Mrcpuk Part 1 Syllabus

MRCPUK Compiled and edited by the MRCP(UK) Part 1 Examining Board

Part 1 Syllabus

and published for the Federation of Royal Colleges of Physicians of the UK by the MRCP(UK) Central Office

Royal College of Physicians of Edinburgh

Royal College of Physicians & Surgeons of Glasgow

Royal College of Physicians of London

1

MRCPUK Part 1 Syllabus

MRCPUK

Part 1 Syllabus

Compiled and edited by the MRCP (UK) Part 1 Examining Board

MRCP (UK) Central Office Royal Colleges of Physicians

 1999 ROYAL COLLEGES OF PHYSICIANS Royal College of Physicians of Edinburgh 9 Queen Street Edinburgh EH2 1JQ Royal College of Physicians & Surgeons of Glasgow 234/242 St Vincent Street Glasgow G2 5RJ Royal College of Physicians of London 11 St Andrews Place Regents Park London NW1 4LE 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 permission of the copyright owners. First Published 1999

F OREWORD The MRCP (UK) Part 1 Examination for the Membership of the Royal Colleges of Physicians of the United Kingdom was introduced in October 1968. Since then there have been major developments in the study of medical education and the certification of competence worldwide. These developments have had an impact both on generic and specialist training. The Royal Colleges of Physicians are committed to the academic development of medical education and as part of that commitment are publishing a raft of publications covering various aspects of the MRCP (UK) Examination. The Syllabus for the MRCP (UK) Part 1 Examination is a key element in the Royal Colleges' on-going commitment to candidates and their tutors. This Syllabus covers those areas of knowledge tested in the MRCP (UK) Part 1 Examination. We believe that a thorough knowledge of common and important disorders is essential and that candidates should also have an understanding of basic sciences relevant to medical practice so that not only can physicians in training develop their full clinical and academic potential but also achieve success in the Examination. A major aim of the MRCP (UK) Part 1 Examination is to encourage candidates to read widely thereby providing a sound basis for continuing medical education.

It has been shown that over-reliance on tests of clinical

performance and clinical skills alone causes candidates to limit their study to those conditions that they see routinely on ward rounds and the result is that physicians in training do not read broadly about other common and important clinical problems and relevant clinical science.

I

The current Examination employs multiple true/false MCQs to test a large body of core knowledge which is at a level appropriate for this stage in a young physician's professional development. Our hope is that this Syllabus will assist candidates and their tutors in knowing the extent of knowledge required to pass the Examination. Although each diet will not test every area of knowledge detailed in the Syllabus, the Examination should be viewed as a representative sample of the items of knowledge set out in the following pages. The Syllabus should be used in conjunction with the MRCP (UK) Part 1 Examination papers which are being published simultaneously. This Syllabus could not have been produced without the considerable input of the following past and present members of the MRCP (UK) Part 1 Examining Board, though the Medical Secretary and Chairman of the Board bear prime responsibility for the edited script:

II

David Barnett

Frank Dunn

Nicholas Bateman

Christopher Ellis

Michael Besser

Paul Emery

Michael Buckley

Gordon Erskine

Desmond Canavan

Michael Ford

Nigel Cooke

Ray Fox

Jane Dacre

Roderick Hay

John Dagg

Parveen Kumar

Kar Neng Lai

John Scadding

Kok-Onn Lee

John Thomson

Ken Lim

Allister Vale

Gary Love

John Walls

Christopher McManus

Alexander Wong

Christine Rodger

Andrew Zealley

In addition, the comments of Kate Horne and Jim Benson, both of Central Office, are acknowledged gratefully.

Barbara Reeves prepared the

manuscript for press notwithstanding multiple revisions. John Reid of Metro Press was a constant source of assistance as this series of books on the MRCP (UK) was produced. Kenneth Cochran and John Thomson generously assisted with proof reading. It is intended that the 2000/2001 Syllabus will be published in late 2000 to reflect the further changes to the Examination which have been agreed in principle by the MRCP (UK) Policy Committee. Jane Dacre

Allister Vale

Medical Secretary

Chairman

MRCP (UK) Central Office 11 St Andrews Place London NW1 4LE November 1999

III

C ONTENTS Introduction Entry requirements Purpose and academic aims Content of the Examination Assessment of a candidate's performance Quality of the Examination Syllabus Genetics Cell, molecular and membrane biology Anatomy Physiology, biochemistry and metabolism Immunology Immunology and immunological tests Clinical conditions Management Infectious diseases and tropical medicine Microbiology Immunology of infectious diseases Pathophysiology Epidemiology Treatment Specific infections Statistics, epidemiology and evidence-based medicine Descriptive statistics Graphical techniques Inferential techniques Evidence-based medicine Clinical trials Clinical haematology Iron metabolism Megaloblastic anaemias Haemolytic anaemias Other anaemias Polycythaemia and myeloproliferative disorders White cell disorders Disorders of haemostasis Clinical pharmacology, therapeutics and clinical toxicology Pharmacology Clinical pharmacokinetics

1 1 2 3 4 4 4 5 5 6 6 7 7 7 9 10 10 10 10 10 11 11 13 13 13 14 14 14 15 15 15 15 16 16 16 16 17 17 17

V

Monitoring drug therapy Adverse drug reactions Drug interactions Pharmacogenetics Therapeutics for specific patient groups Clinical toxicology Criteria for selecting drugs in a therapeutic class Drug formulations and routes of administration Rheumatology Clinical science Clinical conditions Investigations Management Cardiology Anatomy and physiology Pathophysiology and pathology Cell biology Clinical pharmacology Clinical cardiology Respiratory medicine Anatomy and physiology Pathophysiology and pathology Cell biology and genetics Clinical pharmacology Clinical conditions Neurology Neuroanatomy Neurophysiology Neurogenetics Cell biology Neuropharmacology Neuropathology Clinical neurology Psychiatry Mental state Aetiological factors in psychiatric illness Investigations Syndromes of psychiatric disorder and their treatment

VI

17 18 18 18 18 19 19 20 21 21 22 23 23 24 24 24 25 25 25 27 27 27 28 28 28 30 30 30 30 31 31 31 31 33 33 33 33 33

