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.

Thursday, June 14, 2007

Station 5 Quiz

Thank you for the great response for the 1st Quiz.

Here comes the quiz for Station 5.

The diagnosis is rather clear cut but how do we get 4/4 instead of 3/3 ??

This patient has acromegaly and the disease is inactive, currently complicated by bilateral carpal tunnel syndrome and urinary tract infection
Examination of the hands reveals large spade like hand. It is however not sweaty or warm. Positive Tinel sign suggestive of bilateral carpal tunnel syndrome.
There is no proximal muscle weakness
There is prominent supraorbital ridge with prognathism and large nose and large tongue. There is also interdental separation.
There is no visual field defect and no goiter.
There is heel pad thickening

I would also like to check the BP, urine dipstick for glycosuria, organomegaly and the old photograph of this pt.

There are several other signs which are not listed here which may need to be checked. Please identify and tell so that one can score 4/4 !

Any takers ?
Pictures and case contributed by Wuchereria.

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At 6/14/2007 07:33:00 PM, Blogger SoNaR said...

Look for osteoarthritis (joint crepitation, pain, swelling, reduced range of motion) Also check for skin tag, rectal polyps, galactorea.

Is the 2nd photo showing a urinary catheter? My monitor a bit blurry. Hmm..Why is he on the catheter?

At 6/14/2007 11:22:00 PM, Blogger Dr. David Teoh (eMRCPian) said...

The urine is cloudy. Any idea?

At 6/15/2007 10:14:00 AM, Blogger Xiao_zhai said...

Urine is cloudy?Well, you mentioned that he had an UTI

Other signs to check for: CVS system looking for displaced apex and possibly systolic murmur due to hyperdynamic circulation

At 6/15/2007 10:40:00 AM, Blogger Wuchereria said...

Anything else ? I challenge axonopathic to give the answer !!

At 6/15/2007 10:52:00 AM, Blogger Wuchereria said...

xiao zhai ..... good response !

At 6/15/2007 03:01:00 PM, Blogger Axonopathic said...

To my dear buddy, wuchereria

Aha..a challenge huh?


Ok, I think this patient has acromegaly, disease activity currently quiescent. He most probably has prostatomegaly as part of his visceromegaly, thus causing urinary retention needing an indwelling catheter/ intermittent catheterisation. I would be keen to do a per rectal examination to confirm an enlarged prostate. I would examine the abdomen to look for other associated organomegaly as well.

Alternatively as a differential, he might have a vertebral fracture due to osteoporosis with spinal cord compression, thus resulting in neurogenic bladder needing an indwelling catheter. (In real-life PACES, offer to examine the back for step deformity and examine the lower limbs neurologically)

As the urine is cloudy, I would treat him empirically for UTI and change his catheter promptly. His catheter tip is to be sent for C&S.

At 6/15/2007 09:05:00 PM, Blogger Dr. David Teoh aka eMRCPian said...

Should be 4/4
Wuchereria, anything to add:)

At 6/15/2007 09:11:00 PM, Blogger Dr. David Teoh aka eMRCPian said...

Prostatic Hyperplasia: An Unknown Feature of Acromegaly

At 6/16/2007 09:06:00 PM, Blogger Wuchereria said...

In acromegaly, everything becomes bigger except one thing. What is it ?

At 6/18/2007 10:27:00 PM, Blogger Xiao_zhai said...

The eyes

At 6/18/2007 11:22:00 PM, Blogger Dr. David Teoh aka eMRCPian said...

Not really

At 6/20/2007 11:24:00 PM, Blogger Pruritis said...

Very good comments,so far

but !! Why do we still review pts with acromegaly even though we have treated the disease and its quiescent as in our pt?

At 6/24/2007 09:35:00 AM, Blogger Dr. David Teoh aka eMRCPian said...

Even after successful surgery and normalization of hormone levels, patients should be monitored closely for possible recurrence, even years after the surgery.

More commonly, hormone levels will improve, but they may not return to normal. Additional treatment, usually with drug therapy, may be required.

At 6/30/2007 01:49:00 PM, Anonymous Anonymous said...

Testes may be small in Acromegalic patients.


At 6/30/2007 01:53:00 PM, Blogger Axonopathic said...

Yep MK32, you got it!

In fact it's a trick question from Wuchereria ;)

At 6/16/2008 09:44:00 PM, Anonymous Anonymous said...

Thanks for the great answers guys! Can I ask why do acromegalic patients get osteoporosis?

At 6/27/2008 12:28:00 AM, Blogger rectum said...

the reason for osteoporosis in acromegaly is due to hypogonadotrophic hypogonadism secondary to underlying pituitary macroadenoma. It is also the cause for testicular atrophy

At 7/18/2008 07:09:00 PM, Blogger Reaz said...

testes small and osteoporosis , great co-relation.thanks

At 11/06/2011 01:27:00 PM, Anonymous Anonymous said...

the other features of acromegaly :
LVH and heart failure, osteoarthritis, acnthosis negrans,


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