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MRCPI GM Part I study materials
MRCPI GM Part I study resources

MRCPI GM Part I practice questions

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Question 1Cardiology

A 58-year-old man presents 90 minutes after the onset of central crushing chest pain. The ECG shows 2 mm of ST elevation in leads V2 to V4 with reciprocal change inferiorly. He remains pain-free after GTN and his blood pressure is 128/76 mmHg. Which is the most appropriate immediate management?

  1. Exercise tolerance testing
  2. Aspirin monotherapy
  3. Intravenous thrombolysis within 30 minutes
  4. Immediate primary PCI Correct answer.

Explanation

ST elevation myocardial infarction requires emergency reperfusion, and primary percutaneous coronary intervention is the preferred strategy when it can be delivered promptly by an experienced team. Compared with fibrinolysis it achieves higher and more sustained vessel patency with less bleeding and fewer intracranial haemorrhages.

Question 2Cardiology

A 71-year-old man has a slow-rising, low-volume carotid pulse and an ejection systolic murmur loudest at the right second intercostal space that radiates to both carotids. Which valve lesion does this most likely represent?

  1. Hypertrophic cardiomyopathy
  2. Aortic stenosis Correct answer.
  3. Ventricular septal defect
  4. Mitral regurgitation

Explanation

A slow-rising, low-volume pulse with an ejection systolic murmur maximal at the right second intercostal space radiating to the carotids is the classic bedside signature of aortic stenosis. As stenosis worsens the murmur peaks later in systole and the pulse becomes more attenuated.

Question 3Cardiology

A 62-year-old woman is reviewed six months after a myocardial infarction. She is asymptomatic, her LDL cholesterol is 3.2 mmol/L and she is already taking aspirin and a beta-blocker. Which lipid-lowering strategy is most appropriate?

  1. No additional lipid-lowering therapy
  2. High-intensity statin Correct answer.
  3. Bile acid sequestrant
  4. Fenofibrate

Explanation

Established atherosclerotic cardiovascular disease places a patient in the very-high-risk category, in which high-intensity statin therapy is recommended regardless of the baseline cholesterol. The target is a substantial LDL reduction, generally to below 1.4 mmol/L.

Question 4Cardiology

A 68-year-old man with heart failure and an ejection fraction of 28% is stable on furosemide. Which additional agent has been shown to reduce mortality in this condition?

  1. Amlodipine
  2. Furosemide at a higher dose
  3. An ACE inhibitor Correct answer.
  4. Digoxin

Explanation

ACE inhibitors reduce both mortality and hospitalisation in heart failure with reduced ejection fraction and are one of the four foundational disease-modifying classes, together with beta-blockers, mineralocorticoid receptor antagonists and SGLT2 inhibitors. Loop diuretics relieve congestion but do not improve survival.

Question 5Cardiology

A 79-year-old woman taking digoxin for atrial fibrillation presents with nausea, anorexia and yellow-tinged visual disturbance. Her pulse is 44 beats per minute. Which electrolyte abnormality most strongly predisposes to this presentation?

  1. Hypernatraemia
  2. Hypokalaemia Correct answer.
  3. Hypocalcaemia
  4. Hyperkalaemia

Explanation

Hypokalaemia increases digoxin binding at the sodium-potassium ATPase and is the commonest electrolyte precipitant of toxicity, producing gastrointestinal, visual and bradyarrhythmic features. Hypomagnesaemia, hypercalcaemia and renal impairment also increase risk.

Question 6Cardiology

A 72-year-old woman with permanent atrial fibrillation has hypertension and type 2 diabetes. She has no history of stroke, transient ischaemic attack or heart failure, and her renal function is normal. What is the most appropriate antithrombotic strategy?

  1. Clopidogrel 75 mg daily
  2. Aspirin 75 mg daily
  3. Dabigatran Correct answer.
  4. No antithrombotic therapy

Explanation

Her CHA2DS2-VASc score is 3, with one point each for age 65 to 74, hypertension and diabetes, which is well above the threshold for recommending oral anticoagulation. A direct oral anticoagulant is preferred to aspirin, which provides inadequate stroke protection at this risk level.

