Neurology 4 mrcp answers book - part 10 pot

Chapter XV / Dermatology Answers
Q1:
Answer: 4
1- so these should be avoided.
2- true, it will exacerbate the skin disease, if severe join disease is present try
methotrexate which is effective against both skin and joint disease.
3- like the genitals and the natal clefts, so always examine these areas especially in
join diseases with out any apparent skin involvement (so you will think of another
diagnosis like rheumatoid factor negative rheumatoid arthritis); the patient might be
shy from telling you that these areas are involved.
4- false, seen in children, and some children may develop chronic plaque type upon
reaching adulthood.
5- true with many HLA associations like HLA DW6.
Q2:
Answer: 1
1- false, very irritant and should be avoided at these sites.
2- true, also oral retinoids are used in severe cases.
3- true.
4- to prevent relapse upon steroids withdrawal.
5- true, avoid chloroquin in joint disease.
Q3:
Answer: 5
Isotretinoin is used in the treatment of severe scaring acne. Other agents that might
cause this rash: chlorinated hydrocarbons, estrogenic steroids, oils, and tar.
Q4:
Answer: 5
1- false, middle age.
2- false, against the diagnosis; they are more suggestive of acne vulgaris.
3- false, the treatment of choice; sometimes prolonged for 1 year.
4- are prominent part in the clinical picture.
5- but with no comedons.

Q5:
Answer: 4
1- true, by attacking the scalp but it is uncommon, so-called lichen planus pillaris.
2- true, usually seen as white lace-like lesions on the buccal mucosa, but the
ulcerative variety is rare and is clinically challenging.
3- true, think of another disease; but always ask if the patient is taking an antipruritic
agent! The patient may say it is not pruritic!
4- false, self limiting usually within 1-2 years, leaving a prominent hyperpigmentation
on the involved skin areas.
5-true.
Q6:
Answer: 5
Don’t think that pruritis is due to skin diseases only; many diseases in medicine can
produce disabling pruritis. Rifampicin has been shown to be effective against pruritis
in selected patients.
Q7:
Answer: 5
The word "characteristic" means something you have to look for the diagnosis and
absence of itching in such cases either means that your diagnosis is wrong or the
patient is taking a medication against it (so always ask about these anti itching
medications here).
Q8:
Answer: 4
1- true, useful clue when seeing a patient with rigidity, dystonias, and liver
impairment.
2- true, and may not be seen in the fingers because they disappear faster than the toes,
so examine the toes after this long period.
3- true. and may be short also, so-called brachynychia.
4- nail painting!!
5- true, indicating an established uremia, a useful sign to differentiate from acute renal

failure.
Q9:
Answer: 4
1- and usually resistant to treatment
2- true …….the HIV patients are very sensitive for many drug reactions, like Septrin
rashes
3- so take biopsy and examine the mouth
4- false, it is not an AIDS defining illness.
5- true, always keep it in mind.
Q10:
Answer: 2
1- true, a slowly growing tumor.
2- false, distant metastases are extremely rare, the tumor is locally invasive and
destructive.
3- true, may also look like malignant melanoma.
4- radiotherapy is an acceptable alternative in certain areas.
5-true.
Q11
Answers: 5
The 1
st
4 options are true; diabetes per se does not confer an increase risk for
malignant melanoma development.
Q12:
Answer: 2
1- true, but the nodular variety is not preceded by that phase.
2- false, seen mainly in sun exposed areas ( usually the face) of old people.
3- true, and mostly seen in Caucasians.
4- any suspicious change in a melanocytic nevus prompt careful work up.
5- true, but are extremely rare.

