MRCP Part 2 Written Flashcards
What are the monoclonal antibodies used in severe asthma?
Omalizumab in severe asthma with raised IgE
Mepolizumab in severe asthma with eosinophilia
In patients its optic neuritis what is their lifetime risk of developing Multiple Sclerosis?
50% if MRI lesions present
25% Otherwise
Which autoantibodies can help differentiate between Crohn’s and UC?
Anti-Saccharomyces Cerevisae antibodies more common in crohn’s
pANCA more common in ulcerative Colitis.
What are monoclonal antibodies used in severe SLE?
Belimumab an monoclonal antibody that inhibits B cell activating factor (BAFF), also known as B-lymphocyte stimulator BLyS.
It can be used in severe SLE (SELENA-SLEDAI over 10) despite standard management in patients with autoantibody positive disease.
What is the management of Barrett’s oesophagus?
- PPI
- 2 yearly surveillance with quadrantic biopsies per 2 cm affected + any visible lesion
- If biopsy shows low grade dysplasia, first extensive re-biopsy after intensive acid suppression for 8-12 weeks. If still present 6-12mnthly OGD (If regresses after 2 x OGD then back to 2yrly
- If biopsy shows high grade dysplasia patient need MDT and likely resection or radiofrequency ablation.
Which gene is affected in Wilson’s disease?
Autosomal recessive inherited mutation in ATP7B leads to decreased binding of copper to caeruloplasmin and decreased biliary excretion of copper
What is the most common lithium induced nephrotic syndrome?
Minimal Change disease
Which patients should be considered for valve replacement in aortic regurgitation?
Symptomatic patients
Symptomatic patients with resting ejection fraction less than 50% with severe LV dilatation i.e. (LVEDD over 70mm or LVESD over 50mm)
What is the target Hb in patients treated with EPO?
A recent Cochrane review suggested a higher target of 135 was associated with increased risk of hypertensive crises
What is the common chemotherapy schedule for Hodgkin’s lymphoma?
ABVD
Adriamycin
Bleomycin
Vincristine
Dacarbazine
What is the common chemotherapy schedule for high grade non-hodgkins lymphoma?
(R) - CHOP
Rituximab
Cyclophosphamide
Hydroxydaunorubicin (Doxorubicin)
Oncovin (Vincristine)
Prednisolone
What is the common chemotherapy schedule for chronic lymphocytic leukaemia?
FCR
Fludarbine
Cyclophosphamide
Rituximab
(Chlorambucil where Fludarabine fails or is inappropriate)
What is the common chemotherapy schedule for multiple myeloma?
CDT
Cyclophosphamide
Dexamethasone
Thalidomide
(Bortezomib is an alternative to thalidomide if it is contraindicated/non tolerated)
What is the common chemotherapy schedule for acute myeloid leukaemia?
Cytosine and an anthracycline
What is the common chemotherapy schedule for acute lymphoid leukaemia?
Vincristine and steroid
What are the associated features of atrial myxoma?
Finger Clubbing
Normocytic anaemia
Positional murmur
Intracardiac calcification on CXR.
What are the LDL-C targets in statin therapy?
In high risk patient:
- Target LDL-C less than 1.8mmol/l
- OR a reduction of more than 50% in patients with LDL-C between 1.8-3.5
Lower risk patients:
-Target LDL-C of less than 3.0mmol/L
What are some Drugs that can worsen psoriasis?
Beta-blockers
Lithium
Anti-malarials (chloroquine + hydroxychloroquine)
Oral Steroids
NSAIDs
ACE-I
Infliximab
What are the ECG changes seen in brugada syndrome?
ECG Changes:
- Convex ST segment elevation over 2mm of V1-V3 followed by a negative T wave. (There are two types depending on the T wave which is inverted in type 1 and biphasic in type 2)
- Partial RBBB
- Change may be more apparent following flecainide.
What is the management of subclinical thyroid disease?
Hypothyroidism:
- Treat if TSH over 10, (Lower if pregnant or CVD)
- Treat if antibody positive
Hyperthyroidism:
-treat with radioiodine if TSH fully suppressed
How can vasoreactivity testing guide treatment in Pulmonary Arterial Hypertension?
