Cases for PACES E-Book

Stephen Hoole

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 305

Veröffentlichungsjahr: 2024

Beschreibung

Comprehensive Study Resource That Helps Readers Pass the PACES Exam

Concise and ideal for quick reference, Cases for PACES is the perfect resource for MRCP PACES preparation in the run-up to the examination. Its full-colour one-page case study format matches the style of the exam and lets you quickly read up on all the most common cases to ensure you will be prepared.

The authors’ experience in learning and teaching PACES is condensed to provide exactly what is needed to pass. The informal writing style means Cases for PACES is also ideal for self-directed learning in groups. The book will help readers hone their clinical skills and boost their confidence levels throughout their revision time. Study resources covered in the book include:

• Information pertaining to all five stations: respiratory, abdominal system examination with communication, cardiovascular and neurology system examination, and two consultations
• Revised, updated and new cases on all the most common topics in the exam
• Aligned to the new exam format which was introduced in 2023

For MRCP candidates and final-year medical students, Cases for PACES is an accessible learning resource to gain a foundational mastery over all topics included in the PACES exam.

Leseprobe

Table of Contents

Cover

Table of Contents

Title Page

Copyright Page

Foreword

Preface

Acknowledgements

Abbreviations

Advice

Respiratory

Cardiology

COMMON CONGENITAL DEFECTS

ASSOCIATIONS WITH CONGENITAL VSD

Neurology

RETINAL PATHOLOGY

Abdominal

Communication

ETHICS AND LAW IN MEDICINE

TYPES OF COMMUNICATION

WORKED EXAMPLES

Consultations

Index

End User License Agreement

Guide

Cover Page

Table of Contents

Title Page

Copyright Page

Foreword

Preface

Acknowledgements

Abbreviations

Advice

Begin Reading

Index

WILEY END USER LICENSE AGREEMENT

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Cases for PACES

Stephen Hoole

Consultant Cardiologist

Royal Papworth Hospital

Cambridge, UK

Andrew Fry

Consultant in Acute Medicine and Nephrology

Addenbrooke’s Hospital

Cambridge, UK

Rachel Davies

Consultant Respiratory Physician

Hammersmith Hospital

London, UK

Fourth Edition

This fourth edition first published 2025© 2025 by John Wiley & Sons Ltd

Edition HistoryStephen Hoole, Andrew Fry, Daniel Hodson & Rachel Davies (1e, 2003 and 2e, 2010); John Wiley & Sons Ltd (3e, 2015)

All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Stephen Hoole, Andrew Fry and Rachel Davies to be identified as the authors of this work has been asserted in accordance with law.

Registered OfficesJohn Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging‐in‐Publication Data applied forPaperback ISBN: 9781119576501

Cover Design: WileyCover Image: © Kreativorks/iStock/Getty Images

Foreword

Taking the MRCP PACES exam is a defining moment in most physicians’ training life. PACES is undoubtedly a high‐stakes exam both from the perspective of the implications for progression of training but also for the way an individual’s knowledge and skills are placed under the spotlight. All physicians will have strong memories of their PACES experience; both good and bad. It is a stern test, but once completed it acts as a stamp of quality that is indelible and widely recognized. Getting through the exam successfully requires hard work, dedication and a pragmatic approach given the competing pressures of both clinical and home life.

This book can‘t replace hard work and dedication, but it does provide a well‐proven and effective methodology for success. Thousands of physicians have benefited from the use of its wisdom and the fact it is now in its fourth generation is testament to how useful it has been for many. This latest edition takes into account the evolving design of the exam and should lessen the fear of the unknown that some have when approaching the exam. PACES will continue to evolve as medicine itself evolves, but it is striking how much the principles of clinical diagnosis remain constant. The advice to take time to think, look and gather oneself while the hand rub dries is one such principle. These principles are not just for the exam but when used in daily clinical practice will make life simpler and less stressful for the physician and result in better outcomes for the patient.

The breadth of internal medicine is wide and this book reminds us how much we have learned (or indeed still have to learn or relearn). It reminds us how fascinating medicine is and why many of us have chosen life as a physician – and given current clinical pressures such a reminder is always helpful. For those taking the exam, you will never again have such a wide breadth of knowledge and hopefully this book will help you keep much of that accumulated wisdom for all your professional life.

