Cardiff Paces

8/3/2015
CardiffPaces
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LastMinuteAdvice!
WehopeyoufeelthatthecoursehasbeenusefulinfocussingyourrevisionforthePACES.
Justsomelastminuteadvice
HeartSounds
Acandidate'sexperience:
Experience1
Experience2
Experience3
Experience4
Experience5
Experience6
Experience7
Experience8
Experience9
Experience10
Experience11
Experience12
Experience13
Experience14
Experience15
Experience16
Experience17
Experience18
Experience19
Experience20
Experience21
Experience22
Experience23
Experience24
Experience25
Experience26
Justsomelastminuteadvice:
You need to pair up with somebody doing the PACES. You will be compromised if you study alone. See
patients (either organised teaching or going around yourselves) on the wards at least 23 times/ week
andmeetupregularlyintheeveningsorweekendstoblastquestions at one another. Viva technique is
important.Don'tgiveincompleteanswersorexpecttheexaminertoprisetheansweroutofyou.
Examplewithpulmonaryfibrosisshortcase
Examiner:Whatoneinvestigationwillyoudotoconfirmyoursuspicion?
Candidate:CTscan
Examiner:WhatsortofCTscan?
Candidate:IsithighresolutionCTscan?
Examiner:Whatareyoulookingfor?
Candidate:Groundglassappearance?
Examiner:Sowhat?
ZZZZZZZZZZZZZZZzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
It'stedious.
So,ideal1stresponse=
I would arrange a high resolution CT chest to confirm the diagnosis. A ground glass appearance is
associatedwithactivealveolitiswhichrespondswelltosteroids,whereasahoneycombingandinterstitial
fibrosisindicatesmoreadvanceddiseasewhichwillbelesssteroidresponsive,SIR(orMAAM.Don'tget
thiswrong...justbecausesheishirsuite)!!!!!
You only have 3 seconds to come up with something sensible, or else you will appear hesitant. The
examiners will give you a clue and another if you're still stuck, by which time you will be panicking.
http://www.cardiffpaces.co.uk/hints.php#exp1
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Practice makes perfect...if you've answered a question once or twice before, the answer framework is
thereparticularlyforthemoreopenendedquestions.
Get your timings right for the history stations, and make sure you take a solid history. Otherwise the
examinerswilljustspendallthetimetearingyourhistoryapart.WritingthestemslikePC,HPC,PMH,all
5 systems, DH, allergies, FH and SH is useful. Ask specifics about the systems eg 'bowels alright?' is
probably not good enough...better to ask about change in bowel habit, fluctuating diarrhoea/
constipation,blood,mucusetc.Youwillmissthingsotherwise.
Don'tforgettosummarisethehistorywiththepatientinhistorytakingstation,ortheactionplaninthe
communicationstation.
Stopseeingpatientsinthelastweekbeforetheexam.Ideallyyoushouldtakethelastweekoffworkand
meet up with your partner during the daytime, and read by yourself in the evenings. You should go
through the MRCP short cases book case by case, including the minutiae. For example, rheumatoid
hands...describe full house presentation, differential diagnosis (psoriatic or Lyme's disease),
investigations,treatmentetc.Also,canIexamineforcerebellarsyndromeorthyroidstatus?IfI'masked
to look at someone's face, what can it be (Cushing's, Addisons, Parkinsons, myotonia, CREST etc? The
Ryder/Freemanbookcoversthiswell.
Ifyoudothis,youwillbewellprepared.
Beconfidentintheexam.Theycan'tkillyou,whichisalwaysgood.Evenifyougetitwrong,getitwrong
confidently.Youwon'tgetanymorepointsforbeingmeekaboutit.Youneverknow...youmayevenget
awaywithit.
Make time for relaxation...go and watch a silly film like Blazing Saddles, Life of Brian, Borat, Blades of
Gloryetc...orevenexercise!
Good luck!! We would be grateful if you could feed back about your experience with the exam so that
futurecandidatescanbenefit.Youcouldevenrecommendourcoursetoyourfriends.
ManythanksShuandKrishna
Backtotop
HeartSounds
Shu has produced a video to ensure you can recognise the various heart sounds likely to appear in the
exam.
(HighQuality,slowerdownload)Clickheretowatchthevideo
(LowerQuality,fasterdownload)Clickheretowatchthevideo
Backtotop
Acandidate'sexperience:
Experience1
GLwrote:
IattendedyourlastsessioninOctober09andamverypleased(andrelieved)totellyouthatIpassed!
Wewereaskedtosendyousomefeedbackontheexam,inparticularthenewstation5.
Mycaseswere:
Station5:
HHT History was a lady in her 60s admitted with tiredness and SOB. Hb was 6 and Fe deficient. Pt
tranfusedandaskingtogohome.Mytaskwastotakehistoryandfocusedexamination.Pthadnoovert
symptoms of blood loss on questioning. When I asked pt to move onto couch so I could examine
abdomen,examinersstoppedmeandtoldmeitwasnormal.Iproceededwiththehistoryptmentioned
intheFHthatherdadhadsmiliarproblemsandsufferedfromnosebleedswhichshehadalsohadover
thepreviousfewweeks.Ithennoticedtheteleangiectasiaonherlips.Iaskedhertoopenhermouthand
notedsameonbuccalmucosa.Thequestionswerefocusedaroundmanagementofepistaxisinthiscase,
themodeofinheritance,andwhether I thought her anaemia was soley due to epistaxis. I thought that
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she may also be having occult GI blood loss and this should be investigated further. I also tried to
examine her chest (AV mals) examiner asked me what I was listening for. I think some of the other
candidatesdidthesametoo!
GravesEyeDiseaseandGoitre
ThesecondcasewasamiddleagedladyadmittedtothehospitalwithSVT.Askedtotakefocusedhistory
and examination. Immediate observation of exopthalmos and proptosis. Examined neck and thyroid
status.Questionswerefocusedonmydifferentials,whichbloodtestsIwouldrequest,andwhetherIfelt
see was hyperthyroid, eu, or hypo. Clinically she seemed euthyroid but in light of the history of SVT,
hyperthyroidismneededtobeexcluded.
Resp was a pulmonary fibrosis. Asked about differentials, CT findings and what honeycombing
represented.Abdo was an elderly lady with splenomegaly and a stoma/ascites bag on site of previous
paracentesis.(questionswereondiffofsplenomegaly)
Cardio was AR ( I felt there was AS and AR questions focused on which lesion i felt was the most
predominatandthemxofAR)Neurowasamyasthenicpatientwhoonlyhadunilateralptosis.Ithought
theinstructioninthiscasewasdifficultpthavingweaknessinarmsandlegsandblurringofvision.It
may be useful to have a system of examining a myasthenic to illustrate the relevant signs or to show
examinersthatyouknowwhattolookfor.Ididn'thaveoneandIthinkitshowed.
Historytakingwasagentwithprogressivelimbandneckweakness.(?EatonLambert,?MG?MND)
CommskillswasadentalnurserecentlyreturnedfromAfricawithnewdisgnosisofsputumposTB.?had
exposuretoHIVwithpreviouspartnerswhilstinAfrica.MotheralsodiedofTB.Ladywasasingleparent
withtwoyoungchildren....
Backtotop
Experience2
IattendedthecourseinFebruary,andamgladtosayIhavepassed.Thankyouverymuchforyourhelp!
IthoughtofjustsharingthecasesthatIhadfortheexam.
Neurology Lady with difficulty walking. She had wasting, power 0/5 both legs, loss of sensation (dorsal
andst),withclonusontheright.Iwentupuntilthechestandshehadnosensationupuntillowerchest.
ThisstationbasicallyinvolveddiscussionofDDsandinvestigation.
CardiologyThiswasabitofanoddone.largethoracotomyscarscar'L'shaped,withthrill,systolicand
diastolicmurmur(wasratherconfusing)ontheprecordium.IdiscussedthepossibleDDs,thoughIwas
notpersonallyveryhappythewaythisstationwent,IlaterthoughtthatthiswasTOFwithrepair.
EthicsandcommunicationThisinvolvedtalkingtohusbandofaladywithHepCregardingthecondition
andconsentinghimforthetest.Oneoftheothercandidatescommentedthatitgotembaressingforhim,
theactorandexaminersafterawhile.Ihadmorethanaminuteleftinthestation.Mainlyjustwentby
theadvisedpattern.QuestionswereonethicalprinciplesinvolvedandHepCtreatment.
Station5Case155yearoldmanreferredfromskinclinicashehadtremor.MydiagnosiswasBenign
essential tremor, and discussed other causes for tremor and treatment options. Case 2 75 year old
gentleman referred by GP with h/o deteriorating vision. He is waiting to see opthalmology, but that is
another 3m. focused history, examination and advise. This gent had near complete loss of vision
bilaterally,positivefh,didntwantanyhelpfromOT,asheknewwhereeverythinginhishousewasand
washelpedbyhiswife.fundusshowedretinitispigmentosa.(thecaseswereinfactBETandRP)
abdomenhepatosplenomegalywithjaundiceinayoungman.Thiswentwell.ThediagnosisIofferedwas
hemolysis, possibly spherocytosis etiology, and discussed other DDs, investigation. (this was indeed HS,
andamgladcouldcomeupwiththisdiagnosiswhentheexamineraskedforsinglediagnosisIwouldgo
with)
respiratory straightforward, bibasal fine inspiratory crackles. discussion mainly was on drugs that can
causethis.Ijustsaidwhatyouhaveputonthewebsiteasanexampleofhowtopresent,andalsospoke
ofcausesthatIruledoutonexamination.(Icouldnotcomeupwiththedrugexaminerwaslookingfor.I
listed 4, but he asked for more. I could hear this patient telling the examiner, as I walked to the abdo
station,howthemorningsessioncandidatesgotitright,butnottheeveningones!)
History taking 40 year old lady with lethargy and weight loss. Several possible DDs were discussed.
Historywassuggestiveofathyroidproblem.malignancywasanotherpossibility.
Backtotop
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Experience3
Mycaseswere:
CardiacMitralregurgitation.
Neurology Cerebellar dysfunction with evidence of lower motor neuron pattern weakness in the lower
limbs.Probablyduetoalcohol.
History taking 24 year old nurse on the OCP with a three month history of headache not relieved by
simpleanalgesiaandwithsymptomsofraisedICPthedifferentialtheywantedwasBenignIntracranial
hypertensionandtheinvestigationsweresomeformofneuroimagingandLP.
Abdominalpolycystickidneysandrenaltransplant.
Respiratoryrheumatoidpleuraleffusion.
Communication skills and ethics middle aged man admitted with a tropnin positive acute coronary
syndromewhoisalsoanHGVdriverhewantstoselfdischargediscussthiswithhimwiththeaimof
gettinghimtoremaininforinvestigationsissuestouchedonwerecapacity,confidentialityandwhenit
canbebrokenre:DVLAandHGVlicenceincontextofIHD.
Brief clinical consultation (BCC) task 1 gentleman with chronic back pain with recent history of
constipation and then diarrhoea. Clearly an actor. Nil to find on examination. Asked for differential of
infectivediarrhoea.
BCC task 2 patient with rheumatological disease presents with increasing shortness of breath. Had
pulmonaryfibrosisandevidenceofrightsidedheartfailure.
TheBCCstationcanbeabitdisconcertingasitisn'tentirelyclearwhattheexaminersexpectandIthink
using actors in a station that requires examination is very off putting as it is clear from the way they
interactwithyouthattheyareanactorratherthanarealpatient.
Backtotop
Experience4
1.Station5PresentationwasSOB.
PatientclinicallyhadsignsofScleroderma/CREST.
Concernsweredadbroughtasbestosdusthome?asbestosis
2.Station5PatientwithArthritisandrashPsoriasis
Examinerelevantsystemandcounsellingregardstreatment.
3.CommunicationBreakingBadnews.
Patient had blood results has CKD ,prev history of HTN during insurance check up but patient decided
nottotaketablets.
