Preparation for MRCP PACES 1/2007

Last week we began teaching for the MRCP PACES February diet.
As this will be the first attempt for almost all of the candidates from our hospital we thought an early start would be essential.
As usual we started off with basic clinical skills.
I taught two candidates and took them to a patient with a condition involving abdominal examination.
We started off with a general examination and went through in detail how to perform a general examination.
As in the last post, I emphasised the importance of restricting the general examination to what can be performed by inspection from the end of the bed.
We next went through examination of the head, hands and neck.
I emphasised use of the system to examine the head and hands and we then went through how to quickly examine the relevant parts of the neck. Where palpation of the neck is concerned, I pointed out that either it should be done properly by asking the patient to sit up and palpate from behind or one should inform the examiners that one would defer examination of the neck to the end of the examination when one would ask the patient to sit up and one would then examine the neck from behind.
We went though how one would quickly inspect the chest and then proceed to perform a detailed examination of the abdomen. We went through every step of inspection, palpation, percussion and auscultation. No step was left out, as it is essential at this stage to ensure that technique is perfected.
Lastly, I said that the candidate should point out to the examiner that in practice on would routinely examine the inguinal region, the genitalia and perform a rectal examination. This should be done although it may seem redundant.
Next, we had a brief discussion regarding presentation. It is best to present one’s findings in the same order in which one examined the patient. This makes it less likely that one will forget positive findings and relevant negative findings.
We quickly discussed the diagnosis and the reasons for saying so and then had a quick discussion of the relevant investigations and treatment. We did not spend much time on these aspects the main emphasis was on clinical method and getting this right.
The patient was a young man who was quite thin and had pigmentation of his skin. He had a fine tremor of his fingers.
He had a nasogastric tube inserted through his nose. He was deeply icteric. He had cheilitis and angular stomatitis. He had white pseudomembranes on his buccal mucosa.
There was normal chest hair, no spider naevi and no gynaecomastia.
The upper abdomen was distended. He had normal distribution of body hair, no distended veins.
His liver and spleen were enlarged. There was no ascites, no bruits or venous hum.
There was no cervical, axillary or inguinal lymphadenopathy.
We went through the findings and what they meant.
He was emaciated and this could indicate chronic illness or lack of nutrition indicating alcoholism. Pigmentation could indicate malnutrition or chronic liver disease. Haemochromatosis was unlikely as the patient was too young.
The fine tremor also suggests alcoholism.
The nasogastric tube confirms our impression that he is malnourished.
Deep icterus makes us think of the causes of jaundice (haemolytic, hepatocellular, obstructive).
Cheilitis and angular stomatitis are further evidence of malnutrition.
The pseudomembranes suggest candidiasis. This raises the possibility of immunosuppression.
There are no features of chronic hepatocellular failure.
He has hepatosplenomegaly.
Now one has to analyse the cause.
Initially, we thought of alcohol abuse with consequent malnutrition. There were further features such as the tremor, which were in favour of this.
The candidiasis made us think of immunosuppression and blood borne viruses.
In a young patient with hepatosplenomegaly we should also think of the possibility of lymphoma.
In summary, the most likely diagnoses are:
Alcoholic liver disease (acute alcoholic hepatitis since he has features of acute hepatocellular failure)
Hep C , Hep B (with HIV) in view of immunosuppression
Lymphoma
The diagnosis was acute alcoholic hepatitis and the patient was on steroids and hence the cause of the candidiasis.
This led us to what should one revise in relation to this case.
Obviously, one should go through clinical method in relation to abdominal examination.
Next, one should revise all the causes of the various physical signs we elicited.
I emphasised that it would be unwise to go for the MRCP PACES exam without knowing all the causes of hepatosplenomegaly. Remember, however, out of the list of causes concentrate on the causes that are most likely in the centre at which you are taking the exam.