Q13:
Answer: 4
1- the reverse is true.
2- tumors at certain sites like the leg generally are considered to be less aggressive
than tumors of the head and neck.
3- false , it is a reliable predictor of prognosis in stage I.
4- 70% is the correct figure.
5- true, about 90% 5 year survival rate.
Q14:
Answer: 4
1- 50% of those patients (especially heart and kidney recipients) will develop this
cancer.
2- a scaring genetic syndrome affecting the skin.
3- in or around the ulcer; also in chronic skin sinuses.
4- pale skin is a risk factor (like malignant melanoma).
5- and exposure to UV radiation and X ray irradiation.
Q15:
Answer: 4
1- benign tumors affecting old people.
2- partial thickness skin dysplasia.
3- full thickness skin dyspalsia.
4- true, but the behavior is totally different. They are totally benign.
5- they have nothing to do with sebum or sebaceous glands. Better to be called a basal
cell papilloma.
Q16:
Answer: 4
1- this is a common disorder, with repetitive picking or fidding of the prximal nail
fold of the skin.
2- and follow up is indicated to see "movement" of the underlying discoloration.
3- and in nail trauma and infective endocarditis.

4- false, indicates a chronic repetitive skin itching and rubbing with the nails.
5- usually few nails are infected.
Q17:
Answer: 5
1- erythema nodosum.
2- by granulomatous deposits.
3- lupus pernio.
4- or nodules or plaques ( sarcoid plaques).
5- not a manifestation of this multi-systemic granulomatous disease.
Q18:
Answer: 4
Human herpes type 8 infection is linked to the development of Kaposi's sarcoma;
herpes simplex infection can cause eryhtema multiforme.
Q19:
Answer: 2
1- or associated with many systemic illnesses like inflammatory bowel disease,
rheumatoid arthritis…etc.
2- false, there are no diagnostic changes on skin biopsy and hence the diagnosis is a
primarily clinical one.
3- but after successful treatment of the associated disease relapses are uncommon and
intermittent.
4- or systemic steroids, sulphazalazine, dapsone, and cyclosporine.
5- together with pain relief and dressing.
Q20:
Answer: 4
Diffuse skin hyperpigmentation is a striking feature; the 1
st
3 options are seen mainly
in light exposed areas.
Q21:

Answer: 4
Phenylketonuria is cause of fait skin and hair. Other causes of pale skin in the absence
of anemia: vitiligo, oculocutaneous albinism, and panhypopituitarism.
Notice that any chronic illness can cause generalized hyperpigmentation.
Q22:
Answer: 5
1- Beta blockers.
2- Lithium.
3- Chloroquin.
4- Positive Koebner's phenomenon.
5- None of the antiasthma medications have been shown to exacerbate psoriasis.
Q23:
Answer: 5
The 1
st
4 options are the mainstay in the management of eczema in general. No place
at all for regular use of cyclosporine.
Q24:
Answer: 5
OCC are used in the treatment of hirsutism.
Q25:
Answer: 5
1- for a suspected contact allergic dermatitis.
2- to support a diagnosis of atopic eczema, and to detect a specific environmental
allergen or allergens ( animal danders, house dust mites…etc.).
3- same indications for IgE testing ,but less commonly performed.
4- useful in any susoected secondary infections which are common.
5- TB skin lesions are infectious in nature, not eczematous!
Q26:
Answer: 4

1- superinfections are very common unfortunately and add more to the burden of the
disease, particularly with staph areus, herpes simplex (which may cuase a severe
diffuse skin rash called eczema herpeticum); human papilloma virus and molloscum
contagiosum infections are both common especially with the use of topical steroids.
2- and behavioral disturbances.
3- resulting in poor school records.
4- patients with atopic eczema have an increased incidence of food allergy,
particularly to eggs, cow's milk, soya, wheat, and fish. Those foods usually cause
immediate urticarial lesions rather than exacerbation of the eczema per se.
5- because of the breaks in the skin barrier.
Q27:
Answer: 5
Minoxidil is a cause of hirsutism, and that's why minoxidil shampoos are used by bald
people.
Q28:
Answer: 5
Hirsutism is usually familial and racial; and some degree of hirsutism is expected
after menopause. The 1
st
4 options prompt a search for an underlying cause.
Q29:
Answer: 5
Alopecia areata can cause localized or diffuse NON-scarring alopecia.
Q30:
Answer: 5
Androgenetic alopecia can cause localized and generalized non-scarring alopecia.
Notice that discoid lupus can cause localized and diffuse scarring alopecia.
Q31:
Answer: 2
1- and involvement of the oral mucosa is seen in 100% of cases which may predate

