Fawzya Sheet “1” ay 1) Cake at ele a (aT era) Paper 1: 1. The pressure within the pleural space is negative with respect to atmospheric pressure, ‘except for which of the following? (Sep 2016) At end expiration ‘Atend inspiration During a Valsalva maneuver If the patient has a tracheostomy When taking a deep breath eae re Pneumothorax, Hydrorhorax. Hemothorax Pons, = ‘Tends to be more positive In Valsalva Maneuver pleurd pressure becomes more positive. tm reverse Valsafoa/Mueler's Maneuver plewral pressure Becomes less paste. 2. A30-years-old alcoholic man presents with acute severe upper abdominal pain and vomiting. He is admitted to the intensive therapy unit with a diagnosis of severe acute pancreatitis Forty-eight hours later he develops peripheral paraesthesia and carpopedal spasms. The most likely underlying metabolic abnormality is:- (April 2016) a. hypercalcaemia b. hypernatraemia ¢. hypocalcaemia d. hypokalaemia ©. hyponatraemia Ranson Criteria and Prognosis [At Admission ‘At 48 hours +-Age > 55 years + Decrease in nematocrr > 10% ‘Leukocyte count > 16 x 103/mcl _* Increase In BUN of > 8 mg/dL + Blood glucose > 200 mg/dL. ‘Serum calelum less than 8 mg/dL Serum LOH > 350 1U/L Pao; < 60 mm Hg Serum AST > 250 IU/L Base defcit > 4 mEq/L ‘* Estimated fluid sequestration > 6,000 mL Score <3 Mortality 0-386 « Score 2:3 = Mortality 11-150 6 Score 2 6 = Modality 409% MRCSalah Courses3. A50-year-old woman attends her General Practitioner due to a change in appearance. She finds difficulty removing her rings, reports: an increase ‘in shoe size and photographs reveal a change in her facial appearance. Visual field tests are-performed to direct confrontation. Which of the following defects is most likely to be associated with her presentation? . Binasal hemianopia . Bitemporal hemianopia . Homonymous hemianopia |. Inferior quadrantanopia . Unilateral loss of vision Ira val ddbt cme y he pw esa] ot pc PF. .1% Some of ne import feces of comensty 4. A24-year-old man falls off his motorbike, fracturing one arm, both femurs, and rupturing- his spleen. He required surgery and 20 units of blood. Twenty-four hours after admission he has passed 350 ml of urine. His blood pressure is 90/50 mmHg. and he has low skin turgor. Which of the following best describes the changes in the renin-angiotensin system initiated at the juxtaglomerular apparatus in the patient? (Sep 2016) Renin | Angiotensin | aldosterone Cone. # Cone. Cone. A v + v B + * wv c a + v Dil + v + E 3 it a MRCSalah Courses5. A 35-year-old woman presents to the Emergency Department with a second attack of painful frank haematuria. What is the most likely pathology underlying this presentation? Gram negative urinary tract infection Interstitial cystitis - Renal cell carcinoma Transitional cell carcinoma of bladder Urinary tuberculosis SPECIAL TYPES OF evstinis: INTERSTITIAL CYSTITIS, 3 evstitis(chronic pelvic Th form of chronic ey © The etiology of which is unknown, © Some pt with this condition show chronic mucosal uleers (Hunzer ulcers) © Late in this disease, there is transmural fibrosis leading to a contracted bladder © Interstitial cystitis is charncterized by supraps frequency without evidence of bacterial ‘nfectio ic pain, hematuria, dyauria, 6. 60-year-old man presents with a short history of pain in the right cheek and right upper teeth Maxillary sinus infection is diagnosed. This sinus is particularly prone to infection because of? absence of celia on the epithelium lining the sinus closeness of the sinus to the nasal cavity poor blood supply Position of the sinus ostium high on the medial wall Relationship of the front teeth to the floor of the sinus paoge MRCSalah Courses7..A 75-year-old insulin-dependent diabetic man has undergone ahemicolectomy. On the first postoperative day he is nil-by-mouth, on subcutaneous insulin, maintenance IV infusion with- Saline and intravenous morphine via patient controlled analgesia. He is confused after a brief convulsion, has slurred speech and weakness of his right side. His pulse is 110 beats/minute, respiratory rate 25 breaths/minute, blood pressure 160/95 mmHg and Sp02 95% on room air. The most likely cause of this convulsion and confusion is: (Sep 2076) . hypoglycemia hyponatremia inhibition of noradrenaline re-uptake stimulation of d opioid receptors stimulation of GABA receptors Early adrenergic symploms _Neuroglycopenic signs Pall Confusion Diaphoresis ‘Sturred speech Shakiness Inrational or uncontrolled behavior Hunger Dsorientation Anxiety ‘Loss of consciousness leitabity Seizures Headache Pupilay sluggishnoss Dizness Decreased response to naxous stimuli 8. A30-year-old woman presents to the general surgical clinic with a 1.5 cm cervical lymph node along the anterior border of sternocleidomastoid muscle.-Clinical examination and routine blood tests are unremarkable. She undergoes an excisional biopsy of the lump as a day case. The histology report reveals encapsulated infiltrative carcinoma with marked fibrosis and cystic changes within the lymph node. What is the most likely primary pathology? {Sep 2016) Anaplastic thyroid carcinoma Follicular thyroid carcinoma . Malignant lymphoma of the thyroid Medullary thyroid carcinoma Papillary thyroid carcinoma — = Carcinoma of Thyre % Type — (%) age spread Prognosis Papltary 60-79 young oduts—Lymphatie.1o Excellent 20-40 (<48y)_ local nodes Folleuiar 20.25 Young-midse Bloodstream, Good wih 40:50 (48) capectyte. radorndine bone therapy ‘Anaplastic: 10-18 Elly ‘agressive Very poor local extension Medullary 640 Unallyeldery, Local Vorb. Mere (Cees) butter!” hmphate, aggressive in femen occur ood seam famila eaten MRCSalah Courses9. A37-year-old man presents with severe headache, photophobia arid neck stiffness. Karnig's sign is positive and a midline lumbar puncture is performed immediately to determine if a cerebrospinal fluid (CSF) pathogen is involved. In performing this procedure, which is ‘he first of the following structures to be pierced by the lumbar puncture needle? (Sep 2016) Anterior longitudinal ligament ‘Arachnoid mater Dura mater Interspinous ligament Posterior longitudinal ligament Layers traversed by the spinal needle (posterior to anterior) * skin + Subcutaneous tissue * Supraspinous ligament + Interspinous ligament + igamerium favum * Duramater * Sub dural space + Arachnoidmatar + Subarachnoid space 10. A 26-year-old woman presents with severe headache, photophobia and neck stiffness. ‘Among other investigations, a lumbar puncture is earned out and cerebrospinal fluid is sent for microscopy and culture. Culture shows a growth of Neisseria meningitidis. What is likely to be the predominant-cell type in the cerebrospinal Fluid? (Sep 206) a. Basophils b. Eosinophils c. Lymphocytes d. Macrophages =. Nelieppis CSF findings in CNS infections CESSES ERs Bacterial increased. 