About the Book

MRCP PACES: 180 Clinical Cases offers a comprehensive set of over 180 practice cases for candidates preparing for the MRCP Part 2 Clinical Examination (PACES). The cases have been selected to represent the full range of the syllabus, including the new station 5, and provide the clinical knowledge required to pass the exam. Along with an introduction that highlights the approaches required for the different stations, the cases in this book provide an essential revision tool designed to maximise the chances of exam success.

• 180 clinical cases, covering the breadth of topics and skills tested in the exam

• All cases are structured to allow you to provide a comprehensive model answer within the short time available

• Guidance boxes provide valuable insights and clarify difficult concepts,improving your chances of picking up extra marks

About the Author

Kevin O’Gallagher MBBS BA (Hons) MRCP (UK) Daniel Knight MBBS BSc (Hons) MRCP (UK) Michael O’Gallagher MBBCh BAO Eirini Merika MBBS BSc (Hons) MRCP (UK) Omar Malik MBBS BSc PhD FRCP Peter TK Milton MBBS BSc (Hons) MRCP (UK) Nick Oliver MBBS BSc (Hons) FRCP

Table of Contents:
Chapter 1 Cardiovascular system (station 3) 1 Systolic murmur Case 1: Aortic stenosis 2 Case 2: Mitral regurgitation 5 Case 3: Ventricular septal defect 8 Case 4: Hypertrophic obstructive cardiomyopathy 10 Case 5: Tricuspid regurgitation 12 Case 6: Pulmonary stenosis 15 Diastolic murmur Case 7: Mitral stenosis 16 Case 8: Aortic regurgitation 19 Case 9: Pulmonary regurgitation 21 Mixed valve disease: distinguishing the dominant murmur Case 10: Mixed aortic valve disease 24 Case 11: Mixed mitral valve disease 25 Scars and clicks - the cardiothoracic patient Case 12: Prosthetic valves and cardiac surgery 26 Oedema, crepitations, and a raised jugular venous pressure: the failing heart Case 13: Cardiac failure 30 Case 14: The infraclavicular mass – pacemakers 33 implantable devices Abnormal pulses Case 15: The irregular pulse: atrial fibrillation 36 Case 16: Coarctation of the aorta 38 Splinter haemorrhages and a murmur: the infected valve Case 17: Infective endocarditis 40 Congenital heart disease and complex cases Case 18: Pulmonary hypertension 43 Case 19: Atrial septal defect 45 Case 20: Patent ductus arteriosus 46 Case 21: Ebstein’s anomaly: the cyanosed 48 patient with a murmur Case 22: Tetralogy of Fallot 50 Case 23: Eisenmenger’s syndrome 51 Case 24: Dextrocardia 54 Chapter 2 Nervous system (station 3) 55 Examination of cranial nerves: visual field defects Case 25: Monocular blindness 56 Case 26: Homonymous hemianopia 57 Case 27: Bitemporal hemianopia 58 Case 28: Homonymous quadrantanopia 59Contents viii Examination of cranial nerves: ophthalmoplegia Case 29: Sixth nerve palsy 60 Case 30: Fourth nerve palsy 62 Case 31: Internuclear ophthalmoplegia – 63 multiple sclerosis Examination of cranial nerves: pupillary problems with ptosis Case 32: Ptosis, large pupil and 65 ophthalmoplegia: third nerve palsy Case 33: Ptosis and small pupil: Horner syndrome 67 Case 34: Bilateral ptosis with fatigability: 68 myasthenia gravis Examination of cranial nerves: pupillary problems without ptosis Case 35: Relative afferent pupillary defect (RAPD) 70 Case 36: Unilateral large pupil in a young 72 female – Holmes–Adie pupil Case 37: Bilateral small pupils: 73 Argyll Robertson pupils Examination of cranial nerves: cranial nerves V, VII and VIII Case 38: Facial weakness 74 Case 39: Conductive hearing loss 76 Case 40: Sensorineural hearing loss 78 Case 41: V, VII, VIII cranial nerves – 79 cerebellopontine angle Examination of cranial nerves: assessment of speech Case 42: Dysphasia 81 Case 43: Dysarthria – bulbar palsy 82 Examination of cranial nerves: complex presentations Case 44: Lateral medullary syndrome 84 Case 45: Jugular foramen syndrome 85 Examination of upper limbs: weakness Case 46: Myotonic dystrophy 86 Case 47: Cervical myelopathy 88 Case 48: Unilateral arm weakness – 89 neuralgic amyotrophy Examination of upper limbs: tremor and assessment of coordination Case 49: Resting tremor – Parkinsonism 90 Case 50: Intention tremor and problems with 92 co-ordination – cerebellar syndrome Examination of upper limbs: spinal cord syndromes Case 51: Central cord syndrome – syringomyelia 93 Case 52: Brown–Séquard (hemi-cord) syndrome 96 Case 53: Anterior cord syndrome 98 Examination of lower limbs: weakness Case 54: Spastic paraparesis 100 Case 55: Proximal myopathy 101 Examination of lower limbs: sensory disturbance Case 56: Glove and stocking distributions – 102 sensory polyneuropathy Examination of lower limbs: the deformed foot – pes cavus Case 57: Friedreich’s ataxia 104 Case 58: Charcot–Marie–Tooth disease 105 (hereditary sensorimotor neuropathy– type 1)Contents Examination of lower limbs: assessment of gait Case 59: Shuffling gait – Parkinson’s disease 106 Case 60: Ataxic gait 107 Case 61: Unilateral high-stepping gait 107 Case 62: Spastic hemi-paretic gait 108 Case 63: Waddling gait 110 Examination of lower limbs: cases of note Case 64: Cauda equina syndrome 110 Case 65: Absent ankle jerks with extensor 112 plantar reflexes – sub-acute degeneration of the cord Chapter 3 Respiratory system (station 1) 115 Crepitations Case 66: Pulmonary fibrosis 116 Case 67: Consolidation 118 Case 68: Bronchiectasis 120 Dullness to percussion Case 69: Pleural effusion 122 Case 70: Collapse 124 Wheeze Case 71: Chronic obstructive pulmonary 125 disease Chest wall scars: the thoracic surgery patient Case 72: Lobectomy 128 Case 73: Pneumonectomy 129 Case 74: Lung transplantation 130 Diagnostic clues in the respiratory patient: facial signs Case 75: Plethoric face and dilated chest veins – 131 superior vena cava obstruction Case 76: Horner’s syndrome: Pancoast’s tumour 133 Case 77: Cushingoid appearance 135 Diagnostic clues in the respiratory patient: peripheral signs Case 78: Abnormal nails with pleural effusions 136 and lymphadenopathy – yellow nail syndrome Case 79: Signs of right-sided heart failure – 138 cor pulmonale Chapter 4 Abdominal system (station 1) 141 The liver patient Case 80: The syndrome of chronic liver disease 142 Case 81: Organomegaly – isolated 146 hepatomegaly Case 82: The distended abdomen – ascites 147 Case 83: Portal hypertension 149 Case 84: Abnormal skin pigmentation – jaundice 151 Case 85: Abnormal skin pigmentation – haemachromatosis 154 Case 86: Periorbital xanthelasma – primary 156 biliary cirrhosis The renal patient Case 87: The patient requiring renal replacement therapy 157 Case 88: Bilateral ballotable kidneys 159 ixContents Case 89: Iliac fossa scar with a palpable mass – renal transplant 160 Case 90: Flank scar – nephrectomy 162 Spleen and other abdominal cases Case 91: Splenomegaly 163 Case 92: Felty’s syndrome 165 Case 93: Multiple abdominal scars 166 Case 94: Rooftop incision 167 Case 95: Obesity with evidence of laparoscopic procedure 169 Chapter 5 Station 5 171 Hands: symmetrical deforming polyarthropathy Case 96: Rheumatoid arthritis 172 Case 97: Psoriatic arthritis 175 Case 98: Jaccoud’s arthropathy 177 Hands: disease distal interphalangeal joints Case 99: Osteoarthritis 179 Hands: abnormal hands with skin changes Case 100: Sclerodactyly/systemic sclerosis 181 Hands: single swollen metocarpophalangeal joint Case 101: Gout 182 Hands: neurological signs in the hands Case 102: Carpal tunnel syndrome 184 Case 103: Wrist drop – radial nerve lesion 185 Case 104: Ulnar nerve lesion 187 Fundoscopy: diseased lens Case 105: Cataracts 188 Fundoscopy: diseased retina Case 106: Diabetic retinopathy 190 Case 107: Hypertensive retinopathy 194 Case 108: Retinitis pigmentosa 195 Case 109: CMV retinitis 197 Fundoscopy: abnormal optic discs Case 110: Optic atrophy 198 Case 111: Papilloedema 200 Case 112: Foster Kennedy syndrome 201 Endocrinology Case 113: Thyrotoxicosis 202 Case 114: Hypothyroidism 205 Case 115: Acromegaly 206 Case 116: Weight gain and easy bruising – 208 Cushingoid appearance Case 117: Gynaecomastia 209 Case 118: Pseudohypoparathyroidism – 211 Albright’s hereditary osteodystrophy Dermatology: chronic skin conditions Case 119: Chronic plaque psoriasis 212 Case 120: Atopic dermatitis or atopic eczema 216 Dermatology: manifestations of systemic disease Case 121: Pyoderma gangrenosum 218 Case 122: Vasculitis (Henoch–Schönlein purpura) 221 Case 123: Chronic venous insufficiency 223 xContents Case 124: Cutaneous lupus erythematosus 226 Case 125: Discoid lupus erythematosus 230 Case 126: Dermatomyositis 231 Case 127: Alopecia areata 233 Case 128: Sarcoidosis 237 Genetic disease Case 129: Tuberous sclerosis 239 Case 130: Neurofibromatosis 241 Dermatology spot diagnoses Case 131 & 132: Dermatology spot diagnoses 245 Commonly encountered spot diagnoses Case 133: Ankylosing spondylitis 247 Case 134: Marfan syndrome 249 Case 135: Turner syndrome 252 Symptoms as a presenting complaint Case 136: Tremor 254 Case 137: Seizures 255 Chapter 6 History taking (station 2) 257 Cardiovascular Case 138: Chest pain 258 Case 139: Irregular pulse 261 Case 140: Palpitations 265 Case 141: Ankle swelling 268 Case 142: Raised lipids 271 Case 143: Hypertension 273 Respiratory Case 144: Breathlessness and wheeze – 277 new diagnosis of asthma Case 145: Shortness of breath and wheeze – 280 established diagnosis of asthma Case 146: Wheeze – established chronic 282 obstructive pulmonary disease Case 147: Haemoptysis in the returning traveller 285 Case 148: Persistent/change in cough – 287 investigation of cancer Abdominal Case 149: Change in bowel habit – malignancy 290 Case 150: Change in bowel habit – established 293 inflammatory bowel disease Case 151: Difficulty in swallowing 295 Case 152: Cirrhotic liver disease 297 Case 153: Previous renal transplant 299 Neurology Case 154: Headache 303 Case 155: Visual disturbance 306 Case 156: Tremor 308 Case 157: Established multiple sclerosis 310 Infectious disease Case 158: Fever in the returning traveller 313 Rheumatology Case 159: Sore, stiff hands 315 Case 160: Back pain 316 xiContents Endocrinology Case 161: Established diabetes 318 Case 162: Heat intolerance and weight loss 319 Case 163: Diabetes insipidus 321 Case 164: Weight gain 323 Chapter 7 Communication skills and ethical scenarios 327 (station 4) Consent and capacity Case 165: Informed consent for an invasive 328 investigation or procedure – chest drain insertion Case 166: The patient refusing to consent 329 Case 167: Consenting for a clinical trial 330 Case 168: Assessing capacity 332 Case 169: The patient who lacks capacity 333 Breaking bad news and counseling patients Case 170: Breaking bad news to a relative 335 Case 