4 6035373978044861384

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their appropriate positions
p
Dr. Abdulaziz Fakir

1 Examine this gentleman's
1-Examine gentleman s cranial nerves
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 p patient's lower cranial nerves first.
Anyway, even though you have the habit for examining cranial nerves
Anyway
from the every first to the last, you would notice that this gentleman has
very obvious wasting of the tongue.
If you remember from your old medical school time, muscles of the tongue
are supplied by hypoglossal nerve ( XII cranial nerve)
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 palate
Nasal speech.
At this point, there are two important differential diagnosis, patients with Motor
Neuron Disease can present with either bulbar or pseudobulbar palsy.
Another 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.
Although patients with Guillain-Barre

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)
d ) and
d you may fi
find
d ocular
l muscles
l iinvolvement
l t (O
(Ophtalmoplegia)
ht l l i )
especially in Miller-Fisher variant
Common questions examiners would ask you
1) 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)
2) What investigations you would like to order in this gentleman?

Electromyography- shows widespread anterior horn cell damage
damage. You
may want to do MRI to exclude other spinal cord or root compression
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 Hawking
Conclusion
This gentleman has bulbar palsy due to

motor neuron disease!
2 Look at this diabetic lady skin
2-Look
Discussion
OK, examiners
OK i give
i you two clues
l h
here, patient
i iis di
diabetic
b i and
d ffemale.
l
Yes, Necrobiosis Lipoidica Diabeticorum is common among female
diabetic patients.
Classically it is decribed as well-circumscribed papules or nodules that

expand
p with an active border to become waxy, y, atrophic,
p , round plaques
p q
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,
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
location), scalp, trunk and upper extremities
extremities. Suggest to exaimers as
well that you would like to check urine for glucose.
1)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 skin!
Conclusion
This lady has Nercobiosis Lipoidica

Diabeticorum
3 Examine the patient's
3-Examine patient s neck
neck.
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
patient s thyroid status.
status
This lady complains of tremor, would you like to examine her.etc.
It is important
p for yyou to know how to approach
pp this type
yp 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
tremor, pulse rate
rate, sweaty palm
palm, thyroid eye
signs, opthalmoplegia and reflexes.
Then I would pproceed to examine her thyroid
y g
gland and g
give a brief
description about the gland.
However, always remember to check for retrosternal extension, thyroid
b it , proximal
bruit i l myopathy
th and
d pretibial
tibi l myxodema
d
Conclusion
This lady has Grave's disease with diffused goitre and in a

hyperthyroid state.
Extra points
1) For Grave
Grave's
s opthalmoplegia,
opthalmoplegia the first muscle to be involved is inferior
rectus.
2) Radio-iodine
R di i di treatment can worsen G
Grave's
' eye di
disease.
3) Remember precautions to be taken after radioiodine treatment

4-Look at this p
patient and p
proceed
Discussion
Usually this case is popular in skin sub-station
sub station at station 5.
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
1- pattern of distribution of the rash

2- presence/absence of telangiectasia
3- any vasculitic rash
4- 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
hi t
history.
Conclusion
This lady has active SLE with malar rash and was admitted
due to joints pain.
E t points
Extra i t
1-Remember in drug-induced SLE patients, their anti-histon

antibody is positive. Three common drugs that lead to drug
induced SLE are hydralazine,
hydralazine procainamide and isoniazide.
isoniazide
2 Drug induced SLE never involves brain and kidney

2- kidney.
5-Examine the p
patient's hands
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)
d ) andd llower llobe
b fib
fibrosis
i
Common questions they will ask in exams are:
1- Causes of anaemia in RA patients

p
2-
2 Newer therapies available for RA
3- Mechanism for each joint deformity.

(Distinction question!)
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)
hairs).
Always look hard for other associated autoimmune disease namely

Sjogren's syndrome, autoimmune hepatitis etc.
6 Y are the
6-You th SHO in
i charge
h off Infectious
I f ti Disease
Di Clinic
Cli i
Subject: 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
F th CT abdomen
bd and
d th
thorax iin your h
hospital
it l show
h th
thatt h
he h
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.
Discussion
IIt is
i rather
h a common question
i iin MRCP PACES,
PACES breaking
b ki b bad d news iis
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
p are p
patients with:
SLE
Motor neuron disease
Multiple sclerosis
Parkinson's disease
d
dementiai etc.
Another scenario will be breaking bad news to patients with advanced

cancer.
It is more tricky in the first scenario because you are expected to know
f i l wellll the
fairly h management off each h ill
illness, therefore
h f you need
d to h
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
g of the advanced cancer,, yyou 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.
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 available?

7-This patient complains of double vision. Would
you like to examine her
Discussion
If you see bilateral ptosis in your MRCP PACES
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
patient s hand.
hand Patients with DM will have difficulty to release his/her
hand grip.
You can further

Y f h demonstrate
d this
hi bby d
doing
i a percussion
i test. Y
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.
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
f
face ( wasting
ti off ttemporalis,
li masseters
t andd sternomastoids)
t t id ) and
d bil
bilateral
t l
ptosis.
To make a diagnosis of myasthenia gravis (MG), the most important

physical sign you need to demonstrate is fatiguability.
There are two ways to do this, one is asking patient to look upward and
start counting
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 shoulder.
Conclusion
This lady has ocular myasthenia.

myasthenia
Extra points
p
1 Remember a few examples of drugs that can precipitate

