Station 4

Station 4

Station 4 in MRCP PACES is an assessment of communication skills and ethics. Many, particularly Asians whom english is not their first medium find it difficult. However, I believe practice makes perfect. Like history taking station, this is a station that you will be able to practice at anytime, anywhere, all you need is a study partner and An Aid to the MRCP PACES vol. 2 by Ryder.

What I did with my study partners was each of us will take turn to become candidate and surrogate while the others will observe and give their comments after the session. Initially we practised with the senarios from the books. Later, we created our own senarios.

When reading the case senario, you should be able to relate your senario to the 4 ethical principals, this could help you in the discussion with the surrogate later.
The 4 ethical principals:

1. Patient's autonomy

2. Beneficence

3. Non-maleficence (do no harm)

4. Justice

There are few senarios that I think sometimes are difficult to discuss about, one of it is brain death.

Case Senario - Brain death

You are the SHO in medical ITU and you are about to see Mr L, the father of Miss L, a patient in ITU.

Miss L, 25 year-old Chinese lady who was admitted 3 days ago with massive intracranial bleed due to a ruptured cerebral aneurysm. She was intubated immediately in ED for poor GCS and subsequent CT brain showed massive ICB with midline shift. She was referred to neurosurgical team for intervention which was done before she was sent to ITU with 3 inotropes. Sedation was halted 36 hours ago and Miss L has shown no neurological response. Your neurology consultant and the ICU consultant has decided for a brainstem testing which was done earlier today and Miss L has been confirmed brain dead. Currently, Miss L is ventilated, her BP is 100/60 mmHg on 3 inotropes and ECG showed sinus rhythm. Your task to to explain to Mr L the diagnosis of brain death and explore the possibility of organ donation.

I shall leave this to you and your study partners to discuss about it.


Useful website:
Brain Death: A Simple Explanation for Donor Families
http://www.kidney.org/transplantation/donorFamilies/infoBooksBrain.cfm

Station 5 - Reduced Effort Tolerance (part 2)

This is a straight forward senario, this young lady has Marfan syndrome.

First picture - tall and thin build young lady with disporpotionately long arms and legs

Second picture - high-arched palate

Third picture - left eye showing superotemporal subluxation of the lens.

It is not difficult to get the diagnosis of Marfan syndrome as the features are quite prominent. What the examiner want to see is how you take history and perform physical examination to confirm your diagnosis and look for any possible complications of the disease. Of course, not to forget to answer to patient's concerns.

History:
- Family history
- Symptoms of heart failure
- Eye problem

Physical examination:
- Noted tall patient with arm span exceed the height
- Hands – thumb sign and wrist sign
- Eyes – vertical subluxation, myopia
- Head – long headedness
- Palate – high-arched
- Chest – pectus excavatum, cystic lung disease
- Heart – MVP, AR
- Spine – kyphosis and scoliosis

There are few systems that are involved in Marfan syndrome, therefore you have to be systematic when you perform physical examination. The only way to be smooth and systematic in the exam is by practising a lot. Get a member in your group to be the simulated patient and practice the flow on him/her. This is particular useful in cases with multiple systems involvement and neurology cases.

Investigations
Echocardiography, chest and spine radiography, CT/MRI

Management
- Yearly echo – monitor aortic diameter and mitral valve function
- Ophthalmology and orthopaedics referral
- Genetic counseling

A few useful websites:
1. Diagnostic criteria
http://www.marfan.org/cms/uploaded_files/8XJIUG81F3/89/docs/factsheet_mfsbodysystem.pdf
2. National Marfan Foundation
http://www.marfan.org/marfan/

Station 5 - Reduced effort tolerance

Station 5

You are the SHO in medical clinic. You received a referral from a G.P.

Dear Doctor,

Thank you for seeing miss R, 16 year-old Malay lady who complained of reduced effort tolerance for the past 2 months. Her FBC and ECG are both normal. Kindly see her for further assessment and management. Thank you.

Sincerely,
Dr G.P


Please take history from this patient and perform necessary physical examination. You are also required to answer to her concerns.

This is the patient:






What do you think is the most likely diagnosis? How would you approach?

