Pastest essential revision notes for mrcp pdf 4th edition is one of the latest edition to the top class books available for the mrcp course. Essential. Revision Notes for MRCP. Fourth Edition edited by. Philip A Kalra MA MB BChir FRCP MD. Consultant and Honorary Professor of Nephrology. Essential Revision Notes for MRCP Fourth Edition. Dedication To my wife, Marian, and children, Michael, Gabriella and Alicia, who will always inspire. Essential.
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Sumatriptan may lead to permanent neurological damage. Reperfusion arrhythmias VTs and ectopics are common in the first 2 hours after thrombolysis. At 10 years. Its main action is to prolong the refractory period. N Engl J Med In addition: Junctional EB:
Download Now. DMCA Disclaimer: Please bear in mind that we do not own copyrights to these books. We highly encourage our visitors to purchase original books from the respected publishers. If someone with copyrights wants us to remove this content, please contact us immediately. If you feel that we have violated your copyrights, then please contact us immediately. Tuesday, April 16, Sign in. Its duration of action may be significantly increased by dipyridamole.
They are contraindicated in bilateral functional renal artery stenosis and should be used with caution in severe renal impairment.
Its main action is to prolong the refractory period. It reduces mortality in patients with recurrent ventricular tachycardia VT or hypertrophic cardiomyopathy. Amiodarone Amiodarone may be used to control supraventricular and ventricular arrhythmias. It has a limited role as a positive inotrope but may be effective in patients with coexistent heart failure and atrial fibrillation.
Neutropenia is a rare but recognised adverse effect. Chapter There is improved survival in hypertension. Cough is a recognised adverse effect but it is less common than after ACE inhibitors. Clopidogrel Clopidogrel is a prodrug that exerts antiplatelet effects via irreversible binding to the P2Y12 receptor on the platelet surface.
The duration of the antiplatelet effects is longer than with aspirin. Clopidogrel may be used as monotherapy in patients who cannot tolerate aspirin. Angiotensin receptor blockers ARBs also delay progression of diabetic nephropathy see Nephrology. Angio-oedema is a recognised complication. They may precipitate acute renal failure in patients with reduced renal blood flow eg bilateral renal artery stenosis.
Toxicity often causes severe bradycardia and hypotension. Eight-five per cent is eliminated unchanged in the urine. Digoxin Digoxin delays atrioventricular node conduction.
Ivabradine is also licenced for the treatment of heart failure patients in whom the heart rate is not adequately controlled on beta-. Some statins may cause a modest decrease in triglyceride concentrations. Statins reduce mortality in patients with ischemic heart disease. Statins cause upregulation of low-density lipoprotein LDL receptors.
This is more likely in patients with renal impairment. Its half-life is about 16 hours. A signal of harm was noted in a subset of the SHIFT study which may require reassessment of the use of this drug for angina.
It is indicated for the treatment of angina. Drug concentrations and the risk of adverse effects are increased for most statins when patients concomitantly receive an enzymeinhibiting drug. Atrovastatin has been associated with reduction in triglyceride levels. It is contraindicated in patients with resting bradycardia and sick sinus syndrome. The CAST trial suggests that flecainide is pro-arrhythmic after a myocardial infarction and it is normally avoided in patients with ischaemic heart disease or left ventricular impairment.
Although patients may report less angina and have improved exercise times in smaller studies. These novel oral anticoagulants are licensed for prevention of venous thromboembolism after elective hip or knee replacement. Nicorandil A potassium channel opener that induces arterial vasodilatation. Rivaroxaban is also licensed for treatment and prevention of deep vein thrombosis and pulmonary embolus. Thiazide diuretics Thiazides are capable of lowering blood pressure. It is used as an antianginal agent.
Prasugrel and Ticagrelor Both drugs are new generation antiplatelets with greater antiplatelet potency than clopidogrel and a faster time to onset. Maximum blood pressure reduction is achieved using low doses eg bendroflumethiazide 2. Both are P2y12 receptor inhibitors and are used for acute coronary syndrome patients.
The mechanism is uncertain. Apixaban and rivaroxaban are direct inhibitors of activated factor X. Tricagrelor is commonly associated with bradycardia on monitoring and the sensation of breathlessness which may lead to discontinuation. They are associated with a number of dose-dependent metabolic effects: Both are associated with greater rates of bleeding complications. In large doses it may cause hypotension with a reflex tachycardia. The side-effects are transient headache.
