Part 2 Sample Questions Explanations

7/29/2019 Part 2 Sample Questions Explanations

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Part 2 explanation updated Mar-12

MRCP(UK) Part 2 Written Sample Questions Explanations

This document provides explanations of what the correct answers are for each question.


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Q1Answer Key: B

The patient has a raised serum creatinine with hypocalcaemia and a raised serum phosphate. This patterns consistent with chronic kidney disease (CKD) with impaired renal phosphate secretion and deficientactivation of vitamin D (leading to impaired gut absorption of calcium and hypocalcaemia). The raisedplasma parathyroid hormone is due to secondary hyperparathyroidism in an attempt to restore the serum

calcium concentration to normal. The leg pain is arising from renal bone disease.

Explanation:

The correct answer is B. Correction of the vitamin D deficiency is the key to restoring normal calciumhomeostasis, and must be with 1- hydroxycolecalciferol (alfacalcidol) which replaces the deficientactivation step in CKD. Ergocalciferol cannot be activated in CKD.

Q2Answer Key: E

Historically, the presence of liver metastases complicating colorectal carcinoma would have meantnoperable disease. However, in selected cases, a 5-year survival rate of up to 30% can be achieved byresection of the primary colonic tumour and liver metastases. Biopsy of the liver lesions would potentiallyseed the tumour, and render the patient inoperable.

Explanation:

Q3Answer Key: A

The protozoa Cryptosporidium parvum is a common cause of infectious diarrhoea. In healthy persons itusually causes a self-limiting illness. However in the immunocompromised it can cause severe, prolonged

diarrhoea and treatment is very difficult. Cryptosporidium parvum is diagnosed by performing an acid-faststain on faeces and this demonstrates the characteristic cysts of this protozoa.

Explanation:

n the severely immunocompromised patient, Pneumocystis jirovecii typically causespulmonary infections and Toxoplasma gondii causes cystic brain lesions. Entamoebahistolytica and Giardia lamblia are both intestinal protozoa but they are not detected byacid-fast staining methods. Entamoeba histolytica causes dysentery and Giardia lambliacauses flatulence, steatorrhoea and abdominal pain.

Q4Answer Key: B

This elderly womans serum creatinine has risen from normal to 252 mol/L in less than 6 months. Thiseature along with tiredness, arthralgia, a urinalysis that shows moderate amounts of protein and blood,and a mild anaemia makes it likely that she has an ANCA-associated vasculitis. A crescenticglomerulonephritis is the typical renal histological finding in these circumstances.

Explanation:

The other options are all much less likely to cause rapid development of renal failure. In addition, renalamyloidosis and membranous nephropathy usually present with the nephrotic syndrome, and IgAnephropathy and membranoproliferative glomerulonephritis are very much less common at this age.


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Q5Answer Key: E

The clinical scenario suggests a patient with gram negative bacteraemia and shock. Septic shock ischaracterised by hypotension due to systemic arteriolar vasodilatation, and there is a normal or increasedcardiac output. Cardiac filling pressures are usually low or normal.

Explanation:

The correct answer is E which describes hypotension, low-normal right and left heart filling pressures, and

ow-normal cardiac output.

Q6Answer Key: E

This man has developed acute on chronic Type II respiratory failure. He had previously undergone a rightsided thoracoplasty as treatment for TB (an operation which was commonly performed in the 1940s / early1950s before the advent of combination TB chemotherapy). It is likely that he has decompensatedbecause of left lower lobe pneumonia.

Explanation:

The preferred initial form of treatment and correct answer for his respiratory failure is non invasive

ventilation (NIV)- answer E to provide assisted ventilatory support. This is preferable to CPAP in thecontext of a raised pCO2 . Doxapram is less effective and more toxic than NIV (risk of arrhythmias) andhere is no suggestion of bronchospasm or cardiac failure thus aminophylline and furosemide are notndicated.

Q7Answer Key: A

A pulmonary embolus in a 34 year old woman who also has livedo reticularis and a prolonged APTT

suggests either primary antiphospholipid antibody syndrome or SLE with secondary antiphospholipidantibody syndrome. The cold intolerance probably alludes to Raynauds phenomenon.

Explanation:

Thrombocytopenia is more of a feature of SLE than primary antiphospholipid antibody syndrome.However, as the ANA is negative and there is no evidence of complement activation, SLE is ruled out.There is nothing in the history to suggest cryoglobulinaemia, mixed connective tissue disease orhrombotic thrombocytopenic purpura.

Q8Answer Key: C

This young woman has developed an exanthem shortly after a sore throat. The description of the rash, inparticular the size of the lesions, scaling and widespread distribution with relative sparing of the face, isypical of guttate psoriasis. The main differential diagnoses to consider in this setting are pityriasis roseawhich is also common in this age group and follows a sore throat) and secondary syphilis, but these

options are not given. The other diseases given would only follow a sore throat co-incidentally. Atopiceczema does not generally produce scaly papules. The papules in lichen planus are classically flat-toppedand not scaly. Pityriasis versicolor presents with scaling and pigment change rather than papules.Dermatitis artefacta can present in many different ways but not as a widespread scaly rash, and shouldonly be considered when other pathologies have been excluded.

Explanation:


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Q9Answer Key: D

The patient has recently received potent, broad-spectrum antibiotics in hospital. These risk factors, the CTindings and the timescale support a diagnosis of hospital acquired infection such as Clostridium difficile,he causative organism of pseudomembranous colitis. Cryptosporidiosis would be an important differentialdiagnosis in more chronic immunosuppressed states (such as HIV infection), but is unlikely after just 2cycles of solid tumour chemotherapy. Acute diarrhoea would be a very unusual symptom of progressive

solid malignancy even in patients with peritoneal disease. There are no additional features in the stem tosuggest diverticular disease or ischaemic colitis in this patient.

Explanation:

Q10Answer Key: C

This person has low level IgG kappa paraprotein, with no evidence of end-organ damage (normalhaemoglobin, serum calcium, serum creatinine and plain X-rays of skeleton), or immune paresis. This isentirely in keeping with an IgG monoclonal gammopathy of unknown significance.

