MRCPI GM Part II Written cheat sheet

Sodium correction in chronic hyponatraemia: raise serum Na by ≤8–10 mmol/L in the first 24 h to avoid osmotic demyelination; use 3% saline only for seizures or coma.

Corrected calcium (mg/dL) = measured Ca + 0.8 × (4.0 − serum albumin g/dL); in SI units add 0.02 mmol/L per g/L of albumin below 40 g/L.

Anion gap = Na − (Cl + HCO3); normal 8–12 mmol/L; add ~2.5 mmol/L to the gap for every 1 g/dL fall in albumin.

Serum osmolality (mOsm/kg) ≈ 2×Na + glucose/18 + urea/2.8 (conventional units); measured–calculated gap >10 suggests unmeasured osmoles (methanol, ethylene glycol, mannitol).

Wells score for DVT: ≥2 points = likely; for PE: >4 = likely; a negative age-adjusted D-dimer (age × 10 µg/L FEU over 50) safely excludes PE in low/intermediate probability.

CURB-65 (confusion, urea >7 mmol/L, RR ≥30, BP systolic <90 or diastolic ≤60, age ≥65) - 0–1 manage at home, ≥2 consider admission, ≥3 severe.

HbA1c reflects mean glucose over ~8–12 weeks; estimated average glucose (mmol/L) = 1.59 × HbA1c(%) − 2.59.

Metformin should be withheld when eGFR <30 mL/min/1.73 m² and dose-reviewed at eGFR 30–45; it is the first-line agent unless contraindicated.

Frailty phenotype (Fried): unintentional weight loss, exhaustion, low grip strength, slow gait speed, low physical activity - ≥3 criteria = frail, 1–2 = pre-frail.

Comprehensive geriatric assessment reduces mortality and institutionalisation when delivered by a coordinated multidisciplinary team to frail older inpatients.

STOPP/START criteria: STOPP flags potentially inappropriate prescriptions (e.g. benzodiazepines, anticholinergics, NSAIDs in CKD); START flags omitted indicated therapies (e.g. statin in established CVD, vitamin D in falls).

Anticholinergic burden scales (e.g. ACB) predict falls, delirium and cognitive decline; tricyclics, oxybutynin and antihistamines are high-burden agents.

Delirium: hyperactive, hypoactive and mixed subtypes; hypoactive delirium is most often missed and carries the worst prognosis.

Falls assessment should cover gait/balance, vision, footwear, postural BP, medication review, vitamin D and home hazards; multifactorial intervention reduces falls.

Deprescribing principle: taper drugs with withdrawal risk (benzodiazepines, antidepressants, opioids, beta-blockers, PPIs) rather than stopping abruptly.

Rehabilitation dosing: task-specific, progressive and high-intensity practice (e.g. ≥45 min physiotherapy several times weekly) improves post-stroke and post-fracture outcomes.

Sepsis-3: suspected infection plus SOFA increase ≥2; septic shock = vasopressor need to keep MAP ≥65 mmHg with lactate >2 mmol/L despite fluids.

Surviving Sepsis: 30 mL/kg crystalloid within the first 3 h for sepsis-induced hypoperfusion, blood cultures before antibiotics, antibiotics within 1 h of recognition.

Anaphylaxis: IM adrenaline 0.5 mg (0.5 mL of 1:1000) into the anterolateral thigh, repeated every 5 min; antihistamines and steroids are adjuncts only.

Acute coronary syndrome: STEMI requires primary PCI within 120 min of first medical contact; if unavailable, fibrinolysis within 30 min of arrival.

ARDS Berlin definition: onset within 1 week, bilateral opacities, P/F ratio ≤300 mmHg on PEEP ≥5 cmH2O; lung-protective ventilation 6 mL/kg predicted body weight.

Acute upper GI bleed: Glasgow-Blatchford score ≤1 identifies very low risk suitable for outpatient management; endoscopy within 24 h for most, immediately if haemodynamically unstable.

Diabetic ketoacidosis: fixed-rate IV insulin 0.1 units/kg/h, add 10% glucose when capillary glucose <14 mmol/L, and continue insulin until ketones clear and pH normalises.

Status epilepticus: benzodiazepine first line (IV lorazepam 4 mg or IM midazolam 10 mg), then levetiracetam, valproate or phenytoin; consider anaesthesia if refractory.

Heart failure with reduced EF: quadruple therapy (ACEi/ARB or ARNI, beta-blocker, MRA, SGLT2 inhibitor) reduces mortality and is indicated for EF ≤40% with symptoms.

