Monday, June 30, 2008
Top 3 favourite MRCP PACES question besides Diabetic retinopathy and Optic atrophy !
There is widespread scattering black pigments resembling bony corpuscles. The macula is spared. There is tunnel vision. My diagnosis is Retinitis Pigmentosa.
Check the polydactyly, look out for obesity, bilateral ptosis, ichtiosis and also a ICD. Also check for cerebellar signs and hearing.
Laurence-Moon-Biedel-Bardet syndrome (polydactyly, obesity)
Refsum's Disease (cerebellar ataxia, deafness, peripheral neuropathy, cardiomyopathy, ichtiosis)
Kearn's Sayre syndrome (opthalmoplegia, bilateral ptosis, heart block)
Hereditary ataxia (eg Friedreich's ataxia)
You should score if you get this case in MRCP exam !
Sunday, June 29, 2008
This is a 40 years old Indian lady who was admitted with complains of abdominal swelling for the past 6 months. She also has loss of appetite. Clinically she has hepatosplenomegaly with a spleen of 10 cm below the L costal margin and a liver of 5 cm below the R costal margin at R midclavicular line.
A peripheral blood film done shown as above.
Question 1 :
What does the PBF show ?
What further investigations would you do ?
What are the other causes of massive splenomegaly ?
What is the definitive way to find the diagnosis ?
What is the treatment ?
Thursday, June 26, 2008
The peripheral blood film is as above.
Question 1 :
What does the peripheral blood film show ?
Question 2 :
What are the causes of these type of PBF ?
Question 3 :
What is the most likely cause for the above patient ?
Question 4 :
What investigations would you do to confirm your diagnosis ?
Question 5 :
How would you manage this patient ?
Wednesday, June 25, 2008
This is a 80 years old Chinese gentleman with L pleural effusion.
Medical students will often be asked regarding the causes of pleural effusion.
You can divide it into unilateral and bilateral.
What are the common causes of unilateral pleural effusion ?
What is Light's criteria ?
What are the clinical signs of an effusion ?
What are the important investigations you would perform to ascertain the underlying aetiology ?
Tuesday, June 24, 2008
Monday, June 23, 2008
Look at this patient’s face and examine him.
This patient’s brother has similar problems, please examine his upper limbs.
This patient has drooping of the eyelids, examine him.
If you see ptosis, always shake the patient’s hands. You will get the answer if it is myotonic dystrophy. If you did not shake the patient’s hand, you may have failed the station already.
This patient has wasting of the temporalis with bilateral ptosis
Go on to examine for myotonia by percussing the thenar eminence
Look at the pupils for cataract
Ask the patient to grip and open the hands (he may open each finger at a time)
Look for evidence of AICD (Automated implantable cardioverter defribillator) insertion (if cardiomyopathy)
Ask to look for testicular atrophy
During CN examination, we have effectively ruled out Horner and CN III palsy(by looking at the pupil size). So, it is likely partial ptosis due to neuromuscular weakness. At this point, there should be at least 6 differential diagnosis in our mind:
- Myasthenia Gravis/ LEMS (No wasting of temporalis)
- Gullain Barre Syndrome (Miller-Fisher)
- Dystrophic Myotonia
- Fasciomusculoscapular dystrophy
- Oculopharyngeal Muscular Dystrophy
- CPEO (Kearn’s Sayre syndrome)
Therefore, at the end of CN examination, we need to do something extra to get the most likely diagnosis. Do as follow:
- Check for fatiguability (eye lids, upper limbs, nasal speech)
- Check for thymectomy scar (may be hidden by patient's dress, and it would be fatal for missing the scar)
- Check for diplopia on extreme gaze
- Check for opthalmoplegia
- Check for myotonia, by percussing the thenar muscle, and ask patient to grip hands
- Check lower limb reflex for areflexia in GBS
- Check for winged scapula
During presentation, we need to mention about the possibility of medical emergency, in this situation, we should mention:
- "I would like to complete my examination by requesting a bed side spirometry to assess for respiratory mucle weakness" -for suspected Myasthenia/LEMS/GBS
- "I would like to examine upper and lower limb for ascending weakness and aflexia" -for GBS
Sunday, June 22, 2008
Thursday, June 19, 2008
(1) Please see this 80 year old lady who has had 3 falls. Apart from feeling a little more tired than normal over the last few months she has been unwell. I could find no injuries and her examination was normal except for a pulse of 42 beats per minute.
Please take a history.
(2) (Ma’s exam )
72 y.o man
Presented to casualty with recurrent LOC
Last LOC 1/52 ago, fell down, knocked head, developed haematoma @ R temporal region
This admission, admitted to casualty for another episode of LOC
K/C Psychiatric disorder on olanzapine
Pls take full history
Hyponatraemia 2 to Olanzapine
Need TRO Subdural haematoma (treatable)
- How often
- When ( turning head, shavingtight collars)
- Preceeing symptoms (light headed, nausea, sweaty)
- What time of the day ?
- What were you doing at that time ?
- How long ?
