MRCP Rheumatology Questions

Let's us take a break and look at some of common rheumatology

questions in MRCP,
1) A 30 year gentleman was admitted to ward due to history of
backpain for 3 months. He denied small joints pain and history of
family members having the same problem. There was no history of
dysuria and red eye.Below is his X-ray. What is the diagnosis?

1) Ankylosing Spondylitis
2) Riters syndrome
3) Psoriatic arthropathy
4) Enteropathic spondylitis
5) Seronegative Rheumatoid arthritis
2) This gentleman presents with swollen joint and fever.

What is likely to be found on microscopy of aspirated synovial fluid?

1 )Bipyramidal crystals that exhibit strong positive birefringence under
polarised light
2 )Gram positive cocci in clusters
3 )Needle-shaped crystals that exhibit strong negative birefringence
under polarised light
4 )Rhomboid crystals that exhibit weak positive birefringence under
polarised light
5 )Small, non-birefringent crystals visible only under electron
microscopy
3) A 30 year-old man is admitted to casualty with a 24 hour history of
a painful and swollen right knee. He denies any previous history of
joint problems. Over the last two days, he has also noticed redness
and soreness in both eyes. He has returned from a business trip to
Kuala Lumpur a fortnight ago.
On examination, his temperature is 38.5C. His eyes are red. His right
knee is hot, swollen and tender to palpate. No other joint appears to
be affected.
Investigations:
Hb 12.9 g/dl
WBC 14.0 x 109/l

Platelets 200 x 109/l

ESR 75 mm/h
Blood cultures
No growth after 48 hours
Urinalysis
No blood, glucose or protein detected
Knee x-ray
Soft tissue swelling around left knee
What is the most likely diagnosis?
1 )Gout
2 )Gonococcal arthritis
3 )Reiter's syndrome
4 )Rheumatoid arthritis
5 )Viral arthritis
4) Which of the following statements are correct regarding this
patient's condition?

1 )It occurs more commonly in men

2 )Rheumatoid factor is positive in >90% of cases
3 )It is associated with an erosive arthritis
4 )Raynaud's phenomenon is a feature in ~10%
5 )It is associated with a reduced transfer factor
5) A 22 year old lady presents with typical erythema nodosum. She
has a low grade fever and bilateral ankle arthritis but no other
symptoms and has no medical history. There is no history of travel
abroad and she is on no medication. Which of the following would be
the most appropriate investigation for this patient?
1 )Barium enema
2 )Chest x-ray
3 )ESR
4 )Upper GI endoscopy
5 )Viral titres
Get your answers here!
Below is the answers,
1)
2)
3)
4)
5)

1
3
3
5
2

Questions:
1)A 67 year old man presents with sudden onset atrial fibrillation
(ventricular rate of 150/minute). His serum creatinine concentration
was 250 umol/L (70-110).
What is the main factor that determines the choice of loading dose of
digoxin in this patient?
1 ) Absorption 2 ) Apparent volume of distribution 3 ) Lipid solubility
4 ) Plasma half-life 5 ) Renal clearance

ANSWER: 5
2)Serum digoxin concentrations are increased when given
with...EXCEPT
A Amiodarone B Spirolactone C Cholestyramine D Quinine E Verapamil
ANSWER: C
3) A 72 year old man is admitted with fast atrial fibrillation but is
receiving treatment with digoxin. An inadequate dose is suspected. A
sample of blood is drawn six hours after the last dose of digoxin and a
plasma concentration is requested.
Which of the following factors explains the six hour wait before
measuring the digoxin concetration?
1 ) enterohepatic circulation 2 ) the rate of absorption 3 ) the rate of
clearance
4 ) the rate of distribution 5 ) the rate of elimination
ANSWER: 4
4)A 65-year-old was advised to start oral digoxin at a dose of 250 g
daily. His physician explained that the full effect of this treatment
would not be apparent for at least a week.
Which one of the following pharmacokinetic variables did the physician
use to give this explanation?
1 ) bioavailablity 2 ) half-life 3 ) plasma protein binding 4 ) renal
clearance 5 ) volume of distribution
ANSWER: 2
Questions about anticoagulation in MRCP:
1)Which ONE of the following is a contraindication to thrombolysis?
1 ) age over 75 years 2 ) the presence of atrial fibrillation
3 ) asthma 4 ) pregnancy 5 ) background diabetic retinopathy
ANSWER: 4