10050000 100-500 (high) Low < 40 vetoes pu Wialmeningts Norbcreaed Lessthan1000 50-200 hig) Norhigh Mosonadest Vit Nor increased Less than 1000 $0-200{ high) Nor high encephatts Pea, then rmononudear Ta menngts reeves 10300100500 (hah) tow Lymphocres Binabscess increased 10200 100-50 normal hehocres MRCSalah Courses alia11. A 70-year-old woman from a nursing home presents to the! Emergency Department with abdominal pain and vomiting. On examination, she is dehydrated and her abdomen is distended. There is a 3 cm 4 cm swelling in her right groin which is non-tender, and there is no cough impulse. At operation, a femoral Hernia found. Which of the following lies medial to the neck of the hernia? (Sep 2016) Femoralartery Femoral nerve Femoral vein Lacunar ligament Pectineal ligament Boundaries of femoral ring «Anterior: Inguinal ligament + Posterior: Ligament of Cooper | pectineal ligamen}. ‘© Medial: Lacunar Jom ligament (Gimbemat's ligament) + Lateral: Thin septum which separates the moral canal from ic etoe femoral vein (silver faethe | tale fascia). ‘adv pe apa 12. A 26-year-old man presents to the Emergency Department with extensive bleeding from his arm after sustaining a glass injury. On examination there is a 7 cm transverse laceration across the anterior aspect of his elbow. On exploring the cubital fossa you would expect the brachial artery to be: (Sep 2016) anterior to the median nerve lateral to the biceps tendon lateral to the median nerve medial to the median nerve ‘superficial to the bicipital aponeurosis epoge Contents of cubital fossa Cham Radial Nerve Maal Biceps m Biceps Tendon Median Unar 9 Nerve a Aooneurosis MRCSalah Courses13. A 82-year-old man is found to have multiple myeloma. What skull X-ray appearances would be characteristic? (Sep 2016) @. Diffuse thickening of the calvarium b. Hair on end appearance. c. Multiple fractures a shutoie neteotyt lence .. Multiple osteosclerotic lesions a) Whats Active Myeloma? MULTIPLE MYELOMA MNEMONIC: OLD CRAB D- Old Age C = Calcium Elevated (Hypercalcemia) R.- Renal Failure A> Anemia B - Bone Lytic Lesions 14. A 50-year-old woman presents with a history of right upper quadrant pain and jaundice. She reports that her urine was dark in color and that her stools are offensive and difficult to flush. Which of the following explains the dark urine? (Sep 2016) a. increase in conjugated bilirubinuria b. Increase in unconjugated bilirubinuria ¢. Increase in urea excretion . Increase in urinary urobilinogen @. Reduced enterohepatic bile salt circulation Urine bilirubin is normally absent. + When it is present, only conjugated bilirubin is passed into the urine. + This may be evidenced by dark-colored urine seen in patients with obstructive Jaundice or jaundice due to hepatocellular injury. O The lack of bilirubin in the intestinal tract is responsible for the pale stools typically associated with biliary obstruction. 2 The cause of pruritus associated with biliary obstruction is due to accumulation of bile salts in the skin, MRCSalah Courses15. A 45-year-old man presents with backache and leg pain due to a prolapsed lumbar intervertebral disc. The pain, which is aggravated by coughing and sneezing, radiates to the lateral aspect of the foot. On examination, there is weakness of the plantar flexors of the foot, which nerve root is most likely to be involved? (Sep 2076) a T12 b. La c. LS ad. S1 e. 82 16. A 62-year-old woman presents to her General Practitioner with a two-week history of back pain. She has lost 8 cm in height over the last five years Investigations reveal: Y v v v Findings Normal Adjusted ( corrected) Calcium 2.78 mmol/L 2.15-2.55 mmol/L Phosphate 0.84 mmol. 0.8-1.4 N Estimated GFR 0.96mi/minute — Morethan90—N PTH 8.9 pmol 0.95-5.7 * Which of the following is the most likely cause? (Sep 2076) esere MRCSalah Courses PartA Hypoparathyroidism Primary hypemarathyroidism Pseudo hypoparathyroidism Secondary hyperparathyroidism Tertiary hyperparathyroidism Parathyroid ees Cr High High Low Primary Oversecretion yperparathyroidism of parathyroid hormone High Low High Secondary Vitamin D yperparathyroidism deficiency Veryhigh High High Tertiary Chronic reral hyperparathyroidism failure Tass17. A 21-year-old man fractures his ulna and radius. He is treated by means of a plaster cast, which is removed after four weeks. What pathological process is most likely to have affected the immobilized muscles? a. Aplasia b. Atrophy c. Hyperplasia 4. Hypertrophy e. Neoplasia 18. A 22-year-old man has been stabbed in the left fifth intercostal space at the edge of the sternum. Which structure is most likely to have been penetrated? Left atrium Left lobe of the liver Left ventricle Right atrium Right ventricle epeep csp oa 19. An 80-year-old man dislocates his shoulder it is reduced in the Emergency Department. At review three weeks later, he is unable to actively initiate abduction of his arm. Which muscle most likely damaged? (Sep 2016) a. Clavicular head oi pectoralis major f_ lnfrasohratue, ¢. Supraspinatus a. Tone teaior SHOULDER ABDUCTION basset Abduction of the shoulder is { @\ initiated by the Supraspinatus: | otors” > TheDetokdmusciecantnen N/a abduct to 90° Its the major tke abductor. 15° to 90° 180°(elevation)is brought about by +47} rotation of the scapula upwardsby CINE WW the Trapezius and Serratus anterior. Axillary Nerve Injury: Causes Deltoid and teres minor paralysis, Loss of rounded contour of shoulder, Sensory lossin skin covering lower part of deltoid (regimental badge anaesthesia), Loss of Abduction from 15"to 90°. MRCSalah Courses20. An 8-year-old boy is admitted for assessment of rectal blood loss. His mother describes this as bright red blood in the toilet pan. He has no pain on defalcation. There is no family history. What is the most likely cause? (April 2016) Adenomatous polyp Familial adenomatous polyposis Juvenile polyp Metaplastic polyp Peutz-Jegher’s syndrome paogp 21. A 48-year-old woman presents with abdominal pain and five to six episodes of bloody diarrhea each day, She also complains of pain- in the knees and elbows and recent visual problems. What is the most likely diagnosis? (Sep 2076) Collagenous colitis Diverticulitis Infective colitis intestinal tuberculosis Ulcerative colitis eaere Table 1. Common Extraintestinal Manifestations of Ulcerative Colitis Arthritis (21%) Erythema nodosum (3%) Aphthous stomatitis (4%) Ankylosing spondylitis (2%) Primary sclerosing Pyoderma gangrenosum (2%) cholangitis (4%) Psoriasis (1%) Uveitis (4%) 22. A 56-year-old man presents with acute epigastric pain and vomiting. On examination he has guarding in the upper abdomen. Investigations reveal: Value Normal Serum amylase 900 1U/. <100 Serum ALT 611U/ <50 Alkaline Phosphatase 98 1U/ 20-120 Albumin 38 g/L 35-50 GammaGT 76 1U/L <60 Triglyceride 4.6 mmol <1.7 Bilirubin 45 umollL. 0-20 Corrected Calcium 3.30 mmolit. 2.20-2.70 MRCSalah CoursesWhich of the following is the most likely etiology of this condition? (April 2016) Alcohol Choledocholithiasis Hyperparathyroidism Hypertriglyceridaemia eaore Mumps, 72% most common cause n the US Most common enuse nthe US 23. A 30-year-old manis knowinelge admitted to the intensive S Mnemonic: "I GET SMASHED” care unit with an isolated severe head injury. A CT scan shows multiple intracerebral bleeds but no midline shift. He is intubated and ventilated. His pupil: dilated and react sluggishly to light. His heart rate is 50 beats/minute blood pressure 170,110 mmHg and his respiratory rate is set at 10 cycles/minute. The rising blood pressure is likely to be caused by: a. aortic and carotid baroreceptor stimulation Cortisol stimulation ‘sympathetic stimulation related to blood loss ‘sympathetic stimulation related to intracranial pressure b. . renin-angiotensin stimulation 4. e CUSHING'S TRIAD ticce primary “ora hat often nate an ierease i intracranial eee systolic BF Pulse # Respiration ‘eo Po — MRCSalah Courses Effects of Intracranial Pressure (CNS Ischemic Reflex) * inoresond inreceanil pressure leeds to mechanical compression of cerebral Vasculature and decreased flow Sse tense ceeetete tele tee] hypertension (‘Cushing refx”) hay be caused ty bubar cher, which nun serolaise medley eardovescas’ con's snd eres apap ees eae! Somnre ~ Brsjcarcia olen accompanies the hypertensen trcauee of berorecepor action olga teres toe reor24. A 42-year-old multiparous woman is admitted to the Emergency