R R a p i d R e v i e w o f a p The new and completely revised edition of Dr Sharma's bestselling i d Rapid Review of Clinical Medicine for MRCP Part 2 contains R e over 400 self-assessment cases and data interpretation questions vi C L I N I C A L e w covering all aspects of internal medicine. o f C The special 5-star qualities of the First Edition have been retained and L enhanced – breadth of coverage, superb illustration, lively MEDICINE I presentation, precise answers, detailed discussion and, above all, the N author's understanding of the exam candidate's needs while ensuring I the book's broader educational value. C A for MRCP Part 2 New to this edition are a complete content update and some L 300 best-of-five MCQ stems, reflecting the format of the new M MRCP Part 2 and of many similar exams around the world. Second Edition E The new Rapid Review of Clinical Medicine for MRCP Part 2 is Sanjay Sharma (cid:129) Rashmi Kaushal D an invaluable resource for all young doctors studying for higher I qualifications in internal medicine and for medical tutors preparing for C postgraduate examinations. Furthermore, the book provides excellent I evidence based management plans for busy hospital physicians in N acute general medicine encountering difficult medical scenarios. E M R C P P a r t 2 S h a r m a (cid:129) K d ISBN: 978-1-84076-070-5 aushal MPUABLNISSHOINNG (cid:129) BCeasstesse,l l(cid:129)ae rn Rs–e fwlfeerucslt,l sy e nxreeplvwia sneeaxdta iom& nfsu,o prtdumattaoterials (cid:129) Sharma cover 4th imp CMYK Rapid Review of Clinical Medicine for MRCP Part 2 Second Edition Sanjay Sharma BSc (Hons) MD FRCP (UK) FESC Professor of Clinical Cardiology Consultant Cardiologist and Physician St George’s University of London St George’s Hospital NHS Trust University Hospital Lewisham London, UK Rashmi Kaushal BSc (Hons) FRCP (UK) Consultant Physician and Endocrinologist West Middlesex Hospital Kingston, UK MANSON PUBLISHING CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2006 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20150311 International Standard Book Number-13: 978-1-84076-641-7 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. 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Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com 3 Contents Acknowledgements 2 Preface 3 Classification of Cases 4 Abbreviations 5 Clinical Cases 7 Data Interpretations Tutorials 415 Calcium Biochemistry 415 Genetics 415 Audiograms 416 Guidelines for the Interpretation of Cardiac Catheter Data 418 Respiratory Function Tests 419 Interpretation of Respiratory Flow Loop Curves 420 Echocardiography 421 Acid–base Disturbance 426 Normal Ranges 427 Preface Passing specialist examinations in internal medicine is a diagnoses, diagnostic algorithms and up-to-date medical difficult milestone for many doctors, but is a mandatory lists are presented. Many questions comprise illustrated requirement for career progression. Pass rates in these material in the form of radiographic material, electro - examinations are generally low due to ‘high standards’ cardiograms, echocardiograms, blood films, audiograms, and ‘stiff competition’. Thorough preparation is essential respiratory flow loops, histological material, and slides in and requires a broad knowledge of internal medicine. ophthalmology, dermatology and infectious diseases. The pressures of a busy clinical job and nights ‘on call’ Over 200 commonly examined illustrations are included. make it almost impossible for doctors to wade through Tutorials are included at the end of the book to aid heaps of large text books to acquire all the knowledge the interpretation of illustrated material as well as impor- that is required to pass the examinations. tant, and sometimes difficult, clinical data, such as respir - The aim of this book is to provide the busy doctor with atory function tests, cardiac catheter data and dynamic a comprehensive review of questions featured most endocrine tests. frequently in the MRCP (II) examination in internal The book will prove invaluable