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Discussion
During your MRCP PACES examination, your examiners may give you
.clues and tell you that this gentleman has problems with his speech
If they give you clues that patient has problems with speech, I will
.examine the patient's lower cranial nerves first
Anyway, even though you have the habit for examining cranial nerves
from the every first to the last, you would notice that this gentleman has
.very obvious wasting of the tongue
asimgabir@hotmail.com
If you remember from your old medical school time, muscles of the tongue
.are supplied by hypoglossal nerve ( XII cranial nerve)
You must look for other cranial nerves involvment in this gentleman.
:Further examination in this gentleman reveals that
Conclusion
asimgabir@hotmail.com
Discussion
OK, examiners give you two clues here, patient is diabetic and female.
Yes, Necrobiosis Lipoidica Diabeticorum is common among female
. diabetic patients
Classically it is decribed as well-circumscribed papules or nodules that
expand with an active border to become waxy, atrophic, round plaques
centrally. Initially, these plaques are red-brown in color but progressively
.become more yellow and atrophic in appearance
Necrobiosis Lipoidica Diabeticorum is a disorder of collagen
degeneration with a granulomatous response, thickening of blood vessel
walls, and fat deposition. You must always suggest to examiners that
you would like to look for similar lesions over pre-tibial area ( a classical
location), scalp, trunk and upper extremities. Suggest to exaimers as
.well that you would like to check urine for glucose
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
This lady has Nercobiosis Lipoidica
Diabeticorum
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asimgabir@hotmail.com
Discussion
There are different possible questions that can be asked in the
:examination besides the above question, other possibilities include
!Look and proceed
.Would you like to examine this patient's thyroid status
.This lady complains of tremor, would you like to examine her.etc
It is important for you to know how to approach this type of case, if the
question starts as assess this lady's thyroid status.I would most
probably start off by showing the examiners how I assess her thyroid
function by checking tremor, pulse rate, sweaty palm, thyroid eye
. signs, opthalmoplegia and reflexes
Then I would proceed to examine her thyroid gland and give a brief
.description about the gland
However, always remember to check for retrosternal extension, thyroid
bruit , proximal myopathy and pretibial myxodema
asimgabir@hotmail.com
Conclusion
This lady has Grave's disease with diffused goitre and in a
.hyperthyroid state
Extra points
For Grave's opthalmoplegia, the first muscle to be involved is) 1
.inferior rectus
.Radio-iodine treatment can worsen Grave's eye disease ) 2
Remember precautions to be taken after radioiodine treatment ) 3
asimgabir@hotmail.com
Discussion
.Usually this case is popular in skin sub-station at station 5
. Although it is rather uncommon in UK, SLE is endemic in South East Asia
It is a common case especially if you are sitting your MRCP PACES in
Malaysia ,Hong Kong or Singapore. Always remember to present the
following
pattern of distribution of the rash- 1
presence/absence of telangiectasia- 2
any vasculitic rash- 3
.Any signs to suggest patient is on long term steroid therapy-
Conclusion
This lady has active SLE with malar rash and was admitted
.due to joints pain
Extra points
Discussion
It is a gift if you get this case in your MRCP PACES, an important
sentence you must include in your presentation is bilateral, symmetrical
deforming polyarthropathy involving the small joints of hands especially
. over PIP and MCP joints
Psoriatic athropathy may present with similar deformity but look hard for
. other clues such as nail pitting, skin lesion and telescoping of fingers
Always look hard for Cushing's syndrome although patients with RA are
.usually not on long term high dose steroid
Always assess their functional status. Suggest to examiners that you
would like to examine other joints, look for splenomegaly ( Felty's
syndrome) and lower lobe fibrosis
asimgabir@hotmail.com
1
2
asimgabir@hotmail.com
Conclusion
This lady has RA and is on Methotraxate, salazopyrine and low
dose prednisolone
Extra points
Simple functional status you can assess in exam includes pincer grip
( ask patient to hold a key), functions of hands (unbuttoning of cloths)
.and shoulder involvement ( comb the hairs)
Always look hard for other associated autoimmune disease namely
.Sjogren's syndrome, autoimmune hepatitis etc
asimgabir@hotmail.com
Mr Lee is 55 years old chronic Hepatitis B carrier comes to your hospital for
right hypochondrium pain for 1 month. He was previously under his GP
follow up for his Hepatitis B infection. Yearly alfa-fetoprotein and ultrasound
.abdomen are done for him and he was told to be normal
Further CT abdomen and thorax in your hospital show that he has an
advanced hepatoma with lung metastasis. Your consultant has reviewed
.the films and think there is no curative management for him
Your task is to break the bad news to him and tell him there is only
.palliative management available
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Discussion
It is rather a common question in MRCP PACES, breaking bad news is
always a popular question. There are usually two scenarios in this type
.of question
The first scenario will be breaking bad news to patients who are suffering
:from chronic illnesses examples are patients with
SLE
Motor neuron disease
Multiple sclerosis
Parkinson's disease
.dementia etc
Another scenario will be breaking bad news to patients with advanced
.cancer
asimgabir@hotmail.com
It is more tricky in the first scenario because you are expected to know
fairly well the management of each illness, therefore you need to have
. some theories basic to score in this type of question
Whereas in the second scenario, you do not need to know anything about
the management of the advanced cancer, you can even score a four
.without explaining anything about the management
In this case , you must always anticipate that Mr Lee would ask you why
he is having hepatoma (Liver cancer) since all the while his GP tells him
.that the tests are normal
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asimgabir@hotmail.com
Discussion
If you see bilateral ptosis in your MRCP PACES, then the examiners are
either going to give you a clear pass or a clear fail The reason is simple,
. you can either give a clear diagnosis or you do not have any ideas
There are only two possibilities in MRCP, either you are dealing with
.dystrophia myotonica or myasthenia gravis
You can make a diagnosis of dystrophia myotonica (DM) after you shake
the patient's hand. Patients with DM will have difficulty to release his/her
.hand grip
You can further demonstrate this by doing a percussion test. You can use
your tendon hammer to percuss at patient's thenar eminence , what you
notice will be flexion of the thumb and then slow extension of patient's
.thumb
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Conclusion
.This lady has ocular myasthenia
Extra points
Remember a few examples of drugs that can precipitate
.myasthenia crisis
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Discussion
very common short station case in UK. What you notice here is multiple
telangiectasia over patient's face as well as over his ear lobe. Other
common sites to look for this are tongue, palate, nasal mucosa, nail
.beds, arms and trunk
After this, you should look hard for features to suggest heart failure if
there is possibility of presence of shunt. Try to auscultate for bruit over
. the patient's lung and liver
Also check for anemia because patient tends to have PR bleeding.
