‫الحمد هلل والصالة والسالم على رسول هللا‬

My Study Plan For MRCP II:

→ Not less than 4 months.
→ I solved On Examination nearly 2 times.
→ I had a 3 weeks Vacation before exam (during them I studied most of the pat papers
from 2011 to 2018). half Exam /day (I was not so fast ☺)
→ In the Last week, I had a rapid review of X-rays, ECGs, fundoscopies, GIT radiology,
derma, neuro radiology, very quickly.
→ In the last week, do not solve Questions, only Re-read, Re-read.
→ These notes are recorded also, so you can study them by reading or by listening.
→ I readied these notes & listened to them nearly 3 times.
→ Past papers are uploaded on my telegram channel.
→ The Images, are also uploaded on my telegram channel.
There are 150sample Qs on the website of MRCP Exam, you will find 3 or 4 of them in the
real exam

https://www.mrcpuk.org/mrcpuk-examinations/part-2/part-2-sample-questions

These notes are open source, collected from Onexamination, past papers, spread freely, if any
concern, you can find the “Microsoft Word copy of this PDF document” on my channel on
telegram, you can download the Microsoft word document & add or remove or edit any part ,
according to your need.

https://t.me/mrcp_collection

Take chocolate with you in the exam: eat 1 bar of chocolate after 1 hour of the exam (Total of
6 bars in the 2 papers ☺ , I did so).

☺ .‫وال تنسوني من صالح دعائكم بالمغفرة والرحمة وحسن الخاتمة‬

Dr. Khaled Nabeel Elgohary

If any concern, just mail me: dr.khaled.elgohary@gmail.com

1. Nelson's syndrome : After adrenalectomy 30% of ptns. >> Loss of the –ve feedback of cortisol >>
Rapid enlargement of pituitary adenoma>>>
• Mass effect >>>headache.
• Marked increase in ACTH >>> HTN.
• Increase in MSH (melanocyte stimulating hormone) >> Hyperpigmentation.
- MRI defines the extent of the tumor.
2. Acarbose >>> 49% reduction in cardiovascular events.
3. Insulin antibodies are found almost exclusively in young children with type 1 DM.
4. Islet cell autoantibodies in type 1 diabetes.
5. Anti- TPO =HashimOtO.
6. PH >7.3 and ketones <0.3 mmol/L define resolution of DKA, at which time a patient can be
converted back to SC insulin.In DKA , give only HCO3 if PH <7.0
7. ↑PRL, Cushing, Addison,hemochromatsos→ hypogonadotrophic hypogonadism→Amenorrhea.
8. Tryptophan hydroxylase autoantibodies may be found APE syndrome associated with an
autoimmune malabsorption.
9. Anti-adrenal-21 hydroxylase antibodies are typically seen in a high percentage (80-90%) of
Addison.
10. 10% of ppl with thyrotoxicosis >>> Hypokalemic periodic paralysis , & they present with proximal
UL&LL muscle weakness ,falls , hyporeflexia . (Myopathy case) TTT: K IVI.
 ‫بي بي بي‬

Pheo ‫بي إم في‬

Triple M ‫ ومعاها‬phe

‫األخير بيكون معاه‬

Muscloskeletal
deformities

=marfanoid body
habitus/neuromas

11. Laxative abuse →↓ low urinary Na & K, with low serum bicarbonate, due to gastrointestinal losses.
12. In Addisson:
→ In short Synacthen test ,a cortisol response < 550 nmol/L is confirmatory.
→ Sometimes it is associated with slightly low T4 and slightly high TSH (mild hypothyroid
picture).
→ Sick euthyroidism is a recognised feature of Addison's disease and treatment with
thyroxine may exacerbate the condition and precipitate acute hypoadrenalism.
→ Addisonian crises : All are hypo except K.>>> give Hydrocortisone.
→ But if a hypothyroid lady came with Myxedema coma (Low GCS +Low Temp+ Addison-
like features) >>> give her IV Hydrocortisone + IV T3.

13. What is the pathological entity that causes DM &? Islet amyloid deposition

14. Over-replacement with thyroxin → ↑ T3,T4 & very ↓ TSH (the rise in T3 & T4is not proportional to the
very low levels of TSH). Undetectable thyroglobulin clinches Dx of factitious hyperthyroidism.

