MRCP 1

Last Minute
Practice Questions
Second Edition
W Stephen Waring FRCP (Edin) PhD
Consultant Physician & Honorary Senior Lecturer
Acute Medical Unit
York Hospital
York

Philip D Ambery MBChB MRCP (UK) MFPM

Dip Pharm Med
Medical Director
GSK R&D and Honorary Clinical Fellow
Addenbrookes Hospital
Cambridge

CONTENTS
Introduction
Abbreviations
1. Cardiology

v
vii
1

Questions and Answers

2. Clinical Pharmacology

47

Questions and Answers

3. Clinical Sciences

113

Questions and Answers

4. Dermatology

179

Questions and Answers

5. Endocrinology

203

Questions and Answers

6. Gastroenterology

249

Questions and Answers

7. Haematology and Oncology

297

Questions and Answers

8. Infectious Diseases

343

Questions and Answers

9. Nephrology

389

Questions and Answers

10. Neurology

429

Questions and Answers

11. Ophthalmology

477

Questions and Answers

12. Psychiatry

489

Questions and Answers

13. Respiratory

515

Questions and Answers

14. Rheumatology

559

Questions and Answers

Index

609
iii

Q
1. CARDIOLOGY
A 24-year-old traveller comes to the clinic. He is short of breath and
has regular episodes of chest pain. His maximal right ventricular
(RV) pressure is 112 mmHg, his maximal left ventricular (LV)
pressure is 82 mmHg, and his LV O2 saturation is 85%. What is the
most likely finding on examination?

1.1

A An early diastolic murmur

B

Hypoxia which doesnt resolve on oxygen therapy

C Narrow, tented P waves on electrocardiography (ECG)

D Radio-femoral delay
E

Tapping apex beat

A 64-year-old man collapsed in church complaining of chest pains.

On examination his BP is 85/50 mmHg and he has very rapid
palpitations. His ECG shows ventricular tachycardia with a rotating
axis (torsades de pointes). Which of the following drugs is least likely
to be associated with this arrhythmia?

1.2

A Digoxin
B

Flecainide

C Risperidone
D Sotalol
E

Verapamil

A 62-year-old woman with manic depressive psychosis, who is on

lithium, is sent to you for management of hypertension. Her BP is
160/85 mmHg. Which one of these agents would be least likely to
have an adverse interaction with lithium?

1.3

A Amlodipine
B

Bendroflumethiazide

C Bisoprolol
D Enalapril
E

Irbesartan

Cardiology questions

A
1.1

Answer: B
This man has a right-to-left shunt as a result of a longstanding
ventricular septal defect (VSD). There is a pansystolic murmur,
displaced apex and broad P waves.

1.2

Answer: E
Verapamil suppresses depolarisations and suppresses dispersion of
repolarisation in the left ventricular wall. Other drugs which can
predispose to torsades include macrolide antibiotics and antifungals
such as ketoconazole.

1.3

Answer: C
Thiazides have an antidiuretic effect combined with lithium; ACE
inhibitors increase lithium concentration and can promote toxicity in
some patients. Calcium antagonists can provoke lithium
neurotoxicity.

Cardiology answers

Q
A 39-year-old smoker has sharp stabbing chest pain which is made
worse by inspiration and by lying flat. His temperature is 38.2 C
and you can hear a coarse rub at the left sternal edge. His ECG
shows 1-mm ST elevation. What is the most appropriate treatment
for him?

1.4

A Aspirin
B

Clopidogrel

C Diclofenac
D Low molecular weight (LMW) heparin
E

rTPA (recombinant tissue plasminogen activator)

A 65-year-old woman with a history of type 2 diabetes and atrial

fibrillation comes to the clinic. She has failed cardioversion and has
an enlarged left atrium on echocardiography. How should she be
managed?

1.5

A Aspirin
B

Clopidogrel

C Aspirin and dypridamole

D Warfarin
E

Aspirin and clopidogrel

A 60-year-old man comes to the clinic for heart failure review. He is

already taking adequate doses of furosemide, ramipril, bisoprolol
and spironolactone. Over the past few months his heart failure has
got so bad that he has been confined to the downstairs of his home
and can only walk a few paces. On examination he has a blood
pressure (BP) of 110/70 mmHg, significant bilateral crackles on
auscultation and bilateral ankle oedema. His creatinine is
130 mol/l, his ejection fraction is 29% and he has a QRS of 165 ms.
What should you do next?

1.6

A Arrange a single-chamber pacemaker

B

Arrange cardiac resynchronisation therapy

C Implant a cardioverter/defibrillator
D Increase his furosemide
E

Start digoxin

Cardiology questions

A
1.4

Answer: C
This man has symptoms and signs of acute pericarditis, most likely
viral in origin. He should be told to rest and be given an appropriate
NSAID for pain relief.

