Step Up to MRCP Review Notes for P1 & P2 By Dr Khaled El Magraby 1st ed 2015

Step Up To MRCP Review Note For Part I & Part II By Dr Khaled El Magraby Dr Khaled Magraby MRCP Notes ‫بسم هللا الرحمن الرحيم‬ ‫صدق هللا العظيم‬ ‫سورة البقرة ۩ اﻵية { ‪} ٣٢‬‬ ‫‪Dr Khaled Magraby MRCP Notes‬‬ Introduction First of all, I would like to thank ALLAH, the most Merciful and Compassionate Words can never express my sincere thanks to my parents for everything throughout my life from K.G till MRCP and their prayers, encouragement, love, endless care and spiritual support when I was in most need of it; that can never be sufficiently acknowledged I pray to ALLAH to make this work of benefit to the all doctors would like to have MRCP by giving them the important pearls of Internal medicine and to accept our honest intention in this work It is a very helpful and important source for preparation and studying MRCP examination for both part and It is very rich in information from many sources:  www.passmedicine.com  www.onexamination.com  www.pasTest.co.uk 1st edition @ September 2015 Dr Khaled Magraby MRCP Notes ‫دكتور خالد المغربي‬ ‫أخصائى األمراض الباطنة والكلى‬ ‫ماجيستير األمراض الباطنة‬ ‫كلية طب قصر العينى – جامعة القاهرة‬ ‫باحث مساعد بالمركز القومى للبحوث‬ Dr Khaled El Magraby Specialist of Internal Medicine & Nephrology M.Sc Internal Medicine Cairo University, Egypt Assistant Researcher National Research Center, Egypt E-mail: dr_khaled_elmagraby@hotmail.com Facebook: Khaled Elmagraby 00966565084114 (WhatsApp & LINE) 00201223355396 Dr Khaled Magraby MRCP Notes TABLE OF THE CONTENTS Subject Page Chapter 1: Cardiology…………………………………….……………….… … Chapter 2: Pulmonology…………………………… …………………….…… 147 Chapter 3: Gastroenterology & Hepatology ………………………… …… 239 Chapter 4: Endocrinology ………………… …………………….………… … 341 Chapter 5: Haematology…………………………………………………… … 473 Chapter 6: Nephrology……………………… …………………… …… …… 599 Chapter 7: Rheumatology 670 Chapter 8: Pharmaceuticals & Therapeutics………….… ………………… 762 Chapter 9: Infectious Diseases & STDs…………………………………… … 843 Chapter 10: Neurology 946 Chapter 11: Psychiatry 1054 Chapter 12: Ophthalmology…………… …………… ……………….…….… 1084 Chapter 13: Dermatology………………………………………….… ………… 1112 Chapter 14: Basic Sciences, Biostatistics & Miscellaneous …… … … 1158 Dr Khaled Magraby MRCP Notes Chapter 1: Cardiology Cardiology Dr Khaled Magraby MRCP Notes Chapter 1: Cardiology Long QT syndrome (LQTS) LQTS is an inherited condition associated with delayed repolarization of the ventricles It is important to recognise as it may lead to ventricular tachycardia (VT) and can therefore cause collapse/sudden death The most common variants of LQTS (LQT1 & LQT2) are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel A normal corrected QT interval is less than 430 ms (0.43 Sec.) in males and 450 ms (0.45 Sec.) in females Normal range for duration of the corrected QT interval (QTc) is 350 -430 ms Causes of a prolonged QT interval: Congenital:   Jervell-LangeNielsen (JLN) syndrome: (includes deafness and is due to an abnormal potassium channel) Romano-Ward syndrome: (no deafness) Drugs:                 Amiodarone Sotalol Class 1a antiarrhythmic drugs TCA (e.g amitriptyline) (˃ SSRI) SSRI (especially citalopram, Sertraline) Lithium Methadone Chloroquine Mefloquine Terfenadine Macrolides: Erythromycin, Clarithromycin Levofloxacin Domperidone Ketoconazole Haloperidol Tacrolimus Dr Khaled Magraby MRCP Notes Others:        Electrolyte: Hypocalcaemia, Hypokalaemia, Hypomagnesaemia Acute MI Myocarditis HOCM Hypothermia Subarachnoid haemorrhage Hypothyroidism Cardiology Chapter 1: Cardiology Jervell - Lange-Nielsen (JLN) syndrome is caused by mutations in the KCNE1 and KCNQ1 genes The KCNE1 and KCNQ1 genes provide instructions for making proteins that work together to form a channel across cell membranes These channels transport positively charged potassium atoms (ions) out of cells The movement of potassium ions through these channels is critical for maintaining the normal functions of inner ear structures and cardiac muscle Features:        May be picked up on routine ECG or following family screening Long QT1 - usually associated with exertional syncope, often swimming Long QT2 - often associated with