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The Only MRCP Notes You’ll Ever Need Hani Abuelgasim M 1Hussam / 546 www.sudamedica.com A Albanna MRCP, The Only Notes You Will Ever Need, 4th edition © January 2012 3rd edition © October 2010 2nd edition © January 2010 1st edition © September 2009 Copyright © 2012 SudaMediCa Publications ISBN: pending issuance All rights reserved No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher The Only MRCP Notes You’ll Ever Need / 546 www.sudamedica.com PREFACE These notes intended to target those who are appearing in MRCP exam The idea behind it was collecting the most commonly tested topics and facts in the exam for my personal revision The data has been collected from many sources This book was not prepared to be the primary studying source but it can help you after finishing your primary reading by arranging the thoughts in your mind and making every topic as short as possible by highlighting the most important points about it You may use it just before going through your favorite MCQs book or internet site A friend of mine appeared in part one for couple of times, he reached to a conclusion and gave me a valuable advice that said ‘when preparing for MRCP, study MRCP! Don’t study medicine!’ this book helps you to study MRCP rather than studying medicine But at the end, you have to be a good physician otherwise MRCP will be a less valuable recognition, this is why I would advise to study medicine before you study MRCP and for sure before you say that you are a member of the Royal College you have to be upto the expectations This edition contains the latest guidelines including 2011 guidelines and recommendations It is more organized than ever In the 4th edition we have added topics that matters for part two, we have added many pictures, we claim that it’s just enough to get you through the second part comfortably The study pattern we recommend is: Study one chapter of your choice from this book Solve the same chapter’s questions either on www.passmedicine.com, www.onexamination.com or www.pastest.co.uk Study another chapter and go online to solve its question, continue until you finish all the chapters in the book and questions on your website of choice Revise the whole book Start solving questions randomly from another website (other than the website you have chosen to solve chapter by chapter) Now you have probably solved at least 4000 BOF questions, you have seen all the question patterns in MRCP, now you need to stabilize the information you have gained through your journey The most important step is to revise this book again just before the exam, this should be the last thing you just before going to the exam Solving question till the last moment is not recommended, you have probably gathered enough amount of information in your study, try to fix the information by reading this book All candidates who followed this pattern have passed comfortably and no single one gave us a negative feedback in both parts Hani Abuelgasim M., MD Author The Only MRCP Notes You’ll Ever Need / 546 www.sudamedica.com DEDICATION To Mehiara, my late daughter who stole my heart and left To my lovely Ahlam, who kept being patient and kind while I was studying To my parents who always supported me Hani Abuelgasim M The Only MRCP Notes You’ll Ever Need / 546 www.sudamedica.com CONTRIBUTORS Dr.Hussam Albanna Cardiology Registrar MBBS, MRCP UK Dr.Ahmed Ali Abuzaid Medicine Specialist MBBS, MRCP UK, MRCP Ireland Dr.Salma Othman Senior Cardiology Resident MBBS, MRCP Part Dr.Ahmed Elmotaz Mahgoub Nephrology Specialist MBBS, MRCP, Nephrology Diploma (Sheffield, UK) To contribute to the admin@sudamedica.com next The Only MRCP Notes You’ll Ever Need edition, please / 546 send your contributions www.sudamedica.com to ALL BOXES WITH THIS COLOR ARE FOR MRCP PART II WRITTEN EXAM The Only MRCP Notes You’ll Ever Need / 546 www.sudamedica.com