MRCP Part 2 Sample Questions

MRCP(UK) Part 2 Written Sample Questions
Part2SampleQ updated Mar-12
Q1
A 67-year-old woman was referred with a 3-month history of painful legs, malaise and
weight loss. She had had type 2 diabetes mellitus and hypertension for 18 years. Her
medication was gliclazide 160 mg twice daily, ramipril 2.5 mg daily and atorvastatin 20 mg
daily.
On examination, her blood pressure was 145/90 mmHg. There was some tenderness over
her spine and lower legs.
Investigations:
serum sodium
serum potassium
serum creatinine
serum corrected calcium
serum phosphate
plasma parathyroid hormone
138 mmol/L (137144)

5.5 mmol/L (3.54.9)
240 mol/L (60110)
1.80 mmol/L (2.202.60)
1.6 mmol/L (0.81.4)
22.2 pmol/L (0.95.4)
What therapy is most likely to correct the calcium and parathyroid hormone
concentrations?
A
B
C
D
E
alendronic acid
alfacalcidol
calcitonin
cinacalcet
ergocalciferol
Q2
A 52-year-old man presented with a 4-month history of altered bowel habit with occasional
bright-red blood per rectum.
Colonoscopy showed an annular sigmoid tumour, and histology confirmed an
adenocarcinoma. A staging CT scan of abdomen showed two adjacent 1-cm lesions in the
right lobe of the liver, highly suspicious for liver metastases.
What is the most appropriate next management step?
A
B
C
D
E
biopsy of liver lesions

palliative chemotherapy
palliative radiotherapy
stenting of colorectal carcinoma
surgical resection of carcinoma and liver lesions
Q3
A 53-year-old man presented with a 2-week history of diarrhoea associated with cramping
abdominal pain. He was passing up to 15 very loose and watery stools per day. There was
no blood in the stools. He had undergone a heart transplant 2 years previously, and his
medication comprised ciclosporin, prednisolone, aspirin and ramipril.
Investigations:
haemoglobin
white cell count
110 g/L (130180)

12.5 109/L (4.011.0)
serum urea
serum creatinine
serum C-reactive protein
14.4 mmol/L (2.57.0)

135 mol/L (60110)
35 mg/L (<10)
stool culture
stool microscopy
negative
cysts identified on modified acid-fast
stain
What is the most likely pathogen?

A
B
C
D
E
Cryptosporidium parvum
Entamoeba histolytica
Giardia lamblia
Pneumocystis jirovecii
Toxoplasma gondii
Q4
An 82-year-old woman with hypertension presented with tiredness, ankle swelling and
arthralgia.
On examination, her pulse was 92 beats per minute and her blood pressure was
150/90 mmHg. She had bilateral ankle oedema. Her serum creatinine concentration had
been normal 6 months previously. Urinalysis showed blood 2+, protein 2+.
Investigations:
haemoglobin
white cell count
platelet count
103 g/L (115165)

10.5 109/L (4.011.0)
410 109/L (150400)
serum creatinine
252 mol/L (60110)
What is the most likely cause of her renal impairment?

A
B
C
D
E
amyloidosis
crescentic glomerulonephritis
IgA nephropathy
membranoproliferative glomerulonephritis
membranous nephropathy
Q5
A 60-year-old woman was admitted with a 2-day history of dysuria, loin pain and rigors.
On admission, she was unwell and confused. She was also febrile and tachycardic. She
was transferred to the medical high-dependency unit for invasive monitoring.
Which set of haemodynamic values is most likely to be hers?
mean arterial
pressure
(mmHg)
mean
right
atrial
pressure
(mmHg)
3
mean
pulmonary
arterial
pressure
(mmHg)
15
mean
pulmonary
arterial wedge
pressure
(mmHg)
9
mean
cardiac
output
(L/min)
normal
85
80
22
20
3.0
110
18
20
11
4.0
85
16
2.5
66
20
22
20
2.0
60
15
4.5
5.0
Q6
A 78-year-old man presented to the emergency department with a 4-week history of
breathlessness, dry cough and confusion. He also complained of headaches that were
worse in the morning. He had a history of tuberculosis as a teenager.
On examination, he was drowsy. His Glasgow coma score was 14. His pulse was 102
beats per minute, and his respiratory rate was 24 breaths per minute. His oxygen
saturation was 85%, breathing air (9498). Auscultation of his chest showed some
crackles in the left lower zone and generally decreased breath sounds on the right.
Investigations:
arterial blood gases breathing air:
PO2
PCO2
pH
H+
bicarbonate
base excess
6.8 kPa (11.312.6)

9.8 kPa (4.76.0)
7.25 (7.357.45)
56 nmol/L (3545)
32 mmol/L (2129)
10 mmol/L (2)
chest X-ray
see image
What is the most appropriate treatment?

A
B
C
D
E
aminophylline
continuous positive airway pressure
doxapram
furosemide
non-invasive ventilation
Q7
A 34-year-old woman was admitted with shortness of breath and found to have a
pulmonary embolus. On systematic enquiry, she admitted to cold intolerance. She was
taking no medication.
On examination, she had a livedo reticularis rash on the thighs.
Blood tests showed marked thrombocytopenia and a prolonged activated partial
thromboplastin time. Antinuclear antibodies were negative, and serum complement C3 and
C4 concentrations were normal. The blood film was normal, with no evidence of
haemolysis.
What is the most likely diagnosis?
A
B
C
D
E
antiphospholipid antibody syndrome

cryoglobulinaemia
mixed connective tissue disease
systemic lupus erythematosus
thrombotic thrombocytopenic purpura
Q8
A 19-year-old woman presented with a widespread skin eruption 2 weeks after a sore
throat.
On examination, there were multiple 5-mm diameter, scaly, erythematous papules over
her trunk and limbs.
A
B
C
D
E
atopic eczema
dermatitis artefacta
guttate psoriasis
lichen planus
pityriasis versicolor
Q9
A 60-year-old man was admitted with a 3-day history of diarrhoea. A diagnosis of lung and
peritoneal metastases from an unknown primary carcinoma had been made 4 months
previously, and he had been receiving platinum-based combination chemotherapy. He had
been discharged from hospital 5 days previously after an episode of neutropenic sepsis
following his second cycle of chemotherapy.
On examination, he was apyrexial, his pulse was 98 beats per minute and his blood
pressure was 110/65 mmHg lying. He looked dehydrated. His abdomen was soft but
tender over the left iliac fossa.
Investigations:
haemoglobin
white cell count
neutrophil count
platelet count
113 g/L (130180)

6.5 109/L (4.011.0)
5.4 109/L (1.57.0)
170 109/L (150400)
CT scan of abdomen
thickened sigmoid colon

A
B
C
D
E
cryptosporidiosis
flare-up of diverticular disease
ischaemic colitis
pseudomembranous colitis
tumour progression
Q10
A 79-year-old woman was referred to the medical outpatient clinic with a 3-month history
of low back pain. She was taking regular paracetamol and occasional ibuprofen. She was
normally fit and active, with no other complaints.
Examination was normal.
Investigations:
full blood count
normal
serum urea and electrolytes

serum calcium
serum immunoglobulin G
serum immunoglobulin A
serum immunoglobulin M
normal
normal
15.2 g/L (6.013.0)
2.5 g/L (0.83.0)
1.0 g/L (0.42.5)
serum protein electrophoresis:

IgG kappa paraprotein
4.3 g/L
X-ray of lumbar spine
generalised osteopenia; no focal

collapse; mild degenerative change

A
B
C
D
E
amyloidosis
low-grade lymphoma
monoclonal gammopathy of undetermined significance
myeloma
solitary plasmacytoma
Q11
A 24-year-old man presented with a 2-day history of fever and a generalised blistering
rash. He had been taking prednisolone 20 mg daily for more than 2 weeks because of
severe asthma. His son had had chickenpox 2 weeks previously.
On examination, he was low in mood. His temperature was 38.5C, his blood pressure
was 118/76 mmHg and his respiratory rate was 14 breaths per minute. His oxygen
saturation was 96%, breathing air (9498). He had a widespread eruption consisting of
vesicles and pustules. Examination of his chest showed a few wheezes but no crackles.
Investigations:
haemoglobin
white cell count
neutrophil count
lymphocyte count
platelet count
128 g/L (130180)

15.2 109/L (4.011.0)
13.8 109/L (1.57.0)
1.0 109/L (1.54.0)
189 109/L (150400)
chest X-ray
normal

A
B
C
D
E
antipyretic
intravenous aciclovir
intravenous flucloxacillin
oral valaciclovir
varicella zoster hyperimmune globulin
Q12
A 35-year-old man presented with widespread aches and pains. He was
undergoing regular haemodialysis for end-stage kidney failure. An X-ray of his
hand was performed (see image).

