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 Essential
Revision Notes
for MRCP
Fourth Edition
 Dedication
To my wife, Marian, and children, Michael, Gabriella and Alicia, who will always inspire
 Essential
Revision Notes
for MRCP
Fourth Edition
edited by
Philip A Kalra MA MB BChir FRCP MD
Consultant and Honorary Professor of Nephrology,
Salford Royal NHS Foundation Trust and The University of Manchester
© PASTEST LTD 1999, 2004, 2009, 2014
Egerton Court
Parkgate Estate
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Telephone: 01565 755226
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording or otherwise without the prior permissions of the copyright owner.
First published 1999
Reprinted 1999
Revised edition 2002
Reprinted 2003
Second edition 2004
Third edition 2009
Reprinted 2009
Fourth edition 2014
ISBN: 1 905 635 92 4
978 1 905635 92 4
ePub ISBN: 978 1 909491 97 7
Mobi ISBN: 978 1 909491 96 0
A catalogue record for this book is available from the British Library.
The information contained within this book was obtained by the authors from reliable sources. However, whilst every effort has been
made to ensure its accuracy, no responsibility for loss, damage or injury occasioned to any person acting or refraining from action as a
result of information contained herein can be accepted by the publishers or authors.

PasTest Revision Books and Intensive Courses

PasTest has been established in the field of postgraduate medical education since 1972, providing revision books and intensive study
courses for doctors preparing for their professional examinations.
Books and courses are available for the following specialties:
MRCP Parts 1 and 2, MRCPCH Parts 1 and 2, MRCS, MRCOG Parts 1 and 2,
DRCOG, DCH, FRCA, MRCGP, Dentistry.
For further details contact:
PasTest, Freepost, Knutsford, Cheshire WA16 7BR

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Original design and typesetting by EDITEXT, Derbyshire (01457 857622).

Fourth edition text prepared by Keytec Typesetting Ltd, Bridport, Dorset
Printed and bound in the UK by Page Bros (Norwich) Ltd.
 Contents
Contributors to Fourth Edition
Contributors to Third Edition
Permissions
Preface to the Fourth Edition

CHAPTER
Cardiology
1. J E R Davies, S Nijjer
Clinical Pharmacology, Toxicology and
2. Poisoning
S Waring
Dermatology
3. H Robertshaw
Endocrinology
4. T Kearney, S Giritharan, M Kumar
Epidemiology
5. J Ritchie
Gastroenterology
6. S Lal, D H Vasant
Genetics
7. E Burkitt Wright
Genito-urinary Medicine and AIDS
8. B Goorney
Haematology
9. K Patterson
Immunology
10. J Galloway
Infectious Diseases and Tropical Medicine
11. C L van Halsema

Maternal Medicine
12. L Byrd
Metabolic Diseases
13. S Sinha

Molecular Medicine
14. K Siddals
Nephrology
15. P Kalra
Neurology
16. M Jones, C Kobylecki, D Rog
Ophthalmology
17. K Smyth
Psychiatry
18. E Sampson
Respiratory Medicine
19. H Green
Rheumatology
20. M McMahon
Statistics
21. E Koutoumanou
Index
 Contributors to Fourth Edition
Emma Burkitt Wright MBChB PhD MRCP(UK)
Specialist Registrar and Honorary Clinical Research Fellow, Manchester Centre for Genomic
Medicine, Central Manchester University Hospitals Foundation Trust and University of Manchester,
Chapter 7 Genetics

Louise Byrd MBBS, MRCOG, Dip RCR/RCOG Cert. Medical Education

Consultant in High Risk Obstetrics and Maternal Medicine with special interest in Medical
Education, Central Manchester Foundation Trust, Manchester, Chapter 12 Maternal Medicine

Justin E R Davies BSc, MBBS, PhD, MRCP

Senior Research Fellow and Consultant Cardiologist, Imperial College London, Chapter 1
Cardiology

James Galloway MBChB, MRCP, MSc, PhD, CHP

Clinical Lecturer / Honorary Consultant Rheumatologist, Department of Rheumatology, King’s
College Hospital, London, Chapter 10 Immunology

