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Dedication
This book is dedicated to Junie Ong, Jian Bin and Jian Feng, the three most
important people in my life. And to Ong Ah Wan, a mother who has given her
unconditional love to me!
Introduction
You can pass your MRCP PACES, if you have passed your Part 1 and
2, there is no reason why you cannot pass your MRCP PACES. Trust
me, you can do it and if you follow my advice, the good news is you can
pass your PACES in one attempt! Yes, you hear me right,you can pass
in one attempt, save your money, save your time and save your
headache!
Remember....
You always have the best chance to succeed no matter what you do in
life- MRCP PACES included. If you use the right techniques and
strategies, you will get your MRCP( UK) or MRCP (Ireland) title after
only one attempt!
Get your mind firmly focused in the right direction and the rest will fall
into place!
You have to believe that you CAN get whatever results you are after. If
you think you can, YOU CAN!!
Pass Your MRCP PACES in ONE Attempt ™ 4
The Game!
Before you play a game, you must understand the rules, the MRCP
PACES ( Practical Assessment of Clinical Examinations ) consists of five
clinical stations, each assessed by two independent examiners.
Candidates will start at any one of the five stations, and then move
round the carousel of stations, at 20 minute intervals (Figure 1), until
they have completed the cycle. There is a five-minute period between
each Station.
Only one of the Stations, Station 5, will change in the new format of the
examination.
2) Don’t panic, there is still ample time for you to prepare for your
PACES. If I meet any challenges/ problems while forwarding
towards my goal to get my MRCP, I will spend very little time
focusing on the problem while spending most of my time focusing
on the solution!
3) I will also realize and keep reminding myself that every problem,
every challenge has within it the seed of a new opportunity! And
that's what I will focus on - the opportunities.
4) I will keep all the negative influence people out of my life for
months to come before my MRCP PACES because these people
are like disease, they retard your growth to become a better
person!
5) There are people out there whom I think are not as great as me
but they have passed MRCP PACES. If they can do it, definitely I
can do it too..... and of course in only ONE attempt!!
Your brain is the best asset you have in life. You choose to believe
something that people ask you to believe!
Long time ago, people believed that the earth was flat. No one dared to
challenge this fact. Even people were sentenced to death if they tried to
prove this wrong. They firmly held on to this belief until one day
someone proved them wrong by sailing around the world.
Here are a few MRCP PACES myths that hold many candidates from
succeeding in their PACES,
Fact: A lot of people passed their MRCP PACES in one and first
attempt. Trust me, more attempts you try, less likely chance you will
pass! The best shot is always the first shot!!
Fact: Candidates think they need to wait at least 1-2 years before sitting
their PACES after Part 2, I don’t believe that, if you think you are ready,
go ahead! Don’t waste your time!
Come on, you think the examiners can ask you more than 3 questions
during MRCP PACES, forget about it, if you can come to diagnosis and
answer only one question correctly, you will get 3 out of 4 marks!
Myth # 4: I just want try it out for my first attempt, it’s OK to fail
Pass Your MRCP PACES in ONE Attempt ™ 9
Fact: If you want to try, go and pay a few hundred to sit for Mock
examination even though the mock exam and the course can easily cost
more than the real examination. Why? Because you can be demoralized
if you fail badly in real PACES examination and this nightmare can haunt
you for months or even years.
As I said, the best shot is the first shot, when you are ready for first
attempt, you know that you are going to pass in the only one and first
attempt!
Fact: No, no, no..... Even though how much you study from your book,
you will never pass your exam without learning from real patients. Do not
spend too much time digesting your book, you can get ‘ Irritable bowel
syndrome’. My strategy is easy, today if I see an interesting case in the
ward, I will go back and study the illness and picture that patient
whenever I think of that illness! Picture worth more than thousand words!
Fact: There are only two stations that you know you can pass easily and
definitely, they are station 2 and 4. However, these two stations need
you to speak like your counterparts in UK whose mother-tongue is
English.
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If you can’t speak fluently in English, do not worry, practise with your
friends. When I sat for PACES, I spent hours and hours talking to my
friends via Skype because I know I can’t speak like British. After
spending hours talking to my friend, I feel confident and I can talk like I
have lived in UK for years during my MRCP PACES!
