few but very important last minute MRCP facts

1. Osteoporosis is the most common cause of fracture of neck of femur

and is not associated with any specific abnormality in the standard
bone biochemistry profile.
2. Fibrosing alveolitis is the most common pulmonary manifestation of
rheumatoid arthritis.
3. impairment in renal function in Hepatorenal syndrome The hallmark is
oliguria and progressive decline in renal function. The urine is
typically free of protein or any other sediment.
4. Long-term haemodialysis is associated with carpal tunnel syndrome. is
the most common complication
5. the most likely cause of bacterial meningitis in adult patients with
neutropenia :
Listeria monocytogenes.
6. the most frequent cause of a nosocomial wound infection: Insufficient
hand disinfection
7. **Tuberculous arthritis usually affects children aged 25 years. The
hip is one of the most frequently affected joints.
8. **Meningitis due to enterovirus and meningococcus (N. meningitidis)
are the most likely in this age group(28 yrs0
9. **Tuberculous meningitis is rare in the UK and the CSF typically
shows a markedly raised protein (> 1 g/l), a low glucose (< 50%
serum) and a lymphocytosis.
10. **Streptococcus meningitis is the commonest cause of meningitis in
those over 40 years of age; very high neutrophil counts are often seen
in the CSF, which has a high protein and low glucose level.
11. **Factors predisposing to digitalis toxicity are advanced age, hypoxia,
hypokalaemia, hypomagnesaemia, hypercalcaemia, hypothyroidism,
amyloidosis and renal failure. The most common precipitating factor is
hypokalaemia.
12. ** In Hodgkins disease Lymphocyte depleted has the worst prognosis.
It is the least common variant and typically occurs in older people.
13. **The commonest mutation in patients with cystic fibrosis (CF) is the
Delta-F508 mutation.

14. **in systemic lupus erythematosus Recurrent pleurisy and pleural

effusions are the most common manifestations and are often bilateral
15. **Cryptosporidium infection in HIV-positive patients along with
cytomegalovirus, is the commonest cause of HIV-related diarrhoea and
tends to present when the CD4 count is less than 100.
16. **Diarrhoea and flushing, occurring separately or together, are the
most frequent presenting features of carcinoid syndrome
(approximately half of all patients).
17. **Focal necrotising glomerulonephritis is the characteristic renal
lesion of generalised Wegeners granulomatosis. Typically, it presents
with deteriorating renal function that progresses to renal failure within
3 months,
18. **Glomerulonephritis is a common occurrence in chronic Schistosoma
mansoni infection in Brazil, especially in patients with hepatosplenic
disease
19. **Tremor in the legs is a useful sign as it is almost always associated
with idiopathic Parkinsons disease. The tremor is typically a rest
tremor unlike benign essential tremor, where actions such as drinking a
cup of tea make the tremor worse.
20. **Pericardial effusions are more common in patients with rheumatoid
arthritis than constrictive pericarditis and acute pericarditis.
21. **The earliest lesions to be detected in diabetic retinopathy are usually
dot haemorrhages (capillary microaneurysms) and venous dilatation.
22. **Hypertrophic cardiomyopathy is the single, most common cause of
sudden death in young athletes.
23. **the most common cause of paranoid psychosis with visual
hallucination :Alcohol withdrawal
24. **Basal cell carcinomas are the most common malignant skin tumour
and are related to excessive skin exposure. They are common later in
life and may present as a slow-growing nodule or papule.
25. **The most common type of thyroid cancer is papillary cancer, which
accounts for approximately 70% of all thyroid cancers
26. ***Open angle glaucoma is 100 times more common than angle
closure glaucoma, and is asymptomatic until central visual loss appears
at the end stage.
27. **a high white cell count with smear cells and mature lymphocytes.
This is characteristic of chronic lymphocytic leukaemia...

