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1-Examine this gentleman's cranial nerves
DiscussionDuring 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 [email protected]
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:
He has fasciculations of the tongue,Vagus nerve(X) involvement as evidenced by weakness of soft palateNasal speech.At this point, there are two important differential diagnosis, patients with Motor Neuron Disease can present with either bulbar or pseudobulbar palsy. Although patients with Guillain-Barre syndrome may give rise to similar picture ( weakness of tongue with nasal speech), you must remember that wasting is not obvious ( due to short duration of weakness in Guillain Barre syndrome) and you may find ocular muscles involvement (Ophtalmoplegia) especially in Miller-Fisher variantAnother important differential is Syringomyelia because it can involve lower cranial nerves. Therefore, you must suggest to examiners that you would like to examine your patient hands for any fasciculations or dissociated sensory loss in order to differentiate these two conditions.
Common questions examiners would ask you 2) What investigations you would like to order in this gentleman?Electromyography- shows widespread anterior horn cell damage. You may want to do MRI to exclude other spinal cord or root compression1) How do you differentiate bulbar from pseudobulbar palsy? You can find the answers in any medical text book, however, I think the tongue gives you good clues in differentiating these two (conditions)3) What are the clinical patterns of motor neuron disease?( Bulbar, Progressive muscular atrophy and Amyotrophic lateral sclerosis)4) Who is the famous scientist in UK having motor neuron disease?Of course, the most famous motor neuron disease patient is Professor Stephen [email protected]
ConclusionThis gentleman has bulbar palsy due to motor neuron disease! [email protected]
2-Look at this diabetic lady skin
DiscussionOK, examiners give you two clues here, patient is diabetic and female. Yes, Necrobiosis Lipoidica Diabeticorum is common among female diabetic patients. 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.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 [email protected]
Common questions examiners would ask you1)What is the histology of this lesion?Histopathologically, it presents with interstitial and palisaded granulomas that involve the subcutaneous tissue and dermis.
2)What is your differential diagnosis?Sarcoidosis of the [email protected]
ConclusionThis lady has Nercobiosis Lipoidica Diabeticorum [email protected]
3-Examine the patient's neck. [email protected]
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. However, always remember to check for retrosternal extension, thyroid bruit , proximal myopathy and pretibial myxodemaThen I would proceed to examine her thyroid gland and give a brief description about the [email protected]
Conclusion This lady has Grave's disease with diffused goitre and in a hyperthyroid state.Extra points 1) For Grave's opthalmoplegia, the first muscle to be involved is inferior rectus.2) Radio-iodine treatment can worsen Grave's eye disease.3) Remember precautions to be taken after radioiodine [email protected]
4-Look at this patient and proceed
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. 1- pattern of distribution of the rash2- presence/absence of telangiectasia3- any vasculitic rash4- Any signs to suggest patient is on long term steroid therapy. Suggest to examiners that you would do a complete physical examination to look for other systems involvement. Always remember to check the patient's BP, fundoscopy for cytoid body, urine for proteinuria and ask for drugs history.It is a common case especially if you are sitting your MRCP PACES in Malaysia ,Hong Kong or Singapore. Always remember to present the [email protected]
ConclusionThis lady has active SLE with malar rash and was admitted due to joints pain.Extra points 1-Remember in drug-induced SLE patients, their anti-histon antibody is positive. Three common drugs that lead to drug induced SLE are hydralazine, procainamide and isoniazide.2- Drug induced SLE never involves brain and [email protected]
5-Examine the patient's hands
DiscussionIt 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. 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 fibrosisPsoriatic 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 [email protected]
Common questions they will ask in exams are:1- Causes of anaemia in RA patients2- Newer therapies available for RA3- Mechanism for each joint deformity. (Distinction question!)[email protected]
ConclusionThis lady has RA and is on Methotraxate, salazopyrine and low dose prednisoloneExtra pointsSimple 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 [email protected]
6-You are the SHO in charge of Infectious Disease ClinicSubject: Mr Lee, 55 years old 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 [email protected]
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:SLEMotor neuron diseaseMultiple sclerosisParkinson's diseasedementia etc.Another scenario will be breaking bad news to patients with advanced [email protected]
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. 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.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 [email protected]
Common questions patient is going to ask you are:1- Am I going to die, doctor?2- Are you sure about the result, doctor?3- I don't want to die, doctor, can you do anything to help me?4- I don't want to tell my family, can you keep this as a secret?5- Is there any other alternative treatment [email protected]
7-This patient complains of double vision. Would you like to examine [email protected]
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. 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.There are only two possibilities in MRCP, either you are dealing withdystrophia myotonica or myasthenia gravis.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 [email protected]
To make a diagnosis of myasthenia gravis (MG), the most important physical sign you need to demonstrate is fatiguability.The morale of the story is , in neurology station always SHAKE YOUR PATIENT'S HANDS BEFORE YOU PROCEED. The next thing is you need to do is general inspection. If patient has DM, you will pick up by noticing that there is frontal baldness, expressionless face ( wasting of temporalis, masseters and sternomastoids) and bilateral ptosis.There are two ways to do this, one is asking patient to look upward and start counting. You will notice patient will have difficulty to sustain upward gaze and the speech becomes nasal. Another way is asking patient to do repeated flexion and extension of [email protected]