Psychiatric aspects of physical disease Mental retardation Gastroenterology Clinical science Clinical nutrition Disorders of the mouth, tongue and salivary glands Disorders of the oesophagus and stomach Functional disorders Disorders of the small intestine Disorders of the liver, biliary tree and pancreas The acute abdomen Inflammatory bowel diseases Colorectal disorders Endocrinology Thyroid Hypothalamus/Pituitary Adrenal Ovary Testis Growth Parathyroid/bone Diabetes mellitus Disorders of lipid metabolism Nephrology Physiology Molecular biology and genetics Glomerular and tubular disorders Infections of the kidney Calculus formation within the urinary tract Acute and chronic renal failure Hypertension and renal problems in pregnancy Drugs and the kidney Renal replacement therapy Dermatology Basic science Clinical dermatology Investigation Drugs and therapy

34 34 35 35 35 36 36 36 37 37 38 38 38 40 40 40 41 41 42 42 42 43 43 44 44 44 44 45 45 46 46 46 46 47 47 47 48 48

VII

I NTRODUCTION There are three Royal Colleges of Physicians in the United Kingdom: the Royal College of Physicians of Edinburgh, the Royal College of Physicians and Surgeons of Glasgow and the Royal College of Physicians of London. All three Colleges share a common Membership Examination; Part 1 was introduced in October 1968. Since January 1971, the Royal College of Physicians of Ireland has used the MRCP(UK) Part 1 Examination as the first part of its examination leading to Membership of the Royal College of Physicians of Ireland. In addition, the School of Postgraduate Medical Studies in Singapore uses the MRCP(UK) Part 1 Examination paper as Part 1 of its Master of Medicine (Singapore) degree. Although divided into two parts the MRCP(UK) is a single examination. MRCP(UK) Part 1 is not in itself a diploma, nor does it carry Membership status.

E NTRY

REQUIREMENTS

To meet the entry requirements for the Part 1 Examination, you must hold an acceptable medical qualification. You will not be admitted to the Examination before the expiry of 18 months from the date of your graduation. Further details are given in the Regulations.

1

P URPOSE

AND ACADEMIC AIMS

The Part 1 Examination is set at a level which is appropriate for medical graduates of some two years standing. The MRCP(UK) Part 1 Examination is designed to identify those physicians in training who have a broad knowledge and understanding of basic sciences relevant to medical practice as well as of common or important disorders. The MRCP (UK) has three main academic aims:

• To test a wide range of up-to-date medical knowledge so that physicians in training are encouraged to develop their full clinical and academic potential;

• To maintain and improve the practice of clinical medicine; • To provide a sound basis for continuing medical education. The practice of high quality medicine necessitates that you have knowledge of important new advances in disease mechanisms, an understanding of evidence-based medicine, and an ability to apply this knowledge and understanding in the management of patients. Preparation for the Examination will encourage you to acquire relevant knowledge and understanding. It is important that you develop skills and acquire professional habits which will enable you to keep abreast of current medical knowledge and new developments. Preparation for the Examination will help you to develop such skills and professional habits. Hence, reading the medical literature and attending relevant medical meetings should be a normal part of your professional life.

2

C ONTENT

OF THE EXAMINATION

The Examination currently consists of 60 multiple choice questions (MCQs) which are designed to test your knowledge of a wide range of topics in general medicine including the scientific basis of clinical practice.

As a general guide you will wish to know that there are some 14 clinical science MCQs in the Part 1 Examination and these are made up as follows: Genetics Cell, molecular and membrane biology Anatomy Physiology, biochemistry and metabolism Immunology Statistics, epidemiology and evidence-based medicine

1-2 2-3 2 5-6 2-3 1

In addition, questions are set on common or important clinical disorders as follows: Infectious diseases and tropical medicine Clinical haematology Clinical pharmacology, therapeutics and toxicology Rheumatology Cardiology Respiratory medicine Neurology Psychiatry Gastroenterology Endocrinology Nephrology Dermatology Sexually transmitted diseases

4 4 6 2 4 4 4 4 4 4 4 1 0-1

3

ASSESSMENT

OF A CANDIDATE ’ S PERFORMANCE

Your answer sheet is machine read and it is therefore imperative that you adhere strictly to the Examination instructions in completing your answer sheet. The MRCP(UK) Part 1 Examination currently assesses your performance in relation to that of other candidates and not by means of an external standard of performance set by the examiners. As a result the pass mark (but not the pass rate which is currently approximately 35 per cent) does vary at each Examination.

Q UALITY

OF THE EXAMINATION

The MRCP(UK) Part 1 Examining Board considers each question prior to its appearance in the paper and subsequently reviews each question’s performance. In addition to the final scores obtained by the candidates, the MRCP(UK) Part 1 Examining Board will also note the mean score for the Examination and the mean scores for, and the discriminatory power of, the questions that comprise the paper. A detailed analysis of the responses to each item (including a separate index of discrimination for every item), and a coefficient indicating the internal reliability of the Examination as a whole are also considered by the Board to ensure the quality of the Examination is maintained.

S YLLABUS No syllabus can be comprehensive. Hence, this Syllabus is indicative of those areas of knowledge with which you are expected to be familiar, but is not intended to be exhaustive or to exclude other items of knowledge which are of similar relevance. You can expect, however, that the majority of questions will test knowledge in the broad areas specified.

4

G ENETICS You should have an understanding of the structure and function of chromosomes and genes and a knowledge of the principles of inheritance of chromosomal and genetic disorders. Examples of question topics might include:

• Inherited diseases • Chromosome structure • Common chromosome abnormalities C ELL ,

MOLECULAR AND MEMBRANE BIOLOGY

The cell is the fundamental unit of the structure of organs. It is important that you understand the structure and function of the components of the cell and its membrane. You should understand how cells communicate internally and with each other by means of chemical substances and membrane receptors. Examples of question topics might include:

• Function of intracellular organelles • Cellular communication

5

A NATOMY Clinically relevant anatomy will be tested, including neuroanatomy. Examples of question topics might include:

• Peripheral nerve lesions • Cranial nerve abnormalities • Dermatomes, myotomes and reflexes P HYSIOLOGY,

BIOCHEMISTRY AND METABOLISM

It is essential that you understand the structure and function of the different organs which make up the body and how these organs interact, such as through hormonal and neural influences. You should know the broad principles of metabolism such as the production of energy and the pathways of carbohydrate, protein and lipid metabolism, but a detailed knowledge of the chemical processes in the steps of the metabolic pathways is not necessary. You should have an understanding of the principles of nutrition, water, electrolyte and acid-base balance. Knowledge of the physiology and biochemistry of each organ system is examined under that specialty. Examples of question topics might include:

