Elzohry MRCP Questions - ReviseMRCP

1- Ptosis of the upper eyelid on the affected side 2- Inability to laterally deviate the eye on that side 3- The eye is deviated downwards and medially at rest 4- A light shone into the

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Part 1

Khalid Yusuf El-Zohry Sohag Teaching Hospital - Egypt

elzohryxp@yahoo.com https://www.facebook.com/elzohryxp

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Contents

ةمدقم 9

Reference ranges 10

ReviseMRCP 13

[ Q: 1 ] ReviseMRCP - Basic Science 15

[ Q: 376 ] ReviseMRCP - Cardiology 113

[ Q: 574 ] ReviseMRCP - Dermatology 175

[ Q: 692 ] ReviseMRCP - Endocrinology 213

[ Q: 866 ] ReviseMRCP - Gastroenterology 271

[ Q: 1026 ] ReviseMRCP - Haematology 325

[ Q: 1180 ] ReviseMRCP - Nephrology 377

[ Q: 1298 ] ReviseMRCP - Neurology 419

[ Q: 1468 ] ReviseMRCP - Ophthalmology 479

[ Q: 1518 ] ReviseMRCP - Pharmacology 495

[ Q: 1624 ] ReviseMRCP - Psychiatry 523

[ Q: 1736 ] ReviseMRCP - Respiratory 557

[ Q: 1894 ] ReviseMRCP - Rheumatology 607

[ Q: 2152 ] ReviseMRCP - Statistics 685

[ Q: 2209 ] ReviseMRCP - Tropical medicine 703

[ Q: 2331 ] ReviseMRCP - 2010 September 749

[ Q: 2515 ] ReviseMRCP - 2011 January 790

[ Q: 2702 ] ReviseMRCP - 2011 May 833

[ Q: 3255 ] ReviseMRCP - 2012 May 959

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Take the first step , and your mind will

mobilize all its forces to your aid

But

The first essential is that you begin

Once the battle is startled, all that is within and without you will come to your assistance

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ا ددد اقددد ددد ق ذه جدددح لقدددنأ لددددمث دددحل ددددمحلا

دددمعلا ،

، دددح دددل ددد ددد م دنهنددديف ذه جددد مته

ذه

ددددم دددد ل ددددى دددم ،جل ددددعت ددددىلل تددددلل دددحعجف نمحددديملا ق ددديل تقدددا دددل ت ددددل ء ددد م دنهنددديف

نغلا ق ظء قدددنأ لا دددجت دددم لقدددنأ اًدهنددداا ددددقل دددم قدددنأ لا

ا ددد قددد دددم جلددد ذ ددددء ،ت ،ددددص ا ددد ء دددمعلا

لدددللا ددد هلا ق ددد لا ددد ددد ل دددى ه ذه ددددء ا دددل ،

ا معلا

قدددنأ لا اًاقددد دددم دنهنددداه ذه مدددحملا ا ددد ددد يدددل ث دددنتقنلا دددمجلا ددد ذ ددد مجلددد جم ددد ،تلمودددلا دددم لدددف ت ددديث ذاودددنم ددد ذلددد ف ذه جددد مته ،أندددي نلا

.ةم نقلا

مق ولا مالف دل /ج

منحعنلا لا جه نيم –

لا

-

قلم

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اريثك مهنم تدفتساو تملعت نيذلاو يتذتاسأو يئلامز

ديسلا ضاير د ضاير Riyadh Shalabi يملح ريشب د

سواه كلاب د Black House

Ayman Shahin

د

Heba Mohammed

د

Ậquắ Ḿariŋê

د

Faisal Hemeda د

Reem Ali

د

Aburas Ab

د Shiny Moon

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Reference ranges

Reference ranges vary according to individual labs

All values are for adults unless otherwise stated

Full blood count

Haemoglobin Men: 13.5-18 g/dl

Women: 11.5-16 g/dl

Mean cell volume 82-100 fl

Platelets 150-400 x 109/l

White blood cells 4-11 x 109/l|

Urea and electrolytes

Alanine transferase (ALT) 3-40 iu/l

Aspartate transaminase (AST) 3-30 iu/l

Alkaline phosphatase (ALP) 30-100 umol/l

Gamma glutamyl transferase (yGT) 8-60 u/l

Prothrombin time (PT) 10-14 secs

Activated partial thromboplastin time (APTT)

25-35 secs

Ferritin 20-230 ng/ml

Vitamin B12 200-900 ng/l Folate 3.0 nmol/l

Reticulocytes 0.5-1.5%

Other biochemistry Calcium 2.1-2.6 mmol/l Phosphate 0.8-1.4 mmol/l CRP < 10 mg/l

Thyroid stimulating hormone (TSH) 0.5-5.5 mu/l

Free thyroxine (T4) 9-18 pmol/l Total thyroxine (T4) 70-140 nmol/l Amylase 70-300 u/l

Uric acid 0.18-0.48 mmol/l

Arterial blood gases

pH 7.35 - 7.45 pCO2 4.5 - 6.0 kPa

pO2 10 - 14 kPa Lipids

Desirable lipid values depend on other risk factors for cardiovascular disease, below is just a guide:

Total cholesterol < 5 mmol/l Triglycerides < 2 mmol/l HDL cholesterol > 1 mmol/l LDL cholesterol < 3 mmol/l

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[ Q: 1 ] ReviseMRCP - Basic Science

Which organ is anterior to the left

kidney and is not separated by visceral

peritoneum?

1- Left adrenal gland

2- Left psoas muscle

3- Large Intestin

4- Spleen

5- Tail of the pancreas

Answer & Comments

Answer: 5- Tail of the pancreas

The splenorenal ligament contains the tail of

the pancreas and contacts with the left

kidney

A patient with gallstones develops

pain on the tip of his right shoulder

Which nerve is responsible for the pain?

Answer & Comments

Answer: 2- Right phrenic nerve

The phrenic nerve suuplies the diaphragm but

its irritation results in referred pain to the

shoulder This is because the supraclavicular

nerves, which cover the shoulder, have the

same nerve origins (C3,4,5)

Which area of the colon is most

susceptible to mesenteric ischaemia?

Answer & Comments

Answer: 5- Splenic flexure

The splenic flexure is a watershed area where the blood supply to the colon changes from the superior mesenteric to the inferior mesenteric artery and at this point there is little collateral supply and therefore it is highly susceptible to ischaemia

Which of the following suggests damage to the oculomotor nerve (CNIII)?

