I am back! Irritable Bowel Syndrome for MRCP

Yes you are quite right, irritable bowel syndrome is always a diagnosis of exclusion. Always think of other diagnosis than irritable bowel diagnosis if your patient has either the following one,

1) Age more than 50 years

2) Weight loss

3) Per rectal bleeding

4) Anemia

There are two major criteria  either Rome or Manning criteria. Usually patients will have symptoms for at least 3 months. There are three types of IBS- constipated predominant, diarrhoe predominant or mixed type.

Patients usually have very non specific abdominal pain, pain and discomfort which is related to defecation and constipation or diarrhoe.

Minimal Change Nephropathy

Minimal Change Nephropathy (MCN)

There are a few common questions for MRCP Part 1 and 2 about nephrology, minimal change nephropathy is one of them.

There are a few important facts to remember,

1) Minimal change nephropathy is the commonest cause of nephrotic syndrome in children as well as in adult. Another important cause of nephrotic syndrome in adult is Focal Segmental glomerulosclerosis.

2) Minimal change literally means the kidney biopsy of  MCN will be normal unless your have electron miscroscope which shows efficement of foot processes.

3) More than 90% will respond to steroid.

4) There are a few secondary causes of minimal change nepropathy causing nephrotic syndrome- Gold, penicillamine, tumour etc

If a patient with nephrotic syndrome patient comes in with severe abdominal pain, always think of

1) Renal vein thrombosis
2) Spontaneous bacterial peritonitis

Toxoplasmosis for MRCP

Toxoplasmosis for MRCP

I liked cat very much when I was young until I knew there is a disease called Toxoplasmosis. Duing my second year parasitology, when I knew that cat is the intermediate host for a parasite called Toxoplasmosis gondii, I promised myself I would never keep cat as pet anymore in my life. You can see the life cycle of this parasite as below,

For MRCP, just remember that only immunosuppressed patients manifest this illness as reactivation of a primary disease. It is pretty high chances that you are infected before ( general population has high sero conversion- meaning most of us was infected before) and usually we recover from primary infection with good prognosis.

For certain groups of patients especially those with AIDS and on long term immunosuppression ( such as post transplantation) patients, Toxoplamosis usually manifests as central nervous infection- and patients usually present with confusion, seizure  and headache ( with of without fever).

Cerebral toxoplamosis- usually multifoci!

For your MRCP examination, if a HIV patient is admitted with seizure and a CT scan film is shown, 95% of the time is Toxoplasmosis infection, however, you must be aware that another differential diagnosis is cerebral lymphoma!!

Hypercalcemia in MRCP(II)

Hypercalcemia in MRCP (II)

It has been almost 3 years ago when I last talked about hypercalcemia. I mentioned about common causes of hypercalcemia in my previous post. Today, I am going to talk about managing hypercalcemia in clinical practice.

Before this, I think we have to pick up hypercalcemia in daily clinical practice, although I would say most of the time, patients are asymptomatic, you must remember that classically, hypercalcemia leads to,

" groans, moans,bones,stones and psychiatric overtones"

However, I usually noticed they came in unspecific complaints- lethargy,fatigue but quite common they are dehydrated and developed acute kidney injury ( hypercalcemia is one of the major causes of nephrogenic diabetes insipidus and patients with hypercalcemia develop acute kidney injury may be due to dehydration and other factors as well- You may want to find out how hypercalcemia can lead to AKI)

Pamidronate- A bisphosphonate

I always remind my junior doctors that strategies to manage hypercalcemia are
1) To correct hypercalcemia
2) To find out the underlying cause

Various ways to reduce hypercalcemia, they are hydration, steroid, bisphosphonates and calcitonin and of course after treating the hypercalcemia, find out the underlying cause.

I would say that commonly I find that the major causes are either primary tumour ( especially multiple myeloma) or secondary malignancy due to metastasis to the bone!

Heparin Induced Thrombocytopenia

Heparin Induced Thrombocytopenia

Although I will think that thrombocytopenia is not such a common case in MRCP, it is certainly a very common scenario in clinical practice.

The best way to think about high/low level in clinical medicine is the remember logically how a subtance/ product is being produced and destroyed in the normal physiology.

Therefore, low thrombocytopenia can be due to 2 main causes- reduced production from the bone marrow or increased destruction in the periphery.

I will talk about HIT ( Heparin Induced Thrombocytopenia) today in this post.
If you ask who is prone to get HIT, then I think is the group of patients who is being exposed to heparin almost everday. Yes, you are right, these patients are End stage renal failure patients who are on regular haemodialysis.

There are 2 types of HIT- early and late stage HIT. Type 1 HIT refers to condition of thrombocytopenia developing 1-2 days after heparin usage. It is a non immune condition due to direct effect of heparin on platelet. It is usually self-limiting and the platelet count usually normalizes after continued heaprin usage.

For type 2 HIT, it is an immune condition that happens later, usually 4-10 days after usage and it is life-threatening. The only option you have is to stop heparin usage.

Multiple Sclerosis in MRCP

Multiple Sclerosis in MRCP

Yes, you are right, Multiple Sclerosis although is rather rare in Malaysia, it is certainly not unusual in Western countires and certainly a popular question  in MRCP!
I will try to mentione a few important for those who are sitting for MRCP soon.

Multiple sclerosis is an autoimmune demyelinating disease affecting the central nervous system-brain and the spinal cord.

Since Mutiple Sclerosis ( MS) can affect any part in the central nervous system, patients with MS can present in diverse ways. However, 2 clincal syndromes that are popular in MRCP is acute transverse myelitis and Optic neuritis.

Patients with acute transverse myelitis usually have acute paralysis of lower limbs with sensory level ( upper motor neuron signs) with or without autonomic symptoms- urinary/bowel incontinence.

For patients with Optic neuritis, usually one eye is involved and patients may get blurring of vision or even visual loss!

For you to diagnose MS, you can follow the Poser criteria. You can click here to learn more. For you, I think you need to remember only this - you need 2 sites ( central nervous system) involvement at 2 different times ( 2 attacks) to make the diagnosis.

MRI is always helpful in making the diagnosis.

As for the treatment, I think you just need to remember one of them is interferon!

Happy Chinese New Year!

Happy Chinese New Year!

Best wishes to all Chinese readers. May the year of Rabbit brings prosperity and wealth to all of you! And certainly hope all of you will pass your MRCP Part 1 or 2 in just ONE Attempt!!

I will try my best to help you all to pass!!