1-
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 block
8-Look
8 Look at this patient and proceed
Discussion
very common short station case in UKUK. 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
b d arms and
beds, d ttrunk.
k
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.
bleeding
Last but not least, ask for family history because it is inherited in an
autosomal dominant way
Conclusion
This gentleman has hereditary haemorrhagic
telangiectasia ( Rendu-Osler-Weber Disease). He has
history of recurrent PR bleeding.
E t points
Extra i t
1- Remember the simple management about this condition such as

oestogen cauterization etc
oestogen, etc.
2- Remember in your management, one very important part is counseling

especially patient plans to have children in future.
9 You are the SHO in charge of the medical clinic
9-You
Dear Dr
Ref: Mr Lee, 24 years old
Kindly 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.
antibiotics My main concern is that he still complains
of intermittent fevers and breathlessness
Please see and advise
With best wishes
Dr Oh Pee Dee
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 letter
Discussion
This question came out a few years back in Singapore MRCP PACES
examination.
i i I want to show
h you this
hi question
i to remind
i d you that
h iin 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
di
disease etc.
t However,
H patient
ti t refused
f d tto talk
t lk about
b t his
hi sexuall encounters
t
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
10 Look at this patient
10-Look patient's
s skin and proceed!
Discussion
It is a common case in MRCP station 5 of endocrine substation
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
p y p y and spinep 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.
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:
1 Common diseases that requires patients on long term steroid are as

1-
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 complications.
11 You are the SHO in charge of the medical clinic
11-You
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.
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
lt t neurologist
l i t thi
thinks
k that
th t Mrs
M Davis
D i isi suffering
ff i from
f
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.
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 letter.
Conclusion
This is a classical question that can be asked in your counselling station
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
disease, etc.
Usually all these diseases are chronic or they have a lot of social
implications.
p In this case,, since that Mrs Davis is suffering
g from Parkinson's
disease, candidates are expected to do the following.
1-to explain
p the illness in layman's
y terms
2-explain the prognosis and the likely progression of the illness
3-treatment for
3 f the
h di
disease- medical
di l or any new treatment available
il bl such
h
as surgical intervention
4-ask
4 k social
i l hi
history
t especially
i ll th
the iimpactt off th
the ill
illness towards
t d patient's
ti t'
daily activities as well as patient's relationship with other family members
Extra points
The commonest mistake candidates make in this type of

question
ti iis ttrying
i tto explain
l i as much
h as possible
ibl about
b ta
illness and not answering patient's queries about the illness
Tryy to give
g 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 approach.
12-This patient complains of double vision,
would you like to examine him.
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 p yyou 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 yyou are dealing g with third nerve p
palsy
y especially
p y yyou
notice that the eye is abducted
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
i l llymph h nodes,
d mass?)
?) , llung ( P
Pancost's
' tumour// llung
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)
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)
compression).
Conclusion
This patient has left isolated third nerve palsy due to diabetes mellitus
Extra 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/ mass
13-Look at this p
patient and proceed
p
Discussion
IIt is
i sometimes
i rather
h diffi
difficult
l ffor you to diff
differentiate
i panhypopituaitarism
h i i i
from hypothyroidism.
However, if you llook

H k att patient's
ti t' sexuall characteristics,
h t i ti th
they are llostt iin
panhypopituitarism
Patients
P ti t withith h
hypothyroidism
th idi also
l ttend
d tto b
be older
ld b because th
the main
i
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
h as DM
DM, Addi
Addison's
' di
disease, PPernicious
i i anemia
i andd vitiligo.
i ili
Suggest to examiners you would like to check for sensory deafness

especially
i ll tto hi
high
h tone.
t Try
T tot find
fi d outt the
th underlying
d l i cause ffor th
the
hypothyroidism if possible.
Conclusion
This lady has hypothyroidism secondary to previous total

thyroidectomy.
thyroidectomy.
Extra points
1-Although
g it is rather uncommon in PACES,, yyou can find this illness
rather common especially among older population. Always check their
thyroid status if an elderly patient presents to you with dementia
2-The commonest cause for hypothyroidism is previous total

thyroidectomy
14-Look at this patient and what do you think
about
b t her?
h ?
Discussion
As discussed in previous issues
issues, Cushing's
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

striae, proximal myopathy
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 p because in Cushing's
g disease ,the tumour is usually
ya
mircoadenoma.
If you look hard, this lady has multiple vasculitic rash over her hands.
In MRCP examination,
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
di
diagnosis
i ffor this
hi llady
d that
h lleads
d h her to b
be on llong-term steroid.
id
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 adenoma
adrenal carcinoma
and ectopic ACTH production (usually lung CA).
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

y g etiology
gy include p
plasma ACTH
level, high dose dexamethasone test, CXR, ultrasound/CT abdomen and
sometimes inferior petrosal sinus sampling for ACTH level.
15-Kindly
y examine this g
gentleman's abdomen.
Discussion
A common finding
fi di iin a patient
i with
i h transplanted
l d kid
kidney b
but always
l
missed by candidates.
This gentleman
Thi tl h
has a superficial
fi i l right
i ht llumbar
b mass with
ith a scar. Th
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
ff off long
l term immunosuppressants
i such
h as signs
i off C
Cushing’s
hi ’
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 ).
A common q question examiners would ask yyou is ways
y for yyou 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
pp make this unlikelyy to happen
pp even p 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
b ffunctioning
be ti i well.ll
Conclusion
This gentleman has a transplanted kidney and on cyclosporin,
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
hypomagnesaeimia.
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 effective
Azathioprine- bone marrow suppression, cholestatic jaundice, GIT upset.
Azathioprine can cause irreversible bone marrow failure for those with a
particular p
p polymorphism
y p of the TPMT g gene. GlaxoSmithKline has a
predictive DNA test for this type of problem.
Prednisolone- Cushing
Prednisolone Cushing's
s syndrome and its complications.
Mychophenolate-GIT
y p upset,
p , headache,, bone marrow suppression.
pp
Other common causes of gum hypertrophy include acute myeloid leukemia

leukemia,
scurvy, medications such as cyclosporine, calcium channel blocker
especially nifidipine and phenytoin.
16-This lady complains of lethargy, would you like to
examine her abdominal system?
Discussion
In MRCP exam,
exam if you encounter a surgical scar
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)
g ) and further examination reveals jjaundice,, moderate hepatomegaly
p g y
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
L khhardd ffor any multiple
l i l smallll scars at the
h abdomen
bd d
due to
subcutaneous infusion of iron-chelation therapy.The underlying diagnosis
for this lady with chronic haemolysis is Thalassemia with previous
splenectomy.
Although Thalassemia is rather uncommon in UK, it is common in Asia
especially if you are sitting your exam in Singapore
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 patient’s

