*Best of five Clinical scenarios for the MRCP Part 1 Punit Ramrakha and Iqbal Malik Medexam distance learning Volume 1 Erythema Nodosum Q1. The following are true of Erythema nodosum except: A. B. C. D. E. It can present with painful nodular lesions on the arms. Systemic steroids are required as treatment in most cases Brucellosis is a cause It is inflammation of the subcutaneous fat The lesions resolve without scarring Q2. A 35 year old woman presents with tender raised nodules on her shins. Which of the following investigations would not be useful? A. B. C. D. E. Chest xray Serum calcium Throat swab Xray of the lower legs Antistreptolysin O titre Q3. The following are true of erythemia multiforme except: A. B. C. D. E. IT is a blistering disease The commonest cause in UK is herpes simplex virus infection Palms and soles are affected C1 esterase inhibitor deficiency causes a hereditary form of the disease Oral contraceptive use is a recognized cause Q4. A 56 year old woman is admitted to hospital with a rash involving the palms of her hands and feet. It appear red, raised and annular. There is no involvement of the trunk. Which of the following drugs is least likely to be the culprit? A. B. C. D. E. Carbamazepine Allopurinol Ibuprofen Omeprazole Rifampicin Q5. Which of the following cutaneous signs is least likely to be associated with internal malignancy? A. B. C. D. E. Ichthyosis Urticaria Hypertrichosis lanuginose Acanthosis nigricans Necrolytic migratory erythema Q6. A60 year old smoker presents with weight loss and skin and nail changes. Which of the following signs is least likely to suggest the diagnosis of an underlying malignancy? A. B. C. D. E. Erythema gyratum repens Heliotrope rash on eyelids Nicotine staining of nails Migratory thrombophlebitis Finger clubbing Q7. A random blood glucose would be a useful first line investigation in all of the following dermatological conditions except: A. B. C. D. E. Erythema multiforme Necrobiosis lipidoica Vitiligo Eruptive xanthomata Granuloma annulare Q8. A 55 year old overweight lady with Type II diabetes presents with a 6 cm diameter ulcer on the left medial malleolus. What is the most likely cause of this? A. B. C. D. E. Neuropathic ulcer Arterial ulcer Pyoderma gangrenosum Venous ulcer Ulcerated squamous cell carcinoma A9. A 60 year old lady has recently been found to be hypothyroid. Which of the following features is not related to her endocrine disorder? A. B. C. D. E. Eczema Coarse scalp hair Xanthomata Facial oedema Hyperhidrosis Q10. A thin 40 year old lady presents with lesions on her shins. She is noted to have sweaty palms and protruding eyes. The skin lesions are most likely to be: A. B. C. D. E. Erythema nodosum Erythema ab igne Pyoderma gangrenosum Pretibial myxodema Necrobiosis lipoidica Q11. Which of the following is least likely to be associated with a purpuric rash on the legs? A. B. C. D. E. Cutaneous amyloid Sarcoidosis Bechcet disease Hepatitis B infection Waldenstrom macroglobulinaemia Q12. An otherwise well 50 year old male develops a vasculitis skin rash on the legs. Which of the following investigations is it most important to perform? A. B. C. D. E. Blood glucose Thyroid function Renal function Antinuclear antibody Blood cultures Q13. A 43 year old woman is referred with widespread pruritus for several months. There is no obvious rash apart from minor excoriations. Which of the following conditions is the least likely cause of this presentation? A. B. C. D. E. Acute intermittent porphyria Hyperthyroidism Iron deficiency anaemia Hodgkin disease Polycythaemia Q14. A 75 year old woman presents with severe generalized pruritus but no rash. Which of the following investigations is least useful? A. B. C. D. E. Chest xray Liver chemistry Blood glucose Serum ACE FErritin Q15. Which of the following is the least likely cause of oncholysis in a 40 year old woman? A. B. C. D. E. Raynaud phenomenon THyrotoxicosis Fungal infection Trauma Lichen planus Q16. The following are true about nail disease in psoriasis except: A. Toe nail pitting is a feature B. It is associated with arthropathy C. It signifies severe skin disease D. It