1.5

Answer: E
In this patient, who is at high risk of embolic disease, warfarinisation
is recommended according to NICE guidance CG36.

1.6

Answer: B
This man fits the NICE criteria for cardiac resynchronisation therapy;
studies suggest that he might derive significant symptomatic benefit.
Digoxin is useful for symptoms of heart failure where other options
are exhausted.

Cardiology answers

Q
A 58-year-old woman with a history of breast cancer who is
12 months post-chemotherapy comes to the clinic with shortness of
breath. She received a regime including transtuzumab. Her BP is
135/82 mmHg and her pulse is 92/min and regular. Her JVP is raised
and she has bibasal crackles. What is the most likely diagnosis?

1.7

A Carcinomatous pericardial effusion

B

Chemotherapy-related cardiac failure

C Lymphangitis carcinomatosa
D Malignant pleural effusion
E

Radiation-related pulmonary fibrosis

A 62-year-old diabetic man had a bare metal stent inserted for

inferior myocardial infarction. He re-presents with central chest pain
and has new inferior ST depression. His troponin is negative. What
is the most likely diagnosis?

1.8

A Chronic stable angina

B

Coronary artery vasospasm

C Embolism distal to the stent

D In-stent re-stenosis
E

New coronary artery disease distal to the stent

A 52-year-old man comes to the clinic with a history of type 2

diabetes (for which he takes metformin), hypertension and obesity,
with a BMI of 34 kg/m2 despite diet and exercise modification.
Which of the following drugs might be most helpful in managing
his obesity and diabetes?

1.9

A Exenatide
B

Orlistat

C Rimonabant
D Sibutramine
E

Thyroxine

Cardiology questions

A
1.7

Answer: B
Transtuzumab is known to cause congestive cardiac failure. It is
thought that ErbB2 expression might be crucial in preventing the
development of dilated cardiomyopathy.

1.8

Answer: D
In-stent re-stenosis is much commoner in patients with a history of
diabetes. This finding precipitated the increased use of coated stents,
but these appeared to be associated with an increased risk of late
re-stenosis. This has led most recently to guidance being given that
dual antiplatelet therapy with aspirin and clopidogrel should be given
for an extended period in diabetics.

1.9

Answer: A
Exenatide has shown superior reductions in blood glucose to orlistat,
with average reduction in weight of 5 kg during the first year of
therapy.

Cardiology answers

Q
A 74-year-old man who lives alone presents to the Emergency
Department after a collapse in the supermarket. On examination he
has a BP of 110/70 mmHg and a pulse of 62/min with seconddegree heart block. While he is being monitored overnight he has
two episodes of complete heart block, the longest lasting for 8 s.
When you question him in the morning he tells you he has passed
out on two other occasions in the past 6 months. He takes
bisoprolol and ranitidine. Which of the following would be the best
course of action?

1.10

A Dual-chamber permanent pacing

B

Single-chamber permanent pacing

C Stop bisoprolol
D Stop bisoprolol and ranitidine
E

Stop ranitidine

A 72-year-old woman comes to the Emergency Department with

nausea, central crushing chest pain and sweating. Her 12-lead ECG
shows widespread ST elevation in the anterior leads. You diagnose
an anterior myocardial infarction (MI) and prepare to move her to
the Catheter Lab. Her pulse suddenly slows to 40/min complete
heart block. She shows little response to atropine. Which one of the
following could be the optimal treatment for this condition?

1.11

A Adrenaline (epinephrine)
B

External pacing

C Isoprenaline
D Repeated atropine
E

Temporary pacing wire

A 72-year-old man with long-standing chronic obstructive

pulmonary disease (COPD) comes to the clinic with shortness of
breath and ankle swelling. He has a raised JVP and pitting oedema
of his legs consistent with right heart failure. His BP is 152/89
mmHg. Which of the following will have most effect on his
prognosis?

1.12

A Bisoprolol
B

Furosemide

C Home oxygen
D Ramipril
E

Salmeterol/fluticasone inhaler

Cardiology questions

A
1.10

Answer: A
This man has symptomatic complete heart block, and as such
requires permanent pacing. Although both ranitidine and bisoprolol
exacerbate heart block, stopping them is unlikely to resolve the
problem.

1.11

Answer: E
This woman has an anterior myocardial infarction, with complete
heart block a very poor prognostic indicator. Unlike inferior MI, this is
much less likely to resolve completely after re-perfusion.

1.12

Answer: C
This man has right heart failure secondary to severe COPD. His
prognosis is very poor. Of the options given, home oxygen has the
most significant impact on outcome.

Cardiology answers