Conclusion This lady has ocular myasthenia.Extra points 1- Remember a few examples of drugs that can precipitate myasthenia crisis.2- Remember the mode of inheritance of DM- autosomal dominant and other associated symptoms and signs.such as cataract, diabetes, and possible of heart [email protected]
8-Look at this patient and proceed
Discussionvery 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. Last but not least, ask for family history because it is inherited in an autosomal dominant wayAlso 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 [email protected]
Conclusion This gentleman has hereditary haemorrhagic telangiectasia ( Rendu-Osler-Weber Disease). He has history of recurrent PR bleeding.Extra points1- Remember the simple management about this condition such as oestrogen, cauterization etc.2- Remember in your management, one very important part is counseling especially patient plans to have children in [email protected]
9-You are the SHO in charge of the medical clinicDear DrRef: Mr Lee, 24 years oldKindly see Mr Lee who complains of weight loss for the past 3 months. He had recently had a bout of chicken pox. This did affect his lungs and I treated him for a chest infection with a course of antibiotics. My main concern is that he still complains of intermittent fevers and breathlessnessPlease see and adviseWith best wishesDr Oh Pee DeeYou have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the examiners. Be prepared to discuss the solutions to the problems posed by the case and how you might reply the GPs letter [email protected]
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 HIVYou 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 PCPMy 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 PACESRemember 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
10-Look at this patient's skin and proceed!
Discussion It is a common case in MRCP station 5 of endocrine sub- stationThere is presence of obvious purplish striae over his abdomen as well as his upper thighCheck 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 [email protected]
ConclusionThis gentleman has Cushing's syndrome secondary to long term steroid ingestion ( from traditional medicine). He was admitted due to fulminant sepsis with Addisonian crisisExtra points:1- Common diseases that requires patients on long term steroid are as asthma, myasthenia gravis, nephrotic syndrome and other autoimmune diseases. 2- Cushing's disease is always a common case in exam, remember that besides making the diagnosis of Cushing, you need to find out the underlying cause if possible and possible [email protected]
11-You are the SHO in charge of the medical clinic Dear Dr Mrs Lydia David, a 70-year old retired teacher comes to your clinic because of jerky movement of her right hand for the past four months. She has previous history of Diabetes Mellitus on oral medications under her GP follow up. After a careful physical examination and complete investigations, your consultant neurologist thinks that Mrs Davis is suffering from Parkinson's disease. Mrs David is in the clinic waiting to see you for the investigation results and the diagnosis. You are the SHO in charge of the neurology clinic, your task is to explain to Mrs David about the diagnosis and answer her queries.You have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the examiners. Be prepared to discuss the solutions to the problems posed by the case and how you might reply the GP's [email protected]
ConclusionThis 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. 1-to explain the illness in layman's termsUsually 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.2-explain the prognosis and the likely progression of the illness3-treatment for the disease- medical or any new treatment available such as surgical intervention4-ask social history especially the impact of the illness towards patient's daily activities as well as patient's relationship with other family members
Extra pointsThe commonest mistake candidates make in this type of question is trying to explain as much as possible about a illness and not answering patient's queries about the illnessTry to give a lot of details about the illness and not bother about the illness social implication.This gives an impression to the examiners that you are not holistic in your [email protected]
12-This patient complains of double vision, would you like to examine him.
DiscussionPtosis 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 [email protected]
The subsequent relevant physical examination depends on your second step finding, if it is Horner's syndrome, then you must find out the underlying cause for this, the common sites to look for are patient's neck ( any cervical lymph nodes, mass?) , lung ( Pancost's tumour/ lung cancer) or cervical spine ( syringomyelia- patient may have small muscle wasting of hands).If you are dealing with third nerve palsy, look for other cranial nerves involvement, if there is only isolated third nerve palsy, then you are most probably dealing with diabetes mellitus. Isolated third nerve palsy can be a medical or surgical third nerve, if there is pupillary sparing ( the pupil is normal size), then you are dealing with medical third nerve palsy ( such as due to DM, hypertension), if the pupil size also involved, then it is a surgical third nerve palsy ( such as due to aneurysm compression)[email protected]
ConclusionThis patient has left isolated third nerve palsy due to diabetes mellitusExtra points Common question examiners will ask you is the reason behind pupillary sparing in medical third nerve palsy.Sometimes (rarely) you may think that the patient has ptosis but what the patient is having is unilateral proptosis due to retroorbital tumour/ [email protected]
13-Look at this patient and proceed
DiscussionIt is sometimes rather difficult for you to differentiate panhypopituaitarism from hypothyroidism.. 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. 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 patientsSuggest 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.
