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    mrcp part 1 questions

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    ممتاز mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الأربعاء 01 أبريل 2009, 7:59 pm

    بسم الله
    لكل المهتمين بالزمالة البريطانيه للباطنية
    ياريت نتعاون مع بعض ونحاول نجمع اكبر قدر ممكن من اسئله امتحان الزماله الجزءالاول
    عشان تعم الفايده الجميع والله الموفق
    حبدا واضع ما حصلت عليه من اسئله لحد الان وانشالله اكون فدتكم

    ودي المجموعة الاولى من الاسئلة والاجابات حتكون في نهاية المجموعة

    basic science
    Which of the following conditions is associated with a defect in Apo B48?1-
    A.Tropical sprue
    B. Coeliac disease
    C. Crohn's disease
    D. Ankylosing spondylitis
    E. Abetaliproproteinaemia

    2_A 35 year old lady has psychogenic diabetes insipidus. Her blood results show - sodium 124 mmol/l; potassium 4.0 mmol/l; Urea 5 mmol/l; Creatinine 30 mmol/l; Glucose 8 mmol/l. What is the serum osmolality [mosmol/Kg]?
    A. 255
    B. 261
    C. 264
    D. 278
    E. 284

    3-Which of the following statements describes this karyotype 46 XX, t (4;Cool(q26;p21.3) ?
    A. Transversion between the long arm of chromosome 4 (q) and the short arm of chromosome 8 (p)
    B. Transversion between the short arm of chromosome 4 (q) and the short arm of chromosome 8 (p)
    C. Transversion between the long arm of chromosome 4 (p) and the short arm of chromosome 8 (q)
    D. Translocation between the short arm of chromosome 4 (q) and the long arm of chromosome 8 (p)
    E. Translocation between the long arm of chromosome 4 (q) and the short arm of chromosome 8 (p)

    4_A 65 year old man has a parietal lobe infarct. Which one of the following is a likely manifestation?
    A. Finger agnosia
    B. Homonymous hemianopia
    C. Bitemporal hemianopia
    D. Expressive dysphasia
    E. Dysdiadochokinesis

    5-A 55 year old woman has visual problems. On examination, she has a right sided third nerve palsy. Which one of the following occurs typically in a third nerve palsy?
    A. Small pupil
    B. Reactive pupil
    C. Exopthalmos
    D. Ptosis
    E. Eye looks upwards
    6_A 75 year old lady has sudden movements of her arm where she throws her arm outwards, and uncontrollably injures herself. Which one of the following areas could have sustained an infarct?
    A. Globus pallidus
    B. Pontine nucleus
    C. Corpus callosum
    D. Subthalamic nucleus
    E. Thalamus

    7_Which of the following tumour supressor genes is a tumour suppresor gene involved in promoting apoptosis and programmed cell death?
    A. BRCA-1
    B. P53
    C. Bcl-2
    D. Ras
    E. Rb
    8_A 50 year old lady has pain in her right leg. On examination, there was weakness of her right ankle and absent right ankle jerk. She also had sensory loss over the lateral aspect of her ankle. Which of these nerve lesions is likely?
    A. Deep peroneal nerve
    B. Femoral nerve
    C. Sciatic nerve
    D. Lumbosacral plexus
    E. Inferior gluteal nerve
    9-A 40 year old man has an anterior mediastianal mass seen on CT scan. Which of the following is unlikely to be a cause for the mass?
    A. Thyroid
    B. Thymus
    C. Thoracic sarcoma
    D. Teratoma
    E. Tumour

    10_A physician administers iv pentagastrin at 6 mcg/kg of body weight to a patient who has upper abdominal symptoms. Complete achlorhydria after pentagastrin administration occurs in which condition?
    A. Coeliac disease
    B. Acute gastritis
    C. Crohn’s disease
    D. Megaloblastic anaemia of pregnancy
    E. Pernicious anaemia
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 10:05 am


    1-A 55 year old man presented to hospital with chest pains. His troponin I is negative at 12 hours. Following this an exercise test is recommended. In which of the following situations is it safe to perform an exercise test?
    A. Aortic stenosis with a gradient of 50mmHg
    B. Pericarditis
    C. Trifascicular heart block
    D. Blood pressure of 220/100
    E. Dynamic ST changes with chest pain

    2-A 60 year old patient has a cholesterol of 7 mmol/l and triglycerides of 3.5 mmol/l. His blood pressure is 165/90. He has a previous histroy of CVA but not myocardial infarction. Which of the following is appropriate?
    A. Simvastatin
    B. Bezafibrate
    C. Low fat diet
    D. Ezetimide
    E. Cod liver oil

    3-A 55 year old patient had myocardial infarction 6 days ago. He suddenly develops dyspnoea, cough and frothy sputum. For the first time a harsh systolic murmur is heard over the praecordium. This sequence of events might be caused by:
    A. Pulmonary embolism
    B. Aortic dissection
    C. Tricuspid regurgitation
    D. Ruptured papillary muscle
    E. Ruptured aortic cusp

    4-A 23 year old lady has a 6 month history of fever and pains in her elbows, wrist and knee joints. There is a soft systolic murmur and a pericardial rub on auscultation.

    Her bloods reveal Hb 12.0 g/dl, WCC 10 x 10^9/l, platelets 280 x 10^9/l, urea 5 μmol/l, creatinine 70 μmol/l, sodium 138 mmol/l, potassium 3.8 mmol/l, bilirubin 18 μmol/l, AST 18 U/l, ALP 180 U/l, albumin 35 g/l, ESR 100 mm/hr, CRP 140 mg/l.

    What is the likely diagnosis
    A. Viral pericarditis
    B. Rheumatic fever
    C. Subacute bacterial endocarditis
    D. Atrial myxoma
    E. Polyarteritis nodosa

    5_A man with mild bleeding disorder is being considered for aspirin for acute coronary syndrome. Which one of the effects of aspirin is beneficial in coronary artery disease?
    A. Reduction in thromboxane A2 synthesis
    B. Increase in the prostaglandins
    C. Glycoprotein IIB IIIA receptor inhibition
    D. ADP receptor antagonism
    E. Increase in COX enzymes

    6_A 33 year old man presents with chest pains and fatigue for several days. His observations show a temperature of 38°C, pulse 100 bpm, BP 100/7 mmHg. ECG shows T wave inversion in the anterior and inferior leads. The troponin I is 3 ng/mL (<0.04). Which one of the following diagnosis best fits the situation?
    A. Myocardial infarction
    B. Pericarditis
    C. Myocarditis
    D. Pulmonary emboli
    E. Pericardial effusion

    7-A 60 year old man has had myocardial infarction. His pulse rate is 45 and he is feeling lightheaded. Blood pressure is 90/65. In which one of the following conditions is temporary pacing indicated?
    A. First degree heart block
    B. Wenkebach
    C. 2:1 Mobitz type II heart block
    D. Left bundle branch block
    E. Bifascicular block

    8-A 60 year old man has had previous myocardial infarction. He has symptoms of breathlessness consistent with NYHA class III heart failure. Echocardiography shows an LV ejection fraction of 35%. Which of the following combinations of medication is most appropriate?
    A. ACE inhibitor, β blocker, angiotensin II blocker
    B. ACE inhibitor, β blocker, aldosterone antagonist
    C. ACE inhibitor, loop diuretic
    D. β blocker, angiotensin II blocker
    E. ACE inhibitor, β blocker, statin

    9-A 50 year old man presents with breathlessness. His chest XR shows cardiomegaly. Which of the following in the history might elucidate a cause of cardiomyopathy?
    A. Inferior T wave inversion
    B. Systolic murmur in the mitral area
    C. History of diabetes and a tanned complexion
    D. Family history of hyperlipidaemia
    E. Family history of myocardial infarction

    10-A 25 year man presents with episodes lightheadedness. He has no significant past medical history. Cardiac examination reveals no heart murmurs, chest X-ray and ECG are normal. A 24 hour tape is requested. Which arrhythmia might cause his symptoms?
    A. Atrial extrasystole
    B. Supraventricular tachycardia
    C. Wenkebach
    D. Ventricular extrasystole
    E. First degree heart block

    عدل سابقا من قبل Dr.Maha في الجمعة 03 أبريل 2009, 8:28 pm عدل 1 مرات
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 10:55 am


    A 44 year old man presents with frequent diarrhoea and upper abdominal pains. He has had a partial gastrectomy 3 years ago for upper GI bleeding. He is now on high dose omeprazole regularly. A repeat endoscopy now shows two oesopnageal ulcers. What is the appropriate investigation?
    A. Gastrin levels
    B. Barium enema
    C. Insulin tolerance test
    D. H. pylori serology
    E. Colonoscopy

    2-A 30 year old man presents with longstanding epigastric pains. Abdominal CT showed dilated pancreatic ducts. The secretin test is positive. The patient has a HB of 13 g/dl, MCV of 105 fl and platelet count of 350 x 10 ^ 9/l . The high MCV is most likely due to:
    A. Folic acid deficiency
    B. B12 deficiency
    C. Myelodysplastic syndrome
    D. Reticulocytosis
    E. Paroxysmal nocturnal haemoglobinuria

    3-A 35 year old man has chronic liver disease secondary to hepatitis. He comes on having had a depressive episode but also feels tired and unwell. He reveals that he has had a bottle of wine a day for a week. On examination he has gross abdominal distension. A peritoneal tap is done.

    Results from the tap show that it has albumin of 25 g/l, LDH of 320 U/l, glucose 3.5 mmol/l (serum glucose 6.5) and a white cell count of 700 per mm3 (90% neutrophils).

    What is the diagnosis?
    A. Acute reactivation of hepatitis B
    B. Tuberculous peritonitis
    C. Alcoholic liver disease decompensation
    D. Chylous ascites
    E. Spontaneous bacterial peritiontis

    4-A 65 year old woman presents with dysphagia and intermittent vomiting. Endoscopy shows a tight lower oesophageal sphincter. Which of the following medical therapies is most effective?
    A. Diltiazem
    B. Bismuth
    C. Glyceryl trinitrate
    D. Botulinum toxin
    E. Glypressin

    5-A 35 female has a 6 year history of intermittent loose stool and constipation. Her blood tests are normal. An ultrasound of the abdomen and flexible sigmoidoscopy showed no abnormality. What should be the next management plan?
    A. Secretin test
    B. Upper GI endoscopy
    C. Reassure her that no intervention is required
    D. CT scan of abdomen
    E. MRI of abdomen
    6-A 45 year old man has symptoms of epigastric pains. He is on several medications. Which of the following medications may cause lower oesophageal ulcerations?
    A. Misoprostol
    B. Cimetidine
    C. Calcichew D3
    D. Salmeterol
    E. Celecoxib
    7-A 25 year old man presents with pain over the right side of the abdomen, diarrhoea, poor appetite and weight loss. He is pyrexial with a temperature of 39°C. He has oral apthous ulcers and a tender right lower quadrant in the abdomen. Rectal examination is normal.