Explanation:

AL amyloidosis is most commonly associated with renal or cardiac impairment, of which she has noevidence. A low-grade lymphoma is most likely to present with palpable lymphadenopathy orsplenomegaly (the examination is normal here). Myeloma can occur with low levels of paraprotein, but ismost commonly associated with a higher level of paraprotein, immune paresis and evidence of end-organdamage. A plasmacytoma, by definition, is a solitary lump of plasma cells, usually detected on plain X-raysof skeleton and/or MR scan of thoracolumbar spine. There is nothing to suggest this here.

Q11Answer Key: B

Any patient who is receiving 40 mg or more of prednisiolone for more than 7 days or who is taking 20 mgor more of prednisolone for more than 14 days is classed as immunocompromised. Patients receivingower doses of prednisolone (or equivalent doses of other corticosteroids) are not considered to bemmunocompromised unless they are taking additional immunosuppressive medication. The patient has aprimary chickenpox infection, and because he is immunocompromised there is a high risk that this willprogress to cause chickenpox pneumonia which can be fatal. As he already appears to be systemicallyunwell he needs intravenous rather than oral aciclovir. Oral valaciclovir or famciclovir would also bereasonable options. There is no reason to suspect a bacterial infection at present so flucloxacillin is notndicated. It is too late to give varicella zoster immunoglobulin because he has already developed asymptomatic infection. However varicella zoster immunoglobulin could have been given within 7 days of

his son developing chicken pox if the patient had sought medical attention at that time.

Explanation:


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Q12Answer Key: D

The image shows destruction of the terminal phalanges and subperiostial erosions in the first and secondphalanges. These features are consistent with hyperparathyroidism. There is incidental vascularcalcification in the digital arteries which is common in end stage renal disease. As the patient is onhaemodialysis then the most likely diagnosis is secondary hyperparathyroidism as a result of deficientactivation of vitamin D by the kidneys. Gout would result in destructive arthritis, amyloid would not cause

bone destruction and scleroderma would result in soft tissue loss and probable calcinosis.

Explanation:

Q13Answer Key: B

This is a question about episodic inflammatory arthritis. The most common reason for this would be crystalarthritis, either gout or pseudogout. The serum uric acid is normal, but it can be normal in both of theseconditions. The history of alcohol is perhaps suggesting gout is a more likely possibility. However, whenwe get further information that this man also has MCP involvement with hepatosplenomegaly and type 2diabetes, it does point us in the direction of this being more systemic problem.

Explanation:

The only plausible option is haemacromatosis, which can create an episodic arthritis. Alcoholic cirrhosis isnot associated with any crystal arthritis. Palindromic rheumatism and rheumatoid arthritis producesymmetrical joint involvement. The arthritis of sarcodosis is typically large joint, and in a younger agegroup. Therefore, the best answer is haemochromatosis leading to chondrocalcinosis and pseudogout.

Q14Answer Key: E

The presence of diarrhoea and faecal incontinence in an elderly patient with a history of diverticulardisease and taking a codeine preparation analgesic raises the suspicion of faecal impaction with overflowaecal incontinence. The abdominal examination findings would support this diagnosis. An empty rectumon digital rectal examination does not exclude high faecal impaction therefore the appropriate nextnvestigation here is a plain X-ray of abdomen (answer E) looking for evidence of faecal loading and/orsmall or large bowel dilatation.

Explanation:

Q15Answer Key: A

We are shown a picture of a 75-year old man with painful left leg with bowing of the tibia. The most likelyexplanation of this picture is Pagets disease and the most likely treatment therefore is bisphosphonateherapy.

Explanation:


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Q16Answer Key: B

This mans presentation of acute pancreatitis was most likely due to hypertriglyceridaemia; he does nothave evidence of gallstones or diabetes, his alcohol intake is not excessive and his LDL-cholesterol is onlymoderately elevated.

Explanation:

All the drugs, except ezetimibe, lower triglycerides to some degree, but fibrates are most effective and thusmost appropriate.

Q17Answer Key: D

This is a difficult question as pseudomyxoma peritonei is extremely rare and such an image is highlyunusual. However, the correct answer can be deduced by process of elimination. Ascites would have agravitational distribution and could not be loculated around the liver in this way. Constipation is clearlyncorrect as this could not produce these extraluminal changes. Hepatocellular carcinoma can producemultifocal intrahepatic lesions, but in this image, most of the abnormalities can be clearly seen to becompressing the liver from the outside suggesting an extrahepatic cause. Retroperitoneal haemorrhage ofsufficient magnitude to cause these changes would not be compatible with the patients history.

Explanation:

Q18Answer Key: C

The development of livido reticularis, skin ulceration and eosinophilia in a patient with atheromatousvascular disease who has recently started taking warfarin is highly suggestive of atheroembolism.

Explanation:

None of the other conditions is usually associated with eosinophilia. The patient has low

evels of anticardiolipin antibody, but these are present in up to 10% of the general populationand are not diagnostic of the antiphospholipid antibody syndrome. In addition,antiphospholipid antibody syndrome does not usually cause skin ulceration. Calciphylaxisusually occurs in patients with higher levels of PTH, calcium and phosphate. Coumarinnecrosis typically occurs within 2 weeks of starting warfain. Thromboembolism fromarteriovenous fistula would not cause skin changes in the trunk and legs.

Q19Answer Key: A

The main differential diagnosis lies between a pulmonary embolism and an exacerbation of herbronchiectasis with a developing left lower lobe pneumonia. A CTPA (Answer A) allows imaging of bothhe pulmonary vasculature and the lung parenchyma and is the correct answer. A D-dimer is non specificand used as a test of exclusion when thromboembolism is considered less likely, rather than a diagnosticest. An echocardiogram is unlikely to show any right sided intracardiac clot in the absence ofcardiovascular collapse. An ultrasound scan will at best give circumstantial evidence of thromboembolicdisease (right ventricular volume overload) but is better to visualise the pulmonary vasculature with aCTPA if available.

