MRCP Part 1 Jan 06

Discussion in 'MRCP Forum' started by yc, Jan 26, 2006.

  1. Nikos

    Nikos Guest

    mrcp 1 jan 06

    Hi all, thanks for great work!

    There was a q i haven't seen posted? or maybe missed it?

    old man, fragile blisters in mouth : pemphigoid

    good luck w results
  2. Nikos

    Nikos Guest

    or pemphigus?
  3. Guest

    Guest Guest

    pemphigoid
  4. Guest

    Guest Guest

    The q was about a man with blisters alover his body not in mouth so answer is pemphigoid ..
    aboot the smoker i think in the q they were pointing towadrs a CA so i think the answer was ct ,,im not sure does any one know what was the q ?


    Please does anyone know what was the pass mark for the previous exam and wheather it varies from center to another\?
  5. Guest

    Guest Guest

    Another missed q
    1-part of tubule impermeable to water -thich ascending loop of henle
    2-drug causing proteinurea in a rhmatoid patient -gold
    3-dru causing long qt or torsades doeas anyone remember ?
  6. shabana

    shabana Guest

    sotalol (unfortunately i got it wrong)
  7. Guest

    Guest Guest

    Do u remember other options in the q of prolonged qt ,,,wheather amiodrone was an option
  8. Guest

    Guest Guest

    * Old man with blistering eruptions over arms and legs. They only mentioned they were GROUPED and measured 1 to 2 cm. Diagnosis is probably dermatitis herpetiformis based on the grouped vesicles, but I chose bullous pemphigoid which is probably wrong.

    * Prolonged QT and syncope > Answer is sotalol (no amiodarone in options)

    * Man with chronic smoking and sputum production which was purulent and amounted to a cupful on a daily basis. Question asked about which investigation was best for evaluation. Answer was between spirometry and HRCT Thorax. I chose HRCT as the history appeared more typical for bronchiectasis than chronic bronchitis.
  9. Guest

    Guest Guest

    what was the pass mark for previous exam?
  10. Guest

    Guest Guest

    does anyone remember the psychiatry questions and thier answers
    what i remember is a PTSD,benzo withdrawal,a cannabis question
    ????????????????????????????
  11. shabana

    shabana Guest

    patient with sore throat and hematuria. what would u find on renal biopsy? what was the answer for that?
  12. Score: 1 (100%)

    A 42 year man being investigated diabetes impotence noted have following results:

    Alanine aminotransferase 30 U/L (5 35)
    Aspartate aminotransferase 22 U/L (1 31)
    Fasting plasma glucose 7.4 (3.0 6.0)
    Ferritin 500 ug/L (15 300)

    Which one of following would be next appropriate investigation?


    Available marks are shown in brackets
    1 ) bone marrow smear iron stain [0]
    2 ) liver biopsy [0]
    3 ) red cell protoporphyrins [0]
    4 ) serum transferrin receptors [0]
    5 ) transferrin saturation [100]
    option analysis


    --------------------------------------------------------------------------------
    Comments:
    This patient a suspected diagnosis of haemochromatosis as suggested by presentation laboratory investigations including elevated ferritin. The next investigation would be measurement of transferrin saturation then if elevated (above 45%) genotyping (Homozygosity C282y mutations) would next be considered would be expected clinch diagnosis. In event of rarer mutations confirmation liver biopsy may be required.

    --------------------------------------------------------------------------------
  13. Guest

    Guest Guest

    boy with heamaturea and sore throat ,,,
    I remember in this question they were asking about what do u see in light microscopy ?
    Its diffuse proliferative glomerulonephritis u see it under electron microscopy but i cant remember what do u see under light microscopy some people say normal but i doubt?!!
  14. shabana

    shabana Guest

    patient with polyuria, decreased libido and hip pain. what investigation to do diagnosis?
    fasting blood sugar
    serum ferritin
    24 hour urinary cortisol
    ?
  15. Nath

    Nath Guest

    hi,
    reg IGAnephropathy,can anyone say whats the correct answer.I choose normal finding as it was a young boy with relatively short duration of presentation.any comments.

    Diagnosis of IgA nephropathy is confirmed by renal biopsy.
    Histologic Findings:

    Light microscopy

    The most common light microscopy findings are focal or, more often, diffuse mesangial proliferation and extracellular matrix expansion (see Image 1). Morphology can range from normal to moderate or severe intracapillary or extracapillary proliferative lesions. While some patients have IgA deposits on immunofluorescence and little or no change by light microscopy, a few patients have segmental necrotizing lesions with crescent formation due to extensive disruption of the capillaries. Occasionally, patients have focal glomerular sclerosis indistinguishable from focal segmental glomerulosclerosis on light microscopy. A number of other findings can be observed in advanced disease, including interstitial fibrosis, tubular atrophy, and vascular sclerosis. These findings can be helpful prognostic tools in patients with IgA nephropathy.
  16. Guest

    Guest Guest

    The question was describing IgA nephropathy and the likely microscopic finding is that of mesangial hypercellularity.
  17. Guest

    Guest Guest

    what is the answer for a pt with small cell carcinoma in rt main bronchus ?\surgery,chemo,laser,palliative
    and are there any contraindication for surgery
  18. Guest

    Guest Guest

    Hi Guys,

    Relax - do not bother now as already two weeks have passed after the lengthy Paper 2 and bit tougher exam .

    Whatever we could do - we have tried our level best in just 6 hours -now let all the things upon the Almighty Allah .

    The passing % marks have always been around 59 and 62%.

    Do not bother now - relax and wait for the best.

    Good luck to all.
  19. Guest

    Guest Guest

    Hi Guys,

    Relax - do not bother now as already two weeks have passed after the lengthy Paper 2 and bit tougher exam .

    Whatever we could do - we have tried our level best in just 6 hours -now let all the things upon the Almighty Allah .

    The passing % marks have always been around 59 and 62%.

    THIS TIME IT COULD BE 58 OR 59 %

    Do not bother now - relax and wait for the best.

    Good luck to all.
  20. Guest

    Guest Guest

    Hi Guys,

    What happened - nobody, no reply,

    Inshallah the results are on 20th Feb - MONDAY AFTERNOON INSHALLAH.

    ALL THE BEST TO ALL OF YOU,

    GOOD LUCK TO ALL OF YOU.
  21. Try today's Question of the Day based on topics from the January 2006 exam and compare your scores with registered users of the site.

    Registered users have access to all questions with detailed feedback and analysis of results.

    Revising online lets you know exactly how your performance compares to others that are sitting the exam.




    Score: 1 (100%)

    A 70 year man admitted pruritus, jaundice a 2kg weight loss of two weeks duration. He had drank any alcohol at least eight years. One month ago, he had completed a course of Co Amoxiclav which had prescribed by his GP sinusitis was also taking Ibuprofen hip osteoarthritis. Investigations reveal:

    Albumin 38 g/L (37 49)
    Bilirubin 200 umol/L (1 22)
    AST 200 iu/L (5 35)
    Alkaline Phosphatase 200 iu/l (50 110)

    Abdominal ultrasound reveals gallsones but biliary duct dilatation

    What likely cause of his jaundice?


    Available marks are shown in brackets
    1 ) Cholangio carcinoma [0]
    2 ) Co Amoxiclav [100]
    3 ) Hepatitis B infection [0]
    4 ) Hepatitis C infection [0]
    5 ) Ibuprofen [0]
    option analysis


    --------------------------------------------------------------------------------
    Comments:

    Co amoxiclav (Augmentin) notorious causing drug induced jaundice, often a mixed hepatitic/cholestatic picture. A 4 week delay in symptoms signs unusual. Flucloxacillin another common culprit. The patient must be warned this could re occur if he given Co amoxiclav again.


    --------------------------------------------------------------------------------
  22. Have a go at the question of the day
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    Score: 1 (100%)


    A 60 year woman diagnosed giant cell arteritis was commenced on high dose prednisolone therapy. What appropriate treatment prevention of steroid induced osteoporosis?

    Available marks are shown in brackets
    1 )
    Bisphosphonate therapy


    [100]
    2 )
    Calcium vitamin D


    [0]
    3 )
    Hormone replacement therapy


    [0]
    4 )
    Raloxifene


    [0]
    5 )
    Salmon Calcitonin


    [0]
    option analysis
    Comments:

    The appropriate therapy advocated by National Osteoporosis Society prevention of steroid induced Osteoporosis would be bisphosphonate therapy such as Didronel alendronate. These are only class of drug shown offer osteoprotection steroid therapy. Patients taking 7.5 mg more of prednisolone daily 3 months longer should be offered osteoprotection. HRT would really be appropriate this subject who ten years past menopause likely be free of all menopausal symptoms.


    Registered users average score for this question is 54.9%
    Answered 13402 times
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    Score: 1 (100%)


    A 29 year presents acute right sided weakness. She one child aged 4 years had two spontaneous abortions in past. After birth of her child she developed a DVT required three months anticoagulation warfarin. Examination a right hemiparesis. A CT head scan showed a left middle cerebral artery territory infarct. What likely finding on echocardiography?

