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Case ID: 1
Created: 18 June 2006

Look at this lady and proceed.



     A very popular question in MRCP PACES exams. This case can be used as a case in skin as well as locomotor sub-stations. You notice that this lady has tight skin over her face with multiple telangiectasia (arrows). You can see clearly that her mouth appears to be tight. ( Demonstrate by asking the patient to put 3 fingers into her mouth).Describe the nose and proceed to do the following,

- check for dry eye because Sjogren's syndrome can be associated with scleroderma.
- check the hands and look for sclerodactyly ( image below), Raynaud's phenomenon, peudoclubbing and calcinosis.
Also assess the extent of skin involvement!


- assess the patient's hands functions by doing hand grip, pincer grip (holding key) and unbuttoning of clothes.
- ask patient relevant history such as dysphagia, shortness of breath (lung fibrosis) and diarrhoe ( malabsorption)
- ask permission from examiners that you would like to listen to her lungs, check her BP ( ? hypertension), look for other organs involvement and look at her stool for evidence of malabsorption.

Common questions examiners will ask you,

1) what types of autoantibodies can be present? (ANA,anticentromer and anti-topoisomerase)
2) what are the prognostic factors? ( Sex- male tends to do worse, patients with extensive skin involvement and
renal involvement tend to do worse!)
3) How to explain chronic diarrhoe in this type of patient? ( bacterial overgrowth)
4) What are the criteria to diagnose of scleroderma?
5) How would you manage a patient with scleroderma?


This lady has systemic sclerosis.

Extra points,

1) Prednisolone has no role in treating systemic sclerosis.
2) Four reasons for this type of patient to get anemia. They are iron deficiency due to chronic oesophagitis, anemia due to
malabsorption, anemia of chronic illness and microangiopathic haemolytic anaemia.   

Case ID: 2
Created: 18 June 2006

Examine this gentleman's leg.



    My friend got this case in his MRCP PACES in 2005. It is an easy case if you know how to approach this case. You can see obviouly two small swellings over this gentleman's first toe and little toe. Although books describe chronic tophaceous gout as 'chalky 'material, sometimes you would just notice a swelling such as in this case.After you feel, palpate and move the relevant joints, you should look at other sites for similiar swelling. These sites include helices of the ears, olecranon bursae, tendons of hands and Achilles tendon. Another diagnosis that you may confuse with swelling over tendons is tendon xanthomata! Also suggest to examiners that you would look at the urine for haematuria and you are very interested to know about this patient's renal function.

Common questions examiners would ask you,

1) What factors can precipitate acute gouthy arthritis?
2) When do you start to treat hyperuricemia?
3) How do you explain patients with gout to have bilateral leg swelling? ( Fluid overload due to CRF). 


This gentleman has chronic tophaceous gout.

Extra points:

1)Clinical presentations of gout include asymptomatic hyperuricemia, acute arthritis, chronic arthritis and chronic tophaceous gout.
2)Uric acid crystals are negatively birefringent. (Facts from Baliga's book!)

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