Summary of difficult topics fro Sharma MRCP Part2

Discussion in 'MRCP Forum' started by Guest, Dec 1, 2005.

  1. Guest

    Guest Guest

    i put this list together from difficult topics from the Sanjay Sharma MRCP Part 2 book. The numbers in brackets are from his book....hope it can help somebody in their revision...

    1. (8) RUQ pain, fever, jaundice --> ascending cholangitis. can occur even after cholecsytectomy. Inv. blood cultures (E.coli), U/S to exclude abscess. liver biosy should never be 1st test for jaundice and fever.
    2. (10) Histiocytosis X: manifestations are due to histiocytomas 2-4 yrs, M>F. lung fibrosis and COPD, bone infiltration (esp skull), proptosis, deafness, hepatosplenomegally, lymphadenopathy, diabetes insipidus (pituitry infiltration). Dx by histology (small round cells). Rx steroids, occasionally vincritine. occasional spontaneous regression.
    3. (12) flow volume loop: URT obstruction decreased inspiratory flow.
    4. (12, 39) leucoerrythroblastic blood film: marrow infiltration, leaukaemoid reaction to infection (dohle bodies, toxic granulations). Differentiaite by presence of hepatosplenomegally or lymhadenopathy and absense of left shift).
    5. (14) inc Ca, inc BP, palpitations, goitre --> MEN2 = thyroid C cell Carcinoma, parathyroid adenoma, phaeochromocytoma. Ret oncogene (chr 10). calcitonin elevated. Relatives need regular screening.
    6. (15) echoes of mitral valve prolapse (posterior motion of mitral valve in systole) and atrial myxoma (obliteration of mitral valve orifice)
    7. (16) sickle cell disease: hyposplenism means encapsulated bacterial infection, chronic low grade haemolysis --> pigment gallstones
    8. (17) antiphosholipid syndrome – false positive VDRL, recurrent thrombosis/miscarriage, in vitro prolonged clotting --> RAISED APTT +/- PT, does not correct with addition of normal plasma due to lupus anticoagulant. Rx prophylactic anticoagulants. Assoc livedo reticularis (conn tiss disorders), pulm hypertension, cerebral problems, valvular heart disease, low plt.
    9. (18) alkapatonuria aut rec – homogentesic oxidase deficiency. Urine darkens on standing, ochronosis (pigmented cartilage, conn tissue e.g. Ears, joints). Premature arthritis. Xray --> intervertabral disk calcification and aorta. Rx low protein diet, poorly affective.
    10. (27) echordiography: mitral valve lesions
    11. (28) porphyria cutanea tarda – liver disease, skin rash (hands, head). Uroporphyrin decarboxylase deficiency. XS uroporphyrin -> photosensitive blistering rash (PAS staining), cirrhosis. Precipitants are enzyme inducers: alcohol, anticonvulsants, oestrogens. There is often secondary haemaochromatosis, secondary polycythemia. Rx --> alcohol abstainence, avoid sun exposure, venesect if Hb >12. Chloroquin binds uroporphyrin. End product blocked is corporoporphyrin.
    12. (30) purple = positive gram stain. (it went Positively Purple with pleasure). Pink = negative. GPCocci=Strep/Staph. Gndiplococci=Neisseria, GNrods=Haemophilus. TB=ZN red.
    13. (31) precipitants of HONK – XS sugary drinks, infection, thiazides, steroids, MI. If hypernatraemic use 0.45% N Saline, half strength sliding scale, DVT prophylaxis. Decrease osmolality gradually. Treat underlying cause.
    14. (32) genetic pedigrees. 1. look at transmission – no male to male = X linked, 2. female to male/female only then mitochondrial.
    15. (32) alports syndrome: x linked dominant: renal failure in males (females haematuria), senorineural deafness, ocular abnormailities (myopia, cataract, retinitis pigmentosa – see pic). Post renal transplantation anti-GBM disease because original defect was type 4 collagen in GBM (goodpasture antigen).
    16. (34) complications of nephrotic syndrome: portal vein thrombosis (abnormal lfts) diagnose by US, venography Rx. Thrombolysis
    17. (40) Chronic Active hepatitis – risk: old blood transfusion. Usually asymptomatic, chronic progressive. Causes: Hep B (eAg present) and Hep C (anti-HCAb's) also SLE, LKM, methyldopa, isoniazid, antytipsin, Wilsons, UC). AST, BR elevated >>ALP. Piecemeal necrosis. Rx. Iv IFN, success 30%, often relapse.
    18. (41) Cardiac catheter values – 1. look for unusual pressures and saturations, 2. look for gradients across pulmonary and aortic valves. mitral valve disease reflected in PCWP.
    19. (44) Acute intermittent porphyria – aut dom, Chr 11 PBG deaminase deficiency. 5F>M. Increased dALA and PBG blood and urine--. gastro and neuro sequelae, (skin manifestations rare cf PCT). Precipitants: drugs (barbiturates, anticonvulsants), alcohol, fasting, sepsis, OCP. Presents as acute abdominal abdomen (can mimic surgical abdomen but AXR normal). Neuropathy/ANS excitation/motor paralysis including CN's, epilepsy, hyponatraemia (SIADH). Rx 1. withdraw precipitant, 2. high carbohydrate diet /iv dextrose (reduces haem precursors in blood by reducing ALA sythetase activity), 3. haematin iv, 4. opiate analgesia. Avoid metoclopramide (another precipitant), B blockers for tachy. Epilepsy: calories, fluid restriction (inc Na), chlormethiazole or diazepam (most other anticonvulsants are preciptants). Tests: erlichs dye --> red (also jaundice) PLUS chloroform --> purple sedimnt (porhyria).clear (bilirubin). (Watson Scwarz test). Levels elevated in attack but may be normal when well. Can assay red cell PBG deaminase (low), ALA dehydrogenase (high).
    20. (51) Causes of erythema multiforme. Infection (mycoplasma, HSV, orf, TB), drugs (penicillin, barbs, sulphonamides), other (conn tiss dx, vasculitis, internal malignancy)
    21. (52) Hereditory angioedema (c1 esterase inhibitor deficiency) aut dom. Attacks preceded by painful macular rash. precipitants: trauma. Laryngeal oedema, abdominal pain. Normall rx supportive responds in 72 hours. Can give FFP if severe/protracted. Long-term rx. Danazol (inhibits plasmin) Hydrocortisone/chlorpheniramine less effective cf. anaphylaxis. Diagnosis C1 esterase inhibitor (low), c1 esterase (high), c2 & c4 both low.
    22. (57) Aortic dissection: proximal --> urgent surgery. Seen clearly on 2D echo. Important to exclude before thrombolysing any MI. assoc. hypertensive blacks, Marfans, Ehrler Danlos, pregnancy, coarctation.