    Available marks are shown in brackets
    1 )
    Atrial septal defect


    [0]
    2 )
    Bicuspid aortic valve


    [0]
    3 )
    Left atrial myxoma


    [0]
    4 )
    Normal appearances


    [100]
    5 )
    Ventricular septal defect


    [0]
    option analysis
    Comments:
    This patient a prothrombotic tendency suggestive of lupus anticoagulant recurrent abortions, previous DVT now she developed a left hemiparesis. This occurred off warfarin it highly unlikely be due any right left transferance of clot. It more likely be due spontaneous infarct related thrombophilia her heart likely be normal.


    Registered users average score for this question is 54.5%
    Answered 30748 times
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  23. question of the day
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    Score: 1 (100%)


    A 20 year male presents extensive, coalescing, hypopigmented, slightly scaly lesions on his back chest. The rash had BEEN present FOR 2 years had gradually become more extensive. He had otherwise in good health. The lesions were NOT symptomatic but he was concerned about their appearance.
    What IS THE MOST appropriate treatment FOR his condition?

    Available marks are shown in brackets
    1 )
    ketoconazole cream


    [100]
    2 )
    nystatin cream


    [0]
    3 )
    oral itraconazole


    [0]
    4 )
    oral terbinafine


    [0]
    5 )
    terbinafine cream


    [0]
    option analysis
    Comments:

    The patient presents an asymptomatic eruption on his trunk. The lesions are scaly, hypopigmented are NOT associated any systemic disease. This characteristic of pityriasis versicolor, which caused by unicellular yeast Pityrosporum ovale Pityrosporum orbiculare. The yeast lipophilic AND encouraged by an increase in environmental temperature, thus many patients notice TH AT condition begins after a summer vacation. It a disorder of healthy but immunocompromised are at risk. The condition asymptomatic appears pale in comparison skin. The fungus affects melanocytes hence hypo pigmentation.. The treatment options include topical imidazole creams , selenium sulphide shampoo A if NOT responding TO topical treatment oral itraconazole 200mg once a day FOR 7 days.D In this patient THE topical treatment should be tried first.
  24. Guest

    Guest Guest

    Results are OUT

    dear all,

    the results for mrcp part 1 01/06 24th Jan is out on the web.

    cheers
  25. Guest

    Guest Guest

    results r out

    Hi drs.
    The results of Jan'o6 r out.I have cleared part 1 by god's grace.Hope u all have got the results too.Good luck
    dr.radha
  26. Guest

    Guest Guest

    I have also passed!!! Yippee
  27. Guest

    Guest Guest

    ALHAMDULILLAH - ALLAH HAS BLESSED ME WITH SUCCESS IN PART I

    ALHAMDULILLAH,ALHAMDULILLAH,ALHAMDULILLAH.

    GOOD LUCK TO ALL OF YOU GUYS.
  28. SSRAVEE

    SSRAVEE Guest

    regarding mrcp 2

    Hi
    I PASSED MY MRCP PART I HELD THIS JAN.CAN SOMEONE TELL ME WHAT TEXTBOOK I SHOULD USE FOR PART 2
  29. Dr. Shareef

    Dr. Shareef Guest

    PART 2 - MAIN BOOK,

    Rapid Review of Clinical Medicine for Part 2 by SANJAY SHARMA
  30. Guest

    Guest Guest

    hi!
    Regarding the answer for pancreatitis in a girl with epilepsy & htn, right answer wud be antihypertensive eg b-blocker or thiazide, whichever was in options & not antiepileptic!
  31. Guest

    Guest Guest

    I LIKE TO KNOW BOOKS FOR MRCP PART 1
  32. MS Sohail

    MS Sohail Guest

    FREE Questions

    Dear friends

    I passed my MRCP 1 in Jan 2006.

    I am posting some BOFs with the explainations. I have more. Any one intersted may contact me at drmssohail at yahoo.com.

    Good Luck and cheers.

    1- A 40-year-old man presents with a swollen erythematous finger and right axillary tenderness, 24 hours after being bitten by his pet dog. What is the best treatment?
    A. Metronidazole
    B. Aciclovir
    C. Fluconazole
    D. Flucloxacillin
    E. Amoxiclavulanate
    Correct answer E:
    Comments:
    Dog bites become infected in 10% of cases. The commonest organisms are anaerobic mouth flora and Pasteurella multocida. Other organisms include Capnocytophaga spp and Streptococcus pyogenes. Amoxiclavulanate (co-amoxiclav: a mixture of amoxicillin and clavulinic acid) is appropriate as it is effective against all the most likely organisms. Herpes simplex infection is most unusual in cases of dog bites, though monkey bites often transmit this virus. Although dogs harbour fungal infections including Blastomyces, Microsporidium and Trichosporon spp, these are dermatophytes and only produce superficial skin rashes, and therefore the antifungal agent, fluconazole, is not indicated in this patient. Flucloxacillin is not active against anaerobic bacteria. Metronidazole, a good antibiotic against anaerobic bacteria, does not cover aerobic Gram-negative organisms.

    2- A 35-year-old HIV-positive man, evaluated for weight loss and weakness has been found to have disseminated tuberculosis. On examination, he is hypotensive and has hyperpigmentation of the mucosa, elbows and skin creases. Further investigations confirm a diagnosis of Addison’s disease. Which of the following is likely in this condition?
    A. Increased serum Na
    B. Increased serum Cl
    C. Increased serum HCO3
    D. Increased serum K
    E. Decreased serum Ca
    Correct answer: D
    Comments:
    In adrenal destruction, serum Na, Cl and HCO3 levels are reduced, and serum potassium is elevated. The hyponatraemia is due to both loss of sodium in the urine (due to aldosterone deficiency) and to movement into the intracellular compartment. Hyperkalaemia is due to a combination of aldosterone deficiency, impaired glomerular filtration (due to hypotension) and acidosis. Mild to moderate hypercalcaemia occurs in 10–20% patients, the cause of which is uncertain.

    3- A 47-year-old diabetic man is referred from the infertility clinic. He has occasional palpitations and takes diuretics for dyspnoea. He is tanned, has hepatomegaly and a normal full blood count and liver biochemistry. What is the most appropriate investigation?
    A. MRI of the liver
    B. Serum alpha-fetoprotein level
    C. Liver biopsy
    D. Cardiac echocardiography
    E. Serum iron studies
    Correct answer: E
    Comments:
    The combination of diabetes mellitus, probable hypogonadism, hepatomegaly and skin pigmentation suggests haemachromatosis. This is an autosomal-recessive disorder and is more commonly seen in middle-aged men. Excess iron is deposited in the endocrine glands, heart and skin. Gonadal function is impaired. Patients develop arrhythmias and heart failure. Serum iron and serum ferritin levels are raised. The total iron-binding capacity is reduced and transferrin saturation is complete (>60%). Patients may develop cirrhosis and 30% of patients who develop cirrhosis can develop hepatocellular carcinoma.

    4- A woman, aged 55, presents with features consistent with Cushing’s syndrome. She is taking no medication. Her basal cortisol and plasma ACTH levels are significantly raised. She has failed the dexamethasone suppression test. What is the most likely diagnosis?
    A. Adrenal tumour
    B. Carney’s syndrome
    C. Cushing’s disease
    D. Depression
    E. Ectopic ACTH-secreting tumour
    Correct answer: C
    Comments:
    A raised adrenocorticotrophic hormone (ACTH) level with a raised cortisol implies the problem is caused by excess ACTH production, otherwise negative feedback would suppress ACTH. A low ACTH level would therefore be expected in patients with an adrenal tumour. Carney’s syndrome comprises atrial myxoma and freckles with high cortisol levels independent of ACTH. Pituitary tumours producing ACTH and adrenal stimulation are the cause of Cushing’s disease. While ectopic ACTH-secreting tumours are associated with significantly raised ACTH and cortisol levels, it’s unusual to develop classic cushingoid features. Failure of the dexamethasone suppression test can occur in patients with depression, but cushingoid features are not expected.

    5- A 19-year-old woman presents with a severe sore throat, fever and malaise. She has marked cervical lymphadenopathy, gross splenomegaly and scattered petechiae on the soft palate, with enlarged tonsils covered by a confluent white exudate. Her white cell count is mildly elevated, her serum ALT and AST concentrations are twice normal and her alkaline phosphatase concentration is slightly elevated. Which one of the following investigations is most likely to help guide your management?
    A. Fine-needle aspiration of a lymph node
    B. Hepatitis-B surface antigen
    C. Cytomegalovirus IgM
    D. Heterophilic antibodies
    E. HIV test
    Correct answer: D
    Comments:
    The history is strongly suggestive of infectious mononucleosis, which can be confirmed by a heterophilic antibody test (Monospot). Around 80% of patients at this stage of the illness will have a positive test. However, if the Monospot test is negative, it should be repeated a few days later. Specific serological tests to detect the presence of Epstein–Barr virus should be requested if it is still negative and there is a high clinical suspicion of glandular fever. If the EBV tests are negative then other causes for heterophilic-negative acute mononucleosis – including HIV, CMV and toxoplasmosis – should be considered. The LFTs are not sufficiently elevated in this patient for acute viral hepatitis. Other features of a systemic viral infection are present and therefore there is no indication for requesting lymph node aspiration. Clearly, the management of this patient depends on a correct diagnosis. The most frequent misdiagnosis is of bacterial tonsillitis and antibiotic treatment given to someone with glandular fever might result in a severe drug reaction. Confirmation of glandular fever would suggest the need for corticosteroid management of this patient who is toxic and has profound thrombocytopenia. It would be unusual for the acute HIV retroviral syndrome to present with marked exudative tonsillitis and splenomegaly, although a reported sexual history negative for risk factors does not exclude HIV infection.

