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Case ID: 1
Created: 20 March 2011

Pass MRCP PACES in ONE Attempt! - 4th Edition- Coming soon in April 2011

Station 5 ( Short Cases Station):

Subject Madam Sharifah- 44 years old lady

You are required to see Madam Sharifah who complains of joint pain for the past 6 months.The pain is persistent and affects her daily activities. She has been taking very frequent medical leaves for the past 6 months. She was told by her GP to have she has rheumatoid arthritis.

You are required to see Madam Sharifah and address her concerns.



Yes, joint pain is always a popular topic in station 5 in MRCP PACES short station.I always like to divide causes of joint pain into causes leading to symmetrical or asymmetrical joint involvement. Classical causes for symmetrical joint involvement include Rheumatoid arthritis and SLE. For this case, you might initially having difficulty to know the diagnosis. But as I told many of you before- always look beyond in MRCP PACES. If they ask you to examine the hand, do a proper general inspection and the most important area that I will look is patient's lower limbs.

If you look at Madam Sharifah lower limbs, you will know the diagnosis straight away,



YES! You are dealing with Psoriatic arthropathy!! You can see psoraitic plaque in the lower limbs so obviously!Joint involvement in psoriasis has various presentations. These include symmetrical involvement ( such as in Rheumatoid arthritis),asymmetrical involvement, sacroiliitis and arthritis mutilans.

Once you know the diagnosis, you must look hard for other features of psoriatic arthropathy,

arrow1) Nails- Look for nail pitting, onycholysis and discolouration.

arrow2) Other sites of skin involvment- Classical sites include extensor aspects of elbows,scalp,submammary region,umbilicus and natal cleft.

You are not done yet, you need to address the patient's concern, this lady is very worried that she might get Rheumatoid arthritis and her joints will be destroyed in future. You need to inform her that after your assessment, you think she is unlikely to get Rheumatoid arthritis.

Popular questions examiners might ask you during your MRCP PACES,

1) What is the treatment available for her joint pain?

2) Mention a few exacerbating factors for psoriasis.

Extra points:

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Created: 20 March 2011

Breaking trial in Clinical Medicine/Nephrology


Background History:

    Although diuretics is always considered as the major drug used in treating acute heart failure. We are always not sure whether highr or lower dose and whethetr bolus or continuous infusion is a better option. These questions are answered in this recent NEJM study.

Click HERE to look at the report.

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