Department due to pelvic discomfort. The duty gynecologist diagnoses uterine prolapse. Which anatomical structure gives significant direct support to the uterus? (April 2016) Cervical ligaments Mesometrial part of the broad ligament Mesosalpingial part of the broad ligament Round ligaments Transverse perineal Muscles (tendon) eapgp 25. An 80-year-old man is admitted to the surgical admission unit with central abdominal pain. His blood pressure is 100/60 mmHg and his pulse is 110 beats/minute with a respiratory rate of 25 breathsiminute. He is known to have severe chronic obstructive pulmonary disease (COPD) and has been a heavy smoker all his life. On examination he has arigid abdomen Arterial blood gases show: PH poz pco2 Bicarbonate | Base Excess Finding 7.24 BKPA 5.3KPA 17 mmol/l 3 Normal 7.35-7.45 44.9-13.3 4.7-6.0 22-26 -2to +2 What is the most likely diagnosis? Hypovolomic shock complicated by COPD Metabolic acidosis due to COPD Metabolic acidosis due to peritonitis Respiratory-acidosis due to COPD €. Respiratory acidosis due to peritonitis pose 26. In describing the sino-atrial node, which one of the following statements is correct? (April 2016) a. itis part of the somatic nervous system b. Itisusually supplied by the left coronary artery c. Iflies in the wall of the left atrium d. It lies in the wall of the right ventricle e. It receives fibers derived from the vagus nerves MRCSalah Courses27. A fit21-year-old man is admitted with an acute abdomen, subsequently diagnosed a ‘gastroenteritis. As part of the host immune response, which of the following immunoglobulins and cells are correctly paired? (April 2016) a. IgA-macrophage b. IgD-small bowel epithelium . IgE-endothelium d. IgG-plasma cell e. IgM thymocyte 28. A 45-year-old man presents with fever and pain in his right loin and groin. A soft swelling ‘was noted in his femoral triangle, Diagnosis of a psoas abscess was made. Which of the following statements is most accurate regarding psoas major? a b. Itextends the hip arises from the lateral borders of the bodies of 112 to L5 c. Itinserts into the greater trochanter of the femur is innervated from 12 and LI ©. Itpasses posterior to the capsule of the hip joint REVIEW: Muscles of the Posterior Abdominal Wall nue hac ose Worsoxs uanearus towaonun ofhmtor 29. Which one of me following muscles is an extensor of the hip? (Sep2016) a. Adductor longus b, Gracilis Movement c. Iliopsoas —_ d. Pectineus Flexion e. Semitendinosus Extension Muscle iacus, pectineus, rectus femoris and Sartorius luteus maximus and hamstrings (semitendinosus, somimembranotus and bicep femoris) Gluteus maximus, medius and minimus, and tensor fascia lata Internal rotation External rotation MRCSalah Courses | _Adductor magnus, logus and brevis, gracilis, and pectineus _ Gluteus mecius and minimus, tensor fascia lata, psoas major, and iliacus Giuteus maximum, priformis, obturator internus, gemellus superior and inferior, quadrates femoris and obturator30. A tall, thin, 25-year-old woman presents to the surgical clinic with a complaint of swelling in the front of her neck for the last four months. On clinical examination she has a swelling in the left lobe of the thyroid and multiple neuromatous lesions within the oral cavity. Her blood pressure is 220/120 mmHg. Laboratory investigations show that her calcium and electrolytes are normal and serum calcitonin and urinary VMA levels are elevated. Which of the following is the most likely cause of the hypertension? ‘a. Conn's syndrome b. Cushing's disease c. Essential hypertension d. Phaeochromocytoma e. Renal artery stenosis Tree aa Pheochromocytoma + Ginical suspicious * Diagnostic investigation of pheochromocytoma > Biochemical diagnosis ass stanepnin > Localization + CH/M adrenal protoes + Functioningimaging: "or -MIEG sitngraoy 11F-F06 PET sean 34. A 65-year-old man presents with haematuria and left loin pain. Computerised tomography demonstrates a left renal tumour. He undergoes a left radical nephrectomy. Where does the left renal artery lie? (Sep 2016) Anterior to the left gonadal vein Anterior to the left renal vein. Anterior to the splenic vein Posterior to the left renal vein ‘Superior to the superior mesenteric artery eaogp MRCSalah Courses32. Within the posterior triangle, which nerve is at particular risk of damage during surgery? a. Auricular branch of the facial b. Glossopharyngeal cc. Phrenic d. Recurrent laryngeal . Spinal accessory 33. The right and left pulmonary arteries are derived from which of the following embryological aortic arches? (April & Sep) a. Second aortic arch b. Third aortic arch ¢. Fourth aortic arch 4. fh aorte arch a e. Sixth aortic arch ‘Maxillary en mandible, ue Sere Sapedal coe S vo ti ryote | me | etch “ ‘Superior aad laryngeal | Left: aortic arch cinilante fed | vag |r aoa ce MRCSalah Courses34. A 47-year-old man presents to the Emergency Department six hours after a climbing accident initial assessment suggests that he had lost 4 L of blood. His blood pressure is 105/70 mmHg and his pulse rate is 88 beatsiminute. He is catheterised and his bladder contains 120 ml of urine. Activation of which of the following transport systems best describes how aldosterone leads to maintenance of the intravascular volume and oliguria in this men? Na/glucose in the proximal tubule NalH+ in the descending loop of He! Na+IK in the ascending loop of Henle NaviCl in the distal tubule NalK in the collecting ducts eaoge oy ‘azides aahyerase “oniotor se) 35. During arch aortography, the vertebral artery would be seen to arise directly from which of the following? (April & Sep) a. Arch of the aorta b. Brachiocephalic artery Thyrocervical Right Common ¢. Common carotid artery trunk Cerotid a d. Internal carotid artery Costocervicala. ‘Subclavian artery im Subdlavian a, heft common Carotid a Vertebral a. Internal ‘Mammary a Left Subclavian a. Innominate a MRCSalah Courses36. A 65-year-old man remains on the high dependency unit following a gastrectomy, three days previously. His urine output: has averaged 80ml/hour for the last 24 hours. He has one dry abdominal drain arid no nasogastric losses: His urea and electrolytes are normal He isto stay nil by mouth for a further 24 hours. Which of the following fluid regimes is most appropriate to his electrolyte and water requirements over the next 24 hours? (April & Sep) 1 Lof 0.9 % saline plus 1.5 L. of 4% dextrose/0.18 % saline 1 Lof 0.9 % saline plus 1.5 L of 5% dextrose 1 L of 0.9 % saline plus 1.5 L of Hartmann’s solution 2Lof 0.9% saline 2 Lof 4% dextrosel0,18 % saline Routine postoperative orders of LV. wl tort tre days = First 24 irs of surgery : 2 liters 5°-Gestrose or 1.5 liters 5%- dextrose +500 mi isotonic saline, = Second post operative day: 2 ters of 5%-lextrose -+1lter 0.9% saline. a Ti pel praia day: nas Sid +6-60 ny poten Der day. = Maintenance fluids should be administered at a steady rate ‘over an 18 40 24 hour period. paoce 37. A 3-year-old boy is admitted to hospital with severe vomiting. Radiographic examination reveals that he is suffering from annular pancreas. Which of these structures is constricted? First part of duodenum ‘Second part of duodenum Third part of duodenum Proximal jejunum Pylorus of stomach 8 Stomach Blewet ie et Doral stoves ew pencrec bud MRCSalah Courses paesp38. A 20-year-old man with a severe head injury is being ventilated using intermittent positive Pressure. Which of the following is a physiological consequence of this? (April & Sep) Decreased extracellular fluid volume Decreased cardiac preload Increase in intrathoracic blood volume Increased cardiac preload e. Increased cardiac stroke volume 39. A 36-year-old man presents with a two-month history of low back pain radiating to his left leg After clinical examination he is referred for an MRI scan. This shows a prolapsed intervertebral disc. The clinical signs are consistent with pressure on SI roots. Which combination of clinical signs is most likely? pose a, Weak ankle plantarfiexion; altered sensation on the dorsum of the foot; normal ankle jerk reflex b. Weak ankle plantarfiexion; altered sensation on the sole of the foot; loss of ankle jerk reflex. ¢. Weak hallux dorsiflexion; altered sensation on the anterior surface of the leg; loss-of ankle jerk reflex. d. Weak hallux dorsiflexion; altered sensation on the dorsum of the foot; normal ankle jerk reflex. . Weak hallux dorsiflexion; altered sensation on the sole of the foot; loss of knee jerk reflex Nerve root La us sa - Numbness jester Extension of | Oorsifiexion of | Plantar flexion weakness sdeurceps Sand woot Screeni anmanas women en Saomination [Owstend sce | tesclwattine | Weisss’ Reflexes dimininas | Nenerenable | fminitnea MRCSalah Courses40. 