| MRCP 2 Practice Papers | Te etyMRCP format combines the previous three sections of case histories, data n and photographic material in multiple choice papers. The 3rd edition of this has been thoroughly revised and extended to reflect these changes. Lecture notes haematological tests, family trees and histology are again included; ranges of es have been added for reference. V Contains case histories, data interpretations and photographic material «“ V Questions in'best of five’ and'n’ from many format Answers, maximum marks and detailed teaching notes for every question in content and level of difficulty to current examination V Lecture notes on Biochemical tests, Family trees and Histological Stains prehensive Index for easy access to specific topics on Books and Intensive Courses PasTest has been established in the fi ‘evision books, pr Id of postgraduate medical education since 1972 providing tice exams, and intensive study courses for doctors preparing for their professional examinations. Books and courses are available for the following specialties: MRCP Parts | and 2, MRCPCH Parts | and 2, MRCS, MRCOG Parts | and 2, DRCOG, MRCGP, MRCPsych, DCH, FRCA and PLAB.MRCP 2 PRACTICE PAPERS Case Histories Data Interpretations and Photographic Material PASTEST Dedicated to your successFor Immy — who is going to teach me a thing or two. Cover Slides: 3*° Cranial nerve palsy Acute myocardial infarction Haemochromatosis Calcified pleural plaques and folded lung (asbestos) Barrett’s oesophagus ‘Acute lymphocytic leakaemiaMRCP 2 PRACTICE PAPERS Case Histories Data Interpretations and Photographic Material Hans-Ulrich Laasch Dr.med, MRCP, FRCR COOK Fellow in Interventional Radiology Academic Department of GI-Radiology South Manchester University Hospitals© 2003, PASTEST Egerton Court Parkgate Estate Knutsford Cheshire WA16 8DX All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the copyright owner A catalogue record for this book is available irom the British Library. The information contained within this book was oblained by the author from reliable sources, However, while every effort has been made to ensure its accuracy, no responsibilty for loss, damage or injury occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the publishers or author. PasTest Revision Books and Intensive Courses PasTest has been established in the field of postgraduate medical education since 1972, providing revision books and intensive study courses for doctors preparing for their professional examinations, Books and courses are available for the following specialties: MRCP Part 1 and Part 2, MRCPCH Part 1 and Part 2, MRCOG, DRCOG, MRCGP, MRCPsych, DCH, FRCA, MRCS, PLAB. For further details contact PasTest, Freepost, Knutsford, Cheshire WA16 7BR Tel: 01565 752000 Fax: 01565 650264 E-mail: enquiries@pastest.co.uk Web site: www.pastest.co.uk Typeset by Saxon Graphics Ltd, Derby Printed and bound in the UK by Page Bros Ltd, NorwichCONTENTS Preface to 3rd edition Preface to 2nd edition Preface Useful website addresses Index of Normal Ranges QUESTIONS Practice Paper 1 Practice Paper 2 Practice Paper 3 Practice Paper 4 ANSWERS Practice Paper 1 Practice Paper 2 Practice Paper 3 Practice Paper 4 Lecture notes on Biochemical tests in General Medicine Family Trees Histological Stains Revision Index vi vii viii 87 175 263 349 373 399 429PREFACE TO THE THIRD EDITION Further to the changes of the written parts of the MRCP exam, notably the removal of negative marking in Part 1 and the change to MCQ (‘Best of Five’) based. questions in Part 2A, there has also been a change in the content of the MRCP 2A papers. The exam is increasingly orientated around evidence based medicine, up- to-date patient management and current guidelines. This is a move away from the esoteric questions seen in the past and it makes a more useful exam. Candidates have said that a large proportion of questions could now be answered with adequate clinical experience, That does however mean that preparation for Part 2A needs te include the British Medical Journal, the Journal of the Royal College of Physicians and the Drugs and Therapeutics