MRCP Deck 4 June 2023 Flashcards
Which of the following genetic translocations is most likely to be seen in a patient with APML?
A) t(8;14)
B) t(8;21)
C) t(9;22)
D) t(11;14)
E) t(15;17)
t(15;17)
t(11;14) - mantle lymphoma
t(9;22) - AML
t(8;21) - Burkitt lymphoma
What is the definition of functional residual capacity (FRC)?
A) The volume of air present in the lungs at the end of passive expiration
B) The additional amount of air that can be expired from the lungs by determined effort after normal expiration
C) The volume of air left in the lungs after fully exhaling
D) The amount of air that can be forcibly exhaled from the lungs after taking the deepest breath possible
E) The maximal amount of additional air that can be drawn into the lungs by determined effort after normal inspiration
The volume of air present in the lungs at the end of passive expiration.
The volume of air left in the lungs after fully exhaling = residual volume.
The additional amount of air that can be expired from the lungs by determined effort after normal expiration = expiratory reserve volume.
The amount of air that can be forcibly exhaled from the lungs after taking the deepest breath possible = forced vital capacity.
The maximal amount of additional air that can be drawn into the lungs by determined effort after normal inspiration = inspiratory reserve volume.
What is the appropriate treatment for a patient with long QT syndrome who has experienced syncopal episodes but no previous cardiac arrests?
A) Amiodarone
B) High left stellate ganglionectomy
C) ICD
D) Metoprolol
E) Permanent pacing
If a cardiac arrest has not occurred, b-blockers should be trialled in an attempt to abort the syncopal episodes.
Ganglionectomy is considered in patients who do not respond to b-blockers. ICD is reserved for patients who do not respond to either option or who present with non-fatal cardiac arrest.
What is the primary MOA of metformin?
A) Increases glucose uptake in fat
B) Increases glucose-dependent insulin release
C) Increases glucose-independent insulin release
D) Reduces hepatic glucose output
E) Slows gastric emptying
Reduces hepatic glucose output
In HOCM, which of the following is the most likely inherited genetic defect?
A) Troponin I
B) Troponin C
C) Troponin T
D) Myosin-binding protein C
E) Alpha actin
Myosin-binding protein C and beta-myosin heavy chain mutations comprise of the majority of HOCM mutations.
What is the underlying pathophysiology of Graves eye disease?
A) Deposition of extra-orbital fat
B) Deposition of glycosaminoglycans
C) Deposition of immunoglobulins
D) Oedema secondary to immunoglobulins
E) Oedema secondary to carbimazole
Deposition of glycosaminoglycans - Graves orbitopathy involves inflammatory infiltration of fat and extra-ocular muscles by lymphocytes, plasma cells and mast cells, followed by deposition of water and glycosaminoglycans which drive progressive exophthalmos.
What is the treatment of a patient with known Graves disease presenting with worsening diplopia, loss of colour vision and bilateral exophthalmos?
A) Bendroflumethiazide
B) PO selenium
C) Orbital radiotherapy
D) IV methylprednisolone
E) Rituximab
IV methylprednisolone should be administered due to the sight-threatening symptoms of optic nerve compression.
What is the primary MOA of terlipressin?
A) Increased DBP
B) Increased renal salt and water retention
C) Positive inotropic effects
D) Reduced intestinal motility
E) Reduced hepatic portal pressure
Terlipressin inhibits portal hypertension
What is the MOA of flecainide?
A) CCB
B) Muscarinic receptor antagonist
C) K channel blocker
D) Na channel blocker
E) Na+/K+ ATPase inhibtitor
Na channel blocker
Amiodarone = K channel blocker
Which antibodies are found in Hashimoto’s thyroiditis?
A) ANA
B) ASMA
C) Anti-TPO Ab
D) Blocking anti-TSHr Ab
E) Stimulating anti-TSHr Ab
Anti-TPO Ab and anti-thyroglobulin Ab are both associated with Hashimoto’s thyroiditis.
Which of the following medications should not be used in conjunction with theophylline?