    23. (58) Scurvy: elderly, normocytic anaemia, bruising (haematomas), prolonged bleeding time --> always think of vitC deficiency. Easy bruising, bleeding gums, periosteal haemmorhage, muscle haematomas. Classic: perifolicular haemorhage, corkscrew hairs. APTT/PT normal, BT increased. Dx by plt or leucocyte ascorbate concentration. Rx. Vit C.
    24. (71) livedo reticularis: assoc vasculitis and conn tiss disease e.g. PAN
    25. (71) polyarteritis nodosa – males 60-70 myalgia, night sweats, weight loss, livedo reticularis, testicular pain, assoc HbsAg. Multisystem (neuro, gi, renal, cvs), aneuysm --> thrombosis -->organ infarction. dx. ANCA suggestive, organ biopsy , microaneurysms on angiography. Rx. Steroids.
    26. (72) Heinz bodies: low Hb, high retic count -> bleed or haemolysis. Differentiate by blood film --> Hz bodies (pptd Hb) seen in Hbopathies or metHbaemia (Fe3+) e.g. Sulphasalasine Rx esp if G6PD deficiency. Cf Howell Jolly bodies, cf. Malaria blood films (can be confused)
    27. (74) Apical lung fubrosis: TB, EAA, ankylosing spondylitis, apergillosis, radiation, sarcoidosis, histoicytosis X.
    28. (76) Familial benign hypocalciuruc hypercalcaemia – aut dom. Usually lifelong asymptomatic hypercalcaemia occasional gall stones/pancreatitis/joint deposition. Difficult to distinguish between 1ry PTHism so patients often have uneccesary parathyroidectomy and FH parathyroidectmy. Can distgiuish because urinary calcium is LOW (it is high in all other causes of hypercalcaemia). Conservative management.
    29. (77) Eruptive xanthomas: think hypertriglyceridaemia (associated with pancreaitis). There is pseudohyponatreamia due to lipids binding Na – the free sodium only is normally measured. Can differentiate by looking at serum osmolality.
    30. (84) Wolf Parkinson White syndrome: accessory fast conducting atrioventricular pathway (Bundle of Kent). Ventricles depolarise prematurely --> short PR, slurred (delta wave) upstroke of QRS. 2 arrythmias possible: AV re-entrant tachycardia (P burried AFTER QRS Rx. Vagal stim, adenosine) , AF (delta waves sometimes seen Rx adenosine, vagal stim usually fails). 2nd line --> cardioversion. Definitive management radiofrequesncy ablation. Prevention with class I/III
    (sotalol, flecainide, amiodarone, disopyramide). Avoid digoxin and verapamil as they increase accessory pathway conduction predisposing to malignant ventricular arrythmias.
    31. (87) Polycythemia rubra vera – Hb can be normal if coexisting Fe deficiency anaemia (low MCV), look at PCV and rbc count to make the diagnosis. All marrow cells increased (wcc, plt) and splenomegally.
    Incidious onset assoc lethargy, depression, vertigo, tinnitus, amaurosis fugax. Plethora, hypertension, spenomegally. Bledding (usually upper GI) due to throbocythaemia, stroke (hyperviscocity), gout (increased cell tunover). Can progress to myelofibrosis or AML. Rx. Venesection (can cause fe def anaemia). Busuphan and hydroxyurea to control thrombocytosis.
    32. (91) Hypokalaemic periodic paralysis – aut dom, episodic paralysis classically while patient asleep or with prolonged rest. Ppt by dextrose and insulin, alcohol, cho, anxiety, tension. Rx can give K supplements or longeterm K sparing duiretics. Associated with orientals with thyrotoxicosis. Hypokalaemic arrythmias. Rx of thyrotoxicosis prevents paralysis too, propranolol also works. Only affects males. Need to exclude GBS or myasthenia gravis.
    33. (94) Schmidtz syndrome (polyendocrine deficiency type II) – 10% of addisons pients have other endocrine abnormailies too - autoimmune hypothyroidism and IDDM. Type I PED = parathyroid, adrenal, candida, alopecia, pernicous anaemia. Vitiligo and hypogonadism occur in both. Hypothyroidism can cuase a large heart.
    43. (97) Leprospirosis (rat faeces) – liver failure common, renal failure can also occur. Brucellosis (unpasteurised cows milk) – liver failure rare, assoc hepatosplenomegally, high fever and leucopenia.
    44. (98) Atrial enlargement on ECG. R atrium = tall P II, V1 >2.5 small squares tall. L atrium= bifid P in II >3 small squares wide, V1 – negative portion p wave >1 small square duration AND amplitude.
    45. (98) Sokolow's criteria for ventricular hypertrophy look at V1 ad V5/6: Right ventricle >12.5mm. Left ventricle >40mm. LVH shows more toward V6, RVH in V1.
    46. (101) HIV infections: oral hairy leucoplakia (H=EBC infection) - white plaques on the lateral border of tongue Rx. Acyclovir cf candida rx. Nystatin, flucanazole. Crypotosporidium diarrohea – ZN stain of stool --> red cysts. Rx. Symptomtic + spiramycin/paromomycin.
    47. (103) SLE – arthropathy, fever, polyserositis. 10F:1M, blacks, usully <40yrs. Multisystem involvement: renal, resp, CVS, neuro, haematologic, cutaneous. DsDNA positive in 60%, ANA in 90%. ESR usually high, CRP characteristically normal. C3 depressed. Lupus anticoagulant. Rx. NSAIDs (joints), chloroquine (skin), corticsteroids, azathioprine, cyclophosphamide.
    48. (103) coxsackie virus A/B - epidemic myalgia (Borholm's syndrome) usually children/young adulys. Sudden abdo/thoracic pain. Myalgia, fever. Polyserositis. Virus in faeces, retrospective diagnosis by serum antibody x4 rise.
    49. (107) Guillain Barre syndrome – onset often heralded by SEVERE lumbar or intrascapular pain. Ans neuropathy e.g. Bladder atony. Csf – albuminocytogenic dissociation. Rx. Iv Ig. Poor prognstic markers: FVC<1litre, paO2 <8, paco2>6, LRTI, polm oedema, accelerated hypertension, arrythmia, bulbar involvement, campylobacter infection.
    50. (110) Homocytinuria – cystathionine deficiency, aut recessive, chr 21---> homocysteine accumulation--> oxidised to homocystine (elevated urine levels). Cystine NOT produced. Defects in collagen crosslinking. Marfanoid features (tall, arachnodactyly, high arched palate, lens dislocation), osteoperosis, epilepsy/mental hadicap, venous/arterial thrombosis (OCP contraindicated), folate deficiency (inc MCV), premature coronary art disease. Rx. Restrict methionine, add cystine. Give Pyridoxine as soon as diagnosis is made.

