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.

Monday, May 21, 2007

Doc, Every Second Of My Life I Am Dizzy

I am still working in neurology department, still seeing a lot of referrals from the northern region of Malaysia. I was referred a patient from an orthopedic surgeon for difficulty in walking TRO spinal cord compression. The surgeon had done a MRI 0f thoracic and lumbar region which turned out to be normal.

The case mentioned is a 45-year-old Chinese man, working as a mechanic. I remembered he kept on complaining of dizziness from the moment he stepped into my clinic. To cut the story short, he had been having severe dizziness and imbalance gait for nearly 2 years. It was progressively worsen for the past 3 months before he sought treatment from medical doctor. Functionally, he was terribly disabled by those symptoms.

On examination, he was ataxic and hardly able to stand or walk steadily without any assistance. There was bilateral cerebellar signs as evidenced by presence of dysmetria, intentional tremor and failure of performing rapid alternate motion test.

There was obvious nystagmus demonstrated bilaterally. He had staccato speech. Further examination revealed that the lower limbs were hypertonic and hyperreflexic. Clonus was present with bilateral upgoing plantar responses. His sensation of pain and propioception was intact.

In conclusion, he has bilateral cerebellar signs with UMN signs to suggest corticospinal tract involvement.

The possible diagnosis that should be considered in this case:
1. Spinocerebellar ataxia (SCA)
2. Multiple sclerosis

How should you proceed to reach the diagnosis?
What is the investigation of choice at this stage?

Any comments?

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At 5/22/2007 01:30:00 AM, Blogger Xiao_zhai said...

Go back to the history to look for MS signs i.e. any unilateral pain in the eyes/ visual loss.

Going down the MS pathway. I'd do MRI of the brain(he hadn't any done,had he?) looking particularly for any high T2 signal.

Next,I'd like a LP down to check for the myelin oligodendrocyte(MOG) and myelin basic protein(MBP) antibodies.

At 5/25/2007 09:21:00 PM, Blogger Pruritis said...

1.Need good family hx Friedrick's exhibits anticiptaion, does he have pes cavus ?
2.MRI BRIAN/SPINAL CORD (confirm demyelinating lesions
3.LP to confirm oligoclonal bands
4.ESR,B12/folate,syphyllis serology,TSH,

At 5/26/2007 06:12:00 PM, Blogger Dr. David Teoh (eMRCPian) said...

nope, no pes cavus.

At 5/30/2007 06:47:00 PM, Blogger SoNaR said...

I presume MS will be extremely rare in Malaysia (sitting on the equator). you know the prevalance of MS increases the further you are from the equator.

Plus MS in a 45 y.o asian male makes it even less likely.

I will still elicit history that suggests symptoms seperated in time and space to be happy. remitting and relapsing - most common form of MS.

But MS is not my likely bet.

I think SCA will be more likely, though he does not into the most common form (Friedrick ataxia) which requires earlier onset. There are lots of other types of SCAs.

Will do MRI of the brain looking for cerebellar atrophy and genetic testing to look for specific gene that may help point to the specific type of SCA.

At 5/30/2007 10:01:00 PM, Blogger Dr. David Teoh (eMRCPian) said...

MS is not uncommon in Malaysia.
Asian MS is now at a prevalence of 2:100,000. The F:M ratio is 6.6:1 (UMMC figure 1997 by Prof CT Tan).

At 9/13/2007 05:44:00 AM, Anonymous Anonymous said...

What is the correct Diagnosis and DDx? I think SCA .Is that correct?

At 1/15/2008 01:34:00 AM, Anonymous Anonymous said...

why isn't meningioma? and do brain MRI!!!

At 1/15/2008 02:18:00 AM, Anonymous Anonymous said...

i think with the he 2 years duration,and these findings,it could be posterior fossa tumor!!!!!


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