Bulletin, The candidates need to be aware of the latest guidelines regarding the treatment of bread and butter entities such as hypertension, diabetes and chronic chest disease. The bodies involved in these guidelines hesides the National Institute of Clinical Excellence (NICE) are the respective societies such as the British Thoracic Society and the British Society of Gastroenterology. Fortunately these are all now available on the internet and time is well invested in checking the headlines on the respective sites. A short list of these can be found on page ix. The first few of the new papers for Part 2A contained 70-75 questions, most of sshich consisted of a single stem. For each possible correct answer there are 5 possible options i.e. if the question asks for two differential diagnoses there will be ten possible answers. Remember the exam is not negatively marked, therefore all questions must be answered, but do not tick more than requested. If in doubt choose the answer that represents the logical next step in patient management as you would do with a patient in Accident and Emergency or the Outpatient department. Bear in mind this is an entry exam to higher medical training, and increasingly aiming to assess good patient management skills That does however not invalidate my motto from the previous editions: “Ubung macht den Meister!” So get practicing, For this particular edition | am indebted to my friend Ed Gamble, stroke physician South Manchester University Hospitals for his efforts to keep my medicine up-to-date. Good Luck HUL Many thanks also to those who have taken the trouble to send in comments. All feedback serves to improve the next edition.__PREFACE TO THE SECOND EDITION In 2001, the exam for the membership of the Royal College of Physicians remains in a state of change. The College is concerned to produce a fairer and more transparent exam. From next year negative marking for wrong answers in MRCP Part 1 will be removed, and the papers will be criterion referenced rather than peer relerenced, i.e. everybody of a certain standard will pass the exam, rather than a fixed fraction of the candidates. In Part 2, the written and the clinical section have been uncoupled. Once the written exam has been passed three attempts at the clinical part are allowed within a space of two years. Increasingly questions are of a modified multiple choice type. Particularly Case Histories are getting more complex and not only ‘one-of-five’ answers are seen, but several correct answers may be chosen from a selection of up to ten. More importantly, the number of questions in each section have increased. In the July 2001 paper the following number of questions were found in each section: 23 Slides, 14 Data Interpretations, 14 Case Histories. The time available for each section remained unchanged: Slides 50 minutes, Data Interpretations 45 minutes, Case Histories 55 minutes. As before each section carries approximately the same weight in the overall mark. In line with these changes the second edition has now been re- written and consists entirely of modified MCQ The clinical section of part HI has now changed to PACES (Practical Assessment of Clinical Examination Skills). There will no longer be a Viva and a Long Case, but Circuits of live stations with twenty minutes at each, The stations are 1. Short case chest and short case abdomen; 2. History taking; 3. Short case cardiovascular system and short case central nervous system; 4. Communications skills and ethics (e.g. obtaining consent and breaking bad news); 5. Short cases skin, locomotor system, eyes and endocrine. The latest information regarding changes to the exam is available from the following websites: MRCP website — www.mrcpuk.org, RCP website - www.rcplondon.ac.uk Hopefully these changes will reduce the number of people failing the exam however the most important factor in the preparation remains the same: Practice. | wish to thank my wife Rebecca for her continued support and remain grateful to my teachers, who have coached me through more than one attempt at MRCP. HUL viiPREFACE The second part of the MRCP examination