Dr. Muzzammil Ali high yield Acute Medicine SCE 101 facts for the MRCP & FREE EBOOK
MRCP Facts 101 high yield facts for the MRCP & Acute Medicine SCE
101 MRCP Facts Dr. Muzz
101 MRCP Facts Dr. Muzz MRCP Facts 101 high yield facts for the MRCP & Acute Medicine SCE Muzzammil Ali Speciality Trainee in Acute Medicine & Intensive Care Medicine (Dual CCT) West Midlands Deanery, United Kingdom
101 MRCP Facts Dr. Muzz Copyright © Dr Muzzammil Ali All rights reserved This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without written permission. First published 2021 Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the author, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The author, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book.
101 MRCP Facts Dr. Muzz 101 high yield facts for the MRCP & Acute Medicine SCE The purpose of this free ebook is crystal clear: to help you pass your exams through productive and efficient learning. It breaks up your revision into manageable chunks so that it does not feel daunting, tedious or impractical. In fact, if you spend just 1 minute immersed in its text, you will learn a thing or two. You don’t even have to start at the beginning, you can start anywhere you like! Now although these exams are separate entities, they build upon each other with increasing relevance to clinical practice. For example you need MRCP Part 1 knowledge to pass MRCP Part 2. You need MRCP Part 2 knowledge to pass PACES & the Acute Medicine SCE. This book provides such scope and addresses an array of topics across the many syllabi. It functions as a hybrid between an MCQ book and a textbook, presenting these topics as high yield facts. Each fact is in the form of a question to mirror the exams. However, unlike MCQ books, you don’t have to annoyingly jump to the back to read the answer. The answer is right under the question. There are many benefits to this approach: By touching on a variety of different topics, it helps identify your deficiencies and builds upon your strengths It focuses on boosting your memory through strategies like spaced repetition and active recall
101 MRCP Facts Dr. Muzz e.g. you will quickly find that it brings to light information that you previously learnt but may have forgotten The facts are presented like a random generator to train your brain to quickly transition from one specialty to another. Many of them have clinical context to aid with learning through association e.g. it is easier to remember the management of a condition when you have seen or treated someone with it, rather than cramming the NICE guidelines Finally it’s worth mentioning that this book is not just for those doing exams. It facilitates lifelong learning. If you dip into it every so often, you’ll find yourself developing as a better physician and providing a higher standard of care for your patients. Unlike the vast majority of doctors who forget everything that was once learnt, you will be an exception by keeping your knowledge alive with this book.
101 MRCP Facts Dr. Muzz Dr. Muzzammil Ali is the founder of the Instagram page @mrcpfacts He is currently a registrar in the United Kingdom and is training in 2 different specialties: Acute Medicine & Intensive Care Medicine. This career choice means that he has had to do many exams. So far, he has completed the MRCP Part 1, Part 2, PACES and the Acute Medicine SCE, all in his first sitting. He is currently in the process of preparing for the FFICM exams in the near future. His passion for education has translated in him being the Education Lead for the Intensive Care Unit at the Queen Elizabeth Hospital Birmingham, one of the largest tertiary hospitals in the UK. Through his revision, he faced 3 main challenges: Having little time and energy to revise Having to remember lots of information and quickly transition from one specialty to another The lack of dedicated resources to revise for the Acute Medicine SCE He wrote this book with the hope that it will help to address these challenges, and make revision manageable, enjoyable and ultimately successful! There are even COVID-related questions! He wishes you all the best of luck in your exams!
101 MRCP Facts Dr. Muzz The simple answer is this: Cover up! To get the most out of this book, you have to engage your brain. This means that if you read the answers without at least trying to work them out first, then it will defeat the entire learning process. Instead, I am asking you to take a bookmark, a piece of paper or even your hand and cover the answer for each question. Try working it out before you read the answer. It doesn’t matter if you get many wrong because it is through failure that you learn. Remember that revision is the opportunity to get things wrong, time and time again. I also recommend having a sheet of paper to hand so that you can write down which facts/topics are your weaker ones. This will highlight specific gaps in your knowledge so that you can address them later on. Where appropriate, some areas are strategically bolded to help recall, for example: HI for the lens displacement in homocystinuria (Homocystinuria: Inferior displacement) See you’ve already learnt something and you haven’t even started as yet!