Suggest to examiners you would examine fundoscopy to look for retinal
.haemorrahage and do PR to look for bleeding
Last but not least, ask for family history because it is inherited in an
autosomal dominant way
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Conclusion
This gentleman has hereditary haemorrhagic
telangiectasia ( Rendu-Osler-Weber Disease(. He has
.history of recurrent PR bleeding
Extra points
Remember the simple management about this condition such as - 1
.oestrogen, cauterization etc
Discussion
This question came out a few years back in Singapore MRCP PACES
examination. I want to show you this question to remind you that in your
examination, no matter what the patient's symptoms are, if the patient is
young, always think of HIV
My friend who sat for the exam asked patient a lot of questions and
covered most of the possible diagnosis like thyrotoxicosis, inflammatory
bowel disease etc. However, patient refused to talk about his sexual
encounters when asked, a common scenario in PACES
Remember to convince the patient that it is important for you to take this
piece of information and you certainly share with him/her the feeling of
embarassment he/she may have
You must not be judgemental about patient's sexual orientation and inform
patients that you are there to help him/her. My friend failed this station
because he failed to find out that this patient is actually a homosexual and
was practicing unprotected sex with a lot of partners. The diagnosis was
HIV with PCP
Discussion
It is a common case in MRCP station 5 of endocrine sub- station
There is presence of obvious purplish striae over his abdomen as well as his upper
thigh
Check for other obvious clinical signs such as buffalo hump, moon face, thin skin,
multiple bruises especially over venesection site, hirsutism and acne. Look for
.proximal myopathy and spine tenderness
Suggest to examiners that you would like to do the following, check the urine for
glycouria, check this patient's BP and ask relevant history to assess whether the
.patient is on long term steroid. Look at his abdomen to see any surgical scar
asimgabir@hotmail.com
Conclusion
This gentleman has Cushing's syndrome secondary to long term
. steroid ingestion ( from traditional medicine(
He was admitted due to fulminant sepsis with Addisonian crisis
:Extra points
Conclusion
This is a classical question that can be asked in your counselling station. I
call this type of question,Disease explanation question, other diseases that
are common in the exam include Alzheimer's disease, Motor neuron
. disease, Hepatitis B and C , polycystic kidney disease etc
Usually all these diseases are chronic or they have a lot of social
implications. In this case, since that Mrs Davis is suffering from Parkinson's
.disease, candidates are expected to do the following
to explain the illness in layman's terms-1
explain the prognosis and the likely progression of the illness -2
treatment for the disease- medical or any new treatment available such -3
as surgical intervention
ask social history especially the impact of the illness towards patient's -4
daily activities as well as patient's relationship with other family members
Extra points
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Discussion
Ptosis is always a popular question in MRCP PACES, this
. gentleman has left unilateral partial ptosis
After you notice this, there are two common possibilities, either
the patient is suffering from left Horner's syndrome or left third
.nerve palsy
The second step you would like to do is of course to look at the
affected eye's pupil size. This will tell you whether you are
.dealing with a third nerve palsy or Horner's syndrome
If the pupil's size is small then you are dealing with Horner's or
else you are dealing with third nerve palsy especially you
notice that the eye is abducted
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Conclusion
This patient has left isolated third nerve palsy due to diabetes mellitus
Extra points
Discussion
It is sometimes rather difficult for you to differentiate panhypopituaitarism
.from hypothyroidism
However, if you look at patient's sexual characteristics, they are lost in
panhypopituitarism
Patients with hypothyroidism also tend to be older because the main
cause for panhypopituitarism is mainly due to Seehan's syndrome and
skull radiation which is commoner among younger patients
Always remember to look for cerebellar signs which is bilateral in .
hypothyroidism. Also look for other associated endocrine involvement
. such as DM, Addison's disease, Pernicious anemia and vitiligo
Suggest to examiners you would like to check for sensory deafness
especially to high tone. Try to find out the underlying cause for the
.hypothyroidism if possible
Conclusion
This lady has hypothyroidism secondary to previous total
.thyroidectomy
Extra points
Although it is rather uncommon in PACES, you can find this illness -1
rather common especially among older population. Always check their
thyroid status if an elderly patient presents to you with dementia
The commonest cause for hypothyroidism is previous total-2
thyroidectomy
asimgabir@hotmail.com
Discussion
As discussed in previous issues, Cushing's syndrome is a popular
.question in MRCP PACES, this lady has a classical moon-like facies
You must look for other relevant clinical signs such as buffalo hump,
.hirsutism, suprclavicular fat pad
Look for purplish striae, proximal myopathy, spine tenderness and suggest
to examiners that you would like to check for BP, urine for glucose and
.visual field
it is rather uncommon for patient to have Cushing's disease and bitemporal
hemianopia because in Cushing's disease ,the tumour is usually a
.mircoadenoma
.If you look hard, this lady has multiple vasculitic rash over her hands
asimgabir@hotmail.com
Conclusion
This lady has Cushing's syndrome secondary to long
.term steroid ingestion due to lupus nephritis
Extra points
Tests to confirm the presence of Cushing's syndrome are 24-hour
.urinary free cortisol and overnight dexamethasone test
Further tests to find out the underlying etiology include plasma ACTH
level, high dose dexamethasone test, CXR, ultrasound/CT abdomen and
.sometimes inferior petrosal sinus sampling for ACTH level
asimgabir@hotmail.com
asimgabir@hotmail.com
Discussion
A common finding in a patient with transplanted kidney but always missed
. by candidates
This gentleman has a superficial right lumbar mass with a scar. The mass is
dull on percussion and there is an AVF over his right wrist. There is no
.ballotable kidney
.Actually this gentleman develops gum hypertrophy due to cyclosporin
A lot of candidates pick up the clinical signs of a transplanted kidney but
unfortunately majority of them do not examine further to look hard for side
effects of long term immunosuppressants such as signs of Cushings
syndrome ( due to prednisolone), fine tremor, gum hypertrophy,
hypertension (BP), diabetes (urine for sugar) and hypertrichosis (such as in
.this case) due to cyclosporin and jaundice ( side effect of Azathioprine )
asimgabir@hotmail.com
A common question examiners would ask you is ways for you to assess
whether the transplanted kidney is functioning well or not, you can suggest
:the following
look at the patient's 24-hours urine volume, good volume suggests good
function
tell examiners whether the transplanted kidney is tender on palpation, if not
tender most probably it is functioning well,( although current
immunosuppresants make this unlikely to happen even patients have
rejection, this sign is a classical sign we were taught in medical school long
time ago!)