I wish you all the best for the exam and hope this book eases the journey through it. I suspect it will and if you have a hard copy you will keep it to refer to for many years to come. You may even read these words again in 20 years’ time (he says as he looks at the dog‐eared spine of the copy of its predecessor on the office shelf!).

Prof. Andrew Goddard

Consultant Gastroenterologist, Royal Derby HospitalPast President of the Royal College of Physicians, London

Preface

PACES (Practical Assessment of Clinical Examination Skills) was initiated in June 2001 by the Royal College of Physicians as the final stage of the MRCP examination. The initial examination consisted of five stations in a carousel: Station 1: Respiratory/Abdominal (10 minutes each), Station 2: History Taking (20 minutes), Station 3: Cardiology/Neurology (10 minutes each), Station 4: Communication Skills and Ethics (20 minutes) and Station 5: Short Cases (Skin, Locomotor, Eyes and Endocrine: 5 minutes each). The format was refined in October 2009 by restructuring Station 5 into two 10‐minute ‘Brief Clinical Consultations’.

The PACES exam had a further major update introduced from Autumn 2023 that was badged PACES23. Many aspects of the exam remain the same as the old format and the standard required to pass PACES23 is also unchanged. There will still be a five‐station carousel, with each station lasting 20 minutes and 5‐minute intervals in between. Candidates will continue to be examined by two examiners, who will have calibrated the case and agreed the pass threshold before assessing and marking each candidate independently.

The assessment of seven key skills is also retained in PACES23:

Physical Examination

Identifying Clinical Signs

Communication

Differential Diagnosis

Clinical Judgement

Managing Patient Concerns

Maintaining Patient Welfare

Candidates must achieve a pass in all seven key skills and reach a total mark above a set threshold to pass.

The four clinical encounters assessing Respiratory, Abdominal, Cardiovascular and Neurological systems, each in 10 minutes, with 6 minutes to examine and 4 minutes to interact with examiners, also remain the same. However, Station 2 – History Taking without physical examination was thought to be unrepresentative of current clinical practice and has been removed; Station 4 – Communication was believed to be too long, with examiner interaction of little value in assessing the candidate; and Station 5 – Brief Clinical Consultations was too short, although this station provided the best integrated assessment of all seven key skills that emulated real‐life clinical practice. Stations 4 and 5 have now been redesigned, with more emphasis on the clinical consultation:

Old MRCP PACES

New PACES23

Station 2 – 20‐min History Taking

Removed

Station 4 – 20‐min Communication

2 × 10‐min Communication encounter without examiner interaction

Station 5 – 2 × 10‐min Brief Clinical Consultation

2 × 20‐min Consultations: 15 minutes history and examination and 5 minutes examiner interaction

The five‐station carousel has also been redesigned to accommodate these changes, with the two Communication encounters preceding the Respiratory encounter in Station 1 and Abdominal encounter in Station 4, two Consultation encounters (Station 2 and 5) and the Cardiovascular and Neurology encounters in Station 3 remaining unchanged:

Cases for PACES Fourth Edition prepares candidates for the current PACES23 examination. It mimics the new examination format and is designed for use in an interactive way. This fourth edition has a completely revised text that has been informed by recent successful candidate feedback. It has useful advice for the day of the exam and provides updated information on clinical, ethical and medicolegal issues. There are plenty of new scenarios and mock questions for candidates to practise themselves. The two Consultation stations, which assess all seven key skills in an integrated way that most closely reflects day‐to‐day practice, account for two‐fifths of the exam marks and receive particular attention in this new edition.

Avoid further factual cramming at this stage – you know enough! Go and see medical patients on a busy acute medicine unit or outpatient department. This has always been the best way to prepare for PACES and will be particularly beneficial for the new Consultation stations. This book will assist you in self‐directed ward revision in preparation for PACES23. Each section has clinical mark sheets guiding which of the seven skills are being assessed and what you need to demonstrate to pass; this should enable groups of candidates to practise ‘under examination conditions’ at the bedside.

Common cases that regularly appear in the exam, rather than rarities, have been deliberately chosen. We assume candidates who are well practised will be fluent in the examination techniques needed to elicit the various clinical signs. However, in this new edition we provide extra guidance on how to efficiently examine each system to identify and interpret those all‐important clinical signs within the allotted time.

We provide discussion topics that a candidate could be expected to comment on at the end of the case during the 4 or 5 minutes of examiner interaction. Remember that the examiners are specifically assessing your knowledge of the differential diagnosis and organized clinical judgement and management, while addressing the patient’s concerns and maintaining patient welfare throughout this interaction.