Fact: Always remember that you need to have a few clear passes so
that you can cover other stations. You will not do well in all stations and
there are always some surprises in PACES. Always try to score high
mark ( a clear 4 mark) in stations you are confident so that you can be
sure that you still pass the examination even though you have clear fail
in another station!
No matter what your religion is, pray hard months before your
examination, trust me, God only helps those who help themselves!
When you try to open your mouth to teach others, you will soon find that
how lacking you are in term of knowledge and that prompts to study
more and gain more knowledge!
Fact: Good things always come along. Relax your mind and body. Play
hard and work hard. When it is time to study,concentrate to your fullest,
when it is time to play, release all your tension!
Pass Your MRCP PACES in ONE Attempt ™ 11
Many of these myths that have been floating around for years and were
typically conjured up by people who didn't know any better.
Beliefs are very powerful indeed. They, for the most part, are what
dictate the quality of your life. Change your beliefs and you change
your life.
The next thing you want to do is to learn to relax. The more relaxed
you are, the more efficiently your mind (and body) will function.
Lie down in bed or sit in a comfortable chair. Close your eyes and start
taking deep, slow breaths. Let your mind go from all other thoughts and
just focus on your breathing. In and out. With each in-breath, see
yourself filling up with energy. And with each out-breath, see all the
stress, tension, worry and confusion drifting out of your body.
Be focused, your aim is only one- YOU WILL PASS YOUR PACES IN
FIRST ATTEMPT!
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Mistake # 1:
Examiners like easy life. If they ask you a question, try to answer them
and give them your reasons. Never wait for them to open their mouths
twice if possible! Let say you are given a case of Mitral regurgitation in
your cardiology station, at the end of the examination, if the examiner
asks you “ Dr....., what is the diagnosis?”
I will most probably start off by telling the examiners the important
clinical findings and summarise by saying that this patient most probably
has mitral regurgitation. However, I will not stop there, I keep on telling
the examiners that I think the lesion is mild to moderate or moderate to
severe and tell them the reasons why I say so. After that, I will tell the
examiners the most probably underlying cause for that!
Mistake # 2:
You open your mouth, unfortunately you say something that are
clearly wrong and stupid!
Yes, they like you to talk but please talk something correct and sound.
You might think they are not relevant, but some examiners will help you
to come to a diagnosis. However, one rule to remember, never say
something stupid.
You can talk nonsense but never say something obviously wrong and
stupid!
by saying that since the patient is having bilateral, symmetrical joint pain
and the patient is rather young, you are thinking of autoimmune disease
but you do not want to commit any definitive diagnosis, examiners
sometime will guide you to the diagnosis.
However, it will be totally a different scenario if you say the patient has
bilateral and symmetrical joint pain and you are thinking of gout.
Understand?
Mistake # 3:
For example, some examiners will ask you to examine again if you are
giving them wrong physical signs, always try to listen to them. If might be
your lucky day and you pick up the signs after re-examining the patient!
Mistake # 4:
This is the lethal mistake, never try to do this during your PACES even
you are 110% sure that the examiner is wrong! This rule doesn’t apply if
you are ready to sit PACES again!
Mistake # 5:
Mistake # 6:
Mistake # 7:
Second- counselling and explanation- you must tell the patient the
diagnosis and explain to them especially if the disease is a chronic one.
I find that a lot of candidates like to talk about drug,drug and drug again.
Remember that besides drugs, there are other ways to help your patient.
Mistake # 8:
When you say something rare, also prepare to answer a few questions
pertaining to that illness!
Mistake # 9:
During PACES, examiners always tell you the patient’s name. Greet
your patient in their family name and not Uncle, Auntie that a lot of
candidates from Malaysia and Hong Kong like to use!
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Always try to compare your findings with your friends who will be
taking examination together with you. If your friend thinks that the
second heart sound is loud in one case and your finding is contradicting
, always find out the cause of this kind of discrepancy. This will helps
you slowly in future to present your findings confidently.