Question 7Cardiology

A 34-year-old woman presents with exertional dyspnoea. She has a loud first heart sound, an opening snap and a mid-diastolic rumbling murmur at the apex. Which is the most common cause of this condition worldwide?

  1. Infective endocarditis
  2. Carcinoid syndrome
  3. Rheumatic heart disease Correct answer.
  4. Mitral annular calcification

Explanation

Rheumatic heart disease remains the leading cause of mitral stenosis globally, producing leaflet thickening, commissural fusion and chordal shortening. The resulting restricted opening generates the loud first sound, opening snap and diastolic rumble.

Question 8Cardiology

A 19-year-old rugby player collapses during a match. Examination reveals a harsh systolic murmur at the left sternal edge that becomes louder on standing and during the Valsalva manoeuvre and softer on squatting. Which diagnosis is most likely?

  1. Primary mitral regurgitation
  2. Severe calcific aortic stenosis
  3. Hypertrophic cardiomyopathy Correct answer.
  4. Ventricular septal defect

Explanation

A systolic murmur at the left sternal edge that intensifies with manoeuvres reducing preload, such as standing and Valsalva, and softens with squatting indicates dynamic left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. Exertional syncope in a young athlete should always prompt assessment for this condition.

Question 9Cardiology

A 30-year-old man has sharp central chest pain that worsens on inspiration and on lying flat, and eases when he leans forward. The ECG shows widespread saddle-shaped ST elevation with PR depression. Which is the most appropriate initial treatment?

  1. High-dose corticosteroids
  2. NSAID plus colchicine Correct answer.
  3. Fibrinolytic therapy
  4. Urgent pericardiocentesis

Explanation

Acute pericarditis is treated with an NSAID together with colchicine, which improves symptom control and substantially reduces recurrence, alongside restriction of strenuous exercise. Corticosteroids are reserved for specific indications because they increase the likelihood of recurrence.

Question 10Cardiology

Which of the following patients should receive antibiotic prophylaxis before a dental extraction?

  1. Mitral valve prolapse without regurgitation
  2. Previous infective endocarditis Correct answer.
  3. Coronary artery bypass grafting
  4. Permanent pacemaker in situ

Explanation

Prophylaxis before dental procedures is now restricted to the highest-risk groups, namely previous infective endocarditis, prosthetic valves or prosthetic material, and certain cyanotic or repaired congenital lesions. Most other cardiac conditions no longer warrant prophylaxis.

Question 11Cardiology

A 76-year-old woman has had two syncopal episodes. Her pulse is 36 beats per minute and the ECG shows P waves at 95 per minute with no consistent relationship to narrow QRS complexes at 36 per minute. Which is the most appropriate immediate intervention?

  1. Intravenous amiodarone
  2. Exercise treadmill testing
  3. Intravenous atropine
  4. Temporary cardiac pacing Correct answer.

Explanation

Third-degree atrioventricular block with syncope reflects an infranodal escape rhythm, and atropine acts mainly on the sinus and atrioventricular nodes so is usually ineffective. Temporary pacing is required promptly and is followed by implantation of a permanent pacemaker.

Question 12Cardiology

A 55-year-old hypertensive man describes sudden severe tearing chest pain radiating to the back. His blood pressure is 185/100 mmHg, the right radial pulse is weaker than the left, and the chest radiograph shows a widened mediastinum. He is haemodynamically stable. Which investigation should be performed next?

  1. Troponin measurement
  2. Chest radiograph
  3. CT angiography of aorta Correct answer.
  4. Transthoracic echocardiography

Explanation

The presentation suggests acute aortic dissection, and CT angiography of the aorta is the first-line investigation in a stable patient because it identifies the intimal flap, extent and involvement of branch vessels. Rate and blood pressure control with a beta-blocker should begin immediately alongside imaging.

Question 13Cardiology

A 64-year-old woman with metastatic breast cancer develops hypotension, distended neck veins, muffled heart sounds and 15 mmHg of pulsus paradoxus. Echocardiography shows a large pericardial effusion with diastolic collapse of the right atrium. Which is the definitive management?