Counselregardstreatmentoptions
Dialysisinfuture
Patientindenial,nothappywithresult.AlsounhappywithGPaswhyshewasnotexplainedtheproblems
secondarytoHTN.
4.Historytaking
Youngladywithrecurrentattacksofweaknessinrightarmover4weekswhichlaterresolved.
5.Cases
RespiratoryPulmonaryfibrosisandCushingoidappearencesecondarytoSteroids.
AbdomenRenaltransplantwithfistula,transplantkidney
CVSMetalicAVRwithalso?regurgitantAR
Discussionregardingwarfarin.
NeurologyPeripheralNeuropathy(Absentanklereflex)
Discussionregardingcauses.
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Backtotop
Experience5
Iammostgratefulforthiscandidatewhofedbackthefollowingscenariosfromherownandherfriends
experiences.ShepassedherPACES(Shu).
Commmunicationskillstation
1.45yroldgentlemanrecentlydiagnosedmetastaticbowelcancer2monthsago.Heandhisparentsare
shocked by the diagnosis and could not accept it and demanded for any possible treatment. He had
chemotherapyandoncologistdecidedforpalliativetratmentunderpalliativecareteam.
He admitted to A&Es with torrential GI bleed and had 10 units of blood tranfusion. Urgent OGD done
couldnotstoppedbleeding.Surgeonteamdecidednotforsurgeryduetohighrisk.Theonlypossibilityis
to try embolization but no gurantee to stop bleeding. He was shocked and frightened. He asks for any
possibletreatmenttostoppedbleeding.
Hissistercametohospitalandwanttodiscussedwithdoctorregardinghismanagement.
Assumedpatienthasgivenpermissiontodiscusshismatterwithhissister.
( In the exam, the sister wants to do nothing and let him go peacefully, suggested morpine , not for
resusasthepatientandherparentsarenotrealisticwhatisgoingon)
(Examineraskedabouthowtoassesscompetencyofapatient,HowtodecideNotForResusonwhich
ground ? age,? underlying disease or ?what else. Examiner said lets say not this 45 yr old guy,
supposed 85 yr old guy with the same situation , how will you decide for Resus status, If this patient
demandsforResuswhatisyourdecisionetc...)
2.A38yroldgentlemanhadblood test for HIV with GP and GP referred to you for the result which is
positiveforHIV.Yourtaskistodobreakingbadnewsanddiscusswithpatientformanagementplanand
tretmentandaddresshisconcern.
3. 82 yr old lady chronic RA, had hip & knee replacement ,recurent mechanical falls. She denied home
help previously. Now admitted from fall and slow progress, transferred with 2. She initially refused
nursing home but now accept home help and would like to go home. Talk to daughter regarding
dischargeplan.
(Daughterconcernsabouthersafetyathomeandhermedications)
4.50yroldlady,cough,haemoptysis,weightloss.GPdidCXRwhichshowedRthilarmassandreferred
to you. Your task is to discuss possible Dx and management plan. ( patient said she has claudophobia
whenyoutalkaboutCTscan)
5.65yroldmanknownCOPDadmittedwithRtUpperQuadrentpain,hadCXRportableinA&Epoor
quality,diagnosedcholecystitisandsenttosurgicalward.Temperaturenotsettleddown,repeatCXRand
foundoutRtlowerlobepneumonia.ThispatientwastransferredtomedicalwardbutdecisionaboutITU
has not been made yet . He has history of severe COPD and had admitted to ITU previously and has
stayed in ITU for 2 months due to difficult to wean off ventilator. Your task is to talk to angry son
regardingfurthermanagement.
6.Todiscusswithaduaghterofanursinghomeresidence,Parkinsonsdiseaseanddementiaforfeeding
optionsandmanagement.
7. 40 yroldman went to GP with cough & haemoptysis over 6 weeks, and had CXR which showed
metastaticlungCaandreferredtoyou.ThispatienthadCXR9monthsagowithLocumGPwhichshowed
asmalllesionwhichwasmissedatthattime.YourtaskisbreakingbadnewstopatientregardingXray
findingandmanagementplan.HeisveryangryaboutdelayDxandmissedDxin9monthsago.
8.Tocounsel38yroldsputumpositiveTBforHIVtestandfurthermanagementplan.
9.ToexplainapatientwithnewlydiagnosedParkinsonsdiseaseformanagemnetplan.
(hisconcerniswillhebecomedementia?Howistheprognosis?
History
1.53yroldgentlmanreferredbyGPduetoabnormalLFTs(AlkPhos>800,GGT>200andALT>100,
Bilirubinabout50)andpruritus.Heisgenerallyingoodhealth.Hehasonlyhistoryofchestinfection2
months ago. His wife is concerned about his alcohol intake but he said he did not exceed the
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recommendedrange.Pleasetakeahistoryandaddresshisconcern.
2. 40 yr old lady diarrhoea off and on over 78 months, weight loss. Take history and discuss
management.
(malabsorptiondiarrhoeadescribesaspalebulkystool,difficulttoflush)
3.48yroldgentlemandiarrhoeaandweightlossover4months,totakehistory.
4.25yearoldmanacutechestpain.GPdidECGwhichwasnormal&referredtoMAU.Hewasvomiting
withnobloodbutdevelopeddysphagia,tachycardiaandbecameincreasinglyunwell.Pleasetakehistory
anddiscussaboutmanagement.
(inhistoryhetookrecreationdrug?ecstacywiththisepisode)
5. 45yrold man pins & needles & tingling in feet. History of weight loss and tiredness. Blood glucose
normal.Takehishistory.
6. Middle age lady fever, night sweat, weight loss over a few months and Hb of 10.ESR 105 , To take
history
7.35yroldhousewifecomplainsoffatique,tiredness,lethergyandpolyarthragia.Totakehistory
(SLEistopDDx)
8.Youngmanperipheralneuropathy,pinsandneedleinlegstotakehistory.
9.Middleageladymicrocysticanaemia,highBP,tiredness.Historyofmiscarriage,jointsymptoms
(answerSLErenalinvolved,toruleoutAntiphospholipidsyndrome)
10. 35yrold man type 1 DM, hyponatremia , tiredness . On citalopram. Strong family history of lung
cancer.Hisconcerniswhetherthiscanbelungcancer?
11. Middle age lady , anaemia, fatique, Hb 9.8, MCV 80, PMH of irritable bowel syndrome for 10
years.Diary products make her diarrhoea. History of low back pain. Family history of Ca colon. To take
history.
Station5
1.54yroldladyknownIDDMcamefordiabeticreviewclinic.Shehasconcernedaboutherrteyevision,
pleasetakeafocushistory,examinationandaddressherconcern.
(RtDiabeticMaculopathywithLaserscarsbotheyes.Shehasfullrangeofdiabeticcomplicationsshehas
lossofawarenessofhypoifyouaskedforanyhypoepisodes,Ifyou asked for the insulin injection site
reaction she will say she is on insulin pump. When you ask hows her diabetic control she said her
HbA1Cisabout7,hadprevious2MIwithangioplasty,Previousintracranialbleed(smallfullrecovery)
when you asked for TIA/ Stroke, CKD4 but not on replacement Rx , has peripheral neuropathy but no
diabetic foot ulcer, hypothyroid ) O/E visual acuity reduced on Rt eye ( asked to test with snellen chart
whichwasonthetable),thereisredreflex,Laserscarinbothperipheriesandinthemacularareaofrt
eye.
Herconcerniswhetherhervisualproblemistreatableorwillitgettingworse?
2.78yroldgentlemanadmittedtoA&EwithhistoryofweaknessandnumbnessonhisRtarmandrtleg
lasting3to4hours.Pleasetakefocushistory,exminationandaddressedhisconcern.
( Quite straight forward but if you did not ask , you will miss previous episode on the left arm lasted
aboutlessthananhourafewweeksagoandhedidnotseedoctorforthat.O/EslowAF,Systolicmurmur
probablyAS,IsaidMRasheard&loudinapex,examinerwasnotveryhappycounselledforwarfarin
after excluding contra indications ( Liver problem, bleeding disorders and frequent falls) , suggested
investigationsincludingECHOduetomurmur.Hisconcerniswillitcomebackagain?
3. 56yrold gentleman known HIV with vision problem in his right eye. He had history of seminoma of
left testis and had chemotherapy for that. Please take focus history , examination and address his
concern.
4. This gentlman was referred to you due to high BP 180/120 with headache. Please take history,
examinationandmanagementandaddresshisconcern.
(AcromegalyFeatureswhenIwentintotheroom,notmentioninthequestionpaper)
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5.60yroldgentlemanproblemwithLefthandover2months,historyofrthip&leftkneereplacement
in the past ,take focus history, examination and address his concern. ( Acromegaly with Carpal tunnel
syndrome)
6.RAwithSOBonexertionover3months(Pulmonaryfibrosis)
7.56yroldladyhasbeensufferedfromlegulcers,startedwithoneulcerintheright5weeksagoand
thendeveloped2ulcersintheleftlegover3weeks.Takefocusedhistory,examinationandaddressher
concern.
(history of Leukaemia in the past and treated with chemo and in remission. Answer pyoderma
gangrenosum)
8.55yroldgentlemanwithdeteriorationofhisvision(bothsides)overafewmonths.Takefocushistory,
examinationandaddresshisconcern.
(HegavethehsitoryofRetinitisPigmentosawasdiagnosedhewasyoungandgottunnelvisionfromthe
beginingofhistory.Examinationconfirmedtunnelvisionandfundoscopyshowedpigmentedspiculaeand
diabeticretinopathychangesintheeyeswhichmadehisvisionworse)
9.64yroldgentlemanknownmultiplesclerosisfor30years.Hismultiplesclerosisisgettingworseand
startstointerferehismobility.HenoticedheismoreSOBrecentlyandhethinksitiscontributingtohis
multiplesclerosis.HisGPhasreferredtotheclinicandtoreviewhimandaddresshisconcern. ( Patient
asked why he is more SOB , and what is the cause of it?) Answerfrom History he is current heavy
smokerforover40yrs,actuallyhismobilityisnottoopoor,stillmobilizingfromhistory.Onlywhenyou
asked,hewillgivehistoryofoccasionalpalpitationsandwheezinglately.O/EheisinAF,chestisclear,no
wheeze. The candidate who diagnosed AF passed the case . I missed AF as I had no time to examine
pulse and jumped to his back to listen when 2 mins left. I gave the differential of PE and COPD for his
SOB . Examiners were not happy , wanted to link heavy smokerCOPDcausing AF causing SOB &
palpitationsandfailedme)
10. 25 yr old gentleman admitted to A&Es with 2 bouts of coffee ground vomiting , BP 100/60, PR
110/min.Pleaseexamineandaddresshisconcern.
(Patientaskedifhegohomeasnomorevomitingnow?)
11.Acromegaly,headache,bilateralcarpaltunnelsyndrome
12. Middle age lady has arthritis ( RA) on Hydroxychloroquine for 2 years, has hand deformity . Her
concern is her friend, who has RA, is on disease modifying drug. Does her arthritis medication need to
changetogetbenefitforherhanddeformity?
13. Middle age lady known RA, went on holiday vomited, OGD showed oesophagitis She is on
Diclofenac,steroid,Alendronateacid.Totakefocushistory,examinationandaddressherconcern.
14. 50 yr old lady known acromegaly headache for 3 months to take focus history, examination and
addressherconcern.
15.SystemicsclerosisandSOB
16.Difficultyinswallowingover1year,featuresofCRESTsyndrome
17.Chestpaininasystemicsclerosis+RAlady
18.AcromegalyandSOBonexertionwhichisprogressiveinnature
19.KnownRA,swallowingproblemlumpintheneck
20. 45yrold man with pain and pins & needles in hands for many years. Investigation showed normal
FBC, U&Es, CRP. Xray hands showed Radiolucent lesion in metaphalangeal & interphalangeal joints
asymmetrically.