- Injure himself
- Social (Driving)
- Arrhythmia eg SVT, fast AF (palpitation, SOB, ? regular/irregular)
- HOCM (dizziness, chest pain, SOB, orthopnoea, PND, oedema, strong FHx)
- Aortic stenosis (chest pain, SOB)
- Seizure (stiffness, jerky movements, tongue bitting, blue, incontinence, postictal drowsiness, aura, FHx epilepsy)
- Carotid sinus hypersensitivity
- TIA ( weakness, numbness, dysphagia, speech)
- Hypoglycaemia (tremor, sweating, DM)
- Drugs/Alcohol – sedatives, hypnotics
- Vasovagal/Postural hypotension
- Cough/micturation syncopal
What is meant by falls/blackout
Is it seizure – witness account
Onset, duration, how it occurred, frequency
Ass symptoms – chest pain, palpitation, SOB, pedal oedema, orthopnoea, missed beats
- incontinence of urine/feces
- pale during attack with cold, clammy periphery
- aura – visual,sens, auditory, smell, motor
- fever, photophobia, neck stiffness
- focal neurological signs, visual sx, giddiness, speech disturbances, headache, nausea
- happens when coughing
- happens with shaving/turning head too fast
- happens with standing from lying position
- happens with standing for long periods
- happens with getting up to micturate
- symptoms of hypothyroidism
- symptoms of hypoglycaemia
Aggravating fact - getting up to micturate from lying position
- standing long period
- turning head too fast
- flicking lights, stress, lack of sleep, fever
- missing meals
Relieving factors – lying down, sitting down to rest
What have the doctors treated you for ?
Medications ? Side effects ? Useful ?
Progress of disease
Functional status now
Past Med Hx :
HPT, DM, IHD, Valvular heart disease
Diuretics – electrolyte imbalance
P. Surg Hx :
Brain surgery before
Family History :
Sudden myocardial death
Social Hx :
Substance use – alcohol – how much, frequency, withdrawal, dependence, ever tried to stop, get into trouble with law, CAGE
How the condition affects him/her
This was my exam case in Singapore PACES
Please examine this patient's respiratory system.
Position the patient
The patient is tachypnoeic with a respiratory rate of 30/min. Inspection, there is a R sided mass over the breast with peau d'orange appearance. There is also evidence of Tinea corporis under the breasts. There is no clubbing or evidence of CO2 retention. She is pink with no jaundice or cyanosis.
Trachea central (I mistook this which made me fail). There is reduced chest expansion over the R lower zone with reduced vocal fremitus and vocal resonance with stony dullness and also reduced breath sounds. There is an area of bronchial breathing above the dullness.
In conclusion, this lady has R sided pleural effusion most like due to metastatic breast ca. There is also evidence of Tinea corporis which could be due to underlying immunosuppression.
Not many questions can be asked in this station as the examination of the front and back of the patient takes time.
The common causes of unilateral pleural effusion include
1) Malignancy (primary or secondary)
2) TB infection
3) Parapneumonic effusion
It is more likely to get unilateral effusion as compared to bilateral effusion and always look hard for the underlying cause.
CXR - to confirm the diagnosis
Pleural tapping and pleural biopsy
Sputum AFB D/S and C&S
Wednesday, June 18, 2008
Transplanted kidney is the main focus of a short case in 9% of attempts at PACES station 1. It is also a short case for medical students. It is not difficult to diagnose this condition. Just remember, iliac fossa scar with a mass equivalent to transplanted kidney until proven otherwise! However, the story does not end here for MRCPian. As a MRCPian, you need to search for the causes, complications and the functional capacity of the patient (4Cs rule).
* Most of the cases shown are polycystic kidney disease
* Other causes include DM (check for dermopathy and diabetic ulcers), GN and etc
a. Side effects of medications
** Azathioprine - myelosuppression with bruises, pallor, jaundice
** Cyclosporin - hand tremor, hypertrichosis, gum hyperplasia, high BP
** Prednisolone - Cushing's syndrome, pallor secondary to UGIB
b. Hepatitis B/C with CLD signs
3. Functional capacity
* Signs of graft rejection - tender transplanted kidney
* Signs of infections - they have 1001 reasons to get infections
* Uremic/hepatic encephalopathy - unlikely to appear in PACES!
I would complete my examination on this gentleman by checking his blood pressure, looking at his temperature chart and dipstick the urine to look for evidence of haematuria and proteinuria. I would also like to do a per rectal examination to exclude malaena as a possible cause for his pallor.
This gentleman is lying comfortable on one pillow. He is on supplemental O2 administered via nasal prong running at 2L/min. He has a sallow complexion. There is no peripheral stigmata of chronic liver disease. He has no flapping tremour. He has hirsutism as evidenced by coarse hairs over both of his arms as well as on the face. He looks pale however there is no jaundice. There is gum hypertrophy.
On inspection of the abdomen, there is a transverse surgical scar noted at the right lumbar region extending to the infraumbilical region which is well healed. The umbilicus is centrally located and inverted. Palpation of the abdomen has revealed a mass situated at the right iliac fossa which measures around 5x8cm in size, is firm in consistency, non-tender and it produces a dull note upon percussion. There is no other mass felt in the abdomen. There is no ascites and the bowel sounds are normal. There is no signs of fluid overload.
Therefore, I would like to draw conclusion that this gentleman has a right transplanted kidney complicated by signs suggestive of cyclosporin side effects, currently no signs of fluid overload and not in uraemic encephalopathy. The possible etiologies for his renal failure I would like to offer include diabetic nephropathy, hypertensive nephropathy and other primary glomerulonephritis.
Saturday, June 14, 2008
This 20 year old young man was referred from our paediatric colleagues for further follow up and management. Please examine his abdominal system.
(When turning to the examiner)
I would like to complete my examination by examining his genitalia, doing a per rectum examination.