    His Hb is 12.5g/dl, WCC 14 x 10^9/l and platelets 550 x 10^9/l. Urea is 8 μmol/l and creatinine is 90 μmol/l, CRP is 105 mg/l.

    Which of the following is the best test to confirm the diagnosis?
    A. Stool cultures
    B. Barium meal and follow through
    C. Ultrasound of abdomen
    D. Colonoscopy
    E. Surgical laparotomy

    8-A 42 year old man has a diagnosis of Ulcerative Colitis. He was incidentally found to have positive anti smooth muscle antibodies by the GP who sent an autoimmune screen. Which is the next appropriate test for this patient?
    A. CT of the abdomen
    B. Colonoscopy
    C. ESR
    D. Endoscopy
    E. Liver function tests

    9-A 40 year old man visit his GP with symptoms of flusing and dizziness. He also has watery diarrhoea several times a month. On examination he has a systolic murmur in the tricuspid area and a parasternal heave over the left sternal edge. A 24 hour urine for a 5 HT is raised. What is the likely diagnosis?
    A. Zollinger Ellison syndrome
    B. Chronic pancreatitis
    C. Appendicitis
    D. Carcinoid syndrome
    E. Phaeochromocytoma

    10-A 45 year old man has chronic hepatitis C. Which one of the following features is associated?
    A. Polyarteritis nodosa
    B. Porphyria cutanea tarda
    C. Wegener’s granulomatosis
    D. Sclerosing cholangitis
    E. Erythema chronicum migrans

    عدل سابقا من قبل Dr.Maha في الجمعة 03 أبريل 2009, 8:32 pm عدل 1 مرات
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 11:26 am

    1-A 35 year old lady has grey pigmentation of her skin and hypotension. Her early morning cortisol is 45 μmol/l and her sodium is 127 mmol/l. Which of the following is the best replacement regimen?

    A. Hydrocortisone 10mg mane, 5mg mid day and 5 mg evening and also fludrocortisone 100 μg mane
    B. Hydrocortisone 10mg mane, fludrocortisone 100 μg mane
    C. Prednisolone 20 mg mane
    D. Hydrocortisone 40mg mane and fludrocortisone 300 μg mane
    E. Hydrocortisone 20mg mane, 10 mg mid day

    2-A 35 year old lady has had no periods for two years. She also notices increased hair growth. Examination reveals male pattern balding and hair growth, and clitoromegaly. What is the likely diagnosis?

    A. Cushing's disease
    B. Adrenal tumour
    C. MEN
    D. Congenital adrenal hyperplasia
    E. Ovarian tumour

    3-A 45 year old man has polyuria and abdominal pains. His calcium is 2.9 mmol/l, phosphate 0.8 mmol/l and PTH 12 pmol/l. Which one of the following would suggest that he has primary hyperparathyroidism?

    A. Serum alkaline phosphatase is increased
    B. Normal skull
    C. Arthritis
    D. Low urinary phosphate excretion
    E. Low urinary cAMP

    4-A 35 year old lady has complained of syncopal episodes. She has had one previous documented BM of 2.6. Which of the following is the most appropriate investigation?

    A. 24 hour tape recording
    B. Oral glucose tolerance test
    C. Insulin tolerance test
    D. 72 hour fast with insulin, C peptide and plasma glucose sent when BM < 4
    E. MRI of brain

    5-A 25 year old patient presents with tachypnoea and tachycardia . The blood results reveal :

    sodium 135 mmol/l
    Potassium 4.5 mmol/l
    chloride 100 (95-105) mmol/l
    PH 7.29
    PCO2 3.5 kPa
    PO2 is 14.5 kPa
    Bicarbonate is 28 mmol/l

    What is the likely diagnosis?

    A. Diabetic ketoacidosis
    B. Lactic acidosis
    C. Type 2 respiratory failure
    D. Renal tubular acidosis
    E. Salicylate overdose

    6. A 35-year-old black woman comes to see you for a complete physical exam. She has experienced cold intolerance, weakness, and constipation for 3 months. Her menses are regular but scanty. Her history is significant for hypertension and peptic ulcer disease, and her family history includes hypertension and diabetes. The patient is married but has never been pregnant and takes cimetidine 400 mg at bedtime, sustained-release nifedipine 60 mg daily, and docusate sodium 100 mg three times a day. Her pulse is 58 beats/minute with a blood pressure of 135/90 mm Hg. Her skin is dry and scaly, and she has hung-up reflexes. The rest of her exam is normal, and the following labs are obtained: serum chemistries are normal except for a creatine kinase of 300 U/L (normal range, 26-140 U/L); CBC is normal, free thyroxine (T4) is 6.4 pmol/L (normal range,10 – 22 pmol/L), and thyroid stimulating hormone (TSH) is 1.5 mIU (normal range, 0.3-5.0 mIU). Which of the following tests would you order?

    Free triiodothyronine (T3)
    Thyroid scan
    Thyroid uptake
    Pituitary magnetic resonance imaging (MRI)
    Antithyroid antibodies

    Answer: D
    Explanation: This patient has central hypothyroidism and should be evaluated for pituitary and end-organ function as well as the presence of a pituitary tumor. The prolactin level should be measured and the pituitary-adrenal, gonadal, and growth hormone axes assessed. The presence of a pituitary tumor can be determined by imaging the pituitary gland with MRI or CT scan. Where appropriate, this should be followed by evaluation of the visual fields. Measurement of the α subunit, a glycoprotein shared by FSH, LH, and TSH, may also be useful because some pituitary tumors secrete only this peptide.

    7. A 38-year-old black woman comes to you for renewal of her medications. She has had hypertension since her last pregnancy at age 30 and has been maintained on clonidine 0.2 mg twice a day. She gets headaches, dyspnea on exertion, swelling of her feet, and orthopnea but denies chest pain. Her father is also being treated for hypertension. She is married and does not smoke. She is five feet seven inches tall and weighs 257 pounds. Her blood pressure is 180/110 mm Hg; pulse is 92 beats/minute. The rest of her exam is remarkable for hypertensive retinopathy, bibasilar rales, and 1+ pitting edema bilaterally. Initial labs were normal except for a serum potassium of 3.0 mEq/L (normal range, 3.5- 5.0 mEq/L) and serum bicarbonate of 33 mEq/L (normal range, 22-28 mEq/L). You correct hypokalemia and obtain a random serum aldosterone level of 25 ng/dL (normal range, 5-30 ng/dL) with a plasma renin activity of 0.5 ng/mL/hour (normal range, 1.6- 7.4 ng/mL/hour) while the patient is on a normal diet. What additional tests might be appropriate?

    Adrenal computed tomography (CT) scan
    Adrenal vein sampling
    Saline loading test
    A, B, and C

    Answer: E
    Explanation: Primary aldosteronism, a disorder characterized by hypertension, hypokalemia, suppressed plasma renin activity, and increased aldosterone secretion, affects 0.05 to 2% of the hypertensive population. This disorder should be suspected in hypertensive patients in whom spontaneous or easily provoked hypokalemia develops that is slow to correct after discontinuation of diuretics. As important as recognizing the presence of primary aldosteronism is the differentiation of lesions that are surgically curable (60-70% of the cases in some series) from those that are best treated medically. In this patient, the presence of hypertension, hypokalemia, and alkalosis appropriately triggered screening for hyperaldosteronism, which led to the findings of an aldosterone-renin ratio of greater than 30, which constitutes a positive screening test. Aldosteronism can be confirmed by the finding of a 24-hour urine aldosterone secretion of 12 μg in the salt replete state. Adrenal imaging is the next step to differentiate adrenal adenoma from adrenal hyperplasia, although adenomas smaller than 1.5 cm can be missed and thus mistaken for hyperplasia. In confusing cases, adrenal vein sampling for aldosterone measurements is used to localize adenoma with a 95% accuracy. The finding of a lateralizing 10:1 aldosterone ratio in the presence of a symmetrical ACTH-induced cortisol rise diagnoses and localizes an adenoma. Other features suggestive of adenoma include plasma 18-hydroxy corticosterone of 100 ng/dL or more, spontaneous hypokalemia of less than 3 mEq/L, and an anomalous postural decrease of plasma aldosterone concentration. Saline loading is inappropriate in this patient because of heart failure and hypertensive retinopathy.

    8. A 27-year-old white woman was admitted 2 days ago through the emergency room for seizures. She has a history of moderate alcohol use. Two weeks ago she received benzathine penicillin for secondary syphilis. She is complaining of muscle cramps, weakness, and headache. She received 1 g of phenytoin on the day of admission and is now taking 100 mg three times a day. She is also taking acetaminophen, multivitamins, and tapering doses of chlordiazepoxide. There is a history of seizures in her family. She is 5 feet tall and weighs 120 pounds. Her blood pressure is 130/80 mm Hg; pulse is 90 beats/minute. The rest of the physical exam is normal except for a round face, a short neck, short fourth and fifth metacarpals, and bilateral cataracts. Abnormal labs include a calcium of 1.5 mmol/L (normal range, 2.2-2.6 mmol/L), phosphorus of 1.7 mmol/L (normal range, 0.8-1.4 mmol/L), and an intact parathyroid hormone (PTH) of 200 pg/mL (normal range, 15-65). Which of the following is most likely?

    Basal ganglia calcification
    Mental retardation
    All of the above

    Answer: E
    Explanation: The findings of Albright's hereditary osteodystrophy (short stature, brachydactyly, and soft tissue calcification) along with severe hypocalcemia and elevated PTH are diagnostic of pseudohyperparathyroidism (Type IA). This is an autosomal-dominant disorder resulting from a G protein (Gs) defect, which leads to PTH resistance. Hypothyroidism and ovarian failure are also seen because Gs also couples to TSH and gonadotropin receptor signaling, respectively. Mental retardation is seen in 70% of cases.

    9. All of the following thyroid conditions are amenable to RAI treatment, except

    Papillary cancer
    Follicular cancer
    Graves' disease
    Thyroid lymphoma
    Multinodular goiter

    Answer: D
    Explanation: Iodine 131 is a radioactive isotope of iodine (RAI) that is selectively concentrated in the thyroid tissue and metabolized by the same pathways as naturally occurring iodine. This, together with its long half-life (8 days), allows it to deliver high doses of radiation to the thyroid gland (β-radiation) sufficient to destroy thyroid follicular cells. Thus, 131I is used in the treatment of Graves' disease, toxic multinodular goiter, and differentiated thyroid cancer. The doses of RAI used in the treatment of Graves' disease and toxic multinodular goiter are relatively low compared with those used in the treatment of thyroid cancer (in which it is used in conjunction with surgery). RAI has no place in the treatment of thyroid lymphoma because lymphoma cells do not concentrate iodine.