    6- A 64-year-old woman is referred to the medical team from the orthopaedic ward. She underwent a right total-hip replacement six days ago. She is known to suffer from mild COAD and is on regular inhaled steroids and a short-acting ß2-agonist. She now complains of left-sided chest pain and is also dyspnoeic. Your clinical diagnosis is pulmonary embolism (PE). Which one of the following is not a feature of PE?
    A. Dyspnoea
    B. Tachypnoea
    C. New-onset atrial fibrillation
    D. Fever
    E. Bradycardia
    Correct answer: E
    Comments:
    Bradycardia is not a feature of PE. Tachypnoea (respiratory rate > 20/min) is the commonest feature occurring in 85% of patients. Fever is a frequent finding (34-50%). Tachycardia occurs in 30% of patients. Atrial flutter, fibrillation and premature beats are known to occur in patients with PE.

    7- What is the type-1 error most closely related to?
    A. Correlation coefficient
    B. The p value
    C. Positive predictive value
    D. Standard deviation
    E. Standard error of the mean
    Correct answer: C
    Comments:
    A type-1 or alpha error occurs when the null hypothesis is falsely rejected. In other words, a significant difference is found between two drugs when, in actual fact, there is none, and instead the result has occurred by chance. A p value of 0.05 indicates there is a probability of 5/100 (1 in 20) that the result may have occurred by chance.

    8- A 30-year-old man, under investigation for abdominal cramps and passing blood rectally, presents with an acutely painful, red and photophobic eye. What is the most likely sign on ocular examination?
    A. Conjunctival purulent discharge
    B. White corneal stromal infiltrate
    C. Mydriasis of the affected eye
    D. Hypopyon
    E. Swollen optic disc
    Correct answer: D
    Comments:
    Passing blood rectally is a symptom of inflammatory bowel disease. There are many causes of a red eye, but in this context, iritis (anterior uveitis) should be suspected. A cardinal sign of iritis is the presence of inflammatory cells in the anterior chamber of the eye, visible with a slit lamp. In severe cases of iritis, the degree of inflammation in the anterior chamber is enough to cause settling of inflammatory cells inferiorly to form a level: a hypopyon. While a hypopyon usually implies infective endophthalmitis (eg following cataract surgery), a sterile hypopyon can occur in cases of severe iritis (eg Behçet’s disease). Bacterial conjunctivitis causes purulent discharge but is less likely to cause severe pain and photophobia. Microbial keratitis, causing a white corneal infiltrate, is more likely if there is a history of contact lens wear or trauma, such as a corneal abrasion or a corneal foreign body. Iritis often causes pupillary miosis, and while acute angle closure, an ophthalmological emergency, causes mydriasis in a red painful eye, it is less likely in a patient as young as 30. Cerebral metastases from colorectal carcinoma may cause raised intracranial pressure and papilloedema, but this is unlikely in a young patient, and would not cause conjunctival injection (ie a red eye).

    9- A 58-year-old man’s ECG shows a combination of a prolonged QT interval with tall T waves. What is this suggestive of?
    A. Uraemia
    B. Hypocalcaemia
    C. Hypokalaemia
    D. Hypermagnesaemia
    E. Metabolic alkalosis
    Correct answer: A
    Comments:
    A prolonged QT interval is due to hypocalcaemia and tall T waves to hyperkalaemia and/or acidosis, which can be caused by uraemia. The main ECG change resulting from hypocalcaemia is a long QT interval due to prolongation of the ST segment.Hypokalaemia is caused by potassium-wasting diuretics, potassium-wasting diarrhoea and hypokalaemic periodic paralysis. The hallmark of the effect of hypokalaemia on the ECG is the development of large U waves (positive deflection after the T wave). The normal U wave is produced by repolarisation of the His–Purkinje system.

    10- A 45-year-old man presents with prognathism and interdental separation. Which of the following is the most appropriate investigation?
    A. Fasting glucose test
    B. Glucose tolerance test
    C. Basal growth-hormone measurement
    D. Serum prolactin measurement
    E. Thyroid function test
    Correct answer: B
    Comments:
    This patient has acromegaly. Had the illness started before epiphyseal fusion, he would have had gigantism. Measuring the level of basal growth hormone is not an appropriate diagnostic test because of variations in concentration, although levels are often high. Biochemical diagnosis is made by measuring growth-hormone levels in response to a glucose challenge. In normal patients, the concentration of growth hormone should fall. Prolactin is structurally similar to growth hormone. Levels of prolactin increase during sleep and in response to estrogen and stress, as well as during suckling in breast-feeding women.

    11- A 56-year-old woman, who is known to suffer from rheumatoid arthritis, complains she has had recurrent haemoptysis for over 5 years. She has never smoked and only takes a non-steroidal anti-inflammatory agent. According to her, she coughs up phlegm every day and at times this contains streaks of fresh blood. She has no known respiratory disease, but tends to get frequent chest infections that are relieved by a course of antibiotics. What is the most likely diagnosis?
    A. Lung cancer
    B. Bronchiectasis
    C. Tuberculosis
    D. Pulmonary embolism
    E. Atypical pneumonia
    Correct answer: B
    Comments:
    Some 3–4% of patients with rheumatoid arthritis develop bronchiectasis. This is characterised by recurrent haemoptysis. The history of expectorating phlegm on most days and frequent chest infections are suggestive of the diagnosis. A high-resolution computed tomography (CT) scan of her lungs will establish the diagnosis.

    12- A 19-year-old woman presents with fever, rash and cough, and is pyrexial, tachycardic and tachypnoeic. She has a florid erythematous rash on her face, trunk and arms, with scattered whitish papular lesions on the buccal mucosa. What is the most likely diagnosis?
    A. Meningococcaemia
    B. Rubella
    C. Parvovirus B19
    D. Secondary syphilis
    E. Measles
    Correct answer: E
    Comments:
    Adult measles is unusual except in non-immunised persons. The description of this patient’s rash is classical: the rash is maculopapular, starts on the face and migrates caudally; Koplik’s spots are present in the mouth. In contrast, meningococcaemia is a petechial/purpuric macular rash with no buccal lesions, and there is no typical migratory pattern. Rubella is possible, but the lesions are smaller and not intense or darkly coloured: they can also spread caudally but there is no desquamation. Parvovirus infection produces the typical raised erythema on the cheeks (‘slapped cheek’) and usually occurs in young children: bizarre variations in the rash are sometimes seen. The rash of secondary syphilis usually affects the upper trunk, palms and soles and flexural extremities. Mucosal lesions are usually erythematous and coalesce (‘snail track’ ulcers).

    13- A 68-year-old man, although asymptomatic from the cardiac viewpoint, has an ejection systolic murmur best heard in the aortic area. The murmur radiates to the carotids. Echocardiography confirms severe aortic stenosis with a gradient of 85 mmHg across the calcified aortic valve. What is the incidence of sudden cardiac death in such patients?
    A. 3–5%
    B. 6–9%
    C. 10–25%
    D. 25–50%
    E. More than 75%
    Correct answer: A
    Comments:
    The natural history of aortic stenosis (AS) in adults is characterised by a long latent period, during which there is a gradually increasing obstruction and an increase in the pressure load on the myocardium while the patient remains asymptomatic. Once symptoms appear in patients with an unrelieved obstruction, the prognosis is poor. Survival curves have shown that the interval from the onset of symptoms to the time of death is approximately two years in patients with heart failure, three years in those with syncope and five years in those with angina. Before the advent of surgery, sudden cardiac death was quite common in cases of aortic stenosis (in 1968, Campbell reported that of 70 patients with aortic stenosis who died, 44 (73%) of the deaths were sudden. Although AS may be responsible for sudden death, this usually occurs in patients who have previously been symptomatic.There is a 6–9% incidence of sudden cardiac death in asymptomatic children with aortic stenosis.

    14- Which of the following arrhythmias is unusual in digoxin toxicity?
    A. Non-paroxysmal atrial tachycardia with varying block
    B. First-degree heart block
    C. Type-II second-degree heart block
    D. Wenkebach phenomenon
    E. Bidirectional ventricular tachycardia
    Correct answer: C
    Comments:
    Digoxin toxicity can result in any abnormal cardiac rhythm except type-II second-degree atrioventricular (AV) block. The characteristic arrhythmia includes non-paroxysmal atrial tachycardia with varying block. The other common arrhythmias include first-degree heart block, Wenkebach (type-I second-degree block) and complete (third degree) heart block, ventricular ectopics and ventricular tachycardia (VT) (uni- and bi-directional). Ventricular fibrillation (VF) can also rarely occur. Another unusual arrhythmia is atrial flutter.Factors predisposing to digitalis toxicity are advanced age, hypoxia, hypokalaemia, hypomagnesaemia, hypercalcaemia, hypothyroidism, amyloidosis and renal failure. The most common precipitating factor is hypokalaemia. The earliest signs of digitalis toxicity include nausea, vomiting and anorexia. Chronic toxicity causes exacerbation of heart failure, weight loss, gynaecomastia and yellow vision.

