Rapid Review of Clinical Medicine for MRCP Part Second Edition Sanjay Sharma BSc (Hons) MD FRCP (UK) FESC Professor of Clinical Cardiology Consultant Cardiologist and Physician St George’s University of London St George’s Hospital NHS Trust University Hospital Lewisham London, UK Rashmi Kaushal BSc (Hons) FRCP (UK) Consultant Physician and Endocrinologist West Middlesex Hospital Kingston, UK MANSON PUBLISHING Dedication For Ravi, Ashna, Anushka, Ishan, Shivani and Milan Acknowledgements We are grateful for the help of several colleagues who helped provide slides for the book: Dr L Wilkinson, Ms S Gowrinath, Ms H Derry, Mr P Radomskij, Dr J Waktare, Ms A O’Donoghue, Dr S Rosen, Dr A Mehta, Dr L Shapiro, Professor M E Hodson, Dr G Rai, Dr A Ghuran, Professor C Oakley, Ms F Goulder, Dr J Axford, Dr S Jain, Dr M Stodell, Dr B Harold, Dr D Seigler, Dr C Travill, Dr G Barrison, Dr D Hackett, Dr J Bayliss, Dr R Lancaster, Dr R Foale, Dr W Davies, Professor D Sheridan, Professor W McKenna, Professor G MacGregor, Dr A Belli, Dr Adams, Dr J Joseph, Dr M Impallomeni, Dr D Banerjee, Dr N Essex, Dr S Nussey, Dr S Hyer, Dr A Rodin, Dr M Prentice, Dr N Mir, Mrs K Patel and Dr J Jacomb-Hood We are also grateful for the assistance of the Audiovisual Departments at Luton and Dunstable Hospital, St Mary’s (Paddington) Hospital and St George’s Hospital Medical School and the ECG, Echocardiography and Radiology Department at St George’s Hospital Medical School and University Hospital Lewisham Fourth impression 2010 Third impression 2009 Second impression 2007 Copyright © 2006 Manson Publishing Ltd ISBN: 978-1-84076-070-5 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means without the written permission of the copyright holder or in accordance with the provisions of the Copyright Act 1956 (as amended), or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 33–34 Alfred Place, London WC1E 7DP Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages A CIP catalogue record for this book is available from the British Library For full details of all Manson Publishing titles, please write to: Manson Publishing Ltd 73 Corringham Road London NW11 7DL, UK Tel: +44 (0)20 8905 5150 Fax: +44 (0)20 8201 9233 Website: www.mansonpublishing.com Printed in Spain Contents Acknowledgements Preface Classification of Cases Abbreviations Clinical Cases Data Interpretations Tutorials Calcium Biochemistry Genetics Audiograms Guidelines for the Interpretation of Cardiac Catheter Data Respiratory Function Tests Interpretation of Respiratory Flow Loop Curves Echocardiography Acid–base Disturbance Normal Ranges Index 415 415 415 416 418 419 420 421 426 427 429 Preface Passing specialist examinations in internal medicine is a difficult milestone for many doctors, but is a mandatory requirement for career progression Pass rates in these examinations are generally low due to ‘high standards’ and ‘stiff competition’ Thorough preparation is essential and requires a broad knowledge of internal medicine The pressures of a busy clinical job and nights ‘on call’ make it almost impossible for doctors to wade through heaps of large text books to acquire all the knowledge that is required to pass the examinations The aim of this book is to provide the busy doctor with a comprehensive review of questions featured most frequently in the MRCP (II) examination in internal medicine The MRCP (II) examination has a best of 5/n from many answer format The vast majority of the questions in the book follow the same pattern; however, we have chosen to include several scenarios with open ended questions to stimulate the medical thought process The level of difficulty of each question is of the same standard as MRCP (II) examination However, some cases are deliberately more difficult for teaching purposes A broad range of subjects is covered in over 400 questions ranging from metabolic medicine to infectious diseases Precise answers and detailed discussion follow each question Where appropriate, important