"Best Of Five Questions For MRCP UK And Ireland Examinations" Dr. Osama Amin MBChB, MRCPUK part I,MRCPI part I ,MRCPI part II written Senior House Officer and 4th year student of the…..Board of Neurology. Dedication to The Republic Of Iraq and Iraqi Doctors all over the world.
Q1 Rheumatoid factor , all are true except 1-is an antibody directed against Fc portion of IgG 2-may be IgG ,IgM or IgA class 3-is diagnostic of rheumatoid factor 4- can be detected by many lab methods 5-found in almost 100% of cases of secondary Sjogren syndrome and Felty’s syndrome
Answer :3 1-true is an autoantibody 2-but we detect only IgM in the slide agglutination test 3-false ….does not reflect any thing apart from poor prognosis if found in high titer in RA 4-like slide tube agglutination, SCAT and Rose Waaler tests 5-true must be seropositive here
Q2 C reactive protein (CRP) and ESR, all are true except 1-CRP as an acute phase reactant, closely mirrors the degree of inflammatory processes 2-CRP is the single most useful direct measure of the acute phase responses (APR) 3-ESR is an indirect measure of the APR 4-ESR is characteristically very low in hear failure and sickle cell disease 5-in SLE, the ESR and CRP are high during a relapse
Answer 5 1-as it rises rapidly and falls rapidly and hence reflects the degree of the APRs 2-true as it rapidly rises from a low to high levels in acute inflammatory process and closely mirrors the degree of inflammatory 3-true as in cases of improvement in the APR, the CRP normalizes rapidly while the ESR LAGS behind for a variable period of time 4-and in PRV also, so in these cases we measure the plasma viscosity as a measure of APR (remember in PRV there is florid APR yet the ESR is very low) 5-the CRP is elevated in the presence of infection of trauma in SLE, other wise in acute flare ups it is normal …a useful CLUE!!
Q3 The Full blood count in inflammatory disorders, all are true except: 1-normochromic normocytic anemia is much more common than hypochromin microcytic one 2-the platelets are usually elevated and may reflects an active disease 3-the differential white cell count is highly variable 4-in systemic necrtotizing vasculitis, usually there is leukocytosis with neutropenia 5-in systemic inflammatory diseases, neutrophila may simply reflect treatment with corticosteroids
Answer 4 1-hypochromic microcytic one is seen up to 25 % but does nor respond to iron therapy .it is not an IDA states but there is defects in Ferro kinetics and iron utilization .unfortunately may be complicated by true IDA eg long term treatment with NSAIDS 2-true, useful guide to the overall activity eg in RA 3-true, varieties of pictures and may be complicated by drug side effects on the blood count and bone marrow ,so keep it in mind 4-leukocytosis and neutrophilia eg in PAN 5-true a common cause of neutrophila
Q4 Anti-nuclear antibodies (ANA), all are true except: 1-the routine detecting test is indirect immuno-fluorescent technique 2-the higher the titer, the greater the significance 3-the ANA is directed against one or more components of the nucleus 4-in drug induced lupus, it is presenting up to 60% of cases 5-the sensitivity and specificity vary widely
Answer 4 1-eg using rodent organs or human cell lines 2-like RF, low tires may be seen in healthy normal people in a good percentage 3-hence its name 4-FALSE, 100% of cases .negative titer virtually excludes drug induced lupus( here it is mainly anti histone H2 A and B subtypes ) 5-depends on the antigen preparation used in the test and weather we detect IgG or IgM type .however the tests are unfortunately NOT standardized and liaison with local labs is important
Q5 Indications for bone mineral density measurement, all are true except: 1-previuos low trauma fracture 2-family history of osteoporotic fracture 3-systemic diseases associated with high risk of osteoporosis like rheumatoid arthritis 4-a patient on long term glucocorticoid treatment 5-body mass index more than 23
Answer 5 1-with a fall from standing height or less. 2-also radiological evidence of osteoporosis and premature gonadal failure 3-remmeber not only the disease may pose a risk but also ITS treatment like steroids 4-also , clinical features of osteoporosis like loss of height and kyphosis 5-false , BMI less than 19 .Hence Obese patients are usually protected Remember: PCOS patients although may be infertile with irregular or absent cycles but the large BMI and the good amount of estrogens and androgens protect them from osteoporosis
