Revise with the Top Ten Themes from the MRCP Part 2 Exam

Make sure you have the right knowledge for the MRCP Part 2 Written exam. Use our list of Top Ten Themes covering popular clinical topics regularly tested in the exam.

Top Ten Themes from the MRCP Part 2 Exam

1) Use of zoledronic acid in hypercalcaemia
2) New management for Alzheimer’s
3) NOACs inc indications and reversal
4) Pacemaker syndromes
5) WPW management and use of flecainide
6) Asthma guidelines and use of Montelukast
7) Bisphosphonate use, decision based on EGFR
8) Use of GLP-1 agonists in type 2 diabetes
9) Management of Paroxysmal Atrial Fibrillation (PAF)
10) Management of Permanent Atrial Fibrillation

Asthma guidelines and use of Montelukast

A 29 year old man comes to the asthma clinic for review. Despite taking seretide 250 micrograms inhaler x2 puffs BD, he is still short of breath, particularly troubled by coughing and wheezing at night and if he takes exercise. He has a job in an office, has no pets and is a non-smoker. Apart from asthma he has no significant past medical history. On examination his BP is 122/72 mmHg, pulse is 72/min and regular. There is good bilateral air entry on auscultation, although you can hear occasional wheezes. PEFR is 480 L/min, vs 590 L/min predicted.

At this stage with 1mg of inhaled fluticasone per day, and long acting beta agonist therapy (LABA), this patient would be considered to already be taking high dose inhaled corticosteroids and LABA. As such with only partial control, an oral leukotriene receptor antagonist such as montelukast would be the most appropriate next step. In the event that addition of montelukast failed to gain control, specialist referral would be advised. NICE guidance.

Bisphosphonate use, decision based on EGFR

A 64 year old woman with a history of diabetic nephropathy is referred to the rheumatology clinic after suffering a left Colle’s fracture. Current medication for diabetes includes linagliptin, she also takes ramipril and atorvastatin to manage hypertension and for primary cardiovascular prevention. On examination her BP is 138/82mmHg, pulse is 70/min and regular. Her BMI is 27. The cast has been removed from her wrist and there is minimal residual deformity. You are considering starting her on bisphosphonate therapy. Routine bloods reveal a normal range calcium and phosphate and an HbA1c of 58 mmol/mol, (<53).
Data from randomised controlled trials supports use of bisphosphonates down to GFRs as low as 30-35ml/min. Below this level RCT evidence is unavailable, and the risk of adynamic bone disease associated with renal impairment is significantly elevated. As such for patients with CKD 4 or 5, specialist referral / advice from a renal physician on appropriate therapy is advised. In the first instance PTH is measured, although secondary hyperparathyroidism is only treated in the event that PTH is more than twice the upper limit of the normal range.

Use of GLP-1 agonists in type 2 diabetes

A 29 year old man with a 20 year history of Type 1 diabetes and recent poor glycaemic control comes to the clinic for review. He is overweight with abnormal LDL cholesterol and wants to try liraglutide as an adjunct to his insulin therapy. On examination his BP is 155/92mmHg, pulse is 72/min and regular. His BMI is elevated at 32. A recent HbA1c was 66.1 mmol/mol (35 - 55 mmol/mol).

Although some patients may gain a degree of partial remission from GLP-1 therapy in Type 1 diabetes, those with established disease are only likely to gain weight loss benefit. It’s well known that liraglutide is associated with weight loss in Type 2 diabetes and obesity, similarly in obese Type 1 diabetes, weight loss of approximately 6% at 6 months can be achieved with liraglutide 1.8mg.

Liraglutide is associated with an approximately 7 beats per minute increase in heart rate versus control in Type 1 diabetes, this is similar to changes in heart rate seen in patients with Type 2 diabetes. Rather than an increase in hypoglycaemia, liraglutide is associated with a modest reduction in hypoglycaemia, and very little difference in HbA1c for patients with established Type 1 diabetes. In those with early disease who have residual c-peptide, off- loading of hyperglucagonaemia by giving GLP-1 therapy may drive an increase in the percentage of patients achieving partial remission, (HbA1c<7% and insulin dose less than 0.5U/kg/day).

Learning point: The main benefit of GLP-1 therapy in patients with established Type 1 diabetes appears to be in reducing body weight.

Management of Paroxysmal Atrial Fibrillation (PAF)

A 54 year old man presents to the Emergency department with a third episode of paroxysmal atrial fibrillation (PAF) in the past year. He has not tolerated flecainide due to feelings of lethargy and fatigue, and beta blockade is contra-indicated due to a history of brittle asthma and previous admissions to the intensive care unit. On examination his BP is 105/70mmHg, pulse is 120/min (AF). There are bi-basal crackles on auscultation of the chest. Routine bloods are unremarkable. He is successfully cardioverted.