The detail in this book is not exhaustive but rather what is reasonably needed to pass and be a competent and safe Specialty Registrar practising medicine with minimal supervision. There is space to make further notes if you wish. The aim of this book is to put the information that is frequently tested in the clinical PACES23 examination in a succinct, exam‐style format that will enable capable candidates to practise and pass with ease on the day.

We wish you the best of luck.

Stephen HooleAndrew FryRachel Davies

Acknowledgements

We acknowledge the help of Dr Daniel Hodson in the first and second editions, Dr William Brown for his assistance in updating the neurology station and Dr Peter Scanlon for his advice on the retinopathy cases. We thank the doctors who taught us for our own PACES examination, and above all the patients who allow us to refine our examination techniques and teach the next generation of MRCP PACES candidates.

Abbreviations

AAA

Abdominal aortic aneurysm

ABC

Airway, breathing, circulation

ABG

Arterial blood gas

ABPA

Allergic bronchopulmonary aspergillosis

ABPM

Ambulatory blood pressure monitoring

ACE

Angiotensin‐converting enzyme

ACh

Acetylcholine

AChR

Acetylcholine receptor

ACR

Albumin: creatinine ratio

ACS

Acute coronary syndrome

ACTH

Adrenocorticotrophic hormone

ADLs

Activities of daily living

ADPKD

Autosomal dominant polycystic kidney disease

ADRT

Advanced decisions to refuse treatment

AF

Atrial fibrillation

AFB

Acid‐fast bacillus

AFP

Alpha‐fetoprotein

AICD

Automated implantable cardiac defibrillator

AIDP

Acute inflammatory demyelinating polyradiculoneuropathy

AIH

Autoimmune hepatitis

A(I)NOCA

Angina (ischaemia) non‐obstructive coronary artery

AKI

Acute kidney injury

ALP

Alkaline phosphatase

AMD

Age‐related macular degeneration

ANA

Anti‐nuclear antibody

APS

Anti‐phospholipid syndrome

AR

Aortic regurgitation

ARB

Angiotensin II receptor blocker

ARNI

Angiotensin receptor/neprilysin inhibitor

ARVD

Arrhythmogenic right ventricular dysplasia

AS

Aortic stenosis

5‐ASA

5‐Aminosalicylic acid

ASD

Atrial septal defect

ASOT

Anti‐streptolysin O titre

ATP

Anti‐tachycardia pacing

AV

Arteriovenous

AVN

Atrioventricular node

AVR

Aortic valve replacement

AVSD

Atrioventricular septal defect

AXR

Abdominal X‐ray

BAV

Balloon aortic valvuloplasty

BFT

Bone function test

BIPAP

Bi‐level positive airway pressure

BiV

Biventricular

BM

Boehringer Mannheim (glucose)

BMI

Body mass index

BNF

British National Formulary

BNP

Brain natriuretic peptide

BP

Blood pressure

BPA

Balloon pulmonary angioplasty

BPPV

Benign paroxysmal positional vertigo

BSO

Bilateral salpingo‐oophorectomy

BT shunt

Blalock–Taussig shunt

CA

Carcinoma

CABG

Coronary artery bypass graft

CAD

Coronary artery disease

CAP

Community‐acquired pneumonia

CAPD

Continuous ambulatory peritoneal dialysis

CCB

Calcium channel blocker

CCF

Congestive cardiac failure

CCP

Cyclic citrullinated peptide

CF

Cystic fibrosis

CFA

Cryptogenic fibrosing alveolitis

CFTR

Cystic fibrosis transmembrane conductance regulator

CGM

Continuous glucose monitor

CGRP

Calcitonin gene‐related peptide

CIDP

Chronic inflammatory demyelinating polyneuropathy

CK

Creatine kinase

CKD

Chronic kidney disease

CLD

Chronic liver disease

CMD

Coronary microcirculatory dysfunction

CML

Chronic myeloid leukaemia

CMR

Cardiovascular magnetic resonance

CMV

Cytomegalovirus

CNS

Central nervous system

CoA

Coarctation of aorta

COPD

Chronic obstructive pulmonary disease

COMT

Catechol‐o‐methyl transferase

CPET

Cardiopulmonary exercise test

CRP

C‐reactive protein

CRT

Cardiac resynchronization therapy

CRT‐D

Cardiac resynchronization therapy defibrillator

CSF

Cerebrospinal fluid

CT

Computed tomography

CTCA

CT coronary angiography

CTEPH

Chronic thromboembolic pulmonary hypertension

CTPA

CT pulmonary angiography

CV

Cardiovascular

CVA

Cerebrovascular accident

CVID

Common variable immunodeficiency

CVS

Cardiovascular system

CXR

Chest X‐ray (radiograph)