21.Hypothyroidwithtiredness
22.Psoriasisarthropathyandrtkneepain
23.ThispatientisDxFabrayDisease,hehasproblemwithcontrollinghishypertension,takefocushistory
,examandmanagementplan
24.75yroldmanreferredtoTIAclinicwithsuddenonsetlossofonevisionover6hr.
25.Thismiddleageladywasreferredtoyoubyopticianduetounequalpupils,otherwiseasymtomatic.
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Takefocushistory,examandaddressherconcern
(IsitStroke?AnswerHolmeAdiepupils)
26.PainfulcoldfingersRaynaundssyndrome&systemicsclerosis)
27. Young man with loss of right radial pulse and left carotid bruit. Had recurrent blackouts. Elevated
ESR.
(Answer:Takayasussyndrome)
Backtotop
Experience6
Station1
respiratory: instruction was this man has episodic breathlessness, examine chest: he was young and
there were no findings and I presented as normal chest. Then they asked why does he have
breathlessness...Isaidsinceinstructionwastellingepisodic,hecouldbehavingasthmathentheyasked
aboutasthmamanagement.
abdomen:Hadbigliver&telengiectasiasaroundmouthbutnospleen.IpresentedasHHT.Hehadbruit
(Iwronglypresentedasvenoushumthentheyaskeddifferenceb/nhumandbruit).
station2
History taking 56yrold lady with wt loss and loose bowel . They asked all dd's related to
malabsorption...shewasceliac.
Station3
CVS:metallicprostheticvalve:wasabletohearthemetallicsoundoutside.Manwasinhis50's.Asked
possiblecomplications.&indications.
Neuro:Instructionwas:testthisLady'sspeechandproceed..
She had a scanning speech. Had all cerebellar signs including nystagmus, positive finger nose and heel
shintest.Askedwhatcouldbecause...IsaidDDasalcohol,MS,Friedrich'sataxia.Shehadpescavusand
henceIsaiditcouldbefr.ataxia.Alsoaskedinvestigations.
Station4
62yea old diabetic and heavy smoker presented to vascular team with claudication pain. MRI done
showed severe disease and vascular team has decided for conservative management..Patient very
unhappy that it is for medical management . Candidate ( medical team) asked to explain medical
treatmentplan
Patientagitatedsayinghehasnotbeenmanagedproperlysofar.Exploringthesituation,Irealisedthat
hewasnoncompliantwithinsulinadministrationandofferedhimhelpbychangingtolessfreqregime.
Hewascontinuingtosmokeandhasneverbeenofferedsmokingcessationadvice.Thiswasoffered.
AlsoreviewedmedicationlistandevaluatedriskfactorsapartfromDiabetesandsmoking.Hehadissues
athomewithwifenotwell.Explainedthatitisalsoveryimportanthisparticipationandcompliancevery
vital in salvaging limb. Further specialist ( diabetes and chiropody) will be arranged thru GP ( half way
duringtheconverstionhesettled...justgavesometimeforhimtoexpresshisanger)
Station5
Case1
37yearoldfemaleadmittedwithlowerabdominalpain..talktoher.Obschartandurinedipstickchart
werekeptincorner.DipstickwassuggestiveofUTIandobsshowedtemperature.Pthadflankpain
C/osympsuggestiveofpyelonephritis.Abdexaminationwasunremarkable.Shewashypertensive.Ptwas
concernedonlyaboutanythingserious??
Examinersaskedaboutinvestigationsespeciallywhyultrasoundandalsoontreatment
Case2
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47yearold male admitted to MAU with cardiac sounding chest pain. Had risk factor of smoking. No
familyhistory.
Explained to pt investigations planned (ECG CXR TROP etc offered pain relief). Said if normal will need
specialtestslikeETT
NocomplicatedQsfromexaminers
(Candidatepassed)
Backtotop
Experience7
CandidateNo:
IwantedtowritetoletyouknowthatIpassedmyPACESexam.Iwantedtogiveyou,asyourequested
someinformationre.thecasesIwasgiven:
Station5:
Acromegalic gentleman. He had previously had transphenoidal resection of the pituitary,c/o tingling in
the hands. I examined visual fields and sensation. I was asked about investigations, management and
treatments
Ayoungladywithacollapse?cause.Nothingevidentonexamination,thefocusseemedtobemostlyon
investigationsandmanagement
CVS:Mitralvalvereplacement,askedaboutindicationsforvalvereplacementsandcauses.
RS: Stoney dull left lower zone, pleural effusion. Asked about differentials, exudates, transudates and
Light'scriteriaaswellasmanagement.
Neuro:YoungladywithMS
Abdo:MercedesBenzscarnosignsofchronicliverdisease,drainsorotherscarsetc.Askedre.causesof
CLDandALDandimmunosuppressantsposttransplantation
Historytaking:Youngladywhohaslostweightwithouttryingwithassociatedloosestools.Shehadbeen
on a cruise a while before and had no symptoms prior to that. Investigations and management.. re.
infectivecauses,ixofIBD/coeliacs(amusinglyatthetimethewordCoeliaccompletelyslippedmymind
likearealvoid)IwasaskedwhatIwouldexpecttofindoncolonoscopyandwhatIwouldthendo.
Communication & Ethics (?) Patient with known COPD had been brought into hospital with severe
pneumoniaCurb65vhigh(can'trememberthenumber),givenIVantbiotics,admittedtoasurgicalunit
as no medical beds available. During the evening, canula came out, not immediately replaced, dose of
antibiotics missed nurses were busy with another patient being transferred (or something like that)
DelaymovingpatienttoHDUwherehedied.Theactorwasthepatient'sdaughterwhowasveryupset,
understandably,andshesaidhehadbeenfinethedaybeforeadmission.Shewasangryasshefeltthat
herfatherhadbeenmismanaged.
I explained re. bed situation, triaging, patient seen by Medical SHO/SpR and that surgical wards were
able to manage antbiotic therapy and IV Fluids. Agreed that a medical ward would have been more
appropriate. Lots of discussion re. missed antibiotics and transfer to HDU. I said I would escalate her
concerns to the Consultant and arrange a meeting, but could not promise when at the time. PALs was
discussedaswasdatexreportingofclinicalincidents.
Backtotop
Candidate8
IamhappytoinformyouthatIpassmyexamandherearemyquestions....tosharethosepreparingfor
theexam.
Station1:CVSyoungladymidlinesternotomyscarIheardloud2ndsoundandsystolicmurmur.Give
differential tissue AVR, ( ? Cong bicuspid ). VSD, TOF( they want that answer) but no clubbing and
cyanosis
CNS Question a man...balance problem.examine him. He was sitting in a chair. When I ask to walk
...said he can't walk. Then, I found resting tremor of left hand. Parkinsonism causes. Ask me how to
differentiate it from benign essential tremor. Want DAT scan. And also ask me what medication I will
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start
Station2:Respiratory:AmanwithNCO2,clubbing,VBSwithprolongedexpiration.Rackeleschanged
incharacterwithcough.IsaidbronchiecstasieswithunderlyingCOPD.Theyrehappy.....askmeIvand
treatment
Abdomen:renaltransplant(bilateraliliacfossascar,leftsidetendertotouch)previoustiedupfistula
on left arm. New fistula on right arm , no recent venue puncture mark. Finger tip ...blood sugar tests
marks+, so underlying diabetes. Ask me about.....what will u do if that transplant issue is sorted out.
SaidmonitorImmunosuppressantlevel,macro/Microvascularcomplication...Ivandtreatment......happy
Station3:youngladywithchronicdiarrhoeaandnormocyticanaemia.Sheconcernedabout?cancerre:
her dad had similar symptoms and died of ca colon. Back pain on NSAID. DDx: coeliac, NSAID induced
UGIbleeding.Discussedinvestigationforcoeliac.Askedmewhyshehadbackpain....Isaidosteoporosis
#.....happy
Station4 40 yr man on warfarin for AF. Collapse at job. CT SAH, resp arrest, need ventilator. ITU
admission.NeuroSxr/vnotforSx.Pasthistoryhypertension.Tospeaktowife.Aboutbadnewsand
Prognosis.
Wifeask?Warfarin/?HTNcauseit?Willherecover.Sdshebringhersonfrschooltoseehisdad?
Examineraskhowdoufeel?Expecting.....todiscussorgandonation
Station5:
A) pregnant lady, 3rd trimester. Left sided weakness and numbness...resolve in 24 hr. PMH: CVA: full
recovery,ASDrepair.1abortion.DxTIA,.?Antiphospholipidsyndrome.ExamineraskCTsafe?
B)Youngladywithhandtremor.PMH:thyrotoxicosis,recentlystoppedmedication.
O/E... Signs of hyperthyroid. And multinodular goiter. Examiner ask: investigation: TSH, she want to
hearradioiodinetest.
Backtotop
Candidate9
IattendedyourcourserecentlyinJune2012andjustlettingyouknowthatIpasseditwithreallygood
marks160/172.Averybigthankyoufororganisinganexcellentcourse.
HerearethecasesthatIhadformyexam:
Station1
Respiratory:A68yearoldladywithleftupperthoracotomyscarandsubtleleftHorner'ssyndrome.She
had tracheal shift to the left. Questions asked were: What investigations would I organised and the
managementofNSCLC/SCLC.
Abdomen: A 60ish year old guy who was blind with bilateral renal transplant. There was evidence of
immunosupressionhypertrophyandskinthinning.Likelysecondarytodiabetes.Discussionwasregarding
thedifferentsideeffectsofimmunosupressantsandsignsoffailedgraft/transplant.
Station2
A 68 year old lady who came in with nonspecific tiredness. No other symptoms to suggest
malignancy/malabsorption/occultorfrankbloodloss/endocarditis.PMHofrecentaorticvalvereplacement
on warfarin and had transfusion post op. There was a family history of bowel cancer. Blood showed
microcyticanaemia.ThiswasquitestraightforwardasIwentdowntherouteofirondeficiencyanaemia.
Discussion was regarding differential diagnosis malignancy, haemolytic anaemia, coeliac diasease,
angiodysplasia etc and the investigations needed. They did ask what I would do if all my investigations
werenormalsaidBMbiopsybutnotsureifthiswascorrectandhowwouldIdiagnoseangiodysplasia.
PatientwantedtoknowifshecouldstopwarfarinasherHbwaslowandwhetherherprevioustransfusion
causedhertohaveareactionresultinginlowHb.
Station3
CVSmixed aortic valve disease with the predominant lesion being aortic regurgitation. Patient also had
coarctationofaortaandhypertension.DiscussionwasaboutcausesofAR,managementofARandwhat
wouldIlookforintheechocardiogramaorticrootdiameter,LVSFetc.
NeuroIt was similar to the guy who had polio from the course. He had LMN sign in the left arm with
deformity and shortened limb. Discussion was about where the lesion would be and polio disease in
generalvaccinationandwhetherithasbeeneradicatedcompletelynow.Theexamdidn'tgowellforthis
station.
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Station4:
Ethics68yearsoldguywhohadaSTEMI6/52ago.Knowndiabeticininsulin.Essentiallyhewasfound
to have iron deficiency anaemia when he was admitted with MI but this issue was not addressed. He
presented6weekslatertohisGPwithtirednessandshortnessofbreathandbloodsshowedIDA.Station
focusedonexplanationofanaemiaandtheconsequencesofdelayedinvestigationsanddealingwithone
angrypatient.Italsofocusedonexplainingfurtherinvestigationsre:ogd/colonoscopyandpatientneeded
tobeadmittedforbowelpreparationashehaddiabetes.
Station5
A) 79 year old lady with previous non functioning pituitary adenoma had surgery and previous
thyrotoxicosis who complained of worsening had tremor for 1 year. Tremor was worse on movement.
FamilyhistoryofParkinson'sdisease.Thiswasbasicallybenignessentialtremorastherewasnosignsof
hyperthyroidism or cerebellar signs on examination. Discussion was on differential diagnosis, how to
manageessentialtremororifIwoulddoanyinvestigationstodiagnoseitandtreatment.