patient s height due to growth retardation secondary of iron
deposition at the pituitary gland
Check 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
ild splenomegaly
l l and
d tinge
i off jjaundice
di without
ih h
hepatomegalyl iin their
h i
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
Thi l d has
h Thalassemia
Th l i Major
M j and
d underwent
d a splenectomy
l due
d to
recurrent, frequent transfusions.
Extra points
a)Splenectomy should be considered if,
annual blood requirements exceed 1.5 times those of spenectomised

patients, provided they are on the same transfusion scheme and have no
other reasons for increased consumption
consumption.
Splenic enlargement is accompanied by symptoms such as left upper quadrant

pain
i andd early
l satiety.
ti t
Leucopenia or thrombocytopenia due to hypersplenism.

b) Complications of splenectomy include peri-operative complications
such as bleeding,atalectasis and subphrnic abscess, long term
complications
li i iinclude
l d thrombocytosis
h b i and
d overwhelming
h l i sepsis i especially
i ll
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)
17-You
17 You are the SHO in charge of the medical unit.
Dear Dr
R f Mr
Ref: M David
D id L Letterman, 56 years oldld
Thank 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 historyy of Diabetes Mellitus for the past
p 10 y
years currentlyy on T
Daonil 5mg bd. He is worried about his symptoms but unfortunately I can’t
find anything wrong with him.
Kindly see him and advise
With best wishes
Dr GP
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 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 apnoea
You must ask him to explain his symptom. Some patients may associate
shortness of breath with lethargy
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
anyy precipitating
p p g or relieving
g factors ?
any other associated symptoms ?
In this case, you must ask certain questions which are specific for
hypothyroidism such as constipation, weight gain, cold intolerance
You 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
y p to suggest
gg malignancy
g y
Depression is always a differential in your history taking, try to assess his
social history and symptoms to suggest depression
In obstructive sleep apnoe, patient may have snoring, early morning

headache and sleepiness during day time
As I mentioned earlier, myathenia gravis patients always tell you that their
symptoms worsen towards the evening
About his diabetes, you must always ask the following
his usual control, whether he has monitoring at home to monitor his sugar
possible
ibl complications
li ti such
h as IHD
IHD, retinopathy,
ti th peripheral
i h l neuropathy,
th
nephropathy ,TIA, stroke etc
Later,
L t askk other
th relevant
l t pastt history,
hi t such
h as iin thi
this case, askk the
th patient
ti t about
b t his
hi
OGDS and his symptoms
Last but not least

least, always assess patient's
patient s main concern
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,

Actually 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!
18-Would yyou like to examine this lady's
y hands ?
Discussion
You may be panic when you first look at her hands
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
gy station,, always
y 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,
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
i ll subcutaneous
b t nodule
d l over th
the elbow
lb iin rheumatoid
h t id arthritis
th iti )
and any abnormal joint deformity.
Describe any abnormality you can see such as joint deformity, muscles
wasting
g … etc. Do a pproper
p inspection!
p What I mean,, look over p
patient’s
palm as well as the back of the hand. If you do so
Ops……, the diagnosis becomes obvious after turning the patient’s hand
Another important inspection I would pay attention to is whether there is
presence of nail p
p pitting.
g After g
general inspection,
p , then feel the p
patient’s skin
gently to assessment whether there is presence of warmness that might
suggest disease activity.
Then palpate the patient’s 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
patient’s flexor retinaculum to check for carpal tunnel syndrome
The last step is assessing patient’s functional status. Do at least these

three important steps, unbuttoning of clothes, pincer grip ( holding key)
and writing.
g If yyou suspect
p 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 so
You are going to assess patient’s elbow as well as shoulder joints. Then
the last step will be special steps depending on your findings. Such as in
this case
case, I would suggest to examiners that I would look for other joints
involvement and other common sites for psoriasis.
Why in arthritis mutilans, there is shortening of the fingers?

due to marked periarticular osteolysis and erosion
What is ‘pencil in a cup’ appearance in xray ?
Where are the common sites to find psoriatic patches ?
How would you manage psoriatic arthropathy

Conclusion
This lady has psoriatic arthropathy.
E t points
Extra i t
Five types of psoriatic athropathy namely

oligoarticular
li ti l asymmetrical
t i l ttype (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!
19 Examine this gentleman's
19-Examine 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
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
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 over-
warfarinization, signs to suggest endocarditis and murmurs to suggest valve
dysfunction
Common q
questions examiners would ask you
y
Complications of mechanical prosthetic valve
can be divided into complications due to the valve itself such as dysfunction
haemolysis endocarditis
haemolysis,
and complications due to the treatment because of warfarin
Causes 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 clinically?

Conclusion
This gentleman has AVR surgery done before due to previous
aortic stenosis and bypass surgery.
Extra points
You can’t
Y ’t find
fi d any d
donor site
it and
d no mechanical
h i l click
li k when
h 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
Al h h patients
i with
i h valve
l repairsi tendd to h
have lleft
f thoracotomy
h scar
( such as in mitral stenosis), I found out some patients may have
sternotomy scar!
20-Look at this lady lower limbs.
Discussion
It is an uncommon case in MRCP, however, it is worthwhile to learn
about
b this
hi
If you llook
k carefully
f ll att h
her llower lilimbs,
b you actually
t ll notice
ti thi
this llady
d hhas
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,

conditions however,
however .
erythema ab igne usually appear to be more dusky and besides over
the lower limbs, you can find it on the abdomen
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 Malaysia
The 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
pancreatitis
Whereas in livedo reticularis, it is associated with SLE and usually found

in young females
If you find livedo reticularis, always look for other signs to suggest SLE
and also tell examiners that you would look for underlying malignancy as
well
1- Can livedo reticularis be normal ?
Yes, because it can be found in young females especially in cold

weather
th
Wh t other
What th conditions
diti are associated
i t d with
ith livedo
li d reticularis
ti l i ?
Besides SLE
SLE, other conditions include polyarteritis nodosa
nodosa, occult
malignancy and microemboli of skin.
Conclusion
This lady has livedo reticularis due to SLE
Extra points
1- Although
1 Alth h it is
i nott a popular
l question,
ti livedo
li d reticularis
ti l i iis often
ft missed
i d
by candidates in SLE patients during their exam
If you are dealing with a SLE patient