101 MRCP Facts Dr. Muzz You can use this book whenever you feel like it. I particularly recommend using it in the ‘hidden moments’ of everyday life. These moments may include waiting for your train to arrive, waiting for the kids to finish at school, or while queuing for your morning brew. These hidden moments would have otherwise been mundane, but you can convert them into some of the most useful pockets of revision. Even 5 minutes can do a world of good. After all, this book has been structured to facilitate highly effective learning in a short space of time. Let’s take one fact as an example of efficiency: Question: Which surgical procedure can you perform if ventricular arrhythmias continue to occur in long QT syndrome despite beta-blockers and frequent ICD shocks? Answer: Left stellate cardiac ganglionectomy This is an invasive procedure & can result in the development of Horner’s syndrome From this single fact you’ve actually learnt at least 5 different ‘facts’ because there is clinical knowledge in the question itself.
101 MRCP Facts Dr. Muzz The answers are up to date at the time of publication but some facts may change as time goes on e.g. information related to COVID-19 Many common medical acronyms have not been defined in this book e.g. MRI, JVP & ECG, to reduce the length of each fact
101 MRCP Facts Dr. Muzz
101 MRCP Facts Dr. Muzz What is the most common cause of primary hyperaldosteronism? Bilateral idiopathic adrenal hyperplasia (Conn’s Syndrome) Features include: aldosterone, BP & pH (metabolic alkalosis) renin & potassium Which antibody is implicated in vaccineinduced immune thrombotic thrombocytopenia (VITT) in someone who has had 1 dose of an adenoviral-vectored COVID-19 vaccine? Autoantibodies against platelet factor 4 (PF4). These activate platelets via their FcγIIa receptors to cause thrombosis. This is a similar mechanism to heparin-induced thrombocytopenia (HIT)
101 MRCP Facts Dr. Muzz Which coronary artery is usually implicated in complete heart block following a myocardial infarction? The right coronary artery This supplies the AV node in 90% of patients What translocation occurs in acute promyelocytic leukaemia? t(15;17) In 95% of cases, the retinoic acid receptor-alpha (RARA) gene on chromosome 17 is involved in a reciprocal translocation with the promyelocytic leukaemia gene (PML) on chromosome 15 Treatment is with all-trans-retinoic acid
101 MRCP Facts Dr. Muzz What causes tear-drop poikilocytes? Myelofibrosis This is a myeloproliferative disorder caused by hyperplasia of abnormal megakaryocytes. These produce platelet derived growth factor (PDGF) which stimulates fibroblasts. In progressive disease, there is pancytopenia urate & LDH reflect high cell turnover How do you calculate the breakthrough dose of morphine? One-sixth of the daily morphine dose
101 MRCP Facts Dr. Muzz What is the thrombolysis time limit in an acute ischaemic stroke? Within 4.5 hours of symptom onset & haemorrhage has been excluded 1mg of prednisolone is equivalent to how many milligrams of hydrocortisone? 4mg hydrocortisone What is the 1st line drug for treating hypertension in a diabetic patient? ACE-inhibitors regardless of age
101 MRCP Facts Dr. Muzz Which condition causes dysphagia to both solids and liquids from the start? Achalasia There is failure of oesophageal peristalsis & of relaxation of lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach's plexus Which 2 drug classes are most associated with acute tubulointerstitial nephritis? Penicillin & NSAIDS – these cause interstitial inflammation which can later progress to interstitial fibrosis The common triad of presentation is a rash, fever & eosinophilia Eosinophiluria is pathognomonic & a renal biopsy is needed for confirmation
101 MRCP Facts Dr. Muzz What is the key differential for a loss of the corneal reflex? Vestibular schwannoma – a benign tumour of the myelin-forming cells of the vestibulocochlear nerve (CN 8). It can compress CN 5 which results in a loss of the corneal reflex. Bilateral vestibular schwannomas are seen in neurofibromatosis type 2. MRI of the cerebellopontine angle is the investigation of choice. What is the most common cause of acyanotic congenital heart disease? Ventricular Septal Defect – there is usually a pansystolic murmur. These defects close spontaneously in around 50% of cases.