B)58yearoldwhoinitiallyhadhypothyroidismonthyroxineforyearssuddenlydevelopedsymptomsof
thyrotoxicosis with enlarged goitre. Blood test confirmed this and she was on carbimazole and was
referred to clinic. Examination revealed unilateral goitre but no Grave's signs. We discussed the
differentialdiagnosis,investigationsre:specifiallyultrasoundandfineneedleaspirationandwhatiwould
seeinthehistology(??).TheyalsoaskedmeaboutcarbimazoleandPTUandtheirsideeffects.
Allinall,itwasadoableexambutstressful.Again,thankyouforanexcellentcomprehensivecourse.
Backtotop
Candidate10
Abigthankyoutoyouandyourcourse...IgottheresultofPACES.IampleasedtosaythatIpassed
theexamwithaveryhighscore(2012).
Firststationwasstation3
Cvstallman30yrsage...Midlinesternotomyscar,higharchedpalate,systolicmurmur,withloudS1.
Gross finger. Clubbing .... With the previous preexam stress ... I gave them differential about marfans
andcongenitalHeartdisease.....Icouldseethisdidn'tgodownwellwithexaminers....
IgotlessmarksinCVS.
CNS:
A70yroldfemalewithscarbehindleftmastoidandear....Deviationofuvulatoleft,deviationoftongue
torightandfurrowingoftongueonleftside....Withspeechlikebulbarpalsy....
IgavedifferentialofSOLwithIXTOXIICNPALSYandpossibleMND
IfeltCNSwasdefinitelybetterthanCVSanditreflectedinmymarks....
Station4:communicationskills.
ThepracticedoneatCardiffpacescoursereallyhelpedme...
A52yroldfemalehadseencardiologist/rheumatologist/gastroenterologist/neurologistforthepast20
yrs...Hadfurtherinvestigationsandcametoclinic.yourconsultanthasseentheresultssuggestedthathe
doesn'tneedanyIxfurther....
Conversiondisorder...../Munchausen/wentonverywell.Discussedaboutcognitivebehaviouraltherapy
etc.,gotfullmarks...
Station5:
Case1:
A53yroldfemalewithBP212/126,headacheexamineandproceed.....
On taking history and examination .... She had NF Type 2 , all features and diagnosis
phaeochromocytoma....DiscussionwentverywelluntilMIBGSCAN...
Case2:
25yroldfemalewithchestpainassessfurther......LadyhadPE,DDPneumonia/pneumothoraxaspt
hadasthma,...Itwentonverywell.Igotfullmarksinthisstationaswell.
Station1:
Abdo : bilateral nephrectomy scars..... RIF Scar.....no transplant old AV Fistula,and a current fistula on
otherarm...
DiscussionaboutUrineACR/PCR,causesandcomplicationsetc.,
Bingofullmarks...
Resp:
Midlinesternotomyscar,SVGscar,withfeaturesofinspiratorycrepitationsuptomidchest....
DDinterstitiallungdisease,investigations,managementandfinallytheyaskedmewhatisthatyouarea
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reallythinkingifitwasnotrespiratorystation.ItoldthemthisisCCF....theynoddedtheirheads....
Fullmarks.
Station2:history
78 yr old male came with confusion take history from daughter.... Tricky one.. Pt absolutely fine till 1
weekago.Nowrenal failure.... After picking up the cues .. From daughter, I found out that is case was
nephrogenicdiabetesinsipidus.Ptwaslithiumandhehadrecentboutofdiarrhoeathatupsethiskidneys
andhenceLicausingproblems.
DiscussionaboutDDofconfusionandwaterdepreciationtestanalysis.....
Fullmarks....
Havingdonethecourseexactlyoneweekinadvancetomyexamdatereallyhelped....Andmockexamat
Cardiffpacescourse.....Isaverygoodexperience.
IwouldrecommendthecoursetoeveryoneifweletgothecrazeaboutLondoncourses....thisisbyfara
verygoodcourse.
Backtotop
Candidate11
I managed to pass paces!!!!!!! I wanted to thank you for your excellent teaching on the Cardiff course
thatmadethispossible!(2013)
Herearemypacesstations:
CVS:sternotomyscar,loudS1,middiastolicmurmur(didn'tpickit).ItwasMSbutIgaveadifferential
forscaraskedaboutinvestigationandRx
Resp:lobectomy,clubbed.Askeddifferentialsandinvestigations
GI:renaltransplant,bilateralnephrectomiesaskedaetiologyandinvestigations
Neuro:peripheralneuropathy(ThinkshehadCharcotMariebutIdidn'tpickit)
HxTypeIDiabeticrecurrenthyposanddiarrhoeawithanaemia.Isaidmalignancy,coeliac,IBS,carcinoid
askedinvestigationsRxandpt'sconcernswhichwerehishyposandchanceofmalignancy
Ethics: stroke pt talk to daughter about progress and prognosis. Ethical discussion about where she'd
go, daughter wanted NH pt wanted to be d/c home talked about pt autonomy and pt safety acting in
bestinterests
Station5ChurgStrausssyndromepluspalpitationswasAFandIaskedabouthisvascularisequizzed
aboutAFaetiologyandRx
Station 5 pt presenting eye problems thyroid pt thyroidectomy on thyroxine. Felt eyes sticking out.
Askedaboutandexaminedforthyroidstatustheyaskeddifferencebetweenexophthalmosandproptosis
andaetiologyofproptosisotherthanthyroid.
Backtotop
Candidate12
JustaquickemailtosaythankyouforallyourhelpwithmyPacesrevisionandpersuadingmetogoon
your course! I am pleased to tell you it paid off and I passed...I think your course helped with my
preparationsomuchandthebrilliantteachingcombinedwithrangeofpatientswasinvaluable.Ialsofelt
themockexamwasveryhelpful,asalthoughIwasverynervous,itmeantIknewwhattoexpectonthe
day!
Cases
CommunicationIwasaDrattheGUclinic.ATSPwhowasworriedshehadcontractedHIVfromaone
nightstandafewweeksago.Shewasamarriednursetryingforababy.Askedtotellheritwouldbe3
monthsuntildefinitivetestresults.Discussionaboutpersuadinghertotellothersandmyobligationsif
she refuses to tell those at risk. Also asked me to reflect on how the consultation went at the time I
thoughtithadgoneterriblyIhadalottosay.
Station5Patient1:I'lbehoneststillhavenoidea.InfooutsidetoldmehehadahistoryofSOBfewyrs
ago,cxrshowedcannonballlesionswhichwerenotcancer.GPreferredhimwithpainfulfeettomeina
general medical clinic. On entering elderly gentleman, walking aids, carer present. Told to focus on the
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legs,struggledwithtargetedhistoryfromhim.Didnotexpandaboutchestotherthantosayhadasthma
also denied any pain. On examination had a sensorimotor neuropathy. They were cross I did not do
reflexesasranoutoftimeIpresumethiswasrelevant.
Patient2:muchbetterasreflectedinmyresultsofthese2patients!ATSPbyGPrerashvitiligoonface
also rheumatoid hands asked about other autoimmuneconditions and discussed management of vitiligo
anddifferentials.Shewasconcernedaboutcosmeticappearancemainly.
Abdo hepatosplenomegaly with hepatic bruit and stigmata of CLD. Also huge painful mass over left
chest wall ?? I was directed away from this during the examination but then frustratingly asked about
thislater.
RespCOPDaskedaboutdiffdiagnosis/investigationandmanagement.
HistoryPresentedwithwidespreadoedemaalsohxofrecurrentchestinfectionsandsomehaemoptysis.
Measlesasakid.Discussionofnephroticsyndromeandmanagementofhaemoptysis
Neuro MND, asked to examine motor system, told sensation normal. Asked about diff
diagnosis/investigationsandmanagementfutureplanningandadvanceddirectives
CardioAorticstenosis+/MR.Qusaboutdifferentiatingaorticstenosisandsclerosis.Icouldnthereany
radiationasthepatientgotthegiggles,theyaskedmetogobackandlistenbutranoutoftime.
All the patients except stn 5 were clearly current inpatients and the comm/history station were nursing
staff.
Backtotop
Candidate13
I just wanted to say a huge Thank you for the course in January (2013) and the fantastic effort you all
putin,especiallygiventheweather!
Ipassed,asdidJHandBAwhowereonthecoursetoo.Ithoughtitwouldbehelpfultoletyouknowthat
weallpassedwithyourhelpandwhatstationsIhad:
Station1:
Cardiovascular: Mitral regurgitation without compromise. Asked me why the second heart sound was
importantandwhatthecauseswereandwhyshemightbeSOB(?paroxysmalAF)andhowyouwould
investigate
Neuro:Examinethismanseyes:HomonymousHemianopiaincongruous.IsaidIwantedtoexaminehis
carotids,pulseandheart?strokerisk.DiscussionaboutlikelystrokecauseandAFandanticoagulation.
Station2:
History was a 30 year old who was 'tired all the time' and had had a previous DVT, joint pains and a
malar rash. She had also had a miscarriage. Diagnosis SLE with likely Antiphosphlipid treatment.
Questionsabouthowtoinvestigateandtreather.
Station3:
Abdominal: Not sure what this was and none of us scored well on the day. Middle aged lady presenting
withabdominalpain.Grey/pigmentedskin,macroglossiaandaverysubtlepolycycsticrightkidneywith
somesortofsubcutaneoustubingweallthoughtinherperitoneumnoexitportoranyothersignsof
previousrenaltransplantorotherRRT.
Respiratory: A classic fibrosis with clubbing and cyanosis secondary to scleroderma obvious skin
changes.Questionsaboutcomplications,investigations,managementandprognosis.
Station4:
Breakingbadnewsreadvancedlungcancerdiagnosisand6monthdelayinreferral.GPhadnotreferred
despite red flag symptoms for months. She had also had an abnormal CXR that had been reported but
nobody had picked it up during a pre op check for an ovarian cyst removal. You had to break the news
andmanageherconcernsregardingthedelayindiagnosis.
Station5:
A:
33 year old with recurrent headache and collapse. She mentioned early on that she had Tuberous
Sclerosis and therefore epilepsy. Essentially this was very difficult as there were two separate PCs. The
headache sounded very much like hemiplegic migraine and the collapse sounded cardiovascular with
presyncope, although she said that she had been collapsing less since her epileptic seizures had been
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bettercontrolled.TheywouldnotallowmetoexamineherheartwhichIfoundbizarregivenshecamein
with collapse!! They wanted us to look in her yes and briefly assess neurology i think! Discussion was
around investigations and differentials. I said a CT/MRI, ECG, ECHO and 24 hour tape. Somehow I got
fullmarksalthoughthisstationfelthugelyuncomfortableandIfelttheexaminersdidn'tquiteknowwhat
wasgoingoneither!!
B:
50somethingwithhandpain.HadsclerodermaandRAdiscussionre:Investigationandmanagement.
OverallIthoughtIhaddonereallybadlyandfeltthatfartoomuchhadgonewrongforittobeokbutin
theendscoredwelloverthepassmark.Myadvicetopeoplewouldbetostaycalm,notbeflappedbyone
stationgoingbadly(itmightnotbeasbadasyouthink)andnottobelieveallthehypebecausereally
theyjustwantyoutobesafeandsensibleandnotsaystupidthings!
Hopethefeedbackishelpful!
Manythanksagainforyourhardwork!
DrLG(MRCP!!!)
Backtotop
Candidate14
Had2goesatPACES,justshortofpassingfirsttime,goodpass2ndtime(171/172)!
1stgo:
Station1AbdoPleaseexaminethisladysabdomenpallor,8cmsplenomegally,radiotherapytattoo
left breast (told to ignore this) no hepatomegally, no lymphadenopathy, no features RA, no features
chronic liver disease. Gave differential haematological disease/malignancy, infectious, liver disease etc
anddiscussedtests.