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 well!
21-Look at this gentleman skin.
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,
black, velvety overgrowth in the skin
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
C
Common questions
ti examiners
i would
ld ask
k you
1) What conditions are associated with acanthosis nigricans?
2) How do you define metabolic syndrome?

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
R b 1 or 2 examples
l off cutaneous manifestations
if i off viceral
i l
malignancy such as dermatomyositis and Paget's disease of the nipple
22-Look at this lady
y and p
proceed
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
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

Sjogren s syndrome can be associated with
scleroderma.
check the hands and look for sclerodactyly ( image next slide)
slide),
Raynaud's phenomenon, peudoclubbing and calcinosis.
Al assess the
Also th extent
t t off skin
ki involvement
i l t!
assess the patient's hands
functions by doing hand
grip pincer grip (holding
grip,
key) and unbuttoning of
clothes.
ask patient relevant

hi t
history suchh as d
dysphagia,
h i
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
att her
h stool
t l for
f evidence
id off malabsorption.
l b ti
Common questions examiners will ask you
what types of autoantibodies can be present ?
ANA,anticentromer and anti-topoisomerase
what are the prognostic factors ?
Sex- male
S l ttends
d tto do
d worse, patients
ti t with
ith extensive
t i skin
ki iinvolvement
l t
and renal involvement tend to do worse
How to explain chronic diarrhoe in this type of patient ?
bacterial overgrowth
g
What are the criteria to diagnose of scleroderma ?
How would you manage a patient with scleroderma ?

Conclusion
This
s lady
ady has
as syste
systemic
c sc
sclerosis
e os s
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 oesophagitis
anemia due to malabsorption
anemia of chronic illness
and microangiopathic haemolytic anaemia.

23 E
23-Examine
i this
thi gentleman's
tl ' leg
l
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
feel, palpate and move the relevant joints
joints, you should look at other
sites for similiar swelling.
These sites include helices of the ears

ears, olecranon bursae
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.
Wh ffactors can precipitate

What i i acute gouthy
h arthritis
hii ?
When do you start to treat hyperuricemia ?
How do you explain patients with gout to have bilateral leg swelling ?
Fluid overload due to CRF

Conclusion
This gentleman has chronic tophaceous gout.
Extra points
Clinical presentations of gout include asymptomatic hyperuricemia

hyperuricemia,
acute arthritis, chronic arthritis and chronic tophaceous gout.
Uric acid crystals are negatively birefringent.

24-This gentleman has abdominal discomfort.
Examine his abdominal system
Discussion
First lesson to be learned in abdominal examination is appropriate
proper exposure.
exposure
My friend failed this station because he insisted to expose his female

patient
ti t iin hi
his MRCP PACES exam down d to
t thigh.
thi h I would
ld expose the
th
patient up to just above the genitalia.
Obviously you notice this gentleman’s 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.
some clues may help you.
If you find……..
parotid swelling
Dupuytren’s contracture – you may be dealing with alcoholism
skin hyperpigmentation-
yp p g you mayy be dealing
y g 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-

abuse you
may be dealing with Hepatitis B.
Common questions examiners will ask you
What is Child’s grading of liver disease in portal hypertension?
The mnemonic to remember BAPA + E

bilirubin, ascites, PT (INR) and albumin and encephalopathy
What are the possible complications of portal hypertension?

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 Wilson’s disease also can cause chronic liver
disease
di
25-You are the SHO in charge of the Infectious
Disease clinic
You 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).
(PEP)
You task is to explain to him about post exposure prophylaxis

prophylaxis.
You have 14min until the patient leaves the room

room, followed by 1min for
reflection before the discussion with the examiners.
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
the depth of about the time of the event, size of needle he was using,
needle ppenetration and what was his action after the incident
assess the patient’s understanding about certain issue, in this case, Dr

Henry’s
y understanding g 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
assess Dr Henry’s risk to get certain infections such as HIV, Hepatitis B
and Hepatitis C
C. Ask him whether he knows about his status and his
previous Hepatitis B vaccination
askk more about

b that
h HIV patient’s
i ’ status -? ? on treatment,?CD4
?CD4 count, any
other medical problems such his ? Hepatitis B/ VDRL/ Hepatitis C status.
ttellll hi
him you are th
there tto h
help
l hi
him and
d you certainly
t i l understand
d t d hi his ffeeling
li
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 Henryy briefly

y about PEP and maybe y 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 testing.
testing
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
g that they
y want to discuss with yyou
You may miss these issues if you do not ask them specifically
What 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

26-This gentleman has shortness of breath.
Examine his respiratory system
Discussion
You will be happy to see this case in your MRCP PACES
PACES. You can get
the diagnosis after your inspection
You notice that there are multiple distended veins over this
gentleman’s chest.
You can proceed with the usual physical examination of the

respiratory system by bearing in mind that you may find the following
abnormalities:
Pancoast’s 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.
After yyour complete
p p
physical
y examination,, do the following
g steps:
p
Demonstrate the direction of the venous flow.
L k ffor exophthalmos,
Look hh l conjunctival
j i l iinjection.
j i
Look at the JVP( non-pulsatile) and show to examiners how you

measure it.
it
Examine the cervical region for lymph nodes.
Look for small muscles wasting of the hand and Horner’s syndrome if
you are suspecting Pancoast’t tumour.
Suggest to examiners you would like to demonstrate Pemberton’s

sign if possible.
Ask the patient about smoking history.
Talk to patient to assess hoarseness of voice.

