MRCP Paces

asimgabir@hotmail.
com
Examine this gentleman's cranial nerves -1
Discussion
During your MRCP PACES examination, your examiners may give you
.clues and tell you that this gentleman has problems with his speech
If they give you clues that patient has problems with speech, I will
.examine the patient's lower cranial nerves first
Anyway, even though you have the habit for examining cranial nerves
from the every first to the last, you would notice that this gentleman has
.very obvious wasting of the tongue
asimgabir@hotmail.com
If you remember from your old medical school time, muscles of the tongue
.are supplied by hypoglossal nerve ( XII cranial nerve)
You must look for other cranial nerves involvment in this gentleman.
:Further examination in this gentleman reveals that
,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 syndrome may give rise to similar
picture ( weakness of tongue with nasal speech), you must remember that
wasting is not obvious ( due to short duration of weakness in Guillain Barre
syndrome) and you may find ocular muscles involvement (Ophtalmoplegia)
especially in Miller-Fisher variant
Common questions examiners would ask you

?How do you differentiate bulbar from pseudobulbar palsy(
1
You can find the answers in any medical text book, however, I think the
tongue gives you good clues in differentiating these two (conditions)
?What investigations you would like to order in this gentleman ( 2
Electromyography- shows widespread anterior horn cell damage. You
may want to do MRI to exclude other spinal cord or root compression
?What are the clinical patterns of motor neuron disease ( 3
)Bulbar, Progressive muscular atrophy and Amyotrophic lateral sclerosis (
Who is the famous scientist in UK having motor neuron( 4
?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
Look at this diabetic lady skin-2
Discussion
OK, examiners give you two clues here, patient is diabetic and female.
Yes, Necrobiosis Lipoidica Diabeticorum is common among female
. diabetic patients
Classically it is decribed as well-circumscribed papules or nodules that
expand with an active border to become waxy, atrophic, round plaques
centrally. Initially, these plaques are red-brown in color but progressively
.become more yellow and atrophic in appearance
Necrobiosis Lipoidica Diabeticorum is a disorder of collagen
degeneration with a granulomatous response, thickening of blood vessel
walls, and fat deposition. You must always suggest to examiners that
you would like to look for similar lesions over pre-tibial area ( a classical
location), scalp, trunk and upper extremities. Suggest to exaimers as
.well that you would like to check urine for glucose

?What is the histology of this lesion)1
Histopathologically, it presents with interstitial and
palisaded granulomas that involve the subcutaneous
.tissue and dermis
?What is your differential diagnosis)2

!Sarcoidosis of the skin
Conclusion
This lady has Nercobiosis Lipoidica
Diabeticorum
.Examine the patient's neck-3
Discussion
There are different possible questions that can be asked in the
:examination besides the above question, other possibilities include
!Look and proceed
.Would you like to examine this patient's thyroid status
.This lady complains of tremor, would you like to examine her.etc
It is important for you to know how to approach this type of case, if the
question starts as assess this lady's thyroid status.I would most
probably start off by showing the examiners how I assess her thyroid
function by checking tremor, pulse rate, sweaty palm, thyroid eye
. signs, opthalmoplegia and reflexes
Then I would proceed to examine her thyroid gland and give a brief
.description about the gland
However, always remember to check for retrosternal extension, thyroid
bruit , proximal myopathy and pretibial myxodema
Conclusion
This lady has Grave's disease with diffused goitre and in a
.hyperthyroid state
Extra points
For Grave's opthalmoplegia, the first muscle to be involved is) 1
.inferior rectus
.Radio-iodine treatment can worsen Grave's eye disease ) 2
Remember precautions to be taken after radioiodine treatment ) 3
Look at this patient and proceed-4
Discussion
.Usually this case is popular in skin sub-station at station 5
. Although it is rather uncommon in UK, SLE is endemic in South East Asia
It is a common case especially if you are sitting your MRCP PACES in
Malaysia ,Hong Kong or Singapore. Always remember to present the
following
pattern of distribution of the rash- 1
presence/absence of telangiectasia- 2
any vasculitic rash- 3
.Any signs to suggest patient is on long term steroid therapy-
Suggest to examiners that you would do a complete physical examination to

look for other systems involvement. Always remember to check the patient's
BP, fundoscopy for cytoid body, urine for proteinuria and ask for drugs
.history
Conclusion
This lady has active SLE with malar rash and was admitted
.due to joints pain
Extra points
Remember in drug-induced SLE patients, their anti-histon -1

antibody is positive. Three common drugs that lead to drug
.induced SLE are hydralazine, procainamide and isoniazide
.Drug induced SLE never involves brain and kidney- 2
Examine the patient's hands-5
Discussion
It is a gift if you get this case in your MRCP PACES, an important
sentence you must include in your presentation is bilateral, symmetrical
deforming polyarthropathy involving the small joints of hands especially
. over PIP and MCP joints
Psoriatic athropathy may present with similar deformity but look hard for
. other clues such as nail pitting, skin lesion and telescoping of fingers
Always look hard for Cushing's syndrome although patients with RA are
.usually not on long term high dose steroid
Always assess their functional status. Suggest to examiners that you
would like to examine other joints, look for splenomegaly ( Felty's
syndrome) and lower lobe fibrosis
:Common questions they will ask in exams are
Causes of anaemia in RA patientsNewer therapies available for RA-
1
2
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)
Always look hard for other associated autoimmune disease namely
.Sjogren's syndrome, autoimmune hepatitis etc
You are the SHO in charge of Infectious Disease Clinic -6

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 CT abdomen and thorax in your hospital show that he has an
advanced hepatoma with lung metastasis. Your consultant has reviewed
.the films and think there is no curative management for him
Your task is to break the bad news to him and tell him there is only
.palliative management available
Discussion
It is rather a common question in MRCP PACES, breaking bad news is
always a popular question. There are usually two scenarios in this type
.of question
The first scenario will be breaking bad news to patients who are suffering
:from chronic illnesses examples are patients with
SLE
Motor neuron disease
Multiple sclerosis
Parkinson's disease
.dementia etc
Another scenario will be breaking bad news to patients with advanced
.cancer
It is more tricky in the first scenario because you are expected to know
fairly well the management of each illness, therefore you need to have
. some theories basic to score in this type of question
Whereas in the second scenario, you do not need to know anything about
the management of the advanced cancer, you can even score a four
.without explaining anything about the management
In this case , you must always anticipate that Mr Lee would ask you why
he is having hepatoma (Liver cancer) since all the while his GP tells him
.that the tests are normal
:Common questions patient is going to ask you are
?Am I going to die, doctor-
?Are you sure about the result, doctor-
?I don't want to die, doctor, can you do anything to help me-
?I don't want to tell my family, can you keep this as a secret-
?Is there any other alternative treatment availableasimgabir@hotmail.com
This patient complains of double vision. Would -7

you like to examine her
Discussion
If you see bilateral ptosis in your MRCP PACES, then the examiners are
either going to give you a clear pass or a clear fail The reason is simple,
. you can either give a clear diagnosis or you do not have any ideas
There are only two possibilities in MRCP, either you are dealing with
.dystrophia myotonica or myasthenia gravis
You can make a diagnosis of dystrophia myotonica (DM) after you shake
the patient's hand. Patients with DM will have difficulty to release his/her
.hand grip
You can further demonstrate this by doing a percussion test. You can use
your tendon hammer to percuss at patient's thenar eminence , what you
notice will be flexion of the thumb and then slow extension of patient's
.thumb
The morale of the story is , in neurology station always SHAKE YOUR

. PATIENT'S HANDS BEFORE YOU PROCEED
The next thing is you need to do is general inspection. If patient has DM,
you will pick up by noticing that there is frontal baldness, expressionless
face ( wasting of temporalis, masseters and sternomastoids) and bilateral
.ptosis
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. 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
Extra points
Remember a few examples of drugs that can precipitate
.myasthenia crisis
Remember the mode of inheritance of DM- autosomal dominant- 2

and other associated symptoms and signs.such as cataract, diabetes,
and possible of heart block
Look at this patient and proceed -8
Discussion
very common short station case in UK. What you notice here is multiple
telangiectasia over patient's face as well as over his ear lobe. Other
common sites to look for this are tongue, palate, nasal mucosa, nail
.beds, arms and trunk
After this, you should look hard for features to suggest heart failure if
there is possibility of presence of shunt. Try to auscultate for bruit over
. the patient's lung and liver
Also check for anemia because patient tends to have PR bleeding.
Suggest to examiners you would examine fundoscopy to look for retinal
.haemorrahage and do PR to look for bleeding
Last but not least, ask for family history because it is inherited in an
autosomal dominant way
Conclusion
This gentleman has hereditary haemorrhagic
telangiectasia ( Rendu-Osler-Weber Disease(. He has
.history of recurrent PR bleeding
Extra points
Remember the simple management about this condition such as - 1
.oestrogen, cauterization etc
Remember in your management, one very important part is counseling - 2

.especially patient plans to have children in future
You are the SHO in charge of the medical clinic -9

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. 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 GPs letter
Discussion
This question came out a few years back in Singapore MRCP PACES
examination. I want to show you this question to remind you that in your
examination, no matter what the patient's symptoms are, if the patient is
young, always think of HIV
My friend who sat for the exam asked patient a lot of questions and
covered most of the possible diagnosis like thyrotoxicosis, inflammatory
bowel disease etc. However, patient refused to talk about his sexual
encounters when asked, a common scenario in PACES
Remember to convince the patient that it is important for you to take this
piece of information and you certainly share with him/her the feeling of
embarassment he/she may have
You must not be judgemental about patient's sexual orientation and inform
patients that you are there to help him/her. My friend failed this station
because he failed to find out that this patient is actually a homosexual and
was practicing unprotected sex with a lot of partners. The diagnosis was
HIV with PCP
!Look at this patient's skin and proceed-10
Discussion
It is a common case in MRCP station 5 of endocrine sub- station
There is presence of obvious purplish striae over his abdomen as well as his upper
thigh
Check for other obvious clinical signs such as buffalo hump, moon face, thin skin,
multiple bruises especially over venesection site, hirsutism and acne. Look for
.proximal myopathy and spine tenderness
Suggest to examiners that you would like to do the following, check the urine for
glycouria, check this patient's BP and ask relevant history to assess whether the
.patient is on long term steroid. Look at his abdomen to see any surgical scar
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
Common diseases that requires patients on long term steroid are as - 1

asthma, myasthenia gravis, nephrotic syndrome and other
.autoimmune diseases
Cushing's disease is always a common case in exam, remember - 2
that besides making the diagnosis of Cushing, you need to find out the
.underlying cause if possible and possible complications
You are the SHO in charge of the medical clinic -11