There is no specific antidote available for these anticoagulants. Side-effects include gastrointestinal upset and hypersensitivity reactions.
They may also be given alongside metformin. See also Chapter 4. It is licensed for use in patients with type 2 diabetes in combination with metformin or sulfonylurea or both. Similar mechanism of action to sulphonylureas but much shorter duration of action and so can be taken before meals to control postprandial hyperglycaemia.
Hormone replacement therapy On average. Without HRT. It requires subcutaneous administration. They should not be administered at the same time as other anticoagulation therapy. Agranulocytosis may occur within the first 16 weeks of therapy and in the event of sore throat. It takes at least 6 weeks to reduce blood levels of thyroid hormones. Section 4. Other key features are as follows: They suppress local inflammation in ulcerative colitis.
Excess flatus is a common adverse effect. DPP-4 inhibitors depend on intrinsic insulin secretion and therefore are not expected to cause hypoglycaemia. It causes liquid. Sitagliptin may be added to metformin or a thiazolidinedione see below if glycaemic control is inadequate. Probiotic therapy Probiotics have been proposed as a means of reducing the occurrence of antimicrobial-associated. They have some systemic side-effects.
Sitagliptin Sitagliptin is a dipeptidylpeptidase-4 DPP-4 inhibitor that increases insulin secretion and inhibits glucagon secretion. The sulfonamide moiety frequently leads to gastrointestinal upset. It is used in the treatment of ulcerative colitis. These agents cause less dyskinesia than L-dopa but they are associated with more neuropsychiatric adverse effects.
It is highly emetogenic and domperidone must therefore be given 2 days before the start of therapy. Apomorphine is a powerful dopamine agonist which needs to be given by parenteral administration under specialist supervision. It is a prodrug that must be converted to dopamine within the nigrostriatal pathway. The drug is largely metabolised by catechol-Omethyltransferase. After 8 years of therapy with L-dopa.
Lamotrigine inhibits the excitatory effects of glutamate within the central nervous system CNS. Certain of these agents have been associated with pulmonary and retroperitoneal fibrosis bromocriptine. This is now known to be untrue Amantadine potentiates dopamine by preventing its reuptake into presynaptic terminals Levodopa L-dopa is absorbed in the proximal small bowel by active transport.
It is used in combination with other antiepileptic drugs for the treatment of partial or generalised seizures and myoclonic jerks Vigabatrin irreversibly inhibits GABA transaminase. Used to treat partial or generalized seizures. More serious dermal complications have been reported.
Adverse effects include mood changes. Leviracetam binds to SV2A. It may cause alopecia. It is used to treat partial seizures with or without secondary generalization. Severe visual field defects may occur from 1 month to several years after initiation.
It inhibits liver enzymes and thereby increases drug concentrations and toxicity of other antiepileptics such as phenytoin. Used to treat partial complex seizures or secondary generalization. Patients commonly experience headaches and diplopia soon after initiation of carbamazepine. Sumatriptan may lead to permanent neurological damage.
For this reason it is now rarely used. They must not be given in hemiplegic migraine. They maintain vascular tone and prevent headache associated with the vasodilator phase of migraine. It may also cause angina due to coronary vasospasm. Olanzapine and risperidone are associated with an increased risk of stroke in elderly patients.
Lithium Lithium carbonate is used for prophylaxis in bipolar affective disorder. It has a narrow therapeutic range 0. There is a compensatory increase in ADH release. Lithium is thought to downregulate expression of Aquaporin2. Treatment is to provide the active metabolite of folic acid: IV folinic acid. An ECG should be performed before starting treatment in patients with cardiac disease or electrolyte disturbances.
Citalopram and escitalopram Recent data have shown that citalopram and its S-enantiomer escitalopram may cause dose-dependent prolongation of the QT interval on the ECG. Methotrexate is administered once weekly. Citalopram and escitalopram should not be used in patients with congenital long QT syndrome or preexisting QT interval prolongation. Awareness of weekly dosing is important. In standard doses of methotrexate. Methotrexate toxicity may occur when a patient is inadvertently prescribed a second folate antagonist.
Churg—Strauss-like eosinophilic vasculitis and peripheral neuropathy have been reported with these agents. It inhibits the formation of urate and over a sufficient period will lower total body urate and minimize the risk of gout.
