Table of Contents

Frequently, the college will put some sort of horrible LFT picture up for the candidates and ask them to make sense of it. The general trend of questions seems to be coma, flavoured with a recent history of discharge from an alcohol rehab institution of some sort. There is one specific question which is frequently repeated where the ammonia is also elevated, and the LFTs are raised in a non-specific pattern. Give six differentials, they usually ask.

Iron studies are making more frequent appearances in the college exams. Previously, they were only explored in Question 18.1 and Question 18.2 from the first paper of 2015. One might think this would have come up earlier. My database only reaches back to 2000, so perhaps in the ancient era of JFICM there might have been more interest in this from the physicianly contingent of examiners. On top of the anaemia-related applications of iron studies, the college have recently interrogated the candidates about the causes of an absurdly high serum ferritin in  Question 22.1 from the second paper of 2016.

The topic of burns appears in the Part II CICM exam in a number of ways. Typically, as a part of the question, the candidate is either expected to list the characteristic findings of airway burns and smoke inhalation injuries, or to discuss fluid resuscitation for the burns patient. Whenever this is not the case, a generic "discuss your management" question is to be expected. Occasionally the patient is paediatric, but the "paediatricity" of the patient does not exert overmuch influence on the discussion of the burns management.

Very often the college gets lazy and lists a few toxins, with the intention that the candidates can then write down the matching antidotes. It is quick to mark (tick tick tick) and requires little though from the question writers. The candidates also appreciate it; it is easy marks, and having appeared many times in the past papers, the act of matching poisons and their antidotes has become an automatism for many of us. Unfortunately, this specific panel of toxins has not been seen for a few years.

Beta-blockers can be divided into selective and nonselective, depending on their affinity for β1 receptors where most of their desirable effects are exerted. Their main positive effects are a decrease in heart rate, decrease in cardiac contractility, and an increase in diastolic filling time, which results in a decrease in myocardial oxygen demand and an increase in coronary blood supply.They have additional positive antiarrhythmic effects. Negative (β2 receptor-mediated) effects consist of peripheral vascular vasoconstriction and increased bronchial smooth muscle tone.

Frequently, the college will present the candidate with some of this information; eg. "this is a Gram-negative rod in the anaerobic bottle. What could it be?" Thus, the SAQ becomes a game of "Name That Microbe". The table below lists selected organisms which for whatever reason seemed to be of interest. Needless to say, the list is not definitive.

Calcium channel blockers can be divided into dihydropyridines (which selectively affect smooth muscle) and the others (verapamil and diltiazem) which are non-selective and which also affect the heart. They are all highly lipophilic highly protein-bound drugs with a large volume of distribution and mainly hepatic clearance (the only exception is clevidipine which is hydrolysed by plasma esterases over mere seconds). Their mechanism of action involves preventing voltage-gated calcium channel opening, thereby decreasing cardiac and vascular smooth muscle contractility as well as pacemaker automaticity.

Question 7 from the second paper of 2017 just asked for antidotes, but Question 4 from the first paper of 2013 asked for a significant amount of detail about digoxin toxicity. Specific points included the manifestations of toxicity, the indication for specific Fab fragment antidote, and the interpretation of a frustratingly high digoxin level after what should have been an effective course of therapy (the key issue to remember is that the assay measures both the Fab-bound and the free drug). The single most helpful resource for this is the LITFL CCC page. Among the published literature, "Digitalis" by Hauptmann and Kelly (Circulation, 1999) is probably the one article you should read about this topic.

In their preparation,  candidates for the Fellowship Exam may wish to consider the following issues.