Dear Dr
Mrs Lydia David, a 70-year old retired teacher comes to
your clinic because of jerky movement of her right hand for the
past four months. She has previous history of Diabetes Mellitus
on oral medications under her GP follow up. After a careful
physical examination and complete investigations, your
consultant neurologist thinks that Mrs Davis is suffering from
Parkinson's disease. Mrs David is in the clinic waiting to see you
for the investigation results and the diagnosis. You are the SHO
in charge of the neurology clinic, your task is to explain to Mrs
.David about the diagnosis and answer her queries
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. I
call this type of question,Disease explanation question, other diseases that
are common in the exam include Alzheimer's disease, Motor neuron
. disease, Hepatitis B and C , polycystic kidney disease etc
Usually all these diseases are chronic or they have a lot of social
implications. In this case, since that Mrs Davis is suffering from Parkinson's
.disease, candidates are expected to do the following
to explain the illness in layman's terms-1
explain the prognosis and the likely progression of the illness -2
treatment for the disease- medical or any new treatment available such -3
as surgical intervention
ask social history especially the impact of the illness towards patient's -4
daily activities as well as patient's relationship with other family members
Extra points
The commonest mistake candidates make in this type of

question is trying to explain as much as possible about a
illness and not answering patient's queries about the illness
Try to give a lot of details about the illness and not bother
about the illness social implication.This gives an impression
.to the examiners that you are not holistic in your approach
This patient complains of double vision,-12

.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 you would like to do is of course to look at the
affected eye's pupil size. This will tell you whether you are
.dealing with a third nerve palsy or Horner's syndrome
If the pupil's size is small then you are dealing with Horner's or
else you are dealing with third nerve palsy especially you
notice that the eye is abducted
The subsequent relevant physical examination depends on your second

step finding, if it is Horner's syndrome, then you must find out the
underlying cause for this, the common sites to look for are patient's neck
( any cervical lymph nodes, mass?) , lung ( Pancost's tumour/ lung
cancer) or cervical spine ( syringomyelia- patient may have small muscle
.wasting of hands)
If you are dealing with third nerve palsy, look for other cranial nerves
involvement, if there is only isolated third nerve palsy, then you are most
. probably dealing with diabetes mellitus
Isolated third nerve palsy can be a medical or surgical third nerve, if there
is pupillary sparing ( the pupil is normal size), then you are dealing with
medical third nerve palsy ( such as due to DM, hypertension), if the pupil
size also involved, then it is a surgical third nerve palsy ( such as due to
.aneurysm compression)
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
Look at this patient and proceed-13
Discussion
It is sometimes rather difficult for you to differentiate panhypopituaitarism
.from hypothyroidism
However, if you look at patient's sexual characteristics, they are lost in
panhypopituitarism
Patients with hypothyroidism also tend to be older because the main
cause for panhypopituitarism is mainly due to Seehan's syndrome and
skull radiation which is commoner among younger patients
Always remember to look for cerebellar signs which is bilateral in .
hypothyroidism. Also look for other associated endocrine involvement
. such as DM, Addison's disease, Pernicious anemia and vitiligo
Suggest to examiners you would like to check for sensory deafness
especially to high tone. Try to find out the underlying cause for the
.hypothyroidism if possible
Conclusion
This lady has hypothyroidism secondary to previous total
.thyroidectomy
Extra points
Although it is rather uncommon in PACES, you can find this illness -1
rather common especially among older population. Always check their
thyroid status if an elderly patient presents to you with dementia
The commonest cause for hypothyroidism is previous total-2
thyroidectomy
Look at this patient and what do you think -14

?about her
Discussion
As discussed in previous issues, Cushing's syndrome is a popular
.question in MRCP PACES, this lady has a classical moon-like facies
You must look for other relevant clinical signs such as buffalo hump,
.hirsutism, suprclavicular fat pad
Look for purplish striae, proximal myopathy, spine tenderness and suggest
to examiners that you would like to check for BP, urine for glucose and
.visual field
it is rather uncommon for patient to have Cushing's disease and bitemporal
hemianopia because in Cushing's disease ,the tumour is usually a
.mircoadenoma
.If you look hard, this lady has multiple vasculitic rash over her hands
In MRCP examination, it is not enough for you to get the diagnosis of

Cushing's syndrome only. In view of the vasculitic rash over her hands,
you must look for other clues to suggest the possible underlying
.diagnosis for this lady that leads her to be on long-term steroid
The commonest cause for vasculitic rash is autoimmune disease and this
lady is actually having lupus nephritis and on long-term steroid. Suggest to
.examiners that you want to look for other signs of lupus
Common causes of Cushing's syndrome include
long term steroid ingestion (iatrogenic)
pituitary adenoma (Cushing's disease)
adrenal 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 etiology include plasma ACTH
level, high dose dexamethasone test, CXR, ultrasound/CT abdomen and
.sometimes inferior petrosal sinus sampling for ACTH level
.Kindly examine this gentleman's abdomen-15
Discussion
A common finding in a patient with transplanted kidney but always missed
. by candidates
This gentleman has a superficial right lumbar mass with a scar. The mass is
dull on percussion and there is an AVF over his right wrist. There is no
.ballotable kidney
.Actually this gentleman develops gum hypertrophy due to cyclosporin
A lot of candidates pick up the clinical signs of a transplanted kidney but
unfortunately majority of them do not examine further to look hard for side
effects of long term immunosuppressants such as signs of Cushings
syndrome ( due to prednisolone), fine tremor, gum hypertrophy,
hypertension (BP), diabetes (urine for sugar) and hypertrichosis (such as in
.this case) due to cyclosporin and jaundice ( side effect of Azathioprine )
A common question examiners would ask you is ways for you to assess
whether the transplanted kidney is functioning well or not, you can suggest
:the following
look at the patient's 24-hours urine volume, good volume suggests good
function
tell examiners whether the transplanted kidney is tender on palpation, if not
tender most probably it is functioning well,( although current
immunosuppresants make this unlikely to happen even patients have
rejection, this sign is a classical sign we were taught in medical school long
time ago!)
auscultate for renal bruit at the transplanted kidney, long term complication of
a transplanted kidney is artery stenosis
look for any recent punctum wound at the AVF, if no recent wound, this implies that
patient is not dependent on haemodialysis, therefore the transplanted kidney must
.be functioning well
Conclusion
This gentleman has a transplanted kidney and on cyclosporin,
predisolone and azathioprine and he develops gum hypertrophy,
.hypertension due to the drugs
:Extra points
Common side-effects and precautions for immunosuppresants are as

:follows
Cyclosporine- nephrotoxity, hypertension, tremor, gum hypertrophy,
hyperuricemia, hyperkalemia, weight gain, diabetes mellitus, acne,
hypomagnesaeimia. Grapefruit juice and Mediterranean oranges and Sun
Drop, a citrus soda, contain bergamottin which enhances the effect of
cyclosporine, increasing the level of the drug in circulation.St John's wort
reduces the concentration of cyclosporine rendering it less effective
Azathioprine- bone marrow suppression, cholestatic jaundice, GIT upset.

Azathioprine can cause irreversible bone marrow failure for those with a
particular polymorphism of the TPMT gene. GlaxoSmithKline has a
.predictive DNA test for this type of problem
.Prednisolone- Cushing's syndrome and its complications
.Mychophenolate-GIT upset, headache, bone marrow suppression
Other common causes of gum hypertrophy include acute myeloid leukemia,

scurvy, medications such as cyclosporine, calcium channel blocker
.especially nifidipine and phenytoin
This lady complains of lethargy, would you like to-16

?examine her abdominal system
Discussion
In MRCP exam, if you encounter a surgical scar, it is always a good start
because surgical scar can give you a lot of clues that lead to possible
.underlying diagnosis
This lady has a roof-top scar ( can be just a horizontal scar at left lumbar
region) and further examination reveals jaundice, moderate hepatomegaly
but no stigmata of chronic liver disease ( always look for stigmata of
chronic liver disease, due to her illness , she needs multiple transfusions
and tend to get Hepatitis B and C in long run and possibility of liver
.cirrhosis due to iron overload)
Look hard for any multiple small scars at the abdomen due to
subcutaneous infusion of iron-chelation therapy.The underlying
diagnosis for this lady with chronic haemolysis is Thalassemia with
.previous splenectomy
Although Thalassemia is rather uncommon in UK, it is common in Asia

especially if you are sitting your exam in Singapore, Hong Kong and
.Malaysia. Suggest to examiners you would
Examine for secondary sexual characteristics (any hypogonadism)
because there is possibility of delayed puberty due to iron overload
Check for patients height due to growth retardation secondary of iron
deposition at the pituitary 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 splenomegaly and tinge of jaundice without hepatomegaly in their
MRCP PACES, always remember one of the most important causes is
chronic haemolysis ( although book always tells you that you tend to get
hepatomegaly as well, but I notice Thalassemia intermedia patients tend to
.get splenomegaly ONLY)
Conclusion
This lady has Thalassemia Major and underwent a splenectomy due to
.recurrent, frequent transfusions
Extra points
,a)Splenectomy should be considered if

annual blood requirements exceed 1.5 times those of splenectomised
patients, provided they are on the same transfusion scheme and have no
.other reasons for increased consumption
Splenic enlargement is accompanied by symptoms such as left upper quadrant
. pain and early satiety
. Leucopenia or thrombocytopenia due to hypersplenism
b) Complications of splenectomy include peri-operative complications

such as bleeding,atalectasis and subphrnic abscess, long term
complications include thrombocytosis and overwhelming sepsis especially
to encapsulated organisms such as Streptococcus pneumonia,
.Haemophilus influenzae and Neiserria meningitides
c) Preventive measures a physician can utilize to prevent

postsplenectomy sepsis include immunoprophylaxis ( vaccination to
S.pneumonia, H.influenzae and N.meninngitidis), chemoprophylaxis
( oral penicillin) and patient education (explain about potential travelrelated infections)
.You are the SHO in charge of the medical unit -17

