MRCP part o Join Telegram chavnmels ses : Ne a YC LINK: hitps://.me/DrThobanMohammed E.MAIL: Thoban.mrcp.up.to.date@gmail.com Hello Doctor .. MRCP & Medicine Lovers Now on your hand. Passiiedicine question hank 2019 for MRCP part @ which contains the lastest guidelines so as to be updated in internal medicine which reflected in an excellent Knowledge, practices & skilles . Hope all to enjoy this materials Always Medicine is Medicine bleascldonstihesitatesvolcontackimethrourhyE satay pest allysercd sco) yOu al mantertais wihtich mecnited fore MUS 1 Tl Best luck for all. De Toban CldindeongA 22-year-old man is investigated for weight loss and diarrhoea. A rectal biopsy is taken and reported as follows: Deep inflammatory infiltrate from the mucosa to the muscularis propria Numerous granulomata noted What is the most likely diagnosis? Crohn's disease Rectal carcinoma-in-situ Tuberculosis Laxative abuse Ulcerative colitisRectal carcinoma-in-situ Tuberculosis [t-- ive abuse Ulcerative colitis Inflammation in ulcerative colitis is usually limited to the mucosa and submucosa. A% iWhich one of the following is not associated with oesophageal cancer? Achalasia Smoking Gastro-oesaphageal reflux disease Helicobacter pylori AlcoholAchalasia Smoking oesophageal reflux disease Alcohol Helicobacter pylori may actually be protective against oesophageal cancer 0% 8680 6€ 2%A 34-year-old man with a background of polycythaemia rubra vera presented with a 2- day history of sudden onset worsening abdominal pain. On examination of his abdomen, there was tenderness on palpation to his right upper quadrant with moderate shifting dullness and the liver edge was present 2cm below the right costal margin. Given the likely diagnosis, was is the most sensitive first line investigation? Ultrasound with doppler flow CT liver with triple phase MRI liver with contrast Contrast-enhanced CT abdomen Hepatic vein venography[siesiosmmetencn | = CT liver with triple phase [a with contrast Contrast-enhanced CT abdomen 3 Hepatic vein venography 19% Budd-Chiari syndrome - ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation Important forme Less impertant This patient has most likely presented here with Budd-Chiari syndrome. In this situation, an ultrasound with doppler flow studies is highly sensitive and should, therefore, be the first radiological investigation. It will exhibit the absence of blood flow in the hepatic vein or flow reversal and even the thrombus itself. The contrast-enhanced CT scan would be able to visualise the presence of patchy enhancement of the liver tissue and post-hepatic inferior vena cava (VC) may be absent. The caudate liver lobe is often enlarged and pre-hepatic dilatation of the IVC is seen but the thrombus itself can be shown in less than 50% of patients. Splenomegaly with ascites would also be seen. The role of MRI in diagnosing Budd-Chiari syndrome is still up and coming. It is able to detect blood flow or its absence within the hepatic vein or IVC. Hepatic vein venography could help identify the thrombus and further demonstrate a web as a cause of the obstruction. It would also be able te distinctly visualise intrahepatic collaterals.A 59-year-old woman presents with dysphagia. There is no history of heartburn, weight loss or change in bowel habit. During endoscopy there is some difficulty passing through the lower oesophageal sphincter but no other abnormality is noted. Which one of the following tests is most likely to reveal the diagnosis? Oesophageal biopsy Oesophageal manometry Plain chest x-ray Endoscopy ultrasound CT thoraxPlain chest x-ray Endoscony ultrasound CT thoraxA 62-year-old man is called for review after a positive faecal occult blood test done as part of the national screening programme. During counselling for colonascopy he asks what percentage of patients with a positive faecal occult blood test have colorectal cancer. What is the most accurate answer? 0.5 - 2% 5 - 15% 20-30% 30 - 50% 55 - 75%There is also a 30-45% chance of having an adenoma with a positive faecal occult blood testA 28-year-old man undergoes an ileocaecal resection to treat terminal ileal Crohns disease. Post operatively he attends the clinic and complains of diarrhoea. His CRP is within normal limits and small bowel enteroclysis shows na focal changes. Which of the following interventions is most likely to be beneficial? 