auscultate for renal bruit at the transplanted kidney, long term complication of
a transplanted kidney is artery stenosis
look for any recent punctum wound at the AVF, if no recent wound, this implies that
patient is not dependent on haemodialysis, therefore the transplanted kidney must
.be functioning well
asimgabir@hotmail.com
Conclusion
This gentleman has a transplanted kidney and on cyclosporin,
predisolone and azathioprine and he develops gum hypertrophy,
.hypertension due to the drugs
:Extra points
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Discussion
In MRCP exam, if you encounter a surgical scar, it is always a good start
because surgical scar can give you a lot of clues that lead to possible
.underlying diagnosis
This lady has a roof-top scar ( can be just a horizontal scar at left lumbar
region) and further examination reveals jaundice, moderate hepatomegaly
but no stigmata of chronic liver disease ( always look for stigmata of
chronic liver disease, due to her illness , she needs multiple transfusions
and tend to get Hepatitis B and C in long run and possibility of liver
.cirrhosis due to iron overload)
Look hard for any multiple small scars at the abdomen due to
subcutaneous infusion of iron-chelation therapy.The underlying
diagnosis for this lady with chronic haemolysis is Thalassemia with
.previous splenectomy
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Conclusion
This lady has Thalassemia Major and underwent a splenectomy due to
.recurrent, frequent transfusions
Extra points
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Discussion
You must always think of possible differential diagnosis before you enter the
examination room. Mr Letterman complains of lethargy, a very vague
symptom. You must start off by asking him what does he mean by lethargy
Common causes of lethargy/tiredness can be due to anemia,
hypothyroidism, depression, myathenia gravis, obstructive sleep apnoea
You must ask him to explain his symptom. Some patients may associate
shortness of breath with lethargy. In whatever symptoms you are going to
encounter in MRCP PACES,always try to include these questions in your
history-taking if possible
any specific time the symptom becomes worse? If the patient is having
mysthenia gravis, he may tell you that he fells more tired especially during
evening
asimgabir@hotmail.com
Actually, my friend had this case in his MRCP PACES in 2005, the
diagnosis was depression. My friend totally forgot to ask the patient about
his social history
This patient actually just lost his wife in a motor vehicle accident and he had very
!poor social support and he developed depression after the incident
asimgabir@hotmail.com
Discussion
You may be panic when you first look at her hands. Always remember the
general rules for a good physical examination for locomotor system, i.e
inspect, feel, palpate, passive movement, functional assessment and
special steps! Always remember that NEVER SHAKE HAND WITH
.PATIENT in locomotor substation
but for neurology station, always do this first
You may cause pain to patient and examiners have 1 thousand and 1
reason to fail you! Always ask you patient whether he/she has any pain
over any specific joint, then I would ask them to rest their hands on a
. pillow
Second rule is proper exposure, preferably I would ask patient to expose
the whole upper limbs up to shoulder, the reason is simple, you do not
want to miss any skin rash ( especially psoriasis patch) , any 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! What I mean, look over patients
palm as well as the back of the hand. If you do so
Ops, the diagnosis becomes obvious after turning the patients hand
asimgabir@hotmail.com
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Conclusion
.This lady has psoriatic arthropathy
Extra points
Five types of psoriatic athropathy namely
oligoarticular asymmetrical type (70%)
distal interphalangeal type
rheumatoid arthritis-like ( common in exam because want to confuse you!)
ankylosing spondylitis- like
and arthritis mutilans
There are five types of psoriasis. They are chronic plaque, inverse
.psoriasis, pustular, guttate and erythrodermic types
!Facts from Baliga's book
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Discussion
.Patients with scars again I want to show you this case for a simple reason
.There are only a few common causes of a sternotomy scar in CVS station
These causes include previous bypass surgery, valve replacement and
correction of congenital heart diseases such as VSD ( ventricular septal
defect) and ASD ( atrial septal defect )
At the first look, you might think that these patient has had a bypass surgery
.before due to the scar over his leg
The problem is he actually has a bypass and aortic valve replacement
.(AVR) surgery done before
Lesson to be learned here is always look for concomitant AVR if patient has
had a bypass before especially in elderly population because aortic stenosis
is common among this age group
During your examination, always look hard for any bruises to suggest overwarfarinization, signs to suggest endocarditis and murmurs to suggest valve
dysfunction
asimgabir@hotmail.com
Conclusion
This gentleman has AVR surgery done before due to previous
.aortic stenosis and bypass surgery
Extra points
You cant find any donor site and no mechanical click when you
examine the patient but you see a sternotomy scar, you might be
dealing with previous corrective surgery due to congenital heart or a
BIO-PROSTHETIC VALVE
Although patients with valve repairs tend to have left thoracotomy scar
( such as in mitral stenosis), I found out some patients may have
!sternotomy scar
asimgabir@hotmail.com
Discussion
It is an uncommon case in MRCP, however, it is worthwhile to learn
about this
If you look carefully at her lower limbs, you actually notice this lady has
a reticular pigmented rash
There are two common scenarios in PACES that give reticular
pigmented rash. These two conditions are erythema ab igne and livedo
reticularis
It can be quite difficult to differentiate these two conditions, however,.
erythema ab igne usually appear to be more dusky and besides over
the lower limbs, you can find it on the abdomen
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
This lady has livedo reticularis due to SLE
Extra points
Although it is not a popular question, livedo reticularis is often - 1
missed by candidates in SLE patients during their exam
If you are dealing with a SLE patient, skin conditions that are
associated with SLE are hyperpigmentation, discoid rash, malar rash,
.livedo reticularis, alopecia, purpura, telangiectasia and vasculitic rash
If you find erythema ab igne in patient's lower limbs, always look at- 2
!the abdomen as well
asimgabir@hotmail.com
Discussion
This is a commoner question as compared to Q1 in MRCP exams
Yes, you are right, it is acanthosis nigricans! It is always described as
.'black, velvety overgrowth in the skin' by books
Always tell the examiners you would look at other sites for this especially
over the neck ( a very common site other than axilla, especially at the
back of the neck), umbilicus, nipples, groins and facial skin
:Also suggest to examiners that you would
check the urine for glycouria ( because patient may have insulin resistance )
check for occult malignancy especially adenocarcinoma of stomach
ask for menses irregularity if the patient is female because it is associated
with polycystic ovarian syndrome
asimgabir@hotmail.com
Conclusion
.This gentleman has acanthosis nigricans and diabetes mellitus
Extra points
Remember criteria to diagnose metabolic syndrome either based on
.NCEP or WHO criteria
Remember 1 or 2 examples of cutaneous manifestations of viceral
malignancy such as dermatomyositis and Paget's disease of the nipple
asimgabir@hotmail.com
Discussion
A very popular question in MRCP PACES exams. This case can be
used as a case in skin as well as locomotor sub-stations
You notice that this lady has tight skin over her face with multiple
telangiectasia (arrows )
You can see clearly that her mouth appears to be tight.Demonstrate by
asking the patient to put 3 fingers into her mouth
Describe the nose and proceed to do the following
check for dry eye because Sjogren's syndrome can be associated with
.scleroderma
check the hands and look for sclerodactyly ( image next slide),
.Raynaud's phenomenon, peudoclubbing and calcinosis
!Also assess the extent of skin involvement
asimgabir@hotmail.com
ask permission from examiners that you would like to listen to her lungs,
check her BP ( ? hypertension), look for other organs involvement and look
.at her stool for evidence of malabsorption
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Conclusion
This lady has systemic sclerosis
Extra points
.Prednisolone has no role in treating systemic sclerosis
Discussion
It is an easy case if you know how to approach this case
You can see obviouly two small swellings over this gentleman's first toe
.and little toe
Although books describe chronic tophaceous gout as 'chalky 'material,
sometimes you would just notice a swelling such as in this case.After
you feel, palpate and move the relevant joints, you should look at other
.sites for similiar swelling
These sites include helices of the ears, olecranon bursae, tendons of
.hands and Achilles tendon
Another diagnosis that you may confuse with swelling over tendons is
tendon xanthomata
Also suggest to examiners that you would look at the urine for
haematuria and you are very interested to know about this patient's
.renal function
asimgabir@hotmail.com
Conclusion
.This gentleman has chronic tophaceous gout
Extra points
Clinical presentations of gout include asymptomatic hyperuricemia,
.acute arthritis, chronic arthritis and chronic tophaceous gout
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Discussion
First lesson to be learned in abdominal examination is appropriate
.proper exposure
My friend failed this station because he insisted to expose his female