Explanation:

A ventilation / perfusion isotope scan will be indeterminate at best in the context of underlying airwaysdisease / bronchiectasis thus will not help with a definite diagnosis of thromboembolic disease.


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Q20Answer Key: B

The image shows well-demarcated full-thickness skin ulceration around the stoma. There is aExplanation:

ittle slough peripherally and no overt features of bacterial infection. The ulcer edges have apunched out appearance and the wound edges reveal violaceous erythema. These areeatures of pyoderma gangrenosum, which is a recognised complication of Crohns disease.The involvement of peristomal skin is quite common, possibly representing a Koebner

phenomenon. Initial treatment is with oral prednisolone (Answer B).

Q21Answer Key: C

The positive antibodies suggest autoimmune endocrinopathy. Of the two options, pernicious anaemiawould not cause an elevated CK. Polymyositis is excluded by the biopsy; folate deficiency and alcoholabuse might explain the raised MCV and weakness but the most likely diagnosis is hypothyroidism. CK ismodestly elevated (


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Q23Answer Key: E

This patient has had a provoked proximal deep vein thrombosis and has received anticoagulation for aperiod of 3 months. There is no difference in the recurrence rate of venous thromboembolism (VTE) forpatients treated with 3 and 6 months of warfarin.

Explanation:

Testing for protein C and protein S levels cannot be carried out whilst the patient is on warfarin, as the

warfarin results in a fall in the level of these proteins.

Testing for heritable thrombophilia is not routinely recommended, as it does not predict the likelihood ofrecurrence after the first episode of VTE. The risk of recurrent VTE in individuals heterozygous for theFactor V Leiden mutation is low (relative risk 1.4 compared to no mutation). Testing may be considered inndividuals under the age of 40 years, with an unprovoked VTE and a strong family history of thrombosis>2 symptomatic family members).

This patient therefore is at low risk of recurrent VTE, should not have been screened for heritablehromobophilia. She does not require further anticoagulation (answer E).

Ref: British Journal of Haematology, 149, 209220 Clinical guidelines for testing for heritable thrombophilia

Q24Answer Key: A

This patients blood results indicate that he has acute hepatitis. All of the answers are plausible. Howeveracute hepatitis is much more likely to be caused by one of the hepatitis viruses than by other sexuallyransmitted infections. Hepatitis B virus is far more commonly transmitted by homosexual anal intercoursehan hepatitis C virus. In the UK, intravenous drug use is the most important current risk factor for recenthepatitis C virus infection.

Explanation:

Q25Answer key: D

This scenario relates to a presentation of community acquired pneumonia (CAP). The caveat is the manscurrent immunosuppressive treatment for microscopic polyangiitis. Nevertheless, the patient is unlikely tohave a fungal infection, and co-trimoxazole for pneumocystis pneumonia is not required as part of hisnitial treatment regimen. The answer to this question is based on guidelines for managing CAP areavailable from the BTS (

Explanation:

http://www.brit-thoracic.org.uk/guidelines/pneumonia-guidelines.aspx). Both

amoxicillin and a macrolide are advised due to the severity of the presentation. IV cephalosporins arerarely used in the treatment of CAP because of the higher risk of clostridium difficile infection.
http://www.brit-thoracic.org.uk/guidelines/pneumonia-guidelines.aspxhttp://www.brit-thoracic.org.uk/guidelines/pneumonia-guidelines.aspxhttp://www.brit-thoracic.org.uk/guidelines/pneumonia-guidelines.aspxhttp://www.brit-thoracic.org.uk/guidelines/pneumonia-guidelines.aspx


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Q26Answer Key: A

n motor neurone disease, fasciculations are associated with weakness and the clinical disorder presentsn one limb, not all over. There may be fasciculation and weakness in one limb and some fasciculationselsewhere, but not as widespread as this.

Explanation:

McArdles syndrome has cramps on initial exertion, but no fasciculations; myotonic dystrophy has delayed

relaxation following sustained exertion but no fasciculations and polymyositis has neither cramps norasciculations.

One might wonder about neuromyotonia in a patient with prominent cramps, though not in a patientpresenting with fasciculations. Thyrotoxicosis and anxiety should be considered.

Q27Answer Key: B

This woman has bilateral mid and lower zone findings on examination and on the CXR thisExplanation:

makes aspiration pneumonia unlikely as this usually gives right lower zone opacification. TBusually presents with unilateral / bilateral upper zone cavitation / consolidation.Thromboembolic disease is possible from the history but the fever and crackles are atypical forhis diagnosis. Rheumatoid lung tends to give bilateral basal opacification on a CXR, oftenreticulnodular in character (honeycomb pattern on HRCT chest scan).

The likeliest diagnosis is therefore crytogenic organising pneumonia (COP)- answer B. This isa non infectious pneumonic process occurring in the context of pre-existing inflammatory orautoimmune conditions such as rheumatoid arthritis and it can mimic bacterial pneumonia ints x ray appearance. . Crackles are usually present and inflammory markers such as the ESR

are raised. It responds to corticosteroids rather than antibiotics.

Q28Answer Key: E

The very large daily stool weight indicates organic pathology. Maintenance of stool weight on day 4fasting) suggests a secretory diarrhoea. VIPoma is the only cause listed of a secretory diarrhoea andypically causes large volume watery diarrhoea (with associated hypokalaemia).

Explanation:

Q29

Answer Key: C

The development of nephrotic syndrome in a young Chinese woman with arthralgia and a low white cellcount makes SLE the most likely diagnosis. A positive test for antinuclear antibodies is very likely and isone of the diagnostic criteria for SLE.

Explanation:

Serum complement levels are likely to be low but are also low in other glomerular diseases, so are lessmportant than antinuclear antibodies as a diagnostic investigation. The other tests are for conditions thatrarely cause the nephrotic syndrome (anti-glomerular basement membrane antibody disease, ANCA-associated vasculitis, post-streptococcal glomerulonephritis) and are unlikely to be useful in reaching adiagnosis.


