Thursday, June 29, 2006

Dermatology in MRCP (2)

other common dermatology problems in MRCP....

4) Steven Johnson syndrome

A more severe form of erythema multiforme. Remember that it involves mucosal membrane. Causes for this condition are similiar to erythema multiforme. Allergic drug reactions are the fourth leading cause of death in the United States. To learn more , click here !

5) Pyoderma Gangrenosum

An ulcerative cutaneous condition of uncertain etiology. It is painful and usually associated with Inflammatory bowel diseases (ulcerative colitis and Crohn's disease) ,Rheumatoid arthritis, Myeloid blood dyscrasias and Chronic active hepatitis.

6) Mycosis Fungoides


It is usually described as itchy skin lesion. It can present as erythematous macules or raised plaques. The classical areas involved are buttocks, groin, hips, under the arms, and on the breasts/chest. It is a type of cutaneous T-cell lymphomas.

to be continued...........................

Wednesday, June 28, 2006

Dermatology in MRCP (1)

Common skin questions in MRCP
1) Erythema Nodusom


A very popular question in MRCP Part 2 as well as in MRCP PACES skin station, described as " tender erythematous nodular lesion usually on the anterior lower limbs".

Common causes of this skin lesion,

NO cause is found in 60% of cases
D rug (iodides, bromides, sulfonamides)
O ral contraceptives
S arcoidosis or Löfgren's syndrome
U lcerative colitis, Crohn's disease, Behçet's syndrome
M icrobiology: any chronic infection (bacterial, viral, yersinia, tuberculosis, leprosy, deep fungal)

Source: Postgraduate medicine, click here !

Common question in MRCP is about Erythema nodusom with sarcoidosis!

2) Erythema multiforme

It is described as 'target lesion'. Not involving mucous membrane.

Common causes ( only two major causes)

-Drugs- common drugs asked in MRCP- pheytoin, allupurinol, carbamazepine. To find other possible drugs, click here !

-infections- commonly associated with herpes, staphylococcus and mycoplasma.

3) Dermatitis Herpetiformis

It is described as ' chronic itchy rash consisting of blisters'.

It is associated with gluten sensitivity and Coeliac disease. Know about the treatment and foods contain gluten. To learn more, click here !

To be continued..................

Tuesday, June 27, 2006

More Part 2 Questions

1)
An 84-year-old man is admitted via A&E. He was found wandering outside in his pyjamas. He is obviously confused and is talking to people who are not there. The nurses are concerned when he starts wandering about the ward and feel he is going to prove difficult to look after. What is the best management plan for this man?
A : Haloperidol 0.5mg orally given 2hourly to a maximum of 5g in 24 hours
B : Bedrails on both sides of the bed
C : Risperidone 0.5mg orally and repeated 2 hourly up to 3mg in 24 hours
D : Regular reassurance, being placed in a calm environment
E : Lorazepam 0.5mg as required, but no more than tds.

ANSWER: D

2)A 55-year-old female with a recent onset of joint pain and was prescribed with medications by her GP presents with a 5-day history of a widespread erythematous skin eruption and mouth ulcers. She complained of dysuria. She has lesions on the palms and some areas of skin are beginning to blister and ulcerate. What is the most likely diagnosis?
A : Bullous pemphigoid
B : Fixed drug eruption
C : Stevens-Johnson syndrome
D : Pemphigus vulgaris
E : Erythema multiforme.

ANSWER: C

3)A 60-year-old man presents with a palpable, non-blanching rash on the lower legs. Which of the following investigations is least likely to help with the underlying diagnosis?
A : Antistreptolysin-O test (ASOT)
B : Antinuclear antibodies (ANA)
C : Hepatitis B antibodies
D : Thyroid function tests
E : Cryoglobulins.

ANSWER: D

4) You are called to the resuscitation room to see a 20-year-old tall man whose condition has suddenly deteriorated. He had arrived 30 minutes earlier with a 2-hour history of central pleuritic chest pain and breathlessness. He collapsed while awaiting radiograph and now is agitated and cyanosed with pulse 120/min and BP 80/40. Oxygen saturation is reading 72%, with the patient breathing high flow oxygen via a re-breathe mask. Respiratory examination reveals reduced breath sounds in the right lung field with deviation of the trachea towards the left. Percussion is resonant bilaterally. CVS examination reviewed diastolic murmur over left sternal edge with collapsing pulse? What is your diagnosis?
A : Spontaneous pneumothorax
B : Marfan’s syndrome
C : Dissecting aneurysm
D : Acute exacerbation of asthma
E : Parapenumonic effusion

ANSWER: B

5)An 85-year-old man is admitted from home because he has become increasingly confused and is not coping. He is known to have metastatic carcinoma of the prostate and takes Zoladex 3 monthly. You note that he has bruising over the left side of his forehead. Which of the following investigations will not help you diagnose and treat his confusion?
A : CT scan of the head
B : Midstream urine sample
C : Calcium
D : Urea and electrolytes
E : Prostatic specific antigen (PSA).

ANSWER: E

Monday, June 26, 2006

Herpes Encephalitis


As I discussed before, herpes encephalitis is the popular question in MRCP. The above MRI of brain shows T2 hyperintensitiy involving the right temporal lobe. The usual lobe involved is temporal. EEG may show focal temporal lobe involvement.
Classical CSF finding in viral encephalitis is elevated protein with presence of lymphocyte.Diagnosis can be confirmed by PCR detection.
Treatment - acyclovir.

100 Common Questions in MRCP Part 2 (4)

Last part of this topic..............


g) Renal Medicine

57) Renal tubular acidosis Type I,II and IV
58) ACE inhibitor and ARB- know about rennin-angiotension-aldosterone system. Common electrolyte imbalances include hypo/ hyperkalemia and hypo/ hypernatriemia.
59) Acute renal failure- causes and management. Indications for dialysis.
60) Nephrotic syndrome- diagnosis and common causes. Possible complications.
61) Chronic kidney disease-common causes and management including CAPD or haemodialysis.
62) Acute dialysis- indications , also know about drug that can be dialysed by haemodialysis such as salicylate etc
63) Polycystic kidney and possible complications and associations.
64) Renal transplantation- basic principles and common side effects of drugs!

h) Phamarcology

65) Common drugs in cardiology such as digoxin, amiodarone, warfarin and aspirin.
66) Antipsychotic drugs especially anti-schizophrenia, tricyclic antidepressant and mood stablizers such as lithium. Know how to manage lithium toxicity.
67) Paracetamol poisoning.
68) Lead poisoning
69) Drug interactions especially involving anti epileptic, oral contraceptive pills and warfarin. Learn about enzyme inducers and inhibitors.
70) Slow acetylators and common side effects and examples.

i) Neurology

71) Stroke- iscahemic and haemorrhagic stroke. Management, indications for thrombolysis!
72) CNS infections- especially meningitis, common CSF findings. Encephalitis especially Herpes ( learn about the classical EEG and MRI changes) and treatment. TB meningitis- classical CSF finding.
73) Parkinson’s disease and Parkinson plus syndrome!
74) Myasthenia gravis and Eaton Lambert
75) Motor Neuron disease- subtypes and common presentation.
76) Dementia!
77) Common cranial nerves abnormalities especially third, sixth, seventh , Bulbar and pseudo-Bulbar palsy!
78) Epilepsy and common EEG findings. Treatment and side effects!
79) Guillain-Barre syndrome
80) Normal Pressure hydrocephalus
81) Benign intracranial hypertension- Common drugs that can cause this!

j) Infections/HIV

82) Lyme disease. Click here to learn more!
83) HIV and AIDS- common drugs used in treatment such as zidovudin (AZT), lamivudine, protease inhibitors such as indinavir. Common side effects and drug interaction especially with TB medications.
84) Syphilis
85)Malaria.
86) A few rarer infections such as Q fever,Giardiasis and schistosomiasis.

k)Statistics

87) screening tests- specificity and sensitivity
88) Clinical trials- P value, number to treat.

Other topics

88) psoriasis, eczema, and drug- induced macular popular rash
89) Erythema nodusom. Erythema multiforme, Steven Johhson’s syndrome
90) Bullous diseases such as pemphigoid. Click here to learn more!
91) Glaucoma
92) Diabetic eye disease.
93) Common genetics disorders such as Down’s syndrome, Turner etc
94) Basic anatomy such as Ulnar, Median and Radial nerves distribution
95) Common psychiatric disorders especially depression and schizophrenia.
96) Common problems pertaining to pregnancy such as eclampsia and pregnancy induced hypertension.
97) Karposi sarcoma
98) Mutiple myeloma
99) Paget’s disease of the bone
100) Other infections such as Brucellosis, typhoid fever etc…

Good Luck for your exams!

Sunday, June 25, 2006

MRCP Part 2 Mock Exam (1)

Complete the following questions in 12 mins.....