Established gouty tophi may regress with chronic use of allopurinol. Omalizumab Omalizumab is a monoclonal antibody that binds to immunoglobulin E IgE. Urate oxidase enzymatically degrades urate to allantoin.
Febuxostat Febuxostat is a novel xanthine oxidase inhibitor. It is generally reserved for patients intolerant of allopurinol. They are used as adjunctive therapy in mild-to-moderate asthma. Agents used in the treatment of gout Allopurinol inhibits xanthine oxidase. Methotrexate is also an abortive agent and a 3-month washout is needed prior to conception. Infectious Diseases and Tropical Medicine. Tiotropium is an M3-selective muscarinic receptor antagonist that alleviates bronchospasm and minimises respiratory secretions.
Ciprofloxacin This 4-quinolone inhibits DNA bacterial gyrase. As with most immunosuppressants. Adverse effects include dry mouth.
After initiation of therapy when doses are usually highest it causes dose-dependent nephrotoxicity and has a narrow therapeutic range. It has high receptor affinity. Gum hyperplasia is common. It is a liver enzyme inhibitor and may increase the effect of theophylline in particular.
It should be used with caution in patients with narrow-angle glaucoma and bladder neck obstruction. It is active against both Gram-positive and Gram-negative organisms.
They are teratogenic. Similar to other vitamin A derivatives they may cause benign intracranial hypertension. During chronic administration. Dryness of mucous membranes. Adenosine causes bronchoconstriction via adenosine receptors within the bronchial smooth muscle. High-dose retinoids can rarely cause diffuse interstitial skeletal hyperostosis. Sodium valproate may also cause amenorrhoea.
Recognised adverse effects include severe allergy and drug rash with eosinophilia and systemic symptoms DRESS. Sensitivity to these agents relates to pharmacological effects on prostaglandin metabolism. It increases new bone formation and suppresses bone resorption. Oestrogen-like action Digoxin spironolactone diethylstilbestrol Anti-androgen action Cimetidine Cyproterone acetate Luteinising hormone-releasing hormone LHRH analogues eg goserelin 2. Sodium cromoglicate is a mast-cell stabiliser.
It is less common with domperidone due to poorer uptake of this agent across the blood—brain barrier SSRIs may cause dystonias and rarely are associated with serotoninergic syndromes which are a group of clinical disorders characterized by excess serotonergic effects. Lithium inhibits iodide transport into the thyroid gland and inhibits thyroid function.
Dose-dependent liver injury includes paracetamol poisoning. Drug-induced vasculitis can affect the skin or internal organs. Acute pancreatitis is a recognised adverse effect of a number of drugs. SIADH is characterised by hyponatraemia, concentrated urine and low plasma osmolality, all occurring in the absence of oedema, diuretic use or hypovolaemia. Treatment involves cessation of the responsible drug and, in persistent cases, demeclocycline may be considered.
In addition, there are a number of non-pharmacological causes, which include malignancy, CNS disorders, suppurative pulmonary disease and porphyria. See Chapter 4, Endocrinology, Section 4. Drug-induced diabetes insipidus is generally nephrogenic, namely diminished responsiveness of the kidneys to ADH and an impaired ability to concentrate urine.
Other recognised drugs include foscarnet, clozapine, amphotericin B, orlistat, ifosfomide and cidofovir. Management involves stopping the offending drug, and some patients may respond to treatment with thiazide diuretics, amiloride or NSAIDs.
Early features are minor nausea and vomiting. Acute liver injury may occur later, typically with peak transaminases at 2—3 days after ingestion, but fulminant liver may occur in severe poisoning.
Toxicity is thought to be due to excess reactive oxygen species and a paracetamol metabolite that binds to liver cell macromolecules causing necrosis. The international normalised ratio INR , or prothrombin ratio, is the most sensitive indicator of impaired liver function. Anticholinergic effects: Seizures should be treated with benzodiazepines. Duration of venlafaxine toxicity may be prolonged for up to 48 hours after ingestion of standardrelease preparations and up to 72 hours after overdose involving modified-release formulations.
This may cause tachyarrhythmia due to phosphodiesterase inhibition. Electrolyte abnormalities include severe acidosis and hypokalaemia the latter partly due to intractable vomiting. Reduced conscious level, seizures and confusion may also occur. Carbon monoxide binds to haemoglobin with high affinity times that of oxygen , and decreases oxygen-carrying capacity, resulting in tissue hypoxia.