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3) Always feel the pulse properly. You get a bonus if you find that the
patient has irregularly irregular pulse because there are only a few
common possibilities namely mitral stenosis (MS), mitral stenosis (
I mention mitral stenosis TWICE), atrial septal defect(ASD) and
severe mitral regurgitation (MR). If you find the pulse is collapsing,
congratulations , you are only dealing with aortic regurgitation (AR)
or patent ductus arteriosus. (PDA)
5) Never diagnose VSD if you can’t feel the thrill over the left
parasternal area.
9) If you can hear very loud pan systolic murmur over left sternal
edge with central /peripheral clubbing. You are most probably
dealing with ASD/VSD with Eisemenger’s syndrome ( the pan
systolic murmur you are hearing is tricuspid regurgitation and NOT
VSD murmur) or tetralogy of fallot. Only one way to differentiate
these two diagnoses, listen carefully for the second heart sound. In
ASD/VSD with Eisenmenger’s, patients must have developed
pulmonary hypertension, you will hear a very loud second heart
sound. In TOF ( the pan systolic murmur is due to VSD murmur),
because of pulmonary stenosis, the second heart sound is soft.
10) Practice, practice and practice ! This is the only way to make
you a perfect doctor!
Additional points:
S1, S2 (metallic)
S1 and S2 (metallic)
2) MITRAL STENOSIS
Additional points:
3) MITRAL REGURGITATION
Additional points:
4) AORTIC REGURGITATION
Additional points:
( Marfan syndrome)
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5) AORTIC STENOSIS
Additional points:
His apex beat is not displaced, first and second heart sounds were
heard and in normal intensity. There is pansystolic murmur ( can be
ejection systolic murmur) present over the left sternal edge which was
accentuated when patient is in inspiration. There is presence of
pulsatile liver as well. The lung is clear.
Additional points,
c) Always offer to examiners that you would like to ask patients about
any high risk behaviour such as intravenous drug abuse.
7) CONCOMITANT MR/MS
Additional points,
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8) CONCOMITANT AR/AS
Additional points,
Additional points,
( Tetralogy of Fallot)
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Additional points,
a) Do not forget that you may just find patient with tricuspid
regurgitation and right heart failure and loud second heart sound.
The underlying cause for this may be ASD and you will pick up
fixed slitting of second heart sound if you listen carefully.
Additional points,
a) Classically, you will see this kind of patient in their early childhood
however, it is not uncommon to see patient to come to see you in
their mid twenty without any operation done before.
Additional points,
Additional points,
15) Others
Finally, we come to the last question in cardiology, never spend too
much time learning other rare conditions such as coartation of
aorta…..etc, you most probably will not see them in your all life.
Pass Your MRCP PACES in ONE Attempt ™ 40
1) Rude to patients.
2) Forget to dress back patients after physical examinations.
3) Confuse either the murmur is pan systolic or continuous.
4) Presentation is not complete and conscience.
5) Miss cyanosis and even clubbing.
6) Not listen carefully to the second heart sound. You must
always compare the second heart sound over aortic and
pulmonary areas. If it is louder at pulmonary area, this
means that the second heart sound is loud.
7) Not observant enough, if you see a stroke patient with MS,
always remember that the stroke may be due to AF because
of the underlying MS.
8) Create own physical signs.
9) Unable to conclude a diagnosis from physical signs. For
example, pulmonary hypertension is unlikely to develop in
AS,AR, a normal intensity second heart sound is unlikely due
to AS, a displaced apex beat is unlikely due to MS ( except
concomitant MR) etc….
10) Try to argue with examiners!!
The trick to this station is you have to examine confidently and pick
out the important signs, you will pass with a 4 even the examiners do not
have the time to ask you any questions if you can pick up all the
important physical signs.
This is the station that needs the least knowledge because at the
most the examiners will ask you two questions, first is ‘What is your
diagnosis?’ and second is “ What investigations do you want to do?”
No need to spend too much time on the theory part. Just examine
patients again, again and again. Always try to feel the trachea properly
because the trachea can tell you important clues that finally lead you to
the correct diagnosis.