101 MRCP Facts Dr. Muzz What is the mechanism of action of the thiazolidinediones e.g. pioglitazone? PPAR-gamma receptor agonists These act as insulin sensitisers They do not cause hypoglycaemia How is Bartter’s Syndrome inherited and what would you expect the serum potassium-level and blood pressure to be? Autosomal Recessive inheritance Due to defective chloride absorption at the NKCC co-transporter in the ascending loop of Henle Hypokalaemic metabolic alkalosis (urinary potassium wasting) & n ormotension
101 MRCP Facts Dr. Muzz What comprises the triad of clinical features that is seen in Miller Fisher Syndrome? Areflexia + Ataxia + Ophthalmoplegia Associated with antibodies to GQ1b & is considered to be a variant of Guillain Barré syndrome. Bickerstaff's encephalitis is similar to Miller-Fisher but patients are usually drowsy & have brisk reflexes. What are the common types of transformations seen in polycythaemia rubra vera (PRV)? Myelofibrosis & AML A mutation in JAK2 is present in the majority of patients with PRV
101 MRCP Facts Dr. Muzz Which pathogen causes malt workers’ lung? Aspergillus clavatus This is a type of hypersensitivity pneumonitis which exhibits a type 3 hypersensitivity reaction in the acute phase It is not an allergic reaction & therefore eosinophila & IgE levels are not usually present What are 5 causes of a raised transfer factor in spirometry? Asthma Left-to-right cardiac shunts Polycythemia Haemorrhage e.g. Wegener’s, Goodpasture’s Athletics e.g. exercise, especially in males
101 MRCP Facts Dr. Muzz What is the most common cardiac defect in Turner’s Syndrome? Bicuspid aortic valve & then coarctation of the aorta Which malignancies are commonly associated with tumour lysis syndrome? Those with a proliferation index e.g. Burkitt's lymphoma, hyperleukocytic AML & diffuse large B-cell lymphoma What is the 1st line treatment for trigeminal neuralgia? Carbamazepine
101 MRCP Facts Dr. Muzz What is a significant side effect of Trastuzumab (Herceptin)? Cardiotoxicity (DCM) – a transthoracic echocardiogram is usually required before starting treatment Which chemotherapeutic agent is most commonly associated with hypomagnesaemia? Cisplatin – an alkylating agent What does the C-wave in the JVP represent? C-wave Closure of the tricuspid valve
101 MRCP Facts Dr. Muzz What gene translocation occurs in Burkitt’s Lymphoma? c-myc Burkitt lymphoma is an aggressive non-Hodgkin lymphoma characterised by the overexpression of c-myc, most usually due to a chromosomal translocation between chromosomes 8 & 14 Which part of the brain is damaged in hemiballism? The Subthalamic Nucleus Ballisic movements primarily affect the proximal limb musculature & occur contralateral to the side of the lesion Anti-dopaminergic agents (e.g. Haloperidol) are the mainstay of treatment.
