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El-Zohry MRCP Questions Bank OnExamination 2010 PasTest 2010 Medical Masterclass 2010 MRCP Part (1604 questions) Endocrinology (143) Cardiology (130) Gastroentrology (150) Nephrology (149) Rheumatology (104) Hematology (130) Medical Masterclass 2010 Infectious disease (150) Respiratory (160) Neurology (154) Khalid Yusuf El-Zohry Psychiatry (42) Sohag Teaching Hospital - Egypt Dermatology (85) Oncology (80) elzohryxp@yahoo.com https://www.facebook.com/elzohryxp Pharmacology (120) Basic science (7) MRCPstudy Special Thanks to Dr Ahmed Maher Eliwa For his great effort in this material ReviseMRCP https://www.facebook.com/ahmedmahereliwa El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 Dedications To my father, my mother, my wife, my sons: Abd El-Rahman, Muhammed, and Amr To president Muhammad Mursi Special Thanks to Dr Ahmed Maher Eliwa For his great effort in this material https://www.facebook.com/ahmedmahereliwa Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 غفر هللا لنا جميعا،كلما نظرت في وجهه رأيت أبي Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 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 Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 Medical Masterclass 2010 Reference ranges Endocrinology (143 Questions) Cardiology (130 Questions) 101 Gastroenterology (150 Questions) 165 Nephrology (149 Questions) 251 Rheumatology (104 Questions) 333 Hematology (130 Questions) 387 Infectious Disease (150 Questions) 451 Respiratory (160 Questions) 523 Neurology (154 Questions) 605 Psychiatry (42 Questions) 677 Dermatology (85 Questions) 697 Oncology (80 Questions) 735 Pharmacology (120 Questions) 781 Basic Science (7 Questions) 835 Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 Reference ranges Reference ranges vary according to individual labs All values are for adults unless otherwise stated Full blood count Ferritin 20-230 ng/ml Haemoglobin Men: 13.5-18 g/dl Vitamin B12 200-900 ng/l 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| Folate 3.0 nmol/l Reticulocytes 0.5-1.5% Other biochemistry Calcium 2.1-2.6 mmol/l Urea and electrolytes Phosphate 0.8-1.4 mmol/l Sodium 135-145 mmol/l CRP < 10 mg/l Potassium 3.5 - 5.0 mmol/l Thyroid stimulating hormone (TSH) 0.5-5.5 mu/l Urea 2.0-7 mmol/l Creatinine 55-120 umol/l Bicarbonate 22-28 mmol/l Free thyroxine (T4) 9-18 pmol/l Total thyroxine (T4) 70-140 nmol/l Amylase 70-300 u/l Liver function tests Bilirubin 3-17 umol/l 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 Albumin 35-50 g/l Total protein 60-80 g/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 Other haematology Desirable lipid values depend on other risk factors for cardiovascular disease, below is just a guide: Erythrocyte sedimentation rate (ESR) Total cholesterol < mmol/l Men: < (age / 2) mm/hr Triglycerides < mmol/l Women: < ((age + 10) / 2) mm/hr HDL cholesterol > mmol/l Prothrombin time (PT) 10-14 secs LDL cholesterol < mmol/l Activated partial thromboplastin time (APTT) 25-35 secs Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 Endocrinology (143 Questions) (Medical Masterclass – Part 2) [ Q: ] MasterClass Part2 (2010) - Endocrinology A 41-year-old woman is referred by her GP with suspected hypoglycaemic episodes She has previously been fit and well, but has recently gained weight Her daughter has wellcontrolled type diabetes mellitus On examination she is overweight (BMI 28.0 kg/m2) and her BP is 120/80 mmHg lying and 110/75 mmHg standing She is admitted to hospital for a prolonged fast and becomes symptomatic at 18 hours, at which time investigations reveal serum sodium 137 mmol/L (normal range 137144), serum potassium 4.8 mmol/L (normal range 3.5-4.9), serum creatinine 70 μmol/L (normal range 60-110), serum albumin 40 g/L (normal range 37-49), serum total bilirubin 10 μmol/L (normal range 1-22), serum alanine aminotransferase 25 U/L (normal range 5-35), serum alkaline phosphatase 100 U/L (normal range 45-105), plasma glucose 1.9 mmol/L (normal range 3-6) and plasma insulin 65 pmol/L (normal 20mU/l, low free T4, low T3 Treatment is with thyroxine and we should aim for free T4 levels close to upper range /day) This is a high iodine load for body which blocks further thyroid iodide uptake and hormone synthesis It also blocks conversion of T4 to T3 