is usually symmetrical E. Onycholysis can occur. Q17. Which of the following statements about dermatitis herpetiforms is not true? A. Pruritus associated with it is severe B. Patients with G6pD deficiency respond well to dapsone C. It is associated with gluten sensitive enteropathy D. Immunofluorescence tests show Ig A and C3 in dermal papillae E. Skin biopsy of uninvolved skin is useful in making the diagnosis Q18. Dapsone used in the treatment of dermatitis herpetiformis is least likely to cause which of the following side effects: A. Agranulocytosis B. Lichen planus C. Haemolysis D. Neuropathy E. Methaemoglobinaemia Q19. A 56 year old man complains of a rash. The distribution is suggestive of photosensitivity. Which of the following drugs is least likely to be the culprit? A. Amiodarone B. Psoralens C. Chlorpropamide D. Omeprazole E. Bendrofluazide Q20. All of the following skin conditions are aggravated by sunlight except: A. Discoid lupus erythematosus B. Herpes simplex infection C. Porphyria cutanae tarda D. Pellagra E. Scurvy Q21. A 45 year old woman with facial flushing and eye problems is diagnosed as having rosacea. Which of the following is least likely to be true? A. The rash is worse in sunlight B. She has blepharitis as a result of rosacea C. Alcohol triggers her flushing D. Topical steroids are the best treatment for her E. Her flushing may be due to menopausal symptoms Q22. A 20 year old female is on isotretinon therapy for sever cystic acne. All of the following statements are true except: A. Her blood androgens are elevated B. Her treatment is giving her nosebleeds C. She is on the oral contraceptive pill D. Her blood lipids may elevated as a result of her treatment E. Her treatment is giving her dry and gritty eyes Q23. Leg ulceration is a recognized complication of cell of the following conditions except: A. Sickle cell anaemia B. Acute intermittent porphyria C. Cryoglobulinaemia D. Calciphylaxis E. Cholesterol emboli Q24. A 65 year old lady with rheumatoid arthritis develops a painful ulcer on her left shin. Which of the following is least useful as a next step? A. Examine for splenomegaly B. Ankle brachial pressure index C. Full blood count D. Swab of ulcer E. Compression bandaging to left leg Q. An 80 year old lady is admitted to hospital with a rash. For the preceding 3 weeks she has noticed a widespread itchy, blistering rash over her trunk and limbs. On examination there is a widespread bullous erythematous rash with a combination of intact and burst blisters on torso and back. Which of the following features is not typical of this condition? A. Itchy eruption B. RESPIRATORY MEDICINE CASE: LUNG CANCER *Best of five Clinical scenarios for the MRCP Part 1 Punit Ramrakha and Iqbal Malik Medexam distance learning Volume 1 Q1. A 40 year old man is undergoing investigation for acromegaly. MRI of the pituitary fossa is normal , but CXR reveals large central based mass. The patient is a nonsmoker, the most likely type of lung tumour is A. Squamous cell B. Small cell C. Carcinoid D. Large cell E. Adenocarcinoma Case discussion: Answer C A central mass in a nonsmoker showing clinical evidence of neuroendocrine cell origin is consistent with carcinoid. It represents the well differentiated spectrum of small cell lung cancer and surgery in nonmetastatic disease confers 90% survival at 5 years. CASE: LUNG CANCER *Best of five Clinical scenarios for the MRCP Part 1 Punit Ramrakha and Iqbal Malik Medexam distance learning Volume 1 Q2. A patient is diagnosed with primary adenocarcinoma of the left upper lobe of the lung. The FEV1 is 1. 