pass your mrcp paces in one attempt

1 Pass Your MRCP PACES in ONE Attempt ™

Pass Your MRCP PACES in one attempt!

Copyright © 2010 by Dr HK Goh.

All Rights Reserved.

Unauthorized duplication or distribution of this material in any form is strictly prohibited. Violators will be prosecuted to the fullest extent of the law. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permission from the author/publisher. The author, publisher, and distributor of this product assume no responsibility for the use or misuse of this product, or for any injury, damage and/or financial loss sustained to persons or property as a result of using this report. While every effort has been made to ensure reliability of the information within, the liability, negligence or otherwise, or from any use, misuse or abuse of the operation of any methods, strategies, instructions or ideas contained in the material herein is the sole responsibility of the reader.

Visit www.PassPACES.com for more information!

You can contact the writer at [email protected]


Dedication

This book is dedicated to Junie Ong, Jian Bin and Jian Feng, the three most important people in my life. And to Ong Ah Wan, a mother who has given her

unconditional love to me!

If ever there is a lack of any kind, whether it is need for employment, or for money, or for guidance, or even for healing, something is blocking the flow. And the most effective remedy:

Give!

-- Eric Butterworth, Spiritual Economics: The Prosperity Process


Introduction

You can pass your MRCP PACES, if you have passed your Part 1 and 2, there is no reason why you cannot pass your MRCP PACES. Trust me, you can do it and if you follow my advice, the good news is you can pass your PACES in one attempt! Yes, you hear me right,you can pass in one attempt, save your money, save your time and save your headache!

Remember....

You always have the best chance to succeed no matter what you do in life- MRCP PACES included. If you use the right techniques and strategies, you will get your MRCP( UK) or MRCP (Ireland) title after only one attempt!

Get your mind firmly focused in the right direction and the rest will fall into place!

Believe That- It’s Possible For YOU! You have to believe that you CAN get whatever results you are after. If you think you can, YOU CAN!!


The Game! Before you play a game, you must understand the rules, the MRCP PACES ( Practical Assessment of Clinical Examinations ) consists of five clinical stations, each assessed by two independent examiners. Candidates will start at any one of the five stations, and then move round the carousel of stations, at 20 minute intervals (Figure 1), until they have completed the cycle. There is a five-minute period between each Station. Only one of the Stations, Station 5, will change in the new format of the examination.

Figure 1 : The carousel of PACES stations


Remember that in MRCP PACES, the following skills are relevant

• Physical Examination - Demonstrate correct, thorough, systematic (or focused in Station 5 encounters), appropriate, fluent, and professional technique of physical examination.

• Identifying Physical Signs - Identify physical signs correctly, and not find physical signs that are not present.

• Clinical Communication - Elicit a clinical history relevant to the patient’s complaints, in a systematic, thorough (or focused in Station 5 encounters), fluent and professional manner. Explain relevant clinical information in an accurate, clear, structured, comprehensive, fluent and professional manner.

• Differential Diagnosis - Create a sensible differential diagnosis for a patient that the candidate has personally clinically assessed.

• Clinical Judgement - Select or negotiate a sensible and appropriate management plan for a patient, relative or clinical situation. Select appropriate investigations or treatments for a patient that the candidate has personally clinically assessed. Apply clinical knowledge, including knowledge of law and ethics, to the case.

• Managing Patients' Concerns - Seek, detect, acknowledge and address patients’ or relatives’ concerns. Listen to a patient or relative, confirm their understanding of the matter under discussion and demonstrate empathy.

• Maintaining Patient Welfare - Treat a patient or relative respectfully and sensitively and in a manner that ensures their comfort, safety and dignity.

Just remember that- it is a showmanship examination- there are only 3 skills you need to show to your examiners- ‘ cause no harm to your patient, examine your patient properly and of course work out your differential diagnosis logically!’


1) Cause no harm to your patient

Remember- never cause any pain, unnecessary worry to your patient. You can acquire this skill easily unless you are idiots. Talk to your patient clear and gently!

2) Examine your patient properly

This is a more difficult skill to acquire. However, practices make you a perfect person. No short cut for you to acquire this skill. You must practise examination regularly during your rounds in the hospital. Clinical examination should be a spinal reflex for you, no hesitation, no pause and of course no mistakes!

3) Work out your diagnosis!

Before you open your mouth in the examination, think twice first. As I told you earlier, clinical examination needs spinal reflex ( smooth and spontaneous), answering question in MRCP PACES needs cortical reflex ( you need brain cells to answer!) Never dig your own grave because you will be buried alive if you give stupid answers!

Another common syndrome candidates are facing during MRCP PACES is ‘Verbal constipation’, try to say something when examiners ask you, if you are lucky, they might guide you to the answers. If you remain silent, of course, even God can’t help you to pass!

Please, stay focus, if you follow my advice, miracle will happen!

1) No matter what happens in the past, it is a new start from today. No matter how many times you have failed MRCP PACES before, today is a new beginning, you will not make the same mistakes again!


2) Don’t panic, there is still ample time for you to prepare for your PACES. If I meet any challenges/ problems while forwarding towards my goal to get my MRCP, I will spend very little time focusing on the problem while spending most of my time focusing on the solution!

3) I will also realize and keep reminding myself that every problem, every challenge has within it the seed of a new opportunity! And that's what I will focus on - the opportunities.

4) I will keep all the negative influence people out of my life for months to come before my MRCP PACES because these people are like disease, they retard your growth to become a better person!

5) There are people out there whom I think are not as great as me but they have passed MRCP PACES. If they can do it, definitely I can do it too..... and of course in only ONE attempt!!

Every morning, before I do anything else, I will remind myself of the above. My goal is success and that's all I'm going to focus on. Failure is never an option.

Every night, before falling asleep, I will visualize myself as having already passed my MRCP PACES, as clearly and vividly as I can. I am waiting to take my second step after my PACES. Yes, you are right! You will pass your PACES in one attempt!


10 MRCP PACES myths Your brain is the best asset you have in life. You choose to believe something that people ask you to believe! Long time ago, people believed that the earth was flat. No one dared to challenge this fact. Even people were sentenced to death if they tried to prove this wrong. They firmly held on to this belief until one day someone proved them wrong by sailing around the world. When something new were discovered, it opened up my horizon to look beyond. Beliefs are not necessary based on facts. Here are a few MRCP PACES myths that hold many candidates from succeeding in their PACES, Myth # 1: You can’t pass it in one attempt! Fact: A lot of people passed their MRCP PACES in one and first attempt. Trust me, more attempts you try, less likely chance you will pass! The best shot is always the first shot!! Myth # 2: I just passed my Part 2, I have to wait first! Fact: Candidates think they need to wait at least 1-2 years before sitting their PACES after Part 2, I don’t believe that, if you think you are ready, go ahead! Don’t waste your time! Myth # 3: I need to know a lot to pass PACES Fact: Remember that each station is a 20-minute station, after spending 10 min examining your patient and presenting your findings, examiners actually have less than 8 mins to ask you questions. Come on, you think the examiners can ask you more than 3 questions during MRCP PACES, forget about it, if you can come to diagnosis and answer only one question correctly, you will get 3 out of 4 marks! Myth # 4: I just want try it out for my first attempt, it’s OK to fail


Fact: If you want to try, go and pay a few hundred to sit for Mock examination even though the mock exam and the course can easily cost more than the real examination. Why? Because you can be demoralized if you fail badly in real PACES examination and this nightmare can haunt you for months or even years. As I said, the best shot is the first shot, when you are ready for first attempt, you know that you are going to pass in the only one and first attempt!

Myth # 5: Medicine can be learned from Textbook Fact: No, no, no..... Even though how much you study from your book, you will never pass your exam without learning from real patients. Do not spend too much time digesting your book, you can get ‘ Irritable bowel syndrome’. My strategy is easy, today if I see an interesting case in the ward, I will go back and study the illness and picture that patient whenever I think of that illness! Picture worth more than thousand words! Myth # 6: History taking and counselling stations are easy to pass, don’t spend too much time on these stations Fact: There are only two stations that you know you can pass easily and definitely, they are station 2 and 4. However, these two stations need you to speak like your counterparts in UK whose mother-tongue is English.


If you can’t speak fluently in English, do not worry, practise with your friends. When I sat for PACES, I spent hours and hours talking to my friends via Skype because I know I can’t speak like British. After spending hours talking to my friend, I feel confident and I can talk like I have lived in UK for years during my MRCP PACES! Myth # 7: I need all three marks to pass my PACES Fact: Always remember that you need to have a few clear passes so that you can cover other stations. You will not do well in all stations and there are always some surprises in PACES. Always try to score high mark ( a clear 4 mark) in stations you are confident so that you can be sure that you still pass the examination even though you have clear fail in another station! Myth # 8: I do not need luck to pass my PACES Fact: Luck is part of a game in your MRCP PACES, although hardwork minimizes the component of luck playing along in your success, I still believe you need some lucks to pass this examination. No matter what your religion is, pray hard months before your examination, trust me, God only helps those who help themselves! Myth # 9: If I pass, someone else has to fail. Fact: This is absolute, high-grade, premium quality nonsense. Knowledge sharing is the best tool for you to gain more knowledge! When you try to open your mouth to teach others, you will soon find that how lacking you are in term of knowledge and that prompts to study more and gain more knowledge! Myth # 10: When I study for my PACES, I must sacrifice my time with family and leisure Fact: Good things always come along. Relax your mind and body. Play hard and work hard. When it is time to study,concentrate to your fullest, when it is time to play, release all your tension!


Many of these myths that have been floating around for years and were typically conjured up by people who didn't know any better. Beliefs are very powerful indeed. They, for the most part, are what dictate the quality of your life. Change your beliefs and you change your life. Free your mind, and success will follow! The next thing you want to do is to learn to relax. The more relaxed you are, the more efficiently your mind (and body) will function. Here's a simple relaxation technique: Lie down in bed or sit in a comfortable chair. Close your eyes and start taking deep, slow breaths. Let your mind go from all other thoughts and just focus on your breathing. In and out. With each in-breath, see yourself filling up with energy. And with each out-breath, see all the stress, tension, worry and confusion drifting out of your body. Do this for 5 to 15 minutes every morning, and a couple of times during the day when you take breaks. Be focused, your aim is only one- YOU WILL PASS YOUR PACES IN FIRST ATTEMPT!


Common Mistakes Candidates make during MRCP PACES

Mistake # 1:

Open your mouth once only when you are asked!

Examiners like easy life. If they ask you a question, try to answer them and give them your reasons. Never wait for them to open their mouths twice if possible! Let say you are given a case of Mitral regurgitation in your cardiology station, at the end of the examination, if the examiner asks you “ Dr....., what is the diagnosis?”

I will most probably start off by telling the examiners the important clinical findings and summarise by saying that this patient most probably has mitral regurgitation. However, I will not stop there, I keep on telling the examiners that I think the lesion is mild to moderate or moderate to severe and tell them the reasons why I say so. After that, I will tell the examiners the most probably underlying cause for that!

Examiners hate candidates who do not talk!

Mistake # 2:

You open your mouth, unfortunately you say something that are clearly wrong and stupid!

Yes, they like you to talk but please talk something correct and sound. You might think they are not relevant, but some examiners will help you to come to a diagnosis. However, one rule to remember, never say something stupid.

You can talk nonsense but never say something obviously wrong and stupid!