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Q30Answer Key: D

This is about a picture demonstrating keratoderma blennorrhagica on the sole of the right foot. InExplanation:

addition to the rash, this person also has a history of travel about four weeks ago, feverwith an acute phase reaction, and a large joint monoarthritis. Reactive arthritis is the most likelydiagnosis. The rash and the monoarthritis may well be related to psoriatic arthritis. However, psoriaticarthritis is not usually associated with a temperature or such a CRP response. We are not given any

nformation about balanitis or urethritis, but gonococcal arthritis is unlikely. It is usually a migratorypolyarthritis. Syphilis is not usually associated with arthritis, and involvement of the palms and soles is aeature of secondary syphilis. While gonococcal and psoriatic arthritis are both plausible distractors,reactive arthritis is the most likely diagnosis here.

Q31Answer Key: C

This relates to the next most appropriate step in the management of acute severe asthma failing torespond to initial treatment. The author of this question had in mind the BTS guidance, now updated:

Explanation:

http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx.There is no role for subcutaneous terbutaline. Intravenous hydrocortisone does not confer any additionalbenefit over oral prednisolone. Intravenous magnesium sulphate is preferred over aminophylline; the lattercan be given to patients already taking oral theophylline, but magnesium sulphate is more likely to provideadditional bronchodilation. There is a void in clinical research investigating the role of non-invasiveventilation in acute asthma (e.g. compared to COPD where it is more widely used); thus it has yet toreplace invasive ventilation. In addition, ventilator support would still be less preferable to further drugreatment.

Q32Answer Key: D

The patient has a mixture of myelopathic signs (weak hip flexion, extensor plantar responses) andperipheral sensory phenomena; in view of the central signs the answer must involve spinal cord pathology.This excludes diabetic amyotrophy and paraneoplastic sensory ataxic neuropathy. The sensorypresentation of syringomyelia is quite different (central cord syndrome) and a spinal arteriovenousmalformation (AVM) will usually have prominent radicular features at the level of the main AVM feeder.Bearing in mind the stomach surgery in the past, vitamin B12 deficiency would combine the centralnervous system and peripheral nervous system signs and would match with this clinical history. The only

unusual feature is that unsteadiness with a positive Romberg sign would usually be associated with absentoint position sense at the toes.

Explanation:
http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspxhttp://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspxhttp://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx


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Q33Answer Key: A

This degree of change in FEV and FVC post exercise is in keeping with exercise induced asthma Answer A. COPD and bronchiectasis both give fixed airflow obstruction. Hypertensive left ventricularailure doesnt fit with the clinical history and a BMI of 32 kg/m2 wouldnt explain the spirometry results.

Explanation:

Q34

Answer Key: A

Phaeochromocytomas are rare tumours and are even more rarely associated with genetic conditions suchas von Hippel-Lindau disease and multiple endocrine neoplasia type 2 (MEN2). The presence of a thyroidmass and hypocalcaemia raise the possibility of a calcitonin producing medullary cell tumour (MCT). Thushe correct answer is to measure plasma calcitonin. MCT is usually the presenting condition in MEN2 butpatients can be asymptomatic for some time. Hyperparathyroidism can also be a feature but would causehypercalcaemia. Marginally elevated TSH levels are common and are incidental in this case.

Explanation:

Q35Answer Key: A

Acalculous cholecystitis (inflammation of the gallbladder in the absence of gallstones) typically occurs inhe very ill patient on ITU, or after extensive burns. The thickened gallbladder wall and pericholecystic fluidndicate inflammation in the gallbladder wall. The amylase is raised, but this is a non-specific finding.

Explanation:


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Q36Answer Key: B

This individual has evidence of mucosal bleeding and severe thrombocytopenia. A platelet count of


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Q39Answer Key: C

The patient has had a single convulsion but currently has significantly reduced consciousExplanation:

evel. The MRI findings are those of a malignant lesion in the brain. Herpes encephalitis wouldnot be associated with central necrosis or T1 hyperintensity and an abscess would have onlya thin enhancing wall. Dexamethasone may reduce oedema around the lesion, lessening theikelihood of further immediate complications. As the patient is semi-conscious, this would

have to be given parenterally.

Q40Answer Key: D

ntermittent swelling of face and tongue suggests a diagnosis of angioedema withoutExplanation:

urticaria. Angioedema can be inherited or acquired, allergic or drug-induced. Hereditaryangioedema usually occurs for the first time in childhood or adolescence. Drug-inducedangioedema without urticaria is most frequently associated with angiotensin convertingenzyme inhibitors or, less frequently, angiotensin II receptor blockers. This represents a

pharmacological effect on bradykinin metabolism rather than allergy. The answer is D.

Q41Answer Key: C

This woman has a hypokalaemic, hypochloraemic metabolic alkalosis with hypertension consistentwith hyperaldosteronism. The raised plasma renin suggests that this is secondary to renovasculardisease and her age and gender make fibromuscular dysplasia leading to renal artery stenosis thecorrect diagnosis. Bartters syndrome does not cause hypertension, renin levels are low in Conns

syndrome, blood pressure is often low in laxative abuse, and excess liquorice would suppressaldosterone levels.

Explanation:

Q42Answer Key: A

The patient, who is 28 weeks pregnant, presents with chest pain, cardiac arrest and ECG showing anteriorST elevation and inferior ST depression. The ECG suggests anterior ST elevation myocardial infarction. Athis age, and in the absence of risk factors for ischaemic heart disease, this would be most likely to besecondary to spontaneous coronary artery dissection, although coronary spasm, aortic dissection involving

he left coronary artery, and even atheromatous plaque rupture are possible. The differential diagnosiswould also include pulmonary thromboembolism. The incidence of myocardial infarction in pregnancy isabout 5 per 100,000 births.

Explanation:

The correct answer is A. Immediate coronary angiography will identify the cause of coronary obstructionand usually allow treatment by percutaneous coronary intervention if the vessel (left anterior descendingcoronary artery in this case) is occluded. The procedure would require shielding of the patients abdomen,monitoring of the foetus, and careful use of radiation and contrast media.