Contents …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… Infectious & STD Diseases …………… …………………………… …………… …………………………… Gyne & Obs …………… …………………………… Dermatology …………… …………………………… Psychiatry …………… …………………………… Ophthalmology Basic Medical Science Biostatistics & EBM Miscellaneous Neurology Hematology Endocrinology GIT Nephrology Locomotor System Rhematology Cardiovascular System Respiratory Sytem Pharmacology • General Pharma • Nervous Pharma • Cardiac Pharma • Other Medications • Antibiotics Commonly tested facts in MRCP …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… …………… …………………………… The Only MRCP Notes You’ll Ever Need / 546 53 65 83 131 167 203 245 269 287 309 357 389 425 437 459 475 491 492 509 515 523 535 541 www.sudamedica.com The Only MRCP Notes You’ll Ever Need / 546 www.sudamedica.com BASIC SCIENCES The Only MRCP Notes You’ll Ever Need / 546 www.sudamedica.com HLAs: are encoded for by genes on chromosome HLA A, B and C are class I antigens whilst DP, DQ, DR are class II antigens Questions are often based around which diseases have strong HLA associations The most important associations are listed below HLA and autoimmune diseases Ankylosing spondylitis Postgonococcal arthritis HLA-B27 Acute anterior uveitis Reiter's syndrome (reactive arthritis) Narcolepsy HLA-DR2 Goodpasture's Autoimmune hepatitis Primary biliary cirrhosis Diabetes mellitus type HLA-DR3 Dermatitis herpetiformis Coeliac disease (95% associated with HLA-DQ2) Primary Sjögren syndrome Rheumatoid arthritis HLA-DR4 Diabetes mellitus type (> DR3) HLA-DR3 + DR4 combined Diabetes mellitus type HLA-B47 21-hydroxylase deficiency HLA-A3 Hemochromatosis HLA-B5 Behcet's disease HLA B51 is a split of B5 Around 70% of patients with rheumatoid arthritis are HLA-DR4 Patients with Felty's syndrome (a triad of rheumatoid arthritis, splenomegaly and neutropaenia) are even more strongly associated with 90% being HLA-DR4 Clusters of Differentiation (CD): The table below lists the major clusters of differentiation (CD) molecules CD1 HLA molecule that presents lipid molecules Found on thymocytes, T cells, and some natural killer cells that acts as a ligand for CD58 and CD2 CD59 and is involved in signal transduction and cell adhesion CD3 The signalling component of the T cell receptor (TCR) complex CD4 Co-receptor for HLA class II; also a receptor used by HIV to enter T cells CD8 Co-receptor for HLA class I; also found on a subset of myeloid dendritic cells The Only MRCP Notes You’ll Ever Need 10 / 546 www.sudamedica.com Alcohol Withdrawal Mechanism • Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors • Alcohol withdrawal is thought to lead to the opposite (↓ inhibitory GABA and ↑ NMDA glutamate transmission) Features • Symptoms start at 6-12 hours • Peak incidence of seizures at 36 hours • Peak incidence of delirium tremens is at 72 hours Management • Benzodiazepines • Carbamazepine also effective in treatment of alcohol withdrawal • Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures Proton Pump Inhibitors (PPI) are a group of drugs which profoundly ↓ acid secretion in the stomach They irreversibly block the hydrogen/potassium adenosine triphosphatase enzyme system (the H+/K+ ATPase) of the gastric parietal cell Examples include omeprazole and lansoprazole Aminosalicylates: 5-aminosalicyclic acid (5-ASA) is released in the colon and is not absorbed It acts locally as an anti-inflammatory The mechanism of action is not fully understood but 5-ASA may inhibit prostaglandin synthesis Sulphasalazine • A combination of sulphapyridine (a sulphonamide) and 5-ASA • Many side-effects are due to the sulphapyridine moiety: rashes, oligospermia, headache, Heinz body anemia • Other side-effects are common to 5-ASA drugs (see mesalazine) Mesalazine • A delayed release form of 5-ASA • Sulphapyridine side-effects seen in patients taking sulphasalazine are avoided • Mesalazine is still however