Faraz pearl’s MRCP Part-II First

Edition
Volume
-2

By Faraz Ahmed

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 FARAZ PEARL’S
MRCP PART-II
VOLUME-2

For MRCP PART-II,FCPS PART-II,IMM BY DR FARAZ AHMED

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MEDICINE,PLAB,FINAL YEAR
2
MEDICINE,RESISEDENCY TESTS IN MEDICINE
Faraz’s
Pearls for MRCP PART-II
VOLUME -II
MRCP (UK)

Copyright ©2020

All rights reserved

No part of this application may be reproduced, printed or transmitted in any for or by any means,
Electronics of mechanical, including photocopying ,recording or any information storage or retrieval
System without permission in writing from the publisher.

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 Dedicated To

MY FATHER
DR: Ghulam Yaseen ,my sweet brothers
Fayaz hussain and Riaz hussain ,My friends
and my teachers who have always
encouraged me .

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 Contents
1.HOW TO PREPARE FOR MRCP PART- II………………….8

2. NEUROLOGY…………………………………………………………...14

3.PULMONARY ……………………………………………………………42

4.GIT+HEPATOLOGY…………………………………………………..76

5.CARDIOLOGY ……………………………………………………………113

6.NEPHROLOGY ……………………………………………………………………..141
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 Contents
7.HAEMATOLOGY ………………………………………………………166

8.ENDOCRINOLOGY…………………………………………………….194

9.RHEUMATOLOGY………………………………………………………220

10.INFECTIOUS DISEASE ………………………………………………243

11.DERMATOLOGY………………………………………………………..269

12.PHARMACOLOGY &TOXICOLOGY………………………….293

13.PSYCHITARY ………………………………………………………………325

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 Contents
14.ONCOLOGY……………………………………………………………..348

15.OPTHALMOLOGY…………………………………………………..370

16.PAST PAPERS……………………………………………………………387

17.UPDATED GUIDELINES …………………………………………417

17.QUESTIONS DISTURBATION PART-II……………………545

18 .HOW TO ATTEMPT PAPER …………………………………..547

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 How to prepare for MRCP
part-II
Duration required : if your score is very high
in part-I then 5 month is enough,
if your score is low in part -I then 6-8 month...
Sources: Theory books:
what ever theory books you read in part I .
Faraz’s pearls for Mrcp (very much important
during last of your exam ).

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Q banks :
Pass medicine :read at least 1.5 times
Pass test :read it once
On examination :read only those chapters in
which you are weak
Faraz’s pearls read it twice ,it will cover all your q
banks and past papers

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 Past papers :
 Solve at least previous eight years past papers
 Images :
 Radiology =Your Q banks and Google is enough
search every picture from Google.
 Dermatology =DermNEt NZ website, Google Q
banks.
 Rheumatology : use Google and q banks
 Echo :Google, data interpretation by Philip hughes
and sanjay Sharma (read sanjay Sharma first to
understand about Echo )
 Respiratory volume loops questions :sanjay
Sharma and data interpretation by Philip hughes .

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ECG :
do Hampton 150 cases and LITFL ECG library
website
Data interpretation by Philip Hughes:
Solve each chapter data questions from this
book.
Faraz’s Mrcp visuals :
This book has all images collected ,u can skip
above image books if u read only this.

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Sample paper :
Solve 10 days before your exam,this will tell you
whether u pass or not.
 Cover topics which feel you are weak in last 10 days .
 Remember success comes to those who work hard for it, sit it
in chair stop your breadth ,life after your success is beautiful
and loving.
 good luck 

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 How to study this book?
• Read any chapter from your theory book/ Q bank first
,then Read same chapter from Faraz pearls(all volumes as
all Volumes contain more than 300 pearls for each chapter )
and add if any point u think must be there .
• Do this for all chapters by this you will read full Q banks (1st
revision ,2nd revision by reading my pearls sometime )
• by doing this your main points are ready in Faraz pearls
book which you can repeat twice thrice or 4th time ,by this
u can memorize everything in very short time before your
exam ..
• It's smart and very effective way to grip things before exam

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 Neurology Pearls

NEUROLOGY PEARLS
 Expert in anything was once beginner.

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FARAZ’S PEARLS FOR MRCP VOLUME 2
 1.In GBS when FVC below 1.5 then next step is = ITU (came in
diet-2 2018)

 2.Upper respiratory tract infection /pain around shoulder

NEUROLOGY PEARLS
severe + pain resolves weakness in muscles innervated by C5-
C6 +high csf protein is = neuralgic amyotrophy

 3.Treatment of neuralgic amyotrophy is : Conservative self

limiting.

 4.100% Carotid stenosis does not need

Carotid endarterectomy (CEA) but bypass surgery

 5.hypertension + headache +,vomiting + visual field loss is =

Posterior territory infraction Bilateral occipital infarction

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 6.parkinson’s disease patient on sine met (L-dopa)
numbness + unable to move (on and off phenomena) = Give
Entacapone

NEUROLOGY PEARLS
• 7.parkinson’s disease patient + orthostatic hypotension and
excessive sleep = Give Midodrine (diet-2 2017 part-2)

• 8. Fever + Headache + Seizure + Signs of increased ICP

(Papilledema) + focal neurological deficit + history of sinusitis
is = intracerebral abscess

• 9.Treatment of intracerebral Abscess is:

• Surgical drainage supratentorial abscess drained via burr hole
.
• Antibiotic therapy

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
10.causes of neuropathic pain are :
1.Diabetic neuropathy
2.post herpetic neuralgia
3. Trigeminal neuralgia

NEUROLOGY PEARLS
4.prolapsed intervertebral disc

11.Treatment of Neuropathic pain according to NICE guidelines is :

First line : Amitriptyline ,Duloxetine ,Gabapentin , pregablin (diet-3 2018 part-2)
If first drug doesn't work try another first line drug
Tramadol used as rescue therapy for exacerbation of neuropathic pain
Topical capsaicin for localized pain (post herpetic neuralgia )

12. History for drug use of headache for 15 days worse with regular use is =
Medication overuse headache

13.Treatment for Medication overuse headache is :

Stop all drugs ,Analgesics triptans abruptly Give TCA but opioids gradually

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
14: causes of Extensor planters and absent Ankle jerks are :
1.Subacute combined cord degeneration
2.Motor Neuron disease
3.Fridreich Ataxia

NEUROLOGY PEARLS
4.Syringomelia/ syrinobulbia
5.Tabesparesis/ syphilis
6.Conus medullaris lesion

15.causes of Internuclear Opthalmoplegia are :

1.Multiple sclerosis
2.Wernickies encephalopathy
3.stroke

16.eyes closed to resistance + tearful around time of seizure + prolonged

jerking of limbs + psychiatric issues + urinary incontinence is = Pseudo
seizures ( diet-3 2019 part-2)

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 17.Chorea is caused by damage to the basal ganglia, in
particular the Caudate nucleus

 18.Visual field defects:

NEUROLOGY PEARLS
left homonymous hemianopia means visual field defect
to the left, i.e. lesion of right optic tract
19.homonymous quadrantanopia: PITS (Parietal-Inferior,
Temporal-Superior (diet-1 2017 part-2)

 20.incongruous defects = optic tract lesion; congruous

defects= optic radiation lesion or occipital cortex

 21.Amyotrophic lateral sclerosis is associated with mixed

UMN and LMN signs (usually no sensory deficits)

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 22. Hemiballismus = lesion at contralateral sub thalamic
nuclei.

 23.Fluctuating cognitive impairment + visual

NEUROLOGY PEARLS
hallucinations + parkinsonism + neuroleptic use i.e.
Haloperidol is = Diffuse lewy body dementia (diet-3 2016
part-2)

 24.Treatment of diffuse lewy body dementia is :

Rivastigamine.

 25.Restless leg syndrome - management includes

dopamine agonists such as ropinirole.

 26.Narcolepsy is associated with low orexin (hypocretn)

levels
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 27.Young patient with mood swings/depression, pains and
numbness in both legs, rapidly progressive memory loss with
myoclonic jerks new variant CJD.

NEUROLOGY PEARLS
 28. investigations in New variant CJD = EEG normal. MRI on
T2-weighted image reveals thalamic hyper intensity.

 29.Frontotemporal dementia personality change, disinhibition

and inappropriate social behaviour no memory deficit.
Associated with MND frontotemporal atrophy on MRI.(diet-2
2018 part-2 )

 30.Dystrophia myotonica - DM1 --distal weakness initially,

autosomal dominant, diabetes dysarthria

 31.Migraine
acute: triptans NSAID or triptans paracetamol
prophylaxis: topiramate or propranolol
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 32.Amaurosis fugax differentiate middle cerebral artery syndrome
from carotid artery syndrome

 33.Absences seizures + myoclonic jerks + tonic colonic seizures with in

NEUROLOGY PEARLS
hour if waking + precipitate by alcohol , menstruation sleep
deprivation is = juvenile myoclonic epilepsy (diet-1 2017 part-2 )

 34.Treatment of juvenile Myoclonic epilepsy is = sodium valproate

,lamotrigine and topiramate
 Life long drug treatment necessary to avoid relapses in patients
 who achieve seizure free status Chromosome 6

 35.Abnormal Blood pressure control of autonomic nervous system in

Quadriplegic patients + Lesion above in C6 + triggered by Constipation
cystitis retention of urine or blocked catheter is = Autonomic
dysreflexia

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 36.Epilepsy medication: first-line generalised
seizure: sodium valproate partial seizure:
carbamazepine

NEUROLOGY PEARLS
• 37.Neuroimaging is required to diagnose
dementia.

• 38.Lip smacking post - ictal dysphasia are

localising features of a temporal lobe seizure .

• 39.CADASIL is a rare cause of multiple cerebral

infarctions
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 40.HIV + Meningitis (headache, vomiting, seizures, focal
neurological deficit) + CSF opening pressure high
Lymphocytes + India ink positive + meningeal
enhancement + CD4 less than 100 = Cryptococcal disease

NEUROLOGY PEARLS
in HIV (diet-2 2017 part-2 )

 41.Diagnostic test for cryptococcal disease is = MRI brain

 42.Treatment of cryptococcal disease is = amphotericin B +

Flucytosine

• 43.CT head showing temporal lobe changes - think herpes

simplex encephalitis

• 44.Carbamazepine is contraindicated in absence seizures

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 45.Essential tremor is an AD condition that is made worse when arms
are outstretched, made better by alcohol and propranolol ( diet-1
2019 part-2)

• 46.Medicaton overuse headache

NEUROLOGY PEARLS
• simple analgesia triptans: stop abruptly
• opioid analgesia: withdraw gradually

• 47.Syringomyelia - spinothalamic sensory loss (pain and temperature)

• 48.Progressive supranuclear palsy: parkinsonism, impairment of

vertical gaze.

• 49.Brachial neuritis is characterized by acute onset unilateral severe

pain followed by shoulder and scapular weakness several days later.

• 50.Urinary incontinence gait abnormality dementia = normal pressure

hydrocephalus .
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 51.Increased INR in old age patient may cause subdural hematoma and
patient presents with weakness of one side of the body.

 52. Recurrent seizure can occur in NF-1 due to brain tumours

(meningioma, glioma] diagnosis requires axillary freckles, caif-au laite

NEUROLOGY PEARLS
spots and Irish nodules (on slit lamp examination)

 53. Complete ophthalmoplegia, numbness on one side of face,

increased ESR cavernous sinus lesion (3rd, 4th, 6th, V1) (diet-1 2018
part-2 )

 54.Visual loss (due to optic neuropathy) + ophthalmoplegia = orbital

apex syndrome

 55.Superior orbital fissure syndrome or rochon-duvigneaud’s

syndrome diplopia, ophthalmoplegia, exophthalmos and ptosis. If
blindness present it would be orbital apex syndrome.

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 56.Retinal + cerebellar haemangiomas = Von Hippel
Lindau syndrome

• 57.Obese, young female with headaches / blurred vision

NEUROLOGY PEARLS
think idiopathic intracranial hypertension. (diet-3 2017
part-2)

• 58.Dystrophia myotonica - DM1 --distal weakness initially,

autosomal dominant, diabetes dysarthria
•
• 59.- think acoustic neuroma Loss of corneal reflex –

• 60.Brown-Sequard syndrome: ipsilateral weakness, loss

of proprioception and vibration sensation, contralateral
loss of pain and temperature sensation
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 61. Investigation of choice for CRVO is =
Fluorescein angiography

NEUROLOGY PEARLS
 62.CT head showing temporal lobe changes - think
herpes simplex encephalitis.

 63.Carbamazepine is contraindicated in absence

seizures .

 64.IV Lorazapam is the first-line treatment in

patents with early status epileptics.

 65.Trigeminal neuralgia - carbamazepine is first-line

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 66.Best parameter to monitor in GBS is = Forced vital
capacity

 67. Young patient + Cerebellar Hemangioblastomas +

NEUROLOGY PEARLS
Polycythemia + kidney cyst + renal cell carcinoma is =
von Hippel landau syndrome

 68. Middle aged lady + personality changes + sexual

habits + inappropriate in social situations + repeatedly
asking same questions = picks disease (diet-3 2019 part-
2)

 69. first line treatment to prevent vision loss in idiopathic

intracranial hypertension is = urgent LP shunt
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 70. Sensor neural deafness + absent corneal reflex
absent + facial nerve palsy = Acoustic neuroma

NEUROLOGY PEARLS
 71.Young patient + ipsilateral headache + ipsilateral
Horner syndrome + contralateral hemiparesis + neck
pain = Carotid artery dissection

 72. first line drug in status epileptics is =

Benzodiazepines IV Lorazapam (diet-3 2018 part-2 )

 73. Patient on neuroleptic treatment + visual

hallucinations + features of Parkinson + dementia less
than 1 year is = lewy body dementia (diet-1 2019 part-
2)
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 74. History of migraine with Aura + stroke + positive family
history of migraine and early dementia is= CADASIL (cerebral
autosomal dominant arteriopathy with subcortical infract and
encephalopathy) ( diet-1 2018 part-2)

NEUROLOGY PEARLS
 75. Visual hallucinations in clear conscious + visual field defect +
MME score for dementia is normal + history of glaucoma or
cataract is = Charles Bonnet syndrome ( diet-2 2017 part-2 )

 76. Deafness + pulsatile tinnitus + cranial nerve IX,X1 + pulsatile

reddish blue mass in tympanic membrane = Glomus jugulare
tumour.

 77. first line drug treatment in neuroleptic malignant syndrome

is = Bromocriptine

 78. Young patient + pain after excessive exercise + Dark urine

/tea coloured urine is = McArdle disease
 Do muscle biopsy
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 79. Young patient + lancinating pain in extremities after
vigorous exercise + stroke + angiokartomas periumblicaly
is = Fabry's disease

NEUROLOGY PEARLS
 80. Young patient + opthalmoplegia + ptosis +
Retinitis pigmentosa (RP) + cerebral syndrome + cardiac
conduction defect + hearing loss is = Kearns Sayre
syndrome

 81. IV drug use + descending progressive weakness +

Cranial nerve involvement affecting ocular movement +
swallowing facial musculature + autonomic features + loss
of reflexes is = Botulism (diet-3 2016 part-2 )

 82. Optic neuritis + myelitis + vomiting + Aquaporin 4

antibody + MRI spinal cord lesson extend over 3 vertebral
segment = Neuromyelitis optical/ Devic's disease
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 83. 30 to 50 years + chorea(piano playing) + personality changes +
unsteady gait + dementia + saccadic eye movement + lack of
coordination + caudate nucleus atrophy putamen atrophy =
Huntington disease (diet-1 2016 part-2)

NEUROLOGY PEARLS
 84.Treatment of Huntington disease is = Tetrabenazine

 85. History of viral infection + recurrent vertigo + nausea , vomiting

+ horizontal nystagmus + no hearing or tinnitus is= Vestibular
neuronitis

 86. Investigation of choice to diagnose Carotid Artery dissection is =

CT Carotid angiogram

 87. Distal weakness + common peroneal palsy + ulnar nerve palsy +

pescavus + clawed toes+ areflexia + kyphosis is= Charcot Marie
tooth disease

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 88.Yoga exercise + neck pain + occipital headache + numbness of face + loss of
pain and temperature ipsilateral + nausea ,vomiting vertigo + nystagmus is =
Vertebral artery dissection (diet-1 2019 part-2 )

 89.Diagnostic test for Vertebral Artery Dissection is = MRA brain

NEUROLOGY PEARLS
 90. Peripheral neuropathy + sensorneural deafness + anosmia + cerebral
ataxia + pes cavus + night blindness + cardiomyopathy + retinitis pigmentosa
+ short 4th and 5th toe + high phytic acid is = Refsum's disease

 91. Multiple nerves involvement + conduction blocks + fasciculation + sensory

examination normal + reflexes normal + anti GM1 antibodies high =
Multifocal motor neuropathy

 92. Treatment of Multifocal Motor Neuropathy is :

 immunoglobulin's

 93. Headache ,vomiting + local infection sinusitis + perioribital oedema +

opthalmoplegia 6th Cranial nerve involvement + 3rd and 4th cranial nerve
involvement + 5th cranial nerve involvement hyperaesthesia if upper face and
eye pain is= Cavernous sinus thrombosis
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 94. Lower limb is more involve than upper limb causing contralateral hemiparesis is =
Anterior cerebral stroke

 95. Upper limb \face more involve than lower limbs causing contralateral hemiparesis =
Middle cerebral artery stroke

NEUROLOGY PEARLS
 96.Agitation + hallucinations + delusion + seizures + dyskinesia + ovarian tumours +
MRI normal or showing deep subcortical limbic structures = Ct scan of abdomen pelvis
confirms ovarian carcinoma + antiNMDA antibodies is = Anti NMDA receptor
encephalitis (diet-2 2017 part-2 )

 97. Treatment of Anti NMDA receptor encephalitis is = IV steroids and

immunosuppression

 98. After CT scan confirm nontruamatic SAH next step is to confirm It by Urgent
angiography through CT scan or MRI before endovascular clipping or coiling

 99. Seizures + behaviour changes like patient accuses her wife of having affair with
prime minister + headache + oral facial dyskinesia + insomnia is = Autoimmune limbic
encephalitis

 100. Radiotherapy more than chemotherapy in neurooncology

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 95. Cancer patient /chronic immunodefient state/ immunosuppressive drugs +
personality changes +intellectual impairment + focal neurological signs + cortical
blindness + seizures + coma + CSF normal + MRI shows non enhancing white matter
lesions + JC virus is = Progressive multi focal leucoencephlopathy ( diet-1 2015 part-
2)

NEUROLOGY PEARLS
 96 . Most accurate test for myasthenia gravis is = Single fibre electromyography

 97. Moderate sized haematoma in basal ganglia with minimal mass effects next step
is = Admission to stroke unit or observation

 98. L4 =i) anteromedial part of shine ii) knee reflex hip adduction ,knee extension,
ankle dorsiflexion and foot inversion
 L5=hip extension, knee flexion, ankle dorsiflexion, big toe extension
 S1=sole of foot, ankle reflex ,hip extension, ankle plantar flexion and foot eversion

 99. Radiotherapy more than chemotherapy in neurooncology

 100. Smacking his lips and spontaneous recover + remain unaware of episode +as
child had history of febrile convulsion ,is = complex partial seizure

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 RESPIRATORY PEARLS

RESPIRATORY PEARLS
 Nothing great was ever achieve without
element of risk.

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
1.10-50 years exposure to asbestosis + progressive Shortness
of breadth + chest pain + Pleural effusion (mostly right side)+
clubbing + weight loss is = Mesothelioma (diet-1 2019 part-2 )

RESPIRATORY PEARLS
2.Massive Pulmonary embolism + cardiopulmonary arrest give
IV thrombolysis then CPE for 90 minutes

3.Treatment of recurrent pulmonary embolism is = inferior

vena cava filter

4.Young patient + living in hostel +Erythema multiforme +

haemolytic anaemia + bilateral consolidation on x-ray is =
Mycoplasma pneumonia
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
5.Treatment of Legionella pneumonia:
First line= Macrolides (note : now days nice recommends quinolones as 1st line )
doxycycline is also used (diet-3 2019 part-2 )
Hyponatremia = Normal saline

RESPIRATORY PEARLS
6.Indication of ITU in pneumonia:
CURB=4-5
Hypoxia
Hypercapnia
Acidosis
Shock
Decreased consciousness

7.Flow volume loop is the investigation of choice for upper airway compression

8.Management of high altitude cerebral edema (HACE) is with descent

dexamethasone

9.Patients less than 5 years or older with severe acute exacerbation of asthma receive
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
10.Small cell lung carcinoma secreting ACTH can cause Cushing's syndrome
Small cell lung carcinoma .

11.Treatment of pneumonia is :

RESPIRATORY PEARLS
CURB 0-1 home treatment : Amoxicillin
CURB :2 inpatient amoxicillin + clarithromycin
CURB 3-5 ICU:I/V co- amoxiclav, clarithromycin
Staphylococcus areaus = Flucloxacillin

12.Erythema nodosum is associated with a good prognosis in sarcodosis

13.Asthma + eosinophilia + Renal impairment + microscopic haematuria + nerve

lesion(ulnar nerve palsy with foot drop) + high IgE + sinusitis + PANCA is = Chrug
Strauss syndrome (diet-3 2017 part-2 )

14.Treatment of Chrug Strauss syndrome is :

Steroids
Immunosuppressant's : cyclophosamide,azithopurine.
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 15.Serials measurements of peak expiratory flow rate recommended both at
work and away from work in occupational asthma

• 16.Alpha-1 antitrypsin deficiency - autosomal recessive / co-dominant

RESPIRATORY PEARLS
 17.Klebsiella most commonly causes a cavitating pneumonia in the upper
lobes, mainly in diabetics and alcoholics (diet-1 2019 part-2 )

 18.Recurrent chest infections subfertility - think primary ciliary dyskinesia

syndrome (Kartagener's syndrome)

 19.Pneumonia mortality:
 Low severity :CURB -65 0-1=mortality <3%
 Moderate severity:CURB-65 2=mortality 9%
 High severity:CURB-65 3-5=Mortality 15-40%

 20.High grade fever chills rigors + rusty sputum + chest pain + herpes labials'
is = CAP by streptococcus pneumoniae
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
21. Solitary lung nodule on chest x-ray next step is = Fibre Optic
bronchoscopy+/-transbronchial biopsy (diet-3 2016 part-2 )

22.severe cough + Fever with chills and rigors + sweating + weight loss +
Clubbing + chest pain + foul smelling sputum + haemoptysis is = Lung abscess

RESPIRATORY PEARLS
23.labatatory findings in lung abscess is :
High ESR
Sputum for gram statin
Leucocytosis

24.Amoxicilin /Co-amoxiclav /erythromycin plus metronidazole or

Cefuroxime

25. Indications of steroids in sarcodosis are :

Hypercalcemia
Eye (uveitis )
Heart ,CNS ,renal involvement

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 26.causes of nocturnal cough are:
 Asthma
 Reflux disease
 Postural drip

RESPIRATORY PEARLS
 27. investigation of choice for pulmonary Arterial Hypertension is =
Right Heart catheterization

 28. Earlier morning raised Co2 is = Central apnoea syndrome

 29.causes of bilateral Hilar lymphadenopathy are :

 Sarcodosis (diet-3 2016 part-2 )
 Tuberculosis
 Lymphoma
 Pneumoconiosis
 Beryliosis
 Fungi : Histoplasmosis,cocidiomycosis
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 30.causes of Lower lobe fibrosis are :
• CID Agent :
• C= Connective tissue disease (except ankylosing spondylitis )
• I= Idiopathic pulmonary fibrosis (diet-1 2019 part-2 )

RESPIRATORY PEARLS
• D= Drugs ( Methotrexate ,Amiodarone ,bleomycin ,cyclophosphamide
,sulphonylurea)

• 31.Carbon Monoxide transfer factor determine prognosis in Idiopathic

pulmonary fibrosis .
• 32.fracture of long bones + dyspnoea + confusion + multiple patechie in
axilla or upper part of body + low platelets is = Fat Embolism

 33.Confusion in an asthma attack is a life-threatening feature .

 34.Bronchiectasis: most common organism = Haemophilus influenza .

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 35.Sarcoidosis CXR 1 = BHL
 2 = BHL infiltrates
 3 = infiltrates
 4 = fibrosis

RESPIRATORY PEARLS
 36.Aspergillus clavatus causes malt workers' lung, a type of EAA .

 37.Adults with suspected asthma should have both a FeNO test and
spirometry with reversibility

 38.Paraneoplastc features of lung cancer

squamous cell: PTHrp, clubbing, HPOA
small cell: ADH, ACTH, Lambert-Eaton syndrome (Diet-1 2018 part-2 )

 39.The majority of patents with sarcodosis get better without treatment

 40.The majority of patents with

COPD - still breathless despite using inhalers as required?
FEV1 > 50%: LABA or LAMA
FEV1 < 50%: LABA ICS or LAMA
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
41.Aspirin induced asthma = Leukotriene
receptor antagonist

RESPIRATORY PEARLS
42.Indication of intubation in asthma:
pH less than 7. 35Co2 retention

43.When to give Magnesium sulphate (MgS04)

IV? (diet-2 2016 part-2 )
 Patient not responding to salbutamol, oxygen
steroids
Respiratory rate >25
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 44.Apical pneumothorax + asynchronous click with heart sounds + PA chest x-
ray normal = analgesia and discharge.

 45.If history and examination suggestive of pneumothorax and stable next

step confirm with chest x-ray (diet-1 2017 part-2 )

RESPIRATORY PEARLS
 46.For recurrent pneumothorax next investigation is CT scan if not then video
assisted thoracoscopy.

 47.Streptococcus pneumoniae is associated with cold sores.

 48.Pneumonia in an alcoholic - Klebsiella

 49.Legionella pneumophilia is best diagnosed by the urinary antigen test .

 50.Preceding influenza predisposes to Staphylococcus Aureus pneumonia

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 51.Sleep apnoea causes include obesity and
macroglossia

RESPIRATORY PEARLS
• 52.Transfer factor raised: asthma, haemorrhage,
• left-to-right shunts, polycythaemia low: everything else

• 53.COPD- LTOT if 2 measurements of pO2 < 7.3 kPa

• 54.Light's criteria: Effusion LDH level greater than 2/3rds

the upper limit of serum LDH points to exudate.

• 55.Small cell lung carcinoma secreting ACTH can cause

Cushing's syndrome
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
56. Management of choice for second unilateral Pneumothorax
in fit individual is referral for bullectomy and pleuroectomy

57.Pentrating injury/surgery + unilateral chest pain + dyspnoea +

RESPIRATORY PEARLS
shock + tachycardia + hypotension + shifting of trachea or
mediastinum is = tension Pneumothorax

58.Treatment of tension pneumothorax is :

immediate insertion of wide bore needle in 2nd ICS
Intrathoracic tube in 4,5,6ics in mid axillary line
Give oxygen
Morphine

59.If draining Pneumothorax after 3-5 days there is persistent air

leaks(bubbling chest drain) or failure of lung to re-expand =
thoracic surgical opinion (diet-1 2019 part-2 )
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 60.Treatment of occupational asthma
 Review of work environment Change job Better at holiday (diet-3 2016
part-2 )

RESPIRATORY PEARLS
 61.Causes of occupational asthma are : Isocyanate
 Platinum salts
 Flour

 62.Young patient + 10 Months history of nocturnal cough +Shortness

of breadth in morning chest wheezes + GERD+ normal x-ray + low
PEFR is = nocturnal asthma

 63.Treatment of nocturnal asthma: regular low dose steroids.

 64.Allergic asthma treated by = Omalizumab (Side effects : abdominal

pain, headache, fever)

 65.Eosinophilic asthma treated by = Mopolizumab

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 66. Pigeons bird fanciers = avian proteins
 Farmers lung = Saccharopolyspora rectivirguls

RESPIRATORY PEARLS
 Malt workers lung: = Aspergillus clavatus
 Mushroom workers lung: = thermophilic
actinomycetes
 byssinosis = textile industrial cotton hemp dust
 bagassosis = sugarcane (diet-3 2016 part-2 )

 67.Spirometry in extrinsic allergic alevolitis is

mixed

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 68.Treatment of ARDS is :
 Mechanical ventilation with maximal ventilatory
therapy Fi02 100%

RESPIRATORY PEARLS
 PEEP 15cmH20 peak pressure 40cmH20
 If still unresponsive(on maximum ventilatory therapy and
still hypoxia) then Extracorporeal oxygenation (ECMO)
(diet-2 2019 part-2 )

 69.Treatment of type1 :High concentration Oxygen(>35%

usually 60%high flow 6-8L

 70.Treatment of type2:Low concentration (24-28%)Low

flow (1-2L/min
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 71.Gold standard diagnostic test for Obstructive sleep apnoea =
Polysomnography

 72 .Yellow discoloration of nails + lymphedema +pleural effusion +

bronchiectasis is = yellow nail syndrome

RESPIRATORY PEARLS
 73.Obese man + tired all time + day time somnolence + apnoea at
night reduced REM sleep + snoring + Hypertension + retained C02 is =
Obstructive sleep apnoea syndrome (sleep apnoea/hypopnoea)

 74. HRCT is investigation of choice in idiopathic pulmonary fibrosis

showing honey combing (diet-3 2019 part-2 )

 75. Pulmonary function in obesity

 Restrictive pattern
 No effect on KCO

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
76. Findings in Obstructive pattern of respiratory disease :
FEV1 significantly reduced (less 70%)
FVC reduced or normal FEV1/FVC = reduced (less than 80% or 0.7)
Raised total lung capacity

RESPIRATORY PEARLS
Raised residual Volume

77. Findings in Restrictive pattern of respiratory disease :

FEV1 reduced less than 80%
FVC =significantly reduced
FEV1/FVC =normal or increased more than 80%
Lung compliance , TLC RV are decreased

78. Causes of Obstructive pattern :

COPD
Asthma
Bronchiectasis
Bronchiolitis obliterans (diet-1 2017 part-2 )
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
79.Causes of Restrictive pattern
Idiopathic pulmonary fibrosis
Pulmonary haemorrhages
Asbestosis
Sarcodosis

RESPIRATORY PEARLS
ARDS
Extrinsic allergic alevolitis
Histocytosis (diet-2 2017 part-2 )
Coal worker's pneumococcal
Polio
Myasthenia Gravis
Obesity
Scoliosis

80. Causes of increased TLCO are :

Most obstructive has low TLCO except Asthma
Pulmonary haemorrhages (Wegener granulomatosis, Goodpasture syndrome) (diet-3
2019 part-2 )
Left to right shunt
Polycythemia
Exercise
Hyperkinetic state
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
81. Causes of Low TLCO are :
All restrictive pattern disease gives low TLCO except pulmonary haemorrhages)
Pulmonary fibrosis (diet-3 2018 part-2 )
Pulmonary emboli

RESPIRATORY PEARLS
Emphysema
Pulmonary oedema
Anaemia
Pneumonia
Sarcodosis

82. Pulmonary function in obesity is :

Restrictive pattern
No effect on KCO

83.Causes of high KCO with normal or low TLCO are:

Lobectomy / pneumonectomy
Neuromuscular weakness
Scoliosis/kyphosis
Ankylosing spondylitis
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
84. KCO is reduced in :
interstitial lung disease
Restrictive disease
Pulmonary embolism

RESPIRATORY PEARLS
Vasculitis

85.KCO is increased in:

Haemorrhage
Polycythemia

86. Young patient with Diabetes mellitus + recurrent chest infections + Diarrhoea
+ abnormal LFTs + gallstones + steatorrhoea + constipation is = Cystic fibrosis
(Diet-2 2019 part-2 )

87.Oragnisms in Cystic fibrosis patients :

Infants and young children = Staphylococcus Aureus, Haemophilus
Teenagers = Pseudomonas aeruginosa treated by inhaled tobramycin
Aspergillus Burkholderia cepacia
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
88. Features of cystic fibrosis are :
Delayed puberty Short stature
Pancreatic polyps

RESPIRATORY PEARLS
Diabetes Mellitus
Rectal prolapse
Male infertility (due to Mal development of vas deferens)
Female sub infertility
Meconium ileus

89. laboratory of Cystic fibrosis are :

Sweat test : sweat chloride more than 60mmol/L ( diet-1 2018 part-2 )
Decreased chloride secretion
increased sodium absorption
CFTR gene Genetic test is confirmatory F508(DF508)mutation on
chromosome 7

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 90.Teenger with Cystic fibrosis presents with chest infection
treated with Ceftazidime + tobramycin

 91.Rapidly progressive fever + high volume of purulent

RESPIRATORY PEARLS
sputum uncontrolled bronchopneumonia + weight loss +
septicaemia by Burkholderia cepacia treated by Ceftazidime +
aminoglycosides (diet-1 2019 part-2 )

 92.Treatment of Cystic fibrosis is :

 Chest physiotherapy (postural drainage)
 High calorie + high fat Vitamin D
 Pancreatic enzymes
 Supplement of N- Acetylcystein
 Heart lung transplant
 Gene therapy Human Recombinant DNASE

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 93.CT scan of Chest is diagnostic for Pancoast tumour.

 94.Diagnostic investigation of choice for sarcodosis is = Trans bronchial lung

biopsy (came in January 2018 part-2)

RESPIRATORY PEARLS
 95.Mangement of Obstructive sleep apnoea is :
 Weight loss
 CPAP is first line for moderate and severe OSA (diet-1 2019 part-2 )
 Intraoral devices ( Mandibular advancement )
 If CPAP is not tolerated then = Uvulopalatophrngraphy
 Tracheostomy is last resort.

 96.Epworth sleepiness score in Obstructive sleep apnoea is:

 Mild = 4-14
 Moderate=15-30
 Severe = more than 30
 Mild is treated by weight loss
 Moderate and severe is treated by = CPAP

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
97.Survival benefits in stable COPD patients are :
Smoking cessation
LTOT
Lung volume reduction surgery

RESPIRATORY PEARLS
Steriods reduced exacerbation frequency but not the mortality

98.peripheral edema + raised JVP + systolic Parasternal heave + loud p2

+ COPD is = Cor pulmonale (diet-3 2017 part-2 )

99.Treatment of Cor pulmonale is

loop diuretics for oedema
LTOT
ACEI ,CCBs ,Alpha blockers are not recommended.

100. Patients who are critically ill (anaphylaxis is ,shock)

oxygen should be at 15 /min.
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 GASTROENTEROLOGY &

GASTROENTEROLOGY PEARLS
HEPATOLOGY PEARLS

One day all those late nights and early mornings

will pay off

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
1.Young patient + Diarrhoea steatorrhoea + weight loss + abdominal pain + ataxia

GASTROENTEROLOGY PEARLS
weakness + Paresthesia + anaemia low iron low Folate (Folate >B12) + tired all
the time cramping +low FSH + low LH + low Estradiol + Amenorrhea is = Coeliac
disease(came in diet -3 2016 )

2.Selective igA is common in coeliac disease if patient has selective igA defiency
use TTG IgG or anti endomysial antibodies (EMA).

3.If patient still symptomatic despite being compliant with gluten free diet = think
of T cell lymphoma = Do Evaluation of small bowel with CT or MRI
enterography(came in diet-2 2015)

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 4.Tender abdomen + tachycardia + perforated peptic ulcer
first line test is = Chest x-ray (Diet-2 2018 part-2)

GASTROENTEROLOGY PEARLS
 Best test is CT scan abdomen

 5.HbeAg negative means no active infection HbeAg is marker

of Infectivity in all patients except those who have HB
precore mutant.

 6.Active HBV DNA any detectable DNA in blood = need

treatment.

 7.HBV DNA most sensitive index of viral replication

 8.IgM AntiHbc best indicate acute infection

 Absence of IgM AntiHbc indicate chronic infection.
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 9.Hepatitis B and pregnancy Baby born to mother with Hepatitis B
should receive complete course of vaccination + Hep

GASTROENTEROLOGY PEARLS
Immunization(came in diet-2 2017)

• 10.Multiple gastroduodenal ulcers + Diarrhoea + Epigastric pain +

Malabsorption + Vit B-12 defienancy is = Zollinger–Ellison syndrome

• 11.Investigations of Zollinger Ellison Syndrome are :

• Secretin test ( normally secretin inhibits gastrin level but in Zollinger
Ellison syndrome it doesn't)
• CT scan abdomen

• 12. Treatment of Zollinger Ellison syndrome is :

• High dose PPI
• Octreotide to reduce gastrin secretion
• Surgical resection

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 13. Large volume of watery Diarrhoea ( >700 ml /day ) + dehydration +
Hypokalaemia + acidosis + Maintenance if weight it stool with fasting is =

GASTROENTEROLOGY PEARLS
Vipoma (diet 3 2019 part-2 )

• 14. Investigations of Vipoma are :

• Watery Diarrhoea VIP >75
• CT scan of abdomen
• MRI to localize tumor in pancreas

• 15. Treatment of Vipoma is :

• IV fluid
• Somatostatin analogue
• Codeine
• Surgery resection

• 16.Obese T2DM with abnormal LFTs - ? non-alcoholic fatty liver disease.

