Last Minute Advice!

 

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

Just some last minute advice:

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

Example with pulmonary fibrosis short case

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

It's tedious.

So, ideal 1st response =

I would arrange a high resolution CT chest to confirm the diagnosis. A ground glass appearance is associated with active alveolitis which responds well to steroids, whereas a honey combing and interstitial fibrosis indicates more advanced disease which will be less steroid-responsive.

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

For the station 2, make sure you take a solid history. Otherwise the examiners will just spend all the time tearing your history apart. Writing the stems like PC, HPC, PMH, all 5 systems, DH, allergies, FH and SH is useful. Ask specifics about the systems eg 'bowels alright?' is probably not good enough...better to ask about change in bowel habit, fluctuating diarrhoea/ constipation, blood, mucus etc. You will miss things otherwise.

For station 5, briefly ask PC, HPC, PMH and DH before starting to examine within 3-4 minutes and continuing to ask other questions whilst examining. Don't forget to summarise the history/findings with the patient in stations 2, 4 and 5 and go through action plans.

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

Be confident in the exam. They can't kill you, which is always good. Even if you get it wrong, get it wrong confidently. You won't get any more points for being meek about it. You never know...you may even get away with it. The exam has changed so that the emphasis is on doing simple things well rather than focussing on the obscure and esoteric.

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

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

Many thanks Shu and Krishna

 

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Heart Sounds

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

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

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A candidate's experience:

Experience 1

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

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

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

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

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

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

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

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Experience 2

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

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

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

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

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

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

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

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

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Experience 3

My cases were:

Cardiac - Mitral regurgitation.

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

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

Abdominal - polycystic kidneys and renal transplant.

Respiratory - rheumatoid pleural effusion.

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

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

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

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

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Experience 4

1. Station 5 -Presentation was SOB.

Patient clinically had signs of Scleroderma/CREST.

Concerns were -dad brought asbestos dust home ? asbestosis

2. Station 5 -Patient with Arthritis and rash - Psoriasis

Examine relevant system and counselling regards treatment.

3. Communication-Breaking Bad news.
Patient had blood results -has CKD ,prev history of HTN during insurance check up but patient decided not to take tablets.

Counsel regards treatment options

Dialysis in future

Patient in denial ,not happy with result .Also unhappy with GP as why she was not explained the problems secondary to HTN.

4. History taking-
Young lady with recurrent attacks of weakness in right arm over 4 weeks which later resolved .

5. Cases -
Respiratory-Pulmonary fibrosis and Cushingoid appearence secondary to Steroids.
Abdomen-Renal transplant with fistula,transplant kidney
CVS-Metalic AVR with also ? regurgitant AR

Discussion regarding warfarin.

Neurology-Peripheral Neuropathy(Absent ankle reflex)

Discussion regarding causes.

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Experience 5

I am most grateful for this candidate who fedback the following scenarios from her own and her friends’ experiences. She passed her PACES (Shu).

Commmunication skill station

1. 45 yr old gentleman recently diagnosed metastatic bowel cancer 2 months ago.He and his parents are shocked by the diagnosis and could not accept it and demanded for any possible treatment. He had chemotherapy and oncologist decided for palliative tratment under palliative care team.

He admitted to A&Es with torrential GI bleed and had 10 units of blood tranfusion. Urgent OGD done could not stopped bleeding. Surgeon team decided not for surgery due to high risk. The only possibility is to try embolization but no gurantee to stop bleeding. He was shocked and frightened. He asks for any possible treatment to stopped bleeding.

His sister came to hospital and want to discussed with doctor regarding his management.

Assumed patient has given permission to discuss his matter with his sister.

( In the exam, the sister wants to do nothing and let him go peacefully, suggested morpine , not for resus as the patient and her parents are not realistic what is going on )

( Examiner asked about how to assess competency of a patient , How to decide Not For Resus on which ground-- ? age,? underlying disease or ?what else. Examiner said ‘let’s say not this 45 yr old guy, supposed 85 yr old guy with the same situation , how will you decide for Resus status, If this patient demands for Resus –what is your decision etc...)

2. A 38-yr-old gentleman had blood test for HIV with GP and GP referred to you for the result which is positive for HIV . Your task is to do breaking bad news and discuss with patient for management plan and tretment and address his concern.

3. 82 yr old lady chronic RA, had hip & knee replacement ,recurent mechanical falls. She denied home help previously. Now admitted from fall and slow progress, transferred with 2. She initially refused nursing home but now accept home help and would like to go home. Talk to daughter regarding discharge plan.

( Daughter concerns about her safety at home and her medications )

4. 50-yr-old lady, cough, haemoptysis , weight loss. GP did CXR which showed Rt hilar mass and referred to you. Your task is to discuss possible Dx and management plan. ( patient said she has claudophobia when you talk about CT scan)

5. 65-yr-old man known COPD admitted with Rt Upper Quadrent pain , had CXR portable in A&E – poor quality ,diagnosed cholecystitis and sent to surgical ward. Temperature not settled down, repeat CXR and found out Rt lower lobe pneumonia. This patient was transferred to medical ward but decision about ITU has not been made yet . He has history of severe COPD and had admitted to ITU previously and has stayed in ITU for 2 months due to difficult to wean off ventilator. Your task is to talk to angry son regarding further management.

6. To discuss with a duaghter of a nursing home residence, Parkinson’s disease and dementia for feeding options and management.

7. 40 yr-old-man went to GP with cough & haemoptysis over 6 weeks, and had CXR which showed metastatic lung Ca and referred to you. This patient had CXR 9 months ago with Locum GP which showed a small lesion which was missed at that time .Your task is breaking bad news to patient regarding Xray finding and management plan. He is very angry about delay Dx and missed Dx in 9 months ago.

8. To counsel 38 yr old sputum positive TB for HIV test and further management plan.

9. To explain a patient with newly diagnosed Parkinson’s disease for managemnet plan.

( his concern is will he become dementia? How is the prognosis?

History

1. 53-yr-old gentlman referred by GP due to abnormal LFTs ( Alk Phos > 800, GGT > 200 and ALT >100 , Bilirubin about 50) and pruritus. He is generally in good health. He has only history of chest infection 2 months ago. His wife is concerned about his alcohol intake but he said he did not exceed the recommended range. Please take a history and address his concern.

2. 40 yr old lady diarrhoea off and on over 7-8 months, weight loss. Take history and discuss management.

(malabsorption –diarrhoea describes as pale bulky stool, difficult to flush)

3. 48-yr-old gentle man diarrhoea and weight loss over 4 months, to take history.

4. 25-year-old man acute chest pain. GP did ECG which was normal & referred to MAU. He was vomiting with no blood but developed dysphagia , tachycardia and became increasingly unwell. Please take history and discuss about management.

(in history he took recreation drug ? ecstacy with this episode)

5. 45-yr-old man pins & needles & tingling in feet. History of weight loss and tiredness. Blood glucose normal. Take his history.

6. Middle age lady fever, night sweat, weight loss over a few months and Hb of 10.ESR 105 , To take history

7. 35-yr-old housewife complains of fatique, tiredness, lethergy and polyarthragia. To take history

(SLE is top DDx)

8. Young man peripheral neuropathy , pins and needle in legs to take history.

9. Middle age lady microcystic anaemia , high BP, tiredness . History of miscarriage , joint symptoms

( answer SLE renal involved, to rule out Antiphospholipid syndrome)

10. 35-yr-old man type 1 DM, hyponatremia , tiredness . On citalopram. Strong family history of lung cancer. His concern is whether this can be lung cancer?

11. Middle age lady , anaemia, fatique, Hb 9.8, MCV 80, PMH of irritable bowel syndrome for 10 years.Diary products make her diarrhoea. History of low back pain. Family history of Ca colon. To take history.

Station 5

1. 54-yr-old lady known IDDM came for diabetic review clinic. She has concerned about her rt eye vision , please take a focus history , examination and address her concern.

(Rt Diabetic Maculopathy with Laser scars both eyes. She has full range of diabetic complications- she has loss of awareness of hypo if you asked for any hypo episodes, -If you asked for the insulin injection site reaction –she will say she is on insulin pump. When you ask how’s her diabetic control – she said her HbA1C is about 7 , had previous 2 MI with angioplasty, Previous intracranial bleed ( small- full recovery) when you asked for TIA/ Stroke, CKD4 but not on replacement Rx , has peripheral neuropathy but no diabetic foot ulcer, hypothyroid ) O/E visual acuity reduced on Rt eye ( asked to test with snellen chart which was on the table), there is red reflex, Laser scar in both peripheries and in the macular area of rt eye.

Her concern is whether her visual problem is treatable or will it getting worse?

2. 78-yr-old gentleman admitted to A&E with history of weakness and numbness on his Rt arm and rt leg lasting 3 to 4 hours. Please take focus history , exmination and addressed his concern.

( Quite straight forward but if you did not ask , you will miss previous episode on the left arm lasted about less than an hour a few weeks ago and he did not see doctor for that. O/E slow AF, Systolic murmur probably AS, I said MR as heard & loud in apex , examiner was not very happy – counselled for warfarin after excluding contra indications ( Liver problem, bleeding disorders and frequent falls) , suggested investigations including ECHO due to murmur. His concern is – will it come back again ?

3. 56-yr-old gentleman known HIV with vision problem in his right eye. He had history of seminoma of left testis and had chemotherapy for that. Please take focus history , examination and address his concern.

4. This gentlman was referred to you due to high BP 180/120 with headache. Please take history, examination and management and address his concern.

( Acromegaly Features when I went into the room, not mention in the question paper)

5. 60-yr-old gentleman problem with Left hand over 2 months , history of rt hip &left knee replacement in the past ,take focus history, examination and address his concern. ( Acromegaly with Carpal tunnel syndrome)

6. RA with SOB on exertion over 3 months ( Pulmonary fibrosis)

7. 56yr-old -lady has been suffered from leg ulcers, started with one ulcer in the right 5 weeks ago and then developed 2 ulcers in the left leg over 3 weeks. Take focused history , examination and address her concern.

(history of Leukaemia in the past and treated with chemo and in remission. Answer - pyoderma gangrenosum)

8. 55-yr-old gentleman with deterioration of his vision (both sides) over a few months. Take focus history, examination and address his concern.

(He gave the hsitory of Retinitis Pigmentosa –was diagnosed he was young and got tunnel vision from the begining of history. Examination confirmed tunnel vision and fundoscopy showed pigmented spiculae and diabetic retinopathy changes in the eyes which made his vision worse)

9. 64-yr- old gentleman known multiple sclerosis for 30 years. His multiple sclerosis is getting worse and starts to interfere his mobility. He noticed he is more SOB recently and he thinks it is contributing to his multiple sclerosis. His GP has referred to the clinic and to review him and address his concern. ( Patient asked why he is more SOB , and what is the cause of it?) Answer-from History – he is current heavy smoker for over 40 yrs, actually his mobility is not too poor , still mobilizing from history. Only when you asked, he will give history of occasional palpitations and wheezing lately. O/E he is in AF ,chest is clear, no wheeze. The candidate who diagnosed AF passed the case . I missed AF as I had no time to examine pulse and jumped to his back to listen when 2 mins left. I gave the differential of PE and COPD for his SOB . Examiners were not happy , wanted to link heavy smoker—COPD—causing AF –causing SOB & palpitations and failed me)

10. 25 yr old gentleman admitted to A&Es with 2 bouts of coffee ground vomiting , BP 100/60, PR 110/min. Please examine and address his concern.