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Q43Answer Key: A

Serratus anterior receives input from three cervical nerve roots and a single radiculopathy could notaccount for isolated serratus weakness.

Explanation:

Each of the three muscular dystrophies are relatively symmetrical and have features notable by theirabsence in this case (FSH facial and biceps weakness; spinal muscular atrophy - distal wasting and

weakness, e.g. in the hands; spinobulbar muscular atrophy bulbar weakness).

Q44Answer Key: A

This man has visible haematuria without significant proteinuria or urine infection so cystoscopy to check forbladder tumour is the most important investigation, regardless of the past medical history. In addition,previous treatment with cyclophosphamide is a major risk factor for bladder cancer. Male sex, increasingage and cigarette smoking also increase the risk.

Explanation:

Other investigations would only be considered once the result of cystoscopy was known. Intravenousurography is relatively contra-indicated in the presence of renal impairment and is being superseded by CTn the investigation of urinary tract calculi. MR angiogram of renal arteries is an investigation for conditionssuch as renal artery stenosis, renal arterial occlusion and polyarteritis nodosa, of which there is littleevidence in this patient. MR venogram of renal veins may be used to look for renal vein thrombosis as acause of visible haematuria in patients with nephrotic syndrome; this man is in remission from nephroticsyndrome so the risk of renal vein thrombosis is very low. Renal biopsy is likely only to show chronicdamage from previous membranous nephropathy.

Q45

Answer Key: B

A 50 year old woman has evidence of purpura and peripheral sensori-motor neuropathy. ThisExplanation:

combination of her clinical signs should alert us to the possibility of systemic vasculitis. Thepurpura suggests that this is a small vessel vasculitis. Positivity of for a perinuclear ANCA issuggestive of an ANCA associated vasculitis even though we do not know the ELISA results.However even without the ANCA result one could reasonably rule out cryoglobulinaemia and SLEdue to lack of complement activation. The presence of the skin involved rules out PolyarteritisNodosa. This would leave us with Wegeners granulomatosis, (now known as granulomatosis withpolyangiitis) and microscopic polyangiitis. The main differentiating feature between the two of

hese is the presence of granulomatous disease. As neither the purpura nor the neuropathy aresuggestive of granulomatous involvement, we are left with MPA as the only possible answer.


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Q46Answer Key: A

The patient has chronic mitral regurgitation secondary to mitral valve prolapse. He presents with suddenonset severe dyspnoea and left-sided chest pain with clinical signs of acute severe left heart failure.Although a murmur is not heard, the breath sounds are very noisy, and a murmur may not be audible in upo 50% of cases of acute severe mitral regurgitation. The causes of acute severe mitral regurgitationncluded chordal rupture, flail leaflet, and papillary muscle rupture (usually secondary to myocardial

nfarction). The ECG did not show evidence of myocardial infarction and no features to support infectiveendocarditis are given. Sinus of Valsalva rupture usually presents before the age of 30 with chest pain,acute heart failure and a continuous murmur accentuated in diastole.

Explanation:

The correct answer is A. The presence of long standing mitral valve prolapse, usually withmyxomatous degeneration of the valve apparatus in this age group, predisposes to chordalrupture. Acute, short-lived chest pain is often a feature of chordal rupture.

Q47Answer Key: E

This individual has presented with confusion, tachycardia and hypotension. The investigations confirm anormal full blood count, renal impairment, significant hypercalcaemia and abnormal liver biochemistry.

Explanation:

t is most likely that the hypercalcaemia has resulted in the confusion and dehydration, leading to thepresenting signs and symptoms.

The abnormal liver biochemistry would be unusual in myeloma. Pagets disease usually causes an isolatedrise in the alkaline phosphatase, and hypercalcaemia is unusual. Addisons disease is characterised byhyponatraemia in 8590% of individuals and hyperkalaemia in 6065%, but hypercalcaemia is a rare

occurrence.

t is therefore most likely that this individual has metastatic cancer, with liver involvement (resulting in theabnormal liver biochemistry) and skeletal metastases (resulting in the hypercalcaemia). The most likelyprimary sites are breast and lung.

Q48Answer Key: B

Diphtheria is a life-threatening infection which presents with severe pharyngitis and aExplanation:

characteristic membrane. It is uncommon in the UK, but clinicians should be alert to the riskof this condition, particularly in patients presenting from countries where it is endemic.Vincents angina can also cause a pharyngeal membrane but there is usually also severe localissue destruction. Vincents angina is usually caused by a mixture of anaerobes andspirochaetes. The other infections listed cause pharyngeal infections but do not produce thecharacteristic diphtheritic membrane.


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Q49Answer Key: D

The clinical photograph demonstrates that these papules are purple in colour. The image alsoExplanation:

demonstrates that the papules reflect light back, which implies that they are flat topped ratherhan dome shaped. These are all features of lichen planus, as is the distribution on theanterior forearm. Dermatitis herpetiformis classically affects extensor aspects of limbs andesion are vesicles or erosions rather papules. Tinea corporis usually has an annular

configuration and, as with atopic eczema and guttate psoriasis, usually produces scale.

Q50Answer Key: B

The plain abdominal X-ray shows speckled calcification in the line of the pancreas. The high alcohol intakeand dull epigastric pain are compatible with chronic pancreatitis, and probable pancreatic insufficiencyresulting in steatorrhoea

Explanation:

Q51Answer Key: C

REM behaviour disorder (RBD) is the correct answer. RBD is a parasomnia in which the subjects act outdreams with physical movements that are considered to be the equivalent of what they are doing in theirdreams. Dreams often include events that trigger wild motions and flailing of limbs that can be harmful to abed partner or the sufferer themselves. The presence of neurological disorders has been shown toncrease the risk of RBD by as much as 50%, including Parkinsons disease and Multiple System Atrophy,and RBD in people without these disorders could indicate an increased risk of developing them in theuture.