• 17.In life-threatening Clostridium difficle infection treatment is with ORAL

vancomycin and IV metronidazole
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 18. Painless obstructive jaundice + history of diabetes mellitus + weight loss
+ epigastric pain + stoarrhaoe + atypical back pain radiating back + migratory

GASTROENTEROLOGY PEARLS
thrombophlebitis is = Pancreatic cancer

• 19. Investigations of Pancreatic cancer are :

• Ultrasound of abdomen
• CT scan of abdomen is investigation of choice
• CA 19-9 ( monitor response to treatment)

• 20.Treatment of Pancreatic cancer is :

• Surgery : Whipple resection (pancreatoduodenectomy ) side effects are
dumping PUD
 ERCP with stenting

 21.Diarrhoea - biopsy shows pigment laden macrophages = laxative

abuse.(came in diet-3 2017)

 22.Antbiotc prophylaxis reduces mortality in cirrhotic patents with

gastrointestinal bleeding.

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 23. right upper quadrant pain + Fever + Jaundice + Hypotension +
Confusion is = Ascending Cholangitis (diet-1 2016 part-2 )

GASTROENTEROLOGY PEARLS
• 24 Treatment of Ascending Cholangitis is :
• I/V antibiotics
• ERCP + Sphinectomy After 24-48 to relieve any instructions
 if unfit for ERCP percutaneous transhepatic cholangiography

 25.Primary biliary cirrhosis - the M rule - IgM

ant-Mitochondrial antibodies, M2 subtype
Middle aged females

 26.NICE recommend avoiding lactulose in the management of IBS.

 27.Surgery is indicated in patents with on-going acute bleeding

despite repeated endoscopic therapy

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 28.H-pylori causes:


GASTROENTEROLOGY PEARLS
1.peptic ulcer (duodenal)
 2.Gastric Cancer
 3.B cell lymphoma(MALT)
 4.atrophic gastritis

 29.Treatment of coeliac disease is :

 Gluten free diet like wheat ,bread pasta pastry barley rye oats they
contain gluten
 If refractory : then steroids or immunosuppressant (diet-1 2015 part-
2)

 30.Wilson's disease - serum caeruloplasmin is decreased .

 31.Liver failure following cardiac arrest think ischaemic hepatitis .

 32.The gold standard test for achalasia is oesophageal manometry .

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 33.Elderly male + dysphagia + regurgitation + foul

GASTROENTEROLOGY PEARLS
smell breadth + aspiration + palpable mass is =
Zenker's Diverticulum

• 34.Chronic diarrhoea in HIV patients with CD < 180

cells /mm3 is = Cryptosporidium parvum

• 35.systolic ejection murmur ( Right 2nd ICS and

intermittent rectal bleeding mixed with stool is
angiodyplasia (angiography is gold standard ) MCV
is normal (Heyde's syndrome ) (diet-2 2017 part-2 )

• 36. Iron defienancy anaemia in old age GIT cause

do colonoscopy
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 37.Coeliac disease - tissue transglutaminase

GASTROENTEROLOGY PEARLS
antibodies are the first-line test .

 38.The Alvarado score can be used to suggest the

likelihood that a patent has acute appendicitis

 39.Hypophosphataemia is a characteristic
biochemical sign in patents at risk of refeeding
syndrome (diet-3 2017 part-2 )

 40.Transient elastography is now the investigation

of choice to detect liver cirrhosis .

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
41.Lethargy + pruritis + middle age female + jaundice + xanthomata +

GASTROENTEROLOGY PEARLS
hypercholesterolemia + clubbing + hepatosplenomegaly is = Primary
biliary cirrhosis( came in diet -2 2017)

42.Postive AMA + high ALP + dyslipidaemia is = Primary biliary cirrhosis

43.Investigation of Primary biliary cirrhosis is : Anti mitochondrial M2

SMA High
IgM HLA DR3
HLA DR8

44.Complications of Primary biliary cirrhosis are :

Malabsorption of fat soluble vitamins
Osteomalacia ,coagulopathy (bruising) Sicca syndrome
Portal hypertension
Hepatocellular carcinoma

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
45.Associationsof primary biliary cirrhosis are :
Sjogren

GASTROENTEROLOGY PEARLS
RA
Systematic sclerosis crest syndrome
Thyroid disease
Membranous GN
RTA

46.Treatment of primary biliary cirrhosis is:

Ursodeoxycholic improve liver biochemistry delays disease progression
Pruritis : Cholestrayamine
Fat-soluble vitamin supplement
Liver transplantation: if bilirubin >100

47.MRCP is preferred over ERCP biliary tract obstruction (diet-1 2016

part-2 )

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
48.Indications of liver transplantation in primary

GASTROENTEROLOGY PEARLS
biliary cirrhosis are :
If bilirubin >100
Intractable pruritis
Contraindications of liver transplantation :
psychologically,immunosuppresion.
Liver transplantation has 5 year survival is 70-80%

49.High GGT + High ALP = cholestasis ( seen in

Primary biliary cirrhosis . )

50.1st line investigation in coeliac disease is = TTG igA)

tissue transglutaminase antibodies .
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
51.Investigation in coeliac disease are :

GASTROENTEROLOGY PEARLS
aTTG igA 1st line
Anti endomyseal antibody igA
Anti casein antibodies
Anti glidin antibody (igA or igG ) are not recommend
Jujenal Biopsy (resemble tropical sprue) is = gold
standard showing : villous atrophy Crypt hyperplasia
hypertrophy Increase in intraepithelial Lymphocytes

52.Selective igA is common in coeliac disease if

patient has selective igA defienancy use TTG IgG or
anti endomyseal antibody.(diet-1 2019 part-2 )
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 GASTROENTEROLOGY PEARLS
 53.Young patient + Diarrhoea steatorrhoea +
weight loss + abdominal pain + ataxia weakness
parathesia + anaemia low iron low Folate (Folate
>B12) + tired all the time cramping +low FSH + low
LH +low oestradiol + amonaerhae is = coeliac
disease(came in diet -3 2016 )

 54.Association of coeliac disease are :

 HLADQ2 HLADQ8 (95%)
 type 1 DM,
 dermatitis herpetiformis ,
 Hashimoto thyroiditis,
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
55.Complications of coeliac disease are :
1.anemia (low iron,folate,B12 defienancy )

GASTROENTEROLOGY PEARLS
2.hyposplenism (Howell jolly bodies)
3.osteomalcia (low calcium ,high ALP )due to vitamin D defienancy and high
PTH
4.osteoporosis
5.malaborption ,low serum albumin weight loss
6.lectose intolerance
7 subinferlity
8 Oesophageal cancer
9 enteropathy associated T cell Lymphoma of small bowel
10 recurrent mouth ulcers

56.If patient still symptomatic despite being compliant with gluten free diet =
think of T cell lymphoma = Do Evaluation of small bowel with CT or MRI
Enterography (came in diet-2 2015)

57.Antientrocyte is marker for t cell lymphoma

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
• 58.Give 50% of normal energy intake in starved

GASTROENTEROLOGY PEARLS
patents (> 5 days) to avoid refeeding
syndrome

• 59.Hepatorenal syndrome is primarily caused by

splanchnic vasodilation.

• 60.Budd-Chiari syndrome is most likely due to a

thrombophilia .

• 61.Obese T2DM with abnormal LFTs - ? non-

alcoholic fatty liver disease.

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• 62.Terlipressin - method of action = constriction of the

GASTROENTEROLOGY PEARLS
splanchnic vessels.

• 63.Zollinger-Ellison syndrome: epigastric pain and diarrhoea.

 64.Peutz-Jeghers syndrome - autosomal dominant

 65.Ulcerative colitis - the rectum is the most common site

affected

 66.Coeliac disease has a strong association with HLA-DQ2

(present in 95% of patents) .

 67.SeHCAT is the investigation of choice for bile acid

Malabsorption (diet-1 2017 part-2 )

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 68.First marker to appear in Hep B is = HbsAg

GASTROENTEROLOGY PEARLS
 69.Presence of HbsAg shows active infection or chronic infection
HbsAg acute for 1-6 month HbsAg chronic or carrier for >6 month

 70.HbsAb shows immunity (exposure immunization) absent in

chronic disease.(Came in diet 1 2016 )

 71.AntiHbc shows previous or current infection IgM anti Hbc = acute

or recent Hepatitis B present for 6 month IgG anti Hbc persists of
long life. (diet-3 2017 part-2 )

 72. Hbc IgG produced around 14 weeks after exposure In absence of

Hbc IgM indicate = Cleared hepatitis B infection.

 73.HbeAg is marker of infectivity and replication

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 74.Depression + sertraline use + Lymphocytes infiltration is =

GASTROENTEROLOGY PEARLS
 Lymphocytic colitis
 Treatment of Lymphocytic colitis is =
 Withdrawal of drug Loperamide,Cholestryamine,Azthioprine.

 75.Complications of Crohn's diseases are :

 Gallstones oxalate (diet-1 2016 part-2 )
 renal stones
 Fistula
 Anal tags
 Mouth ulcers
 Perianal disease
 Episelritis

 76 .Oligospermia by sulphasalzine
 Pancreatitis with Mesalazine > sulphasalzine

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 77.Management of ulcerative colitis is :


GASTROENTEROLOGY PEARLS
Inducing remission: rectal topical 5ASA,oral ASA (diet-1 2019 part-2 )
 2nd line = oral steroids
 Servere colitis = IV steroids
 Maintaining remission in ulcerative colitis
 Oral 5ASA :
 Mesalazine
 Azathioprine or meracaptopurine
 No Methotrexate here

 78.Toxic megacolon seen in : Ulcerative colitis mainly

Pseudomembranous colitis, Ischemic colitis

 79.Treatment in Toxic megacolon is :

 1st IV steroids then Colectomy + cyclosporine if contraindicated then
Infliximab

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 80.Investigation in IBD are :


GASTROENTEROLOGY PEARLS
Endoscopy is investigation of choice = ileocolonscopy
 C -reactive shows disease activity
 High faecal Cal protectin high in IBD (50)Normal faecal calprotecin
make it less likely

 81.40-60 years + weight loss + Diarrhoea+ seronegative arthropathy +

stoarrhaoe + abdominal distension + seizures + myoclonus + ataxia +
Endocarditis + oculomastictory myoarthytitis + Valvular conduction
problems + anaemia + pleurisy is = Whipple disease by tropheryma
Whipple (diet-3 2018 part-2 )

 82.Irreversible complications of hereditary hemochromatosis are :

 Arthropathy
 Diabetes mellitus
 Liver cirrhosis
 Hypogondasim

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 83.Truma / violet vomiting / endoscopic procedure/

GASTROENTEROLOGY PEARLS
malignancy + shock + pain + left side pleural effusion +
pleural Fluid Exudative and high amylase + ratio of
pleural fluid amylase to serum amylase >1 is =
Oesophageal rupture (diet-1 2016 part-2 )

 84.Oesophageal Rupture is Diagnosed by :

 radio logically with water soluble contrast
 Treatment : Surgical

 85.Gastroenteritis : Empirical antibiotic only indicated if

systemically unwell , immunosuppresion,or elderly even
if patient has bloody Diarrhoea so give oral rehydration
solution otherwise
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 86.Patient taken metronidazole for 7 days for Clostridium difficle and he is

GASTROENTEROLOGY PEARLS
improved and has no symptoms but yet stool shows c.diffcle next step =
Nothing needed (diet-1 2019 part-2 )

 87.Investigation of choice for Barret oesophagus is = Endoscopic biopsy.

 88.Management of Barret oesophagus is :

 No dysplasia + <3 cm of barret = endoscopy every 3 to 5 years with biopsies
 No dysplasia + >3cm = endoscopy every 2 to 3 years + start PPI and repeat
endoscopy and biopsy every 2 .
 grade dysplasia = High dose PPI +every six monthly biopsy.
 High grade dysplasia = oesophagectomy + photodynamic therapy and
ablative therapy. (diet-3 2018 part-2 )

 89.Isolated unconjugated hyperbilirubmina + normal LFTS is = Gilbert

syndrome

 90.Jaundice in Gilbert is exacerbated by : fasting,alchol,acute illness even

like sore throat also by ostrogen improved by low dose barbiturates
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 91.Risk factors for barret oesophagus are :


GASTROENTEROLOGY PEARLS
Gerd
 Male Stricture or ulcer Has increased risk of adenocarcinoma
 Metaplasia of lower oesophagus when normal squamous epithelium replaced
by columnar epithelium

 92.Investigations in Gilbert syndrome are:

 Rise in bilirubin provoked by prolonged fasting or IV nicotinic acid.(diet-1
2016 part-2 )

 93.Management of Gilbert syndrome is :

 No treatment required
 If severe jaundice = Phenobarbitone

 94.Non bloody Diarrhoea + young patient + weight loss + abdominal mass

palpable on right iliac fossa is = Crohn's disease.
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 95.Labatatory findings in Crohn's disease are:
 Histology : all layers trans mural ,High goblet cells ,Granulomas Endoscopy :

GASTROENTEROLOGY PEARLS
deep ulcer, skip lesion , cobblestone
 Radiology : stricture : Kantor's string sign ,rose thorn ulcers, fistula, proximal
bowel dilation
 ASCA +P-ANCA –

 96.Smoking worsen Crohn's but improves ulcerative colitis .

 97.Management of Crohn's diseases:

 Inducing remission : steroids (oral, rectal ,IV) Azathioprine or 6
meracaptopurine add on Methotrexate alternative to azathioprine
(Contraindicated in anaemia ) (diet-3 2019 part-2 )
 2nd line is steroids but not as affective as azathioprine is 5ASA( mesalazine )
 Refractory Crohn's = infliximab IV Fistulating Crohn's = Infliximab
 Perianal disease = Metronidazole
 Diet in Crohn's : short term TPN,enteral feeding elementary diet low
fat medium chain TGA in diet Lactose intolerance dairy free diet.

 98.Crohn's disease in pregnancy is = steroids

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 99.Maintaining remission in Crohn's disease :

GASTROENTEROLOGY PEARLS
 No steroids
 Stop smoking
 Azathioprine or meracaptopurine is first line (diet-1 2019 part-2 )
 Methotrexate 2nd line 5-ASA drugs(Mesalazine) if surgery has done.

 100.Complications of surgery in Crohn's disease:

 1.bile salt Malabsorptive = bile acid diarrhoea with abnormal 14C glucolate
test treatment : Cholestrayamine
 2.Cholesterol gall bladder stones
 3.urinary Cal oxalate stones and renal calculus:
 treatment : good hydration, dietary oxalate restriction (cocoa, peanut tea
coffee wheat germ rhubarb spinach ,Cholestrayamine
 4.pyoderma gangreosum. (diet-3 2016 part-2 )

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 CARDIOLOGY PEARLS

CARDIOLOGY PEARLS
Success begins when you step out from your
comfort zone.

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 1 & 2 EDITION 2
1.Taping apex beat + mid diastolic murmur + loud S1 +
opening snap + malar flush + dysphagia + hoarseness
+ pregnancy or immigrant history is = Mitral stenosis

CARDIOLOGY PEARLS
(diet-3 2018 part-2 )

2.Features of severe Mitral stenosis are :

Length of murmur increase Opening snap closer to
S2

3.Treat Mitral stenosis = only when its symptomatic

Valve replacement when its less than 1cm

4.Post cardiac arrest is treated by Aspirin and

clopidogrel
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
5.Glucose should be kept less than 10mmol/L and Oxygen
saturation 94 to 98 % not 100% to prevent post cardiac arrest
syndrome.

CARDIOLOGY PEARLS
6.Pause of more than 3 needs pacemaker insertion.(diet-1 2017
part-2 )

7.ICD is used for ventricular dysfunction or ventricular

arrthymias.

8. Endocarditis:
IV vancomycin + rifampicin + low dose gentamicin
is the empirical treatment of choice in prosthetic valve
endocarditis.

9. IvAbradine use may be associated with visual disturbances

including phosphenes and green luminescence
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10.Systolic BP more than 180 or diastolic BP 110 + end
organ damage is = Hypertensive emergency

CARDIOLOGY PEARLS
11.Systolic BP more than 180 or diastolic BP more than 110 +
No end organ damage is = Hypertensive Urgency.

12.Systolic BP more than 160 and diastolic below 90 +

elderly is = Isolated systolic Hypertension.

13. Treatment of isolated systolic Hypertension is :

First line = calcium channel blockers . (Diet-1 2017 part-2)
Second line = diuretics

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 14.In management of STEMI if primary PCI cannot be
delivered within 120 minutes then thrombolysis should be
given

CARDIOLOGY PEARLS
 15.In the primary prevention of CV risk using statin aim for a
reduction in non-HDL cholesterol of > 40%
16.Patents with recurrent venous thromboembolic disease
may be considered for an inferior vena cava filter

 17.Treatment of aortic dissection Type A ascending Aorta is =

control BP IV labetalol + surgery aortic arch replacement
 Type B descending aorta = control BP IV labetalol (diet-2
2018)

 Never give thrombolysis in Aortic dissection it will kill

patient
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 18.Pain abrupt in onset tearing pain radiating to scapulae and back +
unequal pulse in arms + diastolic murmur is = Aortic dissection.

CARDIOLOGY PEARLS
 19.Investigation of choice in aortic dissection is CT chest with IV
contrast (diet-3 2016)
 Best initial test is = X-Ray chest showing widening of mediastinum

 20.Infectve endocarditis - strongest risk factor is previous episode of

infective endocarditis

 21. IV amoxicillin is the empirical treatment of choice in native valve

endocarditis.

 22.Intravenous diuretics are first line therapy in acute heart failure,

even in renal failure, with strict fluid management.

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 23.Long QT syndrome - usually due to loss-of-
function/blockage of K channels .

 24.PCI - patents with drug-eluting stents require a

CARDIOLOGY PEARLS
longer duration of clopidogrel therapy

 25.Verapamil is contraindicated in Ventricular

Tachycardia.

 26.Myoglobin rises first following a myocardial

infarction.

 27. Atrial fibrillation: rate control - beta blockers

preferable to digoxin .
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 28.ACEI have reduced efficacy in black patient, and therefore are not
1st line in Hypertension.

 29.Hypertension + BPH is = Alpha blockers.

CARDIOLOGY PEARLS
 30.Hypertension + Heart failure or angina = beta blockers.

 31.Hypertension + post MI = Beta blockers or ACEI

 32. Treatment of Hypertension :

 Less than 55 years non black = ACEI More than 55 years or black Afro-
Caribbean origin = Calcium channel blockers.

 33.Hypertension + Step 4K less than 4.5 then spironolactone

 K more than 4.5 then Higher dose thiazide like diuretics (die-3 2016 )

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 34.Young female + atypical pain + palpitation + panic
attacks + mid systolic click is = mitral valve prolapse
(diet-3 2017)

CARDIOLOGY PEARLS
 35.investigation of choice for Mitral valve prolapse is =
ECHO.

 36.Treatment of MVP Atypical chest pain + Palpitations is

= Beta blockers
 MVP+MR+AF give = Anticoagulation
 MVP + Severe MR is = Surgical Repair.

 37.Chest pain radiating up to neck and to his back b/w

shoulder blades + pain started while eating + BP equal in
both arms + pleural effusion is = Oesophageal rupture.
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 38.When to use Myomectomy or Alcohol septal ablation?
 when gradient threshold is 50mmhg and NYHA III IV (came in diet -1
part-2 )

CARDIOLOGY PEARLS
 39.Poor prognostic factors in HOCM are :
 Septal wall thickness more than 3cm
 Syncope
 Family history
 Young age
 Abnormal blood pressure changes on exercise.(came in part-2 diet-2)

 40.Shock secondary to VSD is treated by Intra aortic balloon counter

pulsation.

 41.Primary adrenal hypercortisolim + lentigious nevi of skin + tumour

myxoma is = Carney complex.

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 42.Signs and symptoms like CHF + pansystolic murmur radiates to axilla
+ handgrip and squatting leg raising increases murmur is = Mitral
regurgitation. (diet-3 2015 )

CARDIOLOGY PEARLS
 43.Valve replacement in Mitral regurgitation when LVESD is more than
40mmhg.

 44.Techycardia induced cardiomyopathy despite of full pharmacological

effects is treated by AV node ablation.

 45.Cold, painful + cyanotic big toe + foot warm is = big toe syndrome
Give Heparin and urgent ECHO

 46.Young adult tall slim male + sudden onset of chest pain radiating to
shoulder + dyspnoea + dry cough + clicking sound synchronous with
heart beat is = Spontaneous pneumothorax.

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 47.Paradoxical embolus - PFO most common cause - do TOE .

 48.Pulsus alternans - seen in left ventricular failure

CARDIOLOGY PEARLS
 49.Restrictve cardiomyopathy: amyloid (most common), hemochromatosis,
Loffler's, syndrome, sarcodosis, scleroderma

 50.Women with pulmonary hypertension should avoid becoming pregnant

due to very high mortality levels

 51. Warfarin is the only licensed anticoagulant drug for stroke prevention in
AF in those with structurally abnormal valves

 52.Irregular cannon 'a' waves points towards complete heart block Irregular
cannon 'a' waves points towards complete heart block

 53.Infectve endocarditis - streptococcal infection carries a good prognosis

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 54.Prosthetic heart valves – anti thrombotic therapy:
 biprosthetic: aspirin
 mechanical: warfarin + aspirin

CARDIOLOGY PEARLS
 55.HOCM - poor prognostic factor on echo = septal wall
thickness of > 3cm .(diet-3 2016)

 56.Primary percutaneous coronary intervention is the

gold-standard treatment for ST-elevation myocardial
infarction

 57.Congenital heart disease cyanotic: TGA most common

at birth, Fallot's most common overall acyanotic:
 VSD most common cause
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 58.Squatting/leg raising increase murmur of =
 Mitral stenosis,
 aortic stenosis,
 Mitral regurgitation, Aortic regurgitation.

CARDIOLOGY PEARLS
 59.Standing/ valsalva decreases murmur of = MS,AS,AR,MR

 60.Squatting/leg raising decreases murmur of = MVP,HOCM

 61.Standing/ valsalva increases murmur of = MVP,HOCM

 62.Right sided failure + Amyloidosis history + Prominent deep y decent + Apex

beat is non palpable prominent + thick ventricles on echo with granular
sparking appearance is = Restrictive cardiomyopathy (diet-3 2017 )

 63.Alcholic patient + low Ejection fraction + thin ventricles + dilated heart is =

Dilated cardiomyopathy

 64. Symptomatic bradycardia is treated with atropine

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 65. Difference gradient of pressure between left ventricle and aortic
pressure LV - Aortic pressure is = Aortic stenosis (diet-2 2016 )

CARDIOLOGY PEARLS
 66.Cause of AS Younger patient less than 65years = bicuspid aortic
valve
 Older patients more than 65years = calcification

 67.I/V drug user cause of infective endocarditis = Staphylococcus

areaus

 68.In dental procedure most common cause of infective endocarditis is

= Strep Virdnas

 69. Bowel resection common cause of endocarditis is = Bacteriods

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 70. Stopping smoking has greatest benefit in reducing cardiovascular
risk factors (diet-1 2019 )

 71. ECG in ASD is

CARDIOLOGY PEARLS
 Ostium scandium = RBBB + Right axis deviation
 Ostium premium = RBBB + Left axis deviation (diet-3 2018 )

 72.Pressure difference in aorta and left ventricle is = Aortic stenosis

 73.Myocardial infraction + low blood pressure + systolic dysfunction +

cardiomegaly + upper lobe diversion is = Cardiogenic shock

 74.Treatment of Cardiogenic shock is :

 diuretics
 inotropes
 intra aortic balloon pump

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 75. 1 to 6 weeks after myocardial infraction + fever + pleurtic chest
pain + pericardial effusion + friction rub + raised ESR is = Dresser
syndrome (diet-3 2018 )

CARDIOLOGY PEARLS
 76.Treatment of Dresser Syndrome is :
 Aspirin Nasid
 If still resistant then steroids

 77. PCI is gold standard treatment in ST elevation MI within 12hrs

 78. Blood pressure controlled by ACEI has greatest effect on

myocardial infraction.

 79. High pressure in left ventricle + steep drop off between LV and
Aortic pressure is = HOCM (diet-2 2019 )

 80. High pressure in left Atrium + normal pressure in left ventricle is =

Mitral stenosis
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81. Features of severe Aortic Stenosis is :
Narrow pulse pressure
Slow raising pulse (diet-1 2017 )
Delayed ESM radiating to Carotid

CARDIOLOGY PEARLS
Soft or absent S2 (diet-3 2019 )
S4Thrill
Duration of murmur

82.Treatment of Aortic Stenosis if asymptomatic = Observe

symptomatic = Valve replacement (diet-1 2018 )
If asymptomatic but gradient more than 50 and features of LV
dysfunction is = Surgery
Before valve replacement do coronary angiography to rule out coronary
artery disease ,
Transcather aortic valve implantation if previous dement inoperable due to
comardites
Pregnancy with symptoms = Porcine valve replacement

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83. Drugs decreasing coronary incidence
Antiplatelet
Beta blockers

CARDIOLOGY PEARLS
ACEi
Gemfibrozil
84. Normal response of exercise tolerance is = increase in
BP and increase in Pulse

85. Treatment of SVT is :

 Vagal manoeuvres ,
 Carotid sinus massage contraindicated in carotid
vascular disease
 IV adenosine 6 mg then 12mg contraindicated in
Asthma use verapamil (diet-3 2017)
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86. SVT + asthma = give verapamil

CARDIOLOGY PEARLS
87.Preganacy + SVT = Adenosine
 Prophylaxis = beta blockers and verapamil avoid BETA
BLOCKERS in 1st trimester (diet-2 2017 )

88.Streptococcal bovis + infective endocarditis do =

Colonoscopy (diet-1 2016 )

89.Post valve surgery less than 2month common cause of

infective endocarditis is = staphy epidermis Post valve
surgery more than 2 month cause of infective endocarditis
is = Staphylococcus areaus
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 90.Useful test to monitor treatment of Infective endocarditis is = C reactive protein

 91. ECG of LVH is : (DIET-2 2019)

 R wave in V5 or V6 plus S wave in V1 or V2 exceeds 35mm

CARDIOLOGY PEARLS
 92.first line treatment in chronic heart failure is = ACEI and Beta blockers
 Second line is = Aldosterone antagonist ,ARBS ,
 hydralazine nitrates.

 93.Drugs improving mortality in Heart failure are :

 ACEi ,
 Beta blockers,
 Spironolactone ,
 Hydralazine with nitrates

 94.Indications of IvAbradine are :

 Ejection fraction less than 35% (DIET-3 2017 )
 When medical therapy has failed
 HR more than 75 NYHP class 2

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 95. Indications of cardiac resynchronization in Heart failure are :
 QRS more than 150ms with LBBB (DIET-1 2019)
 Ejection fraction less than 35
 NYHP class 3,4

CARDIOLOGY PEARLS
 96.Indications of ICD are :
 QRS 120-149 but no LBBB (diet-2 2018 )
 Ejection fraction less than 35 symptomatic heart failure .

 97.Indications of Anticoagulant in Heart failure are :

 Previous thromboembolic event.
 Intrathoracic cardiac thrombus
 Left ventricular aneurysm

 98.INR more than 8 + no bleeding /minor bleeding = stop Warfarin + give

Vitamin K 2.5 to 5mg Give warfarin once INR is less than 5
 INR 5-8 + no bleeding = stop warfarin
 INR 5-8 + minor bleeding = stop Warfarin + give Vitamin K 1-2.5mg and
restart warfarin once INR is less than 5 (diet-1 2017 )
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 99.Treatment of heart blocks 1st degree = no treatment
 2nd degree type 1 mobitz wenckenbach : asymptomatic = Discharge
 With symptoms = permanent pacemaker (diet-3 2017 )

CARDIOLOGY PEARLS
 Type 2 = transvaneous cardiac pacing
 Complete Heart block = pacemaker Temporary transvaneous pacing

• 100.Atropine is not useful in type 2 block and complete heart block

• 101.Complete heart block from inferior myocardial infraction does not

need pacing unlike CHB from anterior MI (diet-3 2015 )

 102. High pressure in right ventricle + normal in pulmonary artery is =

Pulmonary stenosis

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 NEPHROLOGY PEARLS

NEPHROLOGY PEARLS
Work hard in silence , let your success be
your noise.

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 1.Treatment of Haemolytic uremic syndrome is :
 first line is = infusion FFP or plasma exchange
 Plasma exchange is mainly used if CNS symptoms predominant

NEPHROLOGY PEARLS
 2.Diarrhoea positive Haemolytic syndrome is treated with = Supportive
(diet-1 2019 )

 3.Diarrhoea negative Haemolytic syndrome is treated with = plasma

exchange

 4.Treatment of HIV nephropathy is = antiretroviral therapy and ACEI

 5.Less than 50% increase in urine osmolality after DDAVP is = Nephrogenic

Diabetes insipidus (diet-1 2017 )

 6.More than 50% increase in urine osmolality after DDAVP is = Cranial Diabetes
insipidus (diet-3 2016 )

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 7.PSGN develops 1-2 weeks after URTI.
IgA nephropathy develops 1-2 days after URTI (diet-2 2017 )

 8.Goodpasture's syndrome is caused by autoantibodies

NEPHROLOGY PEARLS
against collagen type IV

 9.Diabetc nephropathy histological findings- Kimmelstiel-

Wilson lesions, nodular glomerulosclerosis

 10.Drugs causing retroperitoneal fibrosis are:

 Bromocriptine
 Beta blockers
 Methlyseriglycide

 11.Treatment of lithium induced Nephrogenic diabetes

insipidus = thiazide and amiloride (diet-1 2018)
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 12.IgA nephropathy is more common in coeliac disease even if igA level is normal.

 13.Prognosis in IgA nephropathy :

 Good prognosis:

NEPHROLOGY PEARLS
 Frank haematuria
 Markers of poor prognosis:
 male gender,
 Proteinuria more than 2g/day, (diet-1 2015 )
 Hypertension, smoking,
 hyperlipidaemia,
 ACE genotype DD

 14.Important step in reducing contrast induced nephropathy is = IV 0.9%sodium

chloride pre and post procedure

 15. Alcoholic + haematuria = IgA nephropathy

 16. Main treatment of igA nephropathy is observation

 If proteinuria less than 3 then use ACEi (diet-3 2016 )
 If Proteinuria more than 3 then use Steriods

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 17.Chronic kidney disease + painful narcotic skin lesion + hypercalcuria
+ hypophosphatemia + hyperparathyroidism + warfarin use is =
Calciphylaxis (diet-3 2018 )

NEPHROLOGY PEARLS
 18.Treatment of Calciphylaxis is =
 by reducing calcium, phosphate, controlling hyperparathyroidism
 avoid warfarin
 Surgical debridement wound care or amputation

 19.Investigation of choice for Calciphylaxis is = skin biopsy.

 20.Packed red cells are given when hb is less than 6g or less than
18%hematocrit

 21. Hodgkin lymphoma = minimal change disease (diet-3 2018)

 Non Hodgkin lymphoma =Membranous Glomerulonephritis

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 22. Azathioprine is associated with increased risk of non melanoma skin cancer

 23. Renal angiogram is investigation of choice for Polyarteritis Nodosa (PAN)

NEPHROLOGY PEARLS
 24. 1st line treatment for Raynaud phenomenon is CCB (nifidipine)
 If severe ulceration give prostacyclin iloprost infusion

 25. Steroid use is known to precipitate scleroderma renal crisis

 26. Mainstay treatment for oxalate stone is = High fluid intake and calcium
carbonate

 27.Investigation of choice for renal stones is = Non contrast CT scan

 In pregnancy = ultrasound

 28. IgA nephropathy occurs 1 to 2 days after upper respiratory tract infection
VS post streptococcal glomerulonephritis which occurs 7 -14 days following
group A streptococcal infection (Diet-3 2016 )

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 29. Young patient with hypertension + abdominal pain + haematuria
+ recurrent urinary tract infection + normal hb + ultrasound shows
cysts in kidney is = Autosomal polycystic kidney disease (diet-1
2019 )

NEPHROLOGY PEARLS
 30.Treatment of autosomal polycystic kidney disease is =
 fluids if symptomatic
 tolvaptan for decreasing annual rate of kidney growth 11.

 31.Hematuria shoes cyst rapture

 32. Loin pain shoes infection of cyst haemorrhage (diet-2 2019 )


33 . Palpable purpura at limbs, buttocks + abdominal pain +
haematuria + Proteinuria + arthritis + IgA deposit is = Henoch
schonlein purpura
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 34. All patients with Hypertension and Proteinuria
more than 1g per day should be given ACEI

NEPHROLOGY PEARLS
 35.Weight loss + neurological impairment on long
standing dialysis + joint pain and stiffness in upper
limbs = Amyloidosis (diet-3 2017)

 36.AL amyloid is seen in = Myeloma

,Waldenstrom , MGUS + cardiac ,CNS involvement,
macroglossia, perioribital ecchymosis

 37.AA amyloid is seen in =TB, bronchiectasis

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 38.Lethargy + confusion + vomiting + nystagmus, hyperreflexia + clonus +
high urea and creatinine + history of cancer is = uremic encephalopathy

 39.Treatment of Uremic Encephalopathy is :

NEPHROLOGY PEARLS
 dialysis
 Renal transplant later

 40.Nonpregresive increase in creatinine of 20 to 30% with ACEI is acceptable

 Progressive increase in creatinine with ACEi is = Renal artery stenosis (Diet-
2 2016)

 41.Loin pain + flank tenderness + fever with rigors is = upper UTI

/pyelonephritis

 42.Dysuria + frequency + no fever chills or back pain is = lower UTI /cystitis.

 43.Gold standard test for diagnose of bacteriuria is culture of bladder by

needle aspiration of bladder

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 44.Painless macroscopic haematuria do = CT scan of renal
tract with contrast to exclude malignancy.

NEPHROLOGY PEARLS
 45.Treatment of Rhabdomylosis is = vigorous rehydration with
isotonic crystalloid (diet-1 2017 )
 In severe cases/refractory cases = dialysis.

 46.No anaemia in ADPKD due to EPO realise

 47.Investigation of choice for IgA nephropathy is Renal biopsy

not IgA level

 48.Drug treatment of Nephrogenic Diabetes insipidus =

Bendroflumethiazide (Diet-3 2016)
 Cranial Diabetes insipidus is = Desmopressin
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 49.Treatment of Cystinuria is :
 The cornerstones of cystinuriac stone prevention is by hydration and
urinary alkalinisation by potassium citrate has become the alkalinising
agent of choice. (diet-3 2016)

NEPHROLOGY PEARLS
 If hydration and alkalinisation fail, the chelating agent D-penicillamine can
be used.

 50.Stones after bowel resection for Ulcerative Colitis is = Calcium oxalate

stones.

 51.Contraindications of renal transplantation are :

 i) uncontrolled hypertension
 ii) active malignancy
 iii. chronic infection,
 iv. overt proteinuria,
 v. bilateral renal artery stenosis
 VI. Atherosclerosis
 vii.sickle cell disease.

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 52. In Acute kidney injury, hyperkalaemia which is refractory to
medical management is an indicator for renal replacement therapy

 53. Alport's syndrome - type ID collagen defect

NEPHROLOGY PEARLS
 54. Gentamicin causes an intrinsic Acute kidney injury.

 55. Nephrocalcinosis may be caused by :

 renal tubular acidosis type 1,
 hyperparathyroidism and
medullary sponge kidney.

 56. Nitrofurantoin is best avoided in patents with CKD stage 3 or

higher due to the significant risk of treatment failure and occurrence
of side effects due to drug accumulation.