has seen some interesting changes in 1999. Firstly, the number of attempts is no longer limited to six. Secondly, a multiple choice type format has been introduced in all three parts of the written exam (Slide, Data and Case History sections). We thought that this would make the questions easier to answer however, this is not so! Minor details in the history often onty discriminate between the two best possible answers. it must, however, be remembered that the exam is not negatively marked and it is therefore foolish lo leave any questions unanswered. Thirdly, a bare fail in the written part (9/20 marks) now only requires one extra mark to be gained in the clinical section, as opposed to the three marks previously required. In theory this should make the exam easier to pass, in practice the vast majority of candidates fail on the short cases. bare fail in the shorts (5/1@) or in the long case (4/8) still requires 3 additional marks from the other three parts, thus increasing the total pass mark to 27. The most important aspect for passing the exam is practice. This applies to the clinical part even more than for the written. First-timers do not usually realise that the 4-6 weeks between the written and clinical part is generally insufficient time to practise all the examination routines for heart, chest, abdomen, CNS, cranial nerves, legs... Reading material for the Viva, besides the BMJ editorials, should Drugs and Therapeutics Bulletin, CMOS-update and the Sunday papers include it must be remembered that the exam is set so that overall only 25-30% of all candidates pass. The most enthusiastic and knowledgeable teachers for MRCP often had three or four, or even all six attempts at the exam. Although the College is trying to make the exam more objective, a good portion of luck is required on the day. This book is an attempt to repay all the help | have received from my friends and consultants on my way to membership. A special thanks goes to Dr Datta- Chaudhuri and Dr Downton from the Care of the Elderly Department in Stockport. J also need to thank my wife for her patience as well as her continued input into this work. Finally, if there is one piece of advice that summarises my experience: There is no substitute for having seen or done it before. Best of luck HUL viiiUSEFUL WEBSITE ADDRESSES MRCP website wat nn phon The Royal Coftoue of Physicians, London wang, fe phannefon te th British Whoracic Society wine nih ic org British Cardiac Society weston British Society of Gasteventerafagy wren org.uk National Institute of Clinical Excellence: wane. nice.onp.uk Departnent of Heal (white papers and political issues) www .dohgow.uk Chiet Medic al Officer (CMO guidelines) waww.doh gov.ukemo British National Formulary (Library of drugs and therapy) wa. baton: Drugs and Therapeutics Bulletin (Evakzation of pharmacotherapy) www which.net{health/dtb The Society of Radiologists in Training wy. thesrtorg.uk Google search engine www.google.comINDEX OF NORMAL RANGES These are for reference only, for clinical use check with the local laboratory as ranges as well as units used vary. ACTH, supine Activated partial thromboplastin time (APTT) Adrenaline, urine Alanine amino transferase (ALT, GPT) Aspartate amino transferase (AST, GOT) Albumin Aldosterone supine [standing] Alpha-fetoprotein Aluminium Aminolaevulanic acid, urine [serum] Ammonia Amylase (assay dependent) Angiotensin I, [Angiotensin Il} Anion gap Antinuclear antibody Antitrypsin Aspartate aminotransferase (AST) Arterial blood gases © pH © 0. © pco. © Bicarbonate HCO") B, serum Bilirubin, total (conjugated) Bleeding time reactive protein (CRP) Caeruloplasmin Calcitonin Calcium, total fionised} Carboxyhaemoglobin, [smoker] Cardiac index Chloride, serum [CSF] Cholesterol © Total © HDL e {DL Clotting time (platelet rich plasma) Coeruloplasmin Complement C,1C,) 8-30 ng/l 20-355 <110 nmol/24h 5-40 UA 5-40 U/L 35-55 gil 0.08-0.27 |0.14-0.83} ng/l <10 umg!l 0,22-0.26 umol | 11-57 [1.1-1.8] pmol/24h 11-32 pmol <300 Lil 11-88 [10-60] ng/l 10-18 <1:20 dilution 0.82 g/l 10-40 UA 7.36-7.44 11-13 kPa (80-100 mmHg) 4,7-5.9 kPa (35-45 mmHg) 22-28 mmol/l 160-900 pmol/l 2-17 [<5] umol/l <7 min <10 mg/l 180-450 mgit <19 ng/l 2.2-2.6 [1.1-1.4] mmol/l <5% {< 15%] 2.44.2 minim? 