PACES MRCP UK - Where MRCPians Meet Since 2006

MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.

Saturday, May 13, 2006

5 minutes Horner's Syndrome

It's not easy to write a quick review for Horner's syndrome. Perhaps, there are too many facts to remember about this syndrome.As a PACES candidate, we need to know about:
1. The basic anatomy about oculosympathetic pathway
2. The causes of Horner's syndrome
3. Clinical features
3. The approach of examination

Oculosympathetic pathway involved in Horner's syndrome. This 3-neurone pathway projects from the hypothalamus to the spinal cord i.e. T1, then to the superior cervical ganglion and finally to the pupil, the levator palperbrae and the sweat glands of the face.

A lesion at any site along the pathway can produce Horner's syndrome

1st-order neuron
  • Arnold-Chiari malformation
  • CVA/intrapontine haemorrhage
  • Basal meningitis (syphilis)
  • Intrinsic tumour - glioma
  • Syringobulbia/ syringomyelia
2nd-order neuron

  • Pancoast tumour
  • Occlusion/dissection
  • Tumour
  • Trauma – surgical,birth
  • Thyroid malignancy

3rd-order neuron

  • Tumour
  • Granuloma
  • Herpes zoster
  • NPC

Clinical features:
1. Partial ptosis
2. Miosis
3. Lack of sweating (stroke the face with pen or dorsum of your hand)
4. Enopthalmos (don't need to mention i.e. too subtle to observe)

Approach of examination
1. Confirm the diagnosis of Horner's syndrome

2. Search for the cause
Look for neck scar, wasting of muscles of hand
Neurological - lateral medullary syndrome (common)
Respiratory – Pancoast tumours (common)
Neck - lympadenopathy (mitotic lesion e.g. NPC)



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