Quinine poisoning may result in visual disturbance due to anticholinergic effects and direct neurotoxicity. Blindness may occur at between 6 and 24 hours after ingestion, and may be irreversible. The key features of iron poisoning are shown in the box below. Gastric lavage should be contemplated if the patient presents within 1 hour of life-threatening ingestion.
Desferrioxamine chelates iron and may improve clinical outcome when given by intravenous infusion. The decision to administer desferrioxamine is based on the serum iron concentration, although in severe symptomatic cases it may be started before this is available. Abdominal pain Diarrhoea Haematemesis Lower gastrointestinal blood loss Nausea and vomiting.
As systemic aspirin absorption progresses, patients may develop a metabolic acidosis that can be severe or fatal. Acute renal failure Hypoglycaemia Hypoprothrombinaemia Metabolic acidosis Pulmonary oedema. Key aspects of management of salicylate poisoning involve the following: Poisoning with ethylene glycol may have a similar clinical appearance to ethanol intoxication, within.
Initially there is a raised plasma osmolar gap due to the presence of ethylene glycol. This is then broken down, the degradation products, including oxalate, giving rise to a metabolic acidosis with a wide anion gap. Toxic effects include severe metabolic acidosis, hypocalcaemia, acute tubular necrosis, crystalluria, and cardiac failure and pulmonary oedema. Certain drugs and poisons may be effectively removed by haemodialysis, particularly those with a low volume of distribution that are largely confined to the circulating compartment.
Conversely, haemodialysis is ineffective for drugs with a wide volume of distribution eg amiodarone and paraquat , or those that are highly protein bound eg digoxin and phenytoin. There are limited data concerning the impact of haemodialysis on patient outcomes, and it is normally only undertaken in patients with severe poisoning by selected agents.
Structure and function of skin and terminology of skin lesions 3. Specific dermatoses and infections of the skin 3.
The skin in connective tissue disorders 3. The skin in other systemic diseases 3. Cutaneous markers of internal malignancy 3. The principal cell is the keratinocyte.
The epidermis has four layers, which are the basal cell layer, stratum spinosum, stratum granulosum and the stratum corneum Dermis: The principal cell is the fibroblast, which makes collagen giving the skin its strength , elastin providing elasticity and proteoglycans.
It also contains adnexal structures, including hair follicles, sebaceous glands, apocrine glands and eccrine glands Dermoepidermal junction: Anomalies of this can give rise to some of the blistering disorders Subcutis: The skin has numerous functions, all of which are designed to protect the rest of the body.
Barrier properties: Temperature regulation: It affects both genders equally and occurs at any age, with two peak age ranges 16—22 and 57—60 years. Its aetiology is unknown but multiple genetic factors in combination with environmental factors are thought to be important. The understanding of psoriasis has moved from one of a hyperkeratotic disorder of keratinocytes to a dysregulation of the immune system mediated by cytokines.
Strongly associated with smoking. Lesions are often smooth, red and glazed in appearance. Associations with psoriasis Psoriasis is now known to be a systemic disease mediated via T cells; the inflammatory processes involved are associated with the development of a number of co-morbidities as well as reduced life expectancy. Major cardiac adverse events MACE: There is known to be an increased risk of cardiovascular disease independent of other risk factors, however.
Psoriasis is also strongly associated with the metabolic syndrome hypertension, obesity, diabetes and dyslipidaemia. Obesity has been shown to be a risk factor for the development of psoriasis and an increasing body mass index BMI is associated with greater degrees of severity. Psoriasis of any type, especially if severe, is a risk factor for venous thromboembolism. There are several different forms see Chapter 20 — distal interphalangeal joint disease, large single-joint oligoarthritis, arthritis mutilans, sacroiliitis and psoriatic spondylitis have all been described Gout: Psoriasis Eczema Mycosis fungoides Adverse drug reactions Underlying malignancy Pityriasis rubra pilaris.
Management of psoriasis Offer people with any type of psoriasis support and information tailored to suit their individual needs and circumstances, in a range of different formats, so that they can confidently understand the following: Their diagnosis and treatment options Relevant lifestyle risk factors When and how to use prescribed treatments safely and effectively When and how to seek further general or specialist review Strategies to deal with the impact of psoriasis on physical, psychological and social wellbeing.