    Pictures to know:
    1.Heinz bodies
    2.Livedo reticularis
    3.Lymphoerythroblastic bone marrow
    4.retinitis pigmentosa
    5.eruptive xanthomas

    There will probably e a further 25 opics or so, I will add these when I have finished them....

    Dr Sujit Vasanth
  2. re. Cramming Facts for MRCP Part 2

    Last minute cramming facts for MRCP Part 2

    Great to see aippg have put this as a sticky...hop it helps a lot of people....I posted this list a few days ago and I think the same people would be intersted in this too....

    I have summarised what I think to be the 50 most commonly asked non-picture topics in the Part 2 exam. This list is completely different to the one I previously posted - which is meant for MRCPPart 1. This list is JUST for MRCP Part 2...

    1. renal deterioration is most often due to NSAID's: NSAID' --> renal deterioration, ATN, interstitial nephritis, renal papillary necrosis, chronic tubulo interstitial nephritis. If asked most LIKELY cause of renal failure NSAIDs are likely to be the answer.
    2. wt loss, bronchorrohea --> bronchioalveolar carcinoma
    3. diabetic patient maximum reduction in CVS risk bp (esp ACE i >>> tight glycaemic control, weight reduction unproven.
    4. antipsychotic + fever, rigidity, confusion, ANS dysfunction --> NMS. can be pptd by anticholinergics, lithium and benztropine. Rx. withdraw agent, antipyretics, dantrolene, bromocriptine, levodopa. Can occur at any time since starting antipsychotics.
    5. MS --> 2 neuro lesions seperated in time and location.
    6.blood gases: Normal values: pH 7.36-7.44, O2 11.3-12.6, co2 4.7-6.0, hc03 20-28
    interpretation rules:
    1. pH defines primary disturbance
    2. pO2, pCO2: can be type 1/type 2 resp failure or hypreventilation
    3. hco3: metabolic component
    4. consider lab error if pH is not proportional to HC03:Co2 ratio.
    5. anion gap in poisoning (methanol, ethylene glycol), ketoacidosis
    trap: alkal, hi HCO3, tp1 failure->should be tp2 if compnstry->mixed metalk+resp acd
    7.carbimazole and sore throat --> if WCC normal and neutrophils OK then reassure and continue. rate of leuco/neutropenia is only 1%. Stop if neut <1.5x10exp9. If agranulocytosis i.e. <0.5 -> stop carbimazole, give antibiotics, consider GCSF
    8.occupational asthma: improves away from workplace, worsens markedly on return
    9.trivial trauma in young people --> stroke...think vertebral artery dissection. head and neck pain + stroke --> think of dissection. usually under 40 yrs, trivial trauma with some neck distrotion.stroke is often brainstem/cerebeller.
    10.inversion of biceps and supinator jerks ---> cervical myelopathy C5,6
    11.malabsorption --> hyper oxalataemia --> oxolate renal stones (radiopaque)--> Rx increase fluids, calcium carbonate
    12.alcoholic liver disease and neurological deterioration: nystagmus--> Wernicke's. If decreased GCS only and on opitaes --> opiate overdose. eg. alcoholic, drowsy on cocodamol --> give naloxone!
    13.legionella pneumonia (systemic upset, non porductive cough, inc wcc, lympohopenia, low Na--> Rx. azithromycin or levofloxacin. Legionaires disease --> flu-like prodrome, fever, non-productive cough, confusion, neutrophilia, lymphopenia, HYPONATRAEMIA, non specific liver derangement, proteinuria/myoglobinurua, lobar or bilateral consolidation, macrolides (azithromycin) or quinolones (levofloxacin) (both superior to erythromycin). combination therapy of erythromycin and rifampicin is second line. doxycyclline, cotramoxazole and tetracycline can also be used.
    14.arrythmia + amiodarone leading to hyperthyroidism ---> Start carbimazole. If indication mild, stop amiodarone - carbimazole will often be required if the AF would lead to compromise - as the half life of amiodarone is long and stopping amiodarone alone would have a DELAYED affect.
    15.foreign travel (esp Africa businessman), rash, lyphadenopathy -> HIV conversion illness
    16.>1g/day proteinuria before ANY other treatment ---> ACE inhibitor. indications for ACEi in renal failure: hypertension -->and/or<---- proteinuria
    eg.1 vasculitic GN:control bp with ACEi before renal biopsy, followed by steroids.
    eg.2 recurrent urinary infection and proteinuria. For renal protection ACEi>>> glycaemic control. Antibiotics not to be given prophylactically in this case. Low protein diet beficifal in overt proteinuria not microabluminurea.
    17.CRF + Fe PO + anaemia --> give Fe iv to replenish stores PLUS EPO. keep Hb >11 to prevent LVH. If patient symptomatic i.e. angina then transfuse.
    18.obese female, headache, papilloedema --> BIH --> Rx is peritoneal shunt. Benign intercranial hypertension -- obese lady, pappilloedema, headaches worse in morning. 1. CT to exclude SOL. 2. LP. 3. MRI venogram to exclude venous thrombosis, Space occupying lesion, hydrocephalus (better than CT). causes of BIH --> vitamin A, tetracycline, OCP
    19.metformin contraindicated if creatinine >150. Overweight Diabetics on metformin do better on metformin than on insulin, even if HbA1c improves (mortality dec by 40% in UKPDS)
    20.coeliac disease --> IgA deficiency, dec Ca, Fe anaemia, aphous ulcers, antiendomesial IgA may be negative--> test transglutaminase IgG. hypocalcaemia is seen in Coeliac disease. hypocalcaemia, iron deficiency anaemia, normal inflammatory markers, GI symptoms --> coeliac disease. raised MCV --> tropical sprue.
    21.osteoperosis with hypopituitrism --> correct testosterone deficiency, then other things. GH
    improves symptoms not bone. after testosterone, bisphosphonates are the treatment of choice especially if steroids are used. HRT is controversial and will not be the right answer. T-score <-2.5= osteoperosis <-1= osteopenia.
    22.overdose + broad complex tachycardia --> TCA overdose likely --> Rx. sodium bicarbonate
    (alkalinises, and alters memb potetial)
    23. DM, impotence, normal LFT --> 1. MRI pituitry (pituitry tumor compressing stalk). 2. abnormal LFT ---> check ferritin (Haemochromatosis)
    24.erythema nodusum --> need CXR to exclude sarcoid/TB. erythema nodosum: sarcoid, TB (NB. ALWAYS first do CXR), infection (strep), drugs (sulphonamides, OCP), inflamatory bowel disease, behcets disease. Lesions last 6-8 weeks. other tests: asot titre, throat swab, Mantoux test. Rx underlying cause, NSAIDs, bed rest. not associated with DM or psoriasis.
    25.catheters pressures/sats: Left side of heart: LA, LV, Aorta are all 98%. Right Side heart: RA, RV, Pulm A all 74%, (IVC 70%, SVC 74%). Mean pressures (mmHg). PA 10, Aorta 100, PCWP 1-10. From this info you can calculate where is the lesion.
    26.Guillan Barre syndrome - lower back pain, unconfirmed subjective sensory symptoms (e.g. tingling), CN lesions, absent reflexes, motor weakness, preceding resp illness
    27.adverse risks with aortic stenosis ---> symptomatic LV failure, EF <40%, severe is 100mmHg but this is rarely helpful in answering the question.
    28.cluster headache - daily headache for weaks, periorbital, eye signs --> Rx. Oxygen or sc
    sumitriptan. prophylaxis: verapamil, Lithium or valproate. cf.. mirgaine propranolol cf. Trigeminal neuralgia --> carbamazepine
    29.blisters on dorsum of hand --> porphyria cutanea tarda
    30.epilepsy in pregnancy --> continue antiepileptics..safer than a fit.
    31.Relative of an epileptic patient with diplopia and ataxia --> phenytoin toxicity
    32.steroid responsive nephrotic syndrome --> likely to be minimal change NOT membranous. Childhood recurrent nephrotic syndrome --> likely minimal change disease therefore steroids, biopsy if not responsive, cyclophosphamis if >2 episodes/6 months, >4/year or steroid dependent. Add ACEi if prolonged protenuria. DISTINGUISH FROM post streptococcal GN --> invariably complete recovery.
    33. new hypertensive guidelines: <55yrs ACEi or B-blocker) >55yrs/black (Ca antag or Diuretic) as first line. If hypertension in urinary incontinance --> Ca ch blocker NOT alpha blocker. isolated systolic hypertension in elderly --> thiazides or Ca antagonists. with diastolic hypertension --> ACEi (????not sure about this)
    34.myxoedema coma due to thyoxine non compliance --> 1. iv thyoxine, 2. thyroxine, 3. thyroxine, 4. thyroxine, 5. thyroxine!!! i.e. thyroxine is most important NOT steroids. COMPARE with 35.
    35.slightly hypothyroid patient --> started on thyroxine --> deterioration. Patient has Addison's
    disease with sick euthyroid syndrome and the thyroxine has caused acute Addisonian crisis. --> Rx. steroids iv COMPARE with 34.
    36.total t3/4 up, TSH and free t3/4 normal ---> pregnancy. Compare this with:- normal T3/4, raised TSH --> non compliance – e.g. patient took thyoxine just before clinic appointment!
    37.CN 10, 11, 12 palsy, pulsatile tinnitus ---> glomus jugulare tumor
    38.smoker, proximal muscle weakness, dry mouth --> Eaton Lambert syndrome. Eaton Lambert - dec reflexes, proximal weakness, ANS dysfunction.
    39. Schmitt's disease: autoimmune diabetes and Addison's which can be associated with primary ovarian failure and primary hypothyroidism. In this combination think of Schmitt's before pituitry dysfunction.
    40.AF: flecainide contraindicated in ischaemic heart disease. sotalol can be used for PAF to maintain sinus rythm. Adenosine (used in SVT) contraindicated in asthma.
    41.preg: raised oestrodiol, anorexia - mildly elevated prolactin, ammenorrhea. low BMI, hyperprolatinaemia, excessive exercise --> anorexia nervosa. (prolactin not raised in coeliac disease).
    42.endocrine abnormalities:
    1. PCOS - ostradiol normal, inc LH:FSH ratio, mildly inc prolactin and androgens. Obesity, huruitism, oligomennorhea.
    2. CAH --> elevated 17-hydroxyprogesterone
    3. adrenal testostrn tumor--> testosterone >7, switches off LH/FSH --> low oestrgens
    4. preg --> v high osetrgn and progestrn, normal testostrn. inc TotT4 normal freT4
    43.entrapment palsies: common peroneal --> lost dorsiflexion and eversion, ulnar nerve at elbow. Especially after prolonged bedrest.
    44.3 dementias + 1 parkinsons plus
    1.Pick's disease - frontal lobe dimentia with gradual peronality changes. i.e. hypersexualiy, hyperphagia, impulsiveness. Pick's disease makes you think with your pick!!
    2.Lewy body degeneration --> visual hallucinations, dimentia and parkinsonism (lewy body like LSD!!). recent onset parkinsons + visual halluinations + normal CT --> diffuse Lewy body disease.
    3.CADASIL --> migraine, lacunar strokes, dementia. notch 3 gene mutation , no cure.
    4.multisystem atrophy --> cerebellar dysfunction, AND parkinsonian fearures
    45. Lung function tests
    TLCO=transfer factor = CO diffusing capacity i.e. alveola permeability
    KCO=gas transfer coefficient = CO uptake in 1 maximum 10 sec breath
    FVC FEV1 RV FEV1/FVC TlCO KCO
    COPD dec dec inc <0.8 dec low
    Restric dec dec dec >0.8 norm variable
    Asthma dec dec <0.8 inc/norm inc/norm
    Anaemia NORMAL NORMAL dec dec

