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Case ID: 1
Created: 18 June 2006

This gentleman has shortness of breath. Examine his respiratory system.





       You will be happy to see this case in your MRCP PACES. You can get the diagnosis after your inspection. You notice that there are multiple distended veins over this gentleman’s chest. You can proceed with the usual physical examination of the respiratory system by bearing in mind that you may find the following abnormalities,
- Pancoast’s tumour- you may find reduced breath sound over upper lobe of the lung with dullness on percussion.
- Pleural effusion at one side of the chest.
- Or any physical sign suggesting presence of mass such as dullness on percussion with reduced breath sound.

After your complete physical examination, do the following steps,
- Demonstrate the direction of the venous flow.
- Look for exophthalmos, conjunctival injection.
- Look at the JVP( non-pulsatile) and show to examiners how you measure it.
- Examine the cervical region for lymph nodes.
- Look for small muscles wasting of the hand and Horner’s syndrome if you are suspecting Pancoast’t tumour.
- Suggest to examiners you would like to demonstrate Pemberton’s sign if possible.
- Ask the patient about smoking history.
- Talk to patient to assess hoarseness of voice

Common questions examiners would ask you,

1) What is Permberton’s sign?
2) What is para-neoplastic syndrome and give a few examples?
3) Name types of lung carcinoma.
4) What are the contraindications for surgical intervention?


This gentleman has superior vena cava obstruction due to lung cancer.

Extra points:

1) 1) If possible, non small cell lung cancer should be treated with surgical intervention. For small cell lung cancer, it should be treated with chemotherapy.
2) Indications for radiotherapy include SVC obstruction, local obstruction such as airway, spinal cord compression and brain metastasis.

Case ID: 2
Created: 1 July 2006

Examine this lady upper limbs neurologically..



  In MRCP PACES, after lower limbs examination and Parkinson’s disease, upper limbs examination is the third most popular question. You notice that there are obvious small muscles wasting with loss of thenar and hypothenar eminences. Before you proceed further, you should know that there are only a few possible causes for this. The causes are Motor Neuron Disease, Cervical Spondylosis, Syringomyelia ,Charcot- Marie- Tooth and Guillain Barre Syndrome ( or CIDP-chronic inflammatory demyelinating polyneuropathy). It is unlikely for you to get bilateral Ulnar nerve palsy in exam. Therefore, during your examination, pay attention to assess whether there is sensory involvement or presence of fasciculation ( which may suggest Motor Neuron disease). After you upper limbs examination, suggest to examiners that you would do a proper examination of lower limbs. Pay attention to the following,
- ? presence of pes cavus and 'inverted champagne bottles’ lower limbs. This suggest Charcot -Marie- Tooth.
- Dissociated sensory loss of lower limbs with upper motor signs. This suggests syringomyelia.
- Upper motor signs of lower limbs with possibility of sensory level. This suggests cervical spondylosis.
- Flaccid paralysis of lower limbs with no sensory involvement. This may suggest Guillain Barre syndrome.

After the examination, suggest to examiners that you would look for Horner’s syndrome if you suspect syringomyelia.

Common questions examiners would ask you,

1) What is the CSF finding in GB syndrome?
2) What are the three recognized forms of hereditary motor sensory neuropathy?


This lady has CIDP (due to the chronicity, she has muscles wasting).

Extra points,

1) In MRCP PACES, you are unlikely to get a case of isolated ulnar , radial or median nerve palsy.
2) There are three main clinical patterns of MND, they are progressive muscular atrophy ( obvious small muscles wasting of hand) , Bulbar palsy and amyotrophic lateral sclerosis.

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