A) Azithromycin
B) Ciprofloxacin
C) Co-amoxiclav
D) Cephalexin
E) Doxycycline
Ciprofloxacin is a CYP1A2 and CYP3A4 inhibitor and hence causes an increased exposure to theophylline leading to symptoms of toxicity (nausea, vomiting, hypokalaemia).
Which of the following can precipitate a scleroderma renal crisis?
A) Amlodipine
B) Omeprazole
C) Prednisolone
D) Ramipril
E) Valsartan
Prednisolone
ACEi are protective and are the intervention of choice for BP control.
What is the most appropriate management for a patient presenting with acute GPA?
A) IV belimumab
B) IV methylprednisolone and cyclophosphamide
C) PO methotrexate
D) Plasma exchange
E) IV rituximab
IV methylprednisolone and cyclophosphamide
Corticosteroids form the backbone of treatment with the addition of either cyclophosphamide or rituximab.
What is the most likely composition of renal stones in a patient with Crohns disease who has had multiple small bowel resections?
A) Calcium citrate
B) Calcium oxalate
C) Cystine
D) Magnesium ammonium phosphate
E) Uric acid
Small bowel resections –> short bowel syndrome –> increased intestinal absorption of oxalate –> increased oxalate into urine –> calcium oxalate stones
Which of the following is the inheritance pattern of Von-Hippel Lindau?
A) AD
B) AR
C) Sex-linked dominant
D) Sex-linked recessive
E) Spontaneous mutation only
AD
Although 2 copies of the VHL gene must be altered to trigger tumour and cyst formation - a mutation of the second copy commonly occurs during a persons lifetime - often in the brain, retina and kidneys - which is why the tumours are most commonly found in these tissues.
What is the most appropriate management in a patient with ankylosing spondylitis which has failed to be controlled by 2 different NSAIDs?
A) Apremilast
B) Etanercept
C) Methotrexate
D) Rituximab
E) Toclizumab
After 2 NSAIDs, treatment with anti-TNFa is the most appropriate next step. The evidence is strongest for etanercept and adalimumab.
A 72M is reviewed regarding his hypertension. His PMHx includes T2DM and diverticulosis. He is of African-Caribbean origin and he currently takes amlodipine 10mg and metformin. What would be the most appropriate antihypertensive to add?
A) ACEi
B) A-blocker
C) ARB
D) B-blocker
E) Thiazide diuretic
For patients of black African or African–Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor.
A 30M has fine, fair hair and long arms. He has visible kyphosis and mild learning difficulties. He has had seizures in the past. He has previously been reviewed by ophthalmology due to downward dislocation of his lens and severe myopia. He has also been reviewed in haematology clinic with recurrent DVT. What is the most likely diagnosis?
A) Charcot-Marie-Tooth disease
B) Ehlers-Danlos syndrome
C) Fragile X
D) Homocystinurie
E) Marfan syndrome
Tall, long fingered, downward lens dislocation, learning difficulties, DVT - homocystinuria.
Marfan’s syndrome and homocystinuria can be difficult to differentiate clinically. However, Marfan’s syndrome is typically associated with upwards lens dislocation, unlike the downwards dislocation of the lens in this vignette. The heart is rarely affected in homocystinuria, whereas aortic regurgitation is common in Marfan’s. The recurrent thrombosis noted in this case is also more typical of homocystinuria. Marfan’s syndrome is inherited in an autosomal dominant fashion where homocystinuria is inherited in an autosomal recessive fashion.
A 17M presents with 2W of abdominal pain, diarrhoea and repeated episodes of flushing. Examination reveals urticarial skin lesions on the trunk. What test is most likely to reveal the diagnosis?
A) CXR
B) Urinary catecholamines
C) Serum amylase
D) Urinary HIAA
E) Urinary histamine
Given the history of diarrhoea and flushing a diagnosis of carcinoid syndrome should be considered, which would be investigated with urinary 5-HIAA levels. This does not explain the urticarial skin lesions. In a young person a diagnosis of systemic mastocytosis should be considered (average age of patients with a carcinoid tumour = 61).