171: The decision to resuscitate 336 Case 172: Withdrawing (life-dependent) care 337 Case 173: Brainstem death testing 338 Case 174: Organ donation and harvesting 340 Case 175: Requesting a hospital postmortem 341 Case 176: Driving with disease 342 Case 177: Genetic counselling 345 Case 178: Percutaneous endoscopic 347 gastrostomy feeding Case 179: HIV testing – recent unprotected sex 348 Case 180: HIV testing – needlestick injury 351 When care goes wrong Case 181: Dealing with complaints – medical errors 353 Dealing with colleagues Case 182: The trainee in difficulty 355 xChapter 1 Cardiovascular system (station 3) 1 Systolic murmur Case 1: Aortic stenosis 2 Case 2: Mitral regurgitation 5 Case 3: Ventricular septal defect 8 Case 4: Hypertrophic obstructive cardiomyopathy 10 Case 5: Tricuspid regurgitation 12 Case 6: Pulmonary stenosis 15 Diastolic murmur Case 7: Mitral stenosis 16 Case 8: Aortic regurgitation 19 Case 9: Pulmonary regurgitation 21 Mixed valve disease: distinguishing the dominant murmur Case 10: Mixed aortic valve disease 24 Case 11: Mixed mitral valve disease 25 Scars and clicks - the cardiothoracic patient Case 12: Prosthetic valves and cardiac surgery 26 Oedema, crepitations, and a raised jugular venous pressure: the failing heart Case 13: Cardiac failure 30 Case 14: The infraclavicular mass – pacemakers 33 implantable devices Abnormal pulses Case 15: The irregular pulse: atrial fibrillation 36 Case 16: Coarctation of the aorta 38 Splinter haemorrhages and a murmur: the infected valve Case 17: Infective endocarditis 40 Congenital heart disease and complex cases Case 18: Pulmonary hypertension 43 Case 19: Atrial septal defect 45 Case 20: Patent ductus arteriosus 46 Case 21: Ebstein’s anomaly: the cyanosed 48 patient with a murmur Case 22: Tetralogy of Fallot 50 Case 23: Eisenmenger’s syndrome 51 Case 24: Dextrocardia 54 Chapter 2 Nervous system (station 3) 55 Examination of cranial nerves: visual field defects Case 25: Monocular blindness 56 Case 26: Homonymous hemianopia 57 Case 27: Bitemporal hemianopia 58 Case 28: Homonymous quadrantanopia 59Contents viii Examination of cranial nerves: ophthalmoplegia Case 29: Sixth nerve palsy 60 Case 30: Fourth nerve palsy 62 Case 31: Internuclear ophthalmoplegia – 63 multiple sclerosis Examination of cranial nerves: pupillary problems with ptosis Case 32: Ptosis, large pupil and 65 ophthalmoplegia: third nerve palsy Case 33: Ptosis and small pupil: Horner syndrome 67 Case 34: Bilateral ptosis with fatigability: 68 myasthenia gravis Examination of cranial nerves: pupillary problems without ptosis Case 35: Relative afferent pupillary defect (RAPD) 70 Case 36: Unilateral large pupil in a young 72 female – Holmes–Adie pupil Case 37: Bilateral small pupils: 73 Argyll Robertson pupils Examination of cranial nerves: cranial nerves V, VII and VIII Case 38: Facial weakness 74 Case 39: Conductive hearing loss 76 Case 40: Sensorineural hearing loss 78 Case 41: V, VII, VIII cranial nerves – 79 cerebellopontine angle Examination of cranial nerves: assessment of speech Case 42: Dysphasia 81 Case 43: Dysarthria – bulbar palsy 82 Examination of cranial nerves: complex presentations Case 44: Lateral medullary syndrome 84 Case 45: Jugular foramen syndrome 85 Examination of upper limbs: weakness Case 46: Myotonic dystrophy 86 Case 47: Cervical myelopathy 88 Case 48: Unilateral arm weakness – 89 neuralgic amyotrophy Examination of upper limbs: tremor and assessment of coordination Case 49: Resting tremor – Parkinsonism 90 Case 50: Intention