ConclusionThis lady has hypothyroidism secondary to previous total thyroidectomy.Extra points 1-Although it is rather uncommon in PACES, you can find this illness rather common especially among older population. Always check their thyroid status if an elderly patient presents to you with dementia2-The commonest cause for hypothyroidism is previous total [email protected]
14-Look at this patient and what do you think about her?
DiscussionAs 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.If you look hard, this lady has multiple vasculitic rash over her hands.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 [email protected]
In MRCP examination, it is not enough for you to get the diagnosis of Cushing's syndrome only. In view of the vasculitic rash over her hands, you must look for other clues to suggest the possible underlying diagnosis for this lady that leads her to be on long-term steroid.The commonest cause for vasculitic rash is autoimmune disease and this lady is actually having lupus nephritis and on long-term steroid. Suggest to examiners that you want to look for other signs of lupus.Common causes of Cushing's syndrome include long term steroid ingestion (iatrogenic)pituitary adenoma (Cushing's disease)adrenal adenomaadrenal carcinomaand ectopic ACTH production (usually lung CA). [email protected]
ConclusionThis lady has Cushing's syndrome secondary to long term steroid ingestion due to lupus nephritis.Extra pointsTests 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 [email protected]
15-Kindly examine this gentleman's [email protected]
Discussion A common finding in a patient with transplanted kidney but always missed by candidates. Actually this gentleman develops gum hypertrophy due to cyclosporin.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.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 )[email protected]
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 stenosislook 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 [email protected]
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:Common side-effects and precautions for immunosuppresants are as follows:Cyclosporine- nephrotoxity, hypertension, tremor, gum hypertrophy, hyperuricemia, hyperkalemia, weight gain, diabetes mellitus, acne, hypomagnesaeimia. Grapefruit juice and Mediterranean oranges and Sun Drop, a citrus soda, contain bergamottin which enhances the effect of cyclosporine, increasing the level of the drug in circulation.St John's wort reduces the concentration of cyclosporine rendering it less [email protected]
Azathioprine- bone marrow suppression, cholestatic jaundice, GIT upset. Azathioprine can cause irreversible bone marrow failure for those with a particular polymorphism of the TPMT gene. GlaxoSmithKline has a predictive DNA test for this type of problem.Prednisolone- Cushing's syndrome and its complications.Mychophenolate-GIT upset, headache, bone marrow suppression. Other common causes of gum hypertrophy include acute myeloid leukemia, scurvy, medications such as cyclosporine, calcium channel blocker especially nifidipine and [email protected]
16-This lady complains of lethargy, would you like to examine her abdominal system?
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 [email protected]
Although Thalassemia is rather uncommon in UK, it is common in Asia especially if you are sitting your exam in Singapore, Hong Kong and Malaysia. Suggest to examiners you would.Examine for secondary sexual characteristics (any hypogonadism) because there is possibility of delayed puberty due to iron overload Check for patients height due to growth retardation secondary of iron deposition at the pituitary glandCheck urine for diabetes mellitus Look for signs of hypothyroidism (all these are due to iron overload) Ask the patient any family history of anemia and Haemoglobinpathy.There are in various occasions my friends got a abdominal case of isolated mild splenomegaly and tinge of jaundice without hepatomegaly in their MRCP PACES, always remember one of the most important causes is chronic haemolysis ( although book always tells you that you tend to get hepatomegaly as well, but I notice Thalassemia intermedia patients tend to get splenomegaly ONLY).
Conclusion This lady has Thalassemia Major and underwent a splenectomy due to recurrent, frequent transfusions.Extra points a)Splenectomy should be considered if, annual blood requirements exceed 1.5 times those of splenectomised patients, provided they are on the same transfusion scheme and have no other reasons for increased consumption. Splenic enlargement is accompanied by symptoms such as left upper quadrant pain and early satiety. Leucopenia or thrombocytopenia due to hypersplenism. [email protected]
b) Complications of splenectomy include peri-operative complications such as bleeding,atalectasis and subphrnic abscess, long term complications include thrombocytosis and overwhelming sepsis especially to encapsulated organisms such as Streptococcus pneumonia, Haemophilus influenzae and Neiserria meningitides. c) Preventive measures a physician can utilize to prevent postsplenectomy sepsis include immunoprophylaxis ( vaccination to S.pneumonia, H.influenzae and N.meninngitidis), chemoprophylaxis ( oral penicillin) and patient education (explain about potential travel-related infections)[email protected]
17-You are the SHO in charge of the medical unit. Dear DrRef: Mr David Letterman, 56 years oldThank you for seeing Mr Letterman who complains of lethargy for the past 3 months. I have done a few investigations that turned out to be negative. He has previous history of gastritis and claimed that OGDS done about 5 years ago showed some erosions and he was put on some medications.He has history of Diabetes Mellitus for the past 10 years currently on T Daonil 5mg bd. He is worried about his symptoms but unfortunately I cant find anything wrong with him. Kindly see him and adviseWith best wishes Dr GPYou have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the examiners. Be prepared to discuss the solutions to the problems posed by the case and how you might reply the GPs letter.