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 57.eGFR variables - CAGE - Creatinine, Age, Gender,
Ethnicity

NEPHROLOGY PEARLS
 58.Renal tubular acidosis causes a normal anion gap

 59.Stag-horn calculi Composed of Struvite (ammonium

magnesium phosphate, triple
phosphate)form in alkaline urine (ammonia producing
bacteria such as Ureaplasma urealyticum and Proteus
therefore predispose)
60.difuse proliferative glomerulonephritis is the most
common and severe form of renal disease in SLE patents

 61.Liddle's syndrome: hypokalaemia hypertension

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 62.ADPKD is associated with hepatomegaly (due to hepatic cysts)

 63.ADPKD type 2 = chromosome 4 = 15% of cases

NEPHROLOGY PEARLS
 64.Minimal change disease is the most common cause of nephrotic syndrome in a
child. (diet-3 2019 )

 65.Diffuse proliferative glomerulonephritis, causes: post-streptococcal, SLE

66.NSAIDs should be stopped in AKI except aspirin at cardio-protective dose .

 67.Idiopathic membranous glomerulonephritis is related to ant-phospholipase A2

antibodies

 68.The presence of upper respiratory tract signs points towards granulomatosis

with polyangitis in a patent with rapidly progressive glomerulonephritis

 69.Alport's syndrome - X-linked dominant (in the majority)

 70.Urine dip can be used to differentiate acute tubular necrosis from acute
interstitial nephritis in AKI

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 71 .B2 macroglobulin seen in patient who is on renal dialysis

 72. Loop diuretics causes calcium stones Thiazide diuretics prevent it.

NEPHROLOGY PEARLS
 73.Fever + rash + arthralgia + eosinophilia + eosinophuria (pathognomonic) +
nonoliguric renal failure + no eosinophilia with NSAID + Proteinuria +
mononuclear infiltrate in intersium is =Acute interstial nephritis

 74.Treatment of Acute interstial nephritis is drug withdrawal and steroids

 75 . Long standing dialysis + Renal failure + CNS abnormalities + joint pain and
stiffness in upper limb more than lower limb + beta 2 microglobulin is=
Amyloidosis (diet-3 2016 )

 76. Treatment of renal amyloidosis is Renal transplantation

 77. Haematuria + Loin pain + Abdominal mass + anaemia + Hypertension +

polchythemia + left varicocele is = Renal cell carcinoma (diet-3 2018 )

 78.ultrasound is investigation of choice for renal cell carcinoma

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 79. Malignancy + nephrotic range Proteinuria + IgG ,C3 deposition +
Spike and dome appearance is = Membranous Glomerulonephritis
(diet-2 2017 )

NEPHROLOGY PEARLS
 80. treatment of Membranous Glomerulonephritis is = combination
of cyclophosphamide and methylpredinsone

 81.Pulmonary haemorrhage , haemoptysis + fever, haematuria +

Proteinuria, red cell cast + linear ig G deposit + increase Dclo + antiGM
antibodies is = Good pasture syndrome (DIET-2 2018 )

 82. Treatment of Good pasture syndrome is = IV methylpredinsone

cyclophosphamide
 In severe cases plasmaphresis

 83. Nephrotic range Proteinuria + raised creatinine + normal sized

kidneys on ultrasound scan + focal segmental glomerulonephritis +
normal BP + raised immunoglobulins,raised cholesterol is = HIV
nephropathy (DIET-1 2017 )
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 84. Treatment for high phosphate in end stage renal
failure is = Sevelamer Hyperparathyroidism + dialysis = if
surgery is not option use Cinacalcet (DIET-3 2018 )

NEPHROLOGY PEARLS
 85. Loin pain + peripheral leg oedema + acute renal
injury + Proteinuria is = renal vein thrombosis
 Treatment is life long warfarin

 86. Collapse/seizure/ ecstasy /coma/fall + acute kidney

injury + High P, High uric acid , High K , High CK , low
calcium is = Rhabdomylosis
 Treatment is IV fluid

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87. All patients with diabetes and microabluminuria should be offered with ACEI
or ARBs irrespective of whether they have hypertension

88 . Indication of iron therapy in CKD anaemia Is:

NEPHROLOGY PEARLS
 i) ferritin level less than 100 (DIET-1 2017 )
 ii) transferrin saturation less than 20 Percentage then give iv iron and when
there is functional iron defienancy i.e. transferrin saturation less than 20%
Give oral iron
 when there is no functional iron defienancy i.e. transferrin saturation more
than 20

89. CKD + high calcium + high phosphate + high PTH is = tertiary

hyperparathyroidism (DIET-3 2018 )

90. Treatment of tertiary hyperparathyroidism is :

 1st line is = Para thyroidectomy
 If unfit for surgery then cinacalcet

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 91 . Bilateral sensorneural deafness + corneal dystrophies, lens abnormalities,
retinitis pigmentosa + microscopic,marcoscopic haematuria with or without
Proteinuria + foam cells , basket wave pattern glomerular basement membrane is =
Alport syndrome (DIET-3 2015)

NEPHROLOGY PEARLS
 92. Children/young adults + nephrotic syndrome + selective Proteinuria + normal
Blood pressure + history of Hodgkin's lymphoma\ Nsaid use/gold/
lithium,rifamicin/+ normal looking glomeruli on light microscopy or fusion of
podocytes on electron microscopy is = Minimal change disease

 93. Treatment of Minimal change disease is = steroids if resistant then use

cyclophosphamide

 94. Urine sodium more than 30 + fraction of sodium excretion more than 1+ urea
level more than 35 + urine osmolality less than 350 + brown granular casts + no
response to fluid is = Acute tubular narcosis

 95 . Marked loss of subcutaneous tissue from face + low c3 level+ linear

intramembranous deposit is = Membranoproliferative GN type 2 Lipid lipidystrophy

 96. Nephrotic syndrome Proteinuria or haematuria + low C3 + sub endothelial

immuno complex deposit ,thickening and splitting capillary membrane + hepatitis C
/Cryoglobulimia is = Membranoproliferative GN type 1 (DIET-1 2017 )
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 97. first choice for vascular access for dialysis is = Arteriovenous fistula

 98. Shortness of breath + cough productive of fresh blood + Proteinuria +

haematuria + PANCA,CANCA positive is = Microscopic polyangitis

NEPHROLOGY PEARLS
 99. Asthma + eosinophilia + renal failure + pulmonary haemorrhage + sensory
neuropathy + PANCA positive is = Chrug Strauss syndrome

 100.first line treatment in secondary hyperparathyroidism is = Calcium

acetate

 101.Flush pulmonary edema + urinalysis worse on ACEI /ARBs + asymmetrical

kidney is = Renal artery stenosis (diet-2 2018 )

 102.Investigation of choice for renal artery stenosis is = MR angiography

 103.Treatment of Renal artery stenosis is :

 First line is Medical therapy
 In fibro muscular dysplasia first line is angioplasty
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 104.Angioplasty/ warfarin /CABG + eosinophilia + Proteinuria + purpura + livedo
reticularis + low C3 + high ESR is = Cholesterol embolization (diet-1 2019 )

 105.treatment of Renal cell carcinoma + solitary brain metastases is = nephrectomy +

NEPHROLOGY PEARLS
tyrosine kinase inhibitor
 Chemotherapy and radiotherapy has no role in renal cell carcinoma

 106.Factory/rubber/printing/ cyclophosphamide use + microscopic haematuria +

terminal dribbling + feeling to empty bladder is = transitional cell carcinoma of bladder

 107.Treatment for localized tumours is :

 transurethral tumour of resection use of intravesical chemotherapy

 108. Investigation of choice for bladder cancer is = Cystoscopy

 109.Haematuria + Loin pain + Abdominal mass + anaemia + Hypertension +

polchythemia + left varicocele is = Renal cell carcinoma (diet-2 2016 )

 110.investigation of choice for Renal cell carcinoma is = Ultrasound of kidneys

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 111.Normotension + hypokelmia + hypomagnesmia + hypocalcuria + metabolic
alkalosis = Gittleman syndrome (diet-1 2017)

 112.Treatment of Gittleman syndrome is :

 Spironolactone

NEPHROLOGY PEARLS
 Nsaids

 113.Hypokelmia + hypertension + low renin and aldosterone is = Liddle syndrome

 114.Treatment of Liddle syndrome is :

 amiloride but not spironolactone

 115.Low sodium + low k + normal urinary sodium and potassium is = Diuretics abuse

 116. [Renal transplant patient + sudden deterioration in renal function + 7 -21 days
after + biopsy shows lymphocytes is = Acute cellular rejection

 117.Treatment of Acute cellular rejection is :

 IV bolus of high steroids

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 118. Normotension + alkalosis + hypercalciuria + hypokelmia + high
urinary chloride + high urinary sodium +high renin and aldosterone +
hyponatremia and hypochloremia + hyperplasia of JG apparatus is =
Barter syndrome (diet-1 2018)

NEPHROLOGY PEARLS
 Treat with spironlectone,nsaids

 119 .Young woman +hypertension + high renin +high aldosterone is

=Fibro muscular dysplasia

 120.Urinary retention + catheter than pass urine +enlarged prostate is

=obstructive uropathy

 121.In renal transplant irradiated type of blood is indicated for blood

transfusion

 122.Treatment of renal cell carcinoma is = for confined disease is

partial or total nephrectomy
 For advanced is tyrosine receptor inhibitor sunitinib >sorafenib
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 123. Opioid of choice in syringe driver renal failure is = Alfentanil

 124. Kidney transplant recipients have high risk of developing non

melanoma skin cancer

NEPHROLOGY PEARLS
 125.Treatment of Membranoproliferative GN type 1 is = steroids

 126. Antibiotic for peritoneal dialysis peritonitis is = Intraperitoneal

vancomycin and gentamicin

 127.Infancy/early childhood + recurrent urinary tract infection + small

shrunken scared kidneys + Hypertension is = Reflux
nephropathy/chronic pyelonephritis

 128.Investigation of choice in Reflux nephropathy is = excretion

urography (micturating cystouthrogram) (diet-2 2018)

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 129. Treatment of Renal cell carcinoma is :
 for confined disease is = Partial or total nephrectomy
 For advanced is tyrosine receptor inhibitor= sunitinib

NEPHROLOGY PEARLS
more than sorafenib

 130 .Renal transplant patient after 4 weeks + gradual rise

in creatinine + pneumonitis , colitis + Oesophagitis +
neutropenia is = CMV infection
 Treatment of CMV infection is = ganiclovir

 131.difuse proliferative glomerulonephritis is the most

common and severe form of renal disease in SLE patents

 132.Liddle's syndrome: hypokalaemia hypertension

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 HAEMATOLOGY PEARLS

HAEMATOLOGY PEARLS
Great things never come from comfort zones.

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 1.Hemolytic anaemia + Pancytopenia + Thrombosis is = Paroxysmal
nocturnal Heamoglobinuria (came in diet -2 2017 )
 Dark urine in morning is clue.

HAEMATOLOGY PEARLS
 2.Flow cytometry which detect low levels of CD59,CD55 has now
replaced Hams test as gold standard investigation in PNH Initial
screening test is Hams test

3.Cancer therapy + 10 days after develops Fever 38C or signs

of sepsis + Neutropenia less than 0.5 is =
Neutropenia sepsis (Febrile neutropenia) (came diet -2
2017)

4.Common pathogens in Neutropenic sepsis are = staphylococcus

epidermis = indwelling lines Mucositis or previous Quinolone
treatment = viridian streptococci

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5.Treatment of Neutropenic sepsis is :
First line: Piperacillin-Tazobactam or gentamicin if not
penicillin allergic or renal impairment immediately without

HAEMATOLOGY PEARLS
waiting for Culture. (came diet- 2 2018)
If patients still Febrile or unwell after 48 hours give
meropenam with or without vancomycin
If patients not responding after 4-6 days = investigate for
fungal infection (HRCT) rather giving antifungal blindly
G-CSF for boosting neutrophils

6. For Prophylaxis = Fluoroquinolones

7.Acquired inhibition of the protein ADAMTS13 which cleaves

vWF multimers is the most common cause of TTP
8.HUS or TTP? Neuro signs point towards TTP
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9.M protein less than 30g/l + bone marrow plasma cells less than 10% + no lytic
lesions or renal disease is = MGUS (diet-1 2018 )

HAEMATOLOGY PEARLS
10.Treatment of MGUS is :
Observation
If osteoporosis or osteopenia or neuropathy = bisphosphonates

11 .IgM Paraproteinemia is = Waldenstrom macroglobulinemia

12.Treatment of Aplastic anaemia is :

Blood products
Anti-Thrombocyte Antibody
Cyclosporine
Transplantation

13.Side effects of myeloma drugs are :

Lenalidomide = myelosuppresion,tetratogenic
Thalidomide = somnolence, peripheral neuropathy, constipation, tetratogenic
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14.Treatment of haemophilia is :
Haemophilia A = Recombinant factor 8
Mild cases = Desmopressin

HAEMATOLOGY PEARLS
Haemophilia B = Recombinant factor 9

15.Bone marrow transplant + fever, rash + abnormal LFTs

diarrhoea is = acute graft VS host diseases (diet-2 2017 )

16.Treatment of Acute graft VS host disease is :

methylpredinsone + cyclosporine

17.Acute myeloid leukaemia - good prognosis: t(15;17).

18.Factor D Leiden is the commonest inherited thrombophilia.

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 19.CLL - immunophenotyping is investigation of choice

HAEMATOLOGY PEARLS
 20.Disproportonate microcytic anaemia - think beta -
thalassemia trait

 21.In patients with factor D Leiden, activated factor D is

inactivated 10 times more slowly b activated protein C
than normal

 22.Leukemoid reaction has a high leucocyte alkaline

phosphatase score

 23.Polycythaemia rubra Vera is associated with a low ESR

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 24.Prothrombin complex concentrate is used for the
emergency reversal of anticoagulation in patients with
severe bleeding or a head injury ( came in diet-3 2017)

HAEMATOLOGY PEARLS
 25.Chronic myeloid leukaemia - Imatinib = tyrosine kinase
inhibitor

 26.Desmopressiin - induces release of von Will brand

factor from endothelial cells.

 27.Unprovoked VTE + Flight lasting for 8 hours = Do

below knee compression stockings

 28.Multple myeloma - Bone lesions with no

organomegaly
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 29.Treatment of Waldenstrom macroglobulinemia :
 Plasmaphresis initial therapy (diet-2 2018)

HAEMATOLOGY PEARLS
 Long term = Rituximab, Chlorambucil, Fludrabine,
Prednisolone

 30.Venous thromboembolic + skin necrosis with

warfarin is = protein C defienancy normally protein C
inactivate factor Va and vIIIa

 31.Most common cause of inherited Thrombophilia is =

factor V Leiden (activated protein C resistance)Higher
risk of VTE is = antithrombin III defienancy

 32.Tear-drop poikilocytes = Myelofibrosis

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 33.For urticarial blood transfusion reactions without anaphylaxis, an
antihistamine should be given and the transfusion temporarily
stopped . (diet-3 2016)

HAEMATOLOGY PEARLS
 34.Acute Promyleocytic leukaemia - t(15;17)

 35.Low hepatoglobin levels are found in haemolytic anaemias

 36.Actvated protein C resistance (Factor D Leiden) is the most

common inherited Thrombophilia

 37.ITP - plasma exchange is first-line TTP

 38.Patents with Waldenstrom macroglobulinemia often present with

issues secondary to hyperviscosity

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39.Indications of IV iron in iron defienancy anaemia:
I) GI disorders such as Inflammatory bowel disease (UC,Crohn's disease)
ii) unable to tolerate orally

HAEMATOLOGY PEARLS
iii) history of exertional angina with anaemia (diet-1 2016 )
iv) renal failure.

40.CKD ferritin less than 100 = iron replacement (came in diet -2 2018)
CKD ferritin more than 100 = EPO.

41.Massive intravascular Haemolysis after minutes of transfusion +

Fever + Abdominal ,chest pain + agitation hypotension is = Acute
haemolytic Transfusion reaction (diet-1 2019)

42.Treatment of Acute Haemolytic Transfusion reaction is :

Immediate transfusion termination
Fluid with saline

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 43.IgA defienancy patient develops blood transfusion reactions(came in
diet-1 2018 )

 44.Urticaria minutes after transfusion + hypotension + dyspnoea + wheeze

HAEMATOLOGY PEARLS
stridor + angioedema is = allergic /anaphylactic reaction (diet-2 2016 )

 45. Treatment of allergic /anaphylactic reaction is : discontinuation I/M

adrenaline bronchodilator antihistamine.

 46.Shortness of breadth + respiratory distress 6 hours after transfusion +

dyspnoea,techypnae,hypotension ,fever cyanosis + chest x-ray shows
pulmonary edema + with FFP and platelet not with PCV is = TRALI (came in
diet 1 2017 )

 47.Treatment of TRALI is :
 adequate volume,
 steroids
 Epinephrine


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48. Polycythaemia rubra Vera - around 5-15%
progress to Myelofibrosis or AML

HAEMATOLOGY PEARLS
49.Polycythaemia rubra Vera - JAK2 mutation

50.CLL - treatment: Fludrabine,

Cyclophosphamide and Rituximab (FCR)

51.Philadelphia translocation, t(9;22) - good

prognosis in CML, poor prognosis in AML ALL

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52.investigations in DIC are :
Platelets count = decreased
Blooding time is = increased

HAEMATOLOGY PEARLS
PT = increased
PTT = Increased
Fibrinogen = Decreased
D dimer=increased
FDPs= increased
Schistocytes.

53.D-dimer and FDP assay is most specific and rapid for diagnosis for DIC.

54.Treatment for DIC :

Cyroprecipate is 1st line
FFP and Platelets transfusion when platelets are less than 50 (diet-3 2016)

55. Burkit's lymphoma - c-MYC gene translocation .

56. CML - Philadelphia chromosome - t(9:22)

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 57.Beta 2 microglobulin shows the prognosis in Multiple Myeloma

 58.Absence of erythroblast + anaemia + normal WBC ,platelets + absent

HAEMATOLOGY PEARLS
reticulocytes + high iron and ferritin + antibodies to erythropoietin is = Pure
red cell aplasia (diet-1 2018)

 59.Treatment of pure red cell aplasia is :

 discontinuation of EPO and repeated transfusion

 60. Venous/ arterial thrombosis + recurrent fetal loss + livedo reticularis +

low platelets + prolonged APTT ( fails to correct with addition of normal
human plasma ) History of SLE + lupus anticoagulant + anticardiolipin
antibodies is = Antiphospholipid syndrome (diet-1 2017)

 61.Treatment of Antiphospholipid syndrome is :

 Venous thrombosis = Warfarin with INR 2-3 for 6 month Recurrent venous
thrombosis = lifelong warfarin : if occurred while taking warfarin then
increase INR to 3-4
 Atrial thrombosis = lifelong warfarin target INR 2-3

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 62. Treatment of Antiphospholipid syndrome in pregnancy is = Aspirin
+LMWH

HAEMATOLOGY PEARLS
 63. Causes of Extravascular haemolysis are : WAHH:
 WA-warm Autoimmune
 H- hereditary spherocytosis
 H- Heamoglobinopathies i.e. Sickle cell anaemia , thalassemia
 H- Haemolytic disease of new born

 64. Warm autoimmune haemolytic anaemia has = IgG

 65.Cold Autoimmune haemolytic anaemia has = IgM

 66. Causes of warm autoimmune haemolytic anaemia are :

 Autoimmune disease = SLE
 Neoplasia : Lymphoma, CLL
 Drugs: Methyldopa, penicillin, cephalosporin, levodopa,Nsaids,Quindine
(treated by stopping drugs + oral Prednisolone) (diet-2 2016)

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 67. Causes of Cold autoimmune haemolytic anaemia are : Neoplasia: Lymphoma
Infections :Mycoplasma ,EBV ,legionella , malaria

HAEMATOLOGY PEARLS
 68.Treatment of autoimmune haemolytic anaemia is : Warm: steroids
immnosupression,spleenectomy
 Cold : respond less to steroids

 69.Anemia + jaundice + splenomegaly + retic count more than 3 is = Haemolytic

anaemia (DIET-1 2017)

 70.Features of intravascular haemolytic anaemia are :

 Heamoglobinuria
 Low hepatoglobin
 Haemosiduria
 High LDH Heamoglobenimia

 71. Direct Combs test is diagnostic for haemolytic anaemia

 72. Treatment of Myelofibrosis is :

 First line : hydroxycarbamide (Diet-3 2015)
 interferon A and Bone marrow transplantation
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 73.Diagnostic test for Myelofibrosis is = Trephine bone marrow biopsy

 74. 50 -60 years + fatigue + massive splenomegaly + weight loss , night

HAEMATOLOGY PEARLS
sweats + tear drops poikilocytes + high WBC + high Platelets (initial) + dry
tap + high LDH + Jak2 + large abnormal platelet + portal Hypertension is =
Myelofibrosis (diet-3 2018)

 75.History of treatment chemotherapy for High grade lymphoma/

leukaemia + high K + High Phosphate + high uric acid + low Calcium + kidney
injury (high creatinine ) is = Tumour lysis syndrome (diet-1 2018 )

 76. Prevention of tumour lysis syndrome is :

 Low risk : Hydration (IV fluids) + Allopurinol (diet-3 2019 )
 Intermediate risk: Allopurinol for 7days + IV fluids
 High risk : (high tumour burden, rapid turnover, renal
impairment,age,drugs) Rasburicase + IV fluid

 77. Never combine Rasburicase with Allopurinol when treating tumour

lysis syndrome.

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 78. Haematological disorders associated with Down syndrome are :
 Fanconi's anaemia
 Aplasia

HAEMATOLOGY PEARLS
 AML
 ALL

 79. Abdominal pain + peripheral neuropathy (low radial pulse, wrist drop +
constipation + blue lines on gums + lead level more than 10 + microcytic anaemia +
basophilic stippling + high serum or urine level of Delta aminolevulinic acid + high
urinary level of coporpohyrin other normal is = Lead poisoning (diet-1 2018)

 80. Treatment of Lead poisoning is :

 DMSA for chronic poisoning
 EDTA for acute poisoning D penicillamine Dimercarpol

 81. Purpuric rash + isolated thrombocytopenia + normal PT + normal APTT + high

bleeding time + coombs positive + IgG antibody + Megakaryocytes on bone marrow
exam is = idiopathic thrombocytopenic purpura
 Investigation is = Blood film exam.

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 82. Treatment of ITP Asymptomatic = Observation
 platelets more than 30000 + no bleeding =

HAEMATOLOGY PEARLS
 Observe
 Platelets less than 30000 + mild bleeding = Oral
 Prednisolone (DIET-1 2018 )
 Platelets less than 30000 after 3 months of
 steroids therapy = Splenectomy
 Severe bleeding (GI,CNS) + Platelets less than 10000 =
 IVIG If Splenectomy ineffective = Rituximab,
 azathioprine cyclophosphamide

 83. ITP + autoimmune haemolytic anaemia is = Evan's syndrome

 84. Massive painless lymphadenopathy in young person next step is to

Lymph node biopsy

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 85. Avascular necrosis of hip + hand foot syndrome + dacylitis is =
Thrombotic crisis

HAEMATOLOGY PEARLS
 86. Acute chest syndrome + stroke is = sequestration crisis Stroke in it
treated by Exchange transfusion

 87. Sudden fall in haemoglobin without appropriate increase in

reticulocytosis + infection by parvovirus is = Aplastic crisis

 88. Treatment of sickle cell anaemia is :

 Analgesia : opiates, Rehydration
 Oxygen Exchange transfusion if CNS complication Avoid iron therapy
and intraartucular steroids
 For preventing and acute complication use hydroxyurea (diet-3 2016 )

 89. Osteomyelitis in sickle cell is caused by salmonella

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 90. Investigation for sickle cell anaemia are :
 Sickle cells
 Target cell metabisulfite screen

HAEMATOLOGY PEARLS
 Hb electrophoresis
 HbAs sickle cell trait protective against falciparum malaria

 91.Poor prognostic factors in AML are :

 I) Cytogenetic Deletion chromosome 5 or 7 (diet-3 2019)
 ii) age more than 60 years
 iii) more than 20% blasts after first course of chemo
 Iv ) 3q26 aberrations

 92.20 years + DIC + low platelets + Auer rods + t 15:17 is = APML M3

 Treatment is All trans retinoic acid ATRA plus Anthracycline

 93. Treatment of AML is :

 Initial: Cytarbine and Anthracycline Bone marrow transplantation

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 94. M2:AML with maturation = most common t(8:21)
 M3 acute Promyleocytic :t (15:17) ,DIC

HAEMATOLOGY PEARLS
 M4:acute myelomonocytic inversion 16
 M5:monocytic :Gum organomegaly lymphadenopathy
 M7:megakarytotic : down syndrome in children less than 3 years
and Myelofibrosis

 95. Good prognostic factors in AML :

 i) Promyleocytic leukaemia M3 (diet-1 2017)
 ii) t (8:21) and t(15:17)
 iii) inv 16

 96. 15-59 years + marrow failure + Gum infiltration +

hepatosplenomegaly + Auer rods myeloperoxidase positive +
sudden black positive is = AML

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97.Indications of treatment in CLL are :
i) Lymphocytes doubling time of less than 6 months or more than 50%
increase over 2 months (diet-2 2019 )

HAEMATOLOGY PEARLS
ii) bone marrow compromise anaemia, thrombocytopenia , neutropenia
iii) autoimmune complication : ITP, autoimmune haemolysis
iv) B symptoms (weight loss or Night sweats , fever more than 38 for
more than 2 weeks)
v) massive more than 10 cm or progressive lymphadenopathy
vi) massive more than 6cm or progressive splenomegaly (diet-3 2017)

98. Immunotyping is investigation of CLL B CD19 postive,CD5, CD23 flow

cytometry smudge cells

99.Treatment of CLL FCR :

First line = Fludrabine,chrombicile or cyclophosamide,
Rituximab Chlorambucil
Second line line Fludrabine : give cotrimazole as prophylaxis to prevent
Pneumocystis jirovecii brutinib when FCR ineffective
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100. Poor prognostic factors in CLL are :
i) male sex
Ii) age more than 70 years

HAEMATOLOGY PEARLS
iii)lymphocytes count more than 50
iv) prolymphocytes more than 10% of blood lymphocytes
iv) Lymphocytes doubling time less than 12 months
vi) raised LDH vii) CD38 positive
viii) chromosome del 17Good prognosis is chromosome 13 del (diet-1 2018)

101. Male African , mediaterian, + sudden anaemia and jaundice + Heinz bodies,
bite cells + low enzyme level + high reticulocytes count is = G6PD defienancy

102. Causes causing Haemolysis in G6PD are :

 PCS: P :Promaquine
 C: ciprofloxacin, chloramphenicol
 S: sulphonamides,sulphasalzine, sulfonylurea,
 Quinidine, nasid aspirin vitamin K probencid nitrofurantoin Fava beans

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 ENDOCRINOLOGY PEARLS

ENDOCRINOLOGY PEARLS
• You can never cross the ocean ,until you have
courage to leave sight of shore..

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 1.ESRD + regular dialysis + high PTH + high calcium + high phosphate
is = Tertiary hyperparathyroidism

ENDOCRINOLOGY PEARLS
 2.Treatment of tertiary hyperparathyroidism is :
 First line is : Parathyroidectomy (came n diet -3 2018)
 If unfit of surgery then Cinacalcet (only if not well fit for surgery)
 Phosphate binder : Sevelamer (only patient unable to undergo
surgery)

 3.Hyperparathyrodism + fibrosseous tumours of jaw in Romany family

is = Hyperparathyroidism jaw tumour syndrome

 4.Treatment of hyperparathyroidism jaw tumour syndrome is =

Sevelamer

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 5.Routinely isolated high calcium is = Familial isolated
hyperparathyroidism

ENDOCRINOLOGY PEARLS
 6.Treatment Familial isolated hyperparathyroidism is =
parathyroidectomy

 7.High calcium + low PTH + normal ALP is = Malignancy (diet-2 2017)

 8.High calcium +high phosphate + normal ALP = Myeloma

 9.Low calcium + low phosphate + high ALP = Osteomalacia/vitamin D

defienancy

 10.Normal calcium + normal Phosphate + high ALP is = Paget disease

of bone (diet-1 2018)

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 11.High calcium + low phosphate + high ALP is = Primary
Hyperparathyroidism (diet-3 2016)

ENDOCRINOLOGY PEARLS
 12.Low calcium + high phosphate + Normal ALP is = Hypoparathyroidism

 13.Normal calcium +Normal Phosphate + normal ALP is = Osteoporosis

 14.High Calcium + high Phosphate + high ALP is = Bone metastasis

15.Autoimmunity associated with Graves disease are :

Vertilgo most common
Other DM type 1,Addison's Disease ,Pernicious anaemia and Sjogren

16.Low IQ + short stature + obesity + short 4th and 5th metacarpal +

brachymetacarpals + calcification of nodules + round face + sticky habitus +
dental hypovolemic alright osteodystrophy is
Pseudohypoparathyroidism(came in diet 1 2016)

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 17.Amiodarone use + no underlying thyroid disease + no goitre + decrease
blood flow on Doppler + minimal or none iodine -131 uptake + markedly
high iL-6 is = Amiodarone induced thyrotoxicosis type 2(came in diet-1 2017)

ENDOCRINOLOGY PEARLS
 18.Treatment of Amiodarone induced thyrotoxicosis type 2 is : Withdrawal
of Amiodarone and steroids.(came in diet-3 2018)

 19.Amiodarone use + underlying thyroid disease like graves + Goitre + high

blood flow on Doppler + normal or high iodine uptake+ low iL-6 is =
Amiodarone induced thyrotoxicosis type 1

 20.Treatment of Amiodarone induced thyrotoxicosis type 1 is :

 Carbimazole,
 potassium perchlorate or
 lithium carbonate.

 21.Amiodarone induced hypothyroidism is not serious doesn't need

treatment

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 22.Subacute thyroiditis causes hyper- then hypothyroidism

ENDOCRINOLOGY PEARLS
 23.Graves' disease may present first or become worse during the post-
natal period

 24.Insulinoma is diagnosed with supervised prolonged fasting .

 25. The overnight dexamethasone suppression test is the best test to

diagnosis Cushing's syndrome

 26.Diabetes mellitus - HbA1c of 6.5% or greater is now diagnostic

 27.Prolactin release is persistently inhibited by dopamine

 28.The PTH level in primary hyperparathyroidism may be normal

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 29.Sudden onset headache + vomiting + neck stiffness + bitemporal superior
quadratic defect + 3rd nerve palsy + hypotension hypoaldernlaism is =

ENDOCRINOLOGY PEARLS
pituitary apoplexy (diet-1 2016)

 30.Pituitary Apoplexy Diagnosed by : MRI pituitary

 31.Treatment of pituitary apoplexy is = hydrocortisone IV to prevent

Addisonian crisis.

 32.PPH + electrolytes disturbance (sodium 130 + high K + low TSH ) is =

Sheehan syndrome (DIET-1 2018)

 33. Investigations in Sheehan syndrome are :

MRI pituitary
 pituitary function test LH/FSH

 34.Anterior hypopituitarism is differentiate from secondary hypothyroidism

is by presence weight loss in anterior hypopituitarism not in Secondary
hypothyroidism
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35.Side effects of Exogenous androgens are :
Acne
Gynaecomastia (DIET-3 2015)

ENDOCRINOLOGY PEARLS
Hypertension
Hypercholesterolemia
Hepatic tumours
Paranoid delusions

36.Yellowish hue (Carotinemia)+ obesity + bradycardia + hypothermia + coma + non

compliant to treatment + hair thinning + perioribital edema is = Myxoedema coma

37.Treatment of myxoedema coma is

initial IV thyroid hormone T3 levothyroxine with IV hydrocortisone to avoid Addisonian
crisis Rewarm slowly

38.Inferity loss of libido galtorrhoe(low GNRH )+ delayed growth hypoglycaemia (low

GH ) + secondary hypothyroidism (low TSH) + secondary adrenal insufficiency (low ACTH
)= pan hypopituitarism

39. treatment of panhypopitutarism is :

1st hormone to loss is GNRH 1st hormone to replace is hydrocortisone
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 40.Young women + 10 weeks post partum is unwell with
maladies sweats tiredness anxiety + high T3,T4 low TSH

ENDOCRINOLOGY PEARLS
positive anti TPO is = Postpartum thyroiditis (diet-1
2019)

 41.Treatment of propranolol not Carbimazole

 42.4 to 6 Month after delivery + hyper then

hypothyroidism + anti- TPO antibodies + destructive
lymphocytic thyroiditis is = postpartum thyroiditis

 43.Polyuria + peptic ulceration/constipation/Pancreatitis

+ bone fracture + hypertension + renal stones + High
calcium + low phosphate + high PTH or normal is =
primary hyperparathyroidism
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 44.Markedely high testosterone is androgen secreting
tumour not PCOS

ENDOCRINOLOGY PEARLS
 45.Hirsutism + acne + high libido + testosterone 8.9(N
<2.9) is = Androgen secreting tumour Key here
testosterone more than 3 times upper limit of normal
(Diet-2 2106)

 46.Climotromegaly mainly with high androgen

 47.High testosterone + normal DHEA = ovarian source

 48.Normal testosterone + high DHEA is = Adrenal source

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 49.Obesity - NICE bariatric referral cut-offs
with risk factors (T2DM, BP etc.): > 35 kg/m^2
no risk factors: > 40 kg/m^2

ENDOCRINOLOGY PEARLS
 50.Patents on long-term steroids should have their doses doubled during intercurrent
illness .

 51.A normal short synacthen test does not exclude adrenocortical insufficiency due
to pituitary failure.

 52.HRT: adding a progestogen increases the risk of breast cancer . (diet-3 2018)

 53.Riedel's thyroiditis is associated with retroperitoneal fibrosis .

 54.Bilateral idiopathic adrenal hyperplasia is the most common cause of primary

hyperaldosteronism

 55.Thinning of pubic and axillary hair is seen in females with Addison's disease due to
reduced production of testosterones from the adrenal gland

 56.Thyrotoxicosis with tender goitre = subacute (De Quervain's) thyroiditis

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 57.Radioactive iodine uptake (RAI 131 scan)In graves = high homogeneous
diffuse uptake

ENDOCRINOLOGY PEARLS
 58.Toxic nodular goitre = patchy uptake or solitary area of high uptake

 59.DeQuervain thyroiditis = no uptake or reduced uptake (DIET-1 2018)

60. T scores > -1 =Normal

T score b/w -1 to -2.5 =osteopenia
 T score less than -2.5=osteoporosis

61.Cerebral oedema is an important complication of fluid resuscitation in

DKA, especially in young patents.

 62.Graves' disease is the most common cause of thyrotoxicosis

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 63.High oestrogen + high progesterone + low LH,FSH + high prolactin +
high Beta HCG is = pregnancy (diet-1 2017)

ENDOCRINOLOGY PEARLS
 64.Normal oestrogen + high testosterone + LH high + FSH normal + high
FSH and LH ratio is = Polycystic Ovarian syndrome. (diet-3 2016)

 65.Low oestrogen + high FSH,LH is = Premature ovarian failure

 Treatment is : hormone replacement.

 66.Normal oestrogen + high FSH and LH is = resistant ovary Syndrome.

 67.Elevated LH and testosterone with normal FSH = Polycystic Ovarian

syndrome.

 68.Testosterone >7 + Hirutism + virilisation + deep voice + ciltromegaly

is = Adrenal or ovarian tumour.

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 69.Tall + lack of secondary sexual characteristics + Gynaecomastia + low
testosterone + high LH FSH + firm small tests is = Klinefilters syndrome (diet-2
2017)

ENDOCRINOLOGY PEARLS

 70.Investigation in Klinefilters syndrome are :
 Low testosterone
 High LH FSH
 Karyotype 47,XXY,47XX
 Low HDL cholesterol
 high TGA
 Most appropriate test is FSH LH level.

 71.Treatment of Klinefilters syndrome is
 Testosterone to improve bone minerization

 72.Anosmia + delayed puberty + low Testosterone, low FSH,LH + normal
height + Cryptorchidism + hearing defects/cleft lip plate visual defect +
primary amenorrhea + no mental retardation is = Kallman's syndrome (diet-2
2019)

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 73.Investigation in Kallman's syndrome :
 Diagnostic test is FISH MRI = absent olfactory bulbs
 Low testosterone and low FSH LH

ENDOCRINOLOGY PEARLS
 74.Treatment of Kallman's Syndrome is :
 Pulses not continuous GnRH
 Once family is completed then testosterone.

 75. Klinefilters syndrome = Low testosterone + raised LH and FSH

 Kallman’s Syndrome = Low testosterone + Low FSH and LH.

