MRCPUK Part 1 Syllabus

Royal College of Physicians of Edinburgh

Royal College of Physicians & Surgeons of Glasgow

Royal College of Physicians of London

MRCPUK

Part 1Syllabus

Compiled and

edited by the

MRCP(UK)

Part 1

Examining Board

and

published for the

Federation of

Royal Colleges of

Physicians of the UK

by the MRCP(UK)

Central Office

1

MRCPUK Part 1 Syllabus

MRCPUK

Part 1Syllabus

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 Edinburgh9 Queen StreetEdinburgh EH2 1JQ

Royal College of Physicians & Surgeons of Glasgow234/242 St Vincent StreetGlasgow G2 5RJ

Royal College of Physicians of London11 St Andrews PlaceRegents ParkLondon NW1 4LE

All rights reserved. No part of this publication may bereproduced, stored in a retrieval system, or transmitted, inany form or by any means, electronic, mechanical,photocopying, recording or otherwise without the priorpermission of the copyright owners.

First Published 1999

FOREWORD

The MRCP (UK) Part 1 Examination for the Membership of the Royal Collegesof Physicians of the United Kingdom was introduced in October 1968. Sincethen there have been major developments in the study of medical educationand the certification of competence worldwide. These developments havehad an impact both on generic and specialist training. The Royal Colleges ofPhysicians are committed to the academic development of medicaleducation and as part of that commitment are publishing a raft ofpublications covering various aspects of the MRCP (UK) Examination. TheSyllabus for the MRCP (UK) Part 1 Examination is a key element in the RoyalColleges' on-going commitment to candidates and their tutors.

This Syllabus covers those areas of knowledge tested in the MRCP (UK) Part 1Examination. We believe that a thorough knowledge of common andimportant disorders is essential and that candidates should also have anunderstanding of basic sciences relevant to medical practice so that not onlycan physicians in training develop their full clinical and academic potentialbut also achieve success in the Examination.

A major aim of the MRCP (UK) Part 1 Examination is to encourage candidatesto read widely thereby providing a sound basis for continuing medicaleducation. It has been shown that over-reliance on tests of clinicalperformance and clinical skills alone causes candidates to limit their study tothose conditions that they see routinely on ward rounds and the result isthat physicians in training do not read broadly about other common andimportant clinical problems and relevant clinical science.

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The current Examination employs multiple true/false MCQs to test a largebody of core knowledge which is at a level appropriate for this stage in ayoung physician's professional development.

Our hope is that this Syllabus will assist candidates and their tutors inknowing the extent of knowledge required to pass the Examination.Although each diet will not test every area of knowledge detailed in theSyllabus, the Examination should be viewed as a representative sample ofthe items of knowledge set out in the following pages. The Syllabus shouldbe used in conjunction with the MRCP (UK) Part 1 Examination papers whichare being published simultaneously.

This Syllabus could not have been produced without the considerable inputof the following past and present members of the MRCP (UK) Part 1Examining Board, though the Medical Secretary and Chairman of the Boardbear prime responsibility for the edited script:

David Barnett Frank DunnNicholas Bateman Christopher EllisMichael Besser Paul EmeryMichael Buckley Gordon ErskineDesmond Canavan Michael FordNigel Cooke Ray FoxJane Dacre Roderick HayJohn Dagg Parveen KumarKar Neng Lai John ScaddingKok-Onn Lee John ThomsonKen Lim Allister ValeGary Love John WallsChristopher McManus Alexander WongChristine Rodger Andrew Zealley

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In addition, the comments of Kate Horne and Jim Benson, both of CentralOffice, are acknowledged gratefully. Barbara Reeves prepared themanuscript for press notwithstanding multiple revisions. John Reid of MetroPress was a constant source of assistance as this series of books on the MRCP(UK) was produced. Kenneth Cochran and John Thomson generously assistedwith proof reading.

It is intended that the 2000/2001 Syllabus will be published in late 2000 toreflect the further changes to the Examination which have been agreed inprinciple by the MRCP (UK) Policy Committee.