associated with side-effects such as GI upset, diarrhea, headache, agranulocytosis, pancreatitis*, interstitial nephritis Olsalazine • Two molecules of 5-ASA linked by a diazo bond, which is broken by colonic bacteria *pancreatitis is times more common in patients taking mesalazine than sulfasalazine The Only MRCP Notes You’ll Ever Need 532 / 546 www.sudamedica.com Immunoglobulins: Therapeutics The Department of Health issued guidelines on the use of intravenous immunoglobulins in May 2008 Uses • • • • • • • • • • Primary and secondary immunodeficiency Idiopathic thrombocytopenic purpura (ITP) Myasthenia gravis Guillain-Barre syndrome Kawasaki disease Toxic epidermal necrolysis (TEN) Pneumonitis induced by CMV following transplantation Low serum IgG levels following hematopoietic stem cell transplant for malignancy Dermatomyositis Chronic inflammatory demyelinating polyradiculopathy Basics • Formed from large pool of donors (e.g 5,000) • IgG molecules with a subclass distribution similar to that of normal blood • Half-life of weeks The Only MRCP Notes You’ll Ever Need 533 / 546 www.sudamedica.com METROnidazole Flagyl is named so because it runs after flagellated organisms The Only MRCP Notes You’ll Ever Need 534 / 546 www.sudamedica.com ANTIBIOTICS Inhibit cell wall formation •Penicillins •Cephalosporins •Isoniazid •Vancomycin Inhibit protein synthesis •aminoglycosides aminoglycosides (cause misreading of mRNA) •chloramphenicol chloramphenicol •macrolides macrolides (e.g erythromycin) •tetracyclines tetracyclines •fusidic fusidic acid •(Quin/Dalfo)pristin (Quin/Dalfo)pristin •Linezolid Linezolid Inhibit DNA synthesis Inhibit RNA synthesis •quinolones (e.g ciprofloxacin) •metronidazole •sulphonamides •trimethoprim •rifampicin rifampicin Bactericidal antibiotics • • • • • • • • • Penicillins Cephalosporins Isoniazid Aminoglycosides Quinupristin+Dalfopristin pristin (combination) Metronidazole Quinolones: ciprofloxacin,, levofluxacin Rifampicin Nitrofurantoin → Damages bacterial DNA Bacteriostatic antibiotics • • • • • • • • • Chloramphenicol Macrolides Tetracyclines Fusidic acid Quinupristin Dalfopristin Linezolid Sulphonamides Trimethoprim Macrolides: • • • • • • • Erythromycin Tacrolimus – non antibiotics ics macrolide Azithromycin - Unique, does not inhibit CYP3A4 Clarithromycin Dirithromycin Roxithromycin Telithromycin The Only MRCP Notes You’ll Ever Need 535 / 546 www.sudamedica.com Aminoglycosides: • • • • • • • • • • • Amikacin Arbekacin Gentamicin Kanamycin Neomycin Netilmicin Paromomycin Rhodostreptomycin Streptomycin Tobramycin Apramycin Erythromycin was the 1st macrolide used clinically Newer examples include clarithromycin and azithromycin Erythromycin may potentially interact with amiodarone, warfarin and simvastatin Macrolides act by inhibiting bacterial protein synthesis If pushed to give an answer they are bacteriostatic in nature, but in reality this depends on the dose and type of organism being treated Erythromycin is used in gastroparesis as it has prokinetic properties, Promotes gastric emptying Adverse effects of erythromycin • GI side-effects are common • Cholestatic jaundice: risk may be ↓ if erythromycin stearate is used • P450 inhibitor Quinolones are a group of antibiotics which work by inhibiting DNA synthesis and are bactericidal in nature Examples include: • Ciprofloxacin • Levofloxacin Adverse effects • Lower seizure threshold in patients with epilepsy • Tendon damage (including rupture) - the risk is ↑ in patients also taking steroids Achilles tendon ruptures Tendon damage is a well documented complication of quinolone therapy It appears to be an idiosyncratic reaction, with the actual median duration of treatment being days before problems occur Quinupristin & Dalfopristin Antibiotics Overview • Injectable streptogrammin antibiotic • Combination of group A and group B streptogrammin • Inhibits bacterial protein synthesis by blocking