CHA2DS2-VASc: 1 point each for CHF, hypertension, age ≥75, diabetes, stroke/TIA (2), vascular disease, age 65–74, female sex; anticoagulate at score ≥2 in men, ≥3 in women.

Atrial fibrillation rate control: beta-blocker or non-dihydropyridine calcium channel blocker first line; digoxin for sedentary patients or those with HFrEF and inadequate control.

Aortic stenosis severity: severe if peak velocity ≥4 m/s, mean gradient ≥40 mmHg, or valve area <1.0 cm²; symptoms or LV dysfunction mandate intervention.

Pericarditis: diffuse ST elevation with PR depression, pleuritic pain and positional worsening; treat with NSAID plus colchicine, avoid anticoagulation if possible.

Infective endocarditis: modify Duke criteria; three sets of blood cultures from separate sites before antibiotics; surgery for heart failure, uncontrolled infection, or large vegetations.

Hypertrophic cardiomyopathy: asymmetric septal hypertrophy, systolic murmur increasing with Valsalva; beta-blockers first line, implantable defibrillator for high-risk features.

Acute pulmonary oedema: sit upright, high-flow oxygen or NIV, IV loop diuretic, and nitrates if systolic BP >110 mmHg; avoid nitrates in hypotension or aortic stenosis.

COPD: post-bronchodilator FEV1/FVC <0.70 confirms airflow obstruction; GOLD grades 1–4 by FEV1 percentage predicted (≥80, 50–79, 30–49, <30).

Asthma: FeNO ≥50 ppb or blood eosinophils ≥300 cells/µL predict response to inhaled corticosteroids and biologics.

Pneumothorax: tension requires immediate needle decompression in the second intercostal space mid-clavicular line or fifth space anterior axillary line.

Pulmonary embolism: high-sensitivity troponin and RV strain on CT predict early mortality; low-risk PE (PESI I–II or sPESI 0) may be managed as an outpatient.

OSA: apnoea–hypopnoea index ≥5 with symptoms, or ≥15 regardless of symptoms, defines obstructive sleep apnoea; CPAP is first-line therapy.

Pleural effusion: Light's criteria - exudate if protein ratio >0.5, LDH ratio >0.6, or pleural LDH > two-thirds the upper limit of normal serum LDH.

Tuberculosis: four-drug regimen (rifampicin, isoniazid, pyrazinamide, ethambutol) for 2 months, then rifampicin plus isoniazid for 4 months for drug-sensitive disease.

Idiopathic pulmonary fibrosis: high-resolution CT shows usual interstitial pneumonia with honeycombing and basal-predominant reticulation; antifibrotics slow progression.

Coeliac disease: check IgA tissue transglutaminase with total IgA (IgA deficiency causes false negatives); duodenal biopsy while on a gluten-containing diet confirms diagnosis.

Inflammatory bowel disease: faecal calprotectin differentiates IBD from irritable bowel syndrome; >250 µg/g warrants further investigation.

Acute pancreatitis: diagnose with 2 of 3 criteria (typical pain, lipase >3× upper limit, imaging); early management is aggressive fluids and enteral nutrition.

Hepatorenal syndrome: functional renal failure in cirrhosis; terlipressin plus albumin is first-line, and liver transplantation is definitive.

Hepatitis B: HBsAg positive with IgM anti-HBc indicates acute infection; HBeAg positivity reflects high replication and infectivity.

Wilson disease: low caeruloplasmin, Kayser–Fleischer rings, high urinary copper and Coombs-negative haemolytic anaemia; treat with chelation.

Barrett's oesophagus: intestinal metaplasia on biopsy; surveillance intervals depend on dysplasia grade, and high-grade dysplasia warrants endoscopic eradication.

Spontaneous bacterial peritonitis: ascitic polymorphonuclear count ≥250 cells/mm³ is diagnostic; start third-generation cephalosporin without waiting for culture.

Thyroid: TSH is the first-line test; a suppressed TSH with normal free T4 indicates subclinical hyperthyroidism, and radioiodine or antithyroid drugs are options.

Addisonian crisis: give IV hydrocortisone 100 mg immediately, then 100–200 mg/24 h, with 1 L 0.9% saline over the first hour; do not delay for cortisol results.

Phaeochromocytoma: measure plasma free metanephrines; alpha-blockade (phenoxybenzamine or doxazosin) must precede beta-blockade to avoid hypertensive crisis.

Cushing syndrome: 1 mg overnight dexamethasone suppression test, late-night salivary cortisol and 24-h urinary free cortisol are first-line screening tests.