• The mechanism of blood pressure control • Acid-base balance

6

I MMUNOLOGY Although a detailed knowledge of basic immunology and immunological diseases is not required, you should have a sound working knowledge of the principles of immunomechanisms. Examples of question topics might include:

• Humoral and cell-mediated immunity • Immunodeficiency syndromes • Phagocytic dysfunction diseases • Complement deficiencies • Hypersensitivities including allergies and autoimmune diseases Immunology and immunological tests You should have a basic knowledge of the immune system in health and disease. Examples of question topics might include:

• Common immunological laboratory tests • Evaluation of patients with immune disease • Intercellular communication and signal transduction • Lymphocyte and phagocytic cell biology • Antigen presentation • Humoral, cellular and mucosal immunity including • • •

TH1 and TH2

responses Inflammation Complement system and cytokines Hypersensitivity and autoimmunity

Clinical conditions You should be able to answer questions on the various immunodeficiency syndromes.

7

Examples of question topics might include:

• Mechanisms of immunodeficiency • Antibody immunodeficiency disorders • T-cell immunodeficiency disorders • Combined antibody and cellular immunodeficiency disorders • Phagocytic dysfunction diseases • Complement deficiencies You should know the main clinical characteristics and immediate management of acute allergic emergencies. Examples of question topics might include:

• Anaphylaxis • Angio-oedema • Urticaria You should be familiar with immunology as applied to other medical diseases. Examples of question topics might include immunomechanisms in:

• Rheumatic diseases (connective tissue diseases) • Endocrine diseases (thyroid autoimmune diseases, diabetes mellitus, • • • • •

8

Addison's disease) Haematological diseases (pernicious anaemia, autoimmune haemolytic anaemia, idiopathic thrombocytopenic purpura) Gastrointestinal diseases (Coeliac disease, inflammatory bowel disease, hepatobiliary diseases) Renal diseases (Goodpasture's syndrome, immune-complex glomerulonephritis) Dermatological diseases (discoid lupus, pemphigus, pemphigoid) Neurological diseases (demyelinating diseases, myasthenic syndromes)

Management You should be able to answer questions on the principles of immunosuppressive therapy including major indications and side-effects. Examples of question topics might include:

• Immunosuppressive drug therapy (corticosteroids, cytotoxic agents, and • • • •

cyclosporin) Intravenous immunoglobulin Monoclonal antibodies Cytokine therapy Bone marrow transplantation

You should know about the principles of immunisation and be familiar with vaccines currently in use.

9

I NFECTIOUS

DISEASES AND TROPICAL MEDICINE

Microbiology You should understand the major taxonomy of bacteria in terms of Gram-staining and aerobic/anaerobic metabolism. Virus classification is not important except for members and characteristics of the herpes group. Virus replication with reference to retroviruses should be understood. Major pathogenic protozoa and helminths should be known. Examples of question topics might include:

• Aerobic or anaerobic bacteria • Gram-staining characteristics of bacteria Immunology of infectious diseases You should understand immune deficiency states linked with types of opportunistic infections. Principles of immunisation and knowledge of vaccines currently used should also be known. Examples of question topics might include:

• Opportunistic infections • Immunisation policy Pathophysiology You should have a basic understanding of:

• Septic shock • ARDS • Role of cytokines in infection Epidemiology You should have knowledge of the principles of epidemiology relevant to infectious diseases.

10

Examples of question topics might include:

• Mechanisms of transmission of pathogens • How epidemics happen • Knowledge of carrier states, reservoirs, vectors and zoonoses • Elementary concepts of the control of communicable diseases (including •

immunisation, isolation, contact tracing, chemoprophylaxis of close contacts) Broad awareness of geographical variation in disease including TB, HIV, Hepatitis B, malaria

Treatment You should know the broad indications for, and major adverse effects of, commonly employed antimicrobial agents. Examples of question topics might include:

• B-lactams • Tetracyclines • Macrolides • Aminoglycosides • Quinolines • Trimethoprim • Metronidazole • Antituberculous drugs • Antimalarial drugs • Antiviral agents Specific infections Knowledge of the characteristics, recognition, prevention, eradication and pathological effects of all commonly encountered bacteria, viruses, rickettsia, fungi, protozoa, parasites and toxins, including an understanding of the principles of infection control, will be required. Special attention to differential diagnosis, appropriate investigations and awareness of when presumptive therapy is indicated is essential.

11

Examples of question topics might include:

• Septicaemia • Meningitis and encephalitis • Endocarditis • Pneumonia (community-acquired, • • • • • • • • • • • •

12

hospital-acquired, lung abscess, empyema) Tuberculosis PUO (appropriate investigations, when empirical therapy might be indicated) Soft-tissue infection and osteomyelitis Streptococcal infection, rheumatic fever, nephritis Intra-abdominal sepsis Food-poisoning (especially salmonellosis, campylo-bacter, verocytotoxin producing E coli) Tropical infections (especially malaria, bilharzia, amoebiasis, filariasis, leishmaniasis, hookworm and viral haemorrhagic fevers) Viral hepatitis HIV/AIDS (course of typical infection; CD4 count and HIV viral load as markers of progression; main opportunistic infections including Pneumocystis pneumonia, CNS toxoplasmosis, cryptococcal meningitis, tuberculosis) Glandular fever syndrome and its differentiation from HIV seroconversion illness Spirochaetosis - syphilis, leptospirosis, borrelia Toxic shock syndrome and staphylococcal infections

S TATISTICS , EPIDEMIOLOGY EVIDENCE - BASED MEDICINE

AND

You should have a basic understanding of the usage and limitations of the common statistical tests used in reporting the results of research in clinical journals. The following lists of terms should give some idea of the range of terms and techniques which you should understand, all of which can be found regularly in journals such as The Lancet, British Medical Journal and New England Journal of Medicine. You are not expected to have any knowledge of computer packages for carrying out statistical calculations. You may be expected to carry out simple calculations that do not require the use of a calculator. You are not expected to memorise formulae for statistical tests, but should understand their conceptual basis. The following lists are not intended to be inclusive but as illustrative of the type of knowledge that you need to possess.

