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Original Contents in New Apperance
http://cases4paces.blogspot.com/
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MRCP UK
PACES 2011/1
I started in Station 3.It went well.
Cranial Nv Examination: Lt sided LMN VII Palsy was obvious.Then I looked for cause:auricles,mouth,parotid and neck.Then I asked for smell,Vision and EoM.There was Nystagmas on Lt LGaze.He said Double Vision on Lt Lateral Gaze.Outer image disappeared on covering Rt eye(a bit confused to interpret at that time).Then noted hard of hearing on Lt side.I went for Weber( again he said couldn’t feel it ) then for Rinne ( he cannot follow my instruction),After checking V sensation,I asked to Outstretch arms and finger nose tests.
I gave CPA tumor as Dx.they asked me possible causes( including acoustic neuroma).Rx( Surg/Radio)
CVS: Comfortable pt with AF,purpura over forearm,midline sternotomy & lateral thoracotomy scar.Metallic sound.
Gave Dx as Metallic Mitral Valve,Af on Warfarin,CABG ( When I was about to check legs,times up )
Asked: What U look for in JVP in Af (>absent a),HF Mx.
I was contented when I left that station.Examiners were nice.
Station4:Young lady,admitted with Joint pains.immunological test confirm SLE.blood and protein in urine.unwilling for renal biopsy,talk to her for renal biopsy.
I felt like I got scenario a bit late,went into the room without a strategy.
I was trapped myself into kidney biopsy prematurely.
she was unhappy for being kept in hospital for about 2 weeks without being explained about diagnosis.Other issue was concern about her study.
I did badly in that I should have go through 1,her perception,2.Break SLE Dx.3.Explain/Apologize for not being properly informed during her stay in hospital 4.then benefits of biopsy and procedure.5.Conclude.
Examiner :
why she was angry to hospital?
What to to do next if she refused biopsy.
Station 5
Straight forward:
1_RA ,Peripheral Neuropathy
Concern: Whether her condition got worse as Humira was stopped recently for pneumonia.
Complaint of SoB during interview.
Asked me what might be causes of SoB.
>> my answer was to look for problems related to Lung, Heart or Anaemia
2_Gradual Visual Loss both eyes,T1DM
Soft exudates ( preproliferatve ) without history of laser Rx.
I suspect some len opacities with intact red reflexes.
I explained to the patient referral to Eye doctor,photo of back of the eye and proper glucose control.
examiners asked DDx.(dysglycaemia/cataract/maculopathy etc.)
Station1.
Resp: Mildly Clubbed ,Rt thoracotomy,trachea >lt ( in fact I’m not that confident ),
Dull left side.
L Pneumonectomy
I missed added sound on Rt base when they asked me to listen there again (coarse crackles was my answer ).
asked reason for operation.
asked how to differentiate pleural rub and pericardial rub: I was nervous to hear that Q since it sounded unrelated to my answer!
I simply said ‘stop breathing’.
Abdomen: craniotomy scar,fistula scar over forearm( without thrill or bruit?? )transplant Kid, lobulated mass on other flank.
Standard Qs: PKD mode of transmission,screening,presentation,associations,how to retard progress of kid failure.SEs and caution about ACEI.
Station2
tremor
slow movement
during interview,she
had when she put her hands on lap,
presented on movement,
disturb her ADL,
but not miss the point eg. on eating,drinking
little facial expression noted by her husband,
slowly progressed over a few months.
no memory loss, no depression but dysphagia +, not on anti psychotic
no postural drop on last visit to GP
concern : stroke
family ho tremor + ( i felt it as red herring )
After all,I felt that I might have cleared if I did smoothly in communication and Resp.
Now I m gathering energy to fight back again!
PS: The Candidate was successful in this attempt!
2010 in review
The stats helper monkeys at WordPress.com mulled over how this blog did in 2010, and here’s a high level summary of its overall blog health:
The Blog-Health-o-Meter™ reads This blog is on fire!.
Crunchy numbers
A Boeing 747-400 passenger jet can hold 416 passengers. This blog was viewed about 4,100 times in 2010. That’s about 10 full 747s.
In 2010, there were 24 new posts, growing the total archive of this blog to 45 posts. There were 38 pictures uploaded, taking up a total of 3mb. That’s about 3 pictures per month.
The busiest day of the year was October 11th with 194 views. The most popular post that day was Hands_2.
Where did they come from?
The top referring sites in 2010 were aippg.net, en.wordpress.com, twitter.com, search.aol.com, and refinancing-home.student-loan-consilidation.com.