differential diagnoses, diagnostic algorithms and up-to-date medical lists are presented Many questions comprise illustrated material in the form of radiographic material, electrocardiograms, echocardiograms, blood films, audiograms, respiratory flow loops, histological material, and slides in ophthalmology, dermatology and infectious diseases Over 200 commonly examined illustrations are included Tutorials are included at the end of the book to aid the interpretation of illustrated material as well as important, and sometimes difficult, clinical data, such as respiratory function tests, cardiac catheter data and dynamic endocrine tests The book will prove invaluable to all those studying for higher examinations in internal medicine, and to their instructors Sanjay Sharma Professor of Clinical Cardiology Consultant Cardiologist and Physician Lecturer for Medibyte Intensive Courses for the MRCP Part Rashmi Kaushal Consultant Physician and Endocrinologist Classification of Cases Cardiology 1, 10, 11, 13, 22, 25, 32, 40, 52, 53, 54, 62, 63, 66, 68, 74, 78, 80, 94, 95, 100, 121, 123, 125, 130–132, 138, 144, 150, 160, 167, 178, 180, 184, 193, 197, 199, 202, 203, 207, 208, 223, 226, 229, 232, 235, 237, 243, 246, 259, 266, 270, 285, 287, 291, 296, 301, 305, 307, 309, 318, 323, 324, 327, 331, 332, 335, 342, 350, 353, 362, 368, 377, 387, 389, 391 Dermatology 116, 154, 173, 316 Endocrinology and diabetes 5, 9, 23, 39, 46, 76, 82, 89, 92, 101, 106, 107, 127, 134, 146, 159, 164, 168, 173, 181, 199, 218, 220, 238, 242, 254, 260, 261, 273, 281, 328, 334, 372, 373, 379, 397, 401 Metabolic medicine 9, 29, 34, 38, 50, 71, 74, 81, 82, 84, 90, 129, 134, 136, 147, 153, 161, 179, 189, 214, 215, 230, 248, 257, 271, 275, 283, 310, 321, 326, 329, 333, 334, 398 Nephrology 4, 17, 24, 29, 44, 53, 59, 60, 85, 92, 118, 119, 126, 135, 137, 141, 152, 185, 198, 228, 244, 245, 249, 250, 251, 278, 289, 294, 303, 304, 317, 328, 344, 354, 381, 382 Neurology 30, 65, 67, 93, 98, 103, 105, 108, 112, 128, 139, 145, 190, 192, 200, 239–241, 247, 253, 255, 256, 268, 274, 288, 290, 292, 307, 314, 330, 345, 365, 390, 395, 399 Obstetric medicine 130–132, 190, 193, 348 Environmental medicine 140 Oncology 117, 216, 258, 358, 359 Gastroenterology 3, 6, 19, 24, 33, 64, 72, 75, 104, 127, 133, 143, 148, 162, 169, 182, 188, 201, 231, 276, 293, 306, 338, 339, 347, 367, 369, 371, 383, 393, 394, 400 Ophthalmology 282, 345 Genetics 47, 85, 151, 170, 194, 195, 269, 315, 361 Haematology 12, 38, 49, 69, 70, 73, 86, 87, 102, 114, 115, 117, 120, 122, 142, 156, 163, 175, 191, 204, 211, 216, 219, 233, 258, 263, 265, 295, 297, 299, 308, 313, 336, 346, 351, 352, 358, 376, 385, 392, 394 Radiology 2, 18, 64, 88, 97, 99, 124, 183, 187, 222, 227, 252, 280, 300, 302, 311, 343, 349, 355, 357, 360, 363 Respiratory medicine 8, 14, 21, 35, 36, 37, 43, 45, 55, 56, 58, 61, 72, 79, 91, 99, 111, 113, 157, 164, 196, 217, 225, 272, 279, 298, 304, 327, 341, 349, 356, 370, 380, 384, 396 Immunology 15, 155, 374 Rheumatology 4, 15, 17, 31, 42, 71, 77, 87, 96, 109, 141, 171, 174, 177, 196, 198, 200, 210, 236, 264, 320, 324, 340, 364, 375, 401, 402 Infectious diseases 16, 18, 26, 41, 51, 83, 88, 93, 110, 128, 142, 143, 149, 152, 154, 158, 166, 176, 212, 221, 225, 234, 262, 267, 277, 280, 319, 322, 325, 337, 345, 351, 383, 386, 388 Therapeutics/toxicology 7, 8, 20, 27, 28, 36, 48, 57, 68, 77, 116, 118, 119, 165, 172, 175, 186, 205, 206, 209, 213, 224, 251, 284, 286, 312, 316, 317, 332, 339, 366, 378 Abbreviations 5-HIAA 5'-hydroxyindole acetic acid AIIRB angiotensin II receptor blocker AAFB acid–alcohol fast bacilli ACE angiotensin-converting enzyme ACTH adrenocorticotrophic hormone ADH antidiuretic hormone AF atrial fibrillation AIDS acquired immunedeficiency syndrome AIN acute interstitial nephritis AIP acute intermittent porphyria ALA aminolaevulinic acid ALT alanine transaminase (SGPT) AML acute myeloid leukaemia AMP adenosine 5'monophosphate ANA antinuclear antibody ANCA antineutrophil cytoplasmic antibodies ANF antinuclear