Neurology 4 mrcp answers book - part 4 pot

B-renal failure.
C-SIADH
(syndrome of inappropriate secretion of ADH).
Remember: hyponatremia with NORMAL ECF volume:
A-nephrotic syndrome
B-hypothyroidism.
C-diuretics.
D-NSAIDS.
Answer: 3
Remember: alcohol makes you urinate MORE and smoking makes you urinate LESS.
Q11:
Answer: c
Such a urinary osmolality may indicate compulsive water drinking causing water
intoxication and dilute urine, or diabetes insipidus (urinary osmolaity in SIADH is
usually around 460 mmol / Kg .i.e. inappropriately high).
Q12:
Answer: d
It is beta blockers, other causes: spironolactone, amiloride and triamterene.
Remember: hypokalemia potentiates digoxin toxicity, but in digoxin toxicity
hyperkalemia may occur.
Q13:
Answer: a
Bicarbonate infusion reduces serum potassium by 0.2-0.4 meq / L, so it is a weak
agent; anyhow, it is used in severe acidosis (but watch for circulatory overload).
Calcium resonium is used in the chronic setting. Calcium gluconate infusion is just a
cardio protective agent; it does lower the serum potassium.
Q14:
Answer: d
a- True, due to muscle fiber necrosis, and even rhabdomyolysis.
b- True, usually seen as a difficult weaning from a ventilator in the ICU setting.
c- True, due to impaired red cell membrane ATPase.

d- False, HYPERcalciuria and HYPERmagnisuria.
e- True, usually resistant to anti-arrhythmics.
Q15:
Answer: e
Volume expansion may be a cause of hypophosphatemia. You should know the
causes of hypophophatemia, they are commonly seen in MRCP examination.
Other causes: nutritional recovery syndrome, parenteral nutrition, insulin infusion,
glucose infusion, alkalosis (respiratory and metabolic), oral phosphate binders, and in
the way of treatment of diabetic ketoacidosis.
Remember: Hypophophatemia is USUALLY multi factorial and commonly co-exist
with other electrolyte imbalance.
Q16:
Answer: e
Remember: drug induced hypomagnesaemia: cisplatin, gentamycin, and loop
diuretics.
Remember; magnesium is very poorly absorbed orally, hence oral preparations are of
no use in deficiency states. Other causes: chronic diarrhea, excessive lactation,
hyperparathyroidism, primary and secondary aldosteronism, upper GIT fistula and
protein energy malnutrition.
Q17:
Answer: e
a- True, Diamox (carbonic anhydrase inhibitor).
b- True, by creating uretrosigmoidostomy (a form of ureteric diversion used in the
past).
c- True, due to HCL content.
d- True, and type I and II.
e- False, DKA in the way of recover
and early (not late) uraemia , may cause normal
anion gap metabolic acidosis. Normal anion gap metabolic acidosis is one of the
favorite subjects in the MRCP (both part I and II).

Q18:
Answer: d
In ethylene glycol poisoning there is accumulation of oxalic acid and glycolic acid.
Q19:
Answer: c
Type B is caused by metformin (also sorbitol, isoniazide, and salisylates).
*Type A (also seen in any severe shock, carbon monoxide poisoning) in general is
caused by profound hypotension and or severe anemia.
*Type B (also seen in hepatic failure, severe infections, ethanol, and methanol
poisoning) in general is caused by impaired mitochondrial respiration and increased
lactate production.
Q20:
Answer: e
a- True, if excessive.
b- True, due to direct stimulation of the respiratory center + metabolic acidosis.
c- True, the clue is tetany + normal or increased PaO2 + high PH + very low PaCO2).
d- True, and pulmonary embolism.
e- False, METABOLIC alkalosis due to loss of HCL in vomitus.
Chapter VII / Endocrinology Answers
Q1:
Answer: e
a- True, and hence a sequential or a dynamic testing should be used.
b- True, and hence, a biochemical diagnosis should be done before imaging.
c- True, like adrenal adenomas versus carcinomas.
d- True, and if you suspect a hormonal deficiency then choose a stimulation test.
e- False, the usually story.
Q2:
Answer: e
As the name implies, it is an apoplexy, so the presentation is a catastrophic one.
Lateral extension may involve the 3

