Sarcoid: frequently tested

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.

Station 4 : Discharge

Communication_1

Yet another scenario from 2/2009 diet:


A lady
Smoker

Infective Endocarditis of prosthetic mitral valve
on 10th day of parentral antibiotics
Consultant plans to keep her in hospital for next 2 weeks

She has 2 kids at home,whom need support and
keeps on smoking in hospital premise.

Adamantly asking you to send her back home

Recently Released Book:OST

If you're confident you are well grounded in Clinical Medicine,
just skim the texts there to update yourself.

Station1:Chest Percussion

Clinical Method_Respiratory

A colleague who sit for the paces diet 1 in 2009 was criticized by an examiner that he made percussion of the chest far below the boundaries of the lungs.

How far should we percuss downward on back of the chest in Respiration Station?

• In quiet respiration, the lungs’ inferior
  margin travels around the thoracic wall
  following a VI, VIII, X contour

  (i.e. rib VI in the midclavicular line, rib VIII in the
  midaxillary line, and vertebra TX posteriorly).

STATION 2:Action Plan for DIARRHOEA

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.

PACES 2010/3

from a candidate

Respiratory: ?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,

Abdomen: PKD

Neurology: 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.

What do you expect to be heard?

St. Jude

Station 1 : Issues in COPD

Station1 FAQ_issues in COPD

The most important factor in reducing long-term progression of COPD is to STOP SMOKING.

Patients must stop smoking and they should have support with this and the offer of buproprion or NRT.

(NICE, evidence level B).

PULMONARY REHAB

if functionally disabled by COPD

(usually MRC grade 3 and above)

A programme includes

• physical training,
• disease education,
• nutritional, psychological and behavioural intervention.

PACES 2011/1

PACES Carousel 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.Next, 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).Later, 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.
Ask me 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
Interview reveals she had it 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


Her 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 Respiration Stations.
Now I m gathering energy to fight back again!


PS: successful in this attempt!


My Sincere Thanks to the Authors,Stephen Hoole et. al.,without their concise guide book, I would not have cleared MRCP.

Hands

List 5 Abnormal Findings in the hands.

What are the systemic correlation?

Examine this patient's Upper Limbs

• Scan the whole patient and look at:

  1_FACE,NECK,ELBOW & HANDS
  2_MUSCLE BULK,TREMOR & FASCICULATION
  3_Ask : Hold your arms out infront of you
  4_Test:TONE,POWER,REFLEXES
  5_Test: Coordination and Sensory Screen

  
  

  FINDINGS:

  • Face and Neck look normal.
    Arms and forearms are wasted,more marked proximally.
    No tremor or fasciculation is noted.
    And the patient can not outstretch both arms.

    Tone is reduced both proximally and distally.
    Proximal power 2/5,3/5 distally.

    All of the upper limb reflexes are sluggish.

    Sensation is normal.

    
    

Arm Drift

• FINDINGS:

  Downward Drift,Spreading of Fingers,Pronation of Wrist and Flexion of Elbow on RIGHT side.

  INTERPRETATION:

  ? Pyramidal Weakness
  ? Cerebellar Disease
  ? Pseudoathetosis