MRCP PACES MANUAL Louise Pealing MA Hons (Cantab) MBBS MSc MRCP MRCGP General Practitioner and Clinical Research Fellow, Nuffield Department of Primary Care Health Sciences, University of Oxford Benjamin Mullish MB BChir MA (Cantab) MRCPAFHEA Specialty Registrar/Academic Clinical Fellow, Gastroenterology and Hepatology, St Mary’s Hospital, London Philip J Smith BMedSci (Hons) BMBS (Hons) MRCP MSc (Nutrition) Gastroenterology Specialist Registrar and MRC Clinical Research Training Fellow Gastroenterology Department, University College London Hospital, London Edited by Douglas C Macdonald BM (Hons) BSc (Hons) MRCP PhD Consultant Hepatologist, Royal Free London NHS Foundation Trust Royal Free Hospital, London Contents Preface vi Introduction vii STATION 1 ^ Respiratory and Abdominal Examinations 1 The abdominal examination 3 Abdominal scenarios 7 The respiratory examination 47 Respiratory scenarios 52 STATION 2 ^ History-Taking Examination 71 History-taking scenarios 77 STATION 3 ^ Cardiovascular and Neurological Examinations 169 The cardiovascular examination 170 Cardiovascular scenarios 175 The neurological examination 220 Neurological scenarios 241 STATION 4 ^ Communication skills and Ethics’ Examination 353 Approach to the communication skills and ethics station 355 Communication skills and ethics scenarios 359 STATION 5 ^ Integrated Clinical Assessment 393 Approach to Station 5 398 Integrated clinical assessment scenarios 407 Abbreviations 599 Index 605 v Station 3 Neurological scenarios 1. Multiple sclerosis 17. Median nerve palsy 2. Parkinson’s disease 18. Ulnar nerve palsy 3. Motor neuron disease 19. Radial nerve palsy 4. Hemiparesis 20. Common peroneal nerve 5. Spastic paraparesis palsy and L4–5 root lesions 6. Cervical myelopathy 21. Nystagmus 7. Syringomyelia/Syringobulbia 22. Ophthalmoplegia 8. Myotonic dystrophy 23. Visual field defect 9. Myasthenia gravis 24. Dysphasia 10. Muscular dystrophy 25. Bulbar and pseudobulbar 11. Charcot–Marie–Tooth palsy disease 26. Brain-stem syndromes 12. Friedreich’s ataxia 27. Cerebellopontine angle 13. Cerebellar syndrome lesion 14. Peripheral neuropathy 28. Jugular foramen syndrome 15. Facial nerve palsy 29. Old polio 16. Wasting of the small 30. Involuntary movements and muscles of the hand Huntington’s disease 306 MRCP PACES Manual SCENARIO 17. MEDIAN NERVE PALSY Identifying clinical signs profundus I and II and flexor digitorum super- ficialis, and unopposed action of the radial The median nerve serves the intrinsic small mus- nerve-innervated finger extensors. Some call this cles of the hand not served by the ulnar nerve. the ‘papal sign’. Look for surgical or traumatic The median nerve also serves muscles of the scars at the wrist, palmar crease, forearm or volar surface of the forearm, which includes the elbow. main wrist flexors. Motor function: there is weak thumb abduction The most common median nerve palsy appearing (abductor pollicis brevis), tested for by asking the in the PACES examination is a carpal tunnel patient to place the hand palm up and point the syndrome. Indeed this is the most common per- thumb up to the sky perpendicular to the plane ipheral mononeuropathy. However, there can be of the palm and test against resistance of your more proximal lesions of the median nerve that thumb. There is weakness of thumb opposition , offer more objective clinical signs. tested for by asking the patient to oppose the thumb with the little finger and stop you pulling Distal median nerve lesions (carpal them apart. There may be normal flexion at the tunnel syndrome) thumb MCP joint due to intact ulnar nerve in- Inspection: the hand shows thenar wasting (a nervation of flexor pollicis brevis. There is nor- late sign) with hypothenar and first dorsal inter- mal flexion of the thumb at the IP joint due to osseous sparing. The thumb is externally rotated intact innervation of flexor pollicis longus in the and adducted into the plain of the palm (Figure forearm. Arm pronation and wrist flexion are 3.18) due to weakness of opponens pollicis and also normal if the median nerve lesion is distal. abductor pollicis, and some refer to this as ‘ape- hand’ deformity (but it is best to describe the Sensory loss : there is sensory loss in the palmar position of the thumb). The index (first) and aspect of the thumb and lateral two and a half middle (second) fingers may also be held in fingers but normal sensation over the thenar extension due to weakness of flexor digitorum eminence (supplied by the palmar cutaneous branch of the median nerve which does not pass through the carpal tunnel). Additional tests: you can ask to perform Tinel’s test – tapping over the median nerve at the wrist may cause paraesthesia in the distal median dis- tribution. Phalen’s test involves flexing the wrist to 90 