Do you know any STEMI equivalent condition where there is no actuall ST elevation ?

Those who work in state of art cath labs as well ER probably familiar with this scenerio.

:de Winter ECG pattern is a STEMI equivalent that presents without obvious ST segment elevation.

Upsloping ST depression and peaked T waves in the precordial leads(V2-V6) and some times in I and II.

The de Winter pattern is an indication of Proximal LAD blockage and highly Underreported among clinicians( May be because it's relatively new and lack of expertise in EKG interpretation)

Don't delay in sending the patient directly to cath lab because it leads to catastrophic situation if you fail to send the pt for PCI .

Below is a good example of De winter t wave pattern .
Courtsey: Google Images

Well ,this explains why there was a very high fail rate in May,2014 diet of MRCP Part-1 examination.

http://www.mrcpuk.org/about-us/research/exam-pass-rates

Most Important Biostatatistics topics frequently asked in MRCP part 1

Imp Topics for Biostatistics :-

When you prepare for MRCP it seems time is evaporating as water evaporates from lake in the summer season.

It's very crucial to channelize your effort in most efficient way and there comes studying smartly.

Remember you won't have more than 5 or 6 questions from Biostatistics and majority of questions are asked from simple calculation based concepts such as

1. Sensitivity

2.Specificity

3.PPV

4.NPV

5.odds ratio

6.relative risk

And

7.significance of different stages of clinical trials 

8. Three sigma rule or 68-95-99.7

(68.27% of the values lie within one standard deviation of the mean. Similarly, 95.45% of the values lie within two standard deviations of the mean. Nearly all (99.73%) of the values lie within 3 SD)

I believe knowing only these formula will help you to fetch 70 to 80 % questions.

P.S.- while you are calculating a particular biostatistical parameter such as Sensitivity ,which is 

Basically  =TP/TP+FN 

It looks very simple and it is actually simple but what happens some times Royal college flips the value of TP,FP,FN in different / reverse order in the chart and then if you are not alert probably you will end up choosing wrong answer.

So first make sure which one is TP ,FP ,FN and TN.

Don't dwell too much in this subject coz no one gets right that 1 or 2 ultra difficult questions ,what matters is getting correct the remaining easily scoring biostat questions. 

Frequently asked Qs from Genetics and Molecular Biology in MRCP(UK) Part 1

You can expect 5 or 6 questions from these two Nagging subjects.
I will enlist the important concepts from these subjects below ,

1.i know it can be difficult to memorize the chromosomes involved in various imp genetic conditions but for the heck of MRCP 1 you may want to remember at least following diseases and chromosomes affected

NF1 and 2 , Down syndrome , klinfelter's syndrome ,cystic fibrosis , myotonic dystrophy ,ADPKD ,
Turner's syndrome and hemochromatosis.

2.there will be one or two question based on genetic inheritence   mode and Autosomal dominant / mitochondrial inheritence are favorite of MRCP.
They may just ask you about what is the  probability of being affeted
Or they can ask whether the proband will be affected or carrier.
Its tricky but its virtually always featured in exam.

3.you must know about some important phenomena in genetics such as pleiotropy , anticipitation ,imprinting ,
Hetroplasmy.

Qs are usually present as a clinical case such as a 35 years old male patient who is having abnormal jerking movement and also he is having psychomotor abnormalities ,cognitive decline, and patient also tells you that his father had similar symptoms at the age of 50 .you suspect it as Huntington's disease and test for CAG trinucleotide repeat sequence. Meanwhile patient asks you why he has developed this symptoms much earlier than his father???
So  here the answer would be Anticipation.

This is just an example how royal college frame the genetics questions with a clinical flavor.

4.learn well about what kinda blotting we use for DNA ,RNA AND PROTEINS.
Southern and western blot is often asked.

5.get yourself familiar with the immunoglobulins atleast IgA ,IgG and IgM.

6.acute phase reactants are also asked often and ferritin and ceruloplasmin is imp one.

7.Dont waste time on PCR or Immunofluorescence assay or FISH etc .they dont expect you to know a lot about these stuffs.

8.important immunodeficiency conditions such as SCID ,common variable immunodeficiency , wiskot aldrich sundrome are important.