( Patient asked if he go home as no more vomiting now ?)

11. Acromegaly , headache, bilateral carpal tunnel syndrome

12. Middle age lady has arthritis ( RA) on Hydroxychloroquine for 2 years, has hand deformity . Her concern is her friend, who has RA, is on disease modifying drug. Does her arthritis medication need to change to get benefit for her hand deformity?

13. Middle age lady known RA, went on holiday – vomited, OGD showed oesophagitis She is on Diclofenac, steroid, Alendronate acid. To take focus history, examination and address her concern.

14. 50 yr old lady known acromegaly- headache for 3 months to take focus history, examination and address her concern.

15. Systemic sclerosis and SOB

16. Difficulty in swallowing over 1 year, features of CREST syndrome

17. Chest pain in a systemic sclerosis + RA lady

18. Acromegaly and SOB on exertion which is progressive in nature

19. Known RA, swallowing problem – lump in the neck

20. 45-yr-old man with pain and pins & needles in hands for many years. Investigation showed normal FBC, U&Es, CRP. Xray hands showed Radiolucent lesion in metaphalangeal & interphalangeal joints asymmetrically.

21. Hypothyroid with tiredness

22. Psoriasis arthropathy and rt knee pain

23. This patient is Dx Fabray Disease, he has problem with controlling his hypertension, take focus history , exam and management plan

24. 75-yr old-man referred to TIA clinic with sudden onset loss of one vision over 6 hr.

25. This middle age lady was referred to you by optician due to unequal pupils, otherwise asymtomatic . Take focus history , exam and address her concern

( Is it Stroke ?Answer- Holme Adie pupils)

26. Painful cold fingers- Raynaund’s syndrome & systemic sclerosis)

27. Young man with loss of right radial pulse and left carotid bruit. Had recurrent blackouts. Elevated ESR.

(Answer: Takayasu’s syndrome)

 

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Experience 6

Station 1

respiratory: instruction was this man has episodic breathlessness, examine chest: he was young and there were no findings and I presented as normal chest. Then they asked why does he have breathlessness...I said since instruction was telling episodic , he could be having asthma then they asked about asthma management.

abdomen: Had big liver & telengiectasias around mouth but no spleen. I presented as HHT. He had bruit (I wrongly presented as venous hum then they asked difference b/n hum and bruit).

station 2

History taking 56-yr-old lady with wt loss and loose bowel . They asked all dd's related to malabsorption...she was celiac.

Station 3

CVS: metallic prosthetic valve: was able to hear the metallic sound outside. Man was in his 50's. Asked possible complications. & indications.

Neuro: Instruction was: test this Lady's speech and proceed..

She had a scanning speech. Had all cerebellar signs including nystagmus, positive finger nose and heel shin test. Asked what could be cause...I said DD as alcohol, MS, Friedrich's ataxia. She had pes cavus and hence I said it could be fr.ataxia. Also asked investigations.

Station 4

62-yea- old diabetic and heavy smoker presented to vascular team with claudication pain. MRI done showed severe disease and vascular team has decided for conservative management..Patient very unhappy that it is for medical management . Candidate ( medical team) asked to explain medical treatment plan

Patient agitated saying he has not been managed properly so far. Exploring the situation, I realised that he was non-compliant with insulin administration and offered him help by changing to less freq regime. He was continuing to smoke and has never been offered smoking cessation advice. This was offered.

Also reviewed medication list and evaluated risk factors apart from Diabetes and smoking. He had issues at home with wife not well. Explained that it is also very important his participation and compliance very vital in salvaging limb. Further specialist ( diabetes and chiropody) will be arranged thru GP ( half way during the converstion he settled...just gave some time for him to express his anger)

Station 5

Case 1

37-year-old female admitted with lower abdominal pain.. talk to her. Obs chart and urine dip stick chart were kept in corner. Dip stick was suggestive of UTI and obs showed temperature. Pt had flank pain

C/o symp suggestive of pyelonephritis. Abd examination was unremarkable. She was hypertensive. Pt was concerned only about anything serious??

Examiners asked about investigations especially why ultrasound and also on treatment

Case 2

47-year-old male admitted to MAU with cardiac sounding chest pain. Had risk factor of smoking. No family history.

Explained to pt investigations planned (ECG CXR TROP etc offered pain relief). Said if normal will need special tests like ETT

No complicated Q’s from examiners

(Candidate passed)

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Experience 7

Candidate No:
I wanted to write to let you know that I passed my PACES exam. I wanted to give you, as you requested some information re. the cases I was given:

Station 5:

Acromegalic gentleman. He had previously had transphenoidal resection of the pituitary,c/o tingling in the hands. I examined visual fields and sensation. I was asked about investigations, management and treatments

A young lady with a collapse ? cause. Nothing evident on examination, the focus seemed to be mostly on investigations and management

CVS: Mitral valve replacement, asked about indications for valve replacements and causes.

RS: Stoney dull - left lower zone, pleural effusion. Asked about differentials, exudates, transudates and Light's criteria as well as management.

Neuro: Young lady with MS

Abdo: Mercedes Benz scar - no signs of chronic liver disease, drains or other scars etc. Asked re. causes of CLD and ALD and immunosuppressants post transplantation

History taking: Young lady who has lost weight without trying with associated loose stools. She had been on a cruise a while before and had no symptoms prior to that. Investigations and management.. re. infective causes, ix of IBD/coeliacs (amusingly at the time the word Coeliac completely slipped my mind - like a real void) I was asked what I would expect to find on colonoscopy and what I would then do.

Communication & Ethics (?) Patient with known COPD had been brought into hospital with severe pneumonia Curb 65 v high (can't remember the number), given IV antbiotics, admitted to a surgical unit as no medical beds available. During the evening, canula came out, not immediately replaced, dose of antibiotics missed - nurses were busy with another patient being transferred (or something like that) Delay moving patient to HDU where he died. The actor was the patient's daughter who was very upset, understandably, and she said he had been fine the day before admission. She was angry as she felt that her father had been mismanaged.

I explained re. bed situation, triaging, patient seen by Medical SHO/SpR and that surgical wards were able to manage antbiotic therapy and IV Fluids. Agreed that a medical ward would have been more appropriate. Lots of discussion re. missed antibiotics and transfer to HDU. I said I would escalate her concerns to the Consultant and arrange a meeting, but could not promise when at the time. PALs was discussed as was datex reporting of clinical incidents.

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Candidate 8

I am happy to inform you that I pass my exam and here are my questions....to share those preparing for the exam.

Station 1: CVS- young lady midline sternotomy scar- I heard loud 2 nd sound and systolic murmur. Give differential--- tissue AVR, ( ? Cong bicuspid ). VSD, TOF( they want that answer) but no clubbing and cyanosis

CNS- Question- a man...balance problem.examine him. He was sitting in a chair. When I ask to walk ...said he can't walk. Then, I found resting tremor of left hand. Parkinsonism--- causes. Ask me how to differentiate it from benign essential tremor. Want DAT scan. And also ask me what medication I will start

Station 2: Respiratory: A man with NC O2, clubbing, VBS with prolonged expiration. Rackeles changed in character with cough. I said bronchi ecstasies with underlying COPD. They re happy.....ask me Iv and treatment

Abdomen: renal transplant ( bilateral iliac fossa scar, left side - tender to touch) previous tied up fistula on left arm. New fistula on right arm , no recent venue puncture mark. Finger tip ...blood sugar tests marks+, so underlying diabetes. Ask me about.....what will u do if that transplant issue is sorted out. Said monitor Immuno suppressant level, macro/Micro vascular complication...Iv and treatment......happy

Station 3: young lady with chronic diarrhoea and normocytic anaemia. She concerned about ? cancer re: her dad had similar symptoms and died of ca colon. Back pain on NSAID. DDx: coeliac, NSAID induced UGI bleeding. Discussed investigation for coeliac. Asked me why she had back pain....I said osteoporosis #.....happy

Station 4 - 40 yr man on warfarin for AF. Collapse at job. CT - SAH, resp arrest, need ventilator. ITU admission. Neuro Sx r/v - not for Sx. Past history- hypertension. To speak to wife. About bad news and Prognosis.

Wife ask ? Warfarin/ ? HTN cause it? Will he recover. Sd she bring her son fr school to see his dad?
Examiner ask- how do u feel? Expecting.....to discuss organ donation

Station 5:

A) pregnant lady, 3rd trimester. Left sided weakness and numbness...resolve in 24 hr. PMH: CVA: full recovery, ASD- repair. 1- abortion. Dx- TIA, .? Anti phospholipid syndrome. Examiner ask- CT safe?

B) Young lady with hand tremor. PMH: thyrotoxicosis, recently stopped medication.

O/E... Signs of hyperthyroid. And multinodular goiter. Examiner ask: investigation: TSH, she want to hear - radio iodine test.

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Candidate 9

I attended your course recently in June 2012 and just letting you know that I passed it with really good marks - 160/172. A very big thank you for organising an excellent course.

Here are the cases that I had for my exam:

Station 1
Respiratory: A 68 year old lady with left upper thoracotomy scar and subtle left Horner's syndrome. She had tracheal shift to the left. Questions asked were: What investigations would I organised and the management of NSCLC/SCLC.
Abdomen: A 60ish year old guy who was blind with bilateral renal transplant. There was evidence of immunosupression-hypertrophy and skin thinning. Likely secondary to diabetes. Discussion was regarding the different side effects of immunosupressants and signs of failed graft/transplant.

Station 2
A 68 year old lady who came in with non-specific tiredness. No other symptoms to suggest malignancy/malabsorption/occult or frank blood loss/endocarditis. PMH of recent aortic valve replacement on warfarin and had transfusion post op. There was a family history of bowel cancer. Blood showed microcytic anaemia. This was quite straight forward as I went down the route of iron deficiency anaemia. Discussion was regarding differential diagnosis - malignancy, haemolytic anaemia, coeliac diasease, angiodysplasia etc and the investigations needed. They did ask what I would do if all my investigations were normal - said BM biopsy but not sure if this was correct and how would I diagnose angiodysplasia. Patient wanted to know if she could stop warfarin as her Hb was low and whether her previous transfusion caused her to have a reaction resulting in low Hb.

Station 3
CVS-mixed aortic valve disease with the predominant lesion being aortic regurgitation. Patient also had coarctation of aorta and hypertension. Discussion was about causes of AR, management of AR and what would I look for in the echocardiogram - aortic root diameter, LVSF etc.

Neuro-It was similar to the guy who had polio from the course. He had LMN sign in the left arm with deformity and shortened limb. Discussion was about where the lesion would be and polio disease in general - vaccination and whether it has been eradicated completely now. The exam didn't go well for this station.