95-110 [120-130] mmol/| 3.65-5.5 mmol/l > 0.9 mmolf| < 4.0 mmol! 100-150 sec 270-370 mg/l 0.7-1.3 [0.12-0.27] g/lCopper, serum [urine] Coproporphyrin, urine Cortisol, free, uring Cortisol, total, serum, 8am Creatinine Creatinine phosphokinase (CPK) CSF pressure D-Dimer Differential leucocyte count © Neutrophils © Lymphocytes © Monocytes © Eosinophils © Basophils Dopamine Erythrocyte sedimentation rate (ESR) Faecal fat, 3 day collection Ferritin, male [female] Fibrin degradation products (FDP) Fibrinogen S-hydroxyindolacetic acid (HIAA), urine Folate, RBC [serum] FSH, follicular phase ovulatory peak] Gamma-Gr Gastrin Globulin Glomerular filtration rate (GFR) Glucose [CSF] Growth Hormone (GH), 9am Haematoctit (Hk=PCV), male [female] Haemoglobin © Total Hb, male female! @ HbAl @ HbA2 @ HbF @ Hb @ HbS Haptoglobin HCG Homovanillic acid, urine Hydroxyproline, urine unoglobulins © Iga © gO © Ige © eG INDEX OF NORMAL RANGES 12.5-25 (0.05-0.5] 52-350 nmol/l 28-276 nmol/l 130-150 nmolil 50-120 pmol/l 20-149 U/l 50-180 mm HO. 20-400 pig’! 40-65% 15~45% 410% <4% <2% 425-2600 nmol/l 0-10 mm/h <7 g/24h 20-250 [10-120] g/l <10 ug/ml 15-591 5-75 mol/24h 130-630 [4-18] nmol/| <8 [6-26 U/| 5-30 U/l <100 pmol/l 22-35 gl 90-130mi/min 4.5-5.8 [2.2-3.9] mmolil 4-10 mu/ 40-55% [35-50%] 130-180 {110-160} g/t 95-98% 2-3% 1-2% 0% 0% 40-200 mg/dl <5 UA 8-48 mmol/24h 5-25mg/24h/m? 1-4 gi 0-0.08 gil <0,00025 g/l 15 g/l xiINDEX OF NORMAL RANGES © IgM 0.5-2.5 g/l Insulin, fice {reactive} <120 [40-170] pmolit fnsulin glucose ratio <03 hon 13-32 pmol fron saturation, male [female] 20-50% [75-50% Lactate (lactic acids 0.9-1.7 mmol Lactate dehydrogenase (LDH) 100-190 U/l Lead <1 pmol Lipase <160 U/l Luteinising hormone (LH), follicular phase [midcycle peak} <6 (16-104) Ul Magnesium, fasting 0.65-1.05 mmoi/! Mean corp. Valume (MCV) 80-95 fl Mean corp. Hb (MCH) 27-32 pg ‘Mean corp. Hb concentratrion (MCHC = MCH/MCV) 32-36 gidl Metanephrins, urine total <5 mol/l Methaemoglobnin <3% Noradrenaline, urine 90-475 nmolil Osmolality, serum 270-295 mOsm/kg estrogens, total male [female] 20-80 160-400] ng/t Parathyroid hormone, intact 10-65 ng/l Packed ell volume (PCV=Hk), male [female] 40-55% [35-50%] Phosphatase, acid, male 0-5.5 Uf Phosphatase, alkaline (ALP) 25-100 U/L Phosphate 0.8-1.5 mmol! Plasma viscosity (PV) 1.5-1.75 cp Plasma volume 40-50 ml/kg, Plasminogen, 100-300 mg/l Potassium (K+) 3.5-5.0 mmol/l Porphobilinogen, 24h urine 0.9-8.8 tmol/24h Pressure, CSF 50-180 mmH,O Pressure cardiac, diastole/systole © Right atrium 0/8 mmHg © Right ventricle 0/12 mmHg. © Pulmonary artery [mean] 5/30 [9-17] mmHg © Pulmonary capillary wedge pressure 5-15 mmHg, © Leftatrium 0/12 mmHg, © Left ventricle 5-140 mmHg. Progesteron, male [female] <5 [15-77] nmol/l Prolactin, non-pregnant ipregnant]} 0-20 [20-385] mg/l Protein, serum [CSF] 62-80 [0.15-0.4} g/l Prothrombine time (PT) 10-135 Prostate specific antigen (PSA) <1 mg/l Red cell volume (RCV) 20-30 ml/kg Renin, supine [standing] 3-19 {5-40} ng/l Renin activity, supine [standing] 0.5~1.6 [2-5x increase] jtp/l/hr Rheumatoid factor <1:16 xiiINDEX OF NORMAL RANGES ee eS — Secretin Sex hormone binding globulin, male {female} Sodium (Na*), serum jurine} Testosterone, total, adult male [female] Thyrotopin (TSH) Thyroxoine (T,), total fire] Total iron binding capacity Total blood volume Total red cell volume O'CT or ¥°TO) Total piasma volume (Falbumin) Total protein Triglycerides Triiodothyronine (13), total free} Troponin 1 / Troponin T Urea Uric acid Urine microscopy © Red cells @ White cells Urobilinogen, 24h urine Uroporphyrine, 24h urine, male [female] Vasoactive intestinal polypeptide (VIP) Vanillinmandelicacid, urine 12-75 neil 17-52 [35-104] nmoifl 132-144 [60-160] mmol! 12-30 {0.7-2.6] nmol! 0.5-5.5 mull 75-150 nmol/l (10-29 pmol! 45-75 mmol 60-80 miskg 22-35 millkg, 40-50 ml/kg 62-80 gl <2.3 mmoi/l 1.5-3.0 nmolii [4~7.4 pmol/l] <0.1 ng/ml 2.5-7.5 mmol/l <420 umol/l <5 (ul <10 0.5-4.0 U/l <55 [<26] nmol/24h <20 pmol/l 10-35 pmol/24h xiii