2)A patient presenting with atrial fibrillation who has reverted to sinus
rhythm is more likely to remain in sinus rhythm in the following
circumstances:
A age >75 years old B been commenced on warfarin C left atrium size
> 6 cm on ECHO
D short history on AF E a ventricular rate on presentation of 130 bpm
ANSWER: D
3)A 70-year-old woman has a history of dyspnoea and palpitations for
six months. An ECG at that time showed atrial fibrillation. She was
given digoxin, diuretics and aspirin. She now presents with two shortlived episodes of altered sensation in the left face, left arm and leg.
There is poor coordination of the left hand. ECHO was normal as was a
CT head scan.
What is the most appropriate next step in management?
1 ) anticoagulation 2 ) carotid endarterectomy 3 ) clopidogrel 4 )
corticosteroid treatment 5 ) no action
ANSWER: 1
4)A 62 year old male undergoes cardioversion for idiopathic atrial
fibrillation. Post-procedure he was shown to be in sinus rhythm.
Medication at admission included Warfarin digoxin and atenololwhich
he had been taking for the last six weeks.
Which of the following agents should he continue to take until he is
seen in clinic in six weeks time.
1 ) Aspirin 2 ) Atenolol 3 ) Digoxin 4 ) Sotalol 5 ) Warfarin
ANSWER: 5
5)An 80 year-old male presented with palpitations of 5 hours duration.
One month previously he suffered weakness of the right arm and
problems with his speech which resolved within 4 hours. He was taking
no medication. On examination, he was stable with a pulse of 135
beats per minute which was confirmed to be atrial fibrillation on ECG.

He had a blood pressure of 112/80 mmHg, appeared clinically

euthyroid. Within one hour he reverted to sinus rhythm spontaneously.
Echocardiogram was normal but a 24 hour ECG revealed three
episodes of atrial fibrillation each lasting around ten minutes.
Which one of the following is the most appropriate initial treatment for
this patient?
1 ) Amiodarone 2 ) Aspirin 3 ) atenolol 4 ) digoxin 5 ) warfarin
ANSWER: 5
Common questions in MRCP part 1 and 2 are types of diseases HIV
patients will get according to their CD4 counts. One of the most
popular question is PCP. Always remember that HIV patients will get
PCP once their CD4 is lee than 200! Other common questions are as
follow,
1)A 24-year-old man presented with a ten-week history of
progressively worsening exertional dyspnoea and a dry cough.
Auscultation of his chest revealed fine inspiratory crackles to the midzones. He was afebrile. His chest radiograph is shown below. A Heaf

test was negative.

Which of the following investigations will be most helpful in

establishing a diagnosis?
1 ) Abdominal ultrasound scan 2 ) Atypical serology
3 ) Bone marrow aspiration 4 ) Bronchoalveolar lavage
5 ) CD4 T-lymphocyte count 6 ) Cytoplasmic antineutrophil cytoplasmic
antibody (cANCA)
7 ) C-reactive protein (CRP) 8 ) Erythrocyte sedimentation rate (ESR)
9 ) HIV antibody test 10 ) Peak flow rate
11 ) Plasma lactate dehydrogenase (LDH) 12 ) Sputum culture
13 ) Transbronchial lung biopsy 14 ) Trial of steroids
15 ) 24 hour urinary calcium excretion

ANSWER: 9,13, 15 (POSSIBILITY OF SARCOIDOSIS! CXR CAN BE

SIMILIAR TO PCP)

2)This HIV positive man presented with cough, haemoptysis and a

rash (shown).

What is the causative agent?

1 ) Mycobacterium tuberculosis 2 ) Pneumocystis carinii
3 ) Cytomegalovirus 4 ) Epstein-Barr virus
5 ) Human herpesvirus-8

ANSWER: 5

3) A 35 year-old man is admitted with a three week history of

progressively worsening dyspneoa accompanied by a non-productive
cough. For the 24 hours prior to admission he has been dyspnoeic at
rest. He also reports having occasional 'chills' and has felt febrile on
occasions.He has no other past medical history of note. He works as
an accountant with the local authority. He smokes 20 cigarettes per
day and occasionally smokes cannabis. He drinks 18-20 units of
alcohol per week. He is divorced and currently lives alone.He says that
his diet has been poor since he separated from his wife 2 years
previously; in this time he has lost about 2 stones in weight. He does
not take any regular medication.On examination he is dyspnoeic at
rest with a respiratory rate of 22/minute. He is febrile, 38C. His chest
is clear on auscultation.
Which of the following test results would most strongly support a
diagnosis of Pneumocystis carinii pneumonia?
1 ) Low absolute lymphocyte count 2 ) Lobar consolidation on the
chest radiograph 3 ) Oxygen desaturation on exercise 4 ) A normal
chest X-ray 5 ) Past history of homosexual contact

ANSWER: 3

4)A 44-year-old HIV seropositive patient is seen in a routine outpatient

appointment. He was diagnosed with HIV disease two years ago when
he presented with Pneumocystis carinii pneumonia (PCP) with a CD4 Tlymphocyte count of 40 cells/mm3. After being treated for PCP he was
started on combination antiretroviral therapy. His initial response to
antiretroviral therapy had been promising, with an increase in his CD4
count (210 cells/mm3) and achieving an undetectable HIV viral load in
the peripheral blood. One year ago, his CD4 count started to fall and
HIV RNA became detectable in peripheral blood. An HIV viral
resistance test confirmed resistance to all of his antiretroviral drugs.