 76.Primary hypogondasim ( Klinefilters syndrome ) = High LH + Low

testosterone.
 Hypogondotrophic hypogondasim (Kallman’s Syndrome ) = Low LH and FSH +
Low testosterone .
 Androgen insensitivity syndrome = High LH + Normal / High testosterone.
 Testosterone secreting tumour = Low LH + High testosterone.

 77.thyrotoxicosis + goitre + Autoantibodies + thyroid eye disease is = Graves

disease . (diet-1 2017)
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 78. 5 hypo’s in Addison’s disease :
 Hypotension (postural )
 Hypoglycaemia

ENDOCRINOLOGY PEARLS
 Hyponatremia
 Hypo aldosterone
 HypoPH

 79. 2 HYPER in Addison’s disease :

 Hyperkalaemia
 Hyperreninemia .

 80.Patient of Addison’s disease who undertaken strenuous activity should double

their dose of glucocorticoid and mineralocorticoids .

 81.lethargy , weakness + anorexia + nausea , vomiting + weight loss +

hyperpigmentation at palmer or buccal mucosa + loss of pubic hairs + hypotension +
high K + Low sodium is = Addison’s disease (diet-1 2106)

 82.treatment of Addison’s disease is :

 Hydrocortisone 100 mg IV TDS.
 Fludrocortisone for postural drop
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 83. In Addison’s disease there is low T4 and high TSH so never treat thyroid problems
treat Addison’s thyroid will become normal .

ENDOCRINOLOGY PEARLS
 84.treatment of thyroid overdose is :
 Propranolol
 Plasmaphresis in severe cases.
 Cholestrayamine.

• 85. Investigation in Addison disease:

• ACTH stimulation test(short synacthen test) After giving synacthen of 250ug
normally there increase cortisol of greater than 550 if below this confirm diagnose
of adrenal insufficiency to dx localize it we do long synacthen test where if cortisol
raise then it's secondary adrenal insufficiency if not then it's Primary.

• 86.Other tests in Addison’s diseases :

• Adrenal autoantibodies anti21 hydroxylase Ab
• 9am cortisol and ACTH test low Cortisol and high ACTH
• Metabolic acidosis
• Macrocytic anaemia pernious
• Blood: high Eosinophila,lymphocytosis , neutropenia mild Hypercalcemia.

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• 87.Causes of Addison’s diseases:
• Autoimmune (most common)Infections TB = do CT abdomen showing shrinkage of adrenals
• HIV

ENDOCRINOLOGY PEARLS
• CMV
• Antiphospholipid syndrome (Hughes syndrome)
• Waterhouse fried ache syndrome Metastasis (bronchial breast kidney)

• 88. Female patient with history of recurrent DVT and confirmed hypoaldostrone low sodium
high K positive short synacthen test is = Antiphospholipid syndrome ( Hughes syndrome) (diet-1
2018 )

 89.Sepsis / surgery/ steroid withdrawal/infection + hypotension + hypothermia + syncope +

convulsions + Hyponatremia + hyperkalaemia + hypoglycaemia is = Addisonian crisis (diet-3
2105)

 90.Treatment of Addisonian crisis is =

 IV fluids IL normal saline and steroids IV hydrocortisone 100mg of IV Dexamethasone

 91.Tiredness Lethargy + postural Hypotension + high ESR + DIC + purpura + Hyponatremia high K
is = Waterhouse fridirch syndrome

 92. Treatment of Waterhouse fridrich syndrome is = IV fluids and IV hydrocortisone

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 87.Low ACTH + no skin pigmentation + no hyperkalaemia + BP normal + low Cortisol
+ normal aldosterone is = Secondary hypoadrenalsim

ENDOCRINOLOGY PEARLS
 88.Treatment of Secondary hypoadrenalsim is : Only glucocorticoid.

 89.Cortisol curve can be used to asses how appropriate dosing of glucocorticoid

steroids in Addison patient

 90.Expothalmus + diplopia + conjunctival oedema + optic disc swelling +

opthalmoplegia + inability to close eye lids lid lag lid retraction +
eu,hypo,hyperthyroid is = Thyroid eye disease. (diet-2 2108 )

 91.Management of Thyroid eye disease is :

 Stop smoking
 Stop Radioiodine
 Use topical lubricant
 High dose steroids
 Orbital decompression
 In replased or active disease = Radiotherapy
 Malignant exophthalmos = Steroids

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• 92.Investigation in Insulinoma are :
• Supervised , prolonged fasting (up to 72 hours)
• CT pancreases 90%are less than 2cm in size.

ENDOCRINOLOGY PEARLS
• 93.High insulin + high C peptide + high pro-insulin + normal SU level =
Insulinoma (DIET-2 2016)

• 94.High insulin + high C peptide + high SU level is = sulphonylurea overdose

• 95.High insulin + low C peptide = Exogenous insulin or insulin misuse

• 96.Low insulin + low C peptide is = non beta cell tumour

• 97.Causes of hypoglycaemia less than 60mg/dl are :

• Insulinoma
• Self administration insulin/ sulphonylurea
• Liver failure
• Alcohol
• Addison disease .
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 Rheumatology pearls

RHEUMATOLOGY PEARLS
Push yourself because no else is going to do it
for you.

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1.In suspected case of gout in Infective cause
next step is to perform knee Aspiration to exclude

RHEUMATOLOGY PEARLS
septic arthritis .(came in diet-2 2018)

2.Peripehral neuropathy + 2cm diameter

ulcer on ball of left foot with Frank pus +
erythema is = osteomyelitis

3. investigation of choice in Osteomyelitis is

MRI of foot.

4.In avascular necrosis of femoral head next step is

osteotomy ,If osteotomy fails then total hip
replacement.
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5.Paget's disease - old man, bone pain, raised ALP

6.May be able to see apical fibrosis on chest x-ray in later Ankylosing

RHEUMATOLOGY PEARLS
spondylitis.

7.Rheumatoid factor is an IgM antibody against IgG .

8.Ankylosing spondylitis features - the 'A's

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis

9.Start alendronate in patents >= 75 years following a fragility fracture,

without waiting for a DEXA scan (diet-1 2017)
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 10.Behchet's disease is associated with HLA B5
.
 11.middle aged man with KNEE arthritis --> gonococcal

RHEUMATOLOGY PEARLS
sepsis (older people -> Staph).

 12.Gout – blood urate high/low/normal, joint aspirate

positive birefregent + thiazides use NO
allopurinol/aspirin in acute phase (diet-2 2015)

 13.Osteoarthritis – will present with Short Morning

Stiffness, and will involve DIP and PIP joints.

 14.Rheumatoid Arthritis – will present with a Long

Morning Stiffness that will improve with Exercise, and will
involve MCP and PIP joints

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 15.A patient K/C of HTN taking water pill for it presented with swollen
painful fingers of hands/ feet ----- Gout.

RHEUMATOLOGY PEARLS
 16.Swollen fusiform fingers with hyperaemia ----- Psoriatic arthritis.

 17.Bouchard’s nodes(PIP joint), Heberden nodes (DIP joint) ----- O

Arthritis .

 18.Back pain with low grade fever , Raised ESR and on examination
tenderness present------ Think osteomyelitis (MRI is gold standard
because it is sensitive) (diet-3 2018)

 19.Early Rx start otherwise it may progress to epidural abscess or

spinal cord compression………. Thinking of epidermal abscess gets more
stronger if there is immunosuppression (uncontrolled D.M) drug
abuser (IV) and symptoms of spinal cord compression (lower extremity
weakness, urinary in continence). MRI gold standard

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 20.NSAID in Acute Gout – are the first line of treatment in patients
presenting with Acute Attacks of Gout.

RHEUMATOLOGY PEARLS
 21.Glucocorticoids are used as a first line of treatment in Elderly
Patients or those with Renal Failure.

 22.Rotator cuff tendonitis--- pain on lifting arm overhead differentiated

from Rotator Cuff Tear (similar symptoms) and Frozen Shoulder by
injection of Lidocaine pain and limitation of
movement is resolved with inj. Frozen shoulder also called adhesive
capsulitis.(diet-1 2016)

 23. Patient with R. Arthritis are at increased risk of developing

osteopenia, osteoporosis due to :
 Steroid Rx, female sex, decreased ability to perform weight bearing
exercises that prevent it) septic arthritis (especially by staph. Aureus

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 24.A normal temporal artery biopsy in a patent with
suspected giant cell arteritis does not exclude the disease

RHEUMATOLOGY PEARLS
because of the potential for skip lesions

 25.Bendromethazide use is associated with gout

 26.Anti-Jo-1 antibodies are more common in

Polymyositis than Dermatomyositis (diet-1 2019)

 27.Anti-cyclic citrullinated peptide antibodies are

associated with rheumatoid arthritis

 28.Anti-ribonuclear protein (anti-RNP) = mixed

connective tissue disease

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 29.Septic arthritis - most common organism: Staphylococcus Aureus

RHEUMATOLOGY PEARLS
 30.Septic arthritis: IV Flucloxacillin

 31.SLE - antibodies associated with congenital heart block = anti-Ro (diet-3 2016)

 32.SLE: ANA is 99% sensitive - anti- Sm & anti- dsDNA are 99% specific

 33.SLE: C3 & C4 low

 ·
 34.Rheumatoid arthritis - HLA DR4

 35.Rheumatoid arthritis - TNF is key in pathophysiology

 36.Rheumatoid arthritis: patients have an increased risk of IHD

 37.In Paget disease skeletal survey >bone scan

 38.cANCA = Wegener's; pANCA = Churg-Strauss + others


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 39.α 3 chain of Type IV Collagen – is targeted by anti-glomerular
basement membrane antibodies in Goodpasture’s Syndrome

RHEUMATOLOGY PEARLS
 40.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.

 41.ANCA Ab are of 2 types:

1- C-ANCA which correlates with antiproteinase 3 antibodies--->most
specific for Wegener's granulomatosis. (diet-3 2016)
2- P-ANCA which correlates with anti myeloperoxidase ab. P-
ANCA/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.

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 42.Patient presentation with joint pain (asymmetrical. Oligoarthritis), conjunctivitis
urethritis (urethral discharge) mucocutaneous lesions, euthesitis and synovial fluid
(no organism seen---- sterile)--------- seronegative Reiter’s syndrome (NSAIDS given

RHEUMATOLOGY PEARLS
for pain).

 43.Patient diagnosed of Rheumatoid Arthritis on Rx presented with splenomegaly,

deranged LFTs and painful mouth ulcers and HCT = 33% ----------- Methotrexate S/E
(Reduced by concomitant Folinic Acid).

 44.Patient over 50 years of age presented pain and stiffness in neck shoulders and
pelvic girdle, with morning stiffness lasting over 1 hour and increased ESR. On
examination no inflammation and stiffness noticed and patient says that pain is not
in joints but in soft tissues-------- Think of Polymyalgia Rheumatica (PMR) (Lose dose
prednisolone given) as compared to giant cell arthritis which has above features as
well as headaches + vision disturbance + jaw claudication---------- high dose
prednisolone given. (diet-3 2017)

 45.Patient with R. Arthritis poorly complianced with Rx presented with

Splenomegaly and granulocytopenia WBC count <2000/mm3 ----------
Felty’ssyndrome.

 46.Ankylosing Spondylitis has strong association with HLA B27 (90% of patients).
pain Most common extra articular manifestation is anterior uveitis (photophobia
+blurring + eye
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 47.Patient >50 years of age, female presented with dry mouth and dry eyes
+ arthritis ------- autoimmune disease( Sjogren syndrome: in with there is
lymphocytic infiltration of glands, anti Ro SSA / anti LA, SSB Ab are positive.

RHEUMATOLOGY PEARLS
Parotid enlargement present high risk of B. cell lymphoma and dental caries.

 48.Sicca Syndrome: Dry eyes/ Dry moth/ nasal, vaginal dryness/ chronic
bronchitis/ reflux esophagitis/ No arthritis.

 49.Rotator cuff tendonitis--- pain on lifting arm overhead differentiated from

Rotator Cuff Tear (similar symptoms) and Frozen Shoulder by injection of
Lidocaine pain and limitation of movement is resolved with inj. Frozen
shoulder also called adhesive capsulitis.

 50. Patient with R. Arthritis are at increased risk of developing osteopenia,

osteoporosis (due to steroid Rx, female sex, decreased ability to perform
weight bearing exercises that prevent it) septic arthritis (especially by staph.
Aureus)

 51.Lumbar spinal stenosis (Neurogenic Claudication) is position dependent

and persists while patient standing while PVD. Induced claudication is
exertion dependent and resolves with standing still (came in diet-2 2018)

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 52. Poorly controlled Rheumatoid arthritis + Proteinuria+
hypoalbuminemia is = Systematic Amyloidosis
 Do rectal biopsy

RHEUMATOLOGY PEARLS
 53. Elderly man + pain and stiffness in shoulder pelvic girdle
proximal not weakness is = polymyalgia Rheumatica ,check
ESR level

 54.Turkey patient + oral ulcers + genetic ulcers + anterior

uveitis + thrombosis + aseptic meningitis + abdominal pain +
diarrhoea colitis + erythema nodsum is = Behcets syndrome
(diet-1 2018)

 55. Urethritis + conjunctivitis + Arthritis + history of GI

infection + brown papules on palms and soles + circinate
balnatis is = Reactive Arthritis (diet-2 2017)
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 56. Bone fractures + bone pain + low calcium + low phosphate + high Alp + high PTH
+ losser's zone on x-ray is = Osteomalacia

RHEUMATOLOGY PEARLS
 57. Foot drop + abdominal pain + livedo reticularis + renal failure + HTN + purpura +
testicular pain + Hep B serology + No lung involvement is = Polyarteritis nodusa

 58. Arabs,itians ,Turks Jews Azerbaijan's + fever + abdominal pain + signs of

peritonitis + pluritis + leg joint involvement + inflammation of tunica vaginals +
increase WBC C-Reactive is = Familial mediaterian fever give colchicine (diet-1 2019)

 59. Dull shoulder pain + global restriction of shoulder movement in all direction +
external rotation more effected + pain at rest +movement effected in active and
passive + diagnosis is clinical no investigation is required is = Adhesive capsulitis

 60. Raynaud disease + tight skin in face + below elbow and below knee + anti
centromere antibodies + scerlodactly + oesophageal dysmotility + calcinosis is =
Crest syndrome

 61.Antibody showing renal crisis in systematic sclerosis is = anti RNA polymerase III
antibody

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 62. Tightening of skin in upper limb above elbow lower limb above
knee trunk + Hypertension + lung fibrosis + renal involvement + anti

RHEUMATOLOGY PEARLS
scl 70 is = Diffuse cutaneous systematic sclerosis

 63. Foot drop ,ulnar nerve palsy + Purpuric rash + arthralgia + low C4
level is = Cryoglobulimia (diet-3 2016)

 64. Old patient + pain on base of thumb + tenderness and swelling on

1st carpometacarpal joint + crepitus + pain on abduction of thumb +
atrophy of thenar muscles is = Osteoarthritis

 65. Old man + weakness in finger flexors + weakness of shoulders +

difficulty in swallowing + Ck level normal + muscle biopsy shows
internuclear or cytoplasmic tubofilaments is = Inclusion body
myositis

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 66. Women patient + anticardiolipin antibody + lupus anticoagulant + high APTT
(does not improve after human plasma ) + venous ,arterial thrombosis + low
platelets is = Antiphospholipid antibody syndrome

RHEUMATOLOGY PEARLS
 67. Don't give anticoagulation in Behcets even with thrombosis give steroids

 68. Cyclophosphamide causes premature ovarian failure and infertility

 69. Raynaud phenomenon + myositis + fibrosing alevolitis + mechanic hands i.e.

thickened ,cracking and peeling skin + CK level high + proximal myopathy + anti
jo1 antibody is = anti synthase syndrome /Polymyositis (diet-2 2018)

• 70.Spastic paraplegia + upper motor signs in lower limbs + urinary retention +

HTLV1 positive is = Tropical spastic Para paresis

• 71. Massive hepatosplenomegaly + pancytopenia + bone fractures + yellow

papules (pingueculae )+ no brain pathology + Erlenmeyer flask shaped cyst is =
Gaucher disease

• 72. Long term management in patient with idiopathic intracranial Hypertension is =

weight loss
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 73. Pauci articular still disease has ANA positive
 but systematic still disease has negative ANA + RF

RHEUMATOLOGY PEARLS
 74. Pain and swelling over lateral dorsal aspect of wrist + Finklestein test positive
is = De Quervain's tenosynovitis (diet-3 2015)

 75.Hip replacement gram positive bacillus think of = propionibacterium acnes

 76. Organism associated with development of RA is = Proteus mirablis

 77. Gout + warfarin use give = Rasburicase

 78. African Caribbean lady + Well demarcated macular rash with erythema ,scales,
plaques atrophy + photosensivity +scaring alopecia + negative ANA and anti Ds
DNA is = Discoid lupus

 79. Swollen tender mass in calf + Doppler u/s shows compressible lumen +
osteoarthtris is = Baker's cyst

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 80. 30 year old + absent limb pulses + unequal blood pressure in
upper limbs + Carotid bruit + claudication + TIA + angina + aortic

RHEUMATOLOGY PEARLS
regurgitation + glomerulonephritis + high ESR, CRP is = Takayasu's
disease (diet-2 2018)

 81 . Treatment of Takayasu’s disease is = Steroids

 82.Best way to differentiate primary Raynaud Disease and Raynaud

secondary to connectivity tissue disease is =Nail fold capillarsocopy
i.e. distorted missed nail fold capillary loops

 83. Confirmation test for carpal tunnel syndrome is = EMG /nerve

conduction studies

 84 . Smoker + pain on walking + digital ulcerations + cyanosis and

gangrene of fingers and toes + absence of pulses in radial, dorsal pedis
tibial artery + burning sensation in fingers is = Burger's disease

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 85.⛹‍♂Sitting down..... relieve the pain of spinal stenosis.
 ⛹‍♂Sitting down..... aggravate the disc prolapse pain .
 both cause low back pain which extended to the LEG.

RHEUMATOLOGY PEARLS
 86. Back pain + leg raise pain aggravated + sitting relives pain or leaning forward
while walking + pain with extension of lumbar spine + loss of lumbar lardosis is =
Spinal stenosis (diet-1 2019)

 87. 4 to 8 years of age + hip joint hip pain + limp + decrease hip movement + x-ray
widening of joint space + decrease femoral head size is = Perthes disease

 88. Drug for long term renal involvement in SLE is =Mycophenolate mofetil

 89. Stains has interaction with grape fruit juice

 90. cute gout + colchine contraindicated + small joints involvement + renal failure =
give oral steroids not intraarticular that is used for large joint involvement

 91. SLE: normal CRP unless an infection

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 92. The recommended treatment for myelosuppression secondary to her
methotrexate therapy is with folinic acid rescue therapy

RHEUMATOLOGY PEARLS
 93. Bilateral proximal myopathy + neuropathic pain in thighs + absence of
lumbosacral structural lesson is = Diabetic amyotrophy

 94. Loin pain + haematuria in Antiphospholipid syndrome -> renal vein thrombus

 95. Osteoporosis treatment is :

 1st line oral bisphosphonates (diet-3 2018)
 1st aldereonate if contraindicated then risedronate or etidronate
 2nd line raloxifene and strontium Donosumb
 Raloxifene contraindicated in thromboembolism
 Strontium contraindicated in thromboembolism
 Teriparatide contraindicated in previous hyperparathyroidism
 Denosumab has side effects of diarrhoea ,dyspnoea ,hypocalcaemia and upper
respiratory tract infection.

 96. Bisphosphonates and Donosumb used to prevent pathological fractures in bone

metastasis .
 if eGFR less than 30 , Donosumb is preferred Donosumb is not used for preventing
skeletal related events with bone Mets from prostate carcinoma (diet-1 2017)
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• 97. Painting/playing tennis + pain and tenderness in lateral epicondyle
+ pain worse on wrist extension against resistance with elbow
extended or supination of forearm with elbow extended + pain on

RHEUMATOLOGY PEARLS
wrist dorsiflexion and middle finger extension is = Lateral epicondylitis
/tennis elbow (diet-1 2016)

• 98. Painful abduction between 60 to 120 degree + tenderness over

anterior acromion + calcification on x-ray is = supraspinatus tendonitis/
Sub acromial impingement painful arc

• 99. Pain through out body with tender points + lethargy + sleep
disturbance , headache + normal blood lab normal ESR is =
Fibromyalgia

• 100 . Treatment of Fibromyalgia is :

• explanation, aerobics exercise, CBT
• drugs :pregablin ,duloxetine, amitriptyline

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INFECTIOUS DISEASE PEARLS

INFECTIOUS DISEASE PEARLS

• First they will ask you why you are doing it?
then they will ask you how you did it ?

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 1.Fever(high grade) + headache + retro-orbital pain + back pain +
myalgia + lymphadenopathy + palatal vesicles + sclera injection +

INFECTIOUS DISEASE PEARLS

maculopapular rash beginning in trunk the limbs then face + DIC
epistaxis + low WBC + low platelets + high ALT + low sodium is =
Dengue fever ( came in march 2017 )

 2.Investigation of choice for Dengue Fever is = serology high IgG

dengue virus RNA by PCR

 3.Treatment of Dengue fever is :

 Supportive (symptomatic) fluid resuscitation (normal saline)
 Pain relief but don't use aspirin
 Blood transfusion.

 4.Criteria for discharge in Dengue fever are:

 Stable haematocrit
 Platelets 50 and improving ( came in October 2018)
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 5.Gay men + HIV patient + painless ulcer + painful inguinal lymphadenopathy
+ proctitis is = Lymphogranuloma venereum caused by chlamydia trochmatis

INFECTIOUS DISEASE PEARLS

(DIET-3 2017)

 6.Treatment of Chlamydia trochmatis is :

 Doxycycline or erythromycin if not then azithromycin.

 7.Ingestion of unpasteurized milk + fever + paradoxical bradycardia +

hepatosplenomegaly + lymphadenopathy + spinal tenderness + low WBC +
low platelets is = Brucellosis

 8.Treatment of Brucellosis is :
 first line is = doxycycline
 second line is = rifampicin or gentamicin.

 9.Investigations of Brucellosis are :

 Gold standard = bone marrow aspiration and Culture
 Best test = brucella serology Coccobacilli
 Screening = rose Bengal test
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 10. painful genital(defined ,tagged ,undermined border) ulcer + pustules
and haemorrhages ulcers + unilateral painful lymphadenopathy is =

INFECTIOUS DISEASE PEARLS

Chancroid caused by Haemophilus ducreyi

 11.Chancroid is Diagnosed by Culture using chocolate agar

 12.Treatment of Chancroid is = Azithromycin and quinolones (diet-2 2018)

 13.Small fleshy protuberance lesion which may bleed or itch is = Genital

wart

 14.Genitial wart is caused by = HPV 6 and 11 HPV

 Cervical cancer is = HPV 16,18,33.

 15.Treatment of Genital wart is =

 First line multiple non keratinised wart = topical podophyllum
 Solitary keratinised wart = Cryotherapy 2nd line = imiquimod topical
cream.

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 16. Multiple painful penile vesicles and ulcers + fever + HSV type 2 =
Genital herpes.

INFECTIOUS DISEASE PEARLS


 17.Treatment of Genital Herpes is : Oral acyclovir

18.Staphylococus Aureus = Coagulase positive causes:

skin infection (cellulitis) abscess,
osteomyelitis
toxic shock syndrome

19.Staphylococus epidermis coagulase negative causes = central line

infection. (diet-2 2017)

20.Drugs used for MRSA are :

Vancomycin
Teicoplanin
Linezolid (also for VRE).
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21.Who should screen for MRSA ? =
all awaiting for elective admission except those who wants termination of

INFECTIOUS DISEASE PEARLS

pregnancy and ophthalmic surgery, mental illness
Drugs used to prevent are : Mupirocin 2% for nose
Skin = Chlorhexidine gluconate.
Best way to prevent is by hands hygiene

22.Most appropriate antibiotic regimen for possible line sepsis from indwelling
catheter is = vancomycin + gentamicin

23.Fish tank granuloma + chest x-ray upper lobe fibrosis and cavitation =
mycobacterium marinum (diet-3 2019)

24. EBV: associated malignancies:

Burkit's lymphoma
Hodgkin's lymphoma
nasopharyngeal carcinoma

25. Severe falciparum malaria - intravenous artesunate

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 26.Moutoux test Less than 6 mm + negative = unvaccinated
give BCG

INFECTIOUS DISEASE PEARLS

 6-15mm + positive test = don't give BCG may b due to
previous TB infection or BCG atypical mycobacteria
 More than 15mm + strongly positive = TB do sputum AFB.

 27.Multidrug resistant TB = resistant to 2 or more 1st line

drugs i.e. INH , rifampicin (diet-2 2015)

 28.Treatment of Multidrug resistant TB is :DOT drugs

(amikacin, kanamycin capremycin, Fluoroquinolones) for 18
to 24 Months
 Once sputum negative then for 9months

 29.Risk factors for MDR-TB are : previous TB,

 HIV, contact with drug resistant disease and treatment failure
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 30.People with HIV are at risk of :
 Hepatitis B

INFECTIOUS DISEASE PEARLS

 pneumococcal disease and influenza so fallowing vaccines should be
given :
 Pneumococcal vaccine
 PPV23Influenza vaccine.

 31.HIV patient should be given vaccination at O,1 and 6 Mon or 0,1,2

and 12 months.

 32.HIV history + transplant history + Purple papules or plaques on skin

or mucosa(git or respiratory) + lesion on face + in respiratory can cause
massive haemoptysis or effusion + lymphocytic and spindle cells + is =
= Kaposi's sarcoma caused by HHV-8 (came in October 2018 part-2)

 33.Treatment of Kaposi sarcoma is = Radiotherapy + resection +HAART

(came in march 2017 part-2)

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 34.Single painless indurated ulcer on penile shaft (chance)+
painless lymphadenopathy + 14 days-3 Month after

INFECTIOUS DISEASE PEARLS

unprotected sexual intercourse is = Primary Syphilis

 35. primary Syphilis is diagnosed is diagnosed by = dark field

microscopy of secretions of ulcer or serology.

 36.Fever + painless generalized lymphadenopathy +

generalized symmetrical rash on trunk, palms ,soles + buccal
snail track ulcers + Condylomata lata + 1-6month after
primary infection is = Secondary Syphilis (diet-3 2018 )

 37.Gummas + aortic aneurysm/AR + hyperreflexia+ fits+

hallucinations + tremors + Argyll Robertson pupil + Tabes
dorsalis is= Tertiary Syphilis(cardio- Syphilis and neuro
Syphilis).
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 38. Cottage cheese discharge + Vulvitis itchy Curdy thick
+ pH less than 4 + wet mount WBC spores

INFECTIOUS DISEASE PEARLS

Pseudohyphae = Candida

 39. Travel history + abdominal pain + bloating + non

bloody non foul smelling diarrhoea = Giardiasis (diet-3
2019)

 40.Giardiasis is diagnosed by = duodenale aspirate or

string tests Stool Culture

 41.Treatment of Giardiasis is metronidazole.

 42.Diarrhoea consciousness + hypotension +

hypothermia + tachycardia = Septic shock
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 43.E. coli is the most common cause of travellers' diarrhoea .

INFECTIOUS DISEASE PEARLS

 44.Streptococcus pneumoniae is associated with cold sores

 45 Renal transplant infection ? CMV

 46.HIV - multiple ring enhancing lesions = toxoplasmosis

 47.Animal bite - co-amoxiclav

 48.Pneumonia in an alcoholic - Klebsiella

 49.Live vaccines given by injection may be either given concomitantly

or a minimum interval of 4 weeks apart to prevent risk of
immunological interference

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 50. Patient presents with dysuria + urethral discharge + gram staining
shows neutrophils but no bacteria is = Chlamydia trochmatis (DIET-3

INFECTIOUS DISEASE PEARLS

2018)

 51.Azithromycin is treatment of choice for Lymph granuloma venrum.

 52.Meningitis + brainstem involvement + Immunocompromised

patient is = Listeria meningitis

 53.Ataxia + seizures + headache + menigism + pneumonia + diarrhoea

+ not responding to cephalosporin + trumblibg motility is = Listeria
Monocytogenes (diet-3 2016)

 54.Listeria Monocytogenes is Diagnosed by = Blood Culture

 55.Treatment of Listeria meningitis : IV amoxicillin/ampicillin and

gentamicin (cephalosporin usually inadequate)

 56.Lymphocytic CSF predominates in TB and fungal meningitis

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 57.Urethral discharge + dysuria + gram negative dipplococci = Gonorrhoea

INFECTIOUS DISEASE PEARLS

 58.Tenosynovitis + migratory polyarthritis + dermatitis = Disseminated
gonococcoal infection

 59.Patient with Gonorrhoea received ceftriaxone but unfortunately his

symptoms have not resolved is = Coexistent infection chlamydia

 60. Treatment of Gonorrhoea is :

 Cephalosporin (cefixime or ceftriaxone) Is treatment of choice (diet-1 2018)
 Ciprofloxacin was used

 61.Investigation for Gonorrhoea Standard Culture fail to grow selective media

is needed like Thayer Martin medium

 62.Dysuria + penile discharge thin colourless + had sexual intercourse +

urethral swab 10PMN/HPF no bactermia is = Nongonococal urethritis

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 63.Treatment of Nongonococal Urethritis is :
 doxycycline 7 days or azithromycin

INFECTIOUS DISEASE PEARLS

 Erythromycin is 2nd line

64.Complications of Gonorrhoea are :
 Local: urethral stricture , Epididymitis,Salpingits (infertility)

 65.DGI Monoarthritis + pustular rash synovial fluid is suggestive of

joint sepsis in young woman is gonococcal arthritis

 66. HIV patient + Cottage cheese and tomato ketchup or 🍕 (pizza)

appearance is = CMV Retinitis

 67.Treatment of CMV Retinitis is :

 Ganciclovir (Side effects : myelosuppression do CBC) (diet-2 2018)
 Foscarnet If both contraindicated give = Cidofovir

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 68.Dyspanae + CD count less 200 + dry cough + fever + exercise induced
desaturation + Lymphadenopathy + choroid lesion + HSM + very few chest signs

INFECTIOUS DISEASE PEARLS

is = Pneumocystis jiroveci pneumonia (diet-2 2019)

69.Investigations in pneumocystis jirovecii pneumonia are :

 CXR : bilateral interstial pulmonary infiltrates lobar consolidation or normal
 Exercise induced desaturation
 BAL silver stain showing cysts

70.Treatment of pneumocystis jirovecii pneumonia is :

 Co -Trimoxazole
 IV Clindamycin(not used as prophylaxis)
 IV pentamidine
 severe cases Steriods when Hypoxic PO2 less than 9.3kpa or less than
70mmhg
 Dapsone

71.Treatment of lung abscess is = Cefuroxime + metronidazole (diet-3 2016)

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 72. History of sinusitis + fever + headache CNS signs + seizure + meningeal
irritation + ring enhancing lesion on CT scan is = Pyogenic brain abscess.

INFECTIOUS DISEASE PEARLS

(diet-2 2018)

 73. DD of Ring enhancing lesions are :

 Pyogenic brain abscess
 Toxoplasmosis
 Cerebral metastases
 Histoplasmosis
 Primary brain tumours Giloblastoma multiforme

 74. Walking barefoot + abdominal pain + Diarrhoea + pneumonitis +

papulovesicular rash on soles of feet buttocks linear rash over groin(larva
current) + eosinophilia = Strongyloides stercoralis

 75. Treatment Strongyloides stercoralis is :

 Ivermectin
 Albendazole
 Thiabendazole
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 76.if patient has Strongyloides and HIV diarrhoea then treat first Strongyloides then HIV

INFECTIOUS DISEASE PEARLS

 77.Children + perianal itching at night + sticky plastic tape at perianal area and see eggs is = Enterobius
vermicularis( pinworm)

 78.Treatment of Enterobius Vermicularis is :

 bendazoles i.e. menbendazole

 79.Nemtodes which causes anaemia are =

 ancylostoma duodenale N nector Americans
 Treatment: bendazoles.

 80.Rainforest region + transmitted by chrysops deerfly + Itchy red swelling below skin Calabar swelling +
urticaria + pruritus + eye work is = Loiasis loa loa (diet-3 2018)

 81.Treatment of Loiasis is :
 diethylcarbamazine
 Ivermectin (DOC) Both drugs contraindicated if microfilals exceeds 2500

 82.Eating raw pork + fever + perioribital oedema + myositis is = Trichinella Spiralis

83. Treatment of Trichinella Spiralis is : bendazoles

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84.Black files + blindness + hyper pigmented skin +
allergic reaction to microfilaria is = onchocerca volvus

INFECTIOUS DISEASE PEARLS

85.Treatment of River Blindness is : Ivermectin

86. Tropical eosinophilia + myalgia fatigue + weight loss +

cough + dyspnoea + lymphadenopathy high level of
eosinophilia + bilateral reticulocytosis shadowing is =
Elephantiasis caused by wanchere bancrofti (diet-3 2018)

87.Treatment of Elephantiasis is = diethylcarbamazine

(DEC)

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 88. Dog faces eggs + visceral larva migrans + eye granulomas, liver

INFECTIOUS DISEASE PEARLS

lung involvement is = Toxocara canis

 89.Treatment of Toxocara Canis is : diethylcarbamazine

 90. Pneumonitis + intestinal obstruction + Loffler's syndrome +

biliary pancreatic duct obstruction = Ascaris (diet-1 2017)

 91.Treatment of Ascaris is :
 Piperazine for bowel obstruction
 Menbendazole for other infections.

 92.Painful liver mass + flushing urticaria + anaphylactic reaction +

liver cyst obstructive jaundice + CT abdomen best test is = Hydatid
disease

 93.Treatment of Hydatid Disease is = Albendazole and aspiration.

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 94.Seizures + CT brain shows periventricular cystic lesion in
partial love Swiss cheese appearance is =

INFECTIOUS DISEASE PEARLS

Neurocysticercosis (NCC) caused by Taenia solium (uncooked
pork) Taniae saginata (beef) (diet-1 2016)

 95.Treatment of Neurocysticercosis is : Niclosamide

 96.Swimmer's itch + haematuria + bladder calcification

(Squamous cell carcinoma) + frequency is = Schistosoma
haematobium (urinary blood fluke) (diet-3 2017)
 Schistosoma japonicum causes spinal cord compression

97.Treatment of Schistosomiasis is :
 S.haematobium and S.mansoni = Praziquantel 40mg for
3days
 S.japonicum = Praziquantel 60 mg for 6days+Prednisone 1mg
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 98. Cholangiocarcinoma = Clonirchis sinensis

INFECTIOUS DISEASE PEARLS

 99.Treatment of Clonirchis Sinensis is : Praziquantel

 100.Same as tuberculosis + brown red sputum + fever night sweats

rashes urticaria + eosinophilia + symptoms not as severe as
tuberculosis is = Paragonimiasis
 Treatment: Praziquantel

 101.Cutaneous larva migrans = Ancylostoma brazillience

 Visceral larva migrans = toxocara canis

 102.Treatment of Ancylostoma brazillience is = Ivermectin

 103. High fever + stridor + drooling saliva (specific sign) + rapid onset
+ cheery red epiglottis is = Acute epiglottitis
 Organism : Haemophilus influenza type B
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 DERMATOLOGY PEARLS

DERMATOLOGY PEARLS
• When life gives you hundred reasons to break
down and cry ,show Life that you have million
reasons to smile and laugh and stay strong.

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 1.Red scaly patches on sun exposed areas like lower limbs is =
Bowen's disease type of intra epidermal squamous cell carcinoma

DERMATOLOGY PEARLS
 2.Treatment of Bowen's disease type of intra epidermal squamous
cell carcinoma is:
 topical 5FU or imiquoid ,
 croyrotherpy, excision.

 3.Foot pain + pain provoked by walking + pain worse at night +

smoker + dorsalis pedis difficult to feel toes are cold and dusky +
angiography shows distal stenosis in limb with corkscrew
formation + ANCA negative is = thromboangitis obliterans (came
in diet -3 2018).

 4.Calcineurin inhibitor are alternative to topical steriods in Eczema

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 5.Well defined annular erythematous lesion with pustules and papules
on body is = Tinae corporis

DERMATOLOGY PEARLS
 6.Treatment Of Tinae corporis is : oral fluconazole.

 7.Itchy peeling skin between toes in adolescence is = Tinae pedis

(athletes foot).

 8.Pressure sore with exudate is treated by = Alginate based dressings.

 9.Waterlow score used to identify patients at risk of pressure sores

Happens on sacrum or heel Moist wound treated by ulcer healing
hydrocolloid dressing and hydrogels.