    15- Which of the following statements best describes the standard deviation?
    A. It is derived from the p value
    B. It is derived from the (variance)2
    C. It is a measure of how close the sample mean is to the population mean
    D. It is a measure of the spread of the sample distribution
    E. Its numerical value is 1.96
    Correct answer: D
    Comments:
    The standard deviation (SD) indicates the spread of a distribution of observations. A greater SD represents a greater spread of values. It is derived from the square root of the variance. The standard error is a measure of how close the sample mean is to the population mean. If the sample were normally distributed, 68% of the values would lie within ± 1 SD about the mean and 95% of the values would lie within ± 1.96 SDs about the mean.

    16- A 73-year-old man with chronic lymphocytic leukaemia (CLL) is followed up in clinic. He has become increasingly breathless over the last three months but has no other symptoms and is on no medication. On examination, he is pale and has bilateral cervical and inguinal lymphadenopathy and a firm 5-cm splenomegaly. FBC shows:
    Hb 7.4 g/dl; WCC 25 × 103/mm3; platelets 117 × 103/mm3; urea 15 mmol/l; creatinine 203 mmol/l; bilirubin 49 mmol/l.
    Which investigation is most appropriate to demonstrate the likely cause of anaemia?
    A. Bone marrow aspirate
    B. Autoantibody profile
    C. Erythropoietin level
    D. Antiglobulin test
    E. Urinary haemosiderin
    Correct answer: D
    Comments:
    Anaemia in CLL has several causes including marrow infiltration, marrow suppression from chemotherapeutic agents, hypersplenism and haemolysis (which is extravascular and mediated by IgG antibodies against the erythrocyte membrane). A disproportionately low haemoglobin compared to the platelet count is more likely to reflect a red cell problem alone; and the raised bilirubin level suggests that haemolysis is occurring, rather than the anaemia being due to marrow failure. Autoimmune haemolysis is demonstrated by the antiglobulin test, either indirectly (patients’ serum incubated with human red cells and antiglobulin antibodies) or directly (patients’ cells and serum incubated with antiglobulin antibody). The haemolysis is extravascular and so there will be no increase in urinary haemosiderin.

    17- You are taking a history from a 19-year-old man. He says he has trouble sleeping at night because he is concerned about abusing his special powers. He says he is able to read other people’s thoughts and sometimes feels able to control their hand movements. He knows this to be true because a passage in the Bible can be translated with a special code and the translation dictates his powers. He also says he hears voices talking about him. How is his delusion best categorised?
    A. Delusion of control
    B. Paranoid delusion
    C. Delusion of reference
    D. Delusion of replacement
    E. Delusion of guilt
    Correct answer: C
    Comments:
    A delusion is a false belief that someone refuses to acknowledge as false despite evidence, and typically they change their other beliefs to keep their whole belief system consistent. A delusion of reference describes the belief that a special meaning for that individual lies behind something ‘innocent’ in the public domain, such as a book/TV programme/newspaper or from the way objects are arranged in a room or how cars are parked in a street. Delusions of control consist of beliefs that patients themselves are being controlled by an external force, typically citing electricity or radio waves as the mediator. Paranoid delusions usually consist of people or organisations (such as MI5) plotting to kill, spy on, or harass the patient; while delusions of replacement occur when people in a patient’s life (eg their partner or close relative) have been replaced by an impostor who looks and talks exactly like that person.

    18- A 37-year-old woman presents with a one-year history of increasing deafness and tinnitus in her right ear. Her right corneal reflex is absent, there is hearing loss in her right ear with air conduction greater than bone conduction, and Weber’s test lateralises to the left. What is the most likely diagnosis?
    A. Acoustic neuroma Correct answer

    B. Basilar artery aneurysm
    C. Multiple sclerosis
    D. Meningioma
    E. Ménière’s disease
    The examination findings describe sensorineural deafness and loss of the corneal reflex on the right. These fit very well with the early symptoms of an acoustic neuroma. This is a benign, slowly growing tumour that arises from the VIIIth cranial nerve in the cerebellopontine angle. It usually presents in middle age and is most common in women. As the tumour enlarges it may involve the facial, abducens and bulbar cranial nerves. In addition, during the late stages it may compress the brainstem (causing hydrocephalus) or the cerebellum (causing ataxia and nystagmus). Options B, C and D might present with similar symptoms but it is likely there would be greater neurological impairment with more widespread signs. Ménière’s disease is a common disorder causing recurrent episodes of severe vertigo associated with sensorineural deafness and tinnitus. It does not cause loss of the corneal reflex.

    19- A 17-year-old young woman is referred to the endocrine clinic with primary amenorrhoea. She is of normal height and weight. She has moderate hirsutism. A male cousin was seen in the clinic at the age of 8 years with precocious puberty. What is the most likely cause for her primary amenorrhoea?
    A. Congenital adrenal hyperplasia Correct answer

    B. Hyperprolactinaemia Your answer

    C. Polycystic ovarian syndrome
    D. Turner’s syndrome
    E. Testicular feminisation syndrome
    Turner’s syndrome (genotype XO) is associated with primary amenorrhoea and short stature. Hyperprolactinaemia and PCOS are more commonly associated with secondary amenorrhoea. Testicular feminisation causes primary amenorrhoea and is caused by either a partial or complete androgen-receptor defect. Affected patients are genotypically male (XY) but phenotypically female. Congenital adrenal hyperplasia is most commonly caused by 21-hydroxylase deficiency. Severe forms present in infancy with salt-losing crises and females can have ambiguous genitalia. Milder forms cause precocious puberty in boys and virilism, hirsutism and primary amenorrhoea in girls. Diagnosis is by finding raised serum 17-hydroxyprogesterone levels that show a hyperresponsiveness to ACTH. Treatment is with glucocorticoids.

    20- A 70-year-old man presents with a gradually worsening, droopy, right upper eyelid. There is a right ptosis and anisocoria, greater when the room lights are off than in light conditions. Which of the following is the best investigation?
    A. Anti-acetylcholine receptor antibodies
    B. Blood glucose
    C. Chest X-ray Correct answer

    D. Dilute pilocarpine eye-drop test Your answer

    E. Intraocular pressure
    The signs are consistent with a right Horner’s syndrome. Anisocoria (difference in pupil size) that is greater in the dark implies interruption of the sympathetic supply to the pupil. Horner’s syndrome has several causes, including Pancoast’s tumour of the lung. A IIIrd nerve palsy would cause ptosis and an anisocoria. Old age, smoking, elevated blood pressure and diabetes are all risk factors for microvascular ischaemia that can cause a cranial mononeuropathy. However, the anisocoria would be greater in the light, as parasympathetic input is affected. Furthermore, in a IIIrd nerve palsy, the eye is likely to be deviated in the ‘down and out’ position. Myasthenia gravis causes a variable bilateral ptosis that does not affect the pupil. Diluted pilocarpine drops (0.1%) can be used to diagnose a Holmes–Adie pupil. These drops will not constrict a normal pupil, but will constrict a Holmes–Adie pupil due to denervation sensitivity. Elevated intraocular pressure in an acute angle closure glaucoma causes pupillary dilatation in a red painful eye, and ptosis does not occur, although pain in the eye may cause intermittent blepharospasm.

    21- Which of the following observations is very sensitive to extreme scores in a distribution?
    A. Mean Correct answer

    B. Median
    C. Mode
    D. 50th centile Your answer

    E. All are equally affected
    Mean, median and mode are measures of central tendency. They coincide if the distribution of values is normal and the frequency polygon assumes a bell-shaped Gaussian distribution. However, with extreme scores, the distribution gets skewed and the measures may be affected. Mode is the observed value that occurs at the greatest frequency in a distribution and is totally uninfluenced by a small number of extreme scores. The median is the observation that divides the frequency distribution by half and is equal to the 50th centile. It responds to the number of extreme observations but not their value, and therefore is useful as a measure of central tendency in extremely skewed distributions. The mean is the average value of observations, and therefore very sensitive to extreme values in a distribution.

    22- An 83-year-old man is undergoing cognitive assessment in a psychogeriatric clinic. He was referred because of a change in his behaviour, and his wife has noticed a few aggressive outbursts over the past months. His Mini-Mental test score is 18. Which patterns of cognitive deficit would favour a dementia of subcortical origin?
    A. Poor visuospatial performance Your answer

    B. Preserved verbal fluency
    C. Severe memory disturbance
    D. Constructional apraxia
    E. Reduced verbal output Correct answer

    The distinction between cortical and subcortical dementia is not absolute but is clinically useful. Subcortical dementia is due to disruption in the frontostriatal connections and so results in early frontal lobe problems such as planning difficulties, poor verbal fluency and task switching. Typically, the ‘cortical’ functions of correct word use and complex motor tasks (praxis) are preserved. Basal ganglia involvement results in ‘psychomotor’ slowing with reduced verbal output, slowed rate of response and reduced alertness. Visuospatial performance can be poor in both cortical and subcortical dementia so it is less helpful for use in trying to differentiate them. Severe memory disturbance is more often seen in cortical dementia. Common causes of subcortical dementia include parkinsonism, vascular dementia and multiple sclerosis; rarer causes include normal-pressure hydrocephalus, Huntingdon’s disease and Wilson’s disease.