Vasoreactivity testing involves the administration fo short-acting vasodilatory followed by measurement of the haemodynamic response using a right heart catheter. The test is considered positive if mean pulmonary artery pressure decreased at least 10mmHg and to a value less than 40mmHg, with an increased or unchanged cardiac output, and minimally reduced or unchanged SBP.
Patients with +ve vasoreactivity testing are candidates for treatment with Calcium channel blockers (Dihydropydidine or diltiazem)
Those with -ve vasoreactivity testin should be treated with alternative agents such as prostacyclin pathway agonists or Endothelin recepetor Antagonist.
What antibiotics are used in the treatment of Clostridium Perfrigens?
Benzypenicillin or Clindamycin
What features can help differentiate Beta thalassaemia from IDA?
Iron Deficency Anaemia:
- Normal or reduced A2 level
- Any level of anaemia
- Any Ethnic group
- MCV inkeeping with degree of anaemia
- Low serum ferritin
- Low iron saturation
Beta-Thallassaemia:
- Raised HB A2
- Hb usually less than 90
- Mediterranean or Asian
- surprisingly low MCV for degree of anaemia
- Normal Ferritin
- Normal Iron saturation
What is Familial Mediterranean fever?
Aka recurrent polyserositis. An autosomal recessive disorder which typically presents by the second decade. More common in people of Turkish, Armenian and Arabic descent
Features: Attacks typically last 1-3days. Pyrexia, abdominal pain due to peritonitis, pleurisy, pericarditis, Arthritis, erysipeloid rash on lower limbs.
Management:
-Supportive colchicine may help
Which renal disease has the highest recurrence rate in kidney transplant?
Membranoproliferative Glomerulonephritis (30-90%) Focal Segmental Glomerulosclerosis (40%) Membranous Glomerulonephritis (30%)
What defines a significant short synthacten test?
Cortisol should reach over 550 by 30 mins failure to do this suggest adrenal insufficiency
What are the associations of Anti-Hu Antibodies?
Associated with small cell lung cancer and neuroblastoma
Associated with sensory neuropathy (Often painful), cerebellar syndrome, and encephalomyelitis.
What are the associations of anti-Yo antibodies?
Associated with ovarian and breast cancer
Associated with cerebellar syndrome
What are the associated of anti-Ri antibodies?
Opsoclonus Myoclonus, ataxia
What factors increase the risk of recurrence of seizures on withdrawal of AEDs?
Older age at diagnosis
Use of multiple antivconvulsants
History of Myoclonic or tonic-clonic seizures.
Previous abnormal imaging or EEG
When are Premature Ventricular Ectopics clinically significant?
- Occuring frequently (10 or more beats/hour or 6 or more beats /min)
- PVE in bigeminal rhythm
- PVE in short runs of VT
- PVE exhibiting R-on-T phenomenon
- PVE associated with serious organic heart disease such as in the context of MI or LV decompensation
What are some drugs known to reduce the clearance of theophylline?
Allopurinol Cimetidine Ciprofloxacin Corticosteroids Diltiazem Erythromycin Frusemide Isoprenaline Oral Contraceptives Thiabendazole Verapamil
What cardiac abnormalities are associated with William’s Syndrome?
Deletion of long arm of chromosome 7, Elfin like face, intellectual disability, outgoing personality.
Associated with Supravalvular Aortic stenosis
What are the cardiac defects that make up Tetralogy of Fallot?
Pulmonary Stenosis
Overriding Aorta
Inter-ventricular septal defect
Right ventricular hypertrophy.
What are the distinguishing features between Duchenne and Becker Muscular Dystrophy?
Duchenne:
- Absent/Non functional dystrophin gene
- 1/3600 Male births incidence
- Onset 3-5 yrs
- Fast disease progression
- Mean life expectancy mid 20s
- Onset of cardiomyopathy is after skeletal progression.
Becker’s:
- Partially functional dystrophin gene.
- 6/100 000 male births incidence
- Onset 12 yrs
- Slow disease progression
- Mean life expectancy 40s
- Onset of cardiomyopathy May present before skeletal symptoms.
What are the main types of cryoglobulinaemia?
