Paces Exam Cases

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Guidance To PACES Success[GPS] .. By Dr. Ahmed Maher Eliwa

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Oman - Muskkat
10/10/2016
*chest :clubbing with bilateral basal creps, discussion about possibly
ILD&broncheictasis
*abdomin ,young female with scar RUQ&LIF , ?renal &liver transplant secondary
to polycystic kidney &polycystic liver disease
*Neurology, young male with proximal myopathy with normal sensation and
coordination? Becker dystrophy? Other causes of myopathy
*cardiology, midline sternotomy scar with miteral valvotomy scar and metalic S1
*history, migraine headache
*communication, physiotherapy staff nurse with functional weakness confirmed
by normal brain MRI , I started by reassuring her that normal imaging mean
nothing serious in your brain, she said you mean I am faking symptoms of
weakness, I replied, no you are not faking symptoms and there is a real problem
and we are here only solve your problem
Then she asked what is my problem? I said because of your stressful job of
physiotherapy and stroke units and always seeing crippled and disabled patients,
this makes your brain to misinterpretate the stressful triggers in to a weakness
Then I asked about her social life, which is also stressful due to after her duty she
used to help her younger sisters at home, there is no time to enjoy her hobbies,
she has no friends and single
Then reassured her again this is functional weakness and it's curable condition
Regarding treatment is mostly live style change, change or modify her job,
referral to psychiatrist for behavioral therapy ,talk to social worker for home
support, you are still young try enjoy your life, have friends, enjoy your hobbies,
finally summarized check understanding, give supports.
Hope all of us to pass
*BCC1,headache with visual problem? Acromegaly
*BCC2, young male with heart valve problem and back pain? Ankylosing

(Experience of Dr Iqbal, Copied from another group)

Alhamdullilah I have passed
Score 166/172
PACES DIET 3, Royal Hospital
MUSCAT, OMAN
Day 2 cycle 2
Station 1
Abdomen Renal transplant with failure pt on Hemodialysis....functional AV fistula
left arm.
Questions about signs and complications of ESRD and cause of transplant
failure.
Score 18/20
Chest young male with rt lateral thoracotomy scar and Rt. Lower lobe lobectomy.
He was clubbed.
A case of bronchiectasis.
Questions on causes of bronchiectasis
Management
Organisms
19/20
Station 3
Cardio young male with AS+/-AR .....dominant AS.
Questions on causes of AS
Clinical severity markers
Dx
20/20
CNS a case of Charcot Marie tooth.
Questions on investigations and management
20/20
Station 5
1. Middle aged male with headache and visual disturbance ...a clear case of
Acromegaly
27/28
2. Young male known HTN with recent wt gain, headaches and day time
somnolence....OSAS
Viva on invx and differentials.
26/28
Station 2
A case of MS medical student admitted with attack (vertigo and diplopia)
recovering MRI and LP confirmed dx. Not satisfied with neurologist. Need second
opinion. Your role to explain diagnosis and future outcome.. address concerns.
Examiners very rude.
16/16
4. History
Young male with Abd pain and erratic bowel habits.
Diagnosed with IBS.
Sx related with stress.
No ALARM
Father dx with colonic cancer and recently operated.
Pt got worsening sx for. 6 weeks.
Concerned could be bowel cancer.
Viva on differential.
Since he has very strong FH of bowel cancers in his Father, Grand Father and
paternal uncle @39 yrs.
One aunt with uterine Ca.
So I also included screening and genetic testing.
19/20

(Copied, From UK : Experience of a candidate who passed in this diet)

My exam started with station5 .
BCC 1 was back pain...i went in and started history with differential of ankylosing
spondilitis in mind but patient told me has has rashes as well.on examination
back movements were fine and he had nail pitting.i gave differentials of psoriasis
..as pain was in small joints so examiner asked me is it something else.i told
although it is typical presentation of psoriasis but i will like to rule out RA as
well.then he asked management. ...got 28/28
BCC 2 was hoarseness....i saw a scar on neck of patient while taking history.she
told me she had thyroidectomy about 10 years ago....and now she is having
hoarseness for last 3 months.on further questioning she told she has stopped
taking thyroxin and is gaining wt as well.i asked any other medical problem.she
told me that she is having asthma n takes brown inhaler but does not rinse mouth
afterwards. I advised her about inhaler technique and rinsing mouth n starting on
thyroxin.examined neck n offered to examine tummy to rule out any stria as she
told me she was gaining weight....examiners asked about other differentials .i told
it might be ca larnyx as well.got 28/ 28
Station1 ABDOMEN was Renal transplant. ....was staright forward....was asked
about management of ckd n investigations.
Respiratory was also a lady with clubbing n fine crackles with small scars on rt
chest...she had fine crackles so i gave diagnosis of pulmonary fibrosis.examiners
asked about scar ....i said it might be lung biopsy scar.
Got 19/ 20 in respiratory and 16/ 20 in abdomen.
Station2 was Shortness of breath in 75 years old smoker....i took history n ruled
out all differentials.told possibilities of pE, LRTI , CAlung.got 16/20
Station 3
Cardiology metalic aortic valve was really straight forward...got 20 / 20
Neuro a lady with proximal muscular weakness n intact sensations...i gave dd of
muscular dystrophy n MND ...viva was about investigation n causes .got 18/20
Station 4 to council hypoglycemic unawareness...i forgot to ask about smoking
but satisfied patient so well that he told me that thank you for very good
explanation as you have explained everything....Got 14/16
I think it is all blessing of Allah .
I would advise all my fellows to do as much paractice as you can.see as many
patients as you can with exam cases in mind and finally do a revision course one
week before exam to get into mode of exam.
This is bit different exam but if you practice it is very easy otherwise very difficult
but one should never be disappointed....GLASGOW college is better for overseas
candidates as it looks to me examiners are very very fair

One of my colleague examined in UK

Westmiddle hospital,
I started with st 5
BCC1: middle aged woman with transient LOC ,?! TIA, normal ex, conc. will it
recur?
BCC2: 60 yrs lady with tiredness, h of prev pituitary s ,, ?!!adrenal insuff
Resp: copd
Abd: fistula and scars not tranplant
Hist; ref syncope/epilepsy,, conc is it epilepsy?!!
Cvs: MR
Neuro: median nrve inj, scars of carp t
St4: palliative care for an ILD pt,, con what support/ end of life issues

Kuwait October 2016

History: diarrhea
Comunication: convince the son to do life saving procesure
Resp: pleural effusion
Tb is common cause in kuwait esp indian
Abd: was normal exam with scar in RIF
Dont panic just give DDx
Cvs: mixed aortic valve dis
Neoro: examine cranial case of MG with thymomectomy scar
Bcc: acromegaly
Bcc2: behcet
(Courtesy to Dr Ashwag)
I will share my experience
wish one found it helpfull
i did my exam in Royal Hospital Oman 7/10/2016
start with station 1
when bell ringing i fell stress i couldn't see where hand Sanitizer� so i just look
around searching and examiner ask me to start i run wash with water examiner
said it is ok just start give me tissues � i feel stupid but no time for feeling i just
say hi to pt and ask him to expose his abd and chest it is case of renal transplant
came with abd pain for investigation i think i did it v. fast and did well i answer all
Q what is your finding , diagnosis ,how you know his transplant kidney is
functioning ,investigation and looking for what for any test he ask me you miss to
auscultate kidy did you think it is important in this pt i said yes he said why ? i
said renal artery stenosis he said ok how you investigate for this i said i will start
simply by US then MRI if needed
second case bronchiectasis with lobectomy when i start pt sleeping deeply
examiner wake him � he take second to concentrate then i ask him to examine
did the usuall , i forget to tell this time examiner show me where hand sanitizer �

� it is fix in door from outside � i clean my hand and start i examine v. fast after
i finish examiner tell me i have 1 min left i ascultate again he is english examiner
v. nice also discussion go smooth what is your finding Diagnosis , investigation i
forget sputum test he ask you miss sputum i said yes am sorry i need to do
sputum FB , treatment
i go to next station 2 case od young male 23years with IBS treated symptomaticly
with strong family hx of colon cancer
[10/29, 12:11 AM] .: when i start i want to shake hand surrogate said i didn't
shake hand female � � so i said with smile hello am Doc .... i just started i take
detail hx of diarrhea no alarm sign i finish all part of hx answer concern he afraid
as his father diagnose befor 1 month of colon cancer with strong hx in family i
reasure him as far as no alarm sign no need to do invasive test and i suggest to
referral to psychological i said that the cause of your diarrhea due to stress and
you need to reduce stress on your life as much as you can will improve your
symptom i think to if you do convulsation with my colleges in psychological
department will help you he agree then he ask what about family hx i said i will
come of coarse to this point then i reassure him more and explain we need to to
some blood test to exclude any cause or complication am thinking that time not to
forget about celiac disease and malabsorbtion , then i said regarding family hx
sure we need to to some screening test and genetic test we can make another
appointment to talk in detail
[10/29, 12:34 AM] .: he agree then i summarise and check understanding i agree
plan . examiner English and other Omani one said so you think he had no cancer
i said no alarm sign and his diarrhea chronic with stress he said why you not put
possibility as this attack of diarrhea more sever and prolong as he claim i said
now pt on stress that is why symptom more sever no need to increase stress as
we have nothing said it ca. regarding family hx need refer for screening test said
which test i said genetic said then i said colonoscopy then discussion about plan
of treatment possible DD
third station is hardest one for me first case is young female v. pall , tachypneac
with metallic valve sound going with aortic valve replacement with obvious
sternetomy scar , with sign of pulmonary hypertention , active neck pulsation
,basal crepetation and LL edema to be honest when am still examining pt i
thought she is young female and on AF so mostly the lesion is on mitral no aorta
but i heard it going with first sound and the second sound is free with clear high
volume but i decide not to think and just said finding as i get also i notice pt have
big neck scar so may be have hx of thyroid problem which explain AF???!! any
way i present my case as this keen leady on 45degree tachypneac ... etc so my
diagnosis have aortic valve replacement with pulmonary hypertension and AF ,
on failure no prepheral sign suggest endocarditis examiner English ask me so
many Q causes of replacement
: causes and indication for replacement in stenosis or Regar. type of valve
advantage and disadvantage, how you investigate this pt what you will see in
ECG , echo , last Q about coagulation is any place for other antiagulant apart
from warfarin ?? this only Q i stop and said am not sure he smile and said No
place , actually he ask soooo many Q i answer fast he ask next Q
neuro case is my bad one � i got 8/20 on it case of young male with paraplegia
with sensory level to T4 i got Rt limb spastic with aggressive clonus second limb
down goin with hyporeflexia and no clonus but am not sure about the case i got
confuse� because i think what could be the cause i think simply may be MS , or
Compression in which side there is destruction of vertebrae with compression of
root in one side� till now am confuse i said may be there is prepheral neuropathy
?! actually no place to may be either sure or not so the examiner is Indian v.
tough he ask me So many Q i feel bad but i think i manage not good way
: i already share this case on detail befor i will search and copy best it and i will
she feedback of it when i get it.
station 4 case of young 37 years leady she work as part timer teacher also she
start with ( mature education ... etc not remember exactly but means no she start
to study medicine collage she experience tinnitus and blurred vision which MRI
and LB done diagnose as MS pt already seen by neurologist who tell her about
her condition but she have some issue which confuse about it and some concern
so she ask for adoctor i read scenario twice i understand i have no clear plan i
need just to set and answer what she may ask ���� when i enter examiner
ask me my evaluation sheet � � i forget out side i go back one from out side
�

ask me to wait she will bring so i wait her all this on my time � � so i enter then
told me instruction � then start 1 min may be already left
: i introduce my self and confirm pt then agree agenda of meeting and permission
to discuss, i ask her what she have been told so far she said she is confuse
about it i explain the disease the behavior of it and it may be deference from one
to other i don't now why i offer pt i will give her leaflet and website , supporting
group can help her more to know about disease (although this step usually use to
close meeting but may be she already informed and still confuse� i notice
expression of examiner follow me so just i go on and ask her what she confuse
about she said am study medicine i said it is great as far as you have nothing
disabling you can study she repeat it is medicine � i thought she may give me
clue for some concern i said yes now you regain your did you have any problem
in your vision she said no i said so great as far as you free and you can do
something i encourage you to do it (in discussion examiner ask me did you think
in problem to study medicine?? then i make sure that there is some thing i miss i
said now problem as far as she can but after graduated some issue may will be
concern she said which issues i said may be affect her field as may she need not
to be post in ER or any field deal with surgical skill as Surgery, OBG
according to her health that time, examiner said so you think this important things
to tell her about it now i said yes i wounder may be no need to tell all bad news
�

this admission and to make other appointment she ask then all Q of surrugate
agin as surrugate ask me she care of her old mother i offer referal to social
department she said what they will do for me � i said can give you some expert
advice also can offer you nurse part-timer,a lot of option they can discuss with
you as nurse care or home care for elder but if you want could you tell me about
your mother i close my Q fast by i means did she have any medical problem??
: she said yes have limb pain and couldn't walk i said am sorry so i think also your
GP can help if any treatable or she need medical care at least can give you
suggestion she agree then she ask she need financial support i said who support
you before? she said no one she is work as teacher i said it is great now you can
continue you work as you are free now but i will envolve occupational department
they can help you regarding this issue
: she ask about family planing she plan to marriage also get pregnant also she
afraid to tell her partner
alot of Q time over she still asking am not do any summarization or check
understanding nor doing any thing and surprising things i got 12/16�
: last station 5 first case is acromegaly i did it good get 28/28
second case OSA i think due to hypothyroidism i get 25/28
: conclusion exam about skill and how you can manage cases by defrant way

paces exam date 6/10/16 at

ARMED FORCES HOSPITAL MUSCAT
--------------------------------------------------------------------
I started with :::::::::STATION 5/3/2/1/4
STATION 5
1- PLS EXAMINE THIS LADY HAVING ARTHRITIS SINCE 5 YEARS
COMPLAINING OF HAND PAIN
2- THIS GENTLEMAN WITH HYPERTHYROIDISM ON TREATMENT , HAVING
EYE SYMPTOMS INTERMITTENT DIPLOPIA AND WATERING , PLS TAKE
FOCUS HISTORY AND EXAMINATION
STATION 4
SHORT SCENERIO- PLS SPEEK TO THE SON OF THIS PT AGED 68 Y
HAVING DIAGNOSED AS ILD 1 YEAR BACK , NOT RESPONDED TO
STEROIDS AND HIS LONG STANDING DM IS WORSENED WITH THERAPY ,
LATER TRIED NEWER DRUGS BUT DROPPED FROM TRIAL .IN VIEW OF
HIS ADVANCED DM AND PROGRESSIVE ILD , PLS SPEEK WRT LONG
TERM PLAN OF MX OF ILD AS RESPIRATORY TEAM HAS SUGGESTED
ONLY PALLIATIVE CARE
STATION 3-
RS- PLS EXAMINE THIS MAN AGED 62 WITH SOB AND CHEST PAIN – RT PL
EFFUSION
P/A- PLS EXAMINE THIS MAN AGED 40 Y WITH ABD PAIN AND FATIGUE -
MODERATE SPLEEN
STATION 2-
HISTORY SCENORIA – THIS LADY 30 Y OLD HAS OFTEN TIERDNESS AND
EXHAUSTION , O/E- BP- 140/90 MMHG AND CBC HB- 10 , PLS TAKE
HISTORY AND ADDRESS HER CONCERNS
STATION 1
CVS- 50 Y OLD MALE WITH CHEST PAIN – MURMURS – AS/ AR/ MR – TALL
STATURE , HIGH ARCH PALATE , GYNECOMASIA , SCAR LT ELBOW JOINT
, SCANTY FACIAL HAIR
CNS- 35 Y OLD MAN WITH DIFFICULTY IN WALKING – HAS UMNTYPE
WEAKNESS CLONUS ASYMETRICAL WEAKNESS MORE ON RT , NO
CEREBELAR SIGNS , POST COLUMN SENSATIONNORMAL NO SENSORY
LEVEL

