101 MRCP Facts Dr. Muzz How do you treat Takotsubo Cardiomyopathy? Although there are no evidence-based guidelines to date, standard heart failure medication is recommended until ventricular function recovers Beta-blockers may be needed long term to help suppress stress hormones. Aspirin may be used in patients with evidence of atherosclerosis. What is the mechanism by which metformin exacerbates lactic acidosis? activity of pyruvate dehydrogenase Metformin is a biguanide used in the management of T2DM, PCOS & NAFLD
101 MRCP Facts Dr. Muzz Which agent would you use to treat postmenopausal osteoporosis if your patient takes prednisolone and has a diagnosis of CREST syndrome? Zoledronic Acid – an IV bisphosphonate Oral bisphosphonates are contraindicated in oesophageal disorders e.g. achalasia, scleroderma, strictures & varices. IV alternatives are advised. Bisphosphonates work by inhibiting osteoclastic activity. After suspected anaphylaxis, when should a mass cell tryptase level be sent? A sample should be sent as soon as possible. A second sample should be sent within 1 – 2 hours (but no later than 4 hours) from the onset of symptoms.
101 MRCP Facts Dr. Muzz How is hypokalaemic periodic paralysis inherited and how do you treat it? Autosomal Dominant Potassium replacement Periodic paralysis is rapid development of muscle weakness, often starting in the lower limbs, and spreading to the upper limbs & can affect respiratory muscles What is the mechanism for hypercalcaemia in sarcoidosis? synthesis of 1,25- dihydroxyvitamin-D3 by macrophages Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating granulomas
101 MRCP Facts Dr. Muzz How do you treat thyrotoxic periodic paralysis? Anti-thyroid drugs e.g. carbimazole Cautious replacement of potassium This condition presents similarly to hypokalaemic periodic paralysis but with the presence of thyrotoxicosis It occurs predominantly in Chinese, Japanese, Vietnamese, Pilipino & Korean males Under conditions of thyrotoxicosis, a genetic mutation in potassium transport is activated. This causes hypokalaemia & subsequent muscle weakness Attacks can last from several minutes to hours Triggers include exertion, alcohol & certain foods (high carbohydrate load, high salt). Because the total body potassium level is not low, cautious replacement of potassium is important
101 MRCP Facts Dr. Muzz When do you use a fixed-rate insulin infusion (FRII) to treat hyperosmolar hyperglycemic state? If there is significant ketonaemia at presentation (urine > 2+ or blood > 1 mmol/L) OR If fluid replacement alone does not lead to correction of osmolality & hyperglycaemia e.g. blood glucose is falling by < 5 mmol/hour The FRII infusion rate is 0.05 units/kg/hr
101 MRCP Facts Dr. Muzz What changes would you expect to see in SpO2 in an atrial septal defect (ASD), ventricular septal defect (VSD) & patent ductus arteriosus (PDA)? RA RV PA LA LV Aorta Normal 70% 70% 70% 100% 100% 100% ASD 85% 85% 85% 100% 100% 100% VSD 70% 85% 85% 100% 100% 100% PDA 70% 70% 85% 100% 100% 100% The right atrium, right ventricle & pulmonary artery normally have oxygen saturation levels of around 70%. The left atrium, left ventricle & aorta normally all have oxygen saturation levels of 98-100%. ASD: The oxygenated blood in the LA mixes with the deoxygenated blood in the RA, resulting in intermediate levels of oxygenation from the RA onwards VSD: The oxygenated blood in the LV mixes with the deoxygenated blood in the RV, resulting in intermediate levels of oxygenation from the RV onwards. The RA blood remains deoxygenated. PDA: A PDA connects the higher-pressure aorta with the lower-pressure PA. This results in only the PDA having intermediate oxygenation levels.
