MRCP OFFICIAL PAPER 2

Question 1

Treatment for erythrodermic psoriasis?

Answer 1

Erythroderma is a term used when more than 95% of the skin is involved in a rash of any kind.
‘red man syndrome’

Initial treatment is with topical white soft paraffin smeared all over the skin, which helps to make the skin more comfortable, partially reduces the inflammation, improves the skin barrier, thus helping to prevent entry of bacteria through the skin (), and helps to reduce water loss from the skin (and prevent dehydration).

Question 2

Which protein is abnormal in Marfan’s syndrome?

Answer 2

Marfan’s syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1.

Question 3

At laparotomy, bowel was found to be ischaemic from the lower part of the duodenum through to midway along the transverse colon.
What artery is most likely to be occluded?

Answer 3

Superior Mesenteric Artery.

The superior mesenteric arises from the abdominal aorta and supplies the small intestine from the distal duodenum as well as the large intestine as far as 2/3 of the transverse colon.

Question 4

Erythematous, scaly rash involving the nasolabial folds and eyebrows, and the skin overlying the sternum. There was mild scaling of the scalp. The nails were normal.

What is the most likely diagnosis?

Answer 4

Seborrhoeic dermatitis

Question 5

Mx for fungal nail infections?

onychomycosis

Answer 5

if limited involvement - topical treatment with amorolfine 5%

if more extensive involvement due to a dermatophyte infection: oral terbinafine is currently recommended first-line; 6 weeks - 3 months therapy is needed for fingernail infections whilst toenails should be treated for 3 - 6 months

Question 6

With which condition is H. pylori infection most strongly associated?

Answer 6

Duodenal ulcers

Duodenal ulcers have a strong association with Helicobacter pylori, with over 90% of patients with duodenal ulcers being H. pylori positive. There is also an association with gastric ulceration and carcinoma but to a lesser degree.

GORD is not particularly associated with H. pylori since infection tends to reduce gastric acid secretion.

Question 7

Pulse abnormality seen in cardiac tamponade?

Answer 7

Pulsus paradoxus

Question 8

What additional information would be most useful to support a diagnosis of syndrome of inappropriate antidiuretic hormone?

Answer 8

Thyroid function tests.

SIADH is a diagnosis made once other causes of hyponatraemia are ruled out such as hypocortisolaemia, thyroid dysfunction (hypothyroidism) and adequate renal function.

Question 9

What receptors are chiefly involved in mediating the antipsychotic effects of risperidone?

Answer 9

The primary mechanism of action of antipsychotic drugs is dopamine receptor antagonism.

Question 10

A 68-year-old woman with atrial fibrillation presented for DC cardioversion. The procedure resulted in successful restoration of sinus rhythm.

Which drug would be most likely to maintain sinus rhythm following this procedure?

Answer 10

Amiodarone.

Question 11

Ix for Addison’s disease?

Answer 11

In a patient with suspected Addison’s disease the definite investigation is an ACTH stimulation test (short Synacthen test). Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM.

Question 12

A 32-year-old man presented with weight loss and feeling generally unwell. On direct questioning, he had been having dizzy spells, especially on sudden changes in posture.

On examination, he was tanned. There was a postural drop in his BP.

What is the most likely biochemical finding?

Answer 12

Plasma adrenocorticotropic hormone 95 pmol/L (3.3–15.4)

The clinical picture is compatible with primary adrenal failure. In a young person, Addison’s disease is the most likely cause. The adrenocorticotropic hormone (ACTH) will be raised in the absence of negative feedback due to cortisol deficiency.

• hyperkalaemia
• hyponatraemia
• hypoglycaemia
• metabolic acidosis

Question 13

MOA of isosorbide mononitrates?

Answer 13

Increased cyclic guanosine monophosphate (GMP) production

Question 14

A 25-year-old man presented with a 5-day history of foul-smelling diarrhoea, abdominal pain, nausea, bloating and flatulence. He had returned from a holiday in Borneo 1 week previously.

On examination, he appeared dehydrated. Examination was otherwise normal.

Stool microscopy: trophozoite and cysts

Answer 14

Giardia intestinalis.

the history of small bowel malabsorptive symptoms and of travel to an endemic area is suggestive of giardiasis. This is confirmed by the finding of trophozoites and cysts on microscopy.

Mx: Metronidazole

Question 15

Which antibiotics cause prolonged QT?