Pass Your MRCP PACES in ONE Attempt ™ 42
I would tell you 6 common short cases that will come out in your
MRCP PACES. Always remember that there are very limited short cases
in respiratory station. Memorize them hard and you will pass this station
with flying colours.
1) PNEUMONECTOMY / LOBECTOMY
Additional points,
a) Always look hard for any scar, sometime it is difficult to pick up the
scar if the scar is hidden just under the subscapular region.
Additional points,
a) Never miss peripheral clues which can give you the underlying
aetiology for patient’s lung fibrosis such as rheumatoid hands,
sclerodactyly (in systemic fibrosis), malar rash, skin
hyperpigmentation ( suggestive of amiodarone side effects), rigid
spine (Ankylosing spondylitis) etc…………..
3) BRONCHIECTASIS
Additional points,
4) PLEURAL EFFUSION
Additional points,
5) LUNG CARCINOMA
left lung. Breath sound is reduced on the same side. There are multiple
cervical lymph nodes palpable over the left anterior triangle of the neck.
Additional points:
a) Always look hard for previous radiation scar over the chest which
is the main therapy for superior vena cava obstruction.
6)CONSOLIDATION
Additional points:
a) Usually patient with consolidation is too ill to come out in the exam.
However there is a possibility if patient is partially treated and well.
You may think that respiratory station is a simple station, you are right
and wrong. Respiratory case is always easy if you can complete your
physical examination within 7-8 minutes. Try to examine either from front
or the back based on patient’s trachea location. If the trachea is centrally
located, examine from the back, if it is deviated , examine from the front.
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1) KIDNEY TRANSPLANT
Additional points,
b) There are a few things that may suggest that the transplanted
kidney is functioning well such as good volume of urine production,
no tenderness over transplanted kidney, absence of haematuria
and no recent usage of fistula for haemodialysis.
Additional points,
a) Always remember that the major cause for chronic liver disease in
Asia is Hepatitis B whereas alcoholism is the commonest cause for
CLD in Western world.
e) There are a few specific physical signs that are specific for
alcoholism such as parotid swelling and Duputyren’s contracture.
3) HEPATOMEGALY ( NO SPLENOMEGALY)
Additional points,
4) SPLENOMEGALY ( NO HEPATOMEGALY)
Additional points,
a) Always remember that there are only a few possibilities for a small
spleen, these include chronic haemolysis ( Thalassemia
intermedia, sickle cell disease) , endorcarditis ,thyphoid fever and
glandular fever or patient with myeloproliferative disease on
treatment.
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c) Always suggest to examiners that you would like to examine all the
lymph nodes because lymphoproliferative disorders can present
with a small spleen with lymphadenopathy.
5) HEPATOSLENOMEGALY
well and it is palpable 5 fingers breath below the costal margin. It has a
smooth surface and regular margin. There is no lymphadenopathy and
ascites.
Additional points,
7) POLYCYSTIC KIDNEY
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Additional points,
e) The cyst can happen anyway in the body namely kidney, liver,
spleen, ovary, artery (berry aneurysm).
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3) Not ensuring patients breathe through their mouth when testing for
downward organ movement.
6) Inventing signs.
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When you present you findings, always try to present these three
important points that every neurologist is looking for, “ What is the lesion,
where is the lesion (anatomical diagnosis) and what is the cause for the
lesion ? (pathological diagnosis).
For example , if you find that you patient has left spastic
hemiplegia, then you will say that “ This gentleman has left spastic
hemiplegia (the lesion) without sensory involvement most probably due
to right ischemic lacunar stroke ( anatomical diagnosis) and it is due to
thrombo-embolic event because he also has atrial fibrillation.”
6) If you are examining for cranial nerves, always start with the
most relevant examination first. For example, if the stem
states that this patient has speech problem, then start from
lower cranial nerves examination first because most probably
you are going to find abnormalities there.
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I would divide this chapters to few sections, each section will have
a clinical scenario which is common in your PACES, I would discuss
with you the important steps in examination and the common diagnosis
in certain scenario.