Q6 Radionuclide bone scan, all are true except: 1-utelizes IV injection of 99mTc-biphsphonate and detected by a gamma camera 2-early post injection images reflect increased vascularities as in Paget’s disease or inflamed synovium 3-delayed images reflect increased bone remodeling process. 4-paticularly useful in the assessment of local painful skeletal areas with normal or inconclusive plain radiographs 5-extremely useful in the assessment of multiple myeloma
Answer 5 1-as the isotop is taken by body bones 2-also in primary and secondary bone tumors 3-as the Tc-biphosphanate later localizes to areas of bone remodeling .theses LATE images usually taken after few hours 4-true, the main indication in general 5-false, it depends on the osteoblatstic activity which is inhibited in MM, so it is not useful here,only if complicated by fractures Remember: although bone scan has a high sensitivity, it extremely lacks specificity and lacks high anatomical resolution
Q7 The main indications for bone scintigraphy now a days are all but one of the followings: 1-bone metastasis 2-bone or joint sepsis 3-early osteonecrosis 4-stress fractures 5-multiple myeloma
Answer 5 Also other indications: reflex sympathetic dystrophy and hypertrophic osteoarthropathy and useful in the assessment of the extent of Paget’s disease of the bone In MM, it depends on the osteoblatstic activity which is inhibited in MM, so it is not useful here, only if complicated by fractures
Q8 Red flags for a possible spinal pathology in a patient with back pain, all are true except: 1-Presentation between the ages of 20-50 2-the pain is constant, progressive and unremitting 3-dorsal spine pain per se 4-presence of systemic symptoms like fever, weight loss and sweating 5-past history of TB
Answer: 1 1-less than 20 and more than 50 years 2-also history of a major trauma 3-also , presence of a painful spinal deformity, severe symmetrical spinal deformity , saddle anesthesia , progressive neurological signs in the lower limbs , sphincter dysfunction and sensory level 4-very important indicators 5-and HIV, malignancy, on long term steroids...etc
Q9 Features of simple mechanical back pain, all are true, except: 1-sudden onset, usually precipitated by sudden lifting or bending 2-the pain is variable but improves at rest 3-age of the patients usually between 20-50 years 4-the patient is systemically well 5-90% improves after 1 year
Answer 5 90% improves after 6 weeks so it has an excellent prognosis Also other features: Tendency for recurrent episodes, pain is limited in the back or thigh but NEVER below the knee and no clear cut root signs
Q10 Features of spinal nerve root pain, all are true, except: 1-unilateral leg pain much worse than the associated back pain 2-the pain radiates below the knee 3-there is paresthesias in the same distribution of pain 4-reflex changes in the lower limbs 5-90% recovery at 6 weeks
Answer 5 In general, the prognosis is reasonable with 50% recovery at 6 weeks
Q11 Diffuse idiopathic skeletal hyperostoses (DISH) all are true, except: 1-affects 10% of males and 8 % of females by the age of 65 years 2-in most cases, there is an associated obesity, hypertension type II diabetes mellitus 3-defined as florid new bone formation along the anterolateral aspects of 4 contiguous vertebral bodies 4-there is disc space narrowing and marginal vertebral body sclerosis 5-usually is an asymptomatic radiological finding
Answer 4 1-so it is common 2-true associations, also hyperinsulinemia 3-true, at least 4 4-FALSE, there is NO such features which are (with posterior apophyseal joint involvement) indicate spinal spondylosis 5-true, very rarely have symptoms, usually low back pain
Q12 Osteoarthritis, all are true, except : 1-restriction of joint motion may be due to pain, muscle spasm, capsular fibrosis and intervening large osteophytes 2-the pain is usually variable and intermittent 3-the pain is mainly seen in weight bearing joints and relieved by rest 4-the pain is insidious over many months and years 5-joint deformities usually results in prominent joint instability