9.G6Pd deficiency is also very frequent
Question.

10.thalasemia and its subtype ie alpha and beta thalassemia can be asked.

Frequently asked Qs from Neurology in MRCP(UK) Part 1

Neurology is the subject which is heavily tested in MRCP part 1 and majority of candidate feels that they can't master this subspeciality ,well you don't have to master it ,just  play smart and you will be able to score maximum.

Following are the topics/concept you can't avoid for MRCP 1

1. Stroke and TIA is big time favorite ( for MRCP)

There may be question based on area of territory involved such as in Anterior stroke ,posterior etc.

Remember the area supplied by MCA.

Remember what happens in Posterior inferior cerebellum ssyndrome( it's inevitable qs for part1).

Complete sensory stroke

Upto what time you can give tPA in ischemic stroke, immediate next step in managment after stroke(ct scan to rule out hemorrhage) ,

If pt can't remember the exact time of onset of symptoms ,assume as out of window period and treat as such.

Remember to give warfarin in a patient with AF and with risk factors such as inc age,DM,HTN etc.as prophylaxis.

Clopidogrel is drug of prophylaxis in TIA and stroke,Asp plus dipyridamole is outa seen now( in OHCM 9 they say taht clopidogrel is not licensed for TIA ,well check new NICE guideline, now they recommend it-reference NICE 2014 Guideline)

2. Infectious disease in Neurology:

.Rest assure that you are gonna get a HSV encephalitis ,they will tell you the classic temporal lobe lesion on a patient who has recently developed behavioral changes,aggressive,feverish,they may say pt doesn't have nuchal rigidity ( you don't have to have nuchal rigidity in encephalitis but often seen in meningitis)

.Venous sinus thrombosis is also quite important: young patient with recent sinusitis ,was treated with Abx now he has developed CN.4,5,6 symptoms as well fever and headache , they may ask next step in management : do MRV  and start lmwh.

.neurosarcoidosis can also be featured in exam

.tertiary syphilis /tabes dorsalis  might appear in your exam.they may say a war veteran who fought in Vietnam or Gulf now present with neurological symptoms and then give you TPHA OR RPR positive serology .

.learn the visual pathway very well.

.tubercular meningitis is popular room.patient from India or Pakistan emigrate to UK now he has cough ,wt loss,fever  etc .LP shows characteristic finding of TB meningitis ,they may ask diagnosis or treatment.

.HIV PT with meningitis is virtually always cryptococcal or tubercular ( Offcourse in MRCP )

.Progressive multi focal leucoencephelopathy  syndrome(PMLS) cause by John Cunningham Virus(JC virus ) is also imp.

.Either you like it or not but GBS is gonna appear in your test and they will ask you to what parameter to monitor (FVC)

.iv drug abuser with diplopia and diaphragmatic paralysis and downward weakness :Botulism is sure qs in your exam  don't confuse it with GBS  coz in exam they often give you mixed scenerio and people fall for MRCP traps.

3. Neurodegenerative diseases:

Alzheimer's : yes there will be one qs ,and most likely they would like to test you about available treatment options and how familiar you are with it such as memantine,enatacapone etc.

Parkinson often appeared in exams and usually they ask about when to begin the treatment ,and want to know the different approach we use in relatively young patient vs old patient.

Parkinson qs are also appeared where they only asked about diagnosis.

Dementia of Lewy bodies: old patient who was treated with traditional neuroleptic so for hallucination and his symptoms got worsen ,diagnosis??? Virtually asked in every diet of mrcp1.

Charles Bonnet syndrome( macular degeneration ,pt is partial or severe blind and he claims that he can see people around I. e hallucinations).

Huntington's disease : you may be asked about diagnosis of Huntingtons or they can ask the name of trinucleotide repeat sequence ( genetics ehh:(

CJD : prion disease ,pt with myoclonus as well rapid onset of dementia.

MS : either you'll have diagnosis or they may as which drug to use to stop (not really ,you can't stop all you can do is  delay) the progression.they won't ask you the criteria of B interferon use( that's part 2 stuff)

B12 deficiency and subacute combined degeneration will be in exam.

