My PACES Experience (2)

Ya, as promised, this post is about case presentation in PACES exam, in my humble opinion. There are more than plenty of resources on approaching this exam, hence I won't really elaborate too much. I'd just like to share a "format" that I think is "safe" and can be used even when you're in a panic state (Well, at least it works for me).

Let's just take an abdomen station as an example, and renal transplant case is one of the common ones. Upon completing your examination, you turned to the examiner,

1. General physical findings

"Mr Smith (always use patient's name instead of "this gentleman") is comfortable at rest. He has sallow complexion, conjunctival pallor and I noticed that he has finger prick marks and half-and-half nails, with an arteriovenous fistula at his left arm with no recent needling marks. I also noticed that he has gingival hyperplasia as well as fine tremor of his hands."

2. Main System

"...Moving on to his abdomen, there is a scar at right iliac fossa, with a firm mass beneath which is non-tender and dull on percussion. There rest of the abdomen is soft, and there is no hepato or splenomegaly. The kidneys are not ballotable. There is no ascites, and he has no sacral or pedal edema. "

3. Summary (The most important part - score at this point!)

Always go by - Diagnosis -> Etiology -> Function -> Complication (from disease & Rx)

"In summary, Mr.Smith has a transplanted kidney, which is functioning well, for his underlying end-stage renal failure, which most likely was due to diabetic nephropathy. He has features suggesting that he is on immunosuppressive treatment, most likely a calcineurin-inhibitor. He has no signs suggestive of fluid overload or uremic encephalopathy. There is no lymphadenopathy or any suspicious skin lesion."

Easy? Let me break down the important tips for you:

First of all, spot that this is a renal failure patient (The fistula is obviously the tell-tale sign), then switch on your brain engine and the visual survey, looking for:

1. Other signs of renal failure - as mentioned in textbooks, PLUS the evidence of previous dialysis (neck scar of catheter insertion, abdominal scar for peritoneal dialysis, failed fistula at other sites etc);

2. Possible etiology of the renal failure, e.g
- Finger prick mark - diabetes mellitus. If young patient, suspect Type 1 DM and look also for scar of pancreas transplant (usually done together with renal transplant);

- Nephrectomy scar - trauma, hemorrhage from angiomyolipoma, polycystic kidney, obstructive uropathy etc;

- "Gaunt facies" - lipodystrophy due to underlying Mesangiocapillary glomerulonephritis (Easily missed!);

- Autoimmune features - SLE malar rash, scleroderma, or even just skin vitiligo - could be associated with Type 1 DM - think broadly! ;)


3. Graft function status

Clinically by looking (carefully) at recent needling marks, graft tenderness, and signs of fluid overload/ uremic encephalopathy.

4. Side effects of Immunosuppressive treatment

Steroid: Cushingnoid features (long list)
Calcineurin inhibitor: Tremor, gum hypertrophy, hirsutism
And others (azathioprine, MMF, sirolimus etc)

5. Malignancy - Important!

Mentioning lymph node examination and skin lesion shows that you're aware of the risk of malignancy in post-transplant patient - most important ones being skin cancer (SCC/ BCC) and lymphoproliferative disease.

6. Lastly, mention about blood pressure. It shows that you're aware that cardiac death is the most important cause of deaths in post kidney-transplanted patients, which all cardiovascular risks need to be aggressively controlled. Besides, it could also be the etiology of his renal failure (Hypertensive nephropathy) or as a side effect of cyclosporin/ steroid.

So that's about it. Remember, it's a postgraduate exam so you need to look for "more things" so that you can make the impression. A holistic approach will be essential.

Good luck!

Related posts:
My PACES Experience (1)
PACES Case Sharing

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!