the skin manifestations.
2- oral mucosa is involved in 60% of cases, and the target antigen is BP-220 (part of
hemidesmosomes).
3- frank blisters are uncommonly seen; itching is severe and we may see only
excoriations.
4- but may respond to cyclophosphamide or methotrexate.
5- and oral mucosa involvement is rare, the target antigen is type XVII collagen and
BP-180.
Q32:
Answer: 4
Porphyria cutanea tarda can cause skin blistering, increased fragility, scars, milia,
hyperpigmentation and hypertrichosis, but it does not involve the mouth mucosa.
Q33:
Answer: 5
Other photosensitive dermatoses: chronic actinic dermatitis, SLE, herpes simplex,
certain porphyrias, and medication induced (photo-toxic and photo-allergic reactions).
Q34:
Answer: 5
Porhyria cutanea tarda causes generalized hyperpigmentation. Other causes of
erythroderma: cutaneous T cell lymphoma, eczema, and lichen planus.

Q35:
Answer: 5
The so called obstetric cholestasis, together with the 1
st
4 options, are specific causes
of pruritis encountered only in pregnancy.
Chapter XVI / Genetics Answers
Q1:
Answer: 3

1- a secondary phenomenon to hypogonadism.
2- many other karyotypes are also seen.
3- false, the reverse is true, due to hypogonadism and delayed epiphyseal closure.
4- true, unlike Turner's syndrome.
5- usually very mild and does not affect performance that much.
Q2:
Answer: 5
1- true, renal anomalies are common which may be the cause also.
2- Turner's syndrome has left sided cardiac lesions, unlike Noonan's syndrome which
has right sided cardiac lesions.
3- true. usually transient.
4- true, watch for side effects like gall stones.
5- false, only to induce the appearance of secondary sexual characteristics; they are
totally and irreversibly infertile.
Q3:
Answer: 5
The Word "familial" almost always indicates an autosomal dominant inheritance;
FMF is an exception! Inborn errors of metabolism are usually autosomal recessive.

Q4:
Answer: 5
Post-date pregnancy state is not associated with elevated serum AFT.
Q5:
Answer: 4
1- true, abortion still may occur even in experienced hands.
2- true, when the size of the uterus is large enough but still it is considered to be a
LATE investigation; CVS can done much earlier so that intervention can be done
early also.
3- true, as well as many enzymes assessment.
4- false, under ultrasound guidance.

5- by finding an elevated level of 17 hydroxy progesterone in the amniotic fluid.
Chapter XVII / Toxicology Answers
Q1:
Answer: 5
Digoxin toxicity is enhanced by HYPOkalemia, and its self causes hyperkalemia at
toxicity; other factors that enhance its toxicity are hypocalcaemia, renal impairment,
ischemic cardiopmyopathy, chronic lung disease, and acidosis.
Q2:
Answer: 5
Indication of bicarbonate infusion here: long QT interval, severe hypotension , severe
acidosis, life threatening cardiac dysrrhytmias, and signs of severer CNS toxicity like
seizures. The objective is to raise the blood PH to a level of 7.45-7.55 with serum K
being in the upper range of normal reference.
Q3:
Answer: 3
1- but the red cell free protoporphyrins are increased.
2- due to chronic interstitial nephritis and renal tubular acidosis.
3- indicates chronic exposure, mainly due to deposition of sulphides and irritation of
the near by gum.
4- but the PBG is normal; acute intermittent porphyria is one of the differential
diagnoses.
5- and peripheral motor neuropathy is mainly seen in adults with chronic exposure.
Q4:
Answer: 5
1- true, and acidosis may very severe.
2- true, but it is irreversible if there was a late presentation with delayed treatment.
3- mainly seen in the early phase between 30minutes -12 hours of poisoning.
4- true, peritoneal dialysis also may be used.
5- false, does not combine with it.
Q5:

Answer: 5
1- check PT, PTT, and fibrinogen.
2- in rhabdomyolysis or prolonged seizures.
3- true, drinking too much water and SIADH.
4- also, shock, malignant ventricular dysrrhythmias, aortic dissection. Hypertension is
common and when hypotension is seen, thinks of these complications.
5- one of the causes of unexplained intracranial hemorrhage in young people.
Q6:
Answer: 5
1- true, whenever the clinical setting is suggestive, like a patient found unconscious in
his closed garage.
2- and there is low PaO2; so this discrepancy may be a clue.
3- the rose pink color of the skin is rare antemortem; cyanosis is much more common
4-true, as it may further impair the release of oxygen to tissues; so use diazepam to
control seizures.
5- false, in smokers the level of carboxyHb may be up to 15%. Indications of
hyperbaric O2: pregnancy, severe neurological impairment, coma at any time,
carboxyHB above 40% (some centers give it when it is above 20%).
Q7:
Answer: 4
1-true, but diplopia, ataxia, and coarse tremor are common.
2-true, usually caused rapid IV infusion causing asystole.
3-also any drug that competes with pheytoin albumin binding sites.
4-false, of no use at all.
5-true, look for any precipitating cause and measure serum phenytoin.
Q8:
Answer: 4
1- also by NSAIDS, renal failure, ACE inhibitors, and diarrhea.
2- causing hypothyroidism. Also may cause hyperparathyroidism with high PTH level
(i.e. like primary hyperparathyroidism).

3- and coma, up going planters.
4- false, fine tremor is commonly found at therapeutic levels; but coarse irregular one
indicates poisoning.
5- above 3-3.5 mmol / L.
Q9:
Answer:3
1- true, an acute confusional state which is mainly seen in non-chronic alcoholics.
2- true, although the severity and clinical features of encephalopathy correlate roughly
with blood ethanol levels. Chronic heavy alcoholics might have a very high blood
level although they don't appear to be intoxicated.
3- false, it is characteristically raised . The plasma osmolality roughly increases by 22
mOsm/L for every 100 mg / dl of ethanol presents.
4- true. Can be differentiated by presence of ethanol odor, increased plasma
osmolality (in ethanol poisoning it is raised), blood and urinary toxicology.
5-true. Also predisposes to head injury, lung aspiration, seizures. Chronic alcoholism
increases the risk of bacterial meningitis.
Remember that the treatment is supportive only. All alcoholics should receive 100 mg
of thiamin intravenously to prevent Wernick's encephalopathy.
Q10:
Answer: 4
1- true, with respiratory depression , hypotension, reactive pupils and hypothermia.
2- true, a characteristic feature. However, very large doses of phenobarbitone or
glutethimide may result in LARGE FIXED pupils.
3- true, with ataxia, dysarthria and hyporeflexia.
4- false. The mortality rate is low and mostly due to aspiration pneumonia (with or
without systemic sepsis), or due to iatrogenic fluid overload and pulmonary
edema.Despite severe intoxication, a patient who arrives at the hospital with adequate
cardio-pulmonary function and support should survive without any sequelae.
Remember the treatment is mainly supportive while the drug is being eliminated.
5- true, it is mainly used to increase the urinary clearance of Phenobarbital., but in

general should be avoided as it can lead to fluid overload. Hemodialysis may be used
in severe resistant cases of barbiturate poisoning or when drug elimination is impaired
by renal failure.
Q11:
Answer: 4
1- true, intermediate or short acting agents are more likely to produce a withdrawal
syndrome when stopped abruptly. The syndrome is seen within 1-3 days (for short
acting agents) and may take up to 1 week or even more to appear (for long acting
agents).
2- true, with confusion, agitation, seizures.
3- true, if positive , the patient should receive long acting phenobarbital orally to
maintain a calm state without signs of intoxication. In most patients it is possible to
stop it gradually after progressive decrement in the daily doses within 2 weeks.
4- false. Seizures especially the myoclonic ones should be treated aggressively with
anticonvulsants.
5- true, mainly seen in those taking very high frequent doses.
Q12:
Answer: 4
1- true, as an iatrogenic overdose. Also seen as an accidental overdose in addicts, and
in suicidal attempts.
2- true, and pontine hemorrhage is a differential diagnosis .Although needle tracks
and marks might be seen, they are not diagnostic .
3- true, the test is positive if the pupils dilates and the patient regains his full
consciousness; however, when very large doses of opioids are taken or multiple drug
ingestion is present the pupils may slightly dilate.
4- false, with appropriate treatment , patients should recover uneventfully .
5- true, because nalaxone is a short acting agent
Q13:
Answer: 4
1- true, or with antidepressants and antihistamine overdose.