    In Restrictive lung disease, exttrapulmonry pathology (pleural thickening, weak muscles, silicosis) increases KCO BUT intrinsic lung disease (CFA/EAA) gives decreased/normal KCO.
    asthma --> >15% improvement follwing b2ag or steroid trial

    46.PSC is diagnosed by ERCP, assoc UC.AMA is associated PBC (seen in Crohns).
    47.pacemakers: exertional problems or a patient who is fit and active --> always better to give a rate dependent pacemaker .eg XXX-R
    48.hyperthyroidism: -
    1.DeQuevern's thyroiditis: tender thyroid, wt loss, malaise, fever, ESR >50 or 100.
    2.solitary toxic nodule commonest cause
    3.thyroid autoantibodies: think of Grave's or Hashitoxicosis. If these absent solitary thyroid nodule is likely. Drug induced typically is amiodarone.
    4.transient post partum thyrotoxicois lasts 2-6months, occurs in 5% of women
    5.pregnancy with hyperthyroidism --> carbimazole NOT radioidine, NOT thyroxine plus carmbimazole. surgery increases risk of miscarriage.
    6.thyroid disease on OCP --> check free T4 to exclude hyperproteinaemia falsely elevating T4 and TSH. raised ALP is likely due to thyrotixcoisis.
    49.gut carcinoid: diarrhoea, flushing, wheeze, valvular heart disease, raised 5HIAA. worse prognosis is with cardiac lesions (irrevesible and often require surgery)
    50.decreasing insulin requirements in diabetic, hypos, wt loss and lethargy --> consider Addisson's.
    51.child with hyperkalaemia, metabolic alkalosis and normal blood pressure ---> Barters syndrome (polyuric enuesis, failure to thrive assoc hyperplasia of JGA). hypokalaemic alkalosis --> vomiting e.g. pyloric stenosis
    52.Felty's syndrome is associated with LONSDTANDING Rhematoid arthritis
    53.AML:- M2 t(8;21), M4 t(16;16), M3 t(15;17) promyelocytic assoc DIC, Rx. All trans retinoic acid, Auer rods. acute promyelocytic leukaemia t(15;17) DIC, Rx: all trans retinoic acid (ATRA). Auer rods.
    54.B12 deficiency is associated with other autoimmune conditions e.g. DM, thyroid disease, alopecia areata, vitiligo.
    55.patient looking tired --> think myasthenia gravis, ask to count to 100.
    56.culture negative Bacterial endocarditis --> take 4 cultures at any time before empiricle treatment with benzylpenicillin and gentamycin
    57.hyperkalaemia in heart failure: step 1: monitor, step 2: add a K loosing diuretic step 3: consider stopping amiloride/spirinolactone
    58.botulism: CN dysfunction, ANS dysfunction, later limb/resp paralysis, normal CSF, cholinergic blockade.

    Please feel free to suggest corrections/additions to the list. I would remind you to only give facts THAT HAVE APPEARED REPEATEDLY ON PAST PAPERS OF MRCP PART2.

    Dr Sujit Vasanth
  3. re. added more facts

    Over the last few days I have been studying Sanjay Sharma's book and have summarised the topics

    which I found difficult. Hopefully it might be of help to others during their revision.

    Sanjay Sharma revision (question numbers in brackets)
    ====================================