Answer 15

Antimicrobials that cause QT prolongation are:
- Erythromycin, Clarithromycin
- Moxifloxacin
- Fluconazole and Ketoconazole.

Question 16

Which coagulation factor is most likely to be present at a reduced activity in patient taking Warfarin?

Answer 16

Warfarin inhibits the vitamin K-dependent synthesis of clotting factors including factor II, VII, IX and X as well as the regulatory factors protein C and protein S.

Question 17

Blood abnormality seen in osteomalacia?

Answer 17

1. Low vitamin D levels
2. Low calcium
3. Low Phosphate
4. Raised alkaline phosphatase

Mx: Vitamin D supplementation (Colecalciferol)

Question 18

A 55-year-old woman presented with a 2-month history of lower back pain, for which she had been taking paracetamol 4 g daily. She admitted to drinking 16 units of alcohol per week.

serum alanine aminotransferase 55 U/L (5–35)
serum aspartate aminotransferase 29 U/L (1–31)
serum alkaline phosphatase 90 U/L (45–105)

serum IgG 21.0 g/L (6.0–13.0)
serum IgA 2.4 g/L (0.8–3.0)
serum IgM 1.8 g/L (0.4–2.5)

What is the most likely cause of her abnormal liver function tests?

Answer 18

Autoimmune hepatitis.

The raised IgG levels suggests autoimmune hepatitis and a diagnosis can be provisionally made while awaiting the autoantibody profile.

The ratio of alanine aminotransferase (ALT) to aspartate aminotransferase (AST) is greater than 1, which favours autoimmune or viral over alcoholic cause.

Question 19

Artery occluded in posterior MI?

Answer 19

Posterior descending artery.

It is the left circumflex artery that supplies the posterior descending artery in around 15% of people, called a left dominant system.

In 85% of people, the posterior descending artery arises from the right coronary artery, called a right dominant system.

Question 20

What investigation is most appropriate for assessing response to Hep C antiviral medication?

Answer 20

HCV Viral Load.

Guidance for monitoring response to treatment of hepatitis C is by finding a sustained virological response using HCV viral load.

Question 21

A 67-year-old woman presented with palpitations and a goitre. Propranolol was started to improve her symptoms.

On examination, she had a coarse tremor and sweaty palms, but no thyroid eye signs.

Low TSH
Raised T4

technetium-99m scan of thyroid: increased uptake in right upper lobe, with uptake suppressed in rest of thyroid gland.

What is the most appropriate treatment for her thyroid condition?

Answer 21

Radioiodine.

This case highlights the treatment of an autonomous nodule causing hyperthyroidism (‘toxic adenoma’). The technetium-99m scan highlights the focus of overactivity and does not suggest thyroiditis, therefore prednisolone is not required. The lack of eye signs is further reassurance.

Total thyroidectomy is not an appropriate treatment option given the localisation of the increased activity to the right upper lobe. While carbimazole and propylthiouracil may be an interim treatment, the overactivity would still continue if the medication was stopped and therefore the more appropriate (and definitive) treatment is radioiodine.

Question 22

A 37-year-old woman presented with a 1-day history of abdominal pain and diarrhoea.

On examination, she was drowsy and hallucinating, and had widespread purpura.

Investigations:

haemoglobin 92 g/L (115–165)
white cell count 13.3 × 109/L (4.0–11.0)
platelet count 17 × 109/L (150–400)
serum creatinine 195 µmol/L (60–110)

What abnormality is most likely to be present on blood film examination?

Answer 22

Fragmented cells.

The patient presents with gastrointestinal and neurological symptoms, and the blood results show anaemia, thrombocytopaenia and renal impairment. The neurological features and marked thrombocytopaenia would be in keeping with thrombotic thrombocytopaenic purpura (TTP). Both TTP and HUS are associated with microangiopathic haemolytic anaemia (MAHA). An important blood film feature of MAHA is the presence of fragmented red cells.

Question 23

Formula for calculating serum osmolality?

Answer 23

Calculated osmolality = (2 × Na) + (2 × K) + glucose + urea (all in mmol/L).

As potassium is present and concentration is higher than 5 mmol/L, accounting for this and associated anions should be made by using the formula including potassium multiplied by 2.

Question 24

Organism seen in lyme disease as well as rash?

Answer 24

Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks.

Erythema migrans: ‘Bulls-eye’ rash is typically at the site of the tick bite.

Headache, fever, lethargy, heart block.

dont forget can develop LMN FACIAL PALSY.