What is Permberton’s sign?
What is para-neoplastic syndrome and give a few examples?
Name types of lung carcinoma.
What are the contraindications for surgical intervention?

Conclusion
This gentleman has superior vena cava obstruction due to lung
cancer.
Extra points
If p
possible,, non small cell lung
g cancer should be treated with surgical
g
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.
27-Examine this ladyy upper
pp limbs neurologically..
g y
Discussion
In MRCP PACES, after lower limbs examination and Parkinson’s
disease upper limbs examination is the third most popular question
disease, question.
You notice that there are obvious small muscles wasting with loss of
thenar and hypothenar eminences
eminences.
Before you proceed further, you should know that there are only a few
possible causes for this.
The causes are Motor Neuron Disease,

Disease Cervical Spondylosis
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
th
there iis sensory iinvolvement
l t or presence off ffasciculation
i l ti ( which
hi h 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
gg syringomyelia.
y g y
Upper motor signs of lower limbs with possibility of sensory level. This
suggests cervical spondylosis
spondylosis.
Flaccid paralysis of lower limbs with no sensory involvement. This

may suggest Guillain
G ill i BBarre syndrome.
d
After the examination, suggest to examiners that you would look for
Horner’s syndrome if you suspect syringomyelia
What is the CSF finding in GB syndrome?
What are the three recognized forms of hereditary motor

sensory neuropathy?
Conclusion
This lady has CIDP

(d to
(due t the
th chronicity,
h i it she
h has
h muscles
l wasting).
ti )
E t points
Extra i t
In MRCP PACES,
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.
sclerosis
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
y feel veryy worried when faced with cranial nerves examination.
You notice that this gentleman has obvious loss of right naso-labial fold.
A lot
l t off candidates
did t always
l askk me the
th same question,
ti should
h ld I examine
i
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
i l acuity,
i visual
i l fi
field
ld and
d eye movement.
2-Facial expression, sensation and movement- you will be testing cranial

nerves V andd VII
VII. You
Y mustt check
h k for
f upper and d lower
l portion
ti off facial
f i l
expression, corneal reflex ,masseter and pterygoid movement.
3-Articulation
3 Articulation and gag reflex
reflex- You will be testing cranial nerves IX
IX,X
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
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
pp motor 7th nerve p
palsy.
y
You can differentiate this by observing 2 major upper portion facial

muscles namely orbicularis oculi and frontalis muscles
muscles.
Ask patient to screw his eyes and look upward
If 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
7 h nerve palsy.You
7th l Y can then h complete
l other
h cranial
i l nerves examination.
i i
After your examination, you want to find the possible aetiology for his 7th
nerve palsy
l bby d
doing
i ththe ffollowing
ll i steps:
t
1-look at external auditory canal for herpes zoster

2-palpate for parotid swelling
3-check for hyperacusis
4-examine the taste involvement ( anterior 2/3 )
5-test urine for glycouria
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 palsy?
Conclusion
This gentlema has right Bell's palsy.
Extra points
Bell's p
palsy
y should be treated with combination of steroid and acyclovir.
y
29 Examine this patient's respiratory system.
29-Examine system
Discussion
In MRCP PACES,
PACES if you find clubbing in respiratory station
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.
Crepitation in bronchiectasis is described as coarse and the quality
changes with coughing.
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
that, steroid.
After the
Af h examination,
i i suggest to examiners
i that
h you would
ld lik
like to
look at the temperature chart…
What are the causes of brochiectasis?
How would you manage this condition?
What are other causes of clubbing?

Conclusion
This gentleman has bronchiectasis due to previous tuberculosis.
Extra points
In bronchiectasis , remember postural drainage, postural drainage,

postural drainage…
If yyou find patient

p with bronchiectasis also has dextrocardia, the
diagnosis is Kartagener's syndrome
30-This gentleman has difficulty in walking.
Examine his lower limbs neurologically.
Discussion
An uncommon case iin your d
A daily
il practice
i b but iit iis suprisingly
i i l a popular
l
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

Yes,
further examination reviews that:
This gentleman has waddling gait.
His proximal muscles are weaker that 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
also.
Demonstrate winging of scapula by asking patient to straighten his
elbow and p
push against
g resistance.
Suggest to examiners you would ask about family history of similar
problem.
Look for any surgical scar to suggest recent muscle biopsy.
Why do
Wh d you say that
h iit iis pseudohypertrophy
d h h and
d not true h
hypertrophy
h
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 COUNSELLING

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
p yp p y of calf or deltoid muscles,, it is usually
y due to
Hereditary Muscular Dystrophy.
Other common cases of proximal myopathy in MRCP PACES are either

polymyositis or dermatomyositis.
31 Examine this gentleman lower limbs neurologically
31-Examine
Discussion
Another
A h popular l neurology
l case iin MRCP PACES
PACES, there
h are a ffew
possibilities you are dealing with Pes Cavus in MRCP.
You may b
Y be asked
k d tto ttalk
lk tto a patient
ti t who
h has
h aC
Cerebellar
b ll ( staccato
t t
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
p pp limbs and yyou 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.

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,
suggestt to
t examiners
i that
th t you would
ld like
lik tto:
ask about family history
check fundoscopy to look for optic atrophy.
examine relevant cerebellar signs.
look for kyphoscoliosis

What is the mode of inheritance for Friedreich's

ataxia or Charcot Marie Tooth?
What is the pathogenesis of pes cavus?

