Neurology 4 mrcp answers book - part 1 ppsx

Q11: Answer: c Option A and B are true and indicates the predominance of the right coronary arterial RCA system in cases of RCA occlusion causing AV blocks in inferior wall myocardial i

Answers Book / Contents:

A total of 17 chapters containing 713 Answers

distributed as;

1- Cardiology; 55 answers.

2- Pulmonary medicine; 51 answers.

3- Gastroenterology; 50 answers.

4- Hepato-biliary system; 30 answers.

5- Nephrology; 51 answers

6- Electrolytes and Acid-Base Disturbances; 20 answers.

7- Endocrinology; 50 answers.

8- Diabetes Mellitus; 20 answers.

9- Hematology; 40 answers.

10- Rheumatology; 50 answers.

11- Neurology; 176 answers.

12- Infectious diseases; 40 answers.

13- Immunology; 10 answers.

14- Psychiatry 10 answers.

15- Dermatology; 35 answers.

16- Genetics; 5 answers.

17- Toxicology; 20 answers

NB: Questions regarding basic medical sciences are distributed throughout chapters

This is the Answers Book Please see questions in the Question Book

The art of medicine involves questions It involves

questions asked when taking a medical history, when forming a differential diagnosis, and when planning a diagnostic or therapeutic plan MRCP candidates,

regardless of their level of training, are constantly

confronted with questions posed from past papers, from patients, from mentors, and from within themselves The time-honored, question-based, Socratic approach

of teaching is alive and well in academic and clinical world of internal medicine This book is intended to provide the reader with many of the questions and

answers commonly encountered during their MRCP study and period of preparation This book is not meant

to replace textbooks Rather it intended to focus on the lead-in questions and topics commonly seen in the

MRCP examination Please read textbooks to boost

your level of knowledge Some of the 1st chapters were launched in www.aippg.net website; but these are now modified and updated.

I'm greatly thankful to my direct board supervisor Professor Doctor Khalil Al-Shaikhly (MRCP UK,

FRCP Glasgow) for his continuous support, to our dear patients, and to my dear friends and colleagues

Dr Osama Amin

All Rights Reserved January 2006

http://neurology4mrcp.orgfree.com/

http://neurology4mrcp.bravejournal.com/

mrcpfrcp@gmail.com

Chapter I / Cardiology Answers

Q1:

Answer: e

All other options are true, and also: hypertrophic obstructive cardiomyopathy, and right ventricular hypertrophy Note that the causes are not that many and they are easy

to be remembered

Remember: TRUE and isolated posterior wall MI is very rare, usually associated with inferior wall myocardial infarction, so look also at lead II, III, and aVF (i.e right coronary artery occlusion)

NB: Mirror image dextrocardia and wrong lead connection (so called limb lead

reversal) are usually forgotten as a cause of prominent R wave in lead V1

Q2:

Answer: e

All other options are associated with ST segment depression

Causes of ST elevation:

A- Full thickness myocardial infarction ( so called ST segment elevation myocardial infarction or STEMI)

B- Early repolarization after an attack of angina

C- Acute pericarditis

D- Ventricular aneurysm

E- Transiently during cardiac and coronary angiography

F- Prinzmetal's angina

Again, these are easy to be remembered as they are few in number

Q3:

Answer: e

Remember, ventricular arrhythmias in WPW (apart from ventricular fibrillation degenerated from atrial fibrillation) are highly atypical, and suggest either an

alternative diagnosis or co-existent pathology ( e.g amiodaron given in this patient in the long term to prevent arrhythmias, causing long QT interval and then torsades de pointes ventricular tachycardia)

Q4:

Answer: e

Left sided cardiac lesions are not part of Noonan's syndrome and suggest an acquired defect e.g mitral stenosis following a rheumatic fever attack

Remember: short stature may be seen ( the phenotype is usually mistaken for that of Turner's syndrome), so be ware of a FEMALE Turner's with right sided cardiac lesions, actually she may be Noonan's as it is an autosomal disease (male=female)