    1. (8) RUQ pain, fever, jaundice --> ascending cholangitis. can occur even after cholecsytectomy. Inv. blood cultures (E.coli), U/S to exclude abscess. liver biosy should never be 1st test for jaundice and fever.
    2. (10) Histiocytosis X: manifestations are due to histiocytomas 2-4 yrs, M>F. lung fibrosis and COPD, bone infiltration (esp skull), proptosis, deafness, hepatosplenomegally, lymphadenopathy, diabetes insipidus (pituitry infiltration). Dx by histology (small round cells). Rx steroids, occasionally vincritine. occasional spontaneous regression.
    3. (12) flow volume loop: URT obstruction decreased inspiratory flow.
    4. (12, 39) leucoerrythroblastic blood film: immsture granulocytes, normoblasts Causes: marrow infiltration (including msrble bone dx, myelosclerosis, storage diseases like Gucher's - large white filled cells), severe infection (leaukaemoid dohle bodies, toxic granulations). Differentiaite by presence of hepatosplenomegally or lymhadenopathy and absense of left shift).
    5. (14) inc Ca, inc BP, palpitations, goitre --> MEN2 = thyroid C cell Carcinoma, parathyroid adenoma, phaeochromocytoma. Ret oncogene (chr 10). calcitonin elevated. Relatives need regular screening.
    6. (15) echoes of mitral valve prolapse (posterior motion of mitral valve in systole) and atrial myxoma (obliteration of mitral valve orifice)
    7. (16) sickle cell disease: hyposplenism means encapsulated bacterial infection, chronic low grade haemolysis --> pigment gallstones
    8. (17) antiphosholipid syndrome – false positive VDRL, recurrent thrombosis/miscarriage, in vitro prolonged clotting --> RAISED APTT +/- PT, does not correct with addition of normal plasma due to lupus anticoagulant. Rx prophylactic anticoagulants. Assoc livedo reticularis (conn tiss disorders), pulm hypertension, cerebral problems, valvular heart disease, low plt.
    9. (18) alkapatonuria aut rec – homogentesic oxidase deficiency. Urine darkens on standing, ochronosis (pigmented cartilage, conn tissue e.g. Ears, joints). Premature arthritis. Xray --> intervertabral disk calcification and aorta. Rx low protein diet, poorly affective.
    10. (27) echordiography: mitral valve lesions
    11. (28) porphyria cutanea tarda – liver disease, skin rash (hands, head). Uroporphyrin decarboxylase deficiency. XS uroporphyrin -> photosensitive blistering rash (PAS staining), cirrhosis. Precipitants are enzyme inducers: alcohol, anticonvulsants, oestrogens. There is often secondary haemaochromatosis, secondary polycythemia. Rx --> alcohol abstainence, avoid sun exposure, venesect if Hb >12. Chloroquin binds uroporphyrin. End product blocked is corporoporphyrin.
    12. (30) purple = positive gram stain. (it went Positively Purple with pleasure). Pink = negative. GPCocci=Strep/Staph. Gndiplococci=Neisseria, GNrods=Haemophilus. TB=ZN red.
    13. (31) precipitants of HONK – XS sugary drinks, infection, thiazides, steroids, MI. If hypernatraemic use 0.45% N Saline, half strength sliding scale, DVT prophylaxis. Decrease osmolality gradually. Treat underlying cause.
    14. (32) genetic pedigrees. 1. look at transmission – no male to male = X linked, 2. female to male/female only then mitochondrial.
    15. (32) alports syndrome: x linked dominant: renal failure in males (females haematuria), senorineural deafness, ocular abnormailities (myopia, cataract, retinitis pigmentosa – see pic). Post renal transplantation anti-GBM disease because original defect was type 4 collagen in GBM (goodpasture antigen).
    16. (34) complications of nephrotic syndrome: portal vein thrombosis (abnormal lfts) diagnose by US, venography Rx. Thrombolysis
    17. (40, 123) Chronic Active hepatitis – risk: old blood transfusion, high risk profession. Usually asymptomatic, chronic progressive. Causes: Hep B (eAg present) and Hep C (anti-HCAb's) also SLE, LKM, methyldopa, isoniazid, antytipsin, Wilsons, UC). AST, BR elevated >>ALP. Piecemeal necrosis. Rx. Iv IFN, success 30%, often relapse. consider HIV screening.
    18. (41) Cardiac catheter values – 1. look for unusual pressures and saturations, 2. look for gradients across pulmonary and aortic valves. mitral valve disease reflected in PCWP.
    19. (44) Acute intermittent porphyria – aut dom, Chr 11 PBG deaminase deficiency. 5F>M. Increased dALA and PBG blood and urine--. gastro and neuro sequelae, (skin manifestations rare cf PCT). Precipitants: drugs (barbiturates, anticonvulsants), alcohol, fasting, sepsis, OCP. Presents as acute abdominal abdomen (can mimic surgical abdomen but AXR normal). Neuropathy/ANS excitation/motor paralysis including CN's, epilepsy, hyponatraemia (SIADH). Rx 1. withdraw precipitant, 2. high carbohydrate diet /iv dextrose (reduces haem precursors in blood by reducing ALA sythetase activity), 3. haematin iv, 4. opiate analgesia. Avoid metoclopramide (another precipitant), B blockers for tachy. Epilepsy: calories, fluid restriction (inc Na), chlormethiazole or diazepam (most other anticonvulsants are preciptants). Tests: erlichs dye --> red (also jaundice) PLUS chloroform --> purple sedimnt (porhyria).clear (bilirubin). (Watson Scwarz test). Levels elevated in attack but may be normal when well. Can assay red cell PBG deaminase (low), ALA dehydrogenase (high).
    20. (51) Causes of erythema multiforme. Infection (mycoplasma, HSV, orf, TB), drugs (penicillin, barbs, sulphonamides), other (conn tiss dx, vasculitis, internal malignancy)
    21. (52) Hereditory angioedema (c1 esterase inhibitor deficiency) aut dom. Attacks preceded by painful macular rash. precipitants: trauma. Laryngeal oedema, abdominal pain. Normall rx supportive responds in 72 hours. Can give FFP if severe/protracted. Long-term rx. Danazol (inhibits plasmin) Hydrocortisone/chlorpheniramine less effective cf. anaphylaxis. Diagnosis C1 esterase inhibitor (low), c1 esterase (high), c2 & c4 both low.
    22. (57) Aortic dissection: proximal --> urgent surgery. Seen clearly on 2D echo. Important to exclude before thrombolysing any MI. assoc. hypertensive blacks, Marfans, Ehrler Danlos, pregnancy, coarctation.
    23. (58) Scurvy: elderly, normocytic anaemia, bruising (haematomas), prolonged bleeding time --> always think of vitC deficiency. Easy bruising, bleeding gums, periosteal haemmorhage, muscle haematomas. Classic: perifolicular haemorhage, corkscrew hairs. APTT/PT normal, BT increased. Dx by plt or leucocyte ascorbate concentration. Rx. Vit C.
    24. (71) livedo reticularis: assoc vasculitis and conn tiss disease e.g. PAN
    25. (71) polyarteritis nodosa – males 60-70 myalgia, night sweats, weight loss, livedo reticularis, testicular pain, assoc HbsAg. Multisystem (neuro, gi, renal, cvs), aneuysm --> thrombosis -->organ infarction. dx. ANCA suggestive, organ biopsy , microaneurysms on angiography. Rx. Steroids.
    26. (72) Heinz bodies: low Hb, high retic count -> bleed or haemolysis. Differentiate by blood film --> Hz bodies (pptd Hb) seen in Hbopathies or metHbaemia (Fe3+) e.g. Sulphasalasine Rx esp if G6PD deficiency. Cf Howell Jolly bodies, cf. Malaria blood films (can be confused)
    27. (74) Apical lung fubrosis: TB, EAA, ankylosing spondylitis, apergillosis, radiation, sarcoidosis, histoicytosis X.
    28. (76) Familial benign hypocalciuruc hypercalcaemia – aut dom. Usually lifelong asymptomatic hypercalcaemia occasional gall stones/pancreatitis/joint deposition. Difficult to distinguish between 1ry PTHism so patients often have uneccesary parathyroidectomy and FH parathyroidectmy. Can distgiuish because urinary calcium is LOW (it is high in all other causes of hypercalcaemia). Conservative management.
    29. (77) Eruptive xanthomas: think hypertriglyceridaemia (associated with pancreaitis). There is pseudohyponatreamia due to lipids binding Na – the free sodium only is normally measured. Can differentiate by looking at serum osmolality.