1- Ptosis of the upper eyelid on the affected side

2- Inability to laterally deviate the eye on that side

3- The eye is deviated downwards and medially at rest

4- A light shone into the affected eye does not produce constriction of the opposite pupil

5- Constricted pupil on the affected side

Answer & Comments

Answer: 1- Ptosis of the upper eyelid on the

affected side The oculomotor nerve supplies the levator palpebrae superioris

What would you expect on examination of a patient with paralysis of the deltoid?

1- Anaesthesia over the biceps brachii of the affected side

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2- Weakness of abduction when the shoulder

is internally rotated

3- Concurrent weakness of the brachioradialis

4- Drooping of the shoulder on the affected

side

5- The first 60 degrees of abduction is normal

due to the normal function of the

supraspinatus muscle

Answer & Comments

Answer: 2- Weakness of abduction when the

shoulder is internally rotated

The prime action of the deltiod is abduction of

the arm and this is strongest when the arm is

internally rotated The axillary nerve provides

motor innervation of the deltoid, teres minor

and long head of the tricep, and also sensory

innervation over the acromion and the long

head of the triceps Drooping of the shoulder

would be from trapesius paralysis, often from

accessory nerve (CNXI) damage The first 30

degrees of shoulder abduction is assisted by

the supraspinatus, but it is not always strong

enough to compensate fully

Which of the following may be an

early clinical presentation of an Acoustic

Neuroma?

1- Brisk Jaw Jerk

2- Bilateral Facial Weakness

3- Unilateral Conductive Hearing Loss

4- Unilateral wasting of Tongue and deviation

to one side

5- Reduced or Absent Corneal Reflex

Answer & Comments

Answer: 5- Reduced or Absent Corneal Reflex

Acoustic Neuroma is the most common

cerebellopontine angle tumour which

compresses cranial nerve VII The efferent

limb of the corneal reflex is part of the facial nerve and therefore this reflex can be reduced

or absent in acoustic neuroma and may be evident before facial numbness A brisk jaw jerk would be due an UMN lesion of CNV

In regards to the coronary arteries,

which of the following is correct:

1- The posterior interventricular artery is a branch of the circumflex artery

2- There is a lot of cross over circulation between the right and left coronary arteries

3- The circumflex artery is a branch of the right coronary artery

4- The anterior interventricular artery arises above the left posterior aortic cusp

5- The anterior interventricular artery predominantly supplies the left ventricle

Answer & Comments

Answer: 5- The anterior interventricular artery

predominantly supplies the left ventricle

What is the most common entrance point for contagions to cause septic cavernous sinus thrombosis?

1- Parotid region of the cheek

2- Upper lip

3- Temple

4- Gums (gum disease)

5- Ear

Answer & Comments

Answer: 2- Upper lip

The cavernous sinus lies on surrounds the body of the sphenoid bone and receives blood from the facial veins (via the superior and

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inferior ophthalmic veins) as well as the

sphenoid and middle cerebral veins Infections

of the face including the nose, tonsils, and

orbits can spread easily by this route

Regarding the internal capsule,

which of the following is true:

1- The septum lucidum lies medial to the

posterior limb

2- The anterior limb of the internal capsule lies

between the head of the caudate nucleus

and the head of the lentiform nucleus

3- The junction of the thalamus and the

lenticular nucleus is termed the coronal

junction

4- The internal capsule arterial supply arises

from lenticulostriate vessels which come

off the middle and anterior cerebral

arteries

5- The lentiform nucleus itself comprises an

outer globus pallidus and an inner

amygdaloid body

Answer & Comments

Answer: 4- The internal capsule arterial supply

arises from lenticulostriate vessels which

come off the middle and anterior cerebral

arteries

"The internal capsule is a series of ascending

and descending axons in the brain that relay

information It is made up of an anterior limb,

between the head of the caudate nucleus and

the lentiform nucleus, and a posterior limb

between the latter and the thalamus."

Regarding the spinal cord, which of

the following is true:

1- The spinal cord commonly terminates at

the disc space between L1 and L2, although

it can extend to L3 in some

2- The average spinal cord length is 14 inches (36 cm)

3- The dural sac in the adult extends through the whole length of the sacral canal

4- The spinal cord occupies the full length of the dural sac at birth

5- The extradural space is empty

Answer & Comments

Answer: 1- The spinal cord commonly

terminates at the disc space between L1 and L2, although it can extend to L3 in some The spinal cord adults is 18 inches (45 cm) in length In the newborn it terminates at L3 The extradural space contains fat and vertebral veins

During surgical exploration of the floor of the mouth, the hypoglossal (XII) nerve

is damaged

What is the likely outcome?

1- Sensation for the posterior one third of the tongue is lost

2- The intrinsic muscles of the tongues left side are paralysed

3- The tongue deviates towards the right when it is protruded

4- The uvula deviates towards the left

5- The palatoglossus muscle is paralysed

Answer & Comments

Answer: 2- The intrinsic muscles of the

tongues left side are paralysed The muscular of the tongue is innervated by the hypoglossal nerve, and the hypoglossal nerve has no sensory component for the tongue The palatoglossus muscle is supplied

by the vagus nerve When the hypoglossal nerve is damaged, the tongue deviates to the side of the problem on protrusion

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Regarding the renal artery, which is

correct?

1- The suprarenal artery arises from the renal

artery

2- The aorta passes through the diaphragm at

the level of the eleventh thoracic vertebra

3- The right renal artery is longer than the left

4- They arise from the abdominal artery above

the superior mesenteric artery

5- The gonadal arteries arise above the origin

of the renal artery

Answer & Comments

Answer: 3- The right renal artery is longer than

the left

The origin of the right renal artery is further

from the kidney than the left The renal

arteries arise below the superior mesenteric

artery, the suprarenal arteries arise from the

aorta above the renal arteries and the gonadal

arteries also arise from the aorta at a level

below the renal arteries The aorta passes

through the diaphragm at T12

Bleeding from a posterior gastric

ulcer arise from which vessel?

1- Splenic artery

2- Left gastro omental artery

3- Inferior pancreaticoduodenal artery

4- Right gastro omental artery

5- short gastric artery

Answer & Comments

Answer: 1- Splenic artery

The splenic artery lies along the upper border

of the pancreas, which is directly posterior to

the stomach The left and right gastro omental

arteries supply the superior and inferior

portion of the greater curvature of the stomach respectively The fundus is supplied

by the short gastric and the inferior pancreaticoduodenal artery supplies the second part of the duodenum

Where would you find the azygous lobe on an antero posterior chest X ray ?