Expertience of a candidate with 16/16 in a communication case

Scenario out side said : ( A lady with extreme anger about her lost FNA result
which lost with a doctor who is on leave for 2 weeks... Which is done for
suspected mass on Cxr and confirmed by CT scan ... Abd U/S show mass on
liver.. We don't know which is primary and which is secondary that is why FNA
and decision is to repeat FNA again....!!! )
Candidate: Hello , This is Dr Jack , I am senior house officer in MAU clinic , Nice
to meet you , Would I get you to confirm your name and age please?? You are
Mrs : Jhones and you are 55 years old???
Surrogate: Nice to meet you Doctor , yes I am the one
Candidate: I came today to discuss with you your condition and results of tests
done for you... is that OK with you?
Surrogate:Yes I am waiting for that... please Doc tell me what about my results
..is it some thing bad?
Candidate:First of all Do you want any one be with you here in this meeting?
Surrogate:No Doc I am OK...
Candidate:And would you tell me what do you know so far about your condition?
Surrogate: As you know .. I am waiting for the sample reusult took from my tubes
.. I don't know why they did this but I came with pain on my tummy here in the
right side ..then they did scan of my tummy ..then again they asked about chest
scan... I am confused Doc .. No body told me any thing...they talk about mass in
my liver and tubes... Is it CANCER Doc???
Candidate: I am afraid to tell you that some thing serious going on..( silence
)...The results altogether is showing that you have a spreading Cancer on your
liver and tubes ...so sorry to tell you such bad news....( looking around for tissue ,
patient cried , I gave her tissues , still crying ..I wait for her to raise her head
about 1 mintue then I start to say ) There is another bad news for you as we did
not know the origin of this Cancer, is it from liver go to your tubes or vice
versa....That is why we did a sample test for you....But I am sorry again to tell you
that..my colle...
Surrogate: Yes what about the result..?
Candidate:I am sorry again to tell you my collegue doctor who saw you last time
..he is on vaccation for weeks and unfortunately your result is with him...so we
lost it..
Surrogate: What a bad hospital is this ...what is that mean??
Candidate: I am deeply sorry to tell you that we search here and there for your
result but unfortunately we did not find it .... we tried to call him many times but
his cell phone was switched off all the the time and this is the only way to reach
him...
Surrogate: Why this always happen to me... your system is very bad really .. and i
think you are playing with people lifes..( Got extreme anger ).
Candidate: You are absolutly right regarding the abscence of your result ... and
sure this fault will be ivestigated by our team here ..so not to happen again for
other person.
Surrogate: You are making me confused Doc... I want to complain ...
Candidate: You have Right to complain ...but I need to say to you.. again we want
to repeat the needle sample for your tubes again...
Surrogate: What ..What ..No No Doctor ..Last one is bad experience to me and I
will not repeat it again..
Candidate: I am afraid to tell you that ..this is the only way to know what kind of
cancer you have..by knowing the nature of it..we can deal with it
Surrogate: No I want to complain...
Candidate: As I told you Mrs Jhones ... This is your Right .. and if you want this
we have here in the hospital a complain system and I will tell you what channels
to go through..But Let us think positive about things..You have this cancer and
we are not sure if it is treatable or not(really I dont konw)..and if so what kind of
treatment..is by chemos or Radiation or Surgery or all together..and to answear
all these questions we need to Do the needle sample test for you...and I am sure
that the procedure discussed with you before and you know every thing about it..
Surrogate: It is painful doctor...crying
Candidate: I will be sure that they will make you pain free this time and I will be
with you to make sure of this..
Surrogate : Please Doc I am alone ..would you help me..?
Candidate: Sure and it is my pleasure..But let me know about your family where
are they ?
Surrogate : I left My husband after 20 years marriage last month..and I fired from
my job also..(crying -Tissues... At this time I said to my self How much RCP gave
these surrogates ? As she able to cry with many tears at any point of time..and
surprised that this will be repeated for other 4 candidates with me in the pannel
...Good actress Really..)
Candidate : I will ring now For the social worker and psychologist to attend our
next meeting in Thursday with all of the Team concerning about your condition
after the result of your needle sample test...and this team including cancer doctor,
our consultant, liver doctor ,me and chest doctor...to decide about the way of
making you symptoms free for your rest of life...and I am afraid to say that your
cancer is spreading now and we need to control it by palliation only..that mean to
make you as comfort as we can but No total cure for this..
Surrogate: Crying...WHEN IT WILL BE DONE ?
Candidate: I will make the nearest apointment and ask them to realease the
result on the same day..so as not to delay things
Surrogate : Thank you Doc..
Candidate: As before you need to sign a PAPER if you will Go for this..
Surrogate : OK doc
Candidate: We go through alot of information would you recap for me what you
get from our discussion today..?
* AT this point examiner stop me that time is finish..I felt worried about that as I
did not Summarize and check understanding...Ohh..God
* They ask many questions? I automatically replied by defending mechanism. I
think this helped me to pass this station

Um last group. 26/10/16

Bcc - elderly gentleman, blind since young. Came with ?lethargy and memory
impairment. Went in...he has extensive psoriasis... was given some hormonal
treatment....
Havent got a clue how to link all.. � gone
�

the next one is a thyroid pt...eye sign. Stem Sob and ankle swelling.
Counselling - ms break bad news.
History - collapsed.
Cvs - mvr.
Neuro - blank.again. i think it is myotonic dystrophy.
Respi - inpatient. Clubbing. tracheal deviated to the left. Reduced air entry. Not
sure - said it was left upper lobe collapsed. Ca. Didnt do well.
Abdo - renal transplant.
Looking forward for next seatin

Hospital Serdang, Malaysia.

22nd Oct 2016.
BCC
1. LL swelling, discoloration, with diarrhoea 3 months.
2. SOB, acute onset in a dialysis patient.
Station 1
Resp
Bronchiectasis
Abdo
Failed renal transplant
Station 2
Hx of headache
Station 3
CVS AVR
Neuro: proximal myopathy
Station 4
ADPKD counselling

UM red team 26/10/16

Last carousel
St 1: hepatosplenomegaly with pallor- CML
RA with cushingoid features with interstitial lung disease
St2- syncope with collapse-sounded cardiogenic syncope
St3- MVR in failure
Bilateral claw hand with small muscle wasting of hands probably bilateral ulnar
nerve palsy disucss along differentials
St 4: breaking a news of multiple sclerosis
St5: BCC1- headache, young man has h.o acne taking isotretinoin and pcm,
gave differentials BIH, migraine, tension headache
BCC2: diarrhea with vommiting and fever, skin lesions looks like mix of
pemphigus and psoriasis, taking aza and prednisolone..gave differentials of
infective diarrhea, inflammatory bowel,drug related....just hoping for the
best...dunno whether gud enuff to pass

Um red group. 2nd cycle 25 october, centre UM

Start with BCC 1
Heart pain? Patient said. History more on gerd.
Obvious facial rashes with scar, lucky pt said it is pemfigus on steroid. Has lower
limbs weakness with cushingoid on steroid.
Ddx : I give GERD, IHD, side effects steroids.
I ask concern and examiner said times out .Sad.
�

Bcc 2
Knock into object, vision blurring.
He got DM dermopathy, right BKA.
Vision until waving fingers and light perception. I offer funduscope,.and ecaminer
said ok = eye not dilated, no.red reflex. I.cant visualize.retina.
Ddx. I give poorly controlled dm. Concern is.driving, I said need medical board
and license agency. Multidisciplinary team.
Funduscopy I said I cant visualize �

Station 1
Lady with mass at abdomen, so nodular, I think both kidney balotable, dont know
if its kidney or liver... I said ADPKD. �
Respi
Inhaler on table - before bell.rang than I mentioned ... �

Trachea deviated to right, I said ddx fibrosis, mitotic.

No ronchi no wheeze. I said possible ashma or copd...
Mx I said pulm rehab and stop smoking. And goh bak liong ask how u know pt is
smoking? I said I can see inhaler, possible copd �

St 2
Diarrhea 2days,.he is gardener. Bloods renal failire....On lithium.
Ddx infective age, hus/ttp, and lithium causes nephrohenic DI
St 3
Metalic dual valve replacement. Why pt is sob? I said related to heart and may
not.related. No murmur. Can hear click from bedside.
Neuro, see gait n proceed
Lady with broadbase gait. Cant do knee jerk because pt pain, lucky I do elbow
jerks.= hyper reflexia.... Very sartle nystagmus to horizontal gaze....
Ddx cerebellar, acquired congenital drugs
End with.st.4....
No more adrenaline left... Lucky Miss Ismail so coperativr�...
Angry pt to consultant cardiologist, pacemaker not function, no body explain, she
in ccu, want to home wedding nephews... I adress one by one slowly, and pt
keen to stay and do another repositioning pacemaker... Thank god.
All the best others

um26/10
morning session blue carousel
1)
abdo thalassaemia
respi : lobectomy
2) hx taking : low, night sweats
3) cvs : ms/mr some people got single valve disease ive got mixed mitral valve..
dunno
neuro : bulbar palsy with hearing loss
4) BBN esrd 2' adpkd
counsel for possible rrt
5) bcc 1 abdo discomfort and constipation 80 yo
on morphine/ codamol
bcc 2 recurrent syncopal attack
hoping for the best ��
Hospital Serdang, Malaysia.
22nd Oct 2016.
BCC
1. LL swelling, discoloration, with diarrhoea 3 months.
2. SOB, acute onset in a dialysis patient.
Station 1
Resp
Bronchiectasis
Abdo
Failed renal transplant
Station 2
Hx of headache
Station 3
CVS AVR
Neuro: proximal myopathy
Station 4
ADPKD counselling

2nd cycle 25 october, centre UM

Start with BCC 1
Heart pain? Patient said. History more on gerd.
Obvious facial rashes with scar, lucky pt said it is pemfigus on steroid. Has lower
limbs weakness with cushingoid on steroid.
Ddx : I give GERD, IHD, side effects steroids.
I ask concern and examiner said times out .Sad.
�

Bcc 2
Knock into object, vision blurring.
He got DM dermopathy, right BKA.
Vision until waving fingers and light perception. I offer funduscope,.and ecaminer
said ok = eye not dilated, no.red reflex. I.cant visualize.retina.
Ddx. I give poorly controlled dm. Concern is.driving, I said need medical board
and license agency. Multidisciplinary team.
Funduscopy I said I cant visualize �

Station 1
Lady with mass at abdomen, so nodular, I think both kidney balotable, dont know
if its kidney or liver... I said ADPKD. �

Respi
Inhaler on table - before bell.rang than I mentioned ... �

Trachea deviated to right, I said ddx fibrosis, mitotic.

No ronchi no wheeze. I said possible ashma or copd...
Mx I said pulm rehab and stop smoking. And goh bak liong ask how u know pt is
smoking? I said I can see inhaler, possible copd �

St 2
Diarrhea 2days,.he is gardener. Bloods renal failire....On lithium.
Ddx infective age, hus/ttp, and lithium causes nephrohenic DI
St 3
Metalic dual valve replacement. Why pt is sob? I said related to heart and may
not.related. No murmur. Can hear click from bedside.
Neuro, see gait n proceed
Lady with broadbase gait. Cant do knee jerk because pt pain, lucky I do elbow
jerks.= hyper reflexia.... Very sartle nystagmus to horizontal gaze....
Ddx cerebellar, acquired congenital drugs
End with.st.4....
No more adrenaline left... Lucky Miss Ismail so coperativr�...
Angry pt to consultant cardiologist, pacemaker not function, no body explain, she
in ccu, want to home wedding nephews... I adress one by one slowly, and pt
keen to stay and do another repositioning pacemaker...

Malaysia - UMMC
25/10/2016
Respi : COPD, rhonchi, hyperexpanded chest, on NPO2, tachypnoeic, greenish
sputum dd pneumoni, TB.
Abd : Right transplanted kidney functioning well, no CVL no AVF. Cushingnoid
History : transient global amnesia
CVS : ?MR in failure ???
Neuro : Charcot-Marie-Tooth / dystrophia myotonica
Comm : 50yo man T1DM with hypoglycaemia unawareness. Counsel regarding
hypo.
BCC 1 : 30yo male, LOC with vomitus beside him, PCM 20 tablets, social drinker
with recent increase past 2 weeks stress marriage affair. Physical all normal.
BCC 2 : Dysphagia, typical Dermatomyositis. Likely mixed CTD. Skin tightness
as well. ?hx of breast ca. ?esophageal ca.

Exam cases October 2016

Station 5
RA with CTS
Palpitations secondary to anxiety
Station 1
Pulmonary Fibrosis
PBC
Station 2
Upper GI bleed Mallory weis + on NSAIDS
Station 3
TOF
Peripheral Neuropathy
Station 4
BBN of renal failure requiring dialysis.

Kuwait 2016
Our cases in kuwait
In two days
Neoro: MND
Cardio: Af + MS
Hx: 1) diplopia and fatigue (MG)
2) back pain and hypercalcemia
ABD: splenomegaly >>> Hereditory spherocutosis
Other case: polycystic kidney
Resp: Lobectomy
Comunication: clear medical error FBA sample was lost and you need to repeat
it
Station 5: joint pain in hands
Other pt: garves eye dis

Another Feedback from colleague in Dubai today:

St 1:
Chest: Rt side lung fibrosis.
Abdomen: Renal transplant.
St 2:
DVR, AF, DM, on warfarin, hypothyroidism on thyroxine has IDA on iron but not
responding referred to you to look for a cause. A CASE For DD
St 3:
CVS: DVR.
CNS: spastic paraparesis without sensory level.
St 4:
PT with chest pain who underwent stress ECG which is positive.
Your role to tell him test result & to explain for him that he needs c angiography &
may be CABG after that.
St 5:
BCC1: Pt has SOB: Then found to have Wt loss, diarrhoea, thyroid nodule &
neck scar.
BCC2: ALSO SOB: progressive then found to have RA on MTX.

My colleague exam in dubai

5th October
Station 1
1 /Ascites for differential
2/ rt lower lobe consolidation pt had cannula also
Station 3
1/Aortic regurgitation /AF marfan?
2/ hemiplegia ( examine upper case limbs)
Station 2
Back pain ,ankylosing
Station 4
Somatization disorder
Station 5
1- DVT
2- Amurox fugax

Dubai today:
St 1:
Chest: Rt side lung fibrosis.
Abdomen: Renal transplant.
St 2:
DVR, AF, DM, on warfarin, hypothyroidism on thyroxine has IDA on iron but not
responding referred to you to look for a cause. A CASE For DD
St 3:
CVS: DVR.
CNS: spastic paraparesis without sensory level.
St 4:
PT with chest pain who underwent stress ECG which is positive.
Your role to tell him test result & to explain for him that he needs c angiography &
may be CABG after that.
St 5:
BCC1: Pt has SOB: Then found to have Wt loss, diarrhoea, thyroid nodule &
neck scar.
BCC2: ALSO SOB: progressive then found to have RA on MTX.

My colleague exam in dubai

5th October
Station 1
1 /Ascites for differential
2/ rt lower lobe consolidation pt had cannula also
Station 3
1/Aortic regurgitation /AF marfan?
2/ hemiplegia ( examine upper case limbs)
Station 2
Back pain ,ankylosing
Station 4
Somatization disorder
Station 5
1- DVT
2- Amurox fugax

EGYPT== CAIRO
Maadi hospital exam
12 Oct 2016
laste corrosal
1-HSM +Pallor+left sub mandibular LN +left axilla scare
Mostly lympho proliferative disease
Left upper lobectomy +trachea shifted to left +brochiectasis
2-asthmatic worsening symptoms with pet animal at home +taking propranolol
3- cvs left infra mammary scare +AF+MS so mitral restenosis post valvotomy with
pul HTN
Cns left hemiparesis+left UMN facial palsy
4-young visitor with cruciating occipital headache with
vomiting CT normal for lumbar punture want to go DAMA to fly back to USA
5-BCC1-
psoriatic arthropathy
Bcc2-
generalized strange rash never I saw before started 2 weeks back with alopecia
totalis in HCV patient on interferon 5 months ago +ribaverin
Examiner told one of our collegue may be lichen plans?

Serdang Hospital, Malaysia. MRCP PACES 22nd October. 3rd carousel

1. Abdo: Pt came in with Abdo pain. Transplanted kidney. Both sides have
inverted J shape scars. Both sides palpable mass. Left wrist AvF scar but no
palpable thrill
Respi : Long thoracotomy scar on the right side. I think had fine creps over the
base of right lung. ? Lobectomy secondary to malignancy /abcess/volume
reduction surgery? Transplant. No idea �

2. History : Young chap with history of asthma and cough. Cough and wheeze
worsening for past 4 months despite escalation of therapy/Inhaler. Usually 3,4
episodes per week at night. No failure symptoms. On further history, had problem
at work, possible lay off. Wife seeing psychiatrist for depression. Patient taking
propanolol prescribed for her wife for his own symptoms.
3. Neuro : Young lady with difficulty walking. Broad based gait, positive romberg.
Spastic paraparesis, increased tone, brisk reflexes, upgoing plantar on left. No
sensory or propioception impairment. Heel shin okey. I think MS or SCA or
Friedrich. Have few other differentials for upper motor neuron lesions
CVS: Very young chap with pacemaker or maybe ICD. Came with palpitations.
Really can't appreciate double apical impulse. Just some systolic murmur LSE
and at the apex, I'm not sure what murmur. Maybe systolic murmur.Gave HCOM
or MVP as differential
4. Comm skills : Talk to patient's son about his father prognosis. Diagnosed ILD.
Multiple admissions. Baseline function deteriorating. This admission with chest
infections covered with iv antibiotics. Respi team suggested palliative care.
Patient doesn't want more admission.
5. Case 1: Young chap with double vision and diarrhoea. Looks like Grave
ophthalmopathy. Unsure if AF or not. Visible palpable goitre.
Case 2. Young lady with gum swelling. Not so pretty but make-up so thick.
History of seizure on phenytoin. It's gum hypertrophy.I asked for any rashes or
skin changes . She denied. Later after exam they said its tuberous sclerosis but I
really can't find the rash because of the make-up. Died � �
Malaysia Hosp serdang 22/10/16
Station 1 i think ILD and Renal transplant
Station 2 headache
St 3 proximal.myopathy and AVR
St 4 explain ADPKD diagnosis
St 5 pretibial myxedema with goitre
And Esrf pt with AVR came with 1day of SOB

UK exam 2016
History taking
Jaundice in a traveler after returning from Kenya.
Communication Skills
A patient with end stage COPD: explain to his daughter about the risks and
benefits of mechanical ventilation.
Station No. 5
A. Neurofibromatosis
B. A female patient with tiredness, weight loss and history of Graves
disease/Rheumatoid arthritis? --Coeliac disease/Addisons?

Oman 09/10/16
1-Abdomen: Young adult with mid line upper abdominal scar.
Hepatosplenomegaly. No peripheral stigmata of CLD, not pale nor icteric and no
palpable LNs. Subtile parotid enlargement.
1-Resp: Young not in distress, well built, no clubbing, apex not palpable at Lt
side, but indeed it is on Rt side, with mixed corse creps and some rhonchi.
2-History taking: Young male with typical migraine headache without aura not
responding to overcouter codamol, plus mild chronic tension headache on top of
his migraine. His concern was he has difficult time in his job and others with his
headache.
3-Cardio: Metalic valves.
3-Neuro: Young, obese with bilateral lower limb weakness, mainly proximal, with
good distal power, normal sensory and cerebellar examinations. Planters
downgoing. There was scar at Lt thigh, probably a muscle biopsy. Impression:
Myopathy.
4-Ethics/Communication: Female, physiotherapist at stroke unite, admitted with
acute hemiplegia involving limbs but sparing crandial nerves. Examinations
variable and not conclusive plus normal work-up included CT and MRI brain.
Impression was functional weakness. She is angery and wants to talk to doctor
now as she heard somebody saying that she is faking her symptoms. Plz see her
and discuss the management�.
5-Case1: Young female with headache. Please see her. Fruther history revealed
headache, visual distrubance, amenorrhea, changes of her shape consistent with
acronegaly. Examinations: acromegalic features and bitemporal hemianopia.
5-Case2: Young adult with back pain and found to have cardiac murmur. Please
see him. Fruther history: chronic back pain with morning stiffness and restriction
of movements. No rash, no diarrhea, no trauma, not fever, no neurological deficit.
Examination: typical AS. AR murmur.