    30. (84) Wolf Parkinson White syndrome: accessory fast conducting atrioventricular pathway (Bundle of Kent). Ventricles depolarise prematurely --> short PR, slurred (delta wave) upstroke of QRS. 2 arrythmias possible: AV re-entrant tachycardia (P burried AFTER QRS Rx. Vagal stim, adenosine) , AF (delta waves sometimes seen Rx adenosine, vagal stim usually fails). 2nd line --> cardioversion. Definitive management radiofrequesncy ablation. Prevention with class I/III
    (sotalol, flecainide, amiodarone, disopyramide). Avoid digoxin and verapamil as they increase accessory pathway conduction predisposing to malignant ventricular arrythmias.
    31. (87) Polycythemia rubra vera – Hb can be normal if coexisting Fe deficiency anaemia (low MCV), look at PCV and rbc count to make the diagnosis. All marrow cells increased (wcc, plt) and splenomegally.
    Incidious onset assoc lethargy, depression, vertigo, tinnitus, amaurosis fugax. Plethora, hypertension, spenomegally. Bledding (usually upper GI) due to throbocythaemia, stroke (hyperviscocity), gout (increased cell tunover). Can progress to myelofibrosis or AML. Rx. Venesection (can cause fe def anaemia). Busuphan and hydroxyurea to control thrombocytosis.
    32. (91) Hypokalaemic periodic paralysis – aut dom, episodic paralysis classically while patient asleep or with prolonged rest. Ppt by dextrose and insulin, alcohol, cho, anxiety, tension. Rx can give K supplements or longeterm K sparing duiretics. Associated with orientals with thyrotoxicosis. Hypokalaemic arrythmias. Rx of thyrotoxicosis prevents paralysis too, propranolol also works. Only affects males. Need to exclude GBS or myasthenia gravis.
    33. (94) Schmidtz syndrome (polyendocrine deficiency type II) – 10% of addisons pients have other endocrine abnormailies too - autoimmune hypothyroidism and IDDM. Type I PED = parathyroid, adrenal, candida, alopecia, pernicous anaemia. Vitiligo and hypogonadism occur in both. Hypothyroidism can cuase a large heart.
    34. (97) Leprospirosis (rat faeces) – liver failure common, renal failure can also occur. Brucellosis (unpasteurised cows milk) – liver failure rare, assoc hepatosplenomegally, high fever and leucopenia.
    35. (98) Atrial enlargement on ECG. R atrium = tall P II, V1 >2.5 small squares tall. L atrium= bifid P in II >3 small squares wide, V1 – negative portion p wave >1 small square duration AND amplitude.
    36. (98) Sokolow's criteria for ventricular hypertrophy look at V1 ad V5/6: Right ventricle >12.5mm. Left ventricle >40mm. LVH shows more toward V6, RVH in V1.
    37. (101) HIV infections: oral hairy leucoplakia (H=EBC infection) - white plaques on the lateral border of tongue Rx. Acyclovir cf candida rx. Nystatin, flucanazole. Crypotosporidium diarrohea – ZN stain of stool --> red cysts. Rx. Symptomtic + spiramycin/paromomycin.
    38. (103) SLE – arthropathy, fever, polyserositis. 10F:1M, blacks, usully <40yrs. Multisystem involvement: renal, resp, CVS, neuro, haematologic, cutaneous. DsDNA positive in 60%, ANA in 90%. ESR usually high, CRP characteristically normal. C3 depressed. Lupus anticoagulant. Rx. NSAIDs (joints), chloroquine (skin), corticsteroids, azathioprine, cyclophosphamide.
    39. (103) coxsackie virus A/B - epidemic myalgia (Borholm's syndrome) usually children/young adulys. Sudden abdo/thoracic pain. Myalgia, fever. Polyserositis. Virus in faeces, retrospective diagnosis by serum antibody x4 rise.
    40. (107) Guillain Barre syndrome – onset often heralded by SEVERE lumbar or intrascapular pain. Ans neuropathy e.g. Bladder atony. Csf – albuminocytogenic dissociation. Rx. Iv Ig. Poor prognstic markers: FVC<1litre, paO2 <8, paco2>6, LRTI, polm oedema, accelerated hypertension, arrythmia, bulbar involvement, campylobacter infection.
    41. (110) Homocytinuria – cystathionine deficiency, aut recessive, chr 21---> homocysteine accumulation--> oxidised to homocystine (elevated urine levels). Cystine NOT produced. Defects in collagen crosslinking. Marfanoid features (tall, arachnodactyly, high arched palate, lens dislocation), osteoperosis, epilepsy/mental hadicap, venous/arterial thrombosis (OCP contraindicated), folate deficiency (inc MCV), premature coronary art disease. Rx. Restrict methionine, add cystine. Give Pyridoxine as soon as diagnosis is made.
    42. (112) hypotension, hyperkalaemia, metabolic acidosis --> Addisons, diuretics/salt loosing nephritis.
    43. (114) hypokalaemia --> gi or renal loss. RENAL if 1. HYPERTENSIVE with high renin (malignant hypertension, RAS, diuretics), with low renin (conn's, cushing's, liddle's=tubular defect mimics conn's biochemistry) 2. ACIDOTIC think RTA as most other causes give alkalosis. 3. NORMOTENSIVE diuretics, carbenoxole, liquerish, aminoglycosides, Barters=child JGA hyperplaia, weakness, nocturia, failure to thrive. liquorish and carbenoxalone can also cause hypertension. THINK OF GASTRO CAUSES IF K IS AVIDLY RETAINED FROM KIDNEY ie. <20 MMMOL/L URINARY K.
    44. (115) Coeliac disease - whites esp. irish HLA A1,B8,DR7,DQW2, gluten sensitive enteropathy. 20% do not have diarhhoea. anti gliadin antibodies. children:failure to thrive, adults:abdo pain, fatgue, wt loss. Ankle oedema (albumin), mouth ulcers (Fe), osteomalacia (vit D), hypocalcaemia. Anaemia may be Fe>>B12 but both occur. hyposplenism (Howell Jolly bodies). endoscopic D2 or jejunal bx shows villous atrophy, anti gliadin/anti retiuculin antibodies seen in most patients. antiendomyesial can be absent but are more specific. Rx.gluten free diet. assoc with autoimmune thyroid dx, liver dx, fibrosing alveolitis, IDDM. complications: lymphoma, adenocarcinoma, splenic atrophy.
    45. (116) Cerebral manifestations of HIV - toxoplasmosis (IgM ,Sabin Feldman dye test, CT...Rx pyrimethamine and sulphadiazine), TB meningitis (ZN stain...Rx Ansamycin and clofazamine), crytococcal meningitis (India ink stain, CT..Rx amphotericin), lymphoma (dx brain bx or csf cytology...rx radiotherapy). Uncertain dagnosis on CT --> Rx for toxoplasmosis and repeat CT 2 weeks. biopsy if lesions persist. Other manifesations of HIV: HIV dementa, PMLE, Herpes encephalitis, periph neuropathy).
    46. (118) Charcot Marie Tooth disease - Hereditory Sensory Motor Nueropathy /Peroneal Muscular Atrophy. HSMN1: familial diffuse demyelinating neuropathy, presents <20yrs. wasted lower limbs --> inverted champagne bottle legs, foot deformity,scoliosis, sensory ataxia. dx: FH, nerve conduction, chr 1q. HSMN2 milder. HSMN3 ( Dejerine Sottas dx) aut rec. mixed neuropathy. presents <10yrs with palpable peripheral nerves (palpble nerves also seen in acromegally, leprosy, nft, hiv)
    47. (120) Methaemoglobinaemia (i.e. Haem Fe2+-->Fe3+) assoc with G6PD (low NADPH so Hb more readily oxidatised). MetHb high afinity O2--> ox diss curve left shift--> dec tissue oxygenation. variable degree of cyanosis. metHb level 20% (dyspnoea, headache, angina) 60%+ collapse, sudden death. Blood film intravascular haemolysis, Heinz bodies. Causes: G6PD, drugs (sulphonamide, primaquin, phenacetin), toxins (ferric cyanide, chlorate, aniline dyes)
    48. (120) left shift of O2 dissociation curve: metHb, sulphHb, COHb, FetalHb, decreased 23BPG, alkalosis, hypocapnia, hypothermia.
    49 (121) pain relief and renal failure --> think aute interstitial nephritis most likely.
    50. (123) Hepatitis B serology. Onset of infection-->HBcAb IgM, Marker of previous infection-->HBcAb IgG. HbeAb--> reduced infectivity (cf HBeAg--> increased risk). HBsAb--> immunity, last one to appear. CAH -> usually HBeAg amd HBsAg detected and history is for several months.
    51. (124) Rhematoid arthritis - episcleritis (painless), scleritis (painfull, bilateral, if recurrent can cause perforation). anaemia, Felty's syndrome, renal, resp. Drugsfor rh - pancytopenia (penicillamine or Felty's), nephrotic syndrome (pnicillamine membranous GN, renal amyliod, NSAIDS/analgesics), anaemia (as above plus NSAIDS, chr dx, folate def, atoimmune haemolysis, pernicious). eye dx (scleritis, sjorgens, steroid cateracts, chloroquine retinopathy, eye movement - muscle synovitis, peniciillin inducedmyasthenia, mononeuritis). Resp problems: effusions, fibrosis, bronchiolitis obliterans, pneumonitis, pulm nodules, caplans (nodules plus PMD in coal workers, cricoarytinitis)