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 apnoeaYou 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 possibleany specific time the symptom becomes worse? If the patient is having mysthenia gravis, he may tell you that he fells more tired especially during [email protected]
any precipitating or relieving factors ?any other associated symptoms ?In this case, you must ask certain questions which are specific for hypothyroidism such as constipation, weight gain, cold intoleranceYou need to rule out causes of anemia as well since that this gentleman had a history of gastritis before. Ask about any symtoms to suggest blood loss or symptoms to suggest malignancyDepression is always a differential in your history taking, try to assess his social history and symptoms to suggest depressionIn obstructive sleep apnoe, patient may have snoring, early morning headache and sleepiness during day timeAs I mentioned earlier, myathenia gravis patients always tell you that their symptoms worsen towards the [email protected]
About his diabetes, you must always ask the followinghis usual control, whether he has monitoring at home to monitor his sugarpossible complications such as IHD, retinopathy, peripheral neuropathy, nephropathy ,TIA, stroke etc Later, ask other relevant past history, such as in this case, ask the patient about his OGDS and his symptomsLast but not least, always assess patient's main concern, he may have some hidden agendas that he like to tell you. 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 historyThis patient actually just lost his wife in a motor vehicle accident and he had very poor social support and he developed depression after the [email protected]
18-Would you like to examine this lady's hands ?
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 firstYou 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 soOps, the diagnosis becomes obvious after turning the patients hand [email protected]
Another important inspection I would pay attention to is whether there is presence of nail pitting. After general inspection, then feel the patients skin gently to assessment whether there is presence of warmness that might suggest disease activity. 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 I would always tap at patients flexor retinaculum to check for carpal tunnel syndromeThe last step is assessing patients 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. You can kill two birds with one stone by asking patient to do soYou are going to assess patients elbow as well as shoulder joints. Then the last step will be special steps depending on your findings. Such as in this case, I would suggest to examiners that I would look for other joints involvement and other common sites for psoriasis.
Common questions examiners would ask you Why in arthritis mutilans, there is shortening of the fingers?due to marked periarticular osteolysis and erosionWhat is pencil in a cup appearance in xray ?Where are the common sites to find psoriatic patches ?How would you manage psoriatic [email protected]
ConclusionThis lady has psoriatic arthropathy.Extra points Five types of psoriatic athropathy namelyoligoarticular asymmetrical type (70%)distal interphalangeal typerheumatoid arthritis-like ( common in exam because want to confuse you!)ankylosing spondylitis- likeand arthritis mutilansThere are five types of psoriasis. They are chronic plaque, inverse psoriasis, pustular, guttate and erythrodermic types.Facts from Baliga's [email protected]
19-Examine this gentleman's cardiovascular system
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 groupDuring your examination, always look hard for any bruises to suggest over-warfarinization, signs to suggest endocarditis and murmurs to suggest valve dysfunction
Common questions examiners would ask youComplications of mechanical prosthetic valvecan be divided into complications due to the valve itself such as dysfunction haemolysis, endocarditisand complications due to the treatment because of warfarinCauses of anemia in a patient with prosthetic valve.How to differentiate a tilting disc valve from a ball cage valve clinically? (distinction question!)How to assess whether the valve is functioning well [email protected]
ConclusionThis 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 VALVEAlthough patients with valve repairs tend to have left thoracotomy scar ( such as in mitral stenosis), I found out some patients may have sternotomy scar! [email protected]
20-Look at this lady lower limbs.
Discussion It is an uncommon case in MRCP, however, it is worthwhile to learn about thisIf you look carefully at her lower limbs, you actually notice this lady has a reticular pigmented rashThere 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 [email protected]
It is uncommon to find erythema ab igne in tropical countries, therefore, you shouldn't be too worried if you are going to sit your MRCP in Singapore, Dubai or MalaysiaThe reason is simple because it is associated with repeated exposure to heat especially in the elderly who sit in front of open fireplaces.You seldom need to sit in front of fireplaces to get heat in these countries because of the weather.Look for signs of hypothyroidism and tell the examiners you would look for underlying malignancy such as intra-abdominal malignancy or chronic pancreatitisWhereas in livedo reticularis, it is associated with SLE and usually found in young femalesIf you find livedo reticularis, always look for other signs to suggest SLE and also tell examiners that you would look for underlying malignancy as [email protected]
Common questions examiners would ask you1- Can livedo reticularis be normal ?Yes, because it can be found in young females especially in cold weather What other conditions are associated with livedo reticularis ?Besides SLE, other conditions include polyarteritis nodosa, occult malignancy and microemboli of [email protected]
Conclusion This lady has livedo reticularis due to SLEExtra points 1- Although it is not a popular question, livedo reticularis is often 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. 2- If you find erythema ab igne in patient's lower limbs, always look at the abdomen as [email protected]
21-Look at this gentleman skin.