Jane Dacre Allister ValeMedical Secretary Chairman

MRCP (UK) Central Office11 St Andrews PlaceLondon NW1 4LE

November 1999

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Introduction 1Entry requirements 1Purpose and academic aims 2Content of the Examination 3Assessment of a candidate's performance 4Quality of the Examination 4Syllabus 4Genetics 5Cell, molecular and membrane biology 5Anatomy 6Physiology, biochemistry and metabolism 6Immunology 7

Immunology and immunological tests 7Clinical conditions 7Management 9

Infectious diseases and tropical medicine 10Microbiology 10Immunology of infectious diseases 10Pathophysiology 10Epidemiology 10Treatment 11Specific infections 11

Statistics, epidemiology and evidence-based medicine 13Descriptive statistics 13Graphical techniques 13Inferential techniques 14Evidence-based medicine 14Clinical trials 14

Clinical haematology 15Iron metabolism 15Megaloblastic anaemias 15Haemolytic anaemias 15Other anaemias 16Polycythaemia and myeloproliferative disorders 16White cell disorders 16Disorders of haemostasis 16

Clinical pharmacology, therapeutics and clinical toxicology 17Pharmacology 17Clinical pharmacokinetics 17

CONTENTS

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Monitoring drug therapy 17Adverse drug reactions 18Drug interactions 18Pharmacogenetics 18Therapeutics for specific patient groups 18Clinical toxicology 19Criteria for selecting drugs in a therapeutic class 19Drug formulations and routes of administration 20

Rheumatology 21Clinical science 21Clinical conditions 22Investigations 23Management 23

Cardiology 24Anatomy and physiology 24Pathophysiology and pathology 24Cell biology 25Clinical pharmacology 25Clinical cardiology 25

Respiratory medicine 27Anatomy and physiology 27Pathophysiology and pathology 27Cell biology and genetics 28Clinical pharmacology 28Clinical conditions 28

Neurology 30Neuroanatomy 30Neurophysiology 30Neurogenetics 30Cell biology 31Neuropharmacology 31Neuropathology 31Clinical neurology 31

Psychiatry 33Mental state 33Aetiological factors in psychiatric illness 33Investigations 33Syndromes of psychiatric disorder and their treatment 33

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Psychiatric aspects of physical disease 34Mental retardation 34

Gastroenterology 35Clinical science 35Clinical nutrition 35Disorders of the mouth, tongue and salivary glands 36Disorders of the oesophagus and stomach 36Functional disorders 36Disorders of the small intestine 37Disorders of the liver, biliary tree and pancreas 37The acute abdomen 38Inflammatory bowel diseases 38Colorectal disorders 38

Endocrinology 40Thyroid 40Hypothalamus/Pituitary 40Adrenal 41Ovary 41Testis 42Growth 42Parathyroid/bone 42Diabetes mellitus 43Disorders of lipid metabolism 43

Nephrology 44Physiology 44Molecular biology and genetics 44Glomerular and tubular disorders 44Infections of the kidney 45Calculus formation within the urinary tract 45Acute and chronic renal failure 46Hypertension and renal problems in pregnancy 46Drugs and the kidney 46Renal replacement therapy 46

Dermatology 47Basic science 47Clinical dermatology 47Investigation 48Drugs and therapy 48

There are three Royal Colleges of Physicians in the United Kingdom: the RoyalCollege of Physicians of Edinburgh, the Royal College of Physicians andSurgeons of Glasgow and the Royal College of Physicians of London. All threeColleges share a common Membership Examination; Part 1 was introduced inOctober 1968. Since January 1971, the Royal College of Physicians of Irelandhas used the MRCP(UK) Part 1 Examination as the first part of itsexamination leading to Membership of the Royal College of Physicians ofIreland. In addition, the School of Postgraduate Medical Studies in Singaporeuses the MRCP(UK) Part 1 Examination paper as Part 1 of its Master ofMedicine (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 Membershipstatus.

