PACES MRCP UK - Where MRCPians Meet Since 2006

Frank's sign

emrcpian@yahoo.com (Dr. David Teoh) — Wed, 27 Aug 2008 03:53:11 PDT

Spotted this recent post by Wuchereria in his new blog. I learnt a new sign - Frank's sign. He highlighted that this is a great sign to impress the examiner!

"I just got back from Hong Kong recently for a holiday.During a morning of breakfast, while I looked around I noticed this man who was sitting eating 'Tim Sum' and I am sure he has coronary artery disease.
There was obvious Frank's sign.

Frank's sign is a diagonal crease in the lobule of the auricle :
Grade 3 - a deep cleft across the whole earlobe
Grade 2a - crease more than halfway across the lobe
Grade 2b - crease across the lobe, but superficial
Grade 1 - lesser degree of wrinkling

Ear lobe creases are associated statistically with coronary artery disease in most of the population groups."

Optic atrophy

noreply@blogger.com (Wuchereria) — Wed, 27 Aug 2008 03:57:16 PDT

Look for:

in young patient, mention you like to examine the eyes for internuclear ophthalmoplegia and cerebellar sign for multiple sclerosis
Signs of Cushing's syndrome in SLE pts on steroid
in old patient, look for evidence of vascular diseases such as prominent temporal artery (or old scar indicating temporal artery biopsy) and carotid bruit

(or endarterectomy scar)

Congenital

If congenital, it is usually hereditary with an onset of deterioration in childhood and may be accompanied by nystagmus. Leber's Hereditary Optic Neuropathy, (LHON) or Leber Optic Atrophy is hereditary, but typically has its onset in 20-30 year old males. This is due to a mutation of the mitochondrial genome and hence is passed exclusively through the mothers. Dominant optic atrophy or Kjer's optic neuropathy has autosomal dominant inheritance. It usually presents in early childhood. There are numerous less common genetically related syndromes.^[2]

Alternatively, congenital optic atrophy can be caused by a lack of oxygen during pregnancy, labour or in the early days of a child's life. Some drugs taken during pregnancy are also associated with optic atrophy.

Acquired

The acquired type of optic atrophy may be due to blood supply changes in the eye or optic nerve (anterior ischemic optic neuropathy or posterior ischemic optic neuropathy), may be secondary to inflammation or swelling within the optic nerve (optic neuritis), may be a result of pressure against the optic nerve (such as from a tumour), or may be related to metabolic diseases (e.g., diabetes mellitus), trauma, glaucoma, or toxicity (caused by methanol, tobacco, or other poisons). It is also seen in vitamin B12 deficiency and Paget's disease of the bone.

Googling to save lives?

noreply@blogger.com (Tang Weng Heng) — Sat, 26 Jul 2008 17:50:01 PDT

In a clinical case discussion published on New England Journal of Medicine (July 3, 2008), medical experts opined that "Internet search engines, such as Google, are proving to be an invaluable diagnostic tool", given the rapidly growing body of medical knowledge.

An internet-based study revealed that Google searches may arrive at the correct diagnosis in ~58% of cases. Will this mean physicians may no longer be needed in the future?

Also available at http://tangwengheng.blogspot.com/2008/07/googling-to-save-lives.html

2nd MRCP PACES Preparatory Course

noreply@blogger.com (Axonopathic) — Tue, 15 Jul 2008 23:16:35 PDT

The 2nd MRCP PACES Preparatory Course is finally in place. The organiser, wuchereria would like to take this opportunity to welcome participation from all.

Click here to download the course brochure (great design by wuchereria :) & the registration form.

The link will also be mirrored here.

If sending by mail, please address it to:

C/O Professor Richard Loh/ Dr TT Lim
2nd MRCP PACES Preparatory Course
Penang Medical College
No 4 Sepoy Lines,
10450 Penang
Malaysia

Upcoming 2nd MRCP PACES Preparatory Course

noreply@blogger.com (Axonopathic) — Sat, 20 Sep 2008 23:32:08 PDT

I am pleased to say that recently there has been ample of emails and personal calling-ins to enquire for the 2nd MRCP PACES preparatory course.