Discussion This is a commoner question as compared to Q1 in MRCP examsYes, 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 skinAlso suggest to examiners that you would:check the urine for glycouria ( because patient may have insulin resistance )check for occult malignancy especially adenocarcinoma of stomachask for menses irregularity if the patient is female because it is associated with polycystic ovarian syndrome
Common questions examiners would ask you 1) What conditions are associated with acanthosis nigricans?2) How do you define metabolic [email protected]
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 [email protected]
22-Look at this lady and proceed
DiscussionA very popular question in MRCP PACES exams. This case can be used as a case in skin as well as locomotor sub-stationsYou 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 mouthDescribe 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 [email protected]
assess the patient's hands functions by doing hand grip, pincer grip (holding key) and unbuttoning of clothes.ask patient relevant history such as dysphagia, shortness of breath (lung fibrosis) and diarrhoe (malabsorption )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. [email protected]
Common questions examiners will ask you what types of autoantibodies can be present ?ANA,anticentromer and anti-topoisomerasewhat are the prognostic factors ? Sex- male tends to do worse, patients with extensive skin involvement and renal involvement tend to do worseHow to explain chronic diarrhoe in this type of patient ? bacterial overgrowthWhat are the criteria to diagnose of scleroderma ?How would you manage a patient with scleroderma ?
Conclusion This lady has systemic sclerosis Extra points Prednisolone has no role in treating systemic sclerosis.Four reasons for this type of patient to get anemia. iron deficiency due to chronic oesophagitisanemia due to malabsorptionanemia of chronic illnessand microangiopathic haemolytic [email protected]
23-Examine this gentleman's leg
Discussion It is an easy case if you know how to approach this caseYou 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 xanthomataAlso 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.
Common questions examiners would ask you What factors can precipitate acute gouthy arthritis ?When do you start to treat hyperuricemia ?How do you explain patients with gout to have bilateral leg swelling ?Fluid overload due to [email protected]
Conclusion This gentleman has chronic tophaceous gout.Extra points Clinical presentations of gout include asymptomatic hyperuricemia, acute arthritis, chronic arthritis and chronic tophaceous gout. Uric acid crystals are negatively birefringent. [email protected]
24-This gentleman has abdominal discomfort. Examine his abdominal system
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 [email protected]
some clues may help you.If you find..parotid swellingDupuytrens contracture you may be dealing with alcoholismskin hyperpigmentation- you may be dealing with haemochromatosis or iron overload due to multiple transfusions in Thalassemia patients (although you are unlikely to see this in UK, you may be seeing this type of cases in developing countries)tattoos or punctum wound to suggest intravenous drug abuse- you may be dealing with Hepatitis [email protected]
Common questions examiners will ask you What is Childs grading of liver disease in portal hypertension?The mnemonic to remember BAPA + Ebilirubin, ascites, PT (INR) and albumin and encephalopathyWhat are the possible complications of portal [email protected]
Conclusion This gentleman has chronic liver disease due to Hepatitis B ( He is an ex- intravenous drug abuser.)Extra points Remember that the commonest cause of chronic liver disease in Asia is chronic viral hepatitis whereas in UK is alcoholism.Do not forget that Wilsons disease also can cause chronic liver [email protected]
25-You are the SHO in charge of the Infectious Disease clinicYou are asked by the sister in charge of the surgical ward to see Dr Henry who accidentally pricks himself while taking blood from a HIV patient in the ward. Dr Henry just started his internship 3 months ago in the surgical department and he is very worried about this incident. He is waiting to see you to discuss about post exposure prophylaxis (PEP).You task is to explain to him about post exposure prophylaxis. You have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the [email protected]
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 rulesask 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 incidentassess the patients understanding about certain issue, in this case, Dr Henrys understanding about HIV/AIDSexplain to Dr Henry the current problem/illness, in this case about HIV/AIDS including the disease progression, modes of transmission and possible [email protected]
assess Dr Henrys risk to get certain infections such as HIV, Hepatitis B and Hepatitis C. Ask him whether he knows about his status and his previous Hepatitis B vaccinationask more about that HIV patients status -? on treatment,?CD4 count, any other medical problems such his ? Hepatitis B/ VDRL/ Hepatitis C status.tell him you are there to help him and you certainly understand his feeling right now, (always remember that the strategy in exam is reassure patient, reassure patient and keep on telling them you are there to help everyway possible) then inform Dr Henry briefly about PEP and maybe include some details about the possible side effects. (Do not try to show off to examiners by bombarding patient with very detailed information. This would make you to score less point)also inform Dr Henry about your plan for his follow up, do not forget to ask his permission for HIV [email protected]
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 wifeHe is also worried whether he can continue to function as a houseman while waiting for his blood resultsYou must always remember that patients in MRCP always have some hidden agendas that they want to discuss with youYou may miss these issues if you do not ask them specificallyLast but not least, always ask patient whether they have any other issue to [email protected]
Common questions examiners would ask youWhat is window period for HIV infection?How do you decide what treatment to be offered to Dr Henry?Extra points PEP regime usually consists of combinations of three drugs [email protected]
26-This gentleman has shortness of breath. Examine his respiratory system
Discussion You will be happy to see this case in your MRCP PACES. You can get the diagnosis after your inspectionYou 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 [email protected]
After your complete physical examination, do the following steps:Demonstrate the direction of the venous flow.Look for exophthalmos, conjunctival injection.Look at the JVP( non-pulsatile) and show to examiners how you measure it.Examine the cervical region for lymph nodes.Look for small muscles wasting of the hand and Horners syndrome if you are suspecting Pancoastt tumour.Suggest to examiners you would like to demonstrate Pembertons sign if possible.Ask the patient about smoking history.Talk to patient to assess hoarseness of [email protected]
Common questions examiners would ask youWhat is Permbertons sign?What is para-neoplastic syndrome and give a few examples?Name types of lung carcinoma.What are the contraindications for surgical [email protected]
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 [email protected]
27-Examine this lady upper limbs neurologically..