A
B
C
D
E
dialysis-related amyloidosis
gout
primary hyperparathyroidism
secondary hyperparathyroidism
systemic sclerosis
Q13
A 72-year-old man presented with a 4-year history of acute intermittent pain and swelling
of the knees. The problem affected one knee at a time, and each episode lasted about a
week. He took naproxen for the pain. His serum urate concentration was measured during
one of the attacks and was found to be normal. He had drunk 2428 units of alcohol per
week for 30 years. There was no family history of diabetes mellitus.
On examination, his body mass index was 34 kg/m2 (1825). His pulse was 64 beats per
minute, and his blood pressure was 110/70 mmHg. His liver was enlarged to 5 cm below
the costal margin and his spleen to 3 cm. The metacarpophalangeal joints of the index and
middle fingers in both hands were swollen. Urinalysis showed glucose 3+.
Investigations:
haemoglobin
white cell count
platelet count
165 g/L (130180)

9.5 109/L (4.011.0)
135 109/L (150400)
serum sodium
serum potassium
serum urea
serum creatinine
serum albumin
serum total bilirubin
serum alanine aminotransferase
serum aspartate aminotransferase
fasting plasma glucose
128 mmol/L (137144)

3.1 mmol/L (3.54.9)
3.5 mmol/L (2.57.0)
56 mol/L (60110)
31 g/L (3749)
32 mol/L (122)
133 U/L (535)
110 U/L (131)
13.4 mmol/L (3.06.0)

A
B
C
D
E
alcoholic cirrhosis
haemochromatosis
palindromic rheumatism
rheumatoid arthritis
sarcoidosis
Q14
A frail 85-year-old man presented with a 2-week history of diarrhoea and faecal
incontinence. There had been no rectal bleeding. He had a history of Parkinsons disease,
osteoarthritis of the hips and knees, and diverticular disease of the colon. His medication
comprised co-beneldopa, co-codamol and bendroflumethiazide.
On examination of his abdomen, the sigmoid colon was palpable but non-tender. There
was no distension, and his bowel sounds were normal. Digital rectal examination showed
an empty rectum.
Investigations:
haemoglobin
white cell count
platelet count
erythrocyte sedimentation rate
110 g/L (130180)

9.5 109 /L (4.011.0)
250 109/L (150400)
25 mm/1st h (<20)
serum sodium
serum potassium
serum urea
serum creatinine
130 mmol/L (137144)

2.9 mmol/L (3.54.9)
15.3 mmol/L (2.57.0)
120 mol/L (60110)
What is the most appropriate next investigation?

A
B
C
D
E
barium enema
CT scan of abdomen
faecal occult blood
flexible sigmoidoscopy
plain X-ray of abdomen
Q15
A 75-year-old man presented with a painful left leg (see image).
What is the most appropriate treatment for the underlying disease?

A
B
C
D
E
bisphosphonate
corticosteroid
flucloxacillin
furosemide
vitamin D
Q16
A 42-year-old man was admitted to hospital with severe abdominal pain. His alcohol intake
was 18 units per week. His serum amylase concentration was raised at 1346 U/L (60
180), and a diagnosis of acute pancreatitis was made.
There was no evidence of gallstones. He made an uncomplicated recovery.
Investigations (after recovery):
serum cholesterol
serum LDL cholesterol
serum HDL cholesterol
fasting serum triglycerides
5.7 mmol/L (3.06.0)

5.8 mmol/L (<5.2)
3.41 mmol/L (<3.36)
0.96 mmol/L (>1.55)
22.63 mmol/L (0.451.69)
What is the most appropriate treatment to reduce his risk of recurrent pancreatitis?
A
B
C
D
E
atorvastatin
ciprofibrate
ezetimibe
nicotinic acid
omega-3-marine triglycerides
Q17
A 43-year-old woman was investigated for increasing abdominal girth, nausea and
alteration of bowel habit.
On examination, her abdomen was distended and generally dull to percussion.
Investigations:
CT scan of abdomen
see image
What is the most likely explanation for the CT appearance?

A
B
C
D
E
ascites
constipation
hepatocellular carcinoma
pseudomyxoma peritonei
retroperitoneal haemorrhage
Q18
A 65-year-old man had a 10-year history of dialysis-dependent kidney failure caused by
renovascular disease. He began taking warfarin because of recurrent arteriovenous fistula
thrombosis.
One month later, he presented with livedo reticularis on his trunk, and areas of painful
ulceration on his shins.
Investigations:
haemoglobin
white cell count
eosinophil count
platelet count
international normalised ratio
102 g/L (130180)

5.4 109/L (4.011.0)
0.78 109/L (0.040.40)
478 109/L (150400)
1.9 (<1.4)

serum phosphate
2.58 mmol/L (2.202.60)

1.9 mmol/L (0.81.4)
18.5 pmol/L (0.95.4)
anticardiolipin antibodies:
immunoglobulin G
immunoglobulin M
32 U/mL (<23)
24 U/mL (<11)

A
B
C
D
E

calciphylaxis
cholesterol embolisation
coumarin necrosis
thromboembolism from arteriovenous fistula
Q19
A 27-year-old woman attended the emergency department with a 1-week
history of progressive dyspnoea and cough, and a 2-day history of left basal
thoracic pain on inspiration and haemoptysis. She had a history of
bronchiectasis. She was a non-smoker. She had recently returned from a
holiday in New Zealand, and was taking co-amoxiclav and prednisolone
prescribed by her general practitioner for an exacerbation of her bronchiectasis.
On examination, she was thin. Her temperature was 37.3C, her pulse was 115
beats per minute and regular, her blood pressure was 128/78 mmHg and her
respiratory rate was 22 breaths per minute. Further examination was normal.
Investigations:
haemoglobin
white cell count
157 g/L (115165)

18.0 109/L (4.011.0)
arterial blood gases, breathing air:

PO2
PCO2
pH
H+
bicarbonate
8.9 kPa (11.312.6)

4.9 kPa (4.76.0)
7.40 (7.357.45)
40 nmol/L (3545)
22 mmol/L (2129)
68 mg/L (<10)
ECG
sinus tachycardia
chest X-ray
cystic changes at left base
What is the most appropriate next investigation?

A
B
C
D
E
CT pulmonary angiography
D-dimer
echocardiography
ultrasound scan of legs and pelvis
ventilation/perfusion isotope lung scan
Q20
A 30-year-old woman had a 3-year history of Crohns disease, which had required the
formation of an ileostomy. She presented with a sore area around the stoma (see image).
This was causing problems with adhesion of the stoma pouch.

A
B
C
D
E
oral flucloxacillin
oral prednisolone
radiotherapy
surgical debridement
topical terbinafine
Q21
A 48-year-old woman complained of leg weakness and tenderness, which was worse on
exercise.
Her serum creatine kinase concentration was elevated, but a muscle biopsy was
inconclusive. An antinuclear antibody test was negative, but antibodies to gastric parietal
cells and thyroid peroxidase were both detected. There was no anaemia, but the MCV was
raised.
A
B
C
D
E
alcohol abuse
folate deficiency
hypothyroidism
pernicious anaemia
polymyositis
Q22
An 82-year-old woman presented to the emergency department following a fall. She
denied any loss of consciousness. She had a history of type 2 diabetes mellitus,
osteoarthritis of the hips and spine, diverticular disease and a hiatus hernia. Her
medication comprised gliclazide, ibuprofen, omeprazole, ispaghula husk and paracetamol.
On examination, she appeared well and there were no signs of injury. A 24-hour ECG
showed normal sinus rhythm throughout, with a daytime heart rate of 60100 beats per
minute and a night-time heart rate of 4258 beats per minute. There were frequent
ventricular and supraventricular ectopics, one short run (five beats) of atrial fibrillation and
one pause of 2 seconds duration at 05.30 h. No symptoms were noted.
What is the most appropriate management?
A
B
C
D
E
amiodarone
digoxin
no intervention
permanent pacemaker
warfarin
Q23
A 25-year-old woman was reviewed 6 weeks after stopping anticoagulant therapy. She
had received anticoagulants for 3 months following a right iliofemoral vein thrombosis that
had developed 7 days post partum.
Investigations:
protein C
protein S
antithrombin
prothrombin 20210A allele
factor V Leiden mutation
85 IU/dL (80135)
110 IU/dL (80120)
95 IU/dL (80120)
negative
heterozygous
What is the most appropriate further management?