.‫ منخفض جدا جدا‬TSH ‫مرتفعين حاجة بسيطة اوي مع ان الـ‬T3,T4 ‫يعني الـ‬

15. TSH secreting tumor → ↑ T3, T4 , TSH. ‫ والوحيد اللي بيعمل الصورة دي‬...‫مهم جدا‬
16. Stop metformin if creat > 150.
17. Hyperthyroidism in pregnancy :
 1st trimester use: propylthiouracil.
 2nd & 3rd trimester: use carbimazole.
 18. Nocturnal hypoglycaemia → Vivid dreams & lethargy. REM sleep disruption →daytime weakness
and somnolence. EXAM 2002
19. B cell mass in DM:
 ↓ by 50 % in IGT.
 ↓ by 65% in T2DM.
 ↓ by 90% in T1DM.
20. Type I DM , when they take SGLT-2 inhibitors (as gliflozine)→ DKA.
21. If a patient with DM, became uncontrolled & you want to up titrate insulin → give 10% of total
daily dose for each dose.

.‫ في كل جرعة‬4 units ‫ تزود له‬... ‫ لما تيجي تزود له‬..‫ في جرعات اليوم كله‬40 units total ‫ مريض بياخد انسولين‬:‫مثال‬

‫طب ولو العكس؟‬

‫ هتقلل بنسبة كام؟‬hypoglycemic ‫يعني لو المريض بيكون‬

total daily dose. ‫ من الـ‬%20 ‫بنسبة‬

‫ أيام‬3 ‫ تانيين تقلل امتى؟ بعد آخر مرة قللت فيها بـ‬% 20 ‫طب ولو حبيت تقلل‬

‫ لو قررت تبدأ انسولين لمريض يبقى أول نوع تبدأ به هو‬.22

Human isophane insulin once daily (=NPH= Neutral Protamine Hagedorn).
23. Gonadal failure:
1ry: Hypergonadotropic hypogonadism: (hypogonadism>>↓ testosterone, sperm count) or estradiol ↓

Causes are:

 Congenital: Klinfelter $,‫ وصاحبته‬Turner, Cryptorchidism (US needed),Varicocele(US needed) ,

Myotonic dystrophy, Premature ovarian failure. EXAM 2012
 Acquired: Torsion/radiation/any chronic debilitating disease (RF/LCF), Alkylating agents,
Ketoconazole, steroids, aging.

2ry: Hypogonadotropic hypogonadism (gonadotropes may be ↓ or normal): Kallman, Cushing, Addison

PCO, obesity, DM , ↑PRL,↑ iron (=hemochromatsos),Anorexia nervosa.
‫ فالناس‬...‫ والسكر عالي‬hypogonadotropic hypogonadism ‫ سنة وعنده‬60 ‫فخد بالك بقه جاب سؤال مرة واحد عنده‬
‫ بيجي في سن‬Hemochromatosis ‫ واالجابة طبعا خطأ الن الـ‬DM ‫ على اساس ان فيه‬Hemochromatosis ‫اختارت‬
..‫اصغر من دا‬
hypogonadotropic hypogonadism ‫ بنفسه ممكن يعمل‬DM ‫الن الـ‬.. ↑ PRL ‫وكانت االجابة الصحيحة‬
NB: Hypogonadotropic hypergonadism (estradiol high) : occurs in pregnancy ‫اذا جاز التعبير‬
placenta ‫ أال وهو الـ‬estrogen ‫يبقى فيه مصدر تاني للـ‬
24. Anti TPO Ab may be found in association with Graves', Hashimoto's or De Quervain's.EXAM2002
25. Papillary, follicular thyroid cancers are treated with ? total thyroidectomy followed by radioiodine-
131. EXAM 2004, 2018
26. Sulphonylureas can also be continued with insulin. If the patient is taking a daily isophane , it is
continued at the same dose with monitoring. With other insulins/regimens the dose can be halved or
the sulphonylurea discontinued if desired.
27. Addisonin combination + T1 DM +/- premature ovarian failure is Schmidt's disease (type 2
autoimmune polyendocrine syndrome).
28. Alcohol , depression → pseudo-cushing.
29. Kallmann's syndrome is associated with cleft palate , 1ry amenorrhea (like turner)

Turner →hypergonadotropic hypogonadism ‫إال أن الـ‬

30. Pregnancy →↑Total T3, T4 (not free)

31. Markedly ↑↑↑ oestrogen and PRL occurs at 12 weeks gestation.

32. Postpartum thyroiditis
 Occurs in approximately 5%.
 Initial hyperthyroidism, for 2-6 months post-parum then hypo.
 Usually resolves but permanent hypothyroidism may occur.