You might find these difficult to understand, let me illustrate one example, if you are given a case of bilateral joint pain in your station 5, after examining and taking short history from the patient, you think he is having either SLE or rheumatoid arthritis, when the examiner ask you the diagnosis, you dare not to make any commitment, you can start off


by saying that since the patient is having bilateral, symmetrical joint pain and the patient is rather young, you are thinking of autoimmune disease but you do not want to commit any definitive diagnosis, examiners sometime will guide you to the diagnosis.

However, it will be totally a different scenario if you say the patient has bilateral and symmetrical joint pain and you are thinking of gout. Understand?

Say something obviously right although it might sound nonsense to you ( because you never make any diagnosis) but never say something stupid!

Mistake # 3:

Never pick up clues examiners give you

During your MRCP PACES examination, remember most examiners try to pass you if possible. If any examiner offers help and give you hints to the diagnosis, you must be very vigilant to accept the offer.

For example, some examiners will ask you to examine again if you are giving them wrong physical signs, always try to listen to them. If might be your lucky day and you pick up the signs after re-examining the patient!

Mistake # 4:

Argue with the examiners

This is the lethal mistake, never try to do this during your PACES even you are 110% sure that the examiner is wrong! This rule doesn’t apply if you are ready to sit PACES again!

Mistake # 5:

Cause pain or discomfort to patient as well as to the examiners


Do no harm to your patient! Be gentle to your patient and examiners. Never cause discomfort, pain or embarrassment to your patient.

Touch them and treat them like your girlfriend or boyfriend!

Mistake # 6:

Cannot give more than 2 causes

Remember during your preparation, always learn at least 3 causes for each condition, such as causes for lung fibrosis, proximal myopathy etc. Try to remember at least three but will be better if you can remember more!

Mistake # 7:

Unable to outline simple management

You need to cover 4 important areas when talking about management of any diseases.

First- outline the investigations that you want to do.

Second- counselling and explanation- you must tell the patient the diagnosis and explain to them especially if the disease is a chronic one.

Third- Talk about non pharmacological ways of managing the patient. For example- in epilepsy, always talk about pregnancy and breast feeding if your patient is a child-bearing female. Non- pharmacological management is an important part of a holistic approach to a patient especially if it is a chronic disease.

Final part of your management is of course your pharmacological approach.

I find that a lot of candidates like to talk about drug,drug and drug again. Remember that besides drugs, there are other ways to help your patient.

Remember this 4-step approach!


Mistake # 8:

Try to say some rare diagnosis

I remember my old professor told me long ago.

“ It is easier to find a common disease that presents in a unusual way rather than finding a rare disease that present in a usual manner! “

Lesson to be learned, common diseases are common, never try to impress your examiners by saying something uncommon unless they force you to do so!

When you say something rare, also prepare to answer a few questions pertaining to that illness!

Mistake # 9:

Never greet your patient

During PACES, examiners always tell you the patient’s name. Greet your patient in their family name and not Uncle, Auntie that a lot of candidates from Malaysia and Hong Kong like to use!


CHAPTER 1 CARDIOLOGY STATION

Cardiology station is slightly different from other stations because you seldom can get any clues from just general inspection to come to a diagnosis. This station also needs a lot of practice so that you are familiar with all kinds of murmur.

There is no short cut to this station, listen to all kinds of heart sound and murmur again and again so that you are confident during the PACES. Always reasoning out your diagnosis by paying attention to the intensity of the first, second heart sounds as well as types of murmur you are listening to. For example if you can’t hear a loud first heart sound, that the diagnosis of mitral stenosis is unlikely, and the diagnosis of aortic stenosis is unlikely if you can’t hear a soft second heart sound.

Always try to compare your findings with your friends who will be taking examination together with you. If your friend thinks that the second heart sound is loud in one case and your finding is contradicting , always find out the cause of this kind of discrepancy. This will helps you slowly in future to present your findings confidently.


TOP ADVICE FOR CARDIOLOGY STATION

Always remember the following during your preparation for cardiology station,

1) Always take 5 to 10 seconds for general inspection. Although seldom you can get the diagnosis from just inspection, it is rather embarrassing if you miss the obvious diagnosis such as Marfan’s syndrome.

2) Never miss a central sternotomy scar. This can be easily missed in dark skin patients and patients with chest hair. If you find a central sternotomy scar, you are most probably dealing with prosthetic valve patients, bypass patients or patients with previous corrective surgery of ventricular septal defects, atrial septal defects or open surgery for valvotomy.

3) Always feel the pulse properly. You get a bonus if you find that the patient has irregularly irregular pulse because there are only a few common possibilities namely mitral stenosis (MS), mitral stenosis ( I mention mitral stenosis TWICE), atrial septal defect(ASD) and severe mitral regurgitation (MR). If you find the pulse is collapsing, congratulations , you are only dealing with aortic regurgitation (AR) or patent ductus arteriosus. (PDA)

4) Always palpate the apex beat properly, location and character of the apex beat can tell you the diagnosis. You most probably diagnose mitral stenosis, mitral regurgitation and aortic stenosis(AS) before even you auscultate the precordium! NEVER miss a dextrocardia!!

5) Never diagnose VSD if you can’t feel the thrill over the left parasternal area.

6) Always look for four Cs in your cardiology station namely cause, course, complication and consequences of the illness. For example, if you find that the patient is having mitral stenosis in your PACES, always think of the cause ( in this case, the


underlying etiology is most probably chronic rheumatic disease), course ( the stage of disease progression either mild , moderate or severe), complication ( whether this patient has developed atrial fibrillation, pulmonary hypertension?) and consequences of the complication (whether this patient has embolic stroke before due to atrial fibrillation or he/she is on long term warfarin).

7) Never forget to say that you would to complete the examination by checking this patient’s BP ( especially in patients with aortic stenosis and regurgitation), temperature ( especially patients whom you suspect have infective endocarditis) and fundoscopy ( if you suspect that you are dealing with infective endocarditis).

8) Once you diagnose patient has chronic rheumatic disease, always look for multiple pathology. Patients may have MR with MS, AR with AS or even mixed mitral and aortic lesions.

9) If you can hear very loud pan systolic murmur over left sternal edge with central /peripheral clubbing. You are most probably dealing with ASD/VSD with Eisemenger’s syndrome ( the pan systolic murmur you are hearing is tricuspid regurgitation and NOT VSD murmur) or tetralogy of fallot. Only one way to differentiate these two diagnoses, listen carefully for the second heart sound. In ASD/VSD with Eisenmenger’s, patients must have developed pulmonary hypertension, you will hear a very loud second heart sound. In TOF ( the pan systolic murmur is due to VSD murmur), because of pulmonary stenosis, the second heart sound is soft.

10) Practice, practice and practice ! This is the only way to make you a perfect doctor!

Always remember the above advice when you are seeing cardiology cases. Remember that there are only a few short cases that will come out in cardiology station. Proceed to the following segment to find out the common short cases in this station.


COMMON SHORT CASES IN CARDIOLOGY STATION

I would tell you about 15 common short cases in this station. However different centres may have different preferences in cardiology station. In developed country such as UK, you may not encounter chronic rheumatic heart disease as commonly as you will see it if you decide to sit your PACES in Malaysia or Singapore. However, the following short cases are most probably the commonest in your MRCP PACES,

1) Prosthetic valve (very popular short case in UK, can be either mitral valve or aortic valve alone or both valves. Candidates always miss aortic valve replacement, try to listen to heart sound of patients with aortic valve replacement ALONE at least 10 times before your examination. You may not be required to differentiate either the replaced valve is ball and cage type or tilting disc type but if can differentiate them, it is a plus point for you!)

2) Mitral stenosis ( very common in centres held in developing country such as Malaysia), always look for other concomitant valvular heart diseases.

3) Mitral Regurgitation (you most probably will diagnose this after palpating the apex beat)

4) Aortic Regurgitation ( always look for possible etiologies if you find AR alone, the possible etiologies include Marfan’s syndrome, syphilis and Ankylosing spondylitis) .If there is concomitant other valvular lesion, then the etiology is most probably CHRD.

5) Aortic stenosis ( the only valvular lesion that is common in UK especially in older patients due to degeneration of the aortic valve)

6) Tricupid regurgitation ( commoner than you think it might be, usually not TR alone lesion but TR develops due to other valvular


heart lesions such as severe MR/MS or intracardiac shunt with pulmonary hypertension. If you find TR alone, always think of possibility of infective endorcarditis)

7) Concomitant MR/MS ( very, very common in patients with CRHD, always try to find the predominant lesion. )

8) Concomitant AR/AS (very, very common in patients with CRHD, always try to find the predominant lesion.)

9) Concomitant aortic and mitral valve lesions. ( very difficult scenario, however, you will pass even you miss one or two lesions. Do not worry too much about this.)

10) Ventricular septal defect ( always think of this if you can hear a very loud pan systolic murmur with parasternal thrill.)

11) Atrial septal defect .

Always think of this diagnosis if you encounter the following scenarios,

a) You cannot hear any murmur after complete physical examination, most probably you have missed the fixed splitting of second heart sound.

b) You only can hear an ejection systolic murmur over the pulmonary area ( flow murmur in ASD, pulmonary stenosis ALONE is unlikely in PACES but always due to TOF.)

c) You only can feel that patient is having AF but the first heart sound is not loud.

12) Tetralogy of Fallot ( always suspect this in young patients with cyanosis, patients with Eisenmenger’s due to intracardiac shunt usually present in fourth or fifth decades. Remember, the second heart sound is soft!!)


13) Patent ductus arteriosus ( collapsing pulse, collapsing pulse but NOT AR, some candidates may find machinery murmur sounds like pan systolic murmur but listen carefully each time you have a case of PDA in your ward.)

14) Mitral valve prolapse ( classically murmur for MVP is described as midsystolic murmur after a click, however, it can be pan systolic murmur and you may think that it is MR or VSD, however, if you are in doubt, tell you examiners that you will like to do some dynamic exercise, standing and valsalva manoeuvre will make the murmur longer and louder. The examiners most probably will be very happy and impressed after you tell them this. You are usually not required to do this test.)

15) Others. I mention here others because very, very unlikely you are going to get short cases other than I mention above. Do not worry about other short cases, if you study hard all the above short cases, you most probably will score a 4 in 99.9% of short cases that you will see in your PACES.


COMPLETE PRESENTATION FOR COMMON CASES

1) MITRAL/ AORTIC VALVE REPLACEMENT OR BOTH

Mr / Madam……….. is comfortable at rest . His pulse rate is 80 beat per min, regular ( or irregularly irregular) and it is not collapsing in nature. There is no stigmata of infective endocarditis nor she has central or peripheral cyanosis. His jugular venous pressure is not raised. There is presence of midline sternotomy scar with an audible click. His apex beat is not displaced ( or displaced at ……………). First and second heart sounds were heard but first ( or second or both ) heart sound was replaced by metallic click. There is no audible murmur ( sometimes may have soft ejection systolic murmur). His lung is clear and there is no obvious bruise over the body.

( Sternotomy scar can be missed if the patient has hairy chest or very fair skin!)

In summary, this gentleman/ lady has mechanical prosthetic mitral (or aortic or mitral and aortic ) valve replacement currently in sinus rhytme (or atrial fibrillation). There is no stigmata of infective endocarditis and he is not in failure. There is no sign to suggest over warfarinization. The type of mechanical prosthetic valve that this patient is having is ball and cage (or tilting disc type ) because………………………………………………


The prosthetic valve is/ is not functioning well because……………………….. ..