DBD

Donation after brain death

DBP

Diastolic blood pressure

DCD

Donation after cardiac death

DIOS

Distal intestinal obstruction syndrome

DIPJ

Distal interphalangeal joint

DKA

Diabetic ketoacidosis

DM

Diabetes mellitus

DM1

Dystrophia myotonica type 1

DM2

Dystrophia myotonica type 2

DMARD

Disease‐modifying anti‐rheumatic drug

DNA‐CPR

Do not attempt cardiopulmonary resuscitation

DNAR

Do not attempt resuscitation

DNase

Deoxyribonucleic acid hydrolytic enzyme

DOAC

Direct oral anticoagulant

D&V

Diarrhoea and vomiting

DVLA

Driver and Vehicle Licensing Agency

DVT

Deep vein thrombosis

eGFR

Estimated glomerular filtration rate

EBUS

Endobronchial ultrasound

EBV

Epstein–Barr virus

EC

Ejection click

ECG

Electrocardiogram

ECHO

Echocardiogram

EEG

Electroencephalogram

EF

Ejection fraction

EMG

Electromyogram

EP

Electrophysiology

ERA

Endothelin receptor antagonist

ERCP

Endoscopic retrograde cholangiopancreatography

ESM

Ejection systolic murmur

ESR

Erythrocyte sedimentation rate

EtOH

Ethanol

ETT

Exercise treadmill test

EVAR

Endovascular aortic repair

FBC

Full blood count

FEV

1

Forced expiratory volume in 1 second

FFP

Fresh frozen plasma

FH

Family history

FSGS

Focal segmental glomerulosclerosis

FSH

Follicle‐stimulating hormone

FSHD

Facioscapulohumeral muscular dystrophy

FTA

Fluorescent treponema antibodies

FVC

Forced vital capacity

GA

General anaesthetic

GBS

Guillain–Barré syndrome

GCS

Glasgow Coma Scale

GEP

Gastro‐entero‐pancreatic

GGT

Gamma‐glutamyl transferase

GH

Growth hormone

GI

Gastrointestinal

GLP‐1

Glucagon‐like peptide‐1

GMP

Good medical practice

GnRH

Gonadotropin‐releasing hormone

GORD

Gastro‐oesophageal reflux disease

Gp

Glycoprotein

GRACE

Global Registry of Acute Coronary Events

GTN

Glyceryl trinitrate

Hb

Haemoglobin

HBPM

Home blood pressure monitoring

HBV

Hepatitis B virus

HCC

Hepatocellular carcinoma

HCG

Human chorionic gonadotrophin

HCM

Hypertrophic cardiomyopathy

HCV

Hepatitis C virus

HDU

High‐dependency unit

HF

Heart failure

HGV

Heavy goods vehicle

HIV

Human immunodeficiency virus

HLA

Human lymphocyte antigen

HOCM

Hypertrophic obstructive cardiomyopathy

HR

Heart rate

HRT

Hormone replacement therapy

HSMN

Hereditary sensory motor neuropathy

HSV

Herpes simplex virus

5‐HT

5‐hydroxytryptamine

IABP

Intra‐aortic balloon pump

IBD

Inflammatory bowel disease

ICD

Implantable cardioverter defibrillator

IDDM

Insulin‐dependent diabetes mellitus

IGF

Insulin‐like growth factor

IHD

Ischaemic heart disease

ILD

Interstitial lung disease

INR

International normalized ratio

IPF

Idiopathic pulmonary fibrosis

IRMA

Intraretinal microvascular abnormalities

ITP

Immune thrombocytopenic purpura

ITU

Intensive therapy unit

IV

Intravenous

IVC

Inferior vena cava

IVDA

Intravenous drug abuse

JVP

Jugular venous pressure

K

CO

Transfer coefficient

LA

Left atrial

LAA

Left atrial appendage

LAAO

Left atrial appendage occlusion

LACS

Lacunar anterior circulation stroke

LAD

Left axis deviation

LDH

Lactate dehydrogenase

LEMS

Lambert–Eaton myasthenic syndrome

LFT

Liver function test