55-year-old woman undergoes a cholecystectomy; The gallbladder contains multiple dark irregular small stones. The most likely cause of this type of gallstone is an increased blood level of: a. Bile acids b. calcium ©. cholesterol d. conjugated bilirubin e. unconjugated Bilirubin Types of gallstones 1-Pure cholesterol (10%). Often solitary, large (> 2.5cm), round 2-Pure pigment (bile salts; 10%). Pigment stones are of two types: “black (associated with haemolytic disease); “brown (associated wth chronic cholangitis and biliary parasites). 3-Mixed (80%). Most common; usually multiple 41. A 55-year-old man presents with a deep venous thrombosis. His full blood count shows a hemoglobin of 18.3 g/dL (normal 13.5-17.5), a white cell count of 8 x 109/L (normal 3.9- 10.0 x 109) and a platelet count of 200 x 109/L (normal 150-400 x 109) This hematological picture is most likely to be associated with: a. bronchial carcinoma b. pancreatic carcinoma c. prostatic carcinoma d. renal cell carcinoma e. transitional cell Clinical Findings caterer cr ne icney Paraneoplastic Syndromes ‘+ RCC Is associated with a wide spectrum of paraneoplastic syndromes [occuring in 10 ~40% of patients with RCC) including erythrocytosis, hypercalcemia, hypertension, and nonmetastatic hepatic dysfunction Erythrocytosis ‘+ RCCis the most common cause of paraneoplastic erythrocytosis, (occur in 3~10% of patients) ‘+ May result either from enhanced production of erythropoietin from the tumor of as 2 consequence of regional renal hypoxia promoting erythropoietin production from nonneoplastic renal tissue MRCSalah Courses42. A 27-year-old has had pancolitis for the last five years. Which one of these complications is least likely to develop? a. Arthritis b. Cholangitis c. Iritis, d. Polyarteritis Table 1. Common Extraintestinal ». Toxic megacolon Manifestations of Ulcerative Colitis Arthritis (219%) Erythema nodosum (3%) Aphthous stomatitis (4%) Ankylosing spondylitis (2%) Primary sclerosing Pyoderma gangrenosum (2%) cholangitis (4%) Psoriasis (1%) Uveitis (496) 43. A surgeon makes a Pfannenstiel incision for access to the pelvic organs. He incises the abdominal wall down to and through the rectus sheath.He retracts the rectus abdominis muscles laterally from the midline to expose the: linea alba peritoneum posterior rectus sheath transversalis fascia transversus abdominis muscle paore MRCSalah Courses44. A 25-year-old man undergoes splenectomy following blunt abdominal trauma. Three days postoperatively venous blood testing is likely to reveal a. high platelet count 7 b. high red cell count Causes of Thrombocytosis c. lowplatelet count 5 d. low while cell count : ynrection . e. lowred cell count Inflammation + Malignancy (myeloproliferative disorders, non- hematologic malignancies) + Post-splenectomy (thrombocytosis is common during the first weeks or months following splenectomy) * Iron deficiency * Miscellaneous (acute hemorrhage or trauma, surgery, acute hemolysis, and transiently after an episode of thrombocytopenia-rebound thrombocytosis) 45. A 46-year-old woman is seen in the pre-admission clinic. She had a myocardial infarction two years ago. On examination she is in atrial fibrillation and a recent echocardiogram shows thatshe has a dilated left ventricle: She is on warfarin and her INR is 6.1. Warfarin inhibits which of the following? Inwinsic way Extrnsic way a. Antithrombin ‘b. Kallikrein var > xe) ve — Wa) cc. Plasminogen ‘ d. Prothrombin x — a] e. von Willebrand's factor Warfarin fea ‘Mechanism InhibitsVitK epoxide reductase Potentates ATI Factors WIRES i Pathway aril & Common Intrinde & Common ‘Monitoring PT/INR aT Time Course Slow onset, lng duration Tepid onset chon duration Reversal Vik, fresh frozen plasms prothrombin complex concentrate (PCC) MRCSalah Courses46. A 75-year-old mans admitted for elective repair of an abdominal aortic aneurysm. Following the operation his systolic blood pressure falls below 90 mmHg and during resuscitation he is given an infusion of fluids. There is a choice of colloid or crystalloid. Which of the following best describes why the intensive therapy unit registrar decides to administer a colloi ‘a. Colloids are not freely filterable across semi-permeable membranes b. Colloids can prevent pulmonary oedema by inducing fluid flow out of the interstitial space c. Colloids decrease the transcapillary oncotic pressure gradient d. Colloids expand the plasma volume by 200 ml for each liter infused . Colloids migrate from the intravascular space 47. A.35-year-old man develops septicaemia following surgery for perforated acuteappendicitis He is hypotensive. Arterial blood gas analysis reveals: PH poz pCo2 Bicarbonate Finding 7.25 7.2 kPa 7.5 kPa 47 mmol Normal 7.35-7.45, 41.9-13.3 4.7-6.0 22-26 What is the most likely explanation for these readings? Compensated metabolic acidosis Compensated respiratory acidosis Mixed metabolic and respiratory acidosis Uncompensated metabolic acidosis Uncompensated respiratory acidosis. Arterial Blood Gases rin cise? PH acidosis << 74 > alkalosis paore R Respiratory PHT Pee | ptatesic 0 Opposite PH | Pees Bede M Metabolic PHT Hes 1 Aalosie E Equal PH | Hees | Acidosic Uncompensated : Coz or HCos normal Partially Compensated : Nothing is normal Compensated : PH is normal (7.4 baseline /neutral) MRCSalah Courses48. A.20-year-old man presents to the Emergency Department with a stab injury to the thenar eminence. On examination he is found to have a 2 cm long laceration with loss of sensation in the thumb and index finger and weakness: of the thenar muscles. Which of the following structures is most likely to have been injured? Anterior interoseous nerve Recurrent branch of median nerve Sensory and motor branches of median nerve ‘Sensory and motor branches of radial nerve ‘Sensory and motor branches of ulnar nerve eaege 49. A 65-year-old man presents with vomiting and .weight loss. On examination he had 3 palpable epigastric mass. The transpyloric plane lies at which; vertebral level? a 1 b. T12 oUt 2 e. L3 Abdominal Lines and Planes Vertical Lines: Midline, mid-clavicular line Horizontal Planes: ‘Transpylori Plane : passes through tips of ninth costal cartilages on both sides. I les atlevel of body of frst lumbar vertebra (1), pylorus of the stomach, duodenojejunal junction, neck s, and hila of kidneys. Subcostal Plane: joins lowest point _ of costal margin on both sides that is 10th costal cartilage & at level of third lumbar vertebra ( highest points on iliac crests & lies on level of