 10.Unusual shaped lesion linear or geometric pattern demarcated

from surrounding skin usually by nails ,caustic soda cigarette due to
psychologically stress is = Dermatitis arcfecta (DIET-2 2017)

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 11.Blisters/bullae
no mucosal involvement (in exams at least*): bullous pemphigoid
mucosal involvement: pemphigus vulgaris (DIET-1 2016)

DERMATOLOGY PEARLS
 12.Isotretnoin adverse effects
teratogenicity - females MUST be taking contraception, low mood, dry eyes
and lips, raised triglycerides, hair thinning, nose bleeds.

 13.Seborrhoeic dermatitis - first-line treatment is topical ketoconazole .

 14.Acne rosacea treatment:

mild/moderate: topical metronidazole
severe/resistant: oral tetracycline

 15.Dry skin is the most common side-effect of isotretnoin.

 16 Dermatophyte nail infections - use oral terbinafine.

 17.Hereditary haemorrhagic telangiectasia - autosomal dominant .

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 18.In scabies treatment failure, if application was applied appropriately ,then treat with
difference insecticide e.g. Malathion 0.5% or permethrin 5%. (DIET-1 2018)

DERMATOLOGY PEARLS
 19.Thickened Erythema as plaque indurated + later waxy either pale or
hyperpigemented + 20-40 years + absence systematic symptoms = Morphoe

 20.Treatment of Morphoe is : local steriods, topical and Vitamin D light therapy

 21.Planus,purple, prurutic,polygonal rash on flexor surface on palms, soles ,gentila

flexor of arms + Wickham's Striae over surface +oral involvement is = Lichen planus

 22.Treatment of Lichen planus is :

 topical steriods mainstay (DIET-2 2019)
 Extensive :oral steriods or immunosuppressant.

 23.Drugs causing lichen planus are :

 Gold
 Quinine
 Thiazides

 24.Scalp psoriasis first line treatment is topical potent corticosteroids

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25.Associated conditions with Vitiligo are :
Type 1DM
Addison disease

DERMATOLOGY PEARLS
Autoimmune thyroid disease
Pernicious anaemia
Alopecia Areta

26.Skin manifestation in SLE are :

Photosensitive butterfly rash
Discoid lupus
Alopecia
Livedo reticularis net like rash

27.Upper GI endoscopy is useful for gastric carcinoma

28.Oral steriods mainstay treatment for Bullous pemphigoid

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29.Zinc defienancy causes :
acral dermatitis,
alopecia

DERMATOLOGY PEARLS
diarrhoea
failure to thrive
acrodermatitis enteropathtica beau's lines

30.Aceniform eruption is iatrogenic acne caused by steriods.

31.Koebnar phenomenon seen in:

Wart And ALL :
Wart Autoimmune
psorsis
Vitiligo
Molluscum contiogsum
AIDS
Lichen planus
Lichen sclerosis.

32.Well demarcated patches of depigmented skin peripheral mostly + koebnar phenomenon is = Vitiligo
(DIET-1 2015)

33.Treatment of Vertilgo : sun block , camouflage , topical steriods Topical tacrolimus, phototherapy

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 34.Porphyria cutanea tarda- blistering photosensitive rash
hypertrichosis hyperpigmentation

 35.Keloid scars - more common in young, black, male adults .

DERMATOLOGY PEARLS
 36.Melanoma: the invasion depth of the tumour is the single most important prognostic factor .

 37.Dermatts herpetiformis - caused by IgA deposition in the dermis.

 38.Management of venous ulceration - compression bandaging .

 39.Acne vulgaris in pregnancy - use oral erythromycin if treatment needed (DIET-3 2017)

 40.Topical steroids
moderate: Clobetasone butyrate 0.05%
potent: Betamethasone valerate 0.1%
very potent: Clobetasol propionate 0.05%

 41.Lentgo maligna melanoma: Suspicious freckle on face or scalp of chronically sun-exposed

patents
42.Polymorphic eruption of pregnancy is not associated with blistering

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 43.Scalp psoriasis first line treatment is topical potent corticosteroids.

 44.Acral lentigious melanoma: Pigmentation of nail bed affecting

DERMATOLOGY PEARLS
proximal nail fold suggests melanoma (Hutchinson's sign)

 45.Flexural psoriasis - topical steroid .

 46.Keloid scars are most common on the sternum.

 47.Impetgo - topical fusidic acid → oral Flucloxacillin / topical

retapamulin.

 48.Psoriasis: common triggers are beta-blockers and lithium.

 49.Lichen planus: purple, pruritic, papular, polygonal rash on flexor

surfaces. Wickham's striae over surface. Oral involvement common
sclerosis: itchy white spots typically seen on the vulva of elderly
women (DIET-3 2018)

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50.Symetrical + brown + velvet plaques on neck, axilla and groin is acanthosis nigricans

51.Causes of Acanthosis nigricans:

DERMATOLOGY PEARLS
Adenocarcinoma of stomach
DM
Obesity
PCOS
Acromegaly
Cushing syndrome
Hypothyroidism
Familial Prader Willi syndrome
Drugs: OCP nicotinic acid (DIET-1 2016)

52.Shiny painless areas if yellow red skin on shin of DM patient thickened blood vessel is = Nacrobiasis lipodica

53.Treatment of Nacrobiasis lipodica is : topical steroids Injectable steroids Camouflage creams

54.Tender erythema nodular lesion on shins is = Erythema nodosum (DIET-2 2018)

55.Treatment of Erythema Nodosum is : usually resolve with in 6weeksNsaids ,light compression.

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56.Causes of Erythema nodosum:
Streptococcus infection most common, Brucellosis , tuberculosis ,
sarcodosis , (DIET-2 2017)
IBD.

DERMATOLOGY PEARLS
Behcets
SLE
Malignancy

57. Drugs causing Erythema nodosum :

OCP
Sulphonamides
Penicillin
Antipyretics
Montoleukast
Hepatitis B vaccination
Omeprazole
Pregnancy
HLA B 27 27

58.Pinkish pearly white papules with central umbilical on occur any where except palms and soles +
children + HIV less than 200 count is = Molluscum contagiosum by pox virus (DIET-3 2018)

59.Treatment of Molluscum contagiosum is : usually resolved watchful waiting

Troublesome : simple trauma cryotherapy topical imiquoid cathardin Itchy : topical steroids fusidic acid.

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60.Skin disease associated with HIV :
Molluscum contagiosum

DERMATOLOGY PEARLS
Corweign scabies
Saeborrhic dermatitis (DIET-3 2019)

61.Sysmmetrical erythematous lesion and raised pinkish indurated lesion

and shiny orange peel skin is = Pretibial myxoedema seen in graves
disease

62.Skin disorders with Tuberculosis are :

Lupus Vulgaris
Erythema nodsum
Scarring alopecia
Scrofuloderma
Verrucosa cutis
Gumma

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 63.Erythmatous flat plaque elevated ulcerated with apply jelly colour and centre scar is = Lupus
vulagris (DIET-1 2018)

 64.Treatment of Lupus Vulagris is : AntiTuberculosis Drugs

DERMATOLOGY PEARLS
 65.Papular lesion hyper pigmented depressed centrally associated with DM,HIV lymphoma is =
Granulomas annulare

 66.Treatment of Granuloma annulare is : Resolved spontaneous Steriods

Mainstay treatment of granuloma annulare is = Observation.

 67.Infrated radiation sitting to fire heater + reticulated erythematous patches hyperpigemented

telangiectasia + hypothyroidism is = Erythema Ab igne If not treated with develop squamous cell
cancer

 68.Well circumscribed raised erythematous lesion on finger tender which bleeds when touched =
Pyogenic granuloma. (DIET-1 2019)

 69.Solitary lesion with central areas of ulceration volcano or crater is = Keratoacanthoma

 70.Treatment of Keratoacanthoma is : Regress with in 3 min Such lesion should be excised

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 71.Red indurated papules later narcotic black easchar at centre + middle East with
cattle/sheep/goat is = Cutaneous anthrax (DIET-1 2016)

DERMATOLOGY PEARLS
 72.Treatment of Cutaneous anthrax is : Penicillin

 73.IgA deposit within blood vessel = HSP Granular IgA deposit in Basement
membrane is = dermatitis herpertiformris
 Intracellular igA deposit in pemphigus.

 74..Streptococal sore throat 2-4 weeks + tear drop scaly papules on trunk and limbs is
= Guttate psoriasis (DIET-3 2018)

 75.Treatment of Guttate Psoriasis is : if lesion not widespread (<10%body surface

areas) not impacted physically, psychologically or socially = no treatment resolved
within 2-3month
 if patient desire treatment then topical agents
 If lesion widespread >10%body surface area =Refer urgent dermatologist
phototherapy UVB phototherapy = recurrent episodes referral ENT should be
considered = Tonsillectomy.

 76.Erythmatous sharply demarcated papules and rounded plaques covered by

silvery scales + HLA-B13,B17 cw6 + nail pitting oncycholysis koebnar phenomenon +
anterior uveitis = Psoriasis
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77.Complications of Psoriasis are :
Psoriatic arthropathy
Metabolic syndrome

DERMATOLOGY PEARLS
Increased CVS disease
Venous thromboembolism Psychologically distress

78. Drugs causing psoriasis are :

Beta blockers
Lithium (DIET-1 2019)
Antimalarial (chloroquine, Hydroxychloroquine)
Gold
Nsaids
ACEi infliximab BB >ACEI
Withdrawal systematic steroid
Trauma
Alcohols

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79.Treatment of Psoriasis is :
Topical steroids 1st line : potent steroids once daily + vitamin D (DIET-1 2019)
2nd line: vitamin D twice daily

DERMATOLOGY PEARLS
Third line : potent steroids twice daily diatharnol Side effects are : steroids skin
atrophy Striae rebound symptoms.
Secondary management : UV B light : phototherapy psoralen + UV A light (PUVA)
it's Side affects are : skin ageing Squamous cell carcinoma Systematic :oral
methotrexate cyclosporine TNF inhibitor like
brodalumab = IL-17
Rituximab=CD20
Toculzumab =IL-6
ustekinumab =IL12 and IL-23 Side effects are : dental ulceration.

80. Never use Oral steroids in Psoriasis.

81.Treatment of pyogenic granuloma Lesion in pregnancy and post partum

resolve spontaneously

If persist then removal curettage and electrocautery cryotherapy excision

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82.Herpes simplex virus is commonest cause of Erythema multiforme.

83.Target lesion like bulls eye and symmetrical distribution on dorsal surfaces of extensor extremities is =
Erythema multiforme (DIET-1 2017)

DERMATOLOGY PEARLS
Treatment: supportive.

84.Causes of Erythema multiforme are :

Virus herpes simplex virus
Mycoplasma streptococcus
Drugs: Penicillin, sulphonylurea, barbiturates, carbamazepine, Allopurinol, NSAIDS,OCP nevirapine
SLE
IBD
Sarcodosis
Malignancy.

85.Severe macular atypical target lesion mucosal involvement on face and trunk + less than 10% body
involvement+ fever arthralgia is = Steven Johnson syndrome Causes are same as EM.

86.Pyrexia + tachycardia + niklosky sign positive + severe mucocutaneous exfolitive disease is =Toxic epidermal
Nacrolysis

87.Treatment of Toxic Epidermal Nacrolysis is : stop precipating

Iv immunoglobins
Immunosuppressive cyclosporine
cyclophosphamide
plasmaphresis

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88.Male >60years +HTN/DM/ hyperlipidaemia/smoking + severe pain on heel metatarsal regular deep
green absent swelling + ABI <0.75 no hair rubor thin shiny skin is = Arterial ulcer

89.Causes of scarring alopecia (destruction of hair follicle) are :

Trauma

DERMATOLOGY PEARLS
burns
Radiotherapy
Lichen planus
Discoid lupus
Tinae capitis.

90.Causes of non scarring alopecia (preservation of hair follicle are :

Male pattern baldness
Drugs: cytotoxic drugs , carbimazole,heparin ,OCP colchine Iron zinc defienancy
Alopecia Areta
Tolgen effluvium
Trichotillomania

91.Localized patches of nonscarring hair loss + exclamation marks tapered towards base is = Alopecia
Areta (DIET-3 2017)

92.Treatment of Alopecia Areta is : hair will regrow in 50%Topical or intralesional steroids most
appropriate
Others topical minoxdil, photo therapy diathronl immunotherapy wig

93.After puberty diffuse slow hair loss with characteristic loss over temporal regions and vertex in male is
= Androgenetic alopecia
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 94.1 to 3 month after viral illness, surgery, childbirth , emotional stress diffuse hair
loss + hair loss never complete usually stops after 3 to 5 month is = Tolgen effluvium
 Treatment : hair regrowth.

DERMATOLOGY PEARLS
 95.Children + localized hair loss but in bizarre pattern + patient pull their own hair +
hairs of different length is =Trichotillomania

 96.Scarring alopecia + atrophic with visible loss of hair follicle is = Discoid lupus
erythramatous (DIET-3 2018)

 97.Permanent bald patches with no visible follicles is = Cicatrical alopecia

 98.Treatment of Cicatrical Alopecia is : treatment of underlying cause like (DLE,lichen

palnus ) topical Steriods.

 99.Elderly patient sun exposure + at head and neck pearly flesh colured papule with
telangiectasia ulcerated leaving central crater is = Basal cell carcinoma (DIET-3 2019)

 100.Treatment of basal cell carcinoma is :

 Surgical removal
 Curettage
 Cryotherapy
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fluorouracil Radiotherapy
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 PHARMACOLOGY & TOXICOLOGY

PHARMACOLOGY& TOXICOLOGY PEARLS

PEARLS

• DO IT NOW ,SOMETIMES LATER BECOME

NEVER

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 PHARMACOLOGY& TOXICOLOGY PEARLS
1.NICE guidelines of chronic kidney disease when initiating ACEI a 25%
reduction in eGFR or 30% increase in serum creatinine is tolerable
ACEI should be stopped or dose adjusted if there is rise in serum
potassium levels to greater >6 mmol/l

2.Side effects of ACEI are :

Cough
Angioedema
Hyperkalaemia Decrease GFR and increase creatinine and BUN
Taste change
Orthostatic hypotension
Leukopenia /liver toxicity

3.INH + intractable seizures and profound metabolic acidosis and high

anion gap is = Isoniazid toxicity (DIET-3 2017)

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 PHARMACOLOGY& TOXICOLOGY PEARLS
4.Contraindications of ACEI are :
Pregnancy and breast feeding
Reno vascular disease bilateral renal stenosis Aortic
stenosis
Hereditary angioedema
Hyperkalaemia

5.Acceptable increase in creatinine up to 50% from

baseline or up to 265 and increase k up to 5.5

6.Coarse tremor (acute toxicity )Hyperreflexia + Acute

confusion + Dysarthria + Ataxia + Seizure + Coma =
Lithium toxicity (DIET-2 2019)
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 PHARMACOLOGY& TOXICOLOGY PEARLS
 7.Amiodarone can interact with warfarin causing
increased INR .(DIET-3 2016)

 8.Bendrofumethiazide use is associated with gout

 9.ACE inhibitors have reduced efficacy in black

patents and are therefore not used first-line .

 10.Hypertension in diabetics - ACE-inhibitors are

first-line regardless of age.

 11.Calcium channel blockers are now preferred to

thiazides in the treatment of hypertension .

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 PHARMACOLOGY& TOXICOLOGY PEARLS
12.Vomiting + Diarrhoea + abdominal pain + GI haemorrhages + coffee ground
vomit + small radiopaque shadows in centre of abdomen = Iron poisoning (DIET-
2 2018)

13. Treatment of Iron poisoning is : Iron less than 40 + asymptomatic = Observe

>40 iron level + Symptomatic = Do abdomen x-ray Whole bowel irrigation
procedure of choice within 4Hrs of ingestion
Indications of Deferoxamine are :
Shock Altered mental status
Persistent GI symptoms Metabolic acidosis Pills visible on radiographs

14.Complications of Iron Overdose are :

Metabolic acidosis
Erosions of gastric mucosa GI bleed
Shock
Hepatotoxicity
coagulopathy

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 PHARMACOLOGY& TOXICOLOGY PEARLS
 15. Labetalol is first-line for pregnancy-induced hypertension..

 16.Bisphosphonates can cause a variety of oesophageal

problems . (DIET-1 2017)

 17.Hydroxychloroquine - may result in a severe and

permanent retinopathy

 18. Azathioprine - check thiopurine methyltransferase

deficiency (TPMT) before treatment Azathioprine -

 19.isoniazid can cause drug-induced lupus .

 20.Cyclophosphamide - haemorrhagic cystitis - prevent with

mesna

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 PHARMACOLOGY& TOXICOLOGY PEARLS
 21.Statins causes = Hepatocellular pattern injury high
transaminases

 22. co-amoxiclav, nitrofurantoin OCP sulphonylurea

causes Cholestastaic pattern high ALP.

 23. Jarisch– Herxheimer reaction in acute febrile illness

headache, mylagia,chills rigors on 1st dose of treatment
and resolve in 24 hours so Reassurance
 If CNS involvement or ophthalmic involvement or in
pregnancy don't reassurance but respond

 24.Methamemoglobinemia secondary to Dapsone in

platelet in G6PD defienancy treated by Exchange
transfusion (DIET-2 2016)
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 PHARMACOLOGY& TOXICOLOGY PEARLS
 25.Prothrombin complex concentrate is used for the emergency reversal of
anticoagulation in patents with severe bleeding or a head injury

 26.The sulfamethoxazole in cotrimazole causes haemolysis in G6PD, not the

trimethoprim .

 27. Cisplatin is associated with hypomagnesaemia.

 28.ITP - give oral prednisolone

 29. Antiphospholipid syndrome in pregnancy: aspirin LMWH (DIET-2 2017)

 30.Vincristine - peripheral neuropathy .

 31.Metronidazole is the first line antibiotic for use in patents with Clostridium difficle
infection

 32.Cephalosporins, not just clindamycin, are strongly linked to Clostridium difficle

 33.NICE recommend avoiding lactulose in the management of IBS

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 PHARMACOLOGY& TOXICOLOGY PEARLS
34.Side affects of Lithium are :
LITHIUM
I= Leucocytosis
T= Tremor
H= Hypothyroidism
I=increase urine Mom be aware tetratogenic Epstein anomaly, breast feeding
ECG :T wave inversion flattening
Weight gain Hypercalcemia.

35.Nause + persistent metallic taste + ginvostomatis + tremor+ nephrotic syndrome =

Mercury poisoning (diet-1 2019)

36.Side effects of Amiodarone are :

Corneal deposit most common
Hypothyroidism/hypothyroidism
Photosensitive slate grey appearance
Pulmonary fibrosis/pneumonitis Liver cirrhosis/hepatitis
Peripheral Neuropathy, myopathy
Prolonged QT
Thrombophlelia
Bradycardia
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• 37.In life-threatening Clostridium difficle infection treatment is with
ORAL vancomycin and IV metronidazole (diet-3 2018)

• 38.Isoniazid therapy can cause a vitamin B6 deficiency causing

peripheral neuropathy

• 39. Antipsychotics in the elderly - increased risk of stroke and VTE

• 40.Amiodarone can interact with warfarin causing increased INR .

• 41.Bendrofumethiazide use is associated with gout (diet-1 2016)

• 42.ACE inhibitors have reduced efficacy in black patents and are

therefore not used first-line .

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 43.Clonazepam and carbamazepine use with OCPs decreases the efficacy of
OCPs as they are enzyme inducers.

 44. Drugs with narrow therapeutic window require monitoring ---------

Theophylline lithium, digoxin and phenytoin

 45.Sildenafil causes blue vision and Digoxin causes yellow vision

 46. Heroin overdose causes respiratory depression, constricted pupil and its
withdrawal causes lacrimation, rhinorrhoea and tremors (diet-1 2016)

 47. Alcohol/ Barbiturates /Benzodiazepines overdose cause slurred speech,

dilated pupil, shallow respiration and their withdrawal causes
insomnia/irritability/seizures.

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 48.Teratogenic risks ------
 Androgens (Cardiac Deformities)

 carbamazepine (microcephaly)

 Lithium (cretinism)
 phenobarbital (cleft lip)
 Warfarin (chondrodysplasia punctata)

 49.Heroin Addiction treatment -------- Methadone is first choice. Alternative

is Buprenorphine. Methadone is against at meu receptors, compared to
heroine it has long duration of action, less euphoria, mild withdrawal
symptoms. Buprenorphine is partial agonist, long duration of action, less
respiratory depression. Co abuse of alcohol and benzodiazepines with
heroine, buprenorphine is preferable because these agents cause respiratory
depression

 50.Concomitant use of Digoxin with calcium channel blockers and quinine

results in Digoxin toxicity inhibiting Digoxin secretion in renal tubes

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 51.For a patent under 55 who is intolerant to an ACE-i the next step
would be to offer an angiotensin 2 receptor blocker (ARB)

 52. Adenosine
Dipyridamole enhances effect (diet-1 2016)
aminophylline reduces effect

 53.Methadone is a common cause of QT prolongation

 54. Warfarin - clotting factors affected mnemonic - 1972 (10, 9, 7, 2) .

 55.Bendrofumethiazides can worsen glucose tolerance.

 56.Warfarin is the only licensed anticoagulant drug for stroke

prevention in AF in those with structurally abnormal valves.

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• 57. Overdose of benzodiazepines + reduced conscious
level + respiratory depression = intubate and ventilate
rather than flumazenil (diet-3 2018)

• 58.Clozapine not only cause agranulocytosis but also

myocarditis so never forget to do ECG prior to it's use

• 59. Some clues about poisons :

• ecstasy all hyper except sodium.
• Methotrexate : cerebellar signs
• Cocaine : chest pain , ECG wide QRS .
• Ghb : patient usually in coma and may show some lucid
interval Nexus: nasal pain, tactile sensation increased
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 60. Drugs causing peripheral neuropathy :VITNAM
 Vincristine (diet-1 2017)
 INH
 TCA
 Nitrofurantoin
 Amiodarone
 Metronidazole

 61.Drugs causing retroperitoneal fibrosis are:

 Bromocriptine
 Beta blockers
 Methlyseriglycide

 62.Drugs causing lymphocytic colitis are :

 PPI
 NSAIDS
 SERTALINE

 63.Osteonecrosis of jaw is well recognised complication of bisphosphonates therapy

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• 64.Nsaids: COX-2 selective inhibitor (Celecoxib,rofecoxib) associated
with increased risk of thrombotic risk (MI and stroke) but associated
with lower risk of upper GI side effects good in ulceration or bleeding
• Non selective Nsaid = also associated with Elevated risk of thrombotic
risk(,diclofenac and ibuprofen) Naproxen has lower risk of
thrombosis hence best choice

• 65.Drugs causing acute dystonia :

• Neuroleptics (Haloperidol,levomepromazine) (diet-1 2018)
• Antiemetic's(metoclopramide)
• Antidepressants (amitriptyline,trazodone)

• 66.Management of Acute dystonia is : stop drug fallowed by either

benztropine or diphenhydaramine , benzodiazepines may be
helpful.

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67.Drug causing Hypertension are :
Steroids
monoamine oxidase inhibitors
the combined oral contraceptive pill
NSAIDs
Leflunomide

68.Contraindications of beta blockers :

Heart block
uncontrolled heart failure
Asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia

69.Indication of statin are :

Primary prevention:10 years CV risk is 10%or more OR most type 1diabetes Or CKD if GFR
less than 60 give = Atorvastatin 20mg (if non HDL is not fallen by 40% then titrate up to
80mg Atorvastatin
Secondary prevention : known ischemic disease of stroke or peripheral atrial disease give =
Atorvastatin 80mg

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70.Treatment of carbon monoxide is:
Apply tight fitting non rebreather mask and give 100%oxygen
If patient is comatose then intubation and ventilation with 100% oxygen (diet-
2 2019)

71.Side effects of statins are :

myopathy
myalgia, myositis,
Rhabdomylosis
asymptomatic raised creatinine kinase Myopathy is more common in
(simvastatin, atorvastatin) than (rosuvastatin, pravastatin, fluvastatin).
liver impairment: the 2014 NICE guidelines recommend checking LFTs at
baseline, 3 months and 12 months.

72.Treatment should be discontinued if serum transaminase concentrations rise

to and persist at 3 times the upper limit of the reference range statins may
increase the risk of intracerebral haemorrhage in patients who've previously had
a stroke avoid in patient with intracerebral haemorrhage

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73.Cyclophosphamide Adverse effects are :
haemorrhagic cystitis : incidence reduced by the use of hydration and
mesna (diet-2 2018)
Myelosuppression
transitional cell carcinoma

74.Treatment of cyclophosphamide induced side effects = Mesna2-

mercaptoethane sulfonate and metabolite of cyclophosphamide called
acrolein is toxic to urothelium mesna binds to and inactivates acrolein
helping to prevent haemorrhagic cystitis

75.Phases of drugs Phase I = studies study safety =

phramcokinetics,phramcodymanics first usage in human subjects.
Phase II = studies are designed to elucidate any therapeutic response in
specific settings combined with phase I .
Phase III = Performed once initial safety and efficacy evaluation is
completed , compare the drug with alternative.

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76.Side effects of Ketamine are :
Raised intracranial pressure i.e. headache, papilloedema,vomiting
Hypertension
Hallucinations
Bladder and liver dysfunction

77. Side effects of Exogenous androgens are :

Acne
Gynaecomastia
Hypertension
Hypercholesterolemia
Hepatic tumours
Paranoid delusions

78.Opiates safe in renal impairment are :

Fentanyl
Buprenorphine (diet-2 2017)
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 79.Drugs altering absorption or clearance of Thyroid HARMONES :
 Cholestrayamine (diet-1 2018)
 Ferrous sulphate
 Lovastatin
 Aluminium hydroxide
 Rifampicin
 Amiodarone
 Carbamazepine
 Phenytoin

 80.Drugs causing thrombocytopenia are :

 Quinine
 Diuretics (diet-1 2019)
 Sulphonamides
 Aspirin
 Thiazides
 Pseudo thrombocytopenia occurs with use of EDTA Thrombocypenia occurs on 7day of
transplant unlike graft VS host diseases which occur after 2 weeks

 81. Carboxyheamoglobin cohb is best for prognosis in carbon monoxide poisoning

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82.Contraindictions to metformin are :
Renal failure
hepatic failure
heart failure lactic acidosis
CKD review when Cr>130 Stop when >150 or GFR less than 30 Recent MI within 6 weeks Alcohol use,IV contrast
angiography.

83. side affects of sulphonylurea are :

Hypoglycaemia
Weight gain
SIADH
Liver damage
Photosensitive
Haemolytic anaemia G6PD

84; Side effects of GLP 1 Extentide are :

Severe pancreatitis (DIET-1 2016)
Renal impairment

85.Side effects of DPP-,4 inhibitor Gliptin are:

Git disturbance nausea
diarrhoea
constipation
Little Pancreatitis

86.Side effects of SGLT2 inhibitor :

canagliflozin
depagliflozin empagliflozin Genital infection Flucytosine,DKA Hypoglycaemia UTI (DIET-3 2018)

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 87.SGLT-2 are good in hypertension and cardiovascular disease in diabetes mellitus

 88. Drugs causing photoxiocity are :

 Antibiotics:tetracyclines,fluroquinolones,sulphonamides Nsaids
 Diuretics :furosemide,bumetanide Sulphonylurea
 Neuroleptics : chlorpromazine Antifungals: terbinafine ,Itraconazole
 Other drugs : Amiodarone diltizem

 89.In cases of severe theophylline toxicity ,charcoal haemoperfusion can be used.

 90.Acidosis + hypokelmia + vomiting + tachycardia arrhythmias + seizures is =

Theophylline toxicity (DIET-2 2019)

 91.Treatment of Theophylline toxicity is :

 gastric lavage if <1 he prior to ingestion
 Activated charcoal
 Whole bowel irrigation if Theophylline is sustained release forum
 Charcoal haemoperfusion is preferable to haemodialysis

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 92.Dry cough + dilated pupil + agitation+ sinus tachycardia + blurred vision +
arrthymais, + seizures + 3 Cs convuslion,coma , Cardio toxicity + on ECG sinus
tachycardia widening QRS,prolonged QT is = TCA poisoning
(amitriptyline,Dosulepisn) (DIET-3 2018)
QRS >100 = seizures
 QRS >160 = Ventricular arrhythmias

 93.Treatment of TCA poisoning is :

 Mainstay : I/V bicarbonate reduce acidosis Don't use Quindine,flecainde
Amiodarone
 Gastric lavage =1 hour of ingestion Charcoal 2hr ingestion if GCS is not reduced IV
lipid emulsion Dialysis is not effective in TCA.

 94.Most appropriate intervention in lead poisoning is DMSA

 95.Mixed sensorimotor polyneuropathy + pesticides in farmer + nausea, vomiting

gastroenteritis garlic breath coma seizures+ mees lines + abdominal pain + peripheral
neuropathy is = Arsenic poisoning (DIET-1 2017)

 96.Treatment of Arsenic poisoning is : DMSA (sucimer) penicillamine.

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 97.Agitiation + confusion + sleepiness lasting up to 24 hours or more + pupils
dilated and unreactive to light + visual and auditory hallucinations is =
Procylidine poisoning used to treat parkinsonian side effects of neuroleptics.
 (DIET-1 2019)

 98.Hypokelmic alkalosis + high urine potassium + athletes is = Diuretics

abuse.

99.Farmer + pesticides + DUMBLESS : Diarrhoea,urination,miosis,

bradycardia/ bronchospasm,lacrimation,emesis,salivation,sweating ,
hypotension, twitching fasciculation's, muscle weakness tremor
hyperreflexia is = Organophosphate poisoning (Malathion, parathion)

100.Treatment of Organophosphate poisoning is : Atropine,pralidoxime

101.Alcohol abuser + nausea vomiting headache confusion early + high anion

gap Metabolic acidosis + retinal injury visual problems with blindness optic
neuropathy macular edema is = Methanol toxicity (DIET-2 2017)

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 102.Treatment of methanol poisoning is :
 1st line : Femipizole inhibit alcohol dehydrogenase (DIET-3 2019)
 2nd line : if Femipizole not available ethanol (it competes with alcohol
dehydrogenase
 Na bicarbonate if PH <7.2
 Folic acid to reduce eye symptoms
 Haemodialysis

 103.Indications of haemodialysis in methanol toxicity are :

 Worsening acidosis despite Na bicarbonate
 Visual problems
 Consumer exceeds 30ml Methanol level >20.

 104.Antifreeze used for suicide + stage 1 confusion ,slurred speech

,dizziness 2nd stage metabolic acidosis with high anion gap,
tachycardia Hypertension stage 3 renal failure, respiratory, cardiac
failure , oxalate stone symptoms like alcohol is = Ethylene poisoning
(DIET-1 2019)
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 PSYCHITARY pearls

PSYCHITARY PEARLS
• Shoot for the Moon, even if you miss you will
land among the stars..

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 1.Psychiatric syndrome disruption of consciousness identity
memory motor behaviour environment associated with
traumatic life event bizarre motor symptoms dissociative
identity disorder dissociative fugue and depersonalization is =
dissociative disorder (DIET-2 2017)

PSYCHITARY PEARLS
 2.Treatment of Dissociative disorder is = atypical
antipsychotics

 3.In psychotic depression there is psychotic intensity with

delusional convictions like putrefaction poverty
contaminating others or causing evil

 4.Olanzapine, resperidone, clozapine causes Hyperglycaemia

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5.Haloperidol causes hypoglycaemia

6.Lithium causes diabetes insipidus

PSYCHITARY PEARLS
7.Phelanzine causes dry mouth constipation

8.Treatment of generalized anxiety disorder is :

SSRI (DIET-1 2017)
SNRI
If bleeding then use imipramine not SSRI

9.He is died no longer really exist associated with depression is =

Costard Syndrome or delusional depression

10.Treatment of Costard syndrome is : ECT not SSRI

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 11.first line in schizophrenia is Resperidone and
olanzapine
 Clozapine reserved for schizophrenia where

PSYCHITARY PEARLS
symptoms are resistant to resperidone

 12.Sudden discrete attacks of intense anxiety or

fear accompanied by physical symptoms for
example palpitations and feeling of suffocation is =
panic disorder (DIET-3 2016)

 13. Paroxetine + resperidone = Serotonin syndrome

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14.Memory disturbance (short term) + hospitalized
patient + agitated withdrawn + mood change +
visual + disturbed sleep cycle +poor attention +

PSYCHITARY PEARLS
fearful +UTI pneumonia = Delirium (DIET-2 2018)

15.Treatment of Delirium is : Haloperidol

olanzapine.

16.Absolute contraindications to ECT is raised ICP

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 17.Paroxetine - higher incidence of discontinuation
symptoms

 18.Atypical antipsychotics commonly cause weight gain

PSYCHITARY PEARLS
 19.Social phobia is dear of being in social situations fear
of embarrassing themselves

 20.Agrophobia is fear of open spaces.

 21.Multiple tics + sniffing + snoring + involuntary

voculations + annoying behaviour is = Tourette
syndrome (DIET-1 2015)

 22.Treatment of Tourette syndrome is : Haloperidol.

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 23.Intermittent stereotypical repetitive involuntary
movement in primary school in children blinking of
shurging is= TICS (DIET-3 2018)

PSYCHITARY PEARLS
 24.Treatment of TICS is :
 Clonidine antipsychotics

25.Severe depression can mimic dementia but gives a

pattern of global memory loss rather than short-term
memory loss- this is called pseudo dementia .

26.Paralysis of muscles after waking short steps before

falling asleep is = sleep paralysis
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27. Treatment of sleep paralysis is : clonazepam

28.Treatment of post traumatic stress disorder:

watchful waiting

PSYCHITARY PEARLS
Military personal access
CBT eye movement
Desensitization
Paroxetine
Mirtazapine

29.dysthymic disorder patients mood chronic

depression with never a manic or hypomanic episode
at least 2 years .
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 30. presence of numerous periods of both depression
and hypomania for at least 2 years is cyclothymic
disorder.

PSYCHITARY PEARLS
 31.Severe alterations in mood (mania and depression(
usually episodes and recurrent is = bipolar I disorder
Bipolar II one or more major depressive episodes at
least one hypomanic and no manic episodes

 32.Treatment of Bipolar disorder is :

 First line is : sodium valproate ,carbamazepine in
prophylaxis's of manic (DIET-3 2016)
 and depressive episodes in bipolar type 1 lithium is used
when anticonvulsants of ineffective.
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 33.Guy brought by police + tried to stab his mother he
believes she is possessed by devil and plans to kill him +
he hear voices commenting on his actions and he
believes they are transferred through TV = acute

PSYCHITARY PEARLS
schizophrenia self neglect, auditory hallucinations
delusions thought insertion (DIET-3 2019)

 34 1st line treatment is : resperidone (DIET-3 2017)

 35.Akathasia causes by antipsychotics is treated by

propranolol

 36.Treatment of Dissociative disorder is = atypical

antipsychotics

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• 37.Flight of ideas + pressure speech + grandiose delusions + elevated
mood is = Mania (DIET-2 2018)

• 38.Treatment of Mania is = lithium, sodium valproate ,carbamazepine

PSYCHITARY PEARLS
• 39.Mania and hypomania is differentiate by presence of delusion of
grandeur and auditory hallucination in mania not hypomania

• 40.Major disaster, childhood sexual abuse + re-experiencing

flashbacks, nightmares, repetitive distressing images, avoiding people
or circumstances resembling event is = post traumatic stress disorder

• 41.Winter season + hyperphagia + hyper insomnia + weight gain is =

Seasonal affective disorder

• 42.Treatment of Seasonal affective disorder is = expose patient to

light for few hours of day

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• 43 .Insomnia + tremor + loss of appetite + perspiration + tinnitus + seizures anxiety is =
benzodiazepine withdrawal syndrome

 44.Depression + high mood is = Cyclothymia

 45.Chronic depression + sleep badly, and feel inadequate is = Dysthymia

PSYCHITARY PEARLS
 46.Techycardia + Hypertension + pyrexia + visual hallucinations + agitation is =
delirium tremens

 47 .Treatment of alcohol withdrawal is = benzodiazepines Lorazapam (DIET-1 2019)

 For abstinence = disulfiram
 To reduces craving = Acamprosate
 To reduces pleasure that alcohol brings and craving = Naltrexone

 48.12 to 24 Hours after alcohol withdrawal + visual auditory, tactile hallucinations is

= Alcoholic hallucinosis

 49.Impairment in consciousness + nocturnal worsening + intact memory for recent +

visual hallucinations is = delirium

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50.Fixed ,false, firmly held belief out of keeping with
persons social and cultural background is = delusion
Belief of exaggerated importance and often occur in

PSYCHITARY PEARLS
mania = grandiose delusions (DIET-1 2016)

51.Misperception of stimuli is = illusion

52.Fear of open spaces , crowds + patient can go

outside for years is = Agoraphobia

53 .Specific phobia or fear of heights is = Acrophobia

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54.Lab in Anorexia Nervosa Most things Low except:
3Gs and 3Cs which are high Growth hormone Glucose Salivary Glands
Cortisol Cholesterol Carotinemia High amylase

55.Features of anorexia Nervosa are :

PSYCHITARY PEARLS
BMI <17.5 Amenorrhea
Hyponatremia
Hypokelmia
Hypocalcaemia
Low FSH LH oestrogens but normal testosterone
Ferritin low Normocytic anaemia Lanugo hairs

56.Underweight + hypokalaemia + normal BP + calluses on knuckles + low urinary

potassium is = Laxative abuse from bulimia (DIET-1 2019)

57. 1-6 Month duration + delusions + hallucinations + disorganized

thought and speech + negative symptoms = Schizophreniform disorder.