Hypercalcaemia: PTH low suggests malignancy or vitamin D excess; PTH high suggests primary hyperparathyroidism - check with calcium, phosphate and PTH together.

Acromegaly: IGF-1 screening followed by oral glucose tolerance test showing failure to suppress GH; trans-sphenoidal surgery is first-line.

Hypothyroidism in pregnancy: levothyroxine requirement rises by 25–50% in the first trimester; target trimester-specific TSH ranges.

Diabetic foot: probe-to-bone test and plain radiograph first; MRI for suspected osteomyelitis, and urgent surgical review for deep infection or ischaemia.

AKI KDIGO: rise in creatinine ≥26.5 µmol/L within 48 h, or ≥1.5× baseline within 7 days, or urine output <0.5 mL/kg/h for 6 h.

Hyperkalaemia with ECG changes (peaked T waves, wide QRS): give IV calcium gluconate first for cardiac protection, then insulin–dextrose and salbutamol.

Nephrotic syndrome: proteinuria >3.5 g/day, hypoalbuminaemia, oedema and hyperlipidaemia; biopsy is usual in adults.

Nephritic syndrome: haematuria with red cell casts, hypertension and oliguria; post-streptococcal glomerulonephritis is a classic cause in children.

ACE inhibitors and ARBs reduce proteinuria and slow progression in diabetic nephropathy; check potassium and creatinine 1–2 weeks after starting.

Minimal change disease: abrupt nephrotic syndrome, normal light microscopy, effacement of podocyte foot processes on electron microscopy; steroid-responsive.

Renal replacement: start urgently for refractory hyperkalaemia, acidosis, pulmonary oedema, uraemic pericarditis or encephalopathy, and some poisonings.

IgA nephropathy: mesangial IgA deposits; ACE inhibitor or ARB is first-line for proteinuria, with immunosuppression for rapidly progressive disease.

Acute ischaemic stroke: non-contrast CT excludes haemorrhage; IV thrombolysis within 4.5 h of onset, and mechanical thrombectomy up to 24 h in selected large-vessel occlusion.

NIHSS quantifies stroke severity (0–42); a score ≥6 typically prompts consideration of thrombectomy in anterior circulation occlusion.

Multiple sclerosis: dissemination in space and time on MRI; oligoclonal bands in CSF support diagnosis, and high-dose steroids treat acute relapses.

Myasthenia gravis: fatigable weakness, ptosis and diplopia; anti-acetylcholine receptor antibodies in most; pyridostigmine plus immunosuppression.

Guillain–Barré syndrome: ascending symmetrical weakness with areflexia, albuminocytological dissociation in CSF; IV immunoglobulin or plasma exchange.

Parkinson disease: levodopa plus carbidopa is most effective for motor symptoms; dopamine agonists are preferred in younger patients to delay dyskinesia.

Temporal lobe epilepsy: automatisms, déjà vu and post-ictal confusion; carbamazepine or lamotrigine are first-line for focal seizures.

Raised intracranial pressure: headache worse lying flat, vomiting and papilloedema; urgent imaging before lumbar puncture to avoid herniation.

Rheumatoid arthritis: anti-CCP has higher specificity than rheumatoid factor; early methotrexate within 3 months of diagnosis improves outcomes.

Gout: joint aspiration showing needle-shaped negatively birefringent crystals is diagnostic; start urate-lowering therapy with allopurinol, titrated to target urate <360 µmol/L.

Giant cell arteritis: ESR often >50 mm/h; give high-dose glucocorticoids immediately and arrange temporal artery biopsy or ultrasound within 2 weeks.

Polymyalgia rheumatica: shoulder and hip girdle pain with morning stiffness and raised inflammatory markers; low-dose prednisolone gives rapid response.

Systemic lupus erythematosus: anti-dsDNA and anti-Smith are specific; complement C3/C4 fall during active disease, and hydroxychloroquine is baseline therapy.

ANCA vasculitis: c-ANCA/anti-PR3 associates with granulomatosis with polyangiitis; p-ANCA/anti-MPO with microscopic polyangiitis; urgent immunosuppression.

Antiphospholipid syndrome: recurrent thrombosis or pregnancy loss with lupus anticoagulant, anticardiolipin or anti-beta2-glycoprotein antibodies; anticoagulate with warfarin.

Ankylosing spondylitis: sacroiliitis on imaging plus inflammatory back pain; NSAIDs first line, then TNF inhibitors or IL-17 inhibitors.

Iron deficiency anaemia: low ferritin (<15 µg/L) is diagnostic; ferritin is an acute-phase reactant, so a normal value does not exclude deficiency in inflammation.