Some times HSMN aka Charcot marrie tooth disease is featured.

Fredriech ataxia is big time MRCP qs.

Misclllaneous:-

Some other topics such as

Absence seizure and drug of choice,

DVLA guideline for provoked and unprovoked seizures ,

Patient and GBM tumor and he has undergone resection,when can he drive?

Get yourself familiar with Status epilepticus treatment protocol: they may ask when to use phenytoin,when use anesthetic agent etc.

Differentiate conversion disorder with TIA .

Transient global amnesia is important: they usually ask what are the chances of recurrence: very rare to recur.

Paraneoplastic transverse myelitis

Benign essential tremor and treatment: propranolol ( I know !!!it's very easy;-)

Bell's palsy 

Weber's syndrome

Pseudo tumor cerebri(idiopathic intracranial HTN) - in exam they have already done mri and now they are asking what to do next --- do MRV to rule out venous sinus thrombosis).

Either subdural hematoma or epidural hematoma will be in your exam and if you missed these two some how then probably you'll see subarachnoid hemorrhage .

:- they usually ask culprit vessel I.e. Bridging vein,middle meningeal arteryn,communicating artery etc)

Cerebrllar tumors are also featured some times.

Arnold chiari malformation is also important .

Remember the spinocerebral as well corticospinal pathways coz they test your anatomy knowledge by asking brown sequeard syndrome or anterior or central cord dissection syndromes .( I know it's tedious to learn ,but if you could read this once or twice you may not miss the easy 2 or 3 questions)

P.S.- this is entirely my opinion and I don't claim that these are the concepts you are going to see in exam but chances are quite high that you may stumble upon very similar qs  in your exam.

Thank you for reading:) any suggestion would be appreciated!

To be continued.....................................................

Frequently asked Qs from Cardiology in MRCP(UK) Part 1

Cardiology is a very important speciality for both Part 1 and 2 exam so my suggestion is to understand it very well.
I will summarize some important concepts most frequently asked in Part 1 examination.

1. STEMI and NSTEMI (ACS) are highly important .
They may give you a scenerio of acute myocardial infarction and will ask the are of myocardium involved such as left ventricle (LAD) IN case of anterior lead involvement   , inferior wall and SA node in case of II ,III and aVF leads etc.
Know the anatomy well.coz definitely there is one or 2 qs based on it will be in your exam.

2.how long you should give clopodogrel after drug eluting stent insertion.

3.how frequent restenosis and rethromnosis occurs ( after PCI and stenting)n patient with diabetes and without diabetes. ( very common scenerio in MRCP)

4. Learn in and out of CHF. You should be familiar with NYHA classification and must know when to add beta blocker or spironolactone in a CHF patient.its another sure shot for your exam.

5.you must know your antiarrhythmics and their side effects.
One fav question is a patient was started on Amiodarone for ventricular tachycardia and now after 2 years he complains that his skin color turned Grey----- photo toxicity of amiodarone

They may ask pt now complains the sweling around thyroid and palpitation---hyperthyroidism induced by Amiodarone as amiodarone has iodine(2/3 rd of its constituent)

Beta blockers side effect are also commonly asked .

They also trick you sometime by asking that a first trimester pt with PSVT is concern about aadenosine use on pregnancy --- reassure her that its very safe in pregnancy.

6.ACE inhibitors are very frequently asked may be becuse Diabetic Nephropathy is very imp in Uk and western hemisphere.
Read NICE guidelines about when to stop  Ace inhibitors in case of increase cr level( if cr increses more than 30 percent).

Dont give Ace inh in pregnant and bilateral renostenosis.

7.dont treat CHB by any active intervention if its occurred after INF WALL MI as its gonna resolve once we take care the MI  by eithe PCI OR Thrombolytics. But if its ant wall mi or lateral wall then go ahead with transvenous pacemaker as a bridging therapy of permanent pacemaker.

8.remember when to treat ectopic beats and when to reassure.Mrcp loves this

9.DVLA guidelines , specially post CABG , Post Pci , post STEMI

10.you may get ECG findings such as AVNT,PSVT,WPW, TORSADE.DE.POINTES etc and they may ask the treatment .( you dont get actual ecg picture but findings)

11. Treatment of hypertension In pregnancy is also a biggie.

12. Aortic dissection and whether to do surgical or medical management ? Stanford Type A vs Type B.

13.cholesterol embolism post Angigraphy is also commonly featured.