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
versa.
Remember that other causes of Pes Cavus are poliomyelitis and

muscular
l d dystrophy.
h
32 Look at this lady
32-Look lady's
s lower limbs and proceed.
proceed
Discussion
This is a very popular skin station in MRCP exam 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
generall iinspection
ti b before
f zooming i tto th
the skin
ki llesion.
i
Sometimes,, when youy are asked to examine a skin lesion over the leg,
g,
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
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
h k ffor conjunctivitis.(
j i i i ( mucosall iinvolvement)
l )
check for lymph nodes especially cervical region ( glandular
fever?) and ask for drug history
history.
1) What is Steven Johnson syndrome?

2) Wh
Whatt is
i th
the diff
difference b
between
t St
Steven Johnson
J h syndrome
d
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 condition?
Conclusion
This lady has macular-papular rash due to drug allergy.
Extra points
1) 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 lesion.
33 Examine this gentleman
33-Examine gentleman's
s skin
skin.
Discussion
I give you this example because I think this is a popular case in MRCP.
MRCP
This case can be either come out in station 1 or station 5 (skin station) .
If you notice xanthelasma in a middle

middle-aged
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
h
hepatosplenomegaly.
t l l
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

that, xanthelasma can be asked in station 5 as well
well.
Besides xanthelasma, other stigmata of high cholesterol level include
tendon xanthomata, eruptive xanthomata,palmar xanthomata and
corneall arcus.
Classification of hyperlipidemia is based on Fredrickson which
can be divided to Type I to Type V. After your examination, proceed
to the following:
g
look for other stigmata of hyperlipidemia
assess 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.
hypothyroidism
family history of premature death due to coronary

heart diseas and hyperlipidemia.
hyperlipidemia
1) How do you manage hyperlipidemia?
2) What are classes of drugs available to

manage high cholesterol?
Conclusion
This gentleman has xanthelasma with underlying Diabetes

Mellitus.
Extra points
1) 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 statin.

34 Examine this lady's
34-Examine lady s respiratory system.
system
Discussion
A very popular
l MRCP question i iin respiratory
i station.
i Wh
When you fifind
d
a lateral thoracotomy scar in respiratory station, always think of three
possibilities:
namely lobectomy, pneumonectomy and previous lung

transplantation
p surgery.
g y
A lot of candidates remember the first two possibilities but always miss
the third. The reason is simple,
p , doctors workingg in manyy 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.
Kingdom, transplantation
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
note.
First point, in lobectomy, you may find reduced breath sound in certain
areas such as upper/middle/lower
pp region
g but in p
pneumonectomy,y,
there is reduced breath sound over the whole affected lung.
Second point, there may be no sign to suggest mediastinal shift in
l b
lobectomy ( centrall trachea)
h )b but iin penumonectomy, you are expected
d
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.
1) What are the indications for pneumonectomy or lobectomy?
2) What are the common indications for lung transplant in United

Ki d ?
Kingdom?
3)) What are the common side effects of cyclosporin?

y p
4) What are the contraindications for surgical intervention in lung

cancer?
Conclusion
This lady
Thi l d has
h lateral
l l thoracotomy
h scar due
d to previous
i lobectomy
l b
because of lung cancer.
Extra points
1) Always take your time to observe for any surgical scar in your
respiratory station
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 tuberculosis!
35-Examine lady s cardiovascular system.
system
Discussion
A rather
h uncommon case iin your ddaily
il practice
i b but iit iis popular
l iin
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)
j ) and wrist sign
g (p
put ppatient's fingers
g 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,
heart you would
anticipate you are most
probably to find either
aortic regurgitation or
mitral regurgitation.
Remember to suggest to
examiners
i th
thatt you
would like to ask about
the family history .
1) 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?

Conclusion
This lady has Marfan syndrome and mitral regurgitation .
Extra points
1) When asked about the management of an illness, always

remember that patient education is very important if the illness is
chronic and incurable
incurable. Remember genetic counselling if it is inherited
inherited.
2) Cardiovascular complications are the major cause of death in

Marfan syndrome!
36 Examine this gentleman
36-Examine gentleman's
s abdomen
abdomen.
Discussion
As I mentioned in my previous posts.
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
di
disease suchh as:
Clubbing-Dupuytren's contracture-palmar erythema-spider naevi-

flapping tremor
tremor-leukoonychia-scratch
leukoonychia scratch mark
mark-jaundice-pallor-
jaundice pallor
pigmentation-cyanosis-xanthomata-purpura-koilonychia-paronychia-
oedema-muscle wastimg-tattoos-needle marks....( you would be
surprised
i d to fi
find
d that
h there
h are so many physical
h i l signs
i iin chronic
h i liliver
disease!).
Although
Alth h there
th are a lot
l t off causes for
f gynaecomastia,
ti if you find
fi d this
thi in
i
your abdominal station, always think of chronic liver disease.
Remember that common drugs that are associated with gynaecomastia are
ketoconazole,, spirolactone,
p , H2 antagonist
g such as cimetidine and
psychoactive drugs.If you look at the periphery, you would find the
following,
Yes, you would
Y ld notice
i that
h
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
dullness.
Showmanship is important
in MRCP clinical exam.
Always examine your
patient systematically and
confidently.
1) 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 patients?

Conclusion
Thi patient
This i has
h chronic
h i liver
li cirrhosis
i h i dued to alcoholism.
l h li
Extra points
1) 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!)
37-Examine lady s hands
Discussion
This is the continuation discussion from the previous issue. As I
mentiond in previous article
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

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
j criteria.
it i
Major criteria for Marfan syndrome include Ectopia Lentis ( upward
dislocation of the len)
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
syndrome. If patient does not has family history
history,then
then you need
two systems involvement plus one major criteria!
1) How do you manage this condition?

( Remember about genetic counselling and patient's education)
2) What are common cardiovascular lesions in Marfan syndrome?

Conclusion
This lady has Marfan syndrome
Extra points
Remember the complications of Marfan syndrome!

