis?
A) Lupus pernio
B) Hypercalcaemia
C) Age > 40
D) Erythema nodosum
E) HLA B13 subtype

Answer 8

Factors associated with a good prognosis include HLA B8 and Lofgren’s syndrome (bilateral hilar lymphadenopathy, erythema nodosum, polyarthritis and fever). All the other factors listed above are associated with a poor prognosis.

Factors associated with poor prognosis
-insidious onset, symptoms > 6 months
-absence of erythema nodosum
-extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
-CXR: stage III-IV features
-black people

Question 9

What is the most appropriate initial therapy for a patient with idiopathic membranous glomerulonephritis?
A) Adalimumab
B) Belimumab
C) Rituximab
D) Omalizumab
E) Infliximab

Answer 9

Rituximab

Question 10

What is the immediate precursor to the production of cortisol?
A) Deoxycorticosterone
B) 11-deoxycortisol
C) 17-a hydroxyprogesterone
D) Corticosterone
E) 17-a hydroxypregnenolone

Answer 10

11-deoxycortisol

Question 11

What is the single most important investigation for restless leg syndrome?
A) Serum ferritin
B) Serum folate
C) Clotting
D) Vitamin D
E) Serum B12

Answer 11

Restless legs syndrome - ferritin is the single most important blood test.

A common cause of restless legs syndrome (RLS) is iron deficiency.

Question 12

What is the treatment of choice to permanently restore sinus rhythm in atrial flutter?
A) Radiofrequency ablation of the accessory pathway
B) Radiofrequency ablation of the AV node
C) Radiofrequency ablation of the tricuspid valve isthmus
D) Lifelong amiodarone
E) Permanent pacemaker

Answer 12

Atrial flutter is typically caused by a re-entrant circuit in the right atrium. The ‘tricuspid valve isthmus’ is a critical part of this circuit and its ablation can interrupt this re-entry, thereby restoring sinus rhythm.

Question 13

Which cancer is associated with an increased risk in BRCA2?
A) Kidney
B) Lung
C) Melanoma
D) Pancreas
E) Thyroid

Answer 13

The risk of both pancreatic and prostate cancer are increased in BRCA2.

BRCA1 increases the risk of melanoma.

Question 14

Which cardiac ion channel is most likely to be abnormal in long QT syndrome?
A) Voltage-gated L-type calcium channel
B) Potassium channel b-subunit
C) Sodium channel a-subunit
D) Sodium channel b4-subunit
E) Potassium channel a-subunit

Answer 14

Potassium channel a-subunit mutations are the most common cause of long-QT syndrome.

Question 15

What is the most useful tumour marker to monitor for a testicular teratoma recurrence?
A) Acid phosphatase
B) AFP
C) Ca19-9
D) hCG
E) PTHrP

Answer 15

AFP - they are also elevated in hepatocellular carcinoma and advanced liver cirrhosis. LDH is also elevated in teratomas but is relatively non-specific.

hCG levels are elevated in seminomas and choriocarcinomas.

Question 16

What is the most appropriate management of a patient that presents following a TIA. Carotid ultrasound reveals a 48% stenosis of her right carotid artery and an ECG shows sinus rhythm.
A) Warfarin
B) Clopidogrel
C) Carotid endarterectomy
D) Dipyridamole
E) Aspirin and dipyridamole

Answer 16

TIA: clopidogrel
ischaemic stroke: clopidogrel

Carotid artery endarterectomy is recommend if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be considered if the carotid stenosis is greater than 70% or 50%, depending on the reporting criteria used

Question 17

A 30M enquires about screening for haemochromatosis as his brother was diagnosed with the condition 2 years ago. The patient is currently well with no features suggestive of haemochromatosis.
A) Serum total iron-binding capacity
B) HFE gene analysis
C) Serum transferrin saturation
D) Serum ferritin
E) Serum iron

Answer 17

Screening for haemochromatosis
-General population: transferrin saturation > ferritin
-Family members: HFE genetic testing

Question 18

Which of the following medications is most likely to cause an increase in a patient on warfarin’s INR?
A) Pyrazinamide
B) Isoniazid
C) Rifampicin
D) Ethambutol
E) Streptomycin

Answer 18

Isoniazid inhibits the P450 system.

Isoniazid can also cause drug-induced lupus

Question 19

Which cell surface marker is associated with Reed-Sternberg cells?
A) CD3
B) CD4
C) CD15
D) CD16
E) CD21

Answer 19

CD15

Question 20

What is the most likely medication to have caused bilateral diffuse corneal opacities?
A) Ethambutol
B) Aspirin
C) Bisoprolol
D) Amiodarone
E) Chloroquine

Answer 20

Amiodarone can cause corneal opacities.

