*Best of five Clinical scenarios for the MRCP Part 1Punit Ramrakha and Iqbal Malik – Medexam distance learning Volume 1

Erythema Nodosum

Q1. The following are true of Erythema nodosum except:

A. It can present with painful nodular lesions on the arms.B. Systemic steroids are required as treatment in most casesC. Brucellosis is a causeD. It is inflammation of the subcutaneous fatE. 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. Chest xrayB. Serum calciumC. Throat swabD. Xray of the lower legsE. Antistreptolysin O titre

Q3. The following are true of erythemia multiforme except:

A. IT is a blistering diseaseB. The commonest cause in UK is herpes simplex virus infectionC. Palms and soles are affectedD. C1 esterase inhibitor deficiency causes a hereditary form of the diseaseE. 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. CarbamazepineB. AllopurinolC. IbuprofenD. OmeprazoleE. Rifampicin

Q5. Which of the following cutaneous signs is least likely to be associated with internal malignancy?

A. IchthyosisB. UrticariaC. Hypertrichosis lanuginoseD. Acanthosis nigricansE. 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. Erythema gyratum repensB. Heliotrope rash on eyelidsC. Nicotine staining of nailsD. Migratory thrombophlebitisE. Finger clubbing

Q7. A random blood glucose would be a useful first line investigation in all of the following dermatological conditions except:

A. Erythema multiformeB. Necrobiosis lipidoicaC. VitiligoD. Eruptive xanthomataE. 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. Neuropathic ulcerB. Arterial ulcerC. Pyoderma gangrenosumD. Venous ulcerE. 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. EczemaB. Coarse scalp hairC. XanthomataD. Facial oedemaE. 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. Erythema nodosumB. Erythema ab igneC. Pyoderma gangrenosumD. Pretibial myxodemaE. Necrobiosis lipoidica

Q11. Which of the following is least likely to be associated with a purpuric rash on the legs?

A. Cutaneous amyloidB. SarcoidosisC. Bechcet diseaseD. Hepatitis B infectionE. 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. Blood glucoseB. Thyroid functionC. Renal functionD. Antinuclear antibodyE. 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. Acute intermittent porphyriaB. HyperthyroidismC. Iron deficiency anaemiaD. Hodgkin diseaseE. Polycythaemia

Q14. A 75 year old woman presents with severe generalized pruritus but no rash. Which of the following investigations is least useful?

A. Chest xrayB. Liver chemistryC. Blood glucoseD. Serum ACEE. FErritin

Q15. Which of the following is the least likely cause of oncholysis in a 40 year old woman?

A. Raynaud phenomenonB. THyrotoxicosisC. Fungal infectionD. TraumaE. Lichen planus

Q16. The following are true about nail disease in psoriasis except:

A. Toe nail pitting is a featureB. It is associated with arthropathyC. It signifies severe skin diseaseD. It is usually symmetricalE. Onycholysis can occur.

Q17. Which of the following statements about dermatitis herpetiforms is not true?A. Pruritus associated with it is severeB. Patients with G6pD deficiency respond well to dapsoneC. It is associated with gluten sensitive enteropathyD. Immunofluorescence tests show Ig A and C3 in dermal papillaeE. 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. AgranulocytosisB. Lichen planusC. HaemolysisD. NeuropathyE. 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. AmiodaroneB. PsoralensC. ChlorpropamideD. OmeprazoleE. Bendrofluazide

Q20. All of the following skin conditions are aggravated by sunlight except:A. Discoid lupus erythematosusB. Herpes simplex infectionC. Porphyria cutanae tardaD. PellagraE. 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 sunlightB. She has blepharitis as a result of rosaceaC. Alcohol triggers her flushingD. Topical steroids are the best treatment for herE. 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 elevatedB. Her treatment is giving her nosebleedsC. She is on the oral contraceptive pillD. Her blood lipids may elevated as a result of her treatmentE. 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 anaemiaB. Acute intermittent porphyriaC. CryoglobulinaemiaD. CalciphylaxisE. 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 splenomegalyB. Ankle brachial pressure indexC. Full blood countD. Swab of ulcerE. 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 eruptionB.