  1. Intravenous furosemide
  2. Urgent pericardiocentesis Correct answer.
  3. Rapid intravenous fluid bolus
  4. Intravenous beta-blocker

Explanation

The findings describe cardiac tamponade, in which pericardial pressure impairs diastolic filling and produces obstructive shock, confirmed by chamber collapse on echocardiography. Urgent pericardiocentesis is definitive, whereas fluid loading only temporarily supports cardiac output.

Question 14Cardiology

A 42-year-old woman with a corrected QT interval of 520 ms develops recurrent self-terminating polymorphic ventricular tachycardia with a twisting axis after starting a new antidepressant. She has a pulse and a blood pressure of 105/65 mmHg. Which is the first-line drug treatment?

  1. Intravenous magnesium sulfate Correct answer.
  2. Intravenous flecainide
  3. Intravenous amiodarone
  4. Intravenous calcium gluconate

Explanation

Torsades de pointes is treated with intravenous magnesium sulfate, which stabilises the myocardial membrane even when the serum magnesium is normal. The culprit QT-prolonging drug should be withdrawn and potassium and magnesium levels corrected.

Question 15Cardiology

A 27-year-old man with known Wolff-Parkinson-White syndrome presents with a broad irregular tachycardia at 240 beats per minute. His blood pressure is 78/45 mmHg and he has presyncope. Which is the most appropriate immediate management?

  1. Intravenous digoxin loading
  2. Urgent DC cardioversion Correct answer.
  3. Intravenous adenosine bolus
  4. Intravenous diltiazem bolus

Explanation

Pre-excited atrial fibrillation is a wide-complex irregular tachycardia in which atrioventricular nodal blocking drugs may accelerate conduction down the accessory pathway and precipitate ventricular fibrillation. An unstable patient requires immediate synchronised DC cardioversion.

Question 16Cardiology

A 35-year-old man has recurrent syncope. His ECG shows a coved ST elevation of 3 mm in V1 and V2 followed by T wave inversion, and this pattern is confirmed on a second ECG. Structural heart disease has been excluded. Which management reduces his risk of sudden cardiac death?

  1. ICD implantation Correct answer.
  2. Beta-blocker therapy
  3. Flecainide therapy
  4. Radiofrequency ablation

Explanation

A spontaneous type 1 Brugada pattern with syncope identifies a patient at high risk of polymorphic ventricular tachycardia and sudden death, and an implantable cardioverter defibrillator is the only therapy shown to reduce that risk. Avoidance of triggering drugs and prompt treatment of fever are important adjuncts.

Question 17Respiratory Medicine

Airflow limitation is confirmed on spirometry when the post-bronchodilator FEV1/FVC ratio falls below which value, using the fixed GOLD criterion?

  1. 0.75
  2. 0.80
  3. 0.60
  4. 0.70 Correct answer.

Explanation

The fixed ratio criterion defines persistent airflow limitation as a post-bronchodilator FEV1/FVC below 0.70. This threshold is simple to apply but tends to over-diagnose obstruction in older patients and under-diagnose it in younger adults, so the lower limit of normal is sometimes preferred.

Question 18Respiratory Medicine

According to Light's criteria, a pleural effusion is classified as an exudate when the pleural fluid-to-serum protein ratio exceeds which value?

  1. 0.3
  2. 0.7
  3. 0.5 Correct answer.
  4. 0.2

Explanation

Light's criteria classify an effusion as exudative if the pleural fluid protein/serum protein ratio exceeds 0.5, the pleural fluid LDH/serum LDH ratio exceeds 0.6, or the pleural fluid LDH exceeds two-thirds of the upper limit of normal serum LDH. Any single criterion being met is sufficient.

Question 19Respiratory Medicine

Which investigation is recommended to confirm a diagnosis of asthma in a symptomatic adult who is able to perform it?

  1. Serum total IgE and eosinophil count
  2. Sputum culture and sensitivity
  3. Chest radiography with lateral views
  4. Bronchodilator reversibility testing Correct answer.

Explanation

Asthma is confirmed by demonstrating variable airflow obstruction, typically an FEV1 improvement of at least 12% and 200 mL after an inhaled bronchodilator, or equivalent peak flow variability. A chest radiograph is used to exclude alternative diagnoses rather than to confirm asthma.