Disease severity The impact of disease on physical, psychological and social wellbeing Whether they have psoriatic arthritis The presence of co-morbidities. First-line treatment: The strength of steroid varies according to the body site and severity. Non-biological systemic treatment The benefits must be weighed against the side-effects of the drugs. Methotrexate is used as a first-line non-biological systemic treatment; it blocks DNA synthesis by inhibiting dihydrofolate reductase.
It is administered once weekly, orally or subcutaneously. The risks of nausea, anaemia and pancytopenia are reduced with folic acid supplementation. There is a risk of liver fibrosis with long-term use. A serological marker for fibrosis, amino-terminal peptide procollagen III P3NP , is measured 3-monthly and a liver biopsy is performed if consistently high, further evaluation of liver fibrosis may be indicated.
Major side-effects are renal toxicity and hypertension. Teratogenicity is a problem and treatment should be avoided in women of childbearing potential. Mucocutaneous side-effects are common and elevated triglyceride levels are often observed. Treatments used less commonly include: Third-line treatment: Biologics are considered for patients with severe disease.
A PASI score is a tool used to measure the extent and the severity of the psoriasis and a DLQI dermatology life quality index assesses the impact of the disease on quality of life. For biological treatment these scores must be at least Delivered by infusion Ustekinumab: Eczema is an inflammatory skin disorder with characteristic histology and clinical features, which include itching, redness, scaling and a papulovesicular rash.
Eczema can be divided into two broad groups, exogenous or endogenous: Seborrhoeic dermatitis is a red, scaly rash caused by Pityrosporum ovale. The eruption occurs on the scalp, face and upper trunk, and is more common in young adults and patients with HIV. Pompholyx is characterised by itchy vesicles occurring on the palms and soles. It is a characteristic dermatitic eruption associated with a personal or family history of atopy. Both genetic and environmental factors interact to contribute to pathogenesis, with convincing evidence of both a barrier defect caused by a compromise in epidermal permeability through null mutations in the filaggrin gene and a Thdriven cutaneous inflammatory response.
Management of atopic eczema Initial treatment consists of avoidance of irritants and exacerbating factors. Topical therapy: Occasionally oral prednisolone is used for severe flares.
Alitretinoin is an oral retinoid licensed for hand dermatitis; unresponsive to topical steroids. Acne is the most common of the dermatological disorders and affects most people at some time during their life.
Although not life-threatening, acne can have severe psychosocial consequences and may lead to poor self-esteem, social isolation and depression.
Pathogenesis Acne has a multifactorial pathogenesis and results from the interplay of the following four factors: Plugging of the follicle due to epidermal proliferation Excess sebum production Colonisation with Propionibacterium acnes Inflammation. Clinical features Acne is characterised by comedones, papules, pustules, nodules, cysts and scars. It affects the areas of skin where the sebaceous follicles are most dense: Treatment Choice of treatment should be based on the severity of the disease and the type of acne, eg comedonal, non-inflammatory acne may require only a keratolytic agent.
Most moderate-grade acne needs a combined approach to treat both the comedones and the inflammatory lesions. Topical treatments Topical antibiotics: Co-cyprindiol Dianette , a combination of ethinylestradiol and the anti-androgen cyproterone, may be considered Isotretinoin: It is indicated if there is scarring, if the acne is resistant to multiple treatments including long-term systemic antibiotics or if the disease is causing severe psychological distress.
Women of childbearing age are advised to use two methods of contraception and to have monthly pregnancy testing. The most common side-effects are mucocutaneous, with severe drying of lips and skin. Mood changes and severe depression have been reported.
Rosacea is an inflammatory skin disease that causes erythema, telangiectasia, inflammatory papules and pustules. The skin tends to be dry and sensitive. It may cause flushing and in severe cases rhinophyma usually in men. Ocular rosacea may occur and cause blepharitis, conjunctivitis or keratitis. Trigger factors include alcohol, sunlight, exercise, high and low temperatures, and spicy foods. Treatment Topical Topical metronidazole or azelaic acid may help to control inflammation in mild-to-moderate rosacea.