rd
, 4
th
and 6
th
cranial nerves. Remember: a
TSHoma is responsible for 1 % of all functioning pituitary tumors.
Q3:
Answer: d
a-True, and radiotherapy is a second line treatment.
b-True, and radiotherapy is a second line treatment.
c- True, notice that radiotherapy is more effective in children, and also used to
irradiate the pituitary to prevent Nelson's syndrome.
d- False, dopamine agonists are the first line agents even in macroadenomas unless it
is cystic and or large.
e- True, unfortunately octreotide does not cause tumor shrinkage.
Q4:
Answer: e
Pergolide is a dopamine agonist used in the treatment of hyperprolactinemia. Causes
of hyperprolactinemia are many, and it is one the favorite topics in the MRCP
examination. Other causes are: pregnancy and lactation, medications (oral
contraceptive pills, metoclopromide, reserpine, methyldopa, antipsychotics,
antidepressants, opiates and antiandrogens). However, the commonest causes are:
1- Disconnection hyperprolactinemia, as in non-functioning pituitary
macroadenomas.
2- Prolactinomas, usually microprolactinomas.
3- Primary hypothyroidism.
4- Polycystic ovarian syndrome.
Q5:
Answer: e

External irradiation is used for some macroadenomas to prevent re-growth if
dopamine agonists are stopped. All other options are true.
Q6:
Answer: e
External irradiation although causes shrinkage of the tumor, yet the growth hormone
level takes long to return to normal and there is a high risk of panhypoituitarism.
Q7:
Answer: a
Sampling should be done post exercise, not pre exercise. Other tricks are true.
Q8:
Answer: b
The 250 microgram tetracosactrin injection can be given at ANY time during the day.
Because it relies on ACTH dependent adrenal atrophy in secondary adrenal failure so
it may not diagnose acute adrenal failure secondary to acute ACTH deficiency.
Q10:
Answer: e
Unlike primary hypothyroidism, measuring TSH is not helpful because the pituitary
may secrete glycoproteins which are usually detected by TSH assay but they are NOT
BIOACTIVE. So the aim is to KEEP the T4 in the upper part of reference range
during replacement therapy with T4.
Q11:
Answer: e
a- True, and in the assessment of GH deficiency.
b- True, and in SEVERE hypopituitarism
c- True, with signs of neuroglycopenia.
d- True, at time 0, 30, 45, 60, 90, 120 minutes post administration.
e- False, it is given as soluble insulin 0.15 u / kg intravenously.
Remember: at the end of the test, the serum GH should be > 20 mu / L, and serum
cortisol >550 nmol/ L.
Q12:

Answer: d
DDAVP should not be given if you suspect a severe compulsive water drinking as this
will prevent water excretion and risks severe water intoxication if the patient
continues to drink water.
Q13:
Answer: e
pruritis (with increased sweating), palmar erythema, and spider nevi, skin
pigmentation (but vitilligo is much more common), and clubbing, all are seen in
thyrotoxicosis per se .
Q14:
Answer: c
a- True, and slightly raised serum bilirubin.
b- True, very mildly.
c- False, up to 5 % only, and almost always mild.
d- True, due to associated diabetes mellitus and lag storage.
e- True, a well documented feature.
Q15:
Answer: d
a- True, 0.2% will develop severe reversible agranulocytosis during carbimazole
therapy.
b- True, and in those dependent on voice e.g. singers.
c- True, and planned pregnancy with in 6 months.
d- False, 10% will develop TRANSIENT hypocalcaemia following surgery, and 1%
only will develop long term permanent hypocalcaemia.
e- True, thus regular follow ups are important.
Remember: clinical improvement in a patient on carbimazole is seen after 2 weeks but
the biochemical abnormalities will normalize after 4 weeks.
Q16:
Answer: c
a- True, ike coxsackie, mumps, and adeno viruses.

