MRCP OFFICIAL PAPER 2 Flashcards

1
Q

Treatment for erythrodermic psoriasis?

A

Erythroderma is a term used when more than 95% of the skin is involved in a rash of any kind.
‘red man syndrome’

Initial treatment is with topical white soft paraffin smeared all over the skin, which helps to make the skin more comfortable, partially reduces the inflammation, improves the skin barrier, thus helping to prevent entry of bacteria through the skin (), and helps to reduce water loss from the skin (and prevent dehydration).

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2
Q

Which protein is abnormal in Marfan’s syndrome?

A

Marfan’s syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1.

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3
Q

At laparotomy, bowel was found to be ischaemic from the lower part of the duodenum through to midway along the transverse colon.
What artery is most likely to be occluded?

A

Superior Mesenteric Artery.

The superior mesenteric arises from the abdominal aorta and supplies the small intestine from the distal duodenum as well as the large intestine as far as 2/3 of the transverse colon.

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4
Q

Erythematous, scaly rash involving the nasolabial folds and eyebrows, and the skin overlying the sternum. There was mild scaling of the scalp. The nails were normal.

What is the most likely diagnosis?

A

Seborrhoeic dermatitis

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5
Q

Mx for fungal nail infections?

onychomycosis

A

if limited involvement - topical treatment with amorolfine 5%

if more extensive involvement due to a dermatophyte infection: oral terbinafine is currently recommended first-line; 6 weeks - 3 months therapy is needed for fingernail infections whilst toenails should be treated for 3 - 6 months

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6
Q

With which condition is H. pylori infection most strongly associated?

A

Duodenal ulcers

Duodenal ulcers have a strong association with Helicobacter pylori, with over 90% of patients with duodenal ulcers being H. pylori positive. There is also an association with gastric ulceration and carcinoma but to a lesser degree.

GORD is not particularly associated with H. pylori since infection tends to reduce gastric acid secretion.

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7
Q

Pulse abnormality seen in cardiac tamponade?

A

Pulsus paradoxus

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8
Q

What additional information would be most useful to support a diagnosis of syndrome of inappropriate antidiuretic hormone?

A

Thyroid function tests.

SIADH is a diagnosis made once other causes of hyponatraemia are ruled out such as hypocortisolaemia, thyroid dysfunction (hypothyroidism) and adequate renal function.

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9
Q

What receptors are chiefly involved in mediating the antipsychotic effects of risperidone?

A

The primary mechanism of action of antipsychotic drugs is dopamine receptor antagonism.

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10
Q

A 68-year-old woman with atrial fibrillation presented for DC cardioversion. The procedure resulted in successful restoration of sinus rhythm.

Which drug would be most likely to maintain sinus rhythm following this procedure?

A

Amiodarone.

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11
Q

Ix for Addison’s disease?

A

In a patient with suspected Addison’s disease the definite investigation is an ACTH stimulation test (short Synacthen test). Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM.

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12
Q

A 32-year-old man presented with weight loss and feeling generally unwell. On direct questioning, he had been having dizzy spells, especially on sudden changes in posture.

On examination, he was tanned. There was a postural drop in his BP.

What is the most likely biochemical finding?

A

Plasma adrenocorticotropic hormone 95 pmol/L (3.3–15.4)

The clinical picture is compatible with primary adrenal failure. In a young person, Addison’s disease is the most likely cause. The adrenocorticotropic hormone (ACTH) will be raised in the absence of negative feedback due to cortisol deficiency.

  • hyperkalaemia
  • hyponatraemia
  • hypoglycaemia
  • metabolic acidosis
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13
Q

MOA of isosorbide mononitrates?

A

Increased cyclic guanosine monophosphate (GMP) production

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14
Q

A 25-year-old man presented with a 5-day history of foul-smelling diarrhoea, abdominal pain, nausea, bloating and flatulence. He had returned from a holiday in Borneo 1 week previously.

On examination, he appeared dehydrated. Examination was otherwise normal.

Stool microscopy: trophozoite and cysts

A

Giardia intestinalis.

the history of small bowel malabsorptive symptoms and of travel to an endemic area is suggestive of giardiasis. This is confirmed by the finding of trophozoites and cysts on microscopy.

Mx: Metronidazole

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15
Q

Which antibiotics cause prolonged QT?