38 Inspect this gentleman and proceed.
38-Inspect proceed
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)
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
ti l hhamatormas
t andd check
h k ththe abdomen
bd tto llook
k ffor b
ballotable
ll t bl kid
kidney
(due to renal hamartoma).
After these steps, you should suggest to examiners that you would get a
complete
p family
y history
y of similar p
problem and take history
y from p
patient
about epilepsy.
You would be
interested to test the
patient's
ti t' IQ.One
IQ O
common mistake
candidates make in
exam is they tend to
forget to look for signs
suggesting
gg g side
effects of anti-epilespy
medications.
Look hard for signs suggesting pheytoin side effects such as cerebellar
signs,
i gum h hypertrophy
t h and d hi
hirsutism.
ti Al
Also llook
k ffor side
id effects
ff t off other
th
anti-epileptic!
1) What can you usually find in this patient's CT brain?
2) How do you manage this patient?

Conclusion
This gentleman has tuberous sclerosis.
Extra points
TSC 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,
present. gene discovered in 1997,
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 tuberin.
39-You are the SHO in charge
g of the medical unit
Mr Smith, an ex-IVDU
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
i i from
f him
hi for
f HIV testing.
t ti
You have 14min until the p patient leaves the room,, followed by
y 1min
for reflection before the discussion with the examiners.
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
h di
diagnosis
i (PCP) and d then
h switch
i h the
h topic
i off di
discussion
i fform PCP
to HIV testing.
I always
l tell
t ll my jjunior
i d doctors
t th
thatt b
before
f going
i iinto
t ddeep di
discussion
i
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
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
off candidates
did t fi find
d it diffi
difficult
lt tto talk
t lk about
b t HIV and
dhhow tto switch
it h th
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 pprone him to g 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
patient.
After this, assess patient's risk about HIV infection and ask him
whether he has any question to ask you about HIV.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.
Remember to explain the difference of HIV and AIDS
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

test.
remember that if patient is not agreeable with you about something,
always ask him the reason behind this!
1) 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 result?
40 Inspect this lady and proceed.
40-Inspect proceed
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
Vitili i always
l d
described
ib d as " h
hypopigmented
i t d patches
t h with
ith white
hit
hairs in vitiliginous area".
Areas commonly involved include perioral
perioral, periorbital
periorbital, axilla , upper and
lower limbs.
After yyour initial inspection,
p try
y to look at the p
patient's scalp
p 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
Y ld fi
find
d reduced
d d sensation
ti att th
the h
hypopigmented
i t d skin
ki if you
suspect leprosy.
There are various available treatment for vitiligo
vitiligo.
Topical steroid may be useful at initial stage.Other topical
immunomodulators may y 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.
1) What are the associated conditions in vitiligo?
2) How do you manage this patient?

Conclusion
This lady has vitiligo.
Extra points
About 20-25% of patients has other cutaneous and systemic

diseases associated with vitiligo.
41-Examine this lady's
y hand.(( MRCP Station 5))
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
patient s ear lobe
lobe.
Such as in this patient, you only notice a small swelling over her left
index finger.
g However,, the diagnosis
g of g
gout would be clear if yyou 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
Y i h save a llot off time
i struggling
li to get the
h di
diagnosis
i if you spend
d
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!).
1) 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)
Conclusion
This lady has chronic tophaceous gout.

42 Station 4: You are the SHO in charge of ICU
42-Station ICU.
Subject: Mr Lee Xin Yan 22 years old
Mr 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 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
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 examiners.
Discussion
This type of question is always popular in MRCP PACES station 4. 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 patient’s family members, therefore they couldn’t even
start talking about organ donation
donation.
I think it is a common dilemma in examination, you fail to convince
patient’s
patient s mother that the patient is dead
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 situation
In this case, you can ask Madam Liu, “I know that you son was
admitted to our hospital
p 3 days
y ago,
g did anyone
y inform yyou about his
condition?”
b) Assess your subject about his/her expectation about a

situation
You 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.
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 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
tests,
unfortunately, your son’s condition is not improving.”
Always pause in between important sentences so that your subject

can give you some feedbacks.
d)) Go to y
your task
After seeing your subject’s 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

H h dil
dilemma, the
h subject
bj could
ld not accept h
her son iis d
dead,
d
how do I talk about organ donation?
You actually can explore some social history about Mr Lee
Lee. Actually
Actually, my
friend failed this case in his MRCP PACES because he did not explore
about the patient’s social history and found out that Mr Lee is the only child
i th
in the ffamily.
il
After that, just tell Madam Liu that from the social history you gather from
her , her son is a very helpful young man
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!
43-Examine this lady's
y hand neurologically.
g y
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
M di l ward.
Medical d
You notice this patient has right claw hand.Yes, you are right ,she has
ulnar
l nerve palsy!
l !
Remember that ulnar nerve supplies all small muscles of the hand
exceptt LOAF ( ththe Lateral
L t l ttwo lumbricals,
l b i l Opponens
O pollicis,
lli i Abductor
Abd t
pollicis brevis and Flexor pollicis brevis).
As a medical student before

before,you
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
yyou look hard , you
y notice that there is a scar over the patient’s
p wrist.
She actually sustained

industrial injury
j y 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
d
deep b
branch.(
h ( which
hi h supplies
li th
the smallll muscles
l off th
the h
hand).
d)
If you ask the
patient to grasp
a piece of
paper between
b
the thumb and
lateral aspect of
the forefinger
with each hand
as below,, you
y
would be able
to demonstrate
Froment s
Froment’s
sign.
You notice that the affected thumb will flex ( Flexor pollicis brevis)
because of loss of the adductor of the thumb
thumb.
1) What is ulnar nerve paradox?
2)) All small muscles of hand are supplied

pp by
y ulnar nerve except
p what
muscles?
Conclusion
This lady has right ulnar nerve palsy due to previous trauma
E t points
Extra i t
Besides the cutanous branch of superficial branch of the ulnar nerve

