Philip Kelly MRCP 2 book 2

DERMATOLOGY- QUESTIONSCase 4 This67-year-oldmanwithhypertensionandepilepsy developedthis rash whileonholidayin southern Spain.. DERMATOLOGY - QUESTIONS Case 7This42-year-oldwomanpresente

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Psychiatry Renal Medicine

rons

Dedicated to your Success

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Acknowledgements

Introduction

viiviiiix

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Virginia HubbardMBBS MRCP

ConsultantDermatologist,TheWhittington Hospital,London

Endocrinologyand Metabolism

NeilHarrisonMRCPMRCPsych

Clinical Research Fellow,InstituteofCognitiveNeuroscienceandHonorarySpecialistRegistrar,Neuropsychiatry,NationalHospital,QueenSquare.

RenalMedicine

RaviRajakariaBSc(Hons)MBChBMRCP

Experimental MedicineandNephrology,William HarveyResearch

Institute, London

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Iwould liketoexpressmygratitudetotheteam alPasTestparticularlyAmy Smith andCathyDickensfor theirunswervingsupportand tolerance

duringthe preparation of thisbook andseries.Manypatientshave beengracious enoughtocontributeto ourongoingeducation byallowingtheirimagestobeusedinthesevolumes Theseries would have been

impossible withoutthehelpofthefollowing:DrEdSeward, The

MiddlesexHospital,London for hiscomments onthegastroenterologychapter;Drs.SWhitely,N PowerandOChan,Radiology;Dr RFeakins,

Pathology;Dr RMarley,Hepatology,BartsandTheLondonNHSTrust; Dr

RMakins,HomertonUniversityHospitalNHSTrustandDrJ Mawdsley,Bartsand TheLondon,QueenMary School ofMedicine andDentistry;MedicalPhotography, RadiologyandMedicine, King George Hospital,llford;MedicalIllustrationat Bartsand TheLondon School of Medicineand Dentistry and The Department ofDiabetes andMetabolismatThe

RoyalLondonHospital SpecialthanksareduetoDrAlexandra Nanzerforher consideredandhelpfulcriticismsand delightfulencouragement.PhilipKelly

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The MRCP(UK) Part2writtenexamination consistsoftwo3-hour papers,

eachwithupto 100multiplechoicequestions;theyareeitheronefromfive(bestof5) or'n' frommany, wheretwoanswersarechosen fromten.

Each questionwillhaveaclinicalscenarioandmightcontain

investigationstointerpret;manymightalsocontain animage Thereisapass-markagreedby theexaminersbutacandidate'sperformanceisalsoassessed inrelationtoother candidates

Thisthree-bookseriesprovidespractice questionswithextensive

explanationstoaidcandidatespreparingforthe examination.The authors

areallclinicians writingsectionsintheirchosen fieldsandassuchhavebeen chosenfortheir clearunderstandingoftherequiredknowledgebaseforthis importantexam Thebreadth ofknowledgeforthis exam is vast

andtheyhaveattemptedtocoverthe'syllabus'ascompletelyaspossible.Greatcarehas been takentoexplainareasthatcausedifficultyas

thoroughlyaspossible.Noapologyismade where the format ofthequestionsdiffersslightlyfromtheexam.These booksare notmerelypractice papersbut educationalaids andwhereatopiccanbe bestexplained bydiversion fromthe strictformatof the exam, forthe sake ofunderstanding,this has beendone

Thisbookcoversdermatology,endocrinologyand metabolism,

gastroenterology, psychiatry,and renalmedicine andisbest taken -in

concertwithits partnerswithintheseries-as asupplementto athoroughclinicalgrounding, the general medicaltextsand thecoreclinicaljournals

Anycomments orsuggestionsonthisbookorthe serieswillbegratefullyreceived

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Case1

-442-year-oldwomanpresented witha6-monthhistoryofthis

appearance:

1 Which of thefollowingwould notbe associatedwiththis appearance?

ÿ A Radiolucentbonecysts on aplainX-ray of thehands

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DERMATOLOGY QUESTIONS

Case2

This32-year-oldwomanpresentedwithhair lossfor8months

1 Whichofthefollowing would typicallycausethis patternofhair loss?

ÿ A Discoidlupus erythematosus

ÿ B Dissectingcellulitisofthescalp

C3 C Tineacapitis

O D Hypothyroidism

ÿ E Alopeciaareata

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Case 3

A34-year-oldmanpresented witha3-monthhistoryofdepigmentedpatchesoverhis hands.Hesays theproblemisspreading

1 Which of thefollowingconditions hasanincreased incidence in

associationwiththispicture?

