PSORIASIS IN PACES: Its a popular question in MRCP PACES.

It is easy to diagnose but it can be tricky sometimes , for eg Patient with psoriasis can
present with axial arthropathy mimicking ankylosing spondylitis or Patient with psoriasis can
present with hand arthropathy mimicking rheumatoid pattern or psoriasis can be easily
missed if it is present in hidden sites like infra mammary, scalp area, around naval area ,post
auricular etc. It is not enough for you just giving your examiners the diagnosis of Psoriasis;
you have to tell them severity of the illness & complications of the illness...
Chronic plaque (classical) type Multiple , well-demarcated plaques with a SILVERY scaly
surface with Predilection for extensor surfaces
Always check behind ears, scalp and umbilicus
Always check for joint involvement
Flexural psoriais - is not scaly..
Types of psoriasis: 1. Plaque Psoriasis (psoriasis vulgaris), /2. Guttate Psoriasis
3. Pustular Psoriasis, /4. Erythrodermic Psoriasis, /5. Inverse Psoriasis ,/6. Nail psoriasis, /7.
Scalp psoriasis...
Psoriatic arthropathy (10%)
Five forms of arthropathy:
1.DIP involvement (similar to OA) / 2.Large joint mono/oligo-arthritis ,/ 3.Seronegative
(similar to RA)/ 4.Sacroilitis (similar to ankylosing spondylitis), /
5. Arthritis mutilans...
Read about Complications & treatment of psoriasis.

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PSORIATIC ARTHROPATHY.
Its common to keep psoriatic arthropathy exactly mimicking Rheumatoid pattern.
(Only clue here is skin lesion. Always look for other signs of psoriasis like piting of nails, skin
rash over post auricular area, scalp, umbilicus etc. Check spine for any ankylosing type of
presentation of psoriatic athropathy. )
Five types of psoriatic athropathy.
1.Oligoarticular asymmetrical type (70%).
2.Distal interphalangeal type
3.rheumatoid arthritis-like presentation.
4.Ankylosing spondylitis like presentation.
5.Arthritis mutilans!
Remember, there are five types of psoriasis. They are chronic plaque, inverse psoriasis,
pustular, guttate and erythrodermic type
During exam.
Don't be panic.
Follow General rules. ( Inspect, feel, palpate, passive movement, functional assessment and
special steps).
Always ask your patient whether he/she has any pain over any specific joint, then I would
ask them to rest their hands on a pillow.
LOOK - Expose properly : preferably expose the whole upper limbs up to shoulder for not to
miss any skin rash, skin nodule ( especially subcutaneous nodule over the elbow in
rheumatoid arthritis ) and any abnormal joint deformity.
Describe any abnormality you can see such as joint deformity, muscles wasting etc. Do a
proper inspection, look over patients palm as well as the back of the hands.
Look for presence of nail pitting.
FEEL - feel the patients skin gently to assessment whether there is presence of warmness
that might suggest disease activity.
PALPATE: Then palpate the patients joints by gentle passive movement and look for any
thickening of synovium or joint tenderness. Also try to feel for calcinosis that might be
present in scleroderma. Always tap over patients flexor retinaculum to check for carpal
tunnel syndrome.
FUNCTIONAL STATUS : Do at least these three important steps, unbuttoning of clothes,
pincer grip ( holding key) and writing.
If you suspect there is involvement of elbow and shoulder joints, then ask patient to comb
his/her hair.
Common questions examiners would ask you,
Why in arthritis mutilans, there is shortening of the fingers ?( due to marked periarticular
osteolysis and erosion)
What is pencil in a cup appearance in xray?
Where are the common sites to find psoriatic patches?
How would you manage psoriatic arthropathy?
Always remember that NEVER SHAKE HAND WITH PATIENT! in locomotor sub-station
especially if you suspect patient has pain.
( but for neurology station, ALWAYS do Shake hands first)

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PTOSIS for PACES :