    10. Which of the following statements is/are true regarding PTH?

    Secretion is stimulated by hypocalcemia.
    Secretion is inhibited by hypercalcemia.
    The effect of magnesium on secretion is the same as that of calcium.
    Secretion is stimulated by low 1,25-hydroxyvitamin D and inhibited by high levels of 1,25-hydroxyvitamin D.
    A, B, and D
    All of the above

    Answer: D
    Explanation: PTH, an 84-amino-acid peptide synthesized and secreted by the parathyroid gland, is a potent regulator of the serum calcium level. Hypocalcemia stimulates the secretion of PTH acutely (with increased PTH synthesis and parathyroid cell hypertrophy and hyperplasia after chronic hypocalcemia), whereas hypercalcemia leads to decreased secretion of PTH. Hypomagnesemia inhibits PTH secretion. Elevated 1,25-dihydroxyvitamin D affects PTH synthesis and secretion by directly inhibiting the parathyroid gland and indirectly via hypercalcemia. Low levels of 1,25-dihydroxyvitamin D have the opposite effect.
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 11:40 am


    1. You are asked to see a 25-year-old white man who experienced marked weakness and dyspnea 4 days after being admitted for a compound arm fracture after falling from a tree. Estimated blood loss from the initial fracture episode was 600 mL, and the patient was transfused with one unit of packed erythrocytes. The initial crossmatch was reported as compatible by the transfusion service. The patient has never been transfused before this incident and has no other serious medical illnesses. The patient's arm fracture was treated with surgical pinning and prophylactic antibiotics consisting of cefotetan 2 g IV every 12 hours. On examination, the patient is febrile and mildly tachycardic, with no evidence of wound infection or compartment syndrome. Laboratory data show a hematocrit of 15%, absolute reticulocyte count of 600,000 μL, and total bilirubin of 70 umol/L with direct bilirubin of 9 umol/L. The peripheral smear shows many spherocytes. No hemoglobinemia or hemoglobinuria is seen on visual inspection of the plasma and urine. The transfusion service reports that the direct Coombs' test is now strongly positive using anti-IgG and only weakly positive with anti-C3d antisera. They further report that routine compatibility tests show no new erythrocyte antibodies in the patient's serum and that, when they attempted to elute antibody from the patient's RBCs and test against normal RBCs, the results were negative. What is the most likely diagnosis?

    Hemolytic transfusion reaction caused by an ABO incompatibility
    Delayed hemolytic transfusion reaction
    Autoimmune hemolytic anemia of warm antibody type
    Autoimmune hemolytic anemia of cold antibody type
    Drug-induced immune hemolytic anemia

    Asnwer: E

    Explanation: Recognize drug-induced immune hemolytic anemia of the hapten type, classically developing in patients exposed to high doses of penicillin. The other types of drug-induced immune hemolytic anemia are the [agr ]-methyldopa type (the most common) and the quinidine type (occurring with quinidine, quinine, stibophen, chlorpromazine, and sulfonamides). In this patient the strongly positive direct Coombs test shows that this is an immune hemolytic anemia. Three findings suggest the diagnosis of a drug-induced mechanism rather than an autoimmune mechanism: (1) the patient received a cephalosporin known to induce a hapten-type reaction, (2) routine tests for RBC antibodies in the patient's serum were negative even though the patient's RBCs were strongly coated for antibody, and (3) eluate from the patient's RBCs was not reactive with normal RBCs. In most cases of drug-induced immune hemolytic anemia, the RBC antibodies are detectable only if the offending drug is added to the in vitro system.

    2. Pregnancy-related microangiopathic hemolytic anemia is caused by all of the following, except

    Pregnancy-related ITP
    HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)
    Postpartum hemolytic-uremic syndrome (HUS)

    Answer: B
    Explanation: Pregnancy-related ITP, by definition, affects only the platelets. Microangiopathic hemolytic anemia, which is caused by a variety of disorders, is an RBC fragmentation syndrome resulting from fibrin deposition in partially thrombosed microvasculature. RBCs are caught on the thin fibrin strands, and fragmentation of RBCs into various sizes and shapes results. Preeclampsia/eclampsia, HELLP, and postpartum HUS can give rise to microangiopathic hemolytic anemia. (Hoffman et al, Chs. 32-35; Lee et al, Ch. 49; Cecil, Ch. 169)

    3. All of the following cause microangiopathic hemolytic anemia, except

    Disseminated intravascular coagulation (DIC)

    Asnwer: D
    Explanation: Venoms cause intravascular hemolysis, but not by a mechanism of microangiopathic fibrin deposition. Other causes of intravascular hemolysis, but not by a mechanism of microangiopathic hemolytic anemia, include valve hemolysis, exertional hemolysis, chemical agents, osmotic lysis, thermal injury, infections, PNH, and cold agglutinin disease.

    4. Which of the following statements is true?

    Thalassemias are quantitative disorders of hemoglobin, whereas hemoglobinopathies are qualitative disorders of hemoglobin.
    Thalassemias are qualitative disorders of hemoglobin, whereas hemoglobinopathies are quantitative disorders of hemoglobin.
    Thalassemias are always inherited disorders

    Asnwer: A
    Explanation: In the general classification schema, thalassemias can be classified as disorders of quantitative abnormalities of hemoglobin, wherein the morbidity of the disease is usually a result of the excess globin chains of the unaffected gene (e.g., [agr ]-thalassemia results in decreased [agr ] chains and excess β chains, with the precipitated excess β chains causing the problems). Hemoglobinopathies (e.g., hemoglobin SS, SC) are qualitative abnormalities of the hemoglobin chains usually as a result of point gene mutations. Thalassemias are generally inherited, but acquired cases have been reported.

    5. A 52-year-old black woman comes to you for another opinion regarding a history of anemia that has been unresponsive to oral iron supplementation. She sought your opinion because her other physician was recommending IV iron supplementation. She has been on nearly continuous iron supplementation therapy ever since her second child was born 23 years ago. Over the years she says her doctors have prescribed her to take anywhere from one to three pills daily, sometimes with vitamin C concomitantly. Although she has never needed a transfusion, she says she has been told that her RBC count has never completely normalized. She is otherwise healthy and has no unusual dietary habits. Her menstrual history reveals relatively normal menstrual periods until about 3 years ago, when she attained menopause. The patient believes that her mother was also iron deficient. Your physical exam is normal. Laboratory values show a hemoglobin of 11.6 g/dL; hematocrit, 33%; MCV, 70 fL; normal WBC with differential; normal platelet count; serum iron, 70 μg/L; iron-binding capacity, 255 μg/dL; and ferritin, 158 μg/L. At this point you should next

    Agree with the other physician and recommend IV iron supplementation because she does not appear to be absorbing enough oral iron to totally correct her anemia.
    Perform a hemoglobin electrophoresis.
    Obtain a serum EPO level.
    Discontinue iron supplementation.
    Perform a bone marrow aspirate and biopsy.

    Answer: D
    Explanation: Recognize a clinical history suspicious for two-gene [agr ]-thalassemia. Deletion of two [agr ] genes (-[agr ]/-[agr ] or -/[agr ][agr ]) results in mild to moderate microcytosis and mild anemia, rarely with any progression or development of other signs or symptoms. It is probably the most common hemoglobinopathy in the world, and the combination of one-gene or two-gene [agr ]-thalassemia has an incidence of 20% or more among blacks. It is often mistaken for iron deficiency anemia, and menstruating women with two-gene [agr ]-thalassemia are often treated for prolonged periods with iron supplementation because it is presumed that the mild microcytic anemia is due to iron deficiency. A hemoglobin electrophoresis is a useful test for β-thalassemia wherein one looks for increased levels of hemoglobin A2 and hemoglobin F. However, hemoglobin electrophoresis is generally not helpful for the diagnosis of an [agr ]-thalassemia disorder. A globin chain synthesis study is generally required for a conclusive diagnosis. Because these studies are not routinely available, [agr ]-thalassemias are often diagnosed presumptively by ruling out other possibilities

    عدل سابقا من قبل Dr.Maha في الجمعة 03 أبريل 2009, 8:36 pm عدل 1 مرات
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 11:51 am

    6. A 25-year-old white woman presents to the emergency room with the complaint of extreme shortness of breath of acute onset. She was actually seen in the same emergency room 24 hours previously where she was diagnosed with a urinary tract infection and given prescriptions for phenazopyridine (Pyridium) and sulfamethoxazole. She is overweight and sedentary and smokes two packs of cigarettes a day. On physical exam she is markedly dyspneic and extremely cyanotic. Arterial blood gases fail to reveal any hypoxia, but a ventilation-perfusion scan is obtained anyway, which is read as low probability. What should be the next course of action?

    Repeat the arterial blood gas to look for progression and development of hypoxia.
    Proceed to pulmonary arteriography.
    Begin anticoagulation.
    Administer methylene blue.
    Transfuse two units of packed RBCs.

    Answer: D
    Explanation: Recognize an individual with methemoglobinemia who has been exposed to an offending agent. Rapid development of extreme dyspnea and cyanosis, in the setting of no hypoxia, should be the clue to consider methemoglobinemia. In this case, the patient was exposed to two different known medications (pyridium and sulfamethoxazole) associated with increased levels of methemoglobin in susceptible individuals. Methemoglobin is the derivative of hemoglobin, in which the iron of the heme group is oxidized from the ferrous to the ferric state. It is the oxidation status that determines the oxygen-carrying capacity of hemoglobin. When iron is in the ferrous form (deoxyhemoglobin), oxygen can easily bind, in contrast to the inability to bind to the ferric hemes of methemoglobin. Steady-state methemoglobin levels in the blood are usually <1% but can increase markedly when susceptible individuals (heterozygotes for methemoglobin reductase deficiency) are exposed to certain medications or chemicals. Correct therapy is prompt institution of methylene blue, to which individuals will respond rapidly with resolution of cyanosis.

    7. A 50-year-old white man comes to see you because he was told he had "high blood." Physical exam is normal except for a ruddy complexion, which he says he has had most of his adult life .He has smoked two packs of cigarettes per day since he was 16 years old. A CBC shows a normal WBC count and differential, normal platelet count, a hemoglobin of 18.4 g/dL, and a hematocrit of 57%. To work up this elevated hematocrit, what is the next most appropriate test to order?

    Serum EPO level
    Arterial blood gas analysis
    RBC mass study
    Bone marrow aspirate and biopsy
    Pulmonary function tests

    Asnwer: C
    Explanation: An RBC mass study is the next most appropriate test to order to determine whether the elevated hematocrit is a true polycythemia (erythrocytosis) or a spurious elevation (resulting from reduced plasma volume). Because of the significant smoking history, this patient may have evidence of chronic obstructive pulmonary disease with resultant abnormal arterial blood gases and pulmonary function tests, but these tests will not distinguish a true polycythemia from a spurious one. An EPO level may be indicated later in the work-up once a true polycythemia has been documented.

