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Case ID: 1
Created: 28 May 2006

This patient complains of double vision. Would you  like to examine her.



            If you see bilateral ptosis in your MRCP PACES, then the examiners are either going to give you a clear pass or a clear fail .The reason is simple, you can either give a clear diagnosis or you do not have any ideas. There are only two possibilities in MRCP, either you are dealing with dystrophia myotonica or myasthenia gravis.

            You can make a diagnosis of dystrophia myotonica (DM) after you shake the patient’s hand. Patients with DM will have difficulty to release his/her hand grip. You can further demonstrate this by doing a percussion test. You can use your tendon hammer to percuss at patient’s thenar eminence , what you notice will be flexion of the thumb and then slow extension of patient’s thumb. The morale of the story is , in neurology station always SHAKE YOUR PATIENT’S HANDS BEFORE YOU PROCEED”. The next thing is you need to do is general inspection. If patient has DM, you will pick up by noticing that there is frontal baldness, expressionless face ( wasting of temporalis, masseters and sternomastoids) and bilateral ptosis.
            To make a diagnosis of myasthenia gravis (MG), the most important physical sign you need to demonstrate is fatiguability. There are two ways to do this, one is asking patient to look upward and start counting. You will notice patient will have difficulty to sustain upward gaze and the speech becomes nasal. Another way is asking patient to do repeated flexion and extension of shoulder.  


This lady has ocular myasthenia.

Extra points:

  1. Remember a few examples of drugs that can precipitate myasthenia crisis.
  2. Remember the mode of inheritance of DM- autosomal dominant and other associated symptoms and signs.( such as cataract, diabetes, and possible of heart block)

Case ID: 2
Created: 28 May 2006

Look at this patient and proceed.







            A very common short station case in UK. What you notice here is multiple telangiectasia over patient’s face as well as over his ear lobe. Other common sites to look for this are tongue, palate, nasal mucosa, nail beds, arms and trunk.

            After this, you should look hard for features to suggest heart failure if there is possibility of presence of shunt. Try to auscultate for bruit over the patient’s lung and liver. Also check for anemia because patient tends to have PR bleeding. Suggest to examiners you would examine fundoscopy to look for retinal haemorrahage and do PR to look for bleeding.

            Last but not least, ask for family history because it is inherited in an autosomal dominant way.


This gentleman has hereditary haemorrhagic telangiectasia ( Rendu-Osler-Weber Disease). He has history of recurrent PR bleeding.

Extra points:

  1. Remember the simple management about this condition such as oestogen, cauterization etc.
  2. Remember in your management, one very important part is counseling especially patient plans to have children in future.

Case ID: 3
Created: 28May 2006

You are the SHO in charge of the medical clinic (Station 2)

Dear Dr,

Ref: Mr Lee, 24 years old.

Kindly see Mr Lee who complains of weight loss for the past 3 months. He had recently had a bout of chicken pox. This did affect his lungs and I treated him for a chest infection with a course of antibiotics. My main concern is that he still complains of intermittent fevers and breathlessness.

Please see and advise.

With best wishes,
Dr Oh Pee Dee

You have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the examiners. Be prepared to discuss the solutions to the problems posed by the case and how you might reply the GP’s letter


            This question came out a few years back in Singapore MRCP PACES examination. I want to show you this question to remind you that in your examination, no matter what the patient’s symptoms are, if the patient is young, always think of HIV! My friend who sat for the exam asked patient a lot of questions and covered most of the possible diagnosis like thyrotoxicosis, inflammatory bowel disease……etc. However, patient refused to talk about his sexual encounters when asked, a common scenario in PACES. Remember to convince the patient that it is important for you to take this piece of information and you certainly share with him/her the feeling of  embarassment he/she may have.

            You must not be judgemental about patient’s sexual orientation and inform patients that you are there to help him/her. My friend failed this station because he failed to find out that this patient is actually a homosexual and was practicing unprotected sex with a lot of partners. The diagnosis was HIV with PCP!

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1) 250 Cases in Clinical Medicine, RR Baliga

(Last modified: 22 October 2006)