Sumithra Giritharan MBChB MRCP(UK)

Specialist Registrar, Department of Diabetes and Endocrinology, Salford Royal NHS Foundation
Trust, Manchester, Chapter 4 Endocrinology

Ben Goorney MBChB FRCP

Consultant Genito-Urinary Physician, Department of Genito-Urinary Medicine, Hope Hospital,
Salford, Chapter 8 Genito-Urinary Medicine and AIDS

Heather Green BSc, MBChB (Hons), MRCP(UK), Certificate in Respiratory Medicine

Respiratory Registrar/Research Fellow in Cystic Fibrosis, Manchester Adult Cystic Fibrosis Centre,
University Hospital of South Manchester, Manchester, Chapter 19 Respiratory Medicine

Matthew Jones MD MRCP

Consultant Neurologist and Clinical Teaching Fellow, Department of Neurology, Greater Manchester
Neurosciences Centre, Salford Royal NHS Foundation Trust, Salford, Chapter 16 Neurology

Philip A Kalra MA MB BChir FRCP MD

Consultant and Honorary Professor of Nephrology, Salford Royal NHS Foundation Trust and
University of Manchester, Chapter 15 Nephrology
Eirini Koutoumanou BSc MSc
Senior Teaching Fellow, UCL Institute of Child Health, Population, Policy, Practice Programme,
London, Chapter 21 Statistics

Tara Kearney MB BS, BSc(Hons), FRCP, MD

Consultant Endocrinologist, Salford Royal Foundation NHS Trust, Manchester, Chapter 4
Endocrinology

Mohit Kumar MBChB MRCP

Specialist Trainee, Department of Diabetes, Endocrinology and Weight Management, Salford Royal
Foundation Trust, Salford Manchester, Chapter 4 Endocrinology

Simon Lal BSc MBChB PhD FRCP

Consultant Gastroenterologist, Salford Royal NHS Foundation Trust, Salford, Chapter 6
Gastroenterology

Michael McMahon BSc MBChB FRCP

Consultant Physician and Rheumatologist, Department of Rheumatology, Dumfries and Galloway
Royal Infirmary, Dumfries, Chapter 20 Rheumatology

Sukhjinder S Nijjer BSc (Hons) MBChB (Hons) MRCP(UK)

Cardiology Registrar, Hammersmith Hospital and the International Centre for Circulatory Health,
Imperial College London, Chapter 1 Cardiology

Keith Patterson FRCP FRCPath

Consultant Haematologist, London, Chapter 9 Haematology

James Ritchie MBChB, MRCP PhD

Clinical Research Fellow, Department of Renal Medicine, Salford Royal Hospital, Salford,
Manchester, Chapter 5 Epidemiology

Helen Robertshaw BSc(Hons) MBBS FRCP

Consultant in Dermatology, Royal Bournemouth and Christchurch Hospitals, Bournemouth, Chapter 3
Dermatology

David Rog BMedSci (Hons), BMBS, FRCP, MD

Consultant Neurologist and Honorary Lecturer, Department of Neurology, Greater Manchester
Neurosciences Centre, Salford Royal NHS Foundation Trust, Salford, Chapter 16 Neurology

Liz Sampson MBChB MRCPsych MD MSc

Clinical Senior Lecturer In Old Age Psychiatry, Division of Psychiatry, University College London.
Consultant in Liaison Psychiatry, Barnet Enfield and Haringey Mental Health Trust London, Chapter
18 Psychiatry

Kirk W Siddals BSc PhD

Research Fellow, Vascular Research, Salford Royal Hospital, Manchester, Chapter 14 Molecular
Medicine

Smeeta Sinha MBChB PhD MRCP FRCP

Consultant and Honorary Senior Lecturer in Nephrology, Salford Royal NHS Foundation Trust,
Salford, Chapter 13 Metabolic Diseases

Katherine Smyth MBChB MRCP FRCOpth

Consultant Ophthalmologist, Royal Bolton Hospital, Bolton, Chapter 17 Ophthalmology

