Cardiff Paces

Last Minute Advice!

We hope you feel that the course has been useful in focussing your revision for the PACES.

Just some last minute advice
Heart Sounds
A candidate's experience:

Just some last minute advice:

You need to pair up with somebody doing the PACES. You will be compromised if you study alone. See patients (either organised teaching or going around yourselves) on the wards at least 2-3 times/ week and meet up regularly in the evenings or weekends to blast questions at one another. Viva technique is important. Don't give incomplete answers or expect the examiner to prise the answer out of you.

Example with pulmonary fibrosis short case

Examiner: What one investigation will you do to confirm your suspicion?
Candidate: CT scan
Examiner: What sort of CT scan?
Candidate: Is it high resolution CT scan?
Examiner: What are you looking for?
Candidate: Ground glass appearance?
Examiner: So what?
ZZZZZZZZZZZZZZZzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz

It's tedious.

So, ideal 1st response =

I would arrange a high resolution CT chest to confirm the diagnosis. A ground glass appearance is associated with active alveolitis which responds well to steroids, whereas a honey combing and interstitial fibrosis indicates more advanced disease which will be less steroid- responsive, SIR (or MAAM. Don't get this wrong...just because she is hirsuite)!!!!!

You only have 3 seconds to come up with something sensible, or else you will appear hesitant. The examiners will give you a clue and another if you're still stuck, by which time you will be panicking. Practice makes perfect...if you've answered a question once or twice before, the answer framework is there particularly for the more open- ended questions.

Get your timings right for the history stations, and make sure you take a solid history. Otherwise the examiners will just spend all the time tearing your history apart. Writing the stems like PC, HPC, PMH, all 5 systems, DH, allergies, FH and SH is useful. Ask specifics about the systems eg 'bowels alright?' is probably not good enough...better to ask about change in bowel habit, fluctuating diarrhoea/ constipation, blood, mucus etc. You will miss things otherwise.

Don't forget to summarise the history with the patient in history taking station, or the action plan in the communication station.

Stop seeing patients in the last week before the exam. Ideally you should take the last week off work and meet up with your partner during the daytime, and read by yourself in the evenings. You should go through the MRCP short cases book case by case, including the minutiae. For example, rheumatoid hands...describe full house presentation, differential diagnosis (psoriatic or Lyme's disease), investigations, treatment etc. Also, can I examine for cerebellar syndrome or thyroid status? If I'm asked to look at someone's face, what can it be (Cushing's, Addisons, Parkinsons, myotonia, CREST etc? The Ryder/Freeman book covers this well.
If you do this, you will be well prepared.

Be confident in the exam. They can't kill you, which is always good. Even if you get it wrong, get it wrong confidently. You won't get any more points for being meek about it. You never know...you may even get away with it.

Make time for relaxation...go and watch a silly film like Blazing Saddles, Life of Brian, Borat, Blades of Glory etc...or even exercise!

Good luck!! We would be grateful if you could feed back about your experience with the exam so that future candidates can benefit. You could even recommend our course to your friends.

Many thanks Shu and Krishna

Heart Sounds

Shu has produced a video to ensure you can recognise the various heart sounds likely to appear in the exam.

(High Quality, slower download) - Click here to watch the video
(Lower Quality, faster download) - Click here to watch the video

A candidate's experience:

GL wrote:
I attended your last session in October 09 and am very pleased (and relieved) to tell you that I passed! We were asked to send you some feedback on the exam, in particular the new station 5.

My cases were:
Station 5:
HHT History was a lady in her 60s admitted with tiredness and SOB. Hb was 6 and Fe deficient. Pt tranfused and asking to go home. My task was to take history and focused examination. Pt had no overt symptoms of blood loss on questioning. When I asked pt to move onto couch so I could examine abdomen, examiners stopped me and told me it was normal. I proceeded with the history - pt mentioned in the FH that her dad had smiliar problems and suffered from nosebleeds - which she had also had over the previous few weeks. I then noticed the teleangiectasia on her lips. I asked her to open her mouth and noted same on buccal mucosa. The questions were focused around management of epistaxis in this case, the mode of inheritance, and whether I thought her anaemia was soley due to epistaxis. I thought that she may also be having occult GI blood loss and this should be investigated further. I also tried to examine her chest (AV mals) - examiner asked me what I was listening for. I think some of the other candidates did the same too!

Graves Eye Disease and Goitre
The second case was a middle aged lady admitted to the hospital with SVT. Asked to take focused history and examination. Immediate observation of exopthalmos and proptosis. Examined neck and thyroid status. Questions were focused on my differentials, which blood tests I would request, and whether I felt see was hyperthyroid, eu, or hypo. Clinically she seemed euthyroid but in light of the history of SVT, hyperthyroidism needed to be excluded.