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DERMATOLOGY- QUESTIONS

Case 4

This67-year-oldmanwithhypertensionandepilepsy developedthis rash

whileonholidayin southern Spain

1 Which of hisdrugsis themostlikelyculpritinthis pattern ofdrugrash?

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Case 6

A 31-year-oldmanreturnedfromaholidayinFloridawiththisrashonhis

rightshin Therashspreadat a rateofapproximately1 cmperday.He was

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DERMATOLOGY - QUESTIONS Case 7

This42-year-oldwomanpresentedwithexcessfacialhair

1 Which of thefollowingisnot arecognisedcauseofthis appearance?

ÿ A Spironolactone

ÿ B Congenitaladrenal hyperplasia(CAH)

ÿ C Polycysticovarysyndrome(PCOS)

ÿ D Cushing'sdisease

ÿ E Hyperprolactinaemia

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Case 8

A38-year-oldwomanpresentedwitha6-monthhistoryofthis appearance

in bothaxillae.Her BMI was 35.

1 Whatisthemostappropriate first investigation?

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Case 9

A 78-year-oldwomanpresentsshortofbreath, with haemoptysis

1 What is thediagnosis?

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Case 10

A 31-year-oldmanwithulcerative colitis hadalaparotomy.Three weeks

later thescarbrokedown,leavingthispicture.Microbiologyswabswerenegative

1 What is themostappropriatetreatmentforthis?

ÿ A Broad-spectrumintravascular antibiotics

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DERMATOLOGY-QUESTIONS Case 11

A 31-year-oldengineerreturnedfromatriptoSaudiArabia2monthspreviously.Hepresentedwitharednodule whichsubsequentlyulcerated

togivethis appearance:

1 What is themostlikelydiagnosis?

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Case 12

A38-year-oldintravenousdruguserpresentedwith a 6-monthhistoryof

anitchyrashoverhis wrists andankles.He washepatitis C-positive

1 What is this rash?

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DERMATOLOGY - QUESTIONS

Case 13

A29-year-oldmanfromNigeriawasadmittedtohospitalwhilevisitingrelativesintheUK,withaweakrighthand.He wasalsonotedtohave thisrash

1 What is theunifyingdiagnosis?

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Case 1 4

A34-year-oldwoman wasreferred from thePsychiatricUnitwitha3-weekhistoryofarash.This hadstartedaswidespread erythematous

macules, but evolvedtothepicturebelow Shehadcommenced

carbamazepine1 monthpreviously.Shealsohadaurinarytractinfection

and hadbeenstartedonco-trimoxazole earlier intheweek

D Insertionof acentralvenousline

E Coolthebody

What is themostimportant therapeutic intervention?

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Case 15

A54-year-oldwomanpresentedwithweightloss Theseareherhands

ShewasANA-negative

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ENDOCRINOLOGY AND METABOLISM-QUESTIONS

Case 1

-4ladyisfollowedupinthe clinicwith hypothyroidism.Herthyroid

replacementisbeingtitrated andsheiscurrently taking50microgramsthyroxineoncedialy

On examinationsheis85kg,1.65 mand theskiniscool anddry Thepulseisregular,low-volume and52bpm, JVP4 cm,thereisnooedema

Thepraecordiumandlungsarenormal.Inthe abdomen thereis2-cmhepatomegaly

Thefollowing fastinginvestigationswereperformedbeforeclinic:

HDL cholesterol 0.8mmol/L

LDL cholesterol 1 9mmol/L

Triglycerides 7.3mmol/L

Onherpalmsthefollowingappearance is observed:

Wellcome Trust Mcdic.il Photographic Library

1 Whichisthemostlikely diagnosis?

CD A Hyperlipidaemiaofdiabetes

CD B Familialhypercholesterolemia(type llahyperlipidaemia)

ÿ C Familial combinedhyperlipidaemia(type libhyperlipidaemia)

LJ D Familialhypertriglyceridaemia(type Vhyperlipidaemia)

ÿ E Familialdysbetalipoproteinaemia(typeIIIhyperlipidaemia)

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Case 2

Youarereferredaladywith thyrotoxicosisandexophthalmos.Shehasa

moderate sized nodulargoitre TheCI'hasalreadystarted heron

carbimazole andthisisherthyroidfunctionwhiletaking5mgoncedaily

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1 What is thenextstep?