I can divide the possible scenarios into a few big groups as below,
you are most probably dealing with,
stroke
Brown-sequard synd
-Parasaggital meningioma
-Bilateral stroke
-Cervical/thoracic myelopathy
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You may find a few conditions that have upper motor lesion of
lower limbs (spastic paralysis) that do not fit to above categories. These
conditions include,
i) Friedreich’s ataxia-
ii)Syringomyelia-
So, now you see there are only a few limited diagnosis for patients
with upper motor lesion signs of lower limbs. Sometimes you may find
contradicting signs in lower limbs, such as normal reflexes with up-going
plantar. Always base your finding in the strongest physical signs.
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There are a few common short cases that I think need further
explanation. Patients with these conditions usually present with lower
motor lesion of both lower limbs.
pyramidal
As for cerebellar, if the examiners want to trick you, they may ask you to
examine the lower limbs neurologically, therefore during your PACES, if
you are asked to examine the lower limbs, always start off by asking the
patient to walk! You will never miss cerebellar signs if you ask your
patients to walk!
However, I still think that isolated nerve palsy ( such as median, ulnar or
radial) is becoming less popular in PACES because these conditions are
mainly seen in orthopaedic wards rather than general medical wards.
The below information are for you to remember how to examine these
nerves separately,
a) Median Nerve
To check the abductor pollicis, put a pen above the palmar surface
of patient’s hand and ask him to touch it!
b) Radial Nerve
c) Ulnar nerve
It supplies all small muscles of the hand except LOAF. Its palsy
causes claw hand.
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I think this is always the difficult station if they ask you to examine the
cranial nerves. The only way to do this confidently is practise, practise
and practise again. No short cut for cranial nerves examination, you
must see as many cases as possible!
However, I will try to highlight to you a few important short cases in your
PACES,
Nerve #1 :
Nerve # 3, # 4 and # 6:
( LR6SO4 )3
(Source: www.yorku.ca)
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Nerve #5:
No need to bother about this nerve, just remember how the 3 sensory
components innervate the face.
Nerve#7:
Well, well, well, finally we come to this very, very important nerve.
Why?? Because 7th nerve palsy causes disfigurement to patient and can
be picked up easily in PACES, besides that, it is very common in clinical
medicine!
Bell’s palsy is all time favourite question in MRCP PACES. Know this
condition from inside out and outside in! ( if possible from up to bottown
and bottom to up!)
( source: www.adam.com)
Bell’s Palsy
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Nerve #8:
No need to spend so much of time, just study a bit, but this nerve might
be helpful for you to find out the underlying cause of lower motor lesion
of 7th cranial nerve!
Just remember these nerves are important in palate elevation and Gag’s
reflex.
Nerve #11:
You will never get isolated 11th nerve palsy in PACES. Just remember
this nerve supplies sternocleidomastoid and trapezius muscles.
Nerve # 12:
Tongue movement. Not thing more than that! However, always look for
tongue fasciculation/wasting!
Easy, learn the habit in the ward every day to clerk your patient
and finish clerking them within specific given time (about 14 mins)
I always try to think of the causes from head to toe. CNS, CVS,
Lung, Abdomen and so on..... then I will think of VINDICATE.
You will never miss any diagnosis if you follow this rule!
Candidates always forget about drugs and congenital causes in
their PACES! Even though you know the diagnosis after 2
questions, continue to explore all other possibilities because you
might be caught in the exam!
Remember that try not to make the following mistakes when you sit for
this station in PACES.
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Mistake #1:
Mistake #2:
Look at your watch again and again! Again, this is a fatal mistake.
Examiners hate you and also the patient! Eventually, you hate yourself
too!
Mistake #3:
You do not bother about patient’s concern. I always make the habit to
spend last 5 mins of my time to ask the patient specifically about his/her
concern. For an example, if you get a case of patient presenting with
cough, he might be worried about the cough is due to cancer, therefore,
you must address his worry very well. Also be prepared to answer all
questions posed by patient.
Mistake #4:
Never summarize your history. When examiners start to ask you the
possible diagnosis, always give a summary of relevant history for your
patient and tell them all your differential diagnosis and the reasons why
you say so!