Urinary histamine is used to diagnose systemic mastocytosis
A 17M presents with 2W of abdominal pain, diarrhoea and repeated episodes of flushing. Examination reveals urticarial skin lesions on the trunk. What test is most likely to reveal the diagnosis?
A) CXR
B) Urinary catecholamines
C) Serum amylase
D) Urinary HIAA
E) Urinary histamine
Given the history of diarrhoea and flushing a diagnosis of carcinoid syndrome should be considered, which would be investigated with urinary 5-HIAA levels. This does not explain the urticarial skin lesions. In a young person a diagnosis of systemic mastocytosis should be considered (average age of patients with a carcinoid tumour = 61).
Urinary histamine is used to diagnose systemic mastocytosis
A 55M who was admitted following a stroke 2W ago is reviewed. Yesterday he started to have a temperature and become more confused. A septic screen has shown radiological evidence of pneumonia. O/E his: RR 36/min, HR112/min, O2 sats 95% on RA and BP 102/66 mmHg. What is the most appropriate antibiotic to use?
A) Teicoplanin
B) Cefuroxime
C) Amoxicillin
D) Imipenem
E) Tazocin
Hospital-acquired pneumonia
-Within 5 days of admission: co-amoxiclav or cefuroxime
-More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)
A 55M who was admitted following a stroke 2W ago is reviewed. Yesterday he started to have a temperature and become more confused. A septic screen has shown radiological evidence of pneumonia. O/E his: RR 36/min, HR112/min, O2 sats 95% on RA and BP 102/66 mmHg. What is the most appropriate antibiotic to use?
A) Teicoplanin
B) Cefuroxime
C) Amoxicillin
D) Imipenem
E) Tazocin
Hospital-acquired pneumonia
-Within 5 days of admission: co-amoxiclav or cefuroxime
-More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)
LMWH has the greatest inhibitory effect on which one of the following proteins involved in the coagulation cascade?
A) Factor IXa
B) Factor XIa
C) Factor Xa
D) Thrombin
E) Factor XIIa
Heparins generally act by activating antithrombin III. Unfractionated heparin forms a complex which inhibits thrombin, factors Xa, IXa, XIa and XIIa. LMWH however only increases the action of antithrombin III on factor Xa.
What is the minimum time period to wait before increasing the dose of metformin from 500mg OD to BD?
A) 3D
B) 5D
C) 1W
D) 2W
E) 4W
Metformin should be titrated slowly, leave at least 1 week before increasing dose.
The BNF states that 500mg should be taken once daily, with breakfast, for at least 1 week. It can then be increased to 500mg twice daily, with breakfast and evening meals, again for 1 week. Subsequently, it can be increased to three times a day (with breakfast, lunch and evening meal), for another 1 week. It can then be titrated upwards once more to a total of 2g daily.
Which of the following is the most likely explanation for a poor response to Hep B vaccine?
A) Anti-retroviral therapy
B) HIV positivity
C) Inadequate dosing of vaccine
D) Previous Hep C infection
E) Vaccination with Hep A
HIV positivity
What is the first line anti-hypertensive for a 45YO patient on lithium therapy?
A) Amlodipine
B) Doxazosin
C) Indapamide
D) Ramipril
E) Valsartan
Amlodipine
Ramipril enhances tubular reabsorption of lithium and should hence be avoided.
What treatment should be given to a patient with acute pericarditis with a background of well-controlled asthma?
A) Clopidogrel, aspirin and fondaparinux
B) Naproxen
C) Colchicine
D) PCI
E) Prednisolone
Naproxen
Colchicine, either alone or in combination with NSAIDs should be given to patients with recurrent pericarditis or with symptoms >14 days.
What treatment option is most appropriate in a patient with PMR unable to wean off prednisolone?
A) Bevacizumab
B) Golimumab
C) Infliximab
D) Rituximab
E) Toclizumab
Toclizumab is an anti-IL6 antibody which has been found to be an effective initial therapy for GCA and as an adjunct to prednisolone.
Which of the following medications are most likely to cause gum hypertrophy?