Descriptive statistics Examples of question topics might include:

• Mean, median, mode • Standard deviation, standard error • Confidence interval • Variance • Range, quartile, inter-quartile range • Percentile • Skewness • Contingency table • Population • Missing values • Outliers Graphical techniques Examples of question topics might include:

• Histogram • Box-plot • Scattergram 13

Inferential techniques Examples of question topics might include:

• Null hypothesis • Alternative hypothesis • Parametric and non-parametric tests • Normal distribution • Type 1 and Type 2 errors • False positive and false negative • Statistical power • One and two-tailed tests • Statistical significance, P value • T-test • Mann-Whitney and Wilcoxon test • Chi-square test for 2 x 2 contingency table • Correlation (Pearson's and Spearman's) • Linear regression • Study design Evidence-based medicine You are expected to have an understanding of evidence-based medicine and an ability to apply this understanding in the management of patients.

Clinical trials Examples of question topics might include:

• Interpretation of simple clinical trial data • Randomisation • Placebo-controlled trial • Open trial • Single-blind trial • Double-blind trial • Intention-to-treat • Bias

14

C LINICAL

HAEMATOLOGY

You will be expected to have knowledge of the following:

• Physiology, control and function of formed blood elements • Bone marrow structure and function • Applications of biochemistry, genetics, immunology, and • • • • • •

virology to blood disorders Effects of age and pregnancy on blood disease Splenomegaly, lymphadenopathy, and their causes Principles and hazards of blood and blood product replacement therapy Principles, but not detail, of anti-tumour chemotherapy Principles of marrow transplantation Adverse effects of drugs on the blood

Iron metabolism You should have an understanding of:

• Physiology of iron, including its absorption • Iron overload • Iron deficiency states including diagnosis, causes and treatment • Iron metabolism, including anaemias of chronic disorders

and

sideroblastic anaemias

Megaloblastic anaemias You should understand the physiology of vitamin B12 and folic acid and the mechanisms and investigation of deficiencies and their management. Examples of question topics might include:

• B12 deficiency • Folate deficiency Haemolytic anaemias You should understand:

• Mechanisms of shortened red cell survival • Features and management of congenital and acquired haemolytic states 15

• Molecular

pathology haemoglobinopathies

of

thalassaemia

and

common

Examples of question topics might include:

• Causes of haemolysis • Diagnosis of haemolytic anaemia Other anaemias Examples of question topics might include:

• Anaemias complicating systemic disease • Aplastic anaemia • Myelodysplastic syndromes Polycythaemia and myeloproliferative disorders You should know the causes, investigation and management of polycythaemia and myeloproliferative disorders.

White cell disorders You should understand the:

• Physiology of leucocytes • Leucocytosis and leucopenia • Acute and chronic leukaemias, including diagnosis, management and •

prognosis Lymphoproliferative diseases including Hodgkin's disease, non-Hodgkin’s lymphomas, and plasma cell dyscrasias

Disorders of haemostasis You should possess knowledge of:

• Platelet function and coagulation • Thrombocytopenia and impaired platelet function • Thrombocytosis • Common congenital and acquired disorders of coagulation (especially anticoagulant therapy and disseminated intravascular coagulation)

16

C LINICAL

PHARMACOLOGY, THERAPEUTICS AND

CLINICAL TOXICOLOGY You are expected to have a good knowledge and understanding of the principles of clinical pharmacology, therapeutics and clinical toxicology.

Pharmacology You should understand the:

• Mechanisms by which drugs produce their pharmacological effects • Basic principles of agonism and antagonism • Clinical implication of drugs that act at different receptor sites • Links between the pharmacological effects of drugs at the molecular •

level, the cellular level, and the tissue/organ level, and how these are affected by disease processes and other drugs Principles by which both therapeutic and adverse effects occur

Clinical pharmacokinetics You should understand the principles that underlie:

• Processes of drug absorption and distribution • Biotransformation and excretion • Concepts of drug half-life and clearance • First order and zero order kinetics Application of this knowledge to clinical situations is necessary but detailed kinetic calculations will not be required.

Monitoring drug therapy You should understand the principles that underlie the monitoring of drug therapy including:

• Direct measurement of therapeutic response • Measurement of plasma drug concentrations • Knowledge of the scientific basis for the

measurement of drug concentration and its link to the principles of pharmacokinetics

17

Emphasis will be given to the areas of clinical practice and therapeutics where the narrow therapeutic range of particular pharmacokinetic properties of the drug make this approach important.

Adverse drug reactions You should have an understanding of the epidemiology of adverse drug reactions and know how to recognise and avoid them. You must also be aware of important adverse effects of commonly used drugs and have an understanding of the importance of adverse drug reaction reporting schemes.

Drug interactions You should have an understanding of the epidemiology of adverse drug interactions, and of the mechanisms by which interactions may occur. You should also have a knowledge of common drug interactions and their clinical consequences.

Pharmacogenetics You should understand the principles of pharmacogenetics and its importance in determining variations in response to drugs in man, both in terms of efficacy and toxicity. You should have knowledge of the clinical consequences of the common pharmacogenetic variations relevant to clinical practice.

Therapeutics for specific patient groups You should understand the principles of therapeutics as they apply in the following circumstances:

• The elderly • Pregnancy and breast feeding • Patients with renal disease • Patients with hepatic disease You should understand that the altered physiology in these patient groups may affect the pharmacokinetics and pharmacodynamics of drugs. You

18

should know the principles underlying drug choice, in pregnancy and breast feeding, and have an understanding of the teratogenic effects of drugs that may be used in pregnancy. In the case of renal and hepatic disease it is also necessary for you to have an understanding of drugs that may produce toxicity of these organs and whose use is particularly affected by disease of these organs.

Clinical toxicology You should understand the principles of management of patients who have been poisoned with drugs or other toxic substances. This should include assessment, recognition of common symptom patterns, principles of removal of toxic substances, and their antidotes where these approaches may be appropriate. Examples of question topics might include:

• Paracetamol poisoning • Salicylate poisoning • Tricyclic antidepressant poisoning • Lithium poisoning • Iron poisoning • Digoxin poisoning • Intoxication due to drugs of abuse Criteria for selecting drugs in a therapeutic class You should understand the criteria that may be used to select a drug from among drugs in a popular therapeutic class. This would include:

• Differences in pharmacokinetics and pharmacodynamics • The approved indications of the drug • Possible adverse effects or drug interactions • Cost effectiveness You should also be aware of the nomenclature used in describing studies that may be used to underpin drug selection.