    23- A 25-year-old man presents with right-sided facial weakness and swelling. There is a right LMN facial nerve palsy but no other abnormalities on examination. Lumbar puncture findings are:
    Opening pressure 18 cm CSF
    Protein 0.9 g/l
    Glucose 3.5 mmol/l
    Microscopy 85 lymphocytes
    What is the most likely diagnosis?
    A. Lyme disease Your answer

    B. Multiple sclerosis (MS)
    C. Guillain–Barré syndrome (GBS)
    D. Neurosarcoidosis Correct answer

    E. Ramsey Hunt syndrome
    All the items on the above list can cause an LMN VII lesion. However, the lumbar puncture findings are inconsistent with MS, GBS and Ramsay Hunt syndrome. The right-sided facial swelling is an enlargement of the right parotid gland, which is typical of sarcoid. Therefore the correct answer is neurosarcoidosis.

    24- The epsilon potential is seen on the ECG of patients with which of the following?
    A. Hypertrophic cardiomyopathy
    B. Restrictive cardiomyopathy Your answer

    C. Right ventricular dysplasia Correct answer

    D. Romano Ward syndrome
    E. Digoxin toxicity
    The epsilon potential is a right ventricular conduction delay, and appears as a sharp deflection after termination of the QRS complex during the ST segment or upstroke of the T wave. It is seen in the right ventricular leads V1 and V2. (Fontaine named the waves ‘epsilon’ since epsilon follows delta in the Greek alphabet.)Right ventricular dysplasia is characterised by the displacement of myocytes by fat. This delays the excitation and depolarisation of those viable myocytes enveloped by the fatty tissue, and so leads to epsilon potentials.

    25- A 45-year-old woman with ulcerative colitis is admitted with a history of jaundice, pruritus and intermittent abdominal pain. Examination shows hepatosplenomegaly and mild ascites. Blood tests confirm an obstructive jaundice, and mitochondrial antibodies are not detected. What is the most likely diagnosis?
    A. Liver cirrhosis
    B. Chronic active hepatitis Your answer

    C. Sclerosing cholangitis Correct answer

    D. Metastatic carcinoma
    E. Pancreatic carcinoma
    This patient has inflammatory bowel disease and is at risk of developing sclerosing cholangitis. This results from inflammation and fibrosis of the bile ducts leading to multiple areas of narrowing throughout the biliary system. Patients with AIDS also develop sclerosing cholangitis. Patients may be asymptomatic or may present as above. The alkaline phosphatase level is high and the mitochondrial antibody is not detected. Liver biopsy will show fibrous obliterative cholangitis with loss of interlobular and adjacent septal bile ducts. An ERCP will demonstrate the multiple strictures. Treatment is unsatisfactory – methotrexate has been used, but liver transplantation may be needed.

    26- A teacher presents with a two-week history of increasing malaise, tingling in her hands and feet and difficulty in walking. There is symmetrical distal weakness that is worse in her legs, absent lower limb reflexes, reduced sensation to pinprick and light touch to the knee bilaterally. Lumbar puncture shows an acellular CSF with a raised protein level. Which of the following factors confers the worst prognosis for this illness?
    A. Female sex Your answer

    B. Gradual onset
    C. Previous history of diarrhoeal illness Correct answer

    D. Level of protein greater than 1.5 g/l in CSF
    E. Age less than 40 years
    The clinical history given above is of Guillain–Barré syndrome (GBS). This is the commonest subacute neuropathy, having an incidence of 1.5–2 per 100 000 population per year. There is a slow recovery over weeks or months in 80% of cases. However, 20% of patients will suffer permanent disability and 5% will die. Poor prognostic factors in GBS include: age > 40 years; gradual onset; requirement for ventilatory support; previous history of diarrhoeal illness (specifically Campylobacter spp.); and a high anti-GM1 antibody titre.

    27- An optician refers a 20-year-old asymptomatic man with bilateral retinal lesions. There are seven oval, pigmented, flat-looking areas, each approximately the size of the optic disc and each with a white fishtail, in each retina. What is the most appropriate investigation?
    A. Colonoscopy Correct answer

    B. Fluorescein angiography
    C. Genetic counselling for retinitis pigmentosa Your answer

    D. Blood glucose
    E. Toxoplasmosis antibody levels
    The retinal lesions are CHRPE (congenital hypertrophy of the retinal pigment epithelium). These can be ‘typical’ or ‘atypical’. Typical CHRPE are grey or black, with depigmented lacunas, and are found in one quadrant of one eye. They do not affect vision. Atypical CHRPE have a white fishtail, and are bilateral. They do not affect vision, but if there are more than four atypical CHRPE in each eye then familial adenosis polyposis or Gardner’s syndrome may be suspected as an association. Colonoscopy and examination of all family members would therefore be appropriate. Fluorescein angiography will add nothing in terms of a diagnosis. Retinitis pigmentosa causes ‘bone spicule’ pigmentation in the retinal mid-periphery, along with a waxy disc pallor and retinal arteriolar attenuation. Patients with retinitis pigmentosa often suffer from night blindness and restricted peripheral vision (‘tunnel vision’ when the disease is advanced). Metastases to the choroid can appear as large dark lesions under the retina, often with overlying exudative (as opposed to rhegmatogeneous) retinal detachment. Potential sources of primary lesions include the gastrointestinal tract, breasts, kidneys, testes and prostate. However, the appearance does not sound typical of a metastasis to the choroid. Discrete pigmented spots in the retina, often with pale rims of atrophy, could be due to either previous laser treatment (in a diabetic patient with signs of retinopathy and a history of new blood vessel formation, for example) or scars from previous toxoplasmosis infections. Congenital or old toxoplasmosis lesions can reactivate in adulthood, appearing as pigmented retinal lesions with a white fluffy edge, often obscured on examination by vitreous inflammatory debris (vitritis); hence the descriptive term for the appearance of active toxoplasmosis, ‘a headlight in the fog’. Old inactive lesions require no treatment.

    28- A 25-year-old obese woman presents with headaches and vomiting. A CT of her head is normal. A lumbar puncture is performed and shows an opening pressure of 30 cm. What is the most likely abnormality seen on examination of the visual fields?
    A. Left homonymous hemianopia
    B. Right homonymous hemianopia Your answer

    C. Central visual field defect
    D. Enlarged blind spot Correct answer

    E. Altitudinal field defect
    This woman will have an enlarged blind spot. The clinical description is of benign intracranial hypertension, which typically presents in young obese women with symptoms of raised intracranial pressure and significant papilloedema. Initially, visual acuity is preserved but the blind spot is usually enlarged. If the raised intracranial pressure is allowed to continue there will be progressive visual loss and the appearance of optic atrophy.

    29- A 55-year-old man complains of nausea, loss of appetite and dyspepsia after meals for the last 2 weeks. He is a smoker and has a past history of pernicious anaemia. He is pale, cachexic and tender at the epigastrium. His skin is velvety and hyperpigmented at the neck and axillary folds. What is the diagnosis?
    A. Tylosis
    B. Pyoderma gangrenosum Your answer

    C. Acanthosis nigricans Correct answer

    D. Chloasma
    E. Lentigines
    His clinical features suggest underlying stomach cancer. Acanthosis nigricans is commonly seen in patients with stomach cancer, insulin-resistant diabetes and obesity. It is characterised by a velvety thickening and pigmentation of the major flexures.

    30- A 34-year-old professional footballer is evaluated for symptoms of ‘dizziness’ during exercise. Physical examination reveals a laterally displaced apical impulse. On auscultation, there is a 2/6 mid-systolic murmur in the aortic area that increases on sudden standing. The ECG shows LVH and Q waves in the V2–V5 leads. What is the most likely diagnosis?
    A. Young-onset hypertension
    B. Acute MI Your answer

    C. Aortic stenosis
    D. Hypertrophic cardiomyopathy Correct answer

    E. Atrial septal defect
    Hypertrophic cardiomyopathy is the single, most common cause of sudden death in young athletes. The majority of patients are asymptomatic or only mildly symptomatic. Syncope and sudden death are associated with severe exertion and competitive sports, which should be avoided in patients with hypertrophic cardiomyopathy. The most common symptom is dyspnoea. Typical examination findings include left ventricular hypertrophy and a loud S4. Forceful atrial systole causes a double apical impulse. A triple apical impulse can also occur due to a late systolic bulge. The carotid pulse also demonstrates a late systolic pulse causing the characteristic jerky feature. In contrast to aortic stenosis, the systolic murmur of hypertrophic cardiomyopathy does not radiate to the carotids. Moreover, it decreases on squatting and passive leg elevation and increases with the Valsalva manoeuvre. The most common changes seen on the ECG are ST–T wave abnormalities followed by LVH. Q waves may also occur in leads II, III, aVF or V2–V6. The exact cause of the Q waves remains unclear.

