"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.
Q26 In Rietier’s syndrome, all are true, except: 1-nail dystrophy may be indistinguishable from psoriatic nails 2-circinate balanitis is seen up to 1% of cases and are usually painful 3-buccal erosions are seen up to 10% of cases and usually painless and last only for few days 4-Keratoderma Blenorrhagica is seen in 15% of cases and clinically and histologically indistinguishable from pustular psoriasis 5-spondylitis, chronic erosive arthritis, recurrent acute arthritis and uveitis are the commonest cause of long term morbidity
Answer 2 circinate balanitis is seen up to 20-50% of cases and usually painless and easily escape notice
Q27 Epidemiology of Psoriatic arthropathy, all are true, except: 1-in 20% it precedes the onset of the skin disease 2-simultaneous occurrence of the skin plaques and joint involvement is very common 3-approximately up to 20% of cases seronegative spondyloarthritis is due to psoriatic arthropathy 4-psoriatic arthopathy occurs in 1in 1000 of the general population 5-the usually age of onset is between 25 and 40 years
Answer 2 Synchronous onset of skin disease and joint disease is uncommon in seen up to 5% of cases.
Q28 Psoriatic arthropathy, all are true, except: 1-the commonest clinical pattern is the asymmetrical inflammatory oligoarthritis seen up to 40% of cases 2-the characteristic psoriatic nail changes are uncommon 3-absence of skin lesions may be due to poor examination as there are many hidden areas of involvement 4-uveitis is mainly seen in those with spondyloarthritis and HLA B27 positivity 5-the plain X ray findings of psoriatic spondylitis may exactly resemble those of reactive arthritis
Answer: 2 1-and arthritis mutilans is seen in 5 % only 2-FALSE: they are found more commonly in psoriatic arthritis (85%) than in uncomplicated psoriasis (30%) 3-true .like genitals, natal clefts and scalp 4-but conjunctivitis is much more common 5- They are asymmetrical coarse non marginal syndesmophytes and asymmetrical scarioiliitis
Q29 Epidemiology of gout, all are true, except : 1-it has a strong male predominance with male to female ratio is 10:1 2-the overall prevalence is 1% 3-serum levels of uric acids are higher in females than males 4-probably 95% of hyperuricemic individuals never develop clinical gout 5-serum uric acid levels re distributed in the community as a continuous variable
Answer 3 Serum levels of uric acids are higher in males than females. It is a disease of post pubertal males and post menopausal females
Q30 Drug induced gout and hyperurecemia may be due to all of the followings, except: 1-ciclosporin 2-bendrofluazide 3-low dose aspirin 4-frusamide 5-azapropazone
Answer 5 Azapropazone is a uricosuric agent .other causes: pyrazinamide, alcohol and lead
Q31 Indications of drug prophylaxis in hyperuricemia and gout , all are true except : 1-evidence of tophi per se 2-recurrent attacks of acute gouty arthritis 3-evidence of joint or bone damage 4-associted renal disease 5-treatment with high dose aspirin Answer 5 High dose aspirin promote urate excretion by the kidney Other indications: gout with a very high serum uric acids and hyperuricemia due to congenital enzyme defects like HGPRTase deficiency
Q32 Gout In old people, all are true, except; 1-Should never be considered a primary one but secondary to chronic diuretic therapy or chronic renal failure 2-in contrasts to primary gout, secondary gout in elderlies usually presents as painful tophi rather than acute attacks 3-there is an increased risk of allopurinol toxicity and hence should be started as a small dose 4-acute attacks in elderly are better treated with joint aspiration and intraarticular injection of steroids 5-acute attacks can be safely treated with colchicin
Answer 5 1-the usual story of those on thiazides of more than 18 months duration 2-true and the hands not feet are the usual targets in those patients 3-as 100mg / day 4-true followed by early mobilization 5-NSAIDs and Colchicine are best avoided because of increased incidence and severity of toxicities
Q33 Causes of calcium pyrophosphate crystal deposition, all are true, except: 1-the commonest cause is a sporadic age related process 2-preexistent joint damage and osteoarthritis 3-hypoparathyroidism 4-hypothyroidism 5-Wilson’s disease
Answer 3 Hyper- not hypoparathyroidism Other causes: hemaochromatosis and hypophophatasia
Q34 Indications of screening for metabolic or familial predisposition in cases of calicium pyrophsphate dihydrate (CPPD) deposition and pseudogout are true, except: 1-early onset disease below 55 years of age 2-florid polyarticualr chondrocalcinosis 3-recurrent acute attacks of pseudogout without chronic arthropathy 4-presence of clinical or radiological evidence of a predisposing disease 5-presence of tophi
Answer 5 Tophi are the hallmark of prolonged hyperuricemia not pseudogout, although both may coexisit!!!