33. Again: In hypoadrenalism which is either primary or secondary, the addition of thyroxine can
precipitate acute hypoadrenalism. ‫احذررررررررررررررررر‬
34. Random glucose is not diagnostic of diabete
35. synthetic oestrogen replacement not detectable on the traditional oestradiol assay.
‫ لكن االمر دا مش‬...‫ هتالقي الثيروكسين بيزيد في الدم‬...‫لو حد بياخد ثيروكسين بالفم‬.. ‫يعني على خالف مثال تحليل الثيروكسين‬
estrogen ‫بيحصل مع الـ‬
, so oestradiol level should not be requested whilst patient is taking the combined OCP.

estradiol undetectable. ‫ هيطلع لك ال‬.. exogenous estrogen intake ‫ في حالة الـ‬estradiol ‫ألنك لما تعمل تحليل‬

36. Take care: before sending patient to thyroidectomy, or radioactive iodine , you must achieve an
euthyroid state.
37. In Familial hypocalciuric hypercalcaemia : Ca & Mg are ↑ in serum. PTH normal.NO TTT.
‫ ولكن تفرقهم عن بعض بالـ‬symptoms &blood labs. ‫ في الـ‬hyperparathyroidism ‫بتبقى بالظبط شبه الـ‬
Positive family history &the markedly low urine calcium excretion. Unlike hyperparathyroidism it is
not associated with any specific abnormality, is benign and requires no treatment.
dopamine agonists. ‫ بنستخدم‬prolactionmas ‫ علشان كدا في عالج الـ‬PRL ‫ هو عدو الـ‬Dopamine .38
 2012 ‫ سؤال‬.. ‫ أفضل‬Cabergoline ‫( والـ‬cabergoline and bromocriptine).

39. Which hormone has a role in fetal lung maturation? PRL

40. What is the marker of bone formation? APO : ALP /Procollagen type 1 /osteoclastin.
41. What are the markers of bone resorption? Telo/TRAP/Proline/Pyridin.
Telopeptides /Tartrate-resistant acid phosphatase (TRAP / Pyridinium /Hydroxyproline.
42. Sick euthyroid state → ↑ reverse T3 (rT3) ‫ وليس الـ‬T3

43. Metformin and acarbose are not licensed for the treatment of IFG.
44. Phases of insulin response:

The major event that occurs in DM is: Loss

of 1st phase insulin response→ post-
prandial hyperglycemia.

Anti IA2 ab occurs in Type 1 DM.

45. TTT of diabetic neuropathy:

 1st line: Duloxetine (contraindicated in glaucoma).

 2nd line: Amitriptyline (contraindicated in glaucoma).
 3rd line: Pregabalin or gabapentin. (pREgabaline is safer than gabapentine in REnal failure).

EXAM 2013 Capsaicin ‫في هذه الحالة استخدم‬..urinary retention ‫كلهم بيعملوا‬

46. Diabetic amyotrophy:

Form of neuropathy: due to inflammation rather than chronically poor glycaemic control. ‫يعني ممكن تظهر في‬
‫مريض عنده السكر مبقالوش سنتين تالتة‬

 Higher incidence amongst type 2 diabetics.

 Often affects the femoral nerve, lumosacral plexus or lumbar roots.
 S/S: pain in the hip, buttock or thigh with associated weakness. There is often little sensory loss.
 Plantar responses may be flexor or extensor.
 EMG: shows multifocal denervation in paraspinous & leg muscles.
 Partial or complete resolution occurs with control of hyperglycemia.