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

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INTRODUCTION

ENTRY REQUIREMENTS

PURPOSE AND ACADEMIC AIMS

The Part 1 Examination is set at a level which is appropriate for medicalgraduates of some two years standing. The MRCP(UK) Part 1 Examination isdesigned to identify those physicians in training who have a broadknowledge and understanding of basic sciences relevant to medical practiceas 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 physiciansin training are encouraged to develop their full clinical and academicpotential;

• 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 knowledgeof important new advances in disease mechanisms, an understanding ofevidence-based medicine, and an ability to apply this knowledge andunderstanding in the management of patients. Preparation for theExamination will encourage you to acquire relevant knowledge andunderstanding.

It is important that you develop skills and acquire professional habits whichwill enable you to keep abreast of current medical knowledge and newdevelopments. Preparation for the Examination will help you to develop suchskills and professional habits. Hence, reading the medical literature andattending relevant medical meetings should be a normal part of yourprofessional life.

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

As a general guide you will wish to know that there are some 14 clinicalscience MCQs in the Part 1 Examination and these are made up as follows:

Genetics 1-2Cell, molecular and membrane biology 2-3Anatomy 2Physiology, biochemistry and metabolism 5-6Immunology 2-3Statistics, epidemiology and evidence-based medicine 1

In addition, questions are set on common or important clinical disorders as follows:

Infectious diseases and tropical medicine 4Clinical haematology 4Clinical pharmacology, therapeutics and toxicology 6Rheumatology 2Cardiology 4Respiratory medicine 4Neurology 4Psychiatry 4Gastroenterology 4Endocrinology 4Nephrology 4Dermatology 1Sexually transmitted diseases 0 - 1

CONTENT OF THE EXAMINATION

Your answer sheet is machine read and it is therefore imperative that youadhere strictly to the Examination instructions in completing your answersheet.

The MRCP(UK) Part 1 Examination currently assesses your performance inrelation to that of other candidates and not by means of an externalstandard 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 varyat each Examination.

The MRCP(UK) Part 1 Examining Board considers each question prior to itsappearance in the paper and subsequently reviews each question’sperformance. In addition to the final scores obtained by the candidates, theMRCP(UK) Part 1 Examining Board will also note the mean score for theExamination and the mean scores for, and the discriminatory power of, thequestions that comprise the paper. A detailed analysis of the responses toeach item (including a separate index of discrimination for every item), and acoefficient indicating the internal reliability of the Examination as a wholeare also considered by the Board to ensure the quality of the Examination ismaintained.

No syllabus can be comprehensive. Hence, this Syllabus is indicative of thoseareas of knowledge with which you are expected to be familiar, but is notintended to be exhaustive or to exclude other items of knowledge which areof similar relevance. You can expect, however, that the majority of questionswill test knowledge in the broad areas specified.

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ASSESSMENT OF A CANDIDATE’S PERFORMANCE

QUALITY OF THE EXAMINATION

SYLLABUS

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You should have an understanding of the structure and function ofchromosomes and genes and a knowledge of the principles of inheritance ofchromosomal and genetic disorders.

Examples of question topics might include:

• Inherited diseases• Chromosome structure• Common chromosome abnormalities

The cell is the fundamental unit of the structure of organs. It is importantthat you understand the structure and function of the components of thecell and its membrane. You should understand how cells communicateinternally and with each other by means of chemical substances andmembrane receptors.


• Function of intracellular organelles• Cellular communication

GENETICS

CELL, MOLECULAR AND MEMBRANE BIOLOGY

Clinically relevant anatomy will be tested, including neuroanatomy.


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

It is essential that you understand the structure and function of the differentorgans which make up the body and how these organs interact, such asthrough hormonal and neural influences. You should know the broadprinciples of metabolism such as the production of energy and the pathwaysof carbohydrate, protein and lipid metabolism, but a detailed knowledge ofthe chemical processes in the steps of the metabolic pathways is notnecessary. You should have an understanding of the principles of nutrition,water, electrolyte and acid-base balance. Knowledge of the physiology andbiochemistry of each organ system is examined under that specialty.


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

ANATOMY

PHYSIOLOGY, BIOCHEMISTRY AND METABOLISM

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Although a detailed knowledge of basic immunology and immunologicaldiseases is not required, you should have a sound working knowledge of theprinciples of immunomechanisms.


