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Case ID: 1
Created: 5 May 2006

Examine the patient's neck.



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 the way to start your physical examination, 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 refelexes. 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.


This lady has Grave’s disease with diffused goitre and in a hyperthyroid state.

Extra points:

1) For Grave’s opthalmoplegia, the first muscle to be involved is inferior rectus.
2) Radio-iodine treatment can worsen Grave’s eye disease.
3) Remember precautions to be taken after radioiodine treatment.

Case ID: 2
Created: 5 May 2006

Look at this patient and proceed.



Usually this case will come out in skin sub-station at station 5. Although it is rather uncommon in UK, SLE is rather ‘endemic’ in South East Asia. It is a common case especially if you are sitting your MRCP PACES in Malaysia or Singapore. Always remember to present the following:

  1. pattern of distribution of the rash
  2. presence/absence of telangiectasia
  3. any vasculitic rash
  4. Any signs to suggest patient is on long term steroid therapy.

Suggest to examiners that you would do a complete physical examination to look for other systems involvement. Always remember to check the patient’s BP, fundoscopy for cytoid body, urine for proteinuria and ask for drugs history.


This lady has active SLE with malar rash and was admitted due to joints pain.

Extra points:

  1. Remember in drug-induced SLE patients, their anti-histon antibody is positive. Three common drugs that lead to drug induced SLE are hydralazine, procainamide and isoniazide.
  2. Drug induced SLE never involves brain and kidney.

Case ID: 3
Created: 5 May 2006

Examine the patient's hands.




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:

  1. Causes of anaemia in RA patients.
  2. Newer therapies available for RA.
  3. Mechanism for each joint deformity.( Distinction question!)


This lady has RA and is on Methotraxate, salazopyrine and low dose prednisolone.

Extra points

  1. 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).
  2. Always look hard for other associated autoimmune disease namely Sjogren’s syndrome, autoimmune hepatitis etc.

Case ID: 4
Created: 5 May 2006

You are the SHO in charge of Infectious Disease Clinic

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.


It is rather a common question in MRCP PACES, breaking bad 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:

  1. Am I going to die, doctor?
  2. Are you sure about the result, doctor?
  3. I don’t want to die, doctor, can you do anything to help me?
  4. I don’t want to tell my family, can you keep this as a secret?
  5. Is there any other alternative treatment available?

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