47. De Quervain's & Thyrotoxicosis factitia →↓ isotope uptake on thyroid scanning.

48. Patient with thyroid eye disease came with impaired colour perception ? ‫عمى ألوان‬
 This is Optic neuritis , TTT is hihgh dose steroids, if failed → surgical decompression.EXAM2018
49. Propylthiouracil is best used in breast feeding mothers.
50. Patients taking OCP will have unrecordable ostradiol levels ‫من تاني‬
51. Oestrogen therapy ( ‫ شهور حمل ألن االستروجين فيهم عالي‬3 ‫↑→ )أو حتى في أول‬TBG in the serum →↑total
thyroxine→ misleading (& you suspect that the patient is having hyperthyroidism).
So , if a patient receiving OCP ,& you want to check thyroid status, use free thyroxine.
EXAM2002
52. Erythromycine (enzyme inhibitor)→ ↑level of carbimazole →accelerates shifting of ptn. From
hyperthyroid to hypothyroid state (evidenced by ↑ TSH).
53.
:‫ ييجوا بالتحليل اآلتي‬Hypothyroid ‫ جدا إن مرضى الـ‬Common

Normal T4 , Low T3 , high TSH

‫؟‬.‫ يبقى عالي‬T4 ‫ طب ايه اللي مخلي الـ‬..‫ يكونوا قليلين‬T4 & T3 ‫الطبيعي انك تكون متوقع إن الـ‬

T4 ‫ فرفعت له الـ‬...‫ قبل ما يجي‬Thyroxine ‫ المريض افتكر انه عنده تحليل اليوم فأخد حبوب الـ‬...‫ببساطة شديدة جدا‬

Non compliance to TTT. ‫ اللي بيعمل الصورة اللي فوق دي هي الـ‬... ‫يعني باختصار‬

54. Radioactive iodine (RAI):

Long-term remission following antithyroid drugs is only 15%, with the vast majority relapsing.

Thus, frequently, radio-iodine is advocated as a primary treatment - particularly for multi-nodular or toxic solitary
nodules.

However, approximately 80% will have long-term hypothyroidism following radio-iodine.

There is no evidence of increased risk of thyroid neoplasia or gastric neoplasia following radioactive iodine.

Goiter shrinkage may occur in up to 30% following RAI.

55. In the early stages of pregnancy the TSH is suppressed due do the effect of beta HCG.
56. Cyproterone acetate is an anti-androgen which may have a role in the treatment of prostatic
carcinoma.
57. TTT of Paget’s disease : Bisphosphonate.
 58. Management of HHS:

In HHS; hyperglycemia →osmotic diuresis → the patient will be very dehydrated. (, so there is
hypernatremia (Na may reach 170)).
 1st step: 1 L of normal saline =0.9% will replace the extracellular volume (as it remains in the
extracellular compartment).

If still there is hypotension/or/ postural drop give;

 2nd step : 0.45% saline (replaces intra and extracellular fluid loss). EXAM 2006
 3rd setp: Once glucose reached 15, add 5% dextrose .
Electrolytes should be checked 2-4 hourly, aiming a decrease of Na of no quicker than 10 mmol/day, and patients
managed in a high care environment.

59. Tetracycline→ Nephrogenic DI.

60. TTT of Congenital Nephrogenic DI: ‫فياجرا‬
 Sildenafil: the best.
 Thiazide (not loop), NSAIDs (eg.Indomethacin).
61. PRL level is of no clinical use in prenancy as they will always be elevated.
62. Glucagon response to the mixed meal test is significantly ↑↑↑ in patients with new onset Type 1 DM.

63. Diabetic cheiroarthropathy (= Prayer sign): EXAM 2006

Limited joint mobility that occurs in longstanding DM:

 50% of Type I.
 75% of Type II.
Thickening of the skin → contracture of the fingers.
Affects both hands.

TTT:

 Pain killer and/or anti-inflammatory.

 Physiotherapy.
 Tight glycaemic control.
 64. TTT of hirsutism in PCO: Dianette, a combination of cyproterone acetate and ethinyloestradiol.

65. Mannitol-induced diuresis: polyuria, hyponatraemia , and ↑serum osmolality.

66. Lasix –induced diuresis: polyuria, hyponatraemia , and ↓serum osmolality.
67. Cerebral salt wasting syndrome: polyuria, hyponatraemia , and ↓serum osmolality (there is urinary
Na loss).
68. Estradiol:
 ↑ in Pregnancy.
 Normal or elevated in PCOS.
 ↓ in Cushing's.