1- Left upper zone

2- Right lower zone

3- Right upper zone

4- Left middle zone

5- Left lower zone

Answer & Comments

Answer: 3- Right upper zone

The azygos lobe is a rare congenital malformation that would be found at the right upper zone It is of little clinical significance

A young man develops weakness of his right hand and describes an incident in which he grabbed onto a tree branch to brake

a fall when hiking He has normal range of movement at the shoulder, elbow and wrist but cannot use precision or power grip

What structure is likely to have been damaged?

1- The axillary nerve

2- The C7 nerve root

3- The radial nerve

4- The T1 nerve root

5- The ulnar nerve

Answer & Comments

Answer: 4- The T1 nerve root

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This man has Klumpkes paralysis in which

brachial plexus injury to C8 and/or T1 affects

the forearm and hand The most common

cause is difficult childbirth, although any

stretching of the arm may cause it It is

characterised by a claw hand, forearm

supination, hyperextension of the fingers and

weak grip

Which muscle is associated with

ulnar neuropathy?

1- Lateral lumbricals

2- Adductor pollicis

3- opponens pollicis

4- Flexor pollicis longus

5- Flexor pollicis brevis

Answer & Comments

Answer: 2- Adductor pollicis

The ulnar nerve supplies the hypothenar

muscles (opponens digiti minimi, abductor

digiti minimi, flexor digiti minimi), dorsal

interossei, the lateral lumbrical muscles,

palmar interossei and the adductor pollicis

A patient complains that her left foot

drags and she is often catching it on steps or

kerbs She has a high stepping gair and loss of

dorsiflexion on examination There is reduced

sensation over the foot and shin

What is the likely cause?

1- Tibial nerve injury

2- Femoral nerve injury

3- Common peroneal nerve injury

4- Stroke

5- L5 nerve lesion

Answer & Comments

Answer: 3- Common peroneal nerve injury

Peroneal injury is often caused by a mononeuritis, proximal tibial fractures, compartment syndrome, or a direct trauma Physiotherapy is the primary treatment

An elderly lady presents with problems performing simple tasks such as buttoning blouses or holding the phone She has wasting of the small muscles of the hand and partial clawing of the little and ring fingers

Which nerve is likely to be damaged?

Answer & Comments

Answer: 2- Ulnar nerve

The ulnar nerve passes through the wrist in the ulnar canal, also known as Guyons canal This is the most common site of a lesion compressing the ulnar nerve Compression is often the result of a ganglion or swelling after

a fracture

If the inferior (recurrent) laryngeal nerve is accidentally divided, what would be the result?

1- Nothing the superior branch can compensate

2- All the laryngeal muscles are paralysed on the affected side

3- During laryngoscopy, the affected cord is seen to lie close to the midline

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4- Only the cricothyroid muscle is paralysed

5- The larynx would be paralysed below the

vocal cord on the divided side

Answer & Comments

Answer: 5- The larynx would be paralysed

below the vocal cord on the divided side

The inferior (recurrent) laryngeal nerve

supplies the muscles of the larynx except the

cricothyroid muscle which is supplied by the

superior laryngeal nerve The

inferior/recurrent nerve supplies sensory

fibres to the larynx inferior to the vocal cords

The paralysed cord is seen to lie in the

An 80 year old man with a history of

stroke presents with a lower homonymous

quadrantanopia affecting the temporal side of

the right visual field and the nasal side of the

left visual field

Where is the lesion?

1- Optic chiasm

2- Right parietal lobe

3- Optic nerve

4- Left Occipital lobe

5- Left parietal lobe

Answer & Comments

Answer: 5- Left parietal lobe

Temporal lobe damage results in an upper

homonymous quadrantanopia Parietal lobe

damage results in a lower homonymous

quadrantanopia Bilateral occipital lobe

damage can cause cortical blindness, known

as

Which of the following would

indicate an ulnar nerve lesion?

1- Froments test shows a strong pinch grip

2- Anaesthesia of the 3 and a half digits on the ulnar side of the hand

3- Inability to abduct the little finger

4- The middle and index fingers are in a claw

5- Wasting of the thenar eminence

Answer & Comments

Answer: 3- Inability to abduct the little finger

The ulnar nerve provides sensation to the skin

of the little and the ulnar side of the ring finger The thenar muscles are supplied by the median nerve Froments test is when a patient holds paper between their thumb and index finger, and you attempt to pull it from them A weak grip, especially if there is flexion of the

IP joint of the thumb, suggests ulnar nerve palsy

Which of the following does not lead

to an increase in PSA level?

Which of the following would you

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expect to see on an ECG of a patient with

hypercalcaemia?

1- Prolonged QT interval

2- Shortened QT interval

3- Tall tented T waves

4- Left axis deviation

5- T wave inversion

Answer & Comments

Answer: 2- Shortened QT interval

A shortened QT interval would be seen on the

ECG of a patient with hypercalcaemia

A 62 year old gentleman with type 2

diabetes mellitus presents unwell with fever,

shortness of breath and a cough productive of

green sputum He is found to have a glucose

of 21 mmol/L and a sodium of 129 mmol/L He

is only on metformin normally His urine

osmolality is 350 mmol/Kg and urinary sodium

is 30 mmol/L He appears dehydrated

What is the most likely cause of his

Answer & Comments

Answer: 1- Osmotic diuresis

In patients with type 2 diabetes,

hyperglycaemia may occur due to acute stress

response or poor compliance The resultant

hyperglycaemia can lead to osmotic diuresis

which can lead to hyponatraemia Pneumonia

can also lead to SIADH however the

biochemistry results are not in keeping with

this

Which of the following is most likely

to lead to a metabolic alkalosis?

Answer & Comments

Answer: 2- Ectopic ACTH syndrome

In Cushings syndrome there is often excess mineralocorticoid action which can result in a hypokalaemia and metabolic alkalosis It is more common in ectopic ACTH secretion than

in other causes of cushings syndrome Addisons disease typically leads to a metabolic acidosis as it can cause hyperkalaemia

A 65 year old patient with chronic renal failure is discovered to have slightly low calcium levels His phosphate is high and PTH

is elevated

What is the most likely cause?