LGE

Late gadolinium enhancement

LH

Luteinizing hormone

LMN

Lower motor neurone

LMWH

Low molecular weight heparin

LP

Lumbar puncture

LQTS

Long QT syndrome

LRTI

Lower respiratory tract infection

LTOT

Long‐term oxygen therapy

LTR

Left to right

LV

Left ventricle

LVAD

Left ventricular assist device

LVEDP

Left ventricular end‐diastolic pressure

LVEF

Left ventricular ejection fraction

LVH

Left ventricular hypertrophy

LVOT

Left ventricular outflow tract

mAb

Monoclonal antibody

MAO

Monoamine oxidase

MCPJ

Metacarpophalangeal joint

MC + S

Microscopy, culture and sensitivity

MDM

Mid‐diastolic murmur

MDT

Multi‐disciplinary team

MEN

Multiple endocrine neoplasia

MG

Myasthenia gravis

MI

Myocardial infarction

MIBI

Myocardial perfusion (sestamibi) imaging

MLF

Medial longitudinal fasciculus

MMF

Mycophenolate mofetil

MND

Motor neurone disease

mPAP

Mean pulmonary artery pressure

MPTP

Methyl‐phenyl‐tetrahydropyridine

MR

Mitral regurgitation

MRA

Magnetic resonance angiography

MRCP

Magnetic resonance cholangiopancreatography

MRI

Magnetic resonance imaging

MS

Mitral stenosis

MSA

Multisystem atrophy

MTPJ

Metatarsophalangeal joint

MuSK

Muscle‐specific kinase

MV

Mitral valve

MVP

Mitral valve prolapse

MVR

Mitral valve replacement

6MWD

Six‐minute walk distance

NG

Nasogastric

NHSE

NHS England

NIPPV

Non‐invasive positive pressure ventilation

NOAC

Non‐vitamin K antagonist oral anticoagulant

NSAID

Non‐steroidal anti‐inflammatory drug

NSCLC

Non‐small cell lung cancer

NT‐proBNP

N‐terminal prohormone of brain natriuretic peptide

NVD

Neovascularization of the disc

NVE

New vessels elsewhere

NYHA

New York Heart Association

OA

Osteoarthritis

OAC

Oral anticoagulant

OCP

Oral contraceptive pill

OGD

Oesophago‐gastro‐duodenoscopy

OS

Opening snap

Pa

Partial pressure (arterial)

PACS

Partial anterior circulation stroke

PAH

Pulmonary arterial hypertension

PBC

Primary biliary cirrhosis

PCOS

Polycystic ovary syndrome

PCR

Polymerase chain reaction

PCT

Primary Care Trust

PCWP

Pulmonary capillary wedge pressure

PD

Parkinson’s disease

PDA

Patent ductus arteriosus

PDE5

Phosphodiesterase‐5

PE

Pulmonary embolism

PEA

Pulmonary endarterectomy

PEFR

Peak expiratory flow rate

PEG

Percutaneous endoscopic gastrostomy

PEP

Post‐exposure prophylaxis

PET

Positron emission tomography

PH

Pulmonary hypertension

PICA

Posterior inferior cerebellar artery

PIPJ

Proximal interphalangeal joint

PLA2R

Anti‐phospholipase A2 receptor

PMH

Past medical history

PMR

Polymyalgia rheumatica

PPCI

Primary percutaneous coronary intervention

PPI

Proton pump inhibitor

PPMS

Primary progressive multiple sclerosis

PPRF

Paramedian pontine reticular formation

PPVI

Percutaneous pulmonary valve implantation

PR

Per rectum (rectal)

PRL

Prolactin

PRN

Pro re nata

, when required

PS

Pulmonic stenosis

PSA

Prostate specific antigen

PSC

Primary sclerosing cholangitis

PSM

Pan‐systolic murmur

PSV

Public service vehicle

PTH

Parathyroid hormone

PTHrP

Parathyroid hormone‐related peptide

PUVA

Psoralen ultraviolet A

PV

Per vaginum

(vaginal)