8 (60% predicted) and the staging CT scan shows only ipslateral hilar lymphadenopathy. The next step for the patient is : A. Chemotherapy B. Radiotherapy and chemotherapy C. Lobectomy D. Medistinoscopy and lobectomy E. Best supportive care Case discussion: The best chance to cure primary nonsmall cell lung cancer is surgery. CT is not always able to exclude mediastinal node involvement and mediastinoscopy is always required before surgery. Paraneoplastic syndrome in lung cancer - Cerebellar syndrome: antineuronal antibodies are directed against the purkinje cells of the cerebellum. - Eaton Lambert syndrome: is a presynaptic disorder of autoantibody IG G directed against the presynaptic calcium channel leading to impaired acetycholine release. Clinically patients present with muscle weakness that improves with exercise. - HPOA: most commonly with squamous cell cancer. HPOA does not occur with small cell lung cancer. - Hypercalcemia: PTH RP (squamous cell commonly) - Hyponatraemia: SIADH (small cell commonly) Surgery for NSCLC - NSCLC represents 80% of all lung cancers. - 80% of these are clinically inoperable. Surgery confers a 40% survival at 5 years. - Q. When is NSCLC is inoperable if? NSCLC is inoerapble if o FEV1 is < 1. 5 L for lobectomy o o o o Mediastinal node or contralateral hilar nodes are enlarged ( > 1.5 cm) Pleural effusion or metastatic spread else is present Mediastinal structure involvement is present Satellite nodules are present in same lobe or different lobe or lung CASE: HIV and LUNG Q3. A 38 year old HIV positive man presents with life threatening haemoptysis. Which one of the following features would be consistent with Kaposi sarcoma as the cause? A. B. C. D. E. Pleural effusion Lack of systemic symptoms Generalized lymphadenopathy HIV acquired through IV drug abuse Cavity on chest xray Case discussion: A Kaposi sarcoma is a very vascular tumour and a cause of life threatening haemoptysis. Pleural effusion is commonly involved with lung malignancy and in 30% of cases of KS. Systemic symptoms are common. The finding of generalized lymphadenopathy and cavitation is nonspecific in HIV. Q4. A patient with pneumocystis carinii pneumonia (PCP) has the following blood gases: PaO2 6.9 kPa and PaCO2 3.5 kPa. The most important prognostic step is: A. Nasal ventilation B. Physiotherapy C. IV steroids D. Urgent commencement of retroviral therapy E. Controlled oxygen therapy Case discussion: C In pneumocystis carinii pneumonia, steroids decrease the risk of respiratory failure by 50%, and the risk of death by 33%. Steriods are indicated if the arterial oxygen tension is less than or equal to 9.3 kPa on air. Common causes of respiratory disease in HIV are: - Pneumocystis carinii (the most common opportunistic infection in HIV) - Mycobacterium tuberculosis - Mycobacterium avium-intracellulare (other atypical mycobacteria are rare) - Organisms that commonly cause community acquired pneumonia Strep pneumonia, Haemophilus influenza, Mycoplasma pneumonia, Staphylococcus aureus. In addition both Gram vebacteria and Brahmnella catarrhalis are commonly seen - CMV - Other organisms including fungi and viruses are rare. CASE: Q5. A 34 year old woman presents with prolonged history of epistaxis and rapidly progressive, SOB. The KCO and eosinophil count are raised. The most likely diagnosis is: A. Good pasture syndrome B. Microscopic polyangitis C. Churg strauss syndrome D. Wegner granulomatosis E. Alveolar proteinosis Case discussion: A patient with breathlessness and a raised KCO has alveolar haemorrhage till proven otherwise. A prolonged history of epistaxis and sinusitis is commonly found in wegener s granulomatosis, which in some patients is also associated with an eosinophilia. A history of asthma must usually be present to diagnose the CHurg Strauss syndrome. ** The transfer coefficient (KCO) is the best functional indicator of the presence and severity of emphysema. The measurement of KCO is of clinical value in distinguishing patients with emphysema from those with asthma, in whom KCO is not reduced. TLCO=CO transfer factor for whole lung (single breath CO transfer); KCO=gas transfer coefficient (=TLCO/VA ), ie. it is corrected for lung volume. Q6. A 50 year old patient with asthma is prescribed a leukotriene inhibitor. He presents with severe abdominal pain and a pleural effusion. The most likely cause of the effusion is: A. Carcinoma B. Pancreatitis C. Pneumonia D. Heart failure E. Churg Strauss syndrome Case discussion: Churg strauss syndrome has a predilection for serosal surfaces and therefore can cause both pleural and pericardial effusions and peritonitis. Cytological analysis of this fluid would confirm an eosinophilia. Leukotriene