1- Reduced vitamin D absorption

2- Primary hyperparathyroidism

3- Hypoparathyroidism

4- Pseudohypoparathyroidism

5- Secondary Hyperparathyroidism

Answer & Comments

Answer: 5- Secondary Hyperparathyroidism

In CRF there is reduced hydroxylation of vitamin D which leads to hypocalcaemia This leads to an increased PTH and although normally this would lead to reduced phosphate there is reduced renal excretion of phosphate and therefore it is elevated In

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hypoparathyroidism there would be low PTH

In pseudohypoparathyroidism there is failure

to respond to PTH and this leads to elevated

PTH and low calcium however this presents

earlier and is not the likely cause in chronic

renal failure In primary hyperparathyroidism

there is elevated calcium

Which of the following increases

during the acute phase response?

1- Insulin growth factor 1

Which of the following would you not

expect to be raised in an acute phase

Which of the following is not an

5- Glucose uptake in skeletal muscles

Answer & Comments

Answer: 3- Glycogenolysis

All of the options are actions of insulin except glycogenolysis which is an action of insulin

Which of the following is not an action of glucagon?

Answer & Comments

Answer: 2- Amino acid uptake

All of the options are actions of glucagon except amino acid uptake for which glucagon does not play a role

Plasminogen activator inhibitor 1 is associated with which of the following?

Answer & Comments

Answer: 4- Insulin resistance

Plasminogen activator inhibitor 1 is found in increased levels in obesity and reduced in

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weight loss It is associated with insulin

resistance and the development of type 2

diabetes mellitus

Which substance plays an important

role in the relaxation of smooth muscle?

Answer & Comments

Answer: 4- Nitric oxide

Nitric oxide leads to the production of cGMP

which leads to vascular smooth muscle

relaxation It is produced in endothelial cells

under the action of nitric oxide synthase

Haemophilia B is caused by?

1- Factor VIII deficiency

2- Vitamin K deficiency

3- Factor XIII deficiency

4- Factor IX Deficiency

5- Protein S deficiency

Answer & Comments

Answer: 4- Factor IX Deficiency

Haemophilia B is due to a deficiency of factor

IX

A patient with known alcohol excess

presents with confusion, ataxia and

What is the function of protein C?

1- Inactivation of factor Xa

2- Inactivation of factor Va and VIIa

3- Inactivation of factor Va and VIIIa

4- Modification of factors II, VII, IX and X

5- Increased activation of factor Va and VIIIa

Answer & Comments

Answer: 3- Inactivation of factor Va and VIIIa

Protein C leads to the inactivation of factors

Va and VIIIa Vitamin K leads to the final modification of factors II, VII, IX and X LMWH interact with factor Xa

Which of the following is natriuretic?

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Answer & Comments

Answer: 4- ANP

Atrial natriuretic peptide (ANP) leads to

increased sodium excretion and water

excretion It is secreted from the atria when

there is increased stretch The rest all lead to

an increase in sodium and water absorption

What is the target of rheumatoid

factor?

1- Constant region of IgG

2- Constant region of IgM

3- Chondrocytes

4- Variable region of immunoglobulins

5- Collagen

Answer & Comments

Answer: 1- Constant region of IgG

Rheumatoid factor is directed at the constant

region of IgG

A patient presents recurrently with

swelling in the face, lips and tongue and

abdominal pain and diarrhoea Given the likely

diagnosis which deficiency is the cause?

Answer & Comments

Answer: 4- C1 esterase inhibitor

This patient is presenting with features of

hereditary angio oedema which is due to the

deficiency of C1 esterase inhibitor C1 esterase

inhibitor plays a role in inhibiting bradykinin and when this is unopposed bradykinin leads

to increased permeability of blood vessels and thus oedema

Which antibody is found in greatest proportion in mucosal tissues?

When would parenteral feeding be utilised over enteral feeding?

1- Prolonged time of nutritional support required

2- Dysphagia

3- High risk of aspiration

4- Dysfunctional small bowel

5- High risk of refeeding syndrome

Answer & Comments

Answer: 4- Dysfunctional small bowel

All of these options do not preclude the use of enteral feeding except small bowel dysfunction If the small bowel is dysfunctional then TPN should be utilised

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In obesity, which of the following is

the most likely to lead to increased mortality?

Answer & Comments

Answer: 4- Cardiovascular disease

Cardiovascular disease is greatly increased in

obesity and is one of the biggest causes of

mortality

Which of the following if taken at

toxic levels would lead to a respiratory

Hyperventilation occurs secondary to

salicylate poisoning and none of the other

options thus t us the most likely to lead to a

respiratory alkalosis

Which of the following is not a

common feature of acute salicylate poisoning?

Answer & Comments

Answer: 2- Hepatic dysfunction

Hepatic dysfunction is a rare feature of acute poisoning is more often seen in chronic overdose

In a patient with symptomatic acute iron poisoning who presents 4 hours post ingestion, how should they be managed?

be helpful Gastric lavage is only useful if the patient presents less than one hour after ingestion Whole bowel irrigation can be useful if there is still undissolved tablets and this can be checked via an xray

Which of the following is highly suggestive of ethylene glycol poisoning?

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Answer & Comments

Answer: 2- Hypocalcaemia

Ethylene glycol poisoning as well as leading to

a metabolic acidosis can also lead to profound

hypocalcaemia This is due to the glycolic acid

being metabolised to oxalic acid which binds

calcium

Which of the following is not a

treatment for carcinoid syndrome?

All of these options except cabergoline can be

used for treatment of carcinoid syndrome

except for cabergoline which is utilised in

acromegaly Octreotide is a useful first line

treatment It is a somatostatin analogue and is

good for symptom control

A patient is brought to A and E

drowsy and unwell He is known to have COPD

however appears septic in addition to this

Blood gases revealed elevated hydrogen ions

and elevated PCO2 and a low O2, bicarbonate

Answer & Comments

Answer: 3- Mixed metabolic and respiratory

acidosis

If there is evidence of a pH, elevated hydrogen ions with elevated PCO2 and low bicarbonate then this is a mixed acidosis In Respiratory acidosis with metabolic compensation you would expect to find high bicarbonate levels

In respiratory alkalosis you would expect to see a low CO2 The blood gases are not in keeping with either a respiratory acidosis or metabolic acidosis on their own

A 45 year old gentleman presents to his GP He has noticed on numerous occasions after prolonged sun exposure, blisters forming

on his hands, forearms and face On examination there is evidence of erosions and bullae on these areas of skin and hypertrichosis in the temporal and malar areas He does drink alcohol excessively

What is the most likely diagnosis?