Clare L van Halsema MBChB MSc MD MRCP DTM&H Dip HIV Med
Specialist Registrar in Infectious Diseases, Department of Infectious Diseases and Tropical
Medicine, North Manchester General Hospital, Manchester, Chapter 11 Infectious Diseases and
Tropical Medicine

Dipesh H Vasant MB ChB, MRCP(UK)

Clinical Research Fellow and Specialist Registrar in Gastroenterology and Medicine, The University
of Manchester Clinical Sciences Building, Salford Royal NHS Trust, Chapter 6 Gastroenterology

Stephen Waring PhD FRCP (Edin) FRCP FBPharmacolS

Consultant in Acute Medicine & Toxicology, Acute Medical Unit, York Teaching Hospital NHS
Foundation Trust, York, Chapter 2 Clinical Pharmacology, Toxicology and Poisoning
 Contributors to Third Edition
Emma Burkitt Wright MBCh MPhil MRCP(UK)
Academic Clinical Fellow, Medical Genetics Research Group and University of Manchester, St
Mary’s Hospital, Manchester Genetics

Louise Byrd MRCOG

Specialist Registrar in Obstetrics and Gynaecology, North West Region Maternal Medicine

Colin M Dayan MA MBBS FRCP PhD

Consultant Senior Lecturer in Medicine, Head of Clinical Research, URCN, Henry Wellcome
Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol Endocrinology

Ben Goorney MBChB FRCP

Consultant Genito-Urinary Physician, Department of Genito-Urinary Medicine, Hope Hospital,
Salford Genito-urinary Medicine and AIDS

Philip A Kalra MA MB BChir FRCP MD

Consultant Nephrologist and Honorary Reader, Hope Hospital, Salford Nephrology

Mike McMahon BSc MBChB FRCP

Consultant Physician and Rheumatologist, Department of Rheumatology, Dumfries and Galloway
Royal Infirmary, Dumfries Immunology & Rheumatology

John Paisey DM MRCP

Consultant Cardiac Electrophysiologist, Royal Bournemouth Hospital, Bournemouth Cardiology

Keith Patterson FRCP FRCPath

Consultant Haematologist, Department of Haematology, University College London Hospitals,
London Haematology

Jaypal Ramesh MRCP(UK)

Consultant Gastroenterologist, University Hospital of South Manchester, NHS Foundation Trust,
Manchester Gastroenterology

Geraint Rees BA BMBCh MRCP PhD

Wellcome Senior Clinical Fellow, Institute of Cognitive Neuroscience, University College London
Neurology

Helen Robertshaw BSc(Hons) MBBS MRCP

Specialist Registrar in Dermatology, Southampton University Hospitals Trust, Southampton
Dermatology

Liz Sampson MBChB MRCPsych MD

Lecturer in Old Age Psychiatry, Royal Free and University College Medical School, University
College London Psychiatry

Kirk W Siddals BSc PhD

Research Fellow, Vascular Research, Salford Royal Hospital, Stott Lane, Salford Molecular
Medicine

Smeeta Sinha MBChB MRCP

Specialist Registrar Nephrology, Salford Royal NHS Foundation Trust, Salford, Manchester
Metabolic Diseases

Katherine Smyth MBChB MRCP FRCOpth

Consultant Opthalmologist, Royal Bolton Hosptial, Bolton Ophthalmology

Clare L van Halsema MBChB MRCP DTM&H

Specialist Registrar in Infectious Diseases, Monsall Unit, Department of Infectious Diseases and
Tropical Medicine, North Manchester General Hospital, Manchester Infectious Diseases

Angie Wade MSc PhD CStat ILTM

Senior Lecturer in Medical Statistics, Institute of Child Health and Great Ormond Street Hospital,
London Statistics

Deborah A Wales MBChB MRCP FRCA

Consultant Respiratory Physician, Nevill Hall Hospital, Brecon Road, Abergavenny, Monmouthshire
Respiratory Medicine

GaryWhitlock BHB MBChB MPH(Hons) PhDFAFPHM

Clinical Research Fellow, Clinical Trial Service Unit, University of Oxford Epidemiology

Stephen Waring MRCP(UK)

Consultant Physician in Acute Medicine and Toxicology, The Royal Infirmary of Edinburgh Clinical
Pharmacology
 Permissions
The following have been reproduced with kind permission from BMJ Publishing Group Ltd.