Feel very happy and privileged to tell that by the grace of Almighty passed my
paces exam with a score of 170/172 in Glasgow this diet...very thankful to all the
group members for their efforts of posting such useful information constantly... So
here it my experience of paces in Queen Elizabeth Hosp Glasgow... St1- abd was
ascites due to cld with portal htn, resp was lobectomy due to pul avm/lung
abscess...st2- Dx was transient global amnesia,many got it a bit wrong thinking of
tia,examiner actually at the end of viva told me that I was the only person giving
the right Dx,so that helped to boost the confidence...scenario was a 50yr old lady
became confused for 2hrs and became normal again after the attack.she had a
friend along side who said that she was saying and behaving abnormally,there
was no weakness,no loss of consciousness,no history of trauma or
seizures,sweating,mood changes..this was the fort time she had it...she is all well
now..previous history of diabetes...my Dx was transient global amnesia and dd
were tia,hypoglycemia,electrolyte imbalance and seizures...examiners were very
happy..
Concern as usual is it stroke?...st3- cardiac was aortic stenosis with ejection
systolic murmur radiating to carotids,low vol pulse and a Pansystolic murmur in
apex due to gallavardin phenomenon... Neuro case gave me nightmares as a
young male who on examination had only left up going planter and all normal
findings...it wasn't a hemi,everything else was normal.
I thought I missed something but as it turns now that was the only sign
present...Dx was multiple sclerosis,i reached the Dx thinking of having an upper
motor sign with a 30-40yrs old male... St4- counsel a male pt of 32yrs for
Hickman line for 6 cycles of chemotherapy for Hodgkin's lymphoma...concerns
were-why him?how to tell his wife?what about fertility as he just been married
and wants kids?what is the prognosis(pt had stage two A)?...st5- one was
Turner's syndrome with hypothyroidism...concerns were about mostly all the
complications of Turner's...and sec one was typical psoriatic arthropathy on mtx
but not controlled....examiners main focus was of biological agents and
multidisciplinary approach... Lost a mark in neuro and Turner's...except that it
was a blessing from the doors of Allah and thankfully now can say passed the
biggest hurdle of paces...my advice like most of the experienced doc here will tell
u there is no alternatives to practice...make a scheme,make a plan and practice...
Practice the common cases for st1,3...collect all the past cases as much as
possible for st2,4,it gets repeated so many times...solve it and practice with
friends or anyone... And also practice very very hard for st5... St5 carries one
third of marks of whole exam,a bad st5 makes passing so much difficult...about
books I followed safely al rokh sir's pdf for st4, made my own notes for st2, cases
for paces for st1,3...and ost and sadek al sir's pdf for st5 ... And lastly thankfull to
all the group members for such high standard of work and helping candidates
throughout this tough hurdle of paces....

Glasgow UK on 17/10/16
St.1 - abd- transplanted kidney
resp - pnuemanectomy scar
St.2 - c/o palpitation ,headache - MEN
St.3 - card - AS & Neuro - Parkinson's ds ,examination of lower limb.
St.4 - explain for OGD for bleeding varieces
St.5 - 1)arotic valve replacement in c/o palpitation
2)headache

Malaysia
Cvs- mr
Respi- coad
Abd - renal transplant
Cns- ms
Hx taking -hemoptysis
Comm skill- first unprovoked seizure ,update & advice to wife
Bcc - ankylosing spondy
- churg strauss synd

London. bedford.
my friend cases in uk: respi - kyphoscoliosis and? Rheumatoid arthritis with
crepitations and tracheostomy scar, likely bronchiectasis.
Abd - Mercedes Benz scar.
Hx - SLE.
CVS - AS.
CNS - Right frontal scar with right CN I, partial CN III, LEFT V2?, CN VII
involvement. Sorry don't know what is going on here. Anyone, any input?
Com-speak to daughter of patient who has advanced copd who is doing poorly.
Your consultant thinks the prognosis is poor but intensive Care has not been
ruled out. Patient has mentioned that he would do anything to attend his
granddaughter's wedding in 3/12 time. Your task is to explain to the daughter the
patient's current condition, inform her of current prognosis, and explore patient's
wishes.
Bcc: 50/Caucasian lady post partial thyroidectomy presents with lethargy
(hypothyroidism sx).
Bcc: 72/Caucasian gentleman k/c parkinson's come with frequent falls and
fluctuating BP( postural hypotension&dizziness ).
The cns one of my friends thinks it is operated npc
The bcc parkinson's, pt is on bisoprolol n warfarin for his heart as well

Exam experience in St George hospital London

Start station 5
BCC 1 pto with uncontrolled HTN, previous history of carotid body tumor surgery,
with neck scar, concern is tumor is back, I said it might be possible need further
investigation didn't get much information about recent control so that was
mistake, examination was normal,
BCC2 ankle pain acute with urinary problem, it was fake patient because he was
walking outside normally, on exploration multiple sex partners so gave diagnosis
of gonococcal reactive arthritis, examiner was interested in Reiter syndrome
Station 1 I could only find basal crepts and pedal edema couldn't get it right May
be I was also getting prolong expiration, cough was dry, so I gave ild with
pulmonary hypertension, I don't know it's right or not
Abdomen pt with abdominal pain and fever with peritoneal catheter in place I
think so I got fullness in flank but could not get any visceromegaly they were
asking about causes of abdominal pain I said peritonitist , asking more I couldn't
recall more,
Station 2 hemarthrosis, in old patient with differentials of gout, septic trauma INR
3.5, I forgot to ask about compliance though asked about any problem with
medication but still I miss important issue
Station 3, cardiology I ran out of time in station 1 and 3 due to less practice, there
was long scar in middle age lady with tremors in hands , I couldn't appreciate any
murmur, they were asking about causes of long scar and tremor I said
amiodarone but couldn't recall more I think ciclosporin tremor with heart
transplant but I don't know about isolated heart transplant scar
Station Neuro peripheral neuropathy
Station 4 Esrd need lot of issue as cause was polycystic kidney disease, with
husband blind, issue with dialysis, genetic counseling

Uk Truro (London college)

17/10/2016
Cvs
Congenital heart repair
Median sternotomy scar
No murmurs
Discussion on previous possible causes and complication eg asd ,vsd
Questions focus more on asd
Neuro
Lower limb
Spastic paresis
Mnd likely
St 2
Hx taking
Hx abd pain and diarrhea
Patient has hx irritable bowel syndrome before
Worry as has strong family hx of colon ca
St3
Respiratory
Rt lobectomy with clubbing
Abd
Jaundice with splenomegaly
Com
Newly dx ckd
Previous gp had nt conveyed enough information as she has health screen which
she choose nt to investigate
Counsel on ckd and posibility of dialysis in future
Bcc1
Hx dm type 1
Worsening eye vision
Dm retinopathy
Bcc2
Hx uncontrolled dm with fever and lower limb ulcers
Gt charcot foot changes with dm neuropathy as well as skin redness at left foot ?
Cellulitis
Best of luck to all

Copied
16/10/16
Station1 pulmonary fibrosis
Renal transplant
Station 2 sob
Station3
Avr tissue
Neuro peripheral neuropathy
Station ca lung
Station5 headache likely hemiplegic migraine
Back pain. Ankylosing spondylitis
Cairo 13-10 (Courtesy of Dr Ahmed Farouk )
Abdomen: HSM with ascites.
Chest: lung fibrosis, although clear chest, she has clubbing and thin skin,she has
also cachexia..
Neuro: celebellar syndrome, flaccid paraplegia and areflexia and downgoing
planters with P N, old age excludes f. Ataxia, so it could be due to multiple
strokes
Cardio: AVR and ASand probably Aortic flow murmer or aortic regurge for echo
assessment
History: headache
It was migraine vs drug induced
Communication: angry patient as her dad died due to no beds in HDU also a
missed dose of antibiotics
Station5: blurred vision in one eye, painful eye.. Fundux not accessible..
Diagnosis was Behcet with anterior uveitis, then he said make the complaint
Acne
The other case, rash on elbow and knee, firm nodule, the only positive finding is
Shortness of breathing, xanthoma

Exam cases- bilateral UL lobectomy (resp) renal transplant with functional but
unused AV fistula (abd) MEN1(history) bioprosthetic AV (cardio) sensorimotor
peripheral neuropathy (neuro) explaining diagnosis of MS(comm/ethics)
Neurofibromatosis 1(Bcc1)& Ankylosing spondylitis (Bcc 2)
My friend cases

Uk grimbsy 15/ 10/16

Station 1
Pulmonary fibrosis
Cld only palmar erythema was present.complex patient
Station2
Wt loss night sweats
Dd lymphoma / tb / hiv
Station 3
Cvs
Aortic valve replacement tissue valve only flow murmur was present
Neuro clubbed foot , proximal myopathy
No sensory loss DD Muscular dystrophy examiner asked what else i said i would
examine spine n also do upper limbs to rule out mnd.
Station 4 hypoglycemia with unawareness. Address concerns i forgot to ask
smoking.everything else was ok
Station 5 back pain n hand pain with rash .....psoriasis
Dd psoriasitic arthropathy
Second station 5 hoarseness
Complex case
Lady was smoker n had stopped thyroxin , was also taking steroid inhalers ,
actively somoking no lumps n bumps in neck
I told examiners that i would restart thyroxin n tell correct technique of inhalers to
rinse mouth after use....he asked what else , i said ca larynx .....examiner was
happy.bell rang

UK- Chester 15/ 10/16 (Courtesy of Dr Umar)

Station 1 lung transplant
Polycystic kidney
Station2 hypertension
Station 3 double mettalic valve
Neuro wasting of hand with no sensory loss dd mnd
Station4 hypoglycemia with unawareness
Station 5
Osa
Rheumatoid arthritis with sob

Cairo 13/10/2016
1st carousel
ST3
NEURO: bilateral cebellar lesion, loss of deep sensation, high stocking
hypothesia to superficial sensation+nystagmus bilateral (M.S with peripheral
neuropathy, cerbellospinal degeneration, multiple strokes)
CVS:AVR+AS+??MR
ST4: Death of father 75 yrs copd, pneumonia crub 5, admitted to surgical ward 2
days ago, detoriated, transferred to HDU, cpr failed, cannula dislodger and miss
1 dose of ab...
It was tough one
ST5:
Male 25, blurring of vision in lt eye with retroorbital pain 3 months ...mother is
blind 56yrs.. was not cooperative on fundus ex....lt eye catract & pigmentation.....i
can't appreciate any thing else in both eyes.....he had acne on no rx, stria rubra in
his arms
D.D (what i put)
Lebers
RP
Optic neuritis
I did it badly
BCC2
Rash on lt elbow+htn
I misses analysis of htn...chest pain...yellow rash on elbow and knee...adress
concerns as pemphigoid, D.H,
D.D
Pemphigoid
DH
PSORAISIS
Examiner ask me what is relathion to htn? NF with pheo
He ask again with relation to chest pain, +F.H of stent in mother?....i answer
tuberous xanthomata, then bell ring
St1
Chest: COPD
Abd: hepatomegaly in morbid obese pt
ST2
Headache (1ry type, migrane without aura, cluster, analgesic misuse)
I feel not happy with ST5
Ask god 4 me, it is my 2nd attemp, last one 130/172 fail in identifying signs
I book the next diet...as i had only two attemps then 7yrs will be finished
Again...ask god 4 me

Egypt 13/10
Elmaady
Station 1
COPD
Thalassemia
Station 2
Lithium toxicity nephrogenic DI
station 3
AVR +MR
Facioscapulohumeral
Station 4
Cl. Difficile diarrhea
Station 5
Epigastric pain indomethacin
Paroxysmal nocturnal hemoglobinuria

EGYPT
Cairo 12-10 - 16
St 5
1- Male patient with diarrhea (sometimes bloody) and abdominal pain.. He has
psoriasis and taking methotrexate.. Concern about cause of diarrhea and
abdominal pain ? IBD, NSAID induced errsions, IBD, methotrexate, cancer.
2- Male patient is complaining of sore throat.. By history and examination he has
thyrotoxicosis and on carbimazole.. Concerned about the cause of sore throat..
Carbimazole induced.
St 1
Chest..COPD with? Basal fibrosis.
Abdomen..? CLD but without signs could be early cirrhosis
St 2
Young female presented with fatigue and by history she has joint pains,
photosensitivity and malar rash with previous dvt and miscarriage... Diagnosis is
SLE and antiphoshpolipid syndrome.. Concern about if she can get pregnant.
St 3
Neuro.. Young male with difficulty in walking examine cerebellar syndrome..
Patient has Upper motor pyramidal lesio and cerebellar signs.. MS
Discussion about DD of cerebellar syndrome.
Cardio.. AVR with many murmers! (Not sure of them)
? Aortic stenosis? AR ?MR.. AF
St 4
Young patient type 1 DM on insulin and has anawareness of hypoglycemic
attaks... This case is a history taking case.. Should ask about insulin dose
change, type of food, increased activity, smoking, drugs.. On this patient he is not
compliant to insulin dose written for him, takes b blocker for htn, history of IHD,
smoking.. All these factors should be asked about and corrected to solve his
concern

Egypt 12/10/2016
Communication
Lumber puncture to exclude subarachnoid
Station 5
Skin rash in HCV
Joint pain in psoriasis rheumatoid type
Station 2
B. Asthma uncontrolled
Pets
BB
Station 1
Scare with lobectomy
HSM+LN
Station 3
Spastic paraparesis
MVR+AF
Egypt Cairo 12-10 - 16
second carosel (details will follow later)
St 1
Abdomen : splenonomegaly with shrunken liver for dd? CLD.
Chest COPD.
St 2 young female with joint pain, skin rash, h/o dvt and miscarriage.. SLE And
antiphospholipid.
St 3
Neoro MS
Cardio AVR with some other murmurs!
St 4
Young man type 1 DM on insulin with anawareness if hypoglycemic attaks..
Discuss (as if history case!)
St 5
1- Psoriasis with abdominal pain and diarhea: could be IBD, nsaid effect,
methotrexate,cancer...
2- Hyperthyroidism with sore throat due to carbimazole

UK PACES EXAM Experience--Nottingham

10/10/2016
Resp.
Double lung transplant
Abd.
chr. liver dis
Cvs.
metallic valve
Neuro .
peripheral neuropathy
History.
Upper GIT Bleed.
Communication.
Chr. kidney dis 2ry to APKD (breaking bad news) and mgt
Station 5.
palpitations
carpel tunnel syndrome
Cairo Egypt 11-10-16
second carosel
St 1
Abdomen CLD
Chest COPD with bilateral basal dullness
St 2 night Fever and sweats for dd : tb, lymphoma, hiv, malaria, seretonin
syndrome.
St 3 Cardio?? VSD with cyanosis and clubbing (not sure)
St 4 angry patient post pacemaker insertion and one the wires dislodged.. For
another session of insertion.
St 5
1- Addison with family history of hashimoto.
2- vitiligo with pernicious anaemia.

Cairo 11-10
Station 1
Splenomegaly with lymph node
Clubbing with basal fibrosis
Station 2
Confusion
Station 3
Hemiplegia
AVR
MVR AF
Station 4
Gentamycine toxicity
Station 5
Short stature
Rheumatoid with basal fibrosis

Cairo Egypt 11-10-16 second carosel

St 1
Abdomen CLD
Chest COPD with bilateral basal dullness
St 2 night Fever and sweats for dd : tb, lymphoma, hiv, malaria, seretonin
syndrome.
St 3 Cardio?? VSD with cyanosis and clubbing (not sure)
St 4 angry patient post pacemaker insertion and one the wires dislodged.. For
another session of insertion.
St 5
1- Addison with family history of hashimoto.
2- vitiligo with pernicious anaemia

Dubai
11/10/2016
History
Collapse
Pt known case of breast cancer
St 1
Hepatomegally
CLD
bronchiactesis
St3
VSD
flaccid paraparesis
St4
Pt with history of #
Suspected to have gaint cell arteritis given steroid
So angry
St5
Scleroderma
Graves

EGYPT -- CAIRO= 10/ 10/2016

St 1 : Resp
ILD/COPD
Abdomen
HEPATOSPLENOMEGALY WITH ASCITIS/ A SINGLE SPIDER NAEVUS
ST 2 HISTORY
35 , female k/c T1DM, RETINOPATHY,NEUROPATHY,NEPHROPATHY, AF ON
WARFARIN, HTN, WITH PAST HX OF MI,HF 5 months ago,
presented with a hx of recurrent collapses since three months. She also had night
time diarrhoea since few weeks. She has lost awareness of hypoglycemia.She is
on warfarin 5mg , bisoprolol 2.5mg Lisinopril 20mg,Amlodipine 10mg,Digoxin 0.5
micgm ,Frusemide 80mg.
Viva on DD. Hypoglycemic episodes/arrythmias/autonomic neuropathy/Addison's
dx/ drug induced postural hypotention/ diarrhoea for similar reason. Investigations
(of autonomic neuropathy especially) / management.
St 3
CNS :
25 yr old with spastic paraparesis since 16 yrs. Viva on hereditary spastic
paraparesis.
CVS :
35 yr old with SOB and hx of fever. Soft S1 with soft Pansystolic murmur
radiating to the axilla. S 2 was normal.Could not appreciate a diastolic murmur.
Viva on IE.
St 4 COMMUN
Young female admitted for delivery. Had a normal vaginal delivery. Was given
benzyl penicillin for vaginal streptococcal infection. After being shifted to the ward
,she developed a mild hyperemic rash which progressed rapidly in a day to
involve the whole body with blistering and oral lesions. She is hypotensive with
breathing difficulty and has developed liver and kidney dysfunction. Medical team
is thinking of shifting her to the ICU with a view to a possible intubation. Talk to
her husband who is concerned about her wife's situation.
His concerns :
What happened?
Could it be avoided ?
Was there a negligence involved ? If so , he would demand compensation.
What will happen ?
He overheard some doctors saying that she might need to be put to "Sleep".
What does it means ?
Discussion on:
Could it be avoided ? What might have happened ? What if the skin test negative
,could one still get a Steven Johnson syndrome ?
How would treat a case of Steven Johnson syndrome ?
What is autonomy ? Under what circumstances could you breach it ? Did she
have autonomy ?
St 5
Case 1 : 40 yr old male with itching for 10 months . No skin lesion (actor)
HX of foot joint pains on and off , for which he takes analgesia on and off.
No past medical hx.
Father died of some blood cancer.
Smokes 40 cigs per day for 10 yrs.
St 5
Case 2 :
45 yr old male developed a blistering rash one month ago after his brother died.
He has oral lesions.
No past medical hx of any kind accept some wheezing on and off. He is taking
aspirin for some unknown reason since three months.
No family hx.
EGYPT -- CAIRO= 10/ 10/2016
Station 5:Cushing
Retinitis pigmentosa
Chest thoracotomy scar
Copd bronchiactasis
Abd spleenomegaly
History cramps & diarrhea
Father colon cancer
H/o ibs
Neuro
Flaccid paraperisis
With sensory level
Cardio
Loud s1
AF
Loud s2
Most likely ms phtn
Communication
Copd acute attack improved with bipap not returned to baseline
Daughter wants talk to you

Corrections of date yesterday on 9/10/2016.