1- Pemphigus vulgaris

2- Porphyria Cutanea Tarda

3- Acute intermittent porphyria

4- Epidermolysis Bullosa

5- Bullous pemphigoid

Answer & Comments

Answer: 2- Porphyria Cutanea Tarda

Porphyria cutanea tarda is the most likely diagnosis It leads to the signs and symptoms described and the finding of high urinary porphyrin levels confirm the diagnosis and urine can fluoresce under a wood lamp It has been associated with excessive alcohol intake Acute intermittent porphyria does not lead to

a photosensitive rash and patients can present

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with abdominal pain Bullous pemphigoid and

pemphigus vulgaris are not are not usually in

this distribution or related to light exposure

Which of the following drugs is not

known to be associated with hyperkalaemia?

Prednisolone is the only drug that is not

associated with hyperkalaemia

Spironolactone is an aldosterone antagonist

and is potassium sparing as aldosterone leads

to sodium reabsorption in exchange for

potassium excretion Ramipril blocks the

conversion of angiotensin I to angiotensin II

and thus reduces aldosterone Heparin also

leads to inhibition of aldosterone and thus can

be associated with hyperkalaemia NSAIDs can

lead to hyperkalaemia due to renal

dysfunction

A patient with hypertension is found

How should SIADH be managed initially?

Answer & Comments

Answer: 5- Fluid restriction

In hyponatraemia , sodium should not be corrected too quickly as it can lead to central pontine myelinolysis In the initial stages of management patient should be put on a 1.5l restriction If this fails and the patient is symptomatic then demeclocycline or double strength saline can be utilised

Which of the following suggests a diagnosis of SIADH?

1- Hypernatraemia, low plasma osmolality and increased urine osmolality

2- Hyponatraemia and increased plasma osmolality and low urine osmolality

3- Hyponatraemia and increased plasma osmolality

4- Hyponatraemia, low plasma osmolality and increased urine osmolality

5- Hyponatraemia and low plasma osmolality

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Answer & Comments

Answer: 4- Hyponatraemia, low plasma

osmolality and increased urine osmolality

In SIADH there is inappropriate secretion of

ADH This leads to inappropriate water

absorption and thus a low plasma osmolality,

with a urine that is more concentrated

compared to plasma There is also increased

urinary sodium excretion

A patient with type 1 diabetes

mellitus presents with fatigue, weight loss,

dizziness and nausea She has had numerous

hypoglycaemic events On examination she

appears tanned and there is evidence of a

postural drop in blood pressure

What is the most likely diagnosis?

1- Overzealous treatment of Diabetes

2- Hypopituitarism

3- Addisons disease

4- Poorly controlled diabetes

5- Cushings syndrome

Answer & Comments

Answer: 3- Addisons disease

This patient presents with signs and

symptoms of Addisons disease Addisons due

to reduced steroid production can lead to

hypoglycaemia and thus in type 1 diabetes

this may lead to reduced insulin requirements

and hypoglycaemic attacks Type 1 diabetes is

and autoimmune disease and thus the

development of Addisons can be associated

Impaired glucose tolerance requires

which of the following for diagnosis?

1- Fasting glucose of less than 7.0 mmol/L and

after glucose tolerance test a blood glucose

of between 7.8 mmol/L and 11.0 mmol/L

2- Fasting glucose of less than 7.0 mmol/L or after glucose tolerance test a blood glucose

3- Fasting glucose of less than 6.0 mmol/L and after glucose tolerance test a blood glucose

4- Fasting glucose of greater than 7mmol/L

5- Random glucose of greater than 11.1 mmol/L

Answer & Comments

Answer: 1- Fasting glucose of less than 7.0

mmol/L and after glucose tolerance test a blood glucose of between 7.8 mmol/L and 11.0 mmol/L

Impaired glucose tolerance must have the combination of fasting glucose of less than 7.0 mmol/L and after glucose tolerance test a blood glucose of between 7.8 mmol/L and 11.0 mmol/L for the diagnosis

Which of the following treatment is the initial treatment of choice for an obese patient with type 2 diabetes mellitus?

if the patient is normal or underweight as it can lead to weight gain Pioglitazone should

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be utilised in combination with another

hypoglycaemic agent

Which of the following

autoantibodies is found in type 1 diabetes

Answer & Comments

Answer: 2- Anti GAD

GAD autoantibodies which are directed

against islet cells can occur in type 1 diabetes

mellitus

Which of the following is most

indicative of type 1 diabetes mellitus rather

than type 2 diabetes mellitus?

Answer & Comments

Answer: 2- Weight loss

Weight loss is more suggestive of type 1 Type

2 diabetes mellitus due to rising rates of

obesity unfortunately is occurring in young

patients also Retinopathy and peripheral

neuropathy occur in both and bot have a

genetic link

If thyroid function tests are performed when a patient is pregnant in her first trimester, what would you expect to see?

1- Decrease T3 and T4 and increased TSH

2- Increase T3 and T4 and reduced TSH

3- Increased T3 and T4 and Increased TSH

4- No change

5- Decreased T3 and T4 and reduced TSH

Answer & Comments

Answer: 2- Increase T3 and T4 and reduced

TSH

In the first trimester there is increased levels

of bHCG which can be thyrotropic and stimulate T3 and T4 release which leads to a fall in TSH There is also an increase in thyroglobulin levels

Which of the following pairs shows the correct enzyme as the rate limiting step for the reaction?

1- Glycogen synthase : glycogenolysis

2- Carnitine acyl transferase : fatty acid oxidation

3- Glycogen phosphorylase : glycogenesis

4- Phosphofructokinase 1 : cholesterol synthesis

5- HMG CoA reductase : Glycolysis

Answer & Comments

Answer: 2- Carnitine acyl transferase : fatty

acid oxidation Carnitine acyl transferase is the rate limiting step for fatty acid beta oxidation The rate limiting step for glycogenesis is glycogen synthase and for glycogenolysis is glycogen phosphorylase The rate limiting step for cholesterol synthesis is HMG CoA reductase

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Which of the following does not lead

to an increase in gamma glutamyl

Clofibrate can lead to a decrease in GGT

levels The rest result in an increase

Which of the following is not a cause

of renal tubular acidosis type 4?