Cardiology
Fig 1.5 – Radionuclide myocardial perfusion imaging. Left panel shows the gamma camera. Right
panel shows a reversible inferolateral perfusion defect: left column stress, right column rest.
Fig 1.6 – Mechanism for atrioventricular nodal re-entry tachycardia
Fig 1.7 – Mechanism for atrioventricular re-entry tachycardia
Maternal Medicine
Table 12.4 – Specific renal diseases and pregnancy
Neurology
Figure 16.2 – Demonstrating how the ‘shape’ of three common neurological conditions – seizures,
transient ischaemic attacks and migraine – and their positive and negative neurological features in the
history help to differentiate them.

The following images in this book have been reproduced with kind permission from Science Photo
Library.

Immunology
Fig 10.3 – Angioedema on the tongue
 Preface to the Fourth Edition
I am delighted that ‘Essential Revision Notes for MRCP’ has retained it’s place as one of the key texts
for preparation for the MRCP over a period now extending beyond 15 years. In this latest edition
there has been a significant revision of the text in all of the chapters by experts in the subject, and the
material has been brought right up to date with coverage of the latest clinical developments in the
subject areas.
We continue to use the same successful style of layout within the Essential Revision Notes (ERN)
with emphasis upon ‘user-friendliness’ with succinct text, bullet points and tables. The double-
column format enhances readability and revision. The aim is to provide the practising physician with
accessible, concise and up-to-date core knowledge across all of the subspecialties of medicine. For
candidates who are preparing for the MRCP, it fills a unique gap between large detailed textbooks of
medicine and those smaller texts which concentrate specifically on how to pass the examinations.
However, many physicians use the ERN as a career-long companion to be used as a concise source of
reference long after they have successfully collected their exam certificates.
A special thanks goes to our skilled team of contributing authors for their outstanding efforts which
have ensured that this new edition maintains the standard set by previous editions. I am also
particularly grateful to Cathy Dickens, who has been a key contributor to the ERN effort since it’s
initiation in 1998, and to Brad Fallon, for co-ordinating the book production process at PasTest.
Philip A Kalra
Consultant and Honorary Professor of Nephrology
Salford Royal NHS Foundation Trust and University of Manchester
 Chapter 1
Cardiology

CONTENTS

1.1 Introduction
1.2 Clinical examination
1.2.1 Jugular venous pressure
1.2.2 Arterial pulse associations
1.2.3 Cardiac apex
1.2.4 Heart sounds
1.3 Cardiac investigations
1.3.1 Electrocardiography
1.3.2 Echocardiography
1.3.3 Nuclear cardiology: myocardial perfusion imaging
1.3.4 Cardiac catheterisation
1.3.5 Exercise stress testing
1.3.6 24-hour ambulatory blood pressure monitoring
1.3.7 Computed tomography
1.3.8 Magnetic resonance imaging
1.4 Valvular disease and endocarditis
1.4.1 Murmurs
1.4.2 Mitral stenosis
1.4.3 Mitral regurgitation
1.4.4 Aortic regurgitation
1.4.5 Aortic stenosis
1.4.6 Tricuspid regurgitation
1.4.7 Prosthetic valves
1.4.8 Infective endocarditis
1.5 Congenital heart disease
1.5.1 Atrial septal defect
1.5.2 Ventricular septal defect
 1.5.3 Patent ductus arteriosus
1.5.4 Coarctation of the aorta
1.5.5 Eisenmenger syndrome
1.5.6 Tetralogy of Fallot
1.5.7 Important post-surgical circulations
1.6 Arrhythmias and pacing
1.6.1 Bradyarrhythmias
1.6.2 Supraventricular tachycardias
1.6.3 Atrial arrhythmias
1.6.4 Ventricular arrhythmias and channelopathies
1.6.5 Pacing and ablation procedures
1.7 Ischaemic heart disease
1.7.1 Angina
1.7.2 Myocardial infarction
1.7.3 PPCI for STEMI
1.7.4 Coronary artery interventional procedures
1.8 Heart failure and myocardial diseases
1.8.1 Cardiac failure
1.8.2 Hypertrophic cardiomyopathy
1.8.3 Dilated cardiomyopathy
1.8.4 Restrictive cardiomyopathy
1.8.5 Myocarditis
1.8.6 Cardiac tumours
1.8.7 Alcohol and the heart
1.8.8 Cardiac transplantation
1.9 Pericardial disease
1.9.1 Constrictive pericarditis
1.9.2 Pericardial effusion
1.9.3 Cardiac tamponade
1.10 Disorders of major vessels
1.10.1 Pulmonary hypertension
1.10.2 Venous thrombosis and pulmonary embolism
1.10.3 Systemic hypertension
1.10.4 Aortic dissection
Appendix I
Normal cardiac physiological values
Appendix II
Summary of further trials in cardiology
Cardiology