101 MRCP Facts Dr. Muzz Where in the kidney does Gitelman’s Syndrome affect and how does it differ from Bartter’s Syndrome? Thiazide-sensitive Na+ Cl- transporter in the distal convoluted tubule Both conditions cause hypokalaemia, metabolic alkalosis & normotension. Gitleman’s additionally has hypomagnesaemia & hypocalciuria. Bartter’s is more severe, presents earlier & is associated with nephrocalcinosis What is the most common psychiatric problem in Parkinson’s Disease? Depression (in approximately 40%) Other problems include dementia, psychosis & sleep disturbances
101 MRCP Facts Dr. Muzz What is the investigation of choice for diagnosing carcinoid syndrome? Urinary 5-HIAA (5-hydroxyindoleacetic acid) The triad of facial flushing, chronic diarrhoea & right heart valvular stenosis represents the most common features. Somatostatin analogues e.g. octreotide are often used as part of management. Which drug category is used 1st line to treat restless leg syndrome? Dopamine agonists e.g. ropinirole, pramipexole & rotigotine Other drugs that can be used include benzodiazepines & gabapentin
101 MRCP Facts Dr. Muzz Which HLA is associated with rheumatoid arthritis (RA)? HLA-DR4 (especially in Felty’s Syndrome) TNF is important in the pathogenesis of RA What is a key contraindication to using bupropion in smoking cessation? Epilepsy. Bupropion is a noradrenaline & dopamine reuptake inhibitor & a nicotinic antagonist It the risk of seizures Which condition causes signet ring cells? Gastric adenocarcinoma
101 MRCP Facts Dr. Muzz How do you treat tricyclic antidepressant overdose with ECG changes? IV Sodium Bicarbonate QRS prolongation is associated with an risk of seizures QT prolongation is associated with ventricular arrhythmias How does exenatide work? Glucagon-like peptide-1(GLP-1) mimetic It is a subcutaneous injection which insulin secretion & inhibits glucagon release It typically results in weight loss There are concerns over the risk of acute pancreatitis & renal impairment
101 MRCP Facts Dr. Muzz At what pO2 level would you add steroids to cotrimoxazole to treat pneumocystis jiroveci pneumonia? pO2 < 9.3kPa – indicates severe disease Bronchoalveolar lavage is often needed to demonstrate a diagnosis (silver staining shows characteristic cysts) What is the most common infective cause of pelvic inflammatory disease (PID)? Chlamydia trachomatis followed by Neisseria gonorrhoeae PID results from ascending infection & inflammation from the endocervix
101 MRCP Facts Dr. Muzz What is the specific gravity of the urine in diabetes insipidus (DI)? 1.005 or less DI is characterised by either a deficiency of ADH (cranial DI) or an insensitivity ADH (Nephrogenic DI). This is confirmed with a water deprivation test where failure of urine concentration occurs. What are 3 hereditary syndromes that are associated with phaeochromocytomas? 1. Von Hipple-Lindau Syndrome 2. MEN-2 3. Succinate Dehydrogenase mutations
101 MRCP Facts Dr. Muzz Which agent would you use to treat postmenopausal osteoporosis if your patient’s eGFR < 30 and she had a recent DVT? Denosumab Bisphosphonates should be avoided if the creatinine clearance is < 35. Strontium is contraindicated in current or previous VTE. Is there a role for steroids in treating Guillain Barré syndrome? Nope – steroids are not beneficial Treatment includes either plasma exchange or IV immunoglobulin (IVIG). IVIG is easier to administer & tends to have fewer side-effects.
101 MRCP Facts Dr. Muzz An intracerebral haemorrhage in the basal ganglia, thalamus & internal capsule is strongly associated with which condition? Hypertension When a haemorrhage in these areas, they are referred to as lacunar strokes They present with isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia Which stool test distinguishes between inflammatory & non-inflammatory bowel conditions? Faecal Calprotectin This is in inflammatory bowel conditions
101 MRCP Facts Dr. Muzz What is the valve area and mean gradient across the valve in severe aortic stenosis? Valve area: < 1 cm2 Mean gradient: > 40 mmHg What is the hallmark feature of postural orthostatic tachycardia syndrome (POTS)? An in HR > 30 on standing without a drop in BP How does selegiline & rasagiline work in treating Parkinson’s Disease? Monoamine oxidase-B inhibitors They inhibits the breakdown of dopamine
101 MRCP Facts Dr. Muzz What is the most likely diagnosis if your patient has: Symptoms of asthma that do not resolve with inhalers Proximal bronchiectasis on HRCT Eosinophils & IgE Allergic bronchopulmonary aspergillosis (ABPA) – this is an allergic (hypersensitivity) reaction to Aspergillus spores The diagnosis can be confirmed with a positive skin prick test to aspergillus fumigatus (positive RAST test) In some patients there will also be positive IgG precipitins to aspergillus Oral steroids are the mainstay of initial treatment. Itraconazole is sometimes used 2nd line.