b- True, and by swallowing, and movement of the neck. The pain may radiate to the
jaw and ears.
c- False, the ESR is usually raised and a low titer of thyroid antibodies non-
specifically detected transiently.
d- True, but steroids are occasionally used for severe cases.
e- True, apart from oral propranolol in certain cases and no need for anti-thyroid
drugs.
Q17:
Answer: d
The combination of:
Suppressed TSH, negligible radio-iodine uptake, low serum thryroglubulin, and
greatly raised T4:T3 ratio (usually around 70:1) are diagnostic.
Q18:
Answer: d
There is NO association between post partum depression and post partum thyoriditis.
It is supposed to be an autoimmune in origin.
Q19:
Answer: d
a- True, also precipitated by surgery and radio-iodine treatment in a previously
inappropriately treated patient.
b- True, but should always be kept in mind and the patient should be rendered
euthyroid before the operation.
c- True, anti-thyroid measures are: oral or IV propranolol, oral sodium iopodate (a
radio-contrast medium will restore serum thyroid hormone levels to normal with in 2-
3 days), oral potassium iodate or Lugol's solution, oral or per rectal carbimazole.
d- False, there is NO parenteral preparation for carbimazole , if can not be given
orally , then give it rectally or by an NG tube.
e- True, and the patient should continue on carbimazole.
Q20:
Answer: e

Post ablative and primary atrophic hypothyroidism are both not goitrous.
Q21:
Answer: e
Iron deficiency anemia is a common finding in premenopausal females due to heavy
menses.
There 8 RARE but well recognized features, although SEEN in many textbooks and
QUESTIONS and BOFs, yet in clinical practice if you are in an endocrinology clinic
you will see that they are rare:
1-Myotonia.
2- Cereberallar ataxia.
3- Frank psychosis.
4- Pleural and pericardial effusions and heart failure.
5- Ileus.
6- Impotence (while in thyrotoxicosis it is common!!).
7- Galactorrhea.
8- Ascites.
Q22:
Answer: d
READ the question well "Biochemical findings that are useful
in the assessment of
hypothyroidism". T3 is not a reliable test to differentiate between a euthyroid and
hypothyroid patient. Also, we may see: normochromic anemia, low voltage ECG,
bradycardia and non specific ST-T changes indicate PROLOBGED SEVERE
hypothyroidism.
Q23:
Answer: d
Remember: Subjective improvement is seen after 2-3 weeks, and the reduction in
body weight and periorbital puffiness occurs relatively rapidly, BUT restoration of
skin and hair texture and resolution of any effusion may take 3-6 MONTHS.

Q24:
Answer: e
a- True, a rare presentation rather than to be a complication of an already diagnosed
patient.
b- True, as well as raised CSF protein, so you it may be missed as a PRIMARY CNS
DISEASE.
c- True, it is not a "cold case".
d- True, and start treatment with intravenous hydrocortisone before the biochemical
diagnosis.
e- There is NO parenteral preparation of T4, BUT there is a parenteral form of T3 and
so T3 can be given intravenously.
Q25:
Answer: c
Option "c" is the classical finding in those who are non-compliant and take large
doses before the follow up visit to fool the doctor!
Q26:
Answer: e
Phneytoin is an enzyme inducer, so the dose of thyroxin may need to be increased in
hypothyroidism and concomitant use of phenytoin.
Q27:
Answer: e
Obesity is rarely due to a single gene mutation. Endocrine diseases associated with
obesity are: Cushing' syndrome, hypothyroidism, and polycystic ovarian syndrome.
Q28:
Answer: d
Follicular carcinoma and adenoma are very similar on FNA cytology, but thyroid
biopsy is needed to demonstrate vascular invasion in cases of carcinomas.
Q29:
Answer: e
Secondary tumors are rarely seen.

