MRCGP Questions May answers

1.  Regarding ectopic pregnancy, which TWO of the following are the most common sites for ectopic implantation?  Select TWO answers only

1. The ovary
2. The ampulla of the fallopian tube
3. The fimbria of the fallopian tube
4. The isthmus of the fallopian tube

The correct answers are B and D.

2. Which TWO of the following are risk factors for ectopic pregnancy?  Select TWO answers only

1. Use of the combined oral contraceptive pill
2. Use of the progestogen only pill
3. Use of an intrauterine contraceptive device
4. Being of Caucasian race

The correct answers are B and C.

3.  Regarding ectopic pregnancy, which TWO of the following investigations are the most useful in making an initial diagnosis?  Select TWO answers only

1. Urine beta HCG test
2. Serial Serum HCG tests
3. Abdominal ultrasound
4. Transvaginal ultrasound

The correct answers are A and D

4.  Pelvic inflammatory disease is an important cause of ectopic pregnancy.  Which of the following is the MOST common presenting symptom.  Select ONE answer only

1. Creamy vaginal discharge and pruritis
2. Deep Dyspareunia
3. Bilateral lower abdominal pain
4. Dysuria

The correct answer is C 

5.  Which of the following is the most common causative organism in Pelvic Inflammatory Disease in the UK?  Select ONE answer only

1. Neisseria gonorrhoea
2. Mycoplasma genitalium
3. Mycoplasma hominis
4. Chlamydia trachomatis

The correct answer is D.

An ectopic pregnancy occurs when the conceptus is implanted anywhere outside the endometrial cavity. The most common sites are the ampulla and the isthmus of the fallopian tube.  Less common sites are the ovary or the abdominal cavity. 

Ectopic pregnancy is usually associated with amenorrhoea followed by bleeding and pain.  The most common presenting symptom is bilateral lower abdominal pain, although some cases are asymptomatic. Risk / predisposing factors include:

• previous tubal surgery
• previous ectopic pregnancy
• previous induced abortion
• pelvic inflammatory disease
• use of intrauterine contraceptive devices
• use of the progestogen only pill
• diethylstilboestrol exposure
• being of non-caucasian race

A urine beta HCG (pregnancy test) and urgent transvaginal ultrasound are the most useful initial investigations.  In cases where the diagnosis is uncertain, serial serum bHCG is useful.  Management is usually surgical, although in some cases medical management with Methotrexate is possible.  A Group and Save should be taken to establish the Rhesus status of the mother, to determine the need for AntiD in future pregnancies.

Pelvic inflammatory disease describes a spectrum of inflammatory disorders of the upper genital tract, and includes endometritis, salpingitis, and pelvic peritonitis. The most common causative agent in the UK is Chlamydia trachomatis, which accounts for about 50% of cases.

Further reading:

ectopic pregnancy

PID

6.  Regarding Rheumatoid arthritis, which TWO of the following statements are correct? Select TWO answers only

1. Men are affected more than women
2. RA affects about 5% of the population
3. T cell synovial infiltration is an early histological finding
4. Women are affected more than men 

The correct answers are C and D.

7.  Regarding investigations in patients with suspected Rheumatoid Arthritis, which ONE of the following statements are correct?  Select ONE answer only

1. Rheumatoid factor is present in 90% of patients with RA
2. Rheumatoid factor is present in 50% of patients with RA
3. Rheumatoid factor is present in 80% of patients with RA
4. Rheumatoid factor is present in 60% of patients with RA

The correct answer is C.

8.  For each of the following statements regarding RA, answer TRUE or FALSE

1. Rheumatoid Arthritis is an inheritable condition (T)
2. ulnar deviation of the fingers is due to subluxation at the proximal interphalangeal joints (F)
3. RA is a common cause of anaemia of chronic disease (T)

9.  Which THREE of the following are extra-articular manifestations of Rheumatoid Arthritis?  Select THREE answers only

1. Caplan’s syndrome
2. Reiter’s syndrome
3. keratoconjunctivitis sicca
4. macular degeneration
5. Felty’s syndrome

The correct answers are A, C, and E.

10.  Which of the following statements is correct regarding blood monitoring in the treatment of RA with Methotrexate?  Select ONE answer only

a.      Bloods should be monitored every week for the first two months

b.     Bloods should be monitored every two weeks for the first two months

c.      Bloods should be monitored monthly for the first two months

d.     Bloods should be monitored every two months from commencement

The correct answer is B.

Rheumatoid is a common cause of morbidity in the UK, affecting 1-3% of the population.  Women are affected more than men by a factor of about 2.5:1.  Although the aetiology is still poorly understood, there is a large genetic component.  It is a progressive disease which affects multiple joints, typically symmetrically.  Changes in the small joints of the hands and feet are common.  Ulnar deviation of the fingers is caused by subluxation at the metacarpophalangeal joints.  Rheumatoid factor is present in about 80% of patients, but without clinical symptoms is of little benefit in diagnosis – its main use is as a prognostic indicator.  RA has many extra-articular manifestations including Felty’s syndrome, Caplan’s syndrome and many diseases of the eye.  Treatment of joint pains and swelling is normally with analgesics and NSAIDS.  Long term management using Disease Modifying AntiRheumatic Drugs is usually done under consultant supervision.  Methotrexate is one of the most common DMARDs used.  When first started, blood should be monitored every two weeks for two months, then monthly after this.