    8. For the patient described in question 7, the next set of tests to order after the preliminary assessment would include all of the following, except

    Serum EPO level
    Determination of venous P50 (partial pressure of oxygen at which the hemoglobin is 50% saturated)
    Arterial oxygen saturation determination
    Carbon monoxide determination
    Bone marrow aspirate and biopsy

    Answer: E
    Explanation: Once a true RBC mass elevation has been documented, a search for a cause must ensue. The patient's history of nearly lifelong ruddy complexion could be due to tobacco abuse but may also suggest a congenital polycythemia. Most congenital polycythemias are due to hemoglobin mutants with high oxygen affinity. These abnormal hemoglobin affinities as well as abnormal levels of 2,3-diphosphoglycerate (2,3-DPG) can be detected by measuring a P50 level on the oxygen saturation/desaturation curve. Tumors and other disorders can lead to elevated levels of endogenous erythropoietin. Arterial oxygen saturation and carbon monoxide determinations can rule out pulmonary and environmental conditions. A bone marrow exam is rarely useful in the work-up of erythrocytosis, even for a potential diagnosis of polycythemia rubra vera, in which culture of erythroid progenitor cells for the detection of erythropoietin-independent colony growth is currently the closest thing to a diagnostic test for this disease.

    9. A 53-year-old woman comes to see you regarding a possible diagnosis of essential thrombocytosis. She says her gynecologist has noted a platelet count of >550,000/μL on three separate occasions over the past 2 years. Apart from two uneventful childbirths, the woman says she really has no significant medical history. She says she has never been told she was anemic. Lab values reveal a normal hemoglobin, hematocrit, and MCV. The platelet count is 580,000/μL. Your review of the peripheral smear reveals no microcytosis or hypochromia but does show RBC Howell-Jolly bodies. The platelet count on the smear appears elevated, but there are no giant platelets or platelet clumps. What is the next most appropriate step in your diagnostic work-up?

    Perform bone marrow aspirate and biopsy.
    Obtain a C-reactive protein and a sedimentation rate, looking for a state of chronic inflammation.
    Obtain a ferritin level to confirm that there is no iron deficiency.
    Go back and obtain a more thorough history and repeat the physical exam.
    Perform chest, abdominal, and pelvic CT scans, searching for an occult malignancy.

    Answer: D
    Explanation: The RBC Howell-Jolly bodies should be the tip-off that the patient has had a prior splenectomy. Further questioning would reveal that the patient failed to mention a splenectomy at the age of 14 after splenic injury in a motor vehicle accident. You missed the surgical scar on physical exam. Postsplenectomy patients can sometimes have lifelong mild elevations of either their WBC count or their platelet count. The gynecologist was correct to obtain several platelet counts over time to make sure the platelet elevation was persistently increased. Reasons for reactive thrombocytosis include iron deficiency, splenectomy, postsurgical state, infection or inflammation, and occult malignancy. There is currently no diagnostic test for essential thrombocytosis. It remains a diagnosis of exclusion and can be entertained only after all forms of reactive thrombocytosis have been ruled out.

    10. A 62-year-old woman with a platelet count of 1,350,000/μL has been diagnosed with essential thrombocytosis after an exhaustive search failed to reveal any reactive causes for the elevated platelet count. Her platelet count has been greater than 1 million for more than 6 months. The most appropriate therapy now that a diagnosis of essential thrombocytosis has been established is

    Platelet pheresis
    Interferon-[agr ]

    Answer: C
    Explanation: Anagrelide is an oral imidazoquinazolin derivative that has been approved by the FDA as a platelet-lowering agent in essential thrombocythemia. It appears to lower the platelet count by interfering with the maturation of megakaryocytes. There are some side effects, but they are relatively mild in most cases. It should not be administered in cases of reactive thrombocytosis because their risk of complications from thrombocytosis is much less than in patients with thrombocytosis from inherent marrow disorder. Because essential thrombocytosis patients are at risk for hemorrhage as well as thrombosis, aspirin is not indicated in all cases. Hydroxyurea has a potential leukemogenic risk because it is a chemotherapeutic, although this risk has not been substantiated. Anagrelide lacks this potential risk because it is not a chemotherapeutic agent. Interferon has many more associated side effects with less efficacy. Thus, anagrelide appears to offer the best therapeutic window with the fewest risks and is the treatment of choice for essential thrombocythemia as long as it is tolerated by the patient.
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 11:58 am


    1. 43-year-old woman presents with a 3-year history of progressive rheumatoid arthritis that has been partially responsive to various nonsteroidal anti-inflammatory drugs (NSAIDs) and to low-dose oral corticosteroids. After the examination, you decide to treat her active arthritis with methotrexate, currently the most widely used and effective agent for rheumatoid arthritis. Some of the facts to tell her about methotrexate therapy include

    Therapeutic effects are delayed so that clinical improvement is not generally seen for 3 to 6 weeks after initiation of treatment.
    Adverse effects may include oral ulcers, nausea, vomiting, pneumonitis, bone marrow suppression, and cirrhosis.
    CBC, platelet count, alkaline phosphatase level, and serum glutamic-oxaloacetic transaminase (SGOT) level should be obtained every 4 to 6 weeks to monitor therapy.
    Birth control measures must be in use before methotrexate is started.
    All of the above.

    Answer: E
    Explanation: All of the answers are correct. Methotrexate is currently the best drug used to treat rheumatoid arthritis, with initial improvement seen in 3 to 6 weeks and peak efficacy in 4 to 6 months. Adverse effects such as nausea, abdominal pain, and diarrhea are frequently seen, but serious toxicity is rare. Methotrexate is taken orally (7.5-15 mg/week), and tolerance may be increased by spacing the oral doses over 1 to 2 days, giving a single intramuscular injection each week and daily folic acid (1 mg/day) supplementation. Laboratory tests such as CBC, platelet count, alkaline phosphatase, and SGOT are done every 4 to 6 weeks. The most toxic drug-related side effects are pancytopenia, neutropenia, thrombocytopenia, pneumonitis, and cirrhosis; all are reasons to stop the medications. Transient or sustained (1.5-2 times normal values) elevations in alkaline phosphatase and SGOT are commonly seen and, in the majority of patients, generally do not portend the development of hepatic fibrosis. Methotrexate is known to be teratogenic and should not be given to women with childbearing potential unless they are using an adequate method of birth control. Because of its potential effect on sperm, men should discontinue methotrexate 3 to 4 months before attempting conception.

    2. 54-year-old woman complains of severe right shoulder pain localized mainly to the midhumerus but also diffusely around the anterolateral shoulder. The onset was sudden and not precipitated by trauma. Physical examination reveals limited abduction with point tenderness over the subacromial bursa and the greater tuberosity of the humerus. A radiograph reveals a linear calcific density in the supraspinatus tendon. All of the following statements are true, except

    Treatment consists of cortisone injection into the subacromial bursa, NSAIDs, and physical therapy.
    The calcific density is most likely calcium urate.
    The diagnosis could not be made by an arthrocentesis.
    Local tendon injury may be the major cause.

    Answer: B
    Explanation: The clinical features and radiographic pattern are characteristic for calcific tendinitis, an extremely common rheumatic syndrome characterized by deposits of hydroxyapatite crystals within injured rotator cuff muscles near the humeral attachment region. It most commonly involves the supraspinatus tendon, but the infraspinatus and subscapularis tendons may also be involved. Conservative treatment is indicated and is successful in the vast majority of cases.

    3. A 74-year-old woman complains of worsening left knee pain with weight-bearing and ambulation. Examination of the knee reveals a small effusion without warmth, bony enlargement, and crepitus with flexion and extension of the knee. A diagnostic arthrocentesis is performed. Each of the following characteristics of the synovial fluid would be expected, except

    Pale yellow color
    Good viscosity
    Routine culture negative
    WBC count 800/mm3
    Glucose 22 mg/dL

    Answer: E
    Explanation: Clinically, the patient has osteoarthritis of the left knee. Synovial fluid in patients with osteoarthritis is typically "noninflammatory," meaning that the leukocyte count is less than 2000/mm3. A low level of glucose in the synovial fluid would not be found in this patient but is suggestive of septic arthritis.

    4. A 42-year-old woman with seropositive rheumatoid arthritis has become disabled by pain and tightness behind the right knee. Physical examination reveals cystic swelling over the popliteal fossa and semimembranous tendon. Which of the following is the most appropriate next step?

    Arthrogram of the right knee
    Synovial biopsy of the right knee
    Ultrasound study of the right knee popliteal fossa
    Venogram of right lower extremity
    None of the above

    Answer: C
    Explanation: The physical examination is suggestive of a distended Baker's cyst, but physical examination alone is not diagnostic, particularly if there has been a dissection or rupture. Ultrasonography has been found to be very useful in making a diagnosis of popliteal cyst with or without dissection. An arthrogram could also demonstrate a popliteal cyst but is less desirable because it is an invasive procedure. A venogram of the right lower extremity could be performed if a deep vein thrombosis was suspected clinically but would not be indicated in this case

    5. All of the following conditions involve the distal interphalangeal (DIP) joint, except

    Multicentric reticulohistiocytosis
    Erosive osteoarthritis
    Psoriasis with nail changes
    Juvenile chronic arthritis
    Rheumatoid arthritis

    Answer: E
    Explanation: Although hand involvement is very common in rheumatoid arthritis and occurs in approximately 95% of patients, DIP joint involvement is distinctly unusual. The most commonly involved joints in the rheumatoid hand are the PIPs, MCPs, and wrist joints in a symmetric manner.

    6. Rheumatoid factor may be present in each of these conditions, except

    Adult Still's disease
    Subacute bacterial endocarditis
    Vasculitis syndromes
    Sjögren's syndrome

    Answer: A
    Explanation: Patients with adult Still's disease are "seronegative" and lack serum rheumatoid factor. Rheumatoid factors are antibodies specific for the region of the Fc portion of human IgG. Although present in 75 to 80% of rheumatoid arthritis patients, primarily those with HLA-DR4 haplotype, they are by no means specific for this disorder and are found in normal individuals as well as patients with a variety of other inflammatory illnesses.

    7. An 82-year-old woman was hospitalized for treatment of congestive heart failure. She experienced a warm, painful right knee on the 3rd hospital day. The most appropriate procedure would be

    Blood cultures followed by IV antibiotics
    Arthrocentesis for diagnostic/therapeutic purposes
    IV colchicine
    Ultrasound study of right knee, including popliteal fossa

    Answer: B
    Explanation: Clinically, the patient has a monoarthritis most likely crystal induced, such as pseudogout or gout. She could also have septic arthritis, although this would be less likely. Gout and pseudogout can be rapidly and definitively diagnosed by proper examination of joint fluid, and infection can also be ruled out in this manner.