Dear Dr
Ref: Mr David Letterman, 56 years old
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 history of Diabetes Mellitus for the past 10 years currently on T
Daonil 5mg bd. He is worried about his symptoms but unfortunately I cant
.find anything wrong with him
Kindly see him and 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 GPs letter
Discussion
You must always think of possible differential diagnosis before you enter the
examination room. Mr Letterman complains of lethargy, a very vague
symptom. You must start off by asking him what does he mean by lethargy
Common causes of lethargy/tiredness can be due to anemia,
hypothyroidism, depression, myathenia gravis, obstructive sleep apnoea
You must ask him to explain his symptom. Some patients may associate
shortness of breath with lethargy. In whatever symptoms you are going to
encounter in MRCP PACES,always try to include these questions in your
history-taking if possible
any specific time the symptom becomes worse? If the patient is having
mysthenia gravis, he may tell you that he fells more tired especially during
evening
?any precipitating or relieving factors

?any other associated symptoms
In this case, you must ask certain questions which are specific for
hypothyroidism such as constipation, weight gain, cold 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 to suggest malignancy
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 complications such as IHD, retinopathy, peripheral neuropathy,
nephropathy ,TIA, stroke etc
Later, ask other relevant past history, such as in this case, ask the patient about his
OGDS and his symptoms
Last but not least, always assess patient's main concern, he may have some hidden
.agendas that he like to tell you
Actually, my friend had this case in his MRCP PACES in 2005, the
diagnosis was depression. My friend totally forgot to ask the patient about
his social 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
?Would you like to examine this lady's hands -18
Discussion
You may be panic when you first look at her hands. Always remember the
general rules for a good physical examination for locomotor system, i.e
inspect, feel, palpate, passive movement, functional assessment and
special steps! Always remember that NEVER SHAKE HAND WITH
.PATIENT in locomotor substation
but for neurology station, always do this first
You may cause pain to patient and examiners have 1 thousand and 1
reason to fail you! Always ask you patient whether he/she has any pain
over any specific joint, then I would ask them to rest their hands on a
. pillow
Second rule is proper exposure, preferably I would ask patient to expose
the whole upper limbs up to shoulder, the reason is simple, you do not
want to miss any skin rash ( especially psoriasis patch) , any skin nodule
(especially subcutaneous nodule over the elbow in rheumatoid arthritis )
.and any abnormal joint deformity
Describe any abnormality you can see such as joint deformity, muscles
wasting etc. Do a proper inspection! What I mean, look over patients
palm as well as the back of the hand. If you do so
Ops, the diagnosis becomes obvious after turning the patients hand
Another important inspection I would pay attention to is whether there is

presence of nail pitting. After general inspection, then feel the patients skin
gently to assessment whether there is presence of warmness that might
.suggest disease activity
Then palpate the patients joints by gentle passive movement and look for
any thickening of synovium or joint tenderness. Also try to feel for
calcinosis that might be present in scleroderma I would always tap at
patients flexor retinaculum to check for carpal tunnel syndrome
The last step is assessing patients functional status. Do at least these
three important steps, unbuttoning of clothes, pincer grip ( holding key)
and writing. If you suspect there is involvement of elbow and shoulder
joints, then ask patient to comb his/her hair. You can kill two birds with one
stone by asking patient to do so
You are going to assess patients elbow as well as shoulder joints. Then
the last step will be special steps depending on your findings. Such as in
this case, I would suggest to examiners that I would look for other joints
.involvement and other common sites for psoriasis

?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
Extra points
Five types of psoriatic athropathy namely
oligoarticular asymmetrical type (70%)
distal interphalangeal type
rheumatoid arthritis-like ( common in exam because want to confuse you!)
ankylosing spondylitis- like
and arthritis mutilans
There are five types of psoriasis. They are chronic plaque, inverse
.psoriasis, pustular, guttate and erythrodermic types
!Facts from Baliga's book
Examine this gentleman's cardiovascular system-19
Discussion
.Patients with scars again I want to show you this case for a simple reason
.There are only a few common causes of a sternotomy scar in CVS station
These causes include previous bypass surgery, valve replacement and
correction of congenital heart diseases such as VSD ( ventricular septal
defect) and ASD ( atrial septal defect )
At the first look, you might think that these patient has had a bypass surgery
.before due to the scar over his leg
The problem is he actually has a bypass and aortic valve replacement
.(AVR) surgery done before
Lesson to be learned here is always look for concomitant AVR if patient has
had a bypass before especially in elderly population because aortic stenosis
is common among this age group
During your examination, always look hard for any bruises to suggest overwarfarinization, signs to suggest endocarditis and murmurs to suggest valve
dysfunction

Complications of mechanical prosthetic valve
can be divided into complications due to the valve itself such as dysfunction
haemolysis, endocarditis
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 cant find any donor site and no mechanical click when you
examine the patient but you see a sternotomy scar, you might be
dealing with previous corrective surgery due to congenital heart or a
BIO-PROSTHETIC VALVE
Although patients with valve repairs tend to have left thoracotomy scar
( such as in mitral stenosis), I found out some patients may have
!sternotomy scar
.Look at this lady lower limbs-20
Discussion
It is an uncommon case in MRCP, however, it is worthwhile to learn
about this
If you look carefully at her lower limbs, you actually notice this lady has
a reticular pigmented rash
There are two common scenarios in PACES that give reticular
pigmented rash. These two conditions are erythema ab igne and livedo
reticularis
It can be quite difficult to differentiate these two conditions, however,.
erythema ab igne usually appear to be more dusky and besides over
the lower limbs, you can find it on the abdomen
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

?Can livedo reticularis be normal- 1
Yes, because it can be found in young females especially in cold
weather
?What other conditions are associated with livedo reticularis
Besides SLE, other conditions include polyarteritis nodosa, occult
.malignancy and microemboli of skin
Conclusion
This lady has livedo reticularis due to SLE
Extra points
Although it is not a popular question, livedo reticularis is often - 1
missed by candidates in SLE patients during their exam
If you are dealing with a SLE patient, skin conditions that are
associated with SLE are hyperpigmentation, discoid rash, malar rash,
.livedo reticularis, alopecia, purpura, telangiectasia and vasculitic rash
If you find erythema ab igne in patient's lower limbs, always look at- 2
!the abdomen as well
.Look at this gentleman skin-21
Discussion
This is a commoner question as compared to Q1 in MRCP exams
Yes, you are right, it is acanthosis nigricans! It is always described as
.'black, velvety overgrowth in the skin' by books
Always tell the examiners you would look at other sites for this especially
over the neck ( a very common site other than axilla, especially at the
back of the neck), umbilicus, nipples, groins and facial skin
:Also suggest to examiners that you would
check the urine for glycouria ( because patient may have insulin resistance )
check for occult malignancy especially adenocarcinoma of stomach
ask for menses irregularity if the patient is female because it is associated
with polycystic ovarian syndrome
?What conditions are associated with acanthosis nigricans ( 1
?How do you define metabolic syndrome( 2
Conclusion
.This gentleman has acanthosis nigricans and diabetes mellitus
Extra points
Remember criteria to diagnose metabolic syndrome either based on
.NCEP or WHO criteria
Remember 1 or 2 examples of cutaneous manifestations of viceral
malignancy such as dermatomyositis and Paget's disease of the nipple
Look at this lady and proceed-22
Discussion
A very popular question in MRCP PACES exams. This case can be
used as a case in skin as well as locomotor sub-stations
You notice that this lady has tight skin over her face with multiple
telangiectasia (arrows )
You can see clearly that her mouth appears to be tight.Demonstrate by
asking the patient to put 3 fingers into her mouth
Describe the nose and proceed to do the following
check for dry eye because Sjogren's syndrome can be associated with
.scleroderma
check the hands and look for sclerodactyly ( image next slide),
.Raynaud's phenomenon, peudoclubbing and calcinosis
!Also assess the extent of skin involvement
assess the patient's hands

functions by doing hand
grip, pincer grip (holding
key) and unbuttoning of
.clothes
ask patient relevant
history such as dysphagia,
shortness of breath (lung
fibrosis) and diarrhoe
(malabsorption )
ask permission from examiners that you would like to listen to her lungs,
check her BP ( ? hypertension), look for other organs involvement and look
.at her stool for evidence of malabsorption
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 tends to do worse, patients with extensive skin involvement
and renal involvement tend to do worse
?How to explain chronic diarrhoe in this type of patient
bacterial overgrowth
?What are the criteria to diagnose of scleroderma
?How would you manage a patient with scleroderma
Conclusion
This lady has systemic sclerosis
Extra points
.Prednisolone has no role in treating systemic sclerosis
.Four reasons for this type of patient to get anemia

iron deficiency due to chronic oesophagitis
anemia due to malabsorption
anemia of chronic illness
.and microangiopathic haemolytic anaemia

Examine this gentleman's leg-23
Discussion
It is an easy case if you know how to approach this case
You can see obviouly two small swellings over this gentleman's first toe
.and little toe
Although books describe chronic tophaceous gout as 'chalky 'material,
sometimes you would just notice a swelling such as in this case.After
you feel, palpate and move the relevant joints, you should look at other
.sites for similiar swelling
These sites include helices of the ears, olecranon bursae, tendons of
.hands and Achilles tendon
Another diagnosis that you may confuse with swelling over tendons is
tendon xanthomata
Also suggest to examiners that you would look at the urine for
haematuria and you are very interested to know about this patient's
.renal function

?What factors can precipitate acute gouthy arthritis
?When do you start to treat hyperuricemia
?How do you explain patients with gout to have bilateral leg swelling
Fluid overload due to CRF
Conclusion
.This gentleman has chronic tophaceous gout
Extra points
Clinical presentations of gout include asymptomatic hyperuricemia,
.acute arthritis, chronic arthritis and chronic tophaceous gout
.Uric acid crystals are negatively birefringent
This gentleman has abdominal discomfort. -24

Examine his abdominal system
Discussion
First lesson to be learned in abdominal examination is appropriate
.proper exposure
My friend failed this station because he insisted to expose his female
patient in his MRCP PACES exam down to thigh. I would expose the
.patient up to just above the genitalia
Obviously you notice this gentlemans abdomen to be grossly
.distended and there are multiple tattoos at his supra-pubic region
You also notice presence of jaundice, ascites (shifting dullness),
.clubbing and splenomegaly in this gentleman
You must always remember that beside making a diagnosis of chronic
liver disease, you should try to find out the underlying cause for his
.chronic liver disease
.some clues may help you