1)A 22 year old female who is 23 weeks pregnant is
seen in the outpatient clinic and noted to have
a sustained blood pressure of 170/92 mmHg. She
has no past medical history of note and has
otherwise been well and asymptomatic. This is
her first pregnancy. Urinalysis reveals protein (+) and
blood (+).
What is the most appropriate anti-hypertensive
therapy for this patient?


1 )ACE inhibitor
2 )alpha-Methyldopa
3 )Beta-blocker
4 )Hydralazine
5 )no treatment required

2)A 68 year old woman is admitted to hospital with
acute coronary syndrome and is discharged on day
5 after making a good recovery. She continues to
be under investigation of the cardiologists and
is discharged on atenolol 50 mg daily, enalapril
10 mg daily, isosorbide mononitrate 30 mg daily,
Atorvastatin 20 mg daily and aspirin 75 mg
daily. Her investigations at admission revealed
a serum urea concentration of 12.4 mmol/l with a
serum creatinine of 250 micromol/l. She is
re-admitted one week after discharge with
deteriorating dyspnoea. Investigations reveal a
serum urea of 34.9 mmol/l, a serum creatinine of
900 micromol/l, a serum bicarbonate of 12mmol/L
and a potassium concentration of 7.0 mmol/l with
tall tented T wave in leads over V2-6
What is the next plan of treatment?


1 )Calcium resonium
2 )Dialysis
3 )Insulin and dextrose infusion
4 )Sodium bicarbonate infusion
5 )Stop enalapril

3)A 27-year-old girl presented with a 4-day
history of severe back pain. A plain x-ray film
of her spine is normal. Two days later, she
complained of tingling in her fingers and toes.
The next day she became generally weak. She
presented in A/E.
On examination, she has bilateral leg weakness with power
3/5 , areflexia, flexor
plantars and normal sensation.
A lumbar puncture was performed and the CSF
analysis showed: Protein2.4 g/l (<0.4)
GlucoseNormal
Cells0

What is the most likely diagnosis?

1 )Botulism
2 )Guillain-Barre syndrome
3 )Acute poliomyelitis
4 )Myasthenia gravis
5 )Hysteria

4) In HIV disease, patients first become
susceptible to infection with Pneumocystis
carinii when the CD4 cell count falls to:


1 )<1000 cells/mm3
2 )<500 cells/mm3
3 )<350 cells/mm3
4 )<200 cells/mm3
5 )<50 cells/mm3

5)A 32-year-old male is followed up in the renal
clinic. His creatinine clearance (measured) is
76ml/min. A recent Ultrasound of his renal tract shows
enlarged kidneys bilaterally, with multiple
renal cysts. His father required dialysis at the
age of 45 years. On examination, his blood
pressure is 150/90 mmHg. Which of the following
statements is incorrect?


1 )An ACE inhibitor would be appropriate to
control his hypertension
2 )The risk of his children having the same problem is 50%
3 )Ciprofloxacin should be prescribed for upper
urinary tract infections
4 )Genetic counselling should be offered
5 )He should be informed of the probable need
for dialysis in 5-7 years

6)This patient presented to Casualty with acute
abdominal pain.

What is the diagnosis?


1)Peutz-Jegher's syndrome
2 )Crohn's disease
3 )Addison's disease
4 )Whipple's disease
5 )Porphyria cutanea tarda




7)A 52-year-old man was referred to the medical
outpatient clinic for assessment of fatigue. He
gave a four-month history of feeling 'tired all the time'. He had a past
history of hypertension that had been monitored
by his General Practitioner but this had not
required treatment. He had also reported feeling
in a 'low mood' to his GP, but attributed this
to the fatigue.
Investigations:
Hb14.9 g/dl
WBC8.1 x 109/l
Platelets179 x 109/l
MCV106 fl

Sodium132 mmol/l
Potassium4.0 mmol/l
Urea2.0 mmol/l
Creatinine110 µmol

Bilirubin28 µmol
Total protein69 g/dl
Albumin35 g/dl
Alk phos210 IU/l(NR 30-130)
AST98 IU/l(NR 20-40)
Gamma GT299 IU/l(NR <65)

9am Plasma cortisol877 nmol/l(NR 200-500)
12am Plasma cortisol 720 nmol/l (NR 55-250
nmol/l)

24-hour urinary free cortisol1120 nmol/l(NR
215-860)


What is the most likely underlying cause of
these abnormalities?


1 )Adrenal hyperplasia
2 )Alcohol
3 )Ectopic ACTH secretion
4 )Pituitary adenoma
5 )Depression

8)A 52 year old male presents with general
lethargy and abdominal swelling.
His symptoms have deteriorated over the last
three months and he denied long standing
heavy alcohol consumption but admitted that he was an intravenous drug abused.
Currently he is taking no medication and has no past history of
note. Examination reveals that he is well
orientated, is apyrexial and has a blood
pressure of 132/88 mmHg. He has numerous spider
naevi present on the upper chest and has
gynaecomastia. Abdominal examination reveals
tense ascites. He has splenomegaly on
abdominal examination. Investigations reveal:
Serum Sodium132 mmol/l (133-145)
Serum Potassium4.4 mmol/l (3.5 - 5)
Serum Urea 2.8 mmol/l (3 – 8)
Serum Creatinine135 micromol/l (50-100)
Bilirubin35 micromol/l (10-20)
AST 70 iu/l (10-40) Alkaline Phosphatase 220
iu/l (50-100) Albumin 25 g/l (35-45) Which of
the following measures would be most appropriate
in the initial management of this patient?

The following factors are the prognostic factor except
1 )Albumin
2 )INR
3 )Bilirubin level
4 )Presence of ascites
5 )Urea level

9)An 82-year-old gentleman is referred to your
outpatient clinic by his GP. He gives a two
month history of proximal muscle stiffness,
especially in the morning. He denies any
weakness.
What is the next best investigation?


1 )Plasma creatine kinase
2 )Muscle biopsy
3 )Erythrocyte sedimentation rate
4 )Antinuclear antibody
5 )Electromyography

10) These thyroid function tests were obtained from
a 60 year old male who presents with tiredness.
Past history includes ischaemic heart disease
and depression, for which he takes medication.
Free T4 25.7 pmol/l (NR 9.8 - 23.1 pmol/l)
Free T3 3.0 pmol/l (NR 3.8 - 5.8 pmol/l)
TSH 7.8 mU/l (NR 0.5 - 4.2 mU/l)

Which of the following is the most likely
explanation for these results?


1 )Amiodarone therapy
2 )Grave's disease
3 )Lithium therapy
4 )Sick euthyroid syndrome
5 )Subclinical hyperthyroidism

To check the answers, click here!

Popular drug in MRCP (3)

Today ,I would talk about another very popular drug in MRCP part 1 and 2, the drug is amiodarone. It is used in supraventricular as well as ventricular arrhythmias. The most popular question about amiodarone is about its side effects,

The side effects can be divided to cardiac or extracardiac side effects,
a) Cardiac side effects
-may cause symptomatic bradycardia or heart block.
-use carefully in heart failure patient

b) Extra cardiac side effcets
- hypo/ hyperthyroidism- the most popular question in MRCP!
-skin discolouration- blue-grey in sun- exposed area (photosensitivity). Came out as a MRCP PACES question before in station 5!
-lung fibrosis
-corneal deposit
-tremor

Always remember that amiodarone increases the toxicity of digoxin and warfarin!

More drugs to come in future posts............

100 Common Questions in MRCP Part 2 (3)

From previous post..................

e)Endocrinology/metabolic disorder

38) Cushing’s syndrome- the most popular question in MRCP, learn everything about this!
39) Diabetes mellitus- know about the UKPDS trial and management of DM during acute MI, to know more about DIGAMI trial, click www.passpaces.com/DM.html
40) Thyroid disorders- hypo/hyperthyroidism, Grave’s disease, learn how to interpret T4/TSH results. Sick euthyroid and the T4/TSH results etc.
41) Other rare disorders such as Conn’s syndrome, phaechromocytoma, prolactinoma and acromegaly ( know about causes of increased proclactin level)
42) Wilson's disease.
43) Hypoglycaemia. Common causes.
44) Diabetes inspidus- know how to interpret water deprivation test.
45) SIADH- know about the causes and treatment.
46) Porphyrias- popular questions include skin lesion in Porphyria cutanea tarda. To learn more, click here!
47) Mutiple endocrine neoplasia
48) Polycystic ovarian syndrome

f)Rheumatology

49) Autoimmune diseases especially systemic lupus erythematosis (SLE), learn about drug- induced lupus as well.
50) Osteoporosis/ Osteomalacia- learn about calcium metabolism. Know how to interpret DEXA, Ca/PO4 level with ALP.
51) Rheumatoid arthritis – Criteria to diagnose and available treatment including the latest biologics such as infliximab. Know about the side effects of Disease Modifying Drugs such as methotrexate. Click here to learn more about infliximab!
52) Dermatomyositis/polymyositis- association with what types of malignancy and treatment.
53) Polymyogia rheumatica- diagnosis.
54) Spondyloarthropathies- especially ankylosing spondylitis , Reiter’s and psoriatic arthropathy.
55)Vasculitis- the commonest question in MRCP are about PAN,Wegener’s and Churg-Strauss.
56) Gout/psudogout/osteoarthritis-know about NSAID and the side effects. COX II inhibitors.

to be continued.............