to all those studying medicine. The MRCP (II) examination has a best of 5/n for higher examinations in internal medicine, and to their from many answer format. The vast majority of the instructors. questions in the book follow the same pattern; however, we have chosen to include several scenarios with open ended questions to stimulate the medical thought process. Sanjay Sharma The level of difficulty of each question is of the same Professor of Clinical Cardiology standard as MRCP (II) examination. However, some cases Consultant Cardiologist and Physician are deliberately more difficult for teaching purposes. Lecturer for Medibyte Intensive Courses A broad range of subjects is covered in over 400 for the MRCP Part 2 questions ranging from metabolic medicine to infectious diseases. Precise answers and detailed discussion follow Rashmi Kaushal each question. Where appropriate, important differential Consultant Physician and Endocrinologist 4 Classification of Cases Cardiology Metabolic medicine 1, 10, 11, 13, 22, 25, 32, 40, 52, 53, 54, 62, 63, 66, 68, 9, 29, 34, 38, 50, 71, 74, 81, 82, 84, 90, 129, 134, 136, 74, 78, 80, 94, 95, 100, 121, 123, 125, 130–132, 138, 147, 153, 161, 179, 189, 214, 215, 230, 248, 257, 271, 144, 150, 160, 167, 178, 180, 184, 193, 197, 199, 202, 275, 283, 310, 321, 326, 329, 333, 334, 398 203, 207, 208, 223, 226, 229, 232, 235, 237, 243, 246, 259, 266, 270, 285, 287, 291, 296, 301, 305, 307, 309, Nephrology 318, 323, 324, 327, 331, 332, 335, 342, 350, 353, 362, 4, 17, 24, 29, 44, 53, 59, 60, 85, 92, 118, 119, 126, 135, 368, 377, 387, 389, 391 137, 141, 152, 185, 198, 228, 244, 245, 249, 250, 251, 278, 289, 294, 303, 304, 317, 328, 344, 354, 381, 382 Dermatology 116, 154, 173, 316 Neurology 30, 65, 67, 93, 98, 103, 105, 108, 112, 128, 139, 145, Endocrinology and diabetes 190, 192, 200, 239–241, 247, 253, 255, 256, 268, 274, 5, 9, 23, 39, 46, 76, 82, 89, 92, 101, 106, 107, 127, 288, 290, 292, 307, 314, 330, 345, 365, 390, 395, 399 134, 146, 159, 164, 168, 173, 181, 199, 218, 220, 238, 242, 254, 260, 261, 273, 281, 328, 334, 372, 373, 379, Obstetric medicine 397, 401 130–132, 190, 193, 348 Environmental medicine Oncology 140 117, 216, 258, 358, 359 Gastroenterology Ophthalmology 3, 6, 19, 24, 33, 64, 72, 75, 104, 127, 133, 143, 148, 282, 345 162, 169, 182, 188, 201, 231, 276, 293, 306, 338, 339, 347, 367, 369, 371, 383, 393, 394, 400 Radiology 2, 18, 64, 88, 97, 99, 124, 183, 187, 222, 227, 252, Genetics 280, 300, 302, 311, 343, 349, 355, 357, 360, 363 47, 85, 151, 170, 194, 195, 269, 315, 361 Respiratory medicine Haematology 8, 14, 21, 35, 36, 37, 43, 45, 55, 56, 58, 61, 72, 79, 91, 12, 38, 49, 69, 70, 73, 86, 87, 102, 114, 115, 117, 120, 99, 111, 113, 157, 164, 196, 217, 225, 272, 279, 298, 122, 142, 156, 163, 175, 191, 204, 211, 216, 219, 233, 304, 327, 341, 349, 356, 370, 380, 384, 396 258, 263, 265, 295, 297, 299, 308, 313, 336, 346, 351, 352, 358, 376, 385, 392, 394 Rheumatology 4, 15, 17, 31, 42, 71, 77, 87, 96, 109, 141, 171, 174, Immunology 177, 196, 198, 200, 210, 236, 264, 320, 324, 340, 364, 15, 155, 374 375, 401, 402 Infectious diseases Therapeutics/toxicology 16, 18, 26, 41, 51, 83, 88, 93, 110, 128, 142, 143, 149, 7, 8, 20, 27, 28, 36, 48, 57, 68, 77, 116, 118, 119, 165, 152, 154, 158, 166, 176, 212, 221, 225, 234, 262, 267, 172, 175, 186, 205, 206, 209, 213, 224, 251, 284, 286, 277, 280, 319, 322, 325, 337, 345, 351, 383, 386, 388 312, 316, 317, 332, 339, 366, 378 5 Abbreviations 5-HIAA 5'-hydroxyindole acetic CML chronic myeloid leukaemia FVC forced vital capacity acid CMV cytomegalovirus GBM glomerular basement AIIRB angiotensin II receptor COPD chronic obstructive membrane blocker pulmonary disease GCT giant cell tumour AAFB acid–alcohol fast bacilli CPAP continuous positive airway GFR glomerular filtration rate ACE angiotensin-converting pressure GH growth hormone enzyme CREST calcinosis, Raynaud’s GHRH growth hormone releasing ACTH adrenocorticotrophic syndrome, oesophageal hormone hormone problems, scleroderma, GI gastrointestinal ADH antidiuretic hormone telangiectasia