..If you find
parotid swelling
Dupuytrens contracture you may be dealing with alcoholism
skin hyperpigmentation- you may be dealing with
haemochromatosis or iron overload due to multiple transfusions in
Thalassemia patients (although you are unlikely to see this in UK,
you may be seeing this type of cases in developing countries)
tattoos or punctum wound to suggest intravenous drug abuse- you
.may be dealing with Hepatitis B
Common questions examiners will ask you
?What is Childs 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 Wilsons disease also can cause chronic liver
disease
You are the SHO in charge of the Infectious -25

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)
.You task is to explain to him about post exposure prophylaxis
.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
about the time of the event, size of needle he was using, the depth of
needle penetration and what was his action after the incident
assess the patients understanding about certain issue, in this case, Dr
Henrys understanding about HIV/AIDS
explain to Dr Henry the current problem/illness, in this case about
HIV/AIDS including the disease progression, modes of transmission
and possible treatment
assess Dr Henrys risk to get certain infections such as HIV, Hepatitis B

and Hepatitis C. Ask him whether he knows about his status and his
previous Hepatitis B vaccination
ask more about that HIV patients status -? on treatment,?CD4 count, any
.other medical problems such his ? Hepatitis B/ VDRL/ Hepatitis C status
tell him you are there to help him and you certainly understand his feeling
right now, (always remember that the strategy in exam is reassure
patient, reassure patient and keep on telling them you are there to help
everyway possible)
then inform Dr Henry briefly about PEP and maybe include some details
about the possible side effects. (Do not try to show off to examiners by
bombarding patient with very detailed information. This would make you to
score less point)
also inform Dr Henry about your plan for his follow up, do not forget to ask
.his permission for HIV 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 that they want to discuss with you
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
This gentleman has shortness of breath.-26

Examine his respiratory system
Discussion
You will be happy to see this case in your MRCP PACES. You can
get the diagnosis after your inspection
You notice that there are multiple distended veins over this
.gentlemans chest
You can proceed with the usual physical examination of the
respiratory system by bearing in mind that you may find the following
:abnormalities
Pancoasts tumour- you may find reduced breath sound over upper
.lobe of the lung with dullness on percussion
.Pleural effusion at one side of the chest
Or any physical sign suggesting presence of mass such as dullness
.on percussion with reduced breath sound
:After your complete physical examination, do the following steps

.Demonstrate the direction of the venous flow
.Look for exophthalmos, conjunctival injection
Look at the JVP( non-pulsatile) and show to examiners how you
.measure it
.Examine the cervical region for lymph nodes
Look for small muscles wasting of the hand and Horners syndrome if
.you are suspecting Pancoastt tumour
Suggest to examiners you would like to demonstrate Pembertons
.sign if possible
.Ask the patient about smoking history
.Talk to patient to assess hoarseness of voice
?What is Permbertons 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 possible, non small cell lung cancer should be treated with surgical
intervention. For small cell lung cancer, it should be treated with
.chemotherapy
Indications for radiotherapy include SVC obstruction, local obstruction
.such as airway, spinal cord compression and brain metastasis
..Examine this lady upper limbs neurologically-27
Discussion
In MRCP PACES, after lower limbs examination and Parkinsons
.disease, upper limbs examination is the third most popular question
You notice that there are obvious small muscles wasting with loss of
.thenar and hypothenar eminences
Before you proceed further, you should know that there are only a few
.possible causes for this
The causes are Motor Neuron Disease, Cervical Spondylosis,
Syringomyelia ,Charcot- Marie- Tooth and Guillain Barre Syndrome ( or
.CIDP-chronic inflammatory demyelinating polyneuropathy )
It is unlikely for you to get bilateral Ulnar nerve palsy in exam.
Therefore, during your examination, pay attention to assess whether
there is sensory involvement or presence of fasciculation ( which may
.suggest Motor Neuron disease )
After you upper limbs examination, suggest to examiners that you

would do a proper examination of lower limbs. Pay attention to the
:following
presence of pes cavus and 'inverted champagne bottles lower limbs.
.This suggest Charcot -Marie- Tooth
Dissociated sensory loss of lower limbs with upper motor signs. This
.suggests syringomyelia
Upper motor signs of lower limbs with possibility of sensory level. This
.suggests cervical spondylosis
Flaccid paralysis of lower limbs with no sensory involvement. This
.may suggest Guillain Barre syndrome
After the examination, suggest to examiners that you would look for
Horners syndrome if you suspect syringomyelia
?What is the CSF finding in GB syndrome
What are the three recognized forms of hereditary motor

?sensory neuropathy
Conclusion
This lady has CIDP
(.due to the chronicity, she has muscles wasting(
Extra points
In MRCP PACES, you are unlikely to get a case of isolated ulnar ,
radial or median nerve palsy
There are three main clinical patterns of MND, they are progressive
muscular atrophy ( obvious small muscles wasting of hand) , Bulbar
.palsy and amyotrophic lateral sclerosis
Would you like to examine this gentleman-28

?cranial nerves
Discussion
This is a classical case in MRCP PACES station 3. A lot of candidates
.always feel very worried when faced with cranial nerves examination
.You notice that this gentleman has obvious loss of right naso-labial fold
A lot of candidates always ask me the same question, should I examine
from the first cranial nerve till the 12th cranial nerve or examine the
?nerves according to scenario
I think that it is important for you to divide cranial nerves to 4 main sub:groups, these groups are
Eye group- you will be testing cranial nerves II, III, IV and VI. You will -1
be assessing these cranial nerves by checking eye reflexes, fundoscopy,
.visual acuity, visual field and eye movement
Facial expression, sensation and movement- you will be testing cranial -2
nerves V and VII. You must check for upper and lower portion of facial
.expression, corneal reflex ,masseter and pterygoid movement
Articulation and gag reflex- You will be testing cranial nerves IX,X -3
and XII. Check these nerves by assessing palatal movement, gag
.reflex and tongue movement
Other groups- assess VIII nerve by checking hearing, XI nerves by-4
asking patient to lift the shoulders and the first nerve by assessing
.smell
In this case, since you notice this patient has problem mainly due to
facial expression and movement, I would examine his V and VII nerves
.first
You know that he has 7th nerve palsy, the next question you want to
.ask is whether it is a lower or upper motor 7th nerve palsy
You can differentiate this by observing 2 major upper portion facial
.muscles namely orbicularis oculi and frontalis muscles
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
.7th nerve palsy.You can then complete other cranial nerves examination
After your examination, you want to find the possible aetiology for his 7th
:nerve palsy by doing the following steps
look at external auditory canal for herpes zoster-1

palpate for parotid swelling-2
check for hyperacusis-3
examine the taste involvement ( anterior 2/3 )-4
test urine for glycouria-5

?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 palsy should be treated with combination of steroid and acyclovir
.Examine this patient's respiratory system-29
Discussion
In MRCP PACES, if you find clubbing in respiratory station, you are
dealing with only a few possibilities, the most popular question will be
.bronchiectasis
Other causes of clubbing because of respiratory system are Lung
Cancer, suppurative lung disease ( such as empyema, therefore you
would find signs suggesting pleural effusion, however, it is unlikely in
.MRCP because patients tend to be very ill!) and fibrosing alveolitis
A lot of candidates find it difficult to differentiate lung fibrosis from
.bronchiectasis. I think there are a few important points to take note
Patients with bronchiectasis tend to be more ill because they are
.admitted to hospital because of lung infection
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
After the examination, suggest to examiners that you would 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 you find patient with bronchiectasis also has dextrocardia, the
diagnosis is Kartagener's syndrome
This gentleman has difficulty in walking.-30

.Examine his lower limbs neurologically
Discussion
An uncommon case in your daily practice but it is suprisingly a popular
question in MRCP. Many candidates were asked to examine this case
.in their PACES before
I have friends who sat thier MRCP in Malaysia ( especially at University
Malaya Medical Centre), Singapore ( at National University Hospital)
.and Hong Kong were asked about this case in their Neurology Station
Obviously if you observe properly, you notice there is hypertrophy of
both calf muscles
Yes, you are dealing with PSEUDOHYPERTROPHY of calf muscle
:further examination reviews that

.This gentleman has waddling gait
.His proximal muscles are weaker than his distal muscles
His ankle and knee reflexes may be normal and there is no sensory
.involvement
:After your complete neurological examination, do the following steps
.Demonstrate Gower's sign
Suggest to examiners that you would examine the upper limbs and look
hard of upper limbs involvement as well. Look for pseudohypertrophy of
.deltoid muscle also
Demonstrate winging of scapula by asking patient to straighten his
.elbow and push against resistance
Suggest to examiners you would ask about family history of similar
.problem
.Look for any surgical scar to suggest recent muscle biopsy

Why do you say that it is pseudohypertrophy and not true hypertrophy
?of calf muscle in this condition
?How do you differentiate Duchenne from Becker muscular dystrophy
?What is the inheritance pattern in this condition
?How do you investigate and manage this condition
Remember GENETIC 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 of calf or deltoid muscles, it is usually due to
.Hereditary Muscular Dystrophy
Other common cases of proximal myopathy in MRCP PACES are either
.polymyositis or dermatomyositis
Examine this gentleman lower limbs neurologically -31
Discussion
Another popular neurology case in MRCP PACES, there are a few
.possibilities you are dealing with Pes Cavus in MRCP
You may be asked to talk to a patient who has a Cerebellar ( staccato
and scanning speech) speech and find out that he/she has pes cavus
.with Friedreich's ataxia
Or there is another scenario where you are asked to examine a
patient's upper limbs and you find that he/she has small muscles
wasting of both hands and 'inverted champagne bottles' lower limbs
with pes cavus
.Yes , you are dealing with Charcot-Marie-Tooth Disease
The two commonest causes for Pes Cavus in MRCP are Friedreich's
.ataxia and Charcot-Marie-Tooth Disease
Your further steps of examination depend on your finding, if you
suspect Friedreich's ataxia after your lower limbs examination,
:suggest to examiners that you would like to
ask about family history
.check fundoscopy to look for optic atrophy
.examine relevant cerebellar signs
look for kyphoscoliosis
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
Remember that other causes of Pes Cavus are poliomyelitis and
.muscular dystrophy
.Look at this lady's lower limbs and proceed-32
Discussion
This is a very popular skin station in MRCP exam. A lot of candidates find it
difficult to describe skin lesion. I think there are a few important points you
.must give to examiners when you try to describe any skin lesion
Your description must include the general appearance of the lesion (either
.it is a macule, papule, blister or bullous)
site of the lesion ( is the lesion only localised to certain areas such as
extensor surface, umbilicus, scalp, palm etc?)
any mucosal involvement ( do you notice any mucosal involvement such
as over oral cavity, eye?) , is the skin lesion itchy or tender and any
associated changes that you think is relevant ( any hand/nail or other
changes such as pitting of nail, rheumatoid hands,thyroid swelling which
might be relevant!) I find that it is rather important for candidates to have a
.general inspection before zooming to the skin lesion
Sometimes, when you are asked to examine a skin lesion over the leg,
look at patient's eye and thyroid swelling which might tell you the
.diagnosis ( pretibial myxoedema)
Common skin problems over lower limbs which are popular in MRCP
exam are pretibial myxoedema, erythema nodusom, erythema
.multiforme,pyoderma gangrenosum and psoriasis
In this picture, you notice macular-papular rash over patient's lower
limbs but there is no mucosal involvement, you do not not notice any
:bullous eruption. You should proceed to do the following
?feel the lesion to assess whether it is tender
look at patient's mucosal ( oral cavity to look for ulcer ) and
check for conjunctivitis.( mucosal involvement)
check for lymph nodes especially cervical region ( glandular
. fever?) and ask for drug history
?What is Steven Johnson syndrome) 1