1. Doxycycline if early disease. 2. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)
   People with erythema migrans should be commenced on antibiotic without the need for further tests.

Question 25

Alternative medication for urge incontinence in a patient who did not find oxybutynin beneficial?

Answer 25

As oxybutynin was ineffective, another antimuscarinic drug, like solifenacin, should therefore be used.

Question 26

Mx for GCA?

Answer 26

anterior ischemic optic neuropathy accounts for the majority of ocular complications. It results from occlusion of the posterior ciliary artery (a branch of the ophthalmic artery) → ischaemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins.

1. Urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy.
2. If there is no visual loss then high-dose prednisolone is used.
3. If there is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone.

Urgent ophthalmology review

Bone protection with bisphosphonates.

Question 27

A 72-year-old woman presented with progressive tiredness over the past few months and was found to have iron deficiency anaemia. She had osteoarthritis and was regularly taking ibuprofen and paracetamol.

Investigations:

UGI Endoscopy: 1-cm duodenal ulcer with no evidence of recent bleeding; Helicobacter pylori negative
She was treated with omeprazole.

What is the most appropriate next investigation?

Answer 27

Colonoscopy.

Iron deficiency anaemia (IDA) in a 72-year-old person can be caused by underlying malignancy in up to 10% of cases. This is often right-sided colonic cancers, which are otherwise asymptomatic and, therefore, a colonoscopy is almost always required in such cases. Repeat endoscopy is not required to assess healing of duodenal ulcer. CT scan is less sensitive than colonoscopy in identifying colonic pathology and should only be considered if there are contraindications to colonoscopy.

Question 28

What is the site of origin of circulating B-type natriuretic peptide in patients with chronic heart failure?

Answer 28

B-type natriuretic peptide is released from myocytes in the cardiac ventricles in response to stretch-associated high ventricular filling pressures.

Question 29

Adverse effect of treatment with Cisplastin?

Answer 29

Sensory Neuropathy
Ototoxicity

Question 30

A 52-year-old woman presented with a 6-month history of upper limb weakness that had progressed to affect her lower limbs. Over the previous 2 months, she had been complaining of increasing dysphagia to liquids more than solids, and worsening shortness of breath at rest.

On examination, she had a brisk jaw jerk, tongue fasciculations and MRC grade 4 muscle power in shoulder abduction and hip flexion bilaterally.

What is the most likely diagnosis?

Answer 30

The short, progressive, purely motor history with upper motor neuron (UMN) and lower motor neuron (LMN) signs is characteristic of motor neurone disease (MND).

Multiple sclerosis would not cause LMN signs (tongue fasciculation), myasthenia gravis can mimic MND but would not cause the signs and tends to be fatigable not progressive, spinobulbar muscular atrophy usually has a much longer history and LMN only, and syringobulbia would most likely produce sensory involvement.

Question 31

What criteria makes patient unable to donate blood?

Answer 31

People who have been transfused will not be accepted as blood donors, in order to reduce the risk of transmitting prion diseases such as variant Creutzfeldt–Jakob disease to recipients.

Question 32

What is the best graphical method for illustrating the relation between age and BP?

Answer 32

A scatter plot facilitates the charting of two continuous variables, allowing the correlation to be calculated.

Question 33

What is the main site of action of haloperidol?

Answer 33

Area Postrema.

Haloperidol is a D2-receptor antagonist. It has a central antiemetic action, binding to receptors in the area postrema, which is a medullary structure controlling vomiting.

Question 34

A 76-year-old man presented with a 3-year history of a gradually enlarging red patch on his leg. He was an ex-serviceman who had worked in the Mediterranean for several years.

O/E erythematous scaly patch, 5 × 6 cm in diameter, on his shin. The edge was well demarcated.

What is the most likely diagnosis?

Answer 34

Bowen’s disease (BD) is a sunlight-induced skin disease, classified either as an early noninvasive stage or intraepidermal form of squamous cell carcinoma which if left undiagnosed, untreated, or neglected has <10% chance of malignant transformation into invasive squamous cell carcinoma of the skin. It usually appears as a erythematous, scaly or crusty patch or plaque anywhere on the body but most commonly involves lower legs, with other possible sites of involvement to be head, neck, genitals, and skin folds.

Question 35

In patients with penicillin allergy which Abx should be avoided?

Answer 35

This is a patient with a history suggestive of anaphylaxis to a penicillin. Therefore, beta-lactam drugs should be avoided. This excludes ceftriaxone, meropenem and piperacillin with tazobactam.

