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Examine this gentleman's fundoscopy.

Discussion:

     This is one of three commonest cases you would get in your MRCP PACES fundoscopy sub-station. Candidates should not have problems picking up the physical signs. However, remember that you should have a systematic way of doing fundoscopic examination, I suggest you to do the following steps,

have a general inspection of your patient, pay attention to any surgical scar over patient's scalp ( which may suggest previous head surgery), diabetic dermatopathy or previous amputation, walking stick ( ? blindness) etc which might give you a clue of the patient's underlying disease,
give clear and loud explanation, tell your patient to look straight and avoid moving his/her eye balls. However, remind your patient that he/she CAN blink his/her eyes. Remember to tell your patient that your fundoscopy light may make him/her feel uncomfortable.
you should not remove your spectacles while examining the fundus. This certainly needs practice!
look at the eye from a distance and check for red reflex ( Candidates are likely to fail you if you miss obvious cataract or retinal detachment!)

look at patient's right and left eye using your right and left as well, if you only know how to use your right eye to do a fundoscopic examination, you are going to kiss your patient when examining his/her left eye!
look at the fundus properly, start from centre to periphery or otherwise ( look at patient's optic disc, macula and peripheral retina. Pay attention to the vessels as well),
ask you patient to look directly to your fundoscopy to check for macula pathology again during your last step of examination( because the patient's pupil will constrict after this),repeat these steps while examining the other eye.
last but not least, thank your patient and suggest to examiners what other relevant bed side tests you want to do such as checking urine for mircoalbuminuria, blood pressure, visual field, visual acuity etc.

OK, you notice this patient has irregular balck deposits of clumped pigment in the peripheral retina. ( Always described as bone spicules because of their vague resemblance to the spicules of cancellous bone). Remember that the pigment spots lie anterior to the retinal veins ( as compared to spots of choroidal atrophy in which they lie posterior to the vessels). You also notice the optic disc to be pale.You should proceed to do the following,

suggest to examiners you would like to take a family history, Retinitis Pigmentosa can occur sporadically or in an autosomal recessive, dominant, or X-linked pattern.

check patient's visual field and ask about night blindness ( nyctalopia)( patients tend to have constricted visual field with a ring scotoma and loss of acuity)

check for signs to suggest associated systemic disorders such as cerebellar signs ( Olivopontocerebellar degeneration, Friedreich's ataxia), polydactyly (Laurence-Moon-Biedl Syndrome), external ophthalmoplegia ( Kearns-Sayre Syndrome).I think it is enough to remember three examples, you are unlikely to remember everything in exam!

Common questions examiners would ask you,

1) What are the possible problems faced by this patient in term of vision?
2) How do you manage this patient?

Conclusion:

This gentleman has retinitis pigmentosa with night blindness and constricted visual field .

Extra points:

Station 2: You are the SHO in charge of Respiratory clinic.

Dear Dr,

Subject: Mr Abdul Rashid, 40-year old

Kindly see Mr Rashid who is a Malaysian migrated to UK about 20 years ago. He has had a 6-week history of cough . He has background history of diabetes mellitus for 10 years on oral medications.His last fasting glucose was 11 mmol.I have done a CXR but I couldn't find any abnormality. I am worried about tuberculosis. I would appreciate if you can offer your expert opinion.

Best Regards,

Dr Henry Young

You have 14 min until the patient leaves the room followed by 1 min for reflection before the discussion with the examiners.

Discussion:   

  A popular question in MRCP PACES station 2. There are a few diagnoses you must consider in this case,

asthma
chronic obstructive airway disease ( COPD)
oesophageal reflux/gastritis
postnasal drip
tuberculosis
lung cancer
sarcoidosis and drugs.

As I said in my previous issues, when you try to get history form your patient about a symptom- remember to ask the onset, duration, severity, precipitating or relieving factors and associated symptoms ( in this case, you certainly are very interested to know about haemoptysis, fever and Pulmonary Tuberculosis contact). Get all the relevant history to cover all you differential diagnoses. For this case, you must get history as well for Mr Rashid's diabetic control.

I like to stress again about the importance of getting a proper drug history. Actually, this gentleman was recently diagnosed to have hypertension by another GP and he was started on ACE-inhibitor. Remember that at the end of your history taking, you must be able to answer one important question " Is Mr Rashid having tuberculosis?" because his GP and most probably Mr Rashid himself is very concerned and worried about this!

Outline your plan of action and briefly use 2-3 mins to tell Mr Rashid what is your next plan of action ( either admit him or investigate as out patient). Inform Mr Rashid what kinds of investigation you want to do and what is your provisional diagnosis!

Source:

1) Harrison's Principles Of Internal Medicine, Fauci
2) 250 Cases in Clinical Medicine

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