A anticoagulation for an indefinite period with target international normalised ratio (INR)
2.5
B anticoagulation for an indefinite period with target INR 3.5
C anticoagulation for another 3 months with target INR 2.5
D long-term aspirin
E no further anticoagulation
Q24
A 21-year-old man was admitted to hospital with a 5-day history of fevers and vomiting. He
also complained of knee and ankle pains. He was homosexual, and had last had receptive
anal intercourse 6 weeks previously.
On examination, he had a widespread erythematous macular rash. His temperature was
37.5C, his pulse was 85 beats per minute and his blood pressure was 115/60 mmHg.
There was no joint swelling.
Investigations:
haemoglobin
white cell count
147 g/L (130180)

6.5 109/L (4.011.0)
serum urea
serum alkaline phosphatase
serum gamma glutamyl transferase
4.3 mmol/L (2.57.0)

50 mol/L (122)
687 U/L (535)
110 U/L (45105)
89 U/L (<50)

A
B
C
D
E
acute hepatitis B
acute hepatitis C
acute HIV infection
gonococcal bacteraemia
secondary syphilis
Q25
A 62-year-old man presented with a 2-day history of pleuritic right lower chest pain
associated with a cough productive of red-brown sputum. He had a 1-year history of
microscopic polyangiitis which had initially presented with pulmonary haemorrhage and
rapidly progressive glomerulonephritis. He had responded well to plasma exchange,
methylprednisolone and cyclophosphamide before being switched to azathioprine at 3
months. At his clinic visit 3 weeks previously, his serum C-reactive protein concentration
had been 5 mg/L (<10) and his estimated glomerular filtration rate was 28 mL/min (>60).
His current medication was prednisolone 7.5 mg daily and azathioprine 100 mg daily.
On examination, he was comfortable at rest. His temperature was 37.8C, his blood
pressure was 106/78 mmHg and his respiratory rate was 18 breaths per minute. There
was bronchial breathing and a pleural rub at the right lung base but no crackles.
Investigations:
haemoglobin
white cell count
platelet count
120 g/L (130180)

9.4 109/L (4.011.0)
256 109/L (150400)
estimated glomerular filtration rate (MDRD)
26 mL/min (>60)

PO2
PCO2
pH
H+
bicarbonate
10.6 kPa (11.312.6)

4.2 kPa (4.76.0)
7.44 (7.357.45)
36 nmol/L (3545)
18 mmol/L (2129)
56 mg/L (<10)
chest X-ray
patchy shadowing at right base

A
B
C
D
E
intravenous cefotaxime and clarithromycin

intravenous cefotaxime, clarithromycin and co-trimoxazole
intravenous clarithromycin, amoxicillin and co-trimoxazole
oral amoxicillin and clarithromycin
oral amoxicillin, clarithromycin and co-trimoxazole
Q26
A 32-year-old cyclist had noticed increasingly frequent flickering of his limb muscles,
particularly the calves, and reported occasional cramps over 3 months.
On examination, he had widespread fasciculations in his arms, forearms and calves. His
deep tendon reflexes were normal, and there were no sensory signs.
A
B
C
D
E
benign fasciculations
McArdles syndrome
motor neurone disease
myotonic dystrophy
polymyositis
Q27
A 45-year-old woman was admitted with breathlessness and malaise. She had a 5year history of rheumatoid arthritis and was taking a non-steroidal anti-inflammatory
drug. She had a 20 pack-year smoking history. Over the next 10 days, she had a
persistent pyrexia that was unresponsive to broad-spectrum antibiotics.
On examination, there were rheumatoid changes in her hands and coarse inspiratory
crackles over both lung fields.
Investigations 10 days after admission:
haemoglobin
white cell count
platelet count
92 g/L (115165)
12.8 109/L (4.011.0)
472 109/L (150400)
83 mm/1st h (<20)
serum albumin
33 g/L (3749)

PO2
PCO2
pH
H+
bicarbonate
8.8 kPa (11.312.6)

4.5 kPa (4.76.0)
7.40 (7.357.45)
40 nmol/L (3545)
22 mmol/L (2129)
chest X-ray

A
B
C
D
E
aspiration pneumonia
cryptogenic organising pneumonia
pulmonary tuberculosis
rheumatoid lung disease
thromboembolic disease
right mid-zone and left lower-zone

consolidation (unchanged since
admission)
Q28
A 46-year-old man with profuse diarrhoea was admitted for measurement of his daily stool
weight for 3 days, with a further measurement on day 4 when fasting. He had previously
had a normal colonoscopy and small bowel meal.
Investigations:
serum sodium
serum potassium
serum urea
serum creatinine
135 mmol/L (137144)

2.4 mmol/L (3.54.9)
5.8 mmol/L (2.57.0)
78 mol/L (60110)
daily stool weight:

day 1
day 2
day 3
day 4 (fasting)
1450 g (<200)
1200 g
1560 g
1400 g

A
B
C
D
E
coeliac disease
irritable bowel syndrome
lactose intolerance
pancreatic insufficiency
VIPoma
Q29
A 20-year-old Chinese woman presented with a 2-week history of ankle swelling. She had
had asthma since childhood and was taking paracetamol regularly for pains in her wrists
and knees. She was also taking an oral contraceptive.
Examination showed bilateral pitting oedema to mid-shin level. Her blood pressure was
148/92 mmHg, and her heart sounds were normal. Chest, abdominal and neurological
examinations were normal. Urinalysis showed blood 1+, protein 4+, but was negative for
glucose.
Investigations:
haemoglobin
MCV
white cell count
118 g/L (115165)

79 fL (8096)
3.3 109/L (4.011.0)
serum sodium
serum potassium
serum urea
serum creatinine
24-h urinary total protein
136 mmol/L (137144)

4.1 mmol/L (3.54.9)
5.7 mmol/L (2.57.0)
73 mol/L (60110)
7.8 g (<0.2)
What is the most important diagnostic investigation?

A
B
C
D
E
anti-glomerular basement membrane antibodies

anti-neutrophil cytoplasmic antibodies
antinuclear antibodies
antistreptolysin O titre
serum complement concentrations
Q30
A 22-year-old man presented with acute pain and swelling of his left knee 4 weeks after a
holiday in Spain.
On examination, his temperature was 38.1C and he had a rash on the soles of his feet.
His right foot is shown (see image).
Investigations:
haemoglobin
white cell count
neutrophil count
platelet count
125 g/L (130180)

16.2 109/L (4.011.0)
14.8 109/L (1.57.0)
450 109/L (150400)
210 mg/L (<10)

