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Case ID: 1
Created: 20 Aug 2006

Inspect this lady and proceed.




      A popular skin station in MRCP exam. All candidates would pick up the physical signs and come to a diagnosis after inspection, however, examiners would only pass you if you know how to examine systematically a patient with vitiligo.Vitiligo is a chronic skin disease that causes loss of pigment, resulting in irregular pale patches of skin. Vitiligo is always described as " hypopigmented patches with white hairs in vitiliginous area". Areas commonly involved include perioral, periorbital, axilla , upper and lower limbs.After your initial inspection, try to look at the patient's scalp for white hair and alopecia ( vitiligo is associated with alopecia areata). Then, proceed to look for jaundice ( autoimmune hepatitis), pallor ( pernicious anaemia) and thyroid swelling. Remember that you must suggest to examiners that you would like to check for postural drop of blood pressure which may suggest Addision's disease and check urine for Diabetes Mellitus.Look for other autoimmune diseases as well such as Rheumatoid arthritis, SLE etc.However, always remember that patients with leprosy or Pityriasis versicolor may have hypopigmented skin but the hypopigmented skin tend to be more localized. You would find reduced sensation at the hypopigmented skin if you suspect leprosy. There are various available treatment for vitiligo. Topical steroid may be useful at initial stage.Other topical immunomodulators may be useful such as calcipotriene and tacrolimus.

Combinations of therapy often give better results than single modalities. These include calcipotriol with PUVA (Psoralen ultraviolet A therapy ) and tacrolimus with laser.



Common questions examiners would ask you,

1) What are the associated conditions in vitiligo?
2) How do you manage this patient?


This lady has vitiligo.

Extra points:

1) About 20-25% of patients has other cutaneous and systemic diseases associated with vitiligo.
2) Learn more about Vitiligo from here !

Case ID: 2
Created: 20 August 2006

Examine this lady's hand.( MRCP Station 5)



 I show your this case again because I would like to warn you that you may only find subtle sign in gout during you MRCP PACES exam. My friend was asked to examine a patient's hand in his MRCP PACES in Singapore, actually , he couldn't find any positive signs and he was so panic until he found a small tophi over the patient's ear lobe.Such as in this patient, you only notice a small swelling over her left index finger. However, the diagnosis of gout would be clear if you take a few seconds to look at her face before touching the patient.


Now, the diagnosis is clear, you are dealing with gout. The lesson to be learned here is, when you are asked to examine a patient's hand in MRCP PACES, look at the patient's lower limb and the face as well. You might save a lot of time struggling to get the diagnosis if you spend a few more seconds to inspect the patient properly. I would like to remind you that in Station 5, you would get the diagnosis most of the time after inspecting the patient ( except in fundoscopy, of course!).

Common questions examiners would ask you,

1) How do you diagnose gout?

2) What may be the mechanism of a patient with gout to have renal impairment? ( obstructive uropathy and NSAID abuse)


This lady has chronic tophaceous gout.

Extra points:

1) Related post, click here!

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