The underlying cause of his valve displacement is due to ……………….

Additional points:

a) To differentiate mitral or aortic valve replacement, pay attention to the nature of the first and second heart sounds. If the first heart sound is metallic then it is mitral valve, if the second heart sound is metallic then it is aortic valve. However, be aware that sometimes you may mistaken the opening of the mechanical mitral valve as second heart sound , this will make you to have a wrong conclusion that the second heart sound appears to be metallic.

Normal heart sound

S1 and S2 ( normal character)

Mitral Valve replacement

S1 (metallic), opening snap (metallic), S2


Aortic Valve replacement

S1, S2 (metallic)

Both Valves replacement

S1 and S2 (metallic)

b) To know whether the valve is functioning well or not, remember, ejection systolic murmur can be normal in either mitral or aortic valve replacement. However, diastolic murmur is always pathological in aortic valve replacement. Listen hard for the nature of the metallic click, usually in well functioning valve, it is loud and clear. Also, suspect valve dysfunction if patient has failure.

c) To know why a valve is replaced, feel the apex beat, in MVR, if the apex beat is not displaced then the cause is due to MS, the otherwise is true for MR. In AVR, if the apex beat is displaced then the cause is AR and the otherwise is AS.


d) If patient has AVR especially for AS, always look for concurrent bypass surgery by checking donor site for graft.

e) To know whether the prosthetic valve is cage and ball or tilting disc, listen for crocking sound in patients with ball and cage prosthetic valve.

f) Always look for signs to suggest current or previous over warfarinization such as bruises or scar due to previous brain surgery.

( Never miss a bruise in cardiology station!)

g) AVR lasts longer than MVR because MV tends to calcify

faster.

h) Mechanical prosthetic valve is preferred than bioprosthetic

valve even in child bearing female patients except in patients who have absolute contraindications for warfarin. Bioprosthetic valve maybe prefered in older aged group patients.


2) MITRAL STENOSIS

Mr / Madam………… is comfortable at rest, his pulse rate is 92 beat per min irregularly irregular with variable volume but not collapsing in nature. This is no stigmata of infective endocarditis nor he has peripheral or central cyanosis. His JVP is raised with positive hepatojugular reflux with presence of bilateral lower limbs pitting oedema. His apex beat is not displaced but tapping in nature. First and second heart sounds were heard with presence ( absence) of opening snap. The first heart sound is loud in nature as well as the pulmonary component of the second heart sound. There is presence of long mid diastolic rumbling murmur at the mitral area which is accentuated when the patient is on left lateral position and in expiration. There is another pan systolic murmur best heard over left sternal edge when patient is in inspiration. His lung is clear.

In summary, I suspect this gentleman has severe mitral stenosis currently complicated with pulmonary hypertension and tricuspid regurgitation. He is in atrial fibrillation but there is no stigmata of infective endocarditis. The underlying aetiology for his MS is probably due to chronic rheumatic heart disease.

Additional points:

a) Always look for left sternotomy scar which may suggest previous open valvotomy / valvuloplasty.( always missed by candidates)

b) It is important to listen for opening snap because absence of opening snap means calcified and non pliable valve, therefore percutaneous valvuloplasty is unlikely.

c) Mitral stenosis is severe if you can hear long diastolic murmur, closer open snap to second heart sound and signs to suggest pulmonary hypertension.


( Sometime examiners ask you about classical findings in CXR with pulmonary hypertension-left atrial enlargement with dilated

pulmonary arteries)

d) Always look for concomitant MR if the apex beat is displaced.

3) MITRAL REGURGITATION

Mr /Madam ……………… is comfortable at rest, his PR is 92 beats per min and regular. It is not collapsing in nature. There is no stigmata of infective endocarditis nor he has central or peripheral cyanosis. His JVP is not raised , his apex beat located at sixth intercostals space ,2 cm lateral to the midclavicular line and it is thrusting in nature. First and second heart sounds were heard in which the first heart sound is soft and the second hear sound is loud. Third heart sound was heard. There is presence of pansystolic murmur over the mitral area radiating to the axilla and best heard when the patient is in expiration.


In summary, this gentleman has severe mitral regurgitation currently complicated with pulmonary hypertension. He is in sinus rhytame and not in failure. There is no stigmata of infective endocarditis. The underlying etiology of his MR is most probably due to CRHD.

Additional points:

a) MR secondary to CRHD can cause development of pulmonary hypertension, other causes of MR will not prone patients to get pulmonary hypertension.

b) Signs to suggest severe MR include grossly displaced apex beat, presence of third heart sound, loud second heart sound and heart failure.

c) Always look for presence of concomitant MS if the apex beat is not displaced.

4) AORTIC REGURGITATION

Mr / Madam………… is comfortable at rest. His pulse rate is 80 beat per min with regular rhythm and it is collapsing in nature. There is no stigmata of infective endocarditis nor this gentleman has central or peripheral cyanosis. His JVP is not raised but there is presence of Corrigan’s sign. His apex beat is located at sixth intercostals space and 1 cm lateral to the midclavicular line and it is thrusting in nature . His first and second heart sounds were normal in intensity. The third heart sound is present. There is presence of early diastolic murmur over the left sternal edge when patient leans forward and in expiration.


In summary, this gentleman has severe aortic regurgitation. He is in sinus rhythm and there is no stigmata of infective endocarditis. He is not in failure. The underlying aetiology for his AR is most probably due to CRHD.

Additional points:

a) Always offer to examine this patient’s BP to look for wide pulse pressure that signifies severe AR.

b) Signs to suggest severe AR include wide pulse pressure, grossly displaced apex beat, presence of third heart sound and long diastolic murmur.

c) Always remember a few other AR signs such as de musset’s, pistol shot murmur which can impress the examiners if they ask you.

d) Other causes of isolated AR include Marfan syndrome and syphilis.

( Marfan syndrome)


5) AORTIC STENOSIS

Mr / Madam……….. is an elderly gentleman / lady who is comfortable at rest. His pulse rate is 80 beat per min and regular. His pulse is small in volume and slow rising ( pulsus parvus et tardus). There is no stigmata of infective endocarditis nor he has central or peripheral cyanosis. His JVP is not raised. His apex beat is located at fifth intercostals space, midclavicular line and it is heaving in nature. First and second heart sounds were heard. The second heart sound is soft in intensity. There is presence of fourth heart sound. There is a harsh ejection systolic murmur best heard over the aortic area and radiating to carotid when the patient is in expiration.

In summary, this gentleman has severe aortic stenosis and currently he is in sinus rhythm. There is no stigmata of infective endocarditis and he is not in failure. The underlying aetiology for his AS is most probably due to degenerative changes in view of his age.

Additional points:

a) It is very common to find the ESM in AS all over the precordium (Gallavardin’s phenomenon), however, the murmur is usually loudest in aortic area.

b) Signs to suggest severe aortic stenosis include narrow pulse pressure, slow and small radial pulse, reversed splitting ( unlikely for you to differentiate), presence of fourth heart sound and heart failure .( seldom occur except it is terminal!!)

c) Always look for concomitant bypass surgery!!


6) TRICUPID REGURGITATION (ALONE WITH IE)

Mr / Madam………….. appears to be tachypnoeic at rest. There is a branula over his right hand with intravenous drip. There is stigmata of infective endocarditis as evidenced by presence of Janeway lesion and Osler’s node over both his hands. His PR is 120 beat per min, regular and is not collapsing in nature. He has no central or peripheral cyanosis. His JVP is raised with positive hepatojugular reflux and presence of bilateral lower limb oedema.

His apex beat is not displaced, first and second heart sounds were heard and in normal intensity. There is pansystolic murmur ( can be ejection systolic murmur) present over the left sternal edge which was accentuated when patient is in inspiration. There is presence of pulsatile liver as well. The lung is clear.

In summary, the gentleman has tricuspid regurgitation which is most probably due to infective endocarditis. He is currently in sinus rhythm and intravenous antibiotics in view of presence of brannula.

Additional points,

a) Always offer you like to check this patient’s temperature, do fundoscopy to check for presence of Roth’s spot (vasculitis) and check urine of microscopic haematuria.


( Roth’s spot in endocarditis)

b) Always proceed to examine the abdomen, splenomegaly can be

present.

c) Always offer to examiners that you would like to ask patients about any high risk behaviour such as intravenous drug abuse.

d) Be prepared to be asked about regime of subacute bacterial endocarditis (SBE) prophylaxis in patients with valvular lesions.

e) Always remember criteria to diagnose infective endocarditis. ( check your book NOW!)

7) CONCOMITANT MR/MS

Combination of presentation of MR/MS but in the last segment of presentation, always tell examiners that what the predominant lesion is by giving a few reasons.

Additional points,


a) MR is the predominant lesion if the apex beat is displaced and first heart sound is soft.

b) MS is the predominant lesion if the apex beat is not displaced and tapping and the first heart sound is loud.

c) It can be difficult sometimes to determine the predominant lesion, always suggest to examiners you would like to do echocardiogram to clear the doubt.

8) CONCOMITANT AR/AS

Combination of presentation of AR/AS but in the last segment of presentation, always tell examiners that what the predominant lesion is by giving your reasons.

Additional points,

a) AR is the predominant lesion if the apex beat is displaced ,the second heart sound is normal and there is wide pulse pressure.

b) AS is the predominant lesion if the apex beat is not displaced, the second heart sound is soft and there is narrow pulse pressure.

9) CONCOMITANT AORTIC AND MITRAL VALVES LESIONS

Try to present your findings slowly and systematically. Never commit yourself in saying what the predominant lesion is. ALWAYS tell examiners that you would like to do echocardiogram to clear this difficult issue.

10) VENTRICULAR SEPTAL DEFECT


Mr / Madam…………….. is comfortable at rest. His pulse rate is 80 beat per min, regular and not collapsing in nature. There is no stigmata of infective endocarditis nor he has central or peripheral cyanosis. The JVP is not raised. His apex beat is located at 5th intercostal space and 2 cm lateral to the midclavicular line. There is presence of palpable thrill over the parasternal space. First and second heart sound were heard. The second heart sound is loud. There is loud pansystolic murmur best heard over the left sternal edge especially when the patient is in expiration. The lung is clear.

In summary, I suspect this gentleman has ventricular septal defect currently complicated with pulmonary hypertension. He is in sinus rhythm and not in failure.

Additional points,

a) VSD is rather a common short case in PACES, when pulmonary hypertension develops and the shunt changes from left to right into right to left, the murmur intensity may decreases. However, there will be another pansystolic murmur developing over the left sternal edge ie Triscupid Regurgitation.

b) You must always look for possibility of TOF if you suspect presence of VSD, in TOF, there will be presence of cyanosis with soft second heart sound.

( Tetralogy of Fallot)


c) Try to look for dysmorphism in patient with VSD, you certainly do not want to miss Down’s syndrome.

( Never miss Down syndrome in PACES!)

11) ATRIAL SEPTAL DEFECT

Mr / Madam ……………..is comfortable at rest. His pulse rate is 80 beat per min, regular and not collapsing in nature. He has no stigmata of infective endocarditis nor he has central or peripheral cyanosis. His JVP is not raised ( can be raised if patient develop severe pulmonary hypertension with tricuspid regurgitation). His apex beat is located at 5th intercostals space, midclavicular line. First and second heart sounds were heard. There is fixed splitting of the second heart sound and the pulmonary component of the second heart sound is loud. The lung is clear.