body of fourth Lumbar vertebra (14). This is commonly used 3¢3~ jure surface landmark whet pt performing lumbar anes spinal tap. cere Intertubercular Plane = joinstubercles on iliac crests & lies level of fifth lumbar vertebra (LS). MRCSalah Courses50. A 30-year-cid motorcyclist is brought to the Emergency Department after a road traffic, accident. He has an open fracture of the right femur. On arrival he is tachypnoeic and confused with cold and clammy skin. Which of the following physiological changes is most likely to occur? a. b. c. d. e. Decreased reabsorption of water from the collecting tubules |. Decreased serum bicarbonate level Increased pH of blood Increased secretion of sodium in the urine . increased synthesis of glycogen in the liver 51. In an emergency situation what is the most appropriate surgical method of obtaining an airway? eaere Cutting and retracting the cricothyroid muscle Cutting the thyrohyoid membrane Dividing the thyroid isthmus Entering the trachea at the C7 level Piercing the cricothyroid membrane 52. A 75-year-old man presents with hepatomegaly and ascites. Computerised tomography shows evidence of post hepatic portal hypertension. The inferior vena cava passes through the Diaphragm at which vertebral level? a b. c. a. e. MRCSalah Courses Structures passing through - passing throug! js diaphragmatic apertures mM10 \ ™ mM12 Caval Esophageal Aortic53. A 20-year-old woman presents acutely with abdominal pain, imaging reveals a right ‘ovarian cystic lesion which is excised. Histoiogicai examination shows a cyst lined by keratinizing stratified squamous epithelium. Areas of fat, muscle, thyroid and neural tissue are seen in the wall. Whatiis the appropriate pathological designation for this lesion? a. Adenocarcinoma b. Cystadenoma ¢. Dysgerminoma d. Squamous cell carcinoma e. Teratoma 54. A 25-year old woman who is two months post-partum, presents with a tender mass in the left breast. She is pyrexial with a raised white cell count and a raised C-reactive protein level.- A diagnosis of lactational mastitis with abscess is made. Which of the following is the most likely causative organism? 7 a. Aeromonas hydrophila + Is the most common inflammatory condition of the b. Escherichia coli treass. I's seen most comrnoniy, but nt aways, ¢. Streptococcus’ miileri jena resag d. Lactobacillus casei = “Thm qeusatve cigeblenis ae Stach aureus e. Staphylococcus aureus and Sreptovoceds spaces,” Saphviococns aureus + Clinically:fever, enthema, induration and tendemess. If neglected it may progress to form a breast abscess. + Treatment with broad spectrum antibiotics or penicillin sch as ©. cidoracin can abor the progressien ofthe Infection’ + lactation may continue from the unaffected treast while ‘expressing the affected one in order to prevent milk ‘engorgement. 55. A 62-year-oid alcoholic man is admitted with severe acute pancreatitis. Three days after admission he becomes hypoxic (p02 is 7.5 kPa) and confused. Chest X-ray shows auniform opacification of both lung fields. Which of the following is the most likely clinical diagnosis? a. Acute left ventricular failure b. Adult respiratory distress syndrome c. Bilateral bronchopneumonia d. Bilateral lobar pneumonia e. Massive pulmonary embolism Pancreatic Systemic ‘Abscess Acute kidney failure Fat nocrosis Acute liver failure Hemorrtages Adultrespiratory distress syndrome Infected necrosis Disseminated intravascular coagulation Pseudocyst formation Encephalopathy Sterile necrosis Gut ischemia Hypocalcemia Paralytic ileus ‘Shock MRCSalah Courses56. A 58-year-old woman presented to the Emergency Department with a large fluctuant swelling the site of a recent insect bite. She is anxious, tachycardic and pyrexial. An ECG shows critical fibrillation. She is noted to have a goiter. The swelling at the site of the bite requires surgical drainage. Which of the following classes of drug would be most appropriat as part of her preoperative preparation for surgery? a. Alpha-1 adrenoceptor agonist b. Alpha-2 adrenoceptor agonist c. Alpha adrenoceptor blocker d. Betaadrenoceptor agonist @. Betaadrenoceptor blocker Preoperative preparation for urgent surgery Beta Blockers eta Mochers are the mainstay of therapy and can effective), ‘contra ileal manifestations of hyperthyroidism. Longer acting agents preferred Target HR < 80pm Continued until thyro disease ‘under eontrol CCBis contraindicated + Blocks 4 and T3 release 57. A nulliparous 30-year-old Woman presents with a recurrent painful red area in the areola. She gives a history of smoking cigarettes. The lesion is excised and the histology shows squamous metap/asiaof lactiferous ducts. Microbiological culture does not grow any organism. Which of the following is the most likely diagnosis? a. Breast abscess b. Carcinoma of the breast cc. Fibroadenoma d. Galactorrhea ©. Subareolar abscess Non-Lactating Infection Central or periareolar infections: y. + This is most commonly seen in young women (mean age 32 year). +The undertying cause is periductal mastit + Current evidence suggests that smoking imporiant inthe etiology 0! nonlactabonal infection + Substances in cigarette smoke either recy or indirectly damage the sub ‘oor broast ducts and the domaged ‘issue becames inlecied by either aerobic anaerobic organisms. MRCSalah Courses58. A 65-year-old man undergoes right hemicolectomy; On the second postoperative day he is afebrile, nauseous has a distended abdomen but very little pain. He is on intravenous morphine via a patient-controlled analgesia pump. Plain X-ray confirms distended loops of small intestine. The physiologic basis of postoperative paralytic ileus involves: a. stimulation of dopaminergic receptors b. stimulation of reversed migrating motor complexes. ¢. stimulation of p receptors d. suppression of muscarinic receptors. . suppression of motilin due to starvation Morphine - Adverse Effects - + Severe respiratory depression (yi, 6 and x receptors) * Constipation (variable, wand x receptors) + Nausea and vomiting + Pupillary constriction (y/x receptors) = Caution must be exercised when opiates are used in those with liver or renal failure + Allergy enhanced hypotensive effects, + Elevation of intracranial pressure particularly head injury + Enhance cerebral and spinal ischemia 59. A 42-year-old woman has a Cholicystectomy develops a self-limiting postoperative wound infection. By what process would bacterial ingestion have been enhanced? |. Apoptosis . Autophagy . Metaplasia |. Opsonisation e. Phagocytosis 60. A 60-year-old non-smoker presents with three-month history of loss of weight, malaise and breathlessness. On examination he has left supraclavicular lymph node enlargement. Chest radiograph reveals multiple bilateral opacities. What abnormality would a biopsy of a left supraclavicular lymph node most probably show? Chronic inflammatory cells . Granuloma Neoplasia -. Langerhan's type giant cells u |. Multiple abnormal mitotic figures inccells” (imurtsrty us . Reed Stenberg cells + Pleororphism + Hyperchromatic nuclei + Mulile large nucteol + High NIC ratio + igh mito rate a. b. ©. 