patient in his MRCP PACES exam down to thigh. I would expose the
.patient up to just above the genitalia
Obviously you notice this gentlemans abdomen to be grossly
.distended and there are multiple tattoos at his supra-pubic region
You also notice presence of jaundice, ascites (shifting dullness),
.clubbing and splenomegaly in this gentleman
You must always remember that beside making a diagnosis of chronic
liver disease, you should try to find out the underlying cause for his
.chronic liver disease
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asimgabir@hotmail.com
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Conclusion
This gentleman has chronic liver disease due to
Hepatitis B ( He is an ex- intravenous drug abuser.(
Extra points
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Discussion
HIV is a very important topic in MRCP PACES exam. This is a common
.scenario in station 4 for MRCP PACES
Candidates should start off by expressing their empathy towards this
.event
Before going to the major task of any scenario in the exam, always
remember the following rules
ask about details of the event- in this case, you should ask Dr Henry
about the time of the event, size of needle he was using, the depth of
needle penetration and what was his action after the incident
assess the patients understanding about certain issue, in this case, Dr
Henrys understanding about HIV/AIDS
explain to Dr Henry the current problem/illness, in this case about
HIV/AIDS including the disease progression, modes of transmission
and possible treatment
asimgabir@hotmail.com
Last but not least, always ask patient whether they have any other
issue to discuss
Actually in the real MRCP PACES, Dr Henry was just got married 4
months ago and he is very worried about his relationship with his wife
He is also worried whether he can continue to function as a houseman
while waiting for his blood results
You must always remember that patients in MRCP always have some
hidden agendas that they want to discuss with you
You may miss these issues if you do not ask them specifically
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Discussion
You will be happy to see this case in your MRCP PACES. You can
get the diagnosis after your inspection
You notice that there are multiple distended veins over this
.gentlemans chest
You can proceed with the usual physical examination of the
respiratory system by bearing in mind that you may find the following
:abnormalities
Pancoasts tumour- you may find reduced breath sound over upper
.lobe of the lung with dullness on percussion
.Pleural effusion at one side of the chest
Or any physical sign suggesting presence of mass such as dullness
.on percussion with reduced breath sound
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
This gentleman has superior vena cava obstruction due to lung
.cancer
Extra points
If possible, non small cell lung cancer should be treated with surgical
intervention. For small cell lung cancer, it should be treated with
.chemotherapy
Indications for radiotherapy include SVC obstruction, local obstruction
.such as airway, spinal cord compression and brain metastasis
asimgabir@hotmail.com
Discussion
In MRCP PACES, after lower limbs examination and Parkinsons
.disease, upper limbs examination is the third most popular question
You notice that there are obvious small muscles wasting with loss of
.thenar and hypothenar eminences
Before you proceed further, you should know that there are only a few
.possible causes for this
The causes are Motor Neuron Disease, Cervical Spondylosis,
Syringomyelia ,Charcot- Marie- Tooth and Guillain Barre Syndrome ( or
.CIDP-chronic inflammatory demyelinating polyneuropathy )
It is unlikely for you to get bilateral Ulnar nerve palsy in exam.
Therefore, during your examination, pay attention to assess whether
there is sensory involvement or presence of fasciculation ( which may
.suggest Motor Neuron disease )
asimgabir@hotmail.com
Conclusion
This lady has CIDP
(.due to the chronicity, she has muscles wasting(
Extra points
In MRCP PACES, you are unlikely to get a case of isolated ulnar ,
radial or median nerve palsy
There are three main clinical patterns of MND, they are progressive
muscular atrophy ( obvious small muscles wasting of hand) , Bulbar
.palsy and amyotrophic lateral sclerosis
asimgabir@hotmail.com
Discussion
This is a classical case in MRCP PACES station 3. A lot of candidates
.always feel very worried when faced with cranial nerves examination
.You notice that this gentleman has obvious loss of right naso-labial fold
A lot of candidates always ask me the same question, should I examine
from the first cranial nerve till the 12th cranial nerve or examine the
?nerves according to scenario
I think that it is important for you to divide cranial nerves to 4 main sub:groups, these groups are
Eye group- you will be testing cranial nerves II, III, IV and VI. You will -1
be assessing these cranial nerves by checking eye reflexes, fundoscopy,
.visual acuity, visual field and eye movement
Facial expression, sensation and movement- you will be testing cranial -2
nerves V and VII. You must check for upper and lower portion of facial
.expression, corneal reflex ,masseter and pterygoid movement
Articulation and gag reflex- You will be testing cranial nerves IX,X -3
and XII. Check these nerves by assessing palatal movement, gag
.reflex and tongue movement
Other groups- assess VIII nerve by checking hearing, XI nerves by-4
asking patient to lift the shoulders and the first nerve by assessing
.smell
In this case, since you notice this patient has problem mainly due to
facial expression and movement, I would examine his V and VII nerves
.first
You know that he has 7th nerve palsy, the next question you want to
.ask is whether it is a lower or upper motor 7th nerve palsy
You can differentiate this by observing 2 major upper portion facial
.muscles namely orbicularis oculi and frontalis muscles
asimgabir@hotmail.com
You notice that he is unable to close his right eye tightly as compare to
.the left eye
So the diagnosis is obvious now, you are dealing with right lower motor
.7th nerve palsy.You can then complete other cranial nerves examination
After your examination, you want to find the possible aetiology for his 7th
:nerve palsy by doing the following steps
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
.This gentlema has right Bell's palsy
Extra points
asimgabir@hotmail.com
Discussion
In MRCP PACES, if you find clubbing in respiratory station, you are
dealing with only a few possibilities, the most popular question will be
.bronchiectasis
Other causes of clubbing because of respiratory system are Lung
Cancer, suppurative lung disease ( such as empyema, therefore you
would find signs suggesting pleural effusion, however, it is unlikely in
.MRCP because patients tend to be very ill!) and fibrosing alveolitis
A lot of candidates find it difficult to differentiate lung fibrosis from
.bronchiectasis. I think there are a few important points to take note
Patients with bronchiectasis tend to be more ill because they are
.admitted to hospital because of lung infection
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
.This gentleman has bronchiectasis due to previous tuberculosis
Extra points
In bronchiectasis , remember postural drainage, postural drainage,
postural drainage
If you find patient with bronchiectasis also has dextrocardia, the
diagnosis is Kartagener's syndrome
asimgabir@hotmail.com
Discussion
An uncommon case in your daily practice but it is suprisingly a popular
question in MRCP. Many candidates were asked to examine this case
.in their PACES before
I have friends who sat thier MRCP in Malaysia ( especially at University
Malaya Medical Centre), Singapore ( at National University Hospital)
.and Hong Kong were asked about this case in their Neurology Station
Obviously if you observe properly, you notice there is hypertrophy of
both calf muscles
Yes, you are dealing with PSEUDOHYPERTROPHY of calf muscle
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
This gentleman has proximal myopathy due to Becker Muscular
.Dystrophy
Extra points
There are a lot of causes for proximal myopathy, however if you notice
pseudohypertrophy of calf or deltoid muscles, it is usually due to
.Hereditary Muscular Dystrophy
Other common cases of proximal myopathy in MRCP PACES are either
.polymyositis or dermatomyositis
asimgabir@hotmail.com
Discussion
Another popular neurology case in MRCP PACES, there are a few
.possibilities you are dealing with Pes Cavus in MRCP
You may be asked to talk to a patient who has a Cerebellar ( staccato
and scanning speech) speech and find out that he/she has pes cavus
.with Friedreich's ataxia
Or there is another scenario where you are asked to examine a
patient's upper limbs and you find that he/she has small muscles
wasting of both hands and 'inverted champagne bottles' lower limbs
with pes cavus
.Yes , you are dealing with Charcot-Marie-Tooth Disease
asimgabir@hotmail.com
The two commonest causes for Pes Cavus in MRCP are Friedreich's
.ataxia and Charcot-Marie-Tooth Disease
Your further steps of examination depend on your finding, if you
suspect Friedreich's ataxia after your lower limbs examination,
:suggest to examiners that you would like to
ask about family history
.check fundoscopy to look for optic atrophy
.examine relevant cerebellar signs
look for kyphoscoliosis
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
.This gentleman has pes cavus due to cerebral palsy
Extra points
asimgabir@hotmail.com
Discussion
This is a very popular skin station in MRCP exam. A lot of candidates find it
difficult to describe skin lesion. I think there are a few important points you
.must give to examiners when you try to describe any skin lesion
Your description must include the general appearance of the lesion (either
.it is a macule, papule, blister or bullous)
site of the lesion ( is the lesion only localised to certain areas such as
extensor surface, umbilicus, scalp, palm etc?)