A
B
C
D
E
gonococcal arthritis
HIV seroconversion illness
psoriatic arthritis
reactive arthritis
syphilis
Q31
A 23-year-old man presented to the emergency department with acute severe asthma. His
regular medication was inhaled salbutamol and beclometasone, and oral theophylline.
On examination, he was dyspnoeic and in distress. His pulse was 104 beats per minute,
his blood pressure was 108/64 mmHg and his respiratory rate was 40 breaths per minute.
Auscultation of his lungs showed expiratory wheezes throughout. He was unable to
perform a peak expiratory flow reading, and he failed to respond to initial therapy with
oxygen, nebulised salbutamol and ipratropium bromide, and oral prednisolone 40 mg.
What is the most appropriate next step in treatment?
A
B
C
D
E
intravenous aminophylline
intravenous hydrocortisone
intravenous magnesium sulphate
non-invasive ventilation
subcutaneous terbutaline
Q32
A 60-year-old man with diet-controlled type 2 diabetes mellitus gave a 3-month history of
numbness and pins and needles sensations in his feet. He also felt unsteady. Two years
previously, he had undergone surgery for carcinoma of the stomach.
On examination, he had mild weakness of hip flexion. His ankle reflexes were absent, and
all of his other limb reflexes were diminished. His plantar responses were extensor. There
was diminished sensation to pinprick and light touch below the knees, and vibration sense
was impaired at the ankles, but joint position sense was normal. Rombergs test was
positive.
A
B
C
D
E
diabetic amyotrophy
paraneoplastic sensory ataxic neuropathy
spinal arteriovenous malformation
subacute combined degeneration of the cord
syringomyelia
Q33
A 72-year-old man attended his general practitioner with cough and breathlessness. He
had coughed up one teaspoonful of mucoid phlegm daily for the past 12 years. He gave a
1-year history of breathlessness when walking his dog. He had hypertension and had been
taking atenolol 50 mg once daily for 5 years. He had a 46 pack-year history of smoking
and was a current smoker.
His body mass index was 32 kg/m2 (1825).
Investigations:
ECG
left ventricular hypertrophy
baseline spirometry:
forced expiratory volume in 1 s (FEV1)
forced vital capacity (FVC)
90% predicted
91% predicted
20 minutes after exercise:

FEV1
FVC
63% predicted
84% predicted
What is the most likely cause of his breathlessness?

A
B
C
D
E
asthma
bronchiectasis
chronic obstructive pulmonary disease
hypertensive left ventricular failure
obesity
Q34
A 42-year-old man presented with a 4-cm thyroid swelling. He had undergone an
adrenalectomy for a benign phaeochromocytoma 6 years previously.
Examination confirmed the thyroid swelling but showed no lymph node enlargement or
skin lesions.
Investigations:
serum creatinine
serum thyroid-stimulating hormone
86 mol/L (60110)
2.15 mmol/L (2.202.60)
6.5 mU/L (0.45.0)
What is the most appropriate next test to confirm the diagnosis?

A
B
C
D
E
plasma calcitonin
serum 25-OH-cholecalciferol
serum anti-thyroid peroxidase antibodies
serum thyroid receptor antibodies
Q35
A 66-year-old man who was recovering in the burns unit from a full-thickness burn to the
left leg complained of right upper abdominal pain.
On examination, he had a temperature of 37.8C and there was tenderness over the right
hypochondrium.
Investigations:
haemoglobin
white cell count
101 g/L (130180)

14.9 109/L (4.011.0)
50 mm/1st h (<20)

serum amylase
20 mol/L (122)
51 U/L (535)
100 U/L (45105)
500 U/L (60180)
ultrasound scan of abdomen
thickened gallbladder;
pericholecystic fluid collection and
sonographic-positive Murphys sign;
no evidence of gallstones

A
B
C
D
E
acalculous cholecystitis
acute pancreatitis
common bile duct stone
mesenteric ischaemia
perforated peptic ulcer
Q36
A 29-year-old man with Hodgkins lymphoma was admitted as an emergency with
epistaxis and a petechial rash. He had recently been treated with combination
chemotherapy.
On admission, he was pale and breathless. He had a fine petechial rash on his legs,
bruises on his trunk and two large blood blisters in his mouth.
Investigations:
haemoglobin
white cell count
neutrophil count
platelet count
One adult dose of platelets was requested.
Which special platelet product is required?
A
B
C
D
E
cytomegalovirus-seronegative
gamma-irradiated
HLA-matched
single-donor unit
washed
104 g/L (130180)

0.9 109/L (4.011.0)
0.5 109/L (1.57.0)
5 109/L (150400)
Q37
A 63-year-old man presented with a 4-week history of fever, severe night sweats, anorexia
and muscle pains. His family doctor had recorded persistent microscopic haematuria, but
urine culture had been negative on three occasions.
On examination, his temperature was 39.2C, his pulse was 105 beats per minute and his
blood pressure was 140/75 mmHg. No cardiac murmurs were audible.
Investigations:
haemoglobin
white cell count
neutrophil count
platelet count
87 g/L (130180)
23.5 109/L (4.011.0)
21.9 109/L (1.57.0)
523 109/L (150400)
serum creatinine
135 mol/L (60110)

235 mg/L (<10)
blood cultures 3
negative
urine microscopy
red cells 2+, no white cells; granular

casts present
ultrasound scan of abdomen
normal
transthoracic echocardiogram
no abnormality seen
What further investigation is most likely to be of help in establishing the diagnosis?

A
B
C
D
E
anti-neutrophil cytoplasmic antibodies

CT scan of abdomen
mycobacterial culture of early-morning urine
radiolabelled white cell scan
transoesophageal echocardiography
Q38
A 58-year-old heavy-goods vehicle driver presented to his general practitioner with thirst
and nocturia. He had a past history of chronic kidney failure, ischaemic heart disease and
left ventricular failure. He was taking bisoprolol, aspirin, pravastatin, ramipril,
spironolactone and furosemide.
His body mass index was 35 kg/m2 (1825).
Investigations:
serum creatinine
haemoglobin A1c
230 mol/L (60110)

17.0 mmol/L (3.06.0)
91 mmol/mol (2040)
A diagnosis of type 2 diabetes mellitus was made. He was seen by the practice nurse and
taught urine testing. The dietitian gave him advice on diet.
At review 6 weeks later, he complained that he felt no better. His urine tests continued to
show glucose 3+, despite his adherence to his diet.
What is the most appropriate additional treatment?
A
B
C
D
E
acarbose
glibenclamide
insulin
metformin
pioglitazone
Q39
A 46-year-old woman presented to the emergency department having had a generalised
tonicclonic seizure. She had had recent headaches and nausea, with some left-sided
weakness. Her family mentioned a recent change in personality, which they attributed to
her stopping smoking.
On examination, her Glasgow coma score was 6. She had a left hemiparesis. A chest Xray was normal. An urgent MR scan of brain (T1 weighted) was performed (see image).
What intravenous treatment is the most appropriate next step?

A
B
C
D
E
aciclovir
cefotaxime
dexamethasone
diazepam
sodium valproate
Q40
A 55-year-old woman presented with a 4-week history of intermittent severe swelling
affecting her face and tongue. Each episode lasted 12 days and slowly resolved
spontaneously. Oral antihistamines were unhelpful. She had developed angina and had
been found to have hypertension 6 months previously, and appropriate medication had
gradually been introduced. She was otherwise well, with no relevant previous medical or
family history.
What medication is the most likely cause of her symptoms?
A
B
C
D
E
amlodipine
atenolol
bendroflumethiazide
enalapril
simvastatin
Q41
A previously fit 35-year-old woman presented with headaches.
On examination, her blood pressure was elevated at 180/94 mmHg. Her heart sounds
were normal to auscultation. There was no peripheral oedema. Abdominal
examination was normal.
Investigations:
serum sodium
serum potassium
serum chloride
serum bicarbonate
serum urea
serum creatinine
plasma renin activity (after 30 min supine)
plasma aldosterone (after 30 min supine)
plasma adrenocorticotropic hormone (09.00 h)
24-h urinary free cortisol
A
B
C
D
E
Bartters syndrome
Conns syndrome
fibromuscular dysplasia of the renal artery
laxative abuse
liquorice excess
144 mmol/L (137144)

2.8 mmol/L (3.54.9)
87 mmol/L (95107)
34 mmol/L (2028)
5.6 mmol/L (2.57.0)
99 mol/L (60110)
6.3 pmol/mL/h (1.12.7)
1005 pmol/L (135400)
5.0 pmol/L (<18.0)
105 nmol (55250)
Q42
A 26-year-old woman was brought by ambulance to the emergency department. She
developed ventricular fibrillation immediately on arrival. DC cardioversion restored sinus
rhythm. Her husband said she had complained of chest pain for about 60 minutes before
he had phoned for an ambulance. She was 28 weeks pregnant and was a smoker.
Investigations:
12-lead ECG
see image
She was treated with aspirin and clopidogrel.