GP general practitioner AF atrial fibrillation CRF chronic renal failure GPI glucophosphatidylinositol AIDS acquired immune- CRP C-reactive protein GT glutamyltransferase deficiency syndrome CSF cerebrospinal fluid GTN glyceryl trinitrate AIN acute interstitial nephritis CSS Churg–Strauss syndrome Hb haemoglobin AIP acute intermittent CT computed tomography HbSS sickle cell anaemia porphyria CVA cerebrovascular accident HC Hereditary Copro ALA aminolaevulinic acid CVP central venous pressure porphyria ALT alanine transaminase CXR chest X-ray HCC hydroxy-cholecalciferol (SGPT) DBP diastolic blood pressure HCM hypertrophic AML acute myeloid leukaemia DC direct current cardiomyopathy AMP adenosine 5'- DHCC dihydroxy-cholecalciferol HCV hepatitis C virus monophosphate DIC disseminated intravascular HCG human chorionic ANA antinuclear antibody coagulation gonadotrophin ANCA antineutrophil cytoplasmic DIDMOAD diabetes insipidus, HELLP haemolysis, elevated liver antibodies diabetes mellitus, optic enzymes and low platelets ANF antinuclear factor atrophy and deafness HHT hereditary haemorrhagic APCKD adult polycystic kidney DM diabetes mellitus telangiectasia disease DT delerium tremens HIT heparin-induced APTT activated partial DVT deep-vein thrombosis thrombocytopenia thromboplastin time EAA extrinsic allergic alveolitis HIV human immunodeficiency AR aortic regurgitation EBV Epstein–Barr virus virus ARDS adult respiratory distress ECG electrocardiogram HONK hypersimilar non-ketotic syndrome EEG electroencephalogram diabetic coma ARVC arrhythmogenic right ELISA enzyme-linked HR heart rate ventricular cardiomyopathy immunosorbent assay HRT hormone replacement AS aortic stenosis EMF endomyocardial fibrosis therapy ASD atrial septal defect EMG electromyogram HS hereditary spherocytosis ASO antistreptolysin ENT ear, nose and throat HSMN hereditary sensorimotor AST aspartate transaminase EPO erythropoietin neuropathy (SGOT) ERCP endoscopic retrograde HUS haemolytic uraemic ATN acute tubular necrosis cholangiopancreatogram syndrome AZT zidovudine ESR erythrocyte sedimentation ICD implantable cardioverter BCG bacille Calmette–Guérin rate defibrillator BIH benign intracranial FBC full blood count ICP intracranial pressure hypertension FDP fibrinogen degradation INR International Normalized BP blood pressure product Ratio BT bleeding time FES fat embolism syndrome IPF idiopathic pulmonary BTS British Thoracic Society FEV1 fixed expiration volume in fibrosis CAH chronic active hepatitis 1 second IVP intravenous pyelogram CAP community acquired FFP fresh-frozen plasma IVU intravenous urogram pneumonia FNA fine-needle aspiration JVP jugular venous pressure CCF congestive cardiac failure FSH follicle stimulating KCO corrected carbon monoxide CFTR cystic fibrosis hormone transfer factor transmembrane regulator FTA fluorescent treponemal LBBB left bundle branch block (protein) antibody LDH lactate dehydrogenase 6 LFT liver function tests NSTEMInon-ST elevation TCAD tricyclic antidepressant LH luteinizing hormone myocardial infarction overdose LHON Leber’s hereditary optic NYHA New York Heart TIA transient ischaemic attack neuropathy Association TIBC total iron-binding capacity LHRH luteinizing hormone OSA obstructive sleep apnoea TIPSS transjugular intrahepatic releasing hormone PAN polyarteritis nodosa portosystemic shunt LMWH low-molecular weight PAS periodic acid-Schiff TLC total lung capacity heparin PBC primary biliary cirrhosis TLCO total lung carbon LQTS long QT-syndrome PBG porphobilinogen monoxide transfer factor LVEDP left ventricular end-diastolic PCOS polycystic ovary syndrome TOE transoesophageal pressure PCR polymerase chain reaction echocardiography LVH left ventricular hypertrophy PCT porphyria cutanea tarda TPA tissue plasminogen MAHA microangiopathic PCV packed cell volume activator haemolytic anaemia PCWP pulmonary capillary wedge TPHA treponema pallidum MAOI monoamine oxidase pressure haemagglutination test inhibitor PE pulmonary embolism TRH thyrotrophin releasing MCH mean cell haemoglobin PEFR peak