    8. A 46-year-old man on hemodialysis for 12 years complains of insidious onset of painful nocturnal dysesthesias involving the thumb and three fingers, relieved by shaking the hand. Physical examination of the hand reveals thenar wasting and numbness over the fingers. Each of the following statements is true, except

    Deposits of β2-microglobulin AH (amyloidosis associated with hemodialysis) amyloid compressing the median nerve could produce these findings.
    An entrapment neuropathy could explain these findings.
    Paresthesias involving the radial side of the thumb, second, third, and fourth fingers suggest compression of the medial nerve.
    Carpal tunnel syndrome could explain these findings.
    Deposits of amyloid of the primary type AL (amyloidosis associated with light chains) would be typical.

    Answer: E
    Explanation: Clinically, the patient has carpal tunnel syndrome, an entrapment neuropathy in which the median nerve is compressed within the carpal tunnel area. A new type of amyloid protein identified as β2-microglobulin has been demonstrated in bone and carpal tunnel tissue of patients undergoing long-term (usually greater than 10 years) hemodialysis. It is hoped that modifications of the dialysis membranes may result in improved β2-microglobulin clearance with diminished tissue deposition.

    9. Ophthalmologic manifestations of rheumatoid arthritis may include all of the following, except

    Secondary Sjögren's syndrome with sicca complex
    Corneal melts
    Ischemic optic atrophy

    Answer: E
    Explanation: Ischemic optic atrophy is not routinely seen in patients with rheumatoid arthritis but may be a major ophthalmic manifestation of giant cell arteritis, Wegener's granulomatosis, and, less commonly, SLE.

    10. All of the following are characteristic patterns of joint involvement in rheumatoid arthritis, except

    Polyarticular involvement
    Oligoarticular involvement
    Symmetrical involvement
    Involvement of the proximal interphalangeal (PIP), metacarpophalangeal (MCP) wrist, and metatarsophalangeal (MTP) joints
    Frequent cervical spine involvement

    Answer: B
    Explanation: Clinically, rheumatoid arthritis is a symmetrical polyarthritis especially involving the PIP, MCP, wrist, and MTP joints. In many of these joints, definite articular deformities will develop over time. Cervical spine involvement is common. Rarely is an oligoarticular pattern observed except in the early course of this illness.
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 3:17 pm


    1-A 55 year old man has a pleural effusion which was aspirated. Tests of the pleural fluid show : protein 35 g/L, LDH 350 (<200). Which of the following causes is likely?

    A. Nephrotic syndrome
    B. Cirrhosis
    C. Malignancy
    D. Peritoneal dialysis
    E. Hypoalbuminaemia

    2-A 65 year old man has had 5 kg weight loss. He is an ex smoker and used to work in a coal mine. Chest X ray shows a large right sided pleural effusion and several pleural plaques in both lung peripheries. Pleural aspiration reveals an exudate. What is the next best investigation?

    A. Bronchoscopy
    B. Lung function tests
    C. Spiral CT of the chest
    D. Thoracoscopy and biopsy
    E. Sputum for AFB

    3-A 55 year old man who had two episodes of hemorrhagic shock due to intestinal hemorrhage and post-operative secondary hemorrhage, was admitted to intensive care unit.

    During the following weeks this was followed by bronchopneumonia with symptoms of sepsis persisting over several weeks. Chest x ray showed progressive changes in the interstitial tissues and he became more significantly hypoxic. Pulmonary capillary wedge pressure was 13 mmHg.

    What is the diagnosis?

    A. Congestive cardiac failure
    B. Pneumocystis pneumonia
    C. Pulmonary embolism
    D. Adult respiratory distress syndrome
    E. Community acquired pneumonia

    4-A 45 year old man who works in a cotton mill presents with fluctuating breathlessness. He has been getting progressively more breathless for 10 months. There is also associated chest tightness and cough. He has been smoking 10 cigarettes a day for the past 10 years.

    Upon assessment the patient has oxygen saturations of 95% and a normal chest x ray.

    What is the likely diagnosis?

    A. Occupational asthma
    B. Berylliosis
    C. Extrinsic allergic alveolitis
    D. Byssinosis
    E. Sarcoidosis

    5-A 40 year old lady was admitted to hospital with fevers and cough productive of sputum. Chest X-ray shows diffuse patchy consolidation around the left lung. She has had a flu like illnes 4 weeks ago, and has a past medical history of asthma. She also smokes. Which organism is likely to be responsible?

    A. Mycoplasma
    B. Pseudomonas
    C. Klebsiella
    D. Staphylococcus
    E. Tuberculosis
    6-A 60 year old miner has been in the occupation for 20 years. He presents with a cough and breathlessness. Chest XR shows diffuse interstitial shadowing. A sputum sample is positive for acid fast bacilli. Which of the following dusts is most likely to have predisposed the patient to tuberculosis?

    A. Beryllium
    B. Cadmium
    C. Coal
    D. Silica
    E. House dust

    7-An 70 year woman has a history of dry cough for 2 months. She has lost 5 kg of weight over the 2 months. Her chest X ray shows a left apical shadowing. Blood tests reveal a raised white cell count of 16. She has not managed to cough up any sputum. Which of following tests should be performed?

    A. CT scan of the chest
    B. Serum ANCA
    C. Ultrasound of the chest
    D. Kveim test
    E. Bronchoscopy

    8- A 35 year old man has significant wheezing and breathlessness. Recordings of peak flows shows diurnal variation. He was prescribed with salbutamol but continues to have frequent wheezy episodes. What is the next step in management?

    A. Phosphodiesterase inhibitors
    B. Leukotriene antagonists
    C. Oral antibiotics
    D. Inhaled corticosteroids
    E. Oral steroids

    9-An 18 year old girl with severe difficulty in breathing to A+E. She has had a history of asthma with two previous ITU admissions. Her peak flow is currently 100. She is unable to say more than a few words. She was given nebulised salbutamol and iv hydrocortisone 200mg by the paramedics.Which treatment should she now have?

    A. Further iv hydrocortisone 200 mg
    B. Iv magnesium 2g
    C. Intubation and ventilation
    D. Iv salbutamol
    E. Iv ipatropium

    10-A 32 year old man has a history of dry eyes and mouth. His blood tests reveal a positive ANA, Ro and La extra nuclear antigens are also positive. Which of the following is he predisposed to developing?

    A. SLE
    B. Small cell carcinoma of the lung
    C. Lymphoma of the lung
    D. Restrictive lung disease
    E. Pulmonary eosinophilia

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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 5:28 pm


    1-A 30 year old patient difficulty reading. On examination of her visual fields she has a central scotoma. The diagnosis may be:

    A. Contralateral optic radiation lesion
    B. Contralateral occipital infarct
    C. Optic chiasm tumour
    D. Multiple sclerosis
    E. Venous sinus thrombosis

    2-A 25 year old man has come from Mexico 5 years ago. Since a year ago, he has had two tonic clonic seizures a week. On examination, he appears well, with no focal neurological deficit. A CT scan shows multiple calcified cystic lesions in the brain. Which diagnosis is likely?

    A. Neurosarcoid
    B. Neurocysticercosis
    C. Multiple sclerosis
    D. Cerebral toxoplasmosis
    E. Tuberculosis

    3-A 18 year old male is wheelchair bound and has difficulty with respiration. He also has upper limb weakness. When he was younger he developed marked hypertrophy of his muscles. Blood tests reveal a raised creatine kinase. What is a muscle biopsy likely to show?

    A. Necrotic muscle fibres
    B. Absence of dystrophin
    C. Excessive lipid storage
    D. Macrophage infiltration
    E. Vasculitic changes

    4-A 35 year old woman has been admitted to hospital for investigation of progressive weakness in her legs. For the past 5 years. The patient's mother has similar difficulties with weakness and sensory problems. Examination revealed power of 3/5 distally in the upper and lower limbs with a glove and stocking pattern sensory loss to pain and touch. What is the diagnosis?

    A. Hereditary neuropathy with liability to pressure palsies
    B. Friedrich's ataxia
    C. Chronic inflammatory demyelinating polyneuropathy
    D. Multiple sclerosis
    E. Hereditary sensori motor neuropathy

    5-A young lady visits her neurologist complaining of episodes of generalised weakness after arguments with her partner. She also complains of seeing goblins upon waking up. At work as a secretary, she has difficulty staying awake and may have sleep attacks. What is the diagnosis?

    A. Absence seizures
    B. Narcolepsy
    C. Tonic clonic seizures
    D. Vasovagal attacks
    E. Hemiplegic migraine

    6-A 50 year old lady has a painful cheek (maxillary area) when chewing. The neurologist diagnoses trigeminal neuralgia. Which is the best medication to prescribe?

    A. Benztropine
    B. Tramadol
    C. Diclofenac
    D. Propanolol
    E. Carbamazepine

    7-A 35 year old woman wakes up with a sudden onset severe sharp headache. She has no neurological signs. CT of her head is normal. What is the best next investigation?

    A. MRV
    B. Lumbar puncture
    C. Serum electrophoresis
    D. EEG
    E. Bone scan

    8-A 40 year old man presents with an uncomfortable sensation in his face, to the casualty department. He is unable to lift his eyebrows and also has bilateral facial weakness. Which one of the following is most likely to cause bilateral lower motor neuron weakness?

    A. Cerebrovascular disease
    B. Pontine haemorrhage
    C. Lyme disease
    D. Multiple sclerosis
    E. Motor neuron disease

    9-A 60 year old right handed patient prsesents with disorientation. Examination reveals left right disorientation, acalculia, agraphia and finger agnosia. Which structure is involved?

    A. Right cingulate gyrus
    B. Right angular gyrus
    C. Left fusiform gyrus
    D. Left angular gyrus
    E. Left cingulate gyrus

    10-A 65 year old patient has nystagmus looking to the left, ataxia and vertigo. He also has a left sided Horner’s syndrome. There is numbness on the left side of the face and decreased sensation in the right side of the trunk and limbs. Which of the following is the diagnosis?

    A. Foster Kennedy syndrome
    B. Wallenberg’s syndrome
    C. Gelineau’s syndrome
    D. Gerstmann syndrome
    E. Guillain Barre syndrome
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 6:12 pm


    1-A lady with polycystic kidney disease has several family members who are concerned about having the condition themselves. Which one of the following is the best screening test for adult polycystic kidney disease?

    A. Intravenous urogram
    B. Renal ultrasound
    C. Genetic testing
    D. Isotope renography
    E. Urine dipstick

    2-A 30 year old African woman presents with seizures, hypertension, a malar rash.
    Bloods show :
    Hb 11 g/dl, WCC 8 x 10^9/l, platelets 180 x 10^9/l, urea 22 μmol/l, creatinine 290 μmol/l, sodium 140 mmol/l, potassium 5 mmol/l, ESR 100 mm/hr, CRP 25 mg/l.
    What is the most likely diagnosis?

    A. Anti GBM disease
    B. Multiple myeloma
    C. SLE
    D. Wegener's granulomatosis
    E. Sickle cell disease

    3-A 45 year old man with no previous past medical history presents with a BP of 180/100 mm Hg, frothy urine and peripheral oedema. There is +++ blood and +++ protein on urinalysis. 24-hour protein loss is 5 grams.