tremor and problems with 92 co-ordination – cerebellar syndrome Examination of upper limbs: spinal cord syndromes Case 51: Central cord syndrome – syringomyelia 93 Case 52: Brown–Séquard (hemi-cord) syndrome 96 Case 53: Anterior cord syndrome 98 Examination of lower limbs: weakness Case 54: Spastic paraparesis 100 Case 55: Proximal myopathy 101 Examination of lower limbs: sensory disturbance Case 56: Glove and stocking distributions – 102 sensory polyneuropathy Examination of lower limbs: the deformed foot – pes cavus Case 57: Friedreich’s ataxia 104 Case 58: Charcot–Marie–Tooth disease 105 (hereditary sensorimotor neuropathy– type 1)Contents Examination of lower limbs: assessment of gait Case 59: Shuffling gait – Parkinson’s disease 106 Case 60: Ataxic gait 107 Case 61: Unilateral high-stepping gait 107 Case 62: Spastic hemi-paretic gait 108 Case 63: Waddling gait 110 Examination of lower limbs: cases of note Case 64: Cauda equina syndrome 110 Case 65: Absent ankle jerks with extensor 112 plantar reflexes – sub-acute degeneration of the cord Chapter 3 Respiratory system (station 1) 115 Crepitations Case 66: Pulmonary fibrosis 116 Case 67: Consolidation 118 Case 68: Bronchiectasis 120 Dullness to percussion Case 69: Pleural effusion 122 Case 70: Collapse 124 Wheeze Case 71: Chronic obstructive pulmonary 125 disease Chest wall scars: the thoracic surgery patient Case 72: Lobectomy 128 Case 73: Pneumonectomy 129 Case 74: Lung transplantation 130 Diagnostic clues in the respiratory patient: facial signs Case 75: Plethoric face and dilated chest veins – 131 superior vena cava obstruction Case 76: Horner’s syndrome: Pancoast’s tumour 133 Case 77: Cushingoid appearance 135 Diagnostic clues in the respiratory patient: peripheral signs Case 78: Abnormal nails with pleural effusions 136 and lymphadenopathy – yellow nail syndrome Case 79: Signs of right-sided heart failure – 138 cor pulmonale Chapter 4 Abdominal system (station 1) 141 The liver patient Case 80: The syndrome of chronic liver disease 142 Case 81: Organomegaly – isolated 146 hepatomegaly Case 82: The distended abdomen – ascites 147 Case 83: Portal hypertension 149 Case 84: Abnormal skin pigmentation – jaundice 151 Case 85: Abnormal skin pigmentation – haemachromatosis 154 Case 86: Periorbital xanthelasma – primary 156 biliary cirrhosis The renal patient Case 87: The patient requiring renal replacement therapy 157 Case 88: Bilateral ballotable kidneys 159 ixContents Case 89: Iliac fossa scar with a palpable mass – renal transplant 160 Case 90: Flank scar – nephrectomy 162 Spleen and other abdominal cases Case 91: Splenomegaly 163 Case 92: Felty’s syndrome 165 Case 93: Multiple abdominal scars 166 Case 94: Rooftop incision 167 Case 95: Obesity with evidence of laparoscopic procedure 169 Chapter 5 Station 5 171 Hands: symmetrical deforming polyarthropathy Case 96: Rheumatoid arthritis 172 Case 97: Psoriatic arthritis 175 Case 98: Jaccoud’s arthropathy 177 Hands: disease distal interphalangeal joints Case 99: Osteoarthritis 179 Hands: abnormal hands with skin changes Case 100: Sclerodactyly/systemic sclerosis 181 Hands: single swollen metocarpophalangeal joint Case 101: Gout 182 Hands: neurological signs in the hands Case 102: Carpal tunnel syndrome 184 Case 103: Wrist drop – radial nerve lesion 185 Case 104: Ulnar nerve lesion 187 Fundoscopy: diseased lens Case 105: Cataracts 188 Fundoscopy: diseased retina Case 106: Diabetic retinopathy 190 Case 107: Hypertensive retinopathy 194 Case 108: Retinitis pigmentosa 195 Case 109: CMV retinitis 