expiratory flow rate hormone MCHC mean cell haemoglobin PFO patent foramen ovale TSAT transferrin saturation content PKD polycystic kidney disease TSH thyroid stimulating MCV mean cell volume PMLE progressive multifocal hormone MELAS mitochondrial leucoencephalopathy TT thrombin time encephalopathy, lactic PMR polymyalgia rheumatica TTP thrombotic acidosis, stroke-like PNH paroxysmal nocturnal thrombocytopenic purpura syndrome haemoglobinuria U&E urea and electrolytes MEN multiple endocrine PRL prolactin URTI upper respiratory tract neoplasia PRV polycythaemia rubra vera infection MERRF myoclonic epilepsy and red PSC primary sclerosing US ultrasound ragged fibres cholangitis UTI urinary tract infection MGUS monoclonal gammopathy PT prothrombin time VDRL Venereal Diseases Research of undetermined PTH parathormone or Laboratory test significance parathyroid hormone VF ventricular fibrillation MPO myeloperoxidase PVE prosthetic valve VIP vasointestinal polypeptide MR mitral regurgitation endocarditis VMA vanilyl mandelic acid MRA magnetic resonance RA rheumatoid arthritis VP variegate porphyria angiography RBBB right bundle branch block VR ventricular rate MRCP magnetic resonance REM rapid eye movement VSD ventricular septal defect cholangiopancreatogram RMAT rapid macroagglutination VT ventricular tachycardia MRI magnetic resonance test WCC white cell count imaging RTA renal tubular acidosis WPW Wolff–Parkinson–White MRSA methicillin resistant RV residual volume (syndrome) Staphylococcus aureus SADS sudden adult death MRV magnetic resonance syndrome venography SAM systolic anterior motion of MSH melanocyte stimulating the mitral valve hormone SAP serum amyloid protein NADPH nicotinamide adenine SIADH syndrome of inappropriate dinucleotide phosphate antidiuretic hormone (reduced) SLE systemic lupus NAPQI N-acetyl-p- erythematosus benzoquinoneimine SMA smooth muscle antibody NARP neuropathy, ataxia, retinitis SPECT single photon emission pigmentosa computed tomography NASH non-alcoholic SROS Steele–Richardson– steatohepatitis Olszewski syndrome NIPPV non-invasive positive STEMI ST elevation myocardial pressure ventilation infarction NSAID non-steroidal anti- SVT supraventricular tachycardia inflammatory drug TB tuberculosis Clinical Cases 7 Question 1 A 49-year-old male presented to the Accident and Emergency Department with a one-hour history of severe What is the best treatment to improve coronary perfusion? central chest pain. He smoked 30 cigarettes per day. a. IV Streptokinase. Physical examination was normal. The 12-lead ECG b. IV Tenectoplase. revealed ST segment elevation in leads V1–V4. There c. IV Alteplase. were no contraindications to thrombolysis. d. Half-dose tenectoplase and half-dose abciximab. e. Primary coronary angioplasty. Question 2 A 68-year-old woman presented with pain and tingling in What was the abnormality on the chest X-ray? the left arm when she raised her hands for prolonged a. Left-sided bronchogenic carcinoma. periods. On examination both pulses were palpable in the b. Left cervical rib. upper limbs. The chest X-ray was abnormal. Aortography c. Retrosternal thyroid. was performed with the arms down (2a) and with the d. Notching of the ribs. arms up (2b). e. Widened mediastinum. 22aa 22bb Question 3 A 28-year-old male presented with a six-month history of Hb 9 g/dl weight loss of 8 kg, generalized abdominal discomfort WCC 4.6 (cid:2)109/l and diarrhoea. On examination he was pale and slim, but Platelets 200 (cid:2)109/l there were no other significant abnormalities. MCV 76 fl Investigations are shown. ESR 38 mm/h Sodium 141 mmol/l Potassium 4 mmol/l Urea 3 mmol/l What is the diagnosis? Creatinine 68 (cid:3)mol/l a. Crohn’s disease. Corrected calcium 2.02 mmol/l b. Intestinal lymphangiectasia. phosphate 0.8 mmol/l c. Coeliac disease. Alkaline phosphatase 190 iu/l d. Small bowel lymphoma. Albumin 38 g/l e. Hypogammaglobulinaemia. IgA <0.1 g/l (NR 0.8–4.0 g/l) IgG 9.0 g/l (NR 7.0–18.0 g/l) IgM 0.6 g/l (NR 0.4–2.5 g/l) IgA anti-endomyosial Absent antibody 8 Answer 1 There have been trials