What is the difference between Steven Johnson syndrome) 2
?and toxic epidermal necrolysis
If a patient had joint pain over ankle 3 weeks ago and was ) 3
prescribed a medication by GP,what is the possible medication
?involved
?How do you manage this condition) 4
Conclusion
.This lady has macular-papular rash due to drug allergy
Extra points
Always remember that you are not expected to diagnose all) 1

skin conditions, you would pass if you give a good and
.comprehensive description about the skin lesion
.Examine this gentleman's skin-33
Discussion
I give you this example because I think this is a popular case in
MRCP. This case can be either come out in station 1 or station 5 (skin
. station)
If you notice xanthelasma in a middle-aged woman with jaundice in
your MRCP, always think of Primary Biliary Cirrhosis. You may find
stigmata of chronic liver disease in this type of patient with +/- of
.hepatosplenomegaly
As I mentioned in my previous posts, you can gather some clues from
peripheral to get the underlying cause of a patient's chronic liver
. disease, xanthelasma is one of them
Having said that, xanthelasma can be asked in station 5 as well.
Besides xanthelasma, other stigmata of high cholesterol level include
tendon xanthomata, eruptive xanthomata,palmar xanthomata and
.corneal arcus
Classification of hyperlipidemia is based on Fredrickson which

can be divided to Type I to Type V. After your examination,
:proceed to the following
look for other stigmata of 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
family history of premature death due to coronary
.heart diseas and hyperlipidemia
?How do you manage hyperlipidemia) 1

What are classes of drugs available to) 2
?manage high cholesterol
Conclusion
This gentleman has xanthelasma with underlying Diabetes
.Mellitus
Extra points
Learn a few important clinical trials involving statin such as 4S,) 1
.MIRACL which are commonly asked in MRCP
.Remember the common side effects of statin) 2
.Examine this lady's respiratory system-34
Discussion
A very popular MRCP question in respiratory station. When you find
a lateral thoracotomy scar in respiratory station, always think of three
:possibilities
namely lobectomy, pneumonectomy and previous lung
.transplantation surgery
A lot of candidates remember the first two possibilities but always miss
the third. The reason is simple, doctors working in many countries such
as in Malaysia and Singapore do not deal with post lung transplant
patients so often as thier counterparts in developed country such as
. the United Kingdom and Ireland
Therefore, if you are planning to sit your MRCP PACES in United
.Kingdom, learn well about transplantation
When you see a lateral thoracotomy scar, spend a few seconds to

have a thorough look at your patient, if you notice physical signs
suggesting Cushing's syndrome, then you are most probably dealing
. with a patient after lung transplantation
Always pay attention to look for side effects of cyclosporin as well
.such as gum hypertrophy and excessive hair growth
If you do not notice these, then you are most probably dealing with
lobectomy or pneumonectomy, some candidates find it difficult to
distinguish these two conditions, I think there are a few important
.points to take note
First point, in lobectomy, you may find reduced breath sound in
certain areas such as upper/middle/lower region but in
pneumonectomy, there is reduced breath sound over the whole
.affected lung
Second point, there may be no sign to suggest mediastinal shift in
lobectomy ( central trachea) but in penumonectomy, you are expected
to find signs suggesting mediastinal shift ( based on your tracheal
.position or apex beat)
Third point, percussion would review dullness generally for
. pneumonectomy but not in lobectomy
?What are the indications for pneumonectomy or lobectomy) 1

What are the common indications for lung transplant in United) 2
?Kingdom
? What are the common side effects of cyclosporin) 3
What are the contraindications for surgical intervention in lung) 4
?cancer
Conclusion
This lady has lateral thoracotomy scar due to previous lobectomy
.because of lung cancer
Extra points
Always take your time to observe for any surgical scar in your ) 1
respiratory station. You may be able to diagnose the condition before
!even touching the patient
Lobectomy or even pneumonectomy was done previously for ) 2

!treatment of tuberculosis
. Examine this lady's cardiovascular system-35
Discussion
A rather uncommon case in your daily practice but it is popular in
MRCP cardiovascular station. You notice this lady has long fingers
. (arachnodactyly)
Patient's hand is at the left and mine is over the right. You would be
happy if you get this case,yes, finally you are seeing a case of Marfan
.syndrome in your exam
Demonstrate to examiners and convince them that the patient's fingers
are long by demonstrating thumb sign ( ask patient to clench her
thumb in her fist, the thumb should not exceed the ulnar side of the
hand in normal subjects) and wrist sign ( put patient's fingers around
, her wrist, you would notice her thumb and little finger overlap)
look for other signs to suggest Marfan syndrome such as high arched
palate ( in this patient), small papules in the neck, up-ward dislocation
.of the lens, kyphoscoliosis, and chest wall deformity
For the heart, you would

anticipate you are most
probably to find either
aortic regurgitation or
mitral regurgitation.
Remember to suggest to
examiners that you
would like to ask about
. the family history
? What are the diagnostic criteria for Marfan syndrome) 1
What are the differentiating features between Marfan syndrome) 2

? and Homocyctinuria
? What is inheritance pattern for Marfan syndrome) 3
Conclusion
.This lady has Marfan syndrome and mitral regurgitation
Extra points
When asked about the management of an illness, always) 1
remember that patient education is very important if the illness is
.chronic and incurable. Remember genetic counselling if it is inherited
Cardiovascular complications are the major cause of death in ) 2
!Marfan syndrome
.Examine this gentleman's abdomen-36
Discussion
As I mentioned in my previous posts. You should score in your
abdominal station. This is because there are only very limited
.possibilities in abdominal station
You notice this gentleman has gynaecomastia as evidenced by
presence of breast tissue.Look for other stigmata of chronic liver
:disease such as
Clubbing-Dupuytren's contracture-palmar erythema-spider naeviflapping tremor-leukoonychia-scratch mark-jaundice-pallorpigmentation-cyanosis-xanthomata-purpura-koilonychia-paronychiaoedema-muscle wastimg-tattoos-needle marks....( you would be
surprised to find that there are so many physical signs in chronic liver
.disease!)
Although there are a lot of causes for gynaecomastia, if you find this in
.your abdominal station, always think of chronic liver disease
Remember that common drugs that are associated with gynaecomastia are
ketoconazole, spirolactone, H2 antagonist such as cimetidine and
psychoactive drugs.If you look at the periphery, you would find the
,following
Yes, you would notice that
this gentleman also has
leukonychia. Anticipate to
find hepatosplenomegaly in
this gentleman.
Demonstarte to examiners
that you know how to check
for ascites by showing
shifting dullness.
Showmanship is important
in MRCP clinical exam.
Always examine your
patient systematically and
. confidently
?How would you investigate this patient) 1

?What are the common trigerring factors for hepatic encephalopathy) 2
?How do you diagnose spontaneous bacterial peritonitis) 3
?What is your long term plan for liver cirrhosis patients ) 4
Conclusion
.This patient has chronic liver cirrhosis due to alcoholism
Extra points
Currently there are a few drugs available for Hepatitis B treatment ) 1

.besides intereferon. Learn about Lamivudine, adefovir and entecavir
Learn more about CAGE questions when you want to get further alcohol) 2
history from a patient! ( Study back your medical school book to learn more!)
Examine this lady's hands-37
Discussion
This is the continuation discussion from the previous issue. As I
mentiond in previous article, Marfan Syndrome is a popular cardiology
.case in MRCP. However, this case can come out in Station 5 as well
You notice that this lady fingers are long. I would like to show the thumb
and wrist signs as I mentioned in previous issue. Always remember that
for you to diagnose Marfan syndrome, you need to know about the
. major criteria
Major criteria for Marfan syndrome include Ectopia Lentis ( upward
dislocation of the len), dilatation of aortic root or aortic dissection and
lumbarsacral dural ectasia ( you only can diagnose this by MRI or CT
. scan)
If patient has family history , you need two systems involvement ( either
skeletal system, ocular, cardiovascular or other system ) to diagnose
Marfan syndrome. If patient does not has family history,then you need
!two systems involvement plus one major criteria
? How do you manage this condition) 1

) Remember about genetic counselling and patient's education (
?What are common cardiovascular lesions in Marfan syndrome ) 2
Conclusion
This lady has Marfan syndrome
Extra points
!Remember the complications of Marfan syndrome
.Inspect this gentleman and proceed-38
Discussion
A very, very popular skin station in MRCP exam if you are taking the exam
in Malaysia or Singapore. You notice that this gentleman has multiple
. angiofibroma (adenoma sebaceum) over his face ( malar distribution)
The diagnosis is clear at this moment and you must show to examiners
.that you know a lot about Tuberous sclerosis
Look for other features of Tuberous sclerosis such as subungual/ periungual
fibromas ( next image -a common mistake for majority of candidates is they
usually look hard at patient's hand and forget that these can be present over
.patient's toes as well), Ash-leaf patches ( hypopigmeted) and Shagreen patches
always suggest to examiners you would like to expose patient properly to

look for these skin lesions but if time is limited, at least spend some time
!. to look at patient's back
After you complete your physical examination, tell examiners that you
would be interested to look at the fundus and you are expecting to find
retinal hamatormas and check the abdomen to look for ballotable kidney
.(due to renal hamartoma)
After these steps, you should suggest to examiners that you would get a
complete family history of similar problem and take history from patient
.about epilepsy
You would be
interested to test the
patient's IQ.One
common mistake
candidates make in
exam is they tend to
forget to look for signs
suggesting side
effects of anti-epilespy
.medications
Look hard for signs suggesting pheytoin side effects such as cerebellar
signs, gum hypertrophy and hirsutism. Also look for side effects of other
! anti-epileptic
?What can you usually find in this patient's CT brain) 1
?How do you manage this patient) 2
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, discovered in 1997, is on chromosome 9
and produces a protein called hamartin. The TSC2 gene, discovered
.in 1993, is on chromosome 16 and produces the protein tuberin
You are the SHO in charge of the medical unit -39

