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| Last Minute Advice! |
We hope you feel that the course has been useful in focussing your revision for the PACES. 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? 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. 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
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 GL wrote: My cases were: Graves Eye Disease and Goitre 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. 1. Station 5 -Presentation was SOB.
2. Station 5 -Patient with Arthritis and rash - Psoriasis
3. Communication-Breaking Bad news.
Patient in denial ,not happy with result .Also unhappy with GP as why she was not explained the problems secondary to HTN. 4. History taking- 5. Cases -
Neurology-Peripheral Neuropathy(Absent ankle reflex)
I am most grateful for this candidate who fedback the following scenarios from her own and her friends’ experiences. She passed her PACES (Shu). Commmunication skill station 1. 45 yr old gentleman recently diagnosed metastatic bowel cancer 2 months ago.He and his parents are shocked by the diagnosis and could not accept it and demanded for any possible treatment. He had chemotherapy and oncologist decided for palliative tratment under palliative care team.
2. A 38-yr-old gentleman had blood test for HIV with GP and GP referred to you for the result which is positive for HIV . Your task is to do breaking bad news and discuss with patient for management plan and tretment and address his concern. 3. 82 yr old lady chronic RA, had hip & knee replacement ,recurent mechanical falls. She denied home help previously. Now admitted from fall and slow progress, transferred with 2. She initially refused nursing home but now accept home help and would like to go home. Talk to daughter regarding discharge plan.
4. 50-yr-old lady, cough, haemoptysis , weight loss. GP did CXR which showed Rt hilar mass and referred to you. Your task is to discuss possible Dx and management plan. ( patient said she has claudophobia when you talk about CT scan) 5. 65-yr-old man known COPD admitted with Rt Upper Quadrent pain , had CXR portable in A&E – poor quality ,diagnosed cholecystitis and sent to surgical ward. Temperature not settled down, repeat CXR and found out Rt lower lobe pneumonia. This patient was transferred to medical ward but decision about ITU has not been made yet . He has history of severe COPD and had admitted to ITU previously and has stayed in ITU for 2 months due to difficult to wean off ventilator. Your task is to talk to angry son regarding further management. 6. To discuss with a duaghter of a nursing home residence, Parkinson’s disease and dementia for feeding options and management. 7. 40 yr-old-man went to GP with cough & haemoptysis over 6 weeks, and had CXR which showed metastatic lung Ca and referred to you. This patient had CXR 9 months ago with Locum GP which showed a small lesion which was missed at that time .Your task is breaking bad news to patient regarding Xray finding and management plan. He is very angry about delay Dx and missed Dx in 9 months ago. 8. To counsel 38 yr old sputum positive TB for HIV test and further management plan. 9. To explain a patient with newly diagnosed Parkinson’s disease for managemnet plan.
History 1. 53-yr-old gentlman referred by GP due to abnormal LFTs ( Alk Phos > 800, GGT > 200 and ALT >100 , Bilirubin about 50) and pruritus. He is generally in good health. He has only history of chest infection 2 months ago. His wife is concerned about his alcohol intake but he said he did not exceed the recommended range. Please take a history and address his concern. 2. 40 yr old lady diarrhoea off and on over 7-8 months, weight loss. Take history and discuss management.
3. 48-yr-old gentle man diarrhoea and weight loss over 4 months, to take history. 4. 25-year-old man acute chest pain. GP did ECG which was normal & referred to MAU. He was vomiting with no blood but developed dysphagia , tachycardia and became increasingly unwell. Please take history and discuss about management.
5. 45-yr-old man pins & needles & tingling in feet. History of weight loss and tiredness. Blood glucose normal. Take his history. 6. Middle age lady fever, night sweat, weight loss over a few months and Hb of 10.ESR 105 , To take history 7. 35-yr-old housewife complains of fatique, tiredness, lethergy and polyarthragia. To take history
8. Young man peripheral neuropathy , pins and needle in legs to take history. 9. Middle age lady microcystic anaemia , high BP, tiredness . History of miscarriage , joint symptoms
10. 35-yr-old man type 1 DM, hyponatremia , tiredness . On citalopram. Strong family history of lung cancer. His concern is whether this can be lung cancer? 11. Middle age lady , anaemia, fatique, Hb 9.8, MCV 80, PMH of irritable bowel syndrome for 10 years.Diary products make her diarrhoea. History of low back pain. Family history of Ca colon. To take history. Station 5 1. 54-yr-old lady known IDDM came for diabetic review clinic. She has concerned about her rt eye vision , please take a focus history , examination and address her concern.
2. 78-yr-old gentleman admitted to A&E with history of weakness and numbness on his Rt arm and rt leg lasting 3 to 4 hours. Please take focus history , exmination and addressed his concern.
3. 56-yr-old gentleman known HIV with vision problem in his right eye. He had history of seminoma of left testis and had chemotherapy for that. Please take focus history , examination and address his concern. 4. This gentlman was referred to you due to high BP 180/120 with headache. Please take history, examination and management and address his concern.
5. 60-yr-old gentleman problem with Left hand over 2 months , history of rt hip &left knee replacement in the past ,take focus history, examination and address his concern. ( Acromegaly with Carpal tunnel syndrome) 6. RA with SOB on exertion over 3 months ( Pulmonary fibrosis) 7. 56yr-old -lady has been suffered from leg ulcers, started with one ulcer in the right 5 weeks ago and then developed 2 ulcers in the left leg over 3 weeks. Take focused history , examination and address her concern.
