We hope you feel that the course has been useful in focussing your revision for the PACES.
You need to pair up with somebody doing the PACES. You will be compromised if you study alone. See patients (either organised teaching or going around yourselves) on the wards at least 2-3 times/ week and meet up regularly in the evenings or weekends to blast questions at one another. Viva technique is important. Don't give incomplete answers or expect the examiner to prise the answer out of you.
Example with pulmonary fibrosis short case
Examiner: What one investigation will you do to confirm your suspicion?
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?
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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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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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:
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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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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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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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 -
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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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?
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.
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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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).
History taking 56-yr-old lady with wt loss and loose bowel . They asked all dd's related to malabsorption...she was celiac.
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.
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)
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
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
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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:
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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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
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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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:
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.
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.
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.
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.
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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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.
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....
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...
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...
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.
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...
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....
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 .....
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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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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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!
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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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:
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.
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.
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.
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.
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!!
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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Had 2 goes at PACES, just short of passing first time, good pass 2nd time (171/172)!
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.
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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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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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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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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I just wanted to let you know that I passed my paces. I will let people know about the Cardiff course.
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
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
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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