Type 1: monoclonal usually IgM. E.g. Waldenstroms macroglobulinaemia or multiple myeloma
Type 2: monoclonal IgG ‘mixed cryoglobulin’. Associated HIV + Hep C
Type 3: polyclonal associated connective tissue disease especially Sjögren s syndrome.
Both type 2 and 3 can have rheumatoid factor activity so may be associated with positive RhF
What are the types of amiodarone induced thyroid disorders?
Around 1 in 6 patients taking amiodarone develop thyroid dysfunction.
Amidarone-induced hypothyroidism:
Occurs in patients with a previously normal thyroid gland. This is due to the autoregulatory phenomenon where high levels of circulating iodine reduces thyroid hormone synthesis and is known as the Wolff-Chaikoff effect.
Amiodarone-induced Thyrotoxicosis: Two main types:
- Type 1 -Usually occurs in patients with either pre-existing Thyroid disorders or iodine deficiency. Patients with underlying thyroid disorder or iodine deficiency cannot auto regulate effectively and so there is increased sensitivity and increased production and hyperthyroidism. This is known as the Joe-Basedow phenomenon. There is a goitre and it is managed through carbimazole or potassium perchlorate
-Type 2 amiodarone-related destructive thyroiditis, goitre absent and managed by corticosteroids. Elevated IL 6.
What is the relationship between thymoma and immunodeficinecy.
10% of thymoma develop t + B cell deficiency (good syndrome)
What is the significance of blood products in patients with IgA deficiency?
They are more at risk of anaphylaxis with blood products.
What effect foes St Johns wort have on the P450 system?
Enzyme Inducer
What are the types of Autoimmune polyglandular syndrome?
Type 1:
- Defect on AIRE Gene
- Mucocutaneous Candiasis
- Hypoparathyroidism
- Hypoadrenalism
Type 2:
- Schmidt’s syndrome
- Hypothyroidism
- Hypoadrenalism
- other e.g. Coeliac, T1DM, Vitiligo, Myasthenia, Pernicious anaemia, Ovarian failure.
What are some limitations of the Dexamethasone suppression test?
False +ve in 2-12%.
Dexamethasone metabolised by p450, Enzyme inducers e.g. Phenobarbital, Carbemazepine, Rifampicin, Smokers, Chronic alcohol abuse can lead to false positives.
Classify the causes of hypokalaemia by the association with hypertension
Hypokalaemia with hypertension:
- Cushing’s syndrome
- Conn’s Syndrome
- Liddles Syndrome
- 11-beta hydroxylase deficeincy
- Carbenoxolone
- Liqourice excess
Hypokalaemia without hypertension:
- Diuretics
- GI loss (e.g. D+V)
- Renal tubular acidosis (type 1 + 2)
- Bartter’s syndrome
- Gitelman’s syndrome
What are the subtypes of MODY?
MODY2 (GCK subtype) is caused by mutation in the glucokinase gene on chromosome 7. Usually there is mild asymptomatic stable hyperglycaemia from birth. Microvascular disease is rare and drugs are rarely needed.
- MODY3 (HNF1A subtype) is the most common type. It is caused by a defect on chromosome 12 leading to progressive decrease in insulin production. It features severe hyperglycaemia after puberty which often leads to a diagnosis of type 1 DM. Diabetic retinopathy and nephropathy often occur.
- MODY5 (HNF1B subtype) is associated with pancreatic atrophy, renal abnormalities and genital tract malformations.
- MODY1,4,6 also exist but are very rare.
How long does Vitamin K reversal take?
4-6hours
What is the stereotypical history of Giardiasis?
Prolonged non bloody diarrhoea
What is the stereotypical history of Shigella?
Bloody diarrhoea associated with vomiting and abdominal pain
What are some causes of ascites?
Transudate Causes:
- Cirrhosis
- Portal Hypertension
- Cardiac failure
- Budd-chiari
- myxoedema
Exudate Causes:
- Hepatic/Peritoneal Malignancy
- Intraabdominal TB
- Pancreatitis
What are the main P450 Inhibitors?