Station 1 Resp This gentlemen presents with breathlessness, please examine his chest features
suggestive interstitial lung disease, discussed causes in particular they wanted to discuss occupational
causes
Station 2 History Young woman in general medical clinic with tiredness, malaise and deteriorating
renal function. On further questioning has headache suggestive temporal arteritis with visual changes
(she mentioned headaches on and off and you had to pick that up and go into visual changes etc).
Differentialsandtestsdiscussedmostimportantvasculitisandconsiderrenalbiopsyontopoftheusual
renalscreen(bloods/USS)
Station 3 Cardio Elderly gentleman with midline sternotomy scar and right sided thoracotomy scar,
no scars in the legs but valgus deformity of the ankles and wrists. Normal heart sounds. I had no idea
whatwasgoingonintheexam,butinrestrospectsignscouldhaverepresentedconnectivetissuedisease
withsurgeryforaorticvalve/aorticdissection.
Station 3 Neuro Young woman, asked to examine her face and arms. Left facial weakness, winged
scapula. Asked about her gait (hadnt examined it but they clearly wanted it) so did and she weak hip
abductors.RanoutoftimeforquestionsasItriedtoexaminecranialnervesandupperlimbscompletely
whichIdidntreallyhavetimefor.Again,inretrospectprobablyfacioscapulohumeraldystrophy.
Station4CommunicationAskedtodiscussdiagnosisofIBSwithpatientandaddresshisrequestfora
secondopinion.HewasconcernedaboutCrohnsorbowelcancer,discussedsymtomsnilworrying,and
explainedtothepatientwhatheshouldlookoutforredflagsfortheseconditions.Discussedoptionof
secondopinionandthenfurthercolonoscopywithassociatedrisks.Suggestedreliableinternetsitesrather
thantheforumshewasusing.Ptleftveryhappyanddidntwantthesecondopinionintheend.
Station 5 1st case Complains of joint pain Obvious RA, pt had been on treatment for 20 yrs and
was on methotrexate and rituximab. Pt wanted to know if she needed another rituximab. O/e signs
suggestive of RA with mild synovitis MCPs, also nodal OA affecting DIPs. Talked about DAS scoring to
decideifrituximabneededagain,alsoconsidersteroidsIMifthishelpedbefore.Examinersaskedford/d,
whyaretheDIPsaffected,managementplan.
Station52ndcaseYoungwomanwithpalpations,feelingcoldandconstipation.Obviousthyroideye
disease and thyroidectomy scar. On questioning the palpitations were some years ago when she was
hyperthyroidandnowbradycardic,coldintolerant,constipation,dryskin,describedpretibialmyxoedema
nowsettled.IsuggestedwerepeatherTFTs(likelygravesnowhypothyroid)andincreaseherthyroxine
asrequired,screenforphaeoifanyfurtherpalpitations.
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2ndgo:
Station 1 Resp Elderly gentleman, SOB. Short of breath at rest, no O2. No clubbing, nicotine
staining, barrel chest, fine insp crackles, no wheeze. Also midline sternotomy and scars in legs from
venous harvesting. Discussed d/d COPD/interstial lung disease with CABG. Inx
Blds/CXR/ABG/Spriometry/HRCT.Askedaboutexpectedresultsofpulmfunctiontests.
Station1GastroYoungmanandtoldhehadalongtermgastrointestinalproblem.Clubbed,mouth
ulcers, PEG, scar in RIF, laparotomy scar. Discussed d/d only thing I could really think of was Crohns
withmultipleops.AskedwhatIthoughtPEGwasforashisswallowwasfinesaidnutritionmaybeshort
bowelsyndrome.Askedaboutassessmentofnutritionalstate.
Station 2 Dairy farmer with lymphadenopathy referred by GP. Describes night sweats, lethargy 3
months.Nochestsymptoms.HadtravelledtoEgyptfewmonthsprior,hadsomeloosestools.Otherwise
well. Discussed d/d haematological malignancy, TB (?bovine), other tropical disease, r/o ca bowel.
Suggestedbloodsandlymphnodebiopsy,askedwhatthismightshowifitwereTB.
Station3CardioElderlygentleman,SOB.Nilexternalsigns,pansystolicmurmurloudestrightsternal
edge.Discussedwithexaminerd/dAS(andwhyitwasnottypical)MR(againwhyitwasnottypical)
and VSD ( most likely, but why would it give him problems after all this time). Discussed usual inx.
ExamineraskedifIwoulddoanythingaboutaVSDinan80yroldgentleman,Isaidprobablynotand
lookforanothercauseforhisSOB.
Station3NeurologyElderlyladywithdifficultywalking.Barndoordiabeticperipheralneuropathy(I
wassohappy,patientwasevensmilingandnoddingbehindtheexaminersbackwhenIsuggestedthis).
Station 4 Asked to d/w daughter of patient who came in with CVA, outlied due to lack of stroke unit
beds, improving well from stroke but now has pressure sores both heels and MRSA growing in one of
them.DaughtersconcernsthattheMRSAcouldbelifethreatening,thatthepressuresoresshouldhave
beenprevented,andthathewasnotgettingasgoodcareashewouldonthestrokeunit.
Station 5 Gentleman with acromegally concerned about recurrence. No visual problems, no facial
changes, few nonspecific symptoms. o/e Normal visual fields, features of acromegally. Discussed bloods
forgrowthhormonebutalsoforothercausesofhistiredness.
Station 5 Gentleman with RA. Taken off DMARDs 6 months ago and switched to steroids. C/o back
pain.Tenderoververtebraeinlowerthoracicregion,slightkyphosis,alsoactivesynovitisin1st3rdMCPs
and wrists, features of longstanding RA inc nodules at elbows. Discussed possibility of osteoperotic
fractureofspinefollowinglongtermsteroiduse,notonprevention.ToldexaminerIwantedhisnotesto
find why DMARDs stopped, thoracic xray and DEXA scan. Still active RA so would benefit from further
DMARD.
Backtotop
Candidate15
I passed my exam! Can you pass on my feedback regarding my exam cases, as promised during the
course?Manythanksforthecourse,Ireallyenjoyedit.
Cardio: Dextrocardia and heart failure Qns: ECG of someone with dextrocardia management and
investigationsofheartfailure
Neuro:Leftupperlimbpuremotorneuropathy,underlyingacromegaly,pacemakerQns:Investigations,
DifferentialDiagnosis
Abdo:Renaltransplantworking,mildvolumeoverload,signsofimmunosupression,previoustunnelled
line, peritoneal dialysis, cause: polycystic kidney disease Qns: other potential causes, what
immunosuppression,Investigationswanttodoinclinic.
Resp: Pulm fibrosis with pulm HTN, no obvious underlying cause Qns: Investigations, management,
differentialdiagnosis.
Station 5: Dizzyness young 30 yr old, sudden onset dizzyness that morning Qns: Investigations,
differentialdiagnosis,management
Station 5: Painful hands classic rheumatoid hands, not active currently, on methotrexate Qns:
Investigation,differentialdiagnosis,management,safetynetting(bloods,SOB),howregularlyyou'dlike
toseeherinrheumclinic?
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Communication: Breaking bad news, lady in 30s with young children, husband lives away, SOB over 2
months, CXR done right effusion, aspirate shows adenocarcinoma unknown primary. Break bad news.
Discussed underlying issues pain, SOB limiting quality of life/working, husband away. Further
investigations,management,followup.
History:Tiredness/lethargywithmicrocyticanaemia.Underlyingissuesidentifiednew'IBS'diagnosis,
'mechanical' back pain for 1 year where she is dependent on Diclofenac FHx: father colon ca, mother
anaemiaQnsDifferentials,Investigations,Management,Followup
Backtotop
Candidate16
Ipassedpaces!IwantedtosaythanksandgiveyousomefeedbackfortheCardiffcoursesite:
Resp:Womaninher50's/60'swithinspiratorycrepsbibasally,nothingtosuggestacause.Ipresentedit
asfibrosis.QuestionswereonkeyinvestigationsIsaidHRCTandtalkedaboutappearancesthatwould
suggest steroid responsive disease. They also asked how to assess SOB, I told them ABG/ PFT and
exercisetolerance.20/20
Abdo: Asian man, no peripheral stigmata of chronic liver disease. Abdomen was soft, splenomegaly and
distended veins. Presented as portal hypertension, discussion was around investigation and possible
causes.20/20
History:20yearoldwith3admissionsforpneumoniainthelastyear.Sexualhistorydemonstratedrisk
factors.Butalsohadachildhoodhistoryofgiardia.Theydidn'twantexactdiagnosisjustasingletest
immunoglobulins,20/20
Cardio: Young man with central sternotomy. no vein harvests and normal heart sounds. Discussion was
aroundwhathemighthavehaddone,Iofferedvalverepair,tissuevalveorrepairofcongenitaldisease.
19/20
Neuro:Caucasianman,approx.70's.Askedtoexaminelowerlimbs,hadmonoparesis,normalsensation
andpescavus.Presentedasoldpolioaskedaboutmanagementiesupportivestuff.19/20
Ethics:discussionwithdaughterofawomanwhowasabouttobedischargedfollowingurosepsis.Shehad
apreviousstrokeandthefamilywerenotcoping.Wantedcandidatetotellthemothershehadtogotoa
nursing home. Also on digging further there were marital problems, no holidays for years etc. I offered
thatweshoulddiscusswiththemothertogetherandbehonest.Offeredoptionsre:OT/packageofcare,
respitesupportifrequired.16/16
Station 5 A) referral from ophthalmologist, bilateral papiloedema. history of headaches and poor
peripheral vision. o/e: bitemporal hemianopia. no features of acromegaly. I was pretty unsure what this
was, suggested a pituitary lesion. investigations CT/MRI head and dynamic pituitary function testing.
26/28
B) painful ulcer on lower leg. associated diabetes. Had a central brown discolouration. I suggested
necrobiosis lipoidica which the examiners seemed to like. Discussion was around all the various ulcers
diabeticscanget.InhindsightIwasclearlywrong!14/28.
Backtotop
Candidate17
I attended the PACES course you ran in September 2013 and wanted to thank you for such a brilliant
course.ItwasmostdefinitelythebestcourseIhaveeverattendedwithsomanycasestoseeandmade
mefeelreallypreparedandexcitedaboutsittingPACES.
Ihavenowtakentheexaminationandpassedwithahighscore(166outof172)!