5 ASA drugs Azathioprine Pulsed methylprednisolone Infliximab: Oral cholestyramine5 ASA drugs firs | snr Beleed iriethylprediisotone Infliximab QD Malabsorption of bile salts is a common cause of diarrhoea following ileal resection. A normal small bowel study and CRP effectively excludes active Crohns disease and therefore immunomodulator drugs are not appropriate.A 43-year-old woman presents to the emergency department with confusion, distended abdomen and jaundice. She describes a heavy cough, fever and malaise for three days following a period of heavy drinking. She is known to have cirrhosis secondary to alcoholic liver disease. On examination, she is jaundiced, confused and has tense ascites, and there are audible crackles in the right side of her chest. She also has distended veins on her abdomen and a palpable liver. Blood tests: Ho 94 g/l Mev 104 fl Platelets 92 = 10/1 wc 12.5 * 10/1 Neutrophils 8.4™ 103/I Nat 148 mmol/| « 5.1 mmol/l Urea 6.2 mmol/! Creatinine 122 umol/! Bilirubin 34 mol/l ALP 245 ull ALT 276 ull yet 321 u/| Albumin 21 g/l Prothrombin time 18 s Which of these abnormalities is attributable chronic excessive alcohol use without being secondary to liver decompensation? Macrocytic anaemia Neutrophilia Thrombocytopenia Deranged clotting Hypoalbuminaemiaphilia Thrombocytopenia Deranged clotting Hypoalbuminaemia The correct answer is macracytic anaemia. Macrocytesis is common in patients with alcoholism, often preceding anaemia. It can be independent of vitamin deficiency and the mechanism is not completely understood. Reduced hepatic synthetic function causes reduced production of clotting factors leading to deranged clotting, and similarly a failure in production of albumin. Alcohol is also directly toxic to platelets, and associated splenomegaly in portal hypertension can cause thrombocytopenia, but reduced hepatic function of thrombopoietin can cause low platelets. The neutrophilia is likely secondary to an acute chest infection.A 69-year-old woman was evaluated following the development of a rash on her lower limbs for the last two weeks, worsening breathlessness and weight loss. This eruption started as a small erythematous annular patch, slowly enlarging into polycyclic patches with a wood-grain appearance over the lateral aspects of her left thigh. The patient had a background of atrial fibrillation on warfarin and hypothyroidism on levothyroxine. She has 45 pack year history of smoking with underlying COPD managed with regular inhalers and home nebulisers. She complained of losing 10kg in weight over the last six months. Her symptoms were not being managed using her inhalers and nebulisers. Based on the history and clinical findings, what is the correct diagnosis? Erythema annulare centrifugum Mycosis fungoides Erythema chronicum migrans Erythema gyratum repens Tinea corporisErythema annulare centrifugum Mycosis fungoides im migrans Fe corporis Erythema gyratum repens is a paraneoplastic eruption with a ‘wood-grain’ pattern and figurate erythema commonly seen in patients with lung cancer Important forme Less important Erythema gyratum repens - associated with internal malignancies - is characterised by a number of concentric, erythematous, from either flat to slightly raised bands with fine white scale in waves located at the leading edge of erythema. Their appearance may represent a wood-grain pattern. It can often precede a diagnosis of typically lung cancer by an average of nine months. Erythema annulare centrifugum is defined by the presence of expanding, erythematous annular lesions. Its cause is unknown but likely due to drugs, insect bites, food & infections. Mycosis fungoides is a form of cutaneous T-cell lymphoma characterised by itchy, erythematous scattered patches and plaques. Erythema chronicum migrans is the classical rash caused by Lyme disease fallowing a tick bite. It starts off as a red macule/papule developing into an expanding patch of erythema with a classic bull's eye appearance. Tinea corporis is a superficial fungal ringworm infection.A 64-year-old female with a history of COPD and hypertension presents with pain on swallowing. Current medication includes a salbutamol and beclomethasone inhaler, bendroflumethiazide and amlodipine. What is the most likely cause of the presentation? Myasthenia gravis precipitated by bendroflumethiazide esophageal web Achalasia secondary to amlodipine Oesophageal candidiasis Oesophageal cancerMyasthenia gravis precipitated by bendroflumethiazide Oesophageal web Achalasia secondary to amlodipine esophageal cancer Pain on swallowing (odynophagia) is a typical of oesophageal candidiasis, a well documented complication of inhaled steroid therapy 6% %Which of the following skin conditions associated with malignancy are not correctly paired? Necrolytic migratory erythema and glucagonoma Migratory thrembophlebitis and pancreatic cancer Erythema gyratum repens and lymphoma Acanthosis nigricans and gastrointestinal cancer Erythroderma and lymphomaNecrolytic migratory erythema and glucagonoma Migratory thrombophlebitis and pancreatic cancer Acanthosis nigricans and gastrointestinal cancer Erythroderma and lymphoma Erythema gyratum repens is generally associated with solid organ malignancies such as lung and breast cancerA 59-year-old woman presented with painful dysphagia, peor appetite and weight loss over the past nine months. She is a heavy chain smoker with a 30 pack year history. She admits to consuming alcohol excessively. An urgent barium swallow was arranged and shows the presence of a suspicious malignant oesophageal stricture. What is the best investigation to assess for mural invasion? Contrast-enhanced CT T2-weighted MRI scan Endoscopic ultrasound Conventional side-viewing duodenoscopy Positron-emission tomography (PET) scanContrast-enhanced CT T2-weighted MRI scan ntional side-viewing duodenoscopy €> ap