nerve, it
also gives branch to supply palmaris brevis ( muscular branch).
44-Inspect
p this lady
y and proceed.
p
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.
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 patient’s hand, you notice that she has spade
–like
lik ,sweaty t hand,
h d ththe skin
ki iis thi
thickened
k d and
dddoughy.
h
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.
g
Offer to look for skin tag ( molluscum fibrosum) at axilla
Look at lower limbs for pitting oedema to suggest high cardiac output
failure
Check for proximal myopathy by asking patient to squat down
Check for bitemporal hemianopia-acromegaly tends to be due to

macroadenoma
After showing all the positive signs, suggest to examiners you would
like to complete your physical examination by:
Check her Blood Pressure which is a indicator for active disease
Checkk urine
Ch i for
f glycouria/
l i / haematuria
h t i due
d to
t possible
ibl concomitant
it t
diabetes mellitus or stone because of hypercalciuria
Check fundus to for changes of DM/hypertension and angiod streak
Compare patient with old photos
Examine CVS to look for heart failure, neck for goiter and abdomen
for hepatosplenomegaly
Common q
questions examiners would ask you
y
What are the indicators for disease activity

y in acromegaly?
g y
How do you manage investigate this lady?

Conclusion
This lady has acromegaly due to pituitary macroadenoma.
E t points
Extra i t
IIndicators
di t ffor disease
di activity
ti it are uncontrolled
t ll d symptoms
t such
h 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.
activity
Most important test to diagnose acromegaly is non-suppressibility of

growth
th h
hormone llevell after
ft an orall glucose
l ttolerance
l ttest.
t
45-You are the SHO in charge
g of Neurology
gy Ward.
Subject:
j Miss Sylvia,
y 24-year
y old
Miss Sylvia was diagnosed to have epilepsy about 6 months

ago but she has failed to attend your neurology clinic follow
up. For the past one month, she has been recurrently
admitted to your hospital due to seizure and you found out
that she has not been taking her medications regularly
regularly. Due
to her work as a school teacher, you also noticed that she is
still driving to school. Currently, she is admitted in your
neurology ward and your task is to discuss the management
of her epilepsy.
You have 14 min until the patient leaves the room followed by 1min for
reflection before the discussion with the examiners.
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 h
A her understanding
d t di about b t the
th ill
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 patient’s understanding for the illness
You need to know about patient’s 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’
advanced
discussion with patients.
Generally,
y, when you
y talk about an illness,, tryy to cover the following:
g
General information about an illness. Such as “Epilepsy is due to some
abnormal brain activity that causes you to have abnormal and
uncontrolled
ll d b
body
d 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
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
generation.
If yyou encounter a female p
patient in yyour exam,, always
y think of
the possible impact of the disease and its treatment towards
pregnancy and lactation.
Besides
B id these
h iissues, iin this
hi case, another
h iissue crops up ffor you
to discuss with the patient is the issue of driving.
Actually, a candidate failed this station in his MRCP PACES a few
Actually
years back because he did not find out the following:
1)) The patient
p refused to eat the medications because she was
pregnant at that time and she was worried about the side effects
of the medications to her baby.
2) The candidate did not find out what was the social support for
this lady. Actually, her husband was working outstation and there
was no way y for her to go
g to work except
p driving
g her own car.
3) The patient was very worried about passing the disease
(epilepsy) to her baby and actually wanted to ask the candidate
about
b t abortion.
b ti H
However, my ffriend
i d jjustt iignored
dhher b
because thi
this
task was not mentioned in the paper.
46 Inspect this
46-Inspect
gentleman and
proceed
Discussion:
OK, this is a common case in MRCP PACES station 5 if you are sitting
the
h exam iin Malaysia
M l i andd Singapore.
Si I think
hi k iit iis easy ffor you to d
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
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 yap pillow behind the p
patient’s back.
Patients with Ankylosing Spondylitis usually present with back pain

and this gentleman has chronic back pain since the age of 20 years old
old.
Proceed to do the following after a general inspection:
ask the patient to walk away from you and turn back and walk towards you
you.
Pay attention to patient’s posture.
ask patient to look to either side. You will notice patient may have limited
cervical
i l spine
i movement. Th The patient
i may need d to move hi
his whole
h l bbody
d
when he wants to look to either side.
check his thoracic and lumbar spine
p movement , usually,
y, I would ask patient
p to flex
aside(lateral flexion), rotate and do forward and backward flexion. Remember to fix
the patient pelvis when you ask patient to do rotation. You will notice patient with
Ankylosing Spondylitis has very limited spine movement.
you need to do two tests to demonstrate the patient has limited spine
movement by demonstrating ‘occiput to wall’ test and Schober’s test. In
following picture,
picture when I ask the patient to rest his back against the wall
wall,
you notice that this gentleman has difficulty to make contact his head
against the wall.
for Schober’s 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
f possibility
for ibili off psoriasis
i i (bbecause one variant
i off psoriatic
i i arthropathy
h h
may look like Ankylosing spondylitis)
suggestt to
t examiners
i you will
ill lik
like tto look
l k for
f 4As-
4A Anterior
A t i uveitis,
iti Apical
A i l
fibrosis, Aortic regurgitation and Achilles tendinitis.
What are the diagnostic criteria to diagnose Ankylosing Spondylitis?
How do you manage this gentleman?( Remember that genetic

counseling
li iis iimportant
t t and
d remember
b tto ttalk
lk about
b t HLA
HLA-B27!)
B27!)
Conclusion:
This gentleman has Ankylosing Spondylitis with limited spine
movement.
Extra points:
Diagnostic
g criteria of Ankylosing
y g Spondylitis
p y is based on New York
Criteria (1966)
Limitation of motion of the lumbar spine in all 3 planes: anterior flexion,
lateral flexion and extension
extension.
History of the presence of pain at the dorsolumbar junction or in the
lumbar spine.
p
Limitation of chest expansion to 1 inch (2.5 cm) or less, measured at the
level of the fourth intercostal space
I find the following algorithm interesting and helpful

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Some pictures were missing and

were downloaded and re-entered in

Dr. Abdulaziz Fakir

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