(If asked to present your findings)
This thin young man is pale, jaundiced, hyperpigmented and short for his age. He has frontal bossing, prominent maxillaries and chipmunk facies with maloccluded teeth. There is also sparse axillary and pubic hair
The abdomen is distended and there is a left lower quadrant scar. There is hepatomegaly, extending 4 finger breadths beneath the costal margin. The liver has smooth edges and non tender on palpation. The kidneys are not ballotable. There is no shifting dullness to suggest the presence of ascites.
I did not find any lymph nodes in him. There were no features to suggest chronic liver failure. He does not have any abdominal puncture wounds to suggest the use of desferral
In summary, this is short young man with jaundice, pallor, hepatomegaly, a previous splenectomy done and has thalaessaemic facies and possible underlying hypogonadism and haematochromatosis. He has chronic hemolytic aneamia. He is transfusion dependent.
I would like to offer the differential of a haemoglobinopathy. The most common haemoglobinopathy in this part of the world is Thalaessaemia.
1.What investigations would you like to do?
I would like to confirm the underlying cause of hemolytic anemia by doing serum electrophoresis. I would like assess the complications of treatment and patient’s disease by doing LFT, coagulation profile, hormonal assay, hepatitis serology and echocardiogram, also T2* MRI to assess the heart status from iron overload. I will assess his functional status using FBC.
2.How would you like to manage this young man?
a. Treatment of Disease- hypertransfusion, Splenectomy, Pneumococal vaccination, bone marrow transplant in some centres
b. Treatment of its complications-hormone replacement therapy, iron chelation therapy, control heart failure
c. Patient and family education, genetic counseling is also important so that family members can be screened and treated early.
Scars in Thalassemia may be due to previous cholecystectomy or splenectomy. Laparascopic scars may give you a small scars (Look for it carefully!!)
Tuesday, June 10, 2008
- Medicine is learnt by the bedside, not in the classroom, and certainly not AT HOME!
- One must know what's normal before being able to appreciate the abnormal (hence, make sure to examine enough normal individuals before examining real patients!)
- History-taking is a sensitive but non-specific clinical tool.
- Physical examination, on the other hand, is a specific and non-sensitive clinical tool. Both will complement each other and hence their much deserved emphasis in your early years of clinical training:)
- And lastly, if you are not sure of a sign, it is NOT THERE. Avoiding words like 'maybe', 'a little bit', 'slightly', 'could be' etc is much appreciated!
What are the abnormalities and diagnosis ?
Friday, June 6, 2008
In most parts of the world, the clinical examination is an important examination for medical students once they have reached the clinical years. There are many who fear this but there are also many who excel in this. In summary, whether you like it or not, it is of importance as this is what you would be doing for the rest of your life.
The clinical examination is divided into Long cases, short cases and OSCE.
Long cases - you will be given a patient for about an hour and will be asked to take the history, do a full physical examination and come out with the provisional and differential diagnosis. Thereafter the examiner will come to ask you questions on the patient that you have clerked.
Short cases - you will be given a patient and asked to examine a particular system eg. Cardiovascular, Respiratory, Upper limb nerurologically, Abdomen etc. You are not allowed to take any history and you will be given about 10 minuted including discussion with the examiner.
OSCE - You will be given stations whereby a stimulus eg picture, x-ray etc are displayed and will be asked on paper several questions regarding the stimulus.
Thursday, June 5, 2008
Please examine this patient's abdomen
start with peripheral then the abdomen
Remember to position the patient supine (1 pillow) and go to the end of the bed to inspect the patient
- Palmar erythema
- Dupuytren's contracture
Check for flapping tremor
- Parotid swelling
- Spider naevi
- Loss of axillary hair
- Pedal edema
Ask for PR if anaemia, ask for examining the testicular atrophy
Besides the signs mentioned, try to look for the underlying cause for the liver cirrhosis - eg. tattoos (Hep B,C), parotid swelling/Dupuytren's contracture(alcohol), xanthalesma/excoriation marks esp middle aged ladies(Primary Biliary Cirrhosis), Hyperpigmentation (Haemachromatosis), KF ring/Chorea movements(Wilson's Disease), if paucity of liver cirrhosis signs(Hep C)
Level 1 - Hepatomegaly or splenomegaly or hepatosplenomegaly
Level 2 - Chronic liver disease/Liver cirrhosis
Level 3 - Pulmonary hypertension (splenomegaly, ascites)
Level 4 - Hepatic encephalopathy ( flapping tremor/constructional apraxia) - Complication
Level 5 - Hep B/Hep C/alcohol....as above - Cause
Causes of enlarged liver in chronic liver disease
- Alcoholic liver disease
- Primary biliary cirrhosis
- Malignant transformation
Blood tests(FBC, BUSE/cr, LFT, Coag)
Tests for underlying cause (Hep BsAg, Anti HCV, GGT, serum ceruloplasmin, urine copper, AMA, ANA, Anti Sm, iron studies)
U/S Abdomen or CT scan abdomen
Singapore Experience (The New Beginning)
UK Experience (The Dark Side)
Malaysia Experience (The Return of the Jedi)
Is PACES a torturing exam ?
It was no difficulty for me to get through the Part 1 and Part 2 written exam of MRCP. However, PACES can be a nightmare. Let me share my experience here with those who are planning to sit for the MRCP or the PACES.