I started with stn: 2
Headache which make him suffering in his job and taking co- co- codamol not
improving. He feel fine when rest in a dark room.
Stn: 3= Collapsing pulse and Predominant AR AND mild AS.
Neuro= hypotonia with cerebellar syndrome heel shin test positive with dorsal
column affection. = MS
Stn=4
Pt is a staff nurse admitted with Rt leg and arm flaccid paraparesis ; CT scan
normal and neurologist consultant evaluated and advice for MRI Brain which is
also normal .
Counselling pt about the disease and further treatment.
Stn 5=
Bcc 1= Headache with visual disturbance. Acromegaly.
BBC 2 =
Pt has heart valve problem gp refer for echo. And he complaints of back pain and
neck pain= A. Spondylitis.
Stn 1=
Abdomen: Young female 15 yrs has mid line scar and lt subcostal scar and lt iliac
fossa scar. No AV Fistula. BEneath lt iliac fossa scar mass with spleenomegally.
Diagnosis all over =poly cystic kidney disease , findings are transplantation of lt
kidney with cyst in spleen and liver.Hepatectomy due to cyst in liver.
Respiratory:
Clubbing ,COPD and Pulmonary fibrosis . D/D = Bronchiectasis.
Pls pray for me
Dr. MOHAMMAD SAZZAD HAIDER, Rustaq.

Egypt exam today

10 - 10 - 2016
Station 5
Pemphegus
gout
History
DM with lack of awareness
Communication
Steven Jonson
Neuro
spastic parapresis

Egypt exam today

10 - 10 - 2016
Station 5
Pemphegus
gout
History
DM with lack of awareness
Communication
Steven Jonson
Neuro
spastic parapresis

Dubai 10/10/2016
St 4 polycystic kidney bbn concern about job and her kids.
History: uncontrolled asthma after yrs of control, new factors was pet at home
and propranolol for anxiety
Neuro: upper limb examination in ESRD pt, there was wasting of thenar group.
Cardio: aortic stenosis probably aortic sclerosis
Abd: hepatosplenomegaly and i missed lymph nodes, there was hickman line in
place probably lymphoma
Chest: was very difficult very old man uncooperative. Obstructive changes with
depressed lt side. Probably copd with lt fibrosis.
St 5, 1 recurrence of grave's in a young man
St5, 2 fever and sweating with artificial valve

Oman on 9/8/2016 i started with stn: 2

Headache which make him suffering in his job and taking co- co- codamol not
improving. He feel fine when rest in a dark room.
Stn: 3= Collapsing pulse and Predominant AR AND mild AS.
Stn=4
Pt is a staff nurse admitted with Rt leg and arm flaccid paraparesis ; CT scan
normal and neurologist consultant evaluated and advice for MRI Brain which is
also normal .
Counselling pt about the disease and further treatment.
Stn 5=
Bcc 1= Headache with visual disturbance. Acromegaly.
BBC 2 =
Pt has heart valve problem gp refer for echo. And he complaints of back pain and
neck pain= A. Spondylitis.
Stn 1=
Abdomen: Young female 15 yrs has mid line scar and lt subcostal scar and lt iliac
fossa scar. No AV Fistula. BEneath lt iliac fossa scar mass with spleenomegally.
Diagnosis all over =poly cystic kidney disease , findings are transplantation of lt
kidney with cyst in spleen and liver.Hepatectomy due to cyst in liver.
Respiratory:
Clubbing ,COPD and Pulmonary fibrosis . D/D = Bronchiectasis.
Pls pray for me
Dr. MOHAMMAD SAZZAD HAIDER, Rustaq.

OMAN 9- 10-2016
Another experience
st 5
Acromegly
heart valve problem & complaints of back pain and neck pain
A. Spondylitis
comm
functional weakness physiotherapy nurse
Abd
Heptomegly
Scar mid line
Abd thalassemia
Haemochromatosis
Cvs
AR
PLUS
AS/mr
Chest lt side fibrosis
rt side consolidation /bronchiecta
Stat 2 history
headache migraine aggravated by analgesic over use
Neuron proximal weakness ,cerebeller
DD

Exam cases of my frnd uk

Station 4: explaining and bbn of POLYCYTIC kidney disease young lady .
Concern was about work .
Station 2 : Young pt with collapse histry of sudden uncle death . HOCM :
brugada
Station 5 : CKD WITH knee Joint pain 1 day .. Gout/ pseudogout
Bcc : young pt with feet pain. ANKYLOSING
Chest: pulmonary fibrosis
Cvs : AS
NEURO : spastic Parapersis with dorsal column
Abdo: renal transplant

Exam in Egypt today

9- 10- 2016
abdomen
hepatomegaly and splenectomy and lymphadenopathy pallor and jaundice,
chest
COPD with bibasal fibrosis
history
left sided weakness in young female on OCP recurrent attaks of headache DD
hemiplegic migraine and sinus thrombosis and TIA
neuro
spastic paraparesis without sensory loss MS
cardio
mitral valve replacement and AF and AR
commun
Hodjkin lymphoma for Hickman line and concern about infertility
st 5
psoriasis and back pain
hypothyroidism

Oman 8-10-2016
St1:
Chest: young pt. With multiple scars in his abdomen and one small scar in
rt.lower lobe + rt.lower lobe dullness + cerps
DD
Abd: middle aged man ..multiple scars in abdomen in lt.iliac and rt and lt.iliac
mass
St 2 : 40yrs ...dm +htn + parathyroid ectmy+smoker c/o: palpitations
Examiner ask for issues in this hx
DD for htn
Investigations
St:3
Neuro: middle age male
Catheterize
Both l.l weakness
Hypotonia
Hyporeflexia
Sensory level at t4
Q:
DD
Investigations
Cvs: midsternotomy scar
AVR
Some candidates say both MVR +AVR
Examiner ask what is cause of s.o.b
Station 4
CKD come with urosepsis given gentamycin +amoxicillin develop exacerbation of
renal function and they didn't do measurement for gentamicin level for 3days
Now pt.not need the RRT..gentamycin is stopped ..ivf started
Station 5
Bcc1
Ant.neck swelling
Bcc2
Dm with deterioration..
Neck swelling not clear
In hx surrogate say hand shaking and prefer cold
O/e
No tremor

OMAN ,,, Muscat

08/10/2016
St 01
Res: ILD with obvious clubbing
Abd:
Young boy with l/s Polycyclic kidney
St2
35yrs old lady with left sided weakness of the body lasted for one hour. Only
positive thing in the history was taking ocp and headache with the onset of
symptom
St3
Cvs
MVR WITH Recent pacemaker insertion (pt tachycardic)
Cns
45yrs old man with difficulty in walking. Proximal weakness more than distal.
Plantar down going.reflexes are very sluggish. Sensation intact. No cerebellar
sign.as pt unable to walk could not check gait......myopathy...
St4
52yrs old lady known case of AF on warfarin investigated for anaemia
.colonoscopy bx revealed ca.no distal metastasis.to break the bad news.
Bcc1
Young pt with loss of vision at night.
Retinitis pigment Osama
Bcc2
Pt with numbness of the both feet
Diabetic peripheral neuropathy with charcot joint
Oman exam 8/10/16
St1 -transplanted kidney
-copd with bibasal lung fibrosis
Station 2 male 42 post MI 6 weeks dizziness and epigadtric pain
Sat 3 AVR, Motor nruropathy
Sat 4 diabetic since 32 years with micro and macrovascular complications he lost
his glycemic awareness
Sat 5 systemic sclerosis with skin rash no any signs look MCT
Had recurrent hyloglycamic attack and heart attack
Eye pain and double vision graves opthalmopathy

cairo first courasel:history:hypothyroid patient with history of valve replacement

complain of tiredeness.she is on warfarin,simvastatin and thyroxine,on asking
she has bleeding per rectum mostly piles,DD warfarin induced pr
bleeding........communication Multiple Sclerosis new diagnosed

Egypt Cairo
8_10_2016
History:young lady,prosthetic valve on warfarin also hypothyroid on replacement
presented with s.o.b and anaemia
Communication: multiple sclerosis (breaking bad news)
Cardio
Double aortic with MR
Abd
Massive spleenomegaly
Neuro
MS
EGYPT == cairo
8-10-2016 == first courasel:
History:hypothyroid patient with history of valve replacement complain of
tiredeness.she is on warfarin,simvastatin and thyroxine,on asking she has
bleeding per rectum mostly piles,DD warfarin induced pr bleeding........
communication Multiple Sclerosis new diagnosed ( BBN)
Latest exam experience from UK (Courtesy of Dr Sheraz)
PACES EXP 06.10.2016
queen Elizabeth hospital glasgow
I entered thru station 5..
55yr lady..Turner syndrome, hx of recurrent UTI n Ear infections, never had
daignosis before, physical findings of turner were short stature, low hair line,
shield chest, short stature, squint
Concenred abt future prospects
Discussion abt DD, what can be done now?
50yr old lady vitiligo..presnets with fatigue
Had to rule out all assoctaions on history, when asked had postural drop , BP at
presentation was 95/65
Dx Addison disease
Discussion abt DD, Inv, Mx
Station1
Abdomen renal transplant secondary polycystic kidneys, previous fistula scar on
left radius
Resp Copd superimposed LRTI with parapneumonic effusion left sided
Examiners were not happy
Station 2 was Odd..confusion for 2 to 3 hrs..only prssenting complaint, previously
diabetic..but everything was normal..no presyncope or syncope..was just
confused for long 2 to 3 hrs and then revived on its own..no neurological or
cardiac symptoms or association with posture..gave diff of
TIA/stroke/seizure/cardiogenic..
Station3
CVS midline sternotomy scar..metallic AVR with ESM but pulse was
waterhammer..presenting comp was palpitations, reasons?
CNS classic diabetic peripheral neuropathy..with big toe amputated and
neuropathic ulcer, Discussion on Dx DD Ix Mx
Station 4..
Newly diagnosed hodgkin lymphoma..hematologist asked for
chemotherapy..wanted to discuss
Issues..fertility, employment, hicline, why me ? How to tell wife...

8/10 Muscat
Station 5 c/o difficulty swallowing systemic sclerosis
Thyroid eye disease with no other manifestation of hyperthyroidism... Rt lobe is
multinodular howcome it should be grave's
Station 4 c/o dizziness on standing up and melena.. had mi 6 weeks ago
Forgot to ask about acei
Station 2 type 1 dm with no awareness of hypoglycemia. Who does not want to
change his insulin regimn
Chest lobectomy bronchiectasis
I hope it's not pneumonectomy
The trachia shifted to rt but there are signs of fibrosis upper rt also
Neuro
Proximal myopathy areflexia adductor more weather than abductor.. on hand
shake lefts his arm
Coordination could not be assessed due to weakness
No sensory affection
Plus umnl in the form of spasticity
Cardio
Old patient double valve replacement
Young patient mitral valve replacement

Oman 7/10/2016
st 1:abd renal transplant
other bronchiectasis with lobectomy
st 2: young male have diarrhea and abd pain more than 16 year with strong
family Hx of ca colon he concern as his father diagnosed recently
st:3 mid sternotomy scar with metallic sound low volume irregular pulse with
pulsating neck , there is pulmonary hypertension and lower limb and sacral
edema for me it is aortic valve replacement for some candidate mitral valve
discussion a very one as he said
neuro:young male paraplegic with one limb spastic with positive clones other limb
hyponia with down going planter absent ankle reflex and there is sensory level to
T4 examiner Indian aggressive
st4:young female in medical coll. diagnosed with MS Already inform about
disease but she confused about it with some concern she ask tooooo much
examiner female aggressive with English examiner only observing
st5: acromegaly ,,
obstructive sleep apnea

UK (FRESH) Experience exam

1/10/2016 == FRESH
Resp right lobectomy scar most likely secondary to lung ca. Pt was middle age.i
forgot to palate tracheal position
Abdo renal transplant Pt. Did everything ok.pt was in constant pain.examiner said
Pt has hyperthyroidism do you find any sign.i can say Pt had exophrhalmos and
she was a bit overweight.i may pass or fail
Neuro Pt had charcoal marine tooth ds
I did examination ok gave diabetic neuropathy diagnosis .I
Did not get time to ask him to walk when examiner gave me clue about high arch
foot I said charcoal marie tooth ds and sorry I should have ask him to walk so
again not pass
CVS central and left leg scar so defiantly had CABG otherwise very difficult
finding I presented as AS but don't think they were happy
History taking _ Pt with collapse I think it was ok from my side
Communication_ father had COPD got chest infection not recovering again I think
it was not that difficult and I feel at least I did ok to get pass rest depends on
them.
So overall fail
But I will continue this because I really worked very hard and did nit get chance 4
course
But incase pass then pure luck so less chance
Good luck to you.

Latest history case (Courtesy of Dr Hassan Abuali )

6/10/2016
Oman
Hx
30 yrs female came complains of fatigue and having normocytic normochromic
anaemia
Sle
Antiphospholipid syndrome
Has hx of dvt and miscarriage
Case encounter before in Egypt 6/15

UK Experience exam
3/10/2016
Station 1 resp:pulmomary fibrosis secondary to RA
abdo:failing renal transplant with lots of abdo scars-no idea what they were all for.
Station 2 irritable bowel syndrome in a demanding patient who wants scans etc
station 3 cardio-aortic regurg with collapsing pulse in a patient with marfans ,
neuro-no idea-absent reflexes in upper limb with not much other signs except for
mild weakness of some muscle groups....tough one.
Station 4 uhnappy relative blaming the system for delayed diagnosis,
staton 5; second epileptic fit and
pcp pneumonia in a hiv patient (im guessing)..
James cook university Hospital UK.
23/8/2016
I started with stn. 5 and my first case was vision problems. A young lady having
visual problem started suddenly few days ago. I asked to tell me the story in her
own words. She told me that she is having vision problems at the end of the day
mainly, unable to read. No headache, vomiting, limb weakness. I exclude. She
was a diabetic and on insulin since last 16 yrs. I saw her drug list. Then started
examing also. She can't see in her rt. Eye. I tested lt. Eye movement and field of
vision. Then I did fundoscopy for the rt. Eye. I couldn't see fundus what I saw
diffuse redness all over the visible part of retina . Pupils were not dilated. I
couldn't see any retinal vessels. So I became a bit confused about the findings ,
time finished and examiner asked me what is your diagnosis? I told, this lady with
long standing diabetes and sudden onset blurred vision might be having some
diabetic complication . He asked me what did you saw in fundoscopy. I told there
is diffuse retinal hge. He asked what is your diagnosis? I was wondering and time
finished. I explained to her that I will refer you to eye doctor for further evaluation
and management.
Then I started 2nd case in Stn 5.
My 2nd case in Stn. 5 pain in one eye. It was excruciating pain behind the lt. Eye.
Several attacks before. Stays 4 to 5 hrs.
No vomiting or other alarm symptoms. There was watering from that eye. I took
all the history and examine optic NV, exclude Trigeminal neuralgia. I diagnosed
cluster headache. Address his concern that this is not brain tumor. Examiner
asked me what treatment. I told analgesic to Nsaids to sumatriptan. Time finished
. I told it's clinical diagnosis so I will not advise CT. He accepted.
Then I started chest. Middle aged male with SOB. There was a chest drain on lt.
Axilla. Lt. upper chest expansion, movement was reduced. Breath sounds
diminished to absent on lt. Upper chest. Vocal resonance was also diminished.
Examiner asked me what is your diagnosis. I told lt. Sided lobectomy with plural
effusion. He asked me why you are saying lobectomy. I told there is flattening
and depression on lt. Upper chest. He asked me did you see the scar. I told no.
Then he showed me very faint scar on lt. Infra scapular region. Now he asked me
as this is very faint scar so lobectomy is done long ago, and then why the drain
now. I told he might have CA Lung for that lobectomy was done before and now
again it might have recurred with pleural effusion. He asked me this drain is
temporary or permanent. I told temporary. He asked me it's lobectomy or
pneumonectomy. I said it is lobectomy because the drain was high up in the lt.
Axilla. Time finished.
Abdomen :- Elderly male. With full flanks. Large rt. Iliac fossa scar. There was rt
arm AV fistula. I could not feel thrill but as I saw fresh puncture mark so I put my
stethoscope on the fistula and I heard the brui so I am sure now that it was
functioning fistula. I could palpate lt. Sided enlarged kidney
No shifting dullness or hepato-spleno mealy. I couldn't appreciate clear lump on
RIF. I find some scar on lt. Infra clavicular area. I present the case as failed
transplant with HD. He asked me about the masses I palpated . I told lt.
hydronephrosis and right illiac fossa renal transplant. He asked me, do you think
this scar is on RIF only or. .. I told lt is a large scar extends from RIF to touch the
flank. I wanted to see gum hypertrophy but he had artificial dentures. Examiner
asked me what is the etiology here. I told hydronephrosis, glomerulonephritis,
DM, HTN. Time finished
Station 3:- Cardiology, elderly male with SOB. There was low volume regular
pulse HR- 60bpm. There was pansystolic murmur in the apex with radiation to the
axilla . There was another ejection systolic murmur in aortic area with upward
radiation. Normal 1st heart sound and soft 2nd heart sound. I presented the case
as double valves pathology MR and AS. Examiner asked me what is the etiology
here. I told degenerative, as in old age. But might be rheumatic also. Asked me
investigations, I told echo. She asked me, you told you would like to finish
examination by doing urine dips tick. What is your your purpose of doing that. I
told by that I can exclude endocarditis. Time finished
Neurology :- middle aged male with walking difficulties. I started with gait, it was
high stepping gait . Both legs were wasted and more on rt. lower leg. There was
scar on rt. foot. Tone was normal, reflexes were diminished to absent, because I
saw some muscle flickering on knee reflex. Planters flexor. There was pest
cavus. My diagnosis was freidreick's ataxia, examiner asked me what other
possibilities, I told HSMN because there was loss of vibration sense also. He
asked me how you will investigate the case. I told Nerve conduction studies.
Time finished. Due to time constraints I couldn't see the back and I forgot to do
co-ordination . Overall examiner was satisfied as l felt.
Station 4, The story was one 55 yr. Old female who was admitted to the hospital
6wks ago with bronchial asthma and she was discharged with PEFR of 90 -100%
of predicted. She came today in follow up clinic but there was a chest X-ray
during her last adm. 6wks ago which revealed 2 opacities and it was not written in
discharge summary nor any body informed her about that report. Though it was
not certain about the report whether it was recurrence of her breast cancer which
she had 6 yrs ago and for that she underwent mastectomy and chemotherapy. It
was cured and she has been following up in cancer clinic. They told she is fine.
Today another X-ray done which shows the same uncertain shadows 2 in
number. You have to discuss the matter to that lady . So I started by introducing
myself and go ahead with the matter as Dr. Zein Taught us. I apologized
repeatedly for not informing her about the previous X-ray report. I showed
empathy when she told that her another sister died because of recurrence of
breast cancer. I told her about putting her in priority for CT scan and refer her to
chest specialist. I mentioned about PALS she can put her complaints. I told I'll
discuss the matter with my consultant to invest the matter of communication gap
that it might not happened again. I advised about smoking cessation clinic. I
asked about social support and family support and asked how she will go back
home. Offer support to drop her home if she is hesitate to drive today. Examiner
asked me what the theme here. It was uncertainty. He asked me why I didn't tell
her today 's X-ray report. I told she is already upset and as there are is no charge
in shadow so I didn't want to give her extra mental stress. Before that examiner
asked me what ethical issues involved here. I told Autonomy. She had the right to
know her X-ray report. Then he asked me that why I didn't disclose today 's
report, which I answered already. Time finished.
History stn. It was an young lady 25 yrs. Old got some blurred vision sudden
onset at the time of coming back home from a party with her friend and she was
driving at that moment. She had several same attacks before since last 6 months.
This time her friend was witness of the attack. She became unconscious for few
minutes and she had few low grade jerky movement of the hands and arms. No
headache, vomiting, no tonic clonic shakes of the body or limbs happened. No
fever, neck rigidity or any skin rash or purpura, was there. Giant cell arteritis
excluded. As there was history of tongue bite so I took details history to rule out
epilepsy. No history of clothes wetting was there. She wasn't on any regular
medication. No significant past medical history except the recurrent similar
attacks. At this episode BP was 96/50 and pulse was 56 per minute. She had that
black out on the wheel and her friend any how stop the car and take her out of
the car and took her to the hospital. Her alcohol intake was in excess of the
recommended limits. She used to drink more than 20 units of alcohol. Not
smoking much. I advised about smoking cessation clinic and also the alcohol
cessation clinic. She had a family history of premature death. Her brother died
suddenly at the age of 35 yrs. So in her case I discussed to exclude arrhythmia
also, including investigation for arrhythmia. I checked understanding and advise
investigation. Examiner asked DD. I told Epilepsy, arrhythmia,
hypoglycaemia(blood sugar level was 4.3 ), vasovagal syncope. Then he asked
me tell me one bedside test to confirm the diagnosis. I told tilt table test, he said
no. I told Holter monitor, still he said no. Then he told me BP, and then I said yes,
standing and supine BP measurement. Then time finished. Pray for me and I
wish you all the best to those who are going for exam.