Some visitors came searching, mostly for dermatitis herpetiformis, dermatitis, dermatitis herpetiformis pictures, ascites, and mrcp paces 2009.
Attractions in 2010
These are the posts and pages that got the most views in 2010.
1
Hands_2 October 2009
2 comments
2
Station1_issues in COPD August 2010
3
Station 5_how could I differentiate! August 2010
4
Sarcoid : RCP’s favorite in Station 1-2-4-5 August 2010
1 comment
5
Examine this patient’s Arms_2 October 2009
4 comments
PACES 2010/3_survey1
from a candidate
Resp: ?bronchiectasis with R mastectomy and bilateral thoracotomy scars,
CVS: young lady with small L thoracotomy scar in the back, and asked “why SOB in pregnancy?”
Hx: longstanding SOB+ suddenly worse, FH of CVA, MI and PE,
Abdo: PKD
NEURO: peripheral sensory neuropathy in diabetic
Ethics: explain to a patient recently diagnosed coeliac disease!
Station 5:
1. diabetic w necrobiosis lipoidica,reached to the diagnosis but examiner not happy because I didn’t address her concerns.
2. 60 year old lady w painless LN in cervical area, said all possible malignancies, then pushed and said sarcoidosis and amyloid, think she had sarcoidosis.
Station 2-Diarrhoea
Action Plan:
Follow standard history taking format sensibly.
- You are ……
- tell me more about the symptoms
- how frequent?any blood?
- still much the same or getting worse?
- any medication?help
- Cigarette
- Caffeine Alcohol
- Any change in period
- Any SoB etc.
- Diet
SOCRATES is useful mnemonics for associated PAIN.
- Site
- Onset: ? following infective episodes or travel
- Character? how would you describe
- Radiation
- Timing: ?wake up at night to go to loo, pain goes away after bowel
- Exacerbation:? diet? tried exclusion
- Severity
Preformed broad DDx should aid symptom analysis.
COLON vs MALABSORPTION vs SI
- infective
- inflammatory
- neoplastic
- ischaemic
- Irritable bowel
Alarm Symptoms will guide the speed and types of INVESTIGATIONS.
- > 40
- Weight loss
- Bleed
- Family history
Think about BLOOD,STOOL,ENDOSCOPY,IMAGING
Address patient concern and welfare.
Sarcoid : RCP’s favorite in Station 1-2-4-5
Try practice Sarcoidosis in term of Seven core clinical skills assessed in the PACES examination.
Here is a sample from 2010/2 diet:
station 2- jt pain , dry cough and bilateral gld + in CXR,
two candidates sat apart 2 weeks in a UK centre got the same scenario.
(PS. in station 4,don’t bother skill D, ie.Differential Dx;but it is assessed in all other stations!)
Clinical Skill/Skill Descriptor
A
Physical Examination
Demonstrate correct, thorough, systematic (or focused in Station 5 encounters), appropriate, fluent and professional technique of physical examination.
B
Identifying Physical Signs
Identify physical signs correctly, and not find physical signs that are not present.
C
Clinical Communication
Elicit a clinical history relevant to the patient’s complaints, in a systematic, thorough (or focused in Station 5 encounters), fluent and professional manner.
Explain relevant clinical information in an accurate, clear, structured, comprehensive, fluent and professional manner.
D
Differential Diagnosis
Create a sensible differential diagnosis for a patient that the candidate has personally clinically assessed.
E
Clinical Judgement
Select or negotiate a sensible and appropriate management plan for a patient, relative or clinical situation.
Select appropriate investigations or treatments for a patient that the candidate has personally clinically assessed.
Apply clinical knowledge, including knowledge of law and ethics, to the case.
F
Managing Patients’ Concerns
Seek, detect, acknowledge and address patients’ or relatives’ concerns.
Listen to a patient or relative, confirm their understanding of the matter under discussion and demonstrate empathy.
G
Maintaining Patient Welfare
Treat a patient or relative respectfully and sensitively and in a manner that ensures their comfort, safety and dignity.
Kyphosis in Station 5
Scan as a whole:
enlarged head with hearing aid,bow legs.
tall,thin man with pectus excavatum,arachnodactily and flat feet.
extended neck,kyphoscoliosis with loss of lumbar lordosis.
feel the pulse:
high volume
look at the eyes:
reduced acuity,afferent pupillary defect,optic atrophy and angioid streak.
thick spectacle,tremor of iris and dislocated len,
small pupil,sluggish pupillary response,circumcorneal injection
Listen to the heart.
Proceed for gait and appropriate bed side tests.
COMMUNICATION SKILLS SPECIMEN EXAM QUESTIONS
be interactive!