syncope occurring following emotional stress, exercise or auditory stimuli e.g doorbell or telephone ring Long QT3 - events often occur at night or at rest Sudden cardiac death Diagnosis is based upon the QTc (corrected QT interval), although this may be within the normal range at rest; hence Holter ECG monitoring is recommended Identification of an LQTS genetic mutation confirms the diagnosis However, a negative result on genetic testing is of limited diagnostic value because only approximately 50% of patients with LQTS have known mutations The remaining half of patients with LQTS may have mutations of yet unknown gene Therefore genetic testing of LQTS has high specificity but a low sensitivity The ECG shows a long QT and ventricular premature beats The loss of consciousness may have been due to ventricular arrhythmia, in particular, torsade de pointes VT Dr Khaled Magraby MRCP Notes Cardiology Chapter 1: Cardiology Management (by order): ‫بالترتيب‬ Avoid drugs which prolong the QT interval and other precipitants if appropriate (e.g Strenuous exercise) 2) Beta-blockers (e.g Propranolol, Metoprolol & Atenolol, NOT Sotalol) 3) ICD (Implantable cardioverter defibrillators) in high risk cases (i.e It is only required in high risk cases, for example if the patient has a QTc > 500ms or previous episodes of cardiac arrest 4) Left stellate cardiac ganglionectomy 1) Long QT syn >> usually due to loss-of-function/blockage of K+ channels NB: Beta blockers are the mainstay of therapy for asymptomatic as well as symptomatic patients with idiopathic LQTS Beta blockers decrease sympathetic activation from the left stellate ganglion, also decrease the maximal heart rate achieved during exertion and thereby prevent exercise-related arrhythmic events that occur in LQTS Patients who experience ventricular arrhythmias or aborted SCD despite beta blocker therapy >>> should have an ICD in addition to βB Left stellate cardiac ganglionectomy is an invasive procedure and results in Horner’s syndrome It is performed in patients who have symptoms despite βB and have frequent shocks with ICD NB: Non-sedating antihistamine and classic cause of prolonged QT in a patient, especially if also taking P450 enzyme inhibitor, e.g Patient with a cold takes terfenadine and erythromycin at the same time NB: Sotalol may exacerbate long QT syndrome (due to blockage of K channel) it leads to a risk of ventricular arrhythmias This can be a particular risk in individuals with hypokalaemia So Sotalol is better to be avoided in patients with thiazide diuretics EX: A 75-year-old man with a history of anterior MI is taking amiodarone 400 mg/day for history of VT He has a prolonged QTc interval on his ECG of 550 ms The most appropriate management >>> Stop amiodarone immediately and can replace with atenolol 50 mg a day Dr Khaled Magraby MRCP Notes Cardiology Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Asking the consultant to come to meet him face-to-face in as an option but may not be necessary if the previous conditions are met Saying he is 'doing fine' is unlikely to satisfy a consultant cardiologist Giving details without first getting permission from the patient is breaking confidentiality, however well intentioned Involving a relative in the management of a patient is inappropriate and the worst option Menstrual cycle The menstrual cycle may be divided into the following phases: [ Days Menstruation 1-4 Follicular phase (proliferative phase) 5-13 Ovulation 14 Luteal phase (secretory phase) 15-28 Further details are given in the table below: Ovarian histology Follicular phase Luteal phase (proliferative phase) (secretory phase) A number of follicles develop Corpus luteum One follicle will become dominant around the midfollicular phase Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1249 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Follicular phase Luteal phase (proliferative phase) (secretory phase) Endometrial histology Proliferation of endometrium Endometrium changes to secretory lining under influence of progesterone Hormones A rise in FSH results in the development of follicles which in turn secrete oestradiol Progesterone secreted by corpus luteum rises through the luteal phase When the