Question 20Respiratory Medicine

A tall, thin 24-year-old man develops sudden right-sided pleuritic chest pain and breathlessness. Which examination finding most suggests a pneumothorax?

  1. Hyperresonance with reduced breath sounds Correct answer.
  2. Widespread expiratory wheeze
  3. Bilateral basal inspiratory crackles
  4. Bronchial breathing with percussion dullness

Explanation

Air in the pleural space increases resonance to percussion and reduces the transmission of breath sounds on the affected side. Dullness with bronchial breathing instead suggests consolidation or effusion.

Question 21Respiratory Medicine

Which FEV1 range corresponds to GOLD grade 2 (moderate) airflow limitation in COPD, in a patient with a post-bronchodilator FEV1/FVC below 0.70?

  1. FEV1 below 30% predicted
  2. FEV1 at or above 80% predicted
  3. FEV1 30-49% predicted
  4. FEV1 50-79% predicted Correct answer.

Explanation

GOLD grades airflow limitation by FEV1 percentage predicted: grade 1 is 80% or more, grade 2 is 50-79%, grade 3 is 30-49% and grade 4 is under 30%. Grading is applied only once the FEV1/FVC ratio is below 0.70.

Question 22Respiratory Medicine

A 58-year-old woman with a confirmed large pulmonary embolism is hypotensive with a blood pressure of 82/50 mmHg and has a raised troponin. Which treatment is most appropriate?

  1. Unfractionated heparin infusion alone
  2. Systemic thrombolysis with alteplase Correct answer.
  3. Oral rivaroxaban
  4. Inferior vena cava filter insertion

Explanation

Haemodynamic instability defines high-risk pulmonary embolism, for which systemic thrombolysis is first-line in the absence of absolute contraindications, followed by anticoagulation. Anticoagulation alone is inadequate when shock is present because right ventricular failure needs rapid reperfusion.

Question 23Respiratory Medicine

A 30-year-old woman presents with tender erythema nodosum on both shins, ankle arthralgia, fever and bilateral hilar lymphadenopathy on chest radiography. Which statement about her likely condition is correct?

  1. It usually resolves spontaneously without treatment Correct answer.
  2. Progression to pulmonary fibrosis is expected
  3. It is caused by inhalation of organic dusts
  4. It almost always requires long-term corticosteroids

Explanation

This is Löfgren syndrome, an acute presentation of sarcoidosis with a good prognosis; most patients recover spontaneously within one to two years. Corticosteroids are reserved for symptomatic or organ-threatening disease.

Question 24Respiratory Medicine

A 35-year-old man from a high-incidence country has three weeks of fever, night sweats, weight loss and a right-sided pleural effusion. Pleural fluid is a lymphocyte-predominant exudate with a markedly raised adenosine deaminase. Which diagnosis is most likely?

  1. Tuberculous pleuritis Correct answer.
  2. Parapneumonic effusion
  3. Pulmonary infarction from embolism
  4. Malignant pleural effusion

Explanation

A lymphocyte-predominant exudate with a high adenosine deaminase level in a patient with constitutional symptoms from an endemic area strongly suggests tuberculous pleural disease. Pleural fluid culture is often negative, so biopsy or molecular testing may be needed.

Question 25Respiratory Medicine

A 70-year-old man with GOLD 3 COPD is breathless and drowsy. On air his PaO2 is 6.5 kPa, PaCO2 7.2 kPa and pH 7.28. Alongside nebulised bronchodilators, corticosteroids and antibiotics, which oxygen strategy is most appropriate initially?

  1. Immediate invasive ventilation
  2. High-flow oxygen to keep SpO2 above 98%
  3. Targeted oxygen to keep SpO2 at 88-92% Correct answer.
  4. Continuous nebulised salbutamol alone

Explanation

In acute hypercapnic COPD exacerbations, oxygen is titrated to a target saturation of 88-92% to avoid worsening hypercapnia while correcting hypoxaemia. If acidosis persists despite optimal medical therapy, non-invasive ventilation is the next step.