Explanation:

Excessive daytime sleepiness (hypersomnia) is a sleep related disorder that causes excessive daytimesleepiness in people, often regardless of the presence of other sleeping disorders, or poor sleep hygiene.nsomnia is difficulty falling or staying asleep. It may be primary (defined as sleeplessness that is notattributable to a medical, psychiatric or environmental cause) or secondary (due to co-existing medicalconditions). Sleep apnoea is a common disorder involving breathing interruptions during sleep. The mostcommon type is obstructive sleep apnoea. Somnambulance is characterized by a person doing activitiesduring an apparent sleep, such as walking about and sitting up in bed.

Q52Answer Key: C

This woman has a localised non small cell bronchial carcinoma (T2a N1 M0- Stage IIA) with spread of herprimary tumour to the local hilar nodes. The goal of treatment in such cases is cure if possible and theoptimal form of treatment is surgery Answer C . If the FEV1 is > 60% predicted with no significantcomorbid contraindications and a good performance status (0-1), then a pneumonectomy offers a 5 yearsurvival of approximately 35% compared to radical radiotherapy at 15%. Chemotherapy is not indicated asprimary treatment in Stage IIA non small cell carcinoma and radiofrequency ablation is used to treat earlynon small cell tumours or when surgery is either refused or not feasible in an attempt to reduce the size ofhe tumour. Palliative radiotherapy would only be considered if she was not fit enough for surgery orradical radiotherapy because of other comorbid problems.

Explanation:


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Q53Answer Key: C

A woman in her 70s with a 20-year history of rheumatoid arthritis, now presents with a foot drop,Explanation:

sensory peripheral neuropathy, nail fold infarcts and circulatory compromise of the right indexinger. She very clearly does have systemic vasculitis. Therefore the only possible answers to thisquestion are C,D or E. We are not told that she has SLE in her past medical history. It would beextremely unlikely that she has developed fresh SLE at 72 years of age. The weak positive ANA

may be age-related. Rheumatoid vasculitis and Wegeners granulomatosis are both plausibleanswers. However, in somebody with documented rheumatoid arthritis without fresh involvementof organs typically associated with Wegeners, mainly the ENT and lungs, this is most likely to berheumatoid vasculitis. If we had been given information that this person had not just a positive PANCA but a result typical for myeloperoxidase, then arguably Wegeners might becomes slightly strongeras a possibility. However, even in that situation, in somebody with long-term rheumatoid arthritis, itwould be reasonable to think of systemic rheumatoid vasculitis first.

Q54Answer Key: A

This patient is most likely to have pulmonary tuberculosis as he has multiple risk factors forExplanation:

his infection. In order to confirm this diagnosis, it is necessary to culture Mycobacteriumuberculosis for a respiratory specimen. Bronchoscopy will produce the best respiratoryspecimen for acid-fast staining and mycobacterial culture. Before performing abronchoscopy sputum specimens produced by spontaneous coughing (or by induction)should be sent for acid-fast staining and mycobacterial culture. Routine sputum microscopyand culture will only identify typical bacterial pathogens and will not isolate Mycobacteriumuberculosis.

Q55Answer Key: E

This patient presents with neuromuscular ventilatory weakness, perhaps associated with an intercurrentchest infection, and has a 5-year history of progressively worsening leg weakness.

Explanation:

He is too old for Beckers Muscular Dystrophy, which does not cause ventilatory difficulties, one wouldhave expected upper motor neurone signs for motor neurone disease and a patient with myastheniagravis, so severely affected that ventilation is required, would have evidence of an eye movement disorder.

The long history suggestive of a pre-existing muscular condition makes myotonic dystrophy more likelyhan the Guillain Barre syndrome and the clinical phenotype (bilateral ptosis, facial weakness, distalweakness) is entirely compatible with that diagnosis.


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Q56Answer Key: E

The ECG shows regular p waves with no evidence of atrial arrhythmia. The pacemaker sensesExplanation:

hese correctly, the atrial circuit is inhibited and no atrial pacing spikes are seen. There are nonormally conducted p waves. There are intermittent ventricular pacing spikes which capture theventricular myocardium and lead to a QRS complex. When present, the ventricular pacing spikesare appropriately triggered by the preceding p wave, in the absence of a normally conducted QRS

complex. There are no ventricular pacing spikes which fail to capture. This implies that theventricular pacing circuit is inappropriately sensing electrical activity which it interprets incorrectlyas a native QRS complex and therefore is inhibited from delivering a ventricular pacing impulse.This intermittent fault is most likely to be due a pacing lead fracture in a lead that was implanted 5years earlier. There is no evidence of electromagnetic interference on the ECG strips shown.Pacemaker syndrome is a problem associated with single chamber pacemakers.

Q57Answer Key: B

The scenario is based around a young female presenting with headache and hemiplegia. All of theconditions can occur in a young individual, although cerebral infarction is less likely and not usuallyassociated with headache. A marginally raised CSF opening pressure and normal protein points awayrom idiopathic intracranial hypertension and subarachnoid haemorrhage.

Explanation:

The history of COCP and ecstasy use is important and thus makes the diagnosis of cerebral venoushrombosis more likely. In addition to the COCP and ecstasy, corticosteroids can also induce ahypercoaguable state leading to cerebral venous thrombosis.

Q58Answer Key: B

The image shows excess hair growth which is a common adverse effect of ciclosporin but not of the otheragents.

Explanation:

Q59Answer Key: B

This patient has severe clinical and biochemical thyrotoxicosis, and the presence of proptosis confirms adiagnosis of Graves disease. Amiodorone is associated with thyroid dysfunction in 2 30% of patients but

will not on its own cause ophthalmopathy.. However, because of the iodine load associated with long termuse (200mg contains 6 mg iodine, normal daily requirement 150 g) it may provoke Graves disease inpredisposed individuals. Reidels thyroiditis results in painless replacement of the gland with fibrous tissueand patients are normally euthyroid. Toxic nodules and multinodular goitre do not cause eye signs.