Hyperparathyroidism tends to cause renal

tubular acidosis type 1 SLE can lead to type 1

and type 4 renal tubular acidosis

PiZZ genotype is at increased risk of

Answer & Comments

Answer: 3- Alpha 1 antitrypsin

PiZZ genotype is associated with alpha 1 antitrypsin deficiency

In hypothyroidism, which biochemical test is most useful in the diagnosis and monitoring of treatment?

Which biochemical test is most helpful in differentiating chronic from acute renal failure?

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In chronic renal failure there is reduced

synthesis of calcitriol as there is reduced 1

hydroxylation This occurs over some time and

is not observed in acute renal failure

What are Bence Jones proteins?

1- Monoclonal heavy chains found in urine

2- Monoclonal heavy chains found in serum

3- Paraprotein band

4- Monoclonal light chains found in urine

5- Monoclonal light chains found in serum

Answer & Comments

Answer: 4- Monoclonal light chains found in

urine

Bence Jones are monoclonal light chains

(either kappa or lambda) which are excreted

in the urine There presence is utilised in the

diagnosis of multiple myeloma

Which of the following is consistent

with the diagnosis of Gilberts syndrome?

1- Increased unconjugated bilirubin, increased

conjugated bilirubin, raised urinary

urobilinogen

2- Increased unconjugated bilirubin, reduced

conjugated bilirubin, low urinary

urobilinogen

3- Increased conjugated bilirubin, reduced

unconjugated bilirubin, low urinary

urobilinogen

4- Increased conjugated bilirubin, reduced

unconjugated bilirubin, raised urinary

urobilinogen

5- Increased unconjugated bilirubin, reduced

conjugated bilirubin, raised urinary

urobilinogen

Answer & Comments

Answer: 2- Increased unconjugated bilirubin,

reduced conjugated bilirubin, low urinary urobilinogen

Gilberts syndrome leads to an unconjugated hyperbilirubinaemia This therefore leads to a high levels of unconjugated bilirubin, low conjugated and reduced levels of urobilinogen

in the urine as unconjugated bilirubin is water insoluble

Faecal calprotectin is regularly raised

in which of the following?

1- Inflammatory bowel disease

2- Coeliac disease

3- Irritable bowel disease

4- Acute pancreatitis

5- Chronic pancreatitis

Answer & Comments

Answer: 1- Inflammatory bowel disease

Faecal calprotectin is useful in distinguishing Inflammatory bowel disease from IBS

Which of the following leads to a megaloblastic, macrocytic anaemia?

Answer & Comments

Answer: 5- Folate deficiency

Although all of these options can lead to a macrocytic anaemia, only folate and B12 are

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megaloblastic and the others are

normoblastic

In a TSH secreting tumour what

would you expect to find on thyroid function

testing?

1- High TSH, normal free T4

2- Normal TSH, High free T4

3- Low TSH, high free T4

4- High TSH, reduced T4

5- Normal TSH, normal free T4

Answer & Comments

Answer: 2- Normal TSH, High free T4

In TSH secreting tumours you would expect to

find a normal to high TSH level and high free

T4 level This differs from other causes of

hyperthyroidism where there is normally a

reduction in TSH

Which of the following is not useful

in the diagnosis of Wilsons disease?

In Wilsons disease there is a deficiency of

ceruloplasmin which leads to copper

deposition in various organs, predominantly

the liver and nervous system Kayser Fleischer

rings are pathognomonic There is low copper

and ceruloplasmin levels and high urinary

excretion MRI is not required for the

diagnosis

Which of the following would you not expect to see on an ECG of a patient with hyperkalaemia?

Answer & Comments

Answer: 1- Shortened QT interval

A shortened QT interval would be not be seen

on the ECG of a patient with hyperkalaemia

Which pair is correct in regards to the type of porphyria and the correct deficiency?

1- Variegate Porphyria : ferrochelatase

2- Porphyria cutanea tarda : coproporphyrinogen

3- Erythropoietic protoporphyria : protoporphyrinogen

4- Hereditary coproporphyria : Uroporphyrinogen decarboxylase

5- Acute intermittent porphyria : Porphobilinogen

Answer & Comments

Answer: 5- Acute intermittent porphyria :

Porphobilinogen Acute intermittent porphyria is due to porphobilinogen deficiency and is autosomal dominant Porphyria cutanea tarda is due to deficiency of protoporphyrinogen decarboxylase, hereditary coproporphyria due

to Coproporphyrinogen oxidase deficiency and variegate porphyria due to deficiency of protoporphyrinogen oxidase

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Which GLUT transporter is

GLUT 4 is upregulated by insulin and leads to

glucose uptake in muscles and adipose tissue

etc

At what time of the day should the

cortisol level be at its lowest?

Cortisol is at its lowest level at midnight It

shows a circadian rhythm being highest in the

morning

In G6P deficiency what is the

underlying cause of haemolysis?

1- Increased susceptibility to complement

of there diagnosis however there are certain triggers which precipitate a haemolytic crisis which includes nitrofurantoin and quinolones, primaquine, dapsone, sulphonylureas and aspirin Favism is a haemolytic crisis caused by the consumption of broad beans Investigations will show evidence of haemolytic anaemia such as low haptoglobin, elevated bilirubin and increased reticulocyte count Heinz bodies and bite and blister cells are seen on blood film

A 58 year old gentleman presents with a history of weight loss He has lost 2 stones in weight over the last 6 months He is complaining of a chronic cough He was previously a heavy smoker but has not smoked for over 3 years He has no other symptoms He suffers from hypertension and

is on bendroflumethiazide for which he has been on for years He is found to have a sodium of 127 mmol/l with normal urea, creatinine and potassium His sodium level had been normal 6 months ago

Which of the following is the most likely cause

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Answer & Comments

Answer: 4- SIADH

This patient is likely to be suffering from lung

cancer Small cell lung cancer is commonly

associated with SIADH Bendroflumethiazide

can lead to hyponatraemia however he has

been on this for many years and you would

have expected it to have been found prior to

this

A 19 year old female presents to her

GP with non specific symptoms of muscle

weakness You note she appears slim She

denies any other specific symptoms and states

she is otherwise well Bloods reveal

hypokalaemia and a bicarbonate of 16 She

also has an elevated amylase

Which of the following is the most likely

Answer & Comments

Answer: 2- Bulimia Nervosa

Metabolic alkalosis, hypokalaemia and

hyperamylasaemia are metabolic

complications of bulimia Hyperamylasaemia

can occur due to hypersecretion from salivary

glands due to excessive vomiting Vomiting

also leads to hypokalaemia which if severe can

lead to metabolic acidosis Both gitelmann's

syndrome and bartters syndrome have other

metabolic abnormalities and are usually

present at a young age and hyperamylasemia

is not found

A patient presents with acute renal failure secondary to rhabdomyolysis

Which other biochemical abnormalities may

be seen?