Q35 Septic arthritis, all are true, except: 1-it is a medical emergency 2-unfortunately, has a mortality rate approaching 10% 3-the objectives of treatment are pain relief, parenteral antibiotics, adequate drainage and early active rehabilitation 4-in general, synovial fluid culture is positive in 90% of cases while initial gram stain is positive in only 50% 5-the commonest infective agent in adults is staph albus
Answer 5 1-true, it is not a cold case 2-true, with appreciable morbidity 3-inpatient management, not on an outpatient basis 4-but the culture is positive in only 25% of gonococcal cases but genital tract cultures are positive in 70% in these cases!! 5-staph aureus
Q36 Fibromyalgia, all are true, except: 1-its prevalence is 2-3% of the general population and seen in 7 % of woman above the age of 70 years 2-there is a strong female predominance with female to male ratio of 10:1 3-despite intensive and invasive investigations, no structural, inflammatory or endocrine abnormality has been found 4-the ESR is characteristically high 5-the main stay treatment is low dose amitriptyline with graded aerobic exercises
Answers: 4 1-true, age and female genders are risk factors 2-no age is exempt but it s rare in young 3-only 2 consistent associations had been shown: sleep abnormality and abnormal pain perception 4-false the ESR should be normal 5-true ….this is an evidence based intervention
Q37 Drugs that increase the risk of osteoporosis, all are true, except: 1-corticosteroids 2-heparin 3-GnRH analogues 4-sedatives 5-tibolon
Answer 5 Tibolon is a hormone receptor modulator that acts as a partial agonist at the estrogen, progesterone and androgen receptors, and used in the treatment of osteoporosis
Q38 Proved drugs that decreases the risk of vertebral osteoporotic fractures, all are true, except: 1-Biphosphanates 2-Hormaonal replacement therapy 3-Raloxifene 4-calcitonin 5-Vitamine D and Calcium
Answer 5 Vitamin D and Calcium decrease the risk of NON vertebral osteoporotic fractures and data are still not available regarding the reduction in VERTERBRAL fractures.
Q39 Drugs that don’t decrease the risk of non vertebral osteoporotic fractures, all are true, except: 1-Raloxifene 2-calcium alone 3-tibolon 4-calcitonin 5-biphosphanates
Answer: 5 Only 3 medications till now are approved to decrease the risk of NON vertebral osteoporotic fractures: Biphosphanates, Hormonal replacement therapy and Calcium +Vitamin D
Q40 Osteomalacia and rickets, all are true, except: 1-due to aluminum toxicity, requires bone biopsy for diagnosis and may respond to desferroxamine 2-due to hypophosphatasia, is very resistant to treatment due to pyrophosphate accumulation which inhibits bone mineralization 3-hypophosphatemic rickets respond well to life long phosphate replacement + vitamin D metabolites 4-type II vitamin dependent rickets responds favorably to active vitamin D metabolites 5-biphosphanate induced osteomalacia is usually transient and asymptomatic and seen mainly in Paget’s disease given high doses of etidronate
Answer 4 1-usually seen in the context of chronic renal failure. Very rare now a days 2-congenital defect in bone specific alkaline phosphatase 3-true, no need for calcium at all 4-false Type I responds well to active vitamin D metabolites, type II is very resistant (together with hypophsphatasia, are both the most difficult to treat) 5-true diagnosis by bone biopsy
Q41 Paget’s disease of the bone, all are true, except: 1-the disease rarely spread to new bones once the diagnosis is made 2-the primary abnormality is increased bone osteoclastic resorption accompanied by marrow fibrosis, increased vascularity and osteoblastic repair 3-the classic presentation is with bone pain, bone deformity, deafness and pathological fractures 4- High output cardiac failure is rare and usually seen in those with extensive disease 5-osteosarcoma is unfortunately a common complication
Answer 5 1-indicates that the bone targeting insult occurs early in life 2-causing bone thickening with abnormal architecture and reduced mechanical strength 3-in the majority of patients 4-usually in those with limited cardiac reserve 5-Osteosarcoma is RARE and portends a very POOR prognosis and should be suspected in any rapid increase in pain or swelling of an affected bone
Q42 In SLE, all are true: except: 1-there is monoclonal B and T cell activation 2-none of the diverse clinical manifestations of SLE can be attributed to a single antigenic stimulus 3-exacerbations can be induced by sun light, infection and pregnancy 4-the anti dsDNA antibodies although highly diagnostic but seen only in 30-50 of active disease patients 5-the renal lesions are due to immune complex disease while the brain damaging effect is mainly due to the antibody mediated cell cytotoxicity
Answer 1 There is polyclonal B and T cell activation