101 MRCP Facts Dr. Muzz Which organism is most associated with Lemierre’s Disease? Fusobacterium necrophorum This is thrombophlebitis of the internal jugular vein following an oropharyngeal infection. An infected thrombus forms causing local pain & inflammation. Which test do you use to diagnose carotid sinus hypersensitivity? Carotid sinus massage – this test is positive if syncope is reproduced in the presence of asystole for > 3 seconds OR there is a fall in systolic BP > 50mmHg The diagnosis is only made after ischaemic heart disease and rhythm disturbances have been excluded
101 MRCP Facts Dr. Muzz Which class of Parkinson’s drugs cannot be used for the initial treatment of Parkinson’s Disease (PD)? COMT inhibitors e.g. entacapone Initial treatment of PD is with either levodopa, a dopamine agonist or an MAO-B inhibitor COMT inhibitors have NO effect in the absence of levodopa What is the simplest way of treating a cluster headache? High-flow oxygen & sumatriptan Patients have severe retroorbital pain, lacrimation & nasal stuffiness occurring once or twice a day These clusters typically last 4 -12 weeks
101 MRCP Facts Dr. Muzz What is the definition of gluten-free? Food containing < 20 parts per million of gluten e.g. rice, potatoes & corn (maize) What histological changes do you see on a jejunal biopsy in Coeliac Disease? Villous atrophy Crypt hyperplasia/hypertrophy Intra-epithelial lymphocytosis Lamina propria infiltration with lymphocytes Appearances may resemble severe tropical sprue
101 MRCP Facts Dr. Muzz What are the 3 phases of progression in Churg Strauss Syndrome (eosinophilic granulomatosis with polyangiitis)? Stage 1: Atopy (asthma, rhinitis, sinusitis) Stage 2: Eosinophilia > 10% + lung infiltrates Stage 3: Necrotizing small vessel vasculitis It is associated with pANCA (MPO-ANCA) Which ANCA is positive in most patients with Wegener’s Syndrome (granulomatosis with polyangiitis)? cANCA (PR3-ANCA) The classical triad in Wegener’s is: Necrotising granulomatous inflammation of the respiratory tract Glomerulonephritis Small-vessel vasculitis
101 MRCP Facts Dr. Muzz What are the components of the GRACE score in acute coronary syndrome? Age Systolic BP Heart Rate Killip Class Creatinine ST segment deviation Elevated Troponin Cardiac arrest on admission How is Huntington’s Disease inherited? Autosomal Dominant CAG repeat expansion in the gene coding for the Huntington protein Genetic anticipation occurs whereby subsequent generations experience increasingly earlier onset & more severe disease
101 MRCP Facts Dr. Muzz Which HLA is expressed in the majority of people with Coeliac Disease? HLA-DQ2 in 95% of people HLA-DQ8 in the remainder of people What causes Wernicke-Korsakoff Syndrome? Acquired nutritional deficiency of Thiamine (Vitamin B1) Thiamine stores are relatively small with large daily turnover. Deficiency can occur within 2-3 weeks of intake. Thiamine is an important co-enzyme in glucose & lipid metabolism, amino acid modification & neurotransmitter synthesis
101 MRCP Facts Dr. Muzz What is the aetiology of benign paroxysmal positional vertigo (BPPV) and how do you diagnose it? BPPV is caused by loose otoconia (calcium crystals) in the endolymph of the semi-circular canals The commonest canal to be affected is the posterior canal. These crystals cause abnormal stimulation of the vestibular nerve on head movement. The Dix-Hallpike test helps to diagnose BPPV if the posterior canal is affected. When positive, this test induces torsional nystagmus when the head is turned towards the affected ear
101 MRCP Facts Dr. Muzz What are the 3 features of Wernicke’s encephalopathy? Confusion + Ataxia + Ophthalmoplegia Treat Wernicke’s encephalopathy aggressively with high-potency B vitamins (urgent replacement of thiamine) to prevent the progression to Korsakoff’s psychosis Which 2 conditions commonly cause lymphocyte-predominant pleural effusions? Malignancy & Tuberculosis Both of these cause exudative pleural effusions (> 30g/L protein)