19

Drug formulations and routes of administration You should be aware of the various formulations of medicines available, and of the routes by which medicines may be administered. You should also understand the advantages and disadvantages of various routes and preparations. From this knowledge, you would be expected to be able to select the most appropriate formulation and route of drug administration in common clinical scenarios.

20

R HEUMATOLOGY Detailed knowledge of all the rheumatic conditions is not required. However, you should have a sound working knowledge of the basic principles of the common musculoskeletal conditions. Examples of question topics might include:

• Inflammatory arthritis • Back pain • Periarticular disorders • Osteoarthritis • Connective tissue diseases • Bone diseases Clinical science Basic physiology, biochemistry, anatomy and pathology relating to musculoskeletal disease should be known. Examples of questions topics might include:

• Physiology of pain • Physiology of inflammation • Urate metabolism • Bone metabolism • Applied anatomy, particularly of cervical and lumbar nerve roots, and of peripheral nerves commonly involved in disease The pathology of the common rheumatic conditions should be known. Examples of question topics might include pathological findings in:

• Rheumatoid arthritis • Osteoarthritis • Connective tissue diseases • Bone diseases

21

Clinical conditions You should know the relative prevalence and major associations of the common rheumatological conditions. Examples of question topics might include the relationship to:

• Age • Gender • Genetic influences • Constitutional influences • Environmental influences • Occupational influences You should be able to answer questions on the symptoms and signs of the rheumatic diseases. Examples of question topics might include:

• Rheumatoid arthritis and associated syndromes • Seronegative spondyloarthritis (ankylosing spondylitis, psoriatic arthritis, • • • • • •

reactive arthritis, enteropathic arthritis) Osteoarthritis Crystal arthritis (gout, pyrophosphate arthritis) Connective tissue diseases (systemic lupus erythematosus, Sjogren's syndrome, scleroderma, polymyositis/dermatomyositis) Polymyalgia rheumatica and giant-cell arteritis Systemic vasculitic syndromes Bone disorders (osteoporosis, osteomalacia, Paget’s disease)

You should be familiar with arthritis associated with other medical conditions. Examples of question topics might include:

• Sarcoidosis • Erythema nodosum • Infections and arthritis (e.g. Parvovirus B 19)

22

Investigations You should have knowledge of the investigations relevant to the diagnosis and assessment of rheumatic diseases. Examples of question topics might include:

• Acute phase proteins • Immunological tests relating to the connective tissue diseases (ANA, •

anti-dsDNA, ANCA, anti-Jo1, anti-Ro) Contemporary imaging techniques in rheumatology (x-ray, ultrasound, CAT scanning, MRI scanning)

Management You should be able to answer questions on the management of acute rheumatological emergencies. Examples of question topics might include:

• Septic arthritis • Osteomyelitis • Temporal arteritis • Acute spinal cord compression You should be able to answer questions on the management of rheumatic diseases. Examples of question topics might include:

• Non-drug related therapies (education, physiotherapy) • Drug related therapies (indications and contra-indications, adverse • • • • • •

effects, drug interactions) Simple analgesics Non-steroidal anti-inflammatory drugs Corticosteroids Allopurinol Disease modifying anti-rheumatic drugs Immunosuppressive drugs

23

CARDIOLOGY Anatomy and physiology You should have knowledge of the basic anatomy and physiology of the heart in health and disease: Examples of question topics might include:

• Clinically relevant normal anatomy of the heart, coronary arteries and • • • • • • • •

great vessels Determinants of heart rate and rhythm Cardiac function Cardiac conduction Cardiac output Vascular tone Blood pressure Coronary blood flow Genesis of heart sounds

Pathophysiology and pathology You should know the mechanisms underlying the main pathological processes. Examples of question topics might include:

• Thrombosis • Infarction • Atherogenesis • Hypertrophy • Heart failure • Cardiomyopathies • Dysrhythmias • Hypertension

24

Cell biology You do not need detailed specialised knowledge of cell biology as only topics of proven clinical relevance will be tested. Examples of question topics might include:

• Excitation-contraction process • Molecular and cellular aspects of hypertrophy of the myocardium and of vascular smooth muscle

Clinical pharmacology You should know the indications for drug therapy in cardiac disease and understand the actions, interactions and side effects of the drugs used. The emphasis will often be on new drugs or on novel applications or newly observed side effects of established drugs. Details of drug dosage are asked only rarely.

Clinical cardiology You must know the clinical features and management of the cardiac disorders encountered in hospital practice by the general physician, though detailed specialist knowledge is not expected. You should have knowledge of risk factors. Examples of question topics might include:

• Clinical • • • •

features of constrictive pericarditis, cardiac tamponade, endocarditis, valvular heart disease Management of acute coronary syndromes Management of cardiac failure Management issues in atrial fibrillation Indications for, and types of, permanent pacemaker

Knowledge of important changes in clinical practice, following the publication of major clinical trials, is likely to be tested.

25

Examples of question topics might include:

• Use of ACE inhibitors after myocardial infarction • Use of HMG CoA reductase inhibitors in primary •

and secondary prevention of coronary morbidity and mortality Use of beta-adrenoceptor blocking drugs in left ventricular dysfunction

You should know the:

• Indications for invasive and non-invasive cardiac investigation • Principles of these investigative methods, their limitations

and the

clinical relevance of the results Knowledge of the practical aspects of the investigative techniques is not required. Examples of question topics might include:

• Common ECG abnormalities • Basic echocardiographic abnormalities such as hypertrophic obstructive •

26

cardiomyopathy or pericardial effusion Indications for coronary angiography

R ESPIRATORY

MEDICINE

Anatomy and physiology You should understand clinically relevant anatomy of the upper and lower respiratory tract and thorax including radiological anatomy. You should have knowledge of the principles of respiratory physiology including:

• How respiration is controlled • Principles of gas exchange and oxygen transport • Ventilation-perfusion relationships • Lung volumes and transfer factor • Respiratory aspects of sleep and exercise physiology You should understand the:

• Physical, humoral and cellular aspects of respiratory defence mechanisms • Physiology of the proteinase inhibitors and pulmonary surfactant Pathophysiology and pathology You should understand the effects of disease on pulmonary physiology and anatomy including:

• The pulmonary and bronchial circulations and gas exchange • Adaptations to chronic hypoxaemia • Pleural fluid production and reabsorption You should understand the application of the basic immunological processes to pulmonary pathology including:

• Asthma • Alveolitis • Tuberculosis You should possess knowledge of humoral and cellular immunodeficiency states and sequelae.