Q30:
Answer: b
a- True, it is an aggressive one.
b- False, it is part of MEN type II.
c- True, as there is no curative treatment.
d- This, clinically speaking it is only a tumor MARKER!
e- True, because the para-follicular cells don’t trap iodine and hence it has no role in
the treatment.
Q31:
Answer: e
Even when caused by an adenoma, the tumor is rarely felt in the neck (usually located
at surgical exploration).Other options are true.
Q32:
Answer: e
Secondary bone malignancy is a cause of hypercalcemia with undetectable
parathyroid hormone level (also seen in vitamin D intoxication, milk alkai syndrome,
sarcoidosis , Addison's disease…cet. ). The 1
st
4 options are the cause of
hypercalcemia with normal or high serum parathryoid hormone level.
Q33:
Answer: d
The hypercalcemia of primary hyperparathyroidism does not respond to steroids.
High dose glucocorticoids are very effective in the treatment of malignancy-
associated hypercalcemia patients.
Q34:
Answer: a
It may caused by hypoparathyroidism and pseudohypoparathyroidism. Also may
cause seizures, and Parkinsonian like picture. Pseudopseudohypoparathyroidism
resembles pseudohypoparathryoidism pheonotypically, but it has a normal

biochemical profile.
Q35:
Answer: e
Pseudopseudohypoparathyroidism resembles pseudohypoparathyroidism
phenotypically, but it has a normal biochemical profile.
Q36:
Answer: d
pseudohypoparathyroidism is treated by vitamine D metabolites like alpha calcidol
tablets and follow up the patient with serum PTH and serum calcium.
Q37:
Answer: e
1- True, and weight gain is the commonest symptom.
2- True, so it is seen in 75% of cases.
3- True, as well as prominent hypokalemic alkalosis.
4- True, frank psychosis is uncommon.
5- False, type II fiber atrophy.
Remember:
Striae are seen in 50%
Proximal myopathy 50%
Bruising 50%
Obesity as a sign is seen in 97% of cases, so 3 % are not obese.
Q38:
Answer: c
a- True, as the stress of hospitalization may interfere with many tests and some
normal
persons will even FAIL to suppress on overnight dexamehtason suppression
test (i.e. behaves like Cushing's) because the hypothalamic- pituitary-adrenal axis will
ESCAPE such suppression due to powerful endogenous stress mechanisms.
b- True.
c- False, it does not cross react and that's why it is used in the suppression test.

d- True, hence called pseudo Cushing's.
e- True, and very high levels indicate an ectopic source.
Q39:
Answer: e
Without treatment, the 5 year survival rate is 50%. All other options are true.
Q40:
Answer e
a- True, and liquorice abuse.
b- True, and congenital adrenal hyperplasia due to 11 beta hydroxylase and 17 alpha
hydroxylase deficiency.
c- True, causing hypokalemia, hypertension and low aldosterone.
d- True, and 11 beta HSD deficiency.
e- False, Glucocorticoids suppressible hyperaldosterosnism and Conn's adenoma and
idiopathic bilateral adrenal hyperplasia , all are the cause of PRIMARY
aldosteronism.
Q41:
Answer: e
Although there is an avid sodium retention, leg edema is uncommon and suggests
secondary aldosteronism or a complicating heart failure. Serum potassium is normal
in up to 70% of cases at the time of diagnosis because many patients are already
treated by salt restriction making less sodium available to be exchanged for potassium
at the distal tubule.
Q42:
Answer: c
1- True, like MEN type II, neurofibromatosis, and Von Hipple Lindau.
2- True, and predominantly elevated adrenalin indicates an adrenal tumor that is not
large enough to outgrow its blood supply.
3- False, it commonly occurs in the absence of diabetes.
4- True, indicating a high level of dopamine.
5- True, in urinary bladder tumors.