egg has matured, it secretes enough oestradiol to trigger the acute release of LH > >> LH surge >>> This in turn leads to ovulation If fertilisation does not occur the corpus luteum will degenerate and progesterone levels fall Oestradiol levels also rise again during the luteal phase Cervical mucus Following menstruation the mucus is thick and forms a plug across the external os Under the influence of progesterone it becomes thick, scant, and tacky Just prior to ovulation the mucus becomes clear, acellular, low viscosity It also becomes 'stretchy' - a quality termed spinnbarkeit Basal body temperature Falls prior to ovulation due to the influence of oestradiol Dr Khaled Magraby MRCP Notes Rises following ovulation in response to higher progesterone levels Clinical Sciences, Biostatistics & Miscellaneous 1250 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Energy from food The amount of energy a food product contains is expressed in calories (kcal) The amount of energy that may be derived from gram of food is as follows:  Carbohydrates: kcal  Protein: kcal  Fat: kcal In simple terms, per unit weight, fats contain twice as many calories as protein or carbohydrates Leukotrienes Function:  Mediators of inflammation and allergic reactions  Cause bronchoconstriction, mucous production  Increase vascular permeability, attract leukocytes  Leukotriene D4 has been identified as the SRS-A (slow reacting substance of anaphylaxis) Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1251 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Production:  Secreted by leukocytes  Formed from arachidonic acid by action of lipoxygenase It is thought that the NSAID induced bronchospasm in asthmatics is secondary to the express production of leukotrienes due to the inhibition of prostaglandin synthetase Endothelin Endothelin is a potent, long-acting vasoconstrictor and bronchoconstrictor It is secreted initially as a prohormone by the vascular endothelium and later converted to ET-1 by the action of endothelin converting enzyme It acts via interaction with a G-protein linked to phospholipase C leading to calcium release Endothelin is thought to be important in the pathogenesis of many diseases including primary pulmonary hypertension (endothelin antagonists are now used), cardiac failure, hepatorenal syndrome and Raynaud's Promotes release: 1) Angiotensin II 2) ADH 3) Hypoxia 4) Mechanical shearing forces Inhibits release: 1) Nitric oxide 2) Prostacyclin Raised levels in:  MI  Heart failure  ARF  Asthma  Primary pulmonary hypertension Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1252 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Fluid therapy The prescription of intravenous fluids is one of the most common tasks that junior doctors need to The typical daily requirement is:  1.5 ml/kg/hr fluid - for a 80kg man around 2-3 litres/day  70-150mmol sodium  40-70mmol potassium This is why the typical regime prescribed for patients is  litre 5% dextrose with 20mmol potassium over hours  litre 0.9% normal saline with 20mmol potassium over hours  litre 5% dextrose with 20mmol potassium over hours The amount of fluid patients require obviously varies according to their recent and past medical history For example a patient who is post-op and is having significant losses from drains will require more fluid whereas a patient with heart failure should be given less fluid to avoid precipitating pulmonary oedema The table below shows the electrolyte concentrations (in millimoles/litre) of plasma and the most commonly used fluids: Plasma 0.9% normal saline 5% dextrose Hartmann's solution Na+ Cl- K+ HCO3- Ca2+ 135-145 98-105 3.5-5 22-28 2.3-2.6 150 150 - - - - - - - - 131 111 29 Understanding sodium requirements is important especially when maintenance intravenous fluid prescriptions are required Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1253 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Daily maintenance requirements vary between individuals and the clinical situation, but for a 70 kg male the generally accepted requirements per day are:  2.5-3.0L water  120-140 mmol sodium (~2 mmol/kg)  70 mmol potassium (~1 mmol/kg) Hartmann's solution contains 131 mmol Na per litre, Normal