Thursday, June 22, 2006

MRCP Part 1 - Mock Exam (1)

I have prepared 20 questions for you to answer in 25 minutes, you can find the answers after you complete the questions below,

1)A 55 year old female undergoes a DEXA scan which reveals a bone mineral density T score of -2.5 at the hip and lumbar spine.
Which of the following may contribute to such a result?
1 ) Acromegaly 2 ) Delayed menopause 3 ) Hypothyroidism 4 ) Myeloma 5 ) Obesity

2)In a normal heart, the oxygen saturation of a sample of blood taken from a catheter in the pulmonary capillary wedge position should be equal to a sample from which of the following?

1 ) coronary sinus 2 ) femoral artery 3 ) pulmonary artery 4 ) right atrium 5 ) right ventricle

3)Elevation of the jugular venous pressure during inspiration is most likely to be found in which of the following situations?

1 ) a normal physical exam 2 ) cardiac tamponade 3 ) constrictive pericarditis 4 ) dilated cardiomyopathy 5 ) myocarditis

4)A 50-year-old plumber presented with a dry nocturnal cough and increasing exertional breathlessness.

On examination he had early finger clubbing, cyanosis and bilateral basal crackles. A chest X-ray showed bilateral lower zone shadowing.

Investigations revealed:
PaO2 (breathing air) 8.0 kPa (11.3-12.6) FEV1/FVC ratio 90%
Which of the following investigations is most likely to establish the diagnosis

1 ) Echocardiography. 2 ) High resolution CT scan of the lung 3 ) Measurement of diffusion capacity
4 ) Serun calcium level 5 ) Transbronchial lung biopsy

5)A 40 year old woman presents with an acute attack of asthma. She is able to speak in short sentences.
Her respiratory rate is 20 breaths per minute and the peak expiratory flow rate 320L/min (predicted 480 L/min.
What is the most appropriate treatment for this patient?

1 ) Intravenous aminophylline. 2 ) Intravenous salbutamol 3 ) Nebulized salbutamol
4 ) Oral salbutamol 5 ) Oral theophylline

6)A new diagnostic test for malabsorption has been analysed and the results have yielded the following 2x2 contingency table.
Disease present
test result yes no
+ve 0.9 0.1
-ve 0.2 0.8

Applying this test to a case of chronic diarrhoea from a patient group where the prevalence of malabsorption is known to be 20% (probability = 0.2)
what is the probability of a patient having malabsorption if they have a positive test?

1 ) 0.16 2 ) 0.24 3 ) 0.48 4 ) 0.64 5 ) 0.8

7)A 53-year-old man presented with hypertension of 150/110 mmHg. He is generally asymptomatic and has no previous medical history of note. He is a smoker of 5 cigarettes daily and drinks modest quantities of alcohol. He takes no prescribed medications. Examination reveals a BMI of 33.5 kg/2 but nil else.
The following detail his investigations:
Serum sodium 146 mmol/l (NR 133-145)
Serum potassium 3.2 mmol/l (NR 3.5 - 5)
Urinary potassium excretion 42 mmol/l (NR less than 30)
What is the likely diagnosis?
1 ) Adrenocortical adenoma 2 ) Bartter's syndrome 3 ) Liddle's syndrome 4 ) Liquorice ingestion 5 ) Pheochromocytoma

8)A 74-year-old man presented with acute pain, pallor and absent pulses in his right leg. Investigations revealed an embolus in his femoral artery.

What is the most likely source of this embolus?

1 ) marantic endocarditis 2 ) paradoxical emboli 3 ) rheumatic endocardial vegetations
4 ) right ventricular thrombi 5 ) thrombi from an atheromatous aorta

9)When acclimatised to life at high altitudes

1) the mean corpuscular haemoglobin concentration is increased 2) respiration becomes periodic
3) cardiac output is increased 4) pulmonary diffusion capacity is increased 5) airway resistance is decreased

10)Recognised features of acromegaly include EXCEPT

1) hypocalciuria 2) intestinal polyposis 3) splenomegaly 4) palpable peripheral nerves 5) proximal myopathy

11)Which ONE of the following statements is true of autoimmune hepatitis:
1 ) It usually presents as an acute hepatitis 2 ) It rarely presents before 20 years of age
3 ) It may be associated with keratoconjunctivitis sicca 4 ) It is associated with hypogammaglobulinaemia
5 ) It rarely interferes with menstruation except in later stages

12)A 38 year old female presents with red target lesions confined to the hands and is diagnosed with erythema multiforme.
Which of the following could be the cause? 1 ) Cytomegalovirus infection 2 ) Ureaplasma urealyticum
3 ) Group B Streptococci 4 ) Langerhan's cells histiocytosis 5 ) Penicillin V

13)A 50-year-old man presented in the summer complaining of itching and blistering of his hands and forehead. On examination there were small areas of excoriation on the backs of his hands.
What is the most likely diagnosis?
1 ) dermatitis herpetiformis 2 ) lupus erythematosus 3 ) pemphigoid 4 ) pemphigus 5 ) porphyria cutanea tarda

14)Which of the following statements concerning the thymus is true?

1 ) The majority of cortical thymocytes express either CD4 or CD8.
2 ) CD4/CD8 double positive cells are eliminated by a process of negative selection.
3 ) A proportion of alpha/beta+ thymocytes undergo isotype switching to produce gamma/delta+ T cells.
4 ) Thymocytes whose TcR bind with high affinity to self Ag/MHC complexes are clonally deleted.
5 ) Mature thymocytes express surface IgM and IgD.

15)Which of the following conditions is most likely to be associated with thrombocytopenia?
1 ) haemophilia A 2 ) hereditary haemorrhagic telangiectasia 3 ) pernicious anaemia 4 ) porphyria 5 ) uraemia

16)Concerning Neurofibromatosis Type 1 (NF1),
which one of the following statements is true?

1 ) Bilateral acoustic neuromas are common 2 ) Clinical severity in individuals is similar in a given family
3 ) New mutations occur rarely 4 ) Lisch nodule is a characteristic feature
5 ) The diagnosis is likely if one café-au-lait patches are present

17)A 73 year old female is diagnosed with Cushing's disease. Which of the following is correct?

1 ) Adrenalectomy would be the treatment of choice. 2 ) op-DDD is a treatment if unfit for surgery 3 ) Ketoconazole may be used as a treatment if unfit for surgery 4 ) Recurrence of Cushing's disease after transphenoidal surgery is less than 5%
5 ) yttrium implantation is an effective treatment

18)A 19-year-old male student attends casualty complaining of an urethral discharge. Gram stain shows numerous neutrophils, some of which contain gram-negative intracellular diplococci. The patient is treated with Ceftriaxone, 250 mg as an im injection. Five days later, the patient re-attends with persisting discharge.
Which of the following is the most likely cause of this discharge?
1 ) Chlamydia trachomatis 2 ) Penicillin-resistant Neisseria gonorrhoeae 3 ) Re-infection with Neisseria gonorrhoeae
4 ) Ureaplasma urealyticum 5 ) Urethral stricture

19)A randomised double-blind placebo controlled study of a cholesterol-lowering drug for the primary prevention of coronary heart disease was conducted. It had a five-year follow up period.
The results showed an absolute risk of myocardial infarction in the group-receiving placebo during was 10 per cent. The relative risk of those given the cholesterol lowering medication was 0.8
What number of patients will need to be treated with the drug for five years to prevent one myocardial infarction?
1 ) 20 2 ) 40 3 ) 50 4 ) 80 5 ) 100

20) This gentleman presents with recurrent per-rectal bleeding.What is the risk of his children to have the similiar problem?
1) 25%
2) 50%
3) 100%
4) Depending on the children's gender
5) variable

with permission from www.passpaces.com

Find your answers here!

Wednesday, June 21, 2006

100 Common Questions in MRCP Part 2 (2)

from previous post..........


c) Haematology

17) thrombosis- conditions that prone patients to get thrombosis!
18) Anaemia- causes of microcystic, macrocystic and normachromic anaemia.
19) Haemolysis- especially autoimmune haemolysis- common causes, warm and cold agglutination- examples.
20) sideroblastic and aplastic anaemia- causes of aplastic anaemia.
21) Acute leukaemias especially how to differentiate ALL and AML.
22) Chronic leukaemias- CML- Ph chromosone, latest treatment. CLL ( less popular)
23) Lymphoma.
24) Bleeding disorders- conditions affecting bleeding time, PT, APTT- Von Willebrand’s disease.
25) Anticoagulation- warfarin
26) Pancytopenia- causes.
27) Spleen- indications of splenectomy and complications.
28) Thrombocytopenia- causes and examples of drugs ( especially heparin!)

d) Gastroenterology

29) Hepatitis- A, B, C and D. Learn about autoimmune hepatitis, alcoholic hepatitis and drug-induced hepatitis.
30) Autoimmune disorders such as primary biliary cirrhosis.
31) Wilson’s disease- how to diagnose and common presentations.
32) Haemochromatosis- primary or secondary.
33) Liver cirrhosis- causes and treatment. Complications such as hepatic encephalopathy.
34) Pernious anaemia.
35) Jaundice-causes , a few rare conditions such as Gilbert!
36) ERCP - for a few common conditions.
37) Inflammatory bowel disease- presentations and differences btw the two conditions!

to be continued....................