any mucosal involvement ( do you notice any mucosal involvement such
as over oral cavity, eye?) , is the skin lesion itchy or tender and any
associated changes that you think is relevant ( any hand/nail or other
changes such as pitting of nail, rheumatoid hands,thyroid swelling which
might be relevant!) I find that it is rather important for candidates to have a
.general inspection before zooming to the skin lesion
asimgabir@hotmail.com
Sometimes, when you are asked to examine a skin lesion over the leg,
look at patient's eye and thyroid swelling which might tell you the
.diagnosis ( pretibial myxoedema)
Common skin problems over lower limbs which are popular in MRCP
exam are pretibial myxoedema, erythema nodusom, erythema
.multiforme,pyoderma gangrenosum and psoriasis
In this picture, you notice macular-papular rash over patient's lower
limbs but there is no mucosal involvement, you do not not notice any
:bullous eruption. You should proceed to do the following
?feel the lesion to assess whether it is tender
look at patient's mucosal ( oral cavity to look for ulcer ) and
check for conjunctivitis.( mucosal involvement)
check for lymph nodes especially cervical region ( glandular
. fever?) and ask for drug history
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
.This lady has macular-papular rash due to drug allergy
Extra points
asimgabir@hotmail.com
Discussion
I give you this example because I think this is a popular case in
MRCP. This case can be either come out in station 1 or station 5 (skin
. station)
If you notice xanthelasma in a middle-aged woman with jaundice in
your MRCP, always think of Primary Biliary Cirrhosis. You may find
stigmata of chronic liver disease in this type of patient with +/- of
.hepatosplenomegaly
As I mentioned in my previous posts, you can gather some clues from
peripheral to get the underlying cause of a patient's chronic liver
. disease, xanthelasma is one of them
Having said that, xanthelasma can be asked in station 5 as well.
Besides xanthelasma, other stigmata of high cholesterol level include
tendon xanthomata, eruptive xanthomata,palmar xanthomata and
.corneal arcus
asimgabir@hotmail.com
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
This gentleman has xanthelasma with underlying Diabetes
.Mellitus
Extra points
Learn a few important clinical trials involving statin such as 4S,) 1
.MIRACL which are commonly asked in MRCP
.Remember the common side effects of statin) 2
asimgabir@hotmail.com
Discussion
A very popular MRCP question in respiratory station. When you find
a lateral thoracotomy scar in respiratory station, always think of three
:possibilities
namely lobectomy, pneumonectomy and previous lung
.transplantation surgery
A lot of candidates remember the first two possibilities but always miss
the third. The reason is simple, doctors working in many countries such
as in Malaysia and Singapore do not deal with post lung transplant
patients so often as thier counterparts in developed country such as
. the United Kingdom and Ireland
Therefore, if you are planning to sit your MRCP PACES in United
.Kingdom, learn well about transplantation
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
This lady has lateral thoracotomy scar due to previous lobectomy
.because of lung cancer
Extra points
Always take your time to observe for any surgical scar in your ) 1
respiratory station. You may be able to diagnose the condition before
!even touching the patient
Discussion
A rather uncommon case in your daily practice but it is popular in
MRCP cardiovascular station. You notice this lady has long fingers
. (arachnodactyly)
Patient's hand is at the left and mine is over the right. You would be
happy if you get this case,yes, finally you are seeing a case of Marfan
.syndrome in your exam
Demonstrate to examiners and convince them that the patient's fingers
are long by demonstrating thumb sign ( ask patient to clench her
thumb in her fist, the thumb should not exceed the ulnar side of the
hand in normal subjects) and wrist sign ( put patient's fingers around
, her wrist, you would notice her thumb and little finger overlap)
look for other signs to suggest Marfan syndrome such as high arched
palate ( in this patient), small papules in the neck, up-ward dislocation
.of the lens, kyphoscoliosis, and chest wall deformity
asimgabir@hotmail.com
Conclusion
.This lady has Marfan syndrome and mitral regurgitation
Extra points
When asked about the management of an illness, always) 1
remember that patient education is very important if the illness is
.chronic and incurable. Remember genetic counselling if it is inherited
Cardiovascular complications are the major cause of death in ) 2
!Marfan syndrome
asimgabir@hotmail.com
Discussion
As I mentioned in my previous posts. You should score in your
abdominal station. This is because there are only very limited
.possibilities in abdominal station
You notice this gentleman has gynaecomastia as evidenced by
presence of breast tissue.Look for other stigmata of chronic liver
:disease such as
Clubbing-Dupuytren's contracture-palmar erythema-spider naeviflapping tremor-leukoonychia-scratch mark-jaundice-pallorpigmentation-cyanosis-xanthomata-purpura-koilonychia-paronychiaoedema-muscle wastimg-tattoos-needle marks....( you would be
surprised to find that there are so many physical signs in chronic liver
.disease!)
Although there are a lot of causes for gynaecomastia, if you find this in
.your abdominal station, always think of chronic liver disease
Remember that common drugs that are associated with gynaecomastia are
ketoconazole, spirolactone, H2 antagonist such as cimetidine and
psychoactive drugs.If you look at the periphery, you would find the
,following
Yes, you would notice that
this gentleman also has
leukonychia. Anticipate to
find hepatosplenomegaly in
this gentleman.
Demonstarte to examiners
that you know how to check
for ascites by showing
shifting dullness.
Showmanship is important
in MRCP clinical exam.
