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.

Friday, June 15, 2007

Fundoscopy Quiz

Yesterday, a consultant neurologist came to my hospital and took one of the PACES candidates for a mock.
This was what the patient had(picture above). It was Station 5 Fundoscopy.
Quiz :
1) What is your diagnosis ?
2) What else would you look for ?
3) What are the common causes ?
4) What would you look for in the other eye ?
The patient was a young lady.
What is your complete diagnosis ?

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At 6/16/2007 11:01:00 AM, Blogger Xiao_zhai said... diagnosis.....

either right or wrong the whole thing

This is a glaucoma.

I would like to go back to the patient to take a history and perform a physical examination of the eye,including a funduscopy

Causes are genetic predisposition and steroid use.

I would look for the same pathology in the other eye.

My diagnosis is glaucoma.

At 6/16/2007 07:01:00 PM, Blogger Dr. David Teoh aka eMRCPian said...

OK. Not quite right.
Look at the optic disc again. Observe the color of the disc.

At 6/16/2007 08:58:00 PM, Blogger Xiao_zhai said...

Now that you mention it.

The colour of the optic disc is rather pale rather than pink with a clear margin.
The optic disc is well circumscribed with no uneven border.
There are prominent vessels present.

Could this be a case of optic atrophy?

At 6/16/2007 10:06:00 PM, Anonymous Ronald said...

I will give this a go (1st time):

Optic atrophy??
As the patient is a young lady, could Multiple Sclerosis be a possibility here?
Other associated signs I would like to look for:
1. Looking for a relative afferent pupillary defect (Marcus Gunn pupil).
2. Inspect whether is color vision affected, red in particular
3. If optic neuritis, is there pain on movement of the eye?
4. Other associated sign suggestive of MS: INO, Lhermitte's sign, Upper motor neuron signs in the affected limbs, and sensory changes.

Common causes:
1.Optic neuritis, Multiple sclerosis
2.Tumor impinging optic nerve

The other eye:
Intact direct light reflex, impaired consensual?
Maybe INO

Hope I didn't go totally wrong here,


At 6/16/2007 10:40:00 PM, Blogger Axonopathic said...

Good work ronald :)

And well done to xiao_zhai for 2nd try as well.

Anything to add, buddy wuchereria?

At 6/17/2007 04:23:00 PM, Blogger Wuchereria said...

This comment has been removed by the author.

At 6/17/2007 04:28:00 PM, Blogger Wuchereria said...

Yes, very good. The answer is that the patient had optic atrophy due to recurrent optic neuritis (in fact, the lady had 8 times optic neuritis but still has not fulfilled the criteria of MS based on the Mc Donald's criteria - MRI always normal)
The other important thing is to look for central scotoma and visual field(pituitary tumour eg craniopharyngioma causing optic nerve compression is a common PACES case)
When you look in the other eye, do not forget to look for papilloedema which will be present in Foster Kennedy syndrome(favourite question from Neurologists)
Do not also forget other causes of Optic atrophy such as AION, toxic(methanol, lead, tobacco, ethambutol), B1,B12 deficiency and consecutive optic atrophy from retinitis pigmentosa.
The 5 features of nerve injury includes
2)Decreased visual acuity
3) Attenuated colour vision
4) Central/paracentral scotoma
5) Optic atrophy

3 common fundus PACES questions include retinitis pigmentosa, optic atrophy and diabetic retinopathy.


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