(Special thanks to my ophthalmology colleagues for providing the photos above)

Station 5 - Blurring of Vision (part 2)

This patient has bilateral papilloedema, giving the history of headache and vomiting, the most likely cause is increased in ICP secondary to SOL.

Other differentials that needed to be considered are:
- Raised intracranial pressure d/t space occupying lesions, meiningitis, subarachnoid haemorrhage, benign intracranial hypertension.
- Cerebral oedema following head injury or cerebral anoxia
- Metabolic causes such as carbon dioxide retention, steroid withdrawal, thyroid eye disease, vitamin A intoxication, lead poisoning
- Haematological and circulatory disorders eg central retinal vein thrombosis, superior vena cava obstruction, polycythaemia rubra vera, multiple myeloma, macroglobulinaemia

From history
- Headache
- Transient visual disturbances
- Diplopia (due to associated 6th nerve palsy)
- History of hypertension, brain tumour
- History of ingestion of steroid, hypervitaminosis A (a cause of benign intracranial hypertension)

Physical examination – 1st manifestation of papilloedema is engorgement of veins, field defect – enlargement of blind spot.

Investigations
- CT scan of brain
- CSF analysis depending on CT scan findings

In a young female with blurring of vision and headache, benign intracranial hypertension need to be considered.

Features to suggest BIH – pt alert, no localizing neurological signs except 6th nerve palsy, opening pressure of CSF > 20 cmH2O, normal ventricles and normal study in CT and MRI

Treatment of BIH – discontinuation of steroids, weight loss, drugs such as carbonic anhydrase inhibitor, diuretics, serial lumbar puncture, lumboperitoneal shunt, optic nerve fenestration, subtemporal decompression.

Station 5

Station 5 – Blurring of Vision

You are the SHO in medical clinic. You received a referral letter from a G.P.

Dear Doctor,

RE: Mr S, 40 year-old Indian gentleman

Thank you for seeing the above named, who complained of blurring of vision for the past 1 month, worsening past 2 weeks, associated with headache and vomiting. Kindly see him and do the needful. Thank you.

Sincerely,
Dr G.P

You are required to take appropriate history and examination. Please address his concerns.

How would you approach this scenario?

History Taking - Joint Pain

Differential diagnoses to consider:

Ankylosing sponlylitis
- Any history of back pain, back stiffness

Reactive arthritis – post infection
- Ask about history of gastroenteritis, urethritis, conjunctivits

Gout
- History of similar joint pain, tophi, drug history

Enteropathic arthritis (with inflammatory bowel disease)
- Symptoms of IBD

Psoriatic arthropathy
- Rashes, nail changes

Rheumatoid arthritis
- Symmetrical involvement


Sjögren’s syndrome
- Dry eyes, xerostomia

Vasculitis
- Constituitional symptoms, painful skin lesions, neuropathy

Septic arthritis
- History of gonorrhoea (TRO gonococcal arthritis)

This patient actually has reactive arthritis, Reiter’s syndrome, characterized by triad of arthritis, conjunctivitis and urethritis. He had history of travelling to India 3 weeks before onset of symptoms and developed diarrhoea when he was there. Onset of reactive arthritis usually begins 2-6 weeks after an initiating infection at a distant site (dysentery / urethritis)

Investigations:
Inflammatory markers – ESR, CRP
Culture and sensitivity – Stool sample, sample from urogenital tract
Synovial fluid analysis – to exclude septic arthritis (failure to treat septic arthritis may result in joint destruction) and gout
Radiography of the affected joint

Treatment and management:
Pain relief with NSAIDs
Steroid
Referral to ophthalmology for conjuctivitis
Physiotherapy

History Taking

There are 2 opinions in history taking session, some think it is not difficult to score, some especially those whose English is not their mother tongue might think that it is difficult. My friends and I practiced history taking a lot before our exam. One of my friend taught me a technique to tackle this question and I found that it is very useful.