Mirvaso is a new treatment for the erythema of rosacea. Systemic Most commonly, tetracyclines or erythromycin are used. A third of patients respond to 2 months of treatment. Many patients need long-term treatment. In severe, resistant cases isotretinoin may be used. Other affected sites include mucous membranes, genitalia, palms, soles, scalp and nails. Lichen planus causes a white lace-like pattern on the buccal mucosa. This is usually a maculopapular, targetoid rash, which can occur anywhere, including the palms, soles and oral mucosa.
The cause is unknown but it is thought to be associated with infections, mainly viral. Stevens—Johnson syndrome, on the other hand, is more likely to affect mucosal surfaces and is believed to be associated with drug reactions.
This is a hot, tender, nodular, erythematous eruption lasting 3—6 weeks, which is more common in the third decade and in females. These can be subdivided into bacterial, fungal and viral infections as well as infestations. Bacterial infections Streptococcal: The development of blisters can be due to congenital. Pityrosporum orbiculare. Candida spp. The level of split within the epidermis or within the dermoepidermal junction determines the type of bullous disorder. Lyme disease erythema chronicum migrans Fungal Dermatophytes: Trichophyton rubrum.
Bullous pemphigoid is more common than pemphigus. Cicatricial pemphigoid is a rare. It is a disorder characterised by large. Paraneoplastic pemphigus presents in association with a tumour which may be occult. Dermatitis herpetiformis is an itchy. There are three main types: It most commonly presents with painful erosions or blisters on the oral mucosa.
The bullae are superficial and confined to the epidermal layer. Pemphigus is a rare group of disorders characterised by blistering of the skin and mucous membranes.
EB simplex: The binding process results in loss of cell-to-cell adhesion and the production of superficial bullae in the epidermal layer. Junctional EB: The use of corticosteroids and adjuvant drugs has reduced the mortality rate significantly. Autoantibodies are present to two hemidesmosomal proteins: Three major variants have been described: Pathogenic IgG autoantibodies bind to transmembrane desmosomal proteins of keratinocytes called desmogleins.
It is caused by mutations involving at least 18 genes encoding structural proteins in the skin and mucosae. These superficial bullae rupture easily. Oral mucosal involvement is rare. The incidence peaks in the fifth and sixth decades and women are more affected than men see also Chapter Morphoea localised scleroderma consists of indurated plaques of sclerosis in the skin.
The majority of patients have asymptomatic gluten-sensitive enteropathy. These include malar rash. Systemic lupus erythematosus SLE is commonly associated with dermatological manifestations.
These tend to heal with scarring. Skin signs develop in sunexposed areas. Patients have decreased levels of uroporphyrinogen decarboxylase. It typically affects the legs. Fifty per cent of cases are associated with underlying medical disorders. Diabetic rubeosis is an odd redness of the face. In the absence of localised skin disease or skin signs. These can be either genetically determined syndromes with cutaneous manifestations.
Specific dermatological features and the common types of malignancy with which they are associated. Most of these diseases have an autosomal dominant inheritance. This is produced by melanocytes. Pigmentary disorders usually present with either hypo. Clinical pharmacology. Causes include antibiotics including sulfonamides. This can be associated with allopurinol. The most common drug eruptions are: It is usually characterised by a morbilliform or maculopapular eruption.
This group contains physical. Acute urticaria is common and usually lasts 24—48 hours. Chronic urticaria lasts for more than 6 weeks.
It occurs as chronic spontaneous urticaria CSU or is inducible. Management of urticaria Acute: Early lesions are often curable by surgical excision. The different types of melanoma are: Superficial spreading: Treatment of CSU starts with non-sedating antihistamines. Any changing mole bleeding. The prognosis is related to tumour thickness.
Vemurafenib used for patients with a BRAF gene mutation shows a survival benefit over dacarbazine. Malfunctioning of the hedgehog-signalling pathway and gene mutations increase the risk of BCC development the hedgehog pathway influences differentiation of various tissues during fetal development and continues to play a role in cell growth and differentiation in adults.
With each chapter authored by renowned experts in their respective specialties and with key information displayed in a concise and structured format, this book remains the definitive guide to the MRCP written examinations.
All of you must know about Pastest. Well this is it. You need to study this day and night for better scores in the last days. Download Now and get to work. Dr Kalra qualified from Cambridge University in and has worked as a renal and general physician at Hope Hospital, Salford since If you are preparing for MRCP Part 1 and you have little time like most of us , you definitely need this book. The best revision book for the MRCP.
Its both concise and comprehensive, whereas most books tend to be one at the expense of the other.