4. + Abnormal mitosis + Tumor giant cells MRCSalah Courses PartA61. A 78-year-old woman with emphysema receiving 28% oxygen by mask has thefollowing blood gas resuits The most likely interpretation is: PH poz pCo2 Bicarbonate | Base Excess Finding 7.28 6.2 kPa BKPA 36 mmol/L | +5 Normal 7.35-7.45 11.9-13.3 4.76.0 22-26 -26-2t0 +2 mixed respiratory and metabolic acidosis partially compensated metabolic acidosis partially compensated respiratory acidosis uncompensated metabolic acidosis uncompensated respiratory acidosis paoge ‘Uncompensated : Coz or HCos normal Partially Compensated : Nothing is normal Compensated : PH is normal (7.4 baseline /neutral) 42. A 24ehr-okd ott ia referred becalies offen monipsbte,fetis inthe teft scrotum, We oe the following positions describes an ectopic tes Atthe deep inguinal ring Atthe root of the penis At the superficial inguinal ring In the inguinal canal. in the upper part of the scrotum gaoee MRCSalah Courses63. A 60-year-oid man is found to have a2 om diameter mass in the upper lobe of his left lung. ‘The lesion is excised and it is found that the lesion includes connective tissue, mature cartilage and ciliated epithelium. What is the most likely diagnosis? Adenoma Carcinoma Chondroma Hamartoma . Sarcoma aesp 64, A 23-year-old man presents three months following extraction of carious teeth with a plaque like infiltration over the upper jaw with sinus formation. Yellow granules are pr‘ nt in, the discharging pus. What is the most likely causative organism? Actinomyces Aspergillus Blastomyces Cryptococcus Histoplasma enose ACTINOMYCOSIS Las orsNosts "Sulfur granules m pus specimen Dinect Gram-smear + Fine brarching filamentous bail Gitte on + Blood agar anaerobically for 4-7 days * Mole 120% appearance Histopetholocy Treatment + Surgcal drainage * Penclin for 4-6 weeks 65. An 82-year-old man has complete occlusion of his inferior mesenteric artery on angiography but no symptoms or signs of colonic ischemia. Which of the following arteries is the most likely additional source of blood supply to the territory of the inferior mesenteric artery? Left colic Left gastroepiploic Middle colic Splenic Superior rectal gaore MRCSalah Courses66. An intravenous drug abuser is having an echocardiogram for suspected endocarditis. Closure of the tricuspid valve occurs at the onset of which phase of the cardiac cycle? a. Atrial systole b. Isovolumetric contraction c. Isovolumetric relaxation VP d. Rapid ejection J ‘apid ventricular filling caWave a: atrial contraction caWave ¢: bulging of closed tricuspid into the right atrium during isovolumetric systole caWave x the tricuspid valve moves downward caWave v: venous filling > 67. After being stabbed in the left groin, a previously healthy 20-year-old man was admitted to the emergency Department. He developed hemorrhagic shock. During resuscitation, 10 units: of type O negative red cells and 6 L of colloid were administered; Twenty-four hours later, he noted to have severe dyspnea for which he required intubation and ventilation on the intensive care unit. Which of the following would be the most likely cause of his respiratory insufficiency? a. ABO blood incompatibility b, Adult respiratory distress syndrome (ARDS) . Congestive cardiac failure d. Tension pneumothorax e. Viral pneumonitis Prod Non pulmonary + Prewmonia + Sepsis + Aspiration 2 Trauma + Pulmonary vascultis + Pancreatitis + Pulmonary contusion 2 Severe bums + Inhlational injury + TRALI Nomcardiogenic shock MRCSalah Courses68. An 80-year-old man with a history of hypertension, controlled with thiazide diuretics undergoes transurethral resection of prostate under general anesthesia. The surgery is prolonged and in the recovery room he complains of nausea and a headache. He later becomes agitated and confused. Which of the following is the most likely diagnosis? a. Hypercalcaemia b. Hyperuricaemia ¢. Hypoglycaemia d. Hypokalaemia e. Hyponatremia TURP SYNDROME TURP SYNDROME - HYPERGLYCINEMIA © Glycine, a non essential amino acid, is an inhibitory ‘neurotransmitter in spinal cord and retina, © Rapid absorption of « lange-volume irrigation solution. © Can occur 15 min after resection or upto 24 hrs postop. Incidence : 1 8% © Characterized by intravascular volume shifts and plasma-solute (osmolarity) effects: * Circulatory overlond © Motabelized in liver by oxilative deamination to ‘ammonia and glyoxyhe ani oxalic ald + Water intexication ‘© When absorbed in large amounts, has direct toxie ° Hyponatremia cffecteon heart and retina + Hypeosmelality + Hyperglycinemia © Manifestations of glycine toxcity: nausea, headache, + Hyperam lates, weakass, vin distubaness (tranalest + Hemolysis e@ blindness), seizures, encephalopathy. oO 69. A 35-year-old man is admitted to hospital with vomiting, nausea and severe headaches. An MRI scan reveals a tumor of the cerebellopontine angle. Which one of the following pairs of cranial nerves is most likely to be compressed by this tumour? ‘Accessory and vagus Facial and vagus Facial and vestibulocochlear Glossopharyngeal and vestibulocochlear Vagus and vestibulocochlear gaogp Fret ple z a “CRANIALNERVES ouser< sce MRCSalah Courses70. After resection of d rectal tumour a patient experiences erectile dysfunction. Which of the following nerves is most likely to have been damaged in surgery? ‘a, Genitofemoral nerve b. Lumbosacral plexus What is innervation of c. Pelvic splanchnic nerves ‘ A ld! | Parken Geena of St erection and ejaculation? e. Pudendal nerve * Autonomic = Sympathetic nerves from T11-L2 — Parasympathetic from $2-4, form the pelvic plexus = The cavernosal nerves are branches of pelvic plexus (\®. parasympathetic) that innervate the penis ~ Parasympathetc stimulation causes erection Sympathetic activity causes ejaculation and detumescence (loss of erection) 74. A.45-year-old woman presents with pain, swelling and stiffness affecting all her metacarpophalangeal joints. She has noticed weakness in her grip and her handwriting has changed. She is unable to extend her fingers fully. The index, middle and ring fingers in both hands show an ulnar deviation. The most likely diagnosis is: a. Dupuytren's contracture exmmarienes b, gouty arthritis (late stage) ¢. osteoarthritis d. radial nerve palsy e, rheumatoid arthritis ADAM 72. A 22-year-old man arrives to the Emergency Department with sudden breath less ness due to alarge pneumothorax. A chest drain is inserted into the fifth left intercostal space in 5th mid-axillary line. There is hemorrhage into the drainage bottle. Which of the following structures is the most likely cause of this acute hemorrhage? intercostal artery . Left pericardiophrenic artery Lingula of the lung |. Right ventricle of the heart Spleen MRCSalah Courses73. 65-year-old woman collapses after a total hip replacement. A pulmonary embolism is suspected. Which of the following electrocardiogram changes would support this diagnosis? Dominant R wave in V6 Left axis deviation Left bundle branch block ST elevation in V1-V3 / Twave inversion in V1-V3 paege 74. 