Station 4:
Ethics - 68 years old guy who had a STEMI 6/52 ago. Known diabetic in insulin. Essentially he was found to have iron deficiency anaemia when he was admitted with MI but this issue was not addressed. He presented 6 weeks later to his GP with tiredness and shortness of breath and bloods showed IDA. Station focused on explanation of anaemia and the consequences of delayed investigations and dealing with one angry patient. It also focused on explaining further investigations re: ogd/colonoscopy and patient needed to be admitted for bowel preparation as he had diabetes.

Station 5
A) 79 year old lady with previous non functioning pituitary adenoma- had surgery and previous thyrotoxicosis who complained of worsening had tremor for 1 year. Tremor was worse on movement. Family history of Parkinson's disease. This was basically benign essential tremor as there was no signs of hyperthyroidism or cerebellar signs on examination. Discussion was on differential diagnosis, how to manage essential tremor or if I would do any investigations to diagnose it and treatment.

B) 58 year old who initially had hypothyroidism on thyroxine for years suddenly developed symptoms of thyrotoxicosis with enlarged goitre. Blood test confirmed this and she was on carbimazole and was referred to clinic. Examination revealed unilateral goitre but no Grave's signs. We discussed the differential diagnosis, investigations re: specifially ultrasound and fine needle aspiration and what i would see in the histology( ??). They also asked me about carbimazole and PTU and their side effects.

All in all, it was a do-able exam but stressful. Again, thank you for an excellent comprehensive course.

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Candidate 10

A big thank you to you and your course...I got the result of PACES. I am pleased to say that I passed the exam with a very high score (2012).

First station was station 3
Cvs tall man 30 yrs age... Midline sternotomy scar ,high arched palate, systolic murmur , with loud S 1. Gross finger. Clubbing .... With the previous preexam stress ... I gave them differential about marfans and congenital Heart disease..... I could see this didn't go down well with examiners....
I got less marks in CVS.

CNS:
A 70 yr old female with scar behind left mastoid and ear.... Deviation of uvula to left, deviation of tongue to right and furrowing of tongue on left side.... With speech like bulbar palsy....
I gave differential of SOL with IX TO XII CN PALSY and possible MND
I felt CNS was definitely better than CVS and it reflected in my marks....

Station 4: communication skills.
The practice done at Cardiff paces course really helped me...
A 52yr old female had seen cardiologist / rheumatologist / gastroenterologist / neurologist for the past 20 yrs... Had further investigations and came to clinic.your consultant has seen the results suggested that he doesn't need any Ix further ....
Conversion disorder ...../ Munchausen / went on very well. Discussed about cognitive behavioural therapy etc., got full marks...

Station 5:

Case 1:
A 53yr old female with BP 212/126 ,headache examine and proceed.....
On taking history and examination .... She had NF Type 2 , all features and diagnosis phaeochromocytoma .... Discussion went very well until MIBG SCAN...

Case 2:
25 yr old female with chest pain - assess further ...... Lady had PE, DD Pneumonia/ pneumothorax as pt had asthma,... It went on very well. I got full marks in this station as well.

Station 1:
Abdo : bilateral nephrectomy scars..... RIF Scar.....no transplant old AV Fistula,and a current fistula on other arm...
Discussion about Urine ACR/ PCR, causes and complications etc.,
Bingo full marks...
Resp:
Midline sternotomy scar , SVG scar, with features of inspiratory crepitations up to mid chest....
DD interstitial lung disease, investigations, management and finally they asked me what is that you are a really thinking if it was not respiratory station. I told them this is CCF ....they nodded their heads....
Full marks.

Station 2: history
78 yr old male came with confusion take history from daughter.... Tricky one.. Pt absolutely fine till 1 week ago. Now renal failure.... After picking up the cues .. From daughter, I found out that is case was nephrogenic diabetes insipidus. Pt was lithium and he had recent bout of diarrhoea that upset his kidneys and hence Li causing problems.
Discussion about DD of confusion and water depreciation test analysis .....
Full marks....

Having done the course exactly one week in advance to my exam date really helped.... And mock exam at Cardiff paces course ..... Is a very good experience.
I would recommend the course to everyone if we let go the craze about London courses....this is by far a very good course.

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Candidate 11

I managed to pass paces!!!!!!! I wanted to thank you for your excellent teaching on the Cardiff course that made this possible! (2013)

Here are my paces stations:

CVS: sternotomy scar, loud S1, mid diastolic murmur (didn't pick it). It was MS but I gave a differential for scar asked about investigation and Rx

Resp: lobectomy, clubbed. Asked differentials and investigations

GI: renal transplant, bilateral nephrectomies asked aetiology and investigations

Neuro: peripheral neuropathy (Think she had Charcot Marie but I didn't pick it)

Hx Type I Diabetic recurrent hypos and diarrhoea with anaemia. I said malignancy, coeliac, IBS, carcinoid asked investigations Rx and pt's concerns which were his hypos and chance of malignancy

Ethics: stroke pt - talk to daughter about progress and prognosis. Ethical discussion about where she'd go, daughter wanted NH pt wanted to be d/c home - talked about pt autonomy and pt safety acting in best interests

Station 5 - Churg Strauss syndrome plus palpitations - was AF and I asked about his vascularise quizzed about AF aetiology and Rx

Station 5 - pt presenting eye problems - thyroid pt thyroidectomy on thyroxine. Felt eyes sticking out. Asked about and examined for thyroid status they asked difference between exophthalmos and proptosis and aetiology of proptosis other than thyroid.

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Candidate 12

Just a quick email to say thank you for all your help with my Paces revision and persuading me to go on your course! I am pleased to tell you it paid off and I passed...I think your course helped with my preparation so much and the brilliant teaching combined with range of patients was invaluable. I also felt the mock exam was very helpful, as although I was very nervous, it meant I knew what to expect on the day!

Cases

Communication - I was a Dr at the GU clinic. ATSP who was worried she had contracted HIV from a one night stand a few weeks ago. She was a married nurse trying for a baby. Asked to tell her it would be 3 months until definitive test results. Discussion about persuading her to tell others and my obligations if she refuses to tell those at risk. Also asked me to reflect on how the consultation went - at the time I thought it had gone terribly I had a lot to say.

Station 5 - Patient 1: I'l be honest still have no idea. Info outside told me he had a history of SOB few yrs ago, cxr showed cannon ball lesions which were not cancer. GP referred him with painful feet to me in a general medical clinic. On entering elderly gentleman, walking aids, carer present. Told to focus on the legs, struggled with targeted history from him. Did not expand about chest other than to say had asthma also denied any pain. On examination had a sensorimotor neuropathy. They were cross I did not do reflexes as ran out of time I presume this was relevant.

Patient 2: much better as reflected in my results of these 2 patients! ATSP by GP re rash - vitiligo on face also rheumatoid hands asked about other autoimmuneconditions and discussed management of vitiligo and differentials. She was concerned about cosmetic appearance mainly.

Abdo - hepatosplenomegaly with hepatic bruit and stigmata of CLD. Also huge painful mass over left chest wall ?? I was directed away from this during the examination but then frustratingly asked about this later.

Resp - COPD - asked about diff diagnosis/investigation and management.

History - Presented with widespread oedema also hx of recurrent chest infections and some haemoptysis. Measles as a kid. Discussion of nephrotic syndrome and management of haemoptysis

Neuro - MND, asked to examine motor system, told sensation normal. Asked about diff diagnosis/investigations and management - future planning and advanced directives

Cardio - Aortic stenosis +/- MR. Qus about differentiating aortic stenosis and sclerosis. I couldnt here any radiation as the patient got the giggles, they asked me to go back and listen but ran out of time.

All the patients except stn 5 were clearly current inpatients and the comm/history station were nursing staff.

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Candidate 13

I just wanted to say a huge Thank you for the course in January (2013) and the fantastic effort you all put in, especially given the weather!

I passed, as did JH and BA who were on the course too. I thought it would be helpful to let you know that we all passed with your help and what stations I had:

Station 1:
Cardiovascular: Mitral regurgitation without compromise. Asked me why the second heart sound was important and what the causes were and why she might be SOB (? paroxysmal AF) and how you would investigate

Neuro: Examine this mans eyes: Homonymous Hemianopia - incongruous. I said I wanted to examine his carotids, pulse and heart ? stroke risk. Discussion about likely stroke cause and AF and anticoagulation.

Station 2:
History was a 30 year old who was 'tired all the time' and had had a previous DVT, joint pains and a malar rash. She had also had a miscarriage. Diagnosis SLE with likely Antiphosphlipid treatment. Questions about how to investigate and treat her.

Station 3:
Abdominal: Not sure what this was and none of us scored well on the day. Middle aged lady presenting with abdominal pain. Grey/pigmented skin, macroglossia and a very subtle polycycstic right kidney with some sort of subcutaneous tubing - we all thought in her peritoneum - no exit port or any other signs of previous renal transplant or other RRT.

Respiratory: A classic fibrosis with clubbing and cyanosis secondary to scleroderma - obvious skin changes. Questions about complications, investigations, management and prognosis.

Station 4:
Breaking bad news re advanced lung cancer diagnosis and 6 month delay in referral. GP had not referred despite red flag symptoms for months. She had also had an abnormal CXR that had been reported but nobody had picked it up during a pre op check for an ovarian cyst removal. You had to break the news and manage her concerns regarding the delay in diagnosis.

Station 5:
A:
33 year old with recurrent headache and collapse. She mentioned early on that she had Tuberous Sclerosis and therefore epilepsy. Essentially this was very difficult as there were two separate PCs. The headache sounded very much like hemiplegic migraine and the collapse sounded cardiovascular with presyncope, although she said that she had been collapsing less since her epileptic seizures had been better controlled. They would not allow me to examine her heart which I found bizarre given she came in with collapse!! They wanted us to look in her yes and briefly assess neurology i think! Discussion was around investigations and differentials. I said a CT/MRI, ECG, ECHO and 24 hour tape. Somehow I got full marks although this station felt hugely uncomfortable and I felt the examiners didn't quite know what was going on either!!

B:
50 something with hand pain. Had scleroderma and RA - discussion re: Investigation and management.

Overall I thought I had done really badly and felt that far too much had gone wrong for it to be ok but in the end scored well over the pass mark. My advice to people would be to stay calm, not be flapped by one station going badly (it might not be as bad as you think) and not to believe all the hype because really they just want you to be safe and sensible and not say stupid things!

Hope the feedback is helpful!

Many thanks again for your hard work!

Dr LG (MRCP!!!)

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Candidate 14

Had 2 goes at PACES, just short of passing first time, good pass 2nd time (171/172)!

1st go:

Station 1 – Abdo – Please examine this lady’s abdomen – pallor, 8cm splenomegally, radiotherapy tattoo left breast (told to ignore this) no hepatomegally, no lymphadenopathy, no features RA, no features chronic liver disease. Gave differential – haematological disease/malignancy, infectious, liver disease etc and discussed tests.

Station 1 – Resp – This gentlemen presents with breathlessness, please examine his chest – features suggestive interstitial lung disease, discussed causes in particular they wanted to discuss occupational causes

Station 2 – History – Young woman in general medical clinic with tiredness, malaise and deteriorating renal function. On further questioning has headache suggestive temporal arteritis with visual changes (she mentioned headaches on and off and you had to pick that up and go into visual changes etc). Differentials and tests discussed – most important vasculitis and consider renal biopsy on top of the usual renal screen (bloods/USS)

Station 3 – Cardio – Elderly gentleman with midline sternotomy scar and right sided thoracotomy scar, no scars in the legs but valgus deformity of the ankles and wrists. Normal heart sounds. I had no idea what was going on in the exam, but in restrospect signs could have represented connective tissue disease with surgery for aortic valve/aortic dissection.