tRNA complexes binding to the ribosome Spectrum • Most Gram positive bacteria • Exception: Enterococcus faecalis The Only MRCP Notes You’ll Ever Need 536 / 546 www.sudamedica.com Adverse effects • Thrombophlebitis (give via a central line) • Arthralgia • P450 inhibitor Linezolid is a type of oxazolidonone antibiotic which has been introduced in recent years It inhibits bacterial protein synthesis by stopping formation of the 70s initiation complex and is bacteriostatic nature Spectrum, highly active against Gram positive organisms including: • MRSA (Methicillin-resistant Staphylococcus aureus) • VRE (Vancomycin-resistant enterococcus) • GISA (Glycopeptide Intermediate Staphylococcus aureus) Adverse effects • Thrombocytopenia (reversible on stopping) • Monoamine oxidase inhibitor: avoid tyramine containing foods Sulfonamides: Antibacterial sulfonamides act as competitive inhibitors of the enzyme dihydropteroate synthetase (DHPS), an enzyme involved in folate synthesis Other uses The sulfonamide chemical moiety is also present in other medications that are not antimicrobials, including thiazide diuretics (including hydrochlorothiazide, metolazone, and indapamide, among others), loop diuretics (including furosemide, bumetanide and torsemide) sulfonylureas (including glipizide, glyburide, among others), some COX-2 inhibitors (e g celecoxib) and acetazolamide Sulfasalazine, in addition to its use as an antibiotic, is also utilized in the treatment of inflammatory bowel disease Co-trimoxazole: sulfonamide antibiotic combination of trimethoprim and sulfamethoxazole, in the ratio of to 5, used in the treatment of a variety of bacterial infections The name co-trimoxazole is the British Approved Name, and has been marketed worldwide under many trade names including Septra, Bactrim, and various generic preparations Sources differ as to whether co-trimoxazole usually is bactericidal or bacteriostatic Diethylcarbamazine: There are two (Di) women named Ethyl in this car: Di- ethylcar You will notice that there is an elephant between Ethyl and Ethyl Indication: Treatment of individual patients with certain filarial diseases These diseases include: lymphatic filariasis caused by infection with Wuchereria bancrofti, Brugia malayi, or Brugia timori; (ELEPHANTiasis) tropical pulmonary eosinophilia, and loiasis The Only MRCP Notes You’ll Ever Need 537 / 546 www.sudamedica.com The Only MRCP Notes You’ll Ever Need 538 / 546 www.sudamedica.com The 1st Online Sudanese Medical Community • • • • • • • • • • • Tons of Medical Books Medical Softwares Information about exams: MRCP, MRCS, MRCGP etc Information about medical license exams: PLAB, USMLE, AMC etc Medical Jobs in Sudan, Saudi Arabia, Gulf, Europe, US etc How to pass your IELTS and other language exams Medical Students tools Dental Students tools Pharmacy Students tools Lab Technology Students tools Higher education for all medical and paramedical studies JOIN US www.sudamedica.com The Only MRCP Notes You’ll Ever Need 539 / 546 www.sudamedica.com The Only MRCP Notes You’ll Ever Need 540 / 546 www.sudamedica.com COMMONLY TESTED FACTS IN MRCP Acromegaly – Diagnosis: OGTT followed by GH conc Cushings – Diagnosis:overnight dexamethasone OR 24hr urinary free cortisol Addisons → short synacthen Rash on buttocks – Dermatitis herpetiformis (coeliac dx) AF with TIA → Warfarin Just TIA's with no AF → Aspirin Herpes encephalitis → temporal lobe calicification OR temporoparietal attentuation – subacute onset i.e Several days Obese woman, papilledema/headache → Benign Intercanial Hypertention Drug induced pneumonitis → methotrexate or amiodarone Chest discomfort and dysphagia → achalasia foreign travel, macpap rash/flu like illnes → HIV acute 10 Bullae on hands and fragule SKIN torn by minor trauma → porphyria cutanea tarda 11 Splenectomy → need pneumococcal vaccine AT LEAST weeks pre-op and for life 12 Primary hrperparathyroidism → high