A) Amlodipine
B) Dapagliflozin
C) Indapamide
D) Ramipril
E) Sitagliptin
Amlodipine, and other CCBs, are a recognised cause of gum hypertrophy.
Which artery supplies the most blood to the greater curvature of the stomach?
A) Gastroduodenal
B) Left gastroepiploic
C) Left gastric
D) Right gastric
E) Short gastric
The left gastroepiploic artery is the largest branch of the splenic artery and supplies several ascending branches to the greater curvature.
The left gastric artery supplies the lesser curvature whilst the gastroduodenal artery supplies the pylorus.
In tennis elbow, tendonitis affecting which muscle causes pain?
A) Biceps
B) Extensor carpi radialis brevis
C) Flexor carpi radialis
D) Flexor carpi ulnaris
E) Flexor digitorum superficialis
Tennis elbow is related to tendonitis affecting the common extensor tendon with most of the pain and restriction of movement related to inflammation of the extensor carpi radialis brevis.
What is the best option for treatment in a patient with primary sclerosis cholangitis?
A) Cholestyramine
B) Mycophenolate
C) Penicillamine
D) Colchicine
E) Ursodeoxycholic acid
Ursodeoxycholic acid has been shown to improve LFTs in patients with early PSC.
A patient has myasthenia gravis which is not controlled on PO prednisolone and pyridostigmine. What is the most appropriate next treatment option?
A) Azathioprine
B) Cyclophosphamide
C) Methotrexate
D) Rituximab
E) Thymectomy
Typical steroid sparing agents (e.g. azathioprine, mycophenolate, cyclosporine) can be used second line in MG. Thymectomies are reserved for patients who have MG resistant to medical therapies and where an obvious thymoma are detected.
Which of these medications should be avoided in pregnancy?
A) Amoxicillin
B) Cefalexin
C) Ciprofloxacin
D) Nitrofurantoin
E) Trimethoprim
Ciprofloxacin - quinolones are not recommended in pregnancy due to the risk of tendon rupture in animal models.
Trimethoprim is a second line option for UTI treatment in pregnancy and, during the first trimester, should be prescribed in conjunction with folic acid.
Which of the following is the most appropriate treatment option for a patient with acromegaly?
A) Cabergoline
B) Lanreotide
C) Metyrapone
D) Pegvisomant
E) Trans-sphenoidal surgery
Lanreotide is a long-acting analogue of somatostatin, like octreotide. They are used to reduce pre-operative mortality.
Pegvisomant is a GH antagonist that blocks the peripheral synthesis of IGF-1 - it is third line therapy in patients who fail to gain control of symptoms on somatostatin analogues combined with dopamine agonists.
Which of the following is the most appropriate treatment option for a patient with acromegaly?
A) Cabergoline
B) Lanreotide
C) Metyrapone
D) Pegvisomant
E) Trans-sphenoidal surgery
Lanreotide is a long-acting analogue of somatostatin, like octreotide. They are used to reduce pre-operative mortality.
Pegvisomant is a GH antagonist that blocks the peripheral synthesis of IGF-1 - it is third line therapy in patients who fail to gain control of symptoms on somatostatin analogues combined with dopamine agonists.
A patient has presented with new-onset Graves disease and is 28W pregnant. Which of the following is the most appropriate intervention?
A) Carbimazole
B) Carbimazole and thyroxine
C) Propranolol
D) Propylthiouracil
E) Propylthiouracil and thyroxine
Carbimazole is safe to give later on in pregnancy, propylthiouracil used later in pregnancy is associated with increased risk of hepatic dysfunction. Propylthiouracil is preferred in early pregnancy.
Which of the following features of rheumatoid arthritis stratifies aggressive joint disease?
A) Acute onsent
B) Anti-CCP positivity
C) CRP 89
D) ESR 62
E) RF +ve
Anti-CCP is predictive of significantly more radiological damage, independent of RF status
Which of the following is the most appropriate intervention for a patient presenting with symptomatic pulmonary disease secondary to sarcoidosis?