Station 3 – Neuro – Young woman, asked to examine her face and arms. Left facial weakness, winged scapula. Asked about her gait (hadn’t examined it but they clearly wanted it) so did and she weak hip abductors. Ran out of time for questions as I tried to examine cranial nerves and upper limbs completely which I didn’t really have time for. Again, in retrospect probably facio-scapulo-humeral dystrophy.

Station 4 – Communication – Asked to discuss diagnosis of IBS with patient and address his request for a second opinion. He was concerned about Crohns or bowel cancer, discussed symtoms – nil worrying, and explained to the patient what he should look out for ‘red flags’ for these conditions. Discussed option of second opinion and then further colonoscopy with associated risks. Suggested reliable internet sites rather than the forums he was using. Pt left very happy and didn’t want the second opinion in the end.

Station 5 – 1st case – Complains of joint pain – Obvious RA, pt had been on treatment for 20 yrs and was on methotrexate and rituximab. Pt wanted to know if she needed another rituximab. O/e signs suggestive of RA with mild synovitis MCPs, also nodal OA affecting DIPs. Talked about DAS scoring to decide if rituximab needed again, also consider steroids IM if this helped before. Examiners asked for d/d, why are the DIPs affected, management plan.

Station 5 – 2nd case – Young woman with palpations, feeling cold and constipation. Obvious thyroid eye disease and thyroidectomy scar. On questioning the palpitations were some years ago when she was hyperthyroid and now bradycardic, cold intolerant, constipation, dry skin, described pretibial myxoedema now settled. I suggested we repeat her TFTs (likely graves now hypothyroid) and increase her thyroxine as required, screen for phaeo if any further palpitations.

 

2nd go:

Station 1 – Resp – Elderly gentleman, SOB. Short of breath at rest, no O2. No clubbing, nicotine staining, barrel chest, fine insp crackles, no wheeze. Also midline sternotomy and scars in legs from venous harvesting. Discussed d/d COPD/interstial lung disease with CABG. Inx – Blds/CXR/ABG/Spriometry/ HRCT. Asked about expected results of pulm function tests.

Station 1 – Gastro – Young man and told he had a long term gastrointestinal problem. Clubbed, mouth ulcers, PEG, scar in RIF, laparotomy scar. Discussed d/d – only thing I could really think of was Crohns with multiple ops. Asked what I thought PEG was for as his swallow was fine - said nutrition maybe short bowel syndrome. Asked about assessment of nutritional state.

Station 2 – Dairy farmer with lymphadenopathy referred by GP. Describes night sweats, lethargy 3 months. No chest symptoms. Had travelled to Egypt few months prior, had some loose stools. Otherwise well. Discussed d/d – haematological malignancy, TB (?bovine), other tropical disease, r/o ca bowel. Suggested bloods and lymph node biopsy, asked what this might show if it were TB.

Station 3 – Cardio – Elderly gentleman, SOB. Nil external signs, pansystolic murmur loudest right sternal edge. Discussed with examiner d/d – AS (and why it was not typical) MR (again why it was not typical) and VSD ( most likely, but why would it give him problems after all this time). Discussed usual inx. Examiner asked if I would do anything about a VSD in an 80 yr old gentleman, I said probably not and look for another cause for his SOB.

Station 3 – Neurology – Elderly lady with difficulty walking. Barn door diabetic peripheral neuropathy (I was so happy, patient was even smiling and nodding behind the examiners back when I suggested this).

Station 4 – Asked to d/w daughter of patient who came in with CVA, outlied due to lack of stroke unit beds, improving well from stroke but now has pressure sores both heels and MRSA growing in one of them. Daughters concerns – that the MRSA could be life threatening, that the pressure sores should have been prevented, and that he was not getting as good care as he would on the stroke unit.

Station 5 – Gentleman with acromegally concerned about recurrence. No visual problems, no facial changes, few nonspecific symptoms. o/e Normal visual fields, features of acromegally. Discussed bloods for growth hormone but also for other causes of his tiredness.

Station 5 – Gentleman with RA. Taken off DMARDs 6 months ago and switched to steroids. C/o back pain. Tender over vertebrae in lower thoracic region, slight kyphosis, also active synovitis in 1st-3rd MCPs and wrists, features of longstanding RA inc nodules at elbows. Discussed possibility of osteoperotic fracture of spine following long term steroid use, not on prevention. Told examiner I wanted his notes to find why DMARDs stopped, thoracic xray and DEXA scan. Still active RA so would benefit from further DMARD.

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Candidate 15

I passed my exam! Can you pass on my feedback regarding my exam cases, as promised during the course? Many thanks for the course, I really enjoyed it.

Cardio: Dextrocardia and heart failure - Qns: ECG of someone with dextrocardia management and investigations of heart failure

Neuro: Left upper limb pure motor neuropathy, underlying acromegaly, pacemaker - Qns: Investigations, Differential Diagnosis

Abdo: Renal transplant - working, mild volume overload, signs of immunosupression, previous tunnelled line, peritoneal dialysis, cause: polycystic kidney disease - Qns: other potential causes, what immunosuppression, Investigations want to do in clinic.

Resp: Pulm fibrosis with pulm HTN, no obvious underlying cause - Qns: Investigations, management, differential diagnosis.

Station 5: Dizzyness - young 30 yr old, sudden onset dizzyness that morning - Qns: Investigations, differential diagnosis, management

Station 5: Painful hands - classic rheumatoid hands, not active currently, on methotrexate - Qns: Investigation, differential diagnosis, management, safety netting (bloods, SOB), how regularly you'd like to see her in rheum clinic?

Communication: Breaking bad news, lady in 30s with young children, husband lives away, SOB over 2 months, CXR done - right effusion, aspirate shows adenocarcinoma unknown primary. Break bad news. Discussed underlying issues - pain, SOB limiting quality of life/working, husband away. Further investigations, management, follow-up.

History: Tiredness / lethargy with microcytic anaemia. Underlying issues identified - new 'IBS' diagnosis, 'mechanical' back pain for 1 year where she is dependent on Diclofenac; FHx: father colon ca, mother anaemia; Qns - Differentials, Investigations, Management, Follow-up

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Candidate 16

I passed paces! I wanted to say thanks and give you some feedback for the Cardiff course site:

Resp: Woman in her 50's/60's with inspiratory creps bibasally, nothing to suggest a cause. I presented it as fibrosis. Questions were on key investigations - I said HRCT and talked about appearances that would suggest steroid responsive disease. They also asked how to assess SOB, I told them ABG/ PFT and exercise tolerance. 20/20

Abdo: Asian man, no peripheral stigmata of chronic liver disease. Abdomen was soft, splenomegaly and distended veins. Presented as portal hypertension, discussion was around investigation and possible causes. 20/20

History: 20 year old with 3 admissions for pneumonia in the last year. Sexual history demonstrated risk factors. But also had a childhood history of giardia. They didn't want exact diagnosis just a single test - immunoglobulins, 20/20

Cardio: Young man with central sternotomy. no vein harvests and normal heart sounds. Discussion was around what he might have had done, I offered valve repair, tissue valve or repair of congenital disease. 19/20

Neuro: Caucasian man, approx. 70's. Asked to examine lower limbs, had monoparesis, normal sensation and pes cavus. Presented as old polio - asked about management ie supportive stuff. 19/20

Ethics: discussion with daughter of a woman who was about to be discharged following urosepsis. She had a previous stroke and the family were not coping. Wanted candidate to tell the mother she had to go to a nursing home. Also on digging further there were marital problems, no holidays for years etc. I offered that we should discuss with the mother together and be honest. Offered options re: OT/package of care, respite support if required. 16/16

Station 5 - A) referral from ophthalmologist, bilateral papiloedema. history of headaches and poor peripheral vision. o/e: bitemporal hemianopia. no features of acromegaly. I was pretty unsure what this was, suggested a pituitary lesion. investigations CT/MRI head and dynamic pituitary function testing. 26/28

B) painful ulcer on lower leg. associated diabetes. Had a central brown discolouration. I suggested necrobiosis lipoidica which the examiners seemed to like. Discussion was around all the various ulcers diabetics can get. In hind sight I was clearly wrong! - 14/28.

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Candidate 17

I attended the PACES course you ran in September 2013 and wanted to thank you for such a brilliant course. It was most definitely the best course I have ever attended with so many cases to see and made me feel really prepared and excited about sitting PACES.

I have now taken the examination and passed with a high score (166 out of 172)!

I thought I would feedback by experience as you asked for the website. I hope it may be helpful to some others in the future:

I started on communication skills: this was information giving to a man who had widespread ST segment depression on exercise testing and symptoms suggestive of stable angina. The information before told you he was a well controlled diabetic, non-smoker but had a high cholesterol. The task was around information giving - explaining to him the diagnosis, need for prompt admission for angiography +/- angioplasty and to discuss secondary prevention medications. The patient held a very firm view of managing their own health and was against taking any tablets and was upset that this should happen despite his best efforts to be healthy, which were driven by a fear he would be like his dad who died of an MI aged 50. I explained it was great he was so pro-active but it was likely his cholesterol may have a family basis and he really needed the angiography, explaining about the vessel narrowing process. I managed to persuade him to accept our help before it had ended. The examiners asked me afterwards what I would have done if he refused, to which I said I would have used stronger language still explaining to him that he could have a fatal MI - they were pleased with this as felt it was a proper part of informed consent. I also said would use other formats of portraying the information i.e. statistically using Framington calculator of risk. The questions then became more abstract such as: "what is the difference between empathy and sympathy?" and "how would you have liked to arrange the room?" score 16/16

Station 5: I had spotted a blind dog in the corridor beforehand so knew an eye case was coming! The elderly gentleman had no remaining visual acuity and on fundoscopy had clear retinitis pigmentosa. I was asked what else it could be to which I replied 'nothing, it is exactly as retinitis pigmentosa is but it could be in association with other conditions', and I then discussed mitocondrial conditions such as Kearns-Sayre. Score 26/28

My other station 5 case was a lady with Raynauds, sclerodactly limited to forearms, per-oral puckering and microstomia. I explored the symptoms of CREST with her, asked about SOB and any renal dysfunction before examining her hands and mouth. I went to listen to her chest but the examiners told me it was normal. I presented as limited sclerosis, asked to do ANA and anti-centromere antibodies, U&E's to make sure no renal involvement etc; Score 26/28

Resp: elderly gentleman with instruction "this man has had thoracic surgery and is now increasingly SOB, please examine". He had a big midline sternotomy scar, along with a scar in axilla and on R thorax posteriorly which I presented as consistent with operative drains. He had marked fibrosis to midzone on left side with reduced percussion basally with normal sounds on right. I presented as end-stage fibrosis with a single lung transplant. I discussed concerns re bronchiolitis obliterans in lung transplants, the need to monitor spirometry and discussed the complications of immunosuppressants. Score 20/20