First of all, read the scenario carefully and take note of the important points, it could be the history itself, from physical examination or investigations. Subsequently, generate a list of differential diagnoses (pen and paper will be provided). When you are with the surrogate, you should be able to ask history according to the differential diagnoses in order to exclude them one by one. In between, if you realized there are still other differentials that you have missed, just add it in your list. With this method, you should be able to narrow down your list. If you are still uncertain of the diagnosis, continue with a full systemic review from head to toe. Of course, for an examination like this, knowing the social history and sometimes sexual history is important as well. Some candidates find it difficult to ask about sexual history. You can try opening sentence like this “ I know it could be a little uneasy for you, but there are a few personal question that I have to ask in order to know what is wrong with you, is it ok?” Find out whether the surrogate has a partner, and whether the partner is male or female (particularly important if you sit for exam in UK), whether there is recreational drug usage, smoking and alcohol.

Before you end the session, give the surrogate a summary of what he or she had told you. You may try asking “ Is there anything that I missed?” or “ Is there anything else that you would like to tell me?”. However, sometimes you might not get an answer as the surrogate might be taught to ask you back “Like what?” Then you should ask if he or she has any particular worries and answer to the worried. Lastly, inform the surrogate about what you think could be the diagnosis and advice on further investigations.

The examiner usually would ask for the diagnosis and whether there are other differentials, then the approach to confirm the diagnosis as well as treatment.

Here I have a scenario that my consultant rheumatologist gave me while she took me for a history taking session. Let’s see how we can approach it.

HISTORY TAKING
You are the SHO in the rheumatology clinic, about to see the patient below. Please read the letter from the patient’s general practioner.

Dear doctor,

Re: Mr Mohan, aged 40, lecturer

Mr Mohan has two weeks history of joint pain of right wrist and left knee. He is unable to walk because of the pain. On examination, his right wrist and left knee are swollen , erythematous and tender. X-ray of the right wrist and left knee showed no significant abnormality. His FBC is normal and ESR is 100.

Please give us your expert opinion and advice on the management of this patient.

Yours truly,
Dr G. Practioner.

Sitting for PACES in UK (II)

Now, I would like to share my exam experience. I started with respi/abd station. My respiratory patient was a young, well-built, white man who did not have any respiratory signs except finger clubbing and a chemoport. I struggled while giving differential diagnoses until the examiner reminded me again to look at the questions – “ This patient presented with recurrent, chronic cough.” It was cystic fibrosis, and the chemoport was there as the patient is expected to need multiple courses of antibiotics. There was no time for other questions because I only told the correct diagnosis at the very last minute. 1 examiner passed me while the other failed me in this station. So, bear in your mind the diagnosis of cystic fibrosis when you sit for exam in UK, especially in young patients.


In the abdominal station, I saw a middle age lady who had lapratomy scar and RIF scar. The question was “ This lady presented with diarrhea for 2 weeks”. The only differential that I was thinking was inflammatory bowel disease as there were no other positive signs. I was asked what the 2 scars were for and I tried my luck by saying the patient could have intestinal obstruction and a temporary ileostomy was done which has now been reversed. The examiners seemed happy with the answer and continued to ask me how to assess the patient whether she is in remission. I passed this station.


In the counseling station, I was asked to counsel a patient who was just diagnosed lymphoma and would like to talk to the doctor regarding treatment. There was a hidden agenda – the patient wanted to know if he can still have children after chemotherapy. He only asked me about that when I asked him whether he was married and whether he was planning to have children. I was expected to talk about alternatives including sperm storage before commencing chemotherapy but I did not have enough time. However, when the examiner asked me what should I offer to the patient, I mentioned sperm storage and both the examiners nodded. I got good mark for this station.


The CVS /Neuro station was confusing for me. I thought I got the correct diagnosis for CVS but I did not get good marks, most probably I missed some important findings. The diagnosis I gave was aortic regurgitation and the examiners asked about investigations and management. My neuro station was facioscapulohumeral muscular dystrophy. I found typical weakness for muscular dystrophy with facial weakness but patient did not have winging of scapula. I saw scars at the scapular region instead. I mentioned all my positive findings including the scars and gave a list of differential diagnoses and I told the examiner the most likely diagnosis is FSH. The examiner then asked me why there was no winging of scapula, I told him that a corrective surgery could have been done for the winging of scapula and he said yes. After that, I was asked how to investigate and manage. I scored well in neuro station.