Always examine your
patient systematically and
. confidently
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
.This patient has chronic liver cirrhosis due to alcoholism
Extra points
asimgabir@hotmail.com
Discussion
This is the continuation discussion from the previous issue. As I
mentiond in previous article, Marfan Syndrome is a popular cardiology
.case in MRCP. However, this case can come out in Station 5 as well
You notice that this lady fingers are long. I would like to show the thumb
and wrist signs as I mentioned in previous issue. Always remember that
for you to diagnose Marfan syndrome, you need to know about the
. major criteria
Major criteria for Marfan syndrome include Ectopia Lentis ( upward
dislocation of the len), dilatation of aortic root or aortic dissection and
lumbarsacral dural ectasia ( you only can diagnose this by MRI or CT
. scan)
If patient has family history , you need two systems involvement ( either
skeletal system, ocular, cardiovascular or other system ) to diagnose
Marfan syndrome. If patient does not has family history,then you need
!two systems involvement plus one major criteria
asimgabir@hotmail.com
Conclusion
This lady has Marfan syndrome
Extra points
asimgabir@hotmail.com
Discussion
A very, very popular skin station in MRCP exam if you are taking the exam
in Malaysia or Singapore. You notice that this gentleman has multiple
. angiofibroma (adenoma sebaceum) over his face ( malar distribution)
The diagnosis is clear at this moment and you must show to examiners
.that you know a lot about Tuberous sclerosis
Look for other features of Tuberous sclerosis such as subungual/ periungual
fibromas ( next image -a common mistake for majority of candidates is they
usually look hard at patient's hand and forget that these can be present over
.patient's toes as well), Ash-leaf patches ( hypopigmeted) and Shagreen patches
After these steps, you should suggest to examiners that you would get a
complete family history of similar problem and take history from patient
.about epilepsy
You would be
interested to test the
patient's IQ.One
common mistake
candidates make in
exam is they tend to
forget to look for signs
suggesting side
effects of anti-epilespy
.medications
Look hard for signs suggesting pheytoin side effects such as cerebellar
signs, gum hypertrophy and hirsutism. Also look for side effects of other
! anti-epileptic
asimgabir@hotmail.com
Conclusion
.This gentleman has tuberous sclerosis
Extra points
asimgabir@hotmail.com
Discussion
Pre-test counselling for HIV is always a common scenario in MRCP
PACES. Candidates always find that they have problem to tell patient's
the diagnosis (PCP) and then switch the topic of discussion form PCP
. to HIV testing
I always tell my junior doctors that before going into deep discussion
with the patient, always assess the patient's understanding about his
.problem
Therefore, after introducing yourself and a few simple questions like"
How do you feel today?" I would start off by asking" Mr Smith, I learned
that you were admitted to our hospital about one week ago, did anyone
tell you what's wrong with you?" You may be surprised to find out how
. little patient knows about his condition
Then you can briefly talk about Pneumocystis Carinii Pneumonia
and tell patient that he feels better because of the treatment. After this,
a lot of candidates find it difficult to talk about HIV and how to switch
.the topic of discussion from PCP to HIV
I find a solution to this problem, I would suggest to you that you may
want to try to explain to patient that it is rather rare for you to find young
adults to get PCP infection and mention that there are a few conditions
.that can prone him to get this infection
Mention HIV as one of them and proceed to assess patient's
understanding about HIV. After this, explain to patient about HIV,
relevant information to be included are what HIV is, mode of
transmission, possible long term complications and treatment. Do not
. forget to get futher sexual history and social history from patient
After this, assess patient's risk about HIV infection and ask him
whether he has any question to ask you about HIV. Explain to patient
that your consultant and you think that it is necessary for him to have
. HIV testing
Explain to him how the test is performed and how to interpret positive
and negative results. Mention about possibilities of false negative and
. positive results as well
asimgabir@hotmail.com
If the patient is married and turns out to be postive for the HIV test, ) 2
?would you tell his wife if he refuses to tell his wife about the result
asimgabir@hotmail.com
Discussion
A popular skin station in MRCP exam. All candidates would pick up the
physical signs and come to a diagnosis after inspection
however, examiners would only pass you if you know how to examine
.systematically a patient with vitiligo
Vitiligo is a chronic skin disease that causes loss of pigment,
. resulting in irregular pale patches of skin
Vitiligo is always described as " hypopigmented patches with white
". hairs in vitiliginous area
Areas commonly involved include perioral, periorbital, axilla , upper and
.lower limbs
After your initial inspection, try to look at the patient's scalp for white
.hair and alopecia ( vitiligo is associated with alopecia areata)
Then, proceed to look for jaundice ( autoimmune hepatitis), pallor
.(pernicious anaemia) and thyroid swelling
Remember that you must suggest to examiners that you would like to
check for postural drop of blood pressure which may suggest
.Addision's disease and check urine for Diabetes Mellitus
Look for other autoimmune diseases as well such as Rheumatoid
.arthritis, SLE etc
However, always remember that patients with leprosy or Pityriasis
versicolor may have hypopigmented skin but the hypopigmented skin
. tend to be more localized
You would find reduced sensation at the hypopigmented skin if you
.suspect leprosy
.There are various available treatment for vitiligo
Topical steroid may be useful at initial stage.Other topical
immunomodulators may be useful such as calcipotriene and
.tacrolimus
Combinations of therapy often give better results than single
modalities. These include calcipotriol with PUVA (Psoralen ultraviolet
.A therapy ) and tacrolimus with laser
asimgabir@hotmail.com
Conclusion
.This lady has vitiligo
Extra points
asimgabir@hotmail.com
Discussion
I show your this case again because I would like to warn you that you
.may only find subtle sign in gout during you MRCP PACES exam
My friend was asked to examine a patient's hand in his MRCP PACES
in Singapore, actually , he couldn't find any positive signs and he was
.so panic until he found a small tophi over the patient's ear lobe
Such as in this patient, you only notice a small swelling over her left
index finger. However, the diagnosis of gout would be clear if you take
.a few seconds to look at her face before touching the patient
Now, the diagnosis is clear, you are dealing with gout. The lesson to be
learned here is, when you are asked to examine a patient's hand in
. MRCP PACES, look at the patient's lower limb and the face as well
You might save a lot of time struggling to get the diagnosis if you spend
a few more seconds to inspect the patient properly. I would like to
remind you that in Station 5, you would get the diagnosis most of the
.time after inspecting the patient ( except in fundoscopy, of course!)
asimgabir@hotmail.com
Conclusion
asimgabir@hotmail.com
Discussion
This type of question is always popular in MRCP PACES station 4.
There are two tasks here, the first one- you are expected to break the
. bad news about brain death to Madam Liu about her son
The second task, you are supposed to discuss about organ donation
. with Madam Liu
A lot of candidates told me that they actually have problems to explain
brain death to patients family members, therefore they couldnt even
.start talking about organ donation
I think it is a common dilemma in examination, you fail to convince
patients mother that the patient is dead, how can you possibly proceed
.to tell her about organ donation
The principles are simple, always do the following steps in your exam
(especially in breaking bad news!)
