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Look at this gentleman's hand who comes to hospital due to giddiness. ( Station 5)

Discussion:

     Remember that when you are asked to examine a patient's hands in your MRCP PACES examination, you are not always dealing with locomotor cases. My friend failed this sub-station when she sat her examination in UK. If you can not find any obvious lesion ( swelling or deformity) in patient's hands during your examination. Look hard at the palm, such as in this case, you notice that this gentleman has skin pigmentation over his palmar creases. ( As for your interest, if you can't find anything wrong with your patien's hands, look at the nails as well, examiners may just want you to pick up onycholysis!!)

Once you pick up this clinical sign, you have to show the examiners that you are convinced that this is Addison's disease, therefore you have to look for other sites for skin hyperpigmentation. Common areas include,

Buccal mucosa and lips,
Area around a scar,
Areas not covered by clothing: nipples, areas irritated by belts, straps, collar and rings.

Other clinical signs to suggest Addison's disease include loss/sparse axillary and pubic hair (especially in females), presence of Medic Alert bracelet ( this is very common in UK although you can't find it in Malaysia) and postural hypotension. After your initial examination, you have to show to examiners that you are interested to find out the underlying cause, I would suggest you to examine/ look for the following,

vitiligo or pernicious anaemia to suggest autoimmune in origin,
features of mucocutaneous candidiasis to suggest Polyglandular syndromes Type 1,
features of thyroid disease ( hyper- or hypothyroidism) to suggest Polyglandular syndrome Type 2,
abdomen for adrenal scar due to previous operation.

However, most of the time, you can not find out the underlying cause.I will usually suggest to examiners that I would like to complete my examination by looking at patient's CXR because one of the common causes of Addison's disease is adrenal tuberculosis in which you may find tuberculosis changes in CXR.

Other features of Addison's disease is summarized at the following picture,

One common question you must always ask yourself during your MRCP PACES is " Is this Addison's disease? " because skin hyperpigmentation does not equal to Addison's disease. Other common causes of skin hyperpigmentation,

Common questions examiners would ask you,

1) How do you investigate thsi patient?

2) How do you manage this patient?

3) Mention some common causes of Addison's disease.

Extra points:

Interesting Images in Clinical Medicine

Case Summary:

    This lady presents to us with joint pain and skin lesion. What is the diagnosis? Start your discussion with other PassPACES users our Forum!  

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