Mistake# 5:
Forget about social history of the patient. You might think that it is not
important, just remember that a lot of medical problems are related
directly or indirectly with social history, just spend 1-2 mins asking your
patient relevant social history based on your case.
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Mistake#6:
Mistake # 7:
Mistake #8:
Mistake#9:
No open ended question. I must admit that during your PACES, you are
under stress, you want to get the diagnosis as soon as possible, but I
must tell you examiners hate closed ended questions. What I suggest
you to do, first 3-4 mins, ask open-ended questions,such as “ Tell me
Pass Your MRCP PACES in ONE Attempt ™ 88
Remember, only first 3-4 mins, do not waste too much time especially
they give your patients that are not helpful!
Mistake # 10:
Argue with you patient or examiners- Never try this unless you plan to sit
the exam again and again!
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I will give you a list of 20 common symptoms that are popular in MRCP
PACES, what I suggest you to do, sit down and take a piece of paper
and write down all the possible diagnosis based on VINDICATE
mneumonics.
a) Chest pain
b) Shortness of breath
c) Jaundice
d) Diarrhoea
e) Leg swelling
f) Lethargy
g) Headache
h) Nausea/vomiting
j) Fever
k) Joint pain
l) Skin rash
m) Coughing
n) Giddiness
o) Loss of consciousness
p) Palpitation
r) Blurring of vision
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s) Forgetfulness
t) Peripheral numbness
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I find this station is the easiest for candidates in UK. This is quite similar
for me if MRCP PACES is to be conducted in Mandarin or Cantonese.
However, a lot of foreign candidates find it difficult to speak English like
their mother-tongue. Don’t worry; just remember that practice makes
your perfect.
“This question is rather difficult to answer, however, I will get back to you
once I have discussed with my senior doctors........”
“We are trying our best hoping that your mother will get better,
unfortunately................................”
“I know that this isn’t what you wanted to hear. I wish the news were
better.”
All time favourite. I always say there are 2 main categories here-
terminal illnesses and chronic diseases.
For example, you might be required to tell a patient that she is having
multiple sclerosis, SLE... etc, besides knowing how to break bad news,
you ought to have some knowledge about these illnesses as well.
Epilepsy
Rheumatoid Arthritis
Multiple Sclerosis
Hepatitis B/ C
Tuberculosis
There is no best way for you to deliver bad news to patients, however, I
think Dr Buckman’s SPIKES technique is a systematic and useful way to
follow.
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You should ask the patient who else ought to be present, and let
the patient decide (studies show that different patients have widely
varying views on what they would want).
It is helpful to start with a question like, "How are you feeling right
now?" to indicate to the patient that this conversation will be a two-
way affair.
( You do not need to worry about this step because all will be set up
in PACES, however, always pay attention to second and third point
above!!)
By asking a question such as, "What have you already been told about
your illness?" you can begin to understand :
What the patient has already been told ("I have some lung
problems, and they told me it’s serious"),
Or how much the patient understood about what's been said
("the doctor said something about a spot on my chest x-ray"),
The patients level of technical sophistication ("I've got a
T2N0 adenocarcinoma"),
And the patient's emotional state ("Ian so worried , doc, they
told I might have cancer").
It makes you very easy to break the bad news once you know how much
the patient has been told. If they know little, then you know you have to
Pass Your MRCP PACES in ONE Attempt ™ 94
take longer time for them to digest your information. If they know a lot,
then life will be easier for you!
It is useful to ask patients what level of detail you should cover. For
instance, you can say, "Some patients want me to cover every medical
detail, but other patients want only the big picture--what would you prefer
now?" This establishes that there is no right answer, and that different
patients have different styles.
OK, this is the part that you spend most of your time. For example, after
you told the diagnosis of lung cancer, you might want to tell your patient
there are a few ways of treating the cancer- chemotherapy or
radiotherapy although total cure is unlikely. If they ask you to elaborate
further, you can say ( “ I will have the cancer doctor to tell you further
maybe later this afternoon after I discuss with him”)
Never try to think that you know EVERYTHING under the Sun. Always
tell them there are other doctors that are in better position to clear their
doubts if you do not have the information!