• Humoral and cell-mediated immunity• Immunodeficiency syndromes• Phagocytic dysfunction diseases• Complement deficiencies• Hypersensitivities including allergies and autoimmune diseases

Immunology and immunological testsYou should have a basic knowledge of the immune system in health anddisease.


• 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 conditionsYou should be able to answer questions on the various immunodeficiencysyndromes.

IMMUNOLOGY

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• 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 immediatemanagement of acute allergic emergencies.


• Anaphylaxis• Angio-oedema• Urticaria

You should be familiar with immunology as applied to other medicaldiseases.

Examples of question topics might include immunomechanisms in:

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

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)

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ManagementYou should be able to answer questions on the principles ofimmunosuppressive therapy including major indications and side-effects.


• Immunosuppressive drug therapy (corticosteroids, cytotoxic agents, andcyclosporin)

• Intravenous immunoglobulin• Monoclonal antibodies• Cytokine therapy• Bone marrow transplantation

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

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MicrobiologyYou 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. Majorpathogenic protozoa and helminths should be known.


• Aerobic or anaerobic bacteria• Gram-staining characteristics of bacteria

Immunology of infectious diseasesYou should understand immune deficiency states linked with types ofopportunistic infections. Principles of immunisation and knowledge ofvaccines currently used should also be known.


• Opportunistic infections• Immunisation policy

PathophysiologyYou should have a basic understanding of:

• Septic shock• ARDS• Role of cytokines in infection

EpidemiologyYou should have knowledge of the principles of epidemiology relevant toinfectious diseases.

INFECTIOUS DISEASES AND TROPICAL MEDICINE

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• 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 closecontacts)

• Broad awareness of geographical variation in disease including TB, HIV,Hepatitis B, malaria

TreatmentYou should know the broad indications for, and major adverse effects of,commonly employed antimicrobial agents.


• B-lactams• Tetracyclines• Macrolides • Aminoglycosides• Quinolines• Trimethoprim• Metronidazole• Antituberculous drugs• Antimalarial drugs• Antiviral agents

Specific infectionsKnowledge of the characteristics, recognition, prevention, eradication andpathological effects of all commonly encountered bacteria, viruses, rickettsia,fungi, protozoa, parasites and toxins, including an understanding of theprinciples of infection control, will be required. Special attention todifferential diagnosis, appropriate investigations and awareness of whenpresumptive therapy is indicated is essential.

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• Septicaemia • Meningitis and encephalitis• Endocarditis• Pneumonia (community-acquired, 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 includingPneumocystis pneumonia, CNS toxoplasmosis, cryptococcal meningitis,tuberculosis)

• Glandular fever syndrome and its differentiation from HIVseroconversion illness

• Spirochaetosis - syphilis, leptospirosis, borrelia• Toxic shock syndrome and staphylococcal infections

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You should have a basic understanding of the usage and limitations of thecommon statistical tests used in reporting the results of research in clinicaljournals. The following lists of terms should give some idea of the range ofterms and techniques which you should understand, all of which can befound regularly in journals such as The Lancet, British Medical Journal andNew England Journal of Medicine.

You are not expected to have any knowledge of computer packages forcarrying out statistical calculations. You may be expected to carry out simplecalculations that do not require the use of a calculator. You are not expectedto memorise formulae for statistical tests, but should understand theirconceptual basis.

The following lists are not intended to be inclusive but as illustrative of thetype 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

STATISTICS, EPIDEMIOLOGY ANDEVIDENCE-BASED MEDICINE

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Inferential techniquesExamples 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 medicineYou are expected to have an understanding of evidence-based medicine andan ability to apply this understanding in the management of patients.

Clinical trialsExamples 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

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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 metabolismYou 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 anaemiasYou should understand the physiology of vitamin B12 and folic acid and themechanisms and investigation of deficiencies and their management.


• B12 deficiency• Folate deficiency

Haemolytic anaemiasYou should understand:

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

CLINICAL HAEMATOLOGY

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• Molecular pathology of thalassaemia and commonhaemoglobinopathies


• Causes of haemolysis• Diagnosis of haemolytic anaemia

Other anaemiasExamples of question topics might include:

• Anaemias complicating systemic disease• Aplastic anaemia • Myelodysplastic syndromes

Polycythaemia and myeloproliferative disordersYou should know the causes, investigation and management ofpolycythaemia and myeloproliferative disorders.