B12 deficiency: macrocytic anaemia with neurological signs; treat with IM hydroxocobalamin, and check folate before or alongside to avoid masking.

Microangiopathic haemolytic anaemia with thrombocytopenia and AKI suggests TTP; urgent plasma exchange is life-saving and should not wait for ADAMTS13.

Chronic myeloid leukaemia: Philadelphia chromosome t(9;22) with BCR-ABL1; tyrosine kinase inhibitors (imatinib) achieve durable remission.

Multiple myeloma: CRAB features (calcium raised, renal failure, anaemia, bone lesions) plus M protein; serum free light chains aid monitoring.

Neutropenic sepsis: start empirical anti-pseudomonal beta-lactam within 1 h of presentation, regardless of fever severity.

Warfarin reversal: vitamin K plus prothrombin complex concentrate for major bleeding; fresh frozen plasma is an alternative if PCC unavailable.

Heparin-induced thrombocytopenia: platelet fall 5–10 days after starting heparin with thrombosis; stop heparin and start a non-heparin anticoagulant.

Tumour lysis syndrome: hyperkalaemia, hyperphosphataemia, hyperuricaemia and hypocalcaemia after chemotherapy; treat with aggressive hydration and rasburicase.

Febrile neutropenia is a medical emergency; a single oral temperature ≥38.3 °C or ≥38.0 °C sustained over 1 h in neutropenia mandates urgent assessment.

Spinal cord compression: back pain with neurological signs in cancer requires urgent MRI within 24 h and dexamethasone 16 mg daily.

Superior vena cava obstruction: facial swelling, distended neck veins and dyspnoea; urgent imaging, and stenting or radiotherapy for malignancy.

Malignant hypercalcaemia: IV 0.9% saline rehydration first, then zoledronic acid or denosumab; calcitonin for rapid but temporary control.

Lung cancer staging: non-small cell uses TNM 8th edition; small cell is staged limited versus extensive, with platinum–etoposide chemotherapy.

Breast cancer: oestrogen receptor positivity predicts response to endocrine therapy; HER2 positivity warrants trastuzumab-based regimens.

Colorectal cancer screening: faecal immunochemical testing or colonoscopy; Lynch syndrome screening uses mismatch repair immunohistochemistry.

Community-acquired pneumonia: CURB-65 guides site of care; amoxicillin first line in the UK, with macrolide added for atypical cover in severe disease.

Meningococcal meningitis: give IV ceftriaxone immediately; add dexamethasone before or with the first antibiotic dose in suspected pneumococcal meningitis.

HIV: start antiretroviral therapy regardless of CD4 count; check baseline resistance, HLA-B*5701 before abacavir, and screen for hepatitis B and C.

Tuberculosis infection: latent TB is treated with rifampicin plus isoniazid for 3 months or isoniazid for 6 months; active disease needs full multidrug therapy.

Clostridioides difficile: stop unnecessary antibiotics; oral vancomycin or fidaxomicin for severe disease; avoid antimotility agents.

Malaria: thick and thin films plus rapid antigen test; falciparum with severe features needs IV artesunate, not oral therapy.

Endocarditis prophylaxis is reserved for high-risk patients (prosthetic valve, previous endocarditis, certain congenital lesions) undergoing dental procedures.

Sepsis from urinary source: obtain urine culture before antibiotics; nitrofurantoin is not suitable for pyelonephritis because tissue penetration is poor.

Stevens–Johnson syndrome and toxic epidermal necrolysis: mucosal involvement with epidermal detachment; withdraw the culprit drug and manage in a burns or critical care unit.

Pemphigus vulgaris: flaccid intraepidermal blisters with anti-desmoglein 3 antibodies; treat with systemic steroids and rituximab.

Bullous pemphigoid: tense subepidermal blisters with anti-BP180/BP230 antibodies; potent topical steroids are often first-line in limited disease.

Psoriasis: plaque disease with Auspitz sign; topical vitamin D analogues and corticosteroids for mild disease, methotrexate or biologics for severe.

Melanoma: Breslow thickness drives prognosis; seven-point checklist and ABCDE criteria aid recognition, and excision biopsy with 2 mm margins is diagnostic.

Basal cell carcinoma: pearly nodule with telangiectasia and rolled edge; surgical excision or Mohs micrographic surgery for high-risk sites.

Drug rash with eosinophilia and systemic symptoms: fever, rash, eosinophilia and organ involvement 2–8 weeks after starting a drug; stop the drug and give steroids.

Cellulitis: non-purulent infection usually streptococcal; flucloxacillin or a beta-lactam, with elevation and marking of the erythema border to track response.