c( Warming up
You need to explain to your subject some information before
. breaking the bad news
In this case, you may say that Our consultants have been
reviewing him daily since he was admitted, they have reviewed his
brain scan and actually they have done a few special tests,
.unfortunately, your sons condition is not improving
Always pause in between important sentences so that your subject
.can give you some feedbacks
d( Go to your task
After seeing your subjects respond to your explanation above, you
. then can break the bad news
Always remember to give your subject to breath and avoid
bombarding him/her with a lot of technical details. Try to avoid
!medical jargon in exam
.You will be expecting that Madam Liu could not accept that her son is dead
You certainly should empathize with your subject and NEVER rush or push
. her to accept your explanation
Here comes the dilemma, the subject could not accept her son is dead,
? how do I talk about organ donation
You actually can explore some social history about Mr Lee. Actually, my
friend failed this case in his MRCP PACES because he did not explore
about the patients social history and found out that Mr Lee is the only child
. in the family
After that, just tell Madam Liu that from the social history you gather from
her , her son is a very helpful young man, you explain to her that even
. though Mr Lee is no more here, he is still able to help other needy people
Madam Liu may ask you the way to do this , then you can start the topic by
? saying Have you heard of organ donation before
So....., you see , the mission is accomplished! The rest of the topic such as
!What is organ donation? etc would be a simple job for you all
Discussion
I think that this type of case is still a possiblilty in your MRCP PACES,
although you are often see this case in Orthopedics ward rather than
. Medical ward
You notice this patient has right claw hand.Yes, you are right ,she has
! ulnar nerve palsy
Remember that ulnar nerve supplies all small muscles of the hand
except LOAF ( the Lateral two lumbricals, Opponens pollicis, Abductor
. pollicis brevis and Flexor pollicis brevis)
As a medical student before,you might still remember the function of
lumbricals is to flex the metacarpophalageal joints and extend
. interphalageal joints of fingers except thumb
Therefore you see this this lady has claw hand involving only ring and
little fingers. (because the lateral two lumbricals are supplied by median
nerve)
In you exam, you must always try to find the underlying cause for this, if
. you look hard , you notice that there is a scar over the patients wrist
She actually sustained
industrial injury before
and there is injury of her
ulnar nerve over her
. wrist
As you might remember,
ulnar nerve enters the
palm anterior to the
flexor retinaculum
alongside the lateral
border of the pisiform
bone and divides into
superficial branch ( innervating the palmar aspect of the medial side of
the little finger and the adjacent sides of the little and ring fingers) and the
.deep branch.( which supplies the small muscles of the hand)
asimgabir@hotmail.com
You notice that the affected thumb will flex ( Flexor pollicis brevis)
.because of loss of the adductor of the thumb
asimgabir@hotmail.com
All small muscles of hand are supplied by ulnar nerve except what) 2
?muscles
asimgabir@hotmail.com
Conclusion
This lady has right ulnar nerve palsy due to previous trauma
Extra points
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Discussion
This case is always very popular in MRCP station 5. A lot of candidates
.can pick up the diagnosis but are unable to perform well in this case
. It is a gift if you are asked about acromegaly in MRCP PACES
:I always like to do the following if I suspect acromegaly in exam
Spend a few seconds in general inspection
Start off by examining the patients hand, you notice that she has spade
. like ,sweaty hand, the skin is thickened and doughy
Check for carpal tunnel syndrome
Look at the face- check for prognathism ( causing malocclusion of jaw),
prominent supra-orbital ridges, wide spaced interdental space, big
.tongue
Offer to look for skin tag ( molluscum fibrosum) at axilla
Look at lower limbs for pitting oedema to suggest high cardiac output
failure
asimgabir@hotmail.com
Conclusion
.This lady has acromegaly due to pituitary macroadenoma
Extra points
Indicators for disease activity are uncontrolled symptoms such as
headache, sweating, presence of skin tags, uncontrolled Diabetes,
. hypertension and progressive visual impairment
After your presentation, always tell the examiners what you think about
.the disease activity
Most important test to diagnose acromegaly is non-suppressibility of
. growth hormone level after an oral glucose tolerance test
asimgabir@hotmail.com
Discussion
:Do the following if possible
Introduction
Miss Sylvia, I am Dr., the SHO in charge of this ward. How do
?you feel today
Assess her understanding about the illness
I know that you were admitted to our ward due to fit one day ago, did
?anyone tell you about your problem
Explain the diagnosis based on patients understanding for the illness
You need to know about patients understanding about an illness before
you exaplain about the illness. Some patients might know a lot about
their own illness, therefore, you can go straight to more advanced
.discussion with patients
asimgabir@hotmail.com
:Generally, when you talk about an illness, try to cover the following
General information about an illness. Such as Epilepsy is due to
some abnormal brain activity that causes you to have abnormal and
.uncontrolled body movement
Possible complications about an illness if left untreated
Possible treatment- Remember that besides medications, always talk
about non-pharmacological management. Such as in this patient,
besides anti-epileptic medications, tell patient that she must learn to
protect herself by avoiding involvement of high-risk recreational activity
.such as swimming
Always assess her social support because someone needs to know
.how to take care of an epileptic patient when there is a seizure
Other important issues pertaining to the illness- such as in this patient,
the patient might want to know whether she would pass this illness to
. next generation
asimgabir@hotmail.com
Inspect this-46
gentleman and
proceed
:Discussion
OK, this is a common case in MRCP PACES station 5 if you are sitting
the exam in Malaysia and Singapore. I think it is easy for you to detect
.the abnormality in this gentleman because the clinical signs are obvious
You notice this gentleman has severe spine abnormalities. Yes, you are
right, he has Question mark posture. This is due to fixed
kyphoscoliosis of the thoracic spine with compensatory extension of the
.cervical spine
This case is easy but you must remember to look for these spine
abnormalities especially if you are seeing a patient who is lying in bed
during your MRCP PACES exam because the kyphoscoliosis may not be
.obvious and can be masked by a pillow behind the patients back
Patients with Ankylosing Spondylitis usually present with back pain
.and this gentleman has chronic back pain since the age of 20 years old
asimgabir@hotmail.com
you need to do two tests to demonstrate the patient has limited spine
movement by demonstrating occiput to wall test and Schobers test. In
following picture, when I ask the patient to rest his back against the wall,
you notice that this gentleman has difficulty to make contact his head
. against the wall
for Schobers test, mark two points, one 10 cm above and one 5 cm
below a line joining the dimple of Venus on the sacral promontory. An
increase in the separation of less than 5 cm when the patient does a
. forward flexion signifies limited spine movement
after these tests, check peripheral joints especially hands and also look
for possibility of psoriasis ( because one variant of psoriatic arthropathy
may look like Ankylosing spondylitis)
suggest to examiners you will like to look for 4As- Anterior uveitis, Apical
.fibrosis, Aortic regurgitation and Achilles tendinitis
asimgabir@hotmail.com
:Conclusion
This gentleman has Ankylosing Spondylitis with limited spine
.movement
:Extra points
Diagnostic criteria of Ankylosing Spondylitis is based on New York
Criteria (1966)
Limitation of motion of the lumbar spine in all 3 planes: anterior flexion,
.lateral flexion and extension
History of the presence of pain at the dorsolumbar junction or in the
.lumbar spine
Limitation of chest expansion to 1 inch (2.5 cm) or less, measured at the
level of the fourth intercostal space
asimgabir@hotmail.com
asimgabir@hotmail.com
Discussion
A popular question in MRCP PACES station 2. A patient presents with
chest pain. Remember that besides cardiac pain , you must also
consider other types of pain which may mimic chest pain, diagnoses to
consider include ischaemic heart disease ( either stable, unstable
angina or myocardial infarct(, pulmonary embolism, pericarditis,
reflux oesophagitis, musculoskeletal pain, penumonia ( pleuritic
.chest pain)... etc
When you want to take further history of pain, always remember to take
:the following details
nature of the pain, whether it is similar to his previous pain before
bypass surgery
duration of the pain (each episode)
any radiation
precipitating and relieving factors
other associated symptoms
asimgabir@hotmail.com
However, it is not enough you just get the diagnosis in this patient, you also
notice besides diagnosis problem in this case, you are seeing management
problems as well, Mr Lee's hypertension and diabetes mellitus are not
.properly managed
You must ask relevant questions so that his medical problems can be