Breakdown of MRCP Part 2 Qs.

Which specialty is more important?

I went to check my MRCP Part 2 results that I took in 2003. I find that it is important for candidates to know about the analysis of questions by specialty. This will help you to know which specialty is more important and you can put more time to study these topics.

In 2003/3, the breakdown of questions is as follow based on percentage,

a) Cardiology 11.8%
b) Dermatology 3.9%
c) Endocrinology/Metabolic 9.2%
d) GIT 9.2%
e) Haematology 3.3%
f) Infection/STD 7.2%
g) Neurology 11.2%
h) Oncology 2.0%
i) Eye 0.6%
j) Renal Medicine 12.5%
k) Respiratory 8.6%
l) Rheumatology 7.9%
m) Therapeutics 12.5%

Therefore, MRCP candidates must remember that the main topics to cover in MRCP Part 2 are Cardiology, Respiratory, Endocrinology, Renal, Neurology and Therapeutics ( pharmacology!).

Tuesday, June 20, 2006

100 Common Questions in MRCP Part 2 (1)

I have summarized 100 topics that are commonly asked in MRCP Part 2.

a) Cardiology

1) myocardial infarct- remember the relevant leads signify which part of the myocardium, such as if inferior MI is due to RCA blockage. Know how to read ECGs. Know about complications.
2) Heart block- common questions are about bifasicular/ trifasicular blocks. Also know about first, second and third degree blocks.
3) Congenital heart diseases- know about ASD (primun and secundum and how to differentiate the two from ECG), VSD and the classical cardiac catherization results.
4) Valvular heart conditions- know about AR,MR,MA and AS well and indications for operation.
5) Heart failure- common drugs used in heart failure and causes of heart failure include alcoholic cardiomyopathy.
6) Basic pharmacology- know about digoxin, amiodarone, warfarin, aspirin, anti cardiac arrthymia drugs.
7) Statin. Lean more about the side effects and indications.

b) Respiratory

8) Asthma/COAD- know everything about these two conditions.
9) Lung function test and classical results for restrictive and obstructive changes
10) Tuberculosis- common drugs used and side effects.
11) PCP- a very popular question in MRCP. Know about the treatment.
12) ABPA (allergic bronchopulmoary aspergillosis)- diagnosis and role in asthma.
13) Pulmonary- renal syndrome such as Goodpasture. Common presentations and diagnosis (learn about ANCA)
14) Pneumonia especially community and nosocomial. Popular questions are about Mycoplasma and Legionella infections.
15) Pleural effusion- Know about causes of pleural effusion , especially malignant pleural effusion.
16) Lung CA- Know about indications for operation as well as paraneoplastic complications. Types of lung CA!


To be continued…………

Monday, June 19, 2006

Digoxin- another popular drug in MRCP (2)

As I talked before, another common drug that being asked frequently in MRCP is digoxin. This drug is commonly used in patient with atrial fibrillation for rate control. A lot of candidates misunderstand that digoxin can be used for cardioversion. You mustmember that digoxin is being used to control the rate of atrial fibrillation ( such as beta blocker ) and will never cardiovert AF back to sinus rhytm. Another indication for digoxin is in heart failure and no study so far proves that it improves patient's survival.
There are a few conditions that can enchance digoxin toxicity such as, ( common MRCP question!)

a) hypokalaemia- therefor in clinical practice, always check patient's K level before starting digoxin. The explanation behind this toxicity,I think you have to check your pharmacology book!
b) verapamil, beta blocker , quinidine and amiodarone- because all these drugs reduce renal digoxin clearance by competing for the active tubular secretory mechanism in the distal convoluted tubule.
c) elderly and renal failure patient- due to reduced excretion!
d) other electrolyte abnormality such as hypomagnesiamia and hypercalcaemia.


Questions:
1)A 67 year old man presents with sudden onset atrial fibrillation (ventricular rate of 150/minute). His serum creatinine concentration was 250 umol/L (70-110).

What is the main factor that determines the choice of loading dose of digoxin in this patient?
1 ) Absorption 2 ) Apparent volume of distribution 3 ) Lipid solubility 4 ) Plasma half-life 5 ) Renal clearance


ANSWER: 5

2)Serum digoxin concentrations are increased when given with...EXCEPT

A Amiodarone B Spirolactone C Cholestyramine D Quinine E Verapamil


ANSWER: C

3) A 72 year old man is admitted with fast atrial fibrillation but is receiving treatment with digoxin. An inadequate dose is suspected. A sample of blood is drawn six hours after the last dose of digoxin and a plasma concentration is requested.
Which of the following factors explains the six hour wait before measuring the digoxin concetration?

1 ) enterohepatic circulation 2 ) the rate of absorption 3 ) the rate of clearance
4 ) the rate of distribution 5 ) the rate of elimination


ANSWER: 4

4)A 65-year-old was advised to start oral digoxin at a dose of 250 µg daily. His physician explained that the full effect of this treatment would not be apparent for at least a week.
Which one of the following pharmacokinetic variables did the physician use to give this explanation?
1 ) bioavailablity 2 ) half-life 3 ) plasma protein binding 4 ) renal clearance 5 ) volume of distribution


ANSWER: 2

Useful Links for MRCP.

I visited a few useful sites for those who are preparing for MRCP Part 1 and 2. Check out these sites...

1) Revision guide for MRCP, click here
2) Neurology for MRCP, click here
3) Free BOFs at MRCPass.com, click here
4) Free 1000 BOFs, click here
5) Useful online resources, click here

Hope you find these useful, if you have other FREE MRCP sites to recommend, email me at mrcp1and2.yahoo.com!

Thank you!

Sunday, June 18, 2006

Warfarin- A popular drug in MRCP

There are a few drugs that are commonly asked in MRCP Part 1 exams, these drugs include pheytoin, digoxin, warfarin, isoniazid,,aspirin etc. Today, I am going to discuss more about warfarin. You may be wandering why the above-mentioned drugs are being asked repeatedly in MRCP. The reason is simple because you would see a lot of patients on these drugs in clinical practice.
Warfarin is an anticoagulant. It inhibit the production of Vitamin K dependent coagulation factors namely II, VII, IX and X( a very popular question in Part 1). Warfarin causes prolongation of PT time ( or INR ) and groups of patients on warfarin include,

a) Patients with previous prosthetic valve replacement,
b) Patients with history of thromboembolic events such as pulmonary embolism, DVT and ventricular clot.
c) Patients with very high risk of developing embolic event such as in atrial fibrillation.

Common question in MRCP is warfarin drug interaction. There are numerous examples of drug interaction for warfarin.

However,remember the following,

a) Drugs that increase the effect of warfarin.....
- drugs which are liver enzyme inhibitors such as omeprazole, disulfiram, erthyromycin, valproate, isoniazid, cimetidine, metahnol(acute),sulphonamides (ODEVICES)
-drugs that cause displacement of warfarin from protein such as NSAID, OHA, metronidazole, salicylates, cotrimoxazole

b) Drugs that reduce the effect of warfarin......
- drugs which are liver enzyme inducers such as pheytoin, carbamazepine, barbiturates, rifampicin, alcohol (chronic) and sulphonyureas. (PCBRAS)

Questions about anticoagulation in MRCP:

1)Which ONE of the following is a contraindication to thrombolysis?
1 ) age over 75 years 2 ) the presence of atrial fibrillation
3 ) asthma 4 ) pregnancy 5 ) background diabetic retinopathy


ANSWER: 4

2)A patient presenting with atrial fibrillation who has reverted to sinus rhythm is more likely to remain in sinus rhythm in the following circumstances:
A age >75 years old B been commenced on warfarin C left atrium size > 6 cm on ECHO
D short history on AF E a ventricular rate on presentation of 130 bpm


ANSWER: D

3)A 70-year-old woman has a history of dyspnoea and palpitations for six months. An ECG at that time showed atrial fibrillation. She was given digoxin, diuretics and aspirin. She now presents with two short-lived episodes of altered sensation in the left face, left arm and leg. There is poor coordination of the left hand. ECHO was normal as was a CT head scan.

What is the most appropriate next step in management?

1 ) anticoagulation 2 ) carotid endarterectomy 3 ) clopidogrel 4 ) corticosteroid treatment 5 ) no action


ANSWER: 1

4)A 62 year old male undergoes cardioversion for idiopathic atrial fibrillation. Post-procedure he was shown to be in sinus rhythm. Medication at admission included Warfarin digoxin and atenololwhich he had been taking for the last six weeks.

