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2012,21:27
50LastMinuteCrammingFactsforMRCPPart2Exam(UK)
Author:sujitvasanth
IhavesummarisedwhatIthinktobethe50mostcommonlyaskednonpicturetopicsinthePart2exam.
ThislistiscompletelydifferenttotheoneIpreviouslypostedwhichismeantforMRCPPart1(see
RxPGMRCPpart1section).ThislistisJUSTforMRCPPart2.
1.RenaldeteriorationismostoftenduetoNSAID's:NSAID'>renaldeterioration,ATN,interstitial
nephritis,renalpapillarynecrosis,chronictubulointerstitialnephritis.IfaskedmostLIKELYcauseofrenal
failureNSAIDsarelikelytobetheanswer.
2.wtloss,bronchorrohea>bronchioalveolarcarcinoma
3.diabeticpatientmaximumreductioninCVSriskbp(espACEi>>>tightglycaemiccontrol,weight
reductionunproven.
4.antipsychotic+fever,rigidity,confusion,ANSdysfunction>NMS.canbepptdbyanticholinergics,
lithiumandbenztropine.Rx.withdrawagent,antipyretics,dantrolene,bromocriptine,levodopa.Canoccur
atanytimesincestartingantipsychotics.
5.MS>2neurolesionsseperatedintimeandlocation.
6.bloodgases:Normalvalues:pH7.367.44,O211.312.6,co24.76.0,hc032028
interpretationrules:
i)pHdefinesprimarydisturbance
ii)pO2,pCO2:canbetype1/type2respfailureorhypreventilation
iii)hco3:metaboliccomponent
iv)considerlaberrorifpHisnotproportionaltoHC03:Co2ratio.
v)aniongapinpoisoning(methanol,ethyleneglycol),ketoacidosis
trap:alkal,hiHCO3,tp1failure>shouldbetp2ifcompnstry>mixedmetalk+respacd
7.carbimazoleandsorethroat>ifWCCnormalandneutrophilsOKthenreassureandcontinue.rateof
leuco/neutropeniaisonly1%.Stopifneutstopcarbimazole,giveantibiotics,considerGCSF
8.occupationalasthma:improvesawayfromworkplace,worsensmarkedlyonreturn
9.trivialtraumainyoungpeople>stroke...thinkvertebralarterydissection.headandneckpain+stroke
>thinkofdissection.usuallyunder40yrs,trivialtraumawithsomeneckdistrotion.strokeisoften
brainstem/cerebeller.
10.inversionofbicepsandsupinatorjerks>cervicalmyelopathyC5,6
11.malabsorption>hyperoxalataemia>oxolaterenalstones(radiopaque)>Rxincreasefluids,
calciumcarbonate
12.alcoholicliverdiseaseandneurologicaldeterioration:nystagmus>Wernicke's.IfdecreasedGCS
onlyandonopitaes>opiateoverdose.eg.alcoholic,drowsyoncocodamol>givenaloxone!
13.legionellapneumonia(systemicupset,nonporductivecough,incwcc,lympohopenia,lowNa>Rx.
azithromycinorlevofloxacin.Legionairesdisease>flulikeprodrome,fever,nonproductivecough,
confusion,neutrophilia,lymphopenia,HYPONATRAEMIA,nonspecificliverderangement,
proteinuria/myoglobinurua,lobarorbilateralconsolidation,macrolides(azithromycin)orquinolones
(levofloxacin)(bothsuperiortoerythromycin).combinationtherapyoferythromycinandrifampicinis
secondline.doxycyclline,cotramoxazoleandtetracyclinecanalsobeused.
14.arrythmia+amiodaroneleadingtohyperthyroidism>Startcarbimazole.Ifindicationmild,stop
amiodaronecarbimazolewilloftenberequirediftheAFwouldleadtocompromiseasthehalflifeof
amiodaroneislongandstoppingamiodaronealonewouldhaveaDELAYEDaffect.
15.foreigntravel(espAfricabusinessman),rash,lyphadenopathy>HIVconversionillness
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16.>1g/dayproteinuriabeforeANYothertreatment>ACEinhibitor.indicationsforACEiinrenalfailure:
hypertension>and/or>>glycaemiccontrol.Antibioticsnottobegivenprophylacticallyinthiscase.Low
proteindietbeficifalinovertproteinurianotmicroabluminurea.
17.CRF+FePO+anaemia>giveFeivtoreplenishstoresPLUSEPO.keepHb>11topreventLVH.If
patientsymptomatici.e.anginathentransfuse.
18.obesefemale,headache,papilloedema>BIH>Rxisperitonealshunt.Benignintercranial
hypertensionobeselady,pappilloedema,headachesworseinmorning.1.CTtoexcludeSOL.2.LP.3.