The 1st MRCP PACES Preparatory Course which was held September last year had been a really fruitful one, with candidates passing rate of approaching 60%! Our heart-felt thanks to all the great teachers in our midst.

Unfortunately, I'd most probably be away in the next few months, hence wouldn't be able to host this course again this year. Our associate author, Wuchereria, will tentatively be planning for one.

We'll keep you all informed about the progress. Thanks again for the support!

Regards,
Axonopathic

PS: The comic is just a joke to cheer you all up :)

Cranial Nerves Examination Series II

emrcpian@yahoo.com (Dr. David Teoh) — Tue, 27 May 2008 12:56:41 PDT

Cranial Nerves V and VII

Cranial Nerve VIIl

Cranial Nerves IX, X, XI, and XII

Cranial Nerves Examination Series I

emrcpian@yahoo.com (Dr. David Teoh) — Fri, 18 Apr 2008 17:06:28 PDT

Hey, folks. It had been a long time from the last neurology post. I found some useful videos from Youtube. Hopefully, these video demonstrations will save you from having sympathetic overactivation in the neurology station!

Cranial Nerves I and II

Cranial Nerves III, IV and VI

To be continue..

Basic Echocardiography Workshop

noreply@blogger.com (Axonopathic) — Sat, 20 Sep 2008 23:32:53 PDT

Basic Echocardiography Skills Training Workshop

Jointly Organised by,

Ministry of Health Malaysia

Cardiology Department, Penang Hospital & Penang Hospital Cardiology Society

Also In collaboration with,

Society of Cardiac Imaging Malaysia (SCIM)

Announcing Basic Echocardiography Skill Training Workshop which will be held on 25th-28th April 2008 in Penang Hospital, Malaysia.

This would be the first Echo course to be held in the northern region over the recent years. The organisers warmly welcome participation from all fellow colleagues who are interested in basic echocardiography.

Please click here to download the programme brochure.

Some Drills On Station 5 (Part 5)

noreply@blogger.com (Axonopathic) — Sat, 20 Sep 2008 23:37:14 PDT

Station stem:
This patient presents with intensely itchy skin lesions on both lower limbs for a short duration. Please examine and lay down your differential diagnoses. What are the questions would you like to ask?

Above picture on the shin, and the following picture is on the anteromedial aspect of another leg:

And a close-up:

Happy Chinese New Year

emrcpian@yahoo.com (Dr. David Teoh) — Wed, 06 Feb 2008 06:15:19 PST

Dear all friends & MRCPians:

We would like to take this opportunity to wish all Chinese readers a happy, healthy and prosperous new year.

Wishing you & family "A Happy & Prosperous Chinese New Year 2008"

Quiz: Skin station

emrcpian@yahoo.com (Dr. David Teoh) — Mon, 04 Feb 2008 16:23:28 PST

This gentleman has multiple similar lesions distributed over face, limbs as well as trunk. Please describe the lesions.

What is the significance of these lesions?
Hint: related to any syndrome?

Quiz time again!

emrcpian@yahoo.com (Dr. David Teoh) — Wed, 30 Jan 2008 14:39:08 PST

You see this patient in Station 5: skin.

Describe the skin finding. Then, outline the other system involvements that are relevant to this condition.

Gynaecomastia in PACES

emrcpian@yahoo.com (Dr. David Teoh) — Wed, 30 Jan 2008 14:34:17 PST

This is a man !

The most important tool in PACES is Inspection.