A

Antimicrobials that cause QT prolongation are:
- Erythromycin, Clarithromycin
- Moxifloxacin
- Fluconazole and Ketoconazole.

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16
Q

Which coagulation factor is most likely to be present at a reduced activity in patient taking Warfarin?

A

Warfarin inhibits the vitamin K-dependent synthesis of clotting factors including factor II, VII, IX and X as well as the regulatory factors protein C and protein S.

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17
Q

Blood abnormality seen in osteomalacia?

A
  1. Low vitamin D levels
  2. Low calcium
  3. Low Phosphate
  4. Raised alkaline phosphatase

Mx: Vitamin D supplementation (Colecalciferol)

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18
Q

A 55-year-old woman presented with a 2-month history of lower back pain, for which she had been taking paracetamol 4 g daily. She admitted to drinking 16 units of alcohol per week.

serum alanine aminotransferase 55 U/L (5–35)
serum aspartate aminotransferase 29 U/L (1–31)
serum alkaline phosphatase 90 U/L (45–105)

serum IgG 21.0 g/L (6.0–13.0)
serum IgA 2.4 g/L (0.8–3.0)
serum IgM 1.8 g/L (0.4–2.5)

What is the most likely cause of her abnormal liver function tests?

A

Autoimmune hepatitis.

The raised IgG levels suggests autoimmune hepatitis and a diagnosis can be provisionally made while awaiting the autoantibody profile.

The ratio of alanine aminotransferase (ALT) to aspartate aminotransferase (AST) is greater than 1, which favours autoimmune or viral over alcoholic cause.

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19
Q

Artery occluded in posterior MI?

A

Posterior descending artery.

It is the left circumflex artery that supplies the posterior descending artery in around 15% of people, called a left dominant system.

In 85% of people, the posterior descending artery arises from the right coronary artery, called a right dominant system.

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20
Q

What investigation is most appropriate for assessing response to Hep C antiviral medication?

A

HCV Viral Load.

Guidance for monitoring response to treatment of hepatitis C is by finding a sustained virological response using HCV viral load.

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21
Q

A 67-year-old woman presented with palpitations and a goitre. Propranolol was started to improve her symptoms.

On examination, she had a coarse tremor and sweaty palms, but no thyroid eye signs.

Low TSH
Raised T4

technetium-99m scan of thyroid: increased uptake in right upper lobe, with uptake suppressed in rest of thyroid gland.

What is the most appropriate treatment for her thyroid condition?

A

Radioiodine.

This case highlights the treatment of an autonomous nodule causing hyperthyroidism (‘toxic adenoma’). The technetium-99m scan highlights the focus of overactivity and does not suggest thyroiditis, therefore prednisolone is not required. The lack of eye signs is further reassurance.

Total thyroidectomy is not an appropriate treatment option given the localisation of the increased activity to the right upper lobe. While carbimazole and propylthiouracil may be an interim treatment, the overactivity would still continue if the medication was stopped and therefore the more appropriate (and definitive) treatment is radioiodine.

22
Q

A 37-year-old woman presented with a 1-day history of abdominal pain and diarrhoea.

On examination, she was drowsy and hallucinating, and had widespread purpura.

Investigations:

haemoglobin 92 g/L (115–165)
white cell count 13.3 × 109/L (4.0–11.0)
platelet count 17 × 109/L (150–400)
serum creatinine 195 µmol/L (60–110)

What abnormality is most likely to be present on blood film examination?

A

Fragmented cells.

The patient presents with gastrointestinal and neurological symptoms, and the blood results show anaemia, thrombocytopaenia and renal impairment. The neurological features and marked thrombocytopaenia would be in keeping with thrombotic thrombocytopaenic purpura (TTP). Both TTP and HUS are associated with microangiopathic haemolytic anaemia (MAHA). An important blood film feature of MAHA is the presence of fragmented red cells.

23
Q

Formula for calculating serum osmolality?

A

Calculated osmolality = (2 × Na) + (2 × K) + glucose + urea (all in mmol/L).

As potassium is present and concentration is higher than 5 mmol/L, accounting for this and associated anions should be made by using the formula including potassium multiplied by 2.

24
Q

Organism seen in lyme disease as well as rash?

A

Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks.

Erythema migrans: ‘Bulls-eye’ rash is typically at the site of the tick bite.