MRIvenogramtoexcludevenousthrombosis,Spaceoccupyinglesion,hydrocephalus(betterthanCT).
causesofBIH>vitaminA,tetracycline,OCP
19.metformincontraindicatedifcreatinine>150.OverweightDiabeticsonmetformindobetteron
metforminthanoninsulin,evenifHbA1cimproves(mortalitydecby40%inUKPDS)
20.coeliacdisease>IgAdeficiency,decCa,Feanaemia,aphousulcers,antiendomesialIgAmaybe
negative>testtransglutaminaseIgG.hypocalcaemiaisseeninCoeliacdisease.hypocalcaemia,iron
deficiencyanaemia,normalinflammatorymarkers,GIsymptoms>coeliacdisease.raisedMCV>
tropicalsprue.
21.osteoperosiswithhypopituitrism>correcttestosteronedeficiency,thenotherthings.GHimproves
symptomsnotbone.aftertestosterone,bisphosphonatesarethetreatmentofchoiceespeciallyifsteroids
areused.HRTiscontroversialandwillnotbetherightanswer.TscoreTCAoverdoselikely>Rx.
sodiumbicarbonate
(alkalinises,andaltersmembpotetial)
23.DM,impotence,normalLFT>1.MRIpituitry(pituitrytumorcompressingstalk).2.abnormalLFT
>checkferritin(Haemochromatosis)
24.erythemanodusum>needCXRtoexcludesarcoid/TB.erythemanodosum:sarcoid,TB(NB.
ALWAYSfirstdoCXR),infection(strep),drugs(sulphonamides,OCP),inflamatoryboweldisease,
behcetsdisease.Lesionslast68weeks.othertests:asottitre,throatswab,Mantouxtest.Rxunderlying
cause,NSAIDs,bedrest.notassociatedwithDMorPSORIASIS.
25.catheterspressures/sats:Leftsideofheart:LA,LV,Aortaareall98%.RightSideheart:RA,RV,
PulmAall74%,(IVC70%,SVC74%).Meanpressures(mmHg).PA10,Aorta100,PCWP110.From
thisinfoyoucancalculatewhereisthelesion.
26.GuillanBarresyndromelowerbackpain,unconfirmedsubjectivesensorysymptoms(e.g.tingling),
CNlesions,absentreflexes,motorweakness,precedingrespillness
27.adverseriskswithaorticstenosis>symptomaticLVfailure,EFRx.Oxygenorscsumitriptan.
prophylaxis:verapamil,Lithiumorvalproate.cf..mirgainepropranololcf.Trigeminalneuralgia>
carbamazepine
29.blistersondorsumofhand>porphyriacutaneatarda
30.epilepsyinpregnancy>continueantiepileptics..saferthanafit.
31.Relativeofanepilepticpatientwithdiplopiaandataxia>phenytointoxicity
32.steroidresponsivenephroticsyndrome>likelytobeminimalchangeNOTmembranous.Childhood
recurrentnephroticsyndrome>likelyminimalchangediseasethereforesteroids,biopsyifnot
responsive,cyclophosphamisif>2episodes/6months,>4/yearorsteroiddependent.AddACEiif
prolongedprotenuria.DISTINGUISHFROMpoststreptococcalGN>invariablycompleterecovery.
33.newhypertensiveguidelines:55yrs/black(CaantagorDiuretic)asfirstline.Ifhypertensioninurinary
incontinance>CachblockerNOTalphablocker.isolatedsystolichypertensioninelderly>thiazidesor
Caantagonists.withdiastolichypertension>ACEi(????notsureaboutthis)
34.myxoedemacomaduetothyoxinenoncompliance>1.ivthyoxine,2.thyroxine,3.thyroxine,4.
thyroxine,5.thyroxine!!!i.e.thyroxineismostimportantNOTsteroids.COMPAREwith35.
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35.slightlyhypothyroidpatient>startedonthyroxine>deterioration.PatienthasAddison's
diseasewithsickeuthyroidsyndromeandthethyroxinehascausedacuteAddisoniancrisis.>Rx.
steroidsivCOMPAREwith34.
36.totalt3/4up,TSHandfreet3/4normal>pregnancy.Comparethiswith:normalT3/4,raisedTSH
>noncompliancee.g.patienttookthyoxinejustbeforeclinicappointment!
37.CN10,11,12palsy,pulsatiletinnitus>glomusjugularetumor
38.smoker,proximalmuscleweakness,drymouth>EatonLambertsyndrome.EatonLambertdec
reflexes,proximalweakness,ANSdysfunction.
39.Schmitt'sdisease:autoimmunediabetesandAddison'swhichcanbeassociatedwithprimaryovarian
failureandprimaryhypothyroidism.InthiscombinationthinkofSchmitt'sbeforepituitrydysfunction.
40.AF:flecainidecontraindicatedinischaemicheartdisease.sotalolcanbeusedforPAFtomaintain
sinusrythm.Adenosine(usedinSVT)contraindicatedinasthma.