factor APCKD adult polycystic kidney disease APTT activated partial thromboplastin time AR aortic regurgitation ARDS adult respiratory distress syndrome ARVC arrhythmogenic right ventricular cardiomyopathy AS aortic stenosis ASD atrial septal defect ASO antistreptolysin AST aspartate transaminase (SGOT) ATN acute tubular necrosis AZT zidovudine BCG bacille Calmette–Guérin BIH benign intracranial hypertension BP blood pressure BT bleeding time BTS British Thoracic Society CAH chronic active hepatitis CAP community acquired pneumonia CCF congestive cardiac failure CFTR cystic fibrosis transmembrane regulator (protein) CML CMV COPD chronic myeloid leukaemia cytomegalovirus chronic obstructive pulmonary disease CPAP continuous positive airway pressure CREST calcinosis, Raynaud’s syndrome, oesophageal problems, scleroderma, telangiectasia CRF chronic renal failure CRP C-reactive protein CSF cerebrospinal fluid CSS Churg–Strauss syndrome CT computed tomography CVA cerebrovascular accident CVP central venous pressure CXR chest X-ray DBP diastolic blood pressure DC direct current DHCC dihydroxy-cholecalciferol DIC disseminated intravascular coagulation DIDMOAD diabetes insipidus, diabetes mellitus, optic atrophy and deafness DM diabetes mellitus DT delerium tremens DVT deep-vein thrombosis EAA extrinsic allergic alveolitis EBV Epstein–Barr virus ECG electrocardiogram EEG electroencephalogram ELISA enzyme-linked immunosorbent assay EMF endomyocardial fibrosis EMG electromyogram ENT ear, nose and throat EPO erythropoietin ERCP endoscopic retrograde cholangiopancreatogram ESR erythrocyte sedimentation rate FBC full blood count FDP fibrinogen degradation product FES fat embolism syndrome FEV1 fixed expiration volume in second FFP fresh-frozen plasma FNA fine-needle aspiration FSH follicle stimulating hormone FTA fluorescent treponemal antibody FVC GBM GCT GFR GH GHRH GI GP GPI GT GTN Hb HbSS HC HCC HCM HCV HCG HELLP HHT HIT HIV HONK HR HRT HS HSMN HUS ICD ICP INR IPF IVP IVU JVP KCO LBBB LDH forced vital capacity glomerular basement membrane giant cell tumour glomerular filtration rate growth hormone growth hormone releasing hormone gastrointestinal general practitioner glucophosphatidylinositol glutamyltransferase glyceryl trinitrate haemoglobin sickle cell anaemia Hereditary Copro porphyria hydroxy-cholecalciferol hypertrophic cardiomyopathy hepatitis C virus human chorionic gonadotrophin haemolysis, elevated liver enzymes and low platelets hereditary haemorrhagic telangiectasia heparin-induced thrombocytopenia human immunodeficiency virus hypersimilar non-ketotic diabetic coma heart rate hormone replacement therapy hereditary spherocytosis hereditary sensorimotor neuropathy haemolytic uraemic syndrome implantable cardioverter defibrillator intracranial pressure International Normalized Ratio idiopathic pulmonary fibrosis intravenous pyelogram intravenous urogram jugular venous pressure corrected carbon monoxide transfer factor left bundle branch block lactate dehydrogenase LFT liver function tests LH luteinizing hormone LHON Leber’s hereditary optic neuropathy LHRH luteinizing hormone releasing hormone LMWH low-molecular weight heparin LQTS long QT-syndrome LVEDP left ventricular end-diastolic pressure LVH left ventricular hypertrophy MAHA microangiopathic haemolytic anaemia MAOI monoamine oxidase inhibitor MCH mean cell haemoglobin MCHC mean cell haemoglobin content MCV mean cell volume MELAS mitochondrial encephalopathy, lactic acidosis, stroke-like syndrome MEN multiple endocrine neoplasia MERRF myoclonic epilepsy and red ragged fibres MGUS monoclonal gammopathy of undetermined significance MPO myeloperoxidase MR mitral regurgitation MRA magnetic resonance angiography MRCP magnetic resonance cholangiopancreatogram MRI magnetic resonance imaging MRSA methicillin resistant Staphylococcus aureus MRV magnetic resonance venography MSH melanocyte stimulating hormone NADPH nicotinamide adenine dinucleotide phosphate (reduced) NAPQI N-acetyl-pbenzoquinoneimine