Positron-emission tomography (PET) scan ap Oesophageal/Gastric Cancer - Endoscopic ultrasound (EUS) is better than CT or MRI in assessing mural invasion Important forme Less important The endoscopic ultrasound aids the visualisation of local invasion as it can display all the layers of the wall of the oesophagus and should routinely be performed with CT or MRI scans, Overall, endoscopic ultrasound is far superior to CT or MRI when assessing mural invasion. The positron-emission tomography (PET) scan is increasingly being employed by oncologists in detecting and following up the tumour progression. Duodenoscopes are essentially specialised endoscopes that are used primarily for endoscopic retrograde cholangiopancreatography (ERCP). They are side-viewing (rather than forward-viewing) endoscopes that have an advantage in being able to view the major duodenal papilla.A 72-year-old woman is reviewed following a course of oral flucloxacillin for right lower limb cellulitis. The local protocol suggests oral clindamycin should be used next-line. Which one of the following side-effects of clindamycin is it most important to warn her about? Heartburn or indigestion Jaundice Sore throat, bruising or lethargy Avoid any food or drink containing alcohol DiarrhoeaHeartburn or indigestion Jaundice [e- throat, bruising or lethargy Avoid any food or drink containing alcoholA 45-year woman who you have treated for obesity comes for review. Despite ongoing lifestyle interventions and trials of orlistat and sibutramine she has failed to lose a significant amount of weight. She is currently taking ramipril for hypertension but a recent fasting glucese was normal. For this patient, what is the cut-off body mass index (BMI) that would trigger a referral for consideration of bariatric surgery? BMI > 35 kg/m42 BMI > 40 kg/m*2 BMI > 30 kg/m4*2 BMI > 38 kg/m4*2 BMI > 45 kg/m422 a2 30 kg/m*2 38 kg/m*2 > 45 kg/m*2A 39-year-old man with a history of alcohol excess presents to the Emergency Department with a 2 day history of severe epigastric pain. His amylase is found to be 1260. What is the best marker of severity? CRP Amylase (on admission) Pain scores Lipase (on admission) Number of similar previous admissionsAmylase (on admission) Pain scores Number of similar previous admissions 08066 6 EJ CRP is now a widely used marker of severity in acute pancreatitis. Other methods which have to correlate with prognosis include the Ranson criteria and APACHE II score (Acute Physiology And Chronic Health Evaluation)Which one of the following is most associated with the development of acute pancreatitis? Hyperchylomicronaemia Amyloidosis Hypogammaglobulinaemia Hypercholesterolaemia HypotriglyceridaemiaAmyloidosis [PR ormagouinsen 2 Hypercholesterolaemia Hypotriglyceridaemia Hyperchylomicronaemia may be caused by hereditary lipoprotein lipase deficiency and apolipoprotein Cll deficiency. It predisposes to recurrent attacks of acute pancreatitisA 36-year-old woman presents with flushing, diarrhoea and abdominal discomfort. She says these symptoms have come on over the last few months and do not appear to be getting better. You decide to run some tests. 24-hour urine 5-HIAA is elevated confirming your diagnosis of carcinoid syndrome. A scan is undertaken which localises the neoplastic lesion to the jejunum. You start her on octreotide to calm her symptoms whilst she awaits surgery. What cardiac abnormalities are associated with this conditions? Hypertrophic obstructive cardiomyopathy Acquired ventricular septal defect Pulmonary stenosis and tricuspid insufficiency Aortic dissection Léeffler endocarditisHypertrophic obstructive cardiomyopathy 3% quired ventricular septal defect o as Aortic dissection Léeffler endocarditis He Carcinoid syndrome can affect the right side of the heart. The valvular effects are tricuspid insufficiency and pulmonary stenosis Important forme Less important Carcinoid syndrome is a neuroendocrine tumour. There are many locations that they can occur in such as in the GI tract, in the respiratory tract and many other places. They can secrete serotonin which leads to many of the symptoms this patient suffers. The syndrome is associated with right-sided valvular pathology. The most common pathology is tricuspid insufficiency and pulmonary stenosis. The best way to remember is the acronym ‘TIPS’. HOCM is associated with inherited gene defects on the B-myosin heavy chain. This is not associated with carcinoid syndrome. Acquired VSD would be associated with an MI and not carcinoid syndreme. Aortic dissection is associated with hypertension and connective tissue disorder. Léeffler endocarditis is endocarditis due to eosinophil proliferation in the heart. It is associated with helminthic infections and not carcinoid syndrome.A 71-year-old man presents with two year history of intermittent problems with swallowing. His wife has also noticed he has halitosis and is coughing at night. He has a past medical history of type 2 diabetes mellitus but states he is otherwise well. Of note his weight is stable and he has a good appetite. Clinical examination is unremarkable. What is the most likely