The two station 5 patients were simulated patients. First was a patient with amaurosis fugax and I asked questions to rule out increased intracranial pressure and explained to patient the likely diagnosis and what I would do next. I was only asked about the physical examination that I would do and was not asked to perform. The 2nd patient had symptoms to suggest peripheral neuropathy, he has underlying ankylosing spondylitis as well. I did physical examination for AS but did not get to perform examination for peripheral neuropathy, the examiner stopped me and asked me for differential diagnoses and investigations. After that, he asked me whether I could correlate AS with peripheral neuropathy, I told him I do not know and he accepted it. I still score well even though I did not answer that question.


The history taking station was a bit complicated. There was a lady who presented with generalized swelling, frothy urine and she has history of multiple episodes of chest infection. I could not correlate these two but I told the examiner my differential was nephrotic syndrome/ right heart failure with underlying bronchiectasis. The examiner asked me to correlate nephrotic syndrome and bronchiectasis but I couldn’t. My mark was still quite good despite of that.


Overall my score was not too bad even though I struggled in respiratory station and did not do well in CVS. One point that I noticed is that most patient already received corrective surgery / treatment for their problems in UK. Therefore, the signs might not be very prominent but the scars could give you a clue. Another word of advice is to forget what you have done in the previous station and proceed to the next station with full attention. Last but not least, DO NOT create signs, just tell what you find and try to generate a good list of differential diagnoses; the question itself is also an important clue. Good luck to those sitting for the coming exam and hopefully my experience is useful to some of you.

Sitting for PACES in UK (I)

Dear all, first of all I have to thank MRCPian 03/09 for inviting me to contribute to this blog. I passed PACES on diet 1/10 in UK (2nd attempt). Therefore, I would first like to share my experience of sitting for exam in UK.

My exam date was middle of February in Sheffield. I went with 2 other friends 2 weeks before the exam. We attended the Ealing Paces course in London before we left for Sheffield. I would recommend you to attend a course if you don’t intend or you are unable to get yourself attachment in local hospital. It was my last chance of practicing before my exam and I learnt a few exam tips which were quite useful as well.

We arranged our transport to Sheffield quite early – 5 days before exam and stayed somewhere near the exam centre. It was still winter in UK during February, expected the suffering during travel but yet unexpected things do occur. It was snowing heavily in UK and the transportation system was interrupted now and then, so my advice is plan everything early, arrive at your centre few days before exam and do find out a few ways to go to your centre from the place you stay. What happen during my exam day was the taxi that I booked was not able to come to pick me up due to the heavy snow and I had to walk in the snow……luckily I managed to get into a bus after walking in snow for 5 minutes. ( the exam centre was 20 minutes walk from the place I stayed, I walked to the centre 2 days before the exam to get familiarized).
When I reached the centre, I learnt that I am not the only person facing problem to come for the exam. I was told that some patients could not make it as well! The chief examiner even warned us that he might need to defer the exam if the centre could not find enough patients for the exam. My exam was delayed for 2 hours. Later of the day, I found out that my friend, who was in the 2nd cycle did her exam much later together with the 3rd cycle (the centre combined 2nd and 3rd cycle as there were candidates who were unable to come due to the bad weather).

My only advice to overseas candidate who is going to UK is plan everything early, go early and stay at a place near to the centre. I don't think it's a good idea to travel on the day or a day before exam as interruption of the transport system is not uncommon especially during winter. Train tickets will be much cheaper also if you buy early online.

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Station 5

A young lady with unilateral leg swelling... in station 5. How would you approach this case.

First thing.. in the 5 minutes that you are given to prepare the case.. you should start thinking about the probable differential diagnoses:

1. DVT
2. Lymphoedema
3. Cellulitis
4. Less likely causes - may not be relevant but just standby at the back of your mind.. heart disease, kidney disease, liver disease etc..

Once you start seeing the patient.. you would likely be able to exclude or include the diagnosis and focus in that area more.