Which of the following agents should he continue to take until he is seen in clinic in six weeks time.

1 ) Aspirin 2 ) Atenolol 3 ) Digoxin 4 ) Sotalol 5 ) Warfarin


ANSWER: 5

5)An 80 year-old male presented with palpitations of 5 hours duration. One month previously he suffered weakness of the right arm and problems with his speech which resolved within 4 hours. He was taking no medication. On examination, he was stable with a pulse of 135 beats per minute which was confirmed to be atrial fibrillation on ECG. He had a blood pressure of 112/80 mmHg, appeared clinically euthyroid. Within one hour he reverted to sinus rhythm spontaneously. Echocardiogram was normal but a 24 hour ECG revealed three episodes of atrial fibrillation each lasting around ten minutes.

Which one of the following is the most appropriate initial treatment for this patient?

1 ) Amiodarone 2 ) Aspirin 3 ) atenolol 4 ) digoxin 5 ) warfarin


ANSWER: 5

Books For MRCP Part 1

Before sitting for your MRCP Part 1, you must buy some useful books to read. I have been searching the internet for past few days and found out a few useful books. I also recommend to you books that I read during my Part 1 exams many years ago. These book are,

1) My first MRCP book.
2) Best of Five for MRCP Part 1- Good collection of BOFs!
3) Basic Medical Sciences for MRCP Part 1- a must if you are not strong in your basic sciences!
4) Get through MRCP Part 1

Hope you will find these books useful.


Search other titles here....

Saturday, June 17, 2006

BASIC SCIENCES QUESTIONS FOR MRCP

Hope all of you find these questions helpful........ for MRCP PART 1

1)How many carbon atoms does a molecule of Acetyl Co-A contain?
A : Two B : Three
C : Four D : Five E : Six.


ANSWER:A

2)A Mendelian X-linked dominant condition would be transmitted to:
A : All of the sons of an affected woman.
B : All children of an affected man.
C : None of the sons of an affected woman.
D : All of the sons of an affected man.
E : Half of the daughters of an affected woman.


ANSWER:E

3) A 68-year-old woman is admitted because she is 'off her legs'. Her routine biochemical screen reveals plasma Na 126 mmol/l, K 3.1 mmol/l, urea 3.2 mmol/l, glucose 4.5 mmol/l. Her calculated plasma osmolality (mosmol/l) is:
A : 271.1 B : 273.6 C : 265.9 D : 136.8 E : 144.5.


ANSWER:C

4)Which of the following are common physiological findings during pregnancy?
A : Reduced fractional urate clearance B : 10% reduction in cardiac output
C : Increased peripheral vascular resistance D : A fall in blood pressure during the first trimester
E : Reduced plasma volume.


ANSWER:D

5) The following are NOT used for the estimation of renal function:
A : Serum creatinine B : Serum cystatin C C : Creatinine clearance
D : Ethylenediaminetetraacetic acid (EDTA) clearance E : Urinary albumin/creatinine ratio.


ANSWER:E

6)A 78-year-old man is receiving treatment for a deep venous thrombosis. After five days the pharmacist reminds you to check a full blood count: why?
A : Because of the possibility of gastrointestinal haemorrhageB : Because of the possibility of haemolytic anaemia
C : Because of the possibility of leucocytosisD : Because of the possibility of thrombosis
E : Because of the possibility of thrombocytopenia.


ANSWER: E

7)You are looking after a patient with established long-standing auto-immune haemolytic anaemia. Which one of the following blood film changes would you most expect to see?
A : Spherocytosis B : Schistocytosis
C : Bite cells D : Burr cells E : Pappenheimer bodies.


ANSWER: A

8)Considering the identification of cells by their surface antigens, which one of the following statements is true?
A : CD4 indicates cytotoxic T cell function. B : CD19 is a T cell marker.
C : CD3 is a universal T cell marker. D : CD8 indicates T helper cell function.
E : CD56 is a marker of B cells.


ANSWER:C

9)An 83-year-old woman on carbimazole for thyrotoxicosis:
A : usually takes three to six months to become euthyroid
B : should stop treatment at once if she develops a rash
C : cannot be given propylthiouracil if she has a sensitivity reaction to carbimazole
D : should have her propranolol discontinued
E : should have her white blood count (WBC) checked if she develops a sore throat.


ANSWER: E

10)A 16-year-old girl presents because her menstrual periods have not started. She is in good health, but is the smallest girl in her class at school and has not yet developed any secondary sexual characteristics. The most likely diagnosis is:
A : Cystic fibrosis B : Coeliac disease
C : Klinefelter's syndrome D : Turner's syndrome E : Chronic renal failure.


ANSWER:D

Thursday, June 15, 2006

MORE MRCP QUESTIONS!

Here are some questions for MRCP Part 2.

1) A 63-year-old lady has painful, tender, weak muscles to the extent that she has difficulty on rising from a chair. She also complains of polyarthralgia and Raynaud's syndrome. Examination demonstrates sclerodactyly.
Investigations: ESR 71 mm in the first hour
CRP 34 g/lANA >1/640 speckled pattern
RF 1/160
anti-dsDNA negative
anti-Sm negative
SS-A positive
SS-B negative
anti-RNP >1/640
What is the most likely diagnosis?
A. Mixed connective tissue disease (MCTD)
B. CREST (limited scleroderma)
C. Progressive systemic sclerosis
D. Systemic lupus erythematosus
E. Rheumatoid arthritis


ANSWER: A


2)A 75-year-old woman with metastatic carcinoma of the colon is admitted semi-conscious and dying. Her symptoms had been previously well controlled on oxycodone SR 80mg bd.
What would you do about analgesia?
A.Nothing at present as she is semi-conscious and not obviously in pain.
B.Chart prn oxycodone orally
C.Change to im morphine
D.Chart prn paracetamol pr
E.Start a syringe driver with diamorphine.


ANSWER: E

3) A 30-year-old patient presents with episodes of muscle pain after several minutes of exercise and poor exercise tolerance. However, he describes a 'second wind' phenomenon if he exercises through the initial barrier.
Which two of the following are the most likely diagnoses?
A : Acid maltase deficiency B : Becker's muscular dystrophy
C : Carnitine palmitoyl transferase deficiency D : Inclusion body myositis
E : Lambert-Eaton syndrome F : Motor neurone disease
G : Myasthenia gravis H : Myophosphorylase deficiency
I : Myotonic dystrophy J : Phosphorylase b kinase deficiency.


ANSWER:H AND J

4) A 79-year old female with known aortic stenosis (aortic valve gradient 60 mmHg 2 years previously), presents with uncontrolled atrial fibrillation (140 bpm). She is dyspnoiec on exertion and on examination has an elevated jugular venous pressure and basal crepitations.
Which two of the following are indicated as part of the initial treatment regimen?
A : Angiotensin-converting-enzyme inhibitors B : Amiodarone
C : Beta-blockers D : Digoxin
E : Flecainide F : Intravenous diuretics
G : Intravenous nitrates H : Valvuloplasty
I : Verapamil J : Warfarin.


ANSWER:B AND F

5)A 23 year old man gives a history of dysarthria, clumsiness, unsteadiness on his feet and irritability. He has no history of drug abuse. Bilirubin 44 mmol/l ALT 65 U/lAlk. Phos 450 U/l Albumin 34 g/l
Name 1 investigation to confirm your suspicions
A. Serum and urinary copper and caeruloplasmin
B. Liver Ultrasound
C. Ferritin
D. Urinary toxicology screen
E. CT scan of the head


ANSWER: A

6)You are asked to see a 24-year-old woman who presents after possible exposure to sexually transmitted infection.
Which of the following genital infections (when acquired in the UK) requires combination antimicrobial therapy with two agents or more to ensure complete resolution of all symptoms and the prevention of long-term complications?
A : Pelvic inflammatory disease (PID)B : CandidiasisC : Lymphogranuloma venereum
D : Chlamydial cervicitisE : Bacterial vaginosisF : Syphilis
G : GonorrhoeaH : ChancroidI : ScabiesJ : Human papilloma virus infection.


ANSWER:A AND G

7)A man wakes up noticing a generalized rash over his body. A week previously he had developed a 'flu -like' illness. His complete blood count was Hb 12.4g/dl, WBC 8 x 10^9/l and platelets 2 x10^9/l. A bone marrow showed no atypical cells but adequate megakaryocytes and confirmed peripheral consumption.
Which of these treatments are options in an actively bleeding patient with Immune thrombocytopenic purpura (ITP)?
A : Peripheral vasoconstrictors B : Corticosteroids C : Fresh frozen plasma (FFP) infusions
D : Low molecular weight Heparin E : Intravenous immunoglobulin infusion F : Cautery and laser diathermy of bleeding point G : Single platelet transfusion H : Topical fibrin glueI : Hydroxyurea J : Leucocyte infusions.