O-DEVICES:
- Omeprazole
- Disulfiram
- Erthromycin
- Valproate/ Verapamil
- Isoniazid
- Cimetidine/Ciprofloxacin
- Ethanol intoxication
- Sulphonamides
What are the indications for plasma exchange in renal diseases?
Good pasture syndrome
ANCA positive vasculitis with AKI or pulmonary haemorrhage
Idiopathic crescentic GN
Cryoglobuliaemia
Myeloma with hyperviscosity
TTP (HUS)
Describe kings college criteria for liver transplantation
Paracetamol-induced liver failure:
- arterial pH less than 7.3 24h after ingestion or all of the following
- Prothrombin time greater than 100s
- creatinine over 300umol/L
- Grade III or IV encephalopathy
Non-Paracetamol Liver Failure
- PT over 100s OR 3 of 5 of the following:
- Drug induced liver failure
- less than 10yrs old or over 40
- at least 1wk between jaundice to encephalopathy
- PT over 50s
- Bilirubin over 300umol/L
What are the muscarinic features of organophosphate poisoning?
SLUDGE Salivation Lacrimation Urination Diaphoresis Gastrointestinal upset Emesis, Miosis
What are some HLA related drug reactions?
HLA B1502 is associated with Stevens-Johnson in patient of chines origin taking phenytoin
HLA A3101 is associated with Stevens-Johnson syndrome in European or Japanese patients treated with carbamazepine
HLA B5701 is assoacited with abacavir hypersensitivity, which resulted in the development of HLA screening before the medication was initiated for HIV.
HLA B5801 is associated with allopurinol hypersensitivity
What are the main types of Autoimmune Hepatitis?
Types:
- AIH 1: Positive ANA and SMA, Anti-actin, elevated in IgG
- AIH 2: Positive LKM-1 (Tyically female children/teenagers, rare in adults)
- AIH 3: Positive Soluble liver antigen antibodies.
Which ECG Leads and coronary artery supply the Lateral segment?
Lateral
I, aVL, V5, V6
Circumflex artery
Which ECG leads and coronary artery supply the inferior segment?
Inferior
II, III, aVF
Right Coronary Artery
Which ECG leads and coronary artery supply the Septal segment?
Septal
V1, V2
Left Anterior Descending Artery.
Which ECG leads and Coronary artery supply the anterior segment?
V3-V4
LAD
What are the diagnostic criteria of Type 1 Neurofibromatosis?
Two or more of the following:
- Six or more Cafe-au-last macules larger than 5mm (prepubertal) or 15mm (post-pubertal)
- two or more neurofibromas of any type or one plexiform
- axillary or groin freckling
- optic glioma
- two or more lisch nodules on the iris
- distinctive osseous lesion e.g. Sphenoid dysplasia, pseudo-arthrosis
- a first degree relative with Type 1 NF
What are the X-RAY features of Coal workers pneumoconiosis?
Multiple small round opacities typically 1-10mm in diameter mostly in the upper lobes
What are the X-RAY features of silicosis?
Multiple small nodules scattered throughout the lungs mainly upper zones and egg-shell calcification of the hilar nodes
What are the X-RAY features of berylliosis?
Progressive linear interstitial fibrosis of upper zones
What is the mechanism of hypercalcaemia in sarcoidosis?
1-alpha-hydroxylase is activated by macrophages in sarcoid granulomas and Converts 25-hydroycitamin D3 to 1,25 dihydroxyvitamin D3, the active form of the vitamin leading to absorption of calcium from the gut and increased renal calcium absorption from the distal tubule.
What are the types of WPW?
Type A which indicates a left sided accessory pathway, and show a dominant R wave in V1 and tall R waves and inverted T waves in V1-V3 mimicking right ventricular hypertrophy.
Type B indicates a right sided accessory pathway, there is a dominant S wave in V1 and tall R waves and inverted T waves in inferior leads and V4-V6 mimicking left ventricular hypertrophy.
What cardiac complications can occur in GBS?
Bradycardia or SVT
What are the indications for Digoxin Antibody?
Haemodynamic instability Life-threatening arrhythmias Serum potassium over 5 in acute toxicity Plasma digoxin level over 12nmol/L Ingestion of more than 10mg in adults and 4mg in children Recurrent bradycardia
Describe Myotonic Dystrophy, its types and features.