69. MEN-1 is associated with pancreatic endocrine tumours, 60% of which are gastrinomas.
70. T3 toxicosis should be suspected in patients with symptoms of thyrotoxicosis (including a goitre) in whom
serum T4 and fT4 are normal or low , but the iodine uptake is high.
71. Jod-Basedow effect
72. Wolff-Chaikoff effect & Jod Basedow effects;

‫كل حاجة هنا زايدة ما عدا؟‬ ‫كل حاجة هنا قليلة ماعدا؟‬

Goiter. No Goiter
,so Amiodarone (contains iodine) can cause Jod-Basedow effect (AIT Thyroid auto ab Present Absent EXAM2013
I)(=hyperthyroidism) ‫طب ازاي هتفرق ما بينه ومابين الـ‬AIT II?
↑ Uptake ↓ Uptake
Do iodine uptake: In AIT II there is ↓ uptake.in Jod →↑ uptake.
CFD: ↑ flow ↓ Flow

IL6↑ IL6↑↑↑(coz inflammation)

Amio should be stopped in AIT.CFD is superior to

IL-6 in differentiating between type I & II
73.

74. ↑ Sun exposure →↑ vitamin D→↑ Ca.

75. Once there is a thyroid nodule. So the investigations are as follows:
 US (it can show cystic nodules 2 mm or greater/or solid nodules 3 mm or greater)
 FNA (, so US localizes the site of nodules , then go with FNA).FNA if lesion is solitary.
 RAIU.
 If FNA showed equivocal lesions, then use excision biopsy.
76. Malignant nodules do not uptake iodine.
77. Sitagliptin → GI upset (common Q.)
78. What is the importance of 11-B hydroxylase?
It converts:
11-deoxy corticosterone →corticosterone &
11-deoxy cortisol → cortisol.
, so if it is deficient , there will be ↑ level of these steroid hormones (11 deoxy cortisol, 11 deoxy
corticosterone).
 79. Lithium → inhibits glycogen synthase kinase type 3 beta (GSK3-B) →hypofunction of the
aquaporin-2 water channel → nephrogenic DI. Withdrawal of lithium can lead to an improvement
in symptoms.
80. SGLT-1 transporter found predominantly in the gut, and is responsible for glucose absorption.
81. SGLT-2 transporter in the kidney→ Hyperglycaemia→ Na &water excretion→ dehydration in
patients with significant hyperglycaemia.
82. RAIU:
High uptake =graves/toxic adnoma/TMNG/AIT I) hyperthyroid conditions
Low uptake= thyroiditis / iodine-induced (whether thyrotoxicosis factitia /AIT II).
Patchy uptake: TMN goiter/ thyroid cancer (most commonly papillary thyroid carcinoma). EXAM
2005.
83. Types of OCP :
➢ POP (progesterone only pills).
➢ COCP (combined = progesterone + estrogen).
84. Hyponatremia in SIADH TTT : Fluid restriction , if failed >>> demeclocycline. Saline infusion only
if there is risk of seizures (not confusion). EXAM 2012
85. Female with PCO + dysmenorrhea , how to regularize cycle?: 2012 ‫سؤال‬
 If pregnancy is planned: use Metofrmin → regularize cycle + ↑fertility.
 If pregnancy is not planned: uses Dianette → regularize cycle + no effect on fertility.
86. TTT of Prolactinoma is ? Dopamine agonist , which agent better cabergoline/Bromocriptine?
Cabergoline. EXAM 2012
87. TTT of acromegaly: Somatostatin analouges (octeriotide)
88. Sitagliptin , Liraglutide does not cause hypoglycemia.
89. 1ry Hypothyroidism →↑ PRL .‫سؤال مهم‬
90. PRL ↑ , is it Macroprolactinoma or non-functioning pituitary adenoma compressing the gland &
causing ↑ of PRL ?