What is the most appropriate next step in management?
A
B
C
D
E
coronary angiography
diltiazem
low-molecular-weight heparin
tenecteplase
transthoracic echocardiography
Q43
A 19-year-old man first noticed right-sided shoulder weakness when his scapula stuck
out painlessly during weightlifting. One year previously, he had experienced severe pain
in his right shoulder, which had resolved in 3 weeks. He stated that his first cousin was
wheelchair-bound because of a muscle disease.
On examination, his weakness was limited to the right serratus anterior muscle. His tendon
reflexes were intact, and sensation was normal.
A
B
C
D
E
brachial neuritis
cervical radiculopathy
facioscapulohumeral muscular dystrophy
spinal muscular atrophy
spinobulbar muscular atrophy
Q44
A 63-year-old man attended a routine 6-monthly renal clinic appointment and reported the
occurrence of two episodes of painless visible haematuria during the previous 2 months.
He had a history of nephrotic syndrome resulting from idiopathic membranous
nephropathy 9 years previously, for which he had received a 6-month course of alternate
months of cyclophosphamide and prednisolone. This had resulted in complete remission
from proteinuria, and the serum creatinine concentration had subsequently remained
stable at around 160 mol/L (60110). His blood pressure had been elevated when he had
the nephrotic syndrome but had settled to normal after he had entered remission. He was
not taking any medication. He smoked 25 cigarettes per day.
On examination, his blood pressure was 158/68 mmHg and there was no oedema. There
was no abnormality on examination of the heart, lungs or abdomen. There was a right
femoral bruit. Urinalysis showed blood 3+, protein 1+.
Investigations:
full blood count
normal
serum creatinine
168 mol/L (60110)

0.3 g (<0.2)
urine culture
negative
ultrasound scan of kidneys
right kidney 9.4 cm, left kidney 10.2

cm; no obstruction
What is the most important investigation?

A
B
C
D
E
cystoscopy
intravenous urography
MR angiography of renal arteries
MR venography of renal veins
renal biopsy
Q45
A 50-year-old nursing sister presented with a purpuric rash over the lower legs
preceded 2 weeks previously by tonsillitis. A diagnosis of postviral thrombocytopenia
was made, and the symptoms resolved over a 4-week period. Four months later, she
presented with numbness and weakness of her hands and feet and a recurrence of
the purpuric rash.
Investigations:
haemoglobin
white cell count
platelet count
125 g/L (115165)

8.4 109/L (4.011.0)
120 109/L (150400)
80 mm/1st h (<30)
serum urea
serum creatinine
serum complement C3
serum complement C4
7.0 mmol/L (2.57.0)

105 mol/L (60110)
17 U/L (535)
26 U/L (131)
180 mg/dL (65190)
45 mg/dL (1550)
145 mg/L (<10)
anti-double-stranded DNA antibodies (ELISA)

anti-neutrophil cytoplasmic antibodies:
c-ANCA
p-ANCA
negative
negative
positive
1:20 (negative at 1:20 dilution)
chest X-ray
normal lung fields
urine microscopy
no white cells or casts

A
B
C
D
E
cryoglobulinaemia
microscopic polyangiitis
polyarteritis nodosa
Wegeners granulomatosis
Q46
A 72-year-old man developed sudden severe breathlessness and left-sided chest pain
while working in his garden. A few minutes later, he collapsed and was taken to the
emergency department. Several years previously, he had been found to have a systolic
murmur at a routine medical examination and an echocardiogram had shown mitral valve
prolapse. There was no other significant medical history.
On examination, he was very breathless and cyanosed, with an oxygen saturation of 88%,
breathing air (9498). His pulse was 130 beats per minute and regular, and his blood
pressure was 80/50 mmHg. His neck veins were markedly distended. There was no
cardiomegaly. There were crackles up to the mid-zones of his lungs. His respiration was
very noisy, and his heart sounds could not be easily heard.
Investigations:
ECG
sinus tachycardia
chest X-ray
cardiothoracic ratio 15:30; pulmonary

oedema

A
B
C
D
E
acute mitral regurgitation

acute myocardial infarction
infective endocarditis
pulmonary embolism
rupture of sinus of Valsalva
Q47
A 57-year-old woman, who lived alone, was found in a confused state by neighbours and
brought to hospital.
On examination, her temperature was 36.8C, her pulse was 120 beats per minute and her
blood pressure was 90/60 mmHg. There was no focal neurological deficit. Fundoscopy
was normal.
Investigations:
haemoglobin
white cell count
platelet count
139 g/L (115165)

9.1 109/L (4.011.0)
390 109/L (150400)
serum sodium
serum potassium
serum urea
serum creatinine
131 mmol/L (137144)

5.2 mmol/L (3.54.9)
12.3 mmol/L (2.57.0)
132 mol/L (60110)
3.40 mmol/L (2.202.60)
17 mol/L (122)
129 U/L (535)
643 U/L (45105)
80 U/L (435)
What is the most likely cause of the hypercalcaemia?

A
B
C
D
E
Addisons disease
myeloma
Pagets disease of bone
skeletal metastases
Q48
A 17-year-old Indian boy, who had arrived in the UK 5 days previously, became generally
unwell and developed a sore throat.
On examination, his temperature was 38.1C and his pulse was 86 beats per minute.
There were tender, enlarged cervical glands palpable and an adherent grey membrane
over the soft palate and tonsils.
A candidiasis
B diphtheria
C group A streptococcal tonsillitis
D infectious mononucleosis
E Vincents angina
Q49
A 51-year-old woman presented with a 4-month history of an itchy rash, which had begun
on her feet and rapidly progressed to affect her forearms and lower back. She was
otherwise well and was taking no systemic medication.
On examination, there was a symmetrical papular rash (see image).

A
B
C
D
E
atopic eczema
dermatitis herpetiformis
guttate psoriasis
lichen planus
tinea corporis
Q50
A 40-year-old man, with type 1 diabetes mellitus and a 20-year history of excessive
alcohol intake, presented to the emergency department with a history of severe dull upper
abdominal pain associated with nausea, anorexia and diarrhoea. A plain X-ray of abdomen
was performed (see image).

A
B
C
D
E
calcified gallstones
chronic pancreatitis
ischaemic colitis
nephrocalcinosis
tuberculous adenitis
Q51
A 68-year-old woman attended the movement disorder clinic, accompanied by her son.
For 6 months, she had been bothered by a resting tremor affecting her right hand,
associated with stiffness and slowness of movement. She and her son were informed that
the symptoms were suggestive of idiopathic Parkinsons disease.
Her son was worried about his own health and wanted some information regarding early
signs of Parkinsons disease.
What symptom is most likely to be prognostic of Parkinsons disease?
A
B
C
D
E
excessive daytime sleepiness

insomnia
REM-sleep behaviour disorder
sleep apnoea
somnambulance
Q52
A previously well 64-year-old woman presented with haemoptysis. Biopsy of a right upperlobe endobronchial lesion confirmed the diagnosis of non-small cell bronchogenic
carcinoma.
Investigations:
forced expiratory volume in 1 s
forced vital capacity
61% predicted
78% predicted
CT scan of chest and abdomen
3.5-cm mass in right upper lobe with

ipsilateral hilar lymph node
enlargement; no disease below
diaphragm
PET scan
increased uptake in right upper lobe

and ipsilateral hilar nodes
What is the most appropriate management?

A
B
C
D
E
chemotherapy
palliative radiotherapy
pneumonectomy
radical radiotherapy
radiofrequency ablation
Q53
A 72-year-old woman presented with weakness of her right leg and numbness in her right
hand. She had a 20-year history of rheumatoid arthritis and also had long-standing type 2
diabetes mellitus and hypertension. Her medication comprised gliclazide, amlodipine,
simvastatin and sodium aurothiomalate.
On examination, she had chronic rheumatoid changes in her hands and feet, and
subcutaneous nodules at her elbows. She had bruises in the nailfolds, and her right index
fingertip was cold and discoloured. Neurological examination showed altered sensation in
all of the fingers of her right hand. She was unable to dorsiflex her right ankle.
Investigations:
110 mm/1st h (<30)
anti-neutrophil cytoplasmic antibodies:

c-ANCA
p-ANCA
negative
positive
1:80 (negative at 1:20 dilution)
What is the most likely cause of her symptoms?