Chloroquine can cause retinopathy but corneal opacification is unusual.

Question 21

Where are the cells affected by gentamicin toxicity located?
A) Collecting duct
B) Descending loop of Henle
C) Distal tubule
D) Proximal tubule
E) Thick ascending limb of the loop of Henle

Answer 21

Proximal tubule

Question 22

What is the MOA of ambrisentan?
A) Endothelin A antagonist
B) Endothelin B antagonist
C) Phosphodiesterase-4 antagonist
D) Phosphodiesterase-5 antagonist
E) Prostacyclin receptor agonist

Answer 22

Endothelin A receptor antagonist

Question 23

What is the most appropriate investigation to monitor post-operative prognosis following removal of an adrenal phaeochromocytoma?
A) 24hr urinary catecholamine
B) 24hr BP
C) 24hr urinary free cortisol
D) Post-op MRI
E) Serum potassium

Answer 23

Guidelines recommend 24hr urinary catecholamines are measured 2W after removal of phaeochromocytomas - if levels are normal then prognosis is excellent, although lifelong repeat testing is recommended to monitor for recurrence/metastasis.

Question 24

What is the most likely adverse effect of finasteride?
A) Galactorrhoea
B) Gynaecomastia
C) Night tremors
D) Postural hypotension
E) Priapism

Answer 24

Gynaecomastia is a well-recognised side effect of finasteride therapy.

Question 25

What is the glucose content of 1L 5% dextrose?
A) 0.05g
B) 0.5g
C) 5g
D) 50g
E) 500g

Answer 25

50g

Question 26

Which of the following is the most specific ECG finding in pericarditis?
A) Reciprocal ST depression
B) Shortened PR interval
C) ‘Tombstoning’ ST elevation in all precordial leads
D) Peaked T waves
E) PR depression

Answer 26

The most specific ECG finding in acute pericarditis is PR depression.

Question 27

In AML, which one of the following is associated with a good prognosis?
A) Translocation between chromosome 9 and 14
B) Translocation between chromosome 15 and 17
C) 25% blast following first course of chemotherapy
D) Deletion of chromosome 5
E) Deletion of chromosome 7

Answer 27

A translocation between chromosome 15 and 17 is seen in acute promyelocytic leukaemia, which is known to carry a good prognosis.

Question 28

Eight months after having a prosthetic heart valve a patient develops infective endocarditis. What is the most likely causative organism?
A) Streptococcus viridans
B) Staphylococcus aureus
C) Staphylococcus epidermidis
D) Coxiella burnetii
E) One of the HACEK group

Answer 28

Most common cause of endocarditis:
-Staphylococcus aureus
-Staphylococcus epidermidis if < 2 months post valve surgery

Question 29

Which one of the following types of glomerulonephritis is most characteristically associated with Goodpasture’s syndrome?
A) Diffuse proliferative glomerulonephritis
B) Mesangiocapillary glomerulonephritis
C) Membranous glomerulonephritis
D) Rapidly progressive glomerulonephritis
E) Focal segmental glomerulosclerosis

Answer 29

Rapidly progressive glomerulonephritis, causes:
-Goodpasture’s
-ANCA positive vasculitis

Question 30

Which cell is responsible for the production of IL-1?
A) Neutrophils
B) Basophils
C) Eosinophils
D) T cells
E) Macrophages

Answer 30

The main source of IL-1 is macrophages.

Question 31

Which of the following is most likely to be raised in acute intermittent porphyria?
A) Raised urine lead level
B) Raised urinary porphobilinogen
C) Raised urinary uroporphyrinogen
D) Raised urinary uroporphyrinogen decarboxylase
E) Raised urinary protoporphyrin

Answer 31

In acute intermittent porphyria, urinary porphobilinogen is typically raised.

Uroporphyrinogen is usually raised in porphyria cutanea tarda.

Question 32

Which of the following is a patient with pseudoxanthoma elasticum most at risk of?
A) Ischaemic heart disease
B) Sensorineural deafness
C) Colorectal cancer
D) Epilepsy
E) Complete heart block

Answer 32

Pseudoxanthoma elasticum is associated with mitral valve prolapse and increased risk of ischaemic heart disease.

Question 33

Of the following, which can be a feature of pancreatic cancer?
A) ‘Double duct’ sign
B) Acanthosis nigricans
C) Association with blood group A
D) Necrolytic migratory erythema
E) Raised CA 15-3

Answer 33

The ‘double duct’ sign may be seen in pancreatic cancer.