197 Fundoscopy: abnormal optic discs Case 110: Optic atrophy 198 Case 111: Papilloedema 200 Case 112: Foster Kennedy syndrome 201 Endocrinology Case 113: Thyrotoxicosis 202 Case 114: Hypothyroidism 205 Case 115: Acromegaly 206 Case 116: Weight gain and easy bruising – 208 Cushingoid appearance Case 117: Gynaecomastia 209 Case 118: Pseudohypoparathyroidism – 211 Albright’s hereditary osteodystrophy Dermatology: chronic skin conditions Case 119: Chronic plaque psoriasis 212 Case 120: Atopic dermatitis or atopic eczema 216 Dermatology: manifestations of systemic disease Case 121: Pyoderma gangrenosum 218 Case 122: Vasculitis (Henoch–Schönlein purpura) 221 Case 123: Chronic venous insufficiency 223 xContents Case 124: Cutaneous lupus erythematosus 226 Case 125: Discoid lupus erythematosus 230 Case 126: Dermatomyositis 231 Case 127: Alopecia areata 233 Case 128: Sarcoidosis 237 Genetic disease Case 129: Tuberous sclerosis 239 Case 130: Neurofibromatosis 241 Dermatology spot diagnoses Case 131 & 132: Dermatology spot diagnoses 245 Commonly encountered spot diagnoses Case 133: Ankylosing spondylitis 247 Case 134: Marfan syndrome 249 Case 135: Turner syndrome 252 Symptoms as a presenting complaint Case 136: Tremor 254 Case 137: Seizures 255 Chapter 6 History taking (station 2) 257 Cardiovascular Case 138: Chest pain 258 Case 139: Irregular pulse 261 Case 140: Palpitations 265 Case 141: Ankle swelling 268 Case 142: Raised lipids 271 Case 143: Hypertension 273 Respiratory Case 144: Breathlessness and wheeze – 277 new diagnosis of asthma Case 145: Shortness of breath and wheeze – 280 established diagnosis of asthma Case 146: Wheeze – established chronic 282 obstructive pulmonary disease Case 147: Haemoptysis in the returning traveller 285 Case 148: Persistent/change in cough – 287 investigation of cancer Abdominal Case 149: Change in bowel habit – malignancy 290 Case 150: Change in bowel habit – established 293 inflammatory bowel disease Case 151: Difficulty in swallowing 295 Case 152: Cirrhotic liver disease 297 Case 153: Previous renal transplant 299 Neurology Case 154: Headache 303 Case 155: Visual disturbance 306 Case 156: Tremor 308 Case 157: Established multiple sclerosis 310 Infectious disease Case 158: Fever in the returning traveller 313 Rheumatology Case 159: Sore, stiff hands 315 Case 160: Back pain 316 xiContents Endocrinology Case 161: Established diabetes 318 Case 162: Heat intolerance and weight loss 319 Case 163: Diabetes insipidus 321 Case 164: Weight gain 323 Chapter 7 Communication skills and ethical scenarios 327 (station 4) Consent and capacity Case 165: Informed consent for an invasive 328 investigation or procedure – chest drain insertion Case 166: The patient refusing to consent 329 Case 167: Consenting for a clinical trial 330 Case 168: Assessing capacity 332 Case 169: The patient who lacks capacity 333 Breaking bad news and counseling patients Case 170: Breaking bad news to a relative 335 Case 171: The decision to resuscitate 336 Case 172: Withdrawing (life-dependent) care 337 Case 173: Brainstem death testing 338 Case 174: Organ donation and harvesting 340 Case 175: Requesting a hospital postmortem 341 Case 176: Driving with disease 342 Case 177: Genetic counselling 345 Case 178: Percutaneous endoscopic 347 gastrostomy feeding Case 179: HIV testing – recent unprotected sex 348 Case 180: HIV testing – needlestick injury 351 When care goes wrong Case 181: Dealing with complaints – medical errors 353 Dealing with colleagues Case 182: The trainee in difficulty 355 x