However to differentiate a pass from a fail involves preparing for the exam and of course luck which is difficult to change except by praying hard for the exam. For the former, pls remember that the time for the cases are short and most that comes out from our mouth has been prepared before the exam

So, if you see this picture, always remember which station you are

Nobody will miss the gynaecomastia in the above man

Station 1 : Abdomen - Cirrhosis of liver

Station 1 - Resiratory - Bronchogenic carcinoma

Station 3 : Cardiovascular - Drugs (spironolactone/digoxin)

Station 3 : Neurology - Myotonic dystrophy

Station 5 : Endocrine - Klinefelter's syndrome

I know there are other causes of gynaecomastia such as adrenal... but my mentor (eMRCPian) once told me, always think PACES way when you are going for a PACES exam !!

So, the above patient has gynaecomastia from Klinefelter's syndrome, look for other signs of Klinefelter.

Written by Wuchereria

A Blessed Christmas & Joyful New Year Ahead!

noreply@blogger.com (Axonopathic) — Mon, 24 Dec 2007 08:34:31 PST

We from the PACESMRCPUK blog team would like to wish every fellow MRCPians and aspiring MRCPians a very fine holiday season to come:)

We'll kick start another 'season' after this. Stay tuned:)

Notes Of Congratulations!

noreply@blogger.com (Axonopathic) — Sat, 15 Dec 2007 07:41:16 PST

Congratulations to all my colleagues who have succeeded in the recent PACES diet!

Special congrats note for Wuchereria and Panhypopit who have been writing in this blog and finally succeeded in their quest!

Also a warm congratulation note for all my colleagues who had joined our "1st MRCP PACES Preparatory Course and Mock exam" and succeeded in their exam. Your success really inspired us further :)

May your journey as an MRCPian thrive further in years to come :)

Quiz: Skin Station

emrcpian@yahoo.com (Dr. David Teoh) — Sun, 28 Oct 2007 15:06:30 PDT

Examine this 80 year old lady's hands and comment

(Hint, she should have died long ago, and yet's she's fit as a fiddle. Her mother had the same condition and died her 80s)

Cases and photos contributed by Giant Eagles

Course/ Mock Exam Cases Drill (Part 2)

noreply@blogger.com (Axonopathic) — Sat, 15 Dec 2007 07:41:03 PST

Verbal feedback from the the cardiovascular lecturers indicates that on the average, the candidates performance was quite satisfactory. Nonetheless, some cases were done poorly. I had to admit that some of the cardio cases in the course were considered rare, nonethess, I could bet to my bottom dollars that the registrar in-charge wouldn't hesitate to put them up for PACES if only they're readily available!

As I'd told a few of the candidates, rare cases tend to have a set of signs which is so classical that most examiners are fond of asking:)

And yes, I always believe that rare conditions rely heavily on us (physicians) to diagnose. After all, that's our duty as physicians right? Hence, we should be well prepared for that.

After finished examining the patient, gather your thoughts and face the music!

In summary, this gentleman has ample of signs to suggest the diagnosis of hypertrophic obstructive cardiomyopathy (HOCM). This is because he has a jerky peripheral pulse with a bifid carotid pulse. The apex beat has double impulses and it's not displaced. There is a grade 3 ejection systolic murmur best heard along the left lower sternal border which well accentuated by asking the patient to perform Valsalva maneuvers. There is no S3 or S4 gallop and there is no other signs to suggest cardiac failure.

I would ask for your permission to perform other dynamic maneuvers which would further support my diagnosis.

Examiner:"What dynamic maneuvers that you have in mind?"

I would ask this patient to change from standing stance to squatting position during my auscultation, paying particular attention to the intensity of the murmur. I would expect the murmur to be softer when he is in squatting position, and louder again when he's standing.

Examiner:"How would you investigate him?"

I would do a resting ECG first. I expect voltage-criteria left ventricular hyperthrophy to be evident on the ECG. There might be some secondary ST and T waves changes as well. I would reckon that a CXR in this most probably would be normal since during my examination, the apex beat is not displaced and hence I wouldn't expect cardiomegaly.