Lj A Continuecarbimazole,titrating the dosetosuppresstheTSHtobelow

the normalrange

ÿ B Prednisolone0.5-1mgper kg initiallyfor 2-6weeks

ÿ C Referralto anophthalmicsurgeon

ÿ D Referralto aradiotherapisttoconsider low-doselens-sparingorbital

radiotherapy

ÿ E Continuethecurrentmedicationand consider radioiodine if the goitre

becomestroublesome

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ENDOCRINOLOGY AND METABOI ISM-QUESTIONS

Case 3

A27-year-oldmanisreferred withpolyuriaand thirst.He is on no

medications;thereis nofamily history Weight83kg, height1.92m.I lis24-hoururinevolumeis 3litres

Plasmaosmolality 294mosmol/kg

Urineosmolality 303mosmol/kg

in previous osmolality osmolality

hour(mL) (mosmol/kg) (mosmol/kg)

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t Whal is thediagnosis?

ÿ B Polyuricrenalfailure

LJ C Cranialdiabetesinsipidus

I D Primarypolydipsia

ÿ E Noneofthe above

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endocrinoi ogy and metaboi ism questions

Case 4

A60-year-old ladyis seen intheclinicforhypercalcaemia.Shortlyafterthe deathofherhusband2yearsago,whilebeingtreated fordepression,hypertensionwasnoted; duringthe investigation of thisacorrected

calcium of2.9mmol/Lwasfound,which haspersisted.Shehas beenwell,

apart fromaColics'fracture9years ago sustainedwhen sheslipped whileice-skatingwithher husband inManhattan;she doesnotsmokeordrink,

eats agooddietand lives alonewithhertwogreyhounds,oneofwhich

recentlyhadalitter ofpuppies Shewasadopted,didnot knowherparentsand hasnochildren

Onexaminationsheis 1 67-cmtall,weighs60kg,hasablood pressure of190/90mmHg,withnoposturaldrop,andnocorneal calcification

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ENDOCRINOI OCY AND METABOLISM-QUESTIONS

ÿ A Raisedaniongap metabolicacidosis

ÿ B Secondaryhyperparathyroidism

D C Multipleendocrineneoplasia(MEN)type2A

ÿ D Familialhypercalcaemic hypocalciuria

( ) E Primaryhyperparathyroidism

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Case5

You arecalledto see a68-year-old retirednursewhocollapsedwhilehavingalipomaremovedfrom his back underageneralanaesthetic.Inthepast he hadOsgoodSchlatter'sdisease.He is on nomedication.Hismother hastypeIdiabetes, histwo sisters arewell

Onexamination heis 1 88 m,weighs80kg,thepulseis70bpm,|VP 4 cm

and bloodpressure1 10/70mmHgwithnopostural drop.Hiscapillaryglucosewas 1 8mmol/Lduringthecollapsebuthecameroundwithin

1 0 minutesafterhaving25gintravenousglucose

Thepatientisshown inthefollowing figure:

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ENDOCRINOLOGY AND METABOLISM - QUESTIONS

1 What is thenextbest step?

ÿ A Fastforupto72hours andmeasureinsulin,C-peptideand

P-hydroxybutyrate-ifhypoglycaemiaoccurs

D B Performbasalanteriorpituitary functiontests

CD C Urineorplasma sulphonylureascreen

ÿ D Short tetracosactrintest (250 ugSynacthen®intramuscularly,serum

Cortisolat 0, 30, 60 minutes)

I E MeasureplasmaACTH

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ENDOC RINOLOGY AND METABOLISM QUESTIONS

On examinationthe musclesare nottender andapartfrombeing

proximallyweak -shecannot risefromasquat- the neurological

examination,includingthedeeptendon reflexes,isnormal;examination

ofthe respiratoryandabdominalsystemsarenormal TheJVPis4cmand

showscoupletsofcannonwavesand the BPis 140/94mmHg

Protein trace

Bloodtrace

Specific gravity 1 010

TheECGshowsU waves,butisotherwiseentirelynormal

Herinvestigations areshown:

The wardhouse officerwasconcerned aboutsomeabdominalpain and

requestedthe abdominal film shown opposite:

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ENDOCRINOLOGY AND METABOLISM-QUE ST IONS

Science Photo Library

1 Whatis thediagnosis?

ÿ A Cushing'ssyndrome

ÿ B Distal renaltubular acidosis(type 1 )

ÿ C Proximal renaltubular acidosis(type2)

ÿ D Distal renaltubular acidosis(type4)

ÿ E Primary aldosteronism(Conn'ssyndrome)

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Case 7

A29-year-oldladyIsadmittedwithathunderclapfrontalheadachewith

severepainbehindthe eyes.Ondirect questioningshehadhadsomemild

headachesfortheprecedingfewdaysbut hadputthatdowntobecoming

increasinglyexhaustedoverthepreviousmonthsbecauseofherwork She

haddoublevisiononlookingtothe leftwhentheheadache firstcameon.Recentlyshe has lost4kginweight.Shetakesnomedicationsexcept the

combinedcontraceptive pill

On examinationthetemperatureis37.9°C,pulse1 1 0bpm,BP90/60 mmlIg.ShebecametoounsteadytogetastandingBP.Onexaminationofthe external ocularmovementsshe hasaleftVlthnervepalsy,but thereare

nootherlocalisingsignsintheneurologicalexamination.The discs arenormal.Examinationshows the breasts are normal andthereisnothingtosuggestagynaecological malignancy