In summary, I suspect this gentleman has atrial septal defect currently complicated with pulmonary hypertension. He is in sinus rhythm and there is no stigmata of infective endocarditis.

Additional points,

a) Do not forget that you may just find patient with tricuspid regurgitation and right heart failure and loud second heart sound. The underlying cause for this may be ASD and you will pick up fixed slitting of second heart sound if you listen carefully.

b) Eisemenger’s will usually develops in ASD when patients are in their 4th or 5th decades of life.

12) TETRALOGY OF FALLOT

Mr / Madam…………………. Is comfortable at rest. His pulse rate is 92 beats per min, regular and not collapsing in nature .He has clubbing of the fingers with peripheral and central cyanosis. There is no stigmata of infective endocarditis. The JVP is not raised . His apex beat is located at 5th intercostals space , 2 cm lateral to the midclavicular line. There is a palpable thrill over the pulmonary area. First and second heart sounds were heard. The second heart sound is soft. There is presence of pansystolic murmur best heard over the left sternal edge. There is another ejection systolic murmur heard over the pulmonary area. The lung is clear.

In summary, I suspect this gentleman has tetralogy of fallot and there is no evidence that previous operation was done (if operation was done, such as Blalock-Taussig shunt, there will be equal radial


pulse). He is in sinus rhythm and not in failure, there is no stigmata of infective endocarditis.

( They may ask you what Blalock Taussig shunt is in PACES)

Additional points,

a) Classically, you will see this kind of patient in their early childhood however, it is not uncommon to see patient to come to see you in their mid twenty without any operation done before.

13) PATENT DUCTUS ARTERIOSUS (PDA)

Mr/ Madam…………….is comfortable at rest. His PR is 82 beats per min, regular but collapsing in nature. There is no clubbing nor he has central or peripheral cyanosis. There is no stigmata of infective


endocarditis. His JVP is raised. His apex beat is located at 6th intercostals space, 2 cm lateral to the midclavicular line. There is palpable thrill over the left sternal edge. First and second heart sounds were heard. First heart sound is normal in intensity but the second heart sound is loud. I can appreciate a continuous murmur all over the precordium but it is best heard just below the clavicle. The lung is clear.

In summary , this gentleman has patent ductus arteriosus and currently complicated with pulmonary hypertension. He is in sinus rhythm and there is no stigmata of infective endocarditis. He is not in failure.

Additional points,

a) If patient develop reversal of shunt , there is possibility of differential clubbing. (clubbing presents in toes but not in fingers)

b) You may be confused continuous murmur to pansystolic murmur, try to listen to PDA murmur if you have the chance.

14) MITRAL VALVE PROLAPSE (BARLOW’S SYNDROME)

Mr / Madam…………. Is comfortable at rest. His PR is 80 beats per min, regular and not collapsing in nature. There is no stigmata of infective endocarditis nor he has central or peripheral cyanosis. His JVP is not raised. Apex beat is not displaced. There is no palpable thrill or heart sound. First and second heart sounds were heard and normal. The is presence of midsystolic click followed by systolic murmur. He is not in failure.


In summary, I suspect this gentleman has mitral valve prolapse. He is in sinus rhythm and there is no stigmata of infective endocarditis. I would like to do some dynamic exercise to confirm my diagnosis. I would anticipate the murmur becomes longer and louder when the patient tries to stand up from squatting position and when doing Valvasa’s manouver.

Additional points,

a) MVP can be associated with a few conditions such as Ehler-Danlos, Marfan’s syndrome, Wolff Parkinson White syndrome….etc, do not miss these associated conditions in your exams.

b) MVP’s murmur can be pansystolic, therefore always put MVP as your differential when you diagnose someone to have MR.

c) Remember the possible complications of MVP.

15) Others Finally, we come to the last question in cardiology, never spend too much time learning other rare conditions such as coartation of aorta…..etc, you most probably will not see them in your all life.


COMMON MISTAKES /PITFALLS OF CANDIDATES

1) Rude to patients. 2) Forget to dress back patients after physical examinations. 3) Confuse either the murmur is pan systolic or continuous. 4) Presentation is not complete and conscience. 5) Miss cyanosis and even clubbing. 6) Not listen carefully to the second heart sound. You must

always compare the second heart sound over aortic and pulmonary areas. If it is louder at pulmonary area, this means that the second heart sound is loud.

7) Not observant enough, if you see a stroke patient with MS, always remember that the stroke may be due to AF because of the underlying MS.

8) Create own physical signs. 9) Unable to conclude a diagnosis from physical signs. For

example, pulmonary hypertension is unlikely to develop in AS,AR, a normal intensity second heart sound is unlikely due to AS, a displaced apex beat is unlikely due to MS ( except concomitant MR) etc….

10) Try to argue with examiners!!

GOOD LUCK TO YOUR CARDIOLOGY STATION!


CHAPTER 2 RESPIRATORY STATION

Respiratory station is always the easiest station to pass or fail. It is easy to pass because there are only very limited variety of cases c in the exams. You can easily fail this station as well because it is the station you need the longest time to examine and if you cannot correlate your signs, you most probably will be confused after your physical examination. Remember, this station is a give if you do it properly!

The trick to this station is you have to examine confidently and pick out the important signs, you will pass with a 4 even the examiners do not have the time to ask you any questions if you can pick up all the important physical signs.

This is the station that needs the least knowledge because at the most the examiners will ask you two questions, first is ‘What is your diagnosis?’ and second is “ What investigations do you want to do?”

No need to spend too much time on the theory part. Just examine patients again, again and again. Always try to feel the trachea properly because the trachea can tell you important clues that finally lead you to the correct diagnosis.


TOP ADVICE FOR RESPIRATORY STATION

Always remember the following points during your preparation for respiratory station,

1) Always expose the patient properly,check FRONT and BACK.If you pick up a lateral sternotomy scar at the back, you can come to a diagnosis almost immediately. If you only hope to pick up this when you examine the back of the chest, you may be stopped by examiners in view of time constraints.

2) Crepitation in fibrosing alveolitis is fine and Velcro-like, whereas in bronchiectasis, the crepitation is course in nature.

3) Although lateral sternotomy scar at the back means the diagnosis can be pneumonectomy or lobectomy. Never forget there is possibility of lung transplantation or decortication. If the patient looks Cushingnoid and with side effects of immunosuppression such as presence of gum hypertrophy, excessive hairs etc, always think of possibility of lung transplantation.

4) If you find the trachea is centrally located, always start your physical examination from the back (you can usually find the pathology from the back if trachea is central), if it is deviated, start from the front.

5) Always suggest to examiners you would like to look at the sputum cup and temperature chart after your physical examination.

6) Patients with consolidation ( pneumonia) is not a popular question in exams because they are usually ill.


COMMON SHORT CASES IN RESPIRATORY STATION

I would tell you 6 common short cases that will come out in your MRCP PACES. Always remember that there are very limited short cases in respiratory station. Memorize them hard and you will pass this station with flying colours.

1) Pneumolectomy / lobectomy (very ,very common in UK , always expose the patient properly, look at the back first before you start examining the patient.)

2) Lung fibrosis/ fibrosing alveolitis ( all time popular question, always remember causes for upper and lower lobes fibrosis, look for Cushing’s syndrome in patients with fibrosing alveolitis)

3) Bronchiectasis (some candidates cannot differentiate course from fine crepitation, always practice listening to crepitation. Look at the sputum cup beside the patient.)

4) Pleural effusion (Never miss a small pleural effusion! Look for scar for previous pleural biopsy/aspiration)

5) Lung carcinoma with or without superior vena cava obstruction.It can happen as pleural effusion, or just a lung mass. Always look for SVC obstruction and if present, look hard for radiotherapy scar/ skin changes.


( Superior Vena Cava Obstruction)

6) Consolidation/collapse ( seldom comes out in the real exams, however, study these conditions as well).



1)PNEUMONECTOMY / LOBECTOMY

Mr / Madam………………. appears to be comfortable at rest. He has no clubbing of fingers nor he has central or peripheral cyanosis. There is no sign to suggest any carbon dioxide retention. His trachea is deviated to the right and the apex beat is displaced in the same direction. His JVP is not raised and there is no palpable second heart sound. There is a thoracotomy scar over right side of the chest with reduced expansion at the same side. Tactile and vocal fremitus is reduced. Percussion note is dull and the breath sound is reduced. ( can be absent in a case of pneumonectomy)

In summary, I suspect this gentleman has right lobectomy/ pneumo-nectomy and currently is comfortable. I would like to suggest a few possible causes for his operation such as previous mitotic lesion, tuberculosis or solidatary lung nodule.

Additional points,

a) Always look hard for any scar, sometime it is difficult to pick up the scar if the scar is hidden just under the subscapular region.

b) Always remember that decortication scar can be quite similar to pneumonectomy/lobectomy scars but generally the decortication scar is smaller.

c) Pneumonectomy/ lobectomy used to be treatment for tuberculosis long ,long time again.


2) FIBROISING ALVELOLITIS/ LUNG FIBROSIS

Mr / Madam ……………. Is comfortable at rest .He is not tachynoeic. There is clubbing of fingers with central and peripheral cyanosis. There is no sign to suggest any carbon dioxide retention. His JVP is not raised and the trachea is centrally located. Lung expansion appears to be reduced bilaterally. Tactile and vocal fremitus is normal bilaterally as well as the percussion. However, auscultation reveals bilateral fine basal crepitation. Besides that, I also notice this gentleman to be Cushingnoid as evidenced by presence of moon –like facies with buffalo’s hump and truncal obesity.

In summary, I suspect this gentleman has cryptogenic fibrosing alveolitis and he is currently on long- term steroid with Cushing’s syndrome.

Additional points,

a) Never miss peripheral clues which can give you the underlying aetiology for patient’s lung fibrosis such as rheumatoid hands, sclerodactyly (in systemic fibrosis), malar rash, skin hyperpigmentation ( suggestive of amiodarone side effects), rigid spine (Ankylosing spondylitis) etc…………..

( Systemic Fibrosis- Tight Skin!)


b) Feel the trachea carefully, trachea location is the single most important sign to diagnose upper lobe fibrosis. Breath sound in upper lobe fibrosis can be normal, reduced or even increased. There will be usually presence of bronchial breath sound in upper lobe fibrosis.

c) Always look for side effects of long-term steroid ingestion if you suspect the patient is having fibrosing alveolitis.

3) BRONCHIECTASIS

Mr / Madam………… is tachynoeic at rest and dependent on oxygen supplement via a nasal cannula. There is clubbing of fingers but he has no central or peripheral cyanosis. There is flapping tremor to suggest carbon dioxide retention. His JVP is raised. The trachea is centrally located. Apex beat is not displaced and the second heart sound is loud His lung expansion is generally reduced, percussion note is resonant all over, tactile /vocal fremitus is equal bilaterally. There is coarse crepitation best heard over both bases of the lung .

In summary, this gentleman has bronchiectasis currently complicated with pulmonary hypertension. He is dependent on oxygen supplement.