Mr Smith, an ex-IVDU was admitted to your hospital
1 week ago due to shortness of breath. CXR
revealed bi-hilar haziness and your consultant
thought that he was suffering from pneumocystis
carinii pneumonia. He responded to your treatment
and you are asked by your consultant to ask
.permission from him for HIV testing
You have 14min until the patient leaves the room, followed by 1min
.for reflection before the discussion with the 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 diagnosis (PCP) and then switch the topic of discussion form PCP
. to HIV testing
I always tell my junior doctors that before going into deep discussion
with the patient, always assess the patient's understanding about his
.problem
Therefore, after introducing yourself and a few simple questions like"
How do you feel today?" I would start off by asking" Mr Smith, I learned
that you were admitted to our hospital about one week ago, did anyone
tell you what's wrong with you?" You may be surprised to find out how
. little patient knows about his condition
Then you can briefly talk about Pneumocystis Carinii Pneumonia
and tell patient that he feels better because of the treatment. After this,
a lot of candidates find it difficult to talk about HIV and how to switch
.the topic of discussion from PCP to HIV
I find a solution to this problem, I would suggest to you that you may
want to try to explain to patient that it is rather rare for you to find young
adults to get PCP infection and mention that there are a few conditions
.that can prone him to get this infection
Mention HIV as one of them and proceed to assess patient's
understanding about HIV. After this, explain to patient about HIV,
relevant information to be included are what HIV is, mode of
transmission, possible long term complications and treatment. Do not
. forget to get futher sexual history and social history from patient
After this, assess patient's risk about HIV infection and ask him
whether he has any question to ask you about HIV. Explain to patient
that your consultant and you think that it is necessary for him to have
. HIV testing
Explain to him how the test is performed and how to interpret positive
and negative results. Mention about possibilities of false negative and
. positive results as well
. Remember to explain the difference of HIV and AIDS

Convince the patient about the benefit of early detection and
.reassure him that the test result is confidential
If you have time , you should discuss with patient about the
.implication of the test result regarding to future insurance purchase
Before you end your interview with patient, tell him that your hospital
has a special trained nurse to give him further counselling if he has
.further question to discuss
Arrange next appointment date if he is undecided about the test.
remember that if patient is not agreeable with you about something,
! always ask him the reason behind this
? What is 'window period ' for HIV) 1
If the patient is married and turns out to be postive for the HIV test, ) 2
?would you tell his wife if he refuses to tell his wife about the result
.Inspect this lady and proceed-40
Discussion
A popular skin station in MRCP exam. All candidates would pick up the
physical signs and come to a diagnosis after inspection
however, examiners would only pass you if you know how to examine
.systematically a patient with vitiligo
Vitiligo is a chronic skin disease that causes loss of pigment,
. resulting in irregular pale patches of skin
Vitiligo is always described as " hypopigmented patches with white
". hairs in vitiliginous area
Areas commonly involved include perioral, periorbital, axilla , upper and
.lower limbs
After your initial inspection, try to look at the patient's scalp for white
.hair and alopecia ( vitiligo is associated with alopecia areata)
Then, proceed to look for jaundice ( autoimmune hepatitis), pallor
.(pernicious anaemia) and thyroid swelling
Remember that you must suggest to examiners that you would like to
check for postural drop of blood pressure which may suggest
.Addision's disease and check urine for Diabetes Mellitus
Look for other autoimmune diseases as well such as Rheumatoid
.arthritis, SLE etc
However, always remember that patients with leprosy or Pityriasis
versicolor may have hypopigmented skin but the hypopigmented skin
. tend to be more localized
You would find reduced sensation at the hypopigmented skin if you
.suspect leprosy
.There are various available treatment for vitiligo
Topical steroid may be useful at initial stage.Other topical
immunomodulators may be useful such as calcipotriene and
.tacrolimus
Combinations of therapy often give better results than single
modalities. These include calcipotriol with PUVA (Psoralen ultraviolet
.A therapy ) and tacrolimus with laser
? What are the associated conditions in vitiligo) 1
?How do you manage this patient) 2
Conclusion
.This lady has vitiligo
Extra points
About 20-25% of patients has other cutaneous and systemic

.diseases associated with vitiligo
Examine this lady's hand.( MRCP Station 5(-41
Discussion
I show your this case again because I would like to warn you that you
.may only find subtle sign in gout during you MRCP PACES exam
My friend was asked to examine a patient's hand in his MRCP PACES
in Singapore, actually , he couldn't find any positive signs and he was
.so panic until he found a small tophi over the patient's ear lobe
Such as in this patient, you only notice a small swelling over her left
index finger. However, the diagnosis of gout would be clear if you take
.a few seconds to look at her face before touching the patient
Now, the diagnosis is clear, you are dealing with gout. The lesson to be
learned here is, when you are asked to examine a patient's hand in
. MRCP PACES, look at the patient's lower limb and the face as well
You might save a lot of time struggling to get the diagnosis if you spend
a few more seconds to inspect the patient properly. I would like to
remind you that in Station 5, you would get the diagnosis most of the
.time after inspecting the patient ( except in fundoscopy, of course!)
? How do you diagnose gout) 1
What may be the mechanism of a patient with gout to have renal) 2

? impairment
)obstructive uropathy and NSAID abuse(
Conclusion
. This lady has chronic tophaceous gout
. Station 4: You are the SHO in charge of ICU-42

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. Your consultant
has reviewed him. He and another consultant have performed a few
tests and confirmed that he is brain death. Currently, Mr Lee is being
ventilated in ICU. You are asked to talk to his mother Madam Liu about
.the brain death and discuss with her the possibility of organ donation
You have 14min until the patient leaves the room, followed by
.1min for reflection before the discussion with the examiners
Discussion
This type of question is always popular in MRCP PACES station 4.
There are two tasks here, the first one- you are expected to break the
. bad news about brain death to Madam Liu about her son
The second task, you are supposed to discuss about organ donation
. with Madam Liu
A lot of candidates told me that they actually have problems to explain
brain death to patients family members, therefore they couldnt even
.start talking about organ donation
I think it is a common dilemma in examination, you fail to convince
patients mother that the patient is dead, how can you possibly proceed
.to tell her about organ donation
The principles are simple, always do the following steps in your exam
(especially in breaking bad news!)
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 3 days ago, did anyone inform you 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
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,
.unfortunately, your sons condition is not improving
Always pause in between important sentences so that your subject
.can give you some feedbacks
d( Go to your task
After seeing your subjects respond to your explanation above, you
. then can break the bad news
Always remember to give your subject to breath and avoid
bombarding him/her with a lot of technical details. Try to avoid
!medical jargon in exam
.You will be expecting that Madam Liu could not accept that her son is dead
You certainly should empathize with your subject and NEVER rush or push
. her to accept your explanation
Here comes the dilemma, the subject could not accept her son is dead,
? how do I talk about organ donation
You actually can explore some social history about Mr Lee. Actually, my
friend failed this case in his MRCP PACES because he did not explore
about the patients social history and found out that Mr Lee is the only child
. in the family
After that, just tell Madam Liu that from the social history you gather from
her , her son is a very helpful young man, you explain to her that even
. though Mr Lee is no more here, he is still able to help other needy people
Madam Liu may ask you the way to do this , then you can start the topic by
? saying Have you heard of organ donation before
So....., you see , the mission is accomplished! The rest of the topic such as
!What is organ donation? etc would be a simple job for you all
. Examine this lady's hand neurologically-43
Discussion
I think that this type of case is still a possiblilty in your MRCP PACES,
although you are often see this case in Orthopedics ward rather than
. Medical ward
You notice this patient has right claw hand.Yes, you are right ,she has
! ulnar nerve palsy
Remember that ulnar nerve supplies all small muscles of the hand
except LOAF ( the Lateral two lumbricals, Opponens pollicis, Abductor
. pollicis brevis and Flexor pollicis brevis)
As a medical student before,you might still remember the function of
lumbricals is to flex the metacarpophalageal joints and extend
. interphalageal joints of fingers except thumb
Therefore you see this this lady has claw hand involving only ring and
little fingers. (because the lateral two lumbricals are supplied by median
nerve)
In you exam, you must always try to find the underlying cause for this, if
. you look hard , you notice that there is a scar over the patients wrist
She actually sustained
industrial injury before
and there is injury of her
ulnar nerve over her
. wrist
As you might remember,
ulnar nerve enters the
palm anterior to the
flexor retinaculum
alongside the lateral
border of the pisiform
bone and divides into
superficial branch ( innervating the palmar aspect of the medial side of
the little finger and the adjacent sides of the little and ring fingers) and the
.deep branch.( which supplies the small muscles of the hand)
If you ask the

patient to grasp
a piece of
paper between
the thumb and
lateral aspect of
the forefinger
with each hand
as below, you
would be able
to demonstrate
Froments
. sign
You notice that the affected thumb will flex ( Flexor pollicis brevis)
.because of loss of the adductor of the thumb
?What is ulnar nerve paradox) 1
All small muscles of hand are supplied by ulnar nerve except what) 2
?muscles
Conclusion
This lady has right ulnar nerve palsy due to previous trauma
Extra points
Besides the cutanous branch of superficial branch of the ulnar nerve, it