PVD

Peripheral vascular disease

PVR

Pulmonary vascular resistance

QoL

Quality of life

RA

Rheumatoid arthritis

RAD

Right axis deviation

RADT

Rapid antigen detection test

RAPD

Relative afferent pupillary defect

RAS

Renal artery stenosis

RAST

Radio‐allergo‐sorbent test

RBBB

Right bundle branch block

RCC

Right coronary cusp

RF

Risk factor

RR

Respiratory rate

RRMS

Relapsing‐remitting multiple sclerosis

RTL

Right to left

RUQ

Right upper quadrant

RV

Right ventricle

RVF

Right ventricular failure

RVH

Right ventricular hypertrophy

Rx

Treatment

SAH

Subarachnoid haemorrhage

sAVR

Surgical aortic valve replacement

SBP

Systolic blood pressure

SCD

Sudden cardiac death

SCLC

Small cell lung cancer

SGLT2

Sodium‐glucose co‐transporter 2

SH

Social history

SIADH

Syndrome of inappropriate anti‐diuretic hormone

S‐ICD

Subcutaneous implantable cardiac defibrillator

SLE

Systemic lupus erythematosus

SOA

Swelling of ankles

SOB

Shortness of breath

SOL

Space‐occupying lesion

SPMS

Secondary progressive multiple sclerosis

SSRI

Selective serotonin reuptake inhibitor

SVCO

Superior vena cava obstruction

SVT

Supraventricular tachycardia

T

4

Thyroxine

T°C

Temperature

TACS

Total anterior circulation stroke

TAVI

Transcutaneous aortic valve implantation

TB

Tuberculosis

TEER

Transcatheter edge‐to‐edge repair

TENS

Transcutaneous electrical nerve stimulation

TFT

Thyroid function test

THR

Total hip replacement

TIA

Transient ischaemic attack

TIMI

Thrombolysis in myocardial infarction

TKI

Tyrosine kinase inhibitor

TLC

Total lung capacity

TL

CO

Carbon monoxide transfer factor

TNM

Tumour nodes metastasis (staging)

TOE

Transoesophageal echo

ToF

Tetralogy of Fallot

tPA

Tissue plasminogen activator (alteplase)

TPHA

Treponema pallidum haemagglutination assay

TPMT

Thiopurine methyltransferase

TPW

Temporary pacing wire

TR

Tricuspid regurgitation

TSAT

Transferrin saturation

TSH

Thyroid stimulating hormone

TTE

Transthoracic echo

tTG

Tissue transglutaminase

TTR

Time in therapeutic range

TV‐ICD

Transvenous implantable cardiac defibrillator

TWI

T‐wave inversion

U&E

Urea and electrolytes

uACR

Urine albumin: creatinine ratio

UC

Ulcerative colitis

UFH

Unfractionated heparin

UIP

Usual interstitial pneumonia

UKHSA

UK Health Security Agency

UMN

Upper motor neurone

uPCR

Urine protein: creatinine ratio

US

Ultrasound

UTI

Urinary tract infection

VATS

Video‐assisted thoracoscopic surgery

VEGF

Vascular endothelial growth factor

VEP

Visual evoked potential

VIP

Vasoactive intestinal peptide

VQ

Ventilation–perfusion

VSD

Ventricular septal defect

VT

Ventricular tachycardia

VTE

Venous thromboembolism

WCC

White cell count

Advice

Preparation

Practice makes perfect: it makes the art of eliciting clinical signs second nature and allows you to concentrate on what the physical signs actually mean. Practice makes you fluent and professional and this will give you confidence under pressure. We strongly encourage you to see as many patients as possible in the weeks leading up to the exam. Practise under exam conditions with your peers, taking it in turns to be the examiner, and use the mark sheets provided. This is often very instructive and an occasionally amusing way to revise! It also maintains your motivation as you see your performance improve. We encourage you to seek as much help as possible from senior colleagues too; many remember their MRCP exam vividly and are keen to assist you in gaining those four precious letters after your name.

The day before

Check that you have your examination paperwork in order with your examination number as well as where and what time you are needed – you don’t want to get lost or be late. Also ensure that you have packed some identification (e.g. a passport) as you will need this to register on the day. Remember to take with you vital equipment you are familiar with using, particularly your stethoscope, although avoid weighing yourself down with cotton wool, pins, otoscope and so on. The necessary equipment will be provided for you. Punctuality is important and reduces stress, so we advise that you travel to your exam the day before, unless your exam centre is on your doorstep. Avoid last‐minute revision and try to relax – you will certainly know enough by now. Spend the evening doing something other than medicine and get an early night!