UK experience
My experience at whipps cross hospital 31/8/2016.
Started with station 5
1.young female referred from surgical department due to recurrent abdominal
pain.
History was negative, no diarrhoea, no loss of weight.
No relieving or aggravating factors.
Systemic review showed rash at forearm, mild headache and some joints pain.
No weight loss
Periods normal
Examination; no jaundice, abdomen soft nontender and no viscromagely
Concerns;
1.what is the cause
2.why ultrasound normal.
I explained likely vasculitis or porphyria.
Needs other blood and urine test to confirm .
Examiner asked about differential i said as above and the next question was
investigation of porphyria
2.25 years old university student with collapse. I started what happened he told
he passed out while watching movie.
I ask if happen before, Pt told 3 weeks ago while he was working on computer in
library. I started with prodormal symptoms, they were none.i ask any friends
observed jerky movements, Pt told yes.
Than history goes on with incontinence and fatigue after recovery.
I ask about any thing unusual a night before (lack of sleep ),Pt told no . then
asked about driving, drugs, and hobbies (keen swimmer).grossly examine tone
power in both limbs,gait and ask for fundus. (Examiner refuse).
Concerns 1.what is my problem
2.what you will do (scan +eeg).
Consouil about driving and any attendant while he swims.
Examiner ask! What will be finding in ct? I told him likely to be normal as there is
no neurological deficit but would like to have com
Complete neurological examination.
Is it possible to have any cardiac problem to this patient.
I explained possible but less likely as both events occur while Pt was sitting,
however tacyarrthmias can be possible.
Would you start treatment. I said refereed to seizure clinic and neurologists will
decide
Abdomen# young female with central larotomy scar,subclavian
Dialysis catheter and right palpable kidney. Not sure about larotomy scar (which
was the main question by examiner),other question was about causes of fatigue
in this patient ??I told him uremia, possibility of underlying hypothyroidism,
anemia and infection. Overall not very good
Respiratory # young female, no rheumatological manifestations, wheezing from
bedside. Minimal basal crepetations.
Indian examiner started with respiratory rate (forget??)
Next question was jvp findings (??),followed by did this patient had loud P2 (??).
I said sorry for above 3 questions
Than he ask differential i told him copd /fibrosis.
He ask which will be your priority diagnosis, I told copd due to prominent
wheezing than investigation of copd with xray findings and pulmonary function
test. Overall it was tough
History ##50 years old women complaints of abdominal discomfort and bloating.
I started with usual pattern of pain,location, bowel changes, all none. Nonspecific
pain not related to any thing . half stone weight loss. Than I asked any tummy
distension, she said yes her trouser are tighter and she is using large size from
before. I switch to orthopnea, pnd, negative. No lower leg swelling no periorbital
swelling no problems with water. No signs of liver disease. Clueless I proceed to
past history which was significant for mastectomy secondary to malignancy.
Family history positive for ca breast in sister . mild low feeling due to recent
mother died because of ca breast.post menopausal (no dysparunia/break through
bleeding).
Concern 1. What is cause of tummy distension. I explained likely that some
tumour cell spread .2. Is it too late as I have symptoms since 3 months. I told her
we have to investigate and don't worry we will do your test on priority
Examiner ask# diagnosis i told him metastasis.
He ask if Pt don't have distension than what do you think. I told I consider irritable
bowel as recent death of her mother and only half stone of weight loss.
What other possibilty I told ca ovaries. Then tumour markers of ca ovary. What
do you do? Scan ct . any investigation would you like to offer while she was in
opd. I don't have any answer. He told chest xray.
What measures you told to other sisters and daughters. I told repeated manual
breast examination and after 40 years of age mammogram. Got full marks
Cvs # 75 years old male with sob . murmer of AR. I checked collapsing pulse.
Routine questions about causes.
Causes of acute AR (dissection of aorta, endocarditis and ruptured sinus of
valsulva)
Type of valve
Cns# 50 years old gentle man with difficulty in walking please examine upper
limbs ??
It was parkinsonism. I mentioned to check sitting and standing BP, micographia
and gaze palsy
Examiner ask about causes.
Treatment
New treatment, mention deep brain stimulation and dopamine containg implants.
Who will be involve in management of this patient #MDT.
She asks what occupational therapist will do??
I told occupational therapist will visit the home and arrange some rails and
support to prevent patient from falling.
Alhamdillah went well. Got 19 in both
Communication # spoke to wife, husband in icu. Keen cycle rider and went for
long marathon and take extra fluids to prevent dehydration. At home he also drink
water continously till he was found to seize in garden and brought by neighbours.
CT and all other labs normal. Sodium 114.
Better but still confused with gcs 15 . two weeks ago started on bendrafluthiazide
for htn (Pt age 45)
I started with wife with sympathy, what she Knows so far regarding husband.
Gave good news that scan is normal. Likely seizure due to low salt in body.
She asks why salt become low. I explained . she asks why still confused I told her
take time to correct sodium slowly . she asks about discharge.,explains it will take
coupleof days.
She asked they are moving to dubai, so he can do cycle ride there. Its will
happen again ????like little puzzle with this question but told her that chances
are low but instead of taking plane water if he took carbonated water it contains
some salt!!.
She asked about BP medication attributing. I told possible. She asks continue
bendrafluthiazide. I told we ask cardiology colleges.
Came back to driving and profession .Pt was enginer but not exposed to heavy
machine. I told dvla.
She asks follow up for how long as they are moving to dubai. I told we don't need
long term follow up as prognosis is good and we're will gave detail medical report
to be shown to doctors in dubai.
Last concern where he will ride cycle in dubai as it is very hot there ????
I just mention i am not sure But in dubai you may find indoor cycling track as
most of the activities there are indoor even ski
Examiner ask why Pt confused I told still sodium is not correct. He ask other
reason I told him possible cerebral edema due to seizure and low sodium.
He ask at what rate you will correct sodium. I told 5 -8 meq/day . then he ask
what happens with rapid correction. I answered. He ask at what sodium level you
are happy to discharge. I told him 135 -140. He ask what about cycle riding rules
after seizures in uk.
I told him I have no idea, but advisable not to do in early few months . last
question is bendrafluthiazide was a good choice of anti hypertension for this
patient. I told no as patient ids less than 55 an ACEI should be considered.
Alhamdillah Got full marks
Overall experience of exam in uk was good . there is no problem of
understanding of English with surrogate in station 2 and 4.

Chennai 1st day 3rd cycle

BCC... 1. persistent htn with knee pain. 2. Frequent headache within 2-3mths and
impact on job.
History.... 25yr old lady with hypertension and URE shows RBC and protein.
Communication.... 25 yr old lady come to yesterday ED with haemoptysis and
fever and done CXR show bilateral apical fibrocavitatory lession and sputum
show lots of AFB positive bacilli. Pt discharge from hospital without the result. ED
ph her to come to hospital for result and pt is reluctant to come to hosp but today
come to hosp.
Task... explain the risk to the pt herself and others and advice to protect of spred
of infection to others.
CVS... restenosis MS with AF. Complaint... SOB
CNS... Hemiplegia, only examine LL. Complaint... difficulty in walking.
RESP.... complaint... SOB. lt upper lobe fibrocavitatory lession and lt lower lobe
pleural effusion.
Abd.... complaint... abd discomfort. Lt arm AV fistula functioning and recent
puncture mark present with hepatomegaly.
That's all. Good luck to all.

18.3.2016 last round Chennai

Station 5 loose motion for 3 months
Bilateral knee pain
Station 1 Respiration COPD Bronchiectasis
Abdomen. APKD
Station 2. Headache with menorrhagia
Station 3 CVS MVR
CNS Facial palsy
Station 4 Type 1 DM with proteinuria
Poor drug compliance

I have passed my PACES exam in Mandalay center recently.Thanks to Dr Bebo

Bebo and other friends in this group for sharing invaluable experiences.I w'd like
to share my experiences.
1.Abdomen.heptosplenomegaly w anemia.Q.finding,dx,ddx,mx.14/20
Resp.moderate pleural effusion.w tracheal shift- Q.finding,dx,ddx,mx.20/20
2.History.
unilateral Headache.in female 30 yr.not relieved by simple analgesics,pizotifen
and sumatryptan.
Pt have used OC pill for 6 mth then GP asked to stop.not related to OC pills and
not improved by stopping it.no features of migraine.cluster.increased ICP.stress
present at work and related to HA.
I said tension HA and migraine as DDx.
Q.how to invest.to differentiate.I said clinically and by response to drugs.
Q.how to manage.I said I want to do full neuro.exam and trial of other analgesics
like ibuprofen,diclo. and reduce stress and follow up for new symptoms.
Q.how to reduce stress .l said biofeedback and CBT.
It is not fit to typical history of any paticular HA and I think examiners want
discussions about possible ddx.18/20
3.CVS.MS with valvotomy scar with AF Q.finding,dx,ddx,mx.simple case 15/20
CNS.examine the lower limbs neurologically
flaccid paraparesis with indwelling catheter .
I examined tone.power.reflexes,planter.pinprick and joint position sense and heel
shin test in time.Forgot and do not have time to examine the spine.
DDx.cauda equina and peripheral neuropathies .
I said cauda equina and ddx are peripheral neuropathies like lead
poisoning,porphyria,DM.
Examiner asked about pattern of neurological deficit in each d.dx,then mx.I said
CT or MRI spine,bowel and bladder care..treatment of underlying cause.20/20
Station4-medical error.
pt with psoriatic arthropathy taking methotrexate was given trimethoprim for a
UTI.
pt was admitted for nosebleed with pancytopenia.
I apologize very early after taking rapport and checking pt's prior knowledge
about her condition,I said we shouldd't have given that combination as it have led
to serious damage to you.Surrogate show only little anger and with repeated
apology ,she accepted.Ask if she can conplain,I said yes and explain I will help
her to write conplaint to PALS.
Concern.if she can get recovery and when can she restart methotrexate or not.I
said it depends on recovery of her blood cells and I will ask my consultant and if
necessary will get opinion of joint specialists.when can she go home.? It depends
on her codition and I will let her know after checking her recovery.Then I
summerized and checked pt's understanding and said thank you.We finished
early and we have to sit in silence for 5 mins!
Examiner warned me to say something to pt but we have not much to say at that
time.
What ethical issues,?I said truth telling about our mistake,.non.maleficience,
beneficience 14/16
My BCC cases are interesting and I got dx only in last 2 minutes somewhat
luckily!
BCC 1.a 25 yr old man with repeated blood transfusions since 5 yrs of age
,presented with fever.,high colour urine ,tiredness
Examination show moderate splenomegaly and pallor.
Pt's concern.what is his problem?I said thalassemia intermedia.Why he has
fever?
l said UTI or malaria or other sort of infection and I will do blood tests.How can
you help me to reduce transfusion interval,?
I said you have a big spleen ..that is why it destruct your blood cells and U need
blood transfusion.You need operation to remove spleen to reduce transfusion
interval.
Examiner ask finding .dx.Why he has fever.?I said UTI or other infection.not
satisfied.Why fever in this pt with splenomegaly,.?
I thought long way and said he may have hemochromatosis leading to diabetes
leading to immune suppression and infection.Any other pissibility.? I said
hypersplenism leading to pancytopenia leading to infection.Examiner was very
happy to hear it.How to mx,,,? I said neutropenic regime.not satisfied.What is
definitive mx,?I said splenectomy.Examiner.happy!
what will u do before splenectomy.?
I said vaccination.For what? for encapsulated bacteria.Time was up.
24/28
BCC.2.50yr old smoker present with cough for 2 weeks not responding to 2
courses of antibiotics.pt said cough worse on lying down but no other symptoms.I
ask other chest and CVS symptoms and did chest examination and found no
abnormality.Pt asked what is his problem and I didn't know dx!
I replied it will be chest infection or heart problem and I can't tell exactly at this
stage and I will do some blood tests and imaging of chest .Is it serious?is it
cancer? I said he has no sign of cancer at this stage although it is still a
possibility as he smoked heavily.I will do tests to make sure that everything is
OK.Then.I thought that this pt must have some signs to be in exam and it
appeared in my mind that he had a hyperresonant percussion and reduced BS. I
quickly said to the pt that he has a condition called COPD and I will give him
inhalers and some tablets.pt quickly asked is it related to smoking and I said yes
and advised to quit smoking.Time left only 2 min for discussion.
Examiner asked my findings and accepted.Any other sign that show other
specific dx?I said no.He accepted.As my dx is COPD any other ddx?I said
asthma but no wheezing and rhonchi.Any other ddx?HF but no other CVS
symptoms.accepted.Any other dx for cough worsen by lying down?
I said GERD and examiner was very happy to hear.What advice will U give to
pt?I said high pillows and to avoid food at bed time.Time was up. 23/28
There are 2 types of candidates.The first one is very bright ,smart ,lucky and they
can easily pass exam after studying 2 to 3 months.The second type is majority of
candidates and they have to work very hard and take a year or more of studying
time to pass.I am the second type and have to study a long time waiting to get a
seat in Myanmar for about 2 years.This is my first attempt.
Exam luck is also an important factor.
Then,can we do anything to improve our exam luck?
As for me, yes.
I shared my knowledge to others and shared some books and mp3 podcasts in
this group by my another account.I had also helped other candidates with their
study and practice so that my exam luck can be good.I have met with good
natured examiners!
In the exam, some candidates said they have time only to discuss ddx.They will
lose marks for judgements.
As for me, I have my own note of common causes,inv,mx and I memorized them
so I can discuss fluently in 2 to 4 minutes of discussion time and I reached to
management in every station and passed every station.
Best of luck to all future candidates!