Question 26Respiratory Medicine

A 68-year-old man has progressive exertional breathlessness and fine bibasal inspiratory crackles. High-resolution CT shows peripheral, basal honeycombing with traction bronchiectasis and minimal ground-glass opacification. Which radiological pattern is described?

  1. Non-specific interstitial pneumonia
  2. Hypersensitivity pneumonitis
  3. Usual interstitial pneumonia Correct answer.
  4. Organising pneumonia

Explanation

Peripheral and basal honeycombing with traction bronchiectasis and little ground-glass change is the usual interstitial pneumonia pattern, which in the absence of a known cause indicates idiopathic pulmonary fibrosis. The pattern carries a poor prognosis and prompts antifibrotic therapy assessment.

Question 27Respiratory Medicine

A 64-year-old smoker has a central lung mass, serum sodium of 122 mmol/L, low serum osmolality and inappropriately concentrated urine. Which histological type of lung cancer most commonly causes this picture?

  1. Adenocarcinoma
  2. Large cell carcinoma
  3. Squamous cell carcinoma
  4. Small cell carcinoma Correct answer.

Explanation

This is syndrome of inappropriate antidiuretic hormone secretion, which occurs most often with small cell carcinoma because these neuroendocrine tumours ectopically secrete ADH. Small cell carcinoma also commonly causes ectopic ACTH secretion and Lambert-Eaton syndrome.

Question 28Respiratory Medicine

A 52-year-old obese man with loud snoring and daytime somnolence undergoes a sleep study that records an apnoea-hypopnoea index of 22 events per hour. How is the severity of his obstructive sleep apnoea classified?

  1. Normal study
  2. Severe obstructive sleep apnoea
  3. Moderate obstructive sleep apnoea Correct answer.
  4. Mild obstructive sleep apnoea

Explanation

Severity is graded by the apnoea-hypopnoea index: 5-14 events per hour is mild, 15-30 is moderate and above 30 is severe. A value of 22 therefore falls in the moderate category, which typically warrants a trial of CPAP alongside weight loss and attention to alcohol and sedatives.

Question 29Respiratory Medicine

A 28-year-old with longstanding asthma reports recurrent expectoration of mucus plugs and has blood eosinophilia, a markedly raised total IgE and positive Aspergillus precipitins. Which diagnosis fits best?

  1. Invasive pulmonary aspergillosis
  2. Eosinophilic granulomatosis with polyangiitis
  3. Aspergilloma in a pre-existing cavity
  4. Allergic bronchopulmonary aspergillosis Correct answer.

Explanation

Allergic bronchopulmonary aspergillosis complicates asthma or cystic fibrosis and is characterised by bronchial colonisation with Aspergillus, mucus plugging, eosinophilia, high IgE and central bronchiectasis. Corticosteroids plus itraconazole is the usual treatment.

Question 30Respiratory Medicine

A 40-year-old lifelong non-smoker is found to have emphysema. Which feature on CT most suggests alpha-1 antitrypsin deficiency rather than smoking-related disease?

  1. Emphysema confined to the right upper lobe
  2. Basal panlobular emphysema Correct answer.
  3. Apical centrilobular emphysema
  4. Paraseptal emphysema with subpleural bullae

Explanation

Alpha-1 antitrypsin deficiency typically causes panlobular emphysema that is worst in the lower zones, whereas smoking-related emphysema is centrilobular and upper-zone predominant. Early-onset disease in a non-smoker or a family history should prompt serum alpha-1 antitrypsin measurement.

Question 31Respiratory Medicine

A patient with severe pneumonia has a PaO2 of 6.0 kPa despite breathing 60% oxygen. Which mechanism best explains why supplemental oxygen fails to correct the hypoxaemia?

  1. Right-to-left shunt Correct answer.
  2. Alveolar diffusion impairment
  3. Ventilation-perfusion mismatch
  4. Alveolar hypoventilation

Explanation

When blood perfuses completely unventilated alveoli, the resulting right-to-left shunt cannot be corrected by raising the inspired oxygen fraction because the shunted blood never contacts oxygen. Shunt is therefore characterised by refractory hypoxaemia, in contrast with hypoventilation and mismatch, which respond to oxygen.