40-year-old woman had the anterior lobe of the pituitary removed because of a tumour. Without postoperative supplements, which of the following could occur? a. Failure to produce adequate amounts of thyroxin b. Fail to produce parathyroid hormone in response to hypocalcaemia ©. Failure to secrete catecholamine in response to stress d. Failure to secrete insulin in hyperglycemia e. inability to concentrate urine in response to water deprivation Protuction and relase of anterior ptutary hormones MRCSalah Courses75. A 38-year-oid man in end-stage renal failure resulting from polycystic kidney disease receives a cadaveric renal transplant. Good renal function is established but four weeks later deteriorates, the serum creatinine rising by 25%. Which of the following processes is most likely to be responsible for this deterioration? a. B-cell mediated rejection b. Circulating immune complex disease ¢. IgG antibody mediated rejection d. Post-transplant lymphoproliferative disorder e. T-cell mediated rejection Preformed antibodies directed against the donor tissue. Caused by accidental ABO Immediate | blood type incompatibility which is very " rare. Presents in surgery with thrombosis and occlusion of graft vessels T-Cell mediated immune response directed against the foreign MHC. Inflammation and 7 leukocyte infiltration of graft vessels results. Most common type. T-Cell mediated process resulting from the foreign MHC “looking lke” a self MHC ‘Months to years. | carrying an antigen. Results in intimal maw thickening and fibrosis of graft vessels as ‘well asgratt atrophy Donor T-Cellsin the graft proliferate and attack the recipient’ tissue. Most Varies commonly seen in bone marrow v transplants. Presents with diarrhea, rash and jaundice * The most important thing to remember is the timeframe for the onset of symptomsas you can often etermine what type of rejection it is based on time alone Weeks to months 76. In order to expose the right axillary artery, a transverse skin incision is typically made below the clavicle from a point just lateral to the sternal end of the clavicle to the deltopectoral groove. Which of the following structures would be encountered in the dissection down to the vessel? -eromal a. Lateral thoracic artery ‘bandh b. Phrenic nerve aan ©. Suprascapular artery | fedora d. Thoracic duct ranch e. Thoraco-acromial artery ‘ary 2.— MRCSalah Courses7T. A 4-year-old boy presents to the Emergency Department with a two-day history of headache vomiting and drowsiness. A CT scan reveals dilatation of both his lateral ventricles and his third cerebral ventricle. His fourth ventricle was of normal size. It is suspected that he has an obstruction to his cerebrospinal fluid flow. At which of the following sites is the ‘obstruction most likely to be? Cerebral aqueduct (of Sylvius) Infundibular recess Interventricular foramen (of Monro) Lateral foramen of fourth ventricle (foramen of Luschka) Median foramen of fourth ventricle (foramen of Magendie) a b. c. a. e. ‘Two views ofthe ventricles, which ae fled with cerebrospinal uid 78. A 12-year-old boy presents to the Emergency Department two hours after helping his father cut the grass. He complains of rhinorrhea, itchy eyes, sneezing and a blocked nose. He is apyrexial with a haemoglobin of 12.2 g/dl and white blood cell count of 6.8 * 109/L with a raised eosinophil count. Chest X-ray is clear. Which immunoglobulin is most likely to cause this reaction? (ACID >EGGT) a le Tables b. Igd Classification of hypersensitivity reactions ce. IgE according to Gell and Coombs ealue “hype _Allematine name Associated dieases Mediator ue 1 immediate "Atopy IgE hypersensitivity Anaphylaxis ‘asthma | Antibody-mediated Autoimmune IgG or igo hypisersitviy hemolytic anemia and complement Goodpasture’s disease Erythroblastosis fetalis: 1M Iemmune complex- Serum sickness IgG mediated ‘Afhus Reaction andcomplomont hypersensitivity Lupus nephritis IV Delayed ‘Transplant rejection T cells, hypersensitivity, Contact dermatitis Macrophages, Tuberculosis histiocytes. MRCSalah Courses PartA Tass79. A 36-year-old woman undergoes gastric bypass surgery for morbid obesity. At a subesequent surgical clinic review she complains of dizziness, sweating, palpitation and collapsing episodes after big meals without any vomiting or pain. she is otherwise well and has no medical problems. What is the most likely explanation for her symptoms? a. Operative denervation of stomach b. Release of gastrin ¢. Release of glucagon % o. Vacovagal syncope Dumping Syndrome Gastrectomized Patients: pid and unregulated dumping of = The chyme into the intestine TWO TYPES: Attacks last about 30 minutes 1. Early dumping immediately aftera meal “tssociated with hypovolemia [Fld inblood) ad hypotension ~caused by hyperosmotic chyme entering duodenum “rapidly extracts large amounts of uid from cicUation into interne 2. Latedumping—approx.2h aftera meat “due 1 hypoglyemia—chyme dumped nto intestine resus inrapd absorption of glucose into blood ~sudden blood hyperglycemia ~rapid increase in insulin that cvercorrectsand reautsin hypoghyceria Symptoms: weakness, dizziness and sweating after meals 80. A 56-year-old man with chronic emphysema is on the high dependency unit (HDU), ten days after anterior resection. He has developed acute shortness of breath and hypotension. Which of the following landmarks would be the most appropriate to use to obtain a femoral arterial blood gas sample? a. A point midway between the anterior superior iliac spine and the pubic tubercle b. A point midway between the anterior superior iliac-spine and the' pubic symphysis, c. A point midway between the greater trochanter and the pubic symphysi d. A point 1 cm inferior and 4 cm lateral to the pubic tubercle ‘e. Apoint 2 cm lateral to the midway point between the anterior superior iliac spine and pubic symphysis Femoral a. 1 Mid-ngui ASIS of the pelvis, Midpoint of the inguinal ligament Deep/internal ring recognise Pbeberse ‘ MRCSalah Courses81. A 70-year-old man complains of persistent numbness since an inguinal hernia repair one year previously. The numbness affects the top of the scrotum, root of penis, and a small area below the medial part of the inguinal ligament. Which nerve is likely to have been damaged? Femoral branch of the genitofemoral nerve Genital branch of the genitofemoral nerve Wichypogastric nerve Hioinguinal nerve Medial cutaneous branch of the femoral nerve sose 82. A 12-year-old girl has a diastolic murmur. Itis maximally audible in the second left intercostal space. Pathology of which structure is the most likely cause? a. Aortic valve b. Ductus arteriosus ¢. Mitral valve d. Pulmonary valve e. Tricuspid valve TABLE] EXPLANATIONS OF THE AUSCULTATION AREAS. ‘The postion on the sternum | "hich sounds (a "Ths second intercostal space A(Aortic area) | to meright ofthe aernere Aortic valve Sasie eenener intercostal space | — pom onic valve area) {o the lef of the stermum. ‘CTricuspid | The fourth intercostal space | Tricuspid and right area) to he le ofthe stemun. heart sounds “The fifth intercostal space in| Mitral and ett heart Désitral area) | themidclavicular line, ‘sounds MRCSalah Courses83. A 34-year-old pregnant woman develops a swollen leg. Her mother and maternal aunt also had similar problems during their pregnancies. Which of the following tests is likely to be positive? a. Antiendomysial antibodies b. Antimitochondrial, antibodies c. Antinuclear antibodies d. Antiphospholipid antibodie: e. Antithyroglobuiin antibodies Antiphospholipid syndrome Antiphospholipid antibody syndrome (APS) + Recurrent arterial or venous thromboses and/or pregnancy morbidity with the persistent presence of anticardialipin antibodies or lupus anticoagulant Major types of antiphospholipid antibody + False positive serologic test for syphilis * Lupus anticoagulant : positive in 30% of lupus * Anticardiolipin antibody : positive in 40-47% of lupus + AntiB, olycoprotein f antibedy 84. The “fight or flight", response produces a release of epinephrins primary metabolic effect of epinephrine? a. Alanine shunt activation b. Cortisol release c. Glycolysis d. Tachycardia e. Vasoconstriction MRCSalah Courses85. A 58-year-old-man underwent an emergency appendectomy. Which of the following physiological parameters are consistent with sepsis? ‘Systemic Vascular Heart Rate Resistance Cardiac Output A L v x B 2 t v c © ¥ * D v + v E yr ue H — Lay nou v a Four Kinds of Shock Deu coe a Hypovolemic | Pale andcool| + | T | T | ¢ t Cardiogenic | Pale andcool| 7 | 7 | T | ¢ T Neurogenic | Warm eal Leas + Septic Warmand | + | & | t | t [Nochange | faint 86. A 50-year-old man with a 30-year history of pancolitis undergoes surveillance colonoscopy