Abdo: young man, generally cachetic with abdominal distension, dilated superficial veins and a massive umbilical hernia in a cloth bag! I presented as ascites, portal hypertension likely secondary to CLD with a possible splenic tip although I wasn't sure due to ascites so I would get an USS (he had leuconychia, palmar erythema but was not jaundiced). I then said the causes of CLD - most likely alcohol, chronic hepatitis but used a seive to say could be metabolic, autoimmune, neoplastic etc; Asked about investigations and this took up most of the time! Score 20/20

History: 68 year old with proximal myopathy symptoms, some unitentional weight loss and a mild normocytic anaemia. She had a PMHx of severe osteoporosis. Also, during discussion became apparent she had developed a new cough over last two months and was an ex-heavy smoker. I told patient most likely polymyalgia rheumatica because it is common in age group and very similar symptoms but that also on my differential list was another condition possibly linked to an underlying malignancy (polymyositis) and I would want a CXR. Examiners made me feel afterwards that it was clearly polymyalgia and I felt I had run away with myself thinking of polymyositis. They seemed to just want to discuss osteoporosis and the use of steroids and frequency of DEXA scanning - I said I'd still give her steroids in high dose as this is the treatment of polymyalgia but would do a DEXA scan before and at intervals of approximately 6 months. Score 19/20

Cardio: aortic stenosis! The examiners really tried to throw me here I felt as wouldn't let me present normally, said I was only allowed to mention positive findings and give my most likely diagnosis. They quizzed me on the pulse character and I stuck to saying it was normal but said I knew it can become slow-rising in aortic stenosis but it wasn't in this gentleman. I think this went down well as I wasn't just reading the textbook signs and was being confident in my findings. Questions on investigations and management. Score 19/20

Neuro: amazingly - Parkinsons! Instruction said examine this man's upper limbs and proceed to do anything you need to to make the diagnosis. I thought the man had reduced facial expression. He was sat with his hands held together (trick to try and stop you seeing the tremor). I asked him to let go of his hands and put them by his side and just watched for quite a while hoping to see the asymmetrical tremor, which I did! He was well controlled with meds so all signs were subtle but there. I performed full upper limb exam as this is what instructions said but did it quickly, only testing one spinothalamic and one posterior column sign. I then demonstrated hypokinesia, tested eye movements for progressive supranuclear palsy and watched the man walk. I still had time left so I asked him to move his other arm up and down while feeling the cogwheel rigidity enhance. Questions on making diagnosis (said it was a clinical one, I wouldn't want any imaging unless features atypical for idiopathic PD), complications of PD and managing them. Score 20/20

I hope that's helpful!

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Experience 18

I just wanted to let you know that I passed my paces. I will let people know about the Cardiff course.

Station 1:

Resp- There was a note saying this gentleman has come in with recurrent chest infections. On examination, I noted fine inspiratory crackles so I said it was pulmonary fibrosis. They asked about the infections and then I mentioned bronchiectasis. They asked what tests I would do and what I expected them to show. 19/20

Abdo- Renal transplant- I could not feel a polycystic kidney so I said hypertension induced renal disease. They were pleased that I noted the haemodialysis scar on his chest. He also had an obvious peritoneal dialysis scar. I was asked about any other signs I could see and I mentioned he had a cushingoid appearance likely due to steroids. I was asked what tests I would do. 20/20

Station 2: I had a lady with metastatic breast ca. The medical issue was hypercalcemia and pleural effusion. It was a bit of a strange one because of the non-specific symptoms. I went a bit off course because her main issue seemed to be her family not coping at home with her so I assured her that we can arrange social help, respite care e.t.c. When asked what I would do next I said I would do bloods including a calcium. they were happy with that and that's when it dawned on me that that was the medical issue. She was also SOB and they asked what I would do which was a CXR to rule out effusion 20/20

Station 3:

Cardio- I had a prosthetic mitral valve and mitral regurgitation. I got the prosthetic valve but said aortic stenosis because I thought it radiated to carotids. They asked me causes of mr which I got most of them. 16/20

Neuro- I was asked to examine the legs of a young lady. She had UMN weakness bilaterally. I initially said it was unilateral because the weakness was obviously worse on one side (even though she had b/l upgoing plantars and ankle spasticity). I was asked to go back and recheck after which I changed my answer. She asked me what it was likely to be. I said demylination and they asked what other symptoms I would want to check. I said eyes. the examiner asked me to ask the patient and she confirmed a recent episode of visual loss. They asked about treatment and the bell went so I started shouting MS drugs on my way out. 18/20

Station 4: A bit of a odd one. I was asked to see a guy who had recently been admitted with MI which was treated. Before discharge his Hb was 115 and MCV-72. He was referred by his GP with Hb- 66 and SOB. His GP had started iron tablets. It said not to take a history or examine the patient. i told him about his anaemia and why he was SOB. I told him his blood count was not significantly low when he was discharged but it appears to have dropped over the last few weeks and we need to investigate. He asked about cancer and I told him that it was unlikely in view of how acute the drop was. The examiners asked if I would discharge someone with IDA. I said yes but I would arrange OP investigations.14/16

Station 5:

1- a lady with swollen right leg. She had a recent flight. she was on enoxaparin and she had had previous PEs and DVTs. She had significant venous congestion on the right leg and it was tender. I said it was a DVT. They asked me what else I would want to do I wasn’t sure. They asked me if there is any other treatment I was not sure. I said I would discuss with haematology

I thought I would fail this station because as soon as I left I realised she may have had a malignancy causing compression (hence the enoxaparin) and I should have examined her abdomen and said I would do genital examination. But I am not sure what they wanted to be honest 26/28

2- A lady with change in bowel habit and abdo pains. She also had mouth ulcers. She was obviously an actor/staff (She was reading off a sheet a lot). Nothing on examination of abdomen. I did not examine for other signs. I said crohns disease and I would do colonoscopy and bloods. They asked me what else it could be and what other test I would do. I went blank again. (?coeliac) 18/28

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Experience 19

I passed my PACES exam in February and went to your course in January 2014. I am very thankful for helping me pass on the first attempt and would certainly recommend to anyone - it was very high quality.

Station 1- Respiratory
Difficult case, elderly gentleman with SOB. Difficult to examine patient as could not sit back on bed. Performed exam and no major abnormalities. Asked to reexamine with reference to trachea and posterior upper chest, trachea possibly deviated to right, no scars on posterior chest. Asked me to do vocal resonance, I said there was no significant difference, possibly was upper lobe collapse. Not clear on diagnosis

Station 1- Abdominal
Examine this patient with abdominal pain. Patient had widespread psoriasis. Abdominal exam revealed hepatomegaly, smooth and nil splenomegaly. Questioned on causes of hepatomegaly, gave alcohol as cause and possibly medication induced.

Station 2- History Taking
Gentleman in his late 50s with SOB, cough and weight loss for several months. It was noted he had just had a CXR but no report was available. Had a smoking history. I talked about differentials including COPD, heart failure, malignancy and explained to patient that we need to wait for CXR and consider further tests which will guide treatment etc.

Station 3- Cardiology
Elderly gentleman with SOB. Pulse was slow rising, apex beat displaced. Loud ESM, with no radiation to carotid and minimal to axilla. Gave differentials, suggested most likely aortic stenosis. Talked about investigations, management of condition

Station 3- Neurology
Instruction was to examine cranial nerve, patient has issue with swallowing. Major abnormalities I found were global muscle wasting, slurred speech and globally reduced muscle power which did not fatigue. Also patient had frontal balding and gave my top differential as myotonic dystrophy, also included MND etc. Discussion based around myotonic dystrophy, other complications etc.

Station 4- Communications
Breaking bad news. Asked to explain to partner what has happened to this wife and what is the next steps etc. Information you were given was detailed and suggested partner had been brought in with reduced GCS and found to have brain tumor which was inoperable with associated haemorrhage. Discussed bad news, investigation results and management, answered questions etc.

Station 5- Brief clinical consultation- diplopia.
Lady had recently had an episode of diplopia lasting 2 days, had now completely resolved. Did a cranial nerve exam, offered fundoscopy but told this was not necessary. Assessed CVS exam and for bruits etc. Asked for BP. Suggested would workup for stroke etc and do relevant investigations

Station 5- Haematemesis
Gentlemen with haematemesis, recently taken NSAIDS. Full history, Exam focused on abdominal with CVS exam to assess haemodynamic stability, asked for BP/pulse etc, offered to do PR exam. Discussed management plan with patient, investigations necessary etc. Talked about Rockall score, management of upper GI bleed etc.

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Experience 20

I passed the PACES. You did help me a lot in this regard. Thank you so much.

1. CVS

Middle aged gentleman with palpitations, examine his CVA
Moderate MR – thumb nail had a possible ‘splinter haemorrhage’ but no other evidence of infective endocarditis (IE), JVP not elevated and no oedema, BP normal, sinus rhythm.
No cardiomegaly/ no evidence of R/L heart failure, pulmonary hypertension or associated other valve disease
Finished examination 30 sec ahead of time.

Presented as above and continued with possible aetiology (Degenerative/ MVP/ Ischaemic /IE as common causes………next said few other causes but defended no clinical evidence), investigations – including what to look for- (ECG – rhythm, ischaemia/ atrial enlargement, CXR – cardiomegaly, pulmonary congestion/oedema, evidence of LA enlargement – double L/heart border and splaying of carina, Echo –confirm diagnosis/severity/aetiology/complications, TOE – Depend on Echo if planning for surgery)
I was cautious not committing myself for IE as no other evidence
At this point examiner stopped and asked for the cause of palpitation
Possible PAF – went on to say need frequency of palpitation and arrange 24/72 hour tape or event recorder and assess CHADS vasc score for anticoagulation.
2nd examiner stopped this time and asked to show the splinter haemorrhage – I said it is a possibility and showed him, patient said it was due to trauma.
Then asked Ix for IE – FBC/CRP/ESR/UFR/ Blood cultures/ TOE………….Got 20/20

2. CNS

This patient complains of difficulty in buttoning his shirt, do a relevant nervous system examination – he was seated on a chair.
Noted to have a mask like face and thought PD, no tremors
Asked to walk first – more evidence of PD noted
Then proceed with a full upper limb examination – cogwheel/ lead pipe rigidity/ bradykinesia
Looked for Parkinson plus quickly – finger nose / eye moments for nystagmus and PSP/ reflexes for pyramidal signs
Presented as PD and told it’s a clinical diagnosis and went on with management – MDT approach/ fall prevention……….could not go to pharmacology Rx
Examiner stopped and asked hoe symmetrical was the bradykinesia? I said R>L but subtle. Next what Ix to confirm diagnosis if at all –I said Dopamine gated SPECT – he asked what else ……..bell rang? But still I am not sure how happy he was with SPECT………..?? Expected like CT/MRI to exclude other DDs. But got 20/20