Explanation:


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Q60Answer Key: B

The right upper quadrant pain, fever, and jaundice (Charcots triad) suggests ascending cholangitissecondary to a common bile duct stone.

Explanation:

HELLP syndrome does not typically cause pain or fever, and the platelet count is normal. Autoimmunehepatitis and hepatitis A are characterised by a predominant transaminitis. Although primary sclerosingcholangitis may present with an obstructive pattern of LFTs, pain and fever are unusual.

Q61Answer Key: C

The chest X-rays show a collapsed left lower lobe (image a) followed 6 weeks later by a re-expanded leftower lobe (image b). This is most likely to be due to a reversible cause of a left lower lobe airwayocclusion such as mucus plugging (Answer C).

Explanation:

A bronchial carcinoma causing a collapsed lobe is unlikely to improve after antibiotics. The x-rays areconsistent with lobar collapse rather than consolidation making pneumonia less likely and an aspergillomaclassically appears as a dense shadow within an upper lobe cavity. The x-ray is not typical of a pleuraleffusion.

Q62Answer Key: D

The patient has a large pericardial effusion and the pyrexia suggests an infective aetiology. A 3 weekhistory of fever and night sweats makes a tuberculous pericardial effusion a possibility and viral or otherbacterial cause less likely. In a patient from Africa with HIV infection, tuberculous pericarditis is the mostikely cause. The likelihood of infection with tuberculosis is dependent upon the prevalence of TB in the

population in question. Lymphoma is a possibility, but less likely with this degree of pyrexia and elevatedESR.

Explanation:

Q63Answer Key: E

Answering this question relies on the interpretation of the clinical presentation of agitation, hyperthermia,achycardia and severe hypertension with neurological involvement. The creatine kinase (CK) issuggestive of rhabdomyolysis with some impairment of renal function.

Explanation:

The scenario is classical for serotonin syndrome. Anticholinergic poisoning is not typical of this clinical

presentation: although it can be associated with hyperpyrexia and tachycardia, the CK is not significantlyelevated. Malignant hyperthermia is classically associated with anaesthesia. The clinical presentation ofhe other 3 conditions are similar with serotonin syndrome and neuroleptic malignant syndrome (NMS)almost identical. There is no drug history to tease out the answer: but compared to NMS, serotoninsyndrome is more likely to present with shivering, hyperflexia and clonus (NMS classically has lead-piperigidity). Amphetamine poisoning can affect dopamine, serotonin and noradrenaline neurotransmitters.


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Q64Answer Key: E

The patient is a 65 year old man who has been brought to casualty following a fall down the stairs and isunconscious. A CT brain scan shows an acute intra-parenchymal haematoma in his right hemisphere anda sub-acute subdural haematoma that is at least 24 hours old overlying the left hemisphere and causingsome midline shift. It may well be up to 3 or 4 days old. The patient is also covered in bruises.

Explanation:

The explanation for all of his haematomata (eg those seen on CT) cannot be hypertensive haemorrhage,subarachnoid haemorrhage or haemorrhage into a tumour; however the two intracranial haematomatahave obviously arisen as a consequence of trauma, though one suspects he may be an alcoholic or havean underlying coagulopathy.

Q65Answer Key: A

The patient has had a complete response to chemotherapy. We presume this to have beenExplanation:

completed recently as prophylactic cranial irradiation would be given soon after inducing acomplete response in his thoracic disease. Thus it would be extremely unlikely that he hasnow developed brain metastases particularly given the very recent radiotherapy. Anaemia,hough likely contributory to his fatigue, does not usually cause sleepiness and is likely tohave been more chronic than his symptoms. The level of hyponatraemia is unlikely to beassociated with significant symptoms. Although he has every reason to be depressed,generalised fatigue and sleepiness are common acute side effects of cranial irradiationmaking this the better answer.

Q66Answer Key: D

Severity of pneumonia can be assessed using the CURB-65 score. One point is scored for each of theollowing:

Explanation:

Confusion. This is defined as a mental test score of 8/10 or less, or new disorientation in person, timeor place.

Urea greater than 7.0 mmol/L. Patients with chronic renal impairment are excluded.Respiratory rate greater than or equal to 30 per minute.Blood pressure: systolic less than 90mmHg or diastolic less than 60mmHg.Age greater than or equal to 65 years

Only answer D meets any of these criteria.


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Q67Answer Key: E

This man has incoordination, slurred speech, depressed consciousness and nystagmus, all of which areeatures of phenytoin toxicity.

Explanation:

The urinalysis shows only ketones 1+ and the venous bicarbonate is only slightly low so thepatient does not have significant ketoacidosis. Severe ethanol intoxication and hyperosmolar

hyperglycaemic state can be excluded as plasma osmolality is normal. Methanol poisoningcauses a severe metabolic acidosis and a high anion gap, neither of which are present.

Q68Answer Key: C

Severe left iliac fossa pain and fever would point strongly to a diagnosis of diverticulitis. A CT scan is themost suitable initial investigation for both the diagnosis and also to rule out abscess formation orperforation.

Explanation:

Q69Answer Key: C

The patient has gestational hypertension and NICE guidelines (Hypertension in Pregnancy 2010)recommend labetalol to achieve a target BP of systolic


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Q72Answer Key: C

Many different bacteria can cause infection in prosthetic hips, including bacteria which have generally lowpathogenicity. Propionobacterium acnes, Staphylococcus epidermidis and Streptococcus milleri are allreasonably common causes of prosthetic hip infection. However staphylococci and streptococci are Grampositive cocci not Gram-positive bacilli. Propionibacterium acnes, Corynebacterium diphtheriae andBacillus anthracis are all Gram-positive bacilli. However Bacillus anthracis (the cause of anthrax) and

Corynebacterium diphtheriae (the cause of diphtheria) would not be usual causes of a prosthetic hipnfection. Therefore Propionibacterium acnes is the only organism listed which could be causing this hipnfection.