On the day

Think carefully about your attire – first impressions count both with the examiners and more importantly with the patients. Broadly speaking, exam dress policy is similar to that required of NHS employees. You should look smart and professional, but above all wear something that is comfortable. Shirts should be open collar (not low cut) and short sleeved to enable bare‐below‐the‐elbow and effective hand sanitation. Remove watches/jewellery (wedding bands are permitted) and dangling necklaces/chains that could be distracting or hit the patient. Facial piercings other than ear studs are not recommended.

Examination

You will have 16 mark sheets – two for each encounter. There will be a short problem‐orientated clinical question with an instruction prior to starting the station encounter, for example ‘This man has been inadvertently dropping things – please assess his upper limbs neurologically’ or ‘This woman has been complaining of breathlessness – please assess her cardiovascular system’. Use the preparatory time before each case wisely and remember to answer the question when presenting your findings.

When you enter the station encounter, hand the mark sheets to the examiners and remember to HIT it off with the examiners and the patient:

H

and sanitization (if available).

I

ntroduce yourself to the patient and ask permission to examine them.

T

ake a step back once the patient is appropriately uncovered/positioned and spend 20 seconds observing them closely. This is roughly the time it takes for hand sanitizer to dry. It can feel an extraordinarily long period of time when under exam conditions but it is time well spent. As soon as you start touching the patient, your focus becomes blinkered and you will miss vital peripheral clues to the case.

Remembering to HIT it off will help settle your nerves and then you’ll be underway. The rest will follow fluently if you are well practised.

Rather like when looking in the rear‐view mirror in a driving test, be sure to convey to your examiner what you are doing. Try not to move the patient excessively and repeatedly; your examiner will be expecting to see you do things in an efficient and familiar order and doing so looks systematic, practised and fluent. However, if you do forget to do something halfway through the examination, or you have to go back to check a physical finding, that’s fine. It’s more important to be comprehensive and sure of the clinical findings than just to try to be ‘slick’.

Spend the last few moments of your examination time working out what is going on, what the diagnosis is and what you are going to say to the examiner. There’s still time to check again. Most examinations can be completed by standing up and saying to the examiners a phrase like ‘To complete my examination I would like to check. . .’ and then listing a few things you may have omitted and/or are important to the case, such as blood pressure, urine dipstick and so on.

Presentation

Eye contact and a direct, unambiguous presentation of the case convey confidence and reassure examiners that you are on top of things. Avoid the phrases ‘I’m not sure if it is. . .’ and ‘I think it is. . .’ Be definitive and avoid sitting on the fence, but above all be honest. Don’t make up clinical signs to fit a specific diagnosis (some cases may be normal to assess your ability to detect the absence of signs). Try not to present clinical signs that are inconsistent with the diagnosis or differential diagnosis.

There are two ways to present the case:

State the diagnosis and support this with key positive and negative clinical findings – if (and only if) you are confident you have secured the correct diagnosis.

State the relevant positive and negative clinical signs (it’s often easier to do this in the order you elicited them) and then give the differential diagnosis that is consistent with these – particularly if you are unsure of the diagnosis.

Where possible, you should comment on the disease severity or disease activity. Consider complications of the diagnosis and mention if these are present or not. Know when to stop talking. Brevity can be an asset: it avoids you making mistakes and digging a hole for yourself! Wait for the examiners to ask a question and do not be pre‐emptive – the examiners may follow you down the rabbit hole and possibly expose a gap in your knowledge.

Examiners

Prior to you examining the patient the examiners will have individually ‘calibrated the case’ to assess its difficulty and ensure that the clinical signs are present. This maintains the fairness and robustness of the exam and makes sure consistency exists in exam centre marking. There will be two examiners for every carousel station and usually one will lead the discussion with you. Both will have the mark sheets that you gave them at the start of the encounter and will mark you independently without collaboration. Contrary to popular belief, they both want you to pass. They are there because they are Fellows of the College in good standing and support the training and progression of the talented physicians of the future.

Mistakes happen

If you do make a mistake and realize it, don’t be afraid to correct yourself. To err is human and the examiners may overlook a minor faux pas or mis‐speak if the rest of the case has gone well. It’s not uncommon to think that you have failed a case halfway round the carousel and that your chances of passing PACES have been dealt a fatal blow. We are often our own harshest critics, so don’t write yourself off. Frequently, all is not lost. Don’t let your performance dip on the next cases because you are still reeling from the last. Put any mistakes behind you and keep calm and carry on!

