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.

Sunday, September 03, 2006


This lady has dermatomyositis. She has a heliotrope rash over the knuckles (GOTTRON"S Papules), back of the hands, eyelids and periorbital area. She also has nail fold telangiectasia.

(Look also in elbows and knees for Gottron's papules, it may be the only clue you have)

She also has Cushiongoid features, likely due to steroid treatment. (Mention other complications of steroid treatment if any-Cataract, vertebrae fracture, obesity).

There is also proximal muscle weakness and tenderness and the patient has had a muscle biopsy done (look for scars on thigh/upper arm)

Functionally, she has impaired swallowing as she requires a Nasogastric tube

NB Candidates often mispronouce "Gottron's" as "Grotton's". Be careful! Look for other things such as Raynauds, SLE

Questions that could be asked

1. How would you manage this patient?

**I would like to confirm my diagnosis of dermatomyositis by doing the appropriate investigations (eg muscle biopsy, Electromyelogram)

**As this lady is over 40, I would also investigate for underlying malignancy (mention NPC, breast, ovary, Lung and GIT) I would also investigate for connective tissue diseases.

**I will also start patient on high dose steroids and add on steroid sparing drugs.This patient also needs nutritional support as she is cachetic and has dysphagia caused by the disease.(Hopefully by the time you reach this station, your time is up)

2. How to differentiate this rash from SLE rash?

**In SLE, the rash spares the knuckles, and involves the phalanges.

3. How would you classify polymyositis-dermatomyositi?

**I Primary idiopathic polymyositis

**II Primary idiopathic dermatomyositis

**III Dermatomyositis (Or polymyositis) with neoplasm

**IV Childhood dermatomyositis

**V polymyositis/dermatomyositis with collagen vascular disease

The above case and photos are contributed by Giant Eagle

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At 11/07/2008 01:05:00 PM, Anonymous drrizvanahmed said...

this patient also appears to have diffuse non cicatricial alopecia. also there is diffuse mottled pigmentation of her face which may be due to photosensitivity. I suspect she has MCTD or overlap syndrome ; the dysphagia can be due to associated feature of scleroderma.


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