101 MRCP Facts Dr. Muzz In which condition do you get distal intestinal obstruction syndrome (DIOS)? Cystic Fibrosis (CF) DIOS occurs in 10-20% of patients with CF & the incidence with age What are the 3 commonest causes of viral meningitis? 1. Enterovirus 2. Echovirus 3. Coxsackie A & B Clinical features of meningitis with an CSF pressure, slightly protein & lymphocytosis is likely to be of viral aetiology
101 MRCP Facts Dr. Muzz What type of laxative is Macrogol? Osmotic How do you treat a severe clostridium difficile infection? Oral Vancomycin If there is no response, then the dose of vancomycin & add IV metronidazole Oral metronidazole is used in mild to moderate cases C. difficile is a Gram-positive anaerobic rod which causes pseudomembranous colitis (white plaques on the GI mucosa) through exotoxin A & B It develops when normal gut flora is suppressed by broad-spectrum antibiotics e.g. through the use of 2nd & 3rd generation cephalosporins
101 MRCP Facts Dr. Muzz How is smoking and alcohol consumption associated with obstructive sleep apnoea/hypopnoea syndrome? Smoking causes throat inflammation which contributes to a narrowed airway. Alcohol exacerbates the reduction in throat muscle tone. Which artery is most commonly implicated in lateral medullary syndrome? The vertebral artery followed by the posterior inferior cerebellar artery. IPSILATERAL CONTRALATERAL Horner’s Ataxia Sensory loss (face) Spinothalamic sensory loss below the neck
101 MRCP Facts Dr. Muzz In refeeding syndrome, which 4 electrolytes move intracellularly causing their plasma levels to fall? Potassium Phosphate Magnesium Calcium Which index can be used in pulmonary function testing to diagnose upper-airway obstruction e.g. due to a goitre? The Empey Index This is the FEV1 divided by the PEFR A normal value is < 10 A value > 10 implies upper-airway obstruction
101 MRCP Facts Dr. Muzz Why do you add pyridoxine (vitamin B6) when treating tuberculosis? To the risk of peripheral neuropathy related to isoniazid, which is an inhibitor of mycolic acid synthesis If someone is tested positive for both HIV and tuberculosis, which one do you treat first and why? Anti-tuberculosis treatment should be started before anti-retrovirals Starting anti-retrovirals first would the risk of immune reconstitution inflammatory syndrome (IRIS)
101 MRCP Facts Dr. Muzz When would you substitute 0.9% NaCl for 0.45% NaCl when treating hyperosmolar hyperglycaemic state (HHS)? If the osmolality is not falling and an adequate fall in glucose is not being achieved e.g. a fall of 4 – 6 mmol/L/hr HHS presents with plasma: Osmolality > 320 mOsmol/L Glucose > 30 mmol/L Ketones < 3 mmol/L What is the DVLA driving guidance for someone with homonymous or bitemporal visual defects? Driving must cease
101 MRCP Facts Dr. Muzz What are the 2 patterns of an ulnar nerve palsy (C8,T1)? The ulnar nerve supplies all the muscles of the hand other than the thenar muscles & the lateral 2 lumbricals which are supplied by median nerve. Damage at the wrist: Clawed posture of the 4th & 5th digits with extension at the MCP joints & flexion at the IP joints Wasting & paralysis of the intrinsic hand muscles (except lateral two lumbricals) & of the hypothenar muscles Sensory loss to the medial 1 ½ fingers Damage at the elbow (Guyon’s canal): Similar to above The clawing is less obvious: o The ulnar nerve also innervates the medial half of the flexor digitorum profundus (FDP) o When the ulnar nerve lesion occurs closer to the elbow, the FDP may be denervated o As a result, flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand. This is called the ulnar paradox. Radial deviation of the wrist
101 MRCP Facts Dr. Muzz Which organism is implicated if a returning traveler has foul-smelling diarrhoea with motile trophozoites and cysts on stool microscopy? Giardia lamblia - a flagellate protozoan It can cause chronic non-bloody diarrhoea & malabsorption, including lactose intolerance In which condition do you get a sudden painless loss of vision & severe retinal haemorrhages on fundoscopy? Central retinal vein occlusion This causes venous pressure within the eye which leads to optic nerve swelling & venous haemorrhage Causes include glaucoma, polycythaemia & hypertension