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