    31- A 35-year-old man with type-1 diabetes mellitus on insulin presents in the A&E with fever, cough, vomiting and abdominal pain. Examination reveals a dry mucosa, decreased skin turgor and a temperature of 37.8 °C. Chest examination reveals bronchial breathing in the right lower lobe, and a chest X-ray shows it to be due to a right lower zone consolidation. Other investigations show a blood glucose concentration of 30 mmol/l, Na 130 mmol/l, K 5.7 mmol/l, urea 8.0 mmol/l, creatinine 120 mol/l, pH 7.15, HCO3 12 mmol/l, p(CO2) 4.6 kPa and chloride 106 mmol/l. Urinary ketones are positive (+++). The patient is admitted to the hospital and treated. Which of the following should not be used while treating him?
    A. Fluids, iv
    B. Insulin
    C. Potassium Your answer

    D. Bicarbonate Correct answer

    E. Antibiotics
    This patient has diabetic ketoacidosis (DKA), which is more common in type-I than type-2 diabetes mellitus. Inadequate insulin causes lipolysis, leading to ketosis and acidosis. The common precipitants include inadequate insulin administration, infections (pneumonia, urinary tract infection (UTI)), myocardial infarct (MI), stroke, peripheral gangrene, etc. Treatment is directed at the underlying cause and correction of the ketoacidotic state. Here, the underlying cause, pneumonia, is treated with antibiotics. The most important aspect of treatment is to give iv fluids, as normal saline, along with regular insulin. When the fluid balance is restored, the initial high potassium concentration may fall and therefore has to be monitored and supplemented as required.The role of HCO3 in DKA is controversial. The acidosis usually corrects itself once the fluid and electrolyte balance is restored. Some physicians administer HCO3 if severe acidosis (pH < 7) is present. However, there is a view that rapid correction of acidosis may impair cardiac function.

    32- Which of the following statements regarding the eukaryotic cell cycle is correct?
    A. M phase signifies meiosis
    B. DNA is made in the G1 phase Your answer

    C. DNA is made in the S phase Correct answer

    D. G2 phase commences as G1 finishes
    E. G2 determines variability in the length of the cell cycle in humans
    Mitosis occurs in the M phase of the eukaryotic cell cycle and DNA is synthesised in the S phase. G1 and G2 are gap phases. Cells can enter the G0 phase from G1 if they are not preparing for cell division. This may occur if the cell has reached its final differentiation. The G1 phase determines the variability of the cycle length.

    33- A 46-year-old woman is admitted to hospital with a left basal, community-acquired pneumonia. She is on the appropriate antibiotics. She is still pyrexial four days after admission and a chest X-ray confirms a left pleural effusion. The house officer has performed a diagnostic tap. Which of the following is an indication to insert a chest drain?
    A. Pleural fluid protein level more than 50% of serum protein level
    B. Pleural fluid LDH more than 60% of serum LDH
    C. Haemorrhagic pleural fluid Your answer

    D. Pleural fluid pH < 7.2 Correct answer

    E. Pleural fluid glucose < 1.6 mmol/l
    This woman has a parapneumonic effusion. The indications for chest tube insertion in patients with infected pleural effusions are: presence of organisms on a Gram stain of the pleural fluid, a frankly purulent pleural fluid, pleural pH < 7.2 in the setting of an infected pleural effusion, loculated pleural effusions and poor clinical progress despite antibiotic treatment.

    34- A 23-year-old army cadet is admitted to hospital with cough, headaches and malaise. He has a temperature of 38 °C. His blood count, renal and liver functions are normal. Cold agglutinins are positive. A chest X-ray shows bi-basal shadowing. What is the most likely diagnosis?
    A. Legionella pneumonia
    B. Viral pneumonia
    C. Q fever
    D. Klebsiella pneumonia Your answer

    E. Mycoplasma pneumonia Correct answer

    Mycoplasma pneumonia is a common cause of pneumonia often occurring in young people. It is characterised by headaches, malaise and cough. Chest X-ray findings may not correlate with the patient’s condition. The white blood count may be normal and cold agglutinins occur in half of the patients. Extrapulmonary complications are pericarditis, myocarditis, erythema multiforme, vomiting, diarrhoea and meningoencephalitis.

    35- Nitric oxide is derived from
    A. Cyclic GMP
    B. Endothelium-derived relaxing factor
    C. GTN Your answer

    D. l-Arginine Correct answer

    E. Nitrous oxide
    Nitric oxide (NO), which used to be known as ‘endothelium-derived relaxing factor’, is a local cellular messenger. It is derived from l-arginine (an amino acid) by nitric oxide synthase. Its actions increase the levels of intracellular cGMP (cyclic guanosine monophosphate), which has effects depending on which cell it is acting upon. These include modulation of vascular tone (hence the therapeutic use of glyceryl trinitrate, a synthetic compound) and memory. NO has also been implicated in septic shock, adult respiratory distress syndrome (ARDS) and inflammation. Nitrous oxide, also known as ‘laughing gas’, is often used in obstetrics and trauma for pain relief.

    36- A 20-year-old woman presents with gradually reducing vision in her left eye of two weeks’ duration. Visual acuity is 6/4 (right eye) and 6/36 (left eye). The left pupil reacts sluggishly and the consensual pupillary reaction in the right eye is also sluggish. Optic discs are normal. What is the most likely diagnosis?
    A. Cerebral tumour
    B. Holmes–Adie pupil
    C. Factitious visual loss
    D. Parinaud’s syndrome Your answer

    E. Retrobulbar neuritis Correct answer

    As the optic discs appear normal, and given the transient nature of her previous symptoms occurring during exams, it may be tempting to pass off the alleged blurring as factitious. However, in retrobulbar neuritis it is said that ‘the patient sees nothing and the doctor sees nothing’. As the inflammation is behind the optic nerve head (hence retrobulbar), as opposed to optic neuritis, the optic nerve head or optic disc appears normal. Optic nerve function, however, is affected in the same way in patients with optic and retrobulbar neuritis. Thus visual acuity will be reduced to a very variable degree, and an afferent pupillary defect will be apparent during the ‘swinging flashlight test’. Colour vision will be reduced to a greater extent than might be predicted from visual acuity. Red desaturation – ie when red looks paler to one eye than the other – is a sensitive sign of optic nerve dysfunction. Visual field defects will occur (typically a central scotoma, but the type of defect varies). Retrobulbar neuritis has the same systemic implications as optic neuritis, in that an episode of optic or retrobulbar neuritis can contribute to a diagnosis of multiple sclerosis, if other neurological episodes separated in time and site occur. Holmes–Adie pupil is an idiopathic condition, typically affecting young women, presenting with an enlarged pupil that is poorly reactive to light and accommodation. Absent ankle jerks are a frequent association. A Holmes–Adie pupil causes no harm, except blurring vision when reading in some patients. Parinaud’s syndrome is due to a lesion in the dorsal mid-brain, and causes a variety of signs, including mid-dilated pupils, upper lid retraction and paralysis of upward gaze.

    37- A 24-year-old man is admitted to the psychiatric ward from home, where he lives alone. His neighbours have been increasingly concerned about rubbish piling up inside his flat and sometimes he isn’t seen for days. His family tell you that over the last year he has become very odd and isolated. On examination, he is withdrawn and quiet and you find it difficult to understand his answers as he frequently wanders off the point, as if he is answering a different question. Although spontaneous movements are reduced, there are no neurological signs and he is not on any medication, prescribed or illicit. His mother and two older brothers have both had episodes of major depression. Are there any features that suggest a favourable outcome from this episode?
    A. Young age
    B. Insidious onset Your answer

    C. No favourable features
    D. Quiet speech
    E. Family history of depression Correct answer

    This man has schizophrenia with mainly ‘negative’ symptomatology, ie asocial, reduced spontaneous movements, likely disorganised behaviour given the state of his flat and his speech is disorganised reflecting an underlying formal thought disorder. The ‘positive’ symptoms of delusions and hallucinations are absent. The following are recognised features that predict a poor outcome – young age, insidious onset, poor premorbid social function, negative symptomatology, neurological signs, no recognised precipitating factor, family history of schizophrenia. A good outcome is associated with older age, acute onset, recognisable precipitant, good premorbid social function, being married, prominent mood disorder, family history of mood disorder, positive symptomatology. The overall prevalence of schizophrenia is 1% in all populations. Between 10 and 20% of patients will make a full recovery from one episode.

    38- Which of the following is not a cause of onycholysis?
    A. Trauma
    B. Psoriasis
    C. Porphyria Your answer

    D. Thyrotoxicosis
    E. Mycoplasma pneumonia Correct answer

    Onycholysis is the separation of the distal edge of the nail from the vascular nailbed causing whiteness of the free edge. Mycoplasma pneumonia is not a recognised cause. Other causes are tetracycline and psoralens.

    39- A 17-year-old, non-pregnant, asymptomatic woman with no past medical history is found to have 106 colony-forming units of Escherichia coli/ml urine on a routine health-check. What is the most appropriate management?
    A. Treat with oral co-trimoxazole for 10 days
    B. Treat with a single dose of oral trimethroprim
    C. Investigate her renal tract Your answer

    D. Treat with an intravenous antibiotic
    E. No antibiotics are indicated Correct answer

    This young female has asymptomatic but significant bacteruria. This is common (approximately 3% of non-pregnant females) and does not require treatment as there is no risk of morbidity or mortality. In fact, treatment of asymptomatic bacteruria in a young person may increase the frequency of symptomatic infections. However, treatment is required if there are co-morbid factors – eg diabetes, renal transplantation, invasive GU investigations or a renal stone. Pregnancy is an absolute indication to treat asymptomatic bacteruria because of the increased risk of pyelonephritis (30%), pre-eclampsia, prematurity and perinatal death. In pregnant patients, a single dose of trimethroprim is as effective as the other antibiotic options mentioned in the question. A single finding of asymptomatic bacteruria is not an indication for renal tract investigation.