    52. (125) vit D resistant rickets- no po4 resorption, high urinry po4 plus/minus paraplegia
    53. (128) Kawasakais dx Hx, O/E, echo Rx. 1. aspirin PO, 2. iv Ig.
    54. (129) atypical lymphocytes - HIV seroonversion (2-6weeks after exposure), CMV, EBV, toxoplasma, secondary syphilis.
    55. (129) syphilis serology: VDRL negative--> test FTA for previous infection. HIV IgG (detctable at 6 weeks), p24 (72 hrs) or PCR for HIV RNA.
    56. (130) renal tubular acidosis: serum K USUALLY FOLLOWS serum H but RTA is an exception. hypokalaemic acidosis with hypocalcaemia and hypercholraemia. manifests clinically as osteomalacia and muscle weakness. dx: abnormal acid load test, early morning uirne pH>5.5. distal=RTA 1 (defective H excretion. failure to thrive, renal colic). proximal=RTA 2 (absent H excretion, NaHCO3 loss. polyuria, polydypsia). Rx. 1. Na bicarbonate (correct acidosis), 2. Potassium citrate (provides K and prevents Ca excretion). Can be inherited, drug induced(acetazolaminde, tetracycline, Pb, Argon, vit D), assoc with PBC, CAH, myeloma, hyperPTH, Fanconi, obstructive uropathy.
    57. (131) Pulmonary embolisn - sudden onset, R heart failure, normal CXR, restictive lung defect, low KCO, low pao2 low paco2. pulm bp.
    58. (133) metabolic acidosis and resp alkalosis always think salicylate poisoning! Rx 1. fluids if <500. 2. alkaine duiresis if <750. 3. haemodialysis if >750.
    59. (135) paradoxical emobous with a soft (?stolic) murmur ---> ASD. ECG changes: RBBB, RVH. LAxD-primum RAxD-secundum. for VSD to be soft takes v large defect.
    60. (136) Amphetamines can induce coronary vasospasm, ventricular arrhythmia, myocarditis, torsaeds (they prolong QT): e.g. cocaine i a young athlete --> MI, normal angiogram. Betabloclers contraindicated because unopposed alpha stimulation in amphetamine abusers causes severe hypertension. Amlodipine/verapamil should be used. hocm is the commonest cause of death in young athletes.
    61. (138) Congenital Adrenal Hyperplasia aut recessive. 21OH deficiency commonest. 3 pathways cholesterol can make: progesterone, aldosteron/cortisol (blocked), testosterone. results in high testosterone (F:virulisation, hersuitism M: proc puberty) and progesterone (amennorria), low adrenal hormones (hypotension, vomiting, failure to thrive). High ACTH, 17 OH prigesterone, high urinary ketosteroids (e.g pregnanetriol), low cortisol. Rx hydrocortisone corrects deficiency and supresses androgen production 2. fludrocortisone as necessary. Synacthen test is abnormal cf. PCOS.
    62. (140) Toxicara infection, dog.cat reservoire, faecoral spread, 2 syndromes: visceral migrans syndrom (local eosinophil eosinophil rich granulomas, flu like symptoms, recovery 2-3 weeks, Rx. thiabendazoleor diethylcarbazine), ocular tocicariasis (blindness, round swelling near optic disk, IgM abs to oxocara in aqueous or vitreous humur Rx laser photocalgulation +/- adjunctive stroids.
    63. (144) Amoebic liver abscess. 50% have no dysentry. Enlargement of liver abscess is UPWARADS hence raised Right hemidiaphragm, intecostal tenderness. Jaundica and abnormal LFTs are rare. Dx US/CT, aspirate NOT sigmoidoscopy. Haemagglutination tests have HIGH YIELD. Rx. metronidazole or tindazole. diolxanide to eliminate ongoing gu infection.
    64. (146, 158) Turners syndrome. phenotypical females, can exhibit X linked recessive traits e.g. haemophilia that are normally only associated with men. the combination of short neck, short metacarpals and short stature is seen in Turners and pseudhypoparathyroidism. short fingers are also seen in Noonan's synfdrome. genotype XO, gonadal dysgenesis (primary hypogonadism - > inc LH and FSH, low oestogen, primary amenorohea, infertitlity), buccal smear Barr body.
    65. (146) Haemophila A/B - NORMAL bleeding time (cf. Von Willibrands disease). both conditions have prolonged APTT. Swollen knee (haemarthrosis, chondrocalcinosis).
    66. (148) Pericardial constriction - right heart failure,normal heart size (radiotherapy, TB, bacterial pericarditis). MRI/CXR reveals thickening/calicification. Cardiac catheter: LVEDP=RVEDP and atrial pressures are equal. (restritive cardiomyopathy - which is patchy, LVEDP>RVEDP, usually tricuspid r mitral regurg)
    67. (149) HIV rx CD4<500, viral load >10,000. 2 nucleoside analogues (AZT, ddc/ddi, 3tc) and protease inhibitor (sequinavir, indinavir)
    68. (150) Amyloidosis: nephrotic syndrome and cardiac failure. cardiomyopathy (small QRS, thick walls echo ground glass), macroglossia, peripheral neuropathy, F10 deficiency). rectal/gingival bx --> apple green birefringence. Primary (AL) myeloma Ig light chain and glycopotein deposition. Do serum Ig and eletrophersis, urine Bence Jones. Systemic amylois (AA) chronic inflam (Rh, bronchiectasis, UC/Crohns, familial med fever) --> kidney more affected (ARF, neohrituc syndrome), hepatosplenmegally.
    69. (151) Freidrichs ataxia - aut dom, frataxin chr 9, trinucleotide repeat. spinocerebellar degeneration, 20-40's assoc optic atrophy, HOCM, DM.
    70. (151) Kyphoiscoliosis and high arched palate - Marfans, Freidrichs ataxia, homocystiuria.
    71. (153) high wcc, myeoblasts, splenomegally --> diff diag CML, myelofibrosis. CML --> low neutophil alk phosphatase, 90% philidelphia chr positive. blood film shows granulocytes if varying maturity.
    72. (156) Parkinsons plus syndromes: 1. multisystem atrophy=sporadic adult onset parkinsonism, cerebellar signs, ANS failure. Parkinsone + ANS failure (e.g. impotence, resp stridor, dysarthria) is called Shy Drager. shortened life expectancy (10 years). postural hypotension --> compression stockings, fludrocortisone, ephidrine, poor respons to Ldopa. 2. Steele Richardson syndrome = NFT's, 70's progressive supranuclear palsy (absence of voluntary downgaze gaze), perseverence in speech(palililia, palilogia), falling backwards, involuntary eye closure, frontalis hyperactivity (7 year survival). both are completely different entities to PD.
    73. (159) Hypogonadism - some causes: 1. PCOS - oestradiol slightly reduced, FSH low, 2. coeliac dx - short stature, delayed puberty, 3. testicular feminization syndrme - no receptors on end organs. phenotypic females, intrabdomial testicles, testosterone levels very high. LH and FSH also very high (no testosterone Receptors on pituitry) --> high oestrogens --> breasts. scanty or absent pubic hair. 4. Pituitry Cushings (basophil adenoma). Usuallly cortisol supressed by high dose dexamethasone otherwise petrosal sinus sampling for ACTH.
    74. (162) Sarcoidosis: multisystem granulomas, f > m. assoc blacks, Lofgrens syndrome (erythemna nodsum, arthralgia, hilar lymphadenopthy, ant uveitis). lacrymal or parotid gland enlargement
    (Mikulicz syndrome seen in sarcoid, TB, lymphoma/leukaemia. with uveitis, facial nerve palsy known as Heerfort's syndrome). most patients resolve <2 years, a few chronic lung disease --> apical fibrosis. full spectrum of eye , skin papules (nose=lupus pernio), arthralgia xray=luscent phalenges, aseptic meingitis, psychosis, mononeuritismultiplex, hypercalcaemia (1, 25oh vitD from granlomatous cells).
    75. (162) erythema nodosum: common: strep, sarcoid, ocp, UC/Crohns, sulphonamides, rest: behcets, TB, leprosy, histpolasma, yersinia, neiserria meningitis/gonnorrohea, pasteurella.
    76. (162) diabetes insipidus: abnormal water depriviation test ..urine osmolality < 720. cranial: (respond to desmopressin) familial, aut dom, DIDMOAD, cerebral tumor, sarcoidosis, TB, hitiocytosis X, trauma, piruitry haemmohrage. nephrogenic (unresponsive to desmopressin)x linked vasopressin R defect, aut rec aquaporin defect, hypokalaemia, hypocalcaemia, Lithium, postobstructive uropathy, sicke cell, glibenclamide, aminoglycosides, amphoteracin.