White cell disordersYou 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 haemostasisYou 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)

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You are expected to have a good knowledge and understanding of theprinciples of clinical pharmacology, therapeutics and clinical toxicology.

PharmacologyYou 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 areaffected by disease processes and other drugs

• Principles by which both therapeutic and adverse effects occur

Clinical pharmacokineticsYou 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 detailedkinetic calculations will not be required.

Monitoring drug therapyYou should understand the principles that underlie the monitoring of drugtherapy 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

CLINICAL PHARMACOLOGY, THERAPEUTICS ANDCLINICAL TOXICOLOGY

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Emphasis will be given to the areas of clinical practice and therapeuticswhere the narrow therapeutic range of particular pharmacokineticproperties of the drug make this approach important.

Adverse drug reactionsYou should have an understanding of the epidemiology of adverse drugreactions and know how to recognise and avoid them. You must also beaware of important adverse effects of commonly used drugs and have anunderstanding of the importance of adverse drug reaction reportingschemes.

Drug interactionsYou should have an understanding of the epidemiology of adverse druginteractions, and of the mechanisms by which interactions may occur. Youshould also have a knowledge of common drug interactions and their clinicalconsequences.

PharmacogeneticsYou should understand the principles of pharmacogenetics and itsimportance in determining variations in response to drugs in man, both interms of efficacy and toxicity. You should have knowledge of the clinicalconsequences of the common pharmacogenetic variations relevant toclinical practice.

Therapeutics for specific patient groupsYou should understand the principles of therapeutics as they apply in thefollowing 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 groupsmay affect the pharmacokinetics and pharmacodynamics of drugs. You

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should know the principles underlying drug choice, in pregnancy and breastfeeding, and have an understanding of the teratogenic effects of drugs thatmay be used in pregnancy. In the case of renal and hepatic disease it is alsonecessary for you to have an understanding of drugs that may producetoxicity of these organs and whose use is particularly affected by disease ofthese organs.

Clinical toxicologyYou should understand the principles of management of patients who havebeen poisoned with drugs or other toxic substances. This should includeassessment, recognition of common symptom patterns, principles ofremoval of toxic substances, and their antidotes where these approachesmay be appropriate.


• 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 classYou should understand the criteria that may be used to select a drug fromamong 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 studiesthat may be used to underpin drug selection.

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Drug formulations and routes of administration You should be aware of the various formulations of medicines available, andof the routes by which medicines may be administered. You should alsounderstand the advantages and disadvantages of various routes andpreparations. From this knowledge, you would be expected to be able toselect the most appropriate formulation and route of drug administration incommon clinical scenarios.

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Detailed knowledge of all the rheumatic conditions is not required. However,you should have a sound working knowledge of the basic principles of thecommon musculoskeletal conditions.


• Inflammatory arthritis• Back pain• Periarticular disorders• Osteoarthritis• Connective tissue diseases• Bone diseases

Clinical scienceBasic physiology, biochemistry, anatomy and pathology relating tomusculoskeletal 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

RHEUMATOLOGY

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Clinical conditionsYou should know the relative prevalence and major associations of thecommon 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 therheumatic diseases.


• 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 medicalconditions.


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

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InvestigationsYou should have knowledge of the investigations relevant to the diagnosisand assessment of rheumatic diseases.


• 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)

ManagementYou should be able to answer questions on the management of acuterheumatological emergencies.


• Septic arthritis• Osteomyelitis• Temporal arteritis• Acute spinal cord compression

You should be able to answer questions on the management of rheumaticdiseases.


• 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

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Anatomy and physiologyYou should have knowledge of the basic anatomy and physiology of theheart in health and disease:


• Clinically relevant normal anatomy of the heart, coronary arteries andgreat 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 pathologyYou should know the mechanisms underlying the main pathologicalprocesses.


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

CARDIOLOGY

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Cell biologyYou do not need detailed specialised knowledge of cell biology as only topicsof proven clinical relevance will be tested.