27

The microbiology of acute and chronic respiratory infections should be known.

Cell biology and genetics You should have knowledge of:

• Lung inflammation and repair • Vasculitis • Cystic fibrosis • Anti-protease deficiency You should understand the genetics of:

• Asthma • Cystic fibrosis • Alpha 1 antitrypsin deficiency The role and value of gene therapy should be understood.

Clinical pharmacology The indications for, and mechanisms of action of, drugs used in respiratory disease together with their interactions and side effects should be known. Important respiratory complications of other drugs, e.g., NSAIDs and beta blockers should also be understood.

Clinical conditions The clinical features, investigation and management of respiratory disease likely to be encountered by a general physician must be known. Examples of question topics might include:

• Pleural effusion • Chest pain • Haemoptysis • Breathlessness

28

The impact of systemic disease on the respiratory system should be known. Examples of question topics might include:

• Vasculitis • Neuromuscular diseases • HIV infection Knowledge of occupational lung disease, particularly pneumoconiosis, and asbestos related disease is required.

asthma,

You should know how to assess respiratory malignant conditions and understand the general principles of oncological management including the indications for surgery. The indications for specialised investigations, including bronchoscopy, CT scanning, lung biopsy, lung volumes and exercise testing should be known. You should have knowledge of the investigation of sleep related disorders and of the radiological aspects of respiratory disease. You should know the indications for, and problems of, lung transplantation. You should have knowledge regarding the control of Mycobacterium tuberculosis infection.

Exclusions Knowledge of detailed pulmonary mechanics, oncology drug regimens, drug therapy of environmental mycobacterial infection, inhalation drug kinetics and detailed histological descriptions is not required.

29

N EUROLOGY Neuroanatomy You are not expected to have detailed knowledge of neuroanatomy. Questions with an anatomical bias will be confined to circumstances where an understanding of anatomical structure is of critical importance in appreciating the localisation of a particular neurological problem. Examples of question topics might include:

• The clinical features of a lesion within the cavernous sinus • The manifestations of a particular nerve root or peripheral nerve disorder • The organisation of pathways within the spinal cord Neurophysiology Detailed knowledge of neurophysiology is not expected but, as with neuroanatomy, certain aspects of the subject are particularly relevant to the understanding of neurological disease and may be tested. Examples of question topics might include:

• The formation, circulation, absorption and content of the cerebrospinal • •

fluid Aspects of cerebral blood flow The principles of nerve conduction and its modification by disease processes

Neurogenetics You are expected to have knowledge of recent advances in the understanding of the genetic basis for various neurological disorders. Examples of question topics might include:

• The role of dystrophin in muscle disease • Genetic aspects of myotonic dystrophy • Genetic aspects of Alzheimer's disease

30

Cell biology Questions in this area will relate to advances in the cellular mechanisms of certain neurological disease processes which have provided better understanding of disease mechanisms and which might, in the future, lead to more rational therapy. Examples of question topics might include:

• The genesis of tissue damage in stroke and the role of certain excitatory • •

neurotransmitters The role of the dopaminergic system in various extrapyramidal disorders The role of other neurotransmitters in certain diseases, for example, in Alzheimer's disease

Neuropharmacology You are expected to have some knowledge of new drug developments in neurology, as well as the established drug therapies. Examples of question topics might include:

• The role of some recently introduced anticonvulsants • The present status of immunosuppressant therapy in multiple sclerosis Neuropathology You are not expected to have a detailed knowledge of neuropathology. You will be expected to have an outline knowledge of the pathological aspects of some common diseases, for example, multiple sclerosis, Parkinson's disease and Alzheimer's disease.

Clinical neurology Questions in the field of clinical neurology will test your knowledge of the more common disorders. There will be emphasis on clinical features which have been shown to be of diagnostic value. The choice of subject matter will be influenced by areas of recent advance, particularly those which have

31

either led to better definition of disease entities, or have led to their improved management. In the field of cerebrovascular medicine, examples of question topics might include:

• Epidemiological aspects, in particular the risk factors for stroke • The evidence for the role of anti-platelet agents in transient ischaemic •

32

attacks The role of carotid endarterectomy in the management of stroke patients

P SYCHIATRY Mental state You should understand the conduct and scope of a mental state examination. You are expected to be familiar with the features of abnormal mental states and particularly those that present commonly to physicians and to Accident and Emergency Departments.

Aetiological factors in psychiatric illness You should understand the primary aetiological factors in psychiatric areas including:

• Genetic factors • Environmental factors • Life events Investigations You should be familiar with the potential value of, and indications for, common investigations used in psychiatric illness including:

• Psychometric testing • EEG • Brain imaging Syndromes of psychiatric disorder and their treatment You should have knowledge of:

• Organic brain syndromes (delirium, dementia, focal brain syndromes, • • • •

head injury) Schizophrenia and related syndromes Paranoid disorders and related syndromes Affective disorders (anxiety states, phobic disorders, bipolar affective disorders) Grief and bereavement

33

• Self-harm, attempted suicide, suicide • Substance misuse (including alcohol dependence) • Eating disorders • Obsessive compulsive disorder • Abnormal illness behaviour • Syndromes associated with medically explained

physical symptoms

(including somatization and somatoform syndrome)

Psychiatric aspects of physical disease You should be aware of the psychiatric presentations of physical disease including:

• Endocrine and metabolic disorders • Toxic states • AIDS • Neurological disease • Epilepsy • Pain Mental retardation You should know the features of the commoner syndromes.