28. **Chronic lymphocytic leukaemia

Constitutes 25% of all leukaemias. It is chiefly a disease of the
elderly
It is characterised by an accumulation of mature lymphocytes in the
peripheral blood, bone marrow, spleen, liver and lymph nodes
Clinical findings include painless, symmetrical lymphadenopathy,
hepatosplenomegaly, pruritus and symptoms due to bone marrow
failure
Blood film will show large numbers of mature lymphocytes and
smear or smudge cells. Anaemia and thrombocytopenia are common
Hypogammaglobulinaemia is common and monoclonal paraproteins
are occasionally seen
Staging is by the Binet or Rai systems and depends on number of
areas involved and full blood count results
Median survival is 35 years and one-third die of causes other than
the leukaemia
In early stages no treatment is required. In later stages and in rapidly
progressive disease treatment is with oral or intravenous chemotherapy
such as chlorambucil or fludarabine. Stem cell transplantation is an
option in younger patients
29. **IgG is the most common paraprotein in myeloma.
30. **Myeloma
Median age of diagnosis is 70 years
Diagnosis is made in the presence of two of monoclonal protein in
blood or urine, 10% plasma cells in bone marrow and lytic bone
lesions
Other clinical features are bone disease, hypercalcaemia, renal failure,
bone marrow failure and immune paresis
5 year survival is only 25%
Treatment is supportive, chemotherapy (which can be oral or
intravenous) and autologous or allogeneic stem cell transplantation
Thalidomide has recently been used in relapsed and refractory disease
31. ***Adrenergic inhibitors used in hypertension:
Peripheral neuronal inhibitors: Reserpine, Guanethedine
Central adrenergic inhibitors: M-dopa, Clonidine, Guananbenz,
Guanafacine
Alpha-receptor blockers:
o Alpha 1 and 2 receptor blockers: Phenoxybenzamine, phentolamine
o Alpha 1 blockers: Doxazosin, Terazosin
Beta blockers
Alpha and beta blockers: Labetalol
32. **Polycythaemia rubra vera:
Splenomegaly
Aquagenic pruritus
Bleeding
Gout

 Peptic ulcer
Conversion to myelofibrosis or leukaemia in 10%
33. **Causes of Chorea
Neurodegenerative: Huntingtons disease
Benign hereditary chorea
Dentatorubropallidoluysian atrophy
Inherited metabolic: Wilsons disease
Lesch-Nyhan disease
Neuroacanthosis
Hypoxic/ischaemic: Stroke
Hypotension
Vasculitis Sickle cell disease
Polycythaemia
Toxic: Copper
Mercury
Drug induced: Oral contraceptive pill
L-Dopa
Neuroleptics
Anticholinergics
Cocaine
Amphetamines
Infection: Sydenhams chorea
Meningitis
Viral encephalitis
Mycoplasma pneumoniae
Legionella
Toxoplasmosis
Creutzfeld-Jacob disease
Autoimmune: SLE
Primary anti-phospholipid syndrome
Vasculitis Behcets
Hashimotos thyroiditis (unrelated to hyperthyroidism)
Endocrine: Thyrotoxicosis
Chorea gravidarum
Addisons disease
Metabolic: Hypocalcaemia
Hypomagnesaemia
Hyper/hypoglycaemia
Hyper/hyponatraemia
34. **Causes of sudden cardiac death
Arrhythmia
-Acute myocardial infarction
-Long-QT syndromes
-Hypertrophic cardiomyopathy
-Commotio cardis
-Coronary anomalies
-Myocarditis
Obstruction

-Atrial myxoma
-Infective endocarditis
-Dissection
35. **In Hypertrohpic Cardiomyopathy
Combination of palpable LVS4 and then double systolic apical
impulse due to the mid systolic outflow obstruction
It increases in phase II of the valsalva maneouver (the straining
phase) and decreases in phase IV (post release phase)
Severe diastolic dysfunction
Children have a worse prognosis than affected adults because of
greater incidence of SCD
As in severe AS (because of greater myocardial oxygen demand)
36. **5 histological stages have been described (WHO Classification) and
treatment depends on this. There is a lack of clear correlation between
clinical manifestations and the severity of renal involvement. Biopsy
findings guide the selection of immunosuppressive therapy.
WHO Classification of Lupus Nephritis
Stage I V Lupus nephritis without histological changes
Stage II V Mesangial lupus nephritis
Stage III V Focal proliferative lupus nephritis
Stage IV V Diffuse proliferative lupus nephritis (commonest & most
severe form)
Stage V V Membranous lupus nephritis
Conditions that recur in the transplanted kidney
Focal glomerulosclerosis
Mesangiocapillary glomerulonephritis
Rapidly progressive (Crescentic) glomerulonephritis
IgA nephropathy
Alports syndrome
Cystinosis
Oxalosis
Lupus nephritis
Goodpastures syndrome
Wegners granulomatosis

**The most common renal disease in HIV is collapsing FSGS in which

there is focal sclerosis associated with collapse down of the glomerulus
leaving a space in Bowmans capsule. It has a poor prognosis and
usually leads to ESRF.