I had a patient recently in the ward with the exact problem.. So I told my other colleagues who are going for the exams to see this patient.. in this case.. she had DVT.

Getting the diagnosis of DVT is easy. So what it takes to have 2 in all the 7 components that is full marks? Of course while talking and examining her, keep her comfortable. DVT legs are painful. Any "ouch" will cause you big time "OUCHHHHH".

Once you have ascertained the diagnosis.. again aetiology and risk factors.. especially this young lady, 3 months post-partum.. DO NOT FORGET OCP history (she just delivered, so she might take the Pill). Next thing will come to your mind.. antiphospholipid syndrome (APLS). You now need to determine whether it is primary or secondary.. If secondary, in this part of the world, excluding systemic lupus erythematosus (SLE) is important.. so run through questions related to this and quickly look for the hard signs in the patient.. ie. rash, discoid lesions, alopecia, joint swelling, oral ulcers, vasculitc lesions etc..

Talking about APLS.. getting comprehensive Ob & Gyn history is very important.. number of pregnancies, at what month baby delivered, any complication during delivery ie. pre-eclampsia, any miscarriages (if yes, at what month?), status of the baby at birth and the current status.

Next is to look for complications and associated features ie. migraine, central venous thrombosis, pulmonary embolism, non-healing leg ulcer etc.

Above all else.. maintain patient's welfare and ADDRESS her concern. As she is still young, I am sure she is concerned about subsequent pregnancy, treatment and her future.. ie. can she work etc.

May sound long.. but try practising with your friends.. If you can't get all the points out during exam, getting some of the important once and MAINTANING PATIENT'S WELFARE might suffice.

If you are interested to know more about APLS.. I find this helpful...

1. Guidelines on the Investigation and Management of Antiphospholipid Syndrome
2. Patient information leaflet for Antiphospholipid syndrome

DVT is a very common topic in daily practise... from time to time I am sure we get referrals from our Ob & Gyn colleagues. So it is good to know about this...

In my patient.. the patient fulfilled clinical criteria for APLS - had 2 miscarriages after 10 weeks POA, 1 preterm baby at 32 weeks secondary to pre-eclampsia, had DVT 2 years go and now present with 2nd DVT. Even so, she was treated as left leg cellulitis by the GP for almost 1 month before referred to hospital. Her first anticardiolipin antibody detected. So, this is a case of primary APLS.

Station 5

Mdm Fadilah is 25 year-old lady who has just delivered a baby 3 months ago. Now she comes with left sided lower limb pain and swelling.

Your task is to assess the patient’s problems and address any questions or concerns raised by the patient.

Respiratory Station

Mr A is 60 year old gentleman presents with 1 month history of dyspnoea. Please examine him.

Obviously this is a respiratory station... before you start examining him, you would have to INSPECT him and guest probably diagnosis, ie. bronchiectasis, lung fibrosis, COAD, pleural effusion and pulmonary tuberculosis...

Therefore, from the start of the examination, you would start looking for signs to exclude or include your diagnosis, at the same time looking for aetiology, current status and presence/absence of complications.

Examination techniques.. oh well.. for that you just have to practise till perfect and doesn't show at all on your face that you are thinking while examining. 6 minutes to finish off everything in a respiratory station might not be enough. A tips I had was... once I feel for the trachea, if it is central, I can either go straight to the back first then come back to the front or do the front part quickly. If trachea is central, the pathology most likely won't be detected anteriorly.

Coming back to the case.. this gentleman actually has pleural effusion.. So I leave you with that for now and share with us how you would want to present it, when the examiner tells you.. "Tell me your diagnosis."

Station 5

Increasing weight.. seems to be a simple complaint. At this point when you have that 5 minutes, you must think about several differential diagnoses:

1. Hypothyroidism
2. Cushing's syndrome/disease
3. Metabolic syndrome

Then you must structure your thoughts on how to ask questions and perform physical examination to include or exclude your diagnosis. At the same time, pay attention to her concern (this is VERY important). Don't be to excited to get the diagnosis and forgot about the patient, as this station tests how you interact with your patient.