34

G ASTROENTEROLOGY Clinical science You should understand the:

• Structure and function of the gastrointestinal and hepatobilary tract • Neurohormonal control of gut motility • Secretory and absorptive functions of the gastro-intestinal tract • • •

and liver Symptoms and signs of gastrointestinal, hepatobiliary and pancreatic diseases Genetics of the more common gastrointestinal and liver disorders Clinical pharmacology of drugs used in gastrointestinal disorders including their actions, interactions and adverse effects

Examples of question topics might include:

• Control of gastric acid secretion • Autonomic control of gut function • Genetics of familial adenomatous polyposis • Haemochromatosis • Effects of cholinergic, adrenergic and serotonergic agents on gut function Clinical nutrition You should be familiar with:

• Nutritional requirements in health • Assessment of nutritional status • Nutritional deficiency states • Primary nutritional disorders Examples of question topics might include:

• Calorific requirements • Body water distribution • Derivation of the body mass index • Protein calorie malnutrition

35

• Essential dietary constituents • Vitamin requirements • Pathogenesis and management of obesity Disorders of the mouth, tongue and salivary glands You should have an understanding of:

• Mouth ulcers, periodontal and salivary disorders • Oral manifestations of systemic and dermatological disorders Examples of question topics might include:

• Causes of mouth ulcers and their management • Skin disorders commonly involving the buccal mucosa Disorders of the oesophagus and stomach You should be familiar with the following disorders:

• Achalasia • Carcinomas • Peptic ulceration • Gastritis • Gastrointestinal haemorrhage Examples of question topics might include:

• Presentation, investigation and management of oesophageal strictures • Role of Helicobacter-associated gastritis in peptic ulcer disease • Management of hypovolaemic shock Functional disorders You should have a knowledge of:

• Functional chest pain and functional dyspepsia • Irritable bowel syndrome and functional abdominal pain • Functional constipation and diarrhoea 36

Examples of question topics might include:

• Neural control of visceral nociception and gut motility • Role of emotional and psychosocial factors in illness • Management of chronic pain and the use of pain-modifying drug therapy Disorders of the small intestine You should have knowledge of:

• Malabsorption syndromes and gluten enteropathy • Hormone-secreting tumours of the gut Examples of question topics might include:

• Aetiology, clinical and histopathological features of gluten enteropathy • Investigations commonly used in the assessment of suspected malabsorption

Disorders of the liver, biliary tree and pancreas You should have knowledge of:

• Bilirubin metabolism and the enterohepatic circulation of bile acids • Causes of jaundice and cholestasis • Common pancreatic disorders including carcinoma • Fulminant liver failure • Acute and chronic hepatitis • Drugs, toxins, alcohol and the liver Examples of question topics might include:

• Aetiology, clinical and histopathological features of acute and chronic • •

hepatitic disorders Hepatorenal syndromes and their management Aetiology, presentation and management of acute and chronic pancreatitis

37

The acute abdomen You should have knowledge of:

• Perforated viscus and peritonitis • Intestinal obstruction • Ischaemic disease of the small and large bowel Examples of question topics might include:

• Common causes of acute abdominal pain and their investigation and •

management Management of septic shock associated with intra-abdominal sepsis

Inflammatory bowel diseases You should be familiar with:

• Crohn's disease • Ulcerative colitis • Infective gastroenteritis • Parasitic and protozoal gut infections Examples of question topics might include:

• Causes, investigation and management of acute and chronic enteric •

disorders Manifestations of inflammatory bowel disease and its complications

Colorectal disorders You should have knowledge of:

• Polyps • Carcinomas • Diverticular disease • Anorectal disorders

38

Examples of question topics might include:

• Pathology and clinical genetics of disorders presenting with colonic •

polyps Causes and treatment of haemorrhoids, anal fissures and ano-rectal fistulae

39

E NDOCRINOLOGY Although you are not expected to have a detailed knowledge of biochemistry, it is anticipated that you will have an insight into the mechanisms of hormone action and the importance of receptors and substances involved in control of intracellular metabolism. You should have a knowledge of the clinically relevant anatomical aspects of this specialty. Examples of question topics might include:

• Factors involved in cell signalling • Anatomical relationships of the pituitary gland • The cell types in the pancreatic islets • A broad understanding of the pathways of carbohydrate, protein and fat • • •

metabolism Endocrine tests in routine clinical use Genetic aspects of endocrine disease Disorders affecting multiple endocrine systems

Thyroid Since thyroid disease is common you are expected to have a broad knowledge of the mechanisms of thyroid disease, its clinical presentation and treatment. Examples of question topics might include:

• Thyroid hormone biosynthesis and its control • Important drugs interfering with thyroid function • Indications for use of various types of thyroid function test • Autoimmunity and the thyroid • Clinical features of thyrotoxicosis and hypothyroidism • Goitre and its management • Thyroid neoplasia Hypothalamus/Pituitary Detailed knowledge of the structure of the pituitary and hypothalamic hormones is unnecessary. You will require a knowledge of the physiology and testing of the control mechanisms of the endocrine system.

40

Examples of question topics might include:

• The physiology and pathophysiology of control of pituitary hormone • • • • •

secretion The mechanisms of maintaining plasma osmolality Tests of pituitary hormone secretion Pituitary diseases such as acromegaly, prolactinoma and Cushing’s syndrome Drugs used in the treatment of pituitary disease Pituitary replacement therapy

Adrenal A detailed knowledge of mechanisms of steroid biosynthesis is not required, but you are expected to have some knowledge of those parts which are clinically important. Examples of question topics might include:

• An understanding of the build-up of precursor compounds when there is • • • •

defective cortisol biosynthesis in adrenocortical hyperplasia Tests for adrenocortical function Endocrine causes of hypertension and their differential diagnosis Clinical features and management of adrenal hyper- and hypofunction Complications of steroid therapy

Ovary You are expected to be conversant with the physiology of ovarian function and with the conditions presenting to a physician. Examples of question topics might include:

• Hormonal changes across the menstrual cycle • Physiological changes in pregnancy • The differential diagnosis of hirsutism and virilism • Causes of amenorrhoea and anovulation • Endocrine causes of infertility

41

Testis You are not expected to have a detailed knowledge of the urological investigation of infertility but some concept of relevant investigations and of the endocrine aspects of testicular function is required. Examples of question topics might include:

• The aetiology of hypogonadism both primary and secondary • Causes of male infertility related to general medical disease and its • •

treatment Causes of erectile dysfunction and its investigation Androgen replacement therapy

Growth Growth is a very important topic in relation to general medicine as well as endocrinology. You are expected to be conversant with:

• Factors controlling growth hormone secretion • Normal growth patterns • General medical and endocrine causes of short stature • Control of excessive growth • Growth hormone therapy and its complications Parathyroid/bone Detailed knowledge of the anatomy and physiology of bone metabolism is not required. You are expected however to have some broad concept of the control of bone turnover and the disorders which can result in its failure. Examples of question topics might include:

• Control of calcium metabolism • Laboratory tests of parathyroid function • The causes of hypercalcaemia • The mechanisms of osteomalacia 42