Explanation:

Q73Answer Key: D

Nasopharyngeal carcinoma would be extensive and symptomatic (face pain from bony destruction) byhe time it involved the cranial nerves IX, X and XII where they exit the skull. A fourth ventricleependymoma would be associated with other central nervous system signs and a cholesteatomawould have a history of chronic suppurative otitis media and need to be extensive were it to affect theower cranial nerves as they exit the base of the skull.

Explanation:

An acoustic neurinoma causes sensorineural deafness, not conductive deafness.

This makes a glomus jululare tumour the more likely explanation for the question as stated.

Q74Answer Key: B

This man has severe renal failure with hypercalcaemia and high serum globulins (high serum total protein,ow serum albumin). He is also anaemic and has a very high erythrocyte sedimentation rate. Theseeatures are highly suggestive of myeloma, and the history of diminished urine output probably indicatesdevelopment or progression of cast nephropathy.

Explanation:

Carcinoma of prostate with bone metastases and primary hyperparathyroidism may cause hypercalcaemiabut usually not high serum globulins, and this level of hypercalcaemia alone is unlikely to cause severerenal failure. The normal serum alkaline phosphatase also makes these conditions less likely. Sarcoidosismay cause hypercalcaemia, high serum globulins, renal failure anaemia and a high erythrocyte

sedimentation rate but it is much less common than myeloma in this age group. Tuberculosis rarely causeshypercalcaemia or renal failure.


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Q75Answer Key: B

A succussion splash suggests delayed gastric emptying, the precise cause of which is not known. Of thehree anti-emetics offered, only metoclopramide has prokinetic effects, and so this would be the firstchoice. Although corticosteroids may help all these symptoms, the risk of cumulative side effects meanhat this would not be the first choice of treatment without trying anti-emetics first.

Explanation:

Q76Answer Key: B

The presence of microcytosis suggests iron deficiency. The British Society of Gastroenterology Guidelines2011) advocate gastrointestinal investigation for iron deficiency (without anaemia) in postmenopausal

women and men over the age of 50. A colonoscopy is the investigation of choice here as it has thegreatest sensitivity for detecting polyps and carcinomas. Faecal occult blood testing would not addanything as it is not particularly sensitive or specific.

Explanation:

Q77Answer key: E

This man has many features of Cushings syndrome on a background of severe depression. Depression isa common feature of Cushings but is usually more agitated than psychotic in type. The almost completesuppression of serum cortisol by low dose dexamethasone excludes both adrenal Cushings and ectopicACTH syndrome. Around 8% of patients with proven pituitary Cushings disease will suppress serumcortisol with a low dose suppression test, but the minimally elevated urinary cortisol makes this diagnosisess likely (levels should be > 3 times normal for definitive diagnosis). There is considerable overlapbetween the appearances of Cushings and the metabolic syndrome but the history of depression and the

nvestigations make pseudo-Cushings the most likely diagnosis.

Explanation:

Q78Answer Key: D

The mediastinal lymph node mass (Answer D) makes successful surgical resection impossible and is thecorrect answer. A FEV > 60% predicted is not a contraindication to pneumonectomy in the absence ofother significant comorbidities. The pleural effusion may be reactive rather than malignant and would needo be sampled before any surgery. Hypercalcaemia is not a contraindication to surgery.

Explanation:

The tumour may be abutting rather than invading the pleural surface but this would need to be investigated

by CT / MRI imaging.


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Q79Answer Key: D

This young man has nephrotic syndrome complicated by venous thromboembolism. One week ofcorticosteroid therapy has caused a major reduction in proteinuria and it is likely that he will soon be incomplete remission. This very rapid response to corticosteroid is generally only found in minimal changenephropathy.

Explanation:

n this patient, venous thromboembolism is a consequence of the hypercoagulable state caused by thenephrotic syndrome and there is no reason to suspect antiphospholipid antibody syndrome. Focal andsegmental glomerulosclerosis may respond to corticosteroid therapy, but usually only after several months.Membranous nephropathy rarely responds to corticosteroid alone. Renal vein thrombosis is a recognisedcomplication of the nephrotic syndrome but not the primary renal diagnosis.

Q80Answer Key: B

The scenario describes a randomised placebo-controlled trial investigating digoxin in patients withechocardiographic evidence of heart failure. We do not know the power of the study (E). The only datapresented is a non-significant effect on mortality,so it is not possible to make assumptions regardingmorbidity (C/D). Although a smaller percentage of patients taking digoxin died, the result is insignificant, sohis can happen by chance (A).

Explanation:

Q81Answer Key: B

When there is a family history of sudden cardiac death at a young age it is important to screen siblings for

he conditions listed. This ECG shows sinus rhythm with normal PR and QT intervals. The strikingabnormality is a partial right bundle branch block pattern with elevation of the ST segment leading into Twave inversion in leads V1 and V2. This is characteristic of the Brugada syndrome. There is no evidenceof left ventricular hypertrophy.

Explanation:

Brugada syndrome is an autosomal dominant condition which is associated with a risk of suddencardiac death from ventricular arrhythmia. The ECG abnormality is not always apparent and maybe revealed by administration of a sodium channel blocking drug such as ajmaline or flecainide. Tomake the diagnosis there should be at least one additional feature such as a history of syncope,history of ventricular arrhythmia, or a family history of the ECG abnormality, syncope or ventriculararrhythmia. An asymptomatic family member with the ECG abnormality should be considered for

electrophysiological studies.


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Q82Answer Key: A

This 18 year old woman gives a history of a migrainous prodrome followed by severe headacheassociated with mild neck stiffness and CSF abnormalities.

Explanation:

The history is not compatible with subarachnoid haemorrhage (explosive onset) or with vertebral arterydissection (severe pain behind one eye, usually associated brain stem signs and Horners syndrome).

Nor is the history compatible with temporal lobe epilepsy (migrainous aura too long).

The CSF findings would be compatible with viral meningitis, though the preceding migrainous prodromemakes basilar migraine a more likely diagnosis. It is reported, though rare, to have a CSF pleocytosis inmigraine.

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