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Case ID: 1
Created: 20 January 2008

Examine this gentleman's upper limbs neurologically.

MRCP-Median nerve1


     For MRCP PACES examination, if you are asked to examine a patient's hand neurologically, there are a few possibilities. Generally, it is always some problems with the power, however, remember that you might be asked to examine a patient with Parkinson's disease who has rigidity/bradykinesia.

At first, you may be panic! I find that a lot of candidates think that neurology station especially involving hand examination a difficult station. I always believe the first rule in clinical examination- inspection, inspection and INSPECTION!! You save time and energy if you spend 1 minute observing your patient properly. And NEVER forget to look at the patient's lower limbs as well if the examiners ask you to examine the upper limbs and vice versa.

MRCP-median nerve2

Always remember inspect the dorsum and the palmar aspect of the hand. In this gentleman, you will notice that there is an obvious wasting of right thenar eminence and lateral two lumbricals ( you will see the wasting of the thenar eminence at the following video clip).

Now, the diagnosis becomes so obvious. However, I always advise candidates to do a proper examination of the hand- namely- Inspection, Palpation, Tone, Reflexes testing, Motor movement, Sensory testing and Coordination. However, in this case, insepction alone is enough for you to come to the diagnosis.

Remember that all small muscles of the hand are supplied by ulnar nerve except LOAF- Lateral two lumbricals,Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis. These 5 muscles are supplied by median nerve. I also hope that you remember that thenar eminence is formed by three muscles- namely OAF ( Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis), therefore when there is paralysis of median nerve, there is wasting of thenar eminence!

The sensory part of the median nerve- palmar aspects of the first three and a half fingers. Always show to the examiners the proper way to test of sensation!

OK, now I would like to show you a video clip how to test for thumb abduction which is impaired in this gentleman!


During your MRCP PACES examination, you should not just stop here, you have to find out the underlying cause for this gentleman having Carpal tunnel syndrome, the common causes are,

arrow Idiopathic- although you tend to find this in obese females,
arrow Pregnancy,
arrow Contraceptive pill,
arrow Endocrine causes- acromegaly, hypothyroidism,
arrow Rheumatoid arthritis,
arrow Amyloidosis,

Always show the examiners the proper way to test for Tinel's sign!OK, in this case, you notice that this gentleman has a functioning fistula over his left cubital fossa, so do you know the diagnosis now??

Diagnosis: This gentleman has right carpal tunnel syndrome most probably due to amyloidosis because of prolonged haemodialysis.

Common questions examiners would ask you,

1) What is the action of lumbrical muscles?

2) What muscles form the thenar eminence?

3) Why patients on haemodialysis are prone to get amyloidosis?

Extra points:

1) Learn more about median nerve at

Patient- UK

Case ID:2
Created: 20 January 2008

Interesting Images in Clinical Medicine

MRCP-fungal infection

Case Summary:

    This lady presents with a skin rash. What is the diagnosis? Start your discussion with other PassPACES users in our Forum!  

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