Resp was a pulmonary fibrosis. Asked about differentials, CT findings and what honeycombing represented.Abdo was an elderly lady with splenomegaly and a stoma/ascites bag on site of previous paracentesis. (questions were on diff of splenomegaly)

Cardio was AR ( I felt there was AS and AR - questions focused on which lesion i felt was the most predominat and the mx of AR) Neuro was a myasthenic patient who only had unilateral ptosis. I thought the instruction in this case was difficult - pt having weakness in arms and legs and blurring of vision. It may be useful to have a system of examining a myasthenic to illustrate the relevant signs or to show examiners that you know what to look for. I didn't have one and I think it showed.

History taking was a gent with progressive limb and neck weakness. (? Eaton Lambert, ? MG ?MND)

Comm skills was a dental nurse recently returned from Africa with new disgnosis of sputum pos TB. ? had exposure to HIV with previous partners whilst in Africa. Mother also died of TB. Lady was a single parent with two young children....

I attended the course in February, and am glad to say I have passed. Thank you very much for your help! I thought of just sharing the cases that I had for the exam.

Neurology- Lady with difficulty walking. She had wasting, power 0/5 both legs, loss of sensation (dorsal and st), with clonus on the right. I went up until the chest and she had no sensation up until lower chest. This station basically involved discussion of DDs and investigation.

Cardiology- This was a bit of an odd one. large thoracotomy scar scar 'L' shaped, with thrill, systolic and diastolic murmur (was rather confusing) on the precordium. I discussed the possible DDs, though I was not personally very happy the way this station went, I later thought that this was TOF with repair.

Ethics and communication- This involved talking to husband of a lady with Hep C regarding the condition and consenting him for the test. One of the other candidates commented that it got embaressing for him, the actor and examiners after a while. I had more than a minute left in the station. Mainly just went by the advised pattern. Questions were on ethical principles involved and Hep C treatment.

Station 5- Case1- 55 year old man referred from skin clinic as he had tremor. My diagnosis was Benign essential tremor, and discussed other causes for tremor and treatment options. Case 2- 75 year old gentleman referred by GP with h/o deteriorating vision. He is waiting to see opthalmology, but that is another 3m. focused history, examination and advise. This gent had near complete loss of vision bilaterally, positive fh, didnt want any help from OT, as he knew where everything in his house was and was helped by his wife. fundus showed retinitis pigmentosa. ( the cases were in fact BET and RP)

abdomen- hepatosplenomegaly with jaundice in a young man. This went well. The diagnosis I offered was hemolysis, possibly spherocytosis etiology, and discussed other DDs, investigation. (this was indeed HS, and am glad could come up with this diagnosis when the examiner asked for single diagnosis I would go with)

respiratory- straightforward, bibasal fine inspiratory crackles. discussion mainly was on drugs that can cause this. I just said what you have put on the website as an example of how to present, and also spoke of causes that I ruled out on examination. ( I could not come up with the drug examiner was looking for. I listed 4, but he asked for more. I could hear this patient telling the examiner, as I walked to the abdo station, how the morning session candidates got it right, but not the evening ones!)

History taking- 40 year old lady with lethargy and weight loss. Several possible DDs were discussed. History was suggestive of a thyroid problem. malignancy was another possibility.

My cases were:

Cardiac - Mitral regurgitation.

Neurology - Cerebellar dysfunction with evidence of lower motor neuron pattern weakness in the lower limbs. Probably due to alcohol.

History taking - 24 year old nurse on the OCP with a three month history of headache not relieved by simple analgesia and with symptoms of raised ICP - the differential they wanted was Benign Intracranial hypertension and the investigations were some form of neuro-imaging and LP.

Abdominal - polycystic kidneys and renal transplant.

Respiratory - rheumatoid pleural effusion.

Communication skills and ethics - middle aged man admitted with a tropnin positive acute coronary syndrome who is also an HGV driver - he wants to self discharge - discuss this with him with the aim of getting him to remain in for investigations - issues touched on were capacity, confidentiality and when it can be broken re: DVLA and HGV licence in context of IHD.

Brief clinical consultation (BCC) task 1 - gentleman with chronic back pain with recent history of constipation and then diarrhoea. Clearly an actor. Nil to find on examination. Asked for differential of infective diarrhoea.

BCC task 2 - patient with rheumatological disease presents with increasing shortness of breath. Had pulmonary fibrosis and evidence of right sided heart failure.

The BCC station can be a bit disconcerting as it isn't entirely clear what the examiners expect and I think using actors in a station that requires examination is very off putting as it is clear from the way they interact with you that they are an actor rather than a real patient.