41.preg:raisedoestrodiol,anorexiamildlyelevatedprolactin,ammenorrhea.lowBMI,
hyperprolatinaemia,excessiveexercise>anorexianervosa.(prolactinnotraisedincoeliacdisease).
42.endocrineabnormalities:
1.PCOSostradiolnormal,incLH:FSHratio,mildlyincprolactinandandrogens.Obesity,huruitism,
oligomennorhea.
2.CAH>elevated17hydroxyprogesterone
3.adrenaltestostrntumor>testosterone>7,switchesoffLH/FSH>lowoestrgens
4.preg>vhighosetrgnandprogestrn,normaltestostrn.incTotT4normalfreT4
43.entrapmentpalsies:commonperoneal>lostdorsiflexionandeversion,ulnarnerveatelbow.
Especiallyafterprolongedbedrest.
44.3dementias+1parkinsonsplus
1.Pick'sdiseasefrontallobedimentiawithgradualperonalitychanges.i.e.hypersexualiy,hyperphagia,
impulsiveness.Pick'sdiseasemakesyouthinkwithyourpick!!
2.Lewybodydegeneration>visualhallucinations,dimentiaandparkinsonism(lewybodylikeLSD!!).
recentonsetparkinsons+visualhalluinations+normalCT>diffuseLewybodydisease.
3.CADASIL>migraine,lacunarstrokes,dementia.notch3genemutation,nocure.
4.multisystematrophy>cerebellardysfunction,ANDparkinsonianfearures
45.Lungfunctiontests
TLCO=transferfactor=COdiffusingcapacityi.e.alveolapermeability
KCO=gastransfercoefficient=COuptakein1maximum10secbreath
FVCFEV1RVFEV1/FVCTlCOKCO
COPDdecdecinc0.8normvariable
Asthmadecdec>15%improvementfollwingb2agorsteroidtrial
46.PSCisdiagnosedbyERCP,assocUC.AMAisassociatedPBC(seeninCrohns).
47.pacemakers:exertionalproblemsorapatientwhoisfitandactive>alwaysbettertogivearate
dependentpacemaker.egXXXR
48.hyperthyroidism:
1.DeQuevern'sthyroiditis:tenderthyroid,wtloss,malaise,fever,ESR>50or100.
2.solitarytoxicnodulecommonestcause
3.thyroidautoantibodies:thinkofGrave'sorHashitoxicosis.Iftheseabsentsolitarythyroidnoduleislikely.
Druginducedtypicallyisamiodarone.
4.transientpostpartumthyrotoxicoislasts26months,occursin5%ofwomen
5.pregnancywithhyperthyroidism>carbimazoleNOTradioidine,NOTthyroxinepluscarmbimazole.
Surgeryincreasesriskofmiscarriage.
6.thyroiddiseaseonOCP>checkfreeT4toexcludehyperproteinaemiafalselyelevatingT4andTSH.
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raisedALPislikelyduetothyrotixcoisis.
49.gutcarcinoid:diarrhoea,flushing,wheeze,valvularheartdisease,raised5HIAA.worseprognosisis
withcardiaclesions(irrevesibleandoftenrequireSurgery)
50.decreasinginsulinrequirementsindiabetic,hypos,wtlossandlethargy>considerAddisson's.
51.childwithhyperkalaemia,metabolicalkalosisandnormalbloodpressure>Barterssyndrome
(polyuricenuesis,failuretothriveassochyperplasiaofJGA).hypokalaemicalkalosis>vomitinge.g.
pyloricstenosis
52.Felty'ssyndromeisassociatedwithLONSDTANDINGRhematoidarthritis
53.AML:M2t(821),M4t(1616),M3t(1517)promyelocyticassocDIC,Rx.Alltransretinoicacid,Auer
rods.acutepromyelocyticleukaemiat(1517)DIC,Rx:alltransretinoicacid(ATRA).Auerrods.
54.B12deficiencyisassociatedwithotherautoimmuneconditionse.g.DM,thyroiddisease,alopecia
areata,vitiligo.
55.patientlookingtired>thinkmyastheniagravis,asktocountto100.
56.culturenegativeBacterialendocarditis>take4culturesatanytimebeforeempiricletreatmentwith
benzylpenicillinandgentamycin
57.hyperkalaemiainheartfailure:step1:monitor,step2:addaKloosingdiureticstep3:consider
stoppingamiloride/spirinolactone
58.botulism:CNdysfunction,ANSdysfunction,laterlimb/respparalysis,normalCSF,cholinergic
blockade.
Pleasefeelfreetosuggestcorrections/additionstothelist.IwouldremindyoutoonlygivefactsTHAT
HAVEAPPEAREDREPEATEDLYONPASTPAPERSOFMRCPPART2

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