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 MRCP Part 1 (see RxPG MRCP part 1 section) . 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
i) pH defines primary disturbance
ii) pO2, pCO2: can be type 1/type 2 resp failure or hypreventilation
iii) hco3: metabolic component
iv) consider lab error if pH is not proportional to HC03:Co2 ratio.
v) 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 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>> 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 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 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/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).
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 norm variable
Asthma dec dec >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
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
Note: if you find the above list useful, then do not forget to thank Dr Vasanth and add on to the list here in this thread: http://www.rxpgonline.com/postt36585.html