Clinical Sciences
Cell/molecular and membrane
(72)
biology
Clinical anatomy (67)
Clinical biochemistry and metabolism (118)
Clinical physiology (92)
Genetics (107)
Immunology (118)
Statistics (158)
Passing mark range between 63-66%
Year No. of Q
MRCP 1 May 19 100
MRCP 1 Jan 19 100
MRCP 1 Sept 18 100
MRCP 1 May 18 100
MRCP 1 Jan 18 100
MRCP 1 Sept 17 100
MRCP 1 May 17 100
MRCP 1 Jan 17 100
MRCP 1 Sept 16 100
MRCP 1 May 16 100
MRCP 1 Jan 2016 100
MRCP 1 Sept 2015 100
MRCP 1 May 2015 100
MRCP 1 Jan 2015 100
A. H. Murad
ﻻ ﺗﻨﺴﻮﻧﺎ ﻣﻦ ﺻﺎﻟﺢ دﻋﺎﺋﻜﻢ
ﺗﻢ ﺑﺤﻤﺪ ﷲ وﺗﻮﻓﯿﻘﮫ وﻣﻨﮫ
ﺟﻌﻞ ﷲ ﻋﻤﻠﻨﺎ ﻣﺘﻘﺒﻼ ﺧﺎﻟﺼﺎ ﻟﻮﺟﮭﮫ اﻟﻜﺮﯾﻢ
,A 16-year-old man presents with acute central abdominal pain and vomiting. On examination,
his abdomen was tender but there was no guarding, and bowel sounds were normal. Power
was reduced distally in his lower limbs and ankle and knee reflexes were absent. An older
sister presented with a similar condition.
Investigations:
Hb 11.0 g/dl
MCV 72 fl
PLT 170 × 10 9/l
Blood film Basophilic stippling
Urinary δ-ALA (delta-aminolevulinic acid) 100 mmol/24 h (normal 8–53)
A Arsenic poisoning
B Lead poisoning
C Acute intermittent porphyria (AIP)
D Guillain–Barré syndrome (GBS)
E Diabetic ketoacidosis (DKA)
Explanation
B Lead poisoning
The patient has abdominal pain and a motor neuropathy. Causes of these two symptoms are:
lead poisoning
arsenic poisoning
Guillain–Barré syndrome
diabetic ketoacidosis
polyarteritis nodosa
acute intermittent porphyria (AIP).
,Both AIP and lead poisoning cause an elevation in urinary delta-aminolevulinic acid. However,
only lead poisoning causes basophilic stippling. This patient’s older sister shared the same
environmental lead exposure, accounting for her presentation with similar symptoms.
A Arsenic poisoning
Arsenic poisoning is incorrect. Arsenic is a metallic element, and acute exposure can cause
severe systemic toxicity and death. Subacute exposure causes skin changes, peripheral
neuropathy, diabetes and hepatic toxicity. Exposure is rare, and can occur when metal is
smelted or in similar manufacturing processes, as well as when arsenic-containing pesticides
are used. Acute presentation is usually with abdominal pain, watery diarrhoea and
dehydration. ECG can demonstrate prolonged QTc, which can lead to arrhythmia. The
basophilic stippling makes this diagnosis less likely.
C Acute intermittent porphyria (AIP)
Acute intermittent porphyria (AIP) is incorrect. AIP is caused by inherited deficiency of
porphobilinogen deaminase, which is inherited in a dominant fashion. Acute attacks can be
provoked by exacerbating factors leading to neurological dysfunction, abdominal pain and
weakness. Whilst raised delta-aminolevulinic acid is associated with AIP, it is also associated
with acute lead poisoning and the basophilic stifling makes lead poisoning more likely.
D Guillain–Barré syndrome (GBS)
Guillain–Barré syndrome (GBS) is incorrect. GBS is an auto-immune-mediated
polyneuropathy. It is thought to occur due to molecular mimicry following infection; this is
especially thought to be linked to Campylobacter. It causes progressive and symmetrical
muscle weakness, which can progress to respiratory paralysis. The history of this patient does
not match this description; the antecedent infection in GBS, which could account for the
abdominal pain and vomiting, occurs weeks before any weakness. Also, it would not explain
how another family member has similar symptoms.
E Diabetic ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) is incorrect. This is a diabetic emergency of acidosis and ketosis
occurring in a hyperglycaemic state. It can present with abdominal pain and tenderness as
well as vomiting, and in a 16-year-old it can be the first presentation of type 1 diabetes. This
would not explain the weakness or the blood film findings.