saline has 150 mmol/L and Dextrose saline has 30 mmol/L Q: What is their daily requirement of salt? >>>>> gm/day The daily sodium requirement is 70-150mmol We can convert this to mg by multiplying by 58.5 (molecular weight of sodium is approximately 23, chloride is 35.5) So, 70-150mmol = 4095 - 8775mg = - 8.5g The nearest answer to this is 6g Secondly, this figure ties in with the governments recommended oral salt intake of 6g/day Macroglossia Causes: 1) Acromegaly 2) Hypothyroidism 3) Amyloidosis 4) Duchenne muscular dystrophy 5) Mucopolysaccharidosis (e.g Hurler syndrome) 6) Patients with Down's syndrome are now thought to have apparent macroglossia due to a combination of mid-face hypoplasia and hypotonia Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1254 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Amyloidosis It is characterized by extracellular deposition of fibrous protein in various tissues and organs It may be primary or secondary associated with other chronic diseases like myeloma or rheumatoid arthritis Two major types of protein are deposited in tissues: 1) Protein light chain (AL) in primary amyloidosis and myeloma-associated amyloidosis 2) Non-immunoglobulin protein (AA) in secondary amyloidosis usually associated with chronic diseases such as TB, Bronchiectasis, osteomyelitis, rheumatoid arthritis, FMF and Hodgkin’s disease Symptoms and signs depend on the organ involved     Nephrotic syndrome is a common mode of presentation Cardiac involvement: cardiomegaly, CHF and arrhythmia Hepatic amyloid: hepatomegaly and hepatosplenomegaly Other organs: lung, thyroid, skin, GIT, tongue, adrenals and LNs Diagnosis: demonstration of amyloid fibrils by Congo red staining under polarised light microscopy, abdominal subcutaneous fat pad aspirate or rectal submucosal biopsy are often performed to reach a final diagnosis Clubbing The causes of clubbing may be divided into cardiac, respiratory and other 1) Cardiac causes: 1) Cyanotic congenital heart disease (Fallot's, TGA) 2) Bacterial endocarditis 3) Atrial myxoma 2) Respiratory causes: 1) Pyogenic conditions: cystic fibrosis, bronchiectasis, abscess, empyema 2) TB 3) Asbestosis, mesothelioma 4) Fibrosing alveolitis 5) Lung cancer Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1255 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous 3) Other causes: 1) IBD: Crohn's, to a lesser extent UC 2) Cirrhosis, primary biliary cirrhosis 3) Graves' disease (thyroid acropachy) 4) Rare: Whipple's disease Valsalva manoeuvre The Valsalva manoeuvre describes a forced expiration against a closed glottis This leads to increased intra-thoracic pressure which in turn has a number of effects on the cardiovascular system Uses: 1) To terminate an episode of supraventricular tachycardia 2) Normalizing middle-ear pressures Stages of the Valsalva manoeuvre:  Increased intrathoracic pressure  Resultant increase in venous and right atrial pressure reduces venous return  The reduced preload leads to a fall in the cardiac output (Frank-Starling mechanism)  When the pressure is released there is a further slight fall in cardiac output due to increased aortic volume  Return of normal cardiac output Fitness to fly The Civil Aviation Authority (CAA) has issued guidelines on air travel for people with medical conditions; please see the link www.caa.co.uk Cardiovascular disease:  Unstable angina, uncontrolled hypertension, uncontrolled cardiac arrhythmia, decompensated heart failure, severe symptomatic valvular disease: should not fly  Uncomplicated myocardial infarction: may fly after 7-10 days Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1256 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous  Complicated myocardial infarction: after 4-6 weeks  Coronary artery bypass graft: after 10-14 days  Percutaneous coronary intervention: after days Respiratory disease:  Pneumonia: should be 'clinically improved with no residual infection'  Pneumothorax: absolute contraindication, the CAA suggest patients may travel weeks after successful drainage if there is no residual air The British Thoracic Society used to recommend not travelling by air for a period of weeks but this has now been changed to week post check x-ray