Q5:

Answer: d

Remember, long QT Syndrome is a risk for torsades de pointes ventricular

tachycardia Long QT syndrome can be caused by:

1-Inherited syndromes (congenital long QT syndromes)

2-Electrolyte imbalance (see above)

3-Mitral valve prolapse

4-Rheumatic carditis

5-Drugs (like Class Ic and III anti-arrhythmics)

6-Bardycardia associated: any cause of bradycardia, hence the use of isoprenalin infusion in such cases (be ware, it is contraindicated in congenital cases)

Q6:

Answer: c

a- False, sarcomeric contractile proteins gene mutation Many types of mutations had been detected, and certain gene mutations per se predict a poor prognosis

b- False, 50% of cases 25% of Idiopathic dilated cardiomyopathy patients have a positive family history

c- True, but the presence of obstructive element per se does not predict a poor

prognosis

d- False, many cases are totally asymptomatic and detected by doing

echocardiography for some reason or another

e- False, the asymmetric septal type is the commonest one, but the apical variety is the predominant one in the Far East Note that there are certain variants which do not have cardiac hypertophy at all

Note that the commonest mutations are seen in:

1- Beta myosin heavy chain gene, associated with elaborate ventricular

hypertrophy

2- Troponin gene, little or no ventricular hypertrophy, abnormal vascular

responses upon exercise, and there is a high risk of sudden death

3- Myosin binding protein- C gene, usually manifested later in life, often

associated with prominent cardiac dysrrhythmias and systemic hypertension

Q7:

Answer: b

a- True, the usually seen type with no cause that can be identified, although a viral etiology is supposed to be the culprit

b- False, rarely progresses, and most of cases follow a benign course

c- True, with a risk a hemorrhagic component The presence uremic pericarditis in those on dialysis indicates an inadequate dialysis regime, or if the patient was not on dialysis, then it is an indication to start dialysis

d- Be ware of this, a disappearance of the rub indicates either:

1- A transient phenomenon, which is very common in clinical practice

2- A resolution of the process

3- A fluid collection in the pericardial sac

e- True, usually presents either as a progressive collection of a large effusion or a chronic constrictive picture

Q8:

Answer: a

a- True, type A aortic dissection presenting as an inferior wall myocardial infarction due to involvement of the ostium of the right coronary artery, and an acute aortic regurgitation

b- Pregnancy now is considered to be a relative contraindication

c- Proliferative diabetic retinopathy is a relative contraindication

d- Severe but easily controllable hypertension is a relative contraindication

e- Actually, thrombolysis is STRONGLY indicated here

Q9:

Answer: a

Hydralazine and minoxidil, both have a pure arteriolar dilating effect Others are having arterilolar and veno-dilating effects

Q10:

Answer: e

The followings indicate a high risk unstable angina:

1- Post-infarct angina

2- Recurrent chest pain at rest

3- Development of heart failure

4- Cardiac dysrhythmias

5- The presence of transient ST segment elevation

6- The presence of ST segment depression

7- The persistence of deep T wave inversion

8- Cardiac troponin level of more than 0.1 microgram / L

Q11:

Answer: c

Option A and B are true and indicates the predominance of the right coronary arterial( RCA) system in cases of RCA occlusion causing AV blocks in inferior wall

myocardial infarction

Option c is false Although used by many PTCA centers, such an approach should be done only by those who are highly experienced, otherwise CABG should be used

Q12:

Answer: d

The corneal deposits are usually reversible Other side effects: pulmonary fibrosis, slate grey skin pigmentation, hepatotoxicity Always, be ware of drug interactions in any combinations 40% of the drug is iodine, hence the risk of either hypo or

hyperthyroidism

Q13:

Answer: d

a- Superior vena cava obstruction causing FIXED JVP elevation

b- Pericardical constriction

c- Right ventricular infarction

d- False There is hypovolemia causing low JVP (unless there is a coexistent

pathology like heavy alcoholism causing cirrhosis and cardiomyopathy Also the JVP

is useful in differentiating cirrhosis from pericardial constriction)

e-Ebstein anomaly and tricuspid regurgitation

Q14:

Answer: c

a- True, the usual story (but presents as heart failure in infancy)

b- True, in certain series may reach 50%(remember, both the site of the coarctation and the bicuspid aortic valve are high risk factors for infective endocarditis)

c-False, usually seen after the age of 6 years

d- and e are true, hence in any young patient with SAH and previous "high" blood pressure you must exclude coarctation of the aorta

Q15:

Answer: e

Atenolol had not been studied in these trials

Other drugs that improve the survival figure in chronic congestive heart failure are ACE inhibitors

Remember: Diuretics (apart from spironolactone) and digoxin do not improve the survival figure in chronic congestive heart failure

Q16:

Answer: d

Causes of culture negative endocarditis:

1-The commonest is prior antibiotic treatment

2-Fastidious organism like HACEK group or a difficulty in culturing like brucella species

3-Fungal endocarditis and Q fever

4-Marantic and Libman Sacks endocarditis

5- Poor lab techniques and errors in collection of the blood samples (staph

epidermidis colonies FREQUENTLY reported by the lab as a NORMAL skin

commensal)

Q17:

Answer: e

Any cardiac lesion that is associated with a "JET" lesion due to high flow indicates a high risk, mitral stenosis is actually associated with a SLOW flow across the valve so

it has a low risk Remember the highest risk is seen in: a-previous history of infective endocarditis whatever the original cause was, and b-Prosthetic valves

Q18:

Answer: c

Always GUESS the "best treatment" based on risk factors and history e.g staph or fungal endocarditis in IV drug addicts with a tricuspid valve endocarditis, and give the treatment accordingly, pending the culture results

Always remember that persistent FEVER may indicate failure of medical treatment and persistent infection which is an indication for surgery Other causes should

always be excluded:

1- Resistant organism e.g staph aureus to benzyl penicillin

2- A non-bacterial cause like fungal organisms

3- Superficial thrombophlebitis, as these drugs are given by an iv route

d- "Drug fever "

e- Coexistent pathology like wound infection or a visceral abscess that is difficult to

be treated which may be actually the cause of the endocarditis e.g staph abscess disseminating to produce metastatic lesions including involvement of the heart valves

Q19:

Answer: d

In general, S3 indicates rapid early ventricular filling and /or high flow across the mitral valve (or tricuspid valve in right sided S3) or a systolic dysfunction, so it is not seen in PURE mitral stenosis as the flow is already impeded across the valve If you are sure that it is mitral stenosis and you heard a left ventricular S3 sound, this either indicates MIXED mitral valve disease with the regurgitation is the predominant lesion

or an associated aortic regurgitation or simply a an LV dysfunction from other cause ( always remember that rheumatic heart disease is frequently associated with multiple valvular lesions Be sure it is not a right ventricular S3 as this may be seen in PURE mitral stenosis due to right sided heart failure

Q20:

Answer: c

It is supravalvular in William's (with mental retardation, hypercalcaemia, and elfin faces)

A thrill is commonly felt at the neck (carotid shudder) and once symptoms appear you have to intervene, usually ending with valve replacement

Remember: always see the age of the patient as this may indicate the cause and

always see features of HOCM as the management is totally different Aortic stenosis per se is a risk factor for infective endocarditis before and after surgery

Q21:

Answer: e

Always LEAVE some leg edema (i.e one plus edema) as total DRYNESS means profound hypovolemia and this would result in many complications e.g prerenal failure and electrolyte imbalance

Q22

Answer: b

The objectives of treatment in this diastolic heart failure differ from that of congestive heart failure states with systolic dysfunction Targets of treatment in general are: 1- Control rate: to give time for the ventricle to fill properly, hence tachycardias have

a deleterious effect

2- Control edema: with diuretics

3- Control hypertension

4- Control the original disease: e.g aortic stenosis

Till now and unfortunately there is no general consensus about the optimal medical treatment ACE inhibitors have NO effect on the overall mortality figure (cf systolic congestive heart failure)