diagnosis? Oesophageal cancer Hiatus hernia Pharyngeal pouch Oesophageal candidiasis Benign oesophageal strictureOesophageal cancer Hiatus hernia Oesophageal candidiasis Benign oesophageal stricture Given the two year history and good health oesophageal cancer is much less likely ccdA 44-year-old man with alcoholic liver disease is admitted with pyrexia. He has been unwell for the past three days and has multiple previous admissions before with variceal bleeding. Examination shows multiple stigmata of chronic liver disease, ascites and jaundice. Paracentesis is performed with the following results: Neutrophils | 487 cells/ul What is the most appropriate treatment? Therapeutic abdominal washout Intravenous vancomycin + metronidazole Intravenous cefotaxime Insert an ascitic drain Intravenous ciprofloxacinTherapeutic abdominal washout jancomycin + metronidazole Insert an ascitic drain Intravenous ciprofloxacin eer Important forme Please see the British Society of Gastroenterology guidelines for more details.A 29-year-old woman whe is 30 weeks pregnant is admitted to the Emergency Department with central abdominal pain. Initial blood tests show the following: Amylase 1,438 u/di What is the most likely cause of this presentation? Gestational diabetes HELLP syndrome Gallstones-induced pancreatitis Hypertriglyceridaemia-induced pancreatitis Pre-eclampsiaGestational diabetes HELLP syndrome Hypertriglyceridaemia-induced pancreatitis Pre-eclampsia occurs in around 1 in 2,000 pregnancies. Most cases of pancreatitis in Pancreat pregnancy are gallstone related.A 46-year-old, with an end-stage chronic kidney disease secondary to diabetes, undertakes a renal transplantation with no immediate complications. Two months later, he attends the emergency department with a 3-day history of a febrile syndrome and right upper quadrant pain. Investigations showed a moderated leukopenia and mild transaminasaemia. Hb 119 afi Platelets 234 * 10%/| wec 2.46 * 10/1 ALP 61u/l ALT 75 u/l ycT 72u/l Albumin 38 g/I What would be your first diagnostic impression? Pneumocystis jirovecii infection Varicella-zoster virus infection Renal tuberculosis Cytomegalovirus infection Hepatitis 8Pneumocystis jirovecil infection Varicella-zoster virus infection ‘enal tuberculosis | 80900 Hepatitis B CMV infection is one of the most important in transplant receptors - clinically is characterized by fever, deranged transaminases, leukopenia and thrombocytopenia. Diagnosed by PCR and treated with ganciclovir Important forme _Lessimoortent Cytomegalovirus infection is one of the most important opportunist infections in transplant receptors. Usually happens between the first month after transplant and the sixth month. Clinically is characterized by fever, deranged transaminases, leukopenia and thrombocytopenia. It is diagnosed by polymerase chain reaction (pcr) and treated with Ganciclovir. Pneumocystis jirovecii can also cause an opportunist infection, such as pneumonia, particularly among immunocompromised hosts. Varicella-zoster virus can cause primo-infection or reinfection affecting ane or multiple dermatomes over skin and mucosas, characterized by a skin rash that forms small, itchy blisters, which eventually scab over. It can also affect vital organs causing, for instance, pulmonary varicella. Renal tuberculosis accounts for 15-20% of extra-pulmonary tuberculosis and can result in varied and striking radiographic appearances and often presents with pyuria in the absence of common bacterial infection (ordinary urine cultures persistently negative). Finally, hepatitis B is not an opportunist infection and can present with a variety of symptoms depending on how acute or subacute the infection is - clinically characterized by hyperbilirubinaemia, extremely elevated transaminases and general malaise.A 51-year-old woman is investigated for lethargy and pruritus. Her appetite is normal and she has not lost weight. On examination she is not clinically jaundiced and there is no organomegaly. Bloods tests are reported as follows: Hb 12.8 ofdi Platelets 188 * 109/! wec 6.7 * 10/1 Na* 140 mmol/I Kr 3.9 mmol/! Urea 6.2 mmol/| Creatinine | 68 mol/l Bilirubin 30 umol/l ALP 231 u/l ALT 38 U/l yor 367 u/l Albumin | 39 g/l What further test is most likely to reveal the diagnosis? Anti-nuclear antibodies Liver ultrasound Anti-mitochondrial antibodies Ceruloplasmin Ferritinclear antibodies The demographic (middle-aged female), history (lethargy, pruritus) and liver function tests (rise in ALP and yGT) all point to a diagnosis of primary biliary cirrhosis (PBC). Anti- mitochondrial antibodies are found in 98% of patients with PBC.A 39-year-old man with a history of liver cirrhosis secondary to alcohol excess is admitted with an upper gastrointestinal haemorrhage. He is treated with terlipressin and has an endoscopy with variceal band ligation 6 hours following admission. Which further intervention has been shown to reduce mortality during the acute admission? IV labetalol to induce hypotension for the first 3 days Low-molecular weight heparin prophylaxis Nasogastric tube feeding for the first 3 days Antibiotic prophylaxis