101 MRCP Facts Dr. Muzz What are the diagnostic criteria for SIADH? The following triad must be present: 1. Hyponatremia < 130mmol/L 2. Dilute serum Plasma Osm < 270mOsm/kg 3. Concentrated Urine Urine Osm > 100 mOsm/kg Hypovolemia must be excluded by showing that the Na in the urine is > 20 – 30mmol/L & there is the absence of hypotension You must also exclude other endocrine causes of hyponatremia e.g. Adrenal failure & Hypothyroidism
101 MRCP Facts Dr. Muzz What is most common causative organism of neonatal pyogenic meningitis? E. coli Usually caused by a serotype that contains the capsular antigen K-1 Which antibiotic is used for chemoprophylaxis in those who may have come into contact with someone who has meningococcal meningitis? Prophylaxis needs to be offered to household and close contacts. A single oral dose of Ciprofloxacin 500mg is the recommended drug of choice. Other drugs that can be used include oral Rifampicin & IM Ceftriaxone
101 MRCP Facts Dr. Muzz What are the risk factors for multi-drug resistant tuberculosis (MDR-TB)? An HIV-positive male who lives in London & was born in a country that has a high TB incidence. He was previously treated for TB & has had contact with a known case of MDR-TB. What is the most appropriate antihypertensive to use in a 49-year-old female who takes lithium for bipolar affective disorder? Calcium channel blocker e.g. amlodipine Although NICE recommends ACE inhibitors 1st line in those < 55 years old, amlodipine is preferred as it does not cause a significant in serum lithium concentration ACE inhibitors, angiotensin II receptor antagonists & thiazide diuretics can all cause lithium toxicity by renal lithium clearance
101 MRCP Facts Dr. Muzz Which commonly used antimicrobials can cause QT prolongation? Quinolones e.g. Levofloxacin, moxifloxacin, Macrolides e.g. Erythromycin, Clarithromycin Antimalarials e.g. Quinine Antiprotozoal e.g. Pentamidine Azole antifungals e.g. fluconazole, ketoconazole When would you consider adding tocilizumab to dexamethasone in managing SARS-CoV-2 related pneumonitis? Escalating oxygen requirements & significantly elevated inflammatory markers (e.g. CRP ≥75 mg/L) The RECOVERY trial showed that this: mortality likelihood of requiring invasive ventilation likelihood of successful hospital discharge
101 MRCP Facts Dr. Muzz Why do patients with malignancy develop hypercalcaemia? Solid Tumours High PTHrP e.g. adeno- & squamous cell cancers Bone Lysis e.g. breast cancer Haematological Malignancy High calcitriol e.g. lymphoma, granulomatous disease Bone Lysis e.g. multiple myeloma What is the step-up from salbutamol for COPD in someone who had 1 community exacerbation in the last year and has a: Dyspnoea score = 2 (mMRC) FEV1 = 65% (GOLD 2) Group B treatment Add a LABA or LAMA
101 MRCP Facts Dr. Muzz What is the most likely diagnosis if a 23-year-old who takes the OCP presents to the hospital for the 3rd time with anxiety, abdominal pain, hypertension & a serum Na of 130? Acute intermittent porphyria (AIP) with SIADH AIP is caused by a defect in PBG deaminase in RBCs. This leads to toxic accumulation of porphobilinogen (PBG) & delta aminolaevulinic acid (DALA). One key feature is that the urine turns deep red on standing ( urinary excretion of PBG). Stress, infection, pregnancy, menstruation, the OCP & starvation (low carbohydrate intake) may precipitate acute attacks Generally speaking, cP450 enzyme inducers are associated with an risk of acute attacks e.g. phenytoin & chronic alcohol intake
101 MRCP Facts Dr. Muzz Which antibodies are usually positive in the 3 types of autoimmune hepatitis? TYPE 1 Anti-nuclear antibody (ANA) Anti-smooth muscle antibody (SMA) TYPE 2 Anti-liver kidney microsomal antibodies (LKM-1) TYPE 3 Anti-soluble liver antigen (SLA) How do the CT-Thorax findings differ between Goodpasture’s syndrome and Wegener’s Granulomatosis? Goodpasture’s: Ground-glass changes Wegener’s: Multiple cavitating lesions (usually apically) Both cause pulmonary-renal syndrome
101 MRCP Facts Dr. Muzz According to the NASCET criteria, when should an urgent referral for a carotid endarterectomy be made? Symptomatic carotid stenosis of 50 to 99% Asymptomatic carotid stenosis is treated with best medical management in the 1st instance What triad is seen in Budd-Chiari syndrome? Abdominal pain Hepatomegaly Ascites Budd-Chiari syndrome occurs due to thrombotic or non-thrombotic obstruction of hepatic venous flow
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101 MRCP Facts Dr. Muzz I used a bunch of validated resources. These include: UpToDate.com Pubmed Central (PMC): Case reports, systematic reviews & RCTs The latest NICE, BTS & SIGN guidelines The BNF – June 2021 A variety of different medical textbooks including: o Kalra PA. Essential Revision Notes for MRCP. 4 th ed. PasTest; 2014. o Wilkinson I et al. Oxford Handbook of Clinical Medicine. 10th ed. Oxford University Press; 2017. o Moore K, Dalley A, Agur A. Clinically Orientated Anatomy. 8th ed. Lippincott Williams and Wilkins; 2017 o Lote C. Principles of Renal Physiology. 5 th ed. Springer; 2012 o Feather A, Randall D, Waterhouse M. Kumar and Clark’s Clinical Medicine. 10th ed. Elsevier; 2020 o Lowe J, Anderson P, Anderson I. Stevens & Lowe’s Human Histology. 5 th ed. Elsevier; 2019 o Bear M et al. Neuroscience: exploring the brain. 4 th ed. Jones and Bartlett Publishers, Inc; 2020 o Innes J, Dover A, Fairhurst K. Macleods Clinical Examination. 14th ed. Elsevier; 2018 o Lane N, Powter P, Patel S. Best of Five MCQs for the Acute Medicine SCE. 1st ed. Oxford University Press; 2016 Clinical cases that I have encountered in my clinical practice My personal revision notes including those made when doing MCQs on Passmedicine.com