RESPIRATORY MEDICINE

CASE: LUNG CANCER*Best of five Clinical scenarios for the MRCP Part 1Punit 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 cellB. Small cellC. CarcinoidD. Large cellE. Adenocarcinoma

Case discussion: Answer CA 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 non-metastatic disease confers 90% survival at 5 years.

CASE: LUNG CANCER*Best of five Clinical scenarios for the MRCP Part 1Punit Ramrakha and Iqbal Malik – Medexam distance learning Volume 1Q2. 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. ChemotherapyB. Radiotherapy and chemotherapyC. LobectomyD. Medistinoscopy and lobectomyE. 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 Mediastinal node or contralateral hilar nodes are enlarged ( > 1.5 cm)o Pleural effusion or metastatic spread else is presento Mediastinal structure involvement is presento Satellite nodules are present in same lobe or different lobe or lung

CASE: HIV and LUNGQ3. 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. Pleural effusionB. Lack of systemic symptoms C. Generalized lymphadenopathyD. HIV acquired through IV drug abuseE. Cavity on chest xray

Case discussion: AKaposi 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 non-specific 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 ventilationB. PhysiotherapyC. IV steroidsD. Urgent commencement of retroviral therapyE. Controlled oxygen therapy

Case discussion: CIn 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 syndromeB. Microscopic polyangitisC. Churg strauss syndromeD. Wegner granulomatosisE. 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. CarcinomaB. PancreatitisC. PneumoniaD. Heart failureE. 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 Vasculitis of lung ANCA findingLarge vessel vasculitis(Temporal arteritis)

Rare none

Large vessel vasculitis(Takayasu’s arteritis)

Frequent None

Medium vessel vasculitis(Polyarteritis nodosa)

Rare None

Medium vessel vasculitis(Kawasaki disease)

None None

Small vessel disease(Wegener granulomatosis)

Frequent PR3 – ANCA

Small vessel disease(Churg strauss syndrome)

Frequent MPO-ANCA or PR3-ANCA

Small vessel disease(Microscopic polyangitis)

Frequent MPO-ANCA or PR3-ANCA

Small vessel disease(Henoch Schonlein purpura)

none none

Small vessel disease(Essential cryoglobulinaemia)

none none

SOME QUESTIONS MISSING

CASE: ASTHMA*Best of five Clinical scenarios for the MRCP Part 1Punit Ramrakha and Iqbal Malik – Medexam distance learning Volume 1Q23. The most important finding to confirm the diagnosis of asthma is:

A. High total blood IgE levelB. Demonstration of airway reversibilityC. High levels of IL-5 and Granulocyte macrophage colony stimulating factor (GM-CSF) in bloodD. Family history of asthmaE. A high TLCO and KCO

Case discussion: Answer B. Definition of asthma.

CASE: ASTHMA*Best of five Clinical scenarios for the MRCP Part 1Punit Ramrakha and Iqbal Malik – Medexam distance learning Volume 1Q24. A 20 year old college student is referred with breathlessness. Exercise induced asthma is most likely diagnosis if:

A. Inhaled steroid abolishes symptoms

B. No history of atopyC. Symptoms usually occur at end of strenuous exerciseD. Symptoms reoccur on immediate repeat exerciseE. 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 1Punit Ramrakha and Iqbal Malik – Medexam distance learning Volume 1Q26. 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 dustB. AsbestosC. CadmiumD. SilicaE. 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 1Punit 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 monthsB. BCG vaccinationC. Rifampicin and isoniazid for 2 months and review sensitivityD. Rifampicin, pyrazinamide, ethambutol for 12 monthsE. Rifampicin, isoniazid, pyrazinamide, ethambutol for 2 months and review sensitivity.

Answer: E

CASE: SMOKING*Best of five Clinical scenarios for the MRCP Part 1Punit Ramrakha and Iqbal Malik – Medexam distance learning Volume 1Q28. 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. CounsellingB. Bupropion (Zyban)C. Nicotine patchesD. Counselling and nicotine patchesE. 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.