2- true, also flushing, urinary retention and tachycardia.
3- true, mainly used in antipsychotics or antidepressants overdose.
4- false. Symptoms usually resolve spontaneously.
5- true, although rarely needed . Physostigmine can produce severe bradycardia,
seizures and hypersalivation. Specific treatment is required when there is life
threatening cardiac dysrrythmias.
Q14:
Answer :4
1- true. Their mechanism of action involves a variable combination of inhibiting the
reuptake and or increasing the release of noradrenalin and or dopamine and thus
producing a central stimulant and peripheral sympathomimetic effects.
2- true, and cocaine can produce myocardial infarction.
3- true, either due to sudden severe hypertension, drug induced vasculitis, or rupture
of AVMs.
4- false, should be avoided , especially in cocaine induced myocardial infarctions.
Alpha blockers are useful to attack hypertension.
5- true, and thus attacking the psychotic manifestations of overdose. Because
amphetamines are longer acting than cocaine, amphetamine intoxication is more
likely to require treatment
Q15:
Answer: 3
1- true, and prominent insomnia.
2- true, changes in the mental status are usually the most striking feature. Alterations
in affect and mood may predominate the clinical picture.
3- FALSE, very rare. The presence of a prominent seizure activity should prompt a
search for another pathology or to revise the diagnosis.
4- true, there is prominent sympathetic overactivity.
5- true, and when this fails, treatment with diazepam may be of benefit.
Q16:
Answer: 3

1- true, unlike other hallucinogens (eg LSD).
2- true, also large or small pupils, horizontal and vertical nystagmus, hypertonia,
hyper-reflexia and myoclonus. There may analgesia to a surprising degree.
3- false, phenothiazines reduce seizure threshold and may produce severe
hypotension. Haloperidol can be used safely in such cases. Diazepam can be used for
sedation and treating muscle spasms.
4- true, although in some patients it may take days or even weeks.
5- true, this is especially seen in poisoning with large doses .
Q17:
Answer: 5
1- true, whether accidental or intentional.
2- true, thus such patients may be wrongly diagnosed as having a serious CNS illness.
3- true, like renal or hepatic failures.
4- true. Dementia patients are very susceptible.
5- false, one of the prominent causes especially in old people.
Q18:
Answer: 1
1- false. Usually seen within 48hours; however, in 70% of cases they occur within 7-
24 hours of abstinence.
2- true, and the interval between the first and last seizure is usually 6-12 hours up to
85% of cases . Up 40 % of patients will have ONE seizure only.
3- true. They abate spontaneously; however, diazepam or chlordiazepoxide is given
prophylactically because up to 30% of patients will develop delirium tremens.
4- unusual and atypical features are: focal fits, prolonged duration of the fits ( > 6-12
hours ), more than 6 fits, status epilepticus or a prolonged post-ictal phase. In these
cases, a prompt search for pathology is required.
5- true. Always look for such an association.
Q19:
Answer: 3
1- true. It is the most aggressive type with a high mortality rate, usually seen with 3-5

of abstinence and may last up to 72 hours.
2- true. Also tachycardia and sweating.
3- false. The mortality rate is 15% and mostly due to concomitant: infection,
pancreatitis, cardiovascular collapse, or trauma.
4- true, the total requirement to produce a calm patient may exceed 100 mg/ HOUR.
5- true, like atenolol 50-100 mg/ day.
Q20:
Answer: 4
Item "4" is false because confusion, IF PRESENT, is usually mild. Illusions and
hallucinations, usually visual, are seen up to 25% of cases. It usually responds to
diazepam 5-20 mg or chlordiazepoxide 20-25 mg orally every 4 hours.