Remember: although pallor is commonly seen during the attack, occasionally
FLUSHING is seen.
Q43:
Answer: e
a- TB is the next, hence CXR should be done in all cases.
b- True, and when presents with buccal hyperpigmentation, both are highly
suggestive.
c- True, Addison's disease per se causes fasting hypoglycemia.
d-True.
e- False, it is a rare disease with an incidence of 8 new case/ million of population.
Male to female ratio is 1:2.
Q44:
Answer: d
a- True, up to 90% of cases, and a late onset form with hirsutism is a recognized
presentation.
b- True, many enzymatic deficiencies are documented.
c- True, and salt losing nephropathy and crises in neonates, usually in males.
d- False, associated with hypertension due to increased 11 deoxycorticosterone, a
powerful mineralocorticoid.
e- True, and plastic surgery has a place for the ambiguous genitalia in females
Q45:
Answer 5
Other drugs: estrogens, and GnRH analogues given for prostatic carcinomas.
Q46:
Answer: e
LH: FSH ratio more than 2.5:1.Also there is: hypertension, hyperglycemia,
hyperlipidemia, hirsutism, oligomenorrhea or secondary amenorrhea, and infertility.
Remember : PCOS is treated according to the PRERSENTING feature .eg She is
complaining of infertility, so treat the infertility, or complaining of hirsutism so treat
the hirsutism . DON’T TRY TO TREAT EVERYTHING! However, weight reduction

in obese is important in the overall management.
Q47:
Answer: e
In idiopathic hisutism, female family history is very important, especially seen in
Asians or Mediterraneans.
Q48:
Answer: b
a- True, and mutation in RET proto-oncogen on chromosome 10 in type II.
b- False, hypercalcemia is the commonest presenting feature of type I, while in type
IIa it is uncommon and in type IIb it is absent.
c- True, hence family history is very important.
d- True, unlike the sporadic ones (10% bilateral).
e- True, also Cushing syndrome is uncommon in type I.
Q49:
Answer: e
a- True, next is the cecum and appendix.
b- True, due to obstruction of the mouth of the appendix.
c- True, because they have a low malignant potential.
d- True, Pulmonic stenosis, tricuspid regurgitation and right sided endocardial
fibrosis.
e- False, Cramping abdominal pain and diarrhea with flushing and wheeze are the
commonest presenting features of carcinoid SYNROMS not tumors.
Q50:
Answer: d
1- True, and steatorrhea and achlorhydria.
2- True, and skin rash and diabetes.
3- True, or watery diarrhea and multiple severe peptic ulceration.
4- False, with HYPOKALEMIA, hence called pancreatic cholera.
5- True, due to hypoglycemia.
Chapter VIII / Diabetes Mellitus Answers

Q1:
Answer :5
Nesidioblastosis is a diffuse beta cells hyperplasia and a cause of early life recurrent
hypoglycemia
Q2:
Answer 4
Concordance rate in monozygotic twins is around 40-50 %
Q3:
Answer 5
Concordance rate in monozygotic twins is almost 100 % implying strong yet
unidentified genes involved in the pathogenesis.
Q4:
Answer 5
1-MODY type I, a rare progressive early onset form
2-MODY type III. Progressive early onset
3-MODY type II , mild and relatively stable early onset type
4-very rare
5-it has a maternal inheritance, may be part of MELAS (mitochondrial
encephalopathy with lactic acidosis and stroke like episodes)
Q5:
Answer: 3
It inhibits the action of lipoprotein lipase and hence it enhances lipogensis .
Q6:
Answer: 3
No smoking is allowed and the patient should sit during the test (not walking around
to kill time)
Q7:
Answer 5
The Fasting blood glucose of more than 11.1 mmol/L on 2 or more occasions is
diagnostic for diabetes mellitus

