Rapid Review of Clinical Medicine for MRCP Part 2

431 Pages·2006·8.04 MB·English

by  Sharma

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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
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© 2006 by Taylor & Francis Group, LLC
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Version Date: 20150311
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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.)