Headache, fever, lethargy, heart block.

dont forget can develop LMN FACIAL PALSY.

  1. Doxycycline if early disease. 2. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)
    People with erythema migrans should be commenced on antibiotic without the need for further tests.
25
Q

Alternative medication for urge incontinence in a patient who did not find oxybutynin beneficial?

A

As oxybutynin was ineffective, another antimuscarinic drug, like solifenacin, should therefore be used.

26
Q

Mx for GCA?

A

anterior ischemic optic neuropathy accounts for the majority of ocular complications. It results from occlusion of the posterior ciliary artery (a branch of the ophthalmic artery) → ischaemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins.

  1. Urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy.
  2. If there is no visual loss then high-dose prednisolone is used.
  3. If there is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone.

Urgent ophthalmology review

Bone protection with bisphosphonates.

27
Q

A 72-year-old woman presented with progressive tiredness over the past few months and was found to have iron deficiency anaemia. She had osteoarthritis and was regularly taking ibuprofen and paracetamol.

Investigations:

UGI Endoscopy: 1-cm duodenal ulcer with no evidence of recent bleeding; Helicobacter pylori negative
She was treated with omeprazole.

What is the most appropriate next investigation?

A

Colonoscopy.

Iron deficiency anaemia (IDA) in a 72-year-old person can be caused by underlying malignancy in up to 10% of cases. This is often right-sided colonic cancers, which are otherwise asymptomatic and, therefore, a colonoscopy is almost always required in such cases. Repeat endoscopy is not required to assess healing of duodenal ulcer. CT scan is less sensitive than colonoscopy in identifying colonic pathology and should only be considered if there are contraindications to colonoscopy.

28
Q

What is the site of origin of circulating B-type natriuretic peptide in patients with chronic heart failure?

A

B-type natriuretic peptide is released from myocytes in the cardiac ventricles in response to stretch-associated high ventricular filling pressures.

29
Q

Adverse effect of treatment with Cisplastin?

A

Sensory Neuropathy
Ototoxicity

30
Q

A 52-year-old woman presented with a 6-month history of upper limb weakness that had progressed to affect her lower limbs. Over the previous 2 months, she had been complaining of increasing dysphagia to liquids more than solids, and worsening shortness of breath at rest.

On examination, she had a brisk jaw jerk, tongue fasciculations and MRC grade 4 muscle power in shoulder abduction and hip flexion bilaterally.

What is the most likely diagnosis?

A

The short, progressive, purely motor history with upper motor neuron (UMN) and lower motor neuron (LMN) signs is characteristic of motor neurone disease (MND).

Multiple sclerosis would not cause LMN signs (tongue fasciculation), myasthenia gravis can mimic MND but would not cause the signs and tends to be fatigable not progressive, spinobulbar muscular atrophy usually has a much longer history and LMN only, and syringobulbia would most likely produce sensory involvement.

31
Q

What criteria makes patient unable to donate blood?

A

People who have been transfused will not be accepted as blood donors, in order to reduce the risk of transmitting prion diseases such as variant Creutzfeldt–Jakob disease to recipients.

32
Q

What is the best graphical method for illustrating the relation between age and BP?

A

A scatter plot facilitates the charting of two continuous variables, allowing the correlation to be calculated.

33
Q

What is the main site of action of haloperidol?

A

Area Postrema.

Haloperidol is a D2-receptor antagonist. It has a central antiemetic action, binding to receptors in the area postrema, which is a medullary structure controlling vomiting.

34
Q

A 76-year-old man presented with a 3-year history of a gradually enlarging red patch on his leg. He was an ex-serviceman who had worked in the Mediterranean for several years.

O/E erythematous scaly patch, 5 × 6 cm in diameter, on his shin. The edge was well demarcated.

What is the most likely diagnosis?

A

Bowen’s disease (BD) is a sunlight-induced skin disease, classified either as an early noninvasive stage or intraepidermal form of squamous cell carcinoma which if left undiagnosed, untreated, or neglected has <10% chance of malignant transformation into invasive squamous cell carcinoma of the skin. It usually appears as a erythematous, scaly or crusty patch or plaque anywhere on the body but most commonly involves lower legs, with other possible sites of involvement to be head, neck, genitals, and skin folds.