But really, an echocardiogram would clinch the diagnosis. Classical signs from echocardiogram would include asymmetrical septal hypertrophy (ASH) and systolic anterior motion (SAM) of the mitral valve.

Station 5: Fundus

noreply@blogger.com (Wuchereria) — Sat, 13 Oct 2007 12:18:54 PDT

What is the diagnosis?

What else to look for?

Course/ Mock Exam Cases Drill

noreply@blogger.com (Axonopathic) — Fri, 12 Oct 2007 03:32:11 PDT

Here are some of the cases for the preparatory course/ mock exam.

Case 1: Please examine this lady's hand and tell me your findings.

Case 2: This patient has difficulty in holding objects in her hands. Please examine her.

1st Preparatory Course And Mock Exam Experience

noreply@blogger.com (Axonopathic) — Thu, 11 Oct 2007 02:51:24 PDT

The very 1st MRCP PACES preparatory course and mock exam has ended successfully in Penang Hospital. I wish to thank all my team mates and the participants for their support. I'm indeed grateful for being granted the task of putting up a great team for the event.

By saying a great team, I really mean it! We hope to make it an annual event:)

I would like to thank the following prominent academic gurus for their time and effort in teaching the candidates:
Prof Richard Loh
Prof Amir S Khir
Dato Dr Rozina
Dato Dr Abd Razak Muttalib
Prof Dato Kew
Prof Abd Rashid Abd Rahman
Prof Raymond Azman Ali
Dr Haniffah Abd Ghafoor
Dr Norazizah Aziz
A/Prof Malik Mumtaz
Dr Simon Lo
Dr Eow GB

Without their selfless contribution, this event would not possibly be realised!

PS: Special thanks to eMRCPian for his advice and moral support

Travelling Circus

noreply@blogger.com (Wuchereria) — Sat, 13 Oct 2007 12:21:36 PDT

As correctly mentioned by one of the examiners, we are the travelling circus.......Travel from one hospital to another doing MRCP courses and Mock exams !
Taiping - Sungai Petani - Penang - Alor Setar (today)
Pheww......it has been tiring
? Tomorrow in KL
This is a tiring exam...just need to keep up till the big day.
Wishing all the best to all taking this time ! Don't worry if you don't make it. The circus goes on 3 times a year !
Anyone would like to share their experience for these few weeks of the circus ?

Quiz: Station 5

emrcpian@yahoo.com (Dr. David Teoh) — Sat, 13 Oct 2007 12:20:55 PDT

Please look at this mentally challenged young man's hand and feet and proceed.

Case and pictures contributed by Giant Eagle

Station 5

noreply@blogger.com (Wuchereria) — Sat, 13 Oct 2007 12:21:04 PDT

What is the diagnosis ?

This patient has epistaxis. What is it due to ?

Let's Stick To Our Basic!

emrcpian@yahoo.com (Dr. David Teoh) — Wed, 26 Sep 2007 21:02:15 PDT

Spotted the post of palmdoc in MMR regarding Eternal Clerking. I absolutely agree with palmdoc. I still remember my professor in UM once said, an in-depth clearking and detail examinations are able to make >95% of the clinical diagnosis. We only need investigations to confirm the provisional diagnosis.

Undoubtedly, the advancement of modern medical diagnostic tools have changed the way of our practice. Sometimes, we are over dependent on these new gadgets until we forget the basic skills that we learned during our undergraduate days. In addition, defensive medical practitioner also rely on investigations to self-proof from medical legal issues.

All MRCPians, let's not to forget our eternal basic! I am sure we all can make an accurate clinical diagnosis in 13 minutes of detail history clerking and 5 mins of system examination.

All the best for your coming PACES in Oct/November!

Here is a great melody kudos on the essentials of clinical skills. Cheers!

Station 5

noreply@blogger.com (Wuchereria) — Wed, 26 Sep 2007 21:00:23 PDT

What is the diagnosis ?