The patient admitted that over the preceeding three months that he
had only been taking his therapy intermittently. Despite the risks, he
decided that he did not wish to have any further antiviral therapy. At
this point, his CD4 count was 20 cells/mm3 with a very high HIV viral
load of 120,000 copies/ml.Seven months ago he presented with
malaise, weight loss (8kg), fevers and night sweats. Mycobacterium
avium intracellulare (MAI) was isolated from a blood culture and he
was started on therapy with ethambutol and rifabutin. He subsequently
agreed to re-start antiretroviral therapy.During his clinic consultation,
he states that he has noticed a steady deterioration in his visual acuity
over the past four weeks. His current medications include stavudine
(d4T), didanosine (ddI), nevirapine, ethambutol, and rifabutin. On
examination, fundoscopy is normal.His last CD4 count, taken one
month ago was 30 cells/mm3, with an HIV viral load of 2500
copies/ml.
What is the most likely cause of his reduction in visual acuity?
1 ) Antiretroviral therapy 2 ) Cytomegalovirus retinitis 3 ) Ethambutol
4 ) HIV retinopathy 5 ) Toxoplasma retinitis

ANSWER: 3

5) A 26-year-old homosexual man presented to hospital with a fever,

dry cough and dyspnoea. Oropharyngeal candidiasis was noted. He
was found to be HIV antibody positive and Pneumocystis carinii was
found on bronchoalveolar lavage. His Pneumocystis carinii pneumonia
(PCP) was treated with intravenous co-trimoxazole and he was
subsequently started on highly active antiretroviral therapy
(HAART).Four weeks later he presented to clinic complaining of
weakness and generalised aching. He was taking highly active
antiretroviral therapy (zidovudine (AZT), lamivudine (3TC), nelfinavir),
co-trimoxazole as Pneumocystis carinii prophylaxis and
fluconazole.Investigations:Serum creatine kinase 700 IU/l (24-195)

What is the cause of this problem?

1 ) Co-trimoxazole 2 ) Fluconazole 3 ) Lamivudine (3TC) 4 ) Nelfinavir
5 ) Zidovudine (AZT)

ANSWER: 5
There are always questions about Cushings syndrome in MRCP Part 1
and 2 simply because it is a common disease in clinical practice. Some
of the questions I have about Cushings syndrome are as follow,
1) This 34 year old female( above picture) presents with a nine
month history of weight gain, weakness and
amenorrhoea. Examination reveals the appearances
as shown, a blood pressure of 180/110 mmHg and
proximal myopathy. Urinalysis shows ++ glucose
and a pregnancy test is negative.
Which of the following would be the most
appropriate diagnostic test?
1
2
3
4
5

)Random Cortisol concentration

)Oestradiol concentration
)Oral glucose tolerance test
)Pituitary MRI scan
)Urine free cortisol estimation

ASWER: 5
2) A 22 year old female presents with a one year
history of secondary amenorrhoea and a 5 year
history of facial hirsutism. Examination reveals
normal female secondary sexual characterisitcs
with mild facial hair and hair extending up to
the umbilicus and tops of thighs. Investigations
reveal an oestradiol concentration of 65 pmol/l
(NR 130 - 450), a LH of 3.2 mU/l (NR 3 -10
mU/l), a FSH of 3.5 (NR 3-10 mU/l), a prolactin
of 320 (NR less than 450 mU/l), a testosterone
of 3.4 pmol/l (NR less than 3). From the
following list, select two investigations that
may provide useful diagnostic information.

