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Case ID: 1
Created: 2 January 2007

Look at this gentleman and proceed (Station 5).




     This is an interesting case that you might be seeing in your MRCP PACES station 5. You notice this gentleman has obvious atrophy of the facial subcutaneous tissue. Yes, you are dealing with lipoatrophy. If you search any internal medicine book, generally, there are three types of lipoatrophy, namely generalised lipoatrophy/lipodystrophy, partial lipodystrophy and localised lipoatrophy.We are not very interested in the first one but in MRCP PACES, the later two are always the popular question. You notice this gentleman has very prominent lipoatrophy confined to his face only. You should try to look at this gentlman's upper and lower limbs for lipoatrophy and mention to your examiners that you notice that the lipoatrophy is only marked over this patient's face. ( Classically, HIV patients have wasting of face and limbs along with adipose tissue accumulations in the abdomen and back of the neck!)


If you look hard over this gentleman face again,you notice that he has seborrheic dermatitis over the face. So the diagnosis is clear, this gentleman has HIV and currently is on anti-retroviral medications. You should proceed to suggest to examiners that you would like to know the following,

arrow His latest CD4 count and viral load
arrow Anti-retroviral medications that he is currently on

Common questions examiners would ask you,

1) What other conditions are associated with lipoatrophy?

( Remember Mesangiocapillary glomerulonephritis, Localized scleroderma, Morphoea and Chronic relapsing panniculitis)

2) What type of anti-retroviral medication is generally associated with lipoatrophy?

( Remember the answer is NRTIs ( nucleoside reverse transcriptase inhibitors) especially starvudine!)


This gentleman has HIV and is currently on anti-retroviral medications .

Extra points:

1) Get more information about Lipoatrophy and HIV here

arrow Approaches to Treatment of HIV Facial Lipoatrophy
arrow Lipoatraophy and Drug Switch

Case ID: 2
Created: 2 January 2007

Station 2: You are the SHO in charge of Neurology Clinic.

Subject: Mrs Ong, 29-year old

Kindly see Mrs Ong who is currently 14- week pregnant. She complained to me about her persistent headache associated with vomiting for 2 months. I have started her on some paracetamol but did not help her symptoms at all. Her aunt just passed away about 2 months ago because of brain cancer and she is very worried about her symptoms. She hopes to get a CT brain in view of her symtoms.Kindly advise her about this.

I hope that you can help me to manage Mrs Ong.Thank you!


Dr Lee

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


  A common question in MRCP PACES examination. I always find geeting a history of headcahe is difficult. You must always get the following history while clerking this patient,

arrow TIME- onset, frequency,intervals and patterns and duration
arrow CHARACTER- location,intensity, nature of pain.
arrow CAUSES-predisposing and relieving factors

During you clerking, remember that some symptoms may suggest potential danger in a headache sufferer, these symptoms are,

arrow Recent onset of headaches.
arrow Headaches of uncertain pattern
arrow Presence of progressive neurological signs or systemic disturbance

arrow Presence of fever
arrow Presence of associated epilepic seizures
arrow A change in an existing headache pattern and unusual age of onset

Besides getting the history, you have to resolve the issue og CT brain in this lady. If you think that her symtoms are not significant to suggest any intracranial pathology. You should advise against doinf\g a CT brain!

Summarize your history taking with Mrs Ong and present to the examiners, your examiners will like to know what conclusion you can make from your interview.


1) Consensus Guidelines on the Management of Headache, 2005, MOH, Malaysia
2) Harrison's Principles of Internal Medicine

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