QuickScroll  Case 1 | Case 2

Observe this gentleman's gait and proceed .

Discussion:

     PassPACES.com makes its first attempt to include video in our featured article. Hope you can give us your feedback by contacting us!OK, you are expected to know how to examine a patient's gait in your MRCP PACES examination. However, there are only a few popular cases in MRCP PACES gait examination. You notice this gentleman has a waddling gait. This gait is seen when the patient's legs are held wide apart and the patient shifts weight from one side to the other as he walks. Of course, you may see this gait in a pregnant woman, however, you should anticipate patient to have proximal myopathy if you see this gait in your MRCP PACES examination because you are unlikely to get a case of straight forward pregnancy in your exam!Causes of proximal weakness include,

Hereditary muscular dystrophy ( the most popular case you would see if you notice waddling gait in your MRCP PACES)
Congenital myopathies ( very rare- you are unlikely to get this unless you are if you are sitting for MRCPCH)
Acquired myopathy ( Remember the mnemonic of PACHE,PODS)

     Polymyositis or dermatomyositis ( always pick this up by paying attention to patient's hand and face before you even start examining you patient's lower limbs)

 Alcohol
    Carcinoma
    HIV infection
    Endocrine ( another popular cause of proximal myopathy in MRCP PACES- routinely check for proximal myopathy if you suspect a patient has hyperthyroidism, acromegaly, Cushing's syndrome, hypopituitarism)
    Periodic paralysis
    Osteomalacia
    Drugs-eg steroids, zidovudine, chloroquine   
    Sarcoidosis

After you have observed his gait, shake his hand and introduce your self.Spend a few seconds looking at his hand and facial muscles as well because one of your differential diagnosis is Fascioscapulohumeral dystrophy. You are expected to see obvious facial muscles dystrophy in this condition.Proceed to lower limbs examination. You would notice this gentleman has pseudohypertrophy of calf muscles, proximal weakness, no sensory involvement and usually the reflexes are normal. Suggest to eaxminers you would like to examine upper limbs as well to look for proximal myopthay and look for pseudohypertrophy of deltoids.After your physical examination, ask permission to do the following,

Get a complete family history about similar problem,

Suggest to examiners you would like to look for scar of any recent muscle biopsy ( usually over deltoid region),

Examine patient's heart because some muscular dystrophy are associated with dilated cardiomyopathy,

Common questions examiners would ask you,

1) What is the difference between Duchenne and Becker muscular dystrophy?
2) What is the difference between Limb girdle and Facioscapulohumeral dystrophy?

Conclusion:

This gentleman has Becker muscular dystrophy .

Extra points:

Station 4: You are the SHO in charge of Rheumatology ward.

Subject: Miss Ang Bee Ling, 22-year old

Miss Ang was admitted to your ward about 2 weeks ago due to generalised joint pain with malar rash. Further investigation revealed that she has positive ANA, dsDNA results and she was diagnosed to have SLE by your consultants. She was started on steroids, calcitriol and calcium supplements, her condition improved ever since.She is due for discharge today but she is worried about her condition and wants to discuss with you about her SLE. Your task is to explain to her about SLE and her futher management.

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

Discussion:   

  As I said in my previous issues, this type of case is very popular in MRCP PACES . You are expected to tell Miss Ang the following,

what SLE is,
how the diagnosis is made,
what are the common presentations,
possible complications if she is interested to know,
possible treatment ( always remind her that it is a chronic disease and there is no cure for SLE but reassure her that there are a lot of treatment options available to bring this disease under control),
possible side effects of treatment ( steroids),
pregnancy and breast feeding.

Always remember to talk about fertility and pregnancy problems if you are dealing with young woman in your MRCP PACES examination. If the patient is interested, you may even talk about breast feeding issue with your patient. Actually, my friend failed this station many years ago because he did not manage to talk about this issue with a young female SLE patient in his MRCP PACES. His patient was so worried about her SLE as she was getting married soon and hope to find out about whether pregnancy was contraindicated, however my friend totally forgot about this issue even though his patient reminded him that she was getting married soon!

Source:

1) Clinical Examination-A systematic Guide To Physical Diagnosis, Nicholas J Talley
2) 250 Cases in Clinical Medicine

To see previous issues, click here! To send a quick comment, click here!