Q43 In SLE, all are true, except; 1-the classic butterfly rash is seen only in 20-30% of cases 2-lupus arthritis is non deforming non erosive 3-the commonest renal lesion is diffuse proliferative glomerumonephritis 4-chest pain is usually due to pleuritis and or pericarditis 5-the commonest CNS manifestation is chorea
Answer 5 1-also there may be discoid rash, photosensitive rash, livedo reticularis, lupus panniculitis and lupus profundus , purpura , skin ulceration , nail fold infarcts, bollous lesions . 2-but contractures may occur due to tendon inflammation and may be seen as bone deformity (Jaccoud arthropathy) 3-true, portends poor prognosis and should be treated aggressively 4-the effusions are exudative .rarely chest pain is due to MI 5-false, mild neuropsychiatric manifestations (like depression or psychosis) and seizures . Q44 In Scleroderma, all are true, except: 1-the etiology still unknown with no consistent genetic, geographical or racial associations 2-muscle weakness and wasting is usually due to low grade myositis and erosive arthropathy is very common 3-restricted hand movement is mainly due to skin disease rather than joint disease 4-pulmonary involvement is the major cause of morbidity and mortality 5-one of the main causes of death is hypertensive renal crisis
Answer 2 Erosive arthropathy is highly uncommon
Q45 In scleroderma, all are true, except: 1- 5 year survival is approximately 70% 2- poor prognostic factors at the time of diagnosis are old age, proteinuria, diffuse skin disease , high ESR low TLCO and pulmonary hypertension 3- recurrent occult upper GIT bleeding may indicate a watermelon stomach which is seen in 20% of cases 4- pulmonary hypertension is more common in the diffuse type than the limited type 5- anti SCL70 antibody is positive in 20-30% in the diffuse type while anti-centromere antibody is seen in 70% of the limited type
Answer 4 Pulmonary hypertension is 6 times more common in the LIMITED type than the diffuse type
Q46 In Sjogren’s syndrome, all are true, except: 1-more common in females between 40-60years of age and HLA B8/DR3 2-parotid sialogram may show sialectasis which may be diffuse punctate or cavitory with normal main duct 3-ANA is positive in almost 100% of cases in primary Sjogren's syndrome 4-extensive dental carries and oral candidiasis are common 5-previous history of HIV, Hepatitis C infection, sarcoidosis, head and neck irradiation are considered to be an exclusion criteria
Answer 3 ANA is seen in almost 100% of SECONDARY Sjogren’s syndrome in RA. In the primary one it is seen in about 50-70% of cases. Anti Ro and anti La also between 50-70% of cases and both are more suggestive of primary Sjogren's syndrome
Q47 In polymyositis and dermatomyositis, all are true, except: 1-proximal muscle weakness is very common while facial weakness is seen only in 5 % of cases and extra ocular muscle involvement in 2 % of cases only 2-dermatomyositis muscle biopsy shows characterisitic perifascicular atrophy due to capillaritis 3-CPK is usually normal 4-childhood type carries a poor prognosis as there is an associated visceral vasculitis 5-EMG may show pseudo myotnia pattern
Answer 3 The CPK is usually raised, sometimes to a very high level. Anti Jo1 Antibodies correlate more with pulmonary parenchymal involvement.
Q48 Systemic vasculitides, all are true, except: 1-fever, malaise, weight loss, anorexia and sweating are common non specific manifestations 2-neutrophil leukocytosis with raised ESR 3-Hepatitis B surface antigen is positive in 5-50 % of polyarteritis nodosa 4-oral Cotrimazole has been shown to prevent relapse in localized Wegner’s granulomatosis 5-cANCA is found up to 90% of active Church Strauss casculitis
Answer 5 1-true and other features reflect systemic involvement like MI , stroke , renal failure 2-sometimes esosinophilia like in Church Strauss vasculitits 3-true and the treatment is mainly targeted against the hepatitis 4-sometimes methotrexate 5-cANCA is found up to 90% of active Wegner’s granulomatosis
Q49 Systemic vasculitides , all are true except : 1- hypertension is seen in 30% of cases of ployarteritis nodosa 2- paranasal sinus disease may indicate Church Strauss or Wenger’s granulomatosis 3- pulmonary artery involvement is seen in Takayasu arteritis 4- giant cell arteritis is treated by 10-20mg daily steroids 5- in Kawazaki disease the mortality is fortunately 2% and replase is rare
Answer 4 Is an indication of high does steroids like 80 mg / day
Q50 The following drugs are matched with their musculoskeletal effect except one is false: 1-glucocorticoides–osteomalacia 2-thiazide diuretics – secondary gout 3-procainamide –drug induced lupus 4-penicillamin-myasthenia gravis 5-amphetamines –vasculitis
Answer 1 Glucocorticoids cause: proximal myopathy with type II fiber atrophy , osteonecrosis and osteoporosis
