MRCP quises & Answer Try .......

Best Of 5

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1- A 40-year-old female, with no prior history of thyroid disease, presents with a 5 day history of an acutely painful, left-sided goitre. Clinically she appeared euthyroid, and was apyrexial.

Investigations revealed the following

haemoglobin 13.0 g/dL

white cell count 7.0 x 109/l

platelet count 200

What is the most likely diagnosis?

1) De Quervain's thyroiditis [0]

2) Haemorrhage into a cyst [0]

3) Hashimoto's thyroiditis [0]

4) Staphylococcal abscess [0]

5) Thyroid carcinoma [0]

2- A 36-year-old male with insulin-dependent diabetes mellitus of three years duration presented with decreased libido and erectile dysfunction since diagnosis. No abnormalities were noted on genital examination. Investigations revealed:

plasma testosterone 6.0 nmol/L (9 - 35)

plasma follicle stimulating hormone 1.0 u/L (1- Cool

Which of the following investigations is most appropriate next step?

1) autonomic function testing [0]

2) Doppler studies of penile artery [0]

3) Nerve conduction studies [0]

4) Serum ferritin [0]

5) Serum prolactin [0]

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3- A 24-year-old man presents with a five month history of low back pain, radiating to his buttocks, and back stiffness worse in the morning and worse after periods of inactivity. Which of the following signs is the most likely to be present?

1) exaggerated lumbar lordosis [0]

2) positive femoral stretch test [0]

3) positive Trendelenburg test [0]

4) restricted straight leg raising [0]

5) sacroiliac joint tenderness [0]

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4- A 35-year-old man returned from a two-week holiday complaining of pain in the loins and painful swollen knees. On examination he was afebrile and had significant bilateral knee effusions. Mild penile erythema was also noted. Laboratory investigations showed.

Hb 15.6 g/dL

WBC 16.2 x 109/l

Neutrophils 14.1 x 109/l

ESR 65 mm/h

Rheumatoid factor 10 IU/L

Urinalysis No cells, casts or bacteria seen

What is the most likely diagnosis?

1) Arthritis due to Neisseria gonorrhoeae infection [0]

2) Lymphogranuloma venereum [0]

3) Reactive arthritis [0]

4) Reitter's syndrome [0]

5) Rheumatoid arthritis [0]

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5- What is the most likely cause of upper lobe fibrosis on Chest X-ray?

1) Ankylosing spondylitis [0]

2) Cryptogenic fibrosing alveolitis [0]

3) Rheumatoid arthritis [0]

4) Scleroderma [0]

5) Systemic lupus erythematosus [0]

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6- A diagnosis of diabetes mellitus is being considered in 32-year-old woman who is 16 weeks pregnant. Her body mass index (BMI) was 22 kg/m2 (18 - 25). A 75g oral glucose tolerance test was reported as follows

time Plasma glucose concentration Normal range

0 hr 6.0 mmol/l 3.0-6.0

2hr 12.5 mmol/l <11.1

Which of the following is the most appropriate next step in the management of this patient?

1) Glipizide therapy [0]

2) Insulin therapy [0]

3) Low calorie diet [0]

4) Metformin therapy [0]

5) Repeat OGTT in four weeks [0]

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7- A 64-year-old man has terminal cancer with hepatic metastases. He is treated with oral morphine (Oramorph) solution for pain relief.

Which is the most important pharmacodynamic factor in determining the appropriate timing between doses?

1) bioavailability [0]

2) first pass metabolism [0]

3) gastric emptying [0]

4) plasma half-life [0]

5) renal clearance [0]

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[size=16]8- With respect to lipoprotein transport and metabolism in the body, the following statements are correct EXCEPT: [/size]

1) Chylomicrons are synthesized in the liver. [0]

2) HDL is assembled in the extracellular space. [0]

3) Arterial walls contain cells with LDL receptors. [0]

4) VLDL transformation to LDL occurs in adipose tissue. [0]

5) Cholesterol is required for the formation of red blood cell membranes. [0]

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9- A 92-year-old man was admitted in a confused state. He has a history of immobility due to severe lower back pain. He had been losing weight for three months and had complains of weakness, urinary frequency, thirst, poor urinary stream and constipation. Lumbar spine X-rays show severe osteopenia and collapse of the body of the vertebra at L3. Investigations show

haemoglobin 9.6 g/dl

sodium 144 mmol/l

potassium 3.9

urea 10.4

creatinine 120

glucose 8

dip stick urine blood ++, protein +

What is the most important immediate investigation?

