My PACES Experience (1)

Finally I received my formal result. A pleasant surprise indeed. I scored 93/100. The passing mark this time is 75%, and the passing rate for this diet is 38%, for UK/Non-UK candidates. I'm glad that the hardwork did pay off and in my next few posts or so, I'll be sharing some of my thoughts about this exam (a.k.a my worst nightmare of the year, really!).

If you ask me what is important in the preparation, broadly speaking, I think there are 3 components - REMEMBER, these are EQUALLY important:

1. Knowledge

You might have heard that PACES is about practising. But believe me, if you do not have the core knowledge, you'll have hard time interpretating signs and correlate them together and bear in mind that this exam you are under direct observation and face-to-face oral Q&A, without adequate (or more than adequate) preparation and reading, "thought-block" and "verbal constipation" is extremely common.

As compared to the written tests like your Part 1 & 2A, I think PACES is much more tougher in terms of the spectrum of the questions that you may be asked, it can range from the most basic (eg physiology), or common diseases but in details (eg prevalance and epidemio), or rare stuff (eg a rare sign), to the updated management (most current practice guidelines, trials and future developement).

Hence, for reading material, I'd suggest the "gold standard" - "An Aid to the MRCP PACES" Vol 1&2 by Ryder and the "250 Cases in Clinical Medicine" by Baliga. But bear in mind that these books do not cover the "Station 5" - a new format in PACES.

Beside the books, do keep yourself updated with the latest guidelines (eg NICE, SIGN guidelines) and important medical trials (you need to confidently name them out - to show that you're practising evidence-based medicine).

2. Showmanship

Now we come to the practising part. It's a blessing if you can find a mentor (usually they'll be too busy to guide), or at least you can form your own study group. No doubt for this exam an extensive amount of time need to be spent on practising, for the clinical method, examination routines, history taking and communication skills. I think the tip is you really have to merge it into your daily practice, meaning seeing all your patients like your exam cases, then you'll improve fast.

Among all, I'd say bedside manner is of the utmost importance, and this is really something will make you stand out from other candidates. And make sure that you perform it as something natural, not like showing it just for the exam's sake. Greet the patient warmly, examine them with respect and dignity, and thank them sincerely!

3. Luck

Now we come to the most difficult part. Believe me that this is a highly unpredictable exam, therefore luck does play a role here. The set of examiners that you get, the patients/ surrogates, or even the candidates in your carousel - all are crucial factors in deciding whether or not you will pass. You may be very confident about your knowledge and skill, but luck MAY as well go wrong, and failed you totally. So, for your luck to go smoothly, my sincere advice is - do pray a lot! ;)


Next entry: Case Presentation in PACES

PACES Case Sharing

The UK trip is very rewarding in terms of learning experience. Here I'd just like to share a few "tricky" cases that I've seen during my attachment/ courses:

#1
In station 5, you're asked to see a lady complained of lethargy and joint pain. This lady has intermittent fever, arthralgia and history suggestive of Raynaud's phenomeon. She also has background history of Hypertension for years. So you suspect this is a case of SLE.
Straightforward? Not really.
Examiner hintingly asked what is the link btw hypertension and SLE.
Further history (only if you specifically asked) revealed that she was treated with Hydralazine for months before symptoms onset. So ya, this is a drug-induced lupus. Did that come into your mind?
Questions discussed were about percentage of anti-histone ab positivity (only about 30% in Hydralazine-induced, as compared to other drugs) and what are slow/ fast acetylators.

#2
Cardiac murmurs!
This is gonna be the best case I've auscultated.
Basically there are full of murmurs: You hear ESM over aortic area to carotid, EDM over LLSE, then also systolic murmur over apex to axilla, with MDM in mitral area as well.
So you thought this is a case of mixed mitral (MS/MR) and mixed aortic valve disease (AS/AR)?
Examiner then said there's no primary mitral valve disease.
The diagnosis is actually mixed aortic valve disease. At mitral area, the systolic murmur you heard is just part of the Gallavardin phenomenon, and diastolic murmur is the Austin Flint murmur due to AR.
Tricky enough?

#3
Station 5 again. You're asked to see a lady presented with seizure, and you should examine her hands.
She has family history of epilepsy. On visual survey you noted she has an AVF at left arm.
ESRF with seizure? Was it due to electrolyte imbalance?
In her hands you noted lesions suggestive of peri-ungual fibroma. So you thought this is a case of Tuberous sclerosis, but there's no facial angiofibroma.
Time's up.

Wanna know the answer? Yes she's a case of tuberous sclerosis with epilepsy. ESRF was because she underwent bilateral nephrectomy due to severe renal angiomyolipoma hemorrhage.
Then why is that she doesn't have the typical facial angiofibroma?

Well, she underwent laser therapy for cosmetic reason!

So these are a few..will share more later!

Magic Medicine Formula (4)

Dear friends, time for some medical formulas again;) This time the topic is about poisoning. A fairly common problem to encounter in ER, as well as popular in exam questions, and more importantly, you usually can't obtain any history from the patients! So the "clues" are crucial in helping to reach the diagnosis. Below are some tips that I found useful:

Check if the patient's having:
- Respiratory depression? Think of opiates, benzodiazepine toxicity;
- Coma? Think of benzodiazepines, alcohol, opiates, barbiturates;
- Constricted pupils? Think of opiates or organophosphates;
- Dilated pupils? Think of tricyclics, amphetamines;
- Hyperthermia? Think of amphetamines, ecstacy, aspirin, cocaine;
- Tachycardia? Think of salbutamol, antimuscarinics, tricyclics;
- Metabolic acidosis? Think of alcohol, paracetamol, theophylline, methanol;
- Seizures? Think of tricyclics, phenothiazines, theophyllines.

Quick mnemonics to help in diagnosis/ management:

Think that patient with cholinergic toxicity (eg organophosphate) is "wet" and look for DUMBELS:

D - Diarrhea/ diaphoresis
U - Urination
M - Miosis
B - Bradycardia
E - Emesis
L - Lacrimation
S - Salivation

*Presentation of Glyphosate poisoning can mimic organophosphote poisoning but the management is VASTLY different - must be aware of that!

Anticholinergic toxicity, in contrast, is very "dry" and look for:
"Hot as hades, blind as a bat, dry as a bone, red as a beet, mad as a hatter"!

For tricyclic antidepressants, main presentation can be remembered as:
TCA = Three C's = Convulsion, Coma, Cardiotoxic (remember to do a stat ECG!)

For paracetamol overdose, the important King's college criteria for liver transplantation can be remembered as:
pH less than 7.3 OR all three of PCM:
P - PT>100 sec
C - Creatinine > 300 mmol/L
M - Major encephalopathy (Grade III/ IV)

Severe poisoning of certain drugs might require hemodialysis and they are BLAST:
B - Barbiturates
L - Lithium
A - Alcohol
S - Salicylates
T - Theophylline

And just to remember that the first & last alphabet i.e. Barbiturates & theophylline - hemoperfusion can be done too.

And lastly, must know the antidote for specific overdose/ poisoning and certainly not searching for books when you see a poisoning case! ;)


Related posts:
Magic Medicine Formula (1)
Magic Medicine Formula (2)
Magic Medicine Formula (3)