58.Paranoid schizophrenia prominent hallucinations and delusional ideations with

preservation of affect and cognitive functions
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 59.Delirium = believe that some one poison him or nurse
is trying to get him out of ward (DIET-3 2018)

 60. Treatment OF Delirium is = 1st treated but 1:1 nursing

PSYCHITARY PEARLS
in safe environment Haloperidol and Lorazapam is used
for delirium
 .Olanzapine and resperidone causes Cerebrovascular
disease hence avoided in elderly.

 61.Nacrolepsy treated by = Methylphenidate

 62.Cateplexy is treated = Clomipramine and fluoxetine

 63.Manic episode + risk to herself give = IM Lorazapam

sedation If not available then Haloperidol.
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 64.He said he is Jesus because God spoke to him through TV is = Acute psychosis
which may be related to underlying primary schizophrenia (DIET-2 2016)

 65.Treatment of acute psychosis is : resperidone

 66.False beliefs that she some one trying to harm her she is afraid that they see her

PSYCHITARY PEARLS
and will hurt her she has proves of it like they keep garbage outside to trap her
 Other example is feelings insects crawling over skin = delusions (false believe)

 67.She laughs and giggles for apparent reason and she is unable to dress or shower
herself ,rocking muttering softly herself = Schizophrenia in disorganized type.

 68.Unable to eat or drink anything unresponsive both vocally and nonverbally she
resist any attempt to be moved socially isolated bizarre and speak people no one
else could see = Cationic schizophrenia.

 69.He has not slept ,bathed ,eaten lack of personal care, in talks to himself
hallucinations is and he says some one stealing his thoughts he fallow making him
unable do school material he is crying feeling of suicide is = Schizoaffective disorder

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 70.Hallucinatory voices commanding him to do things
hum or laugh + delusions like girl friend wants to leave
him and he has illness and won't live more than 1 year+
hallucinations of smell i.e. he smell of fish + neglect

PSYCHITARY PEARLS
personal hygiene = Paranoid schizophrenia. (DIET-3
2018)

 71.Side effects of Exogenous androgen is paranoid

delusions and aggressive behaviour.

 72.Sertraline and citalopram appear be safest with

antidepressants with Warfarin.

 73.Alzheimer's + psychic features like slapping his wife

and inhibitor = give antipsychotics like olanzapine
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 74. Abnormal clock drawing test in dementia differentiate it from delirium.

 75.Ropinirole D2/D3 dopamine agonist is associated with changes in

behaviour like gambling high risk sexual intercourse

PSYCHITARY PEARLS
 76.Drugs causing Euphoria are:
 MDMA
 Amphetamines
 Cocaine
 Mephrodone

 77.Delirium is treated by Haloperidol , Lorazapam Nursing safe environment

 78.Alochol withdrawal = benzodiazepines

 79.Disulfiram promotes abstinence but contraindicated in ischemic heart

disease and psychosis

 80.Acromprostate reduces craving weak antagonist of NMDP

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 81.Aggressive behaviour + sweating + Hypertension + tachycardia is
= delirium tremens (DIET-2 2017)

 82.Treatment of Delirium Tremens is : benzodiazepines diazepam.

PSYCHITARY PEARLS
83.first line treatment in obsessive compulsive disorder is CBT if
resistant then SSRI

 84.Preserved awareness + visual attention tracking patients appear

that they are about to speak but don't = Akinetic mutasim

 85.He believed that flickering lights were transmitting messages to

him as new Messiah .believed that red car had passed him that
morning an epic battle with devil is pending is = psychotic delusions
of reference typical feature of Schizophreniform

 86.Treatment of Psychotic Delusions is = 1st line resperidone

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 87.Drinks alcohol daily + sweaty agitated + tells you that nurses are
trying to poison her but she trusts you is = Alcohol withdrawal
syndrome

 88.Treatment of Alcohol withdrawal syndrome is = : give

PSYCHITARY PEARLS
Chlordiazepoxide not resperidone

 89.Impulsive behaviour + repeated self harming over reaction to minor

events accompanied by feelings of emptiness = Borderline personality

 90. Treatment of Alcohol withdrawal is = Lorazapam

 91.Sczhioperhnia (delusions, hallucinations, disorganized speech or

behaviour negative symptoms of at least 6 min with at least 1 month
of active symptoms ) + major depressive episode or manic episode like
u believe that there is devil who wants to kill her hence she wants to
kill herself is = Schizoaffective disorder (DIET-1 2018)

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92.Antipyschotic causes skin rash pigmentation is
chlorpromazine

PSYCHITARY PEARLS
93.Side effects of Atypical antipsychotics is =
Hyperglycaemia
Haloperidol = hypoglycaemia
Phenelzine = dry mouth constipation

94.Psychiatric (anxiety, mood liability ,vivid dreams) +

GI nausea vomiting + dizziness headache paraesthesia
dystonia tremor is = SSRI discontinuation syndrome.
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95.Hallucinatory voices commanding him to do
things or non-verbal forms such as humming or
laughing + delusions which may be jealousy

PSYCHITARY PEARLS
theme or bodily change + hallucinations of smell
is = paranoid schizophrenia (DIET-2 2018)

96.Quetapine used for dopaminergic induced

psychosis and hallucinations

97.Low mood + worry sadness anxiety poor

concentration insomnia following recent stressful
occurrence + loss of pet is = Adjustment disorder
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98. Treatment of Adjustment disorder is :
psychotherapy

PSYCHITARY PEARLS
SSRI

99.No low mood in generalized anxiety disorder.

100.Schzhioaffective disorder has features of

both mood disorder and schizophrenia including
psychomotor retardation features of depression
hallucinations and delusion
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 ONCOLOGY PEARLS

ONCOLOGY PEARLS
• Grind while they sleep , while they party ,live
like while they dream

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 1.Mucositis fallowing radiotherapy to head and neck +
worsening of mouth sores + painful swollen getting worse
= Radiotherapy induced Mucositis

ONCOLOGY PEARLS
 2.Metoclopramide is the first choice to treat hiccup as
well as nausea. (DIET-1 2019)

 3.Management of hiccups is = chlorpromazine is licensed

for the treatment of intractable hiccups
 haloperidol, gabapentin are also used
 dexamethasone is also used, particularly if there are
hepatic lesions(came in diet-3 2018)

 4.Uremia and Hypercalcemia induced nausea and

vomiting treated by = Haloperidol (D2 antagonist
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 5.Methadone can be used as a third line opioid for patients with
complex pain that is poorly responsive to other opioids and adjuvants.

 6.Treatment of radiotherapy induced Mucositis pain by local

anesthetic gel and BENZYDAMINE - mouthwashes

ONCOLOGY PEARLS
 7.Dexathemasone is most useful agent in preventing the delayed
phase of chemotherapy induced emesis

 8.Treatment of high risk chemotherapy induced nausea and vomiting:

 1. 5-HT3 receptor antagonist (Ondansetron) (DIET-3 2017)
 2. ,NK1R antagonist (aprepitant)
 3.dexamethasone
 Low risk symptoms = Metoclopramide.

 9.Thyroid transcription factor TTF-1 is positive in adenocarcinoma of

lung and small cell carcinoma
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 10.Children less than 30years + back pain + weight loss +
tender palpable mass on iliac crest is = Ewing sarcoma
 Poor response to chemotherapy

ONCOLOGY PEARLS
 11.Poor prognosis factors in Ewing sarcoma are :
 Male Age less than 12
 High LDH
 Anaemia

 12.BCL2 and TP53 gene = Diffuse large B cell Lymphoma

 13.BRAF mutated in hairy cell leukaemia

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14.Treatment for bony metastasis from prostate cancer = IV
bisphosphonates and local radiotherapy (DIET-2 2017)

15.Risk factors for malignant melanoma are:

Fair complexion

ONCOLOGY PEARLS
Men sex
Exposure to UV light
Sunny climate.
located equator
Personal family history in 1st degree relative
melanoma Dysplastic naevi greater than 50 naevi 2mm or
more
Xeroderma pigmentosa.

16.Mantle radiotherapy for Hodgkin's lymphoma can

cause= thyroid cancer and breast cancer. (came in diet-2
2017)
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17.Transrectal ultrasonography is used for staging the size and local spread of prostate cancer.

18.Primary brain cancer does not metastasis to lung

19.Fallowing metastasis to lung are :

Breast

ONCOLOGY PEARLS
Colorectal
Bladder
Testis

20.Treatment of small cell carcinoma of lung is :

chemotherapy (etoposide and cisplatin)
surgery is inappropriate even in localized

21.Sezuire + headache + poorly differentiate small round cells + focal neurological deficit is = Giloblastoma
multiforme

22.Treatment of Giloblastoma multiforme is :

surgical debulking
radiotherapy,
chemotherapy (temozolamide, becavizumab,irinotecan)

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• 23.Kaposi's sarcoma - caused by HHD-8 (human herpes virus 8)

• 24.Burkit's lymphoma is commonly associated with c-MYC

• 25.Patents who have received an organ transplant are at risk of skin cancer (particularly
squamous cell carcinoma) due to long-term use of immunosuppressant

ONCOLOGY PEARLS
26.Hepatocellular carcinoma
hepatitis B most common cause worldwide
hepatitis C most common cause in Europe

• 27.Gastric MALT lymphoma - eradicate H. pylori

• 28.Gastric adenocarcinoma - signet ring cells .

• 29.Carcinoembryonic Antigen (CEA) is a tumour marker in colorectal cancer and has a

role in monitoring disease activity (DIET-2 2018)

• 30.Spread into the liver, bone marrow, lungs or other organs would be classified as
stage ID on the Ann Arbor system for Hodgkin's lymphoma

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 31.An MRI whole spine should be performed in a patent suspected of spinal
metastases .

 32.Stage III of the Ann-Arbor clinical staging of lymphomas involve lymph

nodes on both sides of the diaphragm

ONCOLOGY PEARLS
 33.Hodgkin's lymphoma - best prognosis = lymphocyte predominant

 34.Bombesin is a tumour marker in small cell lung carcinomas .

 35.Metastatc bone pain may respond to NSAIDs, bisphosphonates or

radiotherapy . (DIET-1 2016)

 36.Hiccups in palliative care - chlorpromazine or haloperidol

 37.Prostate cancer is the most common primary tumour that metastasises to

the bone .

 38.Breakthrough dose = 1/6th of daily morphine dose .

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 39. Testicular lump + mass on chest X-ray + raised beta HCG = Testicular
seminoma.

ONCOLOGY PEARLS
 40.Treatment of Testicular seminoma is = Chemotherapy + Orchiectomy

 41.Dyspanae + swelling of face,neck ,forarm,headache + JVP raised + visual

disturbance + fixed dilated neck veins is = Superior vena cava obstruction

 42.Investigation of choice For Superior vena cava obstruction is = CT

guided biopsy of mediastinal mass

 43.Treatment of superior vena cava obstruction is :

 General: Dexamethasone treating underlying cause (DIET-3 2018)
 In some cases of no small cell carcinoma stenting is required before
chemotherapy and radiotherapy

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 44.Investigations in breast cancer are :
 Screening : Mammograms sensitive in older not in younger
 BRCA-1 orBRCA-2 mutation screening
 Breast MRI
• Tumour markers:CA15-3

ONCOLOGY PEARLS
• 45.30-40 years + painless + small non palpable mass or hard testis +
symptoms of metastasis + gynaecomastia + markedly raise Beta HCG
and AFP + on ultrasound heamorrgaes,necrosis,cystic calcified =
Choriocarcinoma (DIET-3 2017)

• 46.Chemotherapy used in testicular cancer is :

• B= bleomycin
• E= etoposide
• P= cisplatin (platinum)

• 47.Papillary thyroid cancer is treated by = Thyroidectomy followed by

Radioiodine -131 therapy
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48.High Alpha fetoprotein + high beta HCG = Nonseminoma

49.High beta HCG not AFP is = Seminoma (DIET-2 2016)

ONCOLOGY PEARLS
50.Radical orchiectomy is required for definitive histological
staging and treatment fallowed by additional staging studies
such as Ct scan of abdomen and pelvis and radiographs of
chest in testicular cancer.

51.Horseness + odynophagia + ulcerated lesion projecting

from vocal card friable with bleeding = Squamous cell
laryngeal carcinoma

52.Treatment of Squamous cell carcinoma is : stage II

external beam radiation
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53.Hesitancy,urinary retention + heamaturia,haematospermia + back pain
/ perineal , testicular pain + peripheral zone + asymmetrical hard nodular
enlargement with loss of median sulcus is = Prostatic cancer

54.Treatment of prostate cancer is :

ONCOLOGY PEARLS
Localized T1/T2 palpable disease confined to prostate = Conservative,
radical prostectomy , radiotherapy: external beam and brachytherapy
Localized advanced T3/T4 beyond capsule, bladder neck or rectum =
Hormonal therapy ,radical prostectomy, radiotherapy external beam and
brachytherapy (DIET-1 2017)
Metastatic = hormonal synthetic GnRH agonist : Goserlin luprolide
Anti androgen = Crproteron acetate Orchidectomy

55.Trial of sildenafil is appropriate unless contraindicated for erectile

dysfunction regardless of underlying aetiology

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56.Back pain worse on lying down or coughing + lower limb weakness + sensory loss and
numbness + lesion above L1 UMN signs in legs and sensory level lesion below L1 LMN signs
in legs and perianal lesion = Spinal cord compression (DIET-2 2017)

57.Investigation of choice for Spinal cord compression is = MRI whole spine (DIET-1 2018)

ONCOLOGY PEARLS
58.Treatment for spinal cord compression is =
High dose dexamethasone
Radiotherapy surgery
CNS features=surgery

59.Risk factors for breast cancer are :

BRCA-1 or BRCA-2
Early menarche
Late menopause
Nullparity
OCP

60. Treatment of colon cancer Stage 1 and stage II good risk = Observation
Stage III LN involvement = Surgery + chemotherapy
No role radiotherapy in colon cancer unlike rectal cancer
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 61.Treatment of small cell lung carcinoma is :
 Chemotherapy
 Prophylactic cranial radiation (brain is frequent site of first relapse after complete
therapeutic response)
 No role of surgery

ONCOLOGY PEARLS
 62.Surgery in breast cancer are :
 Indications of mastectomy:
 i) Multifocal tumour
 ii) central tumour
 iii)large lesion in small breast
 iv) DCIS more than 4 cm Indications of wide local excision:
 i) solitary lesion
 ii) peripheral lesion
 iii)small lesion in large breast
 iv) DCIS less than 4cm Radiotherapy adjuvant given after surgery to prevent recurrence

 63.Lower back/ flank pain + fever + lower limb oedema + haematuria + Bromocriptine
is = Retroperitoneal fibrosis (DIET-1 2017)

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 64.Treatment of Colorectal cancer is :
 Stage I (Duke A) mucosal or sub mucosa treatment : Surgery
 Stage II(Duke B) extends into muscularis ,into or through serosa treatment : Surgery
fallowed by radiotherapy
 Stage III(Dukes C) extends to regional lymph nodes treatment : Surgery +
Chemotherapy with 5FU and leucovorin and in some patients radiotherapy (large

ONCOLOGY PEARLS
tumour or invading tissues)
 Stage IV (Dukes D) metastasized to distant sites treatment : surgery , palltive
chemotherapy and or radiotherapy chemotherapy:Cetuximab or becavizumab

 65.Debulking surgery fallowed by chemotherapy is best treatment option for

patients with peritoneal carcinomatosis from ovarian cancer

 66. Nice guidelines on Metastatic malignant diseases of unknown primary origin

recommends that if simple initial investigation fail to indicate a site for further
investigation of malignancy of unknown origin then a CT chest, abdomen and pelvis
should be performed

 67.Dermtomyocitis is associated with which cancers = breast,lung,git and pancreatic

cancer (DIET-3 2018)

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 68.Management of breast cancer is :
 Drug therapy Hormonal therapy : Premenopausal = Tomoxifen blocking
oestrogen receptors Side effects : vaginal bleeding, endometrial cancer,
thromboembolism
 Postmenopausal : aromatase inhibitor : preventing conversion of oestrogen :
Anastrole(1st line),exemestane,letrozole,fulvestrant Side effects :osteoporosis

ONCOLOGY PEARLS
,fragility fracture do Dexa scan Bone disease = bisphosphonates zoledronic
acid 1st lineHer2/neu (c- erb B2) positive = Trastuzumab ( side effects =
Cardiomyopathy so do ECHO)

 69.Typhiltis or Neutropenic colitis is serious complication of Neutropenia

 70.Cetuximab k-ras wild type is used in metastatic colorectal cancer Side

effects : acne type rash

 71. HNPCC is associated with increased risk of ovarian cancer (DIET-2 2016)

 72. Ovarian cancer treated by = First line carboplatin and paclitaxel

combination 2nd line liposomal doxorubicin (caelyx)

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73.AFP + beta HCG + PLAP(placental like isoenzyme of alkaline phosphatase) used for testicular teratoma

74. Tumour antigens are :

PSA = prostatic cancer
AFP=Hepatocellular carcinoma, teratoma, Nonseminoma
CEA=colorectal cancer (DIET-2 2019)
S-100 = melanoma,schwanomas

ONCOLOGY PEARLS
Bombesin = small cell lung carcinoma, gastric carcinoma, neuroblastoma
Beta HCG = choricocarinoma,germ cell tumours lung cancer

75.Tumor markers are :

CA-125 = ovarian cancer
CA19-9= pancreatic cancer
CA 15-3=breast cancer
CEA=colorectal cancer

76.Primary tumours most frequently associated with metastatic spread to brain are :
Lung cancer
Breast cancer
Malignant melanoma melanoma causes multiple metastasis where as breast causes solitary brain lesion
steroids and palliation initial treatment

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77.Cancer pain management WHO analgesic ladder as follows :
Step 1-Non-opiod +/-adjuvants (paracetamol/ Nsaids)
Step-2 weak opioid (codeine)+non opioid +/-adjuvants (co-codamol30/500)
Step3- strong opioid + non opioid +-/adjuvant (morphine, fentanyl, oxycodone)

ONCOLOGY PEARLS
78.Cancer drug causing itching is = Morphine

79. For bone metastasis following can be given:

Nsaid
IV bisphosphonates
Surgery
Radiotherapy

80.Levomepromazine is called as Dirty drug because it blocks all receptors ACh,DA,5HT

broad spectrum antiemetic used as 1st line in last days of life

81. Constipated induced vomiting is treated by metoclopramide ,domperidone

82.Chemotherapy induced vomiting and nausea treated by=cyclize, haloperidol (DIET-2

2018)

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 83.Harmonal management of breast cancer: Tomoxifen = partial agonist
and antagonist of oestrogen .it is 1st line in premenopausal women DVT
is major
 Side effects : Anstrazole,exemestane are aromatase inhibitor = used in
post menopausal women
 Fulvestrant = selective oestrogen receptor down regulator only agent used

ONCOLOGY PEARLS
IV

 84.Morphine is contraindicated in renal failure (DIET-1 2017)

 85. fentanyl can be given in renal impairment.

 86.Opiod used in renal failure is Fentanyl (selective u receptor agonist)

 87.Morphine causes renal impairment.

 88.1st line antiemetic in opioid induced nausea is=Haloperidol

 89.1st line for breathlessness in palltive care is = opioid (morphine)

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 90.Side effects of opioids are :
 Constipation
 Meiosis
 Nausea, vomiting
 Urinary retention

ONCOLOGY PEARLS
 Hallucinations
 Myoclonus
 Delirium

 91. Drug used for constipation in palliative care is = polyethylene glycol (Movicol)

 92.Lyphmodema in cancer patient is treated by = Skin care and compression

bandaging

 93.Treatment of agitation and confusion in terminal phase:1st line Assess for urinary
retention and consider catheterization if that's trigger Drug : midazolam

 94. 1st line drug in treatment of agitation and confusion without terminal stage is =
Haloperidol (DIET-2 2019)

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95. Treatment of liver capsule pain secondary to liver
metastases is dexamethasone ( April 2019 part -2)

96.Antiemetic in palliative care :

ONCOLOGY PEARLS
Cyclizine = it target dopamine and cholinergic receptor's
used in nausea associated with cerebral diseases (brain
Mets) (march 2019 part-2)
Metoclopramide = prokinetic targets dopamine and
serotonin used in delayed gastric emptying a
post chemotherapy, Haloperidol = hits dopamine reception
used in toxic (opioid) or metabolic induced nausea
Levomepromazine = hits all receptors used in terminal
stage
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97. Cancer causing Hypercalcemia are :
Lung cancer
Breast cancer
Renal cell cancer
Multiple myeloma

ONCOLOGY PEARLS
98. Electrolyte disturbance in refeeding syndrome is :
Low P
Low mg
Low K

99. Indication of blood transfusion in palliative care is = disabling

shortness of breath on maximal excretion

100.Metoclopramide is the first choice to treat hiccup as well as nausea

(DIET-3 2017)

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 OPHTHALMOLOGY pearls

OPHTHALMOLOGY PEARLS
• Your eyes shows strength of your soul..

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• 1.episodic total loss of vision on eye (
amourosis fugax ) = Do Carotid Doppler for

OPHTHALMOLOGY PEARLS
ipsilateral Carotid artery disease

• 2.causes of painful 3rd nerve palsy are :

• PCA aneurysm (DIET-2 2018)
• Ophthalmologic migraine

• 3.Marfarin syndrome eye features : high

myopia ,upward dislocation of lens.
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• 4.Early diabetic retinopathy is micro aneurysm

OPHTHALMOLOGY PEARLS
seen on fluorescein angiography

• 5.Painful third nerve palsy = posterior

communicating artery aneurysm

• 6.Optc neuritis is common in patents taking

Ethambutol.

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 7. MS/DM/ syphilis + Unilateral decrease in visual acuity + poor
decrimnation of colours + pain worse on eye movement + relative
afferent pupillary defect + central sctoma is = optic neuritis (DIET-3

OPHTHALMOLOGY PEARLS
2018)

 8.Treatment of Optic Neuritis is = steroids

 9.Resfum disease /Alport syndrome/Kearns Sayre syndrome + Night

blindness + tunnel vision + black bone spicule shaped pigmentation is
= Retinitis pigmentosa

 10. MS/ sarcodosis /DM + Small pupil + accommodation reflex present

but pupillary reflex absent is Argyll Robertson pupil

 11.Dilated pupil + absent leg reflexes + slowly reactive to near

/accommodation reflex + poor response to light is= Holmes Adie pupil

 12.Diagnostic test for Holmes Adie Pupil is weak pilocarpine

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 13.Eye is deviated down and out + ptosis + dilated pupil + unreactive pupil
to light + pain if posterior communicating artery aneurysm is = Third nerve
palsy (DIET-2 2016)

OPHTHALMOLOGY PEARLS
 14.Vesicular rash around eyes + Hutchinson sign i.e. rash on tip or side of
nose is = herpes zoster ophthalmicus

 15.Treatment of Herpes zoster Ophthalmicus is = oral antiviral ,oral

steroids

 16.Red painful eye + photophobia + epiphora + visual acuity decreased+

Fluorescein staining show epithelial ulcer with dendritic pattern is = Herpes
simplex keratitis

 17.Treatment of Herpes Simplex Keratitis is topical acyclovir Never steroids

 18.Nystagmus + ophthalmoplegia + ataxia + alcoholics + confusion +

peripheral sensory neuropathy + decrease red cell transketolase is =
Wernicke's encephalopathy

 19.Treatment of Wernicke’s Encephalopathy is thiamine

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20. Optic atrophy + contralateral papilledema + anosmia
is = Foster Kennedy syndrome

OPHTHALMOLOGY PEARLS
21. Marfan's syndrome has upward lens dislocation
supratentorial ectopia lentis

22.Homocystinuria downward inferonasal dislocation of

lens (DIET-1 2017)

23.Sudden deterioration in vision and flame haemorrhages

in one quadrant is branch retinal vein occlusion

24.Central vein occlusion involve flame haemorrhages in

all four quadrants
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25.Eye disease seen in Alport syndrome is =
Astigmatism

OPHTHALMOLOGY PEARLS
26.Young man + painless loss of vision + visual acuity
fails to improve is = Laber's optic neuropathy

27. optic nerve drusen + progressive loss of visual

perception, coupled with drusen + geographic
atrophy (larger areas of retinal pigment loss) =
Macular degeneration. (DIET-2 2016)

28.investigation of macular degeneration is = Optical

coherence tomography is used to support the initial
diagnosis and to assess severity of disease
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29.Treatment of Macular Degeneration is : Anti-VEGF therapies
are the cornerstone of the treatment of wet age related
macular degeneration to prevent / delay further

OPHTHALMOLOGY PEARLS
neovascularisation.(DIET-1 2018)

30.Glaucoma is associated with enlargement of the blind spot,

blurring of the margins of the optic disc and raised intra-ocular
pressure.

31.Severe hypertensive retinopathy is associated with retinal

haemorrhages.

32.Retinitis pigmentosa presents initially with loss of night

vision, at a much earlier age than 74.

33.Ischaemic optic neuritis associated with pale swollen optic

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• 34.Optic neuropathy + proptosis + chemosis +
opthalmoplegia (sixth nerve palsy )+ blurred
vision ptosis pale optic disk corneal reflex lost is =

OPHTHALMOLOGY PEARLS
Orbital Apex syndrome

• 35.Dilated pupil + slowly responsive to light but

reacts normally to accommodation + loss of reflex
= Holmes Adie pupil (DIET-1 2019)

• 36.Branch retinal vein occlusion where there is

arc of haemorrhages treated by Ranibizumab.

• 37.In central retinal artery occlusion give intra

arterial thrombolysis
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38.Optic neuritis is painful visual acuity
improves in week.

OPHTHALMOLOGY PEARLS
39.Homonymous hemianopia + afferent
pupillary defect + optic pallor + angiod streaks
+ yellow papules on neck + seizures + memory
deficit + MRI shows bilateral infarcts in right
parieto-occpital area visual field defect is =
Pseudoxanthoma elasticum (DIET-3 2017)

40.Vigabatrin causes visual field loss blurred

vision ,ocilospia tunnel vision.
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 41.Homonymous hemianopia with macula
sparing lesion at = Occipital lobe.

OPHTHALMOLOGY PEARLS
 42.Contralateral homonymous inferior
quadrantanopia lesion at = parietal lobe.

 43. Contralateral homonymous superior

quadrantanopia lesion at = temporal lobe.

 44.Bitemporal hemianopia lesion at = optic

chiasm(DIET-1 2016)
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 45.Sudden painless deterioration in vision coupled with pale retina
cherry red spot at centre of macula is = CRAO (DIET-3 2016)

OPHTHALMOLOGY PEARLS
 46.Eye pain eye red with ciliary flush and firm due to raised
intraocular pressure is = Acute glaucoma

 47.Eye pain gradual deterioration in vision,color vision either

normal optic disc or evidence of optic disc swelling is = Acute optic
neuritis

 48.Myopia + sudden appearance of floaters flashes decreased visual

acuity is = Retinal detachment

 49.Retinal tears and holes treated by croyrotherpy or laser

photocoagulation.

 50.Floaters + myopia + no deterioration in vision and flashes unlike

retinal detachment is = Vitreous detachment
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 51.Friedreich ataxia = Optic atrophy

 52.Refsum disease = Retinitis pigmentosa

OPHTHALMOLOGY PEARLS
 53.Differential diagnosis of headache + painful diplopia are :
 Posterior communicating artery aneurysm
 Opthalmogic migraine
 Pituitary adenoma
 Cavernous sinus thrombosis
 Medical mononeuritis

 54.optic atrophy ipsilateral eye + papilledema in contralateral eye + central

sctoma in ipsilateral + Anosmia is = Foster Kennedy Syndrome frontal lobe

 55.Ipislateral fixed dilated pupil (3rd nerve ) + contralateral paralysis due to

compression of cerebral pundcle is = Uncal herniation

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 56.Left homonymous hemianopia + afferent pupillary
defect + optic pallor + angiod streaks + yellow papules
on neck + seizures + mental disturbance is =

OPHTHALMOLOGY PEARLS
Pseudoxanthoma elasticum

 57.MRI of Pseudoxanthoma elasticum shows :

bilateral infarcts on right parieto-occpital area

 58.family history/ black patient /Hypertension

/Myopia/ DM + asymptomatic peripheral visual loss
nasal sctoma loss of nasal visual field + tunnel
decrease visual acuity + optic disc cupping is = primary
open angle glaucoma (DIET-3 2015)

 59.first line treatment of primary open angle glaucoma

is lantoprost . Www.Medicalstudyzone.com
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60.Eye deviated down and out + ptosis + Mydriasis + unreactive pupil to
light is = third nerve palsy (DIET-3 2018)

OPHTHALMOLOGY PEARLS
61. Causes of Third Nerve palsy are :
Diabetes mellitus
Vasculitis.

62.Painful or headache + third nerve palsy + menigism is = posterior

communicating artery aneurysm

63.Ptosis + meiosis = Horner syndrome

64.Ptosis + Mydriasis = Third nerve palsy

65.Causes of bilateral ptosis are :

Myotonic dystrophy
Myasthenia gravis
Syphilis Congenital Www.Medicalstudyzone.com
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66.Severe pain ocular headache + decrease visual acuity + symptoms
worse with mydriasis watching TV dark room + Mydriatic eye drops +
Hard red eye + halos around light + semi dilated non reactive pupil +eye
ball hard to palpate + hypermetropia is = Acute angle closure glaucoma

OPHTHALMOLOGY PEARLS
67.acute glaucoma is diagnosed by : Ganiscope

68. Treatment of acute glaucoma is :

IV analgesia
Antiemetic
Topical pilocarpine
Acetazolamide IV + pilocarpine

69.Night blindness initial sign + tunnel vision + black spicule shaped

pigmentation in peripheral retina mottling of retinal pigment is =
Retinitis pigmentosa (DIET-2 2016)

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70: Causes of Retinitis pigmentosa are :
Refsum's disease
Abetalipoproteinaemia

OPHTHALMOLOGY PEARLS
Lawrence moon bedi syndrome
Kearns Sayre syndrome
Alport syndrome

71.Unilateral decrease in visual acuity over hours and days +

poor discrimination of colures white red looks paler to on eye
than others + relative afferent papillary defect + central sctoma
+ accommodation normal + light reaction is diminished +no
sudden loss of vision + no abnormalities on Fundoscopy retro
bulbar is = Optic neuritis
Diagnosed by MRI of brain

72. Treatment of Optic Neuritis is : IV methylpredinsone

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 PAST PAPERS

PAST PAPERS PEARLS

The past is your lesson.
The present is your Engine.
The future is your Motivation.

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 1.Most common cause of arthralgia from antiTB drugs =
pyrazinamide.

PAST PAPERS PEARLS

 2.Beta blockers should be avoided in cocaine toxicity If
Benzodiazepines fails then give verapamil not beta
blockers.

 3.Interstial haemorrhagic cystitis jelly like material with

in bladder fibrosis = Ketamine

 4.Treatment: discontinue drug and give amitriptyline

 5.Cannabis causes psychosis Methamphetamine causes

dissociative state and risk taking behaviour
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6.Drugs to avoid in renal failure are :
Antibiotic: tetracycline
nitrofurantoin
Nsaids
Lithium

PAST PAPERS PEARLS

Metformin

7.Extensive skin rash + high fever + organ involvement + Eosinophilia +

abnormal LFTs is = DRESS syndrome

8.Drugs associated with DRESS syndrome are:

Allopurinol antiepileptic's
Antibiotics
Immunosuppressant
HIV treatment
Nsaids

9.Treatment of DRESS syndrome are : stop drugs, antihistamine topical steriods

emollients for rash
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 10.Coagulase negative staphylococcus are mostly MRSA so
give vancomycin + Rifampicin in Infective endocarditis

 11.In massive PE has pulmonary artery pressure >40mmhg

PAST PAPERS PEARLS

 12.NG feeding in acute Pancreatitis is preferred option

 13.High calorie supplement drinks in MS when forearm and

hand function unlikely to recover and when swallow is intact

 14.Nitrofurantoin is best avoided in patients with CKD stage 3

or higher due to significant risk of treatment failure and
occurrence of side effects due to drug accumulation

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 15.Rhinorrhea + Diarrhoea + nausea vomiting + lacrimation is =
Heroin withdrawal

 16.Treatment of Heroin withdrawal is : buprenorphine methadone

(better)

PAST PAPERS PEARLS

 17.Hallucinations + increased awareness is = LSD toxicity.

 18.Parathesia + visual field defect + ataxia + dysarthria + hearing loss +

irritability + RTA + triad tremor, neuropsychtric ginvostomatis is =
Mercury poisoning

 19.Smell of toxins: Garlic = Arsenic ,selenium Bitter almonds =

Cyanide
 Rotten eggs = hydrogen sulphide mercaptan
 Winter green = methlysalicyte
 Mothball = naphthalene

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20.You are causing 1:1 conductive block if u are giving Flecainde in arterial
flutter

21Side effects of if I/V IgG immunoglobins is aseptic meningitis 1% of

patients.

PAST PAPERS PEARLS

22.Indications of immunoglobins are:
Primary ,secondary immuno defienancy ITP
Myasthenia gravis
GBS
Kawasaki
Toxic epidermal Nacrolysis
Pneumonitis
Low serum IgG fallowing stem cell transplant for malignancy
Dermatomyositis
CIDP

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23.Reversible unwanted effects of anabolic steriods are :
Increased appetite
GI dysfunction
Mood swings Anxiety

PAST PAPERS PEARLS

Oedema
Libido change
Scrotal pain
Erectile dysfunction
Menstrual irregularities.

24.Irreversible unwanted effects of anabolic steriods are:

Hirutism
Voice pitch changes
Male pattern baldness
Skin Striae or keloid scarring
Chest pain.
Clitoral hypertrophy
Short stature due to premature fusion of growth plates
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 25.Hypotension + blurred vision + xanthopsia +
haemoptysis is = amyl nitrate poisoning

PAST PAPERS PEARLS

 26.Party goer/rape date + CNS and respiratory
depression + hyper salivation + bradycardia+
hypotension + euphoria + amnesia is =
Gammahydrobutyric acid(GHB) toxicity

 27.Treatment of GHB toxicity is : recovery in 6-hrs

 28.Prior to give I/V chlorpromazine in serotonin

syndrome give iv fluid 1st
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29.Drugs contraindicated in pregnancy:
SAFE Mom's Take Really Good Care
S: sulphonamides/stains/sulfonylurea
A:aminoglycides/ACEI/ARBS
F:flourquinolones

PAST PAPERS PEARLS

E: erythromycin
M: metronidazole
T: tetracycline/trimethoprim
R: ribavirin/ retinoid
G:Grifuvin
C:chloramphenichol/cytotoxics

30.CNS: reduced GCS, seizures, perioral parathesia + CVS tachycardia,

Hypotension bradycardia is = Local anesthetic toxicity

31.Treatment of local anesthetic toxicity is : I/V lipid emulsion

32. Avoid grape fruit juice , clarithromycin and Ketoconazole with statin

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33.Skin disease associated with HIV :
Molluscum contagiosum
Corweign scabies
Saeborrhic dermatitis

PAST PAPERS PEARLS

34.Sysmmetrical erythematous lesion and raised pinkish indurated lesion
and shiny orange peel skin is = Pretibial myxoedema seen in graves
disease

35.Skin disorders with Tuberculosis are :

Lupus Vulgaris
Erythema nodosum
Scarring alopecia
Scrofuloderma
Verrucosa cutis
Gumma

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36.Drugs causing lung fibrosis
Amiodarone
Cytotoxic : Busulphan, bleomycin
Anti RA= methotrexate,sulfusalzine ,gold

PAST PAPERS PEARLS

Nitrofurantoin
Bromocriptine, carbergoline,pergoild.

