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Look at this lady's fundus! ( Station 5)

Discussion:

     To learn more how to do a proper fundoscopic examination, kindly go to MRCP Tips on Station 5. As I said earlier, , there are only a few possibilities for your fundoscopy station in your MRCP PACES examination. We have discussed about Retinitis Pigmentosa, we will talk about diabetic retinopathy today.

    During your examination, you must tell your examiners whether your patient has diabetic background, pre-proliferative or proliferative retinopathy because this determines your urgency for referal. Background diabetic retinopathy just means dot and blot hearmorrahges,microaneurysm and hard exudate, preproliferative changes just mean presence of cottonwool exudate/spots and venous dilatation and proliferative changes mean neovascularization and presence of laser burns ( in treated cases). There is always one important part candidates tend to forget during thier examination, I always remind candidates not to miss the macula region because any involvemnt of the macula ( which leads to impaired visual acuity) may prompt you to refer the patient to a opthalmologist.

    In this picture, patient has background diabetic retinopathy. You seldom see more than this in UK centres because usually their diabetic patients present early to a opthalmologist, however, if you decide to sit your MRCP PACES in Malaysia, you will usually get a case with very bad retinopathy such as haermorrhages with laser scar and neovascularization. After this, always remember to ask patient to look into your fundoscopy light to check the macula region. Suggest to examiners that,

You would like to examine the patient's blood pressure because you want to control tightly patient's blood pressure,

Since retinopathy is a microvascular complication, you would like to look for other mircovascular complications as well such as nephropathy. Therefore, suggest to examiners that you would like to look for urine microalbuminemia,

Always look at the patient generally because you do not want to miss other obvious diabetic complications such as previous stroke ( one-sided weakness), diabetic foot ulcer, charcot joint etc..

    Remember that during your presentation, you must tell the examiners what type of diabetic retinopathy you notice and your plan of management ( either an urgent or non-urgent referal to opthamologist)

Common questions examiners would ask you,

1) How do you differentiate a new from an old laser scar?

( It is a popular MRCP PACES question. You can find the answer in your text book. In old laser scar, you would notice hyperpigmentation but not in a brand new laser scar!)

2) What other causes for cottonwool spots?

( Remember that leukemias also give you cottonwool spots. My friend actually got this case in her MRCP PACES in UK, she noticed an obvious chemoport in a patient and she picked up cottonwool spot but she mentioned Diabetic retinopathy as the diagnosis.She failed badly in that station!)

Conclusion:

This lady has background diabetic retinopathy!

Extra points:

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

Subject: Miss Lim, 24 years old

Kindly see Miss Lim who came to me, complaining about recurrent episodes of loss of consciouness for the past 2 weeks. She also told me about the headache she has been having for the past 1 month.Although I do not find any thing wong with her clinically.I am worried about brain tumour as one of her relatives passed away recently because of brain cancer at the age of 29 years old. I hope you can see her.

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

Discussion:

     A common question in MRCP PACES station 2. You are quite lucky in this case because you know that your patient is worried about brain cancer. Therefore, after your 14 minutes with Miss Lim, you must at least have some ideas about the possible diagnosis and be able to answer Miss Lim's queries about brain cancer. As you might remember as a medical student, there are a few important causes for loss of consciousness, these cause include,

    CNS -The most important differential would be seizure, therefore always ask about withness and abnormal movement during the LOC. Since this patient is worried about brain tumour ( neoplasm), ask about 'red flag' symptoms such as symptoms suggesting increased intra-cranial pressure- nausea, vomitting, diplopia,early morning headache. Always remember to ask about body weakness and numbness as well. Chronic meningitis may be your differential diagnosis as well and always ask about symptoms suggesting Tuberculosis!
    CVS- Cardiac arrhythmia , HOCM ( hypertrophic obstructive cardiomyopthy) can lead to LOC as well. However, since this patient has headache also, she is more likely to have CNS lesion for her symptoms. Always ask about palpitation, chest discomfort etc.
    Vasovagal attack-It is rather common among young ladies.
    Endocrine- Patient may be having recurrent hypoglycaemia. Always ask about drug abuse or patient may be having insulinoma!

Remember the following rules, for almost every symptom, ask about this information,
    Duration-duration of the symptoms.   
    Nature of the symptoms-such as for headache, the nature of the pain, one sided, both sided, etc.....
    Precipitating or relieving factors- this informnation may help you to come to the diagnosis!
    Associated symptoms

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