What is the most appropriate long term intervention?

In this situation, with three attacks of atrial fibrillation over the past year, there is significant risk of permanent AF, from which it is much harder to achieve successful ablation. Given beta blockers and flecainide are unsuitable or not tolerated, left atrial catheter ablation to attain permanent sinus rhythm is recommended. This is supported by current NICE
Learning point: Modern NICE guidance recommends much earlier referral for ablation than was previously planned. NICE guidance.

Management of Permanent Atrial Fibrillation

A 67 year old woman with long-term atrial fibrillation (AF) who is anti-coagulated with dabigatran comes to the clinic for review. She hasn’t previously required rate control for her AF, but most recently she has begun to suffer from worsening palpitations and a resting ECG shows a ventricular rate of 90/min irregularly irregular, (AF). She is active and likes to walk her dog some 2-3 miles per day. On examination her BP is 123/84mmHg, pulse is 87/min (AF), heart sounds are normal and her chest is clear. Her BMI is 24. Routine bloods are unremarkable, her creatinine is 95 micromol/l, (60-90).

Which of the following is the most appropriate way to control her ventricular rate?

This patient is active with AF and has a ventricular rate above 60 beats per minute. As such NICE guidance recommends rate control with a standard beta blocker, (not sotalol), commenced at 2.5mg once per day and titrated to achieve the ideal rate control.

Offer rate control as the first‑line strategy to people with atrial fibrillation, except in people:
- whose atrial fibrillation has a reversible cause
- who have heart failure thought to be primarily caused by atrial fibrillation
- with new‑onset atrial fibrillation
- with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
- for whom a rhythm control strategy would be more suitable based on clinical judgement

Amiodarone is incorrect, committing this lady to long term amiodarone therapy where she is in long-term AF is not appropriate with respect to the balance of benefit risk, because the chance of re-attaining sinus rhythm with amiodarone is very small. Diltiazem is an alternative therapy in patients who cannot tolerate beta blockade, and digoxin is now only recommended in patients who lead a sedentary lifestyle.

Learning points: Beta blockade is the first choice intervention for rate control in AF according to current NICE guidelines.

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Top Tips on How to Pass your Medical Exams

Get the right mind-set

The exams are challenging and represent an important stage in your career. The key is to commit to trying them, make the time, and be consistent in your effort.

Have the right knowledge

Think of your memory as a kitchen shelf. You can only put so much in your exam-prep memory at any one time. Time your memory to make sure you have the most useful stuff and don’t try and cram it with a load of other things. Make sure it's the right time in your career. Are you on a busy rotation? You don’t want these things taking over space in your mind and overloading it. You want an even distribution of knowledge and not just lots of one subject such as cardiology. Just like a kitchen shelf make sure your exam shelf has the right ingredients.

Think like an examiner what would they do?

They are just a few years ahead in their career and they are all around you, consultants in NHS hospitals across the UK and internationally. Every hospital has a senior doctor keen to teach. Talk to them and understand how to prepare for the exam.

Practice basic science questions

It’s most important to practice, practice for basic science questions. They generally don’t change and there will be a good section of them in the exam and will be based on the same sorts of topics.

Know the guidelines

Many exam topics will be  based on guidelines. Make sure you get to know where the guidelines for your specialty can be found.

Spot patterns in the questions

The language that is used in the exam papers is something that you can become familiar with. The more you practice the more you will notice they will ask questions in certain ways and they use particular words more often than you would use in other writing.

Common question lead ins

The words ‘may, might and always’ have particular meaning in these exams. If you practice them you will be able to see how you should interpret them when you come across them in the exam. ‘What's the appropriate next step’, comes up often and it's not necessarily a test of knowledge but is asking you to make a judgement as to what may  be the safest or most cost effective answer. Certain types of phrases and patterns in questions can help you answer them correctly.

Know your enemy

Think of your College as your enemy and plan your attack accordingly. You should know them. Read their exam reports, read about the exam on the College website and read through the exam syllabus.

Stuck with a question

If you are really stuck with a question and about to give up think of these tips;

  • As you would when you are on the ward go back over the history, read through the question stem again.
  • Try hiding the options and just answer the question.
  • Try and get into the examiner’s head. Is the diagnosis actually given (in which case they are asking for management) or hidden (in which case you need to work it out first then answer the question).
  • Try analysing the options. Is there something there that gives you a clue to the area of medicine you are being tested on? You can try and exclude the answers that are definitely wrong rather than definitely right.

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