    Plasma albumin is 25 g/L. Plasma C3 is 0.10 (low). Plasma creatinine is 160 umol/l. A renal biopsy is performed. Which of the following is most likely to be found on the biopsy?

    A. Minimal change glomerulonephritis
    B. Mesangiocapillary glomerulonephritis
    C. IgA nephropathy
    D. Post streptococcal glomerulonephritis
    E. Focal segmental glomerulosclerosis

    4-A 45 year old patient with chronic hepatitis C has a creatinine of 140 µmol/l. His BP is 150/90. He has urine dipstick showing blood ++, protein +++. Which of the following might be demonstrated on the histology?

    A. Minimal change glomerulonephritis
    B. Membranous glomerulonephritis
    C. Focal segmental glomerulonephritis
    D. Membranoproliferative glomerulonephritis
    E. Glomerulosclerosis

    5-A 60 year woman has bilateral swollen calves and ankles, with the left calf more painful and swollen. A 24 hr urine protein was 8g/day. Which could explain these findings?

    A. Factor VIII deficiency
    B. Reduced concentration of Von Willebrand’s factor
    C. Reduced d dimer levels
    D. Reduced antithrombin III activity
    E. Reduced fibrinogen concentration

    6-A 55 year old man presents with chest pain and is thrombolysed for an acute myocardial infarction. His blood pressure was 85/40 for several hours on admission. Two days later his blood tests show a urea of 22 mmol/l and creatinine of 300 μmol/l (U+Es were normal on admission). What would a renal biopsy show?

    A. Positive antibody to fibrinogen
    B. Thickened capillary loops
    C. Loss of tubular cells
    D. IgG deposition in the basement membrane
    E. IgA mesangial deposits

    7-A 40 year old woman presents with swollen ankles. Her urine dipstick reveals protein +++, but no other abnormality. She has gout and diabetes. Plasma creatinine is 120 micromoles/l and albumin 28g/l. Which of the following medications would be most likely to account the swollen ankles and proteinuria?

    A. Lisinopril
    B. Bendrofluazide
    C. Prednisolone
    D. Ibuprofen
    E. Allopurinol

    8-A 60 year old man has a history of hypertension. His blood show : urea 20 μmol/l & creatinine 320 μmol/l. Urinalysis showed blood ++ protein ++. Renal ultrasound showed left kidney : 9 cm long, right be 8.5 cm long and no evidence of hydronephrosis. What is the next best investigation?

    A. Renal biopsy
    B. DMSA renography
    C. Intravenous urography
    D. Magnetic resonance angiography
    E. Retrograde pyelography

    9-A 18 year boy presents with a nonblanching rash over his shins and a swollen knee. He has noticed haematuria. Blood test show a urea of 12 μmol/l and creatinine 220 μmol/l. Urine dipstick shows: blood +++ , protein +. What is the renal biopsy likely to show?

    A. Tubular necrosis
    B. Podocyte fusion
    C. Mesangial deposits of IgA
    D. Thickening of basement membranes
    E. Focal segmental sclerosis

    10-A 15 year old boy is being investigated for growth retardation. He has had no previous medical problems. He mentions that he had symptoms of worsening muscle weakness and fatigue. He also has polyuria.

    Investigations revealed:
    urea 8 mmol/l
    serum creatinine 118 µmol/l
    potassium 2.8 mmol/l
    sodium 133 mmol/l
    chloride 79 (95-107) mmol/l
    calcium 2.3(2.25-2.7) mmol/l
    phosphate 0.86 (0.8-Cool mmol/l
    magnesium 0.9 (0.67–0.96) mmol/l

    A metabolic alkalosis was present:
    pH 7.58
    HCO3 40 mmol/l
    BE + 18 mmol/l

    What is the likely diagnosis?
    A. Bartter’s syndrome
    B. Bulimia
    C. Diuretic abuse
    D. Laxative abuse
    E. Congenital adrenal hyperplasia
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 6:41 pm

    infectious diseases

    1-A 65 year old man had been on holiday to Arizona in the united states 6 weeks ago. He was brought to hospital with high fever, rigors, malaise, and mild confusion. He had a generalised, non-pruritic maculopapular rash, predominantly on the trunk but also on the extremities, including the palms and soles. There was no history of animal or arthropod exposure, but his house was on the edge of forest.

    What is the most likely diagnosis?

    A. Falciparum malaria
    B. Rickettsial spotted fever
    C. Tuberculosis
    D. Allergic bronchopulmonary aspergillosis
    E. Schistosomiasis

    2-A 35 year old man has lymphopenia on his white cell differential. He complains of headaches. A CT scan of his brain showed a 5 cm ring enhancing lesion in the frontal lobe. Which is the likely infective organism?

    A. Cryptosporidia
    B. Toxoplasma gondii
    C. Aspergillus
    D. Cryptococcus neoformans
    E. Mycobacterium avium intracellulare

    3-A 35 year old man was in South East Asia on holiday backpacking alone. He has returned 5 days ago, having been there for a month. His temperature is 38 °C and he has a swollen ankle and elbow joint. He also complains of purulent penile discharge. Which of the following conditions/infections is likely?

    A. Reiter's syndrome
    B. Chlamydia trachomatis
    C. Neisseria gonorrhoeae
    D. Staphyloccocus aureus
    E. Treponema pallidum

    4-A 25 year old man presented to an emergency department with a 1-day history of fever, headache and myalgia. Two weeks before his presentation, he had returned from a 10-day trip to Costa Rica, where he had injured the sole of his foot on coral. After injuring his foot, he had swum in freshwater rivers. Thick and thin blood films examined at the time for malaria parasites were negative.

    What is the likely diagnosis?

    A. Amoebiasis
    B. Leishmaniasis
    C. Schistosomiasis
    D. Leptospirosis
    E. Brucella abortius

    5-An 18 year old girl was studying for examinations together with a friend who was hospitalised 2 days ago with meningitis. The blood cultures in her friend grew meningococcus group A. Which of the following actions should be taken towards the girl who was in contact with the patient?

    A. Immunisation with meningococcus A vaccine
    B. Immunisation with meningococcus A and C vaccine
    C. Immunisation with meningococcus A and C vaccine, and rifampicin
    D. Rifampicin only
    E. Full treatment for meningitis A

    6-A 25 year old secretary comes to the clinic complaining of fevers, crampy abdominal pains and diarrhoea. She has returned from Turkey on a holiday. Whilst there, she visited two spas and spent a long time in jacuzzis. Which of the following organisms might be isolated from stool culture?

    A. Vibrio cholerae
    B. Cryptosporidium
    C. Salmonella
    D. Shigella
    E. Actinomyces

    7-A 62 year old lady presents with fever and persistent difficulty in speaking. Her signs show a termperature of 39°C. The patient was alert and oriented with respect to time but unable to name objects properly. Dysarthria and occasional word substitution were noted. The patient followed two but not three-step commands.

    A provisional diagnosis of an aphasic temporal lobe lesion was made. A CT scan showed a low attenuation lesion involving the medial and posterior aspect of the left temporal lobe and inferior basal ganglia. What is the diagnosis?

    A. Polymorpho leukoencephalopathy
    B. Cerebral toxoplasmosis
    C. Herpes simplex encephalitis
    D. Multiple sclerosis
    E. Meningococcal meningitis

    8-A patient with HIV takes several different drugs is concerned about changing facial appearance. Which drug is most likely to cause lipodystrophy?

    A. Lamivudine (3TC)
    B. Zidovudine (AZT)
    C. Didanosine (DDI)
    D. Nevirapine
    E. Saquinavir

    9-A 38 year old man with previously treated early syphilis and hepatitis C infection presented to a hospital complaining of 3 months of tender right inguinal lymphadenopathy. An excisional biopsy showed the formation of necrotising granuloma indicative of Lymphogranuloma venereum.

    What should he be treated with?

    A. Benzylpenicillin
    B. Erythromycin
    C. Clindamycin
    D. Gentamicin
    E. Doxycycline

    10-Which of the following is the commonest world wide cause of traveller's diarrhoea?

    A. E coli
    B. Giardia
    C. Shigella
    D. Salmonella
    E. Campylobacter
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 7:13 pm


    1-A patient has recently been diagnosed with schizophrenia. While assessing the prognosis, which of the following is a poor prognostic feature of schizophrenia?

    A. Good intelligence
    B. Acute onset of symptoms
    C. Visual hallucinations
    D. Drug induced schizophrenia
    E. Strong family history

    2-A 50 year old man has been on lithium for bipolar disorder. His psychiatrist thinks that the dose of lithium may be too high due to a certain symptom. Which of the following symptoms may be a feature of lithium toxicity?

    A. Abnormal eye movements
    B. Abdominal pains
    C. Breathlessness and ankle oedema
    D. Tremor and ataxia
    E. Hallucinations

    3-A 40 year old man was involved in a war and has previously been tortured. He is having nightmares and mood swings. Which of the following is most suggestive of post traumatic stress disorder?

    A. Onset usually about 3 months after the event
    B. More common in older men
    C. Replaying a tramatic scene in his mind
    D. Low incidence in Europe
    E. Predisposing mental illness

    4-A 27 year old man presents with persistent fatigue, lethargy and irritability following a flu like illness which started 12 months ago. A diagnosis of chronic fatigue syndrome was made. What is the appropriate management of this patient?

    A. Antidepressants
    B. Rest
    C. Cognitive behavioural therapy
    D. Intensive exercise
    E. Psychoanalysis

    5-A 63 year old man who has been diagnosed with a glioma is commenced on chemotherapy. 4 days later, he begins to behave strangely, and has suicidal ideation. Which one of the following is the most likely cause of the presentation?

    A. Vincristine encephalitis
    B. Hyponatraemia
    C. Hypoglycaemia
    D. Steroid induced psychosis
    E. Hypocalcaemia

    6-A 45 year old woman has recently lost her husband in a road traffic accident. Which of the following is an abnormal grief reaction?

    A. Insomnia
    B. Poor appetite
    C. Thoughts of dying
    D. Feelings of hopelessness, guilt and worthlessness
    E. Feelings last 6 months

    7-Which one of the following cognitive problems is most likely to occur 6 months following a head injury?

    A. Lower IQ score
    B. Aphasia
    C. Dysphasia
    D. Difficulty executing plans
    E. Short term memory loss

    8-A 50 year old man has been involved in a car accident is admitted for assessment. He is told that he may have frontal lobe damage. Which of the following might be associated with frontal lobe damage?

    A. Left right disorientation
    B. Homonymous hemianopia
    C. Dressing apraxia
    D. Finger agnosia
    E. Perseverance

    9-A 40 year old patient is assessed for periods of breathlessness. Although she is a smoker and has early bronchitis, her symptoms suggests that she may have panic disorder as well. Which of the following would strongly suggest the diagnosis?