I took PACES in 3 different regions – Singapore, Edinburgh and Malaysia and finally passed in October 2007. Many people helped me through this exam and I would also like to thank them on the way of my writing.
I started preparing for PACES since 2005 and it has been a long way. The people who helped me at that time was my colleague Dr. David, who is also one of the authors of this book. He used to take me for short cases everyday whenever there is an interesting case. His motto was practice, practice and practice. Besides that, Dr. Haniffah who is a consultant Neurologist used to take us for Neuro cases every week. We formed a group of 4 and also started practicing on our own. However, I was rather immature at that time when I sat for the Singapore exam.
Singapore Experience (The New Beginning)
As cost was an issue for me, I booked a hotel which was average in Singapore but found myself having difficulty in sleeping the whole night, probably due to anxious state. The next morning just 2 hours before the exam, I found out that I have forgotten to bring my tie to Singapore. It caused me more panic as it was not easy to find a tie at 7.30 to 8.00 am as the malls in Singapore were still closed. I had to run all over Orchard Road to find a tie. Fortunately, I arrived at Meritus Mandarin Hotel where there was a souvenir shop who was selling a tie. I bought it and quickly took a taxi to Alexendra Hospital where I took the exam.
The exam was slightly delayed and we had to wait in the waiting room with symptoms of thyrotoxcicosis. Just before going in for the exam, I saw a clear cut Neurofibromatosis patient whom I thought was one of the patients for exam. However, I saw him taking the taxi away.
I started off with Station 5. I was showed a pair of hands which was classical of arthritis mutilans. There was classical telescoping of the fingers. There was also pitting and onycholysis of the nails. I tried to look for erythematous plaques, however there were only hyperpigmentated patches over the scalp and the legs. So I mentioned that this patient was probably receiving treatment. I was asked the pathophysiology of the telescoping fingers. I was also asked regarding the treatment.
The next case was a locomotor station. I was asked to examine the patient’s legs. From a far, I looked at his eyes which were typical of a Graves opthalmopathy. As I saw the leg, it was a clearcut pretibial myxoedema. There was peau d orange appearance and I described the rash. I continued on by looking for signs of hyperthyroidism. I was asked the pathophysiology of pretibial myxoedema. I mentioned that it was due to deposition of the mucopolyscharide. I was also asked which layer of the skin was involved and I mentioned it was the subcutaneous tissue.
Next I was brought to a lady with moon face. I was not allowed to touch the lady and was asked to just look and comment on the lady. I said that this lady had features of Cushing’s syndrome. I was asked what the other features of Cushing’s syndrome were. I was then asked on how to investigate a patient with Cushing’s syndrome. I mentioned regarding taking a history from the patient regarding steroid/traditional use then doing a 24 hour urine for cortisol then the dexamethasone suppression test. The examiner then asked if the lady had low dose dexamethosone test which was not suppressed and a high dose dexamethasone test which was not suppressed ? I asked for the ACTH level and the examiner said that it was raised. I said that it is most likely from the pituitary gland, probably a pituitary tumour such as adenoma or craniopharyngioma.
The next was the fundus. I was asked to examine the Right fundus. It was totally normal and I panic. I was also told off by the examiner that I was touching the eyelids with the fundoscope and that is why the patient kept on blinking. I apologized and then went on to the left eye. It was a clear cut battlefield fundus. The diagnosis was central retinal vein thrombosis. I was asked regarding the causes of CRVO. Then I was asked regarding the treatment of CRVO.
I score 4/4 for this station.
Next was Station 1 (Respiratory/Abdomen)
I was given a lady who was tachypnoeic and as I examined the lady, I noticed a swelling and peau d orange appeance over the R breast. As I examined the lungs, I noticed an area of bronchial breath sound over the R upper zone and thought the trachea was deviated to the R. There was also signs of R lower zone pleural effusion. I concluded that this patient had R sided pleural effusion with R UZ collapse consolidation most likely secondary to R ca breast with mets. Unfortunately the trachea was actually central and there was no collapse consolidation.
I scored 2/2
In the abdomen station, there was a Malay man with clear cut hepatosplenomegaly. Liver was 2 finger breaths and spleen 3 finger breaths. They asked me what I found from the peripheral signs. I only found palmar erythema and said that the most likely diagnosis was chronic liver disease with portal hypertension. Retrospectively I noticed pigmentation in the oral cavity but did not mention it because I could not correlate the findings at that time. They asked me of other differential diagnosis and I gave a list. However coming out from the examination hall, another candidate from Singapore mentioned that he thought it was thalassaemia. It never clicked my mind ‘coz I was so focused with the diseases from Ryder which never mentioned this disease. The case thought me a great deal of lesson.
I scored 2/2
Station 2 (History)
A 25 year old lady who presented with stiffness and jerky movements, uprolling of the eyeball and drooling of the saliva. Take a history.
It was clear from the stem that the lady had fits. However, after detail history, this was the 2nd episode that she had a fit and previously was on antiepileptic but defaulted due to development of rash. She was not pregnant and works in a departmental store selling clothes. She travels by bus.
I was asked regarding the social history where I was told that I had not taken a thorough one. They wanted to know her hobbies which I missed and asked me how old her parents were. Of course I did not ask those.