evaluating the role of combined e. Primary coronary angioplasty. half-dose thrombolytic therapy and half-dose platelet glycoprotein IIb/IIIa receptor blockers, e.g. tenectoplase Coronary reperfusion may be achieved with thrombolytic plus abciximab (ASSENT 3) and reteplase plus abciximab agents (which promote fibrinolysis) or by coronary (GUSTO IV). These trials suggest that the combination angioplasty. In the UK patients with ST elevation may be associated with slightly higher coronary patency myocardial infarction are conventionally treated with rates and fewer ischaemic events but they have not thrombolytic agents. Early treatment is crucial to salvage demonstrated a mortality benefit. These trials have also myocardium and reduce the risk of sudden death and demonstrated higher rates of intracranial bleeding in the severe left ventricular dysfunction. Current goals for the elderly, hence combination therapy is not recommended speed of treating with a thrombolytic agent include a at present. door-to-needle time of 20 minutes or a call-to-needle Although thrombolytic treatment is associated with a time of 60 minutes. significant reduction in mortality from myocardial Thrombolytic agents used commonly include infarction, it does have important limitations. Firstly, streptokinase, alteplase, tenectoplase and reteplase. greatest benefit from thrombolysis is achieved in patients Streptokinase is less favoured compared with the other treated within 4 hours of the onset of symptoms. Even with thrombolytic agents because it is less effective at restoring thrombolysis normalization of blood flow is seen in only coronary perfusion and is associated with slightly worse 50–60% of cases. Recurrent ischaemia occurs in 30% of outcomes. The GUSTO I study compared front-loaded cases and frank thrombotic coronary occlusion in 5–15%. alteplase therapy with streptokinase in patients with ST Re-infarction occurs in up to 5% of cases while in hospital. EMI. Alteplase was superior to streptokinase in reducing Also major bleeding is recognized in 2–3% of cases. For mortality (1% absolute reduction in mortality at 30 days these reasons several trials were set up comparing primary with alteplase) and was associated with greater coronary angioplasty with thrombolysis in STEMI. patency rates. In the GUSTO trial the benefit was Primary angioplasty is superior to thrombolysis. It is greatest in patients aged under 75 years and those with associated with lower mortality and lower re-infarction anterior myocardial infarction. However, streptokinase is rates. The likelihood of a pre-discharge positive exercise still used extensively in developing countries and in many test is also reduced by primary angioplasty. In hospitals hospitals in the UK. Alteplase, tenectoplase and reteplase where facilities for primary angioplasty are available, appear to be equally effective. Tenectoplase and reteplase primary angioplasty should be considered over are easier to administer (as a single bolus). thrombolysis. Best results occur when the door-to- balloon time is less than 2 hours. Answer 2 ribs are common in the normal population and are b. Left cervical rib. usually asymptomatic. In rare circumstances a cervical rib may cause pressure on the subclavian vessels and the There is mechanical occlusion of the left subclavian artery brachial plexus causing transient vascular insufficiency or on raising the left arm due to a left cervical rib. Cervical paraesthesiae in the upper limb. Answer 3 endomyosial antibodies are IgA antibodies, therefore c. Coeliac disease. they will not be detected in patients with low IgA antibody levels. Since coeliac disease is also associated Diarrhoea, weight loss, abdominal discomfort and with IgA deficiency it is important to be aware of serum isolated IgA deficiency are highly suggestive of coeliac IgA levels before interpreting anti-endomyosial disease. Anti-endomyosial antibodies are highly sensitive antibodies in patients with malabsorption. (See Question and specific for the diagnosis of coeliac disease. Anti- 276.)