Pass MRCP Header

MRCP PACES Home MRCP Featured Article MRCP Previous Issues MRCP Forum Here MRCP Blog Here MRCP Support Here



Make a better site!


QuickScroll  Case 1 | Case 2

Case ID: 1
Created: 29 February 2008

Examine this lady lower limbs neurologically and proceed.



     For MRCP PACES examination, as I told you before, lower limbs examination is the most popular case in neurology station. When you are asked to examine the lower limbs neurologically, there are a few things you must always bear in mind. You are probably dealing with a few possibilities- motor, sensory, combined motor and sensory or extrapyramidal problems. Do a general inspection of your patient. Look for tell-tale signs such as bladder indwelling catheter , obvious muscle wasting and fasciculation.

First step in your lower limbs examination is assessment of tone. I think it is a single most important step in lower limbs examination because you might be able to come to the diagnosis by just assessing the tone. You may find notice spasticity ( increased tone), flaccid tone ( reduced tone), normal or rigidity. Remember how to differentiate spasticity form rigidity becuase it is a popular question in MRCP PACES. You will get a clue what type of case you are dealing by assesing the tone.If you asess the tone of this lady, you notice that there is increased tone and to confirm this, you check for ankle clonus as shown below,


OK, you know that this is a upper motor neuron lesion case. The rest will be quite easy because bilateral spastic paralyisis is usually caused by spinal cord lesion except parasagittal falx meningioma in the brain. Further examination ( especially whether posterior colume or sensory is involved) will tell you the underlying cause.

In this lady, you notice that there is sensory level involvement up to T9 level. Therefore, you know that it is most probabably a spinal cord lesion such as injury to the spinal cord, compression to the spinal cord ( you can further classify the causes into extradural or intradural- extramedullary or intramedullary), spinal cord infarction or myelitis.This lady has spastic paralysis with sensory and cerebellar involvement.

During you MRCP PACES examination, it is your duty to find any physical signs to come to the diagnosis.I would suggest you to do the following,

The Multiple Sclerosis Diet Book: A Low-fat Diet for the Treatment of MS

arrow check for any injury at the back such as previous surgical scar,
arrow look for optic neuritis,
arrow check for upper limbs- any involvement? muscle wasting?
arrow look at temperature chart,Endocrine causes- acromegaly, hypothyroidism,
arrow assess anal tone and peri anal sensation,

Diagnosis: This lady has bolateral spastic paralysis with sensory level and cerebellar involvment and most probably is due to multiple sclerosis.

Common questions examiners would ask you,

1) What are the investigation you will order for this lady?

2) What do you expect to find in this lady CSF after lumbar puncture?

3) How do you manage this lady ?

4) What is your advice about pregnancy?

Extra points:

1) Learn more about Poser's criteria to diagnose Multiple Sclerosis at


Case ID:2
Created: 29 February 2008

Interesting Images in Clinical Medicine

lung fibrosis

Case Summary:

    This lady presents with shortness of breath for 2 months. What is the diagnosis? What are the causes for this condition? Start your discussion with other PassPACES users in our Forum!  

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