My PACES experience in Golden Jubilee Hospital, Glasgow, UK in June 2016

Station 1:
Respi: A elderly man with obvious pectus excavatum. However, the chest signs
were subtle. I got left LZ crepitations with reduced breath sounds, giving the
diagnosis of pectus excavatum with left LZ bronchiectasis. Another candidate got
right LZ crepitations, the 3rd candidate got bilateral LZ crepitations. Turned out
the answer was right LZ bronchiectasis. Lost all marks in physical signs
component. (12/20)
Abdomen: Another station with subtle clinical findings. Stem: this man has
abdominal pain; please examine and find out why. This middle aged man has
very subtle hepatomegaly. Discussion on causes and management. Another
candidate reported hepatosplenomegaly, and the 3rd candidate reported normal
findings. The answer was hepatomegaly, but I missed the gynecomastia, so
identifying physical signs marks were deducted. Gave the correct DDX of
alcoholic liver disease. (18/20)
Station 2:
A middle aged lady with prolonged fever, symptoms persisted despite admission
and treatment for UTI. Further hx revealed prolonged fever with weight loss. She
will also mention a lump in the inguinal area. DDX given was lymphoma, occult
malignancy, CTD, TB, IE. Concern: What is causing my symptoms? Spent a lot
of time explaining diagnosis, the need for biopsy, admissions, further tests. Need
to explore how the fever has affected her daily life and offer solutions.(19/20)
Station 3:
Neurology: Stem: this lady complained of double vision. Please examine her. A
case of Myasthenia gravis with thymectomy. The only sign was double vision with
fatiguability and thymectomy scar. Questions were standard. (20/20)
CVS: An elderly man with central sternotomy scar, vein harvest scar, and MR.
Got panicked and gave the wrong diagnosis of AS. Did badly overall. (10/20)
Station 4:
A elderly man was admitted for pneumonia with confusion. Given amoxicillin in
ward and developed anapylaxis. He recovered but still remained confused. Talk
to the daughter and address her concern. Need to elicit the fact that the daughter
mentioned to a doctor regarding patient's allergy to penicillin. Thus, this is a case
of error of drug administration. Need to apologize profusely. Lodge critical
incident reporting. Need to address her concern and reassure her in every way
this will not happen again, and provide her the example how you intend to avoid
this from happening again. She will have a lot of concerns and anger and you
need to apologize, reassure, offer solutions and answers to her concern. I didnt
mention about PALS as she never mentioned lodging a complaint but if she did,
offer her ways to lodge a complain.(16/16)
Station 5:
BCC1: A elderly lady with dark pigmentations over her shins. Further hx: long
standing DM on OHA, long standing pigmentation for years, not causing
symptoms apart from itchiness. It is a case of necrobiosis lipoidica diabeticorum
(most likely healed lesions). Given differentials of chronic venous insufficiency
with stasis eczema, diabetic dermopathy. (28/28)
BCC2: A case of a young man with headache. A challenging station as there is a
lot to get from history and to examine, and all need to be done within 8 minutes.
Further history revealed symptoms of headache worse in morning and with
sneezing, vomiting and blurring of vision. Examinations were normal. Didn't
perform fundoscopy but did mention it. Concern: Is it brain tumor? My mom had
brain tumor at age of 40. DDX: headache due to raised ICP, e.g. IIH, less likely
SOL, migraine. Mx: Offer urgent CT brain. (25/28)
Overall: 148/172 (PASS)
Personal opinion:
Exam case in UK are generally fair. It has tendency to put up cases with subtle
clinical findings esp. BCC. Normal surrogates are frequently used in BCC, with
scenarios like headache, syncope, fever etc being not uncommon.
The examiners were rather strict and particular about identifying correct physical
signs. This is the component that scared me the most. This applies to PACES
everywhere and a lot of practice is required to be able to pick up subtle signs.
Never create signs as this is really fatal.
Station 4 is very unpredictable. Cases can be easy or complex with multiple
agendas. Suggest to review all the cases posted up here previously and practise
them. Need to have some knowledge regarding DVLA, Mx of meningococcal ds
and prophylaxis etc... Need to really elicit the concerns, and offer
solutions/answer as much as you can.
Good luck and all the best.
This group is very helpful, keep sharing cases and experience guys.

7/ 2016
Station 1
Abdomen: Lady around 50y.o with cushingoid features, Perma cath, scar on the
Right iliac fossa ( failed renal transplant) and multiple scars around the umbilicus
( previous Peritoneal dialysis)
The examiner asked about the complications ( esp. bone complications and he
asked about dietary restriction {Shappati} as the pt and examiners are Indian)
Respiratory: Male pt around 55y.o well- nourished with right thoracotomy scar on
the back+ end-insp crackles. No clubbing, no cyanosis, no signs of pulmonary
HTN
Dx ILD, the scar is for lung biopsy ( I said to the examiner it's for lobectomy but
he asked me what else it could be for, I said for lung biopsy then he agree with
me)
Station 2
Lady aged 55y.o heavy smoker with 3months h/o SOB, coughing blood and loss
of weight. She sought medical advice recently and given antibiotic ( she doesn't
know the name of it) by GP who diagnosed her as acute bronchitis, but no
improvement. One week ago she developed dysphagia for solid food. No h/o
fever, no vasculitis symptoms, no other GI symptoms.
Station3
Cardio: young lady with mid-sternotomy scar and palmar erythema. No signs of
pericarditis. S1 is metalic. No murmurs or additional heart sounds. No signs of
pulm HTN or pulm cngestion
Dx Mitral valve replacement ( metalic)
Neuro: instruction: examine lower limbs
old man with walking aids beside him, indwelling Foley's cath. Perioheral
neuropathy for DD. I mensioned them specifically paraneoplastic syndrome ( ?
Prostatic cancer)
Station 4
Middle age lady diagnosed to have bird fancier lung disease. She presented
today to know the result ( BBN) and to discuss with her the need for
corticosteroid treatment and to avoid exposure to pigeon ( she's breeding pigeon
and she's famous in her region )
She resisted first to take the steroid but when I explained to her its benefits and
risks ( including osteoporosis) and the prophylaxis for the side effects she
accepted. Also she got angry when I suggested to her to avoid exposure to
pigeon.. I appreciated her upset and I explained that she will not get better unless
she avoids exposure. I suggested to wear mask in case she has to see her
pigeon or to train somebody to feed them. She said her son may help her in
taking care of the pigeon finally agreed.
Station5
Case 1
25 y.o. Lady presents with fever (39.5) and diarrhea. She admitted eating from
restaurant. When I asked about travel she said she came from Thailand. I asked
about insect bite including mosquitos she said yes. Then I asked about malaria
prophylaxis before during and after travel she said yes. I also asked about HIV
risks.
O/E : no signs (surrogate)
Case 2
30 y.o male with headache, high blood pressure (180/100) and urine dipstick
showing proteinuria and microscopic hematuria. He had h/o childhood chest
infection and family h/o SLE.
O/E no signs
There is ophthalmoscope on the table. I noticed it late. I said " I would like to do
fundoscopy but no time " :)

Dx AkI ( Glomerulonephritis needed kidney biopsy and Autoimmune profile+

Renal US)
 Paces exam cases-july 2016,london
Station 5-35 year old lady with loss of consciousness for few
minutes,no warning particularly,sometimes some tingling
sensation of face.previuosly investigated for
arrhythmia.examination revealed,heart rate-60/min,i think it
was irregular ,but when I checked for 15 sec ,it was
.regular.but examiners asked about it
questions-DD,expected to tell about the possible cardiac
. causes
,Iinvestigations21/28
station5-2 weeks hx of cough ,phlegm and
+haemoptysis.smoking
-questions
o/e-no clubbing,calf-no swelling.no SOB,but examiner
stopped me halfway thru the chest examination and told left
basal crackles.DD-pul.embo
LRTI
TB
vasculitis
malignancy
.patient was concerned abt cancer
investigations inclTB,vasculitis.28/28
should ask patient concerns and address
-station one
 abdomen-multiple scars including RIF scar,large mass right
hypochondrium ,possibly loin,ran out of time.i was too slow
and could not finish exan/.asked the diagnosis-possibly
polycystic kidney with enlarged liver due to liver cycst.i
.missed the kidneys due to time
didn't get time for further discussion.7/20

respiratory system-most probably pulmonary fibrosis,obvious

.clubbing
questions-DD,for clubbing and crackles
Investigations in detail such as what will you expect in xray,CT
in fibrosis
causes for bronchiectasis
02/02
.station2 history-diag cluster headache
questions-summary
,diag and DDS
investigations
.management of cluster headache
prognosis
.patient concern-concerned abt brain cancer
I also asked about how did affect her work and life and all sort
.of concerns and possible effects
02/02
cardiology-CABG(midline sternotmy scar,venous harvesting
scar)
 aortic stenosis,slow rising pulse was present,ankle oedema
+,no metallic click
questions-DDS
investigations
features of severe aortic stenosis.what were the features in
this patients, 20/20

.neuro-asymmetrical parinsoons features

dds or causes
investigations
management in detail,phrmacological,non phrmacological
how does it affect people,what are the difficult tasks20/20

communication-quite simplescenario,no hidden

issues.daughter is concerned about mothers discharge after
sever pneumonia as she is tired and lethargic and lives
alone.mother has got mental capacity and wanted to go
home.talked about autonomy,asessd by physio and
occ.explained fit to discharge,promised to arrange another r
meeting with physio,OT and possibly mother with mothers
permission,expected to offer some help like community team
visit or similar to make sure things are ok.20/20
.hope its helpful

have passed my PACES exam in Mandalay center

recently.Thanks to Dr Bebo Bebo and other friends in this
 group for sharing invaluable experiences.I w'd like to share
.my experiences

Abdomen.heptosplenomegaly w .1
anemia.Q.finding,dx,ddx,mx.14/20

Resp.moderate pleural effusion.w tracheal shift-

Q.finding,dx,ddx,mx.20/20

.History.0
unilateral Headache.in female 30 yr.not relieved by simple
.analgesics,pizotifen and sumatryptan
Pt have used OC pill for 6 mth then GP asked to stop.not
related to OC pills and not improved by stopping it.no
features of migraine.cluster.increased ICP.stress present at
.work and related to HA
.I said tension HA and migraine as DDx
Q.how to invest.to differentiate.I said clinically and by
.response to drugs
Q.how to manage.I said I want to do full neuro.exam and trial
of other analgesics like ibuprofen,diclo. and reduce stress and
.follow up for new symptoms
.Q.how to reduce stress .l said biofeedback and CBT
It is not fit to typical history of any paticular HA and I think
examiners want discussions about possible ddx.18/20
 CVS.MS with valvotomy scar with AF .3
Q.finding,dx,ddx,mx.simple case 15/20

CNS.examine the lower limbs neurologically

. flaccid paraparesis with indwelling catheter
I examined tone.power.reflexes,planter.pinprick and joint
position sense and heel shin test in time.Forgot and do not
.have time to examine the spine
. DDx.cauda equina and peripheral neuropathies
I said cauda equina and ddx are peripheral neuropathies like
.lead poisoning,porphyria,DM
Examiner asked about pattern of neurological deficit in each
d.dx,then mx.I said CT or MRI spine,bowel and bladder
care..treatment of underlying cause.20/20

.Station4-medical error
pt with psoriatic arthropathy taking methotrexate was given
.trimethoprim for a UTI
.pt was admitted for nosebleed with pancytopenia
I apologize very early after taking rapport and checking pt's
prior knowledge about her condition,I said we shouldd't have
given that combination as it have led to serious damage to
you.Surrogate show only little anger and with repeated
apology ,she accepted.Ask if she can conplain,I said yes and
.explain I will help her to write conplaint to PALS
Concern.if she can get recovery and when can she restart
methotrexate or not.I said it depends on recovery of her
blood cells and I will ask my consultant and if necessary will
 get opinion of joint specialists.when can she go home.? It
depends on her codition and I will let her know after checking
her recovery.Then I summerized and checked pt's
understanding and said thank you.We finished early and we
!have to sit in silence for 5 mins
Examiner warned me to say something to pt but we have not
.much to say at that time
What ethical issues,?I said truth telling about our
mistake,.non.maleficience, beneficience 14/16

My BCC cases are interesting and I got dx only in last 2

!minutes somewhat luckily

BCC 1.a 25 yr old man with repeated blood transfusions since

5 yrs of age ,presented with fever.,high colour urine ,tiredness
.Examination show moderate splenomegaly and pallor
Pt's concern.what is his problem?I said thalassemia
?intermedia.Why he has fever
l said UTI or malaria or other sort of infection and I will do
blood tests.How can you help me to reduce transfusion
?,interval
I said you have a big spleen ..that is why it destruct your blood
cells and U need blood transfusion.You need operation to
.remove spleen to reduce transfusion interval
Examiner ask finding .dx.Why he has fever.?I said UTI or other
infection.not satisfied.Why fever in this pt with
?.,splenomegaly
 I thought long way and said he may have hemochromatosis
leading to diabetes leading to immune suppression and
infection.Any other pissibility.? I said hypersplenism leading
to pancytopenia leading to infection.Examiner was very happy
to hear it.How to mx,,,? I said neutropenic regime.not
satisfied.What is definitive mx,?I said
!splenectomy.Examiner.happy
?.what will u do before splenectomy
I said vaccination.For what? for encapsulated bacteria.Time
.was up
02/02

BCC.2.50yr old smoker present with cough for 2 weeks not

responding to 2 courses of antibiotics.pt said cough worse on
lying down but no other symptoms.I ask other chest and CVS
symptoms and did chest examination and found no
abnormality.Pt asked what is his problem and I didn't know
!dx
I replied it will be chest infection or heart problem and I can't
tell exactly at this stage and I will do some blood tests and
imaging of chest .Is it serious?is it cancer? I said he has no sign
of cancer at this stage although it is still a possibility as he
smoked heavily.I will do tests to make sure that everything is
OK.Then.I thought that this pt must have some signs to be in
exam and it appeared in my mind that he had a
hyperresonant percussion and reduced BS. I quickly said to
the pt that he has a condition called COPD and I will give him
inhalers and some tablets.pt quickly asked is it related to
smoking and I said yes and advised to quit smoking.Time left
.only 2 min for discussion
Examiner asked my findings and accepted.Any other sign that
show other specific dx?I said no.He accepted.As my dx is
COPD any other ddx?I said asthma but no wheezing and
rhonchi.Any other ddx?HF but no other CVS
symptoms.accepted.Any other dx for cough worsen by lying
?down
I said GERD and examiner was very happy to hear.What
advice will U give to pt?I said high pillows and to avoid food at
bed time.Time was up. 23/28

There are 2 types of candidates.The first one is very bright

,smart ,lucky and they can easily pass exam after studying 2 to
3 months.The second type is majority of candidates and they
have to work very hard and take a year or more of studying
time to pass.I am the second type and have to study a long
time waiting to get a seat in Myanmar for about 2 years.This
.is my first attempt

.Exam luck is also an important factor

?Then,can we do anything to improve our exam luck
.As for me, yes
I shared my knowledge to others and shared some books and
mp3 podcasts in this group by my another account.I had also
helped other candidates with their study and practice so that
my exam luck can be good.I have met with good natured
!examiners

In the exam, some candidates said they have time only to

.discuss ddx.They will lose marks for judgements
As for me, I have my own note of common causes,inv,mx and I
memorized them so I can discuss fluently in 2 to 4 minutes of
discussion time and I reached to management in every station
.and passed every station
!Best of luck to all future candidates

My PACES experience in Golden Jubilee Hospital, Glasgow, UK

in June 2016

:Station 1
Respi: A elderly man with obvious pectus excavatum.
However, the chest signs were subtle. I got left LZ crepitations
with reduced breath sounds, giving the diagnosis of pectus
excavatum with left LZ bronchiectasis. Another candidate got
right LZ crepitations, the 3rd candidate got bilateral LZ
crepitations. Turned out the answer was right LZ
.bronchiectasis. Lost all marks in physical signs component
)02/10(

Abdomen: Another station with subtle clinical findings. Stem:

this man has abdominal pain; please examine and find out
why. This middle aged man has very subtle hepatomegaly.
Discussion on causes and management. Another candidate
reported hepatosplenomegaly, and the 3rd candidate
reported normal findings. The answer was hepatomegaly, but
I missed the gynecomastia, so identifying physical signs marks
were deducted. Gave the correct DDX of alcoholic liver
)02/12( .disease
 :Station 2
A middle aged lady with prolonged fever, symptoms persisted
despite admission and treatment for UTI. Further hx revealed
prolonged fever with weight loss. She will also mention a
lump in the inguinal area. DDX given was lymphoma, occult
malignancy, CTD, TB, IE. Concern: What is causing my
symptoms? Spent a lot of time explaining diagnosis, the need
for biopsy, admissions, further tests. Need to explore how the
)02/11(.fever has affected her daily life and offer solutions

:Station 3
Neurology: Stem: this lady complained of double vision.
Please examine her. A case of Myasthenia gravis with
thymectomy. The only sign was double vision with
.fatiguability and thymectomy scar. Questions were standard
)02/02(

CVS: An elderly man with central sternotomy scar, vein

harvest scar, and MR. Got panicked and gave the wrong
)02/12( .diagnosis of AS. Did badly overall

:Station 4
A elderly man was admitted for pneumonia with confusion.
Given amoxicillin in ward and developed anapylaxis. He
recovered but still remained confused. Talk to the daughter
and address her concern. Need to elicit the fact that the
daughter mentioned to a doctor regarding patient's allergy to
penicillin. Thus, this is a case of error of drug administration.
 Need to apologize profusely. Lodge critical incident reporting.
Need to address her concern and reassure her in every way
this will not happen again, and provide her the example how
you intend to avoid this from happening again. She will have a
lot of concerns and anger and you need to apologize,
reassure, offer solutions and answers to her concern. I didnt
mention about PALS as she never mentioned lodging a
complaint but if she did, offer her ways to lodge a
)11/11(.complain

:Station 5
BCC1: A elderly lady with dark pigmentations over her shins.
Further hx: long standing DM on OHA, long standing
pigmentation for years, not causing symptoms apart from
itchiness. It is a case of necrobiosis lipoidica diabeticorum
(most likely healed lesions). Given differentials of chronic
.venous insufficiency with stasis eczema, diabetic dermopathy
)02/02(

BCC2: A case of a young man with headache. A challenging

station as there is a lot to get from history and to examine,
and all need to be done within 8 minutes. Further history
revealed symptoms of headache worse in morning and with
sneezing, vomiting and blurring of vision. Examinations were
normal. Didn't perform fundoscopy but did mention it.
Concern: Is it brain tumor? My mom had brain tumor at age of
40. DDX: headache due to raised ICP, e.g. IIH, less likely SOL,
)02/02( .migraine. Mx: Offer urgent CT brain

Overall: 148/172 (PASS)

 :Personal opinion

Exam case in UK are generally fair. It has tendency to put up

cases with subtle clinical findings esp. BCC. Normal surrogates
are frequently used in BCC, with scenarios like headache,
.syncope, fever etc being not uncommon