I scored 2/3
The stem : Examine this gentlemen’s upper limbs neurologically and locate the site of the lesion
This gentleman has wasting of the right upper limb and was unable to move the R upper limb at all. There was also hypotonia with areflexia. Sensory loss pin prick and light touch from C5 to T1. Left upper limb was normal. I finished rather fast and even saw an abrasion wound over the R scapula region. The told me I still had time and I went on examine the lower limbs which were perfectly normal. I mentioned that this gentleman has features of lower motor neuron lesion of the R upper limb with sensory loss from C5 to T1. I mentioned the most likely cause of trauma. I was asked regarding the investigation which I would have performed and I answered Nerve conduction study. They then asked me the other differential diagnosis. I was rather blank but when I wanted to open my mouth, thank god the bell rang. Looking back, I think the answer would be a cervical rib and also Pancoast tumour.
I scored 4/4
I was once told that a scar is a gift ! Well, it could also be the killer…I was rather confident in this station, probably overconfident that I thought to myself after the exam that I certainly had a 4/4 for this station. I was totally wrong and I would have passed this exam at that time if I had a 4/4
The stem : This gentleman had palpitation. Please examine his cardiovascular system.
This gentleman had a midline sternotomy scar. The examination was smooth and I could hear a metallic click of the first heart sound. There was also a flow murmur at the left sternal edge.
I mentioned that this patient had a mitral valve replacement and in sinus rhythm with no evidence of infective endocarditis and gave my reasons. However I also mentioned that this patient had a raised JVP and a parasternal heave, most likely due to pulmonary hypertension. Later when the feedback came back, I was told that I created the signs for pulmonary hypertension. I was asked the reason for the palpitation and the investigations.
Lesson to learn – do not create signs !
I scored 2/2
I gave up this station before the exam, hoping other stations would cover this coz I was not good at all in communication previously. Moreover, after the mock exam which was held in Penang GH, I did so badly and thought to myself that it was impossible for me to pass this station. However, it was actually a very straight forward case.
This middle aged man who had cough for the past 6 months and CXR and CT scan shows a mass at the left apical region suggestive of a lung malignancy. The task was to break bad news and to advise regarding further investigations.
I broke the bad news with empathy and he cried for only e few seconds then later just before it ended, he asked me whether he could go to China. He said that he had booked the flight earlier on and was very eager to go with his wife. I thought that there was a hidden agenda here. So I went on a wrong track and asked regarding the China trip. I asked regarding which part of China and whether it was on a hill and the reason why he was going to China. He cornered me by asking me whether he could or could not go. I said that it should not be a problem though I would want to discuss with his wife. I also mentioned regarding the need for bronchoscopy and staging. The examiner told me that I should not have allowed him to go to China as he would probably not be fit as would need a bronchoscopy, staging and further treatment after that. I guess at that time I was thinking that if China meant so much for him, I didn’t want to see him die without able to fulfill his wishes to go to China.
I scored 2/2
So, even though I scored four 4’s in the exam, I still failed because I had too many 2s. The bottom line is that you must get the diagnosis right and not create any signs.
I waited for 6 months before I sat for the next exam. Dr. Ma sat after 3 months and passed telling me that passing in London was very easy……yea right, that’s because he passed.
UK experience (The Dark Side)
I would never forget my experience to UK. The journey was long and the price to pay is enormous. Well I guess for Malaysians to go to UK for an exam is not easy as every pound is almost RM7. This means that you have to multiply by 7 anything that you buy over there. I’m sure a lot of us do lots of locums with sleepless nights or over nights just to get enough money to go for the exam. I guess it is the most expensive bet that I have made. So, for those who are going, my advise is that you should also take it as a holiday(not easy though) ‘coz if you fail, you still gain something. A lot of people helped me through to UK. A group of 5 of us went to UK, 2 taking the MRCP, 2 taking Diploma of Dermatology which happens to be the same time and 1(my wife) just went for shopping. I reached London and spent 4 days there with one day in a Communication lecture course, then traveled to Stoke on Trent whereby I failed to get an attachement there due to some unforeseen circumstances. I stayed in the bed and breakfast for a week. Then I traveled to Edinburgh(Livingston) whereby I was fortunate to have a friend who was in France and allowed me, my wife and 3 other friends to stay in her apartment for 2 weeks. I then traveled to Manchester for a PACES course for 2 days before returning back to Edinburgh. I then went to Glasgow for 4 days to do an attachement plus enjoying the beautiful scenery. People in the hospital were nice and friendly. My exam was in Perth, north to Edinburgh.
When I reached Perth by train in the evening, I was already so so tired with traveling. I stayed in the nurses quarters but found it very uncomfortable and could not sleep the whole night.
The next morning when I woke up, I was like zombie.
I started of with the Neurology station. I was asked to examine the patient’s lower limbs. He had stocking distribution of sensory loss with normal motor system examination so I concluded that he had peripheral neuropathy. I was asked the causes and I mentioned DM, drugs and they stopped me asking me which type of drugs. I mentioned anti TB and chemotherapeutic agents. They asked me what was the other big group but I said I was not very sure at the moment. I was also asked the investigations for which I answered FBS and NCS. They asked me why I would want to perform an NCS since it was so clearcut. I mentioned that it could differentiate between axonal and demyelinating and they agreed. During the last one minute, they asked me to assess the patient’s speech. I mentioned that he had dysarthria. They then just said look at the face. At that time the bell rang. My friend in the next session mentioned that the man had resting tremor. This was obviously not there when I examined. Probably he just took his Madopar when I examined him in the first session.