and affects pituitary thyroid axis The following changes in thyroid function tests occur within months of starting amiodarone and are not indicative of thyroid disease: increase in TSH up to 20mU/L, increase in T4 to upper limit of normal range, and decreased T3 levels Diagnosis of hypothyrodism should be based on clinical assessment, together with the following features: high TSH - > 20mU/l, low free T4, low T3 Treatment is with thyroxine and we should aim for free T4 levels close to upper range [ Q: 119 ] MasterClass Part2 (2010) - Pharmacology [ Q: 118 ] MasterClass Part2 (2010) - Pharmacology You see a 36-year-old man in outpatients who is complaining of acid reflux and heartburn A colleague seeks your opinion on a patient who has developed abnormal thyroid function tests after being started on amiodarone recently Which agents have been shown in clinical trials to be efficacious in the treatment of gastrooesophageal reflux disease? Which one of the following features, in conjunction with clinical symptoms and signs, is helpful in diagnosing overt hypothyroidism? A Increase in thyroid-stimulating hormone (TSH) up to 20mU/L B Decrease in T3 A Mebeverine B Lansoprazole C Peppermint oil D Misoprostol E Sucralfate F Prochlorperazine C Elevated free T4 and T3 G Carbenoxolone D T4 at upper end of or just above normal range H Bismuth E Low free T4, and low T3 J Ranitidine I Hyoscine Answer & Comments Answer & Comments Correct answer: E Correct answer: BJ Amiodarone is an iodine rich structure which resembles T4 Daily dose 200mg generates 7mg free iodine (WHO optimal intake 0.15-0.3mg Proton-pump inhibitors are the most effective agents in gastrooesophageal reflux disease and Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | 833 El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 should be used as first-line therapy in patients with severe symptoms (with subsequent dose reduction later) and in those who have complications such as stricture, ulceration or haemorrhage Patients with mild or occasional symptoms can be treated in a step-up manner, starting with over-the-counter preparations, such as antacids The next step would be to try a H2 antagonist such as ranitidine, and failing that, to move up to a proton-pump inhibitor [ Q: 120 ] MasterClass Part2 (2010) - Pharmacology 72 yr old man with hypertension has blood pressure well controlled (134/84 mmHg) on bendroflumethiazide 2.5 mg/d, bisoprolol mg/d and lisinopril 20 mg/d A routine blood test taken in primary care reveals Na 135 mmmol/l, K 5.2 mmol/l, Creatinine 112 micromol/l Which of the following is the most appropriate course of action? A Arrange urgent admission to hospital for treatment of hyperkalaemia B Reassure that no immediate changes in management are required C Start calcium resonium D Stop bendroflumethiazide E Stop lisinopril Answer & Comments Correct answer: B Mild chronic hyperkalaemia is well tolerated and not a cause for concern If serum potassium were to rise to >6.0 mmol/l, standard practice would be to stop the ACEi and - if K >6.0 mmol/l were to persist - to advise a low potassium diet Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | 834 El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 Basic Science (7 Questions) (Medical Masterclass – Part 2) Decreased plasma concentration and osmolality Inappropriately high concentration (>20 osmolality (> plasma) What is the likely cause of his hyponatraemia? A Syndrome of inappropriate antidiuresis (SIADH) B Diuretic treatment C Loss of sodium in vomit D Hypovolaemic stimulation of ADH release E Addison’s disease Answer & Comments Correct answer: D Plasma ADH concentration is normally controlled by plasma osmolality, but pain, nausea, hypovolaemia and anaesthesia are all powerful stimulants of ADH release and can generate much higher plasma levels than are seen in response to tonicity Nausea and hypovolaemia are likely to have stimulated very high ADH levels as the explanation for this man’s hyponatraemia In recognition of these facts, SIADH can only be diagnosed when the following criteria are satisfied: The patient is clinically euvolaemic (JVP seen, no postural hypotension) urine sodium mmol/l) and There is normal adrenal, thyroid and renal function [ Q: ] MasterClass Part2 (2010) – Basic science [ Q: ] MasterClass Part2 (2010) – Basic science A 78-year-old man is admitted weak and unable to stand after vomiting for several days His plasma sodium concentration is 123 mmol/l and his urinary sodium concentration is mmol/l sodium A 70-year-old man presents with breathlessness He has had a history of previous myocardial infarction and peripheral vascular disease He has recently been started on captopril for hypertension He has been anuric for hour His serum urea is 45 mmol/l and his potassium is 7.9 mmol/l His ECG shows features compatible with hyperkalaemia The first most appropriate step in management would be: A ten units of soluble insulin with 50g glucose(50%) IV B haemodialysis C bicarbonate (100 mls of a 4.2% solution) by IVI D calcium resonium 30g E 10-30 ml calcium gluconate (10%) IVI Answer & Comments Correct answer: E Giving calcium gluconate IV will instantly lower myocardial excitability and should produce very quick ECG improvement and hopefully prevent sudden cardiac arrest - it will not affect potassium levels Other measures listed above can be used to promote potassium excretion but may take several hours to become effective The patient may have renal failure precipitated by the use of angiotensin- Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | 835 El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 converting enzyme (ACE) inhibitors underlying renal artery stenosis with [ Q: ] MasterClass Part2 (2010) – Basic science An 80-year-old woman who has been taking a thiazide diuretic presents with a confusional state and has a serum sodium concentration of 118 mmol/l The correct treatment is: A Stop the thiazide diuretic Start a loop diuretic, e.g frusemide 40 mg once daily B Stop the diuretic Infuse 0.9% sodium chloride intravenously, aiming to bring the sodium concentration gradually up to the lower limit of the normal range in 48 hours C Stop the diuretic Restrict fluid intake to litre per day D Stop the diuretic Infuse 1.8% sodium chloride intravenously, aiming to bring the sodium concentration to within the normal range in 12-24 hours E Stop the diuretic Infuse 5% dextrose intravenously, aiming to reduce the serum sodium concentration gradually until her confusional state begins to improve Answer & Comments Correct answer: C Diuretic agents are a very common cause of hyponatraemia Hyponatraemia of gradual onset, as in this case, should be treated by stopping the causative agent (where possible) and by fluid restriction Access to the water allowance should be deliberately spread out throughout the day (not a jug full at 08.00 h and nothing more thereafter) and given as ice cubes for the patient to suck Moist swabs can also be used to relieve unpleasant dryness of the mouth Hyponatraemia of rapid onset (which is usually iatrogenic, being caused by inappropriate intravenous administration of dextrose containing solutions) and associated with severe neurological symptoms, e.g epileptic convulsions, should be treated more rapidly by infusion of saline (0.9%, 1.8% or more concentrated), aiming to increase the serum sodium concentration by 1-2 mmol/l/hr, with rapid correction stopped before the serum sodium concentration has risen into the normal range [ Q: ] MasterClass Part2 (2010) – Basic science A 60-year-old man with a past medical history of renal stones and hypertension presents with thirst, polyuria, vomiting and constipation Initial investigations include a corrected serum calcium of 3.2mmol/L Which of the following statements is true? A Secondary hyperparathyroidism is among the differential diagnoses B Treatment recently started for hypertension may have precipitated this presentation C Malignancy is a more likely cause of his hypercalcaemia than primary hyperparathyroidism D The degree of hypercalcaemia is insufficient to have caused his symptoms E The most important first-line treatment is a bisphosphonate Answer & Comments Correct answer: B A thiazide started for treatment of hypertension may have caused an acute rise in Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | 836 El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 serum calcium (by reducing urinary calcium excretion and potentiating the action of PTH) Secondary hyperparathyroidism is not associated with hypercalcaemia It describes elevation of PTH to compensate for chronic hypocalcaemia