A
B
C
D
E
amyloidosis
diabetes mellitus
rheumatoid vasculitis
Q54
A 32-year-old African man was admitted with a 2-week history of fevers and intermittent
haemoptysis. He was known to be HIV positive.
On examination, his temperature was 37.5C and he had generalised lymphadenopathy.
There was patchy oral candidiasis and seborrhoeic dermatitis. His chest was clear, and
abdominal examination was normal.
Investigations:
haemoglobin
white cell count
neutrophil count
platelet count
107 g/L (130180)

13.5 109/L (4.011.0)
11.9 109/L (1.57.0)
103 109/L (150400)

100 U/L (45105)

95 mg/L (<10)
chest X-ray
mediastinal lymphadenopathy; no
focal lung infiltrate
What further investigation is most likely to identify the cause of this patients haemoptysis?
A
B
C
D
E
bronchoscopy
CT scan of chest
sputum cytology
sputum microscopy and culture
ventilation/perfusion isotope lung scan
Q55
A 65-year-old man presented with a 1-week history of increasing drowsiness and
confusion. He rapidly deteriorated and was intubated, ventilated and transferred to the
intensive care unit. He had a history of recurrent chest infections in the previous year,
treated with several courses of oral antibiotics. He had developed progressive difficulty in
climbing the stairs over the previous 5 years. His father had died of respiratory failure in
his mid-fifties.
On examination, he had bilateral ptosis and facial weakness. His eye movements were
normal. His neck flexors were weak. He had predominantly distal weakness affecting his
arms and legs. The deep tendon reflexes were absent. The plantar responses were flexor.
Sensory examination was normal.
What is the most likely underlying diagnosis?
A
B
C
D
E
Beckers muscular dystrophy

GuillainBarr syndrome
motor neurone disease
myasthenia gravis
myotonic dystrophy
Q56
A 75-year-old man presented to the outpatient clinic complaining of recurrent syncope. A
dual-chamber pacemaker had been inserted 5 years previously.
On examination, his pulse was irregular. A Holter 24-hour ECG recording was obtained
(see image).
What is the most likely explanation for the abnormality shown?

A
B
C
D
E
atrial arrhythmia
atrial lead malfunction
electromagnetic interference
pacemaker syndrome
ventricular lead malfunction
Q57
A 29-year-old woman was admitted to hospital with a 12-hour history of severe throbbing
headache and right-sided weakness. She was otherwise well with no significant past
medical history and was taking no medication apart from the oral combined contraceptive
pill. She denied any regular illicit drug use but admitted to taking an ecstasy tablet 2 days
previously.
Examination confirmed decreased power on the right, with brisk tendon reflexes and an
extensor plantar response. Her pupils were equal and reactive to light. Fundoscopy was
normal.
Investigations:
CT scan of head (18 h after symptom onset)
no evidence of haemorrhage
cerebrospinal fluid:
opening pressure
total protein
200 mmH2O (50180)

0.41 g/L (0.150.45)

A
B
C
D
E
cerebral infarction
cerebral venous thrombosis
hemiplegic migraine
idiopathic intracranial hypertension
subarachnoid haemorrhage
Q58
A 45-year-old man who had undergone a liver transplant developed this feature on his arm
(see image).
What medication is most likely to have been responsible?

A
B
C
D
E
aspirin
ciclosporin
mycophenolate mofetil
prednisolone
sodium valproate
Q59
A 75-year-old man presented to his general practitioner with worsening palpitations and
dyspnoea on exercise. He had lost about 3 kg in weight during the past 2 months. He had
developed a coarse tremor in both hands. His past medical history included ischaemic
heart disease and recurrent supraventricular tachycardia. He was taking aspirin 75 mg
daily, simvastatin 40 mg daily, bisoprolol 5 mg daily, ramipril 10 mg daily, amiodarone 200
mg daily, glyceryl trinitrate spray as required, and warfarin.
On examination, there was a small palpable goitre. He had a tremor, warm hands, bilateral
upper eyelid retraction and proptosis.
Investigations:
serum thyroid-stimulating hormone
serum free T4
serum free T3
<0.1 mU/L (0.45.0)

95.0 pmol/L (10.022.0)
35.2 pmol/L (3.07.0)
ECG
sinus tachycardia
What is the most likely cause of this patients thyroid dysfunction?

A
B
C
D
E
amiodarone-induced thyrotoxicosis
Graves disease
Reidels thyroiditis
solitary toxic nodule
toxic multinodular goitre
Q60
A 26-year-old woman was admitted as an emergency. She complained of right upper
quadrant pain, fever and shaking. She was 30 weeks pregnant with her first child.
On examination, her temperature was 39.5C, her pulse was 120 beats per minute and her
blood pressure was 105/80 mmHg. She was jaundiced and tender over her liver. The
uterine fundus was palpable above the umbilicus.
Investigations:
haemoglobin
white cell count
neutrophil count
platelet count
prothrombin time
107 g/L (115165)

14.9 109/L (4.011.0)
12.1 109/L (1.57.0)
257 109/L (150400)
15.5 s (11.515.5)
serum sodium
serum potassium
serum urea
serum creatinine
serum albumin
138 mmol/L (137144)

3.4 mmol/L (3.54.9)
8.7 mmol/L (2.57.0)
130 mol/L (60110)
34 g/L (3749)
118 mol/L (122)
204 U/L (535)
609 U/L (45105)
748 U/L (435)

A
B
C
D
E
autoimmune hepatitis
common bile duct stone
HELLP syndrome
hepatitis A infection
primary sclerosing cholangitis
Q61
A 42-year-old woman presented with a 1-week history of cough and worsening
breathlessness. She had a history of asthma and was a cigarette-smoker. Her general
practitioner requested a chest X-ray (see image a) and prescribed a course of antibiotics.
A repeat chest X-ray was performed 6 weeks later (see image b).
Image a
Image b
What is the most likely explanation for the appearance in the first chest X-ray?
A
B
C
D
E
aspergilloma
bronchial carcinoma
mucus plugging
pleural effusion
pneumonia
Q62
A 39-year-old South African man was admitted with a 3-week history of fever and night
sweats. He had lost 8 kg in weight. He was HIV positive and had declined antiretroviral
therapy.
On examination, his temperature was 38.9C, his pulse was 92 beats per minute and of
low volume, and his blood pressure was 120/75 mmHg. There was no rash or
lymphadenopathy. The jugular venous pressure was 2 cm above the sternal angle. His
heart sounds were normal. There was a soft pericardial rub at the left sternal border. His
chest was clear. Abdominal examination was normal.
Investigations:
haemoglobin
white cell count
neutrophil count
lymphocyte count
110 g/L (130180)

15.2 109/L (4.011.0)
9.3 109/L (1.57.0)
4.9 109/L (1.54.0)
89 mm/1st h (<15)
chest X-ray
marked globular cardiomegaly
echocardiogram
3-cm global pericardial effusion
What is the most likely cause of the pericardial effusion?

A
B
C
D
E
autoimmune disease
lymphoma
pyogenic infection
tuberculosis
viral infection
Q63
A 19-year-old man presented to the emergency department following a sudden collapse
after taking some unidentified tablets at a nightclub. He complained of shivering and
diarrhoea.
On examination, his temperature was 40.2C, his pulse was 136 beats per minute and
regular, and his blood pressure was 176/112 mmHg. He was tremulous and agitated. His
abdomen was soft but he had increased bowel sounds. Neurological examination showed
dilated pupils, hyper-reflexia and myoclonus of his limbs. His Glasgow coma score was 14.
Investigations:
serum sodium
serum potassium
serum urea
serum creatinine
serum creatine kinase
A
B
C
D
E
amfetamine poisoning
anticholinergic poisoning
malignant hyperthermia
neuroleptic malignant syndrome
serotonin syndrome
138 mmol/L (137144)

5.2 mmol/L (3.54.9)
7.8 mmol/L (2.57.0)
121 mol/L (60110)
31 000 U/L (24195)
Q64
A 65-year-old man was brought to the emergency department after falling downstairs. He
was unconscious and there was no history available.
His Glasgow coma score was 5. Both plantar responses were extensor. He was covered in
bruises.
Investigations:
CT scan of head (unenhanced)
see image
What is the most likely cause of this imaging appearance?