High-dose proton pump inhibitor therapy‘labetalol to induce hypotension for the first 3 days inhibitor therapyA 27-year-old man with multiple pigmented freckles on his lips and face is investigated for iron-deficiency anaemia. A diagnosis of Peutz-Jeghers syndrome is suspected. What is the mode of inheritance? Autosomal recessive Mitochondrial inheritance X-linked dominant Autosomal dominant X-linked recessive“Mitochondrial inheritance X-linked dominant inked recessiveA 20-year-old female with known Crohn's disease presents in gastroenterolagy clinic for review of her management. She is currently being treated with oral prednisolone. She has experienced 3 mild flare ups of her Crohn's disease in the past 12 months, each occurring when oral steroid dose has been tapered. You consider adding azathioprine to her management. Which of the following should be assessed before commencing azathioprine in this patient? Liver function Thiopurine methyltransferase (TPMT) activity Body mass index (BMI) Renal function CoagulationLiver function Body mass index (BMD), Renal function Coagulation TMPT activity should be assessed before offering azathioprine or mercaptopurine therapy in Crohn's disease ‘Important forme Less important Thiopurine methyltransferase (TPMT) is an enzyme involved in the metabolism of azathioprine and mercaptopurine. Some people have a deficiency of TPMT due to genetic mutations, and these people are at a greater risk of experiencing severe side effects from conventional doses of azathioprine or mercaptopurine. TPMT activity should therefore be assessed before offering azathioprine or mercaptopurine therapy. Such medications should not be commenced if TPMT is very low or absent. If TPMT activity is below normal, but not deficient, azathioprine or mercaptopurine can be commenced at a lower dose.Which one of the following adverse effects is least associated with sulfasalazine? Male infertility Skin rashes Visual disturbance Diarrhoea AgranulocytosisMale infertility Skin rashes Agranulocytosis @A 30-year-old woman is admitted to hospital with abdominal pain and diarrhoea. She has ne past medical history other than depression for which she takes citalopram. She smokes 20 cigarettes/day and drinks 20 units of alcohol per week. Ileacolonoscopy shows features consistent with Crohn's disease and she is treated successfully with glucocorticoid therapy. Which one of the following is the most important intervention to reduce the chance of further episodes? Infliximab Stop drinking Stop smoking Mesalazine BudesonideInfliximab ‘Stop drinking Mesalazine Budesonide 800 12%A 22-year-old male with a history of familial adenomatous polyposis (FAP) has a total colectomy. What is the mode of inheritance of FAP? Uniparental disomy of chromosome 12 Autosomal recessive Uniparental disomy of chromosome 14 Autosomal dominant X-linked recessiveUniparental disomy of chromosome 12 Autosomal recessive Uniparental disomy of chromosome 14 inked recessive E @) i R ESA 45-year-old obese man with a history of type 2 diabetes mellitus is reviewed in clinic. He is well and asymptomatic. His recent annual blood tests have shown slightly abnormal liver function tests: Bilirubin 20 umol/l ALP 104 u/l ALT 53 u/l yGT 58 u/l Albumin 38 g/l A follow-up liver ultrasound is reported as showing fatty changes. Other standard liver screen bloods, including viral serology, are normal. His alcoholic intake is within recommended limits. What is the most appropriate next test to perform? Endoscopic ultrasound (EUS) Enhanced liver fibrosis blood test Repeat liver ultrasound after calorific restricted diet for 1 month er biopsy High-sensitivity C-reactive proteinEndoscopic ultrasound (EUS) @ | iments tosses Repeat liver ultrasound after calorific restricted diet for 1 month [Babe - High-sensitivity C-reactive protein @Q In patients with non-alcoholic fatty liver disease, enhanced liver fibrosis (ELF) testing is recommended to aid diagnosis of liver fibrosis Important for me This is a typical patient who has non-alcoholic fatty liver disease - obese and with type 2 diabetes mellitus. NICE recommend that if NAFLD is found incidentally then an enhanced liver fibrosis (ELF) blood test should be performed to assess for more severe liver disease.A 62-year-old man presents with painless jaundice and is diagnosed with pancreatic cancer undergoes pancreaticoduodenectomy. He recovers well from surgery. He is referred to oncology for further management and is started on palliative adjuvant chemotherapy. Two months later he presents with a recurrence of painless jaundice. Apart from routine blood tests and serum cancer antigen 19-9, haw should he be investigated? Magnetic resonance cholangiopancreatography (MRCP) Endoscopic resonance cholangiopancreatography (ERCP) US abdomen Abdominal X-ray CT scan of the chest, abdomen and pelvisMagnetic resonance cholangiopancreatography (MRCP) | eaesepetsoronce cholangiopancreatography (ERCP) 7% US abdomen Abdominal X-ray High-resolution CT scanning is the diagnostic investigation of choice for pancreatic cancer Important forme Less important CT scan of the chest, abdomen and pelvis is the most appropriate investigation. The most likely cause of the patient's jaundice is recurrence of pancreatic cancer, and a CT is the most appropriate modality to assess tumour size and also to investigate for lymphatic and metastatic spread. None of the other investigations would reveal tumour growth, and an endoscopic approach would be difficult post-operatively. Abdominal X-ray and US would not be able to show tumour growth. Source: ‘Pancreatic Cancer.’ BMJ Best Practice.11 Dec. 2015.Which one of the following foodstuffs contains the most calories per unit weight? White bread Butter Pasta Sugar Red meatWhite bread Sugar Red meat 9%A 56-year-old overweight female is found to have nen-alcoholic fatty liver disease on abdominal ultrasound following recent pyelonephritis. She is completely asymptomatic and has normal liver function tests. What is the recommend investigation to monitor for advanced liver fibrosis in this patient? Liver biopsy Yearly liver function tests Yearly albumin and coagulation screen Repeat ultrasound every 3 years Enhanced liver fibrosis test every 3 yearsLiver biopsy Yearly liver function tests eo | xe, albumin and coagulation screen Qo Repeat ultrasound every 3 years In patients with non-alcoholic fatty liver disease, enhanced liver fibrosis (ELF) testing is recommended to aid diagnosis of liver fibrosis Important for me Less important The correct answer is enhanced liver fibrosis or ELF test. Patients who are found at ultrasound to have asymptomatic non-alcoholic fatty liver disease (NAFLD) should undergo an ELF test to check for evidence of advanced liver fibrosis and this should be repeated every three years. People with confirmed NAFLD and an ELF score >10.51 are diagnosed with advanced liver fibrosis. Liver biopsy would be the correct answer if the question asked about a diagnosis of cirrhosis, but only in patients for whom transient elastography is nat an option. Per NICE guidelines routine liver function tests are not indicated for diagnosis of advanced liver fibrosis in patients with NAFLD, making this answer incorrect. Whilst albumin and coagulation screen may demonstrate evidence of impaired liver function these are not diagnostic of advanced liver fibrosis. As such option 3 is incorrect. Repeat ultrasound would not be helpful in the diagnosis of advanced liver fibrosis. In patients with confirmed cirrhosis, however, it may be useful for monitoring for hepatocellular carcinoma but this would be twice yearly.A 23-year-old nurse is reviewed in occupational health following a needle stick injury from a man known to be a carrier of hepatitis B. Which one of the following would appear first during acute hepatitis B infection? HBsAg HBeAg anti-HBg anti-HBs HBcAgHBeAg ~ anti-HBs HBcAg ZsA 78-year-old woman is admitted with a productive cough and pyrexia to hospital. Chest x-ray shows a pneumonia and she is commenced on intravenous ceftriaxone. Four days following admission a stool sample is sent because of diarrhoea. This confirms the suspected diagnosis of Clostridium difficile diarrhoea and a 10-day course of oral metronidazole is started. After 10 days her diarrhoea is ongoing but she remains clinically stable. What is the most appropriate treatment? Oral vancomycin for 14 days IV vancomycin for 3 days Oral rifampicin for 7 days Oral clindamycin for 7 days Oral metronidazole for a further 7 days‘Oral rifampicin for 7 days Oral clindamycin for 7 days ‘Oral metronidazole for a further 7 days The Health Protection Agency suggests switching to oral vancomycin in this scenario.A 27-year-old woman presents for review. She describes herself as having ‘IBS’ and for the past two years has suffered intermittent bouts of abdominal pain, bloating and loose stools. For the past two weeks however her symptoms have been much worse. She is now passing around 3-4 watery, grey, ‘frothy’ stools per day. Her abdominal bloating and cramps have also worsened and she is suffering from excessive flatulence. Judging by the fitting of her clothes she also feels that she has lost weight. Some blood tests are ordered: Hb 10.9 g/dl Platelets 199 * 109/! wec 7.2* 1035/1 Ferritin 15 ng/ml Vitamin B12 225 g/l Folate 2.1 nmol/! What is the most likely diagnosis? Crohn's disease Coeliac disease Infective exacerbation of irritable bowel syndrome Ulcerative colitis Bacterial overgrowth syndromeB Crohn's disease | cotectsese = Infective exacerbation of irritable bowel syndrome Ulcerative colitis Bacterial overgrowth syndrome aE The main clues is this question are the anaemia and low ferritin/folate levels, all characteristic of coeliac disease. The description of the diarrhoea is also typical although some patients may have more overtly ‘fatty’ stools. Why not irritable bowel syndrome? Common things are common and atypical presentations of common conditions are seen more than typical presentations of less common conditions. The main reason is the bloods - a low ferritin and folate would not develop with IBS +/- gastroenteritis. Even if the woman suffered from menorrhagia this would not explain the low folate although it may account for