1 )17 hydroxyprogesterone (17 OHP) concentration

2 )Androstenedione concentration
3 )Dehydroepiandrostenedione sulphate (DHEAS)
concentration
4 )Karyotype
5 )Pregnancy test
6 )Sex Hormone Binding globulin (SHBG)
concentration
7 )Skin biopsy
8 )Thyroid function tests
9 )Transvaginal ovarian ultrasound scan
10 )Urine free cortisol concentration
ANSWER: 1,10
3) A 38 year old female presents with weight gain,
hirsutism and hypertension of 2 years duration. (above image)
She has also noted oligomenorrhoea over the last
2 years and over the last two months has had no
periods.
Examination reveals a BMI of 32.4, a reddish
complexion, with a blood pressure of 168/98 mmHg
and abdominal striae. She has difficulty rising
from a squatting position.
Investigations reveal the following: Normal
U+Es, FBC Normal, plasma glucose 12.1 mmol/l.
Thyroxine 12.4 nmol/l (NR 9.8 -23.1), TSH 0.85
mU/l (NR 0.5 - 4)
Oestradiol less than 80 pmol/l (NR 130 - 510),
LH 4.2 mU/l (NR 2-10 mU/l) FSH 2.1 mU/l (NR
2-10)
9 am Cortisol 550 nmol/l (NR 200 - 550 ) and
ACTH 45 (NR 8-50)
Midnight Cortisol 420 nmol/l (NR less than 180)
and ACTH 35 (8-20)
24hr Urine free cortisol 580 nmol/d (NR 90 290 nmol/d)
Normal chest X-ray, ECG shows LVH
Cortisol at end of low dose dexamethasone test
(48 hrs 0.5 mg qds) = 210 nmol/l
Cortisol at end of high dose dexamthasone test
(48 hrs 2mg qds) =150 nmol/l
MRI of pituitary - Normal
Which of the following apply to this patient?

1 )She is likely to have an adrenal adenoma and

should be confirmed with CT adrenals
2 )She is likely to have ectopic ACTH secretion
and requires CT chest.
3 )She is likely to have pituitary dependent
Cushing's disease and requires Inferior petrosal
sinus sampling with CRF stimulation
4 )She is likely to have ectopic Cushing's
syndrome and should have a labelled octreotide
scan
5 )The results suggest that she has
Pseudo-Cushing's due to polycystic ovarian
syndrome
ANSWER: 3
4) A 73 year old female is diagnosed with Cushing's disease. Which of
the following is correct?
1) adrenalectomy would be the treatment of choice.
2 )op-DDD is a treatment if unfit for surgery
3 )Ketoconazole may be used as a treatment if unfit for surgery
4 )Recurrence of Cushing's disease after transphenoidal surgery is less
than 5%
5 )yttrium implantation is an effective treatment
ANSWER: 3
.
Atrial Fibrillation Questions
MRCP Questions
1)The following are recognised causes of atrial fibrillation EXCEPT
A anxiety
B hyperthyroidism
C atrial septal defect
D alcohol abuse
E COAD

ANSWER: A
2)A patient presenting with atrial fibrillation who has reverted to sinus
rhythm is more likely to remain in sinus rhythm in the following
circumstances:
A age >75 years old
B been commenced on warfarin
C left atrium size > 6 cm on ECHO
D short history on AF
E a ventricular rate on presentation of 130 bpm
ANSWER: D
3)Causes of atrial fibrillation include:
A Aortic stenosis
B Maladie de Roger VSD
C anxiety
D recent MI
E complete heart block
ANSWER: D
4) A 70 year-old lady presents with sudden breathlessness and chest
discomfort. On examination, she was observed to have an irregular
heart beat with rate of 140 bpm, BP 122/74 and normal heart sounds.
On auscultation of the chest, Fine basal crepitations are heard. An ECG
confirms fast. She is anticoagulated with heparin and given diuretics.
Her heart rate remains rapid. What is the most appropriate
management of the lady's AF?

1
2
3
4
5

)
)
)
)
)

Cardioversion.
IV amiodarone.
IV betablocker.
IV digoxin.
Oral quinidine therapy.

ANSWER: 4

5)A 70-year-old woman has a history of dyspnoea and palpitations for

six months. An ECG at that time showed atrial fibrillation. She was
given digoxin, diuretics and aspirin. She now presents with two shortlived episodes of altered sensation in the left face, left arm and leg.
There is poor coordination of the left hand. ECHO was normal as was a
CT head scan.
What is the most appropriate next step in management?
1
2
3
4
5

)
)
)
)
)

anticoagulation
carotid endarterectomy
clopidogrel
corticosteroid treatment
no action

ANSWER: 1

6)A 48 year-old MAN with atrial fibrillation is admitted for DC

cardioversion.He is reverted to sinus rhythm. Which one of the
following drugs would be most likely to maintain sinus rhythm
following this procedure?
1
2
3
4
5

)
)
)
)
)

amiodarone
digoxin
heparin
sotalol
verapamil

ANSWER: 1
7)A 50-year-old politician presented with a strange fluttering sensation
in his chest, but no chest pain. The symptoms had lasted 24 hours. An
ECG revealed atrial fibrillation with a ventricular rate of 130 beats per
minute.
Which one of the following drugs is most likely to restore sinus
rhythm?
1 ) Adenosine
2 ) Bisoprolol
3 ) Digoxin

4 ) Flecainide
5 ) Verapamil
ANSWER: 4
8)The risk of embolic stroke with atrial fibrillation is increased in:
EXCEPT
A Left ventricular ejection fraction of 60%.
B Diabetes mellitus.
C Controlled hypertension.
D Age greater than 75 years.
E Rheumatic mitral valve disease.
ANSWER: A