A
B
C
D
E
coagulopathy
haemorrhage into tumour
hypertensive haemorrhage
traumatic haemorrhage
Q65
A 72-year-old man presented with increasing fatigue and sleepiness over the previous
week. He had a history of small cell lung cancer, which was in complete remission after
combination chemotherapy. He had completed prophylactic cranial irradiation 10 days
previously.
Investigations:
haemoglobin
white cell count
neutrophil count
platelet count
91 g/L (130180)
3.1 109/L (4.011.0)
1.6 109/L (1.57.0)
100 109/L (150400)
serum sodium
132 mmol/L (137144)

2.41 mmol/L (2.202.60)
What is the most likely cause of his symptoms?

A
B
C
D
E
adverse effect of radiotherapy

anaemia
brain metastases
depression
hyponatraemia
Q66
A 23-year-old man was admitted to hospital with a 3-day history of fever and
breathlessness.
On examination, his temperature was 38.9C, his pulse was 110 beats per minute, his
blood pressure was 105/70 mmHg and his respiratory rate was 18 breaths per minute.
Investigations:
haemoglobin
white cell count
105 g/L (130180)

18.5 109/L (4.011.0)
serum sodium
serum urea
128 mmol/L (137144)

9.5 mmol/L (2.57.0)
chest X-ray
consolidation of left lower lobe

with a pleural effusion on same
side
Which finding is most indicative of severe pneumonia?

A
B
C
D
E
blood pressure of 105/70 mmHg

pleural effusion on chest X-ray
respiratory rate of 18 breaths per min
serum urea concentration of 9.5 mmol/L
white cell count of 18.5 109/L
Q67
A 63-year-old man who lived in a hostel for the homeless was brought to the emergency
department after collapsing. Other hostel residents reported that he had been staggering
and speaking in a slurred voice for several hours. He had a history of depression, epilepsy
and type 2 diabetes mellitus. His medication comprised phenytoin and gliclazide. He had a
high alcohol intake, but it was not clear how much he had drunk that day.
On examination, his Glasgow coma score was 12. His pulse was 96 beats per minute and
regular, and his blood pressure was 97/64 mmHg. Examination of his heart, lungs and
abdomen was normal. There was horizontal nystagmus. There were no other focal
neurological signs. Urinalysis showed ketones 1+.
Investigations:
serum sodium
serum potassium
serum chloride
serum bicarbonate
serum urea
serum creatinine
random plasma glucose
serum osmolality
132 mmol/L (137144)

3.2 mmol/L (3.54.9)
110 mmol/L (95107)
18 mmol/L (2028)
2.9 mmol/L (2.57.0)
119 mol/L (60110)
19.1 mmol/L
295 mosmol/kg (278300)
The blood gas analyser was faulty and was being repaired, so blood gas results were
delayed.
What is the most likely cause of his present state?
A
B
C
D
E
diabetic ketoacidosis
ethanol intoxication
hyperosmolar hyperglycaemic state
methanol poisoning
phenytoin overdose
Q68
A 75-year-old woman presented with fever and severe left iliac fossa pain. She was
opening her bowels four times daily with semi-formed stool. She denied passing any
blood. She smoked 20 cigarettes per day.
On examination, she had tachycardia and was tender in her left iliac fossa.
Investigations:
haemoglobin
white cell count
platelet count
What is the most appropriate initial investigation?
A
B
C
D
E
barium enema
colonoscopy
CT scan of abdomen
radiolabelled white cell scan
ultrasound scan of pelvis
133 g/L (115165)

18.5 109/L (4.011.0)
535 109/L (150400)
Q69
A 35-year-old woman was found to have hypertension during her first pregnancy. At 30
weeks gestation, her blood pressure was 150/102 mmHg. Two weeks later, the readings
were 156/106 mmHg and 160/102 mmHg. The pregnancy was otherwise uncomplicated,
and she had no proteinuria. She had no other medical history of note and took no regular
medication.
Methyldopa was prescribed but caused her to become depressed, so it was discontinued.
What is the most appropriate antihypertensive drug?
A
B
C
D
E
atenolol
bendroflumethiazide
labetalol
losartan
ramipril
Q70
A 56-year-old woman with a history of chronic obstructive pulmonary disease was seen in
the outpatient clinic following an admission for a chest infection 2 months previously. She
had been treated with antibiotics, nebulised bronchodilators and a course of prednisolone:
40 mg daily for 7 days, reduced over a further 4 weeks to a daily maintenance dose of
5 mg.
She had visited her grandson the previous day. He was unwell and had a rash that was
typical of chickenpox. She had no personal history of chickenpox.
A
B
C
D
E
check serum varicella zoster antibody titre

give oral aciclovir
give varicella zoster immunoglobulin
give varicella zoster vaccine
no action required
Q71
A 61-year-old man was admitted with a 2-month history of progressive dyspnoea,
recurrent haemoptysis and rhinorrhoea, and several episodes of epigastric pain. His
medical history included coronary artery bypass grafting following a myocardial infarction
with severe left ventricular failure.
On examination, there was a purpuric rash on his feet. His temperature was 37.4C, his
blood pressure was 180/78 mmHg and his oxygen saturation was 92% breathing air (94
98). There was dullness to percussion at both lung bases.
Investigations:
haemoglobin
white cell count
neutrophil count
106 g/L (130180)

10.8 109/L (4.011.0)
9.7 109/L (1.57.0)
serum urea
serum creatinine
23.6 mmol/L (2.57.0)

248 mol/L (60110)
53 mg/L (<10)
CT scan of chest
see image

A
B
C
D
E
bronchial carcinoma
Goodpastures syndrome
polyarteritis nodosa
pulmonary tuberculosis
Q72
A 45-year-old man with haemophilia developed what was thought to be septic loosening of
his prosthetic hip replacement 18 months after surgery. He had pain on walking, but he
was otherwise well and had no fever or rigors.
On examination, the wound was well healed, with no erythema. His temperature was
38.1C. There was some limitation of movement of the prosthetic joint, with associated
pain. Examination showed no other abnormalities.
Investigations:
haemoglobin
white cell count
121 g/L (130180)

12.5 109/L (4.011.0)

98 U/L (131)
65 U/L (45105)
A hip joint aspirate showed straw-coloured fluid, and the Gram stain showed Grampositive bacilli.
What organism is culture most likely to yield?
A
B
C
D
E
Bacillus anthracis
Corynebacterium diphtheriae
Propionibacterium acnes
Staphylococcus epidermidis
Streptococcus milleri
Q73
A 67-year-old woman presented with a history of wasting of the right side of her tongue.
She was unsure how long this had been present. She had gradually become deaf in the
right ear over the past 10 years.
Examination showed a right conductive deafness, a right palatal palsy, dysphonia, a
non-explosive (bovine) cough and wasting of the right side of the tongue.
A
B
C
D
E
acoustic neurinoma
cholesteatoma
fourth ventricle ependymoma
glomus jugulare tumour
nasopharyngeal carcinoma
Q74
A 73-year-old retired man was admitted after he had been found to have renal impairment
by his general practitioner. He gave a 3-month history of lethargy and back pain, with thirst
and constipation over the past 4 weeks. He had noticed that he had passed less urine than
usual in the past 3 days.
Abdominal examination was normal.
Investigations:
haemoglobin
white cell count
platelet count
98 g/L (130180)
5.6 109/L (4.011.0)
380 109/L (150400)
115 mm/1st h (<20)
serum urea
serum creatinine
serum total protein
serum albumin
36.3 mmol/L (2.57.0)

651 mol/L (60110)
2.92 mmol/L (2.202.60)
85 g/L (6176)
34 g/L (3749)
99 U/L (45105)