the anaemia/low ferritin. Coeliac disease is more common than Crohn's by a factor of around 100. In exams there are also usually more clues to point towards a diagnosis of Crohn's (e.g. mouth ulcers etc).A 45-year-old man is noted to have nan-tender, smeoth hepatomegaly associated Dupuytren’s contracture and parotid enlargement. He recently returned from a holiday in Thailand. What is the likely diagnosis? Primary hepatoma Hydatid disease Alcoholic liver disease Viral hepatitis Tricuspid regurgitationPrimary hepatoma Hydatid disease Tricuspid regurgitation Early stage liver cirrhosis is a common cause of hepatomegaly. The liver may shrink in more advanced disease Important forme Less. importee it Both Dupuytren’s contracture and parotitis are associated with alcoholic liver disease. Whilst a history of alcohol excess would normally be volunteered it should be remembered many patients will lie about their alcohol intake. The recent holiday in Thailand is a distractor.A 54-year-old man is investigated for dyspepsia. An endoscopy shows a gastric ulcer and a CLO test done during the procedure demonstrates H. pylori infection. A course of H. pylori eradication therapy is given. Six weeks later the patients comes for review. What is the most appropriate test to confirm eradication? Culture of gastric biopsy H. pylori serology Hydrogen breath test Urea breath test Stool cultureCulture of gastric biopsy H. pylori serology Hydrogen breath test 1% Stool culture It is important to remember that H. pylori serology remains positive following eradication. A stool antigen test, not culture, may be an appropriate alternative.An 84-year-old male presents to the GP following a blood test that demonstrated a haemagloblin of 84 g/L. He also remarked he had been passing some black motions recently but had no weight loss. A previous colonoscopy had been performed which demonstrated no polyps or malignancy but multiple angiodysplastic lesions were documented. On examination, the GP identifies a murmur. What valvular dysfunction was likely to cause the audible murmur? Aortic regurgitation Mitral stenosis Aortic stenosis Mitral regurgitation Pulmonary stenosisAartic regurgitation 1% Mitral stenosis e&» Mitral regurgitation Qo @ Pulmonary stenosis Angiodysplasia is associated with aortic stenosis The combination of aortic stenosis and colonic angiodysplasia resulting in a GI bleed is indicative of Heyde’s syndrome. The condition develops due to a reduction in vWF as the bload passes through a narrow aortic valve. Treatment of the condition is that of treating the aortic stenosis. The other valvular problems are not associated with this syndrome.A 65-year-old man with liver cirrhosis of unknown cause is reviewed in clinic. Which one of the following factors is most likely to indicate a poor prognosis? Alanine transaminase > 200 u/| Caput medusae Ascites Raised urea SplenomegalyAlanine transaminase > 200 u/| Caput medusae Splenomegaly 3% 5 Ascites is part of the Child-Pugh and is a marker of poor prognosis. For patients with chronic liver disease it implies a mortality of 15% per year and around 4596 within five years. Serum creatinine, rather than urea, is part MELD criteria.A 34-year-old male is admitted with central abdominal pain radiating through to the back and vomiting. The following results are obtained: Amylase | 1,245 u/dl Which one of the following medications is most likely to be responsible? Phenytoin Sodium valproate Metoclopramide Sumatriptan PizotifenPhenytoin clopramide Sumatriptan aQ Pizotifen fry Sodium valproate induced pancreatitis is more common in young adults and tends to occur within the first few months of treatment. Asymptomatic elevation of the amylase level is seen in up to 10% of patientsA 25-year-old man presents with lethargy and increased skin pigmentation. Blood test reveal deranged liver function tests and impaired glucose tolerance, Given the likely diagnosis of haemachromatosis, what is the most appropriate initial investigation strategy? Transferrin saturation + ferritin Haematocrit + ferritin Liver biopsy with Perl's stain Serum iron + ferritin Serum iron + haematocrit‘Haematocrit + ferritin Liver biopsy with Perl's stain um iron + haematocrit The British Committee for Standards in Haematology (BCSH) guidelines recommend measuring the transferrin saturation first as this is the most specific and sensitive test for iron accumulation. They also recommend that serum ferritin is measured but this marker is not usually abnormal in the early stages of iron accumulationA 59-year-old woman is admitted to the Emergency Department with a productive cough and pyrexia. She is usually fit and well but is undergoing investigation for dysphagia. This has been present for the past 3 months and affects both food and drink. A chest x-ray shows an air-fluid level behind a normal-sized heart. What is the most likely diagnosis? Massive pericardial effusion Tuberculosis Achalasia Pharyngeal pouch Hiatus hernia59-year-old woman is admitted to the Emergency Department with a productive cough and pyrexia. She is usually fit and well but is undergoing investigation