inhibitor use is associated with an increased incidence of the disease. Name Large vessel vasculitis (Temporal arteritis) Large vessel vasculitis (Takayasu s arteritis) Medium vessel vasculitis (Polyarteritis nodosa) Medium vessel vasculitis (Kawasaki disease) Small vessel disease (Wegener granulomatosis) Small vessel disease (Churg strauss syndrome) Small vessel disease (Microscopic polyangitis) Small vessel disease (Henoch Schonlein purpura) Small vessel disease (Essential cryoglobulinaemia) Vasculitis of lung Rare Frequent Rare None Frequent Frequent Frequent none none ANCA finding none None None None PR3 ANCA MPO-ANCA or PR3-ANCA MPO-ANCA or PR3-ANCA none none SOME QUESTIONS MISSING CASE: ASTHMA *Best of five Clinical scenarios for the MRCP Part 1 Punit Ramrakha and Iqbal Malik Medexam distance learning Volume 1 Q23. The most important finding to confirm the diagnosis of asthma is: A. High total blood IgE level B. Demonstration of airway reversibility C. High levels of IL-5 and Granulocyte macrophage colony stimulating factor (GM-CSF) in blood D. Family history of asthma E. A high TLCO and KCO Case discussion: Answer B. Definition of asthma. CASE: ASTHMA *Best of five Clinical scenarios for the MRCP Part 1 Punit Ramrakha and Iqbal Malik Medexam distance learning Volume 1 Q24. A 20 year old college student is referred with breathlessness. Exercise induced asthma is most likely diagnosis if: A. Inhaled steroid abolishes symptoms B. C. D. E. No history of atopy Symptoms usually occur at end of strenuous exercise Symptoms reoccur on immediate repeat exercise Leukotriene receptor antagonist abolishes the symptoms. Case discussion: Exercise induced asthma is due to cold air drying the mucosa and affecting the periciliary fluid osmotic. This leads to inflammatory release and symptoms occur within 5 10 min of exercise and last up to 1 hour. There is usually a refractory period following this of up to 2 4 hour. Cysteinyl leukotrienes are key players here and leukotriene receptor antagonists are used to prevent exercise induced bronchospasm. Steriods are not helpful. SOME QUESTIONS MISSING CASE: Granulomatous lung disease *Best of five Clinical scenarios for the MRCP Part 1 Punit Ramrakha and Iqbal Malik Medexam distance learning Volume 1 Q26. A 49 year old miner develops smear positive mycobacterium TB. Which of the following dusts is most likely to have increased risk of this infection in this patient? A. Coal dust B. Asbestos C. Cadmium D. Silica E. Beryllium Case discussion: Answer D. Silica is toxic to macrophages and impairs their function. Thus there is an increased risk of mycobacterium tuberculosis in slate workers, stone masons, fettlers and miners (drilling through quartz strata). Indications for immunosuppression in sarcoidiosis - Hypercalcemia - Ocular complications - Cardiac complications - Neurological complications - Skin infiltration - Progressive decrease in lung function - Severe systemic symptoms SOME QUESTIONS MISSING CASE: TB *Best of five Clinical scenarios for the MRCP Part 1 Punit Ramrakha and Iqbal Malik Medexam distance learning Volume 1 Q27. The most appropriate treatment regimen for a Russian man with smear positive mycobacterial disease is: A. Isolation and rifampicin and ethambutol for 12 months B. BCG vaccination C. Rifampicin and isoniazid for 2 months and review sensitivity D. Rifampicin, pyrazinamide, ethambutol for 12 months E. Rifampicin, isoniazid, pyrazinamide, ethambutol for 2 months and review sensitivity. Answer: E CASE: SMOKING *Best of five Clinical scenarios for the MRCP Part 1 Punit Ramrakha and Iqbal Malik Medexam distance learning Volume 1 Q28. A 40 year old window cleaner wants to quit smoking. He is on aspirin, a steroid inhaler and phenytoin. The best treatment for this man is: A. Counselling B. Bupropion (Zyban) C. Nicotine patches D. Counselling and nicotine patches E. Fluoxetine Case discussion: Bupropion (Zyban) is more effective than nicotine patches in smoking cessation. However it is contraindicated in apteints with eating disorder and those with a history of seizures. There is no advantage in combining nicotine patches with bupropion.