Pregnancy:  Most airlines not allow travel after 36 weeks for a single pregnancy and after 32 weeks for a multiple pregnancy  Most airlines require a certificate after 28 weeks confirming that the pregnancy is progressing normally Surgery:  Travel should be avoided for 10 days following abdominal surgery  Laparoscopic surgery: after 24 hours  Colonoscopy: after 24 hours  Following the application of a plaster cast, the majority of airlines restrict flying for 24 hours on flights of less than hours or 48 hours for longer flights this is due to the fact that air may be trapped beneath the cast Haematological disorders:  Patients with a haemoglobin of greater than g/dl may travel without problems (assuming there is no coexisting condition such as cardiovascular or respiratory disease) Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1257 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Vitamin deficiency Vitamin Chemical name Deficiency state A Retinoids Night-blindness (nyctalopia) B1 Thiamine Beriberi: B3 Niacin acid)  Polyneuropathy, Wernicke-Korsakoff syndrome  Heart failure (Nicotinic Pellagra:  Dermatitis  Diarrhoea  Dementia B6 Pyridoxine Anaemia, irritability, seizures B7 Biotin Dermatitis, seborrhoea B9 Folic acid Megaloblastic anaemia, deficiency during pregnancy - neural tube defects B12 Cyanocobalamin Megaloblastic anaemia, peripheral neuropathy C Ascorbic acid Scurvy: Gingivitis and bleeding D Ergocalciferol, cholecalciferol Rickets, osteomalacia E Tocopherol, tocotrienol Mild haemolytic anaemia in newborn infants, ataxia, peripheral neuropathy K Naphthoquinone Haemorrhagic disease of the newborn, bleeding diathesis Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1258 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous The best source of Vit D is Cod liver oil, it provides about 1,300 IU /15 ml serving [ Vitamin C (ascorbic acid) Vitamin C is a water soluble vitamin Functions: [  Antioxidant  Collagen synthesis: acts as a cofactor for enzymes that are required for the hydroxylation proline and lysine in the synthesis of collagen  Facilitates iron absorption  Cofactor for norepinephrine synthesis Vitamin C deficiency (scurvy) leads to defective synthesis of collagen resulting in capillary fragility (bleeding tendency) and poor wound healing Features vitamin C deficiency:  General malaise  Gingivitis, loose teeth  Bleeding from gums, haematuria, and epistaxis  Poor wound healing Vitamin B12 deficiency Vitamin B12 is mainly used in the body for red blood cell development and also maintenance of the nervous system It is absorbed after binding to intrinsic factor I.F (secreted from parietal cells in the stomach) and is actively absorbed in the terminal ileum A small amount of vitamin B12 is passively absorbed without being bound to intrinsic factor Vitamin B12 >>>> is actively absorbed in the terminal ileum by IF Causes of vitamin B12 deficiency: 1) Pernicious anaemia 2) Post gastrectomy 3) Poor diet 4) Disorders of terminal ileum (site of absorption): Crohn's, blind-loop etc Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1259 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Features of vitamin B12 deficiency: 1) Macrocytic anaemia 2) Sore tongue and mouth 3) Neuropsychiatric symptoms: e.g Ataxia and Mood disturbances Management:  If no neurological involvement mg of IM Hydroxocobalamin times each week for weeks, then once every months  If a patient is also deficient in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration (SCD) of the cord Folate metabolism The best source of food for folic acid >>>> Liver, green vegetables and nuts Drugs which interfere with metabolism:  Trimethoprim  Methotrexate  Pyrimethamine Drugs which can reduce absorption:  Phenytoin Zinc deficiency Features: 1) Perioral dermatitis: red, crusted lesions 2) Acrodermatitis 3) Alopecia 4) Short stature (Dwarfism) 5) Hypogonadism 6) Hepatosplenomegaly 7) Geophagia (ingesting clay/soil) 8) Cognitive impairment (mental lethargy) Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1260 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous NB: Zn deficiency is associated with adverse pregnancy outcomes NB: Zn supplementation has also been shown to improve neuropsychological