Additional points,

a) Although classically clubbing is seen in bronchiectasis, you may not find clubbing always in bronchiectasis.

b) Always remember a few causes which predisposes patients to have bronchiectasis such as cystic fibrosis ( in western countries),


Kartagener’s syndrome ( more so if you find dextrocardia) and alfa one anti-trypsin deficiency.

c) It is a very common short case in the exams , always prepare for this!! ( I bet 50% of you will get this!)

d) Always look at sputum cup!

( Thick yellowish sputum!)

4)PLEURAL EFFUSION

Mr/ Madam……… is comfortable at rest. He has no clubbing, central or peripheral cyanosis . There is no sign to suggest carbon dioxide retention. I notice there is a induration over his right upper limb suggesting recent Mantoux test. His jugular venous pressure is not raised and his apex beat is not displaced. There is no palpable P2. There is a small scar over the lower region of his left lung suggesting recent pleural aspiration and biopsy. His lung expansion is reduced over the left side, tactile and vocal fremitus is reduced over the same side


with stony dullness on percussion. Auscultation revealed diminished breath sound at the same area.

In summary, I suspect this gentleman has mild to moderate left pleural effusion and currently is not in respiratory distress.

Additional points,

a) always quantify your pleural effusion to mild to moderate and moderate to severe based on your percussion. ( Never say mild, moderate or severe- you must learn how to talk like a politician in your exam with gray area in between so that in case you are wrong, you still have room to argue!)

b) severe pleural effusion is always due to underlying malignancy.

c) Suggest to the examiner you would like to look at the temperature chart because one of the causes for pleural effusion is para-pneumonic effusion.

5)LUNG CARCINOMA

Mr/Madam……. is tachypneic at rest. He is dependent on oxygen supplement via a nasal cannula. He is cachexic looking. He has no clubbing, central or peripheral cyanosis. The face and the upper extremity are edematous and the eyes are suffused. The veins over the neck are dilated and engorged. His trachea is centrally located. Apex beat is not displaced and there is no palpable P2. Lung expansion appears to be reduced on the left side as well as the tactile and vocal fremitus. Percussion reveal there is dullness over the middle zone of the


left lung. Breath sound is reduced on the same side. There are multiple cervical lymph nodes palpable over the left anterior triangle of the neck.

In summary, I suspect this gentleman has superior vena cava obstruction most probably secondary to mitotic lesion over his left lung. I would like to ask this gentleman any past history of chronic smoking.

Additional points:

a) Always look hard for previous radiation scar over the chest which is the main therapy for superior vena cava obstruction.

b) Suggest to examiner you would like to look for Pemberton sign although it’s unlikely they will ask you to demonstrate the physical sign.

c) Remember all the subtypes of lung cancer and various para-neoplastic presentation of lung carcinoma. ( a popular question if you get lung cancer in your MRCP PACES)

6)CONSOLIDATION

Mr/Madam…… is tachypneic at rest and dependent on oxygen supplement. He has no clubbing, peripheral or central cyanosis. The trachea is centrally located. There is no sign to suggest carbon dioxide retention. Apex beat is not displaced and there is no palpable P2. There is reduced movement of the right chest .There is dullness to percussion over the middle zone with bronchial breath sound, coarse crepitation and increased tactile and vocal fremitus.


In summary, this gentleman has consolidation over the middle zone of the right lung and currently is dependent on oxygen supplement.

Additional points:

a) Usually patient with consolidation is too ill to come out in the exam. However there is a possibility if patient is partially treated and well.

b) Always look at the patient’s temperature chart.

c) Tuberculosis is always a differential diagnosis for consolidation especially in developing countries.

You may think that respiratory station is a simple station, you are right and wrong. Respiratory case is always easy if you can complete your physical examination within 7-8 minutes. Try to examine either from front or the back based on patient’s trachea location. If the trachea is centrally located, examine from the back, if it is deviated , examine from the front.



1) Insufficient time spent on inspection, missing scars and abnormalities of shape and movement of chest wall.

2) Failing to percuss and auscultate over the apices and/or right down to the lung bases.

3) Not knowing normal levels of diaphragm anteriorly and posteriorly.

4) Failing to test for vocal resonance. 5) Inventing signs to fit a diagnosis. 6) Failing to complete physical examination within allocated

time. 7) Unable to read simple CXR.


CHAPTER 3 ABDOMINAL STATION

Trust me, abdominal station is always the easiest station to pass with a four ( clear pass). Always concentrate well in this station because you will usually complete your physical examination in just 3-4 minutes. Examiners will have a lot of time to ask you questions and since they have a lot of time, they can ask quite detailed questions. You must always prepare to answer questions pertaining to full blood picture findings if you get a patient whom you suspect is having leukemia. Always learn classical findings you will find in bone marrow aspiration in various blood malignancy.

You will only be dealing with a few possible clinical signs in abdominal station. These clinical signs include hepatomegaly, splenomegaly, hepatomegaly +splenomegaly, ballotable kidneys, ascites , jaundice………………to name a few.

Therefore always remember before your examinations common causes for all these physical signs.


TOP ADVICE FOR ABDOMINAL STATION

Always remember the following during your preparation for abdominal station,

1) When you see a patient with atrio-venous fistula and a surgical scar over the abdomen, always think of possibility of transplanted kidney.

2) Always look for side effects of immunosuppression if a patient has a transplanted kidney.

3) There are about 20 physical signs for chronic liver disease, remember them all and look hard for them.

4) When there is presence of splenomegaly with jaundice, always give chronic haemolysis as one of the diagnosis. Common causes for haemolysis include Thalassemia, Sickle cell disease etc.

5) The commonest cause for hyperpigmentation is secondary haemochromatosis due to iron overload especially in Thalassemia patients in Asian countries whereas in Western country, it is always due to Primary haemochromatosis.

6) Always remember all the associated complications for Adult polycystic kidney because it is a very common question during examinations.

I would discuss a few common short cases here, always look up your book for all the hard facts about causes for various organomegaly in abdominal system.



1)KIDNEY TRANSPLANT

Mr/Madam……… is comfortable at rest. He has no stigmata of chronic liver disease but he is pale. There is presence of atrio-venous fistula over his left cubital fossa with no obvious punctum wound. There are multiple small scars below his umbilicus suggesting possible previous peritoneal dialysis, there is another small scar over his right iliac fossa. His abdomen is soft and there is fullness under the right iliac fossa scar. Palpation reveals there is a rounded mass which is dull on percussion. It is non tender and there is no bruit heard.

I also noticed that this gentleman appears to be Cushingnoid as evidenced by presence of moon-like facies with acne and multiple telangiectasia over his face. His skin is thin and there are multiple bruises over his body. He has hypertrophied gum and fine tremor.(side effects of cyclosporin).

( Gum hypertrophy is a common side effect of cyclosporine)


In summary, I suspect this gentleman has a functioning transplanted kidney and currently not depending on haemodialysis. He has features to suggest that he is currently on immunosuppression most probably cyclosporin and steroid. I would like to complete my physical examination by…………………….

Additional points,

a) Always suggest to examiners that you would like to do the following things,

- Blood pressure checking- hypertension is a common side effect of cyclosporin,

- Check the urine- daily volume of urine can tell you whether the transplanted kidney is functioning well or not. Besides that, glycouria ( diabetes mellitus) is a common side effect of steroid. Check for presence of haematuria or not which may signify rejection of graft.

- Look for temperature which may signify presence of infection due to side effect of immunosuppression.

b) There are a few things that may suggest that the transplanted kidney is functioning well such as good volume of urine production, no tenderness over transplanted kidney, absence of haematuria and no recent usage of fistula for haemodialysis.

c) Remember all the side effects of cyclosporin, azathioprine, tarcolimus,MMF, sirolimus and steroid.

d) Learn about kidney transplantation and absolute contraindication for kidney transplantation. Remember absolute contraindications to become donor as well.

2) CHRONIC LIVER DISEASE


Mr/Madam …………. Is comfortable at rest. There is presence of stigmata of chronic liver disease such as clubbing, palmar erythema , gynaecomastia and leuconychia. There is presence of flapping tremor.He is jaundice and there are multiple spider naevi over his upper chest wall. There are multiple tattoos over his body. His abdomen is grossly distended with everted umbilicus. There is presence of shifting dullness to suggest presence of ascites. I also noticed there is a small punctum wound over his left flank which may be due to recent peritoneal tapping. Palpation reveals there is presence of hepatomegaly about 2 fingers breath below the costal margin as well as presence of splenomegaly which is about one finger breath below the costal margin.

In summary, I suspect this gentleman has chronic liver disease currently is decompensated and recent peritoneal tapping was done. The underlying cause for his chronic liver disease is due to………………..

Additional points,

a) Always remember that the major cause for chronic liver disease in Asia is Hepatitis B whereas alcoholism is the commonest cause for CLD in Western world.

b) If the patient also looks hyperpigmented then haemochromatosis is a possibility. However, in Asian, this can be due to over transfusion in Thalassemia patients who has Hepatitis B as well.

c) Always suggest to examiners that you would like to do a per-rectal examination if you notice the patient is pale as well because CLD can lead to oesophageal varices and upper gastrointestinal bleeding (UGIB).

d) Also learn about acute management of UGIB.


e) There are a few specific physical signs that are specific for alcoholism such as parotid swelling and Duputyren’s contracture.

3) HEPATOMEGALY ( NO SPLENOMEGALY)

Mr/Madam…………… is comfortable at rest. There is no stigmata of chronic liver disease. He is jaundice and there is presence of bilateral pitting oedema of both lower limbs. Palpation reveals presence of hepatomegaly . The liver span is 16 cm and about 3 fingers breath below the costal margin. The margin is regular and the surface is smooth. It is pulsatile and non tender. There is no splenomegaly nor ascites.

In summary, this gentleman has a pulsatile hepatomegaly with bilateral pitting oedema. I suspect the underlying cause for this is due to congestive heart failure.

Additional points,

a) Common causes for hepatomegaly alone include congestive heart failure, viral hepatitis, fatty liver, liver cancer ( either hepatoma or secondary deposits) and autoimmune hepatitis.

b) Always think of autoimmune hepatitis especially primary biliary cirrhosis if you notice hepatomegaly with xanthelasma and jaundice.

c) Always describe the liver by size, surface, margin and whether it is pulsatile or tender. Massive irregular hepatomegaly is always due to liver mitotic lesion.


d) Although viral hepatitis can cause hepatomegaly as well as splenomegaly, usually it is not possible to appreciate the presence of splenomegaly.

e) Always tell the examiners important negative physical signs, in this scenario, it is important to state that there is no splenomegaly and ascites.

4) SPLENOMEGALY ( NO HEPATOMEGALY)

Mr/Madam……….. is comfortable at rest. He has no stigmata of chronic liver disease. He has tinge of jaundice and pale. Palpation reveals that this gentleman has small spelnomegaly. There is no hepatomegaly as well as ascites.

In summary, this gentleman has splenomegaly with pallor, the likely cause is most probably due to chronic haemolyisis such as Thalassemia.

Additional points,

a) Always remember that there are only a few possibilities for a small spleen, these include chronic haemolysis ( Thalassemia intermedia, sickle cell disease) , endorcarditis ,thyphoid fever and glandular fever or patient with myeloproliferative disease on treatment.