Please examine the patients eyes. > This sign is subtle especially if it is a partial ptosis.
Approach to a patient with ptosis:
1. Look at the level of the eyelid, look for asymmetry
Unilateral/bilateral OR Partial/complete
2. Then, proceed to check the pupil, look for anisocoria (unequal pupil)
Dilated in 3rd nerve palsy
Constricted in Horners syndrome
Normal size pupil in MG, CPEO, dystrophy myotonica
3. Look for eye position, any strabismus.
looking downward and outward in 3rd nerve palsy
variable strabismus in MG
4. Look for associated muscle weakness.
CAUSES:>>
UNILATERAL : 1. 3RD Nerve palsy.
2. Horner's Syndrome
3. congenital
4.Myasthenia gravis (usually bilateral)
BILATERAL PTOSIS :
1.Myasthenia gravis
2.Myotonic dystrophy.
3.Facioscapulohumeral dystrophy .
4.Chronic Progressive External Ophthalmoplegia (Kearns-Sayre
syndrome)
5.Oculopharyngeal muscular dystrophy.
6.3rd nerve nuclear lesions
1. Myotonic dystrophy: Myopathic facies
. Bilateral ptosis.Myotonia with hatchet look Wasting of temporalis, facial muscles, masseter,
sternomastoids.
2.. Myasthenia gravis
> Unilateral/bilateral ptosis,Fatiguibility , Variable strabismus/diplopia
, Bulbar symtoms .
3.. Facioscapulohumeral dystrophy
> Bilateral ptosis,Wasting of facial muscles,sternomastoids and limb-girdle muscles, Winging of
scapula
, Foot drop - classical case has weakness of anterior tibialis.
4. Chronic Progressive External Ophthalmoplegia (Kearns-Sayre Syndrome),Bilateral ptosis
,Symmetric ophthalmoplegia,
>> Look for retinitis pigmentosa.
5.Oculopharyngeal muscular dystrophy
>> Scenario may suggest history of dysphagia
,Extra ocular weakness
,Distal limb weakness..

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RHEUMATOID ARTHRITIS examination need to cover

1.Disease activity
2.Functional status
3.Steroid /other treatment effect
4.Systemic manifestations of disease itself & treatment
5.Any evidence of surgery & cervical stabilization.
1.GENERAL-looks for walking aids,anemia,cushinoid features,paper thin skin , steroid purpura etc
2.Hand examination 3.Focused cardio-respiratory examination - lung fibrosis, pleural effusion.pulmonary
hypertension,pericardial effusion
Investigations- Increased CRP,ESR,platelets, Anemia./ urine - proteins
Rheumatoid factor (positive in 80%),anti-CCP( more specific & used to monitor disease
activity)./CXR,HR CT,ECG,Echo/DEXA scan
MANAGEMENTExplain, Educate,physiotherapy /Encourage regular exercise./Occupational therapy/social service
NSAIDS/COX2(plus gastric protection)
Steroid courses/intraarticular steroids(bone protection , if prolonged steroid treatment ( calcium/vit
D/biphosphanates/)
DMRDS (methotrexate,sulphasalazine,hydroxychloroquine).
BIOLOGICAL AGENTS
Corrective surgeries

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X-ray finding in rheumatoid arthritis
1.Juxta articular osteoporosis
2.Loss of joint space
3.Bony erosion

4.Subluxation
5.Soft tissue thickening

SMALL MUSCLE WASTING IN HANDS :

GO through this video of clinical examination of HANDS
http://www.youtube.com/watch?v=65mjCLGrGTE
Its a Favorite Topic MRCP PACES .Obviously you see small muscle wasting of Hand Possible causes
are
(A) Cervical lesion > Any lesion causing injury to C8 and T1 can lead to generalized muscles wasting
of the hand. Causes are 1.MND 2.syringomyelia ( cervical) 3.bilateral cervical ribs and 4..cervical
spondylosis 5. tumor/Pacoast tumor 6.Old polio
Motor neuron disease ( esp.progressive muscular atrophy) > Small muscle weakness/wasting &
presence of fasculation will confirm the diagnosis of motor neuron disease.
(B) Carpal tunnel syndrome- Affect mainly thenar group of muscles.
(Median nerve supplies LOAF muscles and ulnar nerve supplies other small muscles of the hand).
Look for underlying causes >1.Pregnancy 2.Rheumatoid arthritis 3.Acromegaly 4.Amyloidosis
5.Hypothyroidism 6.Long term hemodialysis ( due to deposition of beta 2 mircoglobulin).
(C) Peripheral nerve problems- CIDP,Charcot Marie Tooth disease.
(D) Part of generalized muscles wasting/disuse/ old age
Points to remember
1. We should localize the lesion as LMN i.e. the lesion is at C8-T1 level including the cord, anterior
horn cell, nerve roots and peripheral nerves.
2. NMJ is not included because it does not cause wasting. Muscular disorder is not included because it
does not usually cause distal weakness.
3. Sensory examination is VERY important in localizing the lesion. For example, if there is sensory
loss then MND is excluded from your differential lists.