14.Blind treatment Aka empirical Tx of Subacute bacterial endocarditis I.e
Iv Benzyl penicillin plus gentamicin .
Don't jump to vancomycin until they specifically tell you its staphylococcus aureus. ( yes my friend I know you will say you need to add rifampicin with Vanco, thank you Genius)

15.transesophageal echo vs  blood culture in SABE .

16.do always transthoracic Echo in case of HOCM , Transesophageal is not very ideal in case of ventricular pathology.

17.Brugada syndrome and arrhytmogenic ventricular dysplasia along with Long Qt syndrome is also good to have a a quick look.

18.Digoxin side effects.

19.Management of Afib is almost sure qs .you must know when to cardiovert .

20.duration of Warfarin use in various cardiovascular problems most imp one is DVT  .learn It well.

21.learn ACLS guideline and various mode of Adrenaline administration such as iv vs io.
We always get some tricku qs based on ACLS guidelines such as what to do after 2 cycle of cpr , when to give Amiodarone , what should be concentration of Adrenaline , what should be mode of cardioversion ie synchronised vs asynchronised.
There will be 1 qs from this topic.
You dont have to remember the dosage so relax!

22.indication of ICD is also some times asked such as a pt with Hocm has non sustained arrhytmia or he was placed on beta blocker but he is having frquent syncope .what should be next step in management?

23.indications of pacemaker insertion .

24. When to treat aortic stenosis vs when to just observe .
Remember aymptomatic AS should always be treated  with valvuloplasty no matter what is his aortic pressure gradient .

25.takayasu arteritis and kawasaki disease are favorite vascular disease of MRCP 1 .also syphilitic aortitis is sometimes been asked.

My MRCP(UK) Part 2 Written Experience

I know my MRCP part 2 experience suppose to be posted here but I forgot,So here I would like to write my experience ( MRCP Part 2 written).

Time taken : approx 11 weeks

Materials Used: Passtest online 
2/3 rd of Offline Onexam and MKSAP16 ( cardiology,gastro,neuro,Nephrology,Oncology,Critical care)
For pictorial questions I used American academy of ophthalmology website(they have excellent collection of Fundoscopic plates)
Radiopedia ,for cxr,ct,Mri,DSA.
Dermnet NZ website for skin conditions .
Don't neglect images as they almost comprise approx 40 qs,and they play an important role in pass or fail.

I have worked in CCU so I really didn't have to go through any book for EKG,but for easy understanding of EKG you may wana refer Lifeinfastlane website.its an excellent free source of important EKG seen in daily life practice.

Final Verdict: 661 (passing score was 425)

What you should do:- revise ,revise and revise .that's the golden rule.stick with limited resources and try to know in and out of that .Pastest fits the bill nicely and it's closest thing to the exam.

What you shouldn't do:- overthinking is highly injurious for your health  
When you are in exam hall stop thinking that it's easy qs and it can't be the answer( you know very well what I am talking about;-)
Go with your hunch coz informations are in your subconscious mind and your brain tries to tell you that this is correct answer( and we call it gut feeling aka Hunch).
Minimize your resources if you can.

We all try to do as many question we can but important thing is to understand the core concepts,if you don't know the reason Behind doing MRV in pseudo motor tumor cerebrl ,I am afraid you won't be able to get it correct in exam ,because Royal college always twist the qs and one line can change the whole scenerio. So beware.
Don't use big text books ,coz this is MRCP Exam and here you need to to know concise and recent guideline sometimes recent as 2013.
Online qbank does the job.

I will end this long experience here with this message.

" life is complex and life of a physician is more complex.what can we do about this???? Nothing ..... But complaining is not a solution so no matter what are the difficulties in your life never let it become a hindrance between you and your goal,you worked hard for it and sooner or later you are gonna get it .don't get bogged down by critics,let them do their job and you do yours.work in silence and let your success do talking:)"
Best wishes,
Dr.Srivastava