37. **The indications for a native nephrectomy prior to renal transplant

are:
1. Uncontrolled hypertension where a differential renin study shows
that one or the other kidney is significantly contributing to
hypertension
2. Pyonephrosis
3. Recurrent attacks of clinically significant UTI
38. **Budd Chiari classically results in a very high protein ascites but may
cause a transudate.
39. **Transudates (protein < 30gdl or 75% of the serum albumin) are due
to:
- Reduced intravascular oncotic pressure (hypoalbuminaemia)
- Increased intravascular hydrostatic pressure (cirrhosis, portal
hypertension, CCF)
40. **Teaching Notes for Question 15
Theme: Pancreatic Secretion
The roles of individual gut hormones are not completely defined, but
cholecystokinin (duodenum & jejunum) increases gall bladder
contraction, increases colonic motility.
Gastrin (gastric antrum & duodenum) increases gastric acid
secretion,increases GI mucosal growth.
Secretin(duodenum & Jejunum) increases pancreatic bicarbonate
production.
VIP(enteric nerves)increased intestinal secretion, splanchnic
vasodilation.
Motilin(whole gut) increases small bowel motility.
Bombesin (gut & Pancreas)stimulates pancreatic exocrine activity.
Neuropeptide Y (enteric nerves)regulates intestinal blood flow.
Somatostatin (stomach & pancreas) inhibits secretion and action of gut
hormones.
Glucagon(pancreas)reduces GI motility
41. **In systemic lupus erythematosus (SLE). Joint involvement is the
most common clinical feature (> 90%).
42. **Prolactinoma is the commonest pituitary tumour, making up 30% of
all adenomas. Microadenomas occur with increasing frequency in
women, macroadenomas more commonly in men.
43. **ASDs account for about 10-15% of all congenital cardiac anomalies
and are the second commonest congenital heart disease seen in adults.
44. **VSDs are the commonest adult congenital heart disease.

45. **Frontal lobe dementia------>a failure to generate list rapidly is the

test of frontal lobe+difficulties with task sequencing and executive
skills. EXPRESSIVE aphasia, primitive reflexes, perseveration,
anosmia and changes in personality.
Parietal lobe--------------->Dyscalculia(inability to perform
mentalarithmetic) is a manifestation of the dominant parietal lobe
Sensory inattention, apraxia, neglect, astereognosis(unable to recognise
an object by feeling it) and visual field defects( typically homonymous
inferior quadrantanopia).
Temporal lobe-----------> typical homonymous superior
quadrantanopia), Wernike's (RECEPTIVE) aphasia, auditory agnosia,
and memory impairment
Occipital lobe---------->cortical blindness(blindness due to damage to
the visual cortex and may present as Anton syndrome where there is
blindness but the patient is unaware or denies blindness), homonymous
hemianopia, and visual agnosia( seeing but not percieving objects - it is
diffirent to neglect since in agnosia the objects are seen and followed
but cannot be named).
Homonymous hemianopia----------> occipital lobe
superior quanranopia---------------->temporal lobe
inferior quanrtanopia------------------->parietal lobe
46. **AUTOIMMUNE ASSOCIATIONS
Thyroid disease, IDDM, Addison disease, pernicious anaemia,
alopecia, vitiligo.
MULTIPLE ENDOCRINE NEOPLASIA
Autosomal dominant. The association of a number of endocrine
tumours.
MEN I MEN IIa
Parathyroid Adrenal (phaeochromocytoma, Cushing)
Pituitary (prolactin or GH or ACTH) Thyroid (medullary carcinoma)
Pancreas Parathyroid hyperplasia
(Thyroid)
(Adrenal)
Fasting calcium level (??) Calcitonin level ? (medullary ca. thyroid)
Look for phaeochromocytoma

MEN IIb is the same as MEN IIa, with Marfanoid features and
multiple neuromas.
Prophylactic total thyroidectomy is performed if the child is known to
carry the gene for MEN II.