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HISTORY TAKING /STATION 2 PACES.

Read all scenarios for history taking from Ryder Mir volume 2. Other books to refer
to are Success in PACES by Philip Kelly and PACES for the MRCP by Tim Hall.
History taking: when you read the scenario:
1. Make a list of differential diagnosis, most are given in that scenario discussion
2. For each differential diagnosis find out which questions to ask to rule it out
3. Learn what are the alarm symptoms for each system of the body
4. Make a problem list as you go on taking history, note on the paper
When you practice history taking with a colleague:
Read the scenario carefully and on a piece of paper make notes where you write down
important points from the scenario and make a structure for taking history like:
1. Introduce yourself and confirm identity of patient.
2. Verify the information given in scenario with the patient.
3. Hx of presenting complaints: Always start with an open question like, Your GP has
written so and so, tell me more about it. Take detailed history about the presenting
complaint. Stress on alarm symptoms like wt loss, bleeding, h/o loss of bladder or
bowel control, leg weakness. chest pain ,confusion etc.
4. Previous investigations: it is good idea to ask the patient about this because it
reveals further information which the patient has not yet revealed.
5. Systemic review and alarm symptoms plus menstrual history for women.
6. Past Hx of relevant or any other diseases including ongoing complaints: diabetes,
asthma, angina, heart attack, high blood pressure. Any surgeries. Any relevant travel
history.
7. Drug Hx and allergies.
8. Family Hx: of similar or any other disease. Diabetes, asthma, angina, heart attack,
high blood pressure. Parents, early death in family due to heart disease in relevant
cases. Family h/o sudden death, etc
9. Social Hx: marital status, occupation, relate occupation to the patients symptoms,
social circumstances. Stairs, etc., in the house in case of mobility problem. Any
assistance at home, any dependents.
Smoking/Drinking: if denies heavy drinking but you suspect symptoms to be drinking
related, then ask the CAGE questions
Illicit Drug History: marijuana, injecting drugs, sharing needles.
Sexual History: If relevant. Partners, contact with prostitutes, homo-hetero sexual.
Unsafe sex, especially during travels to sub-Saharan Africa
10. Patients Concerns/beliefs/insight: What do you think your symptoms are caused
by? Do you have any concerns? Do you have any questions? It is very important to
address any concerns of the patient. Does the patient really understand the severity of
the disease? They may ask do I have cancer, doctor? You need to talk to them
appropriately. You must not rush this part.
11. Summarize, explain plan, and any follow up arrangements
12. Create a problem list including management plan......