If you don't understand the patient's reaction, you will leave a lot of
unfinished business, and you will miss an opportunity to be a caring
physician.
Patients who have a clear plan for the future are less likely to feel
anxious and uncertain.
You may want to tell your patient that you are available again in the
afternoon clinic and if he has any questions, he might want to ask you
again.
You must make clear that when you want to see him back in the clinic
such as after 2 weeks etc.
Always provide patient way to contact you if something arise before next
appointment!
Sounds easy? Try this method during your next practice with your
friends and you will find how easy this method is!
a) You have to ask the patient to go for a HIV testing after diagnosing
him to have PCP.
b) You have to ask a HIV patient’s partner to go for HIV testing.
c) You are required to break the bad news that a patient is having
HIV.
d) You are required to ask permission from a HIV patient to tell his
partner that he has HIV.
e) You are required to see a house-officer who has needle prick
injury from a HIV patient.
f) Discuss about post exposure prophylaxis of needle prick injury
from HIV.
Remember that sometime you have to admit that you have made a
mistake but always convince the family that immediate remedy has been
taken once you notice the problem. Explain to them that you will not
allow this problem to happen again. Also emphasize to that report has
been made to your superiors.
(1) a duty of care was owed by the physician; (2) the physician violated
the applicable standard of care; (3) the person suffered a
compensable injury; and (4) the injury was caused in fact and
proximately caused by the substandard conduct. The burden of proving
these elements is on the plaintiff in a malpractice lawsuit.
Hope you do not get this in your PACES, depending on how nice/bad
your surrogate is, if the surrogate wants to fail you, there is no way you
can pass!
Finally we come to the last chapter of this book, starting from Oct 2009,
changes have been made to station 5 and this station is named as
Integrated Clinical Assessment station.
‘ There will be two cases in this 20 minute station – each lasting 10 minutes (each case will be
The way in which candidates approach this station will be very different to the formal examination
of systems at Stations 1 and 3, and very different to the structured and comprehensive history
Candidates will aim to elicit sufficient history to make an assessment of the problem presented and
will carry out an examination that is relevant to assessing the problem presented. The history
taking and the examination are not intended to be comprehensive – this station is not a “long
Candidates will have 8 minutes to take a focussed history, carry out a relevant examination, and
respond to the patient’s concerns. During the remaining two minutes, an examiner will ask the
candidate to describe the positive physical findings and to give a preferred diagnosis and any
differential diagnosis. Candidates will always be given the full 8 minutes with each of their patients
at Station 5 ( however, the examiners will tell after 6 mins have elapsed) and the examiners will
not begin their two minute discussion until the 8 minutes have elapsed. Candidates undertake two
It is NOT necessary, nor would it be possible for candidates to undertake a complete history or
comprehensive examination in the available time. The aim of the encounters is to allow candidates
to show that they can focus on the most important parts of history and examination when posed
with a clinical problem. In addition, the candidate will be expected to explain their management
plan succinctly to the patient and answer any questions they might have.
It is important to note that candidates may examine the patient and take aspects of the
history in any order, or concurrently. For example, where the patient complains of a physical
abnormality, they may wish to examine affected areas while asking the patient about relevant
history.’
Pass Your MRCP PACES in ONE Attempt ™ 99
I will try to give you as many examples as possible in this station so that
you know the common and popular cases in this station.
Another thing to take note in this new station is you are expected to take
history together while you are examining the patient. Never waste your
time, always have a good look at your patient before opening your
mouth and moving your hands!
I think in this new station, cases which were common in previous old
format will still be asked, however, examiners expect more from you!
Besides getting the correct diagnosis, you also need to ask relevant
history, for example if you are given a case of a lady with thyroid
swelling, of course you need to know the proper way of examining the
goitre, but you won’t pass if you are unable,
Conclusion
I hope this ebook helps you while you are preparing for your MRCP
PACES.
Try your best and I will see you at the top there.
Just want to share with you Joe Vitale’s formula of creating miracle,
Be focused and you will get what you want in life no matter what!
MRCP PACES is just a game, you will win this game if you know the
rules and never repeat the mistakes others have done!
Best Regards
Dr HK Goh