Once you have the diagnosis, you must get into the aetiology of the diagnosis and later assess the complications of the problem/s.

And this is how the patient may look like...

Photo taken from: http://neuromuscular.wustl.edu/msys/mend.htm

Intermittently, explain to the patient what you think as this is usually what the patient is concern about. Tell the patient if this is serious and how you want to go about after that. REMEMBER NOT TO BE TOO TECHNICAL. If patient understands what you want to do with her, you are doing well!

Share with us how would you approach this.. don't mind having a Q&A session here...

If you notice, this kind of scenario may also appear in your history taking station. So, study smart by studying for both stations at the same time! Good luck!

Station 5

Ms Gina is a 30 year old Indian lady. She complains of increasing weight for the past 2 months.

Your task is to assess the patient's problems and address any questions or concerns raised by the patient.

The road trip never ends....

How are all of you doing? Manage to secure a place for the upcoming PACES exams in October? Congratulations to those who have manage to get a place there.. I have a few friends who wanted to sit for the exams in October but didn't get a place... DO NOT FRET! There is always a blessing in disguise... perhaps, other times will be a better time for you. Anyway, to those who manage to get a place, GOOD LUCK! It's time to work hard and smart towards perfection! By the way, do not just study for the exams.. but more importantly, the learning process teaches you to become a better and humane doctor. I particularly think this true about MRCP exams. Some may think MRCP exams is just about who is the best actor or actress. This is not Oscar we are talking about. Dealing with patients is all it is about. I am happy that I decided to take MRCP. It taught me a lot about dealing with patients and their relatives... and I hope it does the same to you...

And the road trip as a doctor never ends... passing MRCP is not the end.. more to come, especially if you are the ambitious type. Some may decide to speed things up and take advanced specialists training in the neighbouring country and some like me... decide to stay back, relax a little bit before focusing in the advanced specialist training. No matter what.. the road trip goes on. Can be easy and can be difficult. Up to us how to go about. While then, enjoy it!

Trying to prove him wrong...

When I first mentioned the idea of creating a blog for MRCP.. must friend reminded me to think about this carefully. He reminded me that I'll be full of spirit creating just few months after passing the exams and I may not continue doing so after awhile. Promised myself to prove him wrong, I continued with my idea on creating this blog... then again, he knew me too well.. I stopped updating this blog for a very long time.. and I am truly sorry about it. I will try my best to keep on updating this blog at least once a week. Meanwhile, stay tune and do give me some response... Thanks!

Station 2 - History taking

Dear doctor,

Thank you for seeing Ms Ramona who's a 40 year-old lady. She presented to me with feeling of tiredness for the past 3 months. She also admits to have lost 4 kg over this 4 months. I have done her thyroid function test and full blood count and both are normal.

Kindly review her for further evaluation and management.

Thank you.

Regards,

Dr. G. Practioner

WHAT IS YOUR DIFFERENTIAL DIAGNOSES?

HOW WOULD YOU LIKE TO APPROACH THIS CASE?

HOW WOULD YOU LIKE TO SUMMARIZE THIS CASE?

Station 5

This 50 year-old lady complains of painful joint swellings over the hands for the past 5 months. Please examine her and address her concern.

Attached here is a photo of the painful joint swellings:(Photo Credit: Joseph Holoshitz, M.D., University of Michigan Medical School)

How do you approach this case?

New Station 5 - Brief Clinical Consultation (BCC)

As everyone knows… from time to time RCP will make changes to the examination format or even marking format. So called to keep up the standard. Oct 2009 was the first time ever those radical changes were introduced. Station 5 had 180 degree transformation. Marking format also changed. I will talk about change in the marking scheme in a different post.

Whatever it is, I think the new Station 5 is more practical and more realistic. It’s not about showing “museum” cases involving locomotor, skin, eyes and endocrine systems. Here, it is about knowing what is important in history and physical examination when dealing with a particular complaint. And of course, not to forget, dealing with patient’s concerns and not neglecting the patient’s welfare.