I thought I did badly but actually got 3/4
This patient has an ejection systolic murmur at the aortic radiating to the neck with a soft pansystolic murmur at the apex. I concluded in the end that this patient has an aortic stenosis and gave my reasons. I was asked whether there was any other murmur. I said that there was a pansystolic murmur in the apex and thought that it was a Gallavardin phenomenon because the murmur did not radiate to the axilla. I was shot at this point. What did you just mention ? Enlighten us about what you said. Is it pathological ? The examiners obviously have not ever heard about Gallavardin phenomenon and thought I had created something. This time I missed the signs of pulmonary hypertension (In Singapore I created it). I was asked the investigations and as the bell rang, they asked me to look again at the JVP and comment. I said it was raised and they were happier.
After learning from what I did before the Singapore exam, I was trained by a fantastic communication expert, Dr. Kok Lai Sun who happened to pass the exam in Singapore, the same time I sat for that exam. She used to train me almost everyday during lunch time and this time I felt very confident especially in the part of breaking bad news. This shows that comm. Skill can be learned and practice, so do not give up this station.
The stem : A middle aged man with valve replacement on T. Warfarin. Came to casualty with reduced consciousness – CT brain shows a massive intracranial bleed. GSC 3/15 , referred to Neurosurgical – not suitable for surgical intervention. Please break the bad news to the wife who just arrived to the hospital.
I broke the news with a warning shot and found out later that the patient actually defaulted the INR appointment. I showed empathy. The examiners asked me what else may I have asked and I said to ask regarding the advance directive. I said I did not ask that because I felt that the patient’s wife was not prepared but I did say I would see her again in the afternoon whereby I planned to ask her that. As I was walking out of the room, the examiners said “Good”.I felt I performed well especially for an Asian in comm..
I scored 3/3
This station was so bad that I knew I failed as I came out of the station. The first case was a middle aged lady. The examiner asked me to examine the patient’s eyes. I was not very focus at that time and went to examine the visual field. The examiner said skip that. Then I examined the visual field and he said skip that as well. The as I went to examine the movements of the eyes, I noticed that she had diplopia on certain gaze and also her eyes strted to droop so I went on to check for fatiguability without thinking which station I was in. The examiner got really annoyed and started to show dissatisfaction in my performance. I knew that I had approached the wrong way. He asked me what I was doing and I said but he was really unhappy. So he asked me the causes of diplopia and I mentioned and I also said dysthyroid eye disease but the lady did not have a goiter. He asked me whether goiter was necessary and I said no. So I went on to examine the thyroid function whereby she was euthyroid. Probably this lady only had exopthalmos(slight lower sclera seen but I thought was rather common in the Caucasians) and diplopia.
The next was the skin station where it was an obvious necrobiosis lipoidica diabeticorum. I said most likely due to diabetes mellitus. The examiner told me that she was not a diabetic. He then asked me how many percent of necrobiosis lipoidica diabeticorum are diabetics. I made a wild guess of 30%. Later I was asked the differential diagnosis and what I would do. I mentioned skin biopsy but said that normally it is not done if the diagnosis is clear cut.
Next was a man sitting on a chair and from a far I noticed that the man had arthropathy of the hands. However I was asked to examine the neck of the patient. This patient had restriction of movement of the neck and I said the possible cause of atlantoaxial dislocation with RA in view of the hands. I was then asked to examine the gait and I knew at once that the patient had features of ankylosing spondylitis. Then I examined the hands and noted some pitting of the nails with symmetrical deforming arthropathy but no rashes. Tying all that together, I said that it is psoriatic arthropathy ankylosing spondylitis type. I was immediately asked to go to the next station. When the answer came back, it was a RA + AS ( I thought seropositive and seronegative never happens together).
The fundus station was bad too. I was asked to look at the left fundus. The fundus was not fully dilated and when I looked inside, I noticed a large pigmented scar and nothing else. I was then asked to look at the other eye. I found dot haemorrhage over the left eye. I concluded that the patient had a choroidal scar. The examiner was surprised and asked me about the other eye and I said that there was dot haemorrhages and my differential was a laser scar. It turned out to be a proliferative DM retinopathy. I felt that I may have missed the exudated as the eyes were not fully dilated.
I scored 1/1
The abdomen was also a nightmare. I was brought to a corner room with a small yellow light by the side. There was a lady with a branulla and I knew that she was definitely an inpatient. She was obese and could not fit in the bed. She was also breathless and was lying at 45 degrees. I was asked to examine the lady’s abdomen. I tried to lower the bed but the examiner stopped me and told me to examine the abdomen as it is. This lady had jaundice(difficult to appreciate as the light was yellow and it was winter) and multiple spider naevi. I was stopped after examining the liver and was asked to present the findings. I thought I felt a liver but it was so difficult as the patient was so obese. I then continued and found ascites. I presented my findings and was asked the cause. I said she had features of chronic liver disease and also hepatomegaly and ascites. I was asked the causes of hepatomegaly in chronic liver disease. I was asked the underlying aetiology and I said alcohol, hepatitis. I also mentioned PBC. They asked me whether the liver was big or small in PBC. I said it is small (I was obviously wrong).
I scored 1/3
Station 1 (Respiratory)
I was shocked when I reach this station and the examiner asked me to do a running commentary on what I find on my way. This patient was tachypnoeic and lung findings suggestive of bilateral lower zone pulmonary fibrosis. I was asked to look at the hands again of which there was very subtle swelling of the MCP joint. I asked the patient whether there was any pain and he mentioned not now but last time. I then said that this patient most likely has rheumatoid lung. They asked me for the causes and I said that I wanted to ask the patient’s occupation and also drug history.