Ca, normal/low PO4, normal/high PTH (in elderly) 13 Middle aged man with KNEE arthritis → gonococcal sepsis (older people → Staph) 14 Sarcoidosis, erythema nodosum, arthropathy → Loffgrens syndrome benign, no Rx needed 15 TREMOR postural, slow progression,titubation, relieved by OH→benign essential TREMOR AutDom (MS – titbation, PD – no titubation) 16 Electrolytes disturbance causing confusion – low/high Na 17 Contraindications lung Surgery → FEV dec bp 130/90, Ace inhibitors (if proteinuria analgesic induced headache 18 1.5 cm difference btwn kidneys → Renal artery stenosis → Magnetic resonance angiogram 19 Temporal tenderness→ temporal arteritis → steroids > 90% ischemic neuropathy, 10% retinal art occlusion 20 Severe retroorbital, daily headache, lacrimation → cluster headache 21 Pemphigus – involves mouth (mucus membranes), pemphigoid – less serious NOT mucosa 22 Diagnosis of polyuria → water deprivation test, then DDAVP 23 Insulinoma → 24 hr supervised fasting hypoglycemia 24 Causes of villous atrophy: coeliac (lymphocytic infiltrate), Whipples , dec Ig, lymphoma, trop sprue (Rx tetracycline) 25 Diarrhea, bronchospasm, flushing, tricuspid stenosis → gut carcinoid c liver mets 26 Hepatitis B with general deterioration → hepaocellular carcinoma 27 Albumin normal, total protein high → myeloma (hypercalcemia, electrophoresis) 28 HBsAg positive, HB DNA not detectable → chornic carier 29 Inf MI, artery invlived → Right coronary artert The Only MRCP Notes You’ll Ever Need 541 / 546 www.sudamedica.com 30 Aut dom conditions: Achondroplasia, Ehler Danlos, FAP, FAMILIAL hyperchol,Gilberts, Huntington's, Marfans's, NFT I/II, Most porphyrias, tuberous sclerosis, vWD, PeutzJeghers 31 X linked: Beck/Duch musc dyst, alports, Fragile X, G6PD, Hemophilia A/B 32 Aortic Stenosis s2 paradoxical split, length proportional to severity Loud S1: MS, hyperdynamic, short PR Soft S1: immobile MS, MR Loud S2: hypertension, AS Fixed split: ASD Opening snap: MOBILE MS, severe near S2 33 Mitral stenosis: loud S1 (soft s1 if severe), opening snap Immobile valve → no snap 34 HOCM/MVP - inc by standing, dec by squating (inc all others) HOCM inc by valsalva, decs all others Sudden death athlete, FH, Rx Amiodarone, ICD 35 MVP sudden worsening post MI Harsh systolic murmur radites to axilla 36 Dilated Cardiomyopathy: OH, bp, thiamine/selenium deficiency, MD, cocksackie/HIV, preg, doxorubicin, infiltration (HCT, sarcoid), tachycardia 37 Restrictive Cardiomyopathy: sclerodermma, amyloid, sarcoid, HCT, glycogen storage, Gauchers, fibrosis, hypereosinophilia Lofflers, caracinoid, malignancy, radiotherapy, toxins 38 Tumor compressing Respiratory tract → investigation: flow volume loop A normal flow volume loop is often described as a 'triangle on top of a semi circle' 39 Guillan Barre syndrome: check VITAL CAPACITY 40 Horners – sweating lost in upper face only – lesion proximal to common carotid artery 41 Internuclear opthalmoplegia: medial longitudinal fasciculus connects CN nucleus 3-4 42 Ipsilateral adduction palsy, contralateral nystagmus Aide memoire (TRIES TO YANK THE ipsilateral BAD eye ACROSS THE nose ) Convergence retraction nystagmus, but convergence reflex is normal Causes: MS, SLE, Miller fisher, overdose(barb, phenytoin, TCA), Wernicke 43 Progressive Supranuclear palsy: Steel Richardson Absent voluntary downward gaze, normal dolls eye i.e Occulomotor nuclei intact, supranuclear Pathology 44 Perinauds syndrome: dorsal midbrain syndrome, damaged midrain and superior colliculus: impaired upgaze (cf PSNP), lid retraction, convergence preserved Causes: pineal tumor, stroke, hydrocephalus, MS 45 Dementia, gait abnormaily, urinary incontinence Absent papilledema→Normal pressure hydrocephalus 46 Acute red eye → acute closed angle glaucoma >> less common (ant uveitis, scleritis, episcleritis, subconjuntival hemmorrhage) 47 Wheeles, URTICARIA , drug induced → aspirin 48 Sweats and weight gain → insulinoma 49 Diagnostic test for asthma → morning dip in PEFR >20% 50 Causes of SIADH : chest/cerebral/pancreas Pathology , porphyria, malignancy, Drugs (carbamazepine, chlorpropamide, clofibrate, atipsychotics, NSAIDs, rifampicin, opiates) The Only MRCP Notes You’ll Ever Need 542 / 546 www.sudamedica.com 51 Causes of Diabetes Insipidus: Cranial: tumor, infiltration, trauma Nephrogenic: Lithium, amphoteracin, domeclocycline, prologed hypercalcemia/hypornatremia, FAMILIAL X linked type 52 Bisphosphonates:inhibit osteoclast activity, prevent steroid incduced osteoperosis (vitamin D also) 53 Returned from airline flight, TIA→ paradoxical embolus TOE 54 Alcoholic, given glucose develops nystagmus → B1 deficiency (wernickes) 55 Confabulation→korsakoff 56 Mono-artropathy with thiazide → gout (neg birefringence) NO ALLOPURINOL for acute 57 Cause of gout → dec urinary excretion 58 Gout – blood urate high/low/normal, joint aspirate pos birif, ppt thiazides, NO allopurinol/aspirin in acute phase 59 Painful 3rd nerve palsy → posterior communicating artery aneurysm till proven otherwise 60 Late complication of scleroderma → pulmonaryhypertention plus/minus fibrosis 61 Causes of erythema mutliforme: lamotrigine 62 Vomiting, abdominal pain, hypothyroidism → Addisonian crisis (TFT typically abnormal in this setting DO NOT give thyroxine) 63 Mouth/genital ulcers and oligarthritis → behcets (also eye /SKIN lesions, DVT) mixed drug overdose most important step → Nacetylcysteine (time dependent prognosis) 64 Cavernous sinus syndrome - 3rd nerve palsy, proptosis, periorbital swelling, conj injection 65 Asymetric parkinsons → likely to be idiopathic 66 Obese, NIDDM ♀ with abnormal LFT's → NASH (non-alcoholic steatotic hepatitis) 67 Fluctuating level of conciousness in elderly plus/minus deterioration → chronic subdural Can last even longer than months 68 Sensitivity → TP/(TP plus FN) e.g For SLE - ANA highly sens, dsDNA:highly specific RR is 8% NNT is → 100/8 → 50/4 → 25/2 → 13.5 69 Ipsilateral ataxia, Horners, contralateral loss pain/temp → PICA stroke (lateral medulary syndrome of Wallenburg) 70 Renal stones (80% calcium, 10% uric acid, 5% ammonium (proteus), 3% other) Uric acid and cyteine stone are radioluscent 71 Hyperprolactinemia (gallactorrohea, amenorrohea, low FSH/LH) → causes are: (metoclopramide, chlorpromazine, cimetidine NOT TCA's), pregnancy, PCOS, pit tumor/microadenoma, stress 72 Distal, asymetric arthropathy → PSORIASIS 73 Episodic headache with tachycardia → Pheochromocytoma 74 Very raised WCC → ALWAYS think of leukemia The Only MRCP Notes You’ll Ever Need 543 / 546 www.sudamedica.com 75 Diagnosis of CLL → immunophenotyping NOT cytogenetics, NOT bone marrow 76 Prognostic factors for AML → bm karyotype (good/poor/standard) → WCC at diagnosis 77 Pancytopenia with raised MCV → check B12/folate first (other causes possble, but this FIRST) Often associayed with phenytoin use → ↓ folate 78 Miscariage, DVT, stroke → LUPUS anticoagulant → lifelong anticoagulation Hb elevated, dec ESR → polycythemua (2ndry if paO2 low) 79 Anosmia, delayed puberty → Kallmans syndrome (hypogonadotrophic hypogonadism) 80 Commonest finding in G6PD hamolysis → haumoglobinuria 81 Flank pain, urinalysis:blood, protein → renal vein thrombosis Causes: nephrotic syndrome, RCC, amyloid, acute pyelonephritis, SLE (atiphospholipid syndrome which is recurrent thrombosis, fetal loss, dec plt Usual cause of cns manifestations assoc with LUPUS ancoagulant, anticardiolipin ab) 82 Anemia in the elderly assume GI malignancy 83 Hypothermia, acute renal failure → rhabdomyolysis (collapse assumed) 84 Burning, Pain, numbness anteriolateral thigh → meralgia paraesthesia (lat cutaneous nerve compression usally by by ing ligament) 85 Diagnosis of hemochromatosis: screen with Ferritin, confirm by tranferrin saturation, genotyping If nondiagnostic liver biopsy 0.3% mortality 86 40 mg hidrocortisone divided