A
B
C
D
E
carcinoma of prostate
myeloma
sarcoidosis
tuberculosis
Q75
A 66-year-old woman with metastatic colon cancer and ascites developed decreased
appetite, continuous nausea and feelings of early satiety.
Examination showed a small volume of ascites and a succussion splash. There was no
hepatomegaly, and there were no abdominal masses palpable.
What is the most appropriate treatment to relieve her symptoms?
A
B
C
D
E
oral dexamethasone
oral metoclopramide
oral morphine
subcutaneous cyclizine
subcutaneous levomepromazine
Q76
A 55-year-old man was referred to the outpatient clinic having been found to have
microcytosis at a well-man screen. He had no gastrointestinal symptoms.
Abdominal examination and digital examination of the rectum were normal.
Investigations:
haemoglobin
MCV
MCH
white cell count
platelet count
serum ferritin
132 g/L (130180)

76 fL (8096)
27 pg (2832)
3.6 109/L (4.011.0)
164 109/L (150400)
15 g/L (15300)

A
B
C
D
E
barium enema
colonoscopy
faecal occult blood testing
flexible sigmoidoscopy
small bowel enema
Q77
A 56-year-old man was referred to the medical clinic from the psychiatric unit because of
weight gain of 20 kg over 4 months. He had a 6-month history of severe depression with
psychosis, which had required inpatient treatment. He was taking olanzapine 20 mg daily
and fluoxetine 40 mg daily.
On examination, he appeared cushingoid, with centripetal obesity and a few abdominal
striae. He had reasonable proximal muscle strength. His blood pressure was 170/100
mmHg.
Investigations:
8.5 mmol/L (36)
serum cholesterol
6.4 mmol/L (<5.2)
serum LDL cholesterol
5.01 mmol/L (<3.36)
serum HDL cholesterol
0.75 mmol/L (>1.55)
fasting serum triglycerides
2.42 mmol/L (0.451.69)
overnight dexamethasone suppression test (after 1 mg dexamethasone):
serum cortisol
55 nmol/L (<50)
24-h urinary free cortisol
310 nmol (55250)
A
B
C
D
E
adrenal Cushings syndrome

ectopic ACTH syndrome
metabolic syndrome
pituitary-dependent Cushings disease
pseudo-Cushings syndrome
Q78
A 65-year-old man presented with history of chest wall pain and breathlessness. He had a
smoking history of 40 pack years.
Investigations:
3.11 mmol/L (2.202.60)
CT scan of chest
6-cm mass lesion extending to

pleural surface and 3-cm subcarinal
lymph node; small pleural effusion
not visible on chest X-ray
forced expiratory volume in 1 s
1.7 L (60% of predicted )
A diagnosis of squamous cell carcinoma was established by needle biopsy.

What factor is most likely to preclude successful surgery in this case?
A
B
C
D
E
extension of tumour to pleural surface

hypercalcaemia
lung function
lymphadenopathy
pleural effusion
Q79
A 22-year-old man was admitted with pleuritic chest pain and swelling of both
lower legs, worse on the right.
Doppler ultrasonography showed a right femoropopliteal thrombosis, and lung
perfusion scans showed a right basal perfusion defect with a high probability of
a pulmonary thromboembolus. Treatment was started with intravenous heparin.
Further investigations:
serum creatinine
serum total protein
serum albumin
serum cholesterol
90 mol/L (60110)
53 g/L (6176)
15 g/L (3749)
7.0 mmol/L (<5.2)

9.3 g (<0.2)
An ultrasound scan of kidneys was normal. A renal biopsy could not be performed, as the
patient was anticoagulated. He was treated with corticosteroids, and 1 week later the 24-h
urinary total protein was 1.5 g.
What is the most likely renal diagnosis?
A
B
C
D
E

focal and segmental glomerulosclerosis
membranous nephropathy
minimal-change nephropathy
renal vein thrombosis
Q80
A recent clinical trial assessed the effect of digoxin on morbidity and mortality in patients
with chronic congestive heart failure (CHF). In the trial, more than 7000 patients with a left
ventricular ejection fraction of 0.45 or less were randomly assigned to receive digoxin or
placebo. All patients were treated with diuretics and an ACE inhibitor. The patients were
observed for an average of 37 months. During the clinical trial, 34.8% of patients treated
with digoxin and 35.1% of patients treated with placebo died (relative risk = 0.99; 95%
confidence interval = 0.911.07; p = 0.80).
Which is the most appropriate interpretation of these data?
A
B
C
D
E
digoxin has a small beneficial effect to reduce mortality in CHF

digoxin has no effect on mortality in CHF
digoxin is likely to reduce morbidity in CHF
there is no clinically significant therapeutic effect of digoxin in patients with CHF
there is no conclusive evidence of an effect of digoxin because of the limited power of
the study
Q81
An asymptomatic 26-year-old man was referred for assessment after his brother suffered
sudden cardiac death at the age of 32 years. An ECG was performed (see image).
What underlying diagnosis is suggested by the ECG appearances?

A
B
C
D
E
arrhythmogenic right ventricular dysplasia

Brugada syndrome
hypertrophic obstructive cardiomyopathy
RomanoWard syndrome
WolffParkinsonWhite syndrome
Q82
An 18-year-old woman was taken to the emergency department following an episode of
blurred vision that had resulted in transient bilateral blindness. As her vision recovered she
developed vertigo, with tingling in both hands and feet, and slurred speech lasting for 30
minutes.
On examination, she was alert and orientated but reported severe occipital headaches
associated with nausea. Her temperature was 37.2C, her pulse was 88 beats per minute
and her blood pressure was 140/80 mmHg. There was mild neck stiffness, but
neurological examination was otherwise normal.
Investigations:
random plasma glucose
6.1 mmol/L
CT scan of head
normal
cerebrospinal fluid:
opening pressure
total protein
glucose
cell count
lymphocyte count
190 mmH2O (50180)

0.52 g/L (0.150.45)
3.7 mmol/L (3.34.4)
10/L (<5)
100% (6070)

A
B
C
D
E
basilar migraine
temporal lobe epilepsy
vertebral artery dissection
viral meningitis

MRCP Part 2 Sample Questions

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MRCP(UK) Part 2 Written Sample Questions

Part2SampleQ updated Mar-12

138 mmol/L (137144)

Part2SampleQ updated Mar-12

biopsy of liver lesions

Part2SampleQ updated Mar-12

110 g/L (130180)

14.4 mmol/L (2.57.0)

What is the most likely pathogen?

Part2SampleQ updated Mar-12

103 g/L (115165)

252 mol/L (60110)

What is the most likely cause of her renal impairment?

Part2SampleQ updated Mar-12

Part2SampleQ updated Mar-12

6.8 kPa (11.312.6)

What is the most appropriate treatment?

Part2SampleQ updated Mar-12

antiphospholipid antibody syndrome

Part2SampleQ updated Mar-12

Part2SampleQ updated Mar-12

113 g/L (130180)

thickened sigmoid colon

What is the most likely diagnosis?

Part2SampleQ updated Mar-12

serum urea and electrolytes

serum protein electrophoresis:

X-ray of lumbar spine

generalised osteopenia; no focal

What is the most likely diagnosis?

Part2SampleQ updated Mar-12

128 g/L (130180)

What is the most appropriate next management step?

Part2SampleQ updated Mar-12

What is the most likely diagnosis?

Part2SampleQ updated Mar-12

165 g/L (130180)

128 mmol/L (137144)

What is the most likely diagnosis?

Part2SampleQ updated Mar-12

110 g/L (130180)

130 mmol/L (137144)

What is the most appropriate next investigation?

Part2SampleQ updated Mar-12

What is the most appropriate treatment for the underlying disease?

Part2SampleQ updated Mar-12

5.7 mmol/L (3.06.0)

Part2SampleQ updated Mar-12

What is the most likely explanation for the CT appearance?

Part2SampleQ updated Mar-12

102 g/L (130180)

serum corrected calcium

2.58 mmol/L (2.202.60)

What is the most likely diagnosis?

antiphospholipid antibody syndrome

Part2SampleQ updated Mar-12

157 g/L (115165)

arterial blood gases, breathing air:

8.9 kPa (11.312.6)

serum C-reactive protein

cystic changes at left base

What is the most appropriate next investigation?

Part2SampleQ updated Mar-12

What is the most appropriate treatment?