Answer: 5 1-with palpable sometimes audible coarse crepitus 2-so called with good days and bad days 3-also may increase upon joint movement 4-usually one or few painful joints (rarely multiple painful areas) 5-false, NO such joint instabilities
Q13 Causes of premature (less than 45 years of age) osteoarthritis, all a re true, except : 1-localised long term joint instability 2-proior joint disease 3-late avascular necrosis 4-ochronosis 5-growth hormone deficiency
Answer 5 1-together with trauma, usually are monoarticular 2-like JIA 3-and so called Endemic OA 4-and hemachromatosis 5-FALSE, arthropathy is seen up to 50% of cases of acromegally (not in GH deficiency)
Q14 Osteoarthritis (OA) in elderlies, all are true, except : 1-OA is the major musculoskeletal disease cause of pain and disability in old people 2-aging per se is not a contraindication strengthening and aerobic exercises 3-total hip replacement with rehabilitation is an excellent cost effectiveness treatment for severe disabling knee or hip OA in elderlies 4-oral paracetamol and topical NSAIDS are safe in elderlies 5-coexistent calcium pyrophosphate crystal deposition is rarely found
Answer 5 1-true, you should treat appropriately to minimize disability 2-true, they are “safe and cheap” 3-true with excellent results 4-true with no significant drug-drug interaction and are often effective at relieving pain 5-false a common age associated phenomenon and may precipitate acute pseudogout attacks
Q15 Rheumatoid arthritis (RA), all are true, except: 1-The commonest cause of inflammatory arthritis 2- RA is seen world wide in all ethnic groups 3-the incidence is lowest in African Americans and highest among Pima Indians 4-In Caucasians, the prevalence is about 10-15 % with female to male ratio of 9:1 5-no single factor as an etiology has been identified to date
Answer 4 In Caucasians, the prevalence is about 1-1.5 % with female to male ratio of 3:1
Q16 Etiologies of rheumatoid arthritis (RA) all are true, except: 1-HLA DR3 is the major susceptibility haplotype in most ethnic groups 2-concordance rate in monozygotic twins is 15% versus 3% in dizygotic twins 3-female gender per se is considered to be a risk factor and this susceptibility is increased post-partum and by breast feeding 4-cigarette smoking is a risk factor for RA and for positivity for rheumatoid factor in non-RA subjects 5-up to 50% of genetic contribution to susceptibility is due to genes in the HLA region
Answer 1 HLA DR4 is the major susceptibility haplotype in most ethnic group eg found in 75% of Caucasian patient with RA and HLA DR4 positivity is more common in those with severe disease .HLA DR1 is more important in Indians and Israelis while HLA DW15 is more important in Japanese .
Q17 Pathology of rheumatoid arthritis, all are true, except: 1-the earliest change is swelling and congestion of the synovial membrane and the underlying connective tissue 2-the infiltrating T lymphocytes are mainly CD8 positive cells 3-subcutaneuos nodules consist of central fibrinoid necrosis surrounded by palisading mononuclear cells 4-the muscles adjacent to the inflamed joints atrophy and there may be a low grade lymphocytic myositis 5-effusions into the joints are mainly seen in active disease
Answer: 2 1-true with infiltrations by lymphocytes, plasma cells and macrophages 2-CD4 positive cells 3-similar granulomatous lesions are seen in the sclera and pericardium, pleura and lungs 4-fibrous or bony ankylosis occurs late 5-the regional lymph nodes draining the actively inflamed joints are frequently hyperplasic
Q18 Rheumatoid arthritis (RA), all are true, except: 1-popeliteal cysts usually occurs in combination with knee synovitis 2-rheumatoid nodules indicate seroposivity and severe erosive disease 3-dry eyes is the commonest ocular complication of RA 4-asypmtomatic pericarditis is the commonest cardiac manifestation 5-brain vaculitis a serious devastating consequence
Answer: 5 1-and when rupture may simulate DVT, but remember both may coexist together as the patient may be immobile and there is an increased risk of DVT, so be careful!! 2-usually seen in extensor body surfaces, sclera and lung 3-scleritis is a benign complication but episclertits is serious 4-seen up to 30% of nodular seropositive patients but constrictive pericarditis is rare 5-the CNS is surprisingly SPARED in RA