:properly managed such as
compliance to treatment
other risk factors for ischaemic heart disease such as high cholesterol,
smoking and family history his normal diet and exercise
Never assume anything before entering the examination room, always bear
in mind all the possible differential diagnoses and ask relevant questions to
come to a provisional diagnosis
Also avoid spending all your time in getting your provisional diagnosis
because there may be other important issues to deal such as social
problems, impact of the disease towards patient's daily life, drug history..ect
Summarize your history before you present to the examiners and outline
your plan of management. Issue that concerns the patient and his GP most
is whether the pain is cardiac in origin, you should be able to answer this
! question at the end of your interview
asimgabir@hotmail.com
Discussion
I have discussed about
this case in my previous
issue. This case is always
a popular case MRCP
PACES station 1. You
notice that there are two
vertical surgical scars
over this gentleman's
flanks. If you have a
general inspection before
you touching this
gentleman's abdomen,
you would have an idea
.what you are dealing with
asimgabir@hotmail.com
Yes, you are seeing a patient with kidney transplantation. You are
expecting to find the following physical signs during your physical
examination
two vague masses in the flanks(he underwent two kidney
transplantations before)
the masses (transplanted kidneys)are dull on percussion ( superficial
and not retro-peritoneal as in normal kidneys)
the masses are not tender on palpation and there is no bruits heard
(always check for possibilities of renal artery stenosis in a post
. transplanted kidney)
Cushingnoid features as evidenced by moon face, truncal obesity and
bruises. ( such as photo)
signs to suggest side effects of cyclosporin such as hypertrichosis and
.gingival hypertrophy
asimgabir@hotmail.com
However, you should try to find the following after you find that he has
previous kidney transplantation
the possible cause of his end stage renal disease, therefore you must
look hard for polycystic kidney and suggest to examiners that you
would like to look at his fundus for diabetic retinopathy as well as
hypertensive changes ( remember that cyclosporin also causes
hypertension)
whether the transplanted kidney is functioning well (therefore suggest
to examiners that you would like to look at this patient's urine output
and check for any haematuria)
look beyond for other possible complications of medications
(immunosuppressants patient is currently on) such as cataract,
osteoporosis ( spine tenderness), proximal myopathy ( secondary to
long term steroid) etc
asimgabir@hotmail.com
asimgabir@hotmail.com
Conclusion
This gentleman has two previous kidney transplantations and
. currently not dialysis dependent
:Extra points
Common side effects of Calcineurin Inhibitor ( such as cyclosporin
:and tacrolimus) are
Nephrotoxicity
Gastrointestinal such as hepatic dysfunction (include raised liver
.enzymes,jaundice and gall stone), anorexia, nausea and vomitting
.Cosmetic-hypertrichosis ( excessive hair growth),gingival hyperplasia
Hyperlipidemia, glucose intolerance ( more in tacrolimus)
Neurotoxicity- coarse tremor,headache, insomnia,dysesthesias
Infection and malignancy
Hyperuricemia and gout
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Discussion
A popular question in MRCP PACES station 4. You are expected to
discuss long term renal replacement therapy with Mr Lee. Before you
proceed, you must remember that there are three possible ways
available namely Haemodialysis, CAPD ( Continuous Ambulatory
.Peritoneal Dialysis) and Kidney Transplantation
However, before you start your formal discussion with Mr Lee,
remember to do the following
?"ask about his current condition ," How do you feel today
. the reason he was admitted four days ago
how much does he know about his condition " What do you know about
?"your condition? Did anyone inform you
how much does he know about kidney failure and the reasons behind
. urgent haemodialysis was done for him
general knowledge about kidney functions and possible ways renal
. replacement therapy can be done
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During you MRCP PACES examination, you must know the basic
knowledge a patient know about his condition before you try to explain
.his illness
In this scenario, briefly talk about how haemodialysis and CAPD is
being done. Try to explain to Mr Lee as well about the pros and cons
about each technique available and their limitations ( such as in CAPD,
patients may need to have adequate visual acuity to handle himself the
. CAPD)
You must explore the option of kidney transplantation as well to Mr
Lee and warn him about the problems he might face in future with all the
immunosuppressants.However, remember to talk about a few other
:related issues with Mr Lee as well such as
his diabetic control and tell him about importance of sugar control
.towards progression of kidney disease
talk about his diest and warn him about diet modification due to his
.kideny function. You might want to refer him to see a dietician
his Blood Presssure control
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Discussion
This is one of three commonest cases you would get in your MRCP
PACES fundoscopy sub-station. Candidates should not have problems
. picking up the physical signs
However, remember that you should have a systematic way of doing
:fundoscopic examination, I suggest you to do the following steps
have a general inspection of your patient, pay attention to any
surgical scar over patient's scalp ( which may suggest previous head
surgery), diabetic dermatopathy or previous amputation, walking stick
( ? blindness) etc which might give you a clue of the patient's
.underlying disease
give clear and loud explanation, tell your patient to look straight and
avoid moving his/her eye balls. However, remind your patient that
he/she CAN blink his/her eyes. Remember to tell your patient that
.your fundoscopy light may make him/her feel uncomfortable
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you should not remove your spectacles while examining the fundus.
!This certainly needs practice
look at the eye from a distance and check for red reflex ( Candidates
are likely to fail you if you miss obvious cataract or retinal
detachment!)
look at patient's right and left eye using your right and left as well, if you
only know how to use your right eye to do a fundoscopic examination,
!you are going to kiss your patient when examining his/her left eye
look at the fundus properly, start from centre to periphery or otherwise
(look at patient's optic disc, macula and peripheral retina. Pay
,attention to the vessels as well)
ask you patient to look directly to your fundoscopy to check for macula
pathology again during your last step of examination( because the
patient's pupil will constrict after this),repeat these steps while
.examining the other eye
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last but not least, thank your patient and suggest to examiners what
other relevant bed side tests you want to do such as checking urine for
. mircoalbuminuria, blood pressure, visual field, visual acuity etc
OK, you notice this patient has irregular balck deposits of clumped
pigment in the peripheral retina. ( Always described as bone spicules
because of their vague resemblance to the spicules of cancellous
. bone)
Remember that the pigment spots lie anterior to the retinal veins ( as
compared to spots of choroidal atrophy in which they lie posterior to the
. vessels)
You also notice the optic disc to be pale.You should proceed to do the
:following
suggest to examiners you would like to take a family history, Retinitis
Pigmentosa can occur sporadically or in an autosomal recessive,
.dominant, or X-linked pattern
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Conclusion
This gentleman has retinitis pigmentosa with night blindness and
.constricted visual field
Extra points
Most cases of Retinitis Pigmentosa are due to a mutation in the gene
for rhodopsin, the rod photopigment or in the gene for peripherin, a
. glycoprotein located in photoreceptor outer segments
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Discussion
A popular question in MRCP PACES station 2. There are a few
diagnoses you must consider in this case
asthma
chronic obstructive airway
disease ( COPD)
oesophageal
reflux/gastritis
postnasal drip
tuberculosis
lung cancer
. sarcoidosis and drugs
Get all the relevant history to cover all you differential diagnoses. For
this case, you must get history as well for Mr Rashid's diabetic
.control
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:Discussion
you are expected to know how to examine a patient's gait in your MRCP
PACES examination. However, there are only a few popular cases in
.MRCP PACES gait examination
You notice this gentleman has a waddling gait. This gait is seen when
the patient's legs are held wide apart and the patient shifts weight from
. one side to the other as he walks
Of course, you may see this gait in a pregnant woman, however, you
should anticipate patient to have proximal myopathy if you see this gait
in your MRCP PACES examination because you are unlikely to get a
!case of straight forward pregnancy in your exam
,Causes of proximal weakness include
Hereditary muscular dystrophy ( the most popular case you would see if
you notice waddling gait in your MRCP PACES)
Congenital myopathies ( very rare- you are unlikely to get this unless
you are if you are sitting for MRCPCH)
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