3. Respiratory

This patient c/o cough, examine his respiratory syatem
Did not have any sputum cup/ inhalers/ O2/ ………………..
No peripheral signs, no clubbing
RS: inspection – R/ thoracotomy scar and Scar on L/ shoulder anteriorly
Signs suggestive of R/ lobectomy and B/L coarse crepitation L>R suggestive of Bronchiectasis and R/lobectomy
Did not want to present formally,
Asked, what signs did you find to explain his cough?
Explained the crepitation and suggested most likely diagnosis is bronchiectasis and the differential diagnosis will be fibrosing alveolitis.
Aske the differentiation of the two clinically – coarse /fine crepts, localised Vs More symmetrical crepts, change with coughing,
Causes of bronchiectasis
Investigations – FBC/CRP/ESR/CXR/ HRCT/ LUNG FUNCTION PARTICULARLY ASKED ABOUT KCO- Explained with expected findings
Management of bronchiectasis, health education, antibiotics, Vaccination/ avoid infections, chest physio, surgery
Asked about scars  - R/ lobectomy possibly as treatment for bronchiectasis, L scar – unrelated – examiner said L/shoulder replacement…………….20/20

4. Abdomen

Examine this patients abdomen
Elderly gentleman propped up at 45 degrees
Peripheral signs – ? Early clubbing, no lymph nodes, few spider nevi, loss of axillary hair, B/l leg oedema with urinary catheter
Made a mistake in trying to examine a t propped up position, but quickly realised and asked to lay flat
Abdomen –Distended abdomen mainly fat,  Mild tenderness over L/ abdomen,  moderate splenomegaly, ? mild ascites
Asked to present the finding – did as above and said probably due to liver cirrhosis and portal hypertension
Asked whether enough evidence to say live disease – I said most likely and also like to consider myeloproliferative disorders and lymphoma
What Investigations with expected findings………Bloods/ USS/ Guided aspiration
Diagnosis of SBP
Still I am not very sure of diagnosis………………….15/20

5. History

Middle aged man with bilaterall leg oedema
When asked it was a generalised oedema including periorbital for last few months.
Associated mild SOB on exertion.

System review: frothy urine. All other negative
PMH: Childhood measles, recurrent cough needing antibiotics, last year 6 episodes
 
Diagnosis : : Childhood measles-------------Bronchiectasis--------------Amyloidosis------------Nephrotic syndrome

Asked about how to explain his symptoms – As above
Ix: All basics/ urine dip/24hour urinary protein/ serum protein/ vasculitis and autoimmune screening/ USS/ renal biopsy
What biopsy for diagnosis of amyloidosis -----anterior abdominal wall fat/ rectal……………got full marks

6. Communication

Middle aged man with T2DM had recent admission with claudication pain and angiogram revealed diffuse disease not for intervention. Had uncontrolled HT, impaired renal function, peripheral neuropathy, very high HbA1c, high cholesterol
Smoker 20/d, Alcohol 30u/week
Not exercise regularly
Care for disabled wife
Poor compliance with medicines and diet
Occasional hypoglycaemia

Explore the patient attitude counsel and plan action……………..full marks

7. Station 5a

This middle aged gentle man with crohn’s disease seen by orthopaedic for back pain and referred to medical side with SOB
Patient had anky. Spondylitis
PMH: IHD with CABG

Examination except spinal stiffness due to  AS could not find anything but forgot to examine carefully for AR

(Could not complete the conversation)

Explained the possibility of lung fibrosis/ AS itself could restrict breathing/ heart failure/ Anaemia……………could not do anything further
Asked the possible causes for his SOB
Investigations………..All basics/ LFT/ HRCT/ Echo/ KCo-----with expected finding
Kept on asking what to look in echo until AR mentioned and he asked how to examine for AR
Probably due to AR………….managed 23/28

8. Station 5b

Young lady with fatigue few months

PMH: Ulcerative colitis, obesity, thyroid surgery, OSA, …………..
Direct questioning had features of hypothyroidism with menorrhagia
Examined for thyroid gland and thyroid state ------------HR/ skin/ tendon reflexes/ had a neck scar

Asked the possible causes for fatigue …….. Most likely hypothyroid but anaemia and poorly controlled OSA need to be considered
What are  signs identified for hypothyroid
(Could not complete the conversation)………………….got 20/28

 

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Experience 21

I attended your PACES course this May 2014 and have just found out I passed my exam last week! I wanted to thank you for your help on the course, and leave some info for others (if it helps at all!).

 Respiratory - thoracotomy scar, trachea central, normal chest examination otherwise, asked for differentials and why I said lobectomy not pneumonectomy, and investigations if patient presents with increasing SOB.

Abdominal - rooftop scar with hepatomegaly, signs of chronic liver disease, asked for indications and criteria for liver transplant, causes of chronic liver disease, and complications of post-transplant immunosuppression.
 
History taking - middle aged lady with intermittent episodes of central abdominal pain 3 in last 6 months, associated nausea and diarrhoea and dark urine at time, completely well in between attacks, GP had investigated with bloods after attacks which were normal. PMHx cholecystectomy.

 Neurology - sensory peripheral neuropathy, likely diabetic, asked for differential of peripheral neuropathy then ran out of time.
 
Cardiology - (found this difficult) lady with large scar across lower chest suggesting lung transplant, normal heart sounds. I gave a long list of differentials!

 Communication skills - explaining a delayed diagnosis of metastatic cancer to a frail elderly lady's son. Patient with weight loss and dysphagia, had oesophagitis on OGD with normal biopsy, symptoms persisted and repeat OGD was done which was normal. Then had CT which showed metastatic gastric malignancy. Had to explain to son sequence of investigations, and why CT was not done earlier, but likelihood that earlier diagnosis would unlikely have changed management.

Station 5 - man with early Parkinson's disease, demonstrated typical features. Limiting daily life now and patient wanted treatment. Explained diagnosis and possible medication treatment. Questioned about Parkinson's plus syndromes, possible investigations, and treatment options.
 
Station 5 - lady with collapse on standing, recently started on bisoprolol, had carotid bruit, discussed acute management plan.
Thanks again for all your help on the course, would definitely recommend it to others.

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Experience 22

I attended your course in May 2014 and had my PACES examination in June 2014. I want to thank-you and everybody at Cardiff Paces for your help and support and share in my success as I thankfully passed PACES. Below is a bit of information about my PACES experience. I
hope this helps, though the best advice I was given was to put on your favourite pair of heels and a nice outfit and be confident!


Abdomen
I had a patient clearly taken from the ward with tense ascites. The patient was icteric, tense ascites. There was not much in the way of peripheral stigmata of CLD but the patient was bruised (secondary to high INR) which the examiner asked me about. Gave my diagnosis
decompensated CLD, possible triggers of decompensation, further investigations I would like to do and management.
20/20

Respiratory
Patient with basal pulmonary fibrosis likely secondary to CTD (connective tissue disease). I was asked about tests to look for CTD. 
20/20

Neuro
Patient with peripheral neuropathy, bilateral Charcot joints and foot ulcers. Discussed diabetes, patient education and management of Charcot joint and diabetic feet. I gave some other causes of peripheral neuropathy.
20/20

CVS
No idea of diagnosis gave some differentials. Mid sternotomy scar with murmur no vein harvesting scars on legs. I explained this could be for tissue valve replacement +/- use of internal mammary for CABG. Murmur could be secondary failing valve or new valvular disease, further investigation namely with history and echo.
19/20


History
Fever and weight loss in a business man who travelled, spent some time in various parts of Africa. Differentials,malaria, TB, HIV all discussed. Concerns raised related to his friend who hadrecently been diagnosed with cancer I told him could not completely rule out lymphoma
although this was most likely to be infective. Needed admission for further investigation.
20/20

Communication and ethics
Young mother with infective endocarditis, had 2 weeks treatment now feeling better she wants to self-discharge as she is not getting on with nursing staff, she misses her children (who are staying with her sister) and her husband works away. Also fed up of being cannulated.

Explored issues, change of ward, side room, I would cannulate and then mid line, social services etc. Then assessed capacity warned risk of death. Agreed I would cannulate, then arrange midline, speak to micro and consultant regarding alternative antibiotics perhaps od
preparation so she could attend ward as home IV team unavailable in her area.
16/16

Station 5 (1)
Gentleman with type 2 diabetes 5 year history of LOC secondary to recurrent hypos. Ran out of time discussed further management, differentials and driving.
22/28

Station 5 (2)
Gentleman with Ankylosing spondylitis on NSAIDS and alendronic acid with
haematemesis. Test was to identify alendronic acid recently restarted by GPcheck method of taking it know its side effects. Discuss further management.

28/28 
Thanks again Cardiff
PACES

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Experience 23

I recently attended the Cardiff Paces course in September 2014.
This was my fourth attempt at the PACES exam and I really was very concerned as to why I 
was not passing. I got to know of the fine techniques and could iron out my shortcomings,
especially the part where I had failed on previous attempts (managing patient’s concerns ).

I am delighted to tell you that I passed the PACES exam and to my surprise I got 156 out of 172, with full marks in history, communication skills and station 5.

Thanks once again for all the help and I must say that all the instructors were excellent and choice of patients was also good. I will recommend the course to all my friends and juniors.

 

MY CASES IN PACES EXAM :

Respiratory : Patient with SOB. had a big thoracotomy scar on left side of back ,  crackles at both lung bases but percussion was near normal. Likely a lobectomy for bronchiectasis with compensatory expansion of remaining lobe.

Abdomen : Patient with A-V fistula and multiple abdominal scars , CKD 

History :  55 y old lady admitted with witnessed collapse, pas h/o Ca Breast 3 years ago , now on anastrazole, childhood history of absent seizures but never needed anti epileptics. Take history , formulate management plan and address concerns 

Neurology : Charcot Marie Tooth disease

Cardiology :  aortic regurgitation in a meddle aged man :  apex in 6th ICS, Lateral to MCL, Water hammer pulse, and Corrigan sign, early diastolic murmur. 

Communication /ethics :  82y , stable COPD  with mild CKD, Past h/o bladder ca and under followup of urology. Admitted with worsening renal function and USG reveals tumour involving ureters now. Being planned for nephrostomy. Has now developed hyperkalemia with K+  = 7.5
Discuss with family and explain situation and management plan .

Station 5 : 

 1) 45y old lady with 4 month history of diplopia and slurred speech, catch in the case was diplopia And slurred speech worse at end of day. Has Myasthenia gravis
Gave DD as : myasthenia, Lambert Eaton syndrome, multiple sclerosis and young stroke/TIA

 2 ) 20 y old with 12 year h/o Type 1 DM. Now having frequent hypo and dizziness .  DD : autonomic neuropathy, CKD and Addison disease …. had Addisons  disease newly diagnosed 

 

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Experience 24


Station 4. 86 year old with urinary retention secondary to Carcinoma bladder . His creatinine and serum calcium were high , he was confused. He had COPD and osteoarthritis. Radiologist was ready to do the percutaneous nephrostomy . I had to discuss treatment options and management plan with his son.

Station 5a. An old female patient with rheumatoid arthritis had numbness of the right arm and right leg for 3 days . She had numbness and weakness of the right arm with exaggerated reflexes. I made it a stroke. Her question was , is it related to my rheumatoid arthritis?

Station 5b was a guy with headaches. He was hypertensive with no visual symptoms or change in body shape . I generated a DD , don’t know if it was tension headache or what.