47. **Adrenergic inhibitors used in hypertension:

Peripheral neuronal inhibitors: Reserpine, Guanethedine
Central adrenergic inhibitors: M-dopa, Clonidine, Guananbenz,
Guanafacine
Alpha-receptor blockers:
o Alpha 1 and 2 receptor blockers: Phenoxybenzamine, phentolamine
o Alpha 1 blockers: Doxazosin, Terazosin
Beta blockers
Alpha and beta blockers: Labetalol
48. **Mixed connective tissue disease (MCTD) is an overlap connective
tissue disease with features of SLE, polymyositis and progressive
systemic sclerosis. The characteristic auto-antibody pattern is of high
titre anti-RNP and speckled pattern ANA.
49. **The antiphospholipid syndrome is one of the commoner causes of
hypoadrenalism and may precipitate adrenal infarction and haemorrage
through adrenal vein thrombosis.
50. **Biphasic high amplitude sharp waves are characteristic of ceutzfeldjacob disease.
51. **Causes of dilated pupils: Holme's adie(myotonic pupils)
Third nerve palsy
drug poisons(atropine, CO, Ethylene glycol)
Causes of small pupils : horner;s syndrome
old age
pontine haemorrhage
Argyl Robertson pupil
Drug poisons(opiate, organophosphate)
52. **Optic neuropathy------------->central scotoma.
Optic tract lesion--------------->incongrous homontmous hemianopia.
Chiasmal lesion---------------->bitemporal hemianopia.
optic radiation and occipital lobe---------------->congrous hemianopia.
53. **Listeria meningitis is typically associated with brain stem signs. CSF
shows neutrophilic pleocytosis, low glucose and high protein.
54. **Nystagmus is defind as involuntary oscillations of the eyes.
THis may be
1-Pendular: when the oscillations are equal in rate and amplitude.
2-Jerking: when there are quick and slow phases(the quick phase is
used to define the direction).
pendular nystagmus is usually duee to loss of macular vision, but
maybe seen in diffuse brain stem lesions.
jerking nustagmus which is of constant direction regardless of the
direction of gaze, suggests a labyrinthine or cerebellar lesion.

Nystagmus which changes with the direction of gaze suggests a

widspread central involvement of vestibular nuclei.
Jerking nystagmus present only on lateral gaze, and who's fast
component is in the direction of gaze, indicates a lesion of brain stem
or cerebellum.
Nystagmus confined to one eye suggests a peripheral lesion of the
nerve or mucsle, or a lesion of the mediallongitudinal bundle.
Nystagmus restricted to the abducting eye on lateral gaze(ataxic
nystagmus) is due to a lesion of the medial longitudinal bundle
between the ponds and midbrain as in MS.
Nystagmus occuring on upward gaze with the fast component
upwards( upbeat nystagmus) maybe due to a lesion in the mid-brain at
the level of the superior colliculus.
Downbeat nystagmus(fast phase downward) suggests a lesion in the
lower part of the medulla. It's therefore, typical of the Arnold Chiari
malformation.
**Causes of absent ankle reflexes and extensor plantars:
subacute combined degeneration of the cord
syphilitic taboparesis
friedreich's ataxia
motor neuron disease
**Bicuspid aortic valve is perhaps the most common form of
congenital heart disease in adults(1-2% of population).
55. **hyporeflexia is a common clinical sign in patients with
hypercalceamia. Biphosphanates inhibit bone resorption and are the
first line pharmacological treatment of hypercalceamia of malignancy.
56. **Premature epiphysial closure is a classical finding of CAH.
57. **Flecainide is the drug most likely to restore sinus rhythm in atrial
fibrillation.
58.
**Lithium can produce Diabetes Insipidus and hypercalceamia.
59. **Constrictive pericarditis produces an elevated JVP, with prominent x
& y descent.Pulsus paradoxus occurs less frequently than in
tamponade.

60. **Streptococcus bovis is a normal commensal of the GI tract.