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

vascular smooth muscle

Clinical pharmacologyYou should know the indications for drug therapy in cardiac disease andunderstand the actions, interactions and side effects of the drugs used. Theemphasis will often be on new drugs or on novel applications or newlyobserved side effects of established drugs. Details of drug dosage are askedonly rarely.

Clinical cardiologyYou must know the clinical features and management of the cardiacdisorders encountered in hospital practice by the general physician, thoughdetailed specialist knowledge is not expected. You should have knowledgeof risk factors.


• 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 thepublication of major clinical trials, is likely to be tested.

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• 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 notrequired.


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

cardiomyopathy or pericardial effusion• Indications for coronary angiography

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Anatomy and physiologyYou should understand clinically relevant anatomy of the upper and lowerrespiratory tract and thorax including radiological anatomy.

You should have knowledge of the principles of respiratory physiologyincluding:

• 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 pathologyYou should understand the effects of disease on pulmonary physiology andanatomy 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 processesto pulmonary pathology including:

• Asthma• Alveolitis• Tuberculosis

You should possess knowledge of humoral and cellular immunodeficiencystates and sequelae.

RESPIRATORY MEDICINE

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The microbiology of acute and chronic respiratory infections should beknown.

Cell biology and geneticsYou 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 pharmacologyThe indications for, and mechanisms of action of, drugs used in respiratorydisease together with their interactions and side effects should be known.Important respiratory complications of other drugs, e.g., NSAIDs and betablockers should also be understood.

Clinical conditionsThe clinical features, investigation and management of respiratory diseaselikely to be encountered by a general physician must be known.


• Pleural effusion• Chest pain• Haemoptysis • Breathlessness

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The impact of systemic disease on the respiratory system should be known.


• Vasculitis• Neuromuscular diseases• HIV infection

Knowledge of occupational lung disease, particularly asthma,pneumoconiosis, and asbestos related disease is required.

You should know how to assess respiratory malignant conditions andunderstand the general principles of oncological management including theindications for surgery.

The indications for specialised investigations, including bronchoscopy, CTscanning, lung biopsy, lung volumes and exercise testing should be known.

You should have knowledge of the investigation of sleep related disordersand 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 Mycobacteriumtuberculosis infection.

ExclusionsKnowledge of detailed pulmonary mechanics, oncology drug regimens, drugtherapy of environmental mycobacterial infection, inhalation drug kineticsand detailed histological descriptions is not required.

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NeuroanatomyYou are not expected to have detailed knowledge of neuroanatomy.Questions with an anatomical bias will be confined to circumstances wherean understanding of anatomical structure is of critical importance inappreciating the localisation of a particular neurological problem.


• 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

NeurophysiologyDetailed knowledge of neurophysiology is not expected but, as withneuroanatomy, certain aspects of the subject are particularly relevant to theunderstanding of neurological disease and may be tested.


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

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

processes

NeurogeneticsYou are expected to have knowledge of recent advances in theunderstanding of the genetic basis for various neurological disorders.


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

NEUROLOGY

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Cell biologyQuestions in this area will relate to advances in the cellular mechanisms ofcertain neurological disease processes which have provided betterunderstanding of disease mechanisms and which might, in the future, leadto more rational therapy.


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

• The role of the dopaminergic system in various extrapyramidal disorders• The role of other neurotransmitters in certain diseases, for example, in

Alzheimer's disease

NeuropharmacologyYou are expected to have some knowledge of new drug developments inneurology, as well as the established drug therapies.


• The role of some recently introduced anticonvulsants• The present status of immunosuppressant therapy in multiple sclerosis

NeuropathologyYou are not expected to have a detailed knowledge of neuropathology. Youwill be expected to have an outline knowledge of the pathological aspects ofsome common diseases, for example, multiple sclerosis, Parkinson's diseaseand Alzheimer's disease.

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

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either led to better definition of disease entities, or have led to theirimproved management.

In the field of cerebrovascular medicine, examples of question topics mightinclude:

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

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

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Mental stateYou should understand the conduct and scope of a mental stateexamination.