    A. Sense of impending doom
    B. An obvious trigger for an attack
    C. Fear of crowded places
    D. Attacks lasting 2 hours
    E. Permanent feeling of nervousness

    10-A 66 year old man was found with decreased consciousness. There were some chlorpromazine, diazepam and amitriptyline tablets in his pocket. He also was found with a half empty bottle of whisky. He had a temperature of 38.2°C, GCS was 13/15 on arrival to A+E. Blood pressure was 170/100 mmHg and there was marked muscle rigidity but reflexes were normal and plantars were downgoing. What is the diagnosis?

    A. Bipolar disorder
    B. Epilepsy
    C. Narcolepsy
    D. Catatonic schizophrenia
    E. Neuroleptic malignant syndrome
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 8:00 pm

    clinical pharmacology

    1-A 45 year old lady has recent recovered from the flu and now presents with a cough. Her temperature is 39 C and chest x ray shows right lower zone consolidation. The best antibiotic regimen out of the following is:

    A. Benzylpenicillin and flucloxacillin
    B. Erythromycin
    C. Levofloxacin
    D. Amoxycillin and metronidazole
    E. Amphotericin

    2-A 40 year old lady is being considered for treatment for rheumatoid arthritis. Which of the following is a disease modifying anti rheumatic drug?

    A. Mercury
    B. Phenylephrine
    C. Silver
    D. Leflunomide
    E. Benzoyl peroxide

    3-A 45 year old man has drunk 10 pints of lager beers a day for 20 years. He presents with haemetemesis and has an OGD which shows oesophageal varices. Which of the following medications have been of prognostic and mortality benefit in this clinical situation?

    A. Octreotide
    B. Terlipressin
    C. Amoxycillin and metronidzaole
    D. Propanolol
    E. Octreotide

    4-A 23 year old student has been started on treatment for pulmonary tuberculosis. She wants to take a contraceptive pill. Failure of contraception could be due to a interaction with which of the following drugs?

    A. Rifampicin
    B. Isoniazid
    C. Pyrazinamide
    D. Ethambutol
    E. Streptomycin

    5-A 46 year male presents to the A&E with complaints of polyuria. He mentions that he has been passing about 4 litres of urine per day. He has recently been prescribed a new drug. Investigations show:

    Serum sodium 141 mmol/l
    Serum potassium 4.2 mmol/l
    Plasma osmolality 290 mosmol/l (275-290)
    Urine osmolality 330 mosmol/l (350-1000)

    What drug was prescribed?

    A. Lithium
    B. Carbamazepine
    C. Chlorpropamide
    D. Fluoxetine
    E. Furosemide

    6-A 65 year old man presents with chest pain. His ECG shows ST eleveation consistent with myocardial infarction and he is thrombolysed with tenecteplase. Which of the following drugs have not been proven to reduce future cardiovascular events and mortality?

    A. Ramipil
    B. Amlodipine
    C. Atenolol
    D. Aspirin
    E. Simvastatin

    7-Frusemide (furosemide) acts on which part of the kidney?

    A. Bowman's capsule
    B. Ascending loop of Henle
    C. Descending loop of Henle
    D. Distal convoluted tubule
    E. Proximal convoluted tubule

    8-A 72 year old woman is assessed for visual disturbance. She complains of visual haloes and mild photophobia, which have been present for a few weeks. Which one of the following drugs is the most likely cause of her symptoms?

    A. Digoxin
    B. Amlodipine
    C. Amiodarone
    D. Atenolol
    E. Thiazide

    9-A 30 year old man has been brought to A+E by a friend. He informs the staff that the patient has taken 40 tablets of ferrous sulphate. Which one of these is an important feature of iron poisoning?

    A. Diarrhoea
    B. Abdominal discomfort
    C. Fever
    D. Hypotension
    E. Slurred speech

    10-A 65 year old man has cardiac risk factors of hypertension and is on aspirin. Echocardiography shows reduced ejection fraction at 50%. Which one of the following medications may reduce the risk of future cardiovascular events?

    A. Furosemide
    B. Isosorbide mononitrate
    C. Ramipril
    D. Verapamil
    E. Clopidogrel
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 8:20 pm


    1-A study investigates whether a certain drug A is better alone with the addition of drug B for ulcerative colitis. After randomizing the patients, a few patients on both drug A+B drop out due to side effects. How should the data be analysed?

    A. Exclude the patients from statistical analysis
    B. Assume that the patients did not drop out
    C. Include these patient outcomes in the drug A+B group
    D. Recruit more patients in the A+B group
    E. Analyse the two groups separately

    2-Coronary artery stenosis and cholesterol levels in patients levels are found to correlate with a coefficient of 0.70. Which is the best deduction from this?

    A. A scattergram of coronary artery stenosis against cholesterol would have a negative gradient
    B. A scattergram of coronary artery stenosis against cholesterol would have a positive gradient
    C. Coronary artery stenosis and cholesterol levels are not correlated
    D. Correlation value r is -0.70
    E. Correlation value r is 1

    3-A blood test for screening heart failure has been introduced. Out of 300 patients, 100 were found to have heart failure with echocardiography. When the blood test is used, 80 patients were found to have heart failure. 70 of these patients had heart failure confirmed with echocardiography but 10 did not. Which is the positive predictive value of the blood test?

    A. 10/80
    B. 70/80
    C. 70/100
    D. 80/100
    E. 70/300

    4-A new diagnostic blood test for pulmonary embolus has been described. Out of all patients tested negative, which parameter measures the true numbers of patient who do not have pulmonary embolus?

    A. Positive predictive value
    B. Negative predictive value
    C. Sensitivity
    D. Specificity
    E. Odds ratio

    5-The frequency of attendance of a 100 medical students at lectures were recorded by an observer over a 3 month period. The students were then assessed at the end with a multiple choice exam with a test score marked out of a hundred. Which of these statistical methods is best used to analyse the effectiveness of frequency of attendance on higher test scores?

    A. Mann-Whitney test
    B. Spearmann correlation
    C. Chi square test
    D. Fisher's exact test
    E. Student's t test

    6-A group of middle aged subjects are recruited to a study which measures cholesterol. The normal distribution is assumed. The mean cholesterol was 5.0mmol/l. The standard deviation is 0.3 mmol/l. Which of these statements is correct?

    A. 68% of subjects have a cholesterol between 4.85 to 5.15
    B. 68% of subjects have a cholesterol between 4.4 to 5.6
    C. 95% of subjects have a cholesterol between 4.4 to 5.6
    D. 95% of subjects have a cholesterol between 4.85 to 5.15
    E. 99% of subjects have a cholesterol between 4.3 to 5.6

    7-A study has been testing for a new drug Z compared to placebo for treating acne. The study shows that there was no statistical difference. A statistician who examined the study suggested that there was a type 2 error. What is the implication of this?

    A. The p value is incorrect
    B. The statistical difference was not true
    C. The study suggests that there is no difference but the trial was too small to detect a difference between treatments
    D. Drug Z should have been compared to a current treatment
    E. The finding is due to observer error

    8-A sample of 2000 patients has a mean weight of 50 kg and a standard deviation of 5kg. Assuming normal distribution, which of the following is true?

    A. 95% of the patients have a weight between 45 and 55 kg
    B. 95% of the patients have a weight between 40-60kg
    C. 95% of the patients have a weight between 35-65kg
    D. 68% of the patients have a weight between 35-65kg
    E. 68% of the patients have a weight between 40-60k

    9-A group of 100 patients were involved in a study of clubbing and endocarditis. There were 8 patients with SBE and clubbing, 2 patients with SBE without clubbing. 90 patients without SBE and 5 of these patients had clubbing. Which of the following is true?

    A. Positive predictive value = 8/(8+2)
    B. Negative predictive value = 85/(85+2)
    C. Sensitivity = 8/(8+5)
    D. Sensitivity = 8/(8+85)
    E. Specificity = 85/(85+2)

    10-Which of the following statements is correct regarding data interpretation of diseases?

    A. Prevalence is the total number of cases out of the whole population
    B. Mortality rate is cumulative of incidence
    C. Prevalence is identical to incidence
    D. Incidence is the number of newly affected individuals out of an at risk population
    E. Cumulative incidence rate is usually over five years
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    ممتاز رد: mrcp part 1 questions

    مُساهمة من طرف Dr.Maha في الجمعة 03 أبريل 2009, 10:11 pm


    Basic Science
    1-Answer: e) abetalipoproteinaemia. Abetalipoproteinaemia is a disorder in the synthesis of serum lipoproteins containing apolipoprotein B, for example chylomicrons, VLDL and LDL. There is a failure of apoB100 in the liver and apo B48 in enterocytes of the intestinal mucosa. The result is malabsorption of fat soluble vitamins.

    2-Answer: b) 261. Serum osmolality is 2 X sodium + Urea + Glucose = 248 + 5 + 8 = 261 mOsmol/Kg. Normal is 280 to 305 hence she has low serum osmolality. An alternative formula is 1.9 x (Na + K) + Ur + Glucose.

    3-Answer: e) translocation between the long arm of chromosome 4 (q) and the short arm of chromosome 8 (p). The karyotype 46 XX, t (4;Cool(q26;p21.3) describes a female with a normal number of chromosomes but a translocation between the long arm of chromosome 4 (q) and the short arm of chromosome 8 (p).

    4-Answer: a) finger agnosia.

    Parietal lobe signs are:

    loss of two point discrimination
    finger agnosia
    Gerstmann syndrome
    receptive dysphasia
    dressing and constructional dyspraxia

    Gerstmann syndrome includes four features (acalculia, agraphia, finger agnosia, left right disorientation), and is due to a lesion in the dominant hemisphere.

    5-Answer: d) ptosis. 3rd nerve palsy leads to ptosis, dilated unreactive pupil and eye looking down and out (due to unopposed superior oblique and abducent nerves. Exopthalmos can be associated (e.g. graves disease) but is not a feature of 3rd nerve palsy

    6-Answer: d) subthalamic nucleus. Hemiballismus is caused by a subthalamic nucleus lesion, which is commonly due to an infarct.

    7-Answer: b) p53. Ras is an oncogene. Bcl-2 inhibits rather than promotes apoptosis

    8-Answer: c) sciatic nerve. The sciatic nerve branches into the tibial nerve and common peroneal nerve. Damage to these branches will cause almost total weakness around the ankle and absent ankle jerk.

    9-Answer: c) thoracic sarcoma. The four Ts for mediastinal masses (anterior) are thyroid, thymoma, teratoma and tumour (lymphomas).

    10-Answer: e) pernicious anaemia. Achlorhydria (absence of gastric acid secretion) can be caused by immune destruction to the stomach wall, malnutrition and marijuana use. The pentagastrin test is used as a diagnostic aid for evaluation of gastric acid secretory function. It is effective in testing for anacidity (achlorhydria) in patients with suspected pernicious anemia, atrophic gastritis, or gastric carcinoma.