.also gives branch to supply palmaris brevis ( muscular branch)
.Inspect this lady and proceed-44
Discussion
This case is always very popular in MRCP station 5. A lot of candidates
.can pick up the diagnosis but are unable to perform well in this case
. It is a gift if you are asked about acromegaly in MRCP PACES
:I always like to do the following if I suspect acromegaly in exam
Spend a few seconds in general inspection
Start off by examining the patients hand, you notice that she has spade
. like ,sweaty hand, the skin is thickened and doughy
Check for carpal tunnel syndrome
Look at the face- check for prognathism ( causing malocclusion of jaw),
prominent supra-orbital ridges, wide spaced interdental space, big
.tongue
Offer to look for skin tag ( molluscum fibrosum) at axilla
Look at lower limbs for pitting oedema to suggest high cardiac output
failure
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
Check urine for glycouria/ haematuria due to possible concomitant
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
? What are the indicators for disease activity in acromegaly
?How do you manage investigate this lady
Conclusion
.This lady has acromegaly due to pituitary macroadenoma
Extra points
Indicators for disease activity are uncontrolled symptoms such as
headache, sweating, presence of skin tags, uncontrolled Diabetes,
. hypertension and progressive visual impairment
After your presentation, always tell the examiners what you think about
.the disease activity
Most important test to diagnose acromegaly is non-suppressibility of
. growth hormone level after an oral glucose tolerance test
.You are the SHO in charge of Neurology Ward-45

Subject: Miss Sylvia, 24-year 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. 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 her understanding about the illness
I know that you were admitted to our ward due to fit one day ago, did
?anyone tell you about your problem
Explain the diagnosis based on patients understanding for the illness
You need to know about patients understanding about an illness before
you exaplain about the illness. Some patients might know a lot about
their own illness, therefore, you can go straight to more advanced
.discussion with patients
:Generally, when you talk about an illness, try to cover the following
General information about an illness. Such as Epilepsy is due to
some abnormal brain activity that causes you to have abnormal and
.uncontrolled body movement
Possible complications about an illness if left untreated
Possible treatment- Remember that besides medications, always talk
about non-pharmacological management. Such as in this patient,
besides anti-epileptic medications, tell patient that she must learn to
protect herself by avoiding involvement of high-risk recreational activity
.such as swimming
Always assess her social support because someone needs to know
.how to take care of an epileptic patient when there is a seizure
Other important issues pertaining to the illness- such as in this patient,
the patient might want to know whether she would pass this illness to
. next generation
If you encounter a female patient in your exam, always think of

the possible impact of the disease and its treatment towards
. pregnancy and lactation
Besides these issues, in this case, another issue crops up for you
. to discuss with the patient is the issue of driving
Actually, a candidate failed this station in his MRCP PACES a few
:years back because he did not find out the following
The patient refused to eat the medications because she was ) 1
pregnant at that time and she was worried about the side effects
.of the medications to her baby
The candidate did not find out what was the social support for) 2
this lady. Actually, her husband was working outstation and there
.was no way for her to go to work except driving her own car
The patient was very worried about passing the disease) 3
(epilepsy) to her baby and actually wanted to ask the candidate
about abortion. However, my friend just ignored her because this
. task was not mentioned in the paper
Inspect this-46
gentleman and
proceed
:Discussion
OK, this is a common case in MRCP PACES station 5 if you are sitting
the exam in Malaysia and Singapore. I think it is easy for you to detect
.the abnormality in this gentleman because the clinical signs are obvious
You notice this gentleman has severe spine abnormalities. Yes, you are
right, he has Question mark posture. This is due to fixed
kyphoscoliosis of the thoracic spine with compensatory extension of the
.cervical spine
This case is easy but you must remember to look for these spine
abnormalities especially if you are seeing a patient who is lying in bed
during your MRCP PACES exam because the kyphoscoliosis may not be
.obvious and can be masked by a pillow behind the patients back
Patients with Ankylosing Spondylitis usually present with back pain
.and this gentleman has chronic back pain since the age of 20 years old
:Proceed to do the following after a general inspection

ask the patient to walk away from you and turn back and walk towards
.you. Pay attention to patients posture
ask patient to look to either side. You will notice patient may have limited
cervical spine movement. The patient may need to move his whole body
.when he wants to look to either side
check his thoracic and lumbar spine movement , usually, I would ask patient 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 Schobers test. In
following picture, when I ask the patient to rest his back against the wall,
you notice that this gentleman has difficulty to make contact his head
. against the wall
for Schobers test, mark two points, one 10 cm above and one 5 cm
below a line joining the dimple of Venus on the sacral promontory. An
increase in the separation of less than 5 cm when the patient does a
. forward flexion signifies limited spine movement
after these tests, check peripheral joints especially hands and also look
for possibility of psoriasis ( because one variant of psoriatic arthropathy
may look like Ankylosing spondylitis)
suggest to examiners you will like to look for 4As- Anterior uveitis, Apical
.fibrosis, Aortic regurgitation and Achilles tendinitis
?What are the diagnostic criteria to diagnose Ankylosing Spondylitis
How do you manage this gentleman?( Remember that genetic

counseling is important and remember to talk about HLA-B27!)
:Conclusion
This gentleman has Ankylosing Spondylitis with limited spine
.movement
:Extra points
Diagnostic criteria of Ankylosing Spondylitis is based on New York
Criteria (1966)
Limitation of motion of the lumbar spine in all 3 planes: anterior flexion,
.lateral flexion and extension
History of the presence of pain at the dorsolumbar junction or in the
.lumbar spine
Limitation of chest expansion to 1 inch (2.5 cm) or less, measured at the
level of the fourth intercostal space
I find the following algorithm interesting and helpful
. You are the SHO in charge of Medical Clinic-47

Subject: Mr Lee, 54-year old
Kindly see Mr Lee who has recently been complaining of chest pain for
the past 2 months. He has previous history of Myocardial Infarct about
5 years ago and bypass was done 4 years ago. I am worried whether
the pain is cardiac in origin. He has history of hypertension and
diabetes mellitus for the past 10 years and currently under my follow
up. I also notice his blood pressure is not controlled and his last fasting
blood sugar and HbA1C were 9.0 and 7.2%.I would appreciate if you
. can help me to manage this patient
You have 14 min until the patient leaves the room followed by 1min for
reflection before the discussion with the examiners
Discussion
A popular question in MRCP PACES station 2. A patient presents with
chest pain. Remember that besides cardiac pain , you must also
consider other types of pain which may mimic chest pain, diagnoses to
consider include ischaemic heart disease ( either stable, unstable
angina or myocardial infarct(, pulmonary embolism, pericarditis,
reflux oesophagitis, musculoskeletal pain, penumonia ( pleuritic
.chest pain)... etc
When you want to take further history of pain, always remember to take
:the following details
nature of the pain, whether it is similar to his previous pain before
bypass surgery
duration of the pain (each episode)
any radiation
precipitating and relieving factors
other associated symptoms
However, it is not enough you just get the diagnosis in this patient, you also
notice besides diagnosis problem in this case, you are seeing management
problems as well, Mr Lee's hypertension and diabetes mellitus are not
.properly managed
You must ask relevant questions so that his medical problems can be
:properly managed such as
compliance to treatment
other risk factors for ischaemic heart disease such as high cholesterol,
smoking and family history his normal diet and exercise
Never assume anything before entering the examination room, always bear
in mind all the possible differential diagnoses and ask relevant questions to
come to a provisional diagnosis
Also avoid spending all your time in getting your provisional diagnosis
because there may be other important issues to deal such as social
problems, impact of the disease towards patient's daily life, drug history..ect
Summarize your history before you present to the examiners and outline
your plan of management. Issue that concerns the patient and his GP most
is whether the pain is cardiac in origin, you should be able to answer this
! question at the end of your interview
.Examine this gentleman's abdomen-48
Discussion
I have discussed about
this case in my previous
issue. This case is always
a popular case MRCP
PACES station 1. You
notice that there are two
vertical surgical scars
over this gentleman's
flanks. If you have a
general inspection before
you touching this
gentleman's abdomen,
you would have an idea
.what you are dealing with
Yes, you are seeing a patient with kidney transplantation. You are
expecting to find the following physical signs during your physical
examination
two vague masses in the flanks(he underwent two kidney
transplantations before)
the masses (transplanted kidneys)are dull on percussion ( superficial
and not retro-peritoneal as in normal kidneys)
the masses are not tender on palpation and there is no bruits heard
(always check for possibilities of renal artery stenosis in a post
. transplanted kidney)
Cushingnoid features as evidenced by moon face, truncal obesity and
bruises. ( such as photo)
signs to suggest side effects of cyclosporin such as hypertrichosis and
.gingival hypertrophy
However, you should try to find the following after you find that he has
previous kidney transplantation
the possible cause of his end stage renal disease, therefore you must
look hard for polycystic kidney and suggest to examiners that you
would like to look at his fundus for diabetic retinopathy as well as
hypertensive changes ( remember that cyclosporin also causes
hypertension)
whether the transplanted kidney is functioning well (therefore suggest
to examiners that you would like to look at this patient's urine output
and check for any haematuria)
look beyond for other possible complications of medications
(immunosuppressants patient is currently on) such as cataract,
osteoporosis ( spine tenderness), proximal myopathy ( secondary to
long term steroid) etc
What are common problems patients face after kidney

transplantation? ( Remember to divide that into acute and chronic
complications.)
What are the possible causes if patient develops chronic kidney
disease after kidney transplantataion. ( Remember that common
causes include de novo glomerular disease, cyclosporin toxicity, renal
.artery stenosis and graft rejection)
What are the causes of kidney failure where patients might have
normal size kidneys when they have end stage renal failure?
( Classical examples are polycystic kideney disease, diabetes
nephropathy and amyloidosis!)
Conclusion
This gentleman has two previous kidney transplantations and
. currently not dialysis dependent
:Extra points
Common side effects of Calcineurin Inhibitor ( such as cyclosporin
:and tacrolimus) are
Nephrotoxicity
Gastrointestinal such as hepatic dysfunction (include raised liver
.enzymes,jaundice and gall stone), anorexia, nausea and vomitting
.Cosmetic-hypertrichosis ( excessive hair growth),gingival hyperplasia
Hyperlipidemia, glucose intolerance ( more in tacrolimus)
Neurotoxicity- coarse tremor,headache, insomnia,dysesthesias
Infection and malignancy
Hyperuricemia and gout
. You are the SHO in charge of Nephrology Ward-49