Question 32Respiratory Medicine

A 55-year-old man with pneumonia has a pleural effusion. Fluid analysis shows pH 7.10, glucose 2.0 mmol/L and LDH 900 IU/L, with no organisms on Gram stain. What is the most appropriate next step?

  1. Continue oral antibiotics alone
  2. Instil intrapleural fibrinolytics
  3. Insert an intercostal chest drain Correct answer.
  4. Repeat thoracentesis in 48 hours

Explanation

A parapneumonic effusion with pH below 7.20, low glucose or high LDH is complicated and requires drainage in addition to antibiotics to prevent loculation and empyema. Intrapleural fibrinolytics are considered only when drainage is inadequate.

Question 33Gastroenterology and Hepatology

A 30-year-old woman with chronic diarrhoea and weight loss is being investigated for coeliac disease. She is still eating gluten. Which serological test is the most appropriate first-line investigation?

  1. IgG anti-gliadin antibody
  2. Antireticulin antibody
  3. Faecal calprotectin
  4. IgA tissue transglutaminase antibody with total IgA Correct answer.

Explanation

IgA tissue transglutaminase is the recommended first-line serological test for coeliac disease, and total IgA is measured at the same time because IgA deficiency causes false-negative IgA-based tests. Anti-gliadin antibodies have poor specificity and are no longer used for diagnosis. Faecal calprotectin reflects intestinal inflammation rather than gluten sensitivity.

Question 34Gastroenterology and Hepatology

A 34-year-old man has been HBsAg positive on repeated testing over the past nine months. Which serological pattern confirms chronic hepatitis B infection?

  1. IgM anti-HBc positive with HBsAg negative
  2. HBsAg negative with anti-HBc IgG and anti-HBs positive
  3. Anti-HBs positive in isolation
  4. HBsAg positive persisting beyond six months Correct answer.

Explanation

Chronic hepatitis B is defined by persistence of HBsAg for more than six months, usually with anti-HBc IgG and without anti-HBs. The other patterns describe resolved infection with immunity, a window period, or vaccination.

Question 35Gastroenterology and Hepatology

Ascitic fluid analysis in a 58-year-old man with known liver disease shows a serum-ascites albumin gradient of 16 g/L. Which underlying process does this finding indicate?

  1. Peritoneal carcinomatosis
  2. Pancreatic ascites
  3. Tuberculous peritonitis
  4. Portal hypertension Correct answer.

Explanation

A serum-ascites albumin gradient of 11 g/L or more indicates ascites driven by portal hypertension, most often cirrhosis. Low-gradient ascites points to peritoneal disease, pancreatic leak or tuberculosis.

Question 36Gastroenterology and Hepatology

A 46-year-old woman has completed a course of triple therapy for Helicobacter pylori infection and is now asymptomatic. She is not taking a proton pump inhibitor. Which test is most appropriate to confirm eradication?

  1. Barium meal follow-through
  2. Serum IgG anti-Helicobacter antibody
  3. 13C urea breath test Correct answer.
  4. Rapid urease test on antral biopsy

Explanation

The urea breath test and stool antigen test are the preferred non-invasive methods for confirming eradication. Serology stays positive for months to years and cannot distinguish past from current infection, and the rapid urease test requires endoscopy.

Question 37Gastroenterology and Hepatology

A 28-year-old man is investigated for chronic diarrhoea and abdominal pain. Which histological feature most favours Crohn's disease over ulcerative colitis?

  1. Transmural inflammation with non-caseating granulomas Correct answer.
  2. Continuous mucosal disease extending from the rectum
  3. Superficial mucosal inflammation with crypt abscesses
  4. Inflammatory pseudopolyps

Explanation

Crohn's disease is characterised by transmural, discontinuous inflammation and non-caseating granulomas, whereas ulcerative colitis affects the mucosa continuously from the rectum. Crypt abscesses and pseudopolyps occur in both but are typical of ulcerative colitis.

Question 38Gastroenterology and Hepatology

A 52-year-old man presents with severe epigastric pain radiating to the back, 24 hours after onset. Which serum test is the most useful single measurement for confirming acute pancreatitis at this stage?