202
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Cell/molecular and membrane
(72)
biology
Clinical anatomy (67)
Clinical biochemistry and metabolism (118)
Clinical physiology (92)
Genetics (107)
Immunology (118)
Statistics (158)
Passing mark range between 63-66%
Year No. of Q
MRCP 1 May 19 100
MRCP 1 Jan 19 100
MRCP 1 Sept 18 100
MRCP 1 May 18 100
MRCP 1 Jan 18 100
MRCP 1 Sept 17 100
MRCP 1 May 17 100
MRCP 1 Jan 17 100
MRCP 1 Sept 16 100
MRCP 1 May 16 100
MRCP 1 Jan 2016 100
MRCP 1 Sept 2015 100
MRCP 1 May 2015 100
MRCP 1 Jan 2015 100
A. H. Murad
ﻻ ﺗﻨﺴﻮﻧﺎ ﻣﻦ ﺻﺎﻟﺢ دﻋﺎﺋﻜﻢ
ﺗﻢ ﺑﺤﻤﺪ ﷲ وﺗﻮﻓﯿﻘﮫ وﻣﻨﮫ
ﺟﻌﻞ ﷲ ﻋﻤﻠﻨﺎ ﻣﺘﻘﺒﻼ ﺧﺎﻟﺼﺎ ﻟﻮﺟﮭﮫ اﻟﻜﺮﯾﻢ
,A 16-year-old man presents with acute central abdominal pain and vomiting. On examination,
his abdomen was tender but there was no guarding, and bowel sounds were normal. Power
was reduced distally in his lower limbs and ankle and knee reflexes were absent. An older
sister presented with a similar condition.
Investigations:
Hb 11.0 g/dl
MCV 72 fl
PLT 170 × 10 9/l
Blood film Basophilic stippling
Urinary δ-ALA (delta-aminolevulinic acid) 100 mmol/24 h (normal 8–53)
A Arsenic poisoning
B Lead poisoning
C Acute intermittent porphyria (AIP)
D Guillain–Barré syndrome (GBS)
E Diabetic ketoacidosis (DKA)
Explanation
B Lead poisoning
The patient has abdominal pain and a motor neuropathy. Causes of these two symptoms are:
lead poisoning
arsenic poisoning
Guillain–Barré syndrome
diabetic ketoacidosis
polyarteritis nodosa
acute intermittent porphyria (AIP).
,Both AIP and lead poisoning cause an elevation in urinary delta-aminolevulinic acid. However,
only lead poisoning causes basophilic stippling. This patient’s older sister shared the same
environmental lead exposure, accounting for her presentation with similar symptoms.
A Arsenic poisoning
Arsenic poisoning is incorrect. Arsenic is a metallic element, and acute exposure can cause
severe systemic toxicity and death. Subacute exposure causes skin changes, peripheral
neuropathy, diabetes and hepatic toxicity. Exposure is rare, and can occur when metal is
smelted or in similar manufacturing processes, as well as when arsenic-containing pesticides
are used. Acute presentation is usually with abdominal pain, watery diarrhoea and
dehydration. ECG can demonstrate prolonged QTc, which can lead to arrhythmia. The
basophilic stippling makes this diagnosis less likely.
C Acute intermittent porphyria (AIP)
Acute intermittent porphyria (AIP) is incorrect. AIP is caused by inherited deficiency of
porphobilinogen deaminase, which is inherited in a dominant fashion. Acute attacks can be
provoked by exacerbating factors leading to neurological dysfunction, abdominal pain and
weakness. Whilst raised delta-aminolevulinic acid is associated with AIP, it is also associated
with acute lead poisoning and the basophilic stifling makes lead poisoning more likely.
D Guillain–Barré syndrome (GBS)
Guillain–Barré syndrome (GBS) is incorrect. GBS is an auto-immune-mediated
polyneuropathy. It is thought to occur due to molecular mimicry following infection; this is
especially thought to be linked to Campylobacter. It causes progressive and symmetrical
muscle weakness, which can progress to respiratory paralysis. The history of this patient does
not match this description; the antecedent infection in GBS, which could account for the
abdominal pain and vomiting, occurs weeks before any weakness. Also, it would not explain
how another family member has similar symptoms.
E Diabetic ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) is incorrect. This is a diabetic emergency of acidosis and ketosis
occurring in a hyperglycaemic state. It can present with abdominal pain and tenderness as
well as vomiting, and in a 16-year-old it can be the first presentation of type 1 diabetes. This
would not explain the weakness or the blood film findings.
202
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Difficulty: Average
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Responses Total: 1
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