IthoughtIwouldfeedbackbyexperienceasyouaskedforthewebsite.Ihopeitmaybehelpfultosome
othersinthefuture:
Istartedoncommunicationskills:thiswasinformationgivingtoamanwhohadwidespreadSTsegment
depression on exercise testing and symptoms suggestive of stable angina. The information before told
you he was a well controlled diabetic, nonsmoker but had a high cholesterol. The task was around
information giving explaining to him the diagnosis, need for prompt admission for angiography +/
angioplasty and to discuss secondary prevention medications. The patient held a very firm view of
managing their own health and was against taking any tablets and was upset that this should happen
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despitehisbesteffortstobehealthy,whichweredrivenbyafearhewouldbelikehisdadwhodiedofan
MI aged 50. I explained it was great he was so proactive but it was likely his cholesterol may have a
family basis and he really needed the angiography, explaining about the vessel narrowing process. I
managed to persuade him to accept our help before it had ended. The examiners asked me afterwards
whatIwouldhavedoneifherefused,towhichIsaidIwouldhaveusedstrongerlanguagestillexplaining
tohimthathecouldhaveafatalMItheywerepleasedwiththisasfeltitwasaproperpartofinformed
consent. I also said would use other formats of portraying the information i.e. statistically using
Framingtoncalculatorofrisk.Thequestionsthenbecamemoreabstractsuchas:"whatisthedifference
betweenempathyandsympathy?"and"howwouldyouhavelikedtoarrangetheroom?"score16/16
Station 5: I had spotted a blind dog in the corridor beforehand so knew an eye case was coming! The
elderlygentlemanhadnoremainingvisualacuityandonfundoscopyhadclearretinitispigmentosa.Iwas
askedwhatelseitcouldbetowhichIreplied'nothing,itisexactlyasretinitispigmentosaisbutitcould
be in association with other conditions', and I then discussed mitocondrial conditions such as Kearns
Sayre.Score26/28
My other station 5 case was a lady with Raynauds, sclerodactly limited to forearms, peroral puckering
and microstomia. I explored the symptoms of CREST with her, asked about SOB and any renal
dysfunctionbeforeexaminingherhandsandmouth.Iwenttolistentoherchestbuttheexaminerstold
me it was normal. I presented as limited sclerosis, asked to do ANA and anticentromere antibodies,
U&E'stomakesurenorenalinvolvementetcScore26/28
Resp:elderlygentlemanwithinstruction"thismanhashadthoracicsurgeryandisnowincreasinglySOB,
please examine". He had a big midline sternotomy scar, along with a scar in axilla and on R thorax
posteriorlywhichIpresentedasconsistentwithoperativedrains.Hehadmarkedfibrosistomidzoneon
left side with reduced percussion basally with normal sounds on right. I presented as endstage fibrosis
withasinglelungtransplant.Idiscussedconcernsrebronchiolitisobliteransinlungtransplants,theneed
tomonitorspirometryanddiscussedthecomplicationsofimmunosuppressants.Score20/20
Abdo: young man, generally cachetic with abdominal distension, dilated superficial veins and a massive
umbilicalherniainaclothbag!Ipresentedasascites,portalhypertensionlikelysecondarytoCLDwitha
possible splenic tip although I wasn't sure due to ascites so I would get an USS (he had leuconychia,
palmar erythema but was not jaundiced). I then said the causes of CLD most likely alcohol, chronic
hepatitis but used a seive to say could be metabolic, autoimmune, neoplastic etc Asked about
investigationsandthistookupmostofthetime!Score20/20
History: 68 year old with proximal myopathy symptoms, some unitentional weight loss and a mild
normocytic anaemia. She had a PMHx of severe osteoporosis. Also, during discussion became apparent
shehaddevelopedanewcoughoverlasttwomonthsandwasanexheavysmoker.Itoldpatientmost
likely polymyalgia rheumatica because it is common in age group and very similar symptoms but that
also on my differential list was another condition possibly linked to an underlying malignancy
(polymyositis) and I would want a CXR. Examiners made me feel afterwards that it was clearly
polymyalgiaandIfeltIhadrunawaywithmyselfthinkingofpolymyositis.Theyseemedtojustwantto
discuss osteoporosis and the use of steroids and frequency of DEXA scanning I said I'd still give her
steroids in high dose as this is the treatment of polymyalgia but would do a DEXA scan before and at
intervalsofapproximately6months.Score19/20
Cardio: aortic stenosis! The examiners really tried to throw me here I felt as wouldn't let me present
normally, said I was only allowed to mention positive findings and give my most likely diagnosis. They
quizzed me on the pulse character and I stuck to saying it was normal but said I knew it can become
slowrisinginaorticstenosisbutitwasn'tinthisgentleman.IthinkthiswentdownwellasIwasn'tjust
reading the textbook signs and was being confident in my findings. Questions on investigations and
management.Score19/20
Neuro: amazingly Parkinsons! Instruction said examine this man's upper limbs and proceed to do
anythingyouneedtotomakethediagnosis.Ithoughtthemanhadreducedfacialexpression.Hewassat
with his hands held together (trick to try and stop you seeing the tremor). I asked him to let go of his
hands and put them by his side and just watched for quite a while hoping to see the asymmetrical
tremor,whichIdid!Hewaswellcontrolledwithmedssoallsignsweresubtlebutthere.Iperformedfull
upper limb exam as this is what instructions said but did it quickly, only testing one spinothalamic and
one posterior column sign. I then demonstrated hypokinesia, tested eye movements for progressive
supranuclearpalsyandwatchedthemanwalk.IstillhadtimeleftsoIaskedhimtomovehisotherarm
up and down while feeling the cogwheel rigidity enhance. Questions on making diagnosis (said it was a
clinicalone,Iwouldn'twantanyimagingunlessfeaturesatypicalforidiopathicPD),complicationsofPD
andmanagingthem.Score20/20
Ihopethat'shelpful!
Backtotop
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Experience18
IjustwantedtoletyouknowthatIpassedmypaces.IwillletpeopleknowabouttheCardiffcourse.
Station1:
Resp There was a note saying this gentleman has come in with recurrent chest infections. On
examination, I noted fine inspiratory crackles so I said it was pulmonary fibrosis. They asked about the
infections and then I mentioned bronchiectasis. They asked what tests I would do and what I expected
themtoshow.19/20
AbdoRenaltransplantIcouldnotfeelapolycystickidneysoIsaidhypertensioninducedrenaldisease.
They were pleased that I noted the haemodialysis scar on his chest. He also had an obvious peritoneal
dialysis scar. I was asked about any other signs I could see and I mentioned he had a cushingoid
appearancelikelyduetosteroids.IwasaskedwhattestsIwoulddo.20/20
Station 2: I had a lady with metastatic breast ca. The medical issue was hypercalcemia and pleural
effusion. It was a bit of a strange one because of the nonspecific symptoms. I went a bit off course
becausehermainissueseemedtobeherfamilynotcopingathomewithhersoIassuredherthatwecan
arrange social help, respite care e.t.c. When asked what I would do next I said I would do bloods
including a calcium. they were happy with that and that's when it dawned on me that that was the
medical issue. She was also SOB and they asked what I would do which was a CXR to rule out effusion
20/20
Station3:
CardioIhadaprostheticmitralvalveandmitralregurgitation.Igottheprostheticvalvebutsaidaortic
stenosisbecauseIthoughtitradiatedtocarotids.TheyaskedmecausesofmrwhichIgotmostofthem.
16/20
NeuroIwasaskedtoexaminethelegsofayounglady.ShehadUMNweaknessbilaterally.Iinitiallysaid
itwasunilateralbecausetheweaknesswasobviouslyworseononeside(eventhoughshehadb/lupgoing
plantarsandanklespasticity).IwasaskedtogobackandrecheckafterwhichIchangedmyanswer.She
askedmewhatitwaslikelytobe.IsaiddemylinationandtheyaskedwhatothersymptomsIwouldwant
to check. I said eyes. the examiner asked me to ask the patient and she confirmed a recent episode of
visualloss.TheyaskedabouttreatmentandthebellwentsoIstartedshoutingMSdrugsonmywayout.
18/20
Station4:Abitofaoddone.IwasaskedtoseeaguywhohadrecentlybeenadmittedwithMIwhich
wastreated.BeforedischargehisHbwas115andMCV72.HewasreferredbyhisGPwithHb66and
SOB.HisGPhadstartedirontablets.Itsaidnottotakeahistoryorexaminethepatient.itoldhimabout
his anaemia and why he was SOB. I told him his blood count was not significantly low when he was
dischargedbutitappearstohavedroppedoverthelastfewweeksandweneedtoinvestigate.Heasked
aboutcancerandItoldhimthatitwasunlikelyinviewofhowacutethedropwas.Theexaminersasked
ifIwoulddischargesomeonewithIDA.IsaidyesbutIwouldarrangeOPinvestigations.14/16
Station5:
1aladywithswollenrightleg.Shehadarecentflight.shewasonenoxaparinandshehadhadprevious
PEsandDVTs.Shehadsignificantvenouscongestionontherightleganditwastender.Isaiditwasa
DVT. They asked me what else I would want to do I wasnt sure. They asked me if there is any other
treatmentIwasnotsure.IsaidIwoulddiscusswithhaematology
I thought I would fail this station because as soon as I left I realised she may have had a malignancy
causingcompression(hencetheenoxaparin)andIshouldhaveexaminedherabdomenandsaidIwould
dogenitalexamination.ButIamnotsurewhattheywantedtobehonest26/28
2Aladywithchangeinbowelhabitandabdopains.Shealsohadmouthulcers.Shewasobviouslyan
actor/staff(Shewasreadingoffasheetalot).Nothingonexaminationofabdomen.Ididnotexaminefor
other signs. I said crohns disease and I would do colonoscopy and bloods. They asked me what else it
couldbeandwhatothertestIwoulddo.Iwentblankagain.(?coeliac)18/28
Backtotop
Experience19
I passed my PACES exam in February and went to your course in January 2014. I am very thankful for
helpingmepassonthefirstattemptandwouldcertainlyrecommendtoanyoneitwasveryhighquality.
18/26
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Station1Respiratory
Difficult case, elderly gentleman with SOB. Difficult to examine patient as could not sit back on bed.
Performedexamandnomajorabnormalities.Askedtoreexaminewithreferencetotracheaandposterior
upper chest, trachea possibly deviated to right, no scars on posterior chest. Asked me to do vocal
resonance, I said there was no significant difference, possibly was upper lobe collapse. Not clear on
diagnosis
Station1Abdominal
Examine this patient with abdominal pain. Patient had widespread psoriasis. Abdominal exam revealed
hepatomegaly, smooth and nil splenomegaly. Questioned on causes of hepatomegaly, gave alcohol as
causeandpossiblymedicationinduced.
Station2HistoryTaking
Gentlemaninhislate50swithSOB,coughandweightlossforseveralmonths.Itwasnotedhehadjust
had a CXR but no report was available. Had a smoking history. I talked about differentials including
COPD, heart failure, malignancy and explained to patient that we need to wait for CXR and consider
furthertestswhichwillguidetreatmentetc.
Station3Cardiology
ElderlygentlemanwithSOB.Pulsewasslowrising,apexbeatdisplaced.LoudESM,withnoradiationto
carotid and minimal to axilla. Gave differentials, suggested most likely aortic stenosis. Talked about
investigations,managementofcondition
Station3Neurology
Instructionwastoexaminecranialnerve,patienthasissuewithswallowing.MajorabnormalitiesIfound
wereglobalmusclewasting,slurredspeechandgloballyreducedmusclepowerwhichdidnotfatigue.Also
patient had frontal balding and gave my top differential as myotonic dystrophy, also included MND etc.
Discussionbasedaroundmyotonicdystrophy,othercomplicationsetc.
Station4Communications
Breaking bad news. Asked to explain to partner what has happened to this wife and what is the next
steps etc. Information you were given was detailed and suggested partner had been brought in with
reduced GCS and found to have brain tumor which was inoperable with associated haemorrhage.
Discussedbadnews,investigationresultsandmanagement,answeredquestionsetc.
Station5Briefclinicalconsultationdiplopia.
Ladyhadrecentlyhadanepisodeofdiplopialasting2days,hadnowcompletelyresolved.Didacranial
nerveexam,offeredfundoscopybuttoldthiswasnotnecessary.AssessedCVSexamandforbruitsetc.
AskedforBP.Suggestedwouldworkupforstrokeetcanddorelevantinvestigations
Station5Haematemesis
Gentlemen with haematemesis, recently taken NSAIDS. Full history, Exam focused on abdominal with
CVS exam to assess haemodynamic stability, asked for BP/pulse etc, offered to do PR exam. Discussed
managementplanwithpatient,investigationsnecessaryetc.TalkedaboutRockallscore,managementof
upperGIbleedetc.
Backtotop
Experience20
IpassedthePACES.Youdidhelpmealotinthisregard.Thankyousomuch.
1.CVS
Middleagedgentlemanwithpalpitations,examinehisCVA
Moderate MR thumb nail had a possible splinter haemorrhage but no other evidence of infective
endocarditis(IE),JVPnotelevatedandnooedema,BPnormal,sinusrhythm.
No cardiomegaly/ no evidence of R/L heart failure, pulmonary hypertension or associated other valve
disease
Finishedexamination30secaheadoftime.