ANSWER:B AND E

8)A 61-year-old lady presents with a 4-year history of hypertension and an incidental finding of massive hepatomegaly. There is a family history of renal failure. A CT scan confirms multiple large thin walled hepatic cysts and multiple cysts in the kidney. Which of the two pieces of information have been correctly given to the patient?
A : It is an autosomal recessive condition.B : There is a risk of subarachnoid haemorrhage.
C : She is likely to develop liver failure with jaundice and coagulopathy.D : Liver transplantation is contraindicated.
E : Abdominal discomfort from the cysts can be treated surgically.
F : Aspiration of liver cysts successfully relieves abdominal discomfort. G : The condition precludes renal transplantation.
H : Cirrhosis occurs in the non cystic liver. I : Angiotensin-converting enzyme (ACE)-inhibitors should not be used to treat the hypertension. J : Pancreatic cysts do not occur.


ANSWER: B AND E

9)A 30-year-old woman with arthritis presents with a painful, rapidly enlarging ulcer on the lower leg.
What is the most likely diagnosis?
A : A venous leg ulcer B : Pyoderma gangrenosum C : Necrobiosis lipoidica
D : Cutaneous vasculitis E : Squamous cell carcinoma.


ANSWER:B

10)A 38-year-old woman presents with severe headache. Your house physician tells you that her 'right eye is not normal', and you suggest that the patient might have a third nerve palsy. The houseman asks you what signs he should look for to confirm this diagnosis. You reply:
A : there is ptosis, a small pupil, and the eye is positioned 'down and out'
B : there is a small pupil and the eye cannot abduct
C : there is ptosis, a dilated pupil, and the eye is positioned 'down and out', but will rotate inwards if the patient attempts to look down
D : there is a small pupil and the eye is positioned 'down and out'
E : there is ptosis, a dilated pupil, and the eye is positioned 'down and in', and will not move in any direction.


ANSWER: C

Tuesday, June 13, 2006

METABOLC ACIDOSIS IN MRCP

Metabolic acidosis is the commonest metabolic disease asked in MRCP exams. I find an easy way to remember the causes, there are two type of metabolic acidosis either can be associated with normal anion gap or increased anion gap ( the commoner type). There is only one important cause for normal anion gap metabolic acidosis. You are right, it is renal tubular acidosis, I would talk about this further in future. Causes of increased anion gap metabolic acidosis are,

MUD-PILES

M- Methanol
U-Uremia ( renal failure)
D-Diabetic ketoacidosis
P-Paraldehyde
I-Infection ( severe sepsis)
L-Lactate acidosis
E-Ethanol, ethylene glycol
S-Salicylates

Monday, June 12, 2006

HIV/AIDS- Popular question in MRCP!


This patient presented to us with fever and painful swallowing, what can you see in his oral cavity?


Yes, you are right, oral candidiasis is common among HIV patients. However, you must remember that it is not a AIDS defining disease because you can find this problem in other immunosuppresed patients such as in diabetic patients and patients after chemotheraphy. Anyway, oesophageal candidiasis is an AIDS defining disease in which I think this patient may be having in view of history of painful swallowing.

Common questions in MRCP part 1 and 2 are types of diseases HIV patients will get according to their CD4 counts. One of the most popular question is PCP. Always remember that HIV patients will get PCP once their CD4 is lee than 200! Other common questions are as follow,

1)A 24-year-old man presented with a ten-week history of progressively worsening exertional dyspnoea and a dry cough. Auscultation of his chest revealed fine inspiratory crackles to the mid-zones. He was afebrile. His chest radiograph is shown below. A Heaf test was negative.

Which of the following investigations will be most helpful in establishing a diagnosis?
1 ) Abdominal ultrasound scan 2 ) Atypical serology

3 ) Bone marrow aspiration 4 ) Bronchoalveolar lavage

5 ) CD4 T-lymphocyte count 6 ) Cytoplasmic antineutrophil cytoplasmic antibody (cANCA)

7 ) C-reactive protein (CRP) 8 ) Erythrocyte sedimentation rate (ESR)

9 ) HIV antibody test 10 ) Peak flow rate

11 ) Plasma lactate dehydrogenase (LDH) 12 ) Sputum culture

13 ) Transbronchial lung biopsy 14 ) Trial of steroids

15 ) 24 hour urinary calcium excretion


ANSWER: 9,13, 15 (POSSIBILITY OF SARCOIDOSIS! CXR CAN BE SIMILIAR TO PCP)


2)This HIV positive man presented with cough, haemoptysis and a rash (shown).

What is the causative agent?

1 ) Mycobacterium tuberculosis 2 ) Pneumocystis carinii

3 ) Cytomegalovirus 4 ) Epstein-Barr virus

5 ) Human herpesvirus-8


ANSWER: 5


3) A 35 year-old man is admitted with a three week history of progressively worsening dyspneoa accompanied by a non-productive cough. For the 24 hours prior to admission he has been dyspnoeic at rest. He also reports having occasional 'chills' and has felt febrile on occasions.He has no other past medical history of note. He works as an accountant with the local authority. He smokes 20 cigarettes per day and occasionally smokes cannabis. He drinks 18-20 units of alcohol per week. He is divorced and currently lives alone.He says that his diet has been poor since he separated from his wife 2 years previously; in this time he has lost about 2 stones in weight. He does not take any regular medication.On examination he is dyspnoeic at rest with a respiratory rate of 22/minute. He is febrile, 38°C. His chest is clear on auscultation.

Which of the following test results would most strongly support a diagnosis of Pneumocystis carinii pneumonia?
1 ) Low absolute lymphocyte count 2 ) Lobar consolidation on the chest radiograph 3 ) Oxygen desaturation on exercise 4 ) A normal chest X-ray 5 ) Past history of homosexual contact


ANSWER: 3


4)A 44-year-old HIV seropositive patient is seen in a routine outpatient appointment. He was diagnosed with HIV disease two years ago when he presented with Pneumocystis carinii pneumonia (PCP) with a CD4 T-lymphocyte count of 40 cells/mm3. After being treated for PCP he was started on combination antiretroviral therapy. His initial response to antiretroviral therapy had been promising, with an increase in his CD4 count (210 cells/mm3) and achieving an undetectable HIV viral load in the peripheral blood. One year ago, his CD4 count started to fall and HIV RNA became detectable in peripheral blood. An HIV viral resistance test confirmed resistance to all of his antiretroviral drugs. The patient admitted that over the preceeding three months that he had only been taking his therapy intermittently. Despite the risks, he decided that he did not wish to have any further antiviral therapy. At this point, his CD4 count was 20 cells/mm3 with a very high HIV viral load of 120,000 copies/ml.Seven months ago he presented with malaise, weight loss (8kg), fevers and night sweats. Mycobacterium avium intracellulare (MAI) was isolated from a blood culture and he was started on therapy with ethambutol and rifabutin. He subsequently agreed to re-start antiretroviral therapy.During his clinic consultation, he states that he has noticed a steady deterioration in his visual acuity over the past four weeks. His current medications include stavudine (d4T), didanosine (ddI), nevirapine, ethambutol, and rifabutin. On examination, fundoscopy is normal.His last CD4 count, taken one month ago was 30 cells/mm3, with an HIV viral load of 2500 copies/ml.

What is the most likely cause of his reduction in visual acuity?
1 ) Antiretroviral therapy 2 ) Cytomegalovirus retinitis 3 ) Ethambutol 4 ) HIV retinopathy 5 ) Toxoplasma retinitis


ANSWER: 3


5) A 26-year-old homosexual man presented to hospital with a fever, dry cough and dyspnoea. Oropharyngeal candidiasis was noted. He was found to be HIV antibody positive and Pneumocystis carinii was found on bronchoalveolar lavage. His Pneumocystis carinii pneumonia (PCP) was treated with intravenous co-trimoxazole and he was subsequently started on highly active antiretroviral therapy (HAART).Four weeks later he presented to clinic complaining of weakness and generalised aching. He was taking highly active antiretroviral therapy (zidovudine (AZT), lamivudine (3TC), nelfinavir), co-trimoxazole as Pneumocystis carinii prophylaxis and fluconazole.Investigations:Serum creatine kinase 700 IU/l (24-195)

What is the cause of this problem?
1 ) Co-trimoxazole 2 ) Fluconazole 3 ) Lamivudine (3TC) 4 ) Nelfinavir 5 ) Zidovudine (AZT)


ANSWER: 5

Sunday, June 11, 2006

MRCP Popular Question!

I would like to share with you all about one of the most popular questions in MRCP Part 1. This question always come out in basic sciences section. It is always asking about HLA specific diseases. Common diseases that are common in exam are,

1) Coelic disease HLA B8 DRW8
2) Spondyarthropathy HLA B27
3) Bechet's syndrome HLA B5
4) Dermatitis herpetiformis HLA DR3
5) Haemochromatosis HLA A3/B14
6) Multiple sclerosis HLA DR2

Always remember that the most popular question is what type of HLA is associated with coelic disease!

Saturday, June 10, 2006

Cushing's syndrome!




I saw this lady during my medical clinic follow up this morning.

