MRCP PACES Blog series

Its been long time since i have visited my blogs and i believe it's high time to begin my blogs for PACES.
I will start with Station 5 as its most fearsome station and most vital too.it can make or break your MRCP dreams and if somehow you manage to score well in this station then even if u fail 1 or 2 other stations ,you will still pass.


  Station 5:
Instruction for candidate: (you are SHO in Rheumatology clinic) Mrs.Ann Miller,56 years old , has been experiencing increasingly painful hands over the last 1 years. Please take a short history and perform a relevant focused examination. Summarise your findings to the patient and explain your investigation and management plan. :-

once you enter the room,greet the patient and please don't shake hand here because patient has pain in hand . "Hello Mrs.Miller My name is Dr.Winchester,and i am the one of junior doctors.i believe that you have been experiencing some difficulties with your hand ,you you like to tell me more about it?

 She might say that well i have been having this nagging pain in my both hands and lately its become worse so i went to my GP and he suggested me to come see you,what do you think doc? what is happening with me?

 you see,here she is throwing you a qs regarding concern ,so try to show empathy and say " Mrs.Miller i can see that you are quite concern about your present condition ,and i am sorry that you have this pain but in order to understand what exactly causing you pain in your hand ,i need to ask few questions and do a brief examinations and then i will be able to tell you why you are having pain,is that okay?

 while you explaining her these lines ,you can quickly do a visual inspection of hand .and you may see the inflamed MCP joints,ulnar deviation ,z thumb ,swan neck deformities ,boutonniere deformities ,nail bed infarct,subluxation etc.this barely takes 30 seconds.

now take a brief history: since when you have been having the pain?

can you describe me what type of pain it is?

is there any morning stiffness in hands?

if yes then how long? where exactly you have the pain?

beside wrists is there anywhere else ?

i.e shoulders,knee .

have you ever had any rash?( rule out psoriatic arthropathy) is there anything which makes it worse or better?

have you tried anything /any medicine /over the counter product/herbal medicine/to help the pain? 

then do a quick Review of systems:

do you have any breathing difficulties?cough? phlegm? blood in phlegm?

any problems with eys?itching sensation?redness?visual disturbances?

any problem with water works?foamy or froathy urine?any swelling in your legs( renal involvement of rheumatoid)

 now ask for any significant family history( looking for autoimmune diseases),past medical Hx,social HX(alcohol and smoking,is there anyone who can help her at home),

how the disease affecting her daily life?can she perform daily chores on her own?

now do a quick exam of hands,symmetrical MCP and PIP involvement,sparing of DIP ,there may be joint effusion or may not,Tender joints, with subluxation and ulnar deviation. Boutonniere and swan neck deformity are clearly demonstrable. Z-shaping of the thumb with 1st and 2nd MCP most markedly involved. There are rheumatoid nodules at the elbow. hand exam shouldn't take more than one and half minutes .


by now already 5 minutes has passed. if possible auscultate the lungs for pulmonary fibrosis,see conjunctiva for pallor,palpate spleen for Felty syndrome( if you are running out of time then just mention it in your discussion ,but lung exam is always recommended)


 now explain the patient"  The pain and stiffness you describe and the changes to the joints in your hands suggest that you have a condition called rheumatoid arthritis. To confirm this, we will need to do some blood tests and imaging (X-rays) of the affected joints. its basically an autoimmune disease meaning our immune system attacks own cells/tissues as foreign bodies. we have certain medication in form of NSAIDs to relieve the pain and other medication to halt/decrease the progression of disease.what i would like you to do is ,come back to the clinic after two weeks along with the reports and then we can decide what treatment will be suitable.meanwhile i will prescribe you some medicines to help you out in terms of pain.i am also going to speak to your GP about this and ask him to refer you to a physiotherapist and occupational therapist to asses your needs further".

at this point i would like to know if you have any specific concern?


 Now comes the discussion with examiner-- they usually ask ,tell me the positive finding!

"this lady complains of pain and stiffness in hand and shoulder with morning stiffness which last around 1 hour,she has symmetrical deformative polyarthropathy .its consistent with a diagnosis of Rheumatoid arthritis."

 what could be other differential?
 Jaccoud arthropathy,
 psoriatic arthropathy

 how would you investigate?
FBC-to see anemia and neutropenia
 ESR and CRP
Rheumatoid factor and anti-CCP antibody
Xray of hands to see joint space narrowing and erosion.

 How would you manage?
Pain control by NSAIDS, steroids for acute exacerbations. DMARDS Biological agents if pt fail to responds 2 DMARDS Disease monitoring by DAS-28 Involve occupational therapist and physiotherapist for preservation of adequate function.

 thank you very much!