You are expected to be familiar with the features of abnormal mental statesand particularly those that present commonly to physicians and to Accidentand Emergency Departments.

Aetiological factors in psychiatric illnessYou should understand the primary aetiological factors in psychiatric areasincluding:

• Genetic factors• Environmental factors• Life events

InvestigationsYou 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 treatmentYou 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

PSYCHIATRY

34

• 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 diseaseYou should be aware of the psychiatric presentations of physical diseaseincluding:

• Endocrine and metabolic disorders• Toxic states• AIDS• Neurological disease• Epilepsy• Pain

Mental retardation You should know the features of the commoner syndromes.

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Clinical scienceYou 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


• 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 nutritionYou should be familiar with:

• Nutritional requirements in health• Assessment of nutritional status• Nutritional deficiency states• Primary nutritional disorders


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

GASTROENTEROLOGY

36

• Essential dietary constituents• Vitamin requirements• Pathogenesis and management of obesity

Disorders of the mouth, tongue and salivary glandsYou should have an understanding of:

• Mouth ulcers, periodontal and salivary disorders• Oral manifestations of systemic and dermatological disorders


• Causes of mouth ulcers and their management• Skin disorders commonly involving the buccal mucosa

Disorders of the oesophagus and stomachYou should be familiar with the following disorders:

• Achalasia• Carcinomas• Peptic ulceration• Gastritis• Gastrointestinal haemorrhage


• 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

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• 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 intestineYou should have knowledge of:

• Malabsorption syndromes and gluten enteropathy• Hormone-secreting tumours of the gut


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

malabsorption

Disorders of the liver, biliary tree and pancreasYou 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


• Aetiology, clinical and histopathological features of acute and chronichepatitic disorders

• Hepatorenal syndromes and their management• Aetiology, presentation and management of acute and chronic

pancreatitis

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The acute abdomenYou should have knowledge of:

• Perforated viscus and peritonitis• Intestinal obstruction• Ischaemic disease of the small and large bowel


• Common causes of acute abdominal pain and their investigation andmanagement

• Management of septic shock associated with intra-abdominal sepsis

Inflammatory bowel diseasesYou should be familiar with:

• Crohn's disease• Ulcerative colitis• Infective gastroenteritis• Parasitic and protozoal gut infections


• Causes, investigation and management of acute and chronic entericdisorders

• Manifestations of inflammatory bowel disease and its complications

Colorectal disordersYou should have knowledge of:

• Polyps• Carcinomas • Diverticular disease• Anorectal disorders

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• Pathology and clinical genetics of disorders presenting with colonicpolyps

• Causes and treatment of haemorrhoids, anal fissures and ano-rectalfistulae

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Although you are not expected to have a detailed knowledge ofbiochemistry, it is anticipated that you will have an insight into themechanisms of hormone action and the importance of receptors andsubstances involved in control of intracellular metabolism. You should havea knowledge of the clinically relevant anatomical aspects of this specialty.


• 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

ThyroidSince thyroid disease is common you are expected to have a broadknowledge of the mechanisms of thyroid disease, its clinical presentationand treatment.


• 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/PituitaryDetailed knowledge of the structure of the pituitary and hypothalamichormones is unnecessary. You will require a knowledge of the physiology andtesting of the control mechanisms of the endocrine system.

ENDOCRINOLOGY

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• The physiology and pathophysiology of control of pituitary hormonesecretion

• 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

AdrenalA detailed knowledge of mechanisms of steroid biosynthesis is not required,but you are expected to have some knowledge of those parts which areclinically important.


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

OvaryYou are expected to be conversant with the physiology of ovarian functionand with the conditions presenting to a physician.


• 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

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TestisYou are not expected to have a detailed knowledge of the urologicalinvestigation of infertility but some concept of relevant investigations and ofthe endocrine aspects of testicular function is required.


• 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

GrowthGrowth is a very important topic in relation to general medicine as well asendocrinology.

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/boneDetailed knowledge of the anatomy and physiology of bone metabolism

is not required. You are expected however to have some broad concept of thecontrol of bone turnover and the disorders which can result in its failure.


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

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• 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 mellitusYou are expected to have detailed knowledge of this very common condition.