35
Q

In patients with penicillin allergy which Abx should be avoided?

A

This is a patient with a history suggestive of anaphylaxis to a penicillin. Therefore, beta-lactam drugs should be avoided. This excludes ceftriaxone, meropenem and piperacillin with tazobactam.

36
Q

MOA of Ropinirole?

A

Ropinirole is an agonist at dopamine receptors and is used as an adjunct to levodopa to treat Parkinson’s disease.

37
Q

Which muscle responsible for torticollis?

A

Sternocleidomastoid.

38
Q

Most common causative organism for Acute epiglottitis?

A

Haemophilus influenzae.

39
Q

Which cellular component contains double-stranded circular DNA?

A

Mitochondrion.

Mitochondrial DNA is matrilineal and is in a covalently bonded circular form. Maternally inherited diseases are associated with mutations in this DNA.

40
Q

Condition in which there is normal pO2 but decreased oxygen saturation?

A

Methaemoglobinaemia describes haemoglobin which has been oxidised from Fe2+ to Fe3+.

41
Q

Mx for Pemphigus vulgaris?

A

The combination of flaccid bullae (e.g. large blisters) with recent oral ulceration suggests that this is likely to be pemphigus vulgaris. Therefore, oral prednisolone is the most appropriate empirical treatment until the diagnosis is confirmed by histology and direct immunofluorescence of the skin biopsy.

42
Q

cluster of lymph nodes at appendix suggestive of mesenteric adenitis
What is the most likely cause of his symptoms?

A

Yersinia enterocolitica infection.

Yersiniosis is an infection caused most often by eating raw or undercooked pork contaminated with Yersinia enterocolitica bacteria.

Develop right sided abdominal pain which may be confused for appendicitis.

43
Q

What associated finding is a contraindication to surgical resection?

A

Superior vena cava obstruction.

The presence of superior vena cava obstruction at presentation is indicative of locally advanced and invasive disease, and portents inoperability and overall poorer survival outcomes.

44
Q

MOA of Alteplase?

A

Acceleration of plasminogen to plasmin conversion.

45
Q

Which transplant drug can cause tremor?

A

Tacrolimus.

It is typically worse in the first few months post transplantation because the target levels of tacrolimus are higher to cover the increased risk of rejection.

46
Q

MOA of renal injury with Aciclovir?

A

Crystalluria.

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

47
Q

Ix of choice for diagnosis of suspected Hodgkin lymphoma?

A

Excision biopsy of cervical lymph node.

Fine-needle aspiration is likely to yield insufficient material for diagnostic purposes in Hodgkin lymphoma.

48
Q

In atherosclerosis, what is the origin of foam cells?

A

Monocytes.

Foam cells are the fat-laden M2 macrophages that serve as the hallmark of early-stage atherosclerotic lesion formation.

49
Q

What antinuclear antibody isotype immunoglobulin is most likely to indicate a diagnosis of SLE?

A

IgG antinuclear antibodies are associated with systemic lupus erythematosus.

50
Q

Abx for prophylaxis of meningitis in household contacts?

A

Ciprofloxacin.

Management:
people who have been exposed to a patient with confirmed bacterial meningitis should be given prophylactic antibiotics if they have close contact within the 7 days before onset.

Oral Ciprofloxacin or Rifampicin may be used. Guidelines state ciprofloxacin is the drug of choice as it is widely available and only requires one dose.

meningococcal vaccination should be offered to close contacts when serotype results are available, including booster doses to those who had the vaccine in infancy.

51
Q

Abx choice for Meningitis?

A

Initial empirical therapy

  • Aged 3 months - 50 years: Intravenous cefotaxime (or ceftriaxone)
  • Initial empirical therapy aged > 50 years: Intravenous cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)

Meningococcal meningitis: Intravenous benzylpenicillin or cefotaxime (or ceftriaxone)

52
Q

Which condition besides haemachromatosis can caused raised ferritin?

A

Adult-onset Still disease is a rare inflammatory arthritis with fevers, rash, and joint pain.

It is a systemic inflammatory illness. Clinical features include fever, joint pain/inflammation and evanescent macular rash. A characteristic lab feature is very high levels of ferritin; additional lab features include anaemia, leukocytosis and high acute-phase reactants.

Haemochromatosis would not cause systemic inflammatory illness