8. 55-yr-old gentleman with deterioration of his vision (both sides) over a few months. Take focus history, examination and address his concern.
9. 64-yr- old gentleman known multiple sclerosis for 30 years. His multiple sclerosis is getting worse and starts to interfere his mobility. He noticed he is more SOB recently and he thinks it is contributing to his multiple sclerosis. His GP has referred to the clinic and to review him and address his concern. ( Patient asked why he is more SOB , and what is the cause of it?) Answer-from History – he is current heavy smoker for over 40 yrs, actually his mobility is not too poor , still mobilizing from history. Only when you asked, he will give history of occasional palpitations and wheezing lately. O/E he is in AF ,chest is clear, no wheeze. The candidate who diagnosed AF passed the case . I missed AF as I had no time to examine pulse and jumped to his back to listen when 2 mins left. I gave the differential of PE and COPD for his SOB . Examiners were not happy , wanted to link heavy smoker—COPD—causing AF –causing SOB & palpitations and failed me) 10. 25 yr old gentleman admitted to A&Es with 2 bouts of coffee ground vomiting , BP 100/60, PR 110/min. Please examine and address his concern.
11. Acromegaly , headache, bilateral carpal tunnel syndrome 12. Middle age lady has arthritis ( RA) on Hydroxychloroquine for 2 years, has hand deformity . Her concern is her friend, who has RA, is on disease modifying drug. Does her arthritis medication need to change to get benefit for her hand deformity? 13. Middle age lady known RA, went on holiday – vomited, OGD showed oesophagitis She is on Diclofenac, steroid, Alendronate acid. To take focus history, examination and address her concern. 14. 50 yr old lady known acromegaly- headache for 3 months to take focus history, examination and address her concern. 15. Systemic sclerosis and SOB 16. Difficulty in swallowing over 1 year, features of CREST syndrome 17. Chest pain in a systemic sclerosis + RA lady 18. Acromegaly and SOB on exertion which is progressive in nature 19. Known RA, swallowing problem – lump in the neck 20. 45-yr-old man with pain and pins & needles in hands for many years. Investigation showed normal FBC, U&Es, CRP. Xray hands showed Radiolucent lesion in metaphalangeal & interphalangeal joints asymmetrically. 21. Hypothyroid with tiredness 22. Psoriasis arthropathy and rt knee pain 23. This patient is Dx Fabray Disease, he has problem with controlling his hypertension, take focus history , exam and management plan 24. 75-yr old-man referred to TIA clinic with sudden onset loss of one vision over 6 hr. 25. This middle age lady was referred to you by optician due to unequal pupils, otherwise asymtomatic . Take focus history , exam and address her concern
26. Painful cold fingers- Raynaund’s syndrome & systemic sclerosis) 27. Young man with loss of right radial pulse and left carotid bruit. Had recurrent blackouts. Elevated ESR.
Station 1 respiratory: instruction was this man has episodic breathlessness, examine chest: he was young and there were no findings and I presented as normal chest. Then they asked why does he have breathlessness...I said since instruction was telling episodic , he could be having asthma then they asked about asthma management. abdomen: Had big liver & telengiectasias around mouth but no spleen. I presented as HHT. He had bruit (I wrongly presented as venous hum then they asked difference b/n hum and bruit). station 2 History taking 56-yr-old lady with wt loss and loose bowel . They asked all dd's related to malabsorption...she was celiac. Station 3 CVS: metallic prosthetic valve: was able to hear the metallic sound outside. Man was in his 50's. Asked possible complications. & indications. Neuro: Instruction was: test this Lady's speech and proceed.. She had a scanning speech. Had all cerebellar signs including nystagmus, positive finger nose and heel shin test. Asked what could be cause...I said DD as alcohol, MS, Friedrich's ataxia. She had pes cavus and hence I said it could be fr.ataxia. Also asked investigations. Station 4 62-yea- old diabetic and heavy smoker presented to vascular team with claudication pain. MRI done showed severe disease and vascular team has decided for conservative management..Patient very unhappy that it is for medical management . Candidate ( medical team) asked to explain medical treatment plan Patient agitated saying he has not been managed properly so far. Exploring the situation, I realised that he was non-compliant with insulin administration and offered him help by changing to less freq regime. He was continuing to smoke and has never been offered smoking cessation advice. This was offered. Also reviewed medication list and evaluated risk factors apart from Diabetes and smoking. He had issues at home with wife not well. Explained that it is also very important his participation and compliance very vital in salvaging limb. Further specialist ( diabetes and chiropody) will be arranged thru GP ( half way during the converstion he settled...just gave some time for him to express his anger) Station 5 Case 1 37-year-old female admitted with lower abdominal pain.. talk to her. Obs chart and urine dip stick chart were kept in corner. Dip stick was suggestive of UTI and obs showed temperature. Pt had flank pain C/o symp suggestive of pyelonephritis. Abd examination was unremarkable. She was hypertensive. Pt was concerned only about anything serious?? Examiners asked about investigations especially why ultrasound and also on treatment Case 2 47-year-old male admitted to MAU with cardiac sounding chest pain. Had risk factor of smoking. No family history. Explained to pt investigations planned (ECG CXR TROP etc offered pain relief). Said if normal will need special tests like ETT No complicated Q’s from examiners (Candidate passed) |
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