I think all of you certainly can pick out what is the underlying diagnosis for this lady. You are right, it is Cushing’s syndrome. If you want to know more about Harvey William Cushing (1869-1939), you can find his story here!

There are always questions about Cushing’s syndrome in MRCP Part 1 and 2 simply because it is a common disease in clinical practice. Some of the questions I have about Cushing’s syndrome are as follow,

1) This 34 year old female( above picture) presents with a nine
month history of weight gain, weakness and
amenorrhoea. Examination reveals the appearances
as shown, a blood pressure of 180/110 mmHg and
proximal myopathy. Urinalysis shows ++ glucose
and a pregnancy test is negative.

Which of the following would be the most
appropriate diagnostic test?

1 )Random Cortisol concentration
2 )Oestradiol concentration
3 )Oral glucose tolerance test
4 )Pituitary MRI scan
5 )Urine free cortisol estimation

ASWER: 5

2) A 22 year old female presents with a one year
history of secondary amenorrhoea and a 5 year
history of facial hirsutism. Examination reveals
normal female secondary sexual characterisitcs
with mild facial hair and hair extending up to
the umbilicus and tops of thighs. Investigations
reveal an oestradiol concentration of 65 pmol/l
(NR 130 - 450), a LH of 3.2 mU/l (NR 3 -10
mU/l), a FSH of 3.5 (NR 3-10 mU/l), a prolactin
of 320 (NR less than 450 mU/l), a testosterone
of 3.4 pmol/l (NR less than 3). From the
following list, select two investigations that
may provide useful diagnostic information.

1 )17 hydroxyprogesterone (17 OHP) concentration
2 )Androstenedione concentration
3 )Dehydroepiandrostenedione sulphate (DHEAS)
concentration
4 )Karyotype
5 )Pregnancy test
6 )Sex Hormone Binding globulin (SHBG)
concentration
7 )Skin biopsy
8 )Thyroid function tests
9 )Transvaginal ovarian ultrasound scan
10 )Urine free cortisol concentration

ANSWER: 1,10

3) A 38 year old female presents with weight gain,
hirsutism and hypertension of 2 years duration. (above image)
She has also noted oligomenorrhoea over the last
2 years and over the last two months has had no
periods.
Examination reveals a BMI of 32.4, a reddish
complexion, with a blood pressure of 168/98 mmHg
and abdominal striae. She has difficulty rising
from a squatting position.
Investigations reveal the following: Normal
U+Es, FBC Normal, plasma glucose 12.1 mmol/l.
Thyroxine 12.4 nmol/l (NR 9.8 -23.1), TSH 0.85
mU/l (NR 0.5 - 4)
Oestradiol less than 80 pmol/l (NR 130 - 510),
LH 4.2 mU/l (NR 2-10 mU/l) FSH 2.1 mU/l (NR
2-10)
9 am Cortisol 550 nmol/l (NR 200 - 550 ) and
ACTH 45 (NR 8-50)
Midnight Cortisol 420 nmol/l (NR less than 180)
and ACTH 35 (8-20)
24hr Urine free cortisol 580 nmol/d (NR 90 -
290 nmol/d)
Normal chest X-ray, ECG shows LVH
Cortisol at end of low dose dexamethasone test
(48 hrs 0.5 mg qds) = 210 nmol/l
Cortisol at end of high dose dexamthasone test
(48 hrs 2mg qds) =150 nmol/l
MRI of pituitary - Normal
Which of the following apply to this patient?

1 )She is likely to have an adrenal adenoma and
should be confirmed with CT adrenals
2 )She is likely to have ectopic ACTH secretion
and requires CT chest.
3 )She is likely to have pituitary dependent
Cushing's disease and requires Inferior petrosal
sinus sampling with CRF stimulation
4 )She is likely to have ectopic Cushing's
syndrome and should have a labelled octreotide
scan
5 )The results suggest that she has
Pseudo-Cushing's due to polycystic ovarian
syndrome

ANSWER: 3

4) A 73 year old female is diagnosed with Cushing's disease. Which of the following is correct?
1) adrenalectomy would be the treatment of choice.
2 )op-DDD is a treatment if unfit for surgery
3 )Ketoconazole may be used as a treatment if unfit for surgery
4 )Recurrence of Cushing's disease after transphenoidal surgery is less than 5%
5 )yttrium implantation is an effective treatment


ANSWER: 3

Other common questions in the exam include,

1) Relative glucocortocoid effect of different steroid as below,

Cortisol/hyrocortisone
1
prednisolone
4
Dexamethasone
30
Fludrocortisone
10

2) Drugs causing hirsutism include
Minoxidil, pheytoin,cyclosporin and androgens.


Hope this post helps you all!

Friday, June 09, 2006

Another set of FREE BOFs for MRCP Part 1!

Hope you find all these questions useful.

1)Transcription RNA (tRNA) has three bases specific for a particular amino acid with which it binds to messenger RNA (mRNA). This specific area of tRNA is called the
1 ) anticodon
2 ) codon
3 ) exon
4 ) intron
5 ) transposon



ANSWER: 1

2)The Polymerase Chain Reaction (PCR) is used to amplify small amounts of DNA for further analysis. First the DNA double helix must be split into two strands. This is achieved by
1 ) alkali solution
2 ) centrifugation
3 ) DNA polymerase
4 ) heating to nearly 100°C
5 )viral reverse transcriptase



ANSWER: 4

3)Two strains of Escherichia coli are isolated and both are resistant to ampicillin. Strain A retains its resistance to amplicillin when grown form multiple generations in the absence of ampicillin. However strain B loses its resistance when grown in the absence of ampicillin. Which of the following best explains the loss of antibiotic resistance in strain B?
1 )Changes in the bacterial DNA gyrase
2 )Downregulation of the resistance gene
3 )Loss of a plasmid containing the resistance gene
4 )Mutations in the resistance gene
5 )Transposition of another sequence into the resistance gene



ANSWER: 3

4)A 36 year old male presents with lethargy. He takes no medication and has generally been otherwise well. Examination reveals that he is obese with a BMI of 36.4 kg/m2 and a blood pressure of 120/72. There are no abnormalities of the cardiovascular, respiratory or abdominal systems. Investigations reveal a sodium of 141 mmol/l, a potassium of 2.8 mmol/l, a urea of 5.6 mmol/l and a creatinine of 76 µmol/l. What is the most likely diagnosis.
1 )Conn's syndrome
2 )Apparent mineralocorticoid excess
3 )Cushing's syndrome
4 )Hypokalaemic periodic paralysis
5 )Bartter's syndrome



ANSWER: 5

5)A 52 year old female presents with tiredness. There are no specific abnormalities noted on examination, but investigations reveal a T4 of 21.1 (NR 9.8 - 23), a T3 of 5.2 pmol/l (NR 3.3 - 5.5) and a TSH of 0.05 mU/l (NR 0.1 - 5 mU/l). Thyroid autoantibody titres are all undetectable. These results suggest a diagnosis of
1 )DeQuervain's thyroidits
2 )Sick euthyroid syndrome
3 )Solitary toxic nodule
4 )Graves' disease
5 )Hashimoto's thyroiditis



ANSWER: 3

6)A 32 year old female presents with a 4 month history of amenorrhoea. She takes no specific therapy. She has two children and her husband has has a vasectomy. Examination reveals an obese individual but no other abnormality. Investigations reveal an oestradiol concentration of 100 pmol/l (NR 130 - 500), an LH of 2.1 mU/l (NR 3.0 - 6.6), an FSH of 2.2 mU/l (NR 3.3 - 10.1), a prolactin concentration of 800 mU/l (NR 50 - 500 mU/l) and a testosterone concentration of 2.1 pmol/l (NR less than 3 pmol/l). Which investigation is the most appropriate?
1 )Insulin tolerance test
2 )A Pregnancy test
3 )17 hydroxy-progesterone
4 )Urine free cortisol concentration
5 )A MRI of the pituitary


ANSWER: 5

More questions are coming...............!

Thursday, June 08, 2006

Top tips for getting through and having successful career!


A lot of us want to go overseas to work. Why? I think simply because some countries offer a much better pay that we may need to work for years to get the same salary if we stay back home.


The most popular choice is UK! We just can't wait to go there to start our new life. There are a lot of problems we might encounter, I found that this article may help those who are planning to go to UK.
Good Luck!

How to relax?

I recently took a week off from my works. I found out that for the past four years, I have been working non-stop to get my MRCP(UK)! A lot of doctors asked me, "How can a doctor relax since that he/she has so many unsettled works and patients in the hospital?"
I answered them," If you don't relax now, you won't have the time to relax in future! Medicine is a continous, life-long committment!"
Junior doctors are facing more stress in thier works now than before, frequent calls, tracing results, explaining to patients......etc, I found a good article in BMJ for junior doctors: REDUCING STRESS AMONG JUNIOR DOCTORS! Check this out, you may find this useful!

Cheers!

pass-MRCP

10 Free BOFs from www.passpaces.com!

MRCP PART 2 : FREE Questions!