Question 36

MOA of Ropinirole?

Answer 36

Ropinirole is an agonist at dopamine receptors and is used as an adjunct to levodopa to treat Parkinson’s disease.

Question 37

Which muscle responsible for torticollis?

Answer 37

Sternocleidomastoid.

Question 38

Most common causative organism for Acute epiglottitis?

Answer 38

Haemophilus influenzae.

Question 39

Which cellular component contains double-stranded circular DNA?

Answer 39

Mitochondrion.

Mitochondrial DNA is matrilineal and is in a covalently bonded circular form. Maternally inherited diseases are associated with mutations in this DNA.

Question 40

Condition in which there is normal pO2 but decreased oxygen saturation?

Answer 40

Methaemoglobinaemia describes haemoglobin which has been oxidised from Fe2+ to Fe3+.

Question 41

Mx for Pemphigus vulgaris?

Answer 41

The combination of flaccid bullae (e.g. large blisters) with recent oral ulceration suggests that this is likely to be pemphigus vulgaris. Therefore, oral prednisolone is the most appropriate empirical treatment until the diagnosis is confirmed by histology and direct immunofluorescence of the skin biopsy.

Question 42

cluster of lymph nodes at appendix suggestive of mesenteric adenitis
What is the most likely cause of his symptoms?

Answer 42

Yersinia enterocolitica infection.

Yersiniosis is an infection caused most often by eating raw or undercooked pork contaminated with Yersinia enterocolitica bacteria.

Develop right sided abdominal pain which may be confused for appendicitis.

Question 43

What associated finding is a contraindication to surgical resection?

Answer 43

Superior vena cava obstruction.

The presence of superior vena cava obstruction at presentation is indicative of locally advanced and invasive disease, and portents inoperability and overall poorer survival outcomes.

Question 44

MOA of Alteplase?

Answer 44

Acceleration of plasminogen to plasmin conversion.

Question 45

Which transplant drug can cause tremor?

Answer 45

Tacrolimus.

It is typically worse in the first few months post transplantation because the target levels of tacrolimus are higher to cover the increased risk of rejection.

Question 46

MOA of renal injury with Aciclovir?

Answer 46

Crystalluria.

Aciclovir is renally eliminated. In the presence of dehydration, aciclovir can precipitate as crystals in the kidney tubules causing acute kidney injury.

Question 47

Ix of choice for diagnosis of suspected Hodgkin lymphoma?

Answer 47

Excision biopsy of cervical lymph node.

Fine-needle aspiration is likely to yield insufficient material for diagnostic purposes in Hodgkin lymphoma.

Question 48

In atherosclerosis, what is the origin of foam cells?

Answer 48

Monocytes.

Foam cells are the fat-laden M2 macrophages that serve as the hallmark of early-stage atherosclerotic lesion formation.

Question 49

What antinuclear antibody isotype immunoglobulin is most likely to indicate a diagnosis of SLE?

Answer 49

IgG antinuclear antibodies are associated with systemic lupus erythematosus.

Question 50

Abx for prophylaxis of meningitis in household contacts?

Answer 50

Ciprofloxacin.

Management:
people who have been exposed to a patient with confirmed bacterial meningitis should be given prophylactic antibiotics if they have close contact within the 7 days before onset.

Oral Ciprofloxacin or Rifampicin may be used. Guidelines state ciprofloxacin is the drug of choice as it is widely available and only requires one dose.

meningococcal vaccination should be offered to close contacts when serotype results are available, including booster doses to those who had the vaccine in infancy.

Question 51

Abx choice for Meningitis?

Answer 51

Initial empirical therapy

• Aged 3 months - 50 years: Intravenous cefotaxime (or ceftriaxone)
• Initial empirical therapy aged > 50 years: Intravenous cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)

Meningococcal meningitis: Intravenous benzylpenicillin or cefotaxime (or ceftriaxone)

Question 52

Which condition besides haemachromatosis can caused raised ferritin?

Answer 52

Adult-onset Still disease is a rare inflammatory arthritis with fevers, rash, and joint pain.

It is a systemic inflammatory illness. Clinical features include fever, joint pain/inflammation and evanescent macular rash. A characteristic lab feature is very high levels of ferritin; additional lab features include anaemia, leukocytosis and high acute-phase reactants.

Haemochromatosis would not cause systemic inflammatory illness