I scored 3/3
Station 2 (History)
It was a good start in this station but a very bad ending. The interview went on very smoothly. It was a 42 years old lady with central chest pain, gripping and she did mention a few worries. I mentioned that this patient most likely has a cardiac origin chest pain (IHD). They asked me what was against it (It was not on exertion). I was asked the differential diagnosis but did not mention anxiety which was the actual diagnosis. I was asked the investigations and mentioned the investigations for the cardiac. The examiners were not happy because I could not get the diagnosis of anxiety.
I scored 1/2
As I went out from the hall, I knew I failed. So, I took the train back to Edinburgh and went on a tour to Edinburgh town. I knew I just wasted about RM20,000 (about 80 nights of locum). But I guess it was an experience I would never forget. Well, at least I saw snow in England(Stoke on trent) when I was there. That was the first time I saw real snow. I was rather depressed when I came back to Malaysia and even applied to change hospital. I am sure that those who have failed twice before would definitely understand my feeling at that time. I even thought of quitting becoming a general practitioner. Well, I do have good friends who tried to console me. I received many sms at that time trying to console me and I do thank all my colleagues in Penang GH who helped me through this period.
I then had to decide on whether to take the exam again in Singapore next or to wait for Malaysia. When I reached my house after coming back, I went through the net and applied for the course in Singapore. I did not get a place as I applied rather late.
My juniors pass the exam and this gives me even more tension and stress. Well, I guess it is not easy to see your houseman become your specialist.
Malaysia experience (The return of the jedi)
I promised myself not to make the same mistakes I made again. I prepared myself very hard and more importantly, I prayed very hard too. I had a new sparing partner Dr. Tee CH who helped me much. Dr. Kok LS continued to give me encouragement and lessons on history and communication. I travel to Sungai Petani every Saturday to do short cases, whereby I was taught by Dr. James Smitt who was so nice to take time to train us for short cases every week without fail. I learned so much especially clinical skills from him and it is rare to find people like him. Before the exam I went for courses in IMU, Penang Hospital (which was organized by Dr. Ma) and mock exams (Alor Setar, Penang GH, Sungai Petani). They were indeed helpful not only to gain confidence but to see such beautiful cases.
This time I brought everything to KL, especially my tie. I went to KL 2 days before to prevent me getting exhausted the next day from traveling. I booked a 4 star hotel in bukit bintang 2 days before and a 5 star hotel one day before, near the exam centre. I felt so comfortable and for the first time could have a good night sleep the day before the exam. Well, anyway our 5 star hotel is much cheaper than a 3 star hotel in Singapore.
This time the first station was the history station which I was not very good in but gave my very best.
Station 2 History
55 years old lady with fever for 2 weeks and FBC shows Hb 8.2 g/dL, WBC 2.4 Plt 108. Please take a history from this patient.
The lady told me that her GP said she had jaundice and also had a thyroid surgery done 3 years ago for a thyroid ca.
The diagnosis was a thyroid ca with bone marrow and liver mets.
I was asked the differential diagnosis – SLE, chronic infection eg malaria, BM disease, HIV. I gave my points for and against.
I was asked of other infection that could happen if patient was swimming in a pond – I said Leptospirosis.
I was also asked the investigations that I would do.
Station 3 CNS
I was asked to examine the gait of a patient middle aged. On examination of the gait, there was broad based and unable to perform tendem walking, falling to the R side. There was cerebellar signs. I noticed loss of arm swing but there was no tremor and I went on examining the lower limbs which was normal. I was then asked to present and state the cause. I said he had cerebellar signs but could not find out the underlying aetiology. I slowly mentioned the causes. The examiner asked me to examine the tone of the upper limb again and I still felt it was not increase or cogwheel. I said in fact it was reduced, thinking in mind the cerebellar signs I got. Just before the bell rang, he asked me to look at the face and I mentioned masked like most likely Parkinsonism. My other friend in the same exam got the Parkinson features but missed the cerebellar signs. In fact the man had Parkinson Plus syndrome (Olivopontocerebellar degeneration).
Station 3 CVS
I moved on without thinking of that station which I did not do that well. As I examined the patient, I noticed the patient had collapsing pulse and a Corrigan’s sign. Apex was displaced and normal S2 with a EDM at LSE and ESM at aortic radiating to the carotids. I diagnosed as mixed aortic valve disease with predominant AR. I was asked the causes of the mixed aortic valve and mentioned degenerative, bicuspid valve and collagen vascular disease. I was asked one single blood test I would perform for this patient and I mentioned VDRL. I was asked the other investigations of which I mentioned ECG, CXR and Echo stating what I would like to look for in those investigations.
Station 4 Comm
The stem was this middle aged man with idiopathic dilated cardiomyopathy and atrial fibrillation on T. warfarin, T. Carvedilol, T. Perindopril, T. Frusemide. Explain the diagnosis to the patient and also the medications that he is taking. After explaining to the patient the diagnosis, he asked me the cause and I mentioned that it is not known even after tests such as Echo, ECG, CXR and so on. I mentioned that this is common and it happens. I explained regarding the medications and he was worried about the T. warfarin as he said that he is working in a construction site and risk of trauma. I told him that the risk is even higher if he does not take the T. Warfarin and told him the complications including a stroke.I advise for regular INR check. He was also worried about impotence with the beta blocker. I also mentioned the side effect of chronic cough with the T. Perindopril. It went on quite smoothly and the examiner asked me whether I thought the patient would comply. I said yes and he asked me whether I was sure. I said probably I would need to reinforce this and perhaps my consultant would also help me advise him. I was asked regarding the impotence part but I mentioned that I did try to ask further on why the patient was worried but he just said nothing.