37.CNS:Agitation,tremor anxiety confusion somnolence syncope,

hallucinations psychosis nystagmus convulsion coma + CVS
tachycardia HTN chest pain Palpitations + renal kidney injury +
hypertonia myoclonus muscle jerky + dry mouth Mydriasis(8mm)
vomiting hypokalaemia = Cannabis poisoning.

38.Irriation of eyes, nose and respiratory tract is=Toluene toxicity

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 39.Young female + atypical pain + palpitation + panic
attacks + mid systolic click is = mitral valve prolapse

 40.investigation of choice for Mitral valve prolapse is =

PAST PAPERS PEARLS

ECHO.

 41.Treatment of MVP Atypical chest pain + Palpitations is

= Beta blockers
 MVP+MR+AF give = Anticoagulation
 MVP + Severe MR is = Surgical Repair.

 42.Chest pain radiating up to neck and to his back b/w

shoulder blades + pain started while eating + BP equal in
both arms + pleural effusion is = Oesophageal rupture.
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 43.Coagulase negative staphylococcus are mostly MRSA
so give vancomycin + Rifampicin in Infective endocarditis

 44.In massive PE has pulmonary artery pressure

PAST PAPERS PEARLS

>40mmhg

 45.NG feeding in acute Pancreatitis is preferred option

 46.High calorie supplement drinks in MS when forearm

and hand function unlikely to recover and when swallow
is intact

 47.Nitrofurantoin is best avoided in patients with CKD

stage 3 or higher due to significant risk of treatment
failure and occurrence of side effects due to drug
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 48 .B2 macroglobulin seen in patient who is on renal dialysis

 49. Loop diuretics causes calcium stones Thiazide diuretics prevent it.

 50.Fever + rash + arthralgia + eosinophilia + eosinophuria (pathognomonic) +

PAST PAPERS PEARLS

nonoliguric renal failure + no eosinophilia with NSAID + Proteinuria + mononuclear
infiltrate in intersium is =Acute interstial nephritis

 51.Treatment of Acute interstial nephritis is drug withdrawal and steroids

 52 . Long standing dialysis + Renal failure + CNS abnormalities + joint pain and stiffness
in upper limb more than lower limb + beta 2 microglobulin is= Amyloidosis

 53. Treatment of renal amyloidosis is Renal transplantation

 54. Haematuria + Loin pain + Abdominal mass + anaemia + Hypertension +

Polycythemia + left varicocele is = Renal cell carcinoma

 55.ultrasound is investigation of choice for renal cell carcinoma

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 56.Ropinirole D2/D3 dopamine agonist is associated with changes in
behaviour like gambling high risk sexual intercourse.

 57.Progressive arthritis which Mimic osteoarthritis or Ankylosing

spondylitis + urine darkens progressively when left standing because of

PAST PAPERS PEARLS

high content of homogenistic acid is = Alkaptonuria

 58.Treatment of Alkaptonuria is :
 dietary restriction of tyrosine and phenylalanine.

 59.T4 is more accurate way to asses thyroid status than TSH

 70.First line in red cell aplasia is steriods

 2nd line : azathioprine, Cyclosporine, cyclophosphamide rituximab
 Refractory cases : plasmapheresis Thymoectomy and Spleenectomy

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71.The history of retching followed by bright red blood in the vomitus
and the normal findings on endoscopy is = Mallory–Weiss tear.

72.treatment of Mallory Weiss tear is =

PAST PAPERS PEARLS

The patient is haemodynamically stable and requires no specific
intervention save reassurance and advice on safe consumption of alcohol.

73.History of codeine use + initial constipation then profuse diarrhoea +

faecal loading on x-ray + normal inflammatory markers and normal WBC
is = Overflow diarrhoea

74.Treatment of Overflow Diarrhoea is :

oral stool softener like sodium docusate, switch codeine into meptazinol

75.Diverticular disease ,Ulcerative colitis ,Clostridium diffcle has high

wbcs,raised inflammatory Markers.

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76. Management of Coarctation of the aorta includes
:control of hypertension and assessment for possible
balloon angioplasty +/- stenting or surgical repair of the
lesion.

PAST PAPERS PEARLS

77. Linezolid more than vancomycin in post influenza if
Flucloxacillin is contraindicated .

78.Diuretics causes gout so stop it.

79. In osteomyelitis next step is MRI ,once diagnosis is

confirmed then surgical debridement.

80. giant A wave seen in pulmonary stenosis and tricuspid

stenosis .
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
81.Cardaic arrest occurred and CNS impairment outcomes
improved by period therapeutic hypothermia with respect to
CNS status at discharge.

PAST PAPERS PEARLS

82.Best next step after chest x-ray for sarcodosis is CT chest .
More accurate is trans bronchial biopsy

83.Majority of cases e coli recover sponteoulsly

 Do not use antibiotics

84.Post transfusion few days after developed patchie, purpura,

bruises is = post transfusion purpura

85.Treatment of Post Transfusion purpura is : high dose IV

immunoglobins
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 86.Low IgG + low igA + respiratory and git infections is = Common variable
immuno defienancy

 87.Treatment of Common variable immuno defienancy is : immunoglobins

replacement.

PAST PAPERS PEARLS

 88.Suspion of celiac disease but antiendomysial antibody and igA negative
next step is immunoglobins electrophoresis to exclude isolated igA defienancy,
you can do duodenal biopsy and other tests of caelic disease after this.

 89.Ingestion of amyl nitrate causes methaeglobimia give methylene blue.

 90.Small poorly reactive pupils + decreased respiratory rate is = Opiate

overdose

 91.Give IV naloxone if consciousness doesn't improve then give intubation

ventilation.

 92.Pseudomonas in cystic fibrosis treated by nebulized tobramycin and oral

azithromycin 6 monthly
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 93.HIV patient + painless lesion on glans penis with rolled edges
inguinal lymphadenopathy is syphilis.

 94.Nice guidelines recommends that all patients who present to

emergency department fallowing episode of self Harm should be

PAST PAPERS PEARLS

offered psychological assessment

 95.Erythema nodsum and you suspected sarcodosis next step chest

chest x-ray not CT thorax.

 96.HIT-2 occurs at 48-72 hour platelets falls below 100

 97.Treatment of HIT-2 is : stop LMWH and change to donaproid or

Lepirudin

 98.HIT- 1 occur after 5-10 days Rarely platelets falls below 100

 100.Treatment of HIT-1 is observation and continue LMWH

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 101.Extrapyramidial signs Parkinson + IV drug user is = Heavy metal
Poisoning.

 102.Thyroxine requirements increased by rifampicin not INH

PAST PAPERS PEARLS

 103.Antipyschotic/slower onset + low reflexes + lead pipe rigidity +
normal pupils + tachycardia + pyrexia diaphoresis high BP + high CK + is =
Neuroleptic malignant syndrome

 104.Treatment Neuroleptic malignant syndrome is :

 IV fluids
 Benzodiazepines
 Dantrolene
 Bromocriptine.

 105.Tramadol co prescribed with SSRI cause serotonin Syndrome.

 106.Agitation + Hyponatremia + serotonin Syndrome + hyperpyrexia is =

Cathinone toxicity
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 107.Treatment of Cathinone toxicity is :
 Benzodiapines,cooling,hypertonic saline if Hyponatremia

 108.He said he is Jesus /Ecstasy/SSRI/amphetamines/monoamine

oxidase inhibitor + Hyperreninemia, myoclonus, rigidity + fever +

PAST PAPERS PEARLS

altered mental status+ clonus + dilated pupil + faster in onset +
tachycardia high BP + high Ck is = Serotonin Syndrome

 109.Treatment of Serotonin syndrome is :

 IV fluid Benzodiapines
 Severe cases cryptoheptadine,chlroprmazine.

 110.He said he is Jesus because God spoke to him through TV is =

Acute psychosis which may be related to underlying primary
schizophrenia
 Treatment: resperidone

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 111.Nice guidelines for management of painful sickle cell crisis
recommends strong opiate delivered by iv route

 112.Manic episode + risk to herself give = IM Lorazapam sedation

PAST PAPERS PEARLS

 If not available then Haloperidol.

 113.High PEEP low tidal volume respiratory rate up to 35 is treatment

for ARDS

 114.If there is still Diarrhoea after Cholestrayamine use in ileal

resection Crohn's then add codeine phosphate

 115.In suspected case of gout therapy in Infective cause 1st is knee

Aspiration

 116.In pregnancy and chlamydia give azithromycin not penicillin

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 117.False beliefs that she some one trying to harm her she is afraid
that they will see her and will hurt her she has proves of it like they
keep garbage outside to trap her
 Other example is feelings insects crawling over skin = Delusions (false
believe)

PAST PAPERS PEARLS

 118.She laughs and giggles for apparent reason and she is unable to
dress or shower herself ,rocking muttering softly herself =
Schizophrenia in disorganized type

 119.Unable to eat or drink anything unresponsive both vocally and

nonverbally she resist any attempt to be moved socially isolated
bizarre and speak people no one else could see = Cationic
schizophrenia

 120.He has not slept ,bathed ,eaten lack of personal care, in talks to
himself hallucinations is and he says some one stealing his thoughts
he fallow making him unable do school material he is crying feeling
of suicide is = Schizoaffective disorder
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
121.Hallucinatory voices commanding him to do things
hum or laugh + delusions like girl friend wants to leave
him and he has illness won't live more than 1 year +
hallucinations of smell i.e. he smell of fish + neglect

PAST PAPERS PEARLS

personal hygiene = Paranoid schizophrenia

122.Side effects of Exogenous androgen is paranoid

delusions and aggressive behaviour

123.Sertraline and citalopram appear be safest with

antidepressants with Warfarin

124.Alzheimer's + psychic features like slapping his wife and

inhibitor = give antipsychotics like olanzapine
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125.Bilateral femoral bruits and absent dorsalis pedis pulses + abnormal lipid profile +
pain in both calves + pain starts after walking relieved by rest is = Periarterial disease

126.Treatment of Periarterial disease is : start statin with target LDL of less than 2

PAST PAPERS PEARLS

127.Buttock and thigh claudication + normal straight leg raise + pain relieved by rest is =
Lumbar Spinal stenosis

128.Investigation of Lumbar Spinal stenosis is : MRI shows loss of epidural fat on T1

weighted images loss of csf signal around Dural sac and degernative disc disease

129.Treatment of Lumbar Spinal Stenosis is : DE compressive lumbar laminectomy first

line surgical intervention

130.Normal straight leg raise in spinal stenosis differentiate it from other causes of lower
limb nerve pain

131.In prolapsed lumbar disc there is pain on straight leg raise

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 132.Peripheral vascular disease associated with reduction in
ABPI

 133.Long term management in obstructive sleep apnoea is

PAST PAPERS PEARLS

weight loss

 134.In overuse headache stop paracetamol taper codeine

and start naproxen

 135.Ventricular bigemini = Reassurance if she compliant of

further episodes of palpitations then 72 Holter monitor

 136. Talc pleurodesis is best for patient of Mesothelioma

with plural effusion

 137.Pharyngitis + abnormal LFTs = CMV infection

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 138.Complicated abscess or those >5 cm in diameter
usually require surgical intervention to achieve adequate
drainage

PAST PAPERS PEARLS

 139.Hypertension + localized cerebellar signs = Cerebellar
haemorrhages.

 140.1st line in human bite is = Co amoxiclav

 2nd line metronidazole doxycycline

 141.Best evidence with respect to virus clearance in

hepatitis B is = Entecavir

 142.Licorice = low Aldosterone and low renin

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143.HIV patient + mononuclear Leucocytosis +
raised csf + Ventricular enlargement is = CMV
encephalitis

PAST PAPERS PEARLS

144.To localize phaeochromocytoma and not to know
that adenoma is realising catecholamine = MIBG scan

145.Student house + headache + nausea vomiting +

confusion vertigo + pink skin mucosa + weakness +
arrthymais + coma + red lip + lactic acidosis is =
Carbon monoxide poisoning

146.Investigation of Carbon Monoxide poisoning is

:pulse oximeter to measure level CO
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 147.Risk factors for barret oesophagus are :
 Gerd
 Male Stricture or ulcer Has increased risk of adenocarcinoma
 Metaplasia of lower oesophagus when normal squamous epithelium
replaced by columnar epithelium

PAST PAPERS PEARLS

 148.Investigations in Gilbert syndrome are:
 Rise in bilirubin provoked by prolonged fasting or IV nicotinic acid.

 149.Management of Gilbert syndrome is :

 No treatment required
 If severe jaundice = Phenobarbitone

 150.Non bloody Diarrhoea + young patient + weight loss + abdominal

mass palpable on right iliac fossa is = Crohn's disease.

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 Updated Guidelines

Updated guidelines
 SUCCESS IS NO ACCIDENT.
 It is hard work, perseverance ,learning ,studying ,sacrifice
and most of all ,Love of what you are doing.

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 Nice guidance on management of

RESPIRATORY UPDATED GUIDELINES

Asthma
• One of the key changes is in step:3 patients on a SABA + ICS whose asthma is not well
controller should be offered a leukotriene receptor antagonist not a LABA

• Step 1 : newly diagnosed asthma = Short acting beta agonist (SABA)

• Step :2 Not controlled on previous step OR newly diagnosed asthma with symptoms
>=3/week or night time waking = SABA+ Low dose inhaled corticosteroid (ICS)

• Step :3 = SABA + Low dose ICS + leukotriene receptor antagonist (LTRA)

• Step:4 SABA + Low dose ICS + long acting beta agonist Continue LTRA depending on
patient's response to LTRA

• Step 5 : SABA +/- LTRA Switch ICS/LABA for a maintenance and reliever therapy ( MART)
that includes low dose ICS
• Continued on next
page………
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• Step 6 : SABA +/- LTRA + medium dose ICS

RESPIRATORY UPDATED GUIDELINES

MART OR consider changing back to fixed dose
of a moderate dose ICS and a separate LABA

• Step 7: SABA +/- LTRA + one of the fallowing

options : Increase ICS to high dose (only as
part of fixed dose regime ,not as a MART) a
trial of an additional drug ( for example a long
acting muscarinic receptor antagonist or
theophylline )Seeking advice from health care
professional with expertise in asthma
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 Guidelines on Asthma in Pregnancy

RESPIRATORY UPDATED GUIDELINES

• In general, the medicines used for asthma are safe
during pregnancy.
• The British Thoracic Society (BTS) guidelines make it
clear that short-acting /long-acting
• beta 2-agonists, inhaled and oral corticosteroids
should all be used as normal during pregnancy.
• The BNF advises that 'inhaled drugs, theophylline
and prednisolone can be taken as normal
• during pregnancy and breast-feeding'.
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 NICE guidelines on COPD

RESPIRATORY UPDATED GUIDELINES

• NICE recommend considering a diagnosis of
COPD:
• in patients over 35 years of age who are
smokers or ex-smokers and have symptoms
such as exertional breathlessness, chronic
cough or regular sputum production.

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 Guidelines on IPAP and EPAP use in

RESPIRATORY UPDATED GUIDELINES

COPD
• Recommended initial settings for bi-level pressure
support in COPD

• Royal College of Physicians guidelines

recommend an initial IPAP of 10 cm H20.

• The British Thoracic Society guidelines had

previously advocated starting at 12-15 cm H20
• Continued to next page…..
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• Expiratory Positive Airway Pressure (EPAP): 4-5

RESPIRATORY UPDATED GUIDELINES

cm H2O
• Inspiratory Positive Airway Pressure (IPAP):
RCP advocate 10 cm H20 whilst BTS suggest
• 12-15 cm H2O.
• back up rate: 15 breaths/min
• back up inspiration: expiration ratio: 1:3

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• NICE guidelines on COPD clearly define which

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patients should be assessed for and offered long-
term oxygen therapy (LTOT).
• Patients who receive LTOT should breathe
supplementary oxygen for at least 15 hours a day.
Oxygen concentrators are used to provide a fixed
supply for LTOT.
• At least 15 hours of oxygen therapy per day is
required to reduce the pulmonary hypertension
• associated with (COPD) and to treat the
underlying pathology of incipient right heart
failure.
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 British Thoracic Society (BTS)

RESPIRATORY UPDATED GUIDELINES

guidelines on LTOT
• (BTS) advises that LTOT may be of benefit in patients with the following conditions:

 Chronic obstructive pulmonary disease

 Severe chronic asthma
 Interstitial lung disease
 Cystic fibrosis
 Bronchiectasis
 Pulmonary vascular disease
 Primary pulmonary hypertension
 Pulmonary malignancy
 Chronic heart failure

 Patients with any of the above conditions can be assessed to see if they would benefit from
LTOT.

 BTS guidelines currently state that patients should have a Pa02 consistently at or below
7.3kPa on

 air at a time when they are clinically stable (absence of exacerbation in previous five weeks.
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 NICE guidelines on management of

RESPIRATORY UPDATED GUIDELINES

Pulmonary embolism
• LMWH or fondaparinux should be continued for at least 5 days
or
• until the international normalised ratio (INR) is 2.0 or above for
at least 24 hours, whichever is longer, i.e. LMWH or
fondaparinux is given at the same time as warfarin until the
INR is in the therapeutic range for patient.
• Warfarin a vitamin K antagonist (i.e. warfarin) should be given
within 24 hours of the diagnosis
• warfarin should be continued for at least 3 months.
• NICE advise extending warfarin beyond 3 months for patients
• with unprovoked PE. This essentially means that if there was no
• obvious cause or provoking factor (surgery, trauma, significant
• immobility)
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 Nice guideline tells what increases

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the risk of AKI
• Acute kidney injury (AKI) (previously termed acute
renal failure or ARF)
• Nice guideline tells what increases the risk of AKI:
• 1. Emergency surgery, risk of sepsis or hypovolemia
• 2. Intraperitoneal surgery
• 3. CKD, i.e. if eGFR < 60
• 4. Diabetes
• 5. Heart failure
• 6. Age >65 years
• 7. Liver disease
• 8. Use of nephrotoxic drugs
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 NICE recommend that screening for

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chronic kidney disease
NICE recommend that screening for chronic kidney disease should be offered to patients
With:
Diabetes
Hypertension
Cardiovascular disease
Structural renal tract pathology
Multisystem disease with potential renal involvement
Opportunistically detected haematuria or proteinuria
A family history of stage 5 chronic kidney disease, or
Hereditary kidney disease.

In the absence of other risk factors the guidelines recommend that age, gender and
ethnicity should not be used as risk markers to test people for chronic kidney disease.
Obesity alone should not be used as a risk factor (features of the metabolic syndrome
should also be present
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 NEPHROLOOGY UPDATED GUIDELINES
NICE guidelines on GFR and creatinine

• NICE suggest that a decrease in eGFR of up

to 25% or a rise in creatinine of up to 30% is
acceptable, although any rise should prompt
careful monitoring and exclusion of other
causes (e.g. NSAIDs). A rise greater than this
may indicate underlying vascular disease.

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 NICE guidelines on CKD and blood

NEPHROLOOGY UPDATED GUIDELINES

pressure
• NICE guidelines recommend BP target range:
• CKD patient who have proteinuria
equivalent to ACR ≥70 mg/mmol 120-
129/<80 mmHg. The same target range
should be used in patients with diabetes.
• Non-diabetic patients with CKD and an ACR
<70 mg/mmol 120-139/<90 mmHg
• continued on next page……
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• CKD and proteinuria NICE recommend using

NEPHROLOOGY UPDATED GUIDELINES

the albumin: creatinine ratio (ACR) in
preference to the protein: creatinine ratio
(PCR) when identifying patients with
proteinuria as it has greater sensitivity.

• For quantification and monitoring of

proteinuria, PCR can be used as an alternative,

• although ACR is recommended in diabetics.

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 NICE guidelines on iron status and

NEPHROLOOGY UPDATED GUIDELINES

CKD
• NICE guidelines : Diagnostic tests to determine iron status and predict response
to iron therapy in anaemia with CKD

• Do it every 3 months (1–3 months for people receiving haemodialysis).

• Use percentage of hypochromic red blood cells (% HRC; more than 6%), but only
if processing of blood sample is possible within 6 hours.
• If using % HRC is not possible, use reticulocyte Hb content (CHr; less than 29 pg)
• If these tests are not available or the person has thalassemia or thalassemia
trait, use a combination of transferrin saturation (less than 20%) and serum
ferritin measurement (less than 100 micrograms/litre).

• Do not request transferrin saturation or serum ferritin measurement alone to

assess iron deficiency status in people with anaemia of CKD.

• NICE guidelines suggest a target haemoglobin of 10 - 12 g/dl

• Continued on next page……

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• Targets for treatment: The Kidney Disease Outcomes

NEPHROLOOGY UPDATED GUIDELINES

Quality Initiative (KDOQI) and European Revised
Evidence-Based Practice Guidelines recommend:
• Hb : maintain Hb range between 100 and 120 g/litre (10
- 12 g/dl) (NICE )
• Ferritin: >100 μg/L in pre-dialysis and peritoneal
dialysis patients, >200 μg/L in haemodialysis patients
• ferritin level maintained at 200-500 μg/L
• NICE should not rise above 800 micrograms/litre
(review the dose of iron when serum ferritin levels
reach 500 micrograms/litre)
• Transferrin saturation >20%
• haematocrit <33%. percentage hypochromic red cells
• Continued on next
page…..
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•

NEPHROLOOGY UPDATED GUIDELINES

If there is Iron deficiency (NICE )
• For patient on haemodialysis or ESA I.V iron therapy.
• For patient not on haemodialysis trial of oral iron
• If they are intolerant of oral iron or target Hb levels are not
reached within 3 months intravenous iron therapy. (part 2
Exam July 2002)

• offer maintenance iron to people with anaemia of CKD who

are receiving ESAs haemodialysis patients will need the
equivalent of 50–60 mg intravenous iron per week (1
mg/kg/week). [NICE 2015]

• If Ferritin is below the recommended level of 200 for

patients receiving erythropoietin treatment iron
supplementation is recommended

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 European Association of Urology

NEPHROLOOGY UPDATED GUIDELINES

guidelines on Renal stones imaging
Ultrasound (US) should be used as the primary diagnostic imaging tool.

US is safe (no risk of radiation), reproducible and inexpensive.

US has a sensitivity of 45% and specificity of 94% for ureteric stones and a
sensitivity of 45% and specificity of 88% for renal stones.
the preferred method of imaging in pregnant women.

KUB (kidney-ureter-bladder radiography) x-ray The sensitivity: 44-77% and

specificity: 80-87%. should not be performed if NCCT is considered.

KUB is helpful in differentiating between radiolucent and radiopaque stones

and be used for comparison during follow-up.

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 Guidelines on management of Renal

NEPHROLOOGY UPDATED GUIDELINES

colic
Acute management of renal colic
Medication the British Association of Urological Surgeons
(BAUS) recommend diclofenac (intramuscular/oral) as the
analgesia of choice for renal colic*
*Diclofenac use is now less common following the MHRA
warnings about cardiovascular risk.
It is therefore likely the guidelines will change soon to an
alternative NSAID such as naproxen
BAUS also endorse the widespread use of alpha-adrenergic
blockers to aid ureteric stone passage
Stones < 5 mm will usually pass spontaneously.
Lithotripsy and nephrolithotomy may be for severe cases.
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 NICE updated their guidance on

NEUROLOOGY UPDATED GUIDELINES

antiepileptics use
 Most neurologists now start antiepileptics following a second epileptic seizure.
NICE guidelines suggest
 starting antiepileptics after the first seizure if any of the following are present:
 the patient has a neurological deficit
 brain imaging shows a structural abnormality
 the EEG shows unequivocal epileptic activity
 the patient or their family or carers consider the risk of having a further seizure
unacceptable
 Sodium valproate is considered the first line treatment for patients with
generalised seizures
 carbamazepine used for partial seizures
 Generalised tonic- clonic seizures
 sodium valproate
 second line: lamotrigine, carbamazepine
 continued on next page.......
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 Absence seizures* (Petit mal)
 sodium valproate or ethosuximide

NEUROLOOGY UPDATED GUIDELINES

 sodium valproate particularly effective if co-existent tonic-clonic seizures in
primary generalised
 epilepsy
 carbamazepine may actually exacerbate absence seizure
 Myoclonic seizures
 sodium valproate
 second line: clonazepam, lamotrigine
 (carbamazepine and phenytoin may worsen myoclonic seizures).
 Partial seizures
 carbamazepine
 second line: lamotrigine**, sodium valproate
 SANAD study indicated that lamotrigine may be a more suitable first-line drug
for
 partial seizures although this has yet to work its way through to guidelines
 Stopping of anti-epileptic drugs (AED) NICE guidelines)
 Can be considered if seizure free for > 2 years, with AEDs being stopped over
2-3 months
 Benzodiazepines should be withdrawn over a longer period
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 NICE updated their guidance on

NEUROLOOGY UPDATED GUIDELINES

management of Alzheimer’s disease
NICE now recommend the three acetyl
cholinesterase inhibitors (donepezil,
galantamine and rivastigmine) as options
for managing mild to moderate Alzheimer's
disease
A well-known side effect of rivastigmine is AV
block memantine (a NMDA receptor
antagonist) is reserved for patients with
moderate – severe Alzheimer's disease
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 NICE updated their guidance on

NEUROLOOGY UPDATED GUIDELINES

management of headache migraines
 Acute treatment
 first-line: offer combination therapy with an oral triptan and an NSAID,
or an oral triptan and
 paracetamol
 for young people aged 12-17 years consider a nasal triptan in preference
to an oral triptan
 if the above measures are not effective or not tolerated offer a non-oral
preparation of
 metoclopramide* or prochlorperazine and consider adding a non-oral
NSAID or triptan
 *caution should be exercised with young patients as acute dystonic
reactions may
 develop with metoclopramide

continued on next page…..

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 Prophylaxis (NICE )

NEUROLOOGY UPDATED GUIDELINES

 prophylaxis should be given if patients are experiencing 2 or more
attacks per month. Modern treatment is effective in about 60% of
patients.
 NICE advise either topiramate or propranolol or amitriptyline
'according to the person's preference, comorbidities and risk of
adverse events'.
 Propranolol should be used in preference to topiramate in women of
child bearing age as it may be tetratogenic and it can reduce the
effectiveness of hormonal contraceptives
 if these measures fail NICE recommend 'a course of up to 10 sessions
of acupuncture over 5-8 weeks'
 gabapentin are not recommended now because evidence shows that it
is not effective in preventing migraine. (NICE )
 NICE recommend: 'Advise people with migraine that riboflavin (400
mg once a day) may be effective in reducing migraine frequency and
intensity for some people‘ for women with predictable menstrual
migraine treatment NICE recommend either frovatriptan
 (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day)
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NICE published updated guidelines for

CARDIOLOOGY UPDATED GUIDELINES

the management of hypertension.
• Some of the key changes include:
• classifying hypertension into stages
• recommending the use of ambulatory blood
pressure monitoring (ABPM) and home blood
• pressure monitoring (HBPM)

Continued on next page

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• NICE advocate.

CARDIOLOOGY UPDATED GUIDELINES

• Stage Criteria
• Stage 1 hypertension
• Clinic BP >= 140/90 mmHg and subsequent ABPM
daytime average or HBPM
• average BP >= 135/85 mmHg
• Stage 2 hypertension
• Clinic BP >= 160/100 mmHg and subsequent ABPM
daytime average or HBPM
• average BP >= 150/95 mmHg
• Severe hypertension
• Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >=
110 mmHg
continued on next page …………
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• Diagnosing hypertension

CARDIOLOOGY UPDATED GUIDELINES

• Firstly, NICE recommend measuring blood pressure in both arms when
considering a diagnosis
• of hypertension. If the difference in readings between arms is more than 20
mmHg then the
• measurements should be repeated. If the difference remains > 20 mmHg
then subsequent blood
• pressures should be recorded from the arm with the higher reading.
• It should of course be remember that there are pathological causes of
unequal blood pressure
• readings from the arms, such as supravalvular aortic stenosis. It is therefore
prudent to listen to
• the heart sounds if a difference exists and further investigation if a very large
difference is noted.
• NICE also recommend taking a second reading during the consultation, if
the first reading is >
• 140/90 mmHg. The lower reading of the two should determine further
management.
• NICE suggest offering ABPM or HBPM to any patient with a blood pressure
>= 140/90 mmHg
• continued on next page
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• If however the blood pressure is >= 180/110

CARDIOLOOGY UPDATED GUIDELINES

mmHg:
• immediate treatment should be considered
• if there are signs of papilledema or retinal
haemorrhages NICE recommend same day
• assessment by a specialist
• NICE also recommend referral if a
phaeochromocytoma is suspected (labile or
postural hypotension, headache, palpitations,
pallor and diaphoresis)
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 Hypertension in pregnancy (NICE

CARDIOLOOGY UPDATED GUIDELINES

guidance )
• Hypertension in pregnancy (NICE guidance ) Labetalol is first line
for pregnancy induced hypertension
• Women who are at high risk of developing pre- eclampsia should
take aspirin 75mg od from 12 weeks until the birth of the baby.
• High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or Antiphospholipid syndrome
• type 1 or 2 diabetes mellitus
• The classification of hypertension in pregnancy is complicated and
varies. Remember, in normal pregnancy:
• blood pressure usually falls in the first trimester (particularly the
diastolic), and continues to fall until 20-24 weeks
continued on next page
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 CARDIOLOOGY UPDATED GUIDELINES
• after this time the blood pressure usually increases
to pre-pregnancy levels by term
• Hypertension in pregnancy in usually defined as:
• systolic > 140 mmHg or diastolic > 90 mmHg
• or an increase above booking readings of > 30
mmHg systolic or > 15 mmHg diastolic
• After establishing that the patient is hypertensive
they should be categorised into one of the
following groups:
• Pre-existing hypertension
• Pregnancy
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 NICE recommends antibiotic

CARDIOLOOGY UPDATED GUIDELINES

prophylaxis for fallowing
procedures.
 NICE recommends the following procedures do not require
prophylaxis:
 dental procedures
 upper and lower gastrointestinal tract procedures
 genitourinary tract; this includes urological, gynaecological and
obstetric procedures and
 childbirth
 upper and lower respiratory tract; this includes ear, nose and
throat procedures and
 bronchoscopy
• continued on next page ……….

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• The guidelines do however suggest:

CARDIOLOOGY UPDATED GUIDELINES

• any episodes of infection in people at risk of
infective endocarditis should be investigated and
• treated promptly to reduce the risk of endocarditis
developing
• if a person at risk of infective endocarditis is
receiving antimicrobial therapy because they are
• undergoing a gastrointestinal or genitourinary
procedure at a site where there is a suspected
• infection they should be given an antibiotic that
covers organisms that cause infective endocarditis
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 ENDOCRINOLOGY UPDATED GUIDELINES
NICE guidelines type 1 diabetes in
adults :
Diagnosis:
People with type 1 diabetes typically (but not always) have one or more
of:
ketosis
rapid weight loss
age of onset below 50 years
BMI below 25 kg/m2
Personal and/or family history of autoimmune disease.

Consider C-peptide and/or diabetes-specific autoantibody titres if:

atypical features (for example, age 50 years or above, BMI of 25 kg/m2 or
above, slow evolution of hyperglycaemia or long prodrome) or
suspicion of monogenic form of diabetes (MODY) (test may guide the use
of genetic testing)

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 ENDOCRINOLOGY UPDATED GUIDELINES
NICE guidelines on GLP-1 use
• Criteria for glucagon-like peptide1 (GLP1) mimetic (e.g. exenatide)
• if triple therapy is not effective, not tolerated or contraindicated
then NICE advise that we
• consider combination therapy with metformin, a sulfonylurea and
a glucagon like peptide1 (GLP1) mimetic if:
• BMI >= 35 kg/m² and specific psychological or other medical
problems associated with obesity or
• BMI < 35 kg/m² and for whom insulin therapy would have
significant occupational implications or Weight loss would benefit
other significant obesity related comorbidities
• only continue if there is a reduction of at least 11 mmol/ mol [1.0%]
in HbA1c and a weight loss of at least 3% of initial body weight in 6
months

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 ENDOCRINOLOGY UPDATED GUIDELINES
NICE guidelines on Metformin
• NICE recommend that the dose should be
reviewed if the creatinine is > 130 mmol/l (or
eGFR < 45 ml/min) (reduce the those and
monitor renal function every three months)
• and stopped if the creatinine is > 150 mmol/l
(or eGFR < 30 ml/min)
• Metformin should not be initiated in patients
with eGFR < 60.
• The drug should be stopped once eGFR falls to
less than 30 mL/min/1.73 m2 (creatinine more
than 150 µmol/L)
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 ENDOCRINOLOGY UPDATED GUIDELINES
NICE guidelines on insulin use
• Starting insulin
• if HbA1c > 58 mmol/mol (DCCT = 7.5%) then consider
human insulin
• Metformin should be continued. In terms of other
drugs NICE advice: 'Review the continued
• need for other blood glucose lowering therapies'
• NICE recommend starting with human NPH insulin
(isophane, intermediate acting) taken at
• bed-time or twice daily according to need
• continued on next page…..
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 ENDOCRINOLOGY UPDATED GUIDELINES
• NICE have reviewed use of long acting insulin analogues and they are
only appropriate in cases of significant hypoglycaemia.
• NICE only recommends use of insulin glargine in patients - with type-2
diabetes – who have significant hypoglycaemia on isophane insulin
• Glargine and detemir are insulin analogues, as such they are considered
by NICE to be only suitable in cases:
• nocturnal hypoglycaemia is a problem on isophane (NPH) insulin
• morning hyperglycaemia on isophane (NPH) insulin results in difficult
day-time blood glucose control
• rapid-acting insulin analogues are used for meal-time blood glucose
control.
• Insulin prescription
• The guidelines recommend starting with either morning or evening
long-acting insulin, or with bedtime intermediate acting insulin.
• 0.2 U/kg or a flat dose of 10 U is the recommended starting dose for
intermediate acting insulin.
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 ENDOCRINOLOGY UPDATED GUIDELINES
NICE guidelines on DPP-4 inhibitors

 continue DPP-4 inhibitor only if there is a

reduction of > 0.5 percentage points in HBA1c
in 6 months
 NICE suggest that a DPP-4 inhibitor might be
preferable to a thiazolidinedione if further
 weight gain would cause significant problems,
a thiazolidinedione is contraindicated or the
person has had a poor response to a
thiazolidinedione
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 NICE recommend the blood pressure

ENDOCRINOLOGY UPDATED GUIDELINES

targets for type 2 diabetics:
• NICE recommend the following blood pressure targets for type 2 diabetics:
• targets for type 2 diabetics
• if end-organ damage (e.g. renal disease, retinopathy) < 130/80 mmHg
• otherwise < 140/80 mmHg
• Patients who were more tightly controlled had a slightly reduced rate of stroke but otherwise
• outcomes were not significantly different.
• Because ACE-inhibitors have a renoprotective effect in diabetes they are the first-line
antihypertensives recommended for NICE.
• Patients of African or Caribbean family origin should be offered an ACE-inhibitor plus either a
• thiazide diuretic or calcium channel blocker.
• Further management then reverts to that of non-diabetic patients, as discussed earlier in the
• module. Remember that autonomic neuropathy may result in more postural symptoms in
patients
• taking antihypertensive therapy. The routine use of beta-blockers in uncomplicated
hypertension should be avoided, particularly when given in combination with thiazides, as
they may cause insulin resistance, impair insulin secretion and alter the autonomic response
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 ENDOCRINOLOGY UPDATED GUIDELINES
NICE guidelines on familial
hypercholesterolemia
• NICE recommend the following that we should consider the possibility
of familial hypercholesterolemia and investigate further if the total
cholesterol concentration is > 7.5 mmol/l and there is a family history of
premature coronary heart disease.
• They also recommend referring people with a total cholesterol > 9.0
mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the
absence of a first-degree family history of premature coronary heart
disease.
• Interpreting the QRISK2 result
• Probably the headline changes in the 2014 guidelines was the new, lower
cut-off of 10-year CVD risk cut-off of 10%.
• NICE now recommend we offer a statin to people with a QRISK2 10-
year risk of >= 10 Lifestyle factors are of course important and NICE
recommend that we give patients the option of having their CVD risk
reassessed after a period of time before starting a statin.
• continued on next page…..
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 ENDOCRINOLOGY UPDATED GUIDELINES
 Atorvastatin 20mg should be offered first-line.
 Special situations
 Type 1 diabetes mellitus
 NICE recommend that we 'consider statin
treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
 atorvastatin 20 mg should be offered if type 1
diabetics who are:
 older than 40 years, or
 have had diabetes for more than 10 years or
 have established nephropathy or
 have other CVD risk factor
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 ENDOCRINOLOGY UPDATED GUIDELINES
Diagnostic criteria for Diabetes

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 ENDOCRINOLOGY UPDATED GUIDELINES
NICE guidelines on Lipids
following the 2014 NICE lipid modification
guidelines only patients with a 10-year

cardiovascular risk > 10% (using QRISK2) should

be offered a statin. The first-line statin of
choice is atorvastatin 20mg

continued on next page ….

