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, March 18, 2007

Expect The Unexpected

Opthalmoplegia

Puan Rahimah complains of giddiness. Please look at her and proceed.







Examiner: Dr. Pan, please present your findings.


Dr. Pan:
Puan Rahimah’s head is rotated to the right. She has right eye ptosis. There is no strabismus at rest. Both her pupils are spared. There is no fatigability. There is mild impairment of upwards and upwards lateral movements of the right eye. Intorsion is intact. She has diplopia upon looking at all direction except looking downwards . The outer image disappears upon closing the right eye. There is no nystagmus. The rest of the cranial nerves are intact.

I would like to complete my examination by examining the patient’s BP (H/T), urine for sugar (DM), upper limbs and lower limbs for any pyramidal signs including the reflexes (CPEO, ELS) and cerebellar sign. I would also like to look into the fundus to look for any papilloedema. (/retinitis pigmentosa)

PANIC!!!!!??????? Dx????

In summary, Puan Rahimah has complex diplopia and I would like to consider differential diagnosis of

1) Mononeuritis multiplex
2) MG ( no fatigability)
3) Miller Fisher
4) CPEO, Ocular muscular dystrophy


5) Grave’s ( proptosis?)
6) Cavernous sinus thrombosis/ superior orbital fissure syndrome( if V CN is involved)


Examiner: What other investigation would you like to do?

Dr. Pan:
1) ESR to screen for vasculitis
2) MRI of the brain ( infarct / SOL esp at the midbrain)


Causes of isolated III CN palsy
Medical:
1) DM/ H/T/ Vasculitis
2) Multiple sclerosis

Surgical
1) Posterior communicating artery aneurysm/ Midbrain tu
2) Subacute meningitis


Causes of isolated VI CN palsy ( look for involvement of VII CN)
1) SOL
2) DM/ H/T/ Vasculitis
3) Multiple sclerosis
4) Subacute meningitis

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4 Comments:

At 3/18/2007 05:06:00 PM, Blogger Dr. David Teoh (eMRCPian) said...

I would proceed to check for signs to suggest Myasthenia gravis. Any fatiguibility?

 
At 3/18/2007 08:35:00 PM, Blogger panhypopit said...

I didn't post the photo where patient was asked to look up continuosly and there was no fatigability.

 
At 6/17/2007 09:14:00 PM, Anonymous jack said...

there is a positive medial movement of the right eyes, it can't be 3rd nerve palsy . but the investigations listed were all pointed towards 3rd nerve palsy.
this variable opthalmoplegia , makes MG more likely.
i would agree with david teoh

 
At 8/23/2009 05:00:00 AM, Anonymous Anonymous said...

i think this pt has rt VI nerve as it shown she has week abduction of rt eye

 

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