NARP neuropathy, ataxia, retinitis pigmentosa NASH non-alcoholic steatohepatitis NIPPV non-invasive positive pressure ventilation NSAID non-steroidal antiinflammatory drug NSTEMI non-ST elevation myocardial infarction NYHA New York Heart Association OSA obstructive sleep apnoea PAN polyarteritis nodosa PAS periodic acid-Schiff PBC primary biliary cirrhosis PBG porphobilinogen PCOS polycystic ovary syndrome PCR polymerase chain reaction PCT porphyria cutanea tarda PCV packed cell volume PCWP pulmonary capillary wedge pressure PE pulmonary embolism PEFR peak expiratory flow rate PFO patent foramen ovale PKD polycystic kidney disease PMLE progressive multifocal leucoencephalopathy PMR polymyalgia rheumatica PNH paroxysmal nocturnal haemoglobinuria PRL prolactin PRV polycythaemia rubra vera PSC primary sclerosing cholangitis PT prothrombin time PTH parathormone or parathyroid hormone PVE prosthetic valve endocarditis RA rheumatoid arthritis RBBB right bundle branch block REM rapid eye movement RMAT rapid macroagglutination test RTA renal tubular acidosis RV residual volume SADS sudden adult death syndrome SAM systolic anterior motion of the mitral valve SAP serum amyloid protein SIADH syndrome of inappropriate antidiuretic hormone SLE systemic lupus erythematosus SMA smooth muscle antibody SPECT single photon emission computed tomography SROS Steele–Richardson– Olszewski syndrome STEMI ST elevation myocardial infarction SVT supraventricular tachycardia TB tuberculosis TCAD TIA TIBC TIPSS TLC TLCO TOE TPA TPHA TRH TSAT TSH TT TTP U&E URTI US UTI VDRL VF VIP VMA VP VR VSD VT WCC WPW tricyclic antidepressant overdose transient ischaemic attack total iron-binding capacity transjugular intrahepatic portosystemic shunt total lung capacity total lung carbon monoxide transfer factor transoesophageal echocardiography tissue plasminogen activator treponema pallidum haemagglutination test thyrotrophin releasing hormone transferrin saturation thyroid stimulating hormone thrombin time thrombotic thrombocytopenic purpura urea and electrolytes upper respiratory tract infection ultrasound urinary tract infection Venereal Diseases Research Laboratory test ventricular fibrillation vasointestinal polypeptide vanilyl mandelic acid variegate porphyria ventricular rate ventricular septal defect ventricular tachycardia white cell count Wolff–Parkinson–White (syndrome) Clinical Cases Question A 49-year-old male presented to the Accident and Emergency Department with a one-hour history of severe central chest pain He smoked 30 cigarettes per day Physical examination was normal The 12-lead ECG revealed ST segment elevation in leads V1–V4 There were no contraindications to thrombolysis What is the best treatment to improve coronary perfusion? a IV Streptokinase b IV Tenectoplase c IV Alteplase d Half-dose tenectoplase and half-dose abciximab e Primary coronary angioplasty Question A 68-year-old woman presented with pain and tingling in the left arm when she raised her hands for prolonged periods On examination both pulses were palpable in the upper limbs The chest X-ray was abnormal Aortography was performed with the arms down (2a) and with the arms up (2b) What was the abnormality on the chest X-ray? a Left-sided bronchogenic carcinoma b Left cervical rib c Retrosternal thyroid d Notching of the ribs e Widened mediastinum 2b 2a Question A 28-year-old male presented with a six-month history of weight loss of kg, generalized abdominal discomfort and diarrhoea On examination he was pale and slim, but there were no other significant abnormalities Investigations are shown What is the diagnosis? a Crohn’s disease b Intestinal lymphangiectasia c Coeliac disease d Small bowel lymphoma e Hypogammaglobulinaemia Hb WCC Platelets MCV ESR Sodium Potassium Urea Creatinine Corrected calcium phosphate Alkaline phosphatase Albumin IgA IgG IgM IgA anti-endomyosial antibody g/dl 4.6 ϫ 109/l 200 ϫ 109/l 76 fl 38 mm/h 141 mmol/l mmol/l mmol/l 68 mol/l 2.02 mmol/l 0.8 mmol/l 190 iu/l 38 g/l