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 ENDOCRINOLOGY UPDATED GUIDELINES
• Follow-up of people started on statins
• NICE recommend we follow-up patients at 3
months repeat a full lipid profile
• if the non-HDL cholesterol has not fallen by at
least 40% concordance and lifestyle changes
• should be discussed with the patient
• NICE recommend we consider increasing the
dose of atorvastatin up to 80m

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 ENDOCRINOLOGY UPDATED GUIDELINES
NICE guidelines on Infertility
 NICE guidelines recommend weight loss as the most
important initial step.
 anti-oestrogen therapies such as clomifene the most
effective treatment work by occupying hypothalamic
oestrogen receptors without activating them. This
 interferes with the binding of oestradiol and thus
prevents negative feedback inhibition of FSH secretion
 metformin is also used, either combined with clomifene
or alone, particularly in patients who are obese but is
not a first line treatment gonadotrophins: usually
reserved for patients who are resistant to clomifene

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 ENDOCRINOLOGY UPDATED GUIDELINES
Nice Guidelines on
Parathyroidectomy
• Parathyroidectomy:
• NICE guidelines clearly stipulate the circumstances under which parathyroidectomy should
be considered in primary hyperparathyroidism. These are listed below:
• Age under 50 years.
• Adjusted serum calcium concentration that is 0.25 mmol/L or more above the upper end of
the reference range.
• Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 although this
• threshold depends on other factors, such as age. creatinine clearance reduced by 30% or
more Renal stones or presence of nephrocalcinosis on ultrasound or CT.
• 24 hour total urinary calcium excretion greater than 10 mmol
• Presence of osteoporosis or osteoporotic fracture.
• bone mineral density T-score less than −2.5 at any site
• Symptomatic disease
• unwillingness of patient to follow advice of medical surveillan

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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on Upper GI bleed
• NICE guidelines do not recommend proton pump
inhibition before endoscopy.
• He may have alcohol dependency and therefore should
be prescribed Pabrinex whilst waiting for endoscopy.
• Management of non - variceal bleeding
• NICE do not recommend the use of proton pump
inhibitors (PPIs) before endoscopy to patients with
suspected non-variceal upper gastrointestinal bleeding
although PPIs should be given to patients with non-
variceal upper gastrointestinal bleeding and stigmata of
recent haemorrhage shown at endoscopy

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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on Oesophageal
varices
• Oesophageal varices vasoactive agents:

• terlipressin is currently the only licensed vasoactive agent and is

supported by NICE guidelines.

• powerful splanchnic vasoconstrictor It has been shown to be of benefit in

initial haemostasis and preventing rebleeding.
• the most appropriate treatment whilst awaiting urgent endoscopy

• As a vasoconstrictor its administration is contraindicated in those with a

history of ischaemic heart disease as it may precipitate myocardial
ischemia.

• Octreotide may also be used although there is some evidence that

terlipressin has a greater effect on reducing mortality

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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on interventions for
peptic ulcer disease
 peptic ulcer + H pylori H pylori eradication therapy
 peptic ulcer + H pylori retesting for H pylori 6 to 8 weeks after beginning
treatment,

 gastric ulcer + H pylori repeat endoscopy 6 to 8 weeks after beginning

treatment In people at high risk (previous ulceration) and for whom
NSAID continuation is necessary,

 consider a COX-2 selective NSAID instead of a standard NSAID with a PPI.

 The Two highly selective or specific in their ability to inhibit COX-2 while
having little or no COX-1 affinity are rofecoxib and celecoxib.

 Offer H2RA therapy if there is an inadequate response to a PP

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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on Indications of
urgent Endoscopy
• indications of Urgent referral for an endoscopy (i.e. within 2
weeks). (NICE )
• dysphagia
• upper abdominal mass consistent with stomach cancer Any sign
of chronic gastrointestinal bleeding
• Persistent vomiting
• Iron deficiency anaemia,
Suspicious barium meal.
• Progressive unintentional weight loss
• Patients aged ≥ 55 years who've got weight loss, AND any of the
following:
• upper abdominal pain
• reflux
• dyspepsia
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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on coeliac disease
screening

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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on investigations in
Coeliac disease

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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on management of
IBS
• First-line pharmacological treatment - according to predominant symptom

• pain: antispasmodic agents

• Pinaverium is used to reduce the pain duration associated with (IBS).

• diarrhoea: loperamide is first-line

• constipation: laxatives but avoid lactulose or patients with constipation who are not responding to
conventional laxatives linaclotide may be considered, if: optimal or maximum tolerated doses of
previous laxatives from different classes have not helped and they have had constipation for at least
12 months

• Second-line pharmacological treatment

• low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective
serotonin reuptake inhibitors
• Continued on next page….

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 GASTROENTEROLOGY Updated guidelines
• Other management options :
• psychological interventions - if symptoms do not respond to
pharmacological treatments after 12 months and who
develop a continuing symptom profile (refractory IBS),
consider referring
• for cognitive behavioural therapy, hypnotherapy or
psychological therapy
• complementary and alternative medicines: 'do not
encourage use of acupuncture or reflexology for the
treatment of IBS'

• General dietary advice

• have regular meals and take time to eat
• avoid missing meals or leaving long gaps between eating
• drink at least 8 cups of fluid per day, especially water or
other non-caffeinated drinks such as herbal teas
• restrict tea and coffee to 3 cups per day
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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on Diagnosis of IBS
The diagnosis of IBS should be considered if the patient has had the following for at least 6 months:
1. abdominal pain, and/or
2. bloating, and/or
3. change in bowel habit

A positive diagnosis of IBS should be made if the patient has abdominal pain relieved by defecation or
associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:

1. altered stool passage (straining, urgency, incomplete evacuation)

2. abdominal bloating (more common in women than men), distension, tension or hardness

3. symptoms made worse by eating

4. passage of mucus

Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis

CONTIUNED ON NEXT PAGE……

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 GASTROENTEROLOGY Updated guidelines
• Red flag features should be enquired about:
• 1. rectal bleeding
• 2. unexplained/unintentional weight loss
• 3. family history of bowel or ovarian cancer
• 4. onset after 60 years of age

• Also on clinical examination the other 'red flag' indicators are:

Anaemia
abdominal mass
rectal mass
Inflammatory markers for IBD

Suggested primary care investigations are:

• full blood count
• ESR/CRP
• coeliac disease screen (tissue transglutaminase antibodies
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 GASTROENTEROLOGY Updated guidelines
NICE guidelines on Tenofovir
• NICE : Offer tenofovir disoproxil to women
with HBV DNA greater than 107 IU/ml in the
• third trimester to reduce the risk of
transmission of HBV to the baby.
• stopped at 4 to 12 weeks after the birth

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 GASTROENTEROLOGY Updated guidelines
Guidelines on Colorectal cancer.
NICE updated their referral guidelines .
The following patients should be referred urgently
(i.e. within 2 weeks) to colorectal services for investigation:
patients >= 40 years with unexplained weight loss AND abdominal pain
patients >= 50 years with unexplained rectal bleeding
patients >= 60 years with iron deficiency anaemia OR change in bowel habit
tests show occult blood in their faeces (see below)

An urgent referral (within 2 weeks) should be 'considered' if:

there is a rectal or abdominal mass
there is an unexplained anal mass or anal ulceration
patients < 50 years with rectal bleeding AND any of the following unexplained
symptoms/findings:
abdominal pain
change in bowel habit
weight loss
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 RHEUMATOLOGY updated guidelines
NICE guidelines on RA investigations
• NICE recommends that patients with suspected
RA with RF negative should be tested for
• Anti-CCP Abs
• NICE state that: Consider measuring anti-cyclic
citrullinated peptide (CCP) antibodies in people
with suspected RA if:
• they are negative for rheumatoid factor, and
• there is a need to inform decision-making about
starting combination therapy
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 NICE guidelines on management of

RHEUMATOLOGY updated guidelines

RA
Patients with evidence of joint inflammation should start a combination of disease-modifying drugs
(DMARD) as soon as possible.
Other important treatment options include analgesia, physiotherapy and surgery.
Pharmacological management DMARDS
first-line for newly diagnosed active RA combination of DMARDs (including
methotrexate and at least one other DMARD, plus short-term glucocorticoids) as soon as possible,
ideally within 3 months of the onset of persistent symptoms.

Consider offering short-term treatment with glucocorticoids (oral, intramuscular or intra-articular) to

rapidly improve symptoms in newly diagnosed RA if they are not already receiving glucocorticoids as
part of DMARD combination therapy.

If DMARD therapy induce disease control reduce drug doses to levels that still maintain disease control.

DMARDs: (Drug-specific Recommendations (BSR guidelines February 2017)

1. Methotrexate (MTX) (the most widely used DMARD).
All patients should be co-prescribed folic acid supplementation at a minimal dose of 5 mg once weekly.

Continued on next pages………

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• Monitoring of FBC & LFTs is essential due to the risk of

RHEUMATOLOGY updated guidelines

myelosuppression and liver
• cirrhosis. Other important side-effects include pneumonitis

• 2. Sulfasalazine
• 3. Azathioprine (AZA)

• Patients should have baseline thiopurine methyltransferase

(TPMT) status assessed
• 4. Leflunomide
• 5. Hydroxychloroquine (HCQ)

• Patients should have baseline formal ophthalmic

examination, ideally including objective retinal assessment
for example using optical coherence tomography, within 1
year of commencing an antimalarial drug
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 NICE guidelines on Chronic Fatigue

RHEUMATOLOGY updated guidelines

Syndrome investigations
NICE guidelines suggest carrying out a large
number of screening blood tests to exclude
other pathology :
e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP,
calcium, CK, ferritin*, coeliac
screening and also urinalysis

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 NICE guidelines on the management

RHEUMATOLOGY updated guidelines

of osteoarthritis (OA)
all patients should be offered help with weight loss, given advice about
local muscle strengthening exercises and general aerobic fitness
paracetamol and topical NSAIDs are first-line analgesics. Topical
NSAIDs are indicated only for OA of the knee or hand

second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids,

capsaicin cream and intraarticular corticosteroids. A proton pump
inhibitor should be co-prescribed with NSAIDs and COX- 2 inhibitors.
These drugs should be avoided if the patient takes aspirin
non-pharmacological treatment options include supports and braces,
Transcutaneous ,Electrical Nerve Stimulation (TENS) and shock
absorbing insoles or shoes

if conservative methods fail then refer for consideration of joint

replacement
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 NICE guidelines on Osteoporosis &

RHEUMATOLOGY updated guidelines

method of risk assessment
NICE recommend using a clinical prediction tool such as FRAX or Q Fracture to assess
a patient's 10-year risk of developing a fracture. This is analogous to the
cardiovascular risk tools such as QRISK.
NICE recommend arranging a DEXA scan if FRAX (without BMD) shows an
intermediate result DEXA scan

There are some situations where NICE recommend arranging BMD assessment (i.e. a
DEXA scan) rather than using one of the clinical prediction tools:
before starting treatments that may have a rapid adverse effect on bone density (for
example, sex hormone deprivation for treatment for breast or prostate cancer).

in people aged under 40 years who have a major risk factor, such as history of
multiple fragility fracture, major osteoporotic fracture, or current or recent use of
high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone
or equivalent per day for 3 months or longer)

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 NICE guidelines on Management of

RHEUMATOLOGY updated guidelines

Osteoporosis
secondary prevention of osteoporotic fractures in postmenopausal women
Key points include
osteoporotic fragility fractures in postmenopausal women + confirmed osteoporosis (a Tscore of -
2.5 SD or below) treatment.

In women aged ≥ 75 years, a DEXA scan may not be required

vitamin D and calcium supplementation should be offered to all women unless the clinical is
confident they have adequate calcium intake and are vitamin D replete
If osteoporosis is established, the treatment includes 1500 mg/day of calcium and 400-800 pg /day
of
vitamin D
Dietary intake of calcium should be:
800-1000 mg/day in childhood through early adulthood
1000-1200 mg/day in the middle years
500 mg/day in the elderly
alendronate is first-line around 25% of patients cannot tolerate alendronate, usually due to upper
gastrointestinal problems. These patients should be offered risedronate or etidronate (see
treatment criteria below)

Continued on next page…..

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• strontium ranelate and raloxifene are recommended if

RHEUMATOLOGY updated guidelines

patients cannot tolerate bisphosphonates (see
treatment criteria below)
• Treatment criteria for patients not taking alendronate:
for patients who do not tolerate alendronate, the most
important thing to remember is:
• the T-score criteria for risedronate or etidronate are less
than the others implying that these are the second line
drugs
• if alendronate, risedronate or etidronate cannot be
taken then strontium ranelate or raloxifene may be
given based on quite strict T-scores (e.g. a 60-year-old
woman would
• need a T-score < -3.5) the strictest criteria are for
denosumab
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 Guidelines on Juvenile idiopathic

RHEUMATOLOGY updated guidelines

Arthritis
• juvenile idiopathic arthritis As per NICE
guidance, if patient had not responded to
methotrexate and should be
• considered for biologic therapy with either
adalimumab, etanercept or Toculzumab.

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 NICE guidelines on DVT

HAEMATOLOGY updated guidelines

• NICE add 'consider extending warfarin beyond 3 months for
patients with unprovoked proximal DVT if their risk of VTE
recurrence is high and there is no additional risk of major
bleeding'.

• This essentially means that if there was no obvious cause or

provoking factor (surgery, trauma, significant immobility) it
may imply the patient has a tendency to thrombosis and
should be given treatment longer than the norm of 3
months. In practice most clinicians give 6 months of warfarin
for patients with an unprovoked DVT/PE

• for patients with active cancer NICE recommend using

LMWH for 6 months.
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 NICE guidelines on Post thrombotic

HAEMATOLOGY updated guidelines

syndrome
• Post thrombotic syndrome Management :
• Compression stockings should be offered to all patients with deep
vein thrombosis to help reduce the risk of post-thrombotic
syndrome.
• NICE state the following:
• Offer below-knee graduated compression stockings with an ankle
pressure greater than 23 mmHg to patients with proximal DVT a
week after diagnosis or when swelling is reduced sufficiently and if
there are no contraindications, and:
• advise patients to continue wearing the stockings for at least 2
years
• ensure that the stockings are replaced two or three times per year or
according to the manufacturer's instructions advise patients that the
stockings need to be worn only on the affected leg or legs.

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 Guidelines on Venous

HAEMATOLOGY updated guidelines

thromboembolism prophylaxis
• Venous thromboembolism: prophylaxis in patients admitted to
hospital
• Venous thromboembolism (VTE) still accounts for a significant
proportion of avoidable hospital deaths. In an effort to tackle this
problem NICE produced guidelines .
• Before admission advise women to consider stopping oestrogen-
containing oral contraception or HRT 4 weeks before surgery.
assess the risks and benefits of stopping antiplatelet therapy 1
week before surgery.
• The following patients are deemed at risk of VTE
• Medical patients if mobility significantly reduced for >= 3 days or
• if expected to have on-going reduced mobility relative to normal
state plus any VTE risk factor (see below)
• continued on next page….
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• Surgical patients and patients with trauma
• if total anaesthetic + surgical time > 90 minutes or if surgery involves pelvis or lower limb and total

HAEMATOLOGY updated guidelines

anaesthetic + surgical time > 60 minutes or if acute surgical admission with inflammatory or intra-
abdominal condition or
• if expected to have significant reduction in mobility or if any VTE risk factor present (see below)

• VTE risk factors:

active cancer or cancer treatment
• age > 60 years
• critical care admission
dehydration
• known thrombophilia's
• obesity (BMI > 30 kg/m2)

• one or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or
respiratory pathologies; acute infectious diseases; inflammatory conditions)

• personal history or first-degree relative with a history of VTE

• use of HRT
• use of oestrogen-containing contraceptive therapy
• varicose veins with phlebitis
•

• continued on next page……..

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• In-patient VTE prophylaxis

HAEMATOLOGY updated guidelines

• As a general rule pharmacological VTE prophylaxis is used for
medical patients unless there is a contraindication.
• For surgical patients mechanical VTE prophylaxis is offered for
patients at risk. Pharmacological VTE prophylaxis is also given
for if the risk of major bleeding is low.

• Pharmacological VTE prophylaxis options:

• fondaparinux sodium
• low molecular weight heparin (LMWH)
• unfractionated heparin (UFH) (for patients with renal failure)
• Mechanical VTE prophylaxis options:
• anti-embolism stockings (thigh or knee length)
•
• continued on next page…..
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• foot impulse devices intermittent pneumatic

HAEMATOLOGY updated guidelines

compression devices (thigh or knee length)
• Post-procedure VTE prophylaxis:
• For certain procedures pharmacological VTE
prophylaxis is recommended for all patients,
using one of the following:
dabigatran, started 14 hours after surgery
• fondaparinux, started 6 hours after surgery
• LMWH, started 6-12 hours after surgery
• rivaroxaban, started 6-10 hours after surgery.
• Apixaban
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 Guidelines on diagnosis of Essential

HAEMATOLOGY updated guidelines

thrombocytosis
British guidelines propose the following five criteria for diagnosis of essential thrombocytosis :

1. Sustained platelet count ≥450 × 109/L

2. Presence of an acquired pathogenetic mutation (eg, in the JAK2, CALR or MPL genes)

3. No other myeloid malignancy, especially Polycythemia Vera, primary Myelofibrosis, chronic myeloid
leukaemia, or myelodysplastic syndrome

4. No reactive cause for thrombocytosis and normal iron stores

5. Bone marrow aspirate and trephine biopsy showing increased megakaryocyte numbers displaying a
spectrum of morphology with predominant large megakaryocytes with hyperlobated nuclei and
abundant cytoplasm; reticulin is generally not increased (grades0–2/4 or grade 0/3)

Diagnosis requires the presence of criteria 1–3 or criterion 1 plus criteria 3–5

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Guidelines on Warfarin High INR

HAEMATOLOGY updated guidelines

management

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 HAEMATOLOGY updated guidelines
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NICE guidelines on Multiple Myeloma

HAEMATOLOGY updated guidelines

Investigations.
• Multiple Myeloma investigations: (NICE )

• 1. to confirm the presence of a Para proteins indicating possible myeloma or

(MGUS): serum protein electrophoresis and serum-free light-chain assay
• (best initial test)
• serum protein electrophoresis If serum protein electrophoresis is
• abnormal use serum immunofixation
• Do not use serum protein electrophoresis, serum immunofixation, serum-
• free light-chain assay or urine electrophoresis (urine Bence – Jones protein
• assessment) alone to exclude a diagnosis of myeloma.

• 2. to confirm a diagnosis of myeloma:

• bone marrow aspirate and trephine biopsy
• the bone marrow aspirate would confirm the diagnosis irrefutably.
• morphology to determine plasma cell percentage
• Continued on next page……
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• Bone marrow examination would reveal increased

HAEMATOLOGY updated guidelines

plasma cells (greater than 4% and usually greater than
30%).
• flow cytometry to determine plasma cell phenotype

• bone marrow aspirate dark red jelly-like material in the

syringe (Plasma cells )

• 3. in a patient presenting with spinal cord compression:

• the most appropriate initial investigation is Urgent MRI

of her spine This should be done before investigation
that used to confirm myeloma.
skeletal survey
bone lesions
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 NICE guidelines on treatment of

HAEMATOLOGY updated guidelines

Multiple Myeloma
previously untreated multiple myeloma (newly diagnosed)

Patients who are eligible for high-dose chemotherapy with stem cell transplantation
bortezomib + dexamethasone,
or bortezomib + dexamethasone + thalidomide
if high-dose chemotherapy with stem cell transplantation is considered inappropriate
thalidomide + alkylating agent + corticosteroid

People who are at first relapse having received one prior therapy and who have
undergone, or are unsuitable for, bone marrow transplantation:
bortezomib (a proteasome inhibitor) monotherapy
People who have received two or more prior therapies:
Lenalidomide + dexamethasone
Lenalidomide immunomodulatory derivatives (structural derivatives of
thalidomide)
People with untreated, newly diagnosed, myeloma-induced acute renal disease:
bortezomib + dexamethasone
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Continued on next page…. 438
• If a bortezomib is unsuitable thalidomide + dexamethasone

HAEMATOLOGY updated guidelines

• Do not perform plasma exchange for myeloma-induced acute renal disease.
• Preventing bone disease, managing non- spinal and spinal bone disease

• bisphosphonates should be given routinely, even in the absence of Hypercalcemia.

• Bisphosphonates reduce bony disease in myeloma, lowering the frequency of
pathological fractures, modulate the disease and have some antitumour activity.
• zoledronic acid or disodium pamidronate, if zoledronic acid is contraindicated or not
tolerated or sodium clodronate, if zoledronic acid and disodium pamidronate are
• contraindicated, not tolerated or not suitable surgical stabilisation followed by
radiotherapy for non-spinal bones that have fractured or are at high risk of
fractures. Consider radiotherapy for people who need additional pain relief

• Managing peripheral neuropathy

• If patient on bortezomib
• switch to subcutaneous injections and/or
• reduce to weekly doses and/or reduce the dose.
• if patient on other than bortezomib
•
• Continued on next page….
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• Temporarily stop neuropathy-inducing myeloma treatments if people develop either
• of the following:

HAEMATOLOGY updated guidelines

• grade 2 neuropathy with pain
• grade 3 or 4 neuropathy

• Managing fatigue
• Erythropoietin analogues (adjusted to maintain a steady state of haemoglobin at 110–120 g/litre) to
improve fatigue in people with myeloma who have symptomatic anaemia.
• Cord compression secondary to bony involvement of multiple myeloma:
• I.V Steroids should be commenced immediately

• However, the treatment of choice is local radiotherapy.

• NICE suggest localised radiotherapy should be the first point of call for urgent treatment.

• Vertebroplasty is typically considered in patients of whom have evidence of metastatic

• changes in the spine, but show no signs of spinal cord compression.
• Surgical decompression: is also considered if imaging suggests any form of spinal
• instability or structural defects, but often after steroids and radiotherapy has been administered.

• Other treatment options include analgesia, with non-steroidal anti-inflammatory drugs of particular
use.

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 INFECTIOUS DISEASE updated guidelines
Guidelines on Gonorrhoea
management
British Society for Sexual Health and HIV (BASHH) guidelines
recommend ceftriaxone 500 mg intramuscularly as a single dose
with azithromycin 1 g oral as a single dose. The azithromycin is
thought to act synergistically with ceftriaxone and is also useful for
eradicating any co-existent Chlamydia infections.

if ceftriaxone is refused or contraindicated other options include

cefixime 400mg PO (single dose)

A test of cure (with culture >72 hours or nucleic acid amplification

testing >2 weeks) is recommended in all cases, and treatment failure
should be reported to Public Health England or your local Health
Protection Agency.

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 INFECTIOUS DISEASE updated guidelines
HIV guidelines on HAART
• Following the 2015 BHIVA guidelines it is now
recommended that patients start HAART as soon
as they have been diagnosed with HIV, rather
than waiting until a particular CD4 count, as
was previously advocated.

• HAART should be made up of two nucleoside

reverse transcriptase inhibitors (NRTIs) and

• one other agent; Atripla® (efavirenz, tenofovir,

emtricitabine) is an acceptable choice
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 INFECTIOUS DISEASE updated guidelines
HIV : immunisation guidelines

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 INFECTIOUS DISEASE updated guidelines
Guidelines on Leprosy management
WHO-recommended triple therapy: rifampicin,
Dapsone and clofazimine

BNF advice:
multibacillary leprosy (>6 lesions) rifampicin,
Dapsone and clofazimine for 12 months.

paucibacillary leprosy (5 or less lesions)

rifampicin and Dapsone for 6 months
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 INFECTIOUS DISEASE updated guidelines
Guidelines on Malaria Uncomplicated
Falciparum
• Malaria Uncomplicated falciparum malaria
• strains resistant to chloroquine are prevalent in certain
areas of Asia and Africa

• WHO guidelines recommend artemisinin - based

combination therapies (ACTs) as first-line therapy

• examples include artemether plus lumefantrine,

artesunate plus amodiaquine, artesunate

• plus mefloquine, artesunate plus sulfadoxine-

pyrimethamine, dihydroartemisinin plus piperaquine
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 INFECTIOUS DISEASE updated guidelines
Guidelines on Severe falciparum
Malaria
• Severe falciparum malaria intravenous artesunate is now recommended by WHO
in preference to intravenous quinine

• I.V quinine is reserved for severe or cerebral malaria (most deaths from M.
• falciparum occur in first 96 hours of starting treatment).

• The initial dose should NOT be reduced in those severely ill with renal/hepatic
• impairment.

• High doses of quinine in pregnancy are tetratogenic in the first trimester.

However in malaria, the benefit of treatment outweighs the risk.

• WHO Guidelines (2006) recommend artemisinin are first line in the second and
• third trimester. In the first trimester, both artesunate and quinine are considered
treatment options.

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 INFECTIOUS DISEASE updated guidelines
NICE guidelines on Sepsis
Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection.
Sepsis with shock is a life-threatening condition that is characterised by low blood pressure despite
adequate fluid replacement, and organ dysfunction or failure.

The new definition attempts to draw upon up-to-date pathobiology and distinguish between sepsis and
uncomplicated infection. A new tool has been developed for this purpose - the SOFA or qSOFA.

The qSOFA (Quick SOFA) criteria are:

Respiratory rate > or equal to 22/min
Altered GCS
Systolic blood pressure < or equal to 100mmHg

Septic shock is defined as "a subset of sepsis in which underlying circulatory and cellular metabolism
abnormalities are profound enough to substantially increase mortality. This changes from the previous
definition to recognise the importance of cellular abnormalities.

Septic shock is defined by persisting hypotension requiring vasopressors to maintain a mean arterial
pressure of 65 mm Hg or higher and a serum lactate level greater than 2mmol/L (18 mg / dL ) despite
adequate volume resuscitation.

continued on next page ……………

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 INFECTIOUS DISEASE updated guidelines
• Risk factors for sepsis:
• Age (< 1 year and > 75 years)
• very frail people
• Immunocompromised
• impaired immune function (eg, DM, Spleenectomy, sickle
cell disease)
• drugs( long-term steroids, chemotherapy,
immunosuppressant)
• surgery, or other invasive procedures, in the past 6 weeks
• any breach of skin integrity (eg, cuts, burns, blisters or
skin infections)
• misuse drugs intravenously
• indwelling lines or catheters
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 INFECTIOUS DISEASE updated guidelines
Guidelines on Management of
Syphilis
Infected patient should be advised to abstain from sex until any lesions (if any) have
resolved or until two weeks after treatment completion

first-line: Procaine penicillin is now an alternative treatment where benzathine

penicillin is suitable. due to the pain and multiple injections associated

Benzedrine dose: 2.4 Mega units IM weekly for up to 3 weeks

Procaine dose: 1.8–2.4 mega units IM daily for 14 days.
second-line oral azithromycin single dose.

Treatment during pregnancy:

first and second trimesters give single dose benzathine penicillin; third trimester two
doses of benzathine penicillin one week apart.

Neurosyphilis: procaine penicillin 1.8-2.4 units once daily (IM, for 14 days) with oral
probencid 500 mg four times a day.
continued on next page……
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 INFECTIOUS DISEASE updated guidelines
Tests for monitoring the effect of treatment
RPR/VDRL test Treponemal enzyme immunoassay
(EIA)/chemiluminescent assay (CLIA), preferably
detecting both IgM and IgG is the screening test of
choice.

Treatment during pregnancy: depends upon which

trimester the presentation is in:

first and second trimesters - give single dose

benzathine penicillin;
third trimester - two doses of benzathine penicillin
one week apart.
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 INFECTIOUS DISEASE updated guidelines
Guidelines on Post-exposure
Prophylaxis
If the source is of unknown status: establish the HIV status of the source.
Source individual known to be HIV-positive: determine the HIV viral load, resistance profile and
treatment history.

if the source is on antiretroviral therapy (ART) with a confirmed and sustained (>6 months) undetectable
plasma HIV viral load PEPSE is no longer recommended However, if there are any doubts about the HIV
viral load history or the source’s adherence to ART PEP should be given following unprotected
receptive anal intercourse.

Initiation of PEPSE is recommended as soon as possible after exposure, preferably within 24 hours of
exposure but can be offered up to 72 hours.

The first-line regimen is Truvada and raltegravir Truvada fixed-dose combination of two antiretroviral
medications: tenofovir disoproxil and emtricitabine (both are Nucleoside analog reverse transcriptase
inhibitors (NRTIs)

Raltegravir (integrase inhibitors, a new class of HIV drugs ) targets integrase,an HIV enzyme that
integrates the viral genetic material into human chromosomes, a critical step in the pathogenesis of
HIV.
•
• continued on next page……
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 INFECTIOUS DISEASE updated guidelines
 PEPSE beyond 72 hours are not recommend duration of
PEPSE should be 28 days

 follow-up HIV testing at 8-12 weeks after exposure

 pregnancy should not alter the decision to start PEPSE.
Women must be counselled that antiretroviral agents
used for PEPSE are unlicensed in pregnancy and risks /
benefits must be carefully discussed

 In the event of a further high-risk sexual exposure in the

last two days of the PEPSE course the PEP should be
continued for 48 hours after the last high-risk exposure

 If the recipient has missed more than 48 hours of PEPSE

then the course should be discontinued.
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 NICE guidelines on Management of

DERMATOLOGY UPDATED GUIDELINES

chronic plaque psoriasis
regular emollients may help to reduce scale loss and reduce pruritus

First-line: potent corticosteroid applied once daily plus vitamin D analogue

applied once daily (applied separately, one in the morning and the other in
the evening) for up to 4 weeks as initial treatment

Second-line: if no improvement after 8 weeks then offer a vitamin D

analogue twice daily

Third-line: if no improvement after 8-12 weeks then offer either: a potent

corticosteroid applied twice daily for up to 4 weeks or a coal tar preparation
applied once or twice daily short-acting diatharnol can also be use

continued on next page……

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FARAZ’S PEARLS FOR MRCP-2 VOLUME 1 & 2 EDITION 2
• Using topical steroids in psoriasis as we know topical

DERMATOLOGY UPDATED GUIDELINES

corticosteroid therapy may lead to skin atrophy, Striae
and rebound symptoms

• systemic side-effects may be seen when potent

corticosteroids are used on large areas e.g. > 10% of the
body surface area

• NICE recommend that we aim for a 4 week break before

starting another course of topical corticosteroids

• they also recommend using potent corticosteroids for no

longer than 8 weeks at a time and very potent
corticosteroids for no longer than 4 weeks at a time
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FARAZ’S PEARLS FOR MRCP-2 VOLUME 2
 Nice guidelines on Antipsychotics

PSYCHITARY UPDATED GUIDELINES

• Atypical antipsychotics should now be used
first-line in patients with schizophrenia,
according to 2005 NICE guidelines.

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FARAZ’S PEARLS FOR MRCP VOLUME 2
 Nice guidelines on SSRI interactions

PSYCHITARY UPDATED GUIDELINES

• NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if
given co-prescribe a proton pump inhibitor

• warfarin / heparin: NICE guidelines recommend avoiding SSRIs

and considering mirtazapine

• the SSRIs least likely to cause drug interactions with warfarin

appear to be sertraline and citalopram.

triptans: avoid SSRIs

fluoxetine and paroxetine have a higher propensity for drug

interactions

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 PSYCHITARY UPDATED GUIDELINES
Nice guidelines on Schizophrenia
• Schizophrenia: management
• Key points: (NICE guidelines 2009)

oral atypical antipsychotics are first-line

cognitive behavioural therapy should be offered to all
patients

close attention should be paid to cardiovascular

risk-factor modification due to the high rates of
cardiovascular disease in schizophrenic patients
(linked to antipsychotic medication and high
smoking rates)

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FARAZ’S PEARLS FOR MRCP VOLUME 2
 PHARMACOLOGY UPDATED GUIDELINES
Nice guidelines on Clopidogrel
• NICE now recommend clopidogrel first-line
following an ischaemic stroke and for
peripheral arterial disease.

• Recent Royal College of Physician (RCP)

guidelines support the use of clopidogrel in
TIAs. However the older NICE guidelines still
recommend aspirin + dipyridamole
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FARAZ’S PEARLS FOR MRCP VOLUME 2
 PHARMACOLOGY UPDATED GUIDELINES
Nice guidelines on ACEI
• Usage of ACEi & ARB as combination (NICE January 2015)

• Do not combine an ACE inhibitor with an ARB to treat hypertension.

• no significant benefits of ACEi & ARB combination were seen in people

who did not have heart failure and there was an increased risk of
hyperkalaemia, hypotension, and impaired renal function.

• The NICE guideline on chronic heart failure recommends that, after

seeking specialist advice, the addition of an ARB licensed for heart failure
is an option that could be considered for people who remain symptomatic
despite optimal therapy with an ACE inhibitor and a beta-blocker

• Candesartan and valsartan are the only ARBs licensed as add-on therapy
to ACE inhibitors in his situation.

• Other options are adding an aldosterone antagonist licensed for heart

failure or hydralazine in combination with nitrate.
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FARAZ’S PEARLS FOR MRCP VOLUME 2
 BNF guidelines on methotrexate &

PHARMACOLOGY UPDATED GUIDELINES

Pregnancy
• Pregnancy and methotrexate

• women should avoid pregnancy for at least 3

months after treatment has stopped

• the BNF also advises that men using

methotrexate need to use effective
contraception for at least 3 months after
treatment
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FARAZ’S PEARLS FOR MRCP VOLUME 2
 Guidelines on Azathioprine

PHARMACOLOGY UPDATED GUIDELINES

monitoring
(BNF) suggest monitoring CBC, LFTs and U&E
every 3 months once patients are established
and stable on azathioprine treatment

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 Nice guidelines on Opioid

PHARMACOLOGY UPDATED GUIDELINES

Dependence
• Management of opioid dependence

• NICE recommend methadone or

buprenorphine as the first-line treatment in
opioid detoxification compliance is
monitored using urinalysis

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FARAZ’S PEARLS FOR MRCP VOLUME 2
 Questions distribution for part-2

• Part -2 has images questions including :

• Ecgs ,chest x- ray ,MRI,CT scan ,bone scan,
pathology slides , ophthalmology pictures
,ECHO, Pulmonary volume loops
• 40 questions approx. are from pictures
questions ,where long scenario with image is
given and investigation diagnosis or treatment
is asked .
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 How to attempt exam paper.
1.Read question well with full concentration (if you don't read
question well no matter how good u are ,u won't make it correct )
2.Exclude options which are pretty wrong 1st
3.when You are confused b/w two options click the one which hit 1st in
your mind and move and don't rethink again
4.never Change your 1st marked question until u are 100% sure that u
marked completely incorrect option
5.when u have no idea about question click the one which has longer
statement (mostly they are right)
6.if you have short time like in Mrcp part-2 written try to read options
1st then come to question ,it will give you an idea ,what question will
ask for and it will save your time too.
7.If u are not sure about correct answer and want to spend bit more
on question then just give little dot on answer which u feel may be
right and come back in the end if time remains .
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 FARAZ PEARLS MRCP PART-II VOLUME-II
DR:FARAZ AHMED
(MRCP PART-I,II CLEARED ,FCPS PART-II TRAINEE)

SALIENT FEATURES :
It contains more 2500 pearls (500 Pearls from past papers)
it contain separate session for 100 updated guidelines based on new exam
pattern
Chapter wise Points for part-i & part-ii
points taken from past papers ,onexam,passmedicine ,passtest
includes scenarios ,investigations, treatments
ALL 18 chapters points are added
Past papers pointes are added in separate section
main points are highlighted
Valid for all exams of MEDICINE ( IMM,FCPS PART-II PLAB)
SINGLE read takes less than 10 Days
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