Station 5 Fundoscopy
I was asked to look at the fundus. There was laser scars in both eyes with lots of hard,soft exudates and also dot blot haemorrhages. There was also flamed shaped haemorrhages in the right eye. Both optic disc looks pale but more on the right. I have never seen such beautiful silver wiring in the left eye before. I told the diagnosis except the optic disc but was later asked regarding that and gave my diagnosis of proliferative diabetic retinopathy with hypertensive retinopathy. I was asked for differential and I said that the left eye could also be a central retinal vein thrombosis as a differential.
I was asked to examine the patient’s hands. There was bilateral symmetrical deforming arthropathy over the MCP and PIP joints of both hands. They were rather subtle. There were no nail changes and rashes. There was positive Tinel on the right and a Rh nodule on the R elbow. I went on to examine the movements, function and other systems including the lungs but was stopped. The examiner asked me my diagnosis and I said that it is RA and the disease is inactive and gave my reasons with carpal tunnel syndrome on the R. I was asked regarding what other signs and I looked back and noticed I forgot to mention the wasting and also the swelling over the wrist and mentioned those confidently. I was then asked the signs of activity and as I was answering, the alarm rang for me to go to the next substation.
I was asked to examine the pateint’s face. This time I am very focus after my experience from the UK experience(The Dark side). I screen through first without touching the patient from a far and noticed he had large hands and feet. I knew that it was a acromegaly and went on examining the face, tongue, teeth, visual field. Then I went on to the hands and look for proximal myopathy. When I reached the neck, I noticed a small scar at the throat and then I wanted to ask the patient to open the shirt but was asked and the examiner told me it was ok. Then I went on the the feet. I was then asked my findings of which I mentioned it smoothly. I was asked what else in the neck besides the scar and I mentioned a goiter. I was then asked about the feet. I mentioned regarding heel pad of the feet and also a large feet, putting my foot next to the patient’s. The examiner told me that mine was also big and he smiled. Then both the examiners laughed.
I was brought to a lady with a rash on the face and was asked to examine the face. I mentioned that she has a malar rash with some areas of hyperpigmentation but no follicular plugging. I was asked other presentation and I mentioned. I was also asked what the commonest mode of presentation neurologically and I said cerebral lupus initially but then later said I was not sure. I was asked regarding activity and mentioned ESR . I was then asked also regarding CRP and said yes I would do that too.
Station 1 (Abdomen)
This was a young Malay lady who has a moon face at a glance with a scar at the RIF. I thought to myself that this must be a renal transplant ! As I went on to examine her, she did not have any fistula and no evidence of cyclosporine usage. She was pale and there was hepatosplenomegaly with liver 2FB and spleen 4 FB. I was thinking to myself this must be thalassaemia as I missed that in the Singapore experience(The new beginning). But to my surprise as I mentioned hepatosplenomegaly, the examiner stopped me and did not ask me for the underlying cause. He asked me what the mass could be and I said spleen. I was asked how to differentiate between the spleen and the kidney and gave a list. I was then asked how to investigate for it and I said ultrasound abdomen. I was then told that the ultrasound could not pick that up. So I said CT scan abdomen. The examiner then challenged me by saying that the CT scan could also not tell. Then I said MRI. I was then asked which was better of which I said CT scan as I read previously that MRI could cause motion artifacts. He still asked me how I would differentiate and I said I would refer to my consultant and both the examiners laughed. I mentioned CT should be able to tell. I was asked the differentials and I mentioned them including arising form the stomach, colon, pancreas. I mentioned that if I suspect it is from the stomach then perhaps an OGDS may help. I was brought to the next station.
Station 1 (Respiratory)
This was a young Indian man with clubbing and coarse crepitations over the bases of the lungs. I asked the patient to cough and it was a wet cough and the crepts also changed. I knew at once that it was a bronchiectasis. It is always a fear to differentiate between bronchiectasis and pulmonary fibrosis of lower lobes. I mentioned my diagnosis and said that it is most likely due to pulmonary tuberculosis which was rather endemic here. I was asked how I would investigate and I mentioned CXR and also HRCT to look for reticular nodular appearance which could help me in my management. I was then asked how it would help me in my management of which I mentioned that surgery could be an option if the bronchiectasis is localised. I was asked the other management and mentioned regarding physiotherapy, postural drainage and antibiotics. I also mentioned regarding vaccination and they asked me which type of vaccination I would give.
This time I felt much better after the exam and went shopping in Wan Utama as I was staying in One World hotel and also watched Bourne Ultimatum that night. I moved back to a 4 star hotel in Bukit Bintang that night in view of the cost.
In conclusion, I think the exam was rather tedious and stressful but did teach me a lot. I had sleepless nights even before obtaining my results from the internet. It took me 2 years just for the PACES and practicing for PACES can be very tiring and I am very glad it is over J I am sure that everyone who has gone through this journey have their own experience and I do hope that sharing these experiences will help those who are thinking of taking the MRCP exam !