    40- Which of the following is a feature of MEN-1?
    A. Marfanoid features
    B. Phaeochromocytoma
    C. Medullary carcinoma of the thyroid Your answer

    D. Parathyroid hyperplasia Correct answer

    E. Mucosal neuromas
    MEN-1 (multiple endocrine neoplasia type-1; Werner’s syndrome) involves the three P’s: parathyroid, pituitary, pancreas.
    Parathyroid Hyperparathyroidism is the most common manifestation in MEN-1
    Pituitary Prolactinomas are most common in the pituitary gland
    Pancreas Second most common involvement in MEN-1. Pancreatic tumours are associated with:
    (a) pancreatic polypeptide (75–85%)
    (b) gastrin (Zollinger–Ellison syndrome) – recurrent peptic ulcers
    (c) insulinoma – hypoglycaemia
    (d) glucagonoma – hyperglycaemia and skin rash (necrolytic migratory erythema)
    (e) VIPoma (vasoactive intestinal polypeptide-secreting tumour) – Verner–Morrison syndrome or watery diarrhoea hypokalaemia achlorhydria (WDHA syndrome)
    MEN-2 usually involves the thyroid and parathyroid glands and phaeochromocytoma. The mode of inheritance in MEN-1 is autosomal-dominant. MEN-2A is characterised by medullary thyroid carcinoma, parathyroid hyperplasia/adenoma and phaeochromocytoma. In addition, MEN-2B (Sipple’s syndrome) has mucosal and gastrointestinal (GI) neuromas and marfanoid features.

    41- A 32-year-old man is seen in the casualty department complaining of breathlessness, which has gradually worsened over the last weeks following an emergency appendicectomy. He received no blood products at the time of operation. He has not noticed any frank blood loss. Currently, he is taking prn diclofenac for postoperative pain relief. This man has a past history of recurrent deep vein thromboses, the last of which was complicated by a pulmonary embolism two years ago. He declined long-term anticoagulation. A full blood count shows:
    Hb 8.8 g/dl; MCV 89 fl; platelets 105 × 103/mm3; WCC 6.3 × 103/mm3
    and urinalysis shows the presence of haemosiderin. Which investigation is most reliably diagnostic?
    A. Bone marrow trephine
    B. Blood immunophenotyping Correct answer

    C. Coombs’ test Your answer

    D. Acid lysis test
    E. Serum haptoglobin
    This young man, with a history of thrombotic events, is likely to be acutely anaemic from his symptomatology and evidence of intravascular haemolysis (haemoglobin released in the plasma is excreted in the urine as haemosiderin) with a slightly reduced platelet count. This has occurred after an infective and traumatic event, ie the removal of an inflamed appendix, and is a characteristic presentation of paroxysmal nocturnal haemoglobinuria (PNH) caused by a red cell membrane defect that renders the cell more liable to complement-mediated lysis. (Affected cells do not express GPI (glycosylphosphatidylinositol) which anchors the decay-accelerating factor (DAF) and membrane inhibitor of reactive lysis (MIRL), both of which help to degrade complement proteins.) Serum haptoglobins are low, but this is non-specific for intravascular lysis, a bone marrow trephine may show reduced cellularity and the acid lysis, or Ham’s test, which can demonstrate greater complement susceptibility, is not always positive over the course of the disease. Immunophenotyping will demonstrate the absence of expression of the CD 59 antigen (GPI protein) due to the abnormal red cell clone. A significant proportion of patients with PNH goes on to develop aplastic anaemia or acute leukaemia.

    42- A 55-year-old woman known to suffer from primary biliary cirrhosis complains of a rash over her wrists and ankles. She also mentions that purplish lesions develop wherever she scratches herself. She has recently seen her gastroenterologist who has told her to continue taking colestyramine. Examination shows purplish, polygonal, flat-topped papules on her wrists and ankles. She also has fine, white lacy papules in her mouth. What is the diagnosis?
    A. Pityriasis rosea
    B. Scabies
    C. Lichen planus Correct answer

    D. Drug reaction
    E. Candidiasis
    Lichen planus is characterised by an itchy, purplish, polygonal, flat-topped rash developing over the wrists and ankles. A lacy fine network of papules develops in over 60% of the patients. It is commonly seen in patients with autoimmune chronic liver disease such as primary biliary cirrhosis and chronic active hepatitis. The presence of Wickham’s striae – a fine, white lacy pattern, over the papules helps in diagnosis. It usually resolves in 12–18 months. Patients with widespread disease and intractable itch may require oral prednisolone.

    43- An 18-year-old woman is referred to the haematology out-patients department by the gynaecologists who can’t find a structural or hormonal cause for her severe menorrhagia. Clinical examination is unremarkable apart from her pallor, and she is on no medication. A full blood count shows:
    Hb 8.4 g/l; MCV 71 fl; RDW 21%; WCC 7.2 × 103/mm3; platelets 501 × 103/mm3.
    Her liver function and renal function are normal, as is her prothrombin time. Which is the most useful investigation to perform next?
    A. Factor VIII:C level
    B. Bone marrow aspirate
    C. Serum ferritin Your answer

    D. Activated partial thromboplastin time
    E. von Willebrand factor level Correct answer

    This young woman most likely has an iron deficiency anaemia and reactive thrombocytosis. Her prothrombin time is normal, so an acquired coagulation disorder is unlikely as they typically affect both the prothrombin time (PT) and activated partial thromboplastin time (APTT). With a normal platelet count (hence a bone marrow differential is less helpful) the defect either lies in the level of factors that affect the APTT or in platelet function. Platelet dysfunction is more commonly acquired due to renal or liver disease, drugs and myeloproliferative disease. Inherited causes include Glanzmann’s thrombaesthenia (lack of glycoprotein (gp) IIb/IIIa expression) and Bernard–Soulier syndrome (lack of binding to intact von Willebrand factor (vWF) ). von Willebrand’s disease (vWD) causes reduced platelet function (as vWF mediates platelet binding to exposed subendothelial cells) as well as a reduced factor VIII:C level as vWF also stabilises factor VIII. Haemophilia A causes a reduced circulating level of factor VIII:C due to the reduced production of factor VIII. Hence the APTT will be prolonged in both these conditions and will not differentiate von Willebrand’s disease from a coagulation-factor deficiency. Furthermore, severe menorrhagia is a typical presentation of vWD as it reflects the reduced platelet function exacerbating mucosal bleeding.

    44- Which statement best describes a crossover trial?
    A. Drugs with long-term effects are typically used
    B. Each patient receives only one drug
    C. Each patient will usually receive all drugs within the study Correct answer

    D. Patients are always blinded to which drug they are receiving
    E. Self-limiting illnesses are easily studied
    In a crossover trial, the patient (who usually has a chronic stable disease) receives one drug (or placebo) and after a washout period, the other. In this way, confounding can be greatly reduced. If a drug had long-lasting effects it may not be easy to see which of the trial drugs was having an effect. A self-limiting illness is difficult to study in this way.

    45- A 30-year-old man gives a history of recurrent bullous eruption on his hands, forearms and trunk whenever he is on holiday, and mentions that these lesions develop whenever he visits sunny places. He has numerous scars on his hands, forearms and chest wall. He is a fit man and works as an interior decorator. He drinks alcohol in moderation. He is single and usually holidays with his friends. What is the diagnosis?
    A. Sunburn
    B. Porphyria cutanea tarda Correct answer

    C. Pemphigous
    D. Pemphigoid
    E. Polymorphic light eruption
    Porphyria cutanea tarda presents with bullous eruptions on exposure to sunlight. The eruptions heal with scarring. Alcohol is the aetiological agent. Diagnosis depends on the presence of increased levels of urinary uroporphyrin. Remission can be induced by venesection. Chloroquine promotes the urinary excretion of uroporphyrin.

    46- A 35-year-old man attends the haematology clinic having found a lump in his neck. He feels generally unwell but has no past history. There is axillary lymphadenopathy and splenomegaly. FBC shows:
    WCC 16 × 103/mm3; Hb 8.3 g/dl; platelets 106 × 103/mm3
    and the blood film and bone marrow aspirate show lymphoblasts. What is the most useful test to make a definitive diagnosis?
    A. Cytogenetic analysis
    B. Lymph node biopsy
    C. Total-body computed tomography (CT) scan Your answer

    D. Total-body positron-emission tomography (PET) scan
    E. Immunophenotyping Correct answer

    Differentiating acute lymphoblastic leukaemias is most simply achieved with immunophenotyping. B-cell lineage leukaemias are all CD10- and CD19-positive, whereas T-cell lineage cells are CD7- and TdT (terminal deoxynucleotidyl transferase) -positive (although pre-B cells are TdT+ve, but if more mature B cells are present they are TdT–ve). Cytogenetic analysis is more useful in differentiating myeloid leukaemias and in myelodysplastic syndrome. Staging and disease progression can be monitored radiologically.

    47- A 25-year-old man presents in the casualty department with a two-day history of a painful and swollen left knee. He is pyrexial with a temperature of 38.5 °C. Examination of his cardiovascular and respiratory system is normal. An abdominal examination is normal. He also mentions that he developed a painful right ear and saw his doctor five days ago who told him he had an infected ear and prescribed antibiotics. His left knee is swollen, red, tender and slightly flexed. A diagnosis of septic arthritis is made. What is the most likely causative organism?
    A. Streptococcus viridans
    B. Staphylococcus epidermidis Your answer

    C. Staphylococcus aureus Correct answer

    D. Escherichia coli
    E. Neisseria meningitides
    Septic arthritis results from infection of the joints with pyogenic organisms, of which Staphylococcus aureus is the commonest. Other organisms responsible are streptococci, Neisseria spp. and Gram-negative bacilli. The organisms reach the joint via the bloodstream, sometimes from known sites of infection such as boils or otitis media. Less commonly, it may spread from osteomyelitis adjacent to the joint or it may be introduced into the joint as a result of trauma. The patient complains of a single painful joint, which appears red, warm and swollen. Aspirating the joint and examining and culturing the fluid should establish diagnosis. Treatment should be started immediately with appropriate antibiotics as delays can result in destruction of the cartilage. The joint should be immobilised. The joint should be drained by needle aspiration. Inaccessible joints such as the hip may require surgical drainage.