1- Hypokalaemia and metabolic acidosis

2- Hypokalaemia and metabolic alkalosis

3- Hypernatraemia

4- Hyperkalaemia and metabolic alkalosis

5- Hyperkalaemia and metabolic acidosis

Answer & Comments

Answer: 5- Hyperkalaemia and metabolic

acidosis

In rhabdomyolysis there is breakdown of muscle fibres and leakage of intracellular substances Potassium in the main intracellular ion and thus rhabdomyolysis can lead to hyperkalaemia and metabolic acidosis

Which of the following is a method for identifying the 3D structure of proteins?

1- Polymerase Chain Reaction

2- Western Blotting

3- In Situ Hybridisation

4- X-ray Crystallography

5- Southern Blotting

Answer & Comments

Answer: 4- X-ray Crystallography

X-ray crystallography is a technique using ray beams to identify atom arrangement and reconstruct 3D images of a protein Western blotting utilises gel electrophoresis to separate polypeptides by length and then identify a specific protein using an antibody probe after transfer of the polypeptides to a membrane.ISH is a type of hybridization that uses a labeled complementary DNA or RNA strand as a radioactive labelled probe to

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x-localize a specific DNA or RNA sequence

Southern blot identifies a specific DNA

sequence through electrophoresis Northern

blots are used in research PCR is utilised to

amplify a specific DNA sequence

Which is true of Crigler Najjar

Answer & Comments

Answer: 1- Autosomal recessive disease with

severe unconjugated hyperbilirubinaemia

Crigler Najjar syndrome is a rare autosomal

recessive condition that results in severe

unconjugated hyperbilirubinaemia due to a

lack of glucuronyl transferase

Haemophilia A is caused by?

1- Protein S deficiency

2- Factor XIII deficiency

3- Factor VIII deficiency

4- Factor IX Deficiency

5- Vitamin K deficiency

Answer & Comments

Answer: 3- Factor VIII deficiency

Haemophilia A is due to a deficiency of factor

VIII

A patient presents with erythema nodosum and is found to have bilateral hilar lymphadenopathy

Which biochemical abnormality is associated with this?

of vitamin D by macrophages in the granulomatous tissue

Which GLUT transporter plays a role

A patient who has recently been commenced on ramipril for hypertension

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presents for his routine bloods He is found to

have a potassium of 5.7 mmol/L, his urea,

creatinine and sodium are within the normal

range and have not changed since his last set

of bloods His ECG is normal He is otherwise

Answer & Comments

Answer: 3- Stop Ramipril and recheck Us and

Es in one week

This patient has hyperkalaemia <6.5 mmol/l

and no evidence of ECG changes therefore no

further treatment is required except stopping

the causative agent and rechecking Us and Es

Calcium resonium is useful for potasiium

between 5.5 and 6.5 mmol/l but only if there

is evidence of anuria or oliguria Insulin

dextrose, salbutamol nebulisers and calcium

gluconate are utilised in the management of

hyperkalaemia when the potassium is over

6.5mmol/l and/or ECG changes

The presence of which feature

suggests proliferative diabetic retinopathy?

1- Neovascularisation

2- Microaneurysms

3- Cotton wool spots

4- Hard exudates and blot haemorrhages

of the earliest features Cotton wool spots then occur followed by hard exudates and blot haemorrhages

How is osteoporosis diagnosed?

1- DEXA scan

2- Clinical diagnosis

3- Bone profile

4- 2 fractures within 6 months

5- X ray of hip and spine

Answer & Comments

Answer: 1- DEXA scan

A DEXA scan is the only definitive way of diagnosis osteoporosis A bone profile will be normal An xray of the hip and spine may appear osteopenic however this cannot confirm the diagnosis 2 fractures with minimal trauma ay make you suspect osteoporosis but will not provide the diagnosis

Which of the following should be checked if there is hypokalaemia refractory to treatment?

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Hypomagnesaemia can lead to hypokalaemia

refractory to treatment until it is corrected

and also hypocalcaemia

A elderly lady is found to have a

raised serum alkaline phosphatase and normal

calcium and phosphate levels

Which of the following is the likely diagnosis?

1- Osteomalacia

2- Pagets disease of bone

3- Osteitis fibrosa cystica

4- Primary hyperparathyroidism

5- Osteoporosis

Answer & Comments

Answer: 2- Pagets disease of bone

Elevated serum alkaline phosphatase activity

is seen most frequently in cholestatic

hepatobiliary disease and in bone disease in

which there is an increase in osteoblastic

activity It is therefore not a feature of

uncomplicated osteoporosis Serum calcium

concentration is usually low

An otherwise healthy female is

found to have a serum calcium of 2.89

mmol/l She takes high doses of vitamins and

Answer & Comments

Answer: 1- Primary hyperparathyroidism

Excessive doses of vitamin D will result in a decrease in endogenous vitamin D production and is very unlikely to raise calcium levels Calcium is actively absorbed by the intestine when levels are low and only passively absorbed when levels are high so calcium supplementation is unlikely Primary hyperparathyroidism is a common cause of calcium and is often asymptomatic

Which is true of low density lipoproteins?

1- Apolipoprotein B100 acts as a ligand for LDL receptors

2- They contain a lower proportion of cholesterol compared to VLDL

3- Insulin promotes LDL formation

4- They transport cholesterol from peripheral cells to the liver

5- Hepatic LDL receptor levels decrease with statins

Answer & Comments

Answer: 1- Apolipoprotein B100 acts as a

ligand for LDL receptors

A LDL molecule contains a apolipoprotein B100 at its core which acts as a ligand for LDL receptors LDL contains a higher proportion of cholesterol than VLDL When a statin is taken and cholesterol levels drop, hepatic LDL receptor levels increase in an attempt to absorb more cholesterol HDL transports

cholesterol from peripheral cells to the liver

What is the best treatment for familial dysbetalipoproteinaemia?