for dysphagia. This has been present for the past 3 months and affects both food and drink. A chest x-ray shows an air-fluid level behind a normal-sized heart. What is the most likely diagnosis? Massive pericardial effusion oe Tuberculosis Pharyngeal pouch bre 8 Hiatus hernia A retrocardiac air-fluid level is sometimes seen in patients with achalasiaWhich one of the following is least associated with hepatosplenomegaly? Glandular fever ‘Chronic myeloid leukaemia Alcoholic liver disease Amyloidosis Infective endocarditisGlandular fever Chronic myeloid leukaemia | wx Amyloidosis Infective endocarditis normally causes an isolated splenomegaly. Theoretically severe infective endocarditis may cause right heart failure and hence hepatomegaly but this would be unusual58-year-old male was admitted with a 8 month history of dysphagia, initially worse on solids, but now encompassing liquids. This is associated with weight loss, vomiting and for the last day odynophagia. Barium swallow shows: Apple core stricture in the proximal third of the oesophagus. Which of the following risk factors is only associated with increased risk of adenocarcinoma of the oesophagus? Alcohol smoking Achalasia Plummer vinson Barrett's oesophagusAlcohol Smoking Achalasia er vinson This 58-year-old male has presented with progressive dysphagia, initially worse on solids and then later to include liquids. This in a history should immediately prompt thoughts regarding malignancy. Barium swallow revealed a proximal apple core stricture, the proximal nature of which may be suggestive of squamous cell. Risk factors for oesophageal cancer: Squamous Adenocarcinoma Alcohol Alcohol Smoking Smoking Achalasia Plummer vinson Barrett's oesophagusA 35-year-old man who is usually fit and well presents with a 2 month history of indigestion. His weight is stable and there is no history of dysphagia. Examination of the abdomen is unremarkable. Of the following options, what is the most suitable initial management? Urea breath testing and non-urgent referral for endoscopy H pylori eradication therapy and full-dose proton pump inhibitor for three months Full-dose Proton pump inhibitor and immediate referral for endoscopy Three month course of a standard-dose proton pump inhibitor One month course of a full-dose proton pump inhibitorUrea breath testing and non-urgent referral for endoscopy H pylori eradication therapy and full-dose proton pump inhibitor for three months Full-dese Proton pump inhibitor and immediate referral for endoscopy nth course of a standard-dose proten pump inhibitor eS ump inhibitor 3 This question highlights the NICE guidelines for the management of dyspepsia. There is na evidence currently to suggest whether a one manth course of a PPI or ‘test and treat’ strategy should be adopted first line. Many clinicians prefer to test for H pylori first as this cannot be done within 2 weeks of acid-suppression therapy, as false-negative results may occur Given the options available, only the answer is in line with current NICE guidelinesWhich of the following skin conditions associated with malignancy are not correctly paired? Erythroderma and lymphoma Necrolytic migratory erythema and gastrinoma Acanthosis nigricans and gastrointestinal cancer Sweet's syndrome and myelodysplasia Erythema gyratum repens and lung cancerErythroderma and lymphoma | secoysemigaan theme angstroms Acanthosis nigricans and gastrointestinal cancer | sees rome and myelodysplasia Erythema gyratum repens and lung cancer Necrolytic migratory erythema is associated with glucagonomasA 54-year-old female is admitted one week following a cholecystectomy with profuse diarrhoea. What is the most likely diagnosis? Campytobacter E. coli Clostridium difficile Salmonella Staphylococcus aureusCampylobacter E, coli Salmonella Staphylococcus aureus @Q @Q Clostridium difficile is the most likely cause as the patient would have been given broad- spectrum antibiotics at the time of the operationWhich of the following statements is true regarding the genetics of colon cancer? Hereditary non-polyposis colorectal carcinoma is a autosomal recessive condition The adenomatous polyposis coli gene is located on chromosome 12 Around 50% of patients with familial adenomatous polyposis develop colen cancer Both hereditary and non-hereditary colon cancers typically present at 60-70 yrs of age Non-inherited colon cancer often involves mutation of the adenomatous polyposis coli geneHereditary non-polyposis colorectal carcinoma is a autosomal recessive condition The adenomatous polyposis coli gene is located on chromosome 12 15% Around 50% of patients with familial adenomatous polyposis develop colon cancer hereditary and non-hereditary colon cancers typically present at 60-70 yrs of omy ‘involves mutation of the adenomatous Pox)A patient with upper gastrointestinal symptoms tests positive for Helicobacter pylori following a urea breath test. Which one of the following conditions is most strongly associated Helicobacter pylori infection? Gastric adenocarcinoma Gastro-oesophageal reflux disease Oesophageal cancer Duodenal ulceration Atrophic gastritis