1) A 78 year old woman is admitted to hospital with acute coronary syndrome and is discharged on day 6 after making a good recovery. She continues to be under investigation of the cardiologists and is discharged on atenolol 50 mg daily, enalapril 10 mg daily, isosorbide mononitrate 30 mg daily,Atorvastatin 20 mg daily and aspirin 75 mg daily. Her investigations at admission revealed a serum urea concentration of 12.4 mmol/l with a serum creatinine of 250 micromol/l. She is re-admitted one week after discharge with deteriorating dyspnoea. Investigations reveal a serum urea of 28.9 mmol/l, a serum creatinine of 600 micromol/l, a serum bicarbonate of 18mmol/L and a potassium concentration of 6.0 mmol/l with T wave inversion in leads II, III and V5-V6. What is the best course of management if the patient is clinically fluid overload?
1 )Dialysis
2 )Frusemide infusion
3 )Oral frusemide
4 )Salbutamol nebulisers
5 )Stop ACEI

ANSWER :A

2) A 19-year-old woman presented to her General
Practitioner with a history of general malaise,
lethargy and fatigue. She was unsure when the
symptoms first started, but felt that they had
been developing slowly over a period of several
months. On examination, a murmur was audible.
She was referred to a Cardiologist on the basis
of the physical findings.
The data obtained from cardiac catheterisation
are shown below:
Anatomical site Oxygen saturation (%) Pressure
(mmHg) End systolic/End diastolic
Superior vena cava 77 -
Right atrium (mean) 79 7
Right ventricle 78 -
Pulmonary artery 87 52/17
Pulmonary capillary wedge pressure - 16
Left ventricle 96 120/11
Aorta 97 130/60

Which of the following best describes the murmur
that can be heard on auscultating this lady's
chest?

Available marks are shown in brackets
1 )A coarse pan-systolic murmur heard all over
the praecordium
2 )A continuous 'machinery' murmur at the left
upper sternal edge with late systolic
accentuation
3 )A low-pitched apical mid-diastolic murmur
that is reduced in pitch during the Valsalva
manoeuvre
4 )A pansystolic murmur, heard loudest at the
apex and radiating to the axilla
5 )No murmur will be heard

ANSWER:2

3) Examine the cardiac catheter data given below.
Anatomical site Oxygen saturation (%) Pressure
(mmHg) End systolic/End diastolic
Superior vena cava 74 -
Inferior vena cava 72 -
Right atrium 73 5
Right ventricle 74 20/4
Pulmonary artery 74 20/5
Pulmonary capillary wedge pressure - 15
Left ventricle 98 210/15
Aorta 99 125/75

Which of the following clinical scenarios is
most compatible with the catheter data presented
above?

Available marks are shown in brackets
1 )A 16-year-old with finger clubbing and
central cyanosis
2 )A 17-year-old boy who presents after an
episode of exercise-induced syncope
3 )A 54-year-old woman who becomes acutely
breathless seven days after an inferior
myocardial infarction
4 )A 65-year-old woman with a 2-year history of
increasing exertional dyspnoea who presents
following a singe episode of haemoptysis
5 )A 77-year-old man who presents with dyspnoea
ten years after a porcine mitral valve
replacement

ANSWER : 2

4) A 17-year-old boy presents to his General
Practitioner complaining of dyspnoea on
exertion. His mother, who is also in attendance,
says that his exercise tolerance has been
diminishing gradually and that he is no longer
able to play football on a Saturday morning.
After examining the patient, the General
Practitioner refers him to a Cardiologist.
Cardiac catheterisation was performed. The
pressure and oxygen saturation data obtained are
shown below:
Anatomical site Oxygen saturation (%) Pressure
(mmHg) End systolic/End diastolic
Superior vena cava 74 -
Right atrium (mean) 75 7
Right ventricle 87 50/12
Pulmonary capillary wedge pressure - 16
Left ventricle 96 95/12
Aorta 97 110/60

What is the diagnosis?

Available marks are shown in brackets
1 )Coarctation of the aorta
2 )Mitral stenosis and pulmonary hypertension

3 )Pulmonary stenosis
4 )Septum secundum atrial septal defect
5 )Ventricular septal defect

ANSWER : 5

5) A 75 year-old man was admitted to hospital when
he became acutely breathless at 3am. He gave a
history of increasing dyspnoea over a period of
at least three months. In recent weeks he
reported that his breathing was usually better
when sleeping in a chair.
Anatomical site Oxygen saturation (%) Pressure
(mmHg) End systolic/End diastolic
Superior vena cava 76 -
Inferior vena cava 72 -
Right atrium (mean) 74 9
Right ventricle 75 60/8
Pulmonary artery 74 58/26
Pulmonary capillary wedge pressure - 30
Left ventricle 98 150/25
Aorta 97 150/44

What is the most likely diagnosis?

1 )Aortic incompetence
2 )Coarctation of the aorta
3 )Hypertrophic obstructive cardiomyopathy
4 )Patent ductus arteriosus
5 )Pulmonary stenosis

ANSWER : 1

6) A previously fit 60 year-old man is admitted
with a middle cerebral artery occlusion
confirmed on brain imaging.
What is the current recommended cut-off
time-point for thromboytic treatment from the
onset of stroke symptoms?

1 )3 hours
2 )6 hour
3 )8 hours
4 )12 hours
5 )24 hours

ANSWER :1

7) An 18-year-old female presented with bilateral
ptosis and tiredness towards afternoons. She had
a short tensilon (edrophonium test which was
positive). A diagnosis of myasthenia Gravis was
made and she was stated on pyridostigmine. She
now relapses and is given edrophonium
intravenously. However her condition
deteriorates and her forced expiratory volume
falls to 1.0. She is transferred to the high
dependency units. An initial CT scan and chest
x-ray were normal.
What should be the next management step?


1 )Azathioprine
2 )Emergency thymectomy
3 )Intravenous methylprednisolone
4 )Neostigmine
5 )Plasmaphoresis

ANSWER : 5

8)A 17-year-old girl presented with a 2-day
history of severe back pain. A plain x-ray film
of her spine is normal. Two days later, she
complained of tingling in her fingers and toes.
The next day she became generally weak. She
presented in A/E.
On examination, she has bilateral lower motor
neurone facial weakness, tetraparesis with
weakness in all limbs (4/5), areflexia, flexor
plantars and normal sensation.
A lumbar puncture was performed and the CSF
analysis showed: Protein1.4 g/l (<0.4)
GlucoseNormal
Cells0

What is the most likely diagnosis?

1 )Botulism
2 )Guillain-Barre syndrome
3 )Acute poliomyelitis
4 )Myasthenia gravis
5 )Hysteria

ANSWER : 2

9) A 38 year-old man presents with an episode of
right-sided weakness affecting his right arm and
leg. The weakness occurred while he was eating
breakfast and resolved completely in 30 minutes.
Three months earlier he has an episode of
slurred speech lasting a few minutes and had
being investigated extensively in hospital.
Aspirin 75 mg had been started as treatment.
On examination, he is overweight with a BMI of
38, pulse 88 beats/min regular and BP 140/85
mmHg. Heart sounds are normal and no carotid
bruits are detectable.
The neurological examination is unremarkable
except for an upgoing plantar response on the
right side.
A Doppler ultrasound of the carotid arteries
reveal 50% stenosis in the proximal carotid
arteries bilaterally.
What evidence-based intervention is most likely
to prevent further episodes of the patient’s
condition?

1 )Add clopidogrel to aspirin
2 )Add dipyridamole to aspirin
3 )Increase the dose of aspirin to 150mg daily
4 )Stop aspirin and start clopidogrel alone
5 )Stop aspirin and start dipyridamole alone

ANSWER : 2

10) A 50 year-old man with learning difficulties is
referred because of urinary incontinence. He
lives alone. Over the last two months, he has
been finding it increasingly difficult to manage
simple household tasks like making meals and
cleaning. He claims his ‘concentration is not as
good as before.?He had a son who died from
complications of multiple sclerosis.
On examination, he is orientated in time, place
and person. On memory testing, he was able to
register information but was only able to recall
not more than three items out of six after five
minutes. Long-term memory was patchy. On testing
serial 3s, he reached 25 after 30 seconds. His
thought content was normal, but affect was
labile. He was unable to interpret the true
meaning of a proverb. Cranial nerve examination
was unremarkable, except for horizontal
nystagmus on lateral gaze bilaterally.
Examination of the limbs revealed past-pointing
in the upper limbs, difficulty with heel-to-toe
walking in the lower limbs, brisk deep tendon
reflexes and extensor plantar responses.
Palmomental reflexes were present bilaterally.
What is the likely diagnosis?


1 )Alzheimer’s disease
2 )Creutzfeldt-Jakob disease
3 )Depression
4 )Korsakoff’s amnestic syndrome
5 )Lewy body dementia

ANSWER : 4

Wednesday, June 07, 2006

Welcome to MRCP Part 1 and 2

Welcome to all of you! More information and stuffs are coming into this website for those who are preparing for Part 1 and 2 MRCP(UK) and MRCP( Ireland).