If the increased PTH secretion persists and becomes autonomous resulting in hypercalcaemia, this is then termed tertiary hyperparathyroidism The patient has a history of renal calculi Most patients with renal calculi (approx 65%) have idiopathic hypercalciuria, but up to 5% have hypercalcaemia, as in this case A renal stone usually indicates long-standing hypercalcaemia, which is therefore unlikely to be secondary to malignancy (although malignancy cannot be excluded on this basis alone) The differential diagnosis of hypercalcaemia is wide, but the most likely cause in this case is primary hyperparathyroidism, which is the commonest underlying cause of hypercalcaemia in the general population A serum calcium above 3.0mmol/L is compatible with symptomatic hypercalcaemia, especially if a precipitant has produced a rapid increase The first priority in treating symptomatic hypercalcaemia of any cause is adequate rehydration and removal of any exacerbating factors (e.g thiazides) If these measures alone are insufficient, bisphosphonates are the next line of therapy Definitive treatment depends upon the underlying cause and in this case may include parathyroidectomy B 273.6 C 265.9 D 136.8 E 144.5 Answer & Comments Correct answer: C Calculated osmolality = x (Na+K) + (Urea) + (Glucose), when osmolality is measured in mosmol/kg and all other factors in mmol/l This calculation is most useful in cases of suspected poisoning, when a difference between calculated and measured osmolality would indicate the presence of other osmotically active substance(s) in the blood, e.g ethylene glycol (antifreeze) [ Q: ] MasterClass Part2 (2010) – Basic science A GP rings you about a 55 year old lady with metastatic carcinoma of the breast who has become acutely confused What advice would you give? A Start the patient on high dose steroids B Start the patient on diazepam C Ask the GP to exclude hypercalcaemia D Start the patient on antibiotics E Offer to send out a Community Macmillan Nurse [ Q: ] MasterClass Part2 (2010) – Basic science (2) A 68-year-old woman is admitted because she is ‘off her legs’ Her routine biochemical screen reveals plasma Na 126 mmol/l, K 3.1 mmol/l, urea 3.2 mmol/l, glucose 4.5 mmol/l Her calculated plasma osmolality (mosmol/l) is: Answer & Comments Correct answer: C Hypercalcaemia can present as acute confusion and can only be diagnosed by a blood test It can be treated with intravenous fluids and bisphosphonates A 271.1 Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | 837 El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 It is important to exclude infection as a cause of confusion If she is very agitated an antipsychotic such as haloperidol would be more appropriate than diazepam [ Q: ] MasterClass Part2 (2010) – Basic science A 78-year-old man presents with an acute confusional state He has postural hypotension and is dehydrated, with serum calcium 3.41 mmol/l Which is the treatment? most appropriate initial A Intravenous sodium pamidronate B Intravenous 5% dextrose C Oral prednisolone (20-60 mg) D Intravenous furosemide (40 mg) E Intravenous 0.9% sodium chloride Answer & Comments Correct answer: E The initial priority is to restore intravascular volume by giving 0.9% sodium chloride intravenously When this has been done, furosemide can be used to increase calcium excretion and sodium pamidronate can be used to effect rapid reduction in serum calcium concentration The commonest causes of hypercalcaemia in an elderly man would be metastatic malignancy, myeloma and primary hyperparathyroidism Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | 838 El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 Dr Khalid Yusuf El-Zohry – Sohag Teaching Hospital (01118391123) Page | 839 ... Questions Bank (Part 2) – Medical Masterclass 2010 Endocrinology (143 Questions) (Medical Masterclass – Part 2) [ Q: ] MasterClass Part2 (2010) - Endocrinology A 41-year-old woman is referred by... Page | 30 El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 [ Q: 35 ] MasterClass Part2 (2010) - Endocrinology You see a 31-year-old gentleman with type diabetes for his annual review... Hospital (01118391123) Page | El-Zohry MRCP Questions Bank (Part 2) – Medical Masterclass 2010 Medical Masterclass 2010 Reference ranges Endocrinology (143 Questions) Cardiology