which reveals a plaque-like lesion in the descending colon. Biopsy reveals a pre-malignant change. What is the name of this pre-malignant change? a. Anaplasia b. Dysplasia c. Hyperplasia d. Metaplasia e. Neoplasia * Dysplasia is a condition marked by abnormal cells that can lead to enlarged tissue or pre- cancerous cells. Norma Cells May Become Cancer Cells ~ typerpesa —> Dyeptna MRCSalah Courses87. A 60-year-old man undergoes cystectomy for a bladder carcinoma. During surgery, the ureters are identified. On which ragion of the bladder do the ureters pierce the bladder wall? a. Anterior surface b. Apex c. Lateral surfaces d. Neck e. Posterior surface 88. A year-old patient in the intensive care unit has a tracheostomy performed via the second, third and fourth tracheal rings. Which intervening structure is most likely to require transaction ? Anterior jugular vein Inferior thyroid veins ‘Sternothyroid muscle Thymus Thyroid isthmus eaose 89. A 23-year old manis assaulted and sustains a stabbing injury to the left groin. The wound- is cleaned anda simple dressing applied; Six months later the patient returns with pulsatile swelling at the site of the injury. The most probable: lesion present is: a. Abscess b. False aneurysm of the femoral artery c. Lymphocoele d. Mycotic aneurysm of the femoral artery fe. Saphena varix MRCSalah Courses90. A 72-year-old man with a body mass index of 18.4 has not eaten for four days following the removal of an adenocarcinoma from his descending colon. His urea is found to be 12 mmol/L (normal 3.2-7.5) and creatinine 346 umol/L (normal 35-110). A blood gas profile is ordered. The most likely set of results would be? A: (Metabolic acidosis) PH poz pOo2 Bicarbonate A 7.23 13.6 kPa 3.8 KPA 13.5 mmol/L 8 7.20 @.8kPa B.3kPa 30.5 mmol/L. c 7.36 14.5 kPa 5.3 kPa 30.5 mmol/L. D 7.43 16.4 kPa 3.7 kPa 21.0 mmol/L E— 7.49 12.6 kPa 3.9 kPa 24.0 mmol/L Normal 7.35-7.45, 11.9-13.3 4.76.0 22-26 91. A 16-year-old boy is hit on the left side of the face by a balll. There are no broken bones but the boy complains of numbness of the face below the eye. Which nerve has most likely been compromised? ‘Abducens nerve. Facial nerve ‘Seprarital neve Glossopharyngeal nerve . Suoravoca neve infra-orbital nerve Zygomatic nerve paegp Metal nerve 92. A 74-year-old man, who has undergone emergency major abdominal surgery two-days previously, is noted to be confused. He has been on furosemide for mild heart failure. The plasma sodium is 122 mmol/L Inspection of the fluid chart shows that he has been written- up for 1L, four-hourly intravenous 5% glucose infusions. What is the most likely cause for the hyponatremia? a. An ACTH (Adrenocorticotrophic hormone) response to surgery nao, b. Excessive sodium-free intravenous fluid mn administration aes ¢. Osmotic effect of hyperglycemia induced by glucose infusions d. Syndrome of inappropriate antidiuretic hormone @. Use of loop diuretic in the long term MRCSalah Courses93. The Cori cycle is important in lactate metabolism in the Septic surgical patient It is used to describe a pathway in which glucose is metabolised anaerobically to lactate in one tissue and the lactate is converted back to glucose in another; Which one of the following relies on this cycle to meet all of its energy needs? Aeneas: rhe Cori's cycle or Lactic acid cycle b. Hey te o temas Cat Cor and Gary Cn wae aware Noel pre d. Osleocyte ir rigsalieia + Lactate formed in . Pneumocyte muscles or RBC transported to liver. + In fiver cell LOH converts lactate to pyruvate. + Pyruvate enters GNG toform glucose. The Cori Cycle operates during exercise. Lactate is efficient reutiized by the body ‘94. After receiving an intermascular Injection in the buttock, a 25 year-old man complains of inability to evert his foot Which nerve is most likely to have been injured? a. Common peroneal (fibular) component of sciatic b. Inferior gluteal c. Pudendal feces d. Superior gluteal peroneal rene e. Tibial component of sciatic tog eves) rare spies eg (Corstens of ‘ein extensors 95. A 73-year-old man with a history of irregular bowel movements presents with dysuria, pneumaturia and an Escherichia coli urinary tract Infection. CT scans show a mass involving the sigmoid colon and the bladder. What is the commonest cause of this presentation? a. Adenocarcinoma of the sigmoid colon b. Colonic diverticular disease ©. Crohn's disease . Transitional cell carcinoma of the bladder @. Ulcerative colitis MRCSalah Courses96. A 7 year-old woman is in the recovery area and receives 28% oxygen by mask. ABG Shows: PH PO2 PCO2 Finding 7.2 iz kPa 10 kPa Normal 735-745, 41.9-13.3 47-60 Reduced sensitivity of which receptors is most likely to be responsible for this blood gas pic? a. Adrenergic receptors b. Baroreceptors c. Central chemo-receptors d. Jreceptors e. Lung stretch-receptors 97. A 76-year-old woman falls and sustains an inter-trochanteric fractured neck of femur Following operative fixation her recovery is prolonged and she is discharged to a rehabilitation unit Six weeks after her original operation she is readmitted. She is drowsy, hypotensive and bradycardic. An ECG shows low voltage complexes and a prolonged QT interval Under-activity of which of the following glands gives the best explanation of the clinical picture? a. Adrenal : b. Pancreas Ai 2 c. Parathyroid ] ae d. Pituitary cs e. Thyroid — |_ [Ve TA VEe \z 98. A 36-year-old man falls on his outstretched right hand. Examination reveals tenderness in the anatomical snuff box. Which one of the following tendons forms a boundary of the anatomical snuff box? Abductor pollicis brevis Extensor carpi radialis brevis Extensor carpi radialis longus Extensor indicis Extensor pollicis longus epesp MRCSalah Courses99. A 65-year-old woman with metastatic breast cancer is admitted to hospital confused and acutely unwell, with nausea and vomiting. Her vital signs are within normal limits. What abnormality is most likely to contribute to her clinical condition? a. Hypercalcaemia Pees nt CR b. Hyperkalemia cs c. Hypocalcaemia Osteoporosis Normal d. Hypokalemia Scacaaeaest v + e Hyponatremia Paget's Normal +4 Myeloma 4,Normal_ Normal Bone Metastasis A.Nommal 1° Hyperparathyroidism itiormal Normal, Hypoperathyroidsm * Normal 4% Normal, 100. A 4-year-old boy presents to the Emergency Department with a two-day history of fever, difficulty walking and is unable to weight bear on the right leg. He has been on oral Amoxycillin 250 mg three times a day for a chest infection over the last five days. H irritable with a temperature of 39.4°C. He does not allow examination and keeps his right hip flexed and abducted. Blood tests are: white blood cell count; (WBC) 12.3 x -109/dL, C-Reactive protein (CRP) 146, haemoglobin 11.3 g/dL What is the most likely diagnosis? a. Acute avascular necrosis of hip b. Dislocation of hip c. Perthes disease d. Septic arthritis €. Slipped upper femoral epiphysis 101. A 35-year-old woman presents with recurrent peptic ulceration. She is on proton pump inhibitors and previously received Helicobacter pylori eradication therapy three months ago. Which of the following is likely to be raised on venous blood testing? a. Cholecystokinin b. Gastrin ©. Histamine GASTRINOMA d. Pancreozymin e. Secretin » -Syndrome: Zollinger-Ellison » -Hormone: gastrin » -Clinical features: abdo pain, peptic ulceration, diarrhoea, gastric hypersecretion » -site: duodenum ~ 70%; pancreas - 25% » - >50% malignant » -Diagnosis: increased serum gastrin >1000p/ml basal acid output >15mEq/hr » -localization: CT/MRI/US -less useful » Somatostatin receptor scin. - sensitive test MRCSalah Courses