Subject: Mr Lee, 52-year old
Kindly see Mr Lee who has recently been diagnosed to have end
stage renal disease with a creatinine level of 1000. He has
background history of diabetes mellitus for the past 15 years
which is poorly controlled. He was admitted to your ward 4 days
due to ureamic symptoms and urgent haemodialysis was done for
him. Currently he is well and waiting to see you to discuss about
further plan.You are asked by your consultant to discuss about
long term renal replacement therapy with him. His latest FBS in
the ward was 12 mmol and HbA1C=10%. His Blood Pressure was
. 150/90 during the morning round
You have 14 min until the patient leaves the room followed by 1
. min for reflection before the discussion with the examiners
Discussion
A popular question in MRCP PACES station 4. You are expected to
discuss long term renal replacement therapy with Mr Lee. Before you
proceed, you must remember that there are three possible ways
available namely Haemodialysis, CAPD ( Continuous Ambulatory
.Peritoneal Dialysis) and Kidney Transplantation
However, before you start your formal discussion with Mr Lee,
remember to do the following
?"ask about his current condition ," How do you feel today
. the reason he was admitted four days ago
how much does he know about his condition " What do you know about
?"your condition? Did anyone inform you
how much does he know about kidney failure and the reasons behind
. urgent haemodialysis was done for him
general knowledge about kidney functions and possible ways renal
. replacement therapy can be done
During you MRCP PACES examination, you must know the basic
knowledge a patient know about his condition before you try to explain
.his illness
In this scenario, briefly talk about how haemodialysis and CAPD is
being done. Try to explain to Mr Lee as well about the pros and cons
about each technique available and their limitations ( such as in CAPD,
patients may need to have adequate visual acuity to handle himself the
. CAPD)
You must explore the option of kidney transplantation as well to Mr
Lee and warn him about the problems he might face in future with all the
immunosuppressants.However, remember to talk about a few other
:related issues with Mr Lee as well such as
his diabetic control and tell him about importance of sugar control
.towards progression of kidney disease
talk about his diest and warn him about diet modification due to his
.kideny function. You might want to refer him to see a dietician
his Blood Presssure control
Remember that counseling is always not an easy station in MRCP

PACES, look beyond your problems and discuss according to your
. scenario
Such as in this case, you certainly would be very interested to know

about Mr Lee's social history, financial support ( such as insurance
coverage) and impact of the disease towards Mr Lee's daily life
.(discuss about depression as well if possible)
Summarize your discussion with Mr Lee and present to the
examiners, your examiners will like to know what problems you
encounter during your counseling with Mr Lee ( such as poor social
or financial support, etc....)
Examine this gentleman's fundus-50
Discussion
This is one of three commonest cases you would get in your MRCP
PACES fundoscopy sub-station. Candidates should not have problems
. picking up the physical signs
However, remember that you should have a systematic way of doing
:fundoscopic examination, I suggest you to do the following steps
have a general inspection of your patient, pay attention to any
surgical scar over patient's scalp ( which may suggest previous head
surgery), diabetic dermatopathy or previous amputation, walking stick
( ? blindness) etc which might give you a clue of the patient's
.underlying disease
give clear and loud explanation, tell your patient to look straight and
avoid moving his/her eye balls. However, remind your patient that
he/she CAN blink his/her eyes. Remember to tell your patient that
.your fundoscopy light may make him/her feel uncomfortable
you should not remove your spectacles while examining the fundus.
!This certainly needs practice
look at the eye from a distance and check for red reflex ( Candidates
are likely to fail you if you miss obvious cataract or retinal
detachment!)
look at patient's right and left eye using your right and left as well, if you
only know how to use your right eye to do a fundoscopic examination,
!you are going to kiss your patient when examining his/her left eye
look at the fundus properly, start from centre to periphery or otherwise
(look at patient's optic disc, macula and peripheral retina. Pay
,attention to the vessels as well)
ask you patient to look directly to your fundoscopy to check for macula
pathology again during your last step of examination( because the
patient's pupil will constrict after this),repeat these steps while
.examining the other eye
last but not least, thank your patient and suggest to examiners what
other relevant bed side tests you want to do such as checking urine for
. mircoalbuminuria, blood pressure, visual field, visual acuity etc
OK, you notice this patient has irregular balck deposits of clumped
pigment in the peripheral retina. ( Always described as bone spicules
because of their vague resemblance to the spicules of cancellous
. bone)
Remember that the pigment spots lie anterior to the retinal veins ( as
compared to spots of choroidal atrophy in which they lie posterior to the
. vessels)
You also notice the optic disc to be pale.You should proceed to do the
:following
suggest to examiners you would like to take a family history, Retinitis
Pigmentosa can occur sporadically or in an autosomal recessive,
.dominant, or X-linked pattern
check patient's visual field and ask about night blindness

(nyctalopia) ( patients tend to have constricted visual field with a ring
scotoma and loss of acuity)
check for signs to suggest associated systemic disorders such as
cerebellar signs ( Olivopontocerebellar degeneration, Friedreich's
ataxia), polydactyly (Laurence-Moon-Biedl Syndrome), external
ophthalmoplegia ( Kearns-Sayre Syndrome).I think it is enough to
remember three examples, you are unlikely to remember everything in
! exam

?What are the possible problems faced by this patient in term of vision
?How do you manage this patient
Conclusion
This gentleman has retinitis pigmentosa with night blindness and
.constricted visual field
Extra points
Most cases of Retinitis Pigmentosa are due to a mutation in the gene
for rhodopsin, the rod photopigment or in the gene for peripherin, a
. glycoprotein located in photoreceptor outer segments
. You are the SHO in charge of Respiratory clinic-51

, Dear Dr
Subject: Mr Abdul Rashid, 40-year old
Kindly see Mr Rashid who is a Malaysian migrated to UK about 20
years ago. He has had a 6-week history of cough . He has
background history of diabetes mellitus for 10 years on oral
medications.His last fasting glucose was 11 mmol.I have done a
CXR but I couldn't find any abnormality. I am worried about
tuberculosis. I would appreciate if you can offer your expert
.opinion
,Best Regards
Dr Henry Young
You have 14 min until the patient leaves the room followed by 1
. min for reflection before the discussion with the examiners
Discussion
A popular question in MRCP PACES station 2. There are a few
diagnoses you must consider in this case
asthma
chronic obstructive airway
disease ( COPD)
oesophageal
reflux/gastritis
postnasal drip
tuberculosis
lung cancer
. sarcoidosis and drugs
As I said in my previous issues, when

you try to get history form your patient
about a symptom- remember to ask the
onset, duration, severity, precipitating or
relieving factors and associated
symptoms ( in this case, you certainly
are very interested to know about
haemoptysis, fever and Pulmonary
. Tuberculosis contact)
Get all the relevant history to cover all you differential diagnoses. For
this case, you must get history as well for Mr Rashid's diabetic
.control
I like to stress again about the importance of getting a proper drug

. history
Actually, this gentleman was recently diagnosed to have
.hypertension by another GP and he was started on ACE-inhibitor
Remember that at the end of your history taking, you must be able
to answer one important question " Is Mr Rashid having
tuberculosis?" because his GP and most probably Mr Rashid
!himself is very concerned and worried about this
Outline your plan of action and briefly use 2-3 mins to tell Mr Rashid
what is your next plan of action ( either admit him or investigate as
. out patient)
Inform Mr Rashid what kinds of investigation you want to do and
!what is your provisional diagnosis
. Observe this gentleman's gait and proceed-52
:Discussion
you are expected to know how to examine a patient's gait in your MRCP
PACES examination. However, there are only a few popular cases in
.MRCP PACES gait examination
You notice this gentleman has a waddling gait. This gait is seen when
the patient's legs are held wide apart and the patient shifts weight from
. one side to the other as he walks
Of course, you may see this gait in a pregnant woman, however, you
should anticipate patient to have proximal myopathy if you see this gait
in your MRCP PACES examination because you are unlikely to get a
!case of straight forward pregnancy in your exam
,Causes of proximal weakness include
Hereditary muscular dystrophy ( the most popular case you would see if
you notice waddling gait in your MRCP PACES)
Congenital myopathies ( very rare- you are unlikely to get this unless
you are if you are sitting for MRCPCH)

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Examine this gentleman's cranial nerves -1

,He has fasciculations of the tongue

Another important differential is Syringomyelia because it can involve

Common questions examiners would ask you

This gentleman has bulbar palsy due to

Look at this diabetic lady skin-2

Common questions examiners would ask you

?What is your differential diagnosis)2

.Examine the patient's neck-3

Look at this patient and proceed-4

Suggest to examiners that you would do a complete physical examination to

Remember in drug-induced SLE patients, their anti-histon -1

Examine the patient's hands-5

:Common questions they will ask in exams are

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You are the SHO in charge of Infectious Disease Clinic -6

:Common questions patient is going to ask you are

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?Are you sure about the result, doctor-

?I don't want to die, doctor, can you do anything to help me-

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?Is there any other alternative treatment availableasimgabir@hotmail.com

This patient complains of double vision. Would -7

The morale of the story is , in neurology station always SHAKE YOUR

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Look at this patient and proceed -8

Remember in your management, one very important part is counseling - 2

You are the SHO in charge of the medical clinic -9

!Look at this patient's skin and proceed-10

Common diseases that requires patients on long term steroid are as - 1

You are the SHO in charge of the medical clinic -11

The commonest mistake candidates make in this type of

This patient complains of double vision,-12

The subsequent relevant physical examination depends on your second

Common question examiners will ask you is the reason

Look at this patient and proceed-13

Look at this patient and what do you think -14

In MRCP examination, it is not enough for you to get the diagnosis of

.Kindly examine this gentleman's abdomen-15

Common side-effects and precautions for immunosuppresants are as

Azathioprine- bone marrow suppression, cholestatic jaundice, GIT upset.

Other common causes of gum hypertrophy include acute myeloid leukemia,

This lady complains of lethargy, would you like to-16

Although Thalassemia is rather uncommon in UK, it is common in Asia

,a)Splenectomy should be considered if

b) Complications of splenectomy include peri-operative complications

c) Preventive measures a physician can utilize to prevent

.You are the SHO in charge of the medical unit -17

?any precipitating or relieving factors

About his diabetes, you must always ask the following

?Would you like to examine this lady's hands -18

Another important inspection I would pay attention to is whether there is

Common questions examiners would ask you

?Where are the common sites to find psoriatic patches

How would you manage psoriatic arthropathy

Examine this gentleman's cardiovascular system-19

Common questions examiners would ask you

.Look at this lady lower limbs-20

It is uncommon to find erythema ab igne in tropical countries, therefore,

Common questions examiners would ask you