However, S.bovis bactereamia and endocarditis has a strong
association with GI malignancy.
61. **Neisseria meningitidis( Gram negative diplococci)
Streptocuccus pneumonia(gram positive diplococci)
Rx:
gram stain unavailable: cefotaxime+- ampicillin
g +ve cocci: Cefotaxime +vancomycin( S.pneumonia)
G +ve bacilli:Ampicillin +gentamicin.(listeria)
G -ve cocci: Benzyl penicillin.(N.meningitidis)
G -ve bacilli: Cefotaxime + gentamicin(heamophilus influenza)
62. **Anaplastic carcinoma carries the worst prognosis in thyroid cancer
followed by thyroid medullary carcinoma in MEN 2B.\
63. **ANCA ab are of 2 types:
1- C-ANCA which correlates with antiproteinase 3 antibodies--->most
specific for wegener's granulomatosis.
2- P-ANCA which correlates with anti myeloperoxidase ab. PANCA/MPO ab. are highly sensitive and specific for rapidly
progressive glomerulonephritis and haemorrhagic alveolar capillaritis.
AMA ab--------> PBC
Anticentromere ab.--------> CREST/scleroderma syndrome
ANA and anticardiolipin ab.----------->SLE.
**Clozapine is associated with agranulocytosis in app.1-2% of patients
64. **Acute pancreatitis with worse prognosis:
Age>55
WCC>16,000
LDH>600
AST>120
Glu>10
65. **Pendred's syndrome
Pendred's syndrome is a rare autosomal recessive condition
characterised by incomplete oxidation of trapped iodide prior to
organification.
It may be confirmed by a positive perchlorate discharge test.
66. **Anti 21 hydroxylase ab. found in about 80% of cases of addison's
disease.

67. **SSRIs are a recognised cause of SIADH.

68. **Astimulatory mutation of thr Gs protein alpha subunit has been
noted in approx.30% of GH secreting pituitary tumours.
69. **Carcinoid tumours of the foregut unlike tumours of the midgut are
not associated with carcinoid syndrome but may secret CRF/ACTH
resulting in ectopic cushing's syndrome.Other associated conditions
include somatostatinoma, Zollinger -Ellison syndrome and
Acromegaly.
70. **The antiphospholipid syn. is one of the commoner causes of
hypoadrenalism and may precipitate adrenal infarction and
haemorrhage through adrenal vein thrombosis.
71. **Osteopenia is defined as a T score of between -1 and -2.5 standard
deviation below the bone mineral density of a young
female.Osteoporosis is defined as <2.5 SD.
72. **bcl-2 is an inhibitor of apoptosis.
fas and caspases promote apoptosis but are nottumour supressor genes
p53 is a tumour supressor gene that inhibits mitosis and promotes
apoptosis.
ras is oncogene.
73. **Congenital adrenal hyperplasia is autosomal recessive disorder.
74. **beta blockers are the mainstay of treatment in long QT interval. The
most commonly used drugs are propranolol and nadolol.
75. **pulmonary complications of reumatoid arthritis"
Fibrosing alveolitis
pleural effusions
empyema
cryptogenic organising pneumonia
bronchiectasis
pulmonary ndules
76. **Fetal alcohol syn., Down's syn., and congenital rubella syn. are ass.
with an ASD(Loud 2nd sound plus fixed splitting.
77. **VIP
Achlorhydria
profuse diarrhea
hypokalaemic acidosis
hyperglycaemia
78. **Cavitations on pulmonary x ray:
squamous cell carcinoma
abscess(staph. aureus, Klebsiella, and pseudomonas aeruginosa0

lymphoma
rheumatoid nodule
pulmonary infarction
wegener's granolumatosis
79. **p-ANCA is present in approx. 70% with UC and less than 20% of
Crohn.
85% of untreated subjects with wegener's will have c-ANCA
80. **prerenal failure:
urinary Na<20
urine osmolality> 500
urine/plasma ratio>8and
urine/plasma creatinine >40\
Renal failure:
Na>40
osmolality urine<350
U/P ratio<3
U/P creat.<20
81. **Vitamin D resistant rickets is x linked dominant.
82. **infection is the commonest cause of death in multiple myeloma.
83. **Antimicrosomal antibodies------>Hashimoto's thyroiditis
84.
**Behchet's disease is associated with HLA B5
85. **Venous beading, loops and soft exudates(cotton wool spots) are
ccharacteristic of preproliferative retinopathy.
Microaneurysms, Hard exudates and Macular edema suggests
background diabetic retinopathy
New vessels suggests proliferative retinopathy.
86. **Hexosaminidase A deficiency is ass. Tay-Sachs disease
Sphingomyelinase deficiency ->Nieman-Pick disease
Arylsulphatase-A Def. ass. with metachromic leucodystrophy
Iduronidase def. ass. with Hurler's syn.
B-glucosidase def.--->Gaucher's disease.
87. **Methotrexate is a well known cause of acute pneumonitisand
interstitial lung disease.
88. **Clopidegrol prevent platelet aggregation through antagonism of the
ADP receptor.

89. **Patients with painful, isolated third nerve palsy with pupillary
involvement are assumed to have posterior communicating artery
aneurysm until proven otherwise.