( Remember how to describe classical features of Thalassemia in Full blood picture)

b) For patients with a large spleen, always consider chronic myeloproliferative disease especially when the patient also has an enlarged liver.

c) Always suggest to examiners that you would like to examine all the lymph nodes because lymphoproliferative disorders can present with a small spleen with lymphadenopathy.

d) Always suggest to examiners you would check the temperature chart if you suspect infection being the cause for the splenomegaly.

e) There is possibility that patients with chronic liver disease only present with splenomegay ( due to portal hypertension) . However, these patients will have some stigmata of chronic liver disease.

5) HEPATOSLENOMEGALY

Mr/Madam…….is comfortable at rest. He has no stigmata of chronic liver disease. He is pale. There is hepatosplenomegaly. The liver is grossly enlarged and palpable 2 fingers breath below the costal margin. It is smooth, regular and non pulsatile. The spleen is grossly enlarged as


well and it is palpable 5 fingers breath below the costal margin. It has a smooth surface and regular margin. There is no lymphadenopathy and ascites.

In summary, this gentleman has massive hepatosplenomegaly and I would consider myeloproliferative disorders especially chronic myeloid leukemia as my provisional diagnosis.

Additional points,

a) Remember the classical full blood picture and bone marrow aspiration findings for this type of patients.

b) Remember ways to differentiate acute myeloid leukemia from acute lymphoblastic leukemia. These can be divided into either histologically or biochemically.

c) Although classically chronic liver disease will have stigmata of CLD, you may find patients just having hepatosplenomegaly because the physical signs for CLD may be very subtle.

d) Always examine for any palpable lympadenopathy. Chronic lymphocystic leukemia (CLL) can present with hepato-splenomegaly and lymphadenopathy.

e) Although CLL is common in Western countries, it is rather rare in Asia.

7)POLYCYSTIC KIDNEY


Mr/Madam………. is comfortable at rest. He has no stigmata of chronic liver disease. He has an Atrio-venous fistula over his left upper limb with a palpable thrill and multiple punctum wound suggesting recent haemodialyisis. Clinically he is pink. There is fullness over his both flanks. Palpation revealed there are two masses over both of his lumbar regions. They are ballotable and resonant on percussion.

In summary, I suspect this gentleman has end stage renal failure currently dependent on haemodialysis via his left arm atriovenous fistula. The underlying cause for his end stage renal failure is most probably secondary to polycystic kidney disease.

Additional points,

a) Always suggest to examiners that you would like to examine other relevant systems such as to look for mitral valve prolapse, cranial nerves examination ( patient may have previous intracranial bleeding) and look for hypertension.

b) Always do a urine dipstick to look for haematuria which is common in polycystic kidney disease.

c) Always suggest that you would like to take a complete family history because this disease is inherited in an autosomal dominant way.

d) Complications of polycystic kidney can be divided either renal or extra renal complications.

e) The cyst can happen anyway in the body namely kidney, liver, spleen, ovary, artery (berry aneurysm).



1) Being too rough and causing discomfort to patient.

2) Not performing light palpation first.

3) Not ensuring patients breathe through their mouth when testing for downward organ movement.

4) Failing to palpate for kidneys.

5) Failing to examine correctly for the presence of ascites.

6) Inventing signs.


CHAPTER 4: NEUROLOGY STATION

This station is always regarded as one of the most challenging stations in PACES. It is due to complexity of the nervous system and the highly variable presentation of neurological disorders.

However, it is very important for you before PACES, to have a complete and systematic way of examining various presentations of neurological patients. It is also important for you to have the ability of pattern recognition. Anyway, you must always ask yourself whenever you see a neurological patient this question,” Is there other possibilities besides this provisional diagnosis, if yes, what are the reasons, if the answer is no, then what are the reasons?” I find that you can learn a lot from this repetitive reasoning.

When you present you findings, always try to present these three important points that every neurologist is looking for, “ What is the lesion, where is the lesion (anatomical diagnosis) and what is the cause for the lesion ? (pathological diagnosis).

For example , if you find that you patient has left spastic hemiplegia, then you will say that “ This gentleman has left spastic hemiplegia (the lesion) without sensory involvement most probably due to right ischemic lacunar stroke ( anatomical diagnosis) and it is due to thrombo-embolic event because he also has atrial fibrillation.”

In this chapter, my approach will be slightly different from previous chapters. I will give common case scenarios in this chapter and later teach the systematic way of examining the patient. I also will try to highlight to you why certain diagnosis is possible and some otherwise with supporting clinical signs.


TOP ADVICE FOR NEUROLOGY STATION

Always remember that before you start examining a patient, you have already in your mind the possible diagnosis and the way how you are going to illicit these signs in patients.

1) Always remember to shake patient’s hand firmly and introduce before you start because you can check two things here, either this patient has dystrophia myotonica or weakness of upper limbs and speech problem.

2) Always expose your patients adequately, for example, if you are asked to examine the upper limb, expose the patient’s upper half or else you may miss muscle atrophy of deltoid and winging of scapula which may suggest proximal myopathy.

3) When examiners ask you to examine the upper limbs, look at patient’s lower limb before you start and vice versa because this may give you the most important sign later and help you to come to a diagnosis.

4) Gait is always a part of a complete lower limbs examination.

5) After your fundoscopy examination, if you find that you patient is having diabetic retinopathy, always suggest you would like to examine urine for microalbuminuria and check the patient’s blood pressure.

6) If you are examining for cranial nerves, always start with the most relevant examination first. For example, if the stem states that this patient has speech problem, then start from lower cranial nerves examination first because most probably you are going to find abnormalities there.


7) If you are given a lower limb examination case, after your examination, if you find there is weakness, always suggest that you would like to check the anal tone and peri-sacral sensation.

8) Always suggest to examiners you would like to check for Parkinson plus syndrome if you have a patient with Parkinsonism.

9) If a young patient presents with Parkinsonism, always think of Wilson’s disease.


I would divide this chapters to few sections, each section will have a clinical scenario which is common in your PACES, I would discuss with you the important steps in examination and the common diagnosis in certain scenario.

1)LOWER LIMBS EXAMINATION

This is by far the commonest case in neurology station in PACES, there are a few possible diagnosis that can come out as a lower limb examination in real PACES examination.

I can divide the possible scenarios into a few big groups as below, you are most probably dealing with,

a) upper motor lesion problems, can be either cerebral or spinal cord lesion.

b) lower motor lesion problems, can be either anterior horn cell, nerves, neuro-muscular junction or muscles problem.

c) Others such as gait problems especially Parkinson’s Disease and cerebellar lesion.

CLINICAL APPROACH TO LOWER LIMBS EXAMINATION Lower limbs examination

Look for obvious signs in inspections, these signs include

- tremor, mask like facies in Parkinson (Parkinsonism?) - obvious small muscles wasting of hands (

syringomyelia, Charcoat Marie Tooth, Motor neuron disease?)

- proximal muscle wasting of lower limbs or upper limbs (proximal myopathy?)


- fasciculation ( Motor neuron disease) - continous bladder drainage (CBD) ( sacral

involvement?) - pes cavus ( Charcoat Marie Tooth, Friedreich’s

ataxia?) - asymmetrical wasting of lower limb ( Poliomyelitis?) - obvious diabetic dermatopathy ( Peripheral

neuropathy?) - one sided weakness ( stroke?)

Shake patient hand firmly and talk to patient

- myotonia ( dytrophia myotonica?) - unilateral weakness ( stroke?) - speech abnormality ( cerebellar, Parkinson?)

Upper motor lesion Lower motor lesion others

While you are examining patients, pay attention to the following to determine that you are dealing with upper or lower motor lesions,

a) Tone- flaccid or spastic, if you find it is rigid, then you are dealing with extrapyramidal conditions such as Parkinson.

b) Reflexes- pay attention to knee and ankle reflexes, if they are increased, you are dealing with upper motor lesions.


c) Plantar- if the plantar is up-going, then you are dealing with upper motor lesions. However, there are a few possibilities that you may have up-going plantar with loss ankle reflex such as peripheral neuropathy in a stroke patient (such as in diabetes), Motor neuron disease, Tabes dorsalis, Conus medullaris-cauda equina lesion and subacute combined degeneration of the spinal cord. (Popular PACES questions)

d) Ankle clonus-if it is present, it signifies upper motor lesion.


POSSIBILITY 1: SPASTIC PARALYSIS (UPPER MOTOR LESION)

This can be either

Bilateral spastic paralyisis ***special Unilateral spastic paralysis

stroke

Brown-sequard synd

Without sensory level with sensory level

-Motor neuron disease -spinal cord compression

-Hereditary spastic paraplegia -transverse myelitis

-Tropical spastic paraplegia -cervical/thoracic myelopathy

-Parasaggital meningioma

-Bilateral stroke

-Cervical/thoracic myelopathy


*** Special groups

You may find a few conditions that have upper motor lesion of lower limbs (spastic paralysis) that do not fit to above categories. These conditions include,

a) Spastic paralysis with cerebellar signs

Possible diagnosis include spinocerebellar degeneration such as Friedreich’s ataxia, multiple sclerosis.

i)Friedreich’s ataxia-

Presence of pyramidal signs of lower limbs with cerebellar sign. Look for pes cavus. Proceed to examine the heart (hypertrophic cardiomyopathy, optic atrophy, spine for kyphoscoliosis and IQ( intellectual deterioration).

ii) Multiple sclerosis-

Presence of pyramidal signs of lower limbs with cerebellar sign. Sensory loss may be patchy. Look for optic atrophy and internuclear opthalmoplegia. Remember the criteria of Poser’s to diagnose Multiple sclerosis.

b) Spastic paralysis with dissociated sensory loss

Patients may have pyramidal signs of lower limbs with only certain modality of sensory loss.


i) Subacute combined degeneration of the spinal cord-

Absence of ankle reflex with up-going plantar. Knee reflex is brisk. Involvement of posterior column only.( light touch , ibration and proprioception is lost)

ii)Syringomyelia-

Presence of pyramidal signs of lower limbs. However, only pain prick sensation is lost over lower limbs. Always look hard for bilateral small muscle wasting of hands and ptosis which may be present. The differential diagnosis of this condition is Anterior spinal artery thrombosis.

So, now you see there are only a few limited diagnosis for patients with upper motor lesion signs of lower limbs. Sometimes you may find contradicting signs in lower limbs, such as normal reflexes with up-going plantar. Always base your finding in the strongest physical signs.


POSSIBILITY 2: FLACCID PARALYSIS (LOWER MOTOR LESION)

This can be either due to

Peripheral neuropathy Muscle problem

Can be either motor or usually proximal myopathy

Mixed picture (but mainly motor)

There are a few common short cases that I think need further explanation. Patients with these conditions usually present with lower motor lesion of both lower limbs.

a) Gulllain Barre syndrome-bilateral flaccid paralysis of lower limbs, predominantly involves only motor component, however patients may have some distal sensory loss. If the condition is chronic, then the diagnosis is Chronic Inflammatory Demyelinating Polyneuropathy (CIDP).

b) Cauda equina syndrome-patients will have flaccid paralysis of both lower limbs with sensory loss up to L1 level. Usually patients will loss the sphincter functions.


c) Poliomyelitis- involvements of anterior horn cell leading to lower motor lesions. Usually patients will have asymmetrical wasting of lower limbs.

d) Other predominant motor polyneuropathy such as Charcot Marie Tooth syndrome (patients will have pes cavus with bilateral small muscles wasting of hands), organophosphate poisoining and porphyria.

e) Proximal muscle myopathy- a few common scenarios can be out in the real exams. Patients will have obvious proximal muscles wasting with or without pseudohypertrophy of calf muscles. There are a whole lists of differential diagnosis for proximal myopathy, however, a few are common in exams, these are Becker’s muscle atrophy, facial scapular humeral atrophy and limbs girdle atrophy.