1- Bile acid sequestrant

2- Ezetimibe

3- Fibrate

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4- Nicotinic acid

5- Statin

Answer & Comments

Answer: 3- Fibrate

Fibrates are effective against high cholesterol

and hyperlipidaemia Bile acid sequestrants

only act against cholesterol and may actually

increase triglyceride levels Ezetimibe and

statins act to lower only cholesterol Nicotinic

acid would lower lipids and cholesterol but are

poorly tolerated

A young man is discovered to have a

raised serum triglyceride during a routine

examination His serum cholesterol

concentration is 5.2 mmol/l and gamma

glutamyltransferase is raised History reveals a

history of depression and he is on treatment

with fluoxetine His BMI is within the healthy

range

What is the diagnosis?

1- Normal variant

2- Non alcoholic steatohepatitis

3- Fluoxetine enzyme induction

4- Hepatic steatosis secondary to alcohol

5- Familial hyperlipidaemia

Answer & Comments

Answer: 4- Hepatic steatosis secondary to

alcohol

Raised GGT suggest alcohol consumption and

the damage caused by the acetaldehyde

results in fatty acid synthesis and

dyslipidaemia Acute hepatitis can occur in

response to the fatty changes of the liver and

would cause raised transaminase levels Non

alcoholic steatohepatitis is seen in obese

patients and fluoxetine would not be expected

to cause this clinical picture

Which of the following is found with familial hypercholesterolaemia?

Answer & Comments

Answer: 2- Xanthelasma palpebrarum

Xanthelasma palpebrarum is indicative of familial hypercholesterolaemia

A 9 year old is brought to her GP with early development of body hair Her blood pressure is normal and tests reveal normal prolactin levels, a raised 17 alpha hydroxyprogesterone level and high testosterone levels

1- 5 Alpha reductase deficiency

2- Mild 11 beta hydroxylase deficiency

3- Mild 21 hydroxylase deficiency

4- Severe 21 hydroxylase deficiency

5- Severe 11 beta hydroxylase deficiency

Answer & Comments

Answer: 3- Mild 21 hydroxylase deficiency

This child has congenital adrenal hyperplasia due to mild 21 hydroxylase deficiency This enzyme normally transforms intermediate molecules into cortisol and aldosterone Deficiencies of these hormones result in adrenal hyperplasia and raised ACTH Raised ACTH stimulates the further production of intermediate molecules including 17 alpha hydroxyprogesterone which can be measured

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for diagnosis The excess 17 alpha

hydroxyprogesterone speeds up the synthesis

of androgens Symptoms can include

virilisation, hypertension, vomiting and

dehydration, amenorrhoea and ambiguous

genitalia The extent of the symptoms

depends on the degree of enzyme deficiency

A mild deficiency will cause mild androgen

effects which typically occur in later childhood

years such as precocious puberty Severe

deficiency results in ambiguous genitals,

virilisation of females and symptoms of

deranged salt levels

Which is an acute porphyria?

1- Hereditary coproporphyria

2- None of the others

3- Congenital erythropoietic porphyria

4- Erythropoietic protoporphyria

5- Porphyria cutanea tarda

Answer & Comments

Answer: 2- None of the others

The acute porphyrias are acute intermittent

porphyria and variegate porphyria and both

are due to abnormal haem metabolism Both

are autosomal dominant and cause a variety

of symptoms including abdominal pain, bowel

change, weakness, seizures and neurological

disturbance Variegate porphyria additionally

causes photosensitivity

A dexamethasone test shows that a

patients cortisol levels fail to change with a

low dose, but fall with a high dose of

dexamethasone ACTH levels are high after a

low dose but fall with a high dose of

dexamethasone although they are still above

the normal range

1- Ectopic ACTH producing tumour

2- Hypothyroidism

3- Pseudo Cushings syndrome

4- Cushings disease

5- Adrenal tumour

Answer & Comments

Answer: 4- Cushings disease

The dexamethasone suppression test is used

to determine the cause of Cushings syndrome

A base level for cortisol and ACTH is first measured then 1mg of dexamethasone is given A normal patient will have their cortisol levels suppressed by this A high dose of 8mg

is then given If the ACTH level is low and cortisol is unaffected by this high dose, it is likely adrenal Cushings syndrome in which an adrenal tumour is producing cortisol and this

is providing negative feedback to suppress ACTH If the ACTH level is normal or slightly elevated and cortisol is unaffected by high dexamethasone then it is likely to be ectopic ACTH syndrome in which a cancer is producing ectopic ACTH If the ACTH level is above normal, even after the high level of dexamethasone, and cortisol has been suppressed by the high dose of dexamethasone then Cushings disease is likely

A patient presents with enlargement

of his hands, feet and tongue

What investigation would you order?

1- Melatonin levels

2- Hourly growth hormone levels

3- Glucose tolerance test, GH and IGF1 levels

4- ACTH levels

5- Fasting glucose test, GH and IGF1 levels

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Answer & Comments

Answer: 3- Glucose tolerance test, GH and

IGF1 levels

Acromegaly is the likely diagnosis and is

caused by high levels of growth hormone

Growth hormone fluctuates throughout the

day and cannot be diagnosed with hourly

growth hormone levels alone A glucose

tolerance test, in which 75g of glucose is given

and blood GH levels are subsequently

measured, would demonstrate suppressed GH

levels in a normal patient IGF1 is also an

accurate test and some argument that this

alone is enough for diagnosis

A patient is found to have

Answer & Comments

Answer: 4- Cushings syndrome

Primary hyperparathyroidism is a common

cause of hypercalcaemia and is usually due to

a single parathyroid adenoma Breast cancer

frequently metastasises to the bone resulting

in hypercalcaemia, although there can be

other methods to raise calcium, and

sarcoidosis commonly raises calcium levels as

the granuloma macrophages convert vitamin

D to its active form thus increasing gut

absorption Multiple myeloma causes bone

damage to release calcium

Which of the following molecules in pulmonary surfactant is mainly responsible for reducing surface tension?

is the main molecule for reducing surface tension Other phospholipids such as DMPC and phosphatidylcholine also play a role Surface associated proteins (SP-A, B, C and D) account for 10%

Which of the following is one of the main roles of p53?

1- Inititiating protein synthesis

2- Initiating cell cycle

Which of the following does cortisol bind to predominantly?

1- Cholesterol

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