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Approach to Station 5
Any cases can be kept in Station 5 , including case with no findings.We shall try to discuss cases in
due course of time. The following is the basic approach to station 5 cases.Please see the official
MRCP video which I have posted today.
In the 5 minutes prior to the start of the station, read the scenarios very carefully, identify key
information present in the scene-setting summary, background medical conditions (e.g. hypertension)
and make notes of this. Use the time allowed to build a differential diagnosis list which will help you
think which questions you need to ask.
Station 5 is the only station where all the 7 areas of assessment in PACES are being evaluated. It is
worth having a mental checklist of all the areas that need to be covered.
Physical examination
Identifying physical signs
Clinical communication
Differential diagnosis
Clinical judgment
Managing patient concerns
Managing patient welfare.
What follows is a suggested breakdown of your time in each scenario.
History and examination: 6 minutes.
It is important to start the history as soon as possible. Keep introductions brief. Practice taking a
history and starting the examination whilst still taking the history. Examination of face, skin, joints,
and pulse can occur whilst taking the history. History must be focused but complete with regard to the
system involved, e.g. if a patient has chest pain dont forget to ask about other cardio respiratory
symptoms, smoking, drug history, family history.Remember to ask for and use all of the available
resources including medication lists, drug charts, observation charts (temperature, blood pressure,
pulse, blood glucose), blood results, urinalysis, ECGs, chest X-rays, etc...
Discussion with patient: 1 minutes
Explain the diagnosis and plan, including investigations required and treatment Planned; answer
questions; address concerns in plain English, avoiding medical terms .Remember that communication
skills are being tested.
Discussion with examiners: 2 minutes.
Explain the diagnosis (have a clear list of differential diagnoses) and examination findings. The
management plan should have been explained to the patient in the 8 minutes but the examiner will ask
about the management plan if it was not clear from your discussions with the patient. Answer the
examiners questions.
Outside the UK, it is possible that there will be a higher rate of proxies being used, e.g. non-speaking
patients with clinical signs, with a relative who provides the history and asks the questions. It is
important to develop an approach for these, including asking the patients permission to speak to their
relative and remembering to involve both the patient and their relative in discussions, answering
their questions and concerns.
Dont be surprised if a patient has no physical signs on examination; surrogates/ actors may well be
used to try to provide a reliable, consistent history in history dependent scenarios which include
normal clinical examinations. Remember that patients with significant presentations, e.g. TIA, often
reach hospital with little to find once they arrive.

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Today's SPOT DIAGNOSIS

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Ahmad Shaheen and 24 others like this.

Mohd. Mosharraf Hossain Khandaker calcinosis cutis

28 October 2013 at 18:28 Like 2

Raisul Islam Khan PPP

28 October 2013 at 18:47 Like

Atiquel Islam Chowdhury Chronic tophacious gout

28 October 2013 at 19:09 Like

Mohamed Bakry tophi of gout

29 October 2013 at 03:38 Like

Mohammed Elagouri could be an eruptive xanthoma....because no joint abnormality obvious....

29 October 2013 at 12:37 Like

Shahad Memo CALCINOSIS

29 October 2013 at 14:59 Like 2

Ahmed Barakah gouty arthritis ..

29 October 2013 at 17:36 Like


Mohd. Mosharraf Hossain Khandaker Shuhaib Kunjhibava- what is the correct answer?
29 October 2013 at 17:44 Like

Purushothaman Kuzhikkathukandiyil i ll go for calcinosis than tophi ..

Reason ....1. There is wasting of hypothenar muscles..especially left hand..
2.Is there a tinge of bluish discoloration of fingers ?
So this patient must be having raynauds phenomenon and an neuropathy .. So rather than gout which
causes arthritis only .. this seems to be a condition causing calcinosis , reynauds and most proably
neurpathy
29 October 2013 at 18:02 Like 4

Zaid Haithem CREST syndrome

29 October 2013 at 21:26 Like 1

Tamer Salem Gout ???

30 October 2013 at 20:36 Like

Karm Karm reiters

30 October 2013 at 21:03 Like

Shuhaib Kunjhibava This patient has multiple, punctate tophaceous deposits in fingers.
Chronic tophaceous gout results from recurrent acute attacks. However, patients with severe tophaceous
disease appear to have milder and less frequent acute attacks than non-tophaceous patients.Areas of
necrotic skin overlying them and may exude chalky or pasty material containing monosodium urate crystals.
Sinuses may form. Tophi may resolve slowly with effective treatment of hyperuricaemia.
A strong DD is calcinosis cutis as suggested by Purushothaman Kuzhikkathukandiyil Sir,.
Calcinosis cutis is present in patients with the CREST variant of systemic
sclerosis,dermatomyositis,cutaneous lupus erythematosus in PACES scenario. The calcinosis appears as
irregular, hard nodules. In places, the overlying skin is thin, and the underlying calcific material appears as
small yellowish patches. Surrounding areas of erythema and tenderness may accompany these lesions.This
fingers may show distal pulp atrophy.Calcinosis cutis divided into four categories according to the
pathogenesis as follows: dystrophic, metastatic, idiopathic, and iatrogenic.In connective tissue diseases,
calcinosis is mostly of the dystrophic type and it seems to be a localized process rather than an imbalance of
calcium homeostasis.
Differentiation between these condition is based on focused history & focused clinical examination for
associated features in station 5 PACES..