1.1 INTRODUCTION
Patients with cardiovascular disease form a large part of clinical work and accordingly have
prominence in the MRCP examination. Ischaemic heart disease, valvular disease and arrhythmic
disorders have the largest preponderance of questions. Many of the conditions have overlapping
causes and cardiac pathophysiology is such that one condition can lead to another. Understanding the
pathophysiology will allow clinicians to unpick diagnoses, understand the diseases and answer
examination questions more effectively.

1.2 CLINICAL EXAMINATION

1.2.1 Jugular venous pressure

This is an essential clinical sign that reflects patient filling status and is essential to detect for correct
fluid management. The jugular venous pressure (JVP) reflects right atrial pressure, and in healthy
individuals at 45° is 3 cm in vertical height above the sternal angle (the angle of Louis, the
manubriosternal junction). Inspiration generates negative intrathoracic pressure and a suction of
venous blood towards the heart, causing the JVP to fall (Figure 1.1).
Figure 1.1 The location and wave-form of the jugular venous pressure (JVP). The JVP must be assessed with the patient at 45°
Normal waves in the JVP
The a wave
Due to atrial contraction – actively push up superior vena cava (SVC) and into the right ventricle
(may cause an audible S4).
The c wave
An invisible flicker in the x descent due to closure of the tricuspid valve, before the start of
ventricular systole.
The x descent
Downward movement of the heart causes atrial stretch and a drop in pressure.
The v wave
Due to passive filling of blood into the atrium against a closed tricuspid valve.
The y descent
Opening of the tricuspid valve with passive movement of blood from the right atrium to the right
ventricle (causing an S3 when audible).

Causes of a raised JVP

1. Raised JVP with normal waveform:
• Heart failure – biventricular or isolated right heart failure
• Fluid overload of any cause
• Severe bradycardia.
Raised JVP upon inspiration and drops with expiration: Kussmaul’s sign is the opposite of
what occurs in health and implies that the right heart chambers cannot increase in size to
 2. accommodate increased venous return. This can be due to pericardial disease (constriction) or
fluid in the pericardial space (pericardial effusion and cardiac tamponade).

Raised JVP with loss of normal pulsations: SVC syndrome is obstruction caused by
3. mediastinal malignancy, such as bronchogenic malignancy, which causes head, neck and/or arm
swelling.

Pathological waves in the JVP

This is a common source of MRCP Part 1 questions. See Table 1.1 and Figure 1.2 for these waves.

Table 1.1 Pathological waves in the jugular venous pressure (JVP)

a
Absent Atrial fibrillation – no co-ordinated contraction
waves
Large Tricuspid stenosis, right heart failure, pulmonary hypertension
Caused by atrioventricular dissociation – allowing the atria and ventricles to
Cannon
contract at same time:
Atrial flutter and atrial tachycardias
Third-degree (‘complete’) heart block
Ventricular tachycardia and ventricular ectopics
v
Giant Tricuspid regurgitation – technically a giant ‘c-V’ wave
waves
x
Steep Tamponade and cardiac constriction
descent
If steep x descent only, then tamponade
y
Steep Cardiac constriction
descent
Slow Tricuspid stenosis
Figure 1.2 Different JVP morphologies can reflect different disease states
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