    48- A 35-year-old woman complains of a painful rash on her legs. She also gives a three-month history of dyspnoea on exertion. Her doctor arranged for her to have a chest X-ray and this shows bilateral hilar prominence. Examination of her legs reveals a purplish-red, maculopapular tender rash on her shins. Apart from few bi-basal crepitations on auscultation, systemic examination is normal. A pulmonary function test shows a mildly impaired DLCO. Which one of the following is the best investigation?
    A. Bronchoscopy
    B. High-resolution CT scan of the thorax Correct answer

    C. Open lung biopsy Your answer

    D. Kveim test
    E. Serum ACE level
    This woman has erythema nodosum and bilateral hilar lymphadenopathy. She has sarcoidosis (Löffgren’s syndrome). This has a good prognosis. However, the diagnosis is clinical as she has dyspnoea and impaired diffusion in the lung of carbon monoxide (DLCO), a high-resolution lung scan will establish the diagnosis.

    49- A 73-year-old man with advanced Parkinson’s disease is being treated on the ward for a urinary tract infection. His regular medication includes co-careldopa, entacapone, cabergoline, and prn subcutaneous apomorphine injections. His wife tells you that for the last month his behaviour has changed and he has become agitated, disinhibited and he keeps asking her for money. His dyskinesia has also become more pronounced over this period. On examination, he is distractable. He denies having hallucinations and, after probing questioning, you can find no evidence of delusional thought. Mood assessment shows him to be cheerful and there are no cognitive or biological features of depression. What is the likely physiological cause of the behavioural change?
    A. Reduced breakdown of dopamine
    B. Change in sensitivity to dopamine
    C. Confusional state due to urosepsis Your answer

    D. Direct dopamine agonism Correct answer

    E. Coexisting dementia
    Neuropsychiatric complications of Parkinson’s disease (PD) are common – experienced by some 70% of all patients. Hedonistic dysregulation is being increasingly recognised; here patients typically take increasing amounts of a dopamine agonist even though it worsens their dyskinesia (usually apomorphine is abused in this way). This results in euphoria, hypersexuality and gambling. There is an extensive body of research literature on dopamine reward pathways (from the ventral tegmental area to the nucleus accumbens) as the mediator of motivation and possibly drug addiction. The commonest psychiatric complication, however, is depression (50%, associated with a younger onset, female gender), anxiety (40%), psychosis (40%, visual hallucinations and persecutory delusions, often drug related) and dementia (20–40% associated with an older onset PD, severe extrapyramidal features).

    50- A 25-year-old pregnant woman complains she has had painful nodules on her shins for over 2 weeks. She suffers from asthma, which is well controlled and is 32 weeks’ pregnant. Examination shows painful nodules over her shins. What is the most likely diagnosis?
    A. Erythema multiforme
    B. Erythema nodosum Correct answer

    C. Cellulitis
    D. Granuloma annulare Your answer

    E. Drug eruption
    Erythema nodosum is an acute panniculitis that produces painful nodules or plaques on the shin. It is commonly seen in sarcoidosis, inflammatory bowel diseases, streptococcal infections, tuberculosis, sulphonamide treatment and may be seen during pregnancy.

    51- A 56-year-old man with polycythaemia vera is admitted with acute abdominal pain, nausea, vomiting and abdominal distension. He is apyrexial with tender hepatomegaly and ascites; an ascitic tap reveals a high protein content and no organisms. What is the most likely diagnosis?
    A. Spontaneous bacterial peritonitis
    B. Budd–Chiari syndrome Correct answer

    C. Veno-occlusive disease Your answer

    D. Malignant liver disease
    E. Haemochromatosis
    Budd–Chiari syndrome occurs following obstruction to the venous outflow of the liver due to occlusion of the hepatic vein. In one-third of the patients the cause is unknown. Patients with hypercoagulable states, such as polycythaemia vera or leukaemia, and women on the contraceptive pill are at risk. The acute form presents with abdominal pain, nausea, vomiting, tender hepatomegaly and ascites. Liver histology shows centrilobular congestion with hepatocyte atrophy. The chronic form presents with hepatomegaly, mild jaundice, ascites and splenomegaly with portal hypertension.

    52- A 16-year-old man presents with difficulty in walking and foot drop. There is weakness of dorsiflexion and eversion of the right foot, with a small area of sensory loss over the dorsum of that foot. What is the most likely diagnosis?
    A. Posterior tibial nerve lesion
    B. Sciatic nerve lesion Your answer

    C. L5 root lesion
    D. Common peroneal nerve lesion Correct answer

    E. Deep peroneal nerve lesion
    The common peroneal (L5, S1) nerve arises from the division of the sciatic nerve in the popliteal fossa. It passes close to the head of the fibula and can be damaged by pressure in this area. It divides into a superficial and a deep branch. The deep peroneal nerve supplies the tibialis anterior, extensor hallucis longus and extensor digitorum longus muscles, which dorsiflex the foot and toes. The superficial nerve supplies the peroneus longus and brevis muscles, which evert the foot. Damage to the posterior tibial nerve produces weakness of planter flexion and inversion of the foot.

    53- A 43-year-old man with a past history of hypothyroidism complains he has had pain and stiffness in the joints of his hand and feet for three months. He also gives a history of dyspnoea of that started six weeks ago. Examination shows swollen hand joints and signs of a right pleural effusion. A diagnosis of rheumatoid arthritis is made. Which one of the following is characteristic of a rheumatoid pleural effusion?
    A. It is a transudate
    B. It has a low glucose level Correct answer

    C. Long-standing rheumatoid effusions have low cholesterol levels Your answer

    D. It has a high pH
    E. It should be treated by decortication
    Up to 5% of patients with rheumatoid arthritis develop pleural effusions at some stage. Pleural effusions are more common in men. These are exudates and typically have a low pH (< 7.2), a high lactic acid dehydrogenase (LDH) level and a low glucose level. Rheumatoid arthritis is unlikely to be the cause of an effusion if the glucose level in the fluid is above 1.6 mmol/l. Large amounts of cholesterol can accumulate in long-standing rheumatoid pleural effusions. Patients should initially be treated with non-steroidal anti-inflammatory drugs (NSAIDs). Decortication should be considered in patients with thickened pleura who are symptomatic with dyspnoea.

    54- A 58-year-old woman is admitted to hospital with a history of general muscle weakness of 12 months’ duration. She also gives a history of pain in the small joints of her hand of over 18 months’ duration. In addition, there is a history of difficulty in swallowing. Examination is normal excep
  33. Guest

    Guest Guest

    Dear Dr. Sohail
    First let me congratulate u on clearing part one and I hope I will be
    passing as well in May Inshaallah.
    Can u kindly send me the Qs please on my e-mail address? if u have
    any tips on how to pass pleeeeeeeeease let me know I'm currently
    studying
    form Karla, plus doing Qs from eMRCP.com amd Medical Masterclass, I
    have also 123 doc folder which I'm going to revise as well I'm planning
    to
    subscribe to Pastest a week before the exam.
    do u reckon this is enough to get me a pass mark?

    Regards
    Dr. Fatheya Al-khaja
    fathiaak3030@yahoo.co.uk
    P.S: I've tried to mail u on ur yahoo address but with no luck. :roll:
  34. Guest

    Guest Guest

    very useful posting.
    thanks
  35. hinkalcity22

    hinkalcity22 Guest

    mrcpi

    can anyone please guide how to prepare for MRCPI Clinicals. i am very anxious.
    thanks
  36. Guest

    Guest Guest

    Request for Questions

    Dear Dr. Mrs Sohail
    first i congratulate u on yr success & i request u to send me all yr MCQs and some tips.I shall b very thankfull to u. My email is
    sohail786_pakistan@yahoo.com
  37. Guest

    Guest Guest

    neither Carbamzepine nor lemotigrine causes pancreatitis so far I am concerned
  38. Guest

    Guest Guest

    avascular necrosis of the bone is a complication of long term steroid use....if this appears in the exam you got to find out the exogenous source of seroid.
  39. Guest

    Guest Guest

    karla and oxford hand book for medicine is fine....harisson is lovely.....beside if you wanna pass solve questions as much as you can....solving Qs alwau=ys freshen your knowledge
  40. Guest

    Guest Guest

    YC first post in this topic
    In my knowledge the true answer is chemotherapy

    http://www.nlm.nih.gov/medlineplus/ency/article/000122.htm
  41. Guest

    Guest Guest

    Thaaaaaaaaaaaaaaaanks for the valuable questions... :wink:
    I guess that I'll start studying them right now... :D
  42. Vinod29

    Vinod29 Guest

    Revision for part I and II

    I think that the new book MRCP II saved my life as it contained all the facts and inspired me in my revision.

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