Before you start the station, you have 5 minutes to read and prepare both questions – about 2.5 minutes each question. The case scenario is usually short and may not be able to help you much until you actually see the patient. However, important history ie. underlying Psoriasis might be disclosed to you. Once the bell rings, it is time for you to start seeing your first patient, please make sure you have the correct patient for the correct case. Then start the show… you have 8 MINUTES to clerk and examine… do it in any order or even simultaneously. I prefer to take a quick look at the patient and start talking with the patient.. just to get hints on how to proceed further. If necessary.. do take past medical history, drug history.. better if can be done in the right order. This can be done while examining the patient. One of the PACES examiner I met during a course said.. even though it can be done in any order, she would prefer it to be done systematically.. ie.. try not to examine the tummy then only look at the face or mouth.

If you notice in the MRCP website, they mentioned that the cases can be of the 4 systems from the old station 5, or CVS, Respiratory, Neurology or Abdomen. They even advise you to study 20 common medical presentation from the JRCPTB website. Well, at this moment, since this new Station 5 stil new.. I personally think more attention will be given towards one of the 4 systems from the old station 5. Here are the possible case scenarios:

• Sudden onset of blurring of vision with irregular pulse

- It could also be transient body weakness/numbness etc associated with irregular pulse

• Blurring of vision in a patient with newly diagnosed HPT (acromegaly with pituitary tumour)
• increasing ring size with diabetes (acromegaly)
• underlying asthma with symptoms of diabetes (Cushing’s secondary to iatrogenic steroid), or any underlying medical problem that usually requires steroid ie. SLE, autoimmune bullous disorder,
• patient admitted with uncontrolled DM and complains of whitish patches at his hands (Autoimmune Polyendocrine Syndrome)
• admitted with recurrent seizure and has multiple skin nodules (tuberous sclerosis)
• admitted with UGIB, and has hyperpigmentation at the lips and buccal mucosa
• underlying psoriasis with multiple joint pains
• underlying psoriasis with neck stiffness (spondylitic type PsA)
• underlying RA with painful red eye/SOB
• complains of SOB (but when you see the patient, she has features of scleroderma)
• complains of blurring of vision (when see the patient, has exophtalmus and ophthalmoplegia – Grave’s ophthalmopathy)
• bilateral LL weakness – prior to that had multiple blisters over a dermatomal distribution (transverse myelitis post Zoster infection)
• abdominal pain (renal colic) in patient who has tophaceous gout.
• Carpal tunnel syndrome in patient who has gout

Basically… it can be anything! Until there is new publication on this nStation 5, I suggest you continue reading Ryder/Baliga. While reading/studying it.. imagine how it’ll come out in Station 5.. possible complaints and how to approach it. I will share some example.. from what my friends and I did and cases I had during PACES courses.

HAPPY NEW YEAR

2009 ended very quickly and now 2010 has arrived. To some 2010, might be just another year that one has got to go through. But I am sure, to most of us, 2010 is much awaited for. A brand new year with a brand new phase in life. Let it be about work, family or social status. Whatever it is, there is more to come!

2009 has brought lots of joy to my life. Just like most of us, 2010 is very much awaited too. Jumping to a slightly different phase in life, I can't wait to get things going. Hope all of us will be able to continue with our road trip with minimal speed trap!

To those who has just got a promotion, congratulations and keep it up! Who has just become a parent.. all the best! Who has just got married, congratulations! And many more good wishes to all of us. Never think that you have never achieved anything just because you didn't get what you want. Being able to wake up in the morning and breathe the air is a SUCCESS indeed.

HAPPY NEW YEAR! LET'S BEGIN 2010'S ROAD TRIP WITH A FRESH MIND.

Genetic Testing (A)

These are some of the important issue need to be covered when handling an issue of genetic testing.

• informed, voluntary decision
• only available to subjects who have reached the age of maturity
• subjects must not be discriminated in any way after the results known
• not part of routine blood investigation without permission, including in symptomatic subjects
• ownership of the results remain with the subject who requested the results
• consent form
• multidisciplinary team involve, including genetic counselor
• select companion
• results should be presented verbally and in written form
• prenatal testing is possible

To know more about Huntington's Disease in particular, a useful site will be at Huntington's Disease Association UK.