  1. Serum alkaline phosphatase
  2. C-reactive protein
  3. Serum amylase
  4. Serum lipase Correct answer.

Explanation

Serum lipase is more sensitive and specific than amylase and remains elevated for longer, so it is preferred when presentation is delayed. Amylase normalises within two to three days and can be falsely elevated by other abdominal pathology.

Question 39Gastroenterology and Hepatology

A patient with cirrhotic ascites develops fever and abdominal discomfort. Diagnostic paracentesis is performed. Which ascitic fluid polymorphonuclear cell count meets the diagnostic threshold for spontaneous bacterial peritonitis?

  1. 50 cells/mm3 or more
  2. 500 cells/mm3 or more
  3. 150 cells/mm3 or more
  4. 250 cells/mm3 or more Correct answer.

Explanation

An ascitic neutrophil count of 250 cells/mm3 or more establishes the diagnosis and is an indication to start empirical antibiotics immediately, even before culture results. Lower counts do not fulfil the diagnostic criterion.

Question 40Gastroenterology and Hepatology

A 60-year-old man with alcohol-related cirrhosis has grade 2 hepatic encephalopathy. Which agent is first-line treatment?

  1. Lactulose Correct answer.
  2. Rifaximin alone
  3. Oral neomycin
  4. Oral metronidazole

Explanation

Lactulose is the first-line treatment for hepatic encephalopathy, titrated to two or three soft stools per day. Rifaximin is used as add-on therapy for recurrent episodes, and antibiotics such as neomycin are reserved for short courses because of toxicity.

Question 41Gastroenterology and Hepatology

A 54-year-old woman presents with fatigue and generalised pruritus. Liver tests show a raised alkaline phosphatase with a normal bilirubin, and IgM is elevated. Which antibody is most likely to be positive?

  1. Antimitochondrial antibody Correct answer.
  2. Anti-smooth muscle antibody
  3. Perinuclear antineutrophil cytoplasmic antibody
  4. Anti-liver-kidney microsomal antibody

Explanation

This picture is typical of primary biliary cholangitis, in which antimitochondrial antibody is positive in the great majority of patients. Anti-smooth muscle and anti-LKM1 antibodies belong to autoimmune hepatitis, and p-ANCA is associated with primary sclerosing cholangitis.

Question 42Gastroenterology and Hepatology

A 35-year-old woman is diagnosed with autoimmune hepatitis after a liver biopsy shows interface hepatitis with raised IgG and positive anti-smooth muscle antibody. Which is the appropriate first-line induction therapy?

  1. Budesonide alone
  2. Azathioprine alone
  3. Mycophenolate mofetil
  4. Prednisolone, with or without azathioprine Correct answer.

Explanation

Induction treatment is with corticosteroids, usually prednisolone, and azathioprine is added as a steroid-sparing agent, often from the outset in maintenance dosing. Azathioprine monotherapy is not adequate for induction.

Question 43Gastroenterology and Hepatology

A 55-year-old man with cirrhosis presents with haematemesis and melaena. After resuscitation and endoscopy, which pharmacological combination forms part of standard initial management of suspected variceal bleeding?

  1. Propranolol and intravenous vitamin K
  2. Intravenous proton pump inhibitor alone
  3. Immediate transjugular intrahepatic portosystemic shunt
  4. Terlipressin plus prophylactic intravenous antibiotics Correct answer.

Explanation

A vasoactive drug such as terlipressin plus prophylactic antibiotics should be started as soon as variceal haemorrhage is suspected; antibiotics reduce mortality and rebleeding. Endoscopic band ligation is performed at endoscopy, and TIPS is reserved for failure to control bleeding.

Question 44Gastroenterology and Hepatology

A 62-year-old man has iron deficiency anaemia with a normal upper gastrointestinal endoscopy and no gastrointestinal symptoms. Which is the most appropriate next investigation?

  1. Repeat full blood count in six months
  2. Colonoscopy Correct answer.
  3. Barium enema
  4. Repeat iron studies after a course of oral iron

Explanation

Iron deficiency anaemia in a man of this age requires bidirectional endoscopy, so colonoscopy is indicated after a normal upper gastrointestinal study to exclude colorectal cancer and other right-sided lesions. Barium enema is less sensitive than colonoscopy.