Respiratory

Clinical mark sheet

Clinical skill

Satisfactory

Unsatisfactory

Physical examination

Correct, thorough, fluent, systematic, professional

Incorrect technique, omits, unsystematic, hesitant

Identifying physical signs

Identifies correct signs Does not find signs that are not present

Misses important signs Finds signs that are not present

Differential diagnosis

Constructs sensible differential diagnosis

Poor differential, fails to consider the correct diagnosis

Clinical judgement

Sensible and appropriate management plan

Inappropriate management Unfamiliar with management

Maintaining patient welfare

Respectful, sensitive Ensures comfort, safety and dignity

Causes physical or emotional discomfort Jeopardizes patient safety

Respiratory exam – general advice

You should be trying to get as many clues to the diagnosis as possible before you lay a hand on the patient

The patient will already have their chest exposed and will usually be sitting comfortably at 45 degrees

Introduce yourself and ensure that the patient appears comfortable

Take a step back to the end of the bed and spend 20 seconds looking at the patient and the area surrounding their bed. Use the following prompts to run through a list in your head to ensure that you are actively looking for information rather than just aimlessly staring

What clues are you expecting to see from the end of the bed in the respiratory exam?

General body habitus – cachexia, Cushingoid features, paper‐thin skin associated with steroid use, short stature secondary to respiratory illness starting in childhood (cystic fibrosis; bronchiectasis)

Sputum pot – look to see the colour; pistachio‐coloured sputum often a sign of pseudomonas infection; pink – pulmonary haemorrhage

Inhalers – make sure you are familiar with new colours of these, particularly combination inhalers

Supplemental oxygen – watch for the presence of portable concentrators as opposed to cylinders that are now rarely used; may be in a ‘rucksack’ that is often navy in colour

Saddle‐shaped nose – pulmonary vasculitis

Face – ptosis associated with Pancoast tumour

Tunnelled lines (upper chest) for delivery of medication in pulmonary hypertension patients or a portacath in a patient with cystic fibrosis

At the end of the bed take a good look at the shape of the chest wall:

Are both sides moving together? Is one expanding further than the other? If one side is expanding less than the other then there might have been previous surgery on that side

Look at the shape of the chest – is there any deformity? Is it hyperexpanded?

Are there any scars on the anterior chest wall? Transplant scars, small scars in the xiphisternum suggestive of surgical chest drains during transplant or pulmonary endarterectomy (see pulmonary hypertension section)

Listen for a cough – dry may point towards pulmonary fibrosis, whereas a cough suggestive of the presence of sputum (more gurgling) might point to bronchiectasis or infection. This is a weak sign as well‐treated patients with bronchiectasis may not currently produce sputum

Note the quality of the patient’s voice. Enlarged pulmonary arteries stretch the recurrent laryngeal nerve leading to a hoarse voice and previous chest surgery may lead to damage to this nerve

Ask the patient to hold their hands up in front of them:

Tremor – short‐acting beta‐agonist use if fine

Rheumatoid hands or those of scleroderma (PH)

Tar‐stained fingers (smoker)

Nail signs – clubbing, rheumatoid nail changes

Get them to cock their wrists – asterixis (‘CO

2

retention flap’); press gently back with your palm against their fingers and feel it if you’re not sure

Wrist – take the pulse; CO

2

retention gives you a bounding pulse

As you move up the arm, always state that you would like to measure the blood pressure at this point

Examine the face, looking for:

Conjunctival pallor (pull down one eyelid with your little finger)

Signs of other systemic disease with respiratory pathology – scleroderma (beaked nose, small mouth with peri‐oral furrowing), hereditary haemorrhagic telangiectasia (facial/oral telangiectasia)

Central cyanosis – lips and tongue

Facial palsy of a Pancoast tumour if not already spotted

Briefly look for a significantly raised JVP while moving to examine the neck

Examine for cervical lymphadenopathy

Take a good look at the anterior and lateral chest wall for scars and also tattoo of radiotherapy. Also examine for well‐healed mastectomy scars, as the patient may have had historical, poorly focused radiotherapy that caused localised damage to the lung resulting in fibrosis. If the patient seems comfortable you might wish to look at the posterior aspect of the thorax for surgical scars at this point. If they seem very breathless remember to do this when you examine the posterior aspect of the chest