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MRCP PART 1 EXAM AND ANSWERS
Pregnancy and Thyroid Hormone - answer-Pregnancy increases the amount of TBG (thyroid
binding globulin) so increases the total thyroxin levels but not free thyroxine
Hyperthyroid in pregnancy - answer-Untreated - fetal loss, premature labour, maternal heart
failure
Graves disease most common
HCG can activate TSH receptors - transient gestational hyperthyroid - these fall in trimester 2 &
3
treatment - propylthiouracil in first trimester
this can cause hepatic injury
carbimazole in 2nd trimester once lower risk of congenital abnormalities
Monitoring - free thyroxine levels should be kept upper third normal so to avoid fetal
hypothyroid
- thyrotrophin receptor stimulating antibodies should be checked weeks 30-36
DO NOT - block and replace or use radioiodine.
Hypothyroid in pregnancy - answer-Thyroxine replacement is safe in pregnancy and
breastfeeding
TSH measured each trimester and 6-8 weeks post partum
Women often require an increased dose - up to 50% by weeks 4-6
untreated - developmental abnormalities, miscarriage, still birth, low birth weight, pre-eclampsia,
anaemia
Gentamicin - answer-Aminoglycoside antibioitic
Given IV or topically
Ototoxic - irreversible due to auditory or vestibular nerve damage
Nephrotoxic - causes tubular necrosis, accumulates in renal failure requiring increased
monitoring, furosemide increases this risk
CI - Myasthenia Gravis
Dosed via height and weight and renal function. Peak and trough levels monitored with dose
adjustments based on trough levels
CSF: Protein levels - answer-normal = 0.2-0.4 g/L
Causes of raised CSF protein
GBS
Froin's syndrome - a spinal canal blockage characterised by xanthochromia, raised protein and
CSF hypercoagulability
TB, bacterial or fungal meningitis
viral encephalitis
Vigabatrin - answer-Irreversibly inhibits GABA transaminase-->increased GABA levels in
synapse
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Uses = tx infantile spasms (Viga"Baby"trin)
Or used as adjunct therapy for adults with refractory complex partial seizures
SE = visual field constriction and even visual loss in 40% of patients- visual fields must be
checked every 6 months as visual loss can be irreversible
Tricuspid regurgitation - answer-Signs: pansystolic murmer, parasternal heave, giant V waves,
pulsatile hepatomegaly
causes: IVDU endocarditis, rheumatic heart disease, right ventricle infarction, pulmonary
hypertension, carcinoid syndrome, epsteins anamoly (rare heart defect that causes tricuspid
regurg)
Corticosteroid side effects - answer-COME IN PIGG
Cushings
opthalmic - glaucoma, catterachts
M - musculoskeletal - OP, proximal myopathy, avascular necrosis
Endocrine- hyperglycaemia, weight gain, hirsuitism, high lipids
Immunosupression
Neutrophilia
Psychiatric - mania, psychosis, insomnia, depression
Intracranial hypertension
Gastric - pancreatitis, ulcers,
Growth suppression in kids
Acne - Systemic glucocorticoids can cause drug-induced acne. This is characterised as
monomorphic papular rash without comedones or cysts. This does not respond to acne treatment
but improves on drug discontinuation
Therapeutic Steroids - answer-Fludocortisone - mostly mineralocorticoid
hydrocortisone - some glucocorticoid, some mineralocoticoid
Dexamethsone - high glucocorticoid
Medication overuse headache - answer-Headache for over 15 days a month, whilst taking regular
analgesia
triptans and opioids are highest risk
very common, can affect 1/50 people
management - stop simple analgesia and triptans, wean down any opioids
the headaches may initially worsen before getting better in severity and duration
other withdrawal symptoms - anxiety, vomiting, restlessness, sleep disturbance, tachycardia,
hypotension
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Multiple Myeloma - answer-malignant tumor of plasma cells in the bone marrow
Peak age 60-70s
Presentation: Signs of hypercalcaemia, including confusion, bone pain and fractures, renal
failure, lethargy, infections,
Ix - high calcium, low phosphate, high total protein, high Cr or low EGFR
Further Ix - Bence Jones proteins, whole body MRI, bone marrow biopsy
Dx- one major and one minor criteria OR 3 minor +signs and symptoms
major criteria are based on bone marrow: Plasmacytoma (as demonstrated on evaluation of
biopsy specimen)
30% plasma cells in a bone marrow sample
Elevated levels of M protein in the blood or urine
minor: 10% to 30% plasma cells in a bone marrow sample.
Minor elevations in the level of M protein in the blood or urine.
Osteolytic lesions (as demonstrated on imaging studies).
Low levels of antibodies (not produced by the cancer cells) in the blood.
Investigation of HTN - answer-clinic measurement >140/90 -> offer home BP monitoring or
ambulatory
if >150/95 - stage 2 HTN - treat everyone
if >135/85 - stage 1 - treat if under 80 AND one of - renal disease, diabetes, cardiovascular
disease, signs end organ damage or 10 yr CV risk >10%
Management HTN - answer-lifestyle: low Na diet, less caffeine, exercise, weight loss, balanced
diet, stop smoking, reduce alcohol
Pharmocotherapy
If <55 or T2DM - A, then A+C or A+D, then A+C+D, then if K <4.5 add spiro, if >4.5 add alpha
or beta blocker
If >55 or black - C, then C+A or C+D, then A+C+D, then as above
if on 4 drugs and not controlled: specialist referral
(A = ACE inhibitor or ARB, C is calcium channel blocker, D is thiazide diriuretic)
Target - <80 - 140/90 in clinic, 135/85 at home
> 80 - 150/90 in clinic, 145/85 at home
Plummer-Vinson syndrome - answer-Dysphagia due to oesophageal webs
glossitis
iron deficiency anaemia
treatment - iron replacement and dilation of the webs via OGD
Behcets - answer-Behcet's syndrome is a complex multisystem disorder associated with
presumed autoimmune-mediated inflammation of the arteries and veins. The precise aetiology
has yet to be elucidated however.
The classic triad of symptoms are
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oral ulcers, genital ulcers and anterior uveitis
Epidemiology
more common in the eastern Mediterranean (e.g. Turkey)
more common in men (complicated gender distribution which varies according to country.
Overall, Behcet's is considered to be more common and more severe in men)
tends to affect young adults (e.g. 20 - 40 years old)
associated with HLA B51
around 30% of patients have a positive family history
Features
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
In severe cases: vision loss and stroke
Diagnosis
no definitive test
diagnosis based on clinical findings
Difficult to diagnose - CRP/ESR may only be mildly elevated
positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with
small pustule forming)
Thyroid Cancer - answer-70% papillary - often young females, excellent prognosis
20% follicular - usually single nodule
5% medullary - medullary C cells, secrete calcitonin, part of Men 2
1 % anaplastic - elderly females, locally invasive, highly aggressive, poor prognosis (5yr 7-
14%), resect if possible, mostly palliative with radiotherapy
lymphoma is rare (association with hashimotos/autoimmune thyroiditis)
mx papillary and follicular - total thyroidectomy, radioiodine then year thyroglobulin tests
Papillary carcinoma - Usually contain a mixture of papillary and colloidal filled follicles.
Histologically tumour has papillary projections and pale empty nuclei. Seldom encapsulated.
Lymph node metastasis predominate. Haematogenous metastasis rare
Follicular adenoma - Usually present as a solitary thyroid nodule. Malignancy can only be
excluded on formal histological assessment
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