Presentedasaboveandcontinuedwithpossibleaetiology(Degenerative/MVP/Ischaemic/IEascommon
causesnextsaidfewothercausesbutdefendednoclinicalevidence),investigationsincludingwhat
to look for (ECG rhythm, ischaemia/ atrial enlargement, CXR cardiomegaly, pulmonary
congestion/oedema,evidenceofLAenlargement double L/heart border and splaying of carina, Echo
confirmdiagnosis/severity/aetiology/complications,TOEDependonEchoifplanningforsurgery)
IwascautiousnotcommittingmyselfforIEasnootherevidence
Atthispointexaminerstoppedandaskedforthecauseofpalpitation
Possible PAF went on to say need frequency of palpitation and arrange 24/72 hour tape or event
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recorderandassessCHADSvascscoreforanticoagulation.
2nd examiner stopped this time and asked to show the splinter haemorrhage I said it is a possibility
andshowedhim,patientsaiditwasduetotrauma.
ThenaskedIxforIEFBC/CRP/ESR/UFR/Bloodcultures/TOE.Got20/20
2.CNS
This patient complains of difficulty in buttoning his shirt, do a relevant nervous system
examinationhewasseatedonachair.
NotedtohaveamasklikefaceandthoughtPD,notremors
AskedtowalkfirstmoreevidenceofPDnoted
Thenproceedwithafullupperlimbexaminationcogwheel/leadpiperigidity/bradykinesia
Looked for Parkinson plus quickly finger nose / eye moments for nystagmus and PSP/ reflexes for
pyramidalsigns
Presented as PD and told its a clinical diagnosis and went on with management MDT approach/ fall
prevention.couldnotgotopharmacologyRx
Examinerstoppedandaskedhoesymmetricalwasthebradykinesia?IsaidR>Lbutsubtle.NextwhatIx
toconfirmdiagnosisifatallIsaidDopaminegatedSPECTheaskedwhatelse..bellrang?Butstill
IamnotsurehowhappyhewaswithSPECT..??ExpectedlikeCT/MRItoexcludeotherDDs.Butgot
20/20
3.Respiratory
Thispatientc/ocough,examinehisrespiratorysyatem
Didnothaveanysputumcup/inhalers/O2/..
Noperipheralsigns,noclubbing
RS:inspectionR/thoracotomyscarandScaronL/shoulderanteriorly
Signs suggestive of R/ lobectomy and B/L coarse crepitation L>R suggestive of Bronchiectasis and
R/lobectomy
Didnotwanttopresentformally,
Asked,whatsignsdidyoufindtoexplainhiscough?
Explained the crepitation and suggested most likely diagnosis is bronchiectasis and the differential
diagnosiswillbefibrosingalveolitis.
Aske the differentiation of the two clinically coarse /fine crepts, localised Vs More symmetrical crepts,
changewithcoughing,
Causesofbronchiectasis
Investigations FBC/CRP/ESR/CXR/ HRCT/ LUNG FUNCTION PARTICULARLY ASKED ABOUT KCO
Explainedwithexpectedfindings
Managementof bronchiectasis, health education, antibiotics, Vaccination/ avoid infections, chest physio,
surgery
AskedaboutscarsR/lobectomypossiblyastreatmentforbronchiectasis,Lscarunrelatedexaminer
saidL/shoulderreplacement.20/20
4.Abdomen
Examinethispatientsabdomen
Elderlygentlemanproppedupat45degrees
Peripheralsigns?Earlyclubbing,nolymphnodes,fewspidernevi,lossofaxillaryhair,B/llegoedema
withurinarycatheter
Madeamistakeintryingtoexamineatproppedupposition,butquicklyrealisedandaskedtolayflat
AbdomenDistendedabdomenmainlyfat,MildtendernessoverL/abdomen,moderatesplenomegaly,?
mildascites
Asked to present the finding did as above and said probably due to liver cirrhosis and portal
hypertension
Asked whether enough evidence to say live disease I said most likely and also like to consider
myeloproliferativedisordersandlymphoma
WhatInvestigationswithexpectedfindingsBloods/USS/Guidedaspiration
DiagnosisofSBP
StillIamnotverysureofdiagnosis.15/20
5.History
Middleagedmanwithbilateralllegoedema
Whenaskeditwasageneralisedoedemaincludingperiorbitalforlastfewmonths.
AssociatedmildSOBonexertion.
Systemreview:frothyurine.Allothernegative
PMH:Childhoodmeasles,recurrentcoughneedingantibiotics,lastyear6episodes
Diagnosis : : Childhood measlesBronchiectasisAmyloidosisNephrotic

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syndrome
AskedabouthowtoexplainhissymptomsAsabove
Ix: All basics/ urine dip/24hour urinary protein/ serum protein/ vasculitis and autoimmune screening/
USS/renalbiopsy
Whatbiopsyfordiagnosisofamyloidosisanteriorabdominalwallfat/rectalgotfullmarks
6.Communication
MiddleagedmanwithT2DMhadrecentadmissionwithclaudicationpainandangiogramrevealeddiffuse
disease not for intervention. Had uncontrolled HT, impaired renal function, peripheral neuropathy, very
highHbA1c,highcholesterol
Smoker20/d,Alcohol30u/week
Notexerciseregularly
Carefordisabledwife
Poorcompliancewithmedicinesanddiet
Occasionalhypoglycaemia
Explorethepatientattitudecounselandplanaction..fullmarks
7.Station5a
This middle aged gentle man with crohns disease seen by orthopaedic for back pain and referred to
medicalsidewithSOB
Patienthadanky.Spondylitis
PMH:IHDwithCABG
ExaminationexceptspinalstiffnessduetoAScouldnotfindanythingbutforgottoexaminecarefullyfor
AR
(Couldnotcompletetheconversation)
Explainedthepossibilityoflungfibrosis/ASitselfcouldrestrictbreathing/heartfailure/Anaemia
couldnotdoanythingfurther
AskedthepossiblecausesforhisSOB
Investigations..Allbasics/LFT/HRCT/Echo/KCowithexpectedfinding
KeptonaskingwhattolookinechountilARmentionedandheaskedhowtoexamineforAR
ProbablyduetoAR.managed23/28
8.Station5b
Youngladywithfatiguefewmonths
PMH:Ulcerativecolitis,obesity,thyroidsurgery,OSA,..
Directquestioninghadfeaturesofhypothyroidismwithmenorrhagia
ExaminedforthyroidglandandthyroidstateHR/skin/tendonreflexes/hadaneckscar
Askedthepossiblecausesforfatigue..MostlikelyhypothyroidbutanaemiaandpoorlycontrolledOSA
needtobeconsidered
Whataresignsidentifiedforhypothyroid
(Couldnotcompletetheconversation).got20/28
Backtotop
Experience21
I attended your PACES course this May 2014 and have just found out I passed my exam last week! I
wantedtothankyouforyourhelponthecourse,andleavesomeinfoforothers(ifithelpsatall!).
Respiratory thoracotomy scar, trachea central, normal chest examination otherwise, asked for
differentials and why I said lobectomy not pneumonectomy, and investigations if patient presents with
increasingSOB.
Abdominal rooftop scar with hepatomegaly, signs of chronic liver disease, asked for indications and
criteria for liver transplant, causes of chronic liver disease, and complications of posttransplant
immunosuppression.
Historytakingmiddleagedladywithintermittentepisodesofcentralabdominalpain3inlast6months,
21/26
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associated nausea and diarrhoea and dark urine at time, completely well in between attacks, GP had
investigatedwithbloodsafterattackswhichwerenormal.PMHxcholecystectomy.
Neurologysensoryperipheralneuropathy,likelydiabetic,askedfordifferentialofperipheralneuropathy
thenranoutoftime.
Cardiology (found this difficult) lady with large scar across lower chest suggesting lung transplant,
normalheartsounds.Igavealonglistofdifferentials!
Communication skills explaining a delayed diagnosis of metastatic cancer to a frail elderly lady's son.
Patient with weight loss and dysphagia, had oesophagitis on OGD with normal biopsy, symptoms
persisted and repeat OGD was done which was normal. Then had CT which showed metastatic gastric
malignancy. Had to explain to son sequence of investigations, and why CT was not done earlier, but
likelihoodthatearlierdiagnosiswouldunlikelyhavechangedmanagement.
Station5manwithearlyParkinson'sdisease,demonstratedtypicalfeatures.Limitingdailylifenowand
patient wanted treatment. Explained diagnosis and possible medication treatment. Questioned about
Parkinson'splussyndromes,possibleinvestigations,andtreatmentoptions.
Station 5 lady with collapse on standing, recently started on bisoprolol, had carotid bruit, discussed
acutemanagementplan.
Thanksagainforallyourhelponthecourse,woulddefinitelyrecommendittoothers.
Backtotop
Experience22
IattendedyourcourseinMay2014andhadmyPACESexaminationinJune2014.Iwanttothankyou
andeverybodyatCardiffPacesforyourhelpandsupportandshareinmysuccessasIthankfullypassed
PACES.BelowisabitofinformationaboutmyPACESexperience.I
hopethishelps,thoughthebestadviceIwasgivenwastoputonyourfavouritepairofheelsandanice
outfitandbeconfident!
Abdomen
I had a patient clearly taken from the ward with tense ascites. The patient was icteric, tense ascites.
TherewasnotmuchinthewayofperipheralstigmataofCLDbutthepatientwasbruised(secondaryto
highINR)whichtheexamineraskedmeabout.Gavemydiagnosis
decompensated CLD, possible triggers of decompensation, further investigations I would like to do and
management.
20/20
Respiratory
Patient with basal pulmonary fibrosis likely secondary to CTD (connective tissue disease). I was asked
aboutteststolookforCTD.
20/20
Neuro
Patient with peripheral neuropathy, bilateral Charcot joints and foot ulcers. Discussed diabetes, patient
education and management of Charcot joint and diabetic feet. I gave some other causes of peripheral
neuropathy.
20/20
CVS
Noideaofdiagnosisgavesomedifferentials.Midsternotomyscarwithmurmurno vein harvesting scars
on legs. I explained this could be for tissue valve replacement +/ use of internal mammary for CABG.
Murmurcouldbesecondaryfailingvalveornewvalvulardisease,furtherinvestigationnamelywithhistory
andecho.
19/20
History
Fever and weight loss in a business man who travelled, spent some time in various parts of Africa.
Differentials,malaria, TB, HIV all discussed. Concerns raised related to his friend who hadrecently been
diagnosedwithcancerItoldhimcouldnotcompletelyruleoutlymphoma
althoughthiswasmostlikelytobeinfective.Neededadmissionforfurtherinvestigation.
20/20
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Communicationandethics
Young mother with infective endocarditis, had 2 weeks treatment now feeling better she wants to self
dischargeassheisnotgettingonwithnursingstaff,she misses her children (who are staying with her
sister)andherhusbandworksaway.Alsofedupofbeingcannulated.
Exploredissues,changeofward,sideroom,Iwouldcannulateandthenmidline,socialservicesetc.Then
assessedcapacitywarnedriskofdeath.AgreedIwouldcannulate,thenarrangemidline,speaktomicro
andconsultantregardingalternativeantibioticsperhapsod
preparationsoshecouldattendwardashomeIVteamunavailableinherarea.
16/16
Station5(1)
Gentleman with type 2 diabetes 5 year history of LOC secondary to recurrent hypos. Ran out of time
discussedfurthermanagement,differentialsanddriving.
22/28
Station5(2)
GentlemanwithAnkylosingspondylitisonNSAIDSandalendronicacidwith
haematemesis. Test was to identify alendronic acid recently restarted by GPcheck method of taking it
knowitssideeffects.Discussfurthermanagement.
28/28
ThanksagainCardiff
PACES
Backtotop
Experience23
IrecentlyattendedtheCardiffPacescourseinSeptember2014.
ThiswasmyfourthattemptatthePACESexamandIreallywasveryconcernedastowhyI
wasnotpassing.Igottoknowofthefinetechniquesandcouldironoutmyshortcomings,
especiallythepartwhereIhadfailedonpreviousattempts(managingpatientsconcerns).
