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Case ID: 1
Created: 22 July 2006

Look at this lady's lower limbs and proceed.



      This is a very popular skin station in MRCP exam. A lot of candidates find it difficult to describe skin lesion. I think there are a few important points you must give to examiners when you try to describe any skin lesion. Your description must include the general appearance of the lesion ( either it is a macule, papule, blister or bullous), site of the lesion ( is the lesion only localised to certain areas such as extensor surface, umbilicus, scalp, palm etc?), any mucosal involvement ( do you notice any mucosal involvement such as over oral cavity, eye?) , is the skin lesion itchy or tender and any associated changes that you think is relevant ( any hand/nail or other changes such as pitting of nail, rheumatoid hands,thyroid swelling which might be relevant!) I find that it is rather important for candidates to have a general inspection before zooming to the skin lesion. Sometimes, when you are asked to examine a skin lesion over the leg, look at patient's eye and thyroid swelling which might tell you the diagnosis ( pretibial myxoedema). Common skin problems over lower limbs which are popular in MRCP exam are pretibial myxoedema, erythema nodusom, erythema multiforme,pyoderma gangrenosum (Find a photo at MRCP Part 1 and 2) and psoriasis. In this picture, you notice macular-papular rash over patient's lower limbs but there is no mucosal involvement, you do not not notice any bullous eruption. You should proceed to do the following,

arrowfeel the lesion to assess whether it is tender ?
arrowlook at patient's mucosal ( oral cavity to look for ulcer ) and check for conjunctivitis.( mucosal involvement)
arrowcheck for lymph nodes especially cervical region ( glandular fever?) and ask for drug history.

Common questions examiners would ask you,

1) What is Steven Johnson syndrome?
2) What is the difference between Steven Johnson syndrome and toxic epidermal necrolysis?
3) If a patient had joint pain over ankle 3 weeks ago and was prescribed a medication by GP,what is the possible medication involved?
4) How do you manage this condition?


This lady has macular-papular rash due to drug allergy.

Extra points:

1) Always remember that you are not expected to diagnose all skin conditions, you would pass if you give a good and comprehensive description about the skin lesion.
2) Use this dermatology atlas to learn about common skin lesions!

Case ID: 2
Created: 22 July 2006

Examine this gentleman's skin.




 I give you this example because I think this is a popular case in MRCP. This case can be either come out in station 1 or station 5 ( skin station) . If you notice xanthelasma in a middle-aged woman with jaundice in your MRCP, always think of Primary Biliary Cirrhosis. You may find stigmata of chronic liver disease in this type of patient with +/- of hepatosplenomegaly.As I mentioned in my previous posts, you can gather some clues from peripheral to get the underlying cause of a patient's chronic liver disease, xanthelasma is one of them. Having said that, xanthelasma can be asked in station 5 as well. Besides xanthelasma, other stigmata of high cholesterol level include tendon xanthomata, eruptive xanthomata,palmar xanthomata and corneal arcus. Classification of hyperlipidemia is based on Fredrickson which can be divided to Type I to Type V. After your examination, proceed to the following,

arrowlook for other stigmata of hyperlipidemia,
arrowassess other risk factors for coronary heart disease such as sugar in urine, blood pressure and smoking,.
arrowtry to assess the possible secondary causes such as look for urine protein ( nephrotic syndrome), signs to suggest hypothyroidism,.
arrowfamily history of premature death due to coronary heart diseas and hyperlipidemia.

Common questions examiners would ask you,

1) How do you manage hyperlipidemia?

2) What are classes of drugs available to manage high cholesterol?


This gentleman has xanthelasma with underlying Diabetes Mellitus.

Extra points,

1) Learn a few important clinical trials involving statin such as 4S, MIRACL which are commonly asked in MRCP, click MRCP trials to learn more.
2) Remember the common side effects of statin.

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