( Pseudohypertrophy of calf muscles)


POSSIBILITY 3:OTHERS- USUALLY EXTRAPYRAMIDAL /CEREBELLAR

This can be either

Rigidity (Parkinson) cerebellar combination of cerebellar +

pyramidal

It is quite easy to pick up the diagnosis of Parkinsonism, however, always look for Parkinson plus signs if are given a case in your MRCP PACES.

As for cerebellar, if the examiners want to trick you, they may ask you to examine the lower limbs neurologically, therefore during your PACES, if you are asked to examine the lower limbs, always start off by asking the patient to walk! You will never miss cerebellar signs if you ask your patients to walk!

For combination of cerebellar and pyramidal, I have discussed them earlier.


2)UPPER LIMBS EXAMINATION

Some candidates always find this much more difficult as compared to lower limbs examination. I also have the same feeling. However, I think the approach is the same. You must always examine the upper limbs thoroughly , hoping not to miss something obvious such as proximal muscles wasting, fasciculation or specific nerve palsy over the hand ( namely radial, median or ulnar nerve palsy).

However, I still think that isolated nerve palsy ( such as median, ulnar or radial) is becoming less popular in PACES because these conditions are mainly seen in orthopaedic wards rather than general medical wards.

The below information are for you to remember how to examine these nerves separately,

a) Median Nerve

Remember that all small muscles of the hands are supplied by ulnar nerves except LOAF.

( Lateral two lumbricals, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis)

To check the abductor pollicis, put a pen above the palmar surface of patient’s hand and ask him to touch it!

b) Radial Nerve

To simplify things, just remember BEST muscles (Brachioradialis Extensors ,Supinator and Triceps)

Remember that radial nerve palsy causes hand drop!

c) Ulnar nerve

It supplies all small muscles of the hand except LOAF. Its palsy causes claw hand.


Check for finger abduction and Froment’s sign (weakness of the adduction of the thumb)

However, you must know how to explain ulnar paradox!

( It means that the ulnar claw deformity is more pronounced for lesions distally e.g. at the wrist as compared to a more proximal lesion e.g. at the elbow.

This is because a more proximal lesion at the elbow also causes weakness of the ulnar half of the flexor digitorum profundus, resulting in less flexion of the interphalangeal joints of the 4th and 5th fingers.)

Remember the sensory innervations of median and ulnar nerve as shown below.

( Blue-median nerve, Red-Ulnar nerve)


3)CRANIAL NERVES EXAMINATIONS

I think this is always the difficult station if they ask you to examine the cranial nerves. The only way to do this confidently is practise, practise and practise again. No short cut for cranial nerves examination, you must see as many cases as possible!

However, I will try to highlight to you a few important short cases in your PACES,

Cranial Nerves ( source: www.spjc.edu)


No. Name Receptor Sensory Pathway

Effector

I Olfactory Olfactory epithelium directly to temporal lobe

II Optic Retina through thalamus to occipital lobe

III Oculomotor eyeball muscle proprioreception

thalamu to midbrain

Eyelid and eyeball muscles, lens (focusing), pupil (constriction)

IV Troclear eyeball muscle proprioreception

thalamus to midbrain

eyeball muscle

V Trigeminal Chewing muscles proprioreception, cutaneous touch and pain receptors for face, jaw and teeth

thalamus to pons, then to somatosensory area .

chewing muscles

VI Abducens eyeball muscle proprioreception

thalamusto midbrain

eyeball muscle

VII Facial Facial muscle proprioreception, tongue taste receptors

thalamus to pons then somatosensory area and/or to gustatory area (taste)

facial expression muscles, saliva and tear glands

VIII Vestibulocochlear or Auditory

Hearing and equilibrium organs

thalamus to pons then totemporal lobe

IX Glossopharyngeal arterial chemoreceptors and baroreceptors, tongue taste receptors, tongue muscle proprioreception

thalamus to medulla/pons

saliva glands, tongue muscles (swallowing), (aids in regulation of breathing and BP)

X Vagus arterial chemoreceptors and baroreceptors, pharangeal taste receptors, pressure/pain receptors in thoracic and abdominal organs

thalamus to medulla/pons

Swallowing and speaking muscles, smooth muscle and secretory glands in GI tract, Heart muscle, (aids in regulation of breathing, BP and slows HR)


XI Accessory Neck and shoulder muscle proprioreceptors

thalamus to medulla

swallowing muscles, head and neck muscles

XII Hypoglossal Swallowing and speaking muscle proprioreceptors

thalamus to medulla,

Swallowing and speaking muscles


OK, let me summarize all these nerves

Nerve #1 :

Don’t need to bother, if you encounter this nerve in your PACES, call me, I will jump down from Petronas Twin Tower in Kuala Lumpur, Malaysia or London Eye in UK.

Nerve# 2 and #3:

Best learn these nerve together, optic nerve receives light ( afferent fibre) and the efferent fibre is occulomotor (parasympathetic component- causing constriction of pupil)

Therefore it is important to understand pupillary reflex.

As for accommodation, the pupils constrict while fixating on an object being moved from far away to near the eyes.

Just remember 2 types of problems here-

- Marcus Gunn pupil-a relative afferent pupillary defect indicating a decreased pupillary response to light in the affected eye.

- Argyll-Robertson pupil- the pupils accommodate but do not react. ( The explanation to this is rather complicated- however, remember it is associated with syphilis. )

Way to remember- prostitutes accommodate ( part of man’s anatomy ) but never react!

It is important to understand visual field defect as well. Look at any textbook to find out!


Nerve # 3, # 4 and # 6:

Occulomotor nerve ( #3) has 2 components- motor and parasympathetic components. We have discussed the parasympathetic component, just remember that these three muscles supply extraocular muscles.

And remember this formula

( LR6SO4 )3

Lateral rectus is supplied by cranial nerve #6, superior oblique by cranial nerve#4 and others by cranial nerve#3!

(Source: www.yorku.ca)


Nerve #5:

No need to bother about this nerve, just remember how the 3 sensory components innervate the face.

Nerve#7:

Well, well, well, finally we come to this very, very important nerve. Why?? Because 7th nerve palsy causes disfigurement to patient and can be picked up easily in PACES, besides that, it is very common in clinical medicine!

Remember how to differentiate lower and upper motor lesion of 7th nerve. You must also able to explain why there are sparing of muscles at the forehead in upper motor lesion.If you find a lower motor lesion, remember all the possible causes!

Bell’s palsy is all time favourite question in MRCP PACES. Know this condition from inside out and outside in! ( if possible from up to bottown and bottom to up!)

( source: www.adam.com)

Bell’s Palsy


Nerve #8:

No need to spend so much of time, just study a bit, but this nerve might be helpful for you to find out the underlying cause of lower motor lesion of 7th cranial nerve!

Nerve# 9 and # 10:

Just remember these nerves are important in palate elevation and Gag’s reflex.

Nerve #11:

You will never get isolated 11th nerve palsy in PACES. Just remember this nerve supplies sternocleidomastoid and trapezius muscles.

Nerve # 12:

Tongue movement. Not thing more than that! However, always look for tongue fasciculation/wasting!

( Never miss tongue muscles wasting!)


CHAPTER 5: HISTORY TAKING

Finally, we come to the easier station in MRCP PACES, candidates always face with 2 main problems here,

a) How do I time myself so that I can finish clerking my patient on time?

Easy, learn the habit in the ward every day to clerk your patient and finish clerking them within specific given time (about 14 mins)

b) How do I know that I have covered all the possible diagnosis?

I always try to think of the causes from head to toe. CNS, CVS, Lung, Abdomen and so on..... then I will think of VINDICATE.

V- Vascular, I-Infectious, N-Neoplasm, D-Drug-induced, I-Inflammatory/Idiopathic, C-Congenital, A-Autoimmune, T-Trauma, E-Endocrine/Metabolic.

You will never miss any diagnosis if you follow this rule! Candidates always forget about drugs and congenital causes in their PACES! Even though you know the diagnosis after 2 questions, continue to explore all other possibilities because you might be caught in the exam!

Remember that try not to make the following mistakes when you sit for this station in PACES.


Mistake #1:

Repeat your questions again during your clerking. Examiners hate to hear this from the mouth of any candidate in PACES, ‘ By the way, can I ask you again, do you..........?’ Fatal mistake, never try it unless you do not want to pass your PACES in one attempt!

Mistake #2:

Look at your watch again and again! Again, this is a fatal mistake. Examiners hate you and also the patient! Eventually, you hate yourself too!

Mistake #3:

You do not bother about patient’s concern. I always make the habit to spend last 5 mins of my time to ask the patient specifically about his/her concern. For an example, if you get a case of patient presenting with cough, he might be worried about the cough is due to cancer, therefore, you must address his worry very well. Also be prepared to answer all questions posed by patient.

Mistake #4:

Never summarize your history. When examiners start to ask you the possible diagnosis, always give a summary of relevant history for your patient and tell them all your differential diagnosis and the reasons why you say so!

Mistake# 5:

Forget about social history of the patient. You might think that it is not important, just remember that a lot of medical problems are related directly or indirectly with social history, just spend 1-2 mins asking your patient relevant social history based on your case.


Mistake#6:

Fail to outline plan of management. When examiners ask you plan of management, remember that you have to discuss about two components- investigations you want to do and how to treat the patient according to your provisional diagnosis.

Mistake # 7:

Fail to outline reasons of performing certain investigations. Let say, you plan to do CT thorax for a patient presenting with cough, you must be able to defend yourself that this investigation needs to be done and its plus points compared to other investigations. However, I want to remind all of you, always tell the examiners non invasive investigations ( simple) first before open your mouth talking some high-tech and costly investigations.

However, if examiners request you to tell him only one investigation to come to a diagnosis, then say out one investigation which is most relevant no matter whether it costs a fortune to do!

Mistake #8:

‘Prolonged verbal constipation’ -You are unable to open your mouth. Trick to overcome this, talk to your consultant more often. No problem for English-speaking candidates, huge problem for candidates from Hong Kong and Middle East!

Mistake#9:

No open ended question. I must admit that during your PACES, you are under stress, you want to get the diagnosis as soon as possible, but I must tell you examiners hate closed ended questions. What I suggest you to do, first 3-4 mins, ask open-ended questions,such as “ Tell me


more about your chest pain, headache, shortness of breath......” then followed by specific questions.

Remember, only first 3-4 mins, do not waste too much time especially they give your patients that are not helpful!

Mistake # 10:

Argue with you patient or examiners- Never try this unless you plan to sit the exam again and again!


20 Common Symptoms in MRCP PACES

I will give you a list of 20 common symptoms that are popular in MRCP PACES, what I suggest you to do, sit down and take a piece of paper and write down all the possible diagnosis based on VINDICATE mneumonics.

a) Chest pain

b) Shortness of breath

c) Jaundice

d) Diarrhoea

e) Leg swelling

f) Lethargy

g) Headache

h) Nausea/vomiting

i) Loss of weight/loss of appetite

j) Fever

k) Joint pain

l) Skin rash

m) Coughing

n) Giddiness

o) Loss of consciousness

p) Palpitation

q) Lower limbs weakness/ one sided weakness

r) Blurring of vision


s) Forgetfulness

t) Peripheral numbness


CHAPTER 6: ETHICAL /COUNSELLING

I find this station is the easiest for candidates in UK. This is quite similar for me if MRCP PACES is to be conducted in Mandarin or Cantonese. However, a lot of foreign candidates find it difficult to speak English like their mother-tongue. Don’t worry; just remember that practice makes your perfect.