The examiners were rather strict and particular about

identifying correct physical signs. This is the component that
scared me the most. This applies to PACES everywhere and a
lot of practice is required to be able to pick up subtle signs.
.Never create signs as this is really fatal

Station 4 is very unpredictable. Cases can be easy or complex

with multiple agendas. Suggest to review all the cases posted
up here previously and practise them. Need to have some
knowledge regarding DVLA, Mx of meningococcal ds and
prophylaxis etc... Need to really elicit the concerns, and offer
.solutions/answer as much as you can

.Good luck and all the best

This group is very helpful, keep sharing cases and experience
.guys

Experience in Mater Dei Hospital Malta on 2/4/16 first

carousel
 Station 1 □
: Chest ☆
A young patient with spares head hair( I Said possibly 2° to
chemo later on upon discussion and actually I picked it up as I
used to see this finding a lot in my practice in oncology).. RT
side of the chest is depressed and moving less, RT
thoracotomy scar and decreased chest expansion, impaired
percussion and dec breath sounds
Diagnosis: RT pneumonectomy
DD of etiology was bronchiactssis, fibrosis, Abcess and
,malignancy
Discussion was about cancer causes in young patient (germ
cell, and Satcoma ) and workup also asked if he developed
SOB what might be the cause , I mentioned infection and
thrombosis PE
?How to investigate him
)I got 20(

: Abdomen ☆
A middle aged male with features of CLD (D contracture, P
erythema, thenar wasting and Tinge of jaundice) and
splenomegaly I said no ascites
DD and work up
Honesty I felt that I missed hepatomegaly
)I got 16(

:History □
A 50 years female , married , works as hospice nurse, travelled
to Kenya with her husband and came back with
nausea,vomiting, fever and upper and pain radiating to back
Heavy alcohol intake
Had 3 miscarriages at Gestational ages of 26,28,28 no
personal or Fx history of VTE
Gp letter mentioned high T bilirubin 70 and high all Liver
enzymes
? Concerned is it cancer
DD : I mentioned Alcoholic hepatitis, viral hepatitis(A) and
dengue, autoimmune hep, and malignancy
discussion was about working her up , and how to manage, I
mentioned that she needs admission, clinical assessment and
rehydration if dehydrated, pain control and fever ttt with
NSAID and avoidance of acetaminophen and teat etiology
I emphasize on alcohol cessation referral
)I got 20(

:Station 3 □
CVS: old male has peripheral features of AR ☆
apex displaced
Systolic murmur all over radiates to carotid
I said AS and AR although I didn't hear the diastolic murmur , I
was not comfortable to the auscultatory findings and I felt
may be something is missing, anyway , they discussed with
me what might be the causes of systolic murmer in this age
 and how to differentiate between AS and sclerosis,
investigations to do
)I got 20(

: CNS ☆
A middle aged patient
Instruction was : this patient has problem lifting objects
I examined his upper limbs , he was sitting on a chair , he is
non English speaker however examiners helped with
instructions and I passed few instructions in Maltese my self(
most of them sounds as in Arabic)
Findings are pure proximal atrophy and weakness at shoulder
girdle and scapular muscles with defined supraclavicular and
scapular margins, no facial involvement

DD : proximal myopathy likely congenital causes as patient

has an atrophy
And I suggested scapulohumeral variant I enlisted few other
causes as well
Investigations including EMG,NCS, and muscles biopsy
He asked me about mode of inheritance I answered that I
can't recall
Management is supportive and I motioned that few Novel
therapies is under study
)I got 20(

:Communication □
 Speak to an angry son of 70+ female admitted initially in
orthopedic ward with # femur and underwent arthroplasty 2
weeks ago , 1 week after she felt while doing rehabilitation,
since this last fall she is on and off confused, orthopedist
assure son that this because of UTI and she is receiving ttt for
that , then patient transferred to medical ward as her
confusion continues, CT scan arranged , showed intracerbral
bleed with midline shift, neurosurgery advised to hold
enoxparin ( which was started as prophylaxis) and her usual
.aspirin and stop her oral feeding until he see her
Role : speak with son about CT findings and subsequent plan
and discuss the clinical judgment when outweighing benefits
.and risk of LMWH

Son was angry but I listened to him empathetically and

reassured that I'm here to help, I broke the news of the CT
findings and explain the role of Neurosurgery opinion, his
concerns : what is the cause of her bleed, why giving anther
blood thinner while she is on ASA , could the fall be avoidable,
?why he has been told that she has UTI
Actually examiner's discussion revolved around whether
LMWH has caused her bleeding or not and wether there is a
way to know that I said unlikely it was the direct cause
however above therapeutic level of anti factor Xa might give a
clue that helps to reveal the uncertainty of her bleeding
.cause
)I got 16(

Station 5 □
: BCC1 ☆
 An old male , c/o slurred speech for 30 minutes, three
previous episodes of near fainting , during episodes he feels
. "fluttering" sensation of his heart
PMHx : HTN on amlodipine 5 mg , AF on pacemaker and
warfarin 3 mg and regular check, ranitidine for gastritis
Exam : AF with rate of 80

Discussion was about DD

,I mentioned TIA , orthostatic hypotension
How to investigate, he ask me will you change his anti
?hypertensive or not
?How do you know if the pacemaker is non functioning
)I got 28(

BCC 2 ☆
A young lady, pregnant in 18 weeks gestation with SOB for
2/52 and cough with occasional whitish phlegm and occurs at
late night and early morning,no any other symptoms upon
discussion
KCO bronchial asthma was controlled before pregnancy on
INH SABA & INH steroids but she stopped them both after got
,pregnant as she thought they're harmful
Examination: all clear , LL clear
I explain for her the role of inhaled Mx in controlling her
asthma and that why she got these sympx , reassure about
safety in pregnancy, adviced PFM diary and FU with GP
Discussion: DD chest infection and less likely PE
 Examiner asked what've s against infection, also asked if PE
? need to be rolled out what to do

Actually I peaked my marking sheet within the examiner

hands while pill was ringing and I'm about to leave the room
with all marks in satisfactory area , I felt it was a comfort
😃 message from Allah at the end of the exam
)I got 28(

Over all I scored 168/172》》

My conclusion that PACES is a MOSIAC experience, it 》

concludes different roles and various methods and the
probability of passing lies in practising as many as one can do
.. of these roles and methods
Inhance your best qualities and fill your defects and as Prof
Zein says eliminate your chance of failure by avoiding the
.failing practice

Thanks Dr Zain again and again for your support and effort
. and may Allah grace you with health and serenity

Thanks all members of the group for the endless effort that 》
.helped me and others, may Allah bless you all
 My exam was in July and exam center was Mandalay,
.Myanmar

Station 1(chest) : Middle aged male patient with clubbing,

trachea shift to the right and crepitations in right upper zone
that were cleared with coughing and dullness in right lower
zone
I gave diagnosis as Right lower lobe collapse with
.broncheatasis
Examiner questions were differential diagnosis of dullness at
lung bases, etiology in this patient and how would you
.manage him

Station 2(Abdomen) : Middle aged male patient with jaundice

and splenomegaly
I gave differential diagnosis as cirrhosis of liver, chronic
haemolytic anemia, tropical splenomegaly syndrome,
.myelopoliferative and lymphopoliferative disorders
Examiner questions were another name of tropical
.splenomegaly syndrome and then how would you manage

Station 2 : Young patient presenting with chronic diarrhea, he

also has history of repeated chest infection, sinusitis,
.deafness
I gave diagnosis as primary immune deficiency most probably
.due to CVID
.Concerns are is it cancer and is it HIV
 Examiner questions were causes of diarrhea in this patient
.and how would you manage

Station 3 (Neuro) : Middle aged patient with ulnar nerve palsy

due to leprosy. Examiner questions were where is the lesion,
which muscles are spared as patient didn't have claw hand
.and management

Station 3 (Cardiac): Middle aged female with diastolic murmur

only at apex. I told examiner that this is not MDM and I heard
EDM at apex. But, I told him that I didn't hear EDM along left
.sternal edge
.I was very stubborn at that time and I gave diagnosis as AR
.Examiner questions were severity of AR and management

Station 4 : The firefighter who is planning to get married had

allergy to smoke. He is also chronic smoker and breadwinner.
My task is to tell the patient to change the job and further
.management plans
Concerns are he didn't want to change the job, didn't want to
tell her fiancé, he is afraid of losing job as he is financially
.dependent on this job and also want to continue smoking
Examiner questions were what concerns the patient had and
did you solve all concerns and what are ethical and legal
.problems in this case

Station 5: Outside question was 40 yr female patient

.presenting with fatigue
 .Diagnosis was OSA with hypothyroid underlying DM
Examiner questions were what is main problem and how
.would you manage

Station 5: Outside question was 50 yr female patient with

.double vision
.Diagnosis was basilar migraine
Examiner questions were differential diagnosis and
.management

,,, Experience of a DEAR Friend ,,, Please : pray 4 Him

North Cambridgeshire Hospital, Wisbech, UK
st day, 3rd cycle 07/07/20161
:Station 1
:Abdomen
middle age lady with signs of scleroderma in rt hand, my
findings was only hepatomegaly and mild lower limb oedema,
I did badly in this station because of stress, I don’t know why I
said to examiner that Dx is CLD, he asked me if this patient
came to u in clinic what will you do ? I said take a full history,
then he interrupted me, history of what ? I said of what might
be the cause like alcohol Hx or any risk factor of getting viral
hepatitis, travel Hx, then he asked about Ix ? then he
interrubted again asked about her left hand if I noticed
anything, I have the feeling that I missed an AV fistula
.because that will make sense
.it was a very bad station for me to start with
 :Chest
Middle aged man with clubbing, crackles on both bases which
changed after coughing but it was not coarse crackles, I think
examiner noticed from previous station that I was in too much
stress, he wanted to smooth it down and asked me “now you
found clubbing in a pt with bilateral crackles if you put them
together what will be the diagnosis?” I told most propable Dx
is ILD but I can not rule out bronchiactesis because character
of crackles changed with coughing, he asked about Ix?
findings you are looking for in HRCT? How to asses severity
? clinically ? how to manage
not a bad station I guess
Station 2
plus year old lady diagnosed with breast cancer she did 22
surgery and received chemo/radio therapy
sent by GP because family are asking to admit here as she
can’t cope at home anymore
The lady told that recently her mode is going more and more
down and she is depressed, I asked here to tell me more
about here condition then she told me that tow years back
they discovered that the cancer reached my bone, in system
review she started to tell me that she had abdominal pain but
she thinks it’s due to conistipation , when I asked about water
work she told me I’m going frequently to bathroom, asked
about polydipsia and it was there also, and the feel short of
breath when she walks to the bathroom, her concer that this
depression may be due to the liqid she is taking for pain and
the abdominal pain might be caused by painkillers and if I can
admit here because here daughter who is caring for her had to
travel for a short period
explained to her about hypercalcaemia and the management
including the need of admission
examiner asked about my differential ? management? What
?will you consider before discharging her
Station 3
CVS
MR and AS, examiner asked about type of murmur? DD of
? pansystolic murmur ? how to investigate
CNS
Could not complete examination, the pt wasted a lot of time
during examination of tone because she was moving, I found
spastic paraparesis without sensory level
examiner asked about DD, investigations and management of
demyelinating disease (MS) including new lines of Rx
Station 4
Patient with psoriasis and psoriatic arthropathy well
controlled with methotrexate her GP prescribed to her a
course of trimethoprim for UTI that interacted with
methotrexate and caused pancytopenia
She presented to ED with nose bleed
Task : explain medical error
Station 5
Lady with neck swelling for 2 weeks -1
from history she has the swelling for years but changed in size
for the last 2 weeks, clinically Euthyroid , concerned about
cancer
?discussion about management
 Lady with skin rash -0
palpable non-blanching purpura affecting both lower limbs
and back
HSP
? discussion about management

I had my exam in Brunei on the last day in second schedule.

Exam was tough with some atypical cases, but
ALHAMDULILLAH (All praise to Allah), I passed it. It was my
first attempt. My sincere thanks to PACES EXAM CASES and all
it's contributors, esp. Bebo bebo and Mahiuddin. I had been a
silent observer here. Dr Mahiuddin gave a lot of useful tips
here which really helped me. I also thank to my all teachers
esp Dr Abdulfattah, who taught me the basics of this exam in
.a very simple way. I would like to share my cases here
Respiration: Young short lady, with SOB. Patient could not .1
lie down, so all examination in sitting position. No clubbing,
central trachea, B/L basal crackles not fine but doesn't change
with cough as well. My diagnosis Pulmonary fibrosis, Other
DD Brochiectasis. Examiner asked about diagnosis and
different causes. British lady examiner was very cooperative
and she sensed my nervousness as it was my first ever PACES
station, that also respiratory (time taking) and plus young
.lady
.I got full marks
Abdomen: Obese man, round face, and abdominal striae; .0
with active fistula at left wrist. Few scars in the neck, left
subcostal scar with few scars beside it. No
 hepatosplenomegaly. I felt some fluid hitting my hand when
patient turned his body. It was a very difficult palpation. I got
shifting dullness as well (??). My diagnosis- Patient with end
stage renal disease on haemodialysis, most probably on
steroids, cause could be due to Glomerulonephritis. Examiner
asked me why he had ascites. I said due to volume overload
(uraemic). Then why not pedal edema? I told may be partially
treated. He asked for any other reason for this ascites in renal
patient. I told he might have peritoneal dialysis, which could
be reason for fluid. He asked me for any proof? I showed him
the scars on abdomen. He said it could be due to surgical
drainage. I said it could be. Then he repeated the question,
any other reason for ascites in renal patient. I was very
.nervous and couldn't answer further and the bell rang
History: Middle aged man with SOB and leg swelling and .3
past history of recurrent chest infection. I finished before
time. Examiner asked me about diagnosis. My diagnosis
Bronchiectasis with cor pulmonale (right heart failure). He
asked me of any other possibility. I could not get it. He asked
me about complications of bronchiectasis, I said local and
systemic. He asked further about systemic. When I told
amyloidosis, he asked, "could it affect kidney" . I told yes, it
can cause Nephrotic syndrome and that is one of the
possibility in this case. He was very happy to hear this from
.me and he gave me thumbs up
Nervous system: Middle aged lady lying down with her .2
right hand near body and wrist looks dropped. I asked her to
put her hands in front and turn the hands up. Initially the right
wrist was dropped but slowly she raised it. That added to my
confusion. I immediately started typical upper limb
examination. Power 4/5 in the right upper limb. Tone -
normal, reflexes - absent bilaterally with negative Hoffmann.
 Sensations - I checked pain and vibration only, due to
shortage of time. And both were reduced on the right side.
There was no obvious facial deviation. I was fully confused. I
went for common thing first and said it could be stroke in
spinal shock. British examiner asked me the proof to support
my diagnosis. I told it is difficult to say without examining the
lower limbs and cranial nerves. But the typical pyramidal
pattern of weakness with unilateral sensation loss of all
modalities could be the clue. She asked what did it mean by
pyramidal weakness, I said "even though it is more typical in
lower limb here I can see that abductors of shoulder and
extensors of elbow and wrist are weaker, giving the typical
".posture
I got full marks ( I can't believe, I am still not sure about
.diagnosis)
CVS : Middle aged man, with midline sternotomy scar. Dual .2
valve replacement with MR, AR and AS, with chest congestion
but no pedal edema. I forgot to check thrills. British examiner
did not agree with my apex finding, which I immediately
accepted. He asked me about diagnosis and complication. It
.was a typical station
Communication skills: Young man from military was .1
referred by GP for further check up as his brother died of
HOCM last year. His ECG done by GP was normal. He had
appointment for Echo after 2 weeks but still couldn't get
appointment for genetic studies. He was not eager for further
tests and had concern that his life would be disturbed and he
might lose job if it came out to be positive. He started
aggressively, Alhamdulillah, I tamed him and convinced him.
My MRCGP skill helped me. Examiner asked some typical
questions and also what would I do if he didn't turn up for
further investigation. I told I would take the help of GP or
 employer to trace him back. Chief examination coordinator
.was present during this consultation
.I got full marks
BCC1: The coordinator confused me with other case. I lost .7
some time in confirmation. Young lady with decreased vision
of sudden onset in both eyes for 2 days. Diabetic for 6
months, not following up, not controlled. Father had
glaucoma. Past history of gestational DM. She could only read
the top line of chart. Field normal. Before I started
fundoscopy, examiner informed that two minutes were left. I
looked in the right eye, there were black pigments suggesting
retinitis pigmentosa. I had no time to look at optic disc or
macula. I told I would like to refer her urgently to
Ophthalmologist and also check her blood sugar. Examiner
asked me about diagnosis. I said it could be due to osmotic
changes in the eye due her uncontrolled sugar. She asked me
about anterior chamber. I said I could not examine due to
shortage of time. As there is no pain the chances of glaucoma
is less. As it is acute and bilateral, Retinitis pigmentosa can't
explain this. She asked me about complications of DM, I
answered everything except Retinopathy (funny? I felt very
depressed that how I forgot this... Exam tension). I am still not
.sure about diagnosis
BCC2: Young lady with hand deformity. She had pain in .2
hand joints and backache. Fingers were deformed just like
rheumatoid arthritis. Nails were normal. On asking I got to
know she had rashes over elbows which were well hidden
with clothes. Alhamdulillah I got it. I examined her properly. I
managed the time very well here. Examiner asked me about
diagnosis I said Psoriatic arthritis. Then he asked about type of
deformities, signs of activity of disease, chest findings and
.management
 .I got full marks
Alhamdulillah, I passed the examination comfortably. All
.praise to Allah