Aortic stenosis, not regurgitation, is a cause

Q23:

Answer: e

Secondary hypertension may develop in the way of long standing essential

hypertension like the development of an atherosclerotic renal artery stenosis and causing deterioration in the in the overall hypertension control

Remember: renal artery stenosis is both a cause and an effect of hypertension

Remember: renal failure is both a cause and an effect of hypertension

Strong family history of hypertension usually goes with essential variety

Q24:

Answer: b

Poorly controlled hypertension is a very powerful risk factor for intracerebral

bleeding, Diuretics (and non-dihydropyridin calcium channel blockers) are the first line agents in old people with essential hypertension In diabetic nephropathy with persistent proteinuria the target should be below 120 / 75 mmHg

Q25:

Answer: 5

Option e is a protective one

Q26:

Answer: 5

Isolated systolic heart failure is highly unusual in long standing hypertension and suggests a coexistent pathology like toxic causes

Q28:

Answer: a

Metoprolol, acebutolol, and atenolol are cardio selective

Q27:

Answer: c

High incidence of recurrence following surgery in seen in familial cases

Remember: the commonest site is the fossa ovalis at the left side of the interatrial septum (70%) Atypical sites usually indicate and occur in familial cases

Q29:

Answer: e

The JVP is a good "window" to see what is happening in the heart

In heart block the cannon "a" waves are irregular; if regular they may indicate a nodal rhythm

Q30:

Answer: d

Short PR interval occurs in:

1- Any tachycardia state (theophyllin may cause tachycardia)

2- Congenital short PR interval (WPW and LGL syndromes)

3- Ventricular ectopic occuring immediately after a sinus "p" wave

4- Nodal rhythms

Q31

Answer: b

WPW has many diverse and atypical ECG manifestations like psudo- MI pattern, pseudo-LVH pattern Posterior wall MI has a prominent R in lead V1 Other causes of pathological Q wave: HOCM and errors in leading and calibration of the ECG

machine

Q32:

Answer: a

Ebstien anomaly is not commonly associated with aortic coarctation All other options are true

Q33:

Answer: e

Morphine should be given IV as there is a risk of hematoma formation in SC route (remember the patient will be on a thrombolytic, aspirin and heparin)

Aspirin per se enhances the effect of the thrombolytic therapy and improves the mortality figure

Q34:

Answer: e

No place for Digoxin in secondary prophylaxis of MI Remember, the 4 drugs in this topic:

Aspirin, ACE inhibitors, beta blockers, and statins

Q35:

Answer: e

Option "e" may interfere with the performance and interpretation of the test There are many contraindications to exercise testing, and these are:

1-any significant left ventricular out flow obstruction eg severe aortic stenosis and hypertrophic cardiomyopathy

2-suspected or documented left main stem stenosis

3-untreated congestive heart failure

4-poorly controlled severe systemic hypertension

5-suspected aortic dissection

6-during the course of acute coronary syndromes eg unstable angina

7-aquired complete heart block

8-any febrile illness in general

9-acute pericarditis or myocarditis

Q36:

Answer: e

Such changes in middle aged woman with chest pain are seen commonly and

unfortunately affect the interpretation of the test as "false positive"

Options a, b, c and d and also development of such changes at an early stage of Bruce protocol (ie low threshold for ischemia) indicate a STRONG positive test and a high risk for subsequent coronary events

Q37:

Answer d

Option "d" actually indicates a strong positive exercise ECG testing and should be followed by angiography as this indicates a high risk patient for subsequent coronary events

Others are truly a cause of such a false positive results, and also electrolyte

disturbances like hypokalemia, anemia, beta blockers, left bundle branch block, and hyperventilation

Q38:

Answer: e