doses (bd) → 10 mg prednisolone (ie Prednislone is x4 stronger) 87 BTS: TB guidlines – close contacts → Heaf test → positive CXR, negative → repeat Heaf in weeks Isolation not required 88 Diptheria → exudative pharyngitis, lymphadenopathy, cardio and neuro toxicity 89 Indurated plaques on cheeks, scarring alopecia, hyperkeratosis over hair follicles →>Discoid LUPUS 90 Wt loss, malabsoption, inc ALP → pancreatic cancer 91 Foreign travel, tender RUQ, raised ALP → liver abscess U/S 92 Wt loss, anemia (macro/micro), no obvious cause → coeliac (diarrhea does NOT have to be present) 93 Hematuria, proteinuria, best investigation → if glomerulonephritis suspected → renal biopsy 94 Venous ulcer treatment → exclude arteriopathy (eg ABPI), control edema, prevent infection, compression bandaging 95 Malaria, incubation within 3/12 can be relapsing /remitting Vivax and Ovale (West Africa) longer imcubation 96 Fever, lymphadenopathy, lymphocytosis, pharygitis →EBV → heterophile antibodies 97 GI bleed after endovascular AAA Surgery → aortoenteric fistula 98 Young girl – suspect Anorexia Nervosa – linugo hair The Only MRCP Notes You’ll Ever Need 544 / 546 www.sudamedica.com 99 Functional hypogonadotrophic hypogonadism → amennorhea LH and FSH both low All other hormones are usually normal Ferritin low 100 Reiters Syndrome – arthritis, uveitis, urethritis – Chlymidia, campylobacter, Yersinia, SALMONELLA , Shigella Balanisits 101 PKD – aut dom Chr 16/4 assoc berry aneurysm, mitral/aortic regurg 102 Diag of PKD → renal US even if think anorexia nervosa 103 Porphyria – photosensitivity, blisters, scars with millia, hypertrichosis 104 Vitiligo – commonest assoctions pernicious anemia → type DM , autoimmune addisons, autoimmune thyoid dx 105 Peripheral neuropathy – a) B12 – rapid, dorsal columns (joint pos, vibration), sensory ataxia, pseudoathetosis of upperlimbs b) diabetic – slow, spinothalamic (pain, temp?) c)alcohol – slow progressive, spinothalamic d) Pb – motor upper limbs 106 CNS abnormalities in HIV: toxoplaasmosis (ring enhancing), lymphoma (solitary lesion) HIV encephalopathy, progressive multifocal leucoencephalopathy (PML – demylination in advanced HIV, low attenuation lesions) 107 Travellers diarrohea: chronic (>2 WEEKS) giardia (incidious onset rx Metronidazole), SALMONELLA (serious systemic illness), E.coli (rx Ciprofloxacin) , Shigella 108 Renal syndrome – minimal change disease, membanous, IgA nephropathy, poststreptococcal 109 If you see blood on urinalysis forget about RAS 110 Thyroid Malignancy – tend to be non-functional, anaplastic has worse prognosis, local infiltration → dysphagia, vocal cord paralysis 111 Fatiguability → myasthenia gravis 112 Fasciculations → Motor neurone diease 113 Silvery white scale → PSORIASIS 114 Hypopigmented → vitiligo/pityriasis versicolor 115 Pretibial myxedema → Graves (NOT lid lag, NOT exopthalmus) 116 R Arthritis with nephritic syndrome → looks for amyloidosis, even by rectal biopsy Disorder Cushing Cushing- vs Pseudo-cushing Addison Pheochromocytoma Acromegaly The Only MRCP Notes You’ll Ever Need Investigation of choice Overnight Dexamethasone Test Insulin Stress Test Short Synacthen Test 24H Urinary Catecholamines Oral Glucose Tolerance Test 545 / 546 www.sudamedica.com The Only MRCP Notes You’ll Ever Need 546 / 546 www.sudamedica.com ... 509 515 523 535 541 www.sudamedica.com The Only MRCP Notes You ll Ever Need / 546 www.sudamedica.com BASIC SCIENCES The Only MRCP Notes You ll Ever Need / 546 www.sudamedica.com HLAs: are encoded... M The Only MRCP Notes You ll Ever Need / 546 www.sudamedica.com CONTRIBUTORS Dr.Hussam Albanna Cardiology Registrar MBBS, MRCP UK Dr.Ahmed Ali Abuzaid Medicine Specialist MBBS, MRCP UK, MRCP Ireland... publisher The Only MRCP Notes You ll Ever Need / 546 www.sudamedica.com PREFACE These notes intended to target those who are appearing in MRCP exam The idea behind it was collecting the most commonly