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We hope you feel that the course has been useful in focussing your revision for the PACES. You need to pair up with somebody doing the PACES. You will be compromised if you study alone. See patients (either organised teaching or going around yourselves) on the wards at least 2-3 times/ week and meet up regularly in the evenings or weekends to blast questions at one another. Viva technique is important. Don't give incomplete answers or expect the examiner to prise the answer out of you. Example with pulmonary fibrosis short case Examiner: What one investigation will you do to confirm your suspicion? It's tedious. So, ideal 1st response = I would arrange a high resolution CT chest to confirm the diagnosis. A ground glass appearance is associated with active alveolitis which responds well to steroids, whereas a honey combing and interstitial fibrosis indicates more advanced disease which will be less steroid-responsive. 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
Shu has produced a video to ensure you can recognise the various heart sounds likely to appear in the exam. (High Quality, slower download) - Click here to watch the video GL wrote: My cases were: Graves Eye Disease and Goitre Resp was a pulmonary fibrosis. Asked about differentials, CT findings and what honeycombing represented.Abdo was an elderly lady with splenomegaly and a stoma/ascites bag on site of previous paracentesis. (questions were on diff of splenomegaly) Cardio was AR ( I felt there was AS and AR - questions focused on which lesion i felt was the most predominat and the mx of AR) Neuro was a myasthenic patient who only had unilateral ptosis. I thought the instruction in this case was difficult - pt having weakness in arms and legs and blurring of vision. It may be useful to have a system of examining a myasthenic to illustrate the relevant signs or to show examiners that you know what to look for. I didn't have one and I think it showed. History taking was a gent with progressive limb and neck weakness. (? Eaton Lambert, ? MG ?MND) Comm skills was a dental nurse recently returned from Africa with new disgnosis of sputum pos TB. ? had exposure to HIV with previous partners whilst in Africa. Mother also died of TB. Lady was a single parent with two young children.... I attended the course in February, and am glad to say I have passed. Thank you very much for your help! I thought of just sharing the cases that I had for the exam. Neurology- Lady with difficulty walking. She had wasting, power 0/5 both legs, loss of sensation (dorsal and st), with clonus on the right. I went up until the chest and she had no sensation up until lower chest. This station basically involved discussion of DDs and investigation. Cardiology- This was a bit of an odd one. large thoracotomy scar scar 'L' shaped, with thrill, systolic and diastolic murmur (was rather confusing) on the precordium. I discussed the possible DDs, though I was not personally very happy the way this station went, I later thought that this was TOF with repair. Ethics and communication- This involved talking to husband of a lady with Hep C regarding the condition and consenting him for the test. One of the other candidates commented that it got embaressing for him, the actor and examiners after a while. I had more than a minute left in the station. Mainly just went by the advised pattern. Questions were on ethical principles involved and Hep C treatment. Station 5- Case1- 55 year old man referred from skin clinic as he had tremor. My diagnosis was Benign essential tremor, and discussed other causes for tremor and treatment options. Case 2- 75 year old gentleman referred by GP with h/o deteriorating vision. He is waiting to see opthalmology, but that is another 3m. focused history, examination and advise. This gent had near complete loss of vision bilaterally, positive fh, didnt want any help from OT, as he knew where everything in his house was and was helped by his wife. fundus showed retinitis pigmentosa. ( the cases were in fact BET and RP) abdomen- hepatosplenomegaly with jaundice in a young man. This went well. The diagnosis I offered was hemolysis, possibly spherocytosis etiology, and discussed other DDs, investigation. (this was indeed HS, and am glad could come up with this diagnosis when the examiner asked for single diagnosis I would go with) respiratory- straightforward, bibasal fine inspiratory crackles. discussion mainly was on drugs that can cause this. I just said what you have put on the website as an example of how to present, and also spoke of causes that I ruled out on examination. ( I could not come up with the drug examiner was looking for. I listed 4, but he asked for more. I could hear this patient telling the examiner, as I walked to the abdo station, how the morning session candidates got it right, but not the evening ones!) History taking- 40 year old lady with lethargy and weight loss. Several possible DDs were discussed. History was suggestive of a thyroid problem. malignancy was another possibility. My cases were: Cardiac - Mitral regurgitation. Neurology - Cerebellar dysfunction with evidence of lower motor neuron pattern weakness in the lower limbs. Probably due to alcohol. History taking - 24 year old nurse on the OCP with a three month history of headache not relieved by simple analgesia and with symptoms of raised ICP - the differential they wanted was Benign Intracranial hypertension and the investigations were some form of neuro-imaging and LP. Abdominal - polycystic kidneys and renal transplant. Respiratory - rheumatoid pleural effusion. Communication skills and ethics - middle aged man admitted with a tropnin positive acute coronary syndrome who is also an HGV driver - he wants to self discharge - discuss this with him with the aim of getting him to remain in for investigations - issues touched on were capacity, confidentiality and when it can be broken re: DVLA and HGV licence in context of IHD. Brief clinical consultation (BCC) task 1 - gentleman with chronic back pain with recent history of constipation and then diarrhoea. Clearly an actor. Nil to find on examination. Asked for differential of infective diarrhoea. BCC task 2 - patient with rheumatological disease presents with increasing shortness of breath. Had pulmonary fibrosis and evidence of right sided heart failure. The BCC station can be a bit disconcerting as it isn't entirely clear what the examiners expect and I think using actors in a station that requires examination is very off putting as it is clear from the way they interact with you that they are an actor rather than a real patient. 1. Station 5 -Presentation was SOB. 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. 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- 5. Cases - Discussion regarding warfarin. Neurology-Peripheral Neuropathy(Absent ankle reflex) Discussion regarding causes. 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)
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) Candidate No: 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. 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? 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. 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 Station 2 Station 3 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: Station 5 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. 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 CNS: Station 4:
communication skills. Station 5: Case 1: Case 2: Station 1: Station 2: history 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 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: 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. 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: 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: Station 3: Respiratory: A classic fibrosis with clubbing and cyanosis secondary to scleroderma - obvious skin changes. Questions about complications, investigations, management and prognosis. Station 4: Station 5: B: 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!!!) 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. 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 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. 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! 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 |
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 Station 1- Abdominal Station 2- History Taking Station 3- Cardiology Station 3- Neurology Station 4- Communications Station 5- Brief clinical consultation- diplopia. Station 5- Haematemesis 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 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) 2. CNS This patient complains of difficulty in buttoning his shirt, do a relevant nervous system examination – he was seated on a chair. 3. Respiratory This patient c/o cough, examine his respiratory syatem 4. Abdomen Examine this patients abdomen 5. History Middle aged man with bilaterall leg oedema System review: frothy urine. All other negative Asked about how to explain his symptoms – As above 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 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 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 8. Station 5b Young lady with fatigue few months PMH: Ulcerative colitis, obesity, thyroid surgery, OSA, ………….. Asked the possible causes for fatigue …….. Most likely hypothyroid but anaemia and poorly controlled OSA need to be considered
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!). Neurology - sensory peripheral neuropathy, likely diabetic, asked for differential of peripheral neuropathy then ran out of time. 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 I recently attended the Cardiff Paces course in September 2014. 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 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 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
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 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. 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. 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. 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 Station 1 - Respiratory Station 2 – History Taking Station 3 – Neurology Station 3 – Cardiovascular Station 4 – Communication Skills Station 5 a Station 5 b 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. 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 Station 1 Abdomen Respiratory 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 Cvs 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 Bcc 2 Station 1 Station 2 Station 3 Station4 Station 5 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. I attended Cardiff paces in May 2016 1. Station 5 Young man with BP 180/100; urine dipstick of 3 plus protein and blood My approach Hypertensive urgency Part 2: young female with diarrhoea and high temp My DD Admit I said in both cases Resp: Renal CVS I said only 2 possibilities, Either aortic or mitral Neuro Counselling History D.D lung Tumor I said I will consider systemic sclerosis and malignancy
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.
Here were my stations at my PACES exam (Jan 2019) Respiratory: Pulmonary fibrosis. Middle aged well looking gentleman. Mild symmetrical rheumatoid deformities in hands (very mild) but some rheumatoid nodules also present. Telltale fine end inspiratory crackles on auscultation. Asked what the likely dx was and said pulmonary fibrosis associated with rheumatoid arthritis, either due to disease itself or due to SE of treatment. Examiners seemed satisfied with the dx. Neuro: ?Old polio. Elderly man with obvious isolated hypoplastic single upper limb with (?spastic) weakness + hyper-reflexia affecting both upper limbs. Sensation intact. Lower limbs unaffected. A little puzzled about the obviously increased reflexes but the grossly hypoplastic upper limb (both upper and lower arm) made me lean towards polio. Cardiac: Aortic stenosis. Typical ESM at aortic area radiating to carotids. Short discussion about dx and mx of AS. Abdomen: Functioning renal transplant. Obese gentleman. Multiple non-functional AVF scars over both forearms. PD scars. HD tunneled line scars. Obvious scar over RIF with underlying mass. Difficult to feel any other organomegaly (e.g. PCKD) Gave a typical "Renal" presentation. Short discussion centered around the introductory blurb about the patient: "patient c/o abdo pain and haematuria." - "what could be the cause of this in the gentleman etc etc". Communication skills: wrong drug given to wrong patient. Asthmatic patient admitted last night due to acute exacerbation, now ready to be discharged but given some beta blockers which was supposed to be given to the chap next to him (a cardiac patient). Now feeling a bit faint. Needed to explain to pt what had happened. Followed formula which worked well: honest explanation followed by profuse apologies. Actor tried to become angry but quickly placated him with the formulaic approach: apologise, what can be done now, what can be done to prevent it happening again. He was also concerned about not being able to go to work because of delayed discharge and his pay being docked. So needed to address his concern (will ring up company, explain what happened, his pay should not be docked). Went well, completely placated patient, asked if he had any other concerns. But lots of time left and then (this was weird) examiner asked "do you want to ask if the patient has any other concerns?" (but I just did and he said he had none ??!). Then there was a discussion over "Never" events. I had perhaps told the patient that this should be a Never event (in fact I was not completely sure whether this was on the NPSA list of Never events but nevertheless I thought it was a sensible thing to have on the Never events list and it seemed to placate the patient well). Was asked why I would mislead the patient if I wasn't sure (I said I honestly thought it was a Never event and wouldn't lie on purpose). Also asked when it might be safe to discharge the patient and proceeded to discuss about half lives of various cardiac drugs?!! I was luckily able to talk about it a bit because I still remembered a little from my Primary FRCA!!!! Overall left feeling I was asked harsh questions when actually I did quite well with the patient. History-taking: typical HOCM or malignant ventricular arrhythmia hx. Young lawyer who collapsed while going for a run. No features of epilepsy. No witnesses. Very concerned as she is trying to train for a marathon. Positive family Hx. Addressed concerns, explained what's next in terms of Investigations etc. Discussion with examiners centered around further investigations, driving advice. Actually overall experience was not terrific and thought I might have failed, but what do you know! Thanks again for a great course
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