Q8:
Answer 2
Total fat should be 30-35%
Saturated fat should be <10%
Monounsaturated fat should be 10-15%
Polyunsaturated fat should be <10%
Carbohydrates 50-55%
Total protein 10-15%
Q9:
Answer 2
Insulin does reduce post prandial glycemia and has a favorable effect on lipid profile
Q10:
Answer 5
1-and anorexia, weight loss
2-and cholestatic jaundice
3-hnece contraindicated in heart failure
4-due to salt and water retention in the short term
5-diarrhea and flatulence
Q11:
Answer 3
It causes hypothermia , MI ,TIAs
Q12:
Answer 1
Unexpected or unusual exercise may cause hypoglycemia if the original dose is not
reduced.
Other causes: malabsorption, errors in anti-diabetic agents dosing and schedules and
administration, impaired hypoglycemia awareness.
Q13:
Answer: 5
Leukocytosis is seen in DKA per se in the absence of infection.

Confusion, drowsiness and Coma occur in 10% of cases.
Q14:
Answer: 1
DIC is rare
Q15:
Answer 4
Mortality usually exceeds 40% even in best centers
Q16:
Answer 5
Venous loops and beadings are seen mainly in PRE-proliferative stage
Q17:
Answer 4
It is mainly sensory
Q18:
Answer 4
The nodular glomeruloscleorsis type is less common than the diffuse type
Q19:
Answer: 4
1-to assess the risks and benefits of treatment and complications of diabetes
2-so that it is controlled at the time of conception
3-and maternal and fetal morbidity and mortality
4-contraindicated, insulin is used
5-due to the physiological and stress changes during pregnancy
Q20:
Answer 5
Hospital admission is needed when there is a cardiovascular or a renal disease and a
poor diabetic control.
Chapter IX / Hematology Answers
Q1:
Answer: 5

1- important in dialysis patients and causes resistance to erythropoietin therapy.
2- especially the minor trait.
3- especially the minor trait, its clue is that the patient is an Asian one with normal
hemoglobin electrophoresis and normal ferritin.
4- and sideroblastic anemias :clue is a dimorphic blood picture
Remember: Microcytosis and hypochromia have a relatively narrow differential
diagnosis so you have to know it because it is a common clinical problem.
5-False, aplastic anemia causes either a normocytic or macrocytic anemia.
Q2:
Answer: 5
Remember: macrocytosis is very common in clinical practice but megaloblastic
anemia is not that common and the term macrocytosis indicates an increase in the
MCV, but megaloblastic changes are pathological changes seen in the cells mainly in
the nucleus. Fish tapeworm infestation causes vitamin B12 deficiency and hence
megaloblastic changes. Note the first 4 items cause characteristic changes in the bone
marrow.
Q3:
Answer: 5
Item 5 causes characteristic changes in the bone marrow.
Q4:
Answer: 5
Dimorphic blood picture is a common problem seen in clinical medicine. It has 4
causes in general that you HAVE TO KNOW:
1- Blood transfusion in a patient with pre-existent macro- or microcytosis.
2- In the way of recovery of a hematinic deficiency (i.e. during its replacement).
3- Combined deficiency states, simultaneously or in succession .e.g. celiac disease.
4- Primary sideroblastic anemia where there is 2 CLONES, one is the normal and the
other is the abnormal one producing the macrocytes.
In item 5, phenytoin causes macrocytosis exacerbated by pregnancy.
Q5:

Answer: 5
1- True, usually tolerated because of the rightward shift in oxyhemoglobin
dissociation curve.
2- True, regular blood transfusions are uncommonly indicated except in those with
recurrent life threatening crisis like recurrent stroke.
3- True, the objective is to reduce the HbS, and NOT TO RAISE THE PCV which if
is high, may induce stagnation and further sickeling!
4-True, unfortunately.
5- False, up to 10% of children.