    1-Answer: b) pericarditis. Significant outflow tract obstruction, advanced heart block, hypertension > 180 mmHg systolic, and unstable angina are all contraindications towards ETT.

    2-Answer: a) simvastatin. A statin is most appropriate. In a patient with vascular disease (CVA or MI), a cholesterol > 5 should be treated. Ezetimide lowers cholesterol by preventing its intestinal absorption through the inhibition of cholesterol transport across the intestinal wall and can be used in conjunction with HMGCoA enzyme inhibitors (i.e. statins).

    3-Answer: d) ruptured papillary muscle. Following an MI, ruptured papillary muscle or interventricular septum is most likely to cause the combination of pulmonary oedema and new murmur (either mitral regurgitation or due to VSD).

    4-Answer: b) rheumatic fever. This patient has polyarthritis, carditis (2 major criteria), fever and raised inflammatory markers (2 minor criteria). The history is consistent with rheumatic fever (β haemolytic strep Group A) infection.

    5-Answer: a) reduction in thromboxane A2 synthesis. Aspirin blocks the synthesis of COX1 and COX2 enzymes. This leads to a reduction in PGG2, PGH2 → TXA2 synthesis↓ leads to → platelet aggregation.

    6-Answer: c) myocarditis. Pyrexia, chest pain (pleuritic), raised troponin, T wave changes on the ECG would be suggestive of myocarditis. Pericarditis usually causes saddle shaped ST elevation on ECG. Coxsackie B is the commonest cause. Other causes are HIV, diphtheria, Chagas disease, Lyme disease, SLE and arsenic poisoning.

    7-Answer: c) 2:1 Mobitz type II heart block. The first form of second degree heart block, Mobitz type I (Wenkebach) is due to progressive prolongation of PR interval and then missing a beat. Mobitz type II second degree heart block can occur with 2:1 (only 1 QRS is conducted for 2 p waves) or 3:1. In a patient who is compromised with symptoms and hypotension, temporary pacing is indicated.

    8-Answer: b) ACE inhibitor, β blocker, aldosterone antagonist. Of all the combinations, ACE inhibitor / angiotensin II blocker with β blocker and aldosterone antagonist (spironolactone) is the most appropriate given the fact that this patient has symptomatic heart failure. Trials have shown that these medications have reduced mortality and also conferred symptomatic benefit.

    9-Answer: c) history of diabetes and a tanned complexion. A history of diabetes and bronze / tanned pigmentation suggest haemochromatosis. Liver function tests and iron studies would help to confirm the diagnosis.

    10-Answer: b) supraventricular tachycardia. Out of the following options, the most likely rhythm which may cause symptoms are supraventricular tachycardia. The other rhythms may cause palpitations but would be unusual to cause light headedness / presyncope.


    1-Answer: A) gastrin levels. Diarrhea and recurrent gastric ulceration is common with Zollinger Ellison syndrome (gastrinoma). There would be demonstrable high fasting plasma gastrin levels. Gastrinomas may occurs as part of a multiple endocrine neoplasia syndrome type 1.

    2-Answer: b) B12 deficiency. In chronic pancreatitis, trypsin secretion is reduced. Trypsin is required in the processing of dietary B12 which enables absorption and hence B12 deficiency is the most likely in this case.

    3-Answer: e) spontaneous bacterial peritonitis. A white cell count of > 350 mm3 is diagnostic of spontaneous bacterial peritonitis. There is underlying cirrhotic liver disease and this should always be considered related to decompensation.

    4-Answer: d) botulinum toxin. Botulinum injections are most effective of all the options for relieving a lower oesophageal sphincter restriction which leads to achalasia. Nifedipine, nitrates or sildenafil can also be used, but are less effective.

    5-Answer: c) reassure her that no intervention is required. She is likely to have irritable bowel syndrome from the history and normal investigation. She should be reassured and also recommended to have a high fibre diet.

    6-Answer: e) celecoxib. COX 2 inhibitors such as celecoxib are used as analgesics instead of NSAIDS in patients who are at high risk of upper GI dyspepsia or ulceration. However, there remains an increased risk of ulceration, though less so compared to NSAIDS. Misoprostol (prostaglandin analogue) and cimetidine are used in treatment of gastro-oesophageal ulceration.

    COX 2 inhibitors have also recently been shown to increase the mortality rate of patients with coronary artery disease by blocking the antithrombotic effects of certain prostaglandins.

    7-Answer: b) barium meal and follow through. The likely diagnosis is Crohn's disease and a barium follow through is the best test to confirm this. Behcet's disease and Yersinia colitis can also present with raised inflammatory markers, oral ulceration and right sided abdominal pathology.

    8-Answer: E) Liver function tests. The features are suggestive of autoimmune hepatitis. Liver function tests may demonstrated elevated levels of bilirubin, AST and ALT. A liver biopsy may then be warranted.

    9-Answer: d) Carcinoid syndrome. Carcinoid syndrome is diagnosed by raised urinary 5-HT levels. A precursor of 5HT, tryptophan is highly metabolised and consequently niacin deficiency (pellagra) occurs.

    10-Answer: e) pantoprazole. Proton pump inhibitors such as omeprazole, lansoprazole and pantoprazole are more effective than H2 receptor blockers such as ranitidine, cimetidine or nizatidine. Healing in oesophagitis is beter with a PPI although all of the options can reduce symptoms due to acid reflux.


    1-Answer: a) hydrocortisone 10mg mane, 5mg mid day and 5 mg evening and also fludrocortisone 100 μg mane. She has Addison's disease and needs both glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement. Steroid replacement is usually given 10/5/5 mg or 10/5 mg, although this is adjusted with cortisol day curves. Fludrocortisone 100 μg mane should be adequate.

    2-Answer: b) adrenal tumour. An adrenal tumour is most likely, with androgen secretion. Virilisation occurs. These are aggressive tumours and the treatment option is surgery or radiotherapy.

    3-Answer: a) serum alkaline phosphatase is increased. Serum alkaline phosphatase is usually increased in primary hyperparathyroidism.

    Primary hyperparathyroidism does not respond to steroids.

    Salt and pepper changes on the skull can be a hallmark.

    Gout, rather than arthritis, is worsened by hyperparathyroidism.

    High urinary phosphate excretion leads to serum phosphate and a high cAMP in the urine suggests active excretion.

    Pepper pot skull

    4-Answer: d) 72 hour fast with insulin, C peptide and plasma glucose sent when BM < 4. The diagnosis is likely to be an insulinoma. Hypoglycaemic attacks are likely to be witnessed during a 72 hour fast. Insulin and C peptide levels are high, whilst glucose is low. Sulphonylurea levels are also sent in cases where oral hypoglycaemic drug misuse is suspected.



    1-Answer: c) malignancy. A protein of >35 g/L suggests an exudate.

    Causes of transudate are:

    Congestive heart failure
    Nephrotic syndrome
    Peritoneal dialysis
    Atelectasis (early)

    Caues of exudate are : Infection (Bacterial, viral, or parasitic)
    Connective tissue disease
    Postcardiotomy syndrome
    Drug-induced (eg, by amiodarone)
    Esophageal rupture
    Subdiaphragmatic abscess

    Light's criteria (suggests exudate) is satisfied if
    pleural fluid protein/serum protein ratio greater than 0.5
    Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6
    Pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH (a cut-off value of 200 IU,/L was used previously)

    2-Answer: d) thoracoscopy and biopsy. This patient probably has a malignant effusion. As he is symptomatic, the best option would be to drain the fluid as well as confirm a diagnosis simultaneously. A video assisted thoracoscopy would help to do this

    3-Answer: d) adult respiratory distress syndrome. Respiratory distress syndrome is associated with profound hypoxia and increased vascular permeability (causing a V/Q mismatch). A normal PCWP differentiates the condition from pulmonary oedema. It does not respond to steroids.

    4-Answer: d) byssinosis.

    Byssinosis is caused by cotton dust, and is commoner among smokers. Immunologically, it is different from farmer’s lung but is more akin to occupational asthma – wheeze occurs after exposure to cotton and hemp.

    The condition is typically worse on Mondays when work begins and lung function stabilises throughout the week. The CXR is normal, unlike extrinsic allergic alveolitis, where mottling is seen on CXR (interstitial pneumonitis).

    6-Answer: d) silica. Slate workers, stonemasons and miners are exposed to silica dust. Silicosis impairs macrophage function, and in particular, predisposes to TB infection.

    7-Answer: e) bronchoscopy. This patient is likely to have TB due to the apical shadowing. In a patient who is unable to expectorate sputum, bronchoscopy with lavage (send for AFB) should be performed to confirm the diagnosis.

    8-Answer: d) inhaled corticosteroids.

    Diurnal PEFR variation points towards a diagnosis of asthma. Patients who do not respond to B agonists should be treated with inhaled steroids.

    9-Answer: b) iv magnesium 2g. According to BTS guidelines, single dose Magnesium of 2g IV should be instituted in cases of acute severe asthma following administration of conventional therapy. Aminophylline is no longer recommended as the second line treatment in most trusts.

    عدل سابقا من قبل Dr.Maha في السبت 04 أبريل 2009, 8:45 pm عدل 1 مرات

    معاذ بشير الهادي
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    مُساهمة من طرف معاذ بشير الهادي في السبت 04 أبريل 2009, 8:46 am

    شكرا يا mind

    مجهود جبار ومقدر
    يديك العافية

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    مُساهمة من طرف اباد في الجمعة 07 مايو 2010, 6:19 am

    اقل كلمة ممكن اقولها لك هي شكرا
    ادعو لك الله ان يجزيك عنا خير الجزاء
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    مُساهمة من طرف dr.maria في الخميس 20 يناير 2011, 4:04 pm

    الله يجزيك بكل خير يارب .معليش بس حبيت اعرف نتيجة امتحانك؟؟ والله اسأله التوفيق لك وللجميع
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    مُساهمة من طرف dr.maria في الثلاثاء 25 يناير 2011, 10:15 am

    يااااااااناس المنتدي ماعرفته الاجابات دي كيف وهل هي مرتبه ؟؟
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    مُساهمة من طرف dr.maria في الأربعاء 26 يناير 2011, 12:24 pm

    نريد منتدي جامعة شندي ضروووووووووووووووووووووري Shocked Sad
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    مُساهمة من طرف dr.maria في الأربعاء 26 يناير 2011, 12:26 pm

    لماذا لا احد يهتم بي اليوم ؟؟ [b][i][quote

    شموخ سالم
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    مُساهمة من طرف شموخ سالم في الخميس 18 أبريل 2013, 7:39 pm

    مشكوووووووووووووورة على المجهود المقدر - ربنا يديك العافية

      الوقت/التاريخ الآن هو الثلاثاء 18 ديسمبر 2018, 11:46 pm