1) Chest X-ray [0]

2) MSU [0]

3) prostate specific antigen [0]

4) serum calcium [0]

5) serum protein electrophoresis [0]

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10- A 19 year-old female is referred following a visit to the dentist where marked erosion of her teeth was noted. She was entirely asymptomatic and her only medication was the oral contraceptive pill. On examination her blood pressure was 110/70 mmHg and her body mass index was 21.5 kg/m2 (18 - 25).

Investigations

sodium 135 mmol/l

potassium 2.1 mmol/l

bicarbonate 42 mmol/l

urea 2.6 mmol/L

corrected calcium 2.08 mmol/

alkaline phosphatase 201 iu/l (50-110)

What is the most likely diagnosis?

1) Bulimia nervosa [0]

2) Conn's syndrome [0]

3) Laxative abuse [0]

4) Pregnancy [0]

5) Primary hypoparathyroidism [0]

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Answer

1- The left side of this patient's goitre becomes acutely swollen with no other signs and FBC is normal which suggests acute haemorrhage into a cyst. Thyroid cancer is usually painless. De Quervain's thyroiditis is a diffusely tender goitre typically with systemic features such as weight loss, pyrexia and a raised ESR.

2- This IDDM patient appears to have hypogonadotrophic hypogonadism (HH) as reflected by low testosterone and low FSH. The combination is compatible with a diagnosis of haemochromatosis and measuring ferritin would be a reasonable investigation. Haemochromatosis typically causes hypogonadotrophic hypogonadism as a consequence of the ferritin deposition within the pituitary rather than primary testicular dysfunction. Autonomic nerve dysfunction is one of the commoner causes of impotence in a diabetic but in this case is not the cause of his HH. For similar reasons, both nerve conduction studies and dopplers are irrelevant. Prolactin would be a sensible measurement but probably if you were looking to confirm a diagnosis that incorporates the diabetes as well, Ferritin would be the investigation of choice.

3- Common presentation of ankylosing spondylitis. Stiffnes first thing in the morning and after inactivity, lower back pain radiating into the buttocks.

4- Gonococcal arthritis typically affects the knees and is the likeliest diagnosis in this scenario.

5- Cryptogenic fibrosing alveolitis (which may be associated with connective tissue disorders) affects lower lobes and is associated with clubbing. Extrinsic allergic alveolitis is not associated with clubbing and affects middle/upper zones.

6- The result confirms a diagnosis of gestational diabetes mellitus with the 2hr OGTT result above 11.1 mmol/l. To minimise the fetal consequences of GDM (macrosomia, fetal malformations, still birth, IUGR etc), the patient's glycaemia should be strictly controlled with insulin. A low calorie diet is inappropriate and neither metformin nor glipizide are licenced for use in pregnancy. There is no point in repeating the OGTT in 4 weeks as control is required NOW.

7- Morphine undergoes extensive first pass metabolism in the liver. And it has got effect on bioavailability and plasma half-life. Oral morphine is well absorbed.

8- Chylomicrons are formed in the gut from exogenous triacylglycerols and cholesterol. They are released into the lymph and thereby enter the blood.They are not formed in the liver.

9- The likely underlying diagnosis is myeloma. The symptoms of constipation, weakness and thirst indicate hypercalcemia. Serum calcium should be the IMMEDIATE investigation.

10- This patient has tooth erosion associated with hypokalaemic metabolic alkalosis and hypocalcaemia. This suggests a diagnosis of hypoparathyroidism. Conn's is unlikely in this age group, is not associated with tooth erosion and hypertension would be expected. Bulimia like laxative abuse would be associated with hypokalaemia but the hypocalcaemia with raised alkaline phosphatase would not be expected. Early pregnancy would not fit this picture.

Thanks
Dr, Aljuraisy

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