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 ).
After you upper limbs examination, suggest to examiners that you would do a proper examination of lower limbs. Pay attention to the following:presence of pes cavus and 'inverted champagne bottles lower limbs. This suggest Charcot -Marie- Tooth. Dissociated sensory loss of lower limbs with upper motor signs. This suggests syringomyelia.Upper motor signs of lower limbs with possibility of sensory level. This suggests cervical spondylosis.Flaccid paralysis of lower limbs with no sensory involvement. This may suggest Guillain Barre syndrome.After the examination, suggest to examiners that you would look for Horners syndrome if you suspect syringomyelia
Common questions examiners would ask you What is the CSF finding in GB syndrome?What are the three recognized forms of hereditary motor sensory [email protected]
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 palsyThere are three main clinical patterns of MND, they are progressive muscular atrophy ( obvious small muscles wasting of hand) , Bulbar palsy and amyotrophic lateral [email protected]
28-Would you like to examine this gentleman cranial nerves?
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:1-Eye group- you will be testing cranial nerves II, III, IV and VI. You will be assessing these cranial nerves by checking eye reflexes, fundoscopy, visual acuity, visual field and eye movement.2-Facial expression, sensation and movement- you will be testing cranial nerves V and VII. You must check for upper and lower portion of facial expression, corneal reflex ,masseter and pterygoid movement.
3-Articulation and gag reflex- You will be testing cranial nerves IX,X and XII. Check these nerves by assessing palatal movement, gag reflex and tongue movement.4-Other groups- assess VIII nerve by checking hearing, XI nerves by 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 [email protected]
Ask patient to screw his eyes and look upwardIf you do this, you notice the following,
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:1-look at external auditory canal for herpes zoster2-palpate for parotid swelling3-check for hyperacusis4-examine the taste involvement ( anterior 2/3 )5-test urine for [email protected]
Common questions examiners would ask you What are three components of facial nerve?Why there is sapring of upper portion of facial muscles in upper motor lesion of facial nerve?How would manage Bell's palsy?What are the common causes of lower motor facial nerve [email protected]
Conclusion This gentlema has right Bell's palsy.Extra points Bell's palsy should be treated with combination of steroid and [email protected]
29-Examine this patient's respiratory system.
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 [email protected]
Patients with bronchiectasis produce copious sputum, therefore, always look at sputum cup.Lung fibrosis patients may have other signs to suggest the underlying cause such as Rheumatoid hands, scleroderma signs etc.Besides that, they might have Cushing features due to long term steroid.After the examination, suggest to examiners that you would like to look at the temperature chartCrepitation in bronchiectasis is described as coarse and the quality changes with [email protected]
Common questions examiners would ask you What are the causes of brochiectasis?How would you manage this condition?What are other causes of [email protected]
Conclusion This gentleman has bronchiectasis due to previous tuberculosis. In bronchiectasis , remember postural drainage, postural drainage, postural drainageExtra points If you find patient with bronchiectasis also has dextrocardia, the diagnosis is Kartagener's [email protected]
30-This gentleman has difficulty in walking. Examine his lower limbs neurologically.
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 musclesYes, you are dealing with PSEUDOHYPERTROPHY of calf [email protected]
further examination reviews that:This gentleman has waddling gait.His proximal muscles are weaker than his distal muscles.His ankle and knee reflexes may be normal and there is no sensory involvement.After your complete neurological examination, do the following steps:Demonstrate Gower's sign.Suggest to examiners that you would examine the upper limbs and look hard of upper limbs involvement as well. Look for pseudohypertrophy of deltoid muscle also.Demonstrate winging of scapula by asking patient to straighten his elbow and push against resistance.Suggest to examiners you would ask about family history of similar problem.Look for any surgical scar to suggest recent muscle biopsy.