• 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 metabolismAlthough a detailed knowledge of lipid metabolism is not required, you areexpected to have an understanding of the importance of this group ofdisorders.


• 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

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PhysiologyYou 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 geneticsYou are expected to possess a basic knowledge of genetic defects of commonkidney disorders including:

• Polycystic kidney• Alport’s syndrome• Hypophosphataemic rickets

You should have an understanding of inflammatory injury of the kidneymediated by various cytokines and growth factors.

Glomerular and tubular disordersYou are expected to have some knowledge of glomerular ultrastructurebased upon techniques of light microscopy, electron microscopy andimmunofluorescence as applied to renal biopsy. These techniques form thebasis of current understanding of primary glomerular disorders as inidiopathic glomerulonephritis, and nephropathies of systemic diseases.


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

NEPHROLOGY

45

Knowledge of interstitial nephritis (especially those cases with reversibleaetiology such as drugs , heavy metals and analgesics) is expected.

You should be acquainted with the metabolic sequelae of acute nephriticand nephrotic syndromes.

You should be aware of the investigation and assessment of glomerular andtubular disorders, including ultrasonic studies and nuclear medicine.

You should have an understanding of disturbed renal and metabolicfunctions in nephrotic syndrome from a variety of causes.

Infections of the kidneyYou should be familiar with the management of urinary tract infectionsincluding their detection, predisposing factors, prevention and treatment. Aknowledge of anatomical abnormalities leading to repeated urinary tractinfection is expected.


• Reflux nephropathy• Prostatic hypertrophy

You should be aware of other infections that could affect the kidney by directinvasion 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 tractYou should possess a knowledge of metabolic disorders predisposing to

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stone formation, their investigation, prevention and treatment.


• Idiopathic hypercalciuria• Primary hyperparathyroidism• Cystinuria• Hyperoxaluria

Acute and chronic renal failureA knowledge of the management of acute and chronic renal failure and ofthe disturbed physiology involved is expected. You should be familiar withpathophysiological changes and non-dialytic treatment in different stages ofprogressive renal failure.

Principles of nutritional requirements and dietary intervention for patientswith chronic renal failure is required.

Other therapeutic means to slow down the progression of renal failureshould be understood.

Hypertension and renal problems in pregnancyYou are expected to be familiar with renal adaptation to pregnancy, themanagement and prophylaxis of renal disease and hypertension inpregnancy.

Drugs and the kidneyA knowledge of the role of the kidney in the normal elimination of drugs isexpected and you should understand the mechanisms by which drugs causenephrotoxic damage. The principles of dose adjustment according toresidual renal function should be known.

Renal replacement therapyA knowledge of different dialysis modalities and their complications isexpected. You should know the complications related to immunosuppressivetherapy following renal transplantation.

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Basic scienceYou will be expected to have a working knowledge of the structure andfunction of the epidermis and dermis.

Clinical dermatologyMany diseases affecting internal organs will present with skin signs orsymptoms. You are expected to be able to recognise the cutaneoussymptoms and signs of systemic diseases.


• 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 oftherapeutic immunosuppression (for example, systemic corticosteroidtherapy, cyclosporin etc.) or of diseases such as HIV which causeimmunosuppression.

In addition you should know the differential diagnosis and plan ofinvestigation of patients who present with the following cutaneous signs orsymptoms 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

DERMATOLOGY

• Erythema multiforme• Purpura• Ulceration• Vasculitis

A knowledge of the clinical features of the following skin diseases isrequired:

• 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

InvestigationYou should know the principles but not details of dermatologicalinvestigation such as patch testing.

Drugs and therapyYou will not be expected to have a detailed knowledge of the treatment ofskin diseases or dermatoses. However you should know the drugs whichcause life-threatening skin conditions such as erythroderma or Stevens-Johnson syndrome, angio-oedema and toxic epidermal necrolysis.

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Royal College of Physicians of EdinburghRoyal College of Physicians & Surgeons of Glasgow

Royal College of Physicians of London

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

MRCP (UK) Part 1 Questions 2003.

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Documents

MRCPUK Part 1 Syllabus