Question 45Gastroenterology and Hepatology

A 22-year-old man presents with tremor, jaundice and a recent episode of haemolytic anaemia. Which combination of results most supports a diagnosis of Wilson disease?

  1. Positive antimitochondrial antibody
  2. Raised ferritin with transferrin saturation of 65%
  3. Low serum alpha-1 antitrypsin
  4. Low serum caeruloplasmin with high urinary copper Correct answer.

Explanation

Wilson disease classically causes low serum caeruloplasmin with increased urinary copper excretion, and Kayser-Fleischer rings may be seen on slit-lamp examination. The combination of neuropsychiatric features, liver disease and Coombs-negative haemolysis is highly suggestive.

Question 46Gastroenterology and Hepatology

A 26-year-old woman presents 36 hours after a paracetamol overdose with grade 3 encephalopathy and a rising INR. Which variable forms part of the King's College criteria predicting a poor prognosis in paracetamol-induced acute liver failure?

  1. Serum ALT greater than 1000 U/L
  2. Arterial pH less than 7.30 after adequate fluid resuscitation Correct answer.
  3. Presence of ascites
  4. Serum bilirubin greater than 100 micromol/L

Explanation

The King's College criteria for paracetamol-induced liver failure include arterial pH below 7.30 after resuscitation, together with INR, creatinine and grade of encephalopathy. Transaminase and bilirubin levels are not part of these criteria.

Question 47Gastroenterology and Hepatology

A 40-year-old man with a ten-year history of ulcerative colitis develops pruritus and cholestatic liver tests. MRCP shows multifocal stricturing of the intrahepatic and extrahepatic bile ducts. Which antibody is most commonly associated with this condition?

  1. Perinuclear antineutrophil cytoplasmic antibody Correct answer.
  2. Antimitochondrial antibody
  3. Anti-smooth muscle antibody
  4. Anti-double-stranded DNA antibody

Explanation

The findings indicate primary sclerosing cholangitis, which is strongly associated with ulcerative colitis and in which perinuclear ANCA is positive in the majority of patients. MRCP showing multifocal strictures and beading is diagnostic.

Question 48Gastroenterology and Hepatology

A 45-year-old man has recurrent duodenal ulcers, chronic diarrhoea and a fasting serum gastrin of 900 pg/mL with a gastric pH of 1.2. Which diagnosis is most likely?

  1. Helicobacter pylori infection
  2. Autoimmune atrophic gastritis
  3. Gastrinoma Correct answer.
  4. Antral G-cell hyperplasia

Explanation

Marked hypergastrinaemia accompanied by a low gastric pH indicates gastrin-driven acid hypersecretion, characteristic of Zollinger-Ellison syndrome due to a gastrinoma. Multiple or refractory ulcers and diarrhoea are typical.

Question 49Endocrinology and Diabetes Mellitus

Which condition is the commonest cause of thyrotoxicosis in iodine-replete populations?

  1. Graves disease Correct answer.
  2. Toxic multinodular goitre
  3. Subacute (de Quervain) thyroiditis
  4. Amiodarone-induced thyrotoxicosis

Explanation

Graves disease accounts for roughly 70-80% of thyrotoxicosis and is driven by TSH-receptor stimulating immunoglobulins, producing a diffuse goitre, ophthalmopathy and pretibial myxoedema. Nodular disease and destructive thyroiditis together make up the remainder.

Question 50Endocrinology and Diabetes Mellitus

Which HbA1c value, measured on a single sample, is diagnostic of diabetes mellitus in a non-pregnant adult?

  1. 39 mmol/mol (5.7%)
  2. 48 mmol/mol (6.5%) Correct answer.
  3. 44 mmol/mol (6.2%)
  4. 42 mmol/mol (6.0%)

Explanation

An HbA1c of 48 mmol/mol (6.5%) or above meets WHO diagnostic criteria for diabetes, provided the assay is standardised and the result is not confounded by anaemia, haemoglobinopathy or renal disease. Values of 42-47 mmol/mol represent non-diabetic hyperglycaemia and warrant lifestyle advice and retesting.