Common questions examiners would ask you Why do you say that it is pseudohypertrophy and not true hypertrophy of calf muscle in this condition?How do you differentiate Duchenne from Becker muscular dystrophy?What is the inheritance pattern in this condition?How do you investigate and manage this condition? Remember GENETIC [email protected]
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 [email protected]
31-Examine this gentleman lower limbs neurologically
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 cavusYes , you are dealing with Charcot-Marie-Tooth [email protected]
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 historycheck fundoscopy to look for optic atrophy.examine relevant cerebellar signs.look for [email protected]
Common questions examiners would ask you What is the mode of inheritance for Friedreich's ataxia or Charcot Marie Tooth?What is the pathogenesis of pes [email protected]
Conclusion This gentleman has pes cavus due to cerebral palsy. Extra points In MRCP PACES, if you are asked to examine lower limbs, always look at the upper limbs as well and vice versa.Remember that other causes of Pes Cavus are poliomyelitis and muscular [email protected]
32-Look at this lady's lower limbs and proceed.
DiscussionThis 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 [email protected]
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. [email protected]
Common questions examiners would ask you1) What is Steven Johnson syndrome?2) What is the difference between Steven Johnson syndrome and toxic epidermal necrolysis?3) If a patient had joint pain over ankle 3 weeks ago and was prescribed a medication by GP,what is the possible medication involved?4) How do you manage this [email protected]
ConclusionThis lady has macular-papular rash due to drug allergy.Extra points1) Always remember that you are not expected to diagnose all skin conditions, you would pass if you give a good and comprehensive description about the skin [email protected]
33-Examine this gentleman's skin.
DiscussionI 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 [email protected]
Classification of hyperlipidemia is based on Fredrickson which can be divided to Type I to Type V. After your examination, proceed to the following:look for other stigmata of hyperlipidemiaassess other risk factors for coronary heart disease such as sugar in urine, blood pressure and smoking.try to assess the possible secondary causes such as look for urine protein ( nephrotic syndrome), signs to suggest hypothyroidism.family history of premature death due to coronary heart diseas and [email protected]
Common questions examiners would ask you1) How do you manage hyperlipidemia?2) What are classes of drugs available to manage high [email protected]
ConclusionThis gentleman has xanthelasma with underlying Diabetes Mellitus.Extra points1) Learn a few important clinical trials involving statin such as 4S, MIRACL which are commonly asked in MRCP.2) Remember the common side effects of [email protected]
34-Examine this lady's respiratory system.
DiscussionA 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 [email protected]
When you see a lateral thoracotomy scar, spend a few seconds to have a thorough look at your patient, if you notice physical signs suggesting Cushing's syndrome, then you are most probably dealing with a patient after lung transplantation. Always pay attention to look for side effects of cyclosporin as well such as gum hypertrophy and excessive hair growth.If you do not notice these, then you are most probably dealing with lobectomy or pneumonectomy, some candidates find it difficult to distinguish these two conditions, I think there are a few important points to take note.First point, in lobectomy, you may find reduced breath sound in certain areas such as upper/middle/lower region but in pneumonectomy, there is reduced breath sound over the whole affected lung.Second point, there may be no sign to suggest mediastinal shift in lobectomy ( central trachea) but in penumonectomy, you are expected to find signs suggesting mediastinal shift ( based on your tracheal position or apex beat).Third point, percussion would review dullness generally for pneumonectomy but not in lobectomy.
Common questions examiners would ask you1) What are the indications for pneumonectomy or lobectomy?2) What are the common indications for lung transplant in United Kingdom?3) What are the common side effects of cyclosporin? 4) What are the contraindications for surgical intervention in lung [email protected]
ConclusionThis lady has lateral thoracotomy scar due to previous lobectomy because of lung cancer.Extra points1) Always take your time to observe for any surgical scar in your respiratory station. You may be able to diagnose the condition before even touching the patient!2) Lobectomy or even pneumonectomy was done previously for treatment of [email protected]
35-Examine this lady's cardiovascular system.
DiscussionA 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.
For the heart, you would anticipate you are most probably to find either aortic regurgitation or mitral regurgitation. Remember to suggest to examiners that you would like to ask about the family history .
Common questions examiners would ask you1) What are the diagnostic criteria for Marfan syndrome? 2) What are the differentiating features between Marfan syndrome and Homocyctinuria? 3) What is inheritance pattern for Marfan syndrome? [email protected]
ConclusionThis lady has Marfan syndrome and mitral regurgitation .Extra points1) When asked about the management of an illness, always remember that patient education is very important if the illness is chronic and incurable. Remember genetic counselling if it is inherited.2) Cardiovascular complications are the major cause of death in Marfan [email protected]
36-Examine this gentleman's abdomen.