Further Reading:

Rheumatoid Arthritis

extar articular manifestations

11.  Regarding childhood vaccinations, which TWO of the following statements are correct?  Select TWO answers only

1. A single dose of MMR vaccine protects approximately 85% of children against measles and mumps
2. A single does of MMR vaccine protects approximately 95% of children against rubella
3. A minimum of 6 months should elapse before administering a second dose of MMR
4. Patients with a significant history of anaphylactic reaction to egg or egg protein should be vaccinated in a hospital setting

The correct answers are B and D.

12.  Regarding childhood vaccinations, which ONE of the following statements are correct?  Select ONE answer only

1. The new combined diphtheria, tetanus, acelular pertussis, inactivated polio and haemophilus inflenzae type B (DTaP/IPV/Hib) and meningococcal C vaccine should be given together at 2, 3 and 4 months
2. The new combined diphtheria, tetanus, acelular pertussis, inactivated polio and haemophilus inflenzae type B (DTaP/IPV/Hib) and meningococcal C vaccine should be given together at 3, 4 and 12 months
3. The new combined diphtheria, tetanus, acelular pertussis, inactivated polio and haemophilus inflenzae type B (DTaP/IPV/Hib) and meningococcal C vaccine should be given together with MMR at 12-15 months
4. History of allergy to egg proteins is a contraindication to having the combined vaccine ( DTaP/IPV/Hib )

The correct answer is A

The current guidelines recommend that the DTaP/IPV/Hib vaccine be given with Meningitis C at 2, 3 and 4 months.  MMR vaccine is normally given at 12-15 months and then again before starting school.  A minimum of three months must pass between doses.  A single dose will provide immunity against rubella in 95% of children, and 90-95% against measles and mumps.

Further reading:

http://www.immunisation.nhs.uk/

13.  Regarding treatments for acne:

a.      Topical isotretinoin

b.     Topical clindamycin

c.      Topical benzoyl peroxide

d.     Oral lymecycline

e.      Oral co-cyprindol (oral contraceptive)

f.        Oral isotretinoin

For each of the following patients, select the MOST suitable treatment.  You may use each option ONCE, MORE than ONCE, or not at all

13.1 A 15 year old girl presenting with mild acne affecting her face only.  She has multiple comedones with no infected / severe inflammatory patches.

The correct answer is C. 

13.2 A 19 year old male with inflammatory acne affecting his face, back and chest.  He has no scarring, and has been using topical washes and cleansers purchased over the counter for 6 weeks with no effect.

The correct answer is D

13.3 A 19 year old female who is sexually active, with moderately severe acne affecting her face, chest and back.  She is not planning to have children at this stage.

The correct answer is D or E

13.4 A 17 year old male with severe inflammatory acne.  His face is the worst affected, and this is causing him a lot of anxiety with bullying at school.  He has been treated for 12 weeks with oral tetracycline with little improvement.

The correct answer is F 

14. Regarding the use of oral Isotretinoin in the treatment of severe acne, which ONE of the following statements is correct?  Select ONE answer only

1. Female patients MUST avoid pregnancy while on treatment and for 6 months after completing therapy.
2. Female patients MUST avoid pregnancy while on treatment and for 3 months after completing therapy
3. Female patients MUST avoid pregnancy while on treatment and for 1 month after competing therapy
4. Female patients MUST avoid using Isotretinoin in the first three months of pregnancy

15.  Regarding treatment with oral isotretinoin, which TWO of the following are ABSOLUTE contraindications?  Select TWO answers only.

1. Uncontrolled hyperlipidaemia
2. Liver disease
3. Renal disease
4. Hypervitaminosis A
5. Hypertension
6. Migraine

Acne is a very common problem in primary care.  Mild cases of acne can usually be treated topically, with benzoyl peroxide (first line) or topical antibiotics (especially where the face is the main affected area).  In cases where the back and chest are affected, or where the acne is moderately severe and / or inflammatory, oral antibiotics such as tetracycline or lymecycline can be used.  In sexually active women who also require contraception, an oral contraceptive pill such as co-cyprindol (Dianette) is an effective alternative to oral antibiotics.  Severe acne, or acne that has not responded to antibiotics can usually be treated with oral isotretinoin.  Before commencement on isotretoin baseline blood tests are required (FBC, lipid profile, liver function tests). If the patient is female then it is important to be certain that the patient is not pregnant as Isotretinoin is a powerful teratogen.  Female patients must not become pregnant while on treatment and for at least one month after treatment stops.  Absolute contraindications to starting Isotretinoin include hypervitaminosis A, uncontrolled hyperlipidaemia, and pregnancy or lactation. It should be used with caution in patients with renal and liver disease.

Further reading:

acne

Isotretinoin

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