Ans: Look @ PRL level if:

→ >5000 = Macroprolactioma.
→ <5000 = non-functioning pituitary adenoma (responds poorly to dopamine agonist
or somatostatin therapy)  EXAM2012 , EXAM2018
91. Patient suspected pheochromocytoma , you found a mass in adrenal gland by CT , How to
confirm/localize pheochromocytoma? Ans: MIBG scan EXAM2013
92. Hypothyroidism in pregnancy, Target is T4, not TSH; the target is to keep T4 on the upper normal.
EXAM2013
93. Propylthiouracil >>>hepatotoxicity.
 94. Patients who had extensive pituitary surgery, if they suffered hypothyroidism , & you are replacing
Levothyroxine , do not depend on TSH in F/UP (because it will be low) EXAM2013
95. Phenytoin → thyroiditis-type picture.
96. SGLT-2 inhibitors →↑ PTH → bone turnover, ↑ Gout. (Core Q).
97. DPP-4 inhibitors were not studied in DM with cardiovascular disorders, so beter to avoid.
Anabolic steroids? ‫ ازاي تعرف اذا كان المريض بياخد‬.98

Normally: The ratio of testosterone to DHEA is between 1:1 and 2:1.If you found the ratio of 4:1 or
greater= exogenous administration of testosterone.

99. Lady with 21 hydroxylase↓, she is now pregnant, how to manage her steroids? EXAM2013
Ans: according to free testosterone level. Measure it every 6 weeks in the first trimester, then every
8 weeks thereafter.
100. Congenital Adrenal hyperplasia: Hirsutism is present in a female. Progesterone , Testosterone ↑.21
hydroxylase↓
 Classical (CAH) : Severe form (because hydroxylase activity is ZERO) , present in infancy =
Verilization+ Salt wasting, the most common cause of ambiguous genitalia in genotypically
normal female infants.
 Non classical (NCAH) = Mild form (because hydroxylase activity 20-50%) , in adulthood
=Virlization without salt wasting

EXAM2014

101. Glucagon stimulation test as insulin stress test , both used in Dx of GH ↓ EXAM2014

102. Pretibial myxoedema does not need TTT, unless there is significant pain and discomfort, topical
fluocinolone is the 1st line treatment.
103. Cushing or pseudo-Cushing? In both , you may find ↑ urinary cortisol.
 If Urinary cortisol > 3 folds of normal =Cushing
104. TTT of :
1. De Quervian thyroiditis: (temporary ↑ in thyroxin release for 6 weeks)
 For pain: NSAID.
 For temporary thyrotoxicosis : use propranolol. (NO anti-thyroid drugs).
105. Fecal elastase is a single test taken from a random stool sample, for pancreatic
insufficiency.
106.
107. Asymptomatic subclinical hypothyroidism follow up:
➢ If Anti-TPO –ve: Follow up every 3 years.
➢ If Anti-TPO +ve: Follow up every 1 year.
108. Empagliflozine (SGLT-2 inhibitor) →↓ cardiovascular events. Unlike sulfonylureas.
109. Head trauma, complicated with cranial DI, what to do?
 Observe for few weeks (coz, usually it is temporary).
 If no improvement give Desmopressin
110.
111. Lugol’s iodine is used for short term period in thyrotoxic patients going to surgery.
112. Calcium (used in osteomalacia) →↓ absorption of Levothyroxine → poor control of
hypothyroidism. .‫إنما يخلي بينهم كم ساعة‬...‫قول للمريض مياخدش الكالسيوم مع الثيروكسين في نفس الوقت‬
October EXAM 2018
113. DM in pregnancy: lifestyle →metformin →Insulin →sulfonylurea (safe, give only if
ptn is refusing insulin).
114. Significant thyroid eye disease , how to TTT?
 Oral Prednisolone 30-40 mg , no need for high dose (effect is the same).
 If sight threatening >>use IV methyl prednislone.
115. Hint : Patient receiving Metformin may suffer lactic acidosis due to metformin therapy,
in this case→ look @ ketone bodies ,
→ If you found them markedly elevated, so this is a DKA.

→ If the elevation of ketone bodies in urine was mild to moderate (<1.5), so this is Lactic
acidosis, not DKA. EXAM2018
ketone bodies. ‫ ممكن يكون معاها هي كمان ارتفاع بسيط في الـ‬lactic acidosis ‫يعني باختصار الـ‬
116. What is the 1st thing to give in hypercalcemia? Fluid.
117. What is the most effective thing to lower hypercalcemia? Pamidronate , then calcitonin
(more than IV fluid) EXAM2018
118. Acarbose is contraindicated if eGFR <25
119.
120.