Shehasa CT scanwhich doesnotshow anybloodandafter12 hours hasalumbarpuncture:

13 cmH.OClearand colourless

4mmol/L

80pmol/L

253mosmol/kg

360mosmol/kg

1 Whichinvestigationwillbemosthelpful?

0 A CTbrainwithcontrast

0 B CortisolandACTII

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ENDOCRINOLOGY AND METABOLISM-QUESTIONS Case 8

/\ 14-year-old boyisbeing investigatedforthepossibilityofdiabetes.He is

fairlywell and hasnotlost anyweight.Hehadbeen treated for

seborrhoeiceczemain thepastwithout muchsuccess-therashisstill

present As achild,while inanothercountry,he hadbeeninvestigatedfor

asoft-tissuemass onhishead;themassisstillpresent Hismother haskept

hisX-rays from when hewas ayounger childand the skull X-rayisshown

Urinalysis

His morningchemistryisshown:

Ketones+Specificgravity 1 002

80umol/L

Plasma glucoseAlbumin

ALPALTBilirubin

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Case 9

A39-year-old ladyattendedforremovalofabreastlump.Surgerywaspostponedbecauseher BPwas 200/1 10mmHg,withnopostural drop.Sheis on nomedication andeats anormal diet.The/VPwas 4 cm.

Renal ultrasound Normal

TheadrenalCT isshown opposite

ÿ A Primary aldosteronism - bilateraladrenalhyperplasia

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Case 10

A49-year-oldmanwithtype Idiabetes whoisawaitingpanretinal

photocoagulationforproliferativeretinopathyhascentral crushing chestpain with associatednauseaandbreathlessness.Hehas diabetic

nephropathy,isontwice-daily Novomix-30®, witha recentHbAuof

11.6%and hadrecentlybeenadvisedtodiscontinuedriving because of

loss ofhypoglycaemiaawareness.His other medicationisaspirin75mg

oncedaily and20mg ofsimvastatin atnight

On examinationhehasa regularpulseof88bpm,thevenouspressureis

4 cm,BP95/68mmHg,athird heartsoundis present attheapex and the

chestisclear HisECGshowsanteriorSTelevation, suggestive of

myocardialinfarction.Primaryangioplastyisunavailable

The capillary glucoseis 1 2.0mmol/L

1 Which of thefollowingstatements is incorrect?

ÿ A Thrombolysis should beadministered

ÿ B p-Blockade should be givenpost-infarct

ÿ C ACEinhibitionshould be givenpost-infarct

ÿ D Intravenousp-blockadeshouldnotbe given alongside thrombolysis

ÿ E Thestatinshouldbediscontinued

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FNDOCRINOLOCY METABOLISM QUESTIONS

Case 11

A39-year-oldresearcherattheEuropeanParliament has abdominaland

back pain which hascomeandgoneforthe last18monthsand is

worsening.Hesmokes20cigarettesaclay.Hehadalwaysenjoyedwine

while studying politicsatuniversity However, because of therecurrent

abdominalpain, he hasnotdrunk for the lastyear.Hehas lostalittle

weight.He is notmarried

Onexamination heweighs68kgandis1.88 mtall Thereisnospinal

tenderness Thecapillary glucose is 7.9mmol/L

97fL

150 x 107L

42 pmol/L36g/L

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Case 12

You see a22-year-oldmanforasecondopinionregardinghis

endocrinologyinvestigations forlassitude,weakness andcrampsafterexercise Ilis serumCortisolhadbeen measuredat 170nmol/L

Hewasalwaystiredas achildandperformedpoorlyat sports

inpart,hisparentsusedtosaytohis annoyance, because hewas

alwaysafrail,sicklychild.Hesuffers withsuchseverecramp when

climbingeven afewstairsthat henowalwaystakes thelift.Hedoesnot

Specificgravity 1.021

Glucosenegative

Bilirubinnegativefasting 9-aminvestigationsafterexertionshow:

24 mmol/L2.2 mmol/L

50pmol/L

320U/L

NormalNormal

2.4mmol/L

Noredcellsor casts seen

Sparsegranularandhyalinecasts

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ENDOCRINOLOGY AND MFTABOI ISM-QUESTION'S

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ÿ B Impaired fastingglucose

0 C Impaired glucosetolerance

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