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1. Part 1 Khalid Yusuf El-Zohry Sohag Teaching Hospital - Egypt [email protected] https://www.facebook.com/elzohryxp (18351 Questions) MRCPass OnExamination PassMedicine PasTest ReviseMRCP MRCPstudy (2475 Questions)

2. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 3 Contents ...........................................................................................8 ...................................................................10 How to register for MRCP part 1................................................28 Reference ranges.......................................................................31 MRCPass ....................................................................................33 [ Q: 1 ] MRCPass - Gastroenterology ................................................................................... 35 [ Q: 141 ] MRCPass - Rheumatology.................................................................................... 91 [ Q: 268 ] MRCPass - Respiratory....................................................................................... 141 [ Q: 389 ] MRCPass - Nephrology....................................................................................... 189 [ Q: 529 ] MRCPass - Neurology......................................................................................... 243 [ Q: 682 ] MRCPass - Infectious disease............................................................................. 299 [ Q: 840 ] MRCPass - Haematology.................................................................................... 365 [ Q: 999 ] MRCPass - Endocrinology .................................................................................. 429 [ Q: 1155 ] MRCPass - Clinical pharmacology.................................................................... 487 [ Q: 1287 ] MRCPass - Cardiology ...................................................................................... 529 [ Q: 1412 ] MRCPass - Basic Science .................................................................................. 573 [ Q: 1582 ] MRCPass - Dermatology................................................................................... 633 [ Q: 1611 ] MRCPass - Ophthalmology............................................................................... 645 [ Q: 1670 ] MRCPass - Psychiatry....................................................................................... 667 [ Q: 1729 ] MRCPass - Statistics ......................................................................................... 687 [ Q: 1777 ] MRCPass - 2010 January.................................................................................. 703 [ Q: 1876 ] MRCPass - 2010 May ....................................................................................... 745 [ Q: 1976 ] MRCPass - 2010 September............................................................................. 783 [ Q: 2076 ] MRCPass - 2011 January.................................................................................. 825 [ Q: 2176 ] MRCPass - 2011 May ....................................................................................... 867 [ Q: 2275 ] MRCPass - 2011 September............................................................................. 913 [ Q: 2375 ] MRCPass - 2012 January.................................................................................. 955

3. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 5 Dedications To my father, my mother, my wife, my sons: Abd El-Rahman, Muhammed, and Amr To president Muhammad Mursi

4. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 6

5. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 7 Take the first step, and your mind will mobilize all its forces to your aid. But The first essential is that you begin Once the battle is startled, all that is within and without you will come to your assistance

6. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 8 . . . / - https://www.facebook.com/elzohryxp

7. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 9 . Riyadh Shalabi . . Black House .Inas Mohamed Alassar . .Ayman Shahin .Heba Mohammed .Ahmed Gabr .Amira Hefney .qu ari .Faisal Hemeda .Reem Ali .Aburas Ab .Shiny Moon

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15. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 17 www.Passmedicine.com www.Onexamination.com www.Pastest.co.uk Basic science pharmacology 01 genetics ,immunology ,statistics clinical basic Basic science for MRCP basic karla MRCP notes the only MRCP notes u will ever basic science MRCP notes passmedicine passmedicine MRCP notes passmedicine pastestonexamination passmedicine karlaoxford passmedicine

16. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 18 Experience of Dr. Mohamed Sabagh for MRCP part 1&2 Heba MohammedRaheem Fathy-Mahmoud AbdelMRCP part1, 2 written and PACES side effects of corticosteroids kumar or karla or handbook of clincal medicine ; oxoford MRCP part 1 passmedicine q guidelines onexamination 5 3 3 55%

17. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 19 onexamination mandatory passmedicine mandatory kumar or karla or oxoford handbook any of them is helpful 4 monthes enough to pass MRCP Part 2 pastestonexamination google atlas clincal medicine differential diagnosis 565 405

18. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 20 Experience of Dr Salem Omar for part 1 ohammedHeba MEgyptians for MRCP part 1 : 0-0113 0- 054 3- : 4-The only MRCP notes you will ever need 01% 5-51% 6-51% guidelinesnice The only MRCP notes ---: 0-Onexamination

19. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 21 01- 05- 0-Passmedicine 3-Pastest 4-Revisemrcp 43- 0 : A 30-year-old femalepresents with a one year history of galactorrhoea. She has been receivingtreatment for hay fever, depression, obesity anddyspepsia. Her investigationsreveal: Full blood count Normal Urea and electrolytes Normal Prolactin 820 mU/l( 300 mg/dL). The serumtransferrin saturation is a sensitive parameter of increased Fe and merits evaluation when > 50%. The serum ferritin is increased. Urinary Fe excretion is markedly increased (> 2 mg/24 h) by the chelating drug deferoxamine (500 to 1000 mg IM based on the size of the patient), and this has been used as a diagnostic test. In addition, when the Fe content in the liver is significantly increased, an MRI may reflect this change. Liver biopsy had been the gold standard in diagnosis; it now serves only to

35. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 39 provide evidence of fibrosis (cirrhosis). Gene assay (Homozygosity C282y mutations) is also an excellent diagnostic test. [ Q: 11 ] MRCPass - Gastroenterology A 65 year old woman presents with dysphagia and intermittent vomiting. Endoscopy shows a tight lower oesophageal sphincter suggestive of achalasia. Which of the following medical therapies is most effective? 1- Diltiazem 2- Bismuth 3- Glyceryl trinitrate 4- Botulinum toxin 5- Glypressin Answer & Comments Answer: 4- 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. [ Q: 12 ] MRCPass - Gastroenterology Which of the following factors decreases large intestinal motility? 1- Lactulose 2- Parasympathetic activity 3- CCKPZ 4- Gastric Distension 5- Anticholinergic agents Answer & Comments Answer: 5- Anticholinergic agents Anticholinergic agents, e.g. atropine, reduce intestinal motility. All the other agents increase intestinal motility. [ Q: 13 ] MRCPass - Gastroenterology A 50 year old presents with tiredness and heavy periods. She is known to drink large amounts of alcohol. Her investigations reveal: Haemoglobin 7.3 g/dl MCV 72 fL white cell count 7.5 x 109 /L platelet count 250 x 109 /L serum ferritin 7 g/L, (15-300) She was commenced on oral iron therapy one month later but her haemoglobin concentration was 7.8 g/dl. What is the likely cause of the failure of her haemoglobin to respond? 1- Folate deficiency 2- Poor compliance therapy 3- Sideroblastic anaemia 4- Alcoholism 5- Irreversible cause of iron deficiency Answer & Comments Answer: 2- Poor compliance therapy The likely explanation failure of an iron deficiency anaemia to respond iron therapy in a patient with heavy periods is poor compliance. [ Q: 14 ] MRCPass - Gastroenterology A 55 year old man with a history of heavy alcohol intake presents with acute confusion. A diagnosis of hepatic encephalopathy is made and treatment with lactulose is commenced. What is its mode of action in this context? 1- Reduces absorption of chlordiazepoxide 2- Inhibits proliferation of ammonia forming organisms in the gut 3- Absorbed from gut

36. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 40 4- Contraindicated in diabetes mellitus 5- Causes hypermagnesaemia Answer & Comments Answer: 2- Inhibits proliferation of ammonia forming organisms in the gut Lactulose is used in patients with cirrhosis/hepatic encephalopathy. It limits the proliferation of ammonia forming gut organisms and increases clearance of protein load in gut. It causes hypomagnesaemia. Chlordiazepoxide absorption is not affected. [ Q: 15 ] MRCPass - Gastroenterology A 35 year old lady has sudden onset right upper quadrant pain and abdominal distension. She was well until 5 weeks ago, when over several days she rapidly developed abdominal distension and pain. She was also nauseous and vomiting. On examination, temperature was 37.1C, her JVP was not raised and breath sounds were clear. Abdominal examination revealed tender hepatomegaly, jaundice and gross ascites. There was also bilateral ankle oedema. What is the likely diagnosis? 1- Dubin Johnson syndrome 2- Gilbert's syndrome 3- Budd Chiari syndrome 4- Lymphoma 5- Myeloma Answer & Comments Answer: 3- Budd Chiari syndrome Budd-Chiari syndrome is a condition induced by thrombotic or nonthrombotic obstruction to hepatic venous outflow. The classic clinical triad of abdominal pain, hepatomegaly, and ascites was described by Budd in 1845, and the histopathological features were described by Chiari at the turn of the 20th century. The syndrome most often occurs in patients with underlying thrombotic diathesis, including myeloproliferative disorders such as polycythemia vera and paroxysmal nocturnal hemoglobinuria, pregnancy, tumors, chronic inflammatory diseases, clotting disorders, and infections. Doppler ultrasonography, as was used in this case, is the most effective primary initial screening method. CT and magnetic resonance angiography are both more sensitive than ultrasonography. The gold standard for diagnosis is hepatic venography, which should be performed when there is a high index of clinical suspicion and the results of noninvasive testing are either equivocal or negative. [ Q: 16 ] MRCPass - Gastroenterology A 40 year old man who usually drinks only 2 units of alcohol a day went on an alcohol binge with his friends. On that day, he vomited 10 times and was brought to hospital feeling very unwell. He has not previously had any symptoms of dyspepsia or abdominal pains. During physical assessment, he vomits a large bowlful of blood. What is the likely cause of his haemetemesis? 1- Oesophageal varices 2- Duodenal ulcer 3- Mallory Weiss tear 4- Gastritis 5- Gastric outlet obstruction Answer & Comments Answer: 3- Mallory Weiss tear A Mallory-Weiss tear occurs in the mucous membrane typically in the lower oesophagus. Mallory-Weiss tears are usually caused by forceful or prolonged vomiting or coughing. They may also be caused by epileptic convulsions.

37. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 41 The tear may be followed by vomiting bright red blood or by passing blood in the stool. The incidence is 4 in 100,000 people. Mallory Weiss tear [ Q: 17 ] MRCPass - Gastroenterology A 30 year old lady has altered bowel habit. At the gastroenterology clinic, her symptoms are reviewed. She has a 2 year history of bloating and abdominal pains. Some weeks she is constipated and during others she has diarrhoea. What is the likely diagnosis? 1- Whipple's disease 2- Tropical sprue 3- Coeliac disease 4- Irritable bowel syndrome 5- Ulcerative colitis Answer & Comments Answer: 4- Irritable bowel syndrome Weight loss, fevers and blood in the stool are features which suggest a different organic cause other than irritable bowel syndrome. [ Q: 18 ] MRCPass - Gastroenterology A 60 lady has symptoms of intermittent abdominal pain and loose stool which have occurred over 1 year. Investigations reveal: Hb 8.5 g/dl MCV 85 fl WCC 6 x 109 /l Iron 11 (14-29) mol/l Ferritin 20 (15-200) mol/l Folate 2 (3-20) ?g/l What investigation should be done? 1- Ultrasound of abdomen 2- Small bowel biopsy 3- Smooth muscle antibodies 4- ERCP 5- Rigid sigmoidoscopy Answer & Comments Answer: 2- Small bowel biopsy The combined iron and folate deficiency anaemia as well as symptoms suggestive of malabsorption makes celiac disease a likely diagnosis. Small bowel biopsy may show partial or subtotal villous atrophy. Anti endomysial antibodies will also be helpful. [ Q: 19 ] MRCPass - Gastroenterology A 25 year old bartender has had abdominal pains and loose stools for 3 years. He also has symptoms of myalgia and profound fatigue. He mentions that the abdominal pains are often worse after he has bread. Anti endomysial antibody is positive. An enzyme-linked immunosorbent assay test was conducted and it showed positive reactions to gluten, albumin, lactose, barley, and rye. What is the diagnosis? 1- Diverticulosis 2- Tropical sprue 3- Ulcerative colitis 4- Crohn's disease

38. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 42 5- Coeliac disease Answer & Comments Answer: 5- Coeliac disease Signs of coeliac disease include fatigue, weight loss, diarrhoea, arthralgia and myalgia. The "gold standard" for diagnosing celiac disease is through a jejunal mucosal biopsy sample to measure the extent of the damage. Another method is the enzyme-linked immunosorbant assay (ELISA). Celiac disease patients cannot tolerate gluten, a protein found in the grains wheat, rye, and barley. In order to preserve their gastrointestinal integrity, patients with celiac disease need to take extra precaution when selecting foods. [ Q: 20 ] MRCPass - Gastroenterology A 55 year old man is suspected of having a duodenal ulcer recurrence despite being on omeprazole. Which of the following is the most sensitive test in detecting ongoing infection with Helicobacter pylori? 1- The (13C) urea breath test 2- The urease test on a gastric biopsy 3- A gastric fundal biopsy culture 4- Helicobacter pylori serology 5- Stool culture Answer & Comments Answer: 1- The (13C) urea breath test The urea breath test is expensive but has up to 98% sensitivity. The gastric biopsy culture has high specificity but sensitivity of 90%. Histology of gastric biopsy (not listed above) has both high sensitivity and specificity. [ Q: 21 ] MRCPass - Gastroenterology A 35 year old lady presents with abdominal pain to the GP who suspects irritable bowel syndrome. Which of the following is a recognised feature of irritable bowel syndrome? 1- Lactase deficiency 2- Bloating 3- A past history of dysentery 4- Late development of carcinoma of the colon 5- Diarrhoea but not constipation Answer & Comments Answer: 2- Bloating Abdominal pain relieved by defecation, bloating, as well as alternating bowel habits is common. [ Q: 22 ] MRCPass - Gastroenterology A 28 year old intravenous drug user complains about severe epigastric pains, nausea and vomiting. He has upper GI endoscopy which shows small areas of ulceration and white plaques. Which of the following is the best treatment option? 1- Metronidazole 2- Amoxycillin 3- Ranitidine 4- Fluconazole 5- Aciclovir Answer & Comments Answer: 4- Fluconazole This is a patient with possible HIV who has oesophageal candidiasis. Fluconazole, ketoconazole and itraconazole can be used.

39. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 43 Oesophageal Candidiasis [ Q: 23 ] MRCPass - Gastroenterology A couple develops profuse vomiting after attending a dinner in a chinese restaurant. They ate at 7 pm but became ill early in the next morning. What is the likely infective organism? 1- Bacillus cereus 2- Salmonella enteriditis 3- Bacillus anthracis 4- Clostridium perfringens 5- E. Coli Answer & Comments Answer: 1- Bacillus cereus Bacillus Cereus food poisoning is a gastrointestinal intoxication caused by toxins produced by the Bacillus Cereus bacteria. There are two types of toxin, - the Diarrhoeal and the Emetic toxins. Symptoms with the diarrhoeal toxin are nausea, cramplike abdominal pains and watery diarrhoea. The diagnosis is confirmed by a laboratory test on a faecal specimen. Bacillus cereus exists in normal bacterial and spore forms in foods. The normal form is inactivated by cooking, but most illness is a result of the multiplication of spores during inadequate refrigeration of moist cooked protein foods and rice (hence its association with chinese takeaways). [ Q: 24 ] MRCPass - Gastroenterology A 36 year old lady has noticed mild jaundice, worsening joint pains and is complaining of itching on her skin for the past 8 months. On examination, she has palpable hepatomegaly and a bronze pigmentation on her skin. Her liver function tests show a bilirubin of 25 mol/l, ALT 100 U/l, ALP 480 U/l. ANA is negative, anti-mitochondrial antibody is positive at 1/320. Which of the following medications is helpful? 1- Desferrioxamine 2- Hydrocortisone 3- Propanolol 4- Ursodeoxycholic acid 5- Tranexemic acid Answer & Comments Answer: 4- Ursodeoxycholic acid Primary biliary cirrhosis is described. Liver transplantation does not cure the condition. Histology shows white cell damage to the biliary epithelium with non necrotising granuloma formation in the portal triad. Ursodeoxycholic acid lowers serum bilirubin and symptoms of itching, and prolongs the progression tow ards requirement for liver transplantation. IgM levels are particularly high in PBC. [ Q: 25 ] MRCPass - Gastroenterology A 45 year old man has a diagnosis of coeliac disease. He presents with a one month history of intermittent, colicky, central abdominal pain and weight loss of 5 kg. There is positive faecal occult blood. What is the most appropriate investigation?

40. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 44 1- Duodenal biopsy 2- Barium enema 3- Surgical exploration 4- CT scan of abdomen 5- Colonoscopy Answer & Comments Answer: 5- Colonoscopy Colonoscopy is necessary to exclude a colonic carcinoma. There is a relatively high prevalence of colorectal neoplasia among older patients with coeliac disease who can present with iron deficiency or altered bowel habit. [ Q: 26 ] MRCPass - Gastroenterology A 60 year old man has symptoms of lethargy and vomiting. He drinks 10 pints of beer a day. He was started on an intravenous glucose infusion and chlordiazepoxide. For a day, he symptomatically improved. However, the next day, he became confused and started vomiting several times. He also had diplopia and was unable to stand. What is the likely diagnosis? 1- Delirium tremens 2- Hepatic encephalopathy 3- Cerebellar stroke 4- Vitamin B deficiency 5- Pancreatitis Answer & Comments Answer: 4- Vitamin B deficiency Wernicke's encephalopathy is a neurologic disorder of acute onset caused by a thiamine deficiency. The condition is characterized by ocular abnormalities, ataxia, and a global confusional state. Wernicke's encephalopathy results from a deficiency in vitamin B-1 (ie, thiamine). The episode may have been precipitated by intravenous dextrose administration which exhausted his vitamin B reserves. B vitamins should be administered to all alcoholic patients requiring dextrose. [ Q: 27 ] MRCPass - Gastroenterology A 30 year old psychology lecturer has deranged liver function tests. She also has jaundice, pruritus and xanthelasmata. Blood tests reveal elevated levels of conjugated bilirubin, alkaline phosphatase, gamma-glutamyltranspeptidase and positive anti-mitochondrial antibody. She seeks advice about the associations of the disease. Which one of the following is likely to be associated? 1- Raised IgA 2- Osteomalacia 3- Hyperparathyroidism 4- Nephrotic syndrome 5- Vitamin A deficiency Answer & Comments Answer: 2- Osteomalacia The diagnosis is primary biliary cirrhosis (PBC). It is based on a combination of findings including cholestatic liver enzymes, a positive antimitochondrial antibody (AMA), and characteristic liver biopsy findings. Elevated serum alkaline phosphatase of liver origin is the most common laboratory finding. Fatigue, jaundice, pruritus and xanthelasmata are other features of primary biliary cirrhosis. In the disease, IgM is raised. Primary biliary cirrosis is associated with autoimmune conditions such as scleroderma and Sjogren's syndrome. These conditions are also associated with distal RTA (type 1). There is xanthelasma formation due to impaired cholesterol excretion and also osteomalacia due to impaired Vitamin D absorption.

41. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 45 [ Q: 28 ] MRCPass - Gastroenterology 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 39C. 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 109 /L and platelets 550 x 109 /L. Urea is 8 mol/l and creatinine is 90 mol/l, CRP is 105 mg/l. Which of the following is the best test to confirm the diagnosis? 1- Stool cultures 2- Barium meal and follow through 3- Ultrasound of abdomen 4- Colonoscopy 5- Surgical laparotomy Answer & Comments Answer: 2- 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. Strictures seen on the Barium Follow through in Crohn's disease [ Q: 29 ] MRCPass - Gastroenterology A 52 year old male presents with general weakness. He drinks approximately 20 units of alcohol each week and smokes 10 cigarettes daily. Examination reveals jaundice, numerous spider naevi and he has a temperature of 37.5C. Abdominal examination reveals hepatosplenomegaly. Investigations show : Bilirubin 140 micromol/L (1-22) Alkaline phosphatase 525 iu/l (45-105) AST 178 iu/l (1-31) Albumin 28 g/L (37-49) Hepatitis B virus surface antigen - negative Hepatitis B virus e antigen - negative Hepatitis B virus e Antibody- positive Hepatitis B core Antigen (anti-HBc) - positive Hepatitis B virus DNA - undetectable What is the likely diagnosis? 1- Chronic hepatitis D (delta) infection 2- New hepatitis A infection

42. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 46 3- Alcoholic liver disease 4- Chronic hepatitis B infection 5- New hepatitis C infection Answer & Comments Answer: 4- Chronic hepatitis B infection A negative HbsAg and HbeAg, along with positive hepatitis B antibodies (anti-HBc) would suggest past or chronic infection. [ Q: 30 ] MRCPass - Gastroenterology A 35 year old man presents with 2 bowls full of haemetemesis. He drinks 10 pints of beer a day and has done so for 10 years. Upper GI endoscopy reveals oesophageal varices. Which of the following is effective in reducing the rates of rebleeding in the future? 1- Lisinopril 2- Propanolol 3- Simvastatin 4- Ranitidine 5- Naproxen Answer & Comments Answer: 2- Propanolol Beta blockers (propanolol, nadolol), nitrates, vasopressin analogues and somatostatin analogues can be used for reducing rebleeding in oesophageal varices. [ Q: 31 ] MRCPass - Gastroenterology A 30 year old woman who has been on the contraceptive pill presents with abdominal pain and distension of 5 days duration. On examination she has no stigmata of chronic liver disease. She has distended veins over the anterior abdominal wall. She also has ascites, an enlarged tender palpable liver with absent hepato-jugular reflux. Her ankles are oedematous. What is the diagnosis? 1- Congestive cardiac failure 2- Antiphospholipid syndrome 3- Fatty liver 4- Budd Chiari syndrome 5- Pulmonary hypertension Answer & Comments Answer: 4- Budd Chiari syndrome Budd-Chiari syndrome is thrombosis of the hepatic vein, the major vein that leaves the liver. Most patients have an underlying thrombotic tendency. About 10% have polycythemia vera, and about 10% have been on the OCP. The most common symptoms in Budd-Chiari syndrome are ascites and jaundice. [ Q: 32 ] MRCPass - Gastroenterology A 25 year old woman with cystic fibrosis presents with abdominal pain. The abdominal pain is colicky and localised in the lower abdomen. On examination, she was pyrexial and tachycardic. Her abdomen was distended. There was guarding and bowel sounds were present. Which of the following is likely to be the cause? 1- Renal Calculi 2- Ulcerative colitis

43. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 47 3- Meconium Ileus Equivalent Syndrome 4- Pyelonephritis 5- Irritable Bowel Syndrome Answer & Comments Answer: 3- Meconium Ileus Equivalent Syndrome Meconium Ileus is the earliest clinical manifestation of cystic fibrosis (CF) and occurs in approximately 16% of patients with CF. Meconium in patients with ileus has higher protein and lower carbohydrate concentration than that in control populations. Signs of peritonitis include tenderness, abdominal wall edema, distension, and clinical evidence of sepsis. A palpable mass may indicate pseudocyst formation. Surgical exploration is indicated for patients with progressive distension, signs of peritonitis, or clinical deterioration. Complicated Meconium Ileus requires resection more often than simple cases and always requires temporary stomas. [ Q: 33 ] MRCPass - Gastroenterology A 40 year old woman has previously had a right hemicolectomy and resection of 30 cms of terminal ileum for ileocaecal Crohn's disease. She has persistent diarrhoea, which is not explosive. She does not have abdominal pain, bloating, or loss of weight. Investigations have failed to demonstrate evidence of recurrent Crohn's disease. Which is the best therapy for the symptoms? 1- Prednisolone 2- Mesalazine 3- Azathioprine 4- Cholestyramine 5- Loperamide Answer & Comments Answer: 4- Cholestyramine The patient has had resection of the terminal ileum and the cause of the diarrhoea is likely to be Bile Acid Malabsorption (BAM). Bile acid sequestrants such as cholestyramine should help the symptoms of persistent diarrhoea. [ Q: 34 ] MRCPass - Gastroenterology A 45 year old man has had a 5 year history of severe sharp, epigastric pains and diarrhoea. He gets 2-3 episodes of these symptoms a day. His GP has prescribed proton pump inhibitors which has helped partly, but he still complains that the symptoms are severe. Which one of the following might confirm the diagnosis? 1- Amylase 2- ERCP 3- C-peptide 4- Insulin 5- Gastrin level Answer & Comments Answer: 5- Gastrin level The diagnosis is likely to be Zollinger Ellison syndrome which is frequently secondary to a gastrinoma. Gastrin levels are significantly elevated. The secretin test can help to confirm the diagnosis. There is increased gastrin elevation (greater than 200 pg/mL) in a positive test after secretin is given intravenously . There is an association with the MEN 1 syndrome, so calcium levels should be checked (to screen for a parathyroid adenoma).

44. El-zohry MRCP Questions Bank (Part 1) 2013 (For my personal use) Dr. Khalid Yusuf El-Zohry Sohag Teaching Hospital (01118391123) Ref MRCPass OE OE 2012 PasTest 2009 PassMedicine 2009 PasTest Exam ReviseMRCP 48 [ Q: 35 ] MRCPass - Gastroenterology 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 recommended test for this patient? 1- CT of the abdomen 2- Colonoscopy 3- ESR 4- Endoscopy 5- Liver function tests Answer & Comments Answer: 5- Liver function tests The features are suggestive of autoimmune hepatitis. Liver function tests may demonstrated eleveated levels of bilirubin, AST and ALT. A liver biopsy may then be warranted. [ Q: 36 ] MRCPass - Gastroenterology 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 unw ell. 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? 1- Acute reactivation of hepatitis B 2- Tuberculous peritonitis 3- Alcoholic liver disease decompensation 4- Chylous ascites 5- Spontaneous bacterial peritiontis Answer & Comments Answer: 5- Spontaneous bacterial peritiontis 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. [ Q: 37 ] MRCPass - Gastroenterology A 60 year old male presents with a two month history of shorness of breath, weight loss and lethargy. He looks pale and is jaundiced. Investigations show : Haemoglobin 6 g/dL MCV 106 fL White cell count 2.2 x 109 /L Platelets 60 x 109 /L Urinalysis: Increased urobilinogen. What is the next appropriate test? 1- Coomb's test 2- Colonoscopy 3- Vitamin B12 concentration 4- Bone marrow aspirate 5- Reticulocyte count Answer & Comments Answer: 3- Vitamin B12 concentration The clinical picture is one of megaloblastic anaemia. B12 and folate measurement is the first test to confirm this, and then other tests such as blood film and marrow aspirates can be done to investigate the cause. [ Q: 38 ] MRCPass - Gastroenterology A 30 year old man had previous bowel resection for acute abdomen. He continues to have frequent episodes of bloody diarrhea and abdominal pain.

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