Q19 Felty’s syndrome, all are true, except: 1-it is incidence is up to 10% of rheumatoid arthritis (RA) patients 2-seen in the context of long standing deforming but inactive RA 3-leg ulceration and hyper pigmentation are seen 4-there is thrombocytopenia and abnormal liver function tests 5-more common in Caucasian elderly females
Answer: 1 1-less than 1 % only 2-and nodular seropositive disease 3-also weight loss recurrent infections, sicca syndrome 4-normochromic anemia, defective T and B cell function and neutropenia 5- Usually between 50-70 years of age
Q20 Side effects of D penicillamine , all are true, except : 1-meatallic taste in the mouth is fortunately reversible 2-mysthenia gravis is serious but fortunately rare 3-thrombocytopenia and pancytopenia can develop at any time and are the major concerns 4-febrile reactions are a common and benign condition 5-membranous nephropathy had been seen
Answer 4 1-mouth ulceration and Pemphigus are both rare 2-drug induced lupus and Goodpasture syndrome are also rare 3-rapidly falling platelet count, mild thrombocytopenia and proteinuria are indications to stop the drug and reintroduce it slowly but if they recur then stop it for good 4-febrile reactions and pancytopenia are absolute indication to stop the drug IMMEDIATELY and for GOOD 5-and glomerulonephritis
Q21 Side effects of gold therapy, all are true, except : 1-pruritic skin rash may respond to antihistamines 2-cortcisteroids are given for severe exfoliative skin rash 3-fortunately unlike d-penicillamine, pancytopenia and aplastic anemia are not seen 4-memebranous nephropathy may occur 5-alopecia is seen
Answer 3 Marrow suppression and aplastic anemia may occur and carries a significant mortality
Q22 Common features of seronegative spondyloarthritides, all are true, except: 1-there sacrioiliitis and spondylitis 2-peripheral symmetrical oligoarthritis affecting the upper limbs more than the lower 3-no association with rheumatoid factor 4-tendency for familial aggregation 5-characterisitic overlapping extraarticular manifestations
Answer 2 1-an association with HLA B27 2-peripheral asymmetrical oligoarthritis affecting the lower limbs more than the upper 3-but there is association with enthesopathy 4-true 5-like iritis (up to 20-25%) and aortitis(4%)which are the commonest extra particular manifestations.
Q23 Epidemiology of Ankylosing spondylitis , all are true, except: 1-HLA is positive up to 90% of affected patients 2-its peak onset is between 6th and7th decades 3-male to female ration is 3:1 4-the overall incidence is 0.5% but may be much higher in Pima and Haida Indians 5-there is an association with fecal Klebsiella aerogenes carriage and chronic non infective prostatitis
Answer 2 The peak incidence is in the 2nd and 3rd decades. The incidence is higher in Pima and Haida Indians because of higher prevalence of HLA B27. The Kelbsiella carriage may be responsible for joint and eyes disease flares up
Q24 Ankylosing spondylitis , all are true, except: 1-anterior uveitis is the commonest extraarticular disease 2-peripheral arthropathy is responsible for 10% of the disease presentation 3-apical upper lobe pulmonary fibrocystic disease occurs up to 10 % of patients 4-bilateral hip involvement portends a poor prognosis 5-osteoporosis unfortunately may complicate the spinal involvement and adds more to the disability
Answer 3 1-occurs in 25% and conjunctivitis in 20% 2-although extra spinal involvement is seen up to 40% 3-up to 1% only .also aortitis, aortic andmitral regurgitations and cardiac conduction defects 4-because there will be loss of hip flections which can not compensate for the spinal rigidity 5-true and the patients should receive biphosphanates
Q25 Epidemiology of Rieter’s syndrome, all are true, except: 1-the commonest cause of inflammatory arthritis in men aged 16-35 2-1-2% of young males with non specific urethritis attending STD clinics are having Rieter’s syndrome 3-it has been shown that during Shigella epidemics up to 20% of HLA B27 positive young men will develop Rieter’s syndrome 4-male to female ratio is 1:5 5-may be preceded by a chlamydia urethritis
Answer: 4 Male to female ratio is 15:1. May be preceded by: chlamydia urethritis and GIT salmonella, shigella, compylobacter and yersinea infections