Station 1a was an old male patient with a left lateral thoracotomy scar , a laparotomy scar , steroid purpura , telangiectasias on the face , eyes were so red ,visible veins on the chest and upper back. O/E  he had decreased breath sounds on the right with normal percussion and resonance, it was a disaster for me.

Station 1b was a young guy with tattoos, a ring in the nipple, 4 finger breath hepatomegaly with visible veins on the lower chest and abdomen . He was not tender , I give DD's including vein thrombosis , viva was about anti coagulation options

Station 2 was a 30 year old lady with anaphylaxis . She had a history of hay fever . No risk factors and it was a 1st episode of anaphylaxis. Anaphylaxis was secondary to some kind of food ingestion. This one went well.

Station 3a was old man with a midline sternotomy scar, metallic aortic valve with bibasal crepts. I made it aortic prosthesis with LV dysfuction , secondary to valvular or ischemic cardiomyopathy , though there were no saphenous vein scars , but i said LIMA to LAD can not be ruled out.

Station 3b was right homonymous hemianopia. I had to examine the cranial nerves . Could not find any other nerve impairment . I said I wanted to examine the limbs 

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Experience 25

My both station 5 had actors. CASE 1) IDDM 20 year old Female with recent RTA due to hypoglycemic episode, she had few episodes of hypoglycemic recently with no hypo awareness.

On taking history, she mentioned she had not seen a Diabetic nurse for last 6 months with no bloods in last 6 months and Her last HbA1C was 7.8 just over 6 months ago. She had her eye and feet check done every year. Not losing weight or dieting. Injecting TDS short acting Insulin with meals and  Levemire in evening. She was regularly changing the injection sites. No particular timings or associations of hypos. No tachycardia, nausea or vomiting. On examination,I was told that she had background retinopathy on Fundoscopy, I asked for lying / standing BP and I Was told there was a 30 mm Hg difference in systolic BP. Pulse was normal. Patient refused to get the injection site viewed and examiners asked to leave it.
Then I asked concerns and she mentioned why I am getting these episodes and I mentioned may be due to poor diabetes control and we need to do her bloods to check glucose control and arrange her to be seen by diabetic nurse.

I also advised her not to drive and inform DVLA as she had recent RTA due to hypos.

Then examiners asked me is there any other condition other than diabetes which could cause low BP and low glucose , on this I mentioned yes, there is Addison's disease and there is a strong autoimmune link with type 1 diabetes. Then they asked me for tests for Addison's disease. 

 

2) Youg 22 year old female patient with slurred speech and diplopia for last 4 months, on taking history - none significant , only +ve thing in history was that sx occurring at end of the day- exam was normal, speech gait normal, no fatiguability or nystagmus as patient was an actor, they asked me for provisional diagnosis , my diagnosis was Myasthenia, examiners asked for differentials and tests for a new patients seen on OPD suspected of myasthenia gravis.

RESP- Left lower  Lobectomy with B/L INSPIRATORY crackles, not changing on coughing not on oxygen , no sputum pot 
NEURO - HSP - b/L upper motor neurone signs in lower limbs , sensory system normal

ABDO - LIF mass with no scar on scar, there was a midline scar ----> probably has renal transplant through central scar as there was a non functioning fistula at RT wrist.

CVS- No idea till end , obese pt with very thick loud S2 , + a systolic murmer with no radiarion to carotids or axils , central sternotomy scar with no metallic click.
Obese patient with very thick chest wall and loud S2
I explained may be bio prosthetic valve done in past which is not getting calcified and sclerosis 

History : collapse at home with LOC and shaking , typical of an epileptic seizure, DVLA, examiner asked if it was a metastasis in brain with brain oedema  how will u treat would you give steroids , if yes which steroid you will give and what dose.

Communication : counselling a relative , son of 82 year old male , known Bladder cancer, comorbidities : Moderate to severe COPD and O.A., now admitted with acute renal failure due to B/L Hydronephrosis secondary to obstructive uropathy on USS, Radiologist has offered to do an emergency nephrostomy and your consultant has asked you to speak to family for nephrostomy.

My overall score was 146 /172 . The station I think I did the best ( history taking ) has lowest marks 16/20. But for patient welfare  I was hoping to score low I had scored 32/32. 
Thank you all of u for your input in my success. 

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Experience 26

Just wanted to let you know that I passed my PACES Exam on 19th April 2015, having attended your course in January.

As a GP and 'mature' candidate I must say that I will be tempted to come on your course again in the future even though I passed the exam...because I really enjoyed it! It's not often that GPs like myself get to see so much pathology / clinical signs in one location in such a short time!

Everyone was so helpful and enthusiastic and the location was ideal, with very reasonable (read: affordable) accommodation close by.

Please continue the great work....

PS - Dr Ho's Heart Sounds impersonations should be on "Britain's Got Talent" - Excellent stuff!!!  

Station 1 - Gastroenterology
Young man with ‘anaemia’ (though he didn’t have signs and examiners agreed with me he wasn’t clinically anaemic!) – dystrophic nails and palmar erythema. May have had hepatosplenomegaly but I was not convinced – however, the examiners’ question included the line ‘OK, lets presume he has hepatosplenomegaly’ which suggests I was wrong! (this was also my lowest scoring station!) Then asked about causes and investigation, with degree of focus on haematological results and interpretation.

Station 1 - Respiratory
Middle aged man with ‘breathlessness’. Midline sternotomy scar and bilateral basal fine end inspiratory creps. I thought pulmonary fibrosis and questions followed this direction so I presume this was right. Asked about management of fibrosis and when steroids might be indicated.

Station 2 – History Taking
A middle aged man with cough / wheeze / breathlessness for 3/12.
Ex smoker (stopped 10y ago) but when asked about occupation said he worked as car mechanic and didn’t wear masks etc and symptoms improved when on holiday. Also element of exercise asthma. Questions included what investigations to perform and what to expect on spirometry. Concerned about lung cancer.

Station 3 – Neurology
A young man with expressionless face, pill rolling tremor and dyskinetic movement (esp L hand), examination revealed weakness of small muscles of hands bilaterally. I was puzzled by the ‘choreoathetoid movements’ and weakness. He had a splint on his L wrist which he said was for tendon surgery. Increased tone (lead-pipe I think). Sensory examination NAD. We discussed differential diagnoses and talked about Parkinsons but I said it was unusual at his age (early 40s). I didn’t think of potential other causes (Wilsons, drug induced etc). I thought I messed this one up but actually scored OK!!

Station 3 – Cardiovascular
Elderly Asian man with systolic murmur consistent with aortic stenosis (I thought) but no other signs. Examiners were difficult to gauge on this one, asked about alternative diagnoses and what investigations might be required, causes of aortic stenosis and what an echo might show (I wondered after whether they were looking for me to mention cardiomyopathy…?)

Station 4 – Communication Skills
A young lady with T1DM and small children who was non-compliant with treatment and had several admissions with DKA – to talk about treatment. I tried various techniques but not sure at the time whether I really understood what I was supposed to be looking for or doing – but scored full marks so presumably covered all the important stuff.

Station 5 a
A middle aged woman with breathlessness and obvious systemic sclerosis (diffuse) on mycophenylate and steroids. History of Raynauds and examination suggestive of pulmonary fibrosis but no pulmonary hypertension.

Station 5 b
A young girl (who I suspect was an actress – probably a medical student or junior doctor), who was ‘tired all the time’ for 3 months and bumping into things. Worked as a District Nurse and had knocked off both wing mirrors on car. History revealed galactorrhoea. She had sweaty palms but I think this was just the actress (she seemed embarrassed about this and the examiners were not keen on discussing thyroid function particularly). She had a bitemporal hemianopia and questions focussed on causes, levels of prolactin associated with prolactinoma and consideration of acromegaly (I said she didn’t have the features – as I thought she was very pretty actually!!!)

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Experience 27


I took my PACES exam in Cambridgeshire. I thought the exam was fair and well organised there.


Station respiratory

I started on the respiratory station. I immediately noted that the lady was breathless at rest and that the chest looked to be hyper-inflated. There were no scars, chest expansion was reduced bilaterally. I didn’t hear any crepitation’s. I made it obvious I was looking for right sided heart failure by looking for a raised JVP, peripheral oedema and listened for a loud P2 which I didn’t elicit.

I presented saying that I thought this lady had COPD.I then got asked about the management of COPD which I separated into acute management and chronic management which the examiners seemed quite impressed about. They then asked me to have another look at the lady so see if I had missed anything. I noted then that she had some bruising on her arms and her skin looked thin which suggested long term steroid use and severe COPD. I scored 18/20 on this station


Station abdominal

When I got to this station I was a little bit disappointed that he had no scars as it likely meant that he would have some organomegaly.

On peripheral examination I noted palmar erythema, spider naevi and gynaecomastia. He had a bruise on his arm. I spent a long time palpating for hepatomegaly and splenomegaly but I couldn’t feel either. The rest of the examination was normal

I stated that I thought this gentleman had Chronic Liver disease and listed off a differential. They asked me about how I would investigate him and manage him. Then then proceeded to ask me complications of CLD. I scored full marks for this station.


History taking

The instruction sheet sheet showed some blood results of a lady with an iron deficiency anaemia and asked me to take a history.

The lady had become more tired over the last few months and it was starting to effect her job as a teacher. She had noted that her stools were more difficult to flush but there was no change in bowel habit, no blood or any other red flags.

Ultimately I stated that I thought she had a malabsortive syndrome and I would like to exclude celiac disease. They asked me how I would investigate her to which I stated some more blood tests including TTG and if positive an endoscopy. I didn’t ask any questions about menorrhagia but explained to the examiner that this was an important cause of iron deficiency in a lady. They asked me about other causes of malabsorption and we talked about potential parasites such as giardia. I felt the consultation hadn’t been as structured as I would have liked but scored full marks.


Cardiology

On inspection the patient had really visible pulsation in his neck which I thought might have been Corrigan’s sign but I had not really seen this before just read about it so I wasn’t sure. There were no scars or any other peripheral signs. He had a pan systolic murmur which was loudest at the apex. I tried to listen to see if it was loudest on inspiration or expiration but could really tell to be honest.

I ended up saying that I thought this was mitral regurgitation but tricuspid regurgitation was a possibility. They asked me for another differential and seemed to be happy when I said VSD. They then asked me about investigations which I started with the simple investigations first and said bloods, ECG, chest x-ray but an ECHO would ultimately be the most useful. I scored 19/20


Neurology

I found this the hardest station as I struggled for time.

I nearly got him to walk first but I saw a stick and the examiner stated if I was going to get him to walk to only ask him to take a few steps as he was unsteady. I therefore thought this would take a long time so thought I would come back to that at the end. I’m not sure still if that was the correct thing to do as I ran out of time before I could ask him to walk and there were obviously things to pick up there any may have given me the diagnosis straight away.

On inspection I couldn’t see any wasting or fasciculation’s but when I presented that the examiner looked at me strangely so I think there probably was some distal wasting. His tone was reduced. His power reduced distally and I couldn’t  elicit reflexes. He clearly had glove and stocking sensory loss in all domains. I only quickly managed coordination before the time ran out. I presented that he had a motor sensory distal neuropathy. The examiners asked me for differentials, investigations and specifically wanted me to say a multidisciplinary management approach which I needed guiding to. I spoke to another candidate after the exam and they stated they found timing difficult in this case but did mention that he had a scar on his lower back which I missed which I may well have looked for if I had got him to walk at the beginning of the examination. I scored 17/20


Communication

I had a lady that recently had been diagnosed with SLE and I needed to discuss with her the need for a renal biopsy. This was something I hadn’t really prepared for and had never seen or read about a renal biopsy so I just stuck to a simple structure.