AKA dystrophia myotonica, an inherited autosomal dominant, myopathy with features developing at around 20-30 years old. It affects skeletal, cardiac and smooth muscles.
Types:
There are two main types DM1 and DM2.
- DM1 present with more distal weakness caused by trinucleotide CTG repeat at the end of DMPK gene on chromosome 19
- DM2 is more proximal, caused by a tetranucleotide repeat expansion of the (CNBP) ZNF9 gene on chromosome 3.
Symptoms:
-DM1 (Distal weakness, Autosomal Dominant, Diabetes, Dysarthria)
General Features: Myotonic fancies (long, haggard appearance), frontal balding, bilateral ptosis, cataracts, dysarthria, myotonia (tonic spasm of muscle), weakness of arms and legs, mild mental impairment, diabetes Mellitus, testicular atrophy, heart block, cardiomyopathy, dysphagia.
What is Oculomasticatory Myorhythmia?
Pathognomic of whipples
Pendular vergance oscillations of the eyes associated with simultaneous jaw contraction
What is the management of Angina?
- modify risk factors e.g. Stop smoking, encourage excercise, weight loss, control hypertension and diabetes.
- aspirin + statin
- sublingual glyceryl trinitrate for acute attacks
- b-blocker or Ca blocker first line
- consider dual therapy if fails
- if unable to tolerate the above dual therapy consider long-acting nitrat, ivabradine, nicorandil, or ranolazine.
- if steal symptomatic refer for PCI or CABG.
Which factors need to be considered when deciding between Percutaneous Mitral Balloon Valvotomy or Mitral valve replacement?
Most patients can be managed with Percutanous mitral balloon valvotomy unless they have contraindications such as:
- moderate to severe mitral regurgitation
- heavily calcified mitral valve
- Left atrial thrombus
- Concomitant coronary artery or other valve disease requiring surgery
In these groups patients should undergo mitral valve replacement
Describes Friedrich’s ataxia and its features.
Most common of the early-onset hereditary ataxias. Autosomal Recessive, trinucleotide repeat disorder characterised by a GAA repeat in the X25 gene on chromosome 9. Unusual in trinucleotide repeat disorders in not demonstrating anticipation.
Typical age of onset is 10-15yrs. Gait ataxia and kyphoscoliosis are most common presenting features:
Neurological features:
- Absent ankle jerks/extensor plantars
- Cerebellar ataxia
- Optic atrophy
- Spinocerebellar tract degeneration - Decreased vibration and proprioception, pyramidal weakness
Other features:
- HOCM (90%, most common cause of death)
- Diabetes Mellitus (10-20%)
- High-arched palate
- deafness
Which drugs can and cant be cleared by haemodialysis?
Drugs that can be cleared: BLAST
- Barbiturate
- Lithium
- Alcohol (inc methanol, ethylene glycol)
- Salicylates
- Theophyllines (charcoal haemoperfusion is preferable)
Drugs that cannot be cleared:
- Tricyclics
- Benzodiazepines
- Dextropropoxyphene (Co-Proxamol)
- Digoxin
- Beta-blockers
The presence of a supraseller calcified cyst is the radiological hallmark of which condition?
Craniopharyngioma
Which condition increase the risk of osteosarcoma?
Paget’s disease of the bone
Hereditary multiple ostochondromas
Retinoblastoma
Li-Fraumeni Syndrome
How long do patient need to be monitored post anaphylaxis?
12hrs. Most secondary reaction occur by 10hrs.
Which cancer is TRAP stain associated with?
Hairy Cell Leukaemia
Which cancer is associated with Sudan black B Stain and Myeloperoxidase?
Acute Myeloblastic Leukaemia
Which cancer is associated with Terminal deoxynucleotidyl transferase stain (TDT)?
Acute lymphoblastic leukaemia
Which cancer is associated with LAP stain?
Tends to be raised in Polycythaemia Rubra Vera and Myelofibrosis and decreased in chronic myeloid leukaemia.
What are the main causes of massive splenomegaly?
Chronic Myeloid leukaemia Malaria Leishmaniasis Myelofibrosis Gaucher's dIsease (Lysosomal storage disease)