DiscussionAs 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 naevi- flapping tremor-leukoonychia-scratch mark-jaundice-pallor- pigmentation-cyanosis-xanthomata-purpura-koilonychia-paronychia- oedema-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. [email protected]
Common questions examiners would ask you1) How would you investigate this patient?2) What are the common trigerring factors for hepatic encephalopathy?3) How do you diagnose spontaneous bacterial peritonitis?4) What is your long term plan for liver cirrhosis [email protected]
ConclusionThis patient has chronic liver cirrhosis due to alcoholism.Extra points1) Currently there are a few drugs available for Hepatitis B treatment besides intereferon. Learn about Lamivudine, adefovir and entecavir.2) Learn more about CAGE questions when you want to get further alcohol history from a patient! ( Study back your medical school book to learn more!) [email protected]
37-Examine this lady's hands
DiscussionThis 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!
Common questions examiners would ask you1) How do you manage this condition? ( Remember about genetic counselling and patient's education) 2) What are common cardiovascular lesions in Marfan [email protected]
ConclusionThis lady has Marfan syndrome Extra pointsRemember the complications of Marfan [email protected]
38-Inspect this gentleman and proceed.
DiscussionA 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.always suggest to examiners you would like to expose patient properly to look for these skin lesions but if time is limited, at least spend some time to look at patient's back!. After you complete your physical examination, tell examiners that you would be interested to look at the fundus and you are expecting to find retinal hamatormas and check the abdomen to look for ballotable kidney (due to renal hamartoma).
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!
Common questions examiners would ask you1) What can you usually find in this patient's CT brain?2) How do you manage this [email protected]
ConclusionThis gentleman has tuberous sclerosis.Extra pointsTSC is caused by defects, or mutations, on two genes-TSC1 and TSC2. Only one of the genes needs to be affected for TSC to be present. The TSC1 gene, discovered in 1997, is on chromosome 9 and produces a protein called hamartin. The TSC2 gene, discovered in 1993, is on chromosome 16 and produces the protein [email protected]
39-You are the SHO in charge of the medical unitMr Smith, an ex-IVDU was admitted to your hospital 1 week ago due to shortness of breath. CXR revealed bi-hilar haziness and your consultant thought that he was suffering from pneumocystis carinii pneumonia. He responded to your treatment and you are asked by your consultant to ask permission from him for HIV testing.You have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the [email protected]
DiscussionPre-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. [email protected]
Remember to explain the difference of HIV and AIDS. Convince the patient about the benefit of early detection and reassure him that the test result is confidential.If you have time , you should discuss with patient about the implication of the test result regarding to future insurance purchase.Before you end your interview with patient, tell him that your hospital has a special trained nurse to give him further counselling if he has further question to discuss.Arrange next appointment date if he is undecided about the test. remember that if patient is not agreeable with you about something, always ask him the reason behind this! [email protected]
Common questions examiners would ask you1) What is 'window period ' for HIV? 2) If the patient is married and turns out to be postive for the HIV test, would you tell his wife if he refuses to tell his wife about the [email protected]
40-Inspect this lady and proceed.
DiscussionA popular skin station in MRCP exam. All candidates would pick up the physical signs and come to a diagnosis after inspectionVitiligo 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.however, examiners would only pass you if you know how to examine systematically a patient with vitiligo.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.
Common questions examiners would ask you1) What are the associated conditions in vitiligo? 2) How do you manage this [email protected]
ConclusionThis lady has vitiligo.Extra pointsAbout 20-25% of patients has other cutaneous and systemic diseases associated with [email protected]
41-Examine this lady's hand.( MRCP Station 5)
DiscussionI 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!).
Common questions examiners would ask you1) How do you diagnose gout? 2) What may be the mechanism of a patient with gout to have renal impairment? ( obstructive uropathy and NSAID abuse)[email protected]
ConclusionThis lady has chronic tophaceous gout. [email protected]
42-Station 4: You are the SHO in charge of ICU. Subject: Mr Lee Xin Yan 22 years oldMr Lee was admitted to your hospital due to motor vehicle accident 3 days ago. He sustained a severe brain injury with massive intra-cranial haemorhage. He showed no sign of improvement. His sedation was off 24 hours ago and he showed no sign of waking up. Your consultant has reviewed him. He and another consultant have performed a few tests and confirmed that he is brain death. Currently, Mr Lee is being ventilated in ICU. You are asked to talk to his mother Madam Liu about the brain death and discuss with her the possibility of organ donation.You have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the [email protected]
DiscussionThis 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!)
a) Assess your subject understanding about a situationIn this case, you can ask Madam Liu, I know that you son was admitted to our hospital 3 days ago, did anyone inform you about his condition?b) Assess your subject about his/her expectation about a situationYou can ask Madam Liu, Did you visit your son in ICU this morning, what do you think about his condition as compared when he was admitted?Madam Liu may tell you that she does not think that his son is improving, her answer can give you some ideas how to approach in the next step. If she think that her son s condition is improving, you may need more time to explain some details such as CT scan reports etc to hint to her that her son is not doing well.
c) Warming upYou need to explain to your subject some information before breaking the bad news. Always pause in between important sentences so that your subject can give you some feedbacks.d) Go to your taskAfter seeing your subjects respond to your explanation above, you then can break the bad news. In this case, you may say that Our consultants have been reviewing him daily since he was admitted, they have reviewed