function in Chinese children EX: A 25-year-old female presents with red crusted lesions around the mouth and finger pulps three months after having had small bowel resection for Crohn's disease What is the most likely cause of her skin condition >> Zinc deficiency Pellagra It is characterized by 4Ds: Dementia, Diarrhoea, Dermatitis and Death The rash is photosensitive and normally affects the face, neck and forearm It is rare and can be primary or secondary Primary causes include niacin or tryptophan (precursor of niacin) deficiency Secondary caused include:  Carcinoid syndrome, as the tumour cells convert tryptophan to serotonin, therefore reducing endogenous niacin production  Chronic alcoholism  Anorexia nervosa  GIT TB  HIV Patients usually develop right-sided valvular disease >>> Echo: tricuspid regurgitation and pulmonary stenosis Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1261 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Classification of haemorrhage: Parameter I II III IV Blood loss (ml) 2000 Blood loss (%) 40% Pulse rate (beats/min) 100 >120 >140 Blood pressure Normal Decreased Decreased Decreased Respiratory rate (breaths/min) 14-20 20-30 30-40 >35 Urine output (ml/hour) >30 20-30 5-15 Negligible CNS symptoms Normal Anxious Confused Lethargic [ Malignant hyperpyrexia (MH) [ Malignant hyperpyrexia (MH) is characterised by increased temperature and muscle rigidity during anaesthesia, which results from abnormal skeletal muscle contraction and increased metabolism The predisposing gene is thought to be on chromosome 19, close to the gene for the ryanodine/dihydropyridine receptor complex Known triggering agents include the volatile anaesthetic agents and suxamethonium Patients show different sensitivity to the triggering agents and the reaction can be delayed by several hours Intravenous dantrolene (up to 10 mg/kg) is the only available specific ttt and care must be taken when administering as the solution has a pH of 9-10 The prognosis of malignant hyperpyrexia is good when the appropriate treatment is instigated early, mortality being less than 5% (prior to dantrolene the mortality was 80%) Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1262 Chapter 14: Clinical Sciences, Biostatistics & Miscellaneous Serum creatine kinase elevation and myoglobinuria are suggestive but not diagnostic of MH Myoglobin and creatine kinase are both known to increase after giving suxamethonium to normal patients Contracture tests using caffeine and halothane are the investigations of choice Muscle biopsies may appear histologically normal Hiccup Hiccup is caused by frequent or rhythmic clonic contraction of the diaphragm When prolonged, other causes should be considered including:     CNS disease - posterior fossa tumour, brain injury, encephalitis Phrenic nerve or diaphragm irritation - tumour, pleurisy, pneumonia, intrathoracic adenopathy, pericarditis, GERD Systemic causes include alcohol intoxication and uraemia Other causes include foreign body or insect in the ear In infants it may be associated with apnoea or hyperventilation Folk remedies include aerophagia, breath holding, pharyngeal stimulation, distraction Haloperidol, metoclopramide and several anaesthetic agents are also said to work [ Levels: - The carotid artery bifurcates at C4 - The manubriosternsal joint (angle of Louis) lies at the level of the T4/5 intervertebral disk - The IVC opening in the diaphragm lies at T8 - The oesoghageal opening of the diaphragm lies at T10 - The aortic opening is at T12 " ‫"وما توفيقى اال باهلل‬ Dr Khaled Magraby MRCP Notes Clinical Sciences, Biostatistics & Miscellaneous 1263 ... Dermatology………………………………………….… ………… 1112 Chapter 14: Basic Sciences, Biostatistics & Miscellaneous …… … … 1158 Dr Khaled Magraby MRCP Notes Chapter 1: Cardiology Cardiology Dr Khaled Magraby MRCP Notes. . .Dr Khaled Magraby MRCP Notes ‫بسم هللا الرحمن الرحيم‬ ‫صدق هللا العظيم‬ ‫سورة البقرة ۩ اﻵية { ‪} ٣٢‬‬ ‫ Dr Khaled Magraby MRCP Notes ‬ Introduction First of all, I would like to thank... Center, Egypt E-mail: dr_ khaled_ elmagraby@hotmail.com Facebook: Khaled Elmagraby 00966565084114 (WhatsApp & LINE) 00201223355396 Dr Khaled Magraby MRCP Notes TABLE OF THE CONTENTS Subject Page