DETAILED Experience of colleague Dr Aisha Elamin

This is my paces exam experience in eygpt,it was a tough one
.,but al7mdolellah kathiran i passed
I started with station 1
Chest: Copd+bilateral lung fibrosis+ some brochiectetic
.changes on z right side
I took 5 mins examining the pt generally and the ant chest
,the examiner told me that i have just 1 min left ,so i
.examined z pt back and lymph nodes and sacral oedema
?the examiners ,asked me for z positive findings
i told her there are obst changes with end insp crackles
bilaterally ,and medium sized crackels littly changed by cough
,so there r brocheictatic changes
She asked me what type of crackels again,what invs you want
? to do for him
when i told her lung f test and it will be obst changes she
. asked me just that, i said mixed
why he has these changes i told her pcoz he may have
,repeated infections on top of copd
like the usual bacterial inf ,she asked me what other inf i told
TB
 what management ,i told pharmaclogical and non ,
. pharmaclogical ,and i told her all till steriod
I got 19/20
abdominal station
D: decompensated chronic liver disease +huge splenomegaly
+ascites
They asked me what the cause,then what other infections
cause huge spleen i told kalzar and shcistosoma, what invs i
told all till i came to ascitic tapping ,she said for even small
.ascites i told her according to US
when i said check serum albumin she asked why you want to
? do it
What mangement ?accordingly to dd,complications
?she asked when you want to give antibiotics
? Why is he decompensated i said j+ ascites,she asked is he j
02/02
Station 2
History: it was advanced breast ca + hypercalcemia
The scenario was tough they just told us she has breast ca and
she was treated with chemo and radio ,she feels unwell pls
.asses her
So i couldnt figured what is happening and i thought that i am
.going to talk to z daughter
r u z ,So when i entered i shaked hands i was blank,i greet her
daughter of ms.maha, she said no i am ms maha,so i
surpreised and said sorry,then i told her would you just tell
me about your condition,she told me the story ,she feels
drowsy and unwell recently ,i said may be brain matestsis ,so i
asked about all cns system,then i didnt get anything i said may
be dermatomyositis ,but nothing ,then i asked her about the
treatment ,what she was given and for how long,i thought it
may be tamoxifen induced cardiomyopathy ,but no hf .just
sob on moving to bath
. Till i came to z water system ,she has ploy uria at night
and she is so depressed ,i was lost,then i told her i want to
reherse what i get from her ,i said you have increase water
frequency +depression+ constipation (i think it may be from
morpheine)+ back pain (metastasis)
The examiner told me u have just 2 mins left ,so iasked about
smoking,alchohol,impact & drug history ,then concern,i told
her i want to admitt you and do some imaging n blood tests
,may be you have some metastasis,and i want to ask the
phsycatry to asses you and give you some nuritional support
and fluides then time finish
examiner asked me what do you think,and why you want to
?admitt her
i told him i want to give her nutritional support + iv fluides+
.do imaging
Asked why you want to give her iv fluides i said pcoz she is not
.eating,and dehydrated,i want to asess her first
?then what else
she is dehyderated
And has polyuria and polydepsia,so it may be hyponitremia
,then the examiner told me so z pt has
😱😱😱polyuria,depression,abd pain ,what do you think
😒 i siad hypercalcaemia
 What is z management?Rehydration + calcitonin ,he asked
what else ?i forgot z besphosphonate totally 😔so replied i
.couldnt remember
Then asked me what other speciality you want to
.consult,apart from the psychatrist ,i said z oncologist
?Finally what z dd o her sob on moving
I said PE, or metastasis or pleural effusion ,n i will do imaging
.,but i think he was looking for anaemia
What is z cause of her abd pain ? I said could obst or
metatsis,he said could z hypercalcamia
I said yes ,lastly he asked what abour her social issues
I said i am so sorry i couldnt ask her with whome she lives ,he
asked is it important i said sure because if i want to admitt her
,she may have some issues to be solved.(lives with her
.daughter who travelling now
I got 10 /20
:Station 3
Cvs :As+Ar with dominant AR
?They asked me what is d?what you want to do for him
What is cause? In this young pt bicusbed aortic valve or
.rhuamtic heart disease
What about his pulse rate? large volume collapsing and
.regular
What you want to see in echo? What r signs o severity on
?echo
then what else?what about complications ?IE,but he is not
.febrile and has no signs
 What management? Accordingly,duretics if he present in
Hf,asked me is he in hf ? No,i couldnt appreciate any crackles
.or ll oedema
then ACEI ,examiner :*even with this AS,i said according to
.ECO if is it significant or not
Then surgical,aortic valve replacement most probabely
.metalic pcoz he is young
02/02
Neuro: Rt hemiparesis((upper motor neuron lesion+cerbellar
signs))
DD:(Ms or multiple strocks or spino cerbellar degeneration)
.The instructions was examine z motor system
I started by the LL,then UL finally the face i examine for
.horzintal nystagmus, facial nerve and hypoglossal nerve
pt has rt hemiparesis,has cerbellar signs in form of
dysdyadokinsia ,rebound phenomenon,finger nose test,all
.evident on the rt upper limb plus horzintal nystagmus
In addition he has UMN signs in form of upgoing planter in the
Rt side , the refelexes r normal in the LL but increased in UL on
.the rt side
?want to examine his gait and speech (what type of speech
? examiner asked
. what about the Lt side i said it was normal
.what about z tone ? hyptonia
.asked why ?due to cerbellar lesion
?What diagnosis?DD
What investigations? MRi brain looking for plaques of ms,Ncs
? (he asked what do you see
Lumbar puncture(looking for what ? Oligoclonal band (what is
? it
? What management
Pharmaclogical and non pharmaclogical
Staion 4: the senario was about an elderly lady which had
multiple strocks and recent brain heamorrhage,known DM
and ESRD on regular heamodialysis ,now she is deteriorating
,and her wishes was to stop the dialysis if she is getting
deteriorating,and the treating team decided to follow her
.wishes
My task was to inform her son about her wishes and the team
.decision
I started by asking the son ,is he z next of keen,does he want
anyone to attened this meeting with us,did he see his mother
?recently and what does he know about her condition
Then i told him unfortantely her condition is deteriorating as
he told me ,and about her wishes,and that our team decided
. to respect her wishes
?Surrogate: if you stop dialysis what will happen
?S: is she going to die?and when
S: ok if so ,let me to take her home ,i will bring a nurse to stay
?with her
Me : i apprecite your feeling ,i know yr keen about your
beloved mother,but it is difficult to be managed at home,pcoz
we need to ,there is substance called k ,it is going to be high
.monitor her closely. to give her the proper management
 ?S: what about her Dm and other things
Me: i assure you ,we are going to treat her respectfuly and
with diginty, taking care about all her needs and manage her
blood sugar.only the dialysis was stopped
?S : i am afriad she is feeling pain
.Me : she is not aware about her surroundings most probabley
?Do u want me to call any one for you
What about you? Who was taking care of your mother at
?home ? And with whome she was living
S :i am a business man,was so busy recently ,i couldnt stay
with her,i hired a nurse for her, i have no siblings or other
.family member
Me: i can understand how is difficult for you,and appreciat yr
. feelings
? Do you want us to offer any social support for you
?What is concerning u more about her
S : ok thanks dr, i jusr want to be sure that she is not feeling
.pain,and to stay with her for now
Me :your more than welcome ,if u want i can arranged a
meeting with my consultant ,and the kidney consultant to
.discuss with them.and your welcome to visit her at any time
. Only 2 min was left
Me : did your mother has any advance directive or did she tell
?you about her wishes ? Or anyone told you about that
S : no she didnt
.Then i summarize for him and he agreed
?Examiner asked me? What z issues in this senario
 .Bbn, empathy,autonomy of z pt ,advance care of ill pt
? What z issues of her son
?How do you konw this is rt decision
Me : i trusted z senario & my team so most probabely they r
.sure that z pt was competent when she decided
?E : how do u know z pt is competent
Me : that she can understand z information ,recall
E : no there r 4 componenets of it�
Me : recall and weight benifits and risks and no one inforce
.her
😁E :not recalling it is retaining
😫😫😫Me :yes that what i mean
? E :what ethical issues in it
Me : autonomy ,empathy
E : empathy isnt an ethical issues
? Me : benfecience (what is it
Malefecience (what is it )
.😰😰😰 Finally finished
11/11
: Station 5
:1
Female 40 ,came with headache
I was totally exhuasted and it was my last station,when i read
.i suppose it was a male and i put different dd
 So when i entered the room,examiner told let us start with
😱😱 female pt ,i was shocked
she has headache for 2 months,no signs of ICP ,no fever or
symptoms of manangism,no trauma,no cns symptons,no
.aura,i felt i was lost .no drug history
Till asked about her period ,she have just gave birth to her
.baby 2 month ago,period stopped from that time
, asked did she bled a lot,she said yes
? what happen,asked about lactation
.she couldnt lactate her baby since that time
).it is shehan syndrome(
asked about symptoms of panhypopitutrism.she is
depressed,feeling hot ,fatigue,etc
:examination
Started by hands ,checking PR,rough skin,i asked to do bp
standing and sitting.examiner told me it is written behinde
😫😫you in z wall
I asked to examine her neck,gave her water to drink for
,thyroid examination
to check her for breast atrophy and examine the axilae( for
hair distribution). Examine abdomen (for straie) ,back for
. interscapular fat, examiner told me no need
.to do fundoscopy ,examiner told no need
. I forgot to do visual field
Then i answered concern, the need for urgent admission,give
.iv fluides.do some imaging and blood tests
?Examiner asked what is d
 pitutary apoplexy due to post partum haemmorrahage
.causing panhypopiturism
iv fluides ,iv ,What management? Urgent Admission
.steriods,thyroxin
What investigations?MRI brain for pitutary and blood
tests,etc
?What dd
.I said migrane but there was no a typical aura
.Infection but no fever
I think they r were looking for bengin ICP,and pitutary tumor i
.forget to say
02/01
:Bcc2
yrs male with facial weakness,vitals r normal 22
He has rt facial weakness for 1 week ,no other cns symptoms
,when came to hearing problem,surrogate told me he has rt
.ear vesicles 1 week before with ear pain
.Also he is a heavy smoker
I examined facial nerve,rough examination for hearing ,asked
for torch to examine the mouth for 9th crn.examiner told no
.need
.Examine the ear for rash
.Examine arms for pronator driift
Asked to examine for upgoing planter,speech and walking.
.and to do chest examination ,examiner told all r normal
.Concern was what z d? Is it strock?does he need admittion
 I said it facial nerve affection most probably due to recent
viral infection, no need for anti viral pcoz it is not active now
.it is unlikely to be strock because he has no signs of cva or
weakness ,but we need to refer him to nerve dr ,do MRI brian
as out pt ,to be sure there is no lesion in z brain,esp he is a
.heavy smoker
.I adviced regarding to stop smoking
We will gave him drugs called steriods,he should cover his eye
.and eat gums to move his mouth
We will give him refreshing eye drops and refer him to
.physiotherapist
?Then examiner asked: what z d
Is it strock? I said it is unlikely pcoz most probably it will be in
.the brain stem,has weakness and more ill
😅He said but it could be strock .i said may be
?Asked what invst
Brain MRi to be sure there is cerebellopontine lesion esp he is
.a heavy smoker
.Then basic invt
.I replied the same managment i said to surrogate
What complications ? Eye keratitis
What speciallity dr you need to ask him to see the pt a part of
?the nerologist ,ENt,physiotherapist
Opthalmologist
?What abou his speech
02/02
 Regarding the books ryder book2 ,for history and .3
.communication.(however i didnt complete half of z book)
As well as,please have a look on the sample cases on the . 2
mrcp uk.(i came on few of them but it was really good and
.give you a clue about what they need u to do in z exam
. Oxford bocket book for station 5 .2
. The only thing i found it useful in OST books .1
. OST book 2 ,is really good in history
OST book1: the first 20 cases in station 5 section,(although i
.knew that very late
Thanx a lot for all of you i tried my best to write in detial to
prove that the exam is simple and you can lost inside the
😊 exam,and say a silly thing but finally u can pass

Mandalay Center Q 2015/2nd diet

Day 1, R 1 & 2
History – Middle aged lady with fatigue, Hb% - 8 g%, MCV –
77, Previous history of IBS, Dx – Coeliac disease
Communication – 56 year old lady with PCKD by USG,
Creatinine – 450, BBN
BCC1 – 25 year old lady, C/O – Blurring of vision x 6 month, Dx
– Bilateral OA (?MS)
BCC2 – 36 year old male with neck swelling x 9 months,
palpitation & SOB x 1 wk, Dx – Diffuse Toxic goiter
Resp – Left sided pleural effusion
Abdo – Massive splenomegaly with left supraclavicular
… lymphadenopathy – DDx – lymphoma, CML
 CVS – Midline sternotomy scar, Mitral valvotomy scar, loud
P2, sinus rhythm
CNS – C/O diplopia, Examine CN - ?Bilateral ptosis, CN –
normal – Dx - MG
Day 1, R 3
History – 25 yrs old man C/O palpitation & chest discomfort,
glycosuria (+). Past H/O – intermittent hypertension (GP told
him it would be white coat hypertension). Frequent panic
.)+( attacks & anxiety
DDx – Pheochromocytoma, Thyrotoxicosis, Anxiety + white
coat hypertension, ?Type 1 DM & heart disease
Communication – Known case of DM, hypertension & AF
presented with ?TIA (can’t speak for mins). Past history of
bleeding d/t warfarin use & also had bad experience about
warfarin (his relative died of ICH during taking warfarin). So
he don’t want to take warfarin. He is now taking aspirin.
.Counseling about anticoagulation
BCC1 – Puffy face & body ache & pain. Past history – HT, DM,
)+( Bleeding d/o x 15 yrs. Methylpred 4mg od
O/E – Proximal myopathy (+). DDx – Drug induced Cushing’s $,
Cushing’s disease
.BCC2 – Known Parkinson d/s presenting with frequent falls
Day 2, R 1 & 2
History – Young lady, presenting with fatigue. Hb% 10, BP –
$150/90. Joint pain (+). Dx – SLE with APL
Communication – Peanut allergy in a chef
BCC1 – Chronic smoker presented with productive cough –
worse at night. Concern – Ca?. DDx – GERD, COPD, ?Ca
 BCC2 – Joint pain. Dx – Systemic sclerosis
Day 2, R 3
Histroy – Known type 1 DM with good control, C/O wt loss -
hypoglycaemic attacks (+), postural dizziness
Dx - Addison’s disease
Communication – Known Parkinson’s disease admitted for
UTI. Antibiotics were given. The patient’s daughter blamed
that her mom’s Parkinsonism became worse. Counseling the
patient’s daughter about her mother’s disease and ongoing
.treatment (ask detailed side effect of drugs in PD)
BCC1 – Chest pain – DDx – Angina, GERD, Musculoskeletal
pain
BCC2 – Poor DM control, HTN, ?Goiter – Dx – Acromegaly +
Hyperthyroidism
CVS - MS with PHT
Neuro - flaccid paraparesis / left sided complete ptosis &
complete opthalmoplegia
Respi - bronchiectasis
Abd - COL / Hepatomegaly
Day 3, R 1 & 2
History – AKI due to excess fluid loss from ileostomy (watery
diarrhea) with underlying UC
Communication – Asthma management. The patient was
afraid to take steroid inhaler & prefer to home nebulizer.
.Counseling for correct treatment
BCC1 – Recurrent fits
BCC2 – Right shoulder pain – haemarthrosis with haemophilia
 Day 3, R 3
History – Headache with blurred vision, Dx – SOL brain
Communication - Newly diagnosed UC
BCC1 – Difficulty in walking, DM with proximal myopathy, Dx -
?Polymyositis
BCC2 – Palpitation, Dx – MS, AF

COPIED from Paces uk study group on TELEGRAM

Exam experience of Aberdeen Royal Infirmary 24/6/16
Station 1
Abdomen renal transplant,/pckd
Resp fibrosis due to RA
Station 2 Exertional syncope
St 3 cvs aortic stenosis
Neuro umn and lmn in lower limb
St 4 dicuss with pt PMR diagnosis, management, treatment,
prognosis
St 5 left superior homonymous quadrantopia
Paracetamol poisoning

Collection of U.K. Exam cases this diet by Dr.Nazia Asim

Scleroderma e swallwaing diffeculty ..and rynouds...Dibetic pt
.+ addison With skin rash Necrobiosis lipeditecorum
 asthma does not want to have a steroid inhalers due to 2
horse voice
.Scleroderma with SOB , Neurofibromatosis
, Histry HOCM
Station 4 bbnews. Mesothelioma fr palliative care, Brain
tumor
CNS.Huntington disease
, Station 5. TIA,Collapse
Neuro ,,, eyes examination

Mandalay, 2015/3rd Diet

Day 1 round 1
St 2- back pain
St 4- barette oesophagus
St 5- recurrent fits, OSA
st day 3rd round station 3 neurology was ask me to assess pt 1
speech n proceed. cerebellar speech with cerebellar sign. cvs
MVR with mid line scar n valvotomy scar comm copd FEV1
24%, spo2 -94%. confused. talk to daughter. consultant
thought poor prognosis, enquire about ventilation. concern
whether can go home n attend grand daughter wedding yr
end. examiner ask will i surprise if pt died tonight, i said no. n
then asked how about daughter, i said yes. he want me to talk
to pt he is having a life threathening condition but i only
mentioned severe to daughter 5:1 hand n foot pain for 3mth,
malar rash, oral ulcer, hand stiff morning relief with exercise n
 raynaud phenomena present 5:2 h/o chest injury 3mth ago.
chest pain 2mth. worse on walking n after meal. relief to
certain extand after pain killer station 1 resp broncheatasis
with right upper lobe collapse n consolidation with trachea
deviation abdo only anaemia with no hair in axilla. liver 1f n
only tip of spleen palpable tender. no lymph node. d/d history
new onset unilateral headache for 3mth. all symptoms fit
migraine n no neurological deficit at all. cocodamol tanken
more than 15d/mth. concern brain tumor
Day 2 round 1
H/o - Asthma d/t beta blocker
Comm - GE with DVT
BCC - foot drop
AS with fixed drug eruption -
Day 2 round 3
St 2- angioedema
St 4- MS and Mx
St 5- painful hand - systemic sclerosis
Blindness at left eye ? OA
Last day second round
History - traveller diarrhoea
Comm - ECG ST depression for explain coronary angiogram
BCC 1 thyroid, neck swelling - palpitation d/t Post partum
thyroiditis
BCC 2 blood disorder with facial swelling - Dx - drug induced
Cushings underlying ITP
Last day last round
 bcc 1 - bilateral leg swelling due to amlodipine
bcc 2 - double vision. pt is normal. Dx not