Anyway, I always remember a few important sentences and memorize them hard so that I can speak like a British during my PACES, here are a few important sentences I used to remember by hard,

“I understand your predicament and I certainly share your worry.......”

“This question is rather difficult to answer, however, I will get back to you once I have discussed with my senior doctors........”

“If I were in your shoes, I most probably will do the same..........”

“We are trying our best hoping that your mother will get better, unfortunately................................”

“Mr....., I am afraid I have some bad news for you........”

“ This must be a bit bewildering, but do you follow what I am trying to say......”

“I know that this isn’t what you wanted to hear. I wish the news were better.”

Try to document as many phrases as possible during your preparation for this station. I always remember what my friends say during this station because I know they can speak better than me!


I will discuss a few common scenarios in PACES and outline a few important points,

Scenario 1: Breaking Bad News

All time favourite. I always say there are 2 main categories here- terminal illnesses and chronic diseases.

First category is easy because since it is terminal, usually examiners will not bother much about management, you are probably only required to discuss about palliative care ( pain relief of symptoms etc), however, for second category, it is a bit tricky.

For example, you might be required to tell a patient that she is having multiple sclerosis, SLE... etc, besides knowing how to break bad news, you ought to have some knowledge about these illnesses as well.

Chronic illnesses that are very popular in your PACES are,

Systemic Lupus Erythematosis ( SLE)

Epilepsy

Rheumatoid Arthritis

Multiple Sclerosis

Dementia/ Alzheimer’s Disease

Motor Neuron Disease

Hepatitis B/ C

Tuberculosis

There is no best way for you to deliver bad news to patients, however, I think Dr Buckman’s SPIKES technique is a systematic and useful way to follow.


Dr Buckman is a medical oncologist in Canada and in his publication way back in 2000 in Journal ‘The Oncologist ‘, he proposed the way what he termed as ‘SPIKES’.

OK, let me outline his six-step protocol, ( SPIKES )

Step 1: S- Setting up the interview

• The physical setting ought to be private, with both physician and patient comfortably seated.

• You should ask the patient who else ought to be present, and let the patient decide (studies show that different patients have widely varying views on what they would want).

( During my PACES, I always ask this question!)

• It is helpful to start with a question like, "How are you feeling right now?" to indicate to the patient that this conversation will be a two-way affair.

( You do not need to worry about this step because all will be set up in PACES, however, always pay attention to second and third point above!!)

Step 2: P- Assessing patient’s Perception

By asking a question such as, "What have you already been told about your illness?" you can begin to understand :

• What the patient has already been told ("I have some lung problems, and they told me it’s serious"),

• Or how much the patient understood about what's been said ("the doctor said something about a spot on my chest x-ray"),

• The patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"),

• And the patient's emotional state ("Ian so worried , doc, they told I might have cancer").

It makes you very easy to break the bad news once you know how much the patient has been told. If they know little, then you know you have to


take longer time for them to digest your information. If they know a lot, then life will be easier for you!

Step 3: I- Obtaining patient’s Invitation

It is useful to ask patients what level of detail you should cover. For instance, you can say, "Some patients want me to cover every medical detail, but other patients want only the big picture--what would you prefer now?" This establishes that there is no right answer, and that different patients have different styles.

Step 4: K- Giving Knowledge and Information to patient

OK, this is the part that you spend most of your time. For example, after you told the diagnosis of lung cancer, you might want to tell your patient there are a few ways of treating the cancer- chemotherapy or radiotherapy although total cure is unlikely. If they ask you to elaborate further, you can say ( “ I will have the cancer doctor to tell you further maybe later this afternoon after I discuss with him”)

Never try to think that you know EVERYTHING under the Sun. Always tell them there are other doctors that are in better position to clear their doubts if you do not have the information!

Always remember to give the information in small chunks, and be sure to stop between each chunk to ask the patient if he or she understands ("I'm going to stop for a minute to see if you have questions").

Speak in layman terms, please!

Step 5: E- Addressing the patient’s Emotions with Empathy

If you don't understand the patient's reaction, you will leave a lot of unfinished business, and you will miss an opportunity to be a caring physician.

Step 6: S- Strategy and Summary


Patients who have a clear plan for the future are less likely to feel anxious and uncertain. Always outline your plans with your patient. You may want to tell your patient that you are available again in the afternoon clinic and if he has any questions, he might want to ask you again. You must make clear that when you want to see him back in the clinic such as after 2 weeks etc. Always provide patient way to contact you if something arise before next appointment!

Sounds easy? Try this method during your next practice with your friends and you will find how easy this method is! Scenario 2: HIV Related Issues A few possibilities here,

a) You have to ask the patient to go for a HIV testing after diagnosing him to have PCP.

b) You have to ask a HIV patient’s partner to go for HIV testing. c) You are required to break the bad news that a patient is having

HIV. d) You are required to ask permission from a HIV patient to tell his

partner that he has HIV. e) You are required to see a house-officer who has needle prick

injury from a HIV patient. f) Discuss about post exposure prophylaxis of needle prick injury

from HIV. No trick for this scenario, learn your facts right!


Scenario 3: Medical Negligence/ Misconduct of Healthcare Workers A few possibilities here ( usually milder forms of medical negligence)

a) Antibiotics/ drug allergy ( your house-officer forgets to ask about drug allergy)

b) You are asked to see a house-officer who is an alcoholics/ drug addict or someone who always escape from on calls.

c) To explain to family members of a demented patient who fell down from bed in your ward.

Remember that sometime you have to admit that you have made a mistake but always convince the family that immediate remedy has been taken once you notice the problem. Explain to them that you will not allow this problem to happen again. Also emphasize to that report has been made to your superiors. A person who alleges negligent medical malpractice must prove four elements: (1) a duty of care was owed by the physician; (2) the physician violated the applicable standard of care; (3) the person suffered a compensable injury; and (4) the injury was caused in fact and proximately caused by the substandard conduct. The burden of proving these elements is on the plaintiff in a malpractice lawsuit. Scenario 4: End of Life Discussion/ Brain Death Issues A few possibilities here,

a) To discuss about withdrawal of treatment in a terminally ill cancer patient with family members.

b) To discuss about resuscitation status of an ill patient with the family members.

c) Advance directive discussion with a terminally ill cancer patient who is still mentally sound.

d) Explain to family about brain death and discuss about offing ventilators.


Just adopt an approach that combines empathy, care and understanding! Scenario 5: Organ Donation A few possibilities here,

a) Discuss with a prospective organ donor and issues involved. b) Ask permission for organ donation from family members in a brain

dead patient.( who has signed up as organ donor) Scenario 6: An Angry Patient Hope you do not get this in your PACES, depending on how nice/bad your surrogate is, if the surrogate wants to fail you, there is no way you can pass! Therefore, just pray you do not get this type of patient!


CHAPTER 7: FINAL STATION ( STATION 5) Finally we come to the last chapter of this book, starting from Oct 2009, changes have been made to station 5 and this station is named as Integrated Clinical Assessment station. From the official MRCP(UK) website, the following advice is given,

‘ There will be two cases in this 20 minute station – each lasting 10 minutes (each case will be

known as a ‘Brief Clinical Consultation’).

The way in which candidates approach this station will be very different to the formal examination

of systems at Stations 1 and 3, and very different to the structured and comprehensive history

taking and communication exercise at Stations 2 and 4.

Candidates will aim to elicit sufficient history to make an assessment of the problem presented and

will carry out an examination that is relevant to assessing the problem presented. The history

taking and the examination are not intended to be comprehensive – this station is not a “long

case” nor is it a full outpatient consultation.

Candidates will have 8 minutes to take a focussed history, carry out a relevant examination, and

respond to the patient’s concerns. During the remaining two minutes, an examiner will ask the

candidate to describe the positive physical findings and to give a preferred diagnosis and any

differential diagnosis. Candidates will always be given the full 8 minutes with each of their patients

at Station 5 ( however, the examiners will tell after 6 mins have elapsed) and the examiners will

not begin their two minute discussion until the 8 minutes have elapsed. Candidates undertake two

ten minute encounters in the Station.

It is NOT necessary, nor would it be possible for candidates to undertake a complete history or

comprehensive examination in the available time. The aim of the encounters is to allow candidates

to show that they can focus on the most important parts of history and examination when posed

with a clinical problem. In addition, the candidate will be expected to explain their management

plan succinctly to the patient and answer any questions they might have.

It is important to note that candidates may examine the patient and take aspects of the

history in any order, or concurrently. For example, where the patient complains of a physical

abnormality, they may wish to examine affected areas while asking the patient about relevant

history.’


I will try to give you as many examples as possible in this station so that you know the common and popular cases in this station.

Case 1: Neck Swelling

Possible diagnoses include goitre, thyroglossal cyst or lymph-adenopathy. Case 2: Facial rash or body lesion Possible diagnoses include SLE ( malar rash or discoid rash ), tuberous sclerosis, systemic sclerosis, dermatomyositis, neurofibromatosis. Case 3: Joint Pain ( hand, neck or lower limbs) Possible diagnoses include rheumatoid arthritis, ankylosing spondylitis, gout, osteoarthritis, dermatomyositis..... etc Case 4: Blurring of vision Possible causes diabetic retinopathy, optic atrophy, retinitis pigmentosa, retina detachment... etc Case 5: Leg swelling- Bilateral or unilateral Possible causes: Nephrotic syndrome, DVT, cellulitis... etc Case 6: Changes in the face Possible causes: Acromegaly, hypothyroidism,hyperthyroidism, Cushing’s syndrome, Parkinson’s disease.... etc Case 7: Difficulty to walk Possible causes: Anklylosing spondylitis, Parkinson’s disease, gout, osteoarthritis etc


Another thing to take note in this new station is you are expected to take history together while you are examining the patient. Never waste your time, always have a good look at your patient before opening your mouth and moving your hands! I think in this new station, cases which were common in previous old format will still be asked, however, examiners expect more from you! Besides getting the correct diagnosis, you also need to ask relevant history, for example if you are given a case of a lady with thyroid swelling, of course you need to know the proper way of examining the goitre, but you won’t pass if you are unable,

- To illicit relevant history to suggest whether the patient is euthyroid, hyperthyroid or hypothyroid,

- To ask history suggesting Grave’s disease such as double vision etc and of course you need to know how to illicit signs of Grave’s disease and relevant investigations.

- To address patient’s concern. I always like to ask the patient,” Is there anything specific that you are worried about?”Always address and clarify patient’s doubts!


Conclusion

I hope this ebook helps you while you are preparing for your MRCP PACES. Try your best and I will see you at the top there. Just want to share with you Joe Vitale’s formula of creating miracle,

1) Know what you don’t want 2) Decide what you do want 3) Get clear 4) Feel your intention already achieved 5) Let go

Be focused and you will get what you want in life no matter what! MRCP PACES is just a game, you will win this game if you know the rules and never repeat the mistakes others have done! Good luck to all of you! Best Regards Dr HK Goh

pass your mrcp paces in one attempt

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