• Hyperparathyroidism, both primary and secondary • The differentiation of primary, secondary and pseudo-hypoparathyroidism • The prophylaxis and treatment of osteoporosis • Calcitonin and its role in metabolism Diabetes mellitus You are expected to have detailed knowledge of this very common condition. Examples of question topics might include:

• Control of carbohydrate metabolism • Genetics of diabetes • Aetiology of type 1 diabetes and type 2 diabetes • Long-term complications of diabetes • Insulin resistance • Management of diabetic emergencies • Differential diagnosis and treatment of hypoglycaemia Disorders of lipid metabolism Although a detailed knowledge of lipid metabolism is not required, you are expected to have an understanding of the importance of this group of disorders. Examples of question topics might include:

• Control of cholesterol metabolism • Aetiology of different types of • •

hyperlipidaemia including both

cholesterol and triglyceride disorders Indications for lipid lowering agents and their complications Types of secondary hyperlipidaemia

43

N EPHROLOGY Physiology You should have knowledge of:

• Discrete functions of glomerular ultrafiltration and tubular function • Proximal and distal parts of the nephron, with particular reference to • • •

control of water and electrolyte balance Renal tubular acidosis Cystinuria Fluid, electrolyte, and acid-balance disturbances

Molecular biology and genetics You are expected to possess a basic knowledge of genetic defects of common kidney disorders including:

• Polycystic kidney • Alport’s syndrome • Hypophosphataemic rickets You should have an understanding of inflammatory injury of the kidney mediated by various cytokines and growth factors.

Glomerular and tubular disorders You are expected to have some knowledge of glomerular ultrastructure based upon techniques of light microscopy, electron microscopy and immunofluorescence as applied to renal biopsy. These techniques form the basis of current understanding of primary glomerular disorders as in idiopathic glomerulonephritis, and nephropathies of systemic diseases. Examples of question topics might include:

• Diabetes mellitus • SLE • Hypertensive nephrosclerosis • Vasculitis • Amyloidosis

44

Knowledge of interstitial nephritis (especially those cases with reversible aetiology such as drugs , heavy metals and analgesics) is expected. You should be acquainted with the metabolic sequelae of acute nephritic and nephrotic syndromes. You should be aware of the investigation and assessment of glomerular and tubular disorders, including ultrasonic studies and nuclear medicine. You should have an understanding of disturbed renal and metabolic functions in nephrotic syndrome from a variety of causes.

Infections of the kidney You should be familiar with the management of urinary tract infections including their detection, predisposing factors, prevention and treatment. A knowledge of anatomical abnormalities leading to repeated urinary tract infection is expected. Examples of question topics might include:

• Reflux nephropathy • Prostatic hypertrophy You should be aware of other infections that could affect the kidney by direct invasion or by immune-complex deposition. Examples of question topics might include infection of the urinary tract with:

• Mycobacteria • HIV • CMV • HBV • HCV Calculus formation within the urinary tract You should possess a knowledge of metabolic disorders predisposing to

45

stone formation, their investigation, prevention and treatment. Examples of question topics might include:

• Idiopathic hypercalciuria • Primary hyperparathyroidism • Cystinuria • Hyperoxaluria Acute and chronic renal failure A knowledge of the management of acute and chronic renal failure and of the disturbed physiology involved is expected. You should be familiar with pathophysiological changes and non-dialytic treatment in different stages of progressive renal failure. Principles of nutritional requirements and dietary intervention for patients with chronic renal failure is required. Other therapeutic means to slow down the progression of renal failure should be understood.

Hypertension and renal problems in pregnancy You are expected to be familiar with renal adaptation to pregnancy, the management and prophylaxis of renal disease and hypertension in pregnancy.

Drugs and the kidney A knowledge of the role of the kidney in the normal elimination of drugs is expected and you should understand the mechanisms by which drugs cause nephrotoxic damage. The principles of dose adjustment according to residual renal function should be known.

Renal replacement therapy A knowledge of different dialysis modalities and their complications is expected. You should know the complications related to immunosuppressive therapy following renal transplantation.

46

D ERMATOLOGY Basic science You will be expected to have a working knowledge of the structure and function of the epidermis and dermis.

Clinical dermatology Many diseases affecting internal organs will present with skin signs or symptoms. You are expected to be able to recognise the cutaneous symptoms and signs of systemic diseases. Examples of question topics might include:

• Collagen vascular disease such as SLE, systemic sclerosis • Metabolic and endocrine disorders • Infectious diseases • Cancers • Leukaemias • Respiratory and cardiovascular diseases • Common inherited diseases such as neurofibromatosis You should have knowledge of the main dermatological complications of therapeutic immunosuppression (for example, systemic corticosteroid therapy, cyclosporin etc.) or of diseases such as HIV which cause immunosuppression. In addition you should know the differential diagnosis and plan of investigation of patients who present with the following cutaneous signs or symptoms which may indicate internal disease:

• Itch • Hyperpigmentation • Generalised erythema • Loss of hair • Increased hair growth • Common patterns of nail dystrophy such as clubbing • Erythema nodosum

47

• Erythema multiforme • Purpura • Ulceration • Vasculitis A knowledge of the clinical features of the following skin diseases is required:

• Psoriasis • Eczema • Urticaria • Superficial fungal infections (dermatophytosis, pityriasis versicolor) • Common skin cancers such as melanoma • Vitiligo and alopecia areata • Pemphigus and pemphigold • Cutaneous herpes virus infections (herpes simplex, varicella zoster) • Cutaneous staphylococcal and streptococcal infections • Leprosy Investigation You should know the principles but not details of dermatological investigation such as patch testing.

Drugs and therapy You will not be expected to have a detailed knowledge of the treatment of skin diseases or dermatoses. However you should know the drugs which cause life-threatening skin conditions such as erythroderma or StevensJohnson syndrome, angio-oedema and toxic epidermal necrolysis.

48

The publication of this Syllabus for the MRCP (UK) Part 1 Examination is a key element in the Royal Colleges of Physicians commitment to candidates and their tutors. The Syllabus is indicative of those areas of knowledge required to pass the Examination. Although each diet will not test every area of knowledge detailed in the Syllabus, the Examination should be viewed as a representative sample of the items of knowledge set out in the Syllabus.

This Syllabus should be used in conjunction with the

Royal College of Physicians of Edinburgh Royal College of Physicians & Surgeons of Glasgow Royal College of Physicians of London

Design & Print Production by Metro Press, Edinburgh

MRCP (UK) Part 1 Questions 2003.