I quickly explored what symptoms she had and how they were affecting her. The patient said she was unsure what SLE was so I started by trying to explain what SLE was in layman terms. I explained that some of the symptoms she was getting were because the SLE was effecting her kidneys and therefore we needed to investigate this further. This is normally done with a renal biopsy.

I then tried to explain roughly what a renal biopsy was, the benefits of helping management and some generic complications such as bleeding and infection. Ultimately she didn’t want the biopsy. I explained it was a big decision and offered her some time to think about it and some leaflets. I said she could return with her husband and we could go over any outstanding questions when she came back to clinic next week.

The examiners stated if she still said no what would it do – I said I would raise inform my consultant and see if she would want to discuss it with him. This led on to a discussion of capacity. The examiner gave nothing away and I wasn’t sure if my answers were correct, however I scored full marks


Station 5)

When I went into both station 5’s there were four people in the room, the patient, two examiners and an external marker so the room was quite crowded

The instructions stated that the patient had noted numbness of one side of the face. I presumed that this was going to be a stroke and was preparing to ask and examine for stroke risk factors. However when I looked at her although she clearly had a facial droop it seemed to be lower motor neurone. I checked this and thought for a minute whether to commit to LMN questioning rather pursuing a stroke like consultation. Ultimately I’m glad I committed to a LMN diagnosis. I examined her ears and felt her parotid for any masses. I explained to the patient that I didn’t think this was a stroke and likely bells palsy. I offered treatment and reassured her.

I was relieved when the examiner agreed that this was LMN and asked me for a differential. We then discussed management including steroids and antivirals. I scored 27/28


Station 5)

My second station 5 was someone who had noted eye changes. I walked in and noted proptosis. I asked a few questions and it turned out she had had a thyroidectomy for hyperthyroidism. I examined her eyes and thyroid status and ultimately thought this was thyroid eye disease secondary to graves disease but that she was currently euthymic as she was taking levothyroxine. The patient asked me if there was anything she could do to help herself and I wasn’t sure about this. I said we should get some upto date TFTs.

The examiner asked me about acute management. I stated it would be important to check visual acuity and if any concerns refer her to ophthalmology for consideration of IV steroids. The examiner also asked me if there was anything the patient could do to help herself and I just had to tell them I wasn’t sure about this and would have to ask for some advice.

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Experience 28

I have got my PACES exam results and I have passed this time (July 2015).

I am very thankful to Cardiff Paces Course. The course has good quality cases and focused teaching. I had always problems in communication and patient concerns, but I managed to score full marks in both the skills.

..

I started with respiratory I think it was pulmonary fibrosis but I think I missed few signs. It didn't go that well and I got 11.


Abdomen - moderate splenomegaly. Gave decent differentials and discussion. Went well and got 20.


History known COPD on inhalers presenting with sob, swelling of legs and secondary polycythemia. Still smoking lots of social issues went very well. Got 20


CVS midline sternotomy scar bilateral venous harvesting graft scar on legs muffled heart sounds gave differentials. AVR tissue valve or CABG with heart failure I think the diagnosis should be wrong failed badly got only 5


Neurology -  hemiplegia with facial nerve palsy task is to do full neurology examination could not complete but discussed everything got 20


Communication talking to the daughter whose mother was admitted with fall and diagnosed Parkinson's recently. Lots of concerns went ok got 14


BCC1 elderly gentle man coming with 3 collapses it was aortic stenosis had ESM. Got 28

BCC2 known diabetic Addisons presenting with visual loss. Did fundus examination. Got 28


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Experience 29

Station 1

Abdomen
Renal transplant with previous permanent cathrter dialysis...graft functioning well. Discussion causes of renal failure


Respiratory
Barrel shape chest with generalized reduced air entry..COPD. Questions regarding management of COPD


Station 2

Young lady presented with palpitation for 6weeks. Post partum 4 months. Dx post partum thyroiditis. Questions..ddx difference between Graves and post-partum thyroiditis and management


Station 3

Neurology
Bilateral reduce sensation and distal symmetrical weakness of lower limbs. Pt also had a increase tone and a brisk knee reflex. Like a combined sensorimotor peripheral neuropathy and a cervical myelopathy. Questions included cause of neuropathy and necessary investigations to identify the cause


Cvs
Aortic valve replacement..asked indication of valve replacement surgical indications of aortic stenosis requiring surgery and Gorlins equation


Station 4

An elderly lady admitted for #NOF develops intracerebral bleeding due to lmwh and aspirin. Speak to son regarding CT findings and discuss risk versus benefit of stopping lmwh.


Station 5

Bcc 1
Elderly lady complain of a few months of loss of vision as well as significant dx of vision loss. O/E loss of peripheral vision and retinitis pigmentosa on fundoscopy. Question regarding management of RP

Bcc 2
Middle age gentleman with history of diabetes mellitus for 20yrs on s/c insulin comes with an ulcer on 4th toe. Previous rays on 4th toes. Pt also had a left BKA however tried to conceal it. Questions regarding differential diagnosis of lesion and management


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Experience 30

Station 1
Resp - CREST syndrome with pulmonary fibrosis
Abdo - Polycystic kidney disease with transplant

Station 2
History taking
Businessman with loose stools after trip to Africa but actually has HIV

Station 3
Cardio-Avr
Neuro-post circulation stroke with UMN and cerebellar signs. Upper limb examination

Station4
Breaking bad news, lung cancer.

Station 5
1. Carpal tunnel syndrome with acromegaly
2. COPD relapse/exacerbation


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Experience 31

Thank you so much for all your help I am so relieved to have passed. I found out today. I only dropped 10 marks which I can’t quite believe!

Station 1  Failed renal transplant back on haemodialysis. And pulmonary fibrosis.

Station 3 Mitral regurgitation, Neuro -  isolated diplopia on up-gaze with no fatigability but was myaesthenia gravis

Station 2 was photosensitive rash caused by doxycycline but felt more like a communication station

Station 4 unhappy relative for a man with a stroke no beds on stroke ward, pressure sores with MRSA ( not clinically infected) concerned about seriousness of MRSA, not in stroke ward and complaining of there not being enough nurses and ward not clean. I had personal feedback from the actress who said I had done well! 

Station five - lady with resolved abdomen pain, easy bruising and bleeding and previous splenectomy. Second was myotonic dystrophy.

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Experience 32

I attended Cardiff paces in May 2016
Happy to let u know that I passed my paces
Wanted to share the stations so that they can be of help to future candidates

1. Station 5

Young man with BP 180/100; urine dipstick of 3 plus protein and blood

My approach

Hypertensive urgency
Causes of HTN: renal; endocrine; cardiac; meds; pulmonary-renal syn; vasculitis
Forgot about about illicit drugs
Questioning: no symptoms except some headache 10 days back with some reduced urine output
Told me fundus ok
Abdomen: I thought I found some ballotability
FH: lupus but nothing in him

Part 2: young female with diarrhoea and high temp
On questioning
Recent return from Thailand
PMH; traumatic Colectomy with redo
Lot of operative scars on tummy

My DD
Travellers diarrhoea (they asked me causes)
IBD
Adhesions
She did not take malaria prophylaxis regularly

Admit I said in both cases

Resp:
Fine crepts at both bases with lot of scars in safe triangle and a small scar posteriorly
I said ILD with scars for VATS; chest drain; open lung biopsy

Renal
Cushingoid facies with PICC via chest with right iliac fossa scar site with no mass palpable and multiple scars on abdomen
ESRF with failed transplant currently on hemosislysis no CSI with cushingoid facies
Causes for ESRF

CVS
Young to Middle Aged female I saw her in waiting area she walked into hosp with me
Clear central sternotomy scar
Audible metallic click
No other scars
Weak pulse
Presented as metallic first HS with the usual stuff
MS may be rheumatic; iEC; IVDu, degenerative

 I said only 2 possibilities, Either aortic or mitral
They started pointing towards Palm
There was erythema no stigmata of IEC I said she had varnish no clubbing clearly

 Neuro
I have no clue, scored only 5/20

 Counselling
Bird fancier lung with proven blood tests and CT
Explain diagnosis and start on steroids
Pt depends on birds for livelihood
Son also involved in same work
Very tearful pt
Explained diagnosis; unnecessarily used word protein; though apologised for medical term and explained what it was
Occupational lung disease; Pension
So much to talk so many questions from pt
Son def at risk as some gene sharing with mum
Pt very scared of steroids
concerns from pt: very tearful, scared of steroids, can she use a mask while with birds, is son at risk
 Questions from examiner: capacity; how did I do
Lots more

History
Middle aged female with sub acute onset SOB losing weight smoker
recent LRTI, CXR: clear
Said no other complaints
I asked all ROS except for swallowing

D.D lung Tumor
Worsening COPD
R/o thyroid (no symptoms)
CCF (no symptoms)
No renal or as cites
Examiner said she would have complained of diff in swallowing if u asked

I said I will consider systemic sclerosis and malignancy
As red flag I will consider OGD
Hope this is useful

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Experience 33


I  attended your course in 2015 and did the exam in October 2015 and realised I never sent an email with my cases! I was sure I failed but I actually did quite well (1st attempt)! Below are my stations - I hope they can be shared to help others!

1. Station 5 (1): Neck mass. She was in AF. No other signs of thyroid disease. Thought it was thyroid mass but gave lymphoma as differential

2. Station 5 (2): elderly man with fevers, myalgia and headache. I thought PMR/GCA and went down that route.

3. Resp: Young lady. Right thoracotomy scar (I thought pneumonectomy) with healed tracheostomy scar. I thought there was tracheal deviation but in hindsight, there probably wasn't. Not sure what diagnosis was but thought either childhood infection or malignancy. I went completely blank when he asked me what sort of childhood infections (and had to be offered TB!)

4. Abdo: lymphadenopathy and splenomegaly ? CLL (I felt this was the only one which was ok)

5. Cardio: Bilateral thoracotomy scars and midline sternotomy scar. MR murmur. I wondered about TOF repair which led to a discussion about other congenital conditions. I also wondered if she had a bilateral lung transplant but dunno.

6. Neuro: I was asked to do BOTH upper and lower limbs so naturally ran out of time. But I think she had myotonic dystrophy (wouldn't let go when shook hand and had bilateral ptosis but mostly distal weakness). She was wasted but bloody forgot to mention this.

7. History taking - headache. Had 2 types. Sounded migrainous with possible analgesic overuse or tension. I was asked about a CT scan but said I wouldn't do this at the moment as no evidence of raised ICP, young man, etc. Safety-netted him regarding this and would discuss with consultant whether OP CT head was necessary.

8. Communication skills: This was very hard. Had to counsel a woman about MEN2A. They did say a bit about it but she kept asking about prenatal screening, etc and I just didn't know the answer.

 


 

 

 

 

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