IamdelightedtotellyouthatIpassedthePACESexamandtomysurpriseIgot156outof172,with
fullmarksinhistory,communicationskillsandstation5.
Thanks once again for all the help and I must say that all the instructors were excellent and choice of
patientswasalsogood.Iwillrecommendthecoursetoallmyfriendsandjuniors.
MYCASESINPACESEXAM:
Respiratory : Patient with SOB. had a big thoracotomy scar on left side of back , crackles at both lung
basesbutpercussionwasnearnormal.Likelyalobectomyforbronchiectasiswithcompensatoryexpansion
ofremaininglobe.
Abdomen:PatientwithAVfistulaandmultipleabdominalscars,CKD
History : 55 y old lady admitted with witnessed collapse, pas h/o Ca Breast 3 years ago , now on
anastrazole, childhood history of absent seizures but never needed anti epileptics. Take history ,
formulatemanagementplanandaddressconcerns
Neurology:CharcotMarieToothdisease
Cardiology : aortic regurgitation in a meddle aged man : apex in 6th ICS, Lateral to MCL, Water
hammerpulse,andCorrigansign,earlydiastolicmurmur.
Communication/ethics:82y,stableCOPDwithmildCKD,Pasth/obladdercaandunderfollowupof
urology. Admitted with worsening renal function and USG reveals tumour involving ureters now. Being
plannedfornephrostomy.HasnowdevelopedhyperkalemiawithK+=7.5
Discusswithfamilyandexplainsituationandmanagementplan.
Station5:
1)45yoldladywith4monthhistoryofdiplopiaandslurredspeech,catchinthecasewasdiplopiaAnd
slurredspeechworseatendofday.HasMyastheniagravis
GaveDDas:myasthenia,LambertEatonsyndrome,multiplesclerosisandyoungstroke/TIA
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2 ) 20 y old with 12 year h/o Type 1 DM. Now having frequent hypo and dizziness . DD : autonomic
neuropathy,CKDandAddisondisease.hadAddisonsdiseasenewlydiagnosed
Backtotop
Experience24
Station4.86yearoldwithurinaryretentionsecondarytoCarcinomabladder.Hiscreatinineandserum
calcium were high , he was confused. He had COPD and osteoarthritis. Radiologist was ready to do the
percutaneousnephrostomy.Ihadtodiscusstreatmentoptionsandmanagementplanwithhisson.
Station5a.Anoldfemalepatientwithrheumatoidarthritishadnumbnessoftherightarmandrightleg
for 3 days . She had numbness and weakness of the right arm with exaggerated reflexes. I made it a
stroke.Herquestionwas,isitrelatedtomyrheumatoidarthritis?
Station5bwasaguywithheadaches.Hewashypertensive with no visual symptoms or change in body
shape.IgeneratedaDD,dontknowifitwastensionheadacheorwhat.
Station 1a was an old male patient with a left lateral thoracotomy scar , a laparotomy scar , steroid
purpura,telangiectasiasontheface,eyesweresored,visibleveinsonthechestandupperback.O/E
hehaddecreasedbreathsoundsontherightwithnormalpercussionandresonance,itwasadisasterfor
me.
Station1bwasayoungguywithtattoos,aringinthenipple,4fingerbreathhepatomegalywithvisible
veinsonthelowerchestandabdomen.Hewasnottender,IgiveDD'sincludingveinthrombosis,viva
wasaboutanticoagulationoptions
Station2wasa30yearoldladywithanaphylaxis.Shehadahistoryofhayfever.Noriskfactorsandit
was a 1st episode of anaphylaxis. Anaphylaxis was secondary to some kind of food ingestion. This one
wentwell.
Station3awasoldmanwithamidlinesternotomyscar,metallicaorticvalvewithbibasalcrepts.Imade
itaorticprosthesiswithLVdysfuction,secondarytovalvularorischemiccardiomyopathy,thoughthere
werenosaphenousveinscars,butisaidLIMAtoLADcannotberuledout.
Station3bwasrighthomonymoushemianopia.Ihadtoexaminethecranialnerves.Couldnotfindany
othernerveimpairment.IsaidIwantedtoexaminethelimbs
Backtotop
Experience25
My both station 5 had actors. CASE 1) IDDM 20 year old Female with recent RTA due to hypoglycemic
episode,shehadfewepisodesofhypoglycemicrecentlywithnohypoawareness.
Ontakinghistory,shementionedshehadnotseenaDiabeticnurseforlast6monthswithnobloodsin
last 6 months and Her last HbA1C was 7.8 just over 6 months ago. She had her eye and feet check
done every year. Not losing weight or dieting. Injecting TDS short acting Insulin with meals and
Levemireinevening.Shewasregularlychangingtheinjectionsites.Noparticulartimingsorassociations
of hypos. No tachycardia, nausea or vomiting. On examination,I was told that she had background
retinopathy on Fundoscopy, I asked for lying / standing BP and I Was told there was a 30 mm Hg
differenceinsystolicBP.Pulsewasnormal.Patientrefusedtogettheinjectionsiteviewedandexaminers
askedtoleaveit.
ThenIaskedconcernsandshementionedwhyIamgettingtheseepisodesandImentionedmaybedue
topoordiabetescontrolandweneedtodoherbloodstocheckglucosecontrolandarrangehertobeseen
bydiabeticnurse.
IalsoadvisedhernottodriveandinformDVLAasshehadrecentRTAduetohypos.
ThenexaminersaskedmeisthereanyotherconditionotherthandiabeteswhichcouldcauselowBPand
lowglucose,onthisImentionedyes,thereisAddison'sdiseaseandthereisastrongautoimmunelink
withtype1diabetes.ThentheyaskedmefortestsforAddison'sdisease.
2)Youg22yearoldfemalepatientwithslurredspeechanddiplopiaforlast4months,ontakinghistory
none significant , only +ve thing in history was that sx occurring at end of the day exam was normal,
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speechgaitnormal,nofatiguabilityornystagmusaspatientwasanactor,theyaskedmeforprovisional
diagnosis , my diagnosis was Myasthenia, examiners asked for differentials and tests for a new patients
seenonOPDsuspectedofmyastheniagravis.
RESPLeftlowerLobectomywithB/LINSPIRATORYcrackles,notchangingoncoughingnotonoxygen,
nosputumpot
NEUROHSPb/Luppermotorneuronesignsinlowerlimbs,sensorysystemnormal
ABDO LIF mass with no scar on scar, there was a midline scar > probably has renal
transplantthroughcentralscarastherewasanonfunctioningfistulaatRTwrist.
CVSNoideatillend,obeseptwithverythickloudS2,+asystolicmurmerwithnoradiariontocarotids
oraxils,centralsternotomyscarwithnometallicclick.
ObesepatientwithverythickchestwallandloudS2
Iexplainedmaybebioprostheticvalvedoneinpastwhichisnotgettingcalcifiedandsclerosis
History:collapseathomewithLOCandshaking,typicalofanepilepticseizure,DVLA,examineraskedif
it was a metastasis in brain with brain oedema how will u treat would you give steroids , if yes which
steroidyouwillgiveandwhatdose.
Communication : counselling a relative , son of 82 year old male , known Bladder cancer, comorbidities
: Moderate to severe COPD and O.A., now admitted with acute renal failure due to B/L Hydronephrosis
secondarytoobstructiveuropathyonUSS,Radiologisthasofferedtodoanemergencynephrostomyand
yourconsultanthasaskedyoutospeaktofamilyfornephrostomy.
My overall score was 146 /172 . The station I think I did the best ( history taking ) has lowest marks
16/20.ButforpatientwelfareIwashopingtoscorelowIhadscored32/32.
Thankyouallofuforyourinputinmysuccess.
Backtotop
Experience26
Just wanted to let you know that I passed my PACES Exam on 19th April 2015, having attended your
courseinJanuary.
As a GP and 'mature' candidate I must say that I will be tempted to come on your course again in
thefutureeventhoughIpassedtheexam...becauseIreallyenjoyedit!It'snotoftenthatGPslikemyself
gettoseesomuchpathology/clinicalsignsinonelocationinsuchashorttime!
Everyone was so helpful and enthusiastic and the location was ideal, with very reasonable (read:
affordable)accommodationcloseby.
Pleasecontinuethegreatwork....
PSDrHo'sHeartSoundsimpersonationsshouldbeon"Britain'sGotTalent"Excellentstuff!!!
Station1Gastroenterology
Young man with anaemia (though he didnt have signs and examiners agreed with me he wasnt
clinicallyanaemic!)dystrophicnailsandpalmarerythema.MayhavehadhepatosplenomegalybutIwas
not convinced however, the examiners question included the line OK, lets presume he has
hepatosplenomegalywhichsuggestsIwaswrong!(thiswasalsomylowestscoringstation!)Thenasked
aboutcausesandinvestigation,withdegreeoffocusonhaematologicalresultsandinterpretation.
Station1Respiratory
Middle aged man with breathlessness. Midline sternotomy scar and bilateral basal fine end inspiratory
creps. I thought pulmonary fibrosis and questions followed this direction so I presume this was right.
Askedaboutmanagementoffibrosisandwhensteroidsmightbeindicated.
Station2HistoryTaking
Amiddleagedmanwithcough/wheeze/breathlessnessfor3/12.
Ex smoker (stopped 10y ago) but when asked about occupation said he worked as car mechanic and
didnt wear masks etc and symptoms improved when on holiday. Also element of exercise asthma.
Questions included what investigations to perform and what to expect on spirometry. Concerned about
lungcancer.
Station3Neurology
A young man with expressionless face, pill rolling tremor and dyskinetic movement (esp L hand),
examinationrevealedweaknessofsmallmusclesofhandsbilaterally.Iwaspuzzledbythechoreoathetoid
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movementsandweakness.HehadasplintonhisLwristwhichhesaidwasfortendonsurgery.Increased
tone(leadpipeIthink).SensoryexaminationNAD.Wediscusseddifferentialdiagnosesandtalkedabout
Parkinsons but I said it was unusual at his age (early 40s). I didnt think of potential other causes
(Wilsons,druginducedetc).IthoughtImessedthisoneupbutactuallyscoredOK!!
Station3Cardiovascular
Elderly Asian man with systolic murmur consistent with aortic stenosis (I thought) but no other signs.
Examinersweredifficulttogaugeonthisone,askedaboutalternativediagnosesandwhatinvestigations
mightberequired,causesofaorticstenosisandwhatanechomightshow(Iwonderedafterwhetherthey
werelookingformetomentioncardiomyopathy?)
Station4CommunicationSkills
A young lady with T1DM and small children who was noncompliant with treatment and had several
admissions with DKA to talk about treatment. I tried various techniques but not sure at the time
whether I really understood what I was supposed to be looking for or doing but scored full marks so
presumablycoveredalltheimportantstuff.
Station5a
Amiddleagedwomanwithbreathlessnessandobvioussystemicsclerosis(diffuse)onmycophenylateand
steroids. History of Raynauds and examination suggestive of pulmonary fibrosis but no pulmonary
hypertension.
Station5b
Ayounggirl(whoIsuspectwasanactressprobablyamedicalstudentorjuniordoctor),whowastired
allthetimefor3monthsandbumpingintothings.WorkedasaDistrictNurseandhadknockedoffboth
wingmirrorsoncar.Historyrevealedgalactorrhoea.ShehadsweatypalmsbutIthinkthiswasjustthe
actress (she seemed embarrassed about this and the examiners were not keen on discussing thyroid
function particularly). She had a bitemporal hemianopia and questions focussed on causes, levels of
prolactin associated with prolactinoma and consideration of acromegaly (I said she didnt have the
featuresasIthoughtshewasveryprettyactually!!!)
Backtotop
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8/3/2015

Diagnosis : : Childhood measlesBronchiectasisAmyloidosisNephrotic

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