    THE END!!!!

    Pictures to know:
    ================
    1.Heinz bodies (denatured Hb seen in haemolysis)
    2.Livedo reticularis
    3.Lymphoerythroblastic bone marrow
    4.retinitis pigmentosa
    5.eruptive xanthomas
    6. dermatitis herpetiformis (rx dapsone --> metHb)
    7. atypical lymphocyte

    Approach
    ========
    A&E dept, think overdose
    CRF with normal Hb (APKD). due to epo ectopic secretion.
    chornic GI and RESP infection in a child --> always think CF
    smoker think malignancy

    Calcium metabolism
    ==================
    1. raised ALP (bone): 1. function hyperparathyroidism 2. damaged cortex 3. low vit D
    2. hypercalcaemia: 1. 1ry/3ry PTH, 2. malignacy, 3. myeloma 4. vit D intox, 5.some sarcoid
    3. low calcium: rickets/osteomalacia, hypoparathyroidism, 2ry hyperpth
    4. po4 metabolism: po4 follows calcium in vit D pathology, in parathyroid dysfunction it does the

    opposite. in other pathologies usually normal.

    ====================================
    Disease.....................Ca.............PO4..................ALP
    ====================================
    1ry/3ry pth................high...........low..................high
    malignancy................high...........norm/high........high
    myeloma no fracture..high............norm............norm (think marrow)
    vit D intox.................high............high..............normal
    sarcoid.....................high/norm.....norm.............norm
    =======================================
    osteoperosis..............norm...........norm..............norm
    pagets dx and mobile..norm...........norm..............high
    =======================================
    2ry pth/crf/mg def.......low/norm.....high..............high
    rickets/osteomalacia.......low...........low...............high
    hypoPTH/psudohypoPTH..low...........high..............norm
    =======================================

    Dr Sujit Vasanth.
  4. How to pass MRCP Part 2, my advice

    Thank God,

    passed part 2 on first attempt.

    keys to passing
    1) onexamination.com - do past papers and all pictures
    2) sanjay sharma textbook - read the book from cover to cover and make notes.

    memorising NICE/BTS guidlines is not necessary at all
    not necessary to read Harrison's or Kumar and Clarke

    to all those who passed, congratulations
    to all those who didn't would suggest you try the above formula

    the other amazing book for the exam is the Oxford Handbook of Medicine which has the answers for everything in it, but is very difficult to memorise. If you CAN memorise it - it is better than Harrisons or Kumar.

    PS. Please look at my summary of difficult cases from the Sanjay Sharma textbook and commonly tested facts both of which I posted on this site.

    Lastly timing is very difficult in the exam, especially as there is so much information to take in - labs + vignette + stems. Basically you must make sure to do at least 30 questions per hour. The questions are longer than on onexamination but the standrad is the same.

    in summary:-
    1. onexamination
    2. Sanjay Sharma Textbook
    3. exam time management

    dont waste your time on anything else.

    with best wishes

    Dr Sujit Vasanth
  5. Guest

    Guest Guest

    about sharma book

    i wish to know the full name of the book its publishers so that i can have this book.
    pl.reply at
    matinahmadkhan@gmail.com
    thanks
    dr. matin
  6. Guest

    Guest Guest

    sharma book

    sorry i forgot to mention the name its sanjay sharma"s book on mrcp 2
    pl. anybody let me know where from can i have , the name of its publishers.my id
    matinahmadkhan@gmail.com
  7. Guest

    Guest Guest

    Re: about sharma book


    Rapid Review of Clinical Medicine for MRCP Part 2
    S.Sharma-R.Kaushal
    Manson Publishing

    This book is very helpful. I believe if you have time to review it more than once and read Oxford Handbook of Clinical Medicine success in MRCP2 is very likely

    best of luck
  8. Sanjay Sharma

    Dear Dr Vasant

    I am flattered at the high score I have received in your poll. Would there be scope in running the course in India?

    Best Wishes
    Sanjay Sharma
  9. dr kay

    dr kay Guest

    Dear Dr shrma,
    Yes u shuld start a course.If u want i can help u and join u as a team member as well.
  10. Guest

    Guest Guest

    THANK YOU FOR YOUR HELP
    BEST WISHES
  11. Guest

    Guest Guest

    thanks a lot
  12. Guest

    Guest Guest

    i think its absolutely true only these books are needed no extra information needed

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