8 for at least 60 seconds, which may cause paraesthesia in the distal median distribution. The median nerve compression test involves pressing on the palmar aspect of the wrist for up to 60 seconds, which may cause paraesthesia in the distal median distribution. Figure 3.17 Median nerve cutaneous dis- Additional signs tribution Examine for signs of other diseases associated with carpal tunnel syndrome such as: The Cardiovascular and Neurological Examinations 307 Median nerve Pronator teres Flexor carpi radialis Palmaris longus Anterior interosseous nerve Flexor digitorum profundus I & II Flexor digitorum Flexor pollicis longus superficialis Pronator quadratus Abductor pollicis brevis Flexor pollicis brevis Opponens pollicis Second lumbrical First lumbrical Figure 3.18 Route and muscles innervated by the median nerve • Hypothyroidism: goitre, slowly relaxing Anterior interosseous nerve palsy reflexes, pretibial myxoedema This nerve has branches to flexor digitorum pro- • Acromegaly: supraorbital ridge, prognathism, fundus I and II, flexor pollicis longus and prona- interdental separation, bitemporal tor quadratus. It is typically affected by a hemianopia, large doughy hands, midshaft fracture of the radius, excessive exercise hypertension or penetrating injuries of the forearm. There is • Rheumatoid arthritis : deforming arthropathy, weakness of the thumb and index finger flexion , elbow nodules, steroid skin changes, best shown with the ‘okay’ sign, ie flattened due episcleritis/scleritis, interstitial lung disease to failure of distal flexion (see Figure 3.17). The • Diabetes mellitus: finger-prick testing, thenar eminence muscles are spared. There is no peripheral neuropathy, retinopathy sensory loss . • Gout: deforming arthropathy and gouty tophi on hands, ears and feet. Di¡erential diagnosis Proximal median nerve lesions Pronator syndrome: compression of the median • Elbow lesions: nerve can occur as it passes between the two • Fracture: supracondylar fractures are most heads of the pronator teres, high in the volar common aspect of the forearm. It can present with purely • Dislocation sensory symptoms of pain over the volar surface • Compression: ligament of Struthers of the forearm at rest or with forearm pronation. • Forearm lesions: There will be sensory loss within the median • Fracture: midshaft radial fracture causing distribution including the thenar eminence (un- anterior osseous nerve palsy like carpal tunnel syndrome). • Injury: penetrating injuries of the forearm 308 MRCP PACES Manual • Compression: pronator teres syndrome pothyroidism, diabetes, acromegaly, rheumatoid • Wrist lesions: arthritis, gout, renal failure, multiple myeloma • Fracture/trauma and amyloidosis. • Carpal tunnel syndrome (CTS). Investigations Electrophysiology: nerve conduction studies and Clinical judgement and EMG. maintaining patient welfare Imaging: seldom needed, but MRI might be con- CTS is caused by compression of the median sidered. nerve within the carpal tunnel, which is bound by the carpal bones below, flexor retinaculum Management above, radially by the scaphoid and trapezium, • Treat any underlying associated conditions and medially by the pisiform and hamate. • Physiotherapy and splint the wrists with a degree of dorsiflexion It is most commonly idiopathic, but associated • Steroid injections into the carpal tunnel area conditions include: pregnancy, menopause, hy- • Surgical decompression of the carpal tunnel. The Cardiovascular and Neurological Examinations 309 SCENARIO 18. ULNAR NERVE PALSY Identifying clinical signs the radial nerve). With the hands held supine, marked hypothenar wasting with sparing of the The ulnar nerve serves most of the intrinsic small thenar eminence can be seen, and no wasting of muscles of the hand. However, the ulnar nerve the forearm muscles. Look for scars or deformity also supplies two important extrinsic muscles of from trauma, surgery or arthritis around the fore- the hand: flexor carpi ulnaris and flexor digitor- arm and wrist. um profundus 4 and 5; it is important to remem- ber this when considering a claw hand deformity. Motor function: there is weak abduction (dorsal Clues pointing towards an ulnar nerve lesion interossei) and weak adduction (palmar inter- include unilateral signs, clawing of the hand and ossei) of the fingers. There is weak thumb adduc- wasting of the hypothenar eminence with sparing tion (adductor pollicis) as demonstrated by of the thenar eminence. attempting to grip a piece of paper held between the borders of the index finger and extended Distal ulnar nerve lesion (distal to the thumb. Grip can be maintained only using thumb elbow) flexion (intact flexor pollicis longus served by the Inspection: with the hands held prone there is median nerve), known as Froment’s sign