Necrolytic migratory erythema is seen characteristically in patients with glucagonoma. Pancreatic cancer is associated with migratory thrombophlebitis.

Question 34

What is the MOA of digoxin?
A) Increases intracellular potassium
B) Inhibits Na-Ca exchange pump
C) Inhibits Na-K exchange pump
D) Reduces intracellular calcium
E) Reduces intracellular sodium

Answer 34

Inhibits Na-K exchange pump - drives an increase in intracellular Na which drives the Na-Ca exchange pump and hence an increase in intracellular Ca.

Question 35

In CKD, what is the driver of iron deficiency anaemia?
A) Decreased ferritin
B) Decreased hepcidin
C) Increased ferritin
D) Increased ferroportin
E) Increased hepcidin

Answer 35

Increased hepcidin (reduces oral iron absorption by inducing degradation of ferroportin).

Question 36

Which HLA type is associated with psoriatic arthritis?
A) B8
B) B27
C) B51
D) DR3
E) DR4

Answer 36

B27 - psoriatic arthritis, ank spond, arthritis associated with Crohns and UC

Question 37

A 27F presented with a right-sided thyroid swelling with associated cervical lymphadenopathy. What is the most likely cause?
A) Anaplastic carcinoma
B) Follicular adenoma
C) Follicular carcinoma
D) Hashimoto’s thyroiditis
E) Papillary carcinoma

Answer 37

Papillary thyroid carcinoma is the most common thyroid malignancy.

Question 38

What feature most strongly favours an L5 radiculopathy over a peroneal nerve palsy?
A) Complete paralysis of extensor hallucis longus
B) Loss of sensation confined to the lower calf
C) Positive Tinel’s sign lateral to the knee
D) Weakness of ankle eversion
E) Weakness of ankle inversion

Answer 38

Weakness of inversion is not seen in common peroneal nerve lesion but may be present with L5 lesion (tibialis posterior muscle is supplied by tibial nerve, L4/5).

Question 39

What is the most appropriate definition of an SNP?
A) Alteration in nucleotide sequence that causes a change in amino acid sequence
B) Alteration in nucleotide sequence that does not cause a change in amino acid sequence
C) Deletion of a single nucleotide
D) Repetition of a nucleotide two or more times
E) Substitution of a nucleotide for any other nucleotide

Answer 39

Single nucleotide polymorphisms (SNPs) are the most common type of genetic variation. They are most commonly found in non-coding DNA between genes. SNPs in regulatory or coding regions of DNA are more clinically significant.

Question 40

What is the most important MOA of ISMN?
A: calcium channel blockade
B: increased cyclic adenosine monophosphate production
C: increased cyclic guanosine monophosphate production
D: potassium channel activation
E: sodium channel blockade

Answer 40

Isosorbide mononitrate act as a nitric oxide (NO) donor, leading to stimulation of guanylate cyclase to produce cyclic guanosine monophosphate (GMP), which mediates the vasodilatory effect of nitrates.

Question 41

What is the most likely adverse effect of cisplatin?
A) Acute hepatitis
B) Cardiomyopathy
C) Hypocalcaemia
D) Pulmonary fibrosis
E) Sensory neuropathy

Answer 41

Recognised adverse effects of platinum compounds include nephrotoxicity and neurotoxicity which manifests as sensory neuropathy or hearing loss.

Question 42

A 65M with AF was treated with the addition of oral digoxin 250 micrograms daily. His physician explained that the full effect of this treatment would not be apparent for at least a week. On which pharmacokinetic variable did the physician base this explanation?
A) Bioavailability
B) Half-life
C) Plasma protein binding
D) Rate of hepatic metabolism
E) Renal clearance

Answer 42

Digoxin has an average half-life of 36 hours. Steady state digoxin concentration after daily oral dosing is achieved after 5 half-lives i.e. around 1 week.

Question 43

Which drug is most likely to be the cause a tremor?
A) Co-trimoxazole
B) Mycophenolate mofetil
C) Prednisolone
D) Tacrolimus
E) Valganciclovir

Answer 43

Tacrolimus

Question 44

What is the mechanism of renal injury with aciclovir?
A) Acute tubular necrosis
B) Crystalluria
C) Glomerulonephropathy
D) Interstitial nephritis
E) Renal ischaemia

Answer 44

Aciclovir is renally eliminated. In the presence of dehydration, aciclovir can precipitate as crystals in the kidney tubules causing acute kidney injury.