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YOUR LATEST ISSUE ABOUT MRCP PACES IS HERE!
Inspect this gentleman and proceed.
Discussion:
A very, very popular skin station in MRCP exam if you are taking the exam in Malaysia or Singapore. You notice that this gentleman has multiple angiofibroma (adenoma sebaceum) over his face ( malar distribution). The diagnosis is clear at this moment and you must show to examiners that you know a lot about Tuberous sclerosis. Look for other features of Tuberous sclerosis such as subungual/ periungual fibromas ( image below-a common mistake for majority of candidates is they usually look hard at patient's hand and forget that these can be present over patient's toes as well), Ash-leaf patches ( hypopigmeted) and Shagreen patches. ( always suggest to examiners you would like to expose patient properly to look for these skin lesions but if time is limited, at least spend some time to look at patient's back!). After you complete your physical examination, tell examiners that you would be interested to look at the fundus and you are expecting to find retinal hamatormas and check the abdomen to look for ballotable kidney ( due to renal hamartoma). After these steps, you should suggest to examiners that you would get a complete family history of similar problem and take history from patient about epilepsy.You would be interested to test the patient's IQ.One common mistake candidates make in exam is they tend to forget to look for signs suggesting side effects of anti-epilespy medications. Look hard for signs suggesting pheytoin side effects such as cerebellar signs, gum hypertrophy and hirsutism. Also look for side effects of other anti-epileptic!
Common questions examiners would ask you,
1) What can you usually find in this patient's CT brain?
2) How do you manage this patient?
Conclusion:
This gentleman has tuberous sclerosis.
Extra points:
1) TSC is caused by defects, or mutations, on two genes-TSC1 and TSC2. Only one of the genes needs to be affected for TSC to be present. The TSC1 gene, discovered in 1997, is on chromosome 9 and produces a protein called hamartin. The TSC2 gene, discovered in 1993, is on chromosome 16 and produces the protein tuberin.
2) Learn more about Tuberous sclerosis from here !
| Case ID: 2 | Created: 14 August 2006 |
You are the SHO in charge of the medical unit
Subject: Mr Smith, 22 years old
Mr Smith, an ex-IVDU was admitted to your hospital 1 week ago due to shortness of breath. CXR revealed bi-hilar haziness and your consultant thought that he was suffering from pneumocystis carinii pneumonia. He responded to your treatment and you are asked by your consultant to ask permission from him for HIV testing.You have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the examiners.
Discussion:
Pre-test counselling for HIV is always a common scenario in MRCP PACES. Candidates always find that they have problem to tell patient's the diagnosis (PCP) and then switch the topic of discussion form PCP to HIV testing. I always tell my junior doctors that before going into deep discussion with the patient, always assess the patient's understanding about his problem. Therefore, after introducing yourself and a few simple questions like" How do you feel today?" I would start off by asking" Mr Smith, I learned that you were admitted to our hospital about one week ago, did anyone tell you what's wrong with you?" You may be surprised to find out how little patient knows about his condition. Then you can briefly talk about Pneumocystis Carinii Pneumonia and tell patient that he feels better because of the treatment. After this, a lot of candidates find it difficult to talk about HIV and how to switch the topic of discussion from PCP to HIV.I find a solution to this problem, I would suggest to you that you may want to try to explain to patient that it is rather rare for you to find young adults to get PCP infection and mention that there are a few conditions that can prone him to get this infection. Mention HIV as one of them and proceed to assess patient's understanding about HIV. After this, explain to patient about HIV, relevant information to be included are what HIV is, mode of transmission, possible long term complications and treatment. Do not forget to get futher sexual history and social history from patient.
After this, assess patient's risk about HIV infection and ask him whether he has any question to ask you about HIV. Explain to patient that your consultant and you think that it is necessary for him to have HIV testing. Explain to him how the test is performed and how to interpret positive and negative results. Mention about possibilities of false negative and positive results as well. Remember to explain the difference of HIV and AIDS. Convince the patient about the benefit of early detection and reassure him that the test result is confidential. If you have time , you should discuss with patient about the implication of the test result regarding to future insurance purchase.
Before you end your interview with patient, tell him that your hospital has a special trained nurse to give him further counselling if he has further question to discuss. Arrange next appointment date if he is undecided about the test. remember that if patient is not agreeable with you about something, always ask him the reason behind this!
Common questions examiners would ask you,
1) What is 'window period ' for HIV?
2) If the patient is married and turns out to be postive for the HIV test, would you tell his wife if he refuses to tell his wife about the result?
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