A) Azathioprine
B) High dose fluticasone
C) Infliximab
D) Mycophenolate mofetil
E) PO prednisolone
Oral corticosteroids are the mainstay of initial therapy for sarcoidosis, although treatment is only indicated for patients with symptomatic pulmonary disease or have hypercalcaemia.
What is the most appropriate initial intervention for a patient with carpal tunnel syndrome?
A) Acupuncture
B) Gabapentin
C) Local corticosteroid injection at the wrist
D) Regular NSAIDs
E) Surgical carpal tunnel release
Local corticosteroid injection at the wrist are the most appropriate initial intervention.
NSAIDs have been shown to be no better than placebo.
Which of the following medications can be used to treat early NASH on a background of obesity, HTN and T1DM?
A) Atorvastatin
B) Fenofibrate
C) Liraglutide
D) Metformin
E) Pioglitazone
Liraglutide is licensed for the treatment of obesity where HTN and T2DM are present.
What is the MOA of exenetide?
A) Alpha glucosidase inhibitor
B) DPPIV inhibitor
C) GLP-1 agonist
D) PPAR-gamma activator
E) SGLT-2 inhibitor
GLP-1 agonist
Empagliflozin = SGLT2 inhibitor
What is the best intervention for a pregnant patient who has been exposed to two people who have just been diagnosed with Hepatitis A?
A) Advice on avoidance of paracetamol
B) Hepatitis A IgM testing
C) Hepatitis A vaccination
D) Weekly LFTs
E) Reassurance
Hepatitis A vaccination. PEP may reduce the risk of infection occurring, especially given serious sequelae are more common in pregnancy.
What is the most appropriate treatment for Yersinia diarrhoea infection?
A) Amoxicillin
B) Cephalexin
C) Gentamicin
D) Loperamide
E) Ofloxacin
Yersinia is sensitive to treatment with quinolones, co-trimoxazole and tetracyclines. Ofloxacin and gentamicin could both be options (ofloxacin preferred in renal impairment).
A 33F is admitted due to R-sided weakness. She has a past history of DVT following the birth of her daughter. She has also had two miscarriages. A CT head confirms an ischaemic stroke in the left MCA territory. What is the likely finding on echocardiography?
A) Normal
B) Dilated cardiomyopathy
C) Bicuspid aortic valve
D) ASD
E) VSD
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. Hence it is likely the echo will show a normal result.
What is the best screening test for hereditary angioedema between attacks?
A) Immunoglobulins
B) Mast cell tryptase
C) C1 esterase inhibitor
D) C2
E) C4
C4 is the most reliable screening test for hereditary angioedema.
C1-INH can be tested during an acute attack of hereditary angioedema and are often low. However, this is not a valid screening tool for hereditary angioedema and so shouldn’t be performed between episodes.
Which one of the following adverse effects is most strongly associated with cabergoline?
A) Optic neuritis
B) Transient rise in LFTs
C) Pulmonary fibrosis
D) Renal failure
E) Thrombocytopenia
Pulmonary fibrosis
Which one of the following conditions would contraindicate the prescription of bupropion?
A) History of SVT
B) Previous acute pancreatitis
C) Epilepsy
D) Depression
E) Hypertension
Bupropion should not be used in a patient with epilepsy as it reduces seizure threshold.
Which one of the following conditions would contraindicate the prescription of bupropion?
A) History of SVT
B) Previous acute pancreatitis
C) Epilepsy
D) Depression
E) Hypertension
Bupropion should not be used in a patient with epilepsy as it reduces seizure threshold.
A patient has been titrated up to 75mg OD amitriptyline for neuropathic pain that is still not well controlled. What is the next most appropriate management strategy to manage her pain?
A) Stop amitriptyline and start duloxetine
B) Continue amitriptyline at current dose and re-review in 2W
C) Continue amitriptyline at current dose and start duloxetine
D) Increase amitriptyline in gradual increments over 6W
E) Refer to pain clinic for increasing dose of amitriptyline
The NICE guidelines advise that when a first-line medication is not effective then that medication should be stopped and another first-line medication should be tried. Neuropathic medications should be given as monotherapy outside of specialist pain clinics.
When prescribing amitriptyline it should be trialled for a period of 6-8 weeks with at least 2 weeks at the maximum dose.
What is the mechanism of action of azathioprine?
A) Inhibits purine synthesis
B) Inhibits inosine monophosphate dehydrogenase
C) Mercaptopurine antagonist
D) Thiopurine methyltransferase inhibitor
E) Causes cross-linking in DNA
Azathioprine is metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis. A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.
What is the first line antibiotic in the treatment of Shigella dysentery?
A) Flucloxacillin
B) Vancomycin
C) Ciprofloxacin
D) Metronidazole
E) Ampicillin
Shigella infection is usually self-limiting and does not require antibiotic treatment. Antibiotics (e.g. ciprofloxacin) are indicated for people with severe disease, who are immunocompromised or with bloody diarrhoea.
Which of the following would cause a normal anion gap metabolic acidosis?
A) DKA
B) Salicylate poisoning
C) Renal tubular acidosis
D) Methanol poisoning
E) Sepsis
Renal tubular acidosis causes a normal anion gap. Diarrhoea is also a cause of normal anion gap acidosis.
The remaining 4 choices would give a raised anion gap.
Diabetic ketoacidosis - ketones
Salicylate and methanol - exogenous acid poisons
Sepsis - lactate
What is the most likely adverse effect associated with cisplatin-based chemotherapy?
A) AF
B) Dilated cardiomyopathy
C) HUS
D) Pulmonary fibrosis
E) Transitional cell carcinoma of the bladder
Rhythm disturbances are common in patients treated with cisplatin-based chemotherapy, with AF seen in approximately 1 in 25.
Pulmonary fibrosis is seen in patients with bleomycin based chemotherapy. TCC is seen with increased risk in people with cyclophosphamide based therapy.
What treatment should be offered to patients with pemphigus vulgaris that has not responded to PO prednisolone and azathioprine?
A) Change azathioprine to cyclophosphamide
B) Change azathioprine to methotrexate
C) IVIG
D) IV rituximab
E) Plasma exchange
When rituximab is added to traditional therapies (prednisolone + steroid sparing agent), remission can be achieved in 80% of patients. IVIG IS an alternative to rituximab but it is slower to improve symptoms.
What is the mode of inheritance of hereditary hypophosphataemic rickets?
A) AR
B) AD
C) Mitochondrial
D) X-linked dominant
E) X-linked recessive
X-linked dominant
X-linked dominant means the disease will present in women but not as severely as in men (who only have one X chromosome)
A patient suffering from HFrEF post anterior MI is currently taking DAPT, ramipril, bisoprolol, atorvastatin and furosemide. Which medication should be added for long term improvement?
A) Digoxin
B) Eplerenone
C) Increase furosemide
D) Valsartan
E) Switch ramipril to valsartan sacubitril
Eplerenone is an aldosterone receptor antagonist - it is indicated as an adjunct to therapy in patients with LVF<40% and following an MI.
Which antibodies are most likely to be found in a patient with mixed connective tissue disease?
A) Anti-Jo1
B) Anti-Ro
C) Anti-Scl70
D) Anti-smooth muscle
E) Anti-U1 RNP
Anti-U1 RNP
You have a strong suspicion a patient is suffering from Lyme disease but there is no rash. What is the next most important step?
A) Amoxicillin
B) Clarithromycin
C) Doxycycline
D) Lyme serology
E) Prednisolone
If there is a high suspicion of Lyme disease, even if no rash (erythema migrans) is present, patients should be treated with doxycycline without waiting for the results of Lyme serology.
What is the most appropriate intervention for pneumocystis prophylaxis in a HIV positive patient with previous PCP pneumonia and a CD4 count of 140?
A) Dapsone
B) Dapsone + trimethoprim
C) Pentamidine
D) Pyrimethamine
E) Trimethoprim-sulfamethoxazole
For patients with a CD4 count of <200 and previous episode of PCP, they are at a significant risk of a future episode. Prophylaxis with trimethoprim-sulfamethoxazole is recommended.
