Ankylosing Spondylitis

30 years old male computer software engineer has presented with back stiffness since 1 year.

kindly proceed!

History: present complain

since when pain ,progression,no of joints involved,any rash,if back pain then any radiation,

associated symptoms: eye symptoms,breathing difficulty,syncope,other joint pain

exam: neck flexion,extension,lateral movement,schooner’s test,reduced chest expansion and protuberant abdomen due to diaphragmatic breathing,? posture,fixed thoracic kyphoscoliosis,loss of lumbar lordosis,extension of cervical spine, auscultate for apical fibrosis,

hows it affecting his daily routine,is he able to cook ,wash ,bath and drive? can he drive? how it has affected his work?if he is working

complication:

5 As

Anterior uveitis

Apical fibrosis

AV conduction block( pt may have infraclavicular scarf ICD placement)

Arthritis ( large joint)

Aortic regurgitation: look for sternotomy scar

mention absence of abdominal scar ,absence of rash to r/0 IBD,Psoriasis.

other cause of back pain could be  trauma ,mechanical,seronegative arthropathy.

what to say to patient:

Based upon what you have told me and examination i did ,it appears that you have an inflammatory condition called Ankylosing Spondylitis.its basically manifest as neck and back pain.we are going to do some blood test to see the degree of inflammation and X-ray of your back /spine and we may also need to do more sophisticated scan of spines such as MRI .mean while i will prescribe some pain killers i.e. NSAID to help with pain ,as you told me the symptoms are affecting daily activity hence i will speak to GP to refer you for occupational therapist and physiotherapist.i will also make arrangement for you to be seen in rheumatology clinic with the test result.

at this point do you have any questions for me?

What is the diagnosis?

How would you manage this patient?

Plain xray spine: to look for bilateral sacroiliitis,syndesmophyte

MRI L-S spine

ESR,CRP

HLAB27

ECG TO LOOK FOR CONDUCTION BLOCK

2D ECHO: TO CONFIRM AORTIC REGURGITATION

NSAIDs: SPECIALLY INDOMETACIN

TNF-aLpha inhibitors—adalimumab,infliximab,golimumab,etanercept

what are the side effects of Biological agents?

beside nausea ,vomitting and diarrhea,injection site reaction other side effects are reactivation of pulmonary tuberculosis ,fungal infection.

need to do screening for HIV,HCV,HBV before starting the treatment.

Suppose this patient presented to a neurologist with acute pain in back,what would be the cause???

>Dural ectasia ! 

Station 5 case no 2 : Marfan's syndrome

Scenerio: You are SHO in MAU and you have been asked to see Ms.Nadia ,28 years old female ,with complaint of shortness of breath,she has had multiple admission in past with similar complaints.

take a focus history,do a brief exam and present your findings and discuss with examiner.

:- the moment you enter the room ,you see a patient with unusually long fingers( arachnodactyly) and a tall stature

now within 15 second you have realised that its Marfan's and now you gotta take a focused history:

1.How long you have been having the breathing difficulty?

has it occured before? have you sought any treatment before? ever told that you have Pneumothorax or problems with your heart valves?

if she tells you that she had pneumothorax previously then considering asking the quality of pain,improvement in pain with sitting or worsening with inspiration.

ask her if she was told she had marfan's? if she was diagnosed then when? any family member with similar problems?

A brief review of systems might me good idea here:

ask for any joint pain,hypermobile joints

any eye problems( MYOPIA BEING Most common, ectopia lentis)

any previous problem with breathing( spontaneous pneumothorax) --in this case she has already told you

any cardiac abnormalities( AR)

BACK PAIN(DURAL ECTASIA)

Now proceed to examination--

(Knowing Ghent criteria is good but examiner never bother asking!)

arachnodactyly

arm span > height

ectopia lentis

high arched palate

back pain?? dural ectasia

joint hyper mobility

look for precuts excavatum

collapsing pulse,look for aortic regurgitation,mitral regurgitation and mitral prolapse( due to cystic medial degeneration)

suppose here you heard AR( diastolic murmur in left upper sternal border) and collapsing pulse is evident then most likely pt is suffering SOB cause of Aortic regurgitation,

if this is not the case then you can stick with pneumothorax!

Now comes the Best part:

Examiner : what is your findings and diagnosis

My diagnosis for this lady who came with c/o SOB and n on examination found to have large fingers( arachnodactyly),the arm length span is more than height,the joints are hypermobile,there is upward dislocation of lens bilaterally,there is high arched palalte and on auscultation of precordium there is mid to late diastolic murmur in left upper sternal border, along with collapsing large volume pulse suggestive of Aortic regurgitation.

How would you manage this patient?

i will order a CXR to r/o pneumothorax and see if there is any evidence of cardiomegaly

ecg: see LVH

TTE: to see aortic root size

pharmacologically i would like to put pt on Beta blockers and ARBs to halt the progression of aortic root dilatation,

annual TTE would be a good idea to monitor aortic root,as patient has visual problems i would like him to be seen by ophthalmologist.

i would also ask the patient about her future plans of getting pregnant and if she has any then i would explain her the risk of developing Aortic dissection during pregnancy,and in that circumstances it must include multidisciplinary team consist of obstetrician,cardiologist with expertise in this area.

pt also need to be genetically counselling considering Autosomal dominant nature

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!

Do you know any STEMI equivalent condition where there is no actuall ST elevation ?

Those who work in state of art cath labs as well ER probably familiar with this scenerio.

:de Winter ECG pattern is a STEMI equivalent that presents without obvious ST segment elevation.

Upsloping ST depression and peaked T waves in the precordial leads(V2-V6) and some times in I and II.

The de Winter pattern is an indication of Proximal LAD blockage and highly Underreported among clinicians( May be because it's relatively new and lack of expertise in EKG interpretation)

Don't delay in sending the patient directly to cath lab because it leads to catastrophic situation if you fail to send the pt for PCI .

Below is a good example of De winter t wave pattern .
Courtsey: Google Images

Well ,this explains why there was a very high fail rate in May,2014 diet of MRCP Part-1 examination.

http://www.mrcpuk.org/about-us/research/exam-pass-rates

Most Important Biostatatistics topics frequently asked in MRCP part 1

Imp Topics for Biostatistics :-

When you prepare for MRCP it seems time is evaporating as water evaporates from lake in the summer season.

It's very crucial to channelize your effort in most efficient way and there comes studying smartly.

Remember you won't have more than 5 or 6 questions from Biostatistics and majority of questions are asked from simple calculation based concepts such as

1. Sensitivity

2.Specificity

3.PPV

4.NPV

5.odds ratio

6.relative risk

And

7.significance of different stages of clinical trials 

8. Three sigma rule or 68-95-99.7

(68.27% of the values lie within one standard deviation of the mean. Similarly, 95.45% of the values lie within two standard deviations of the mean. Nearly all (99.73%) of the values lie within 3 SD)

I believe knowing only these formula will help you to fetch 70 to 80 % questions.

P.S.- while you are calculating a particular biostatistical parameter such as Sensitivity ,which is 

Basically  =TP/TP+FN 

It looks very simple and it is actually simple but what happens some times Royal college flips the value of TP,FP,FN in different / reverse order in the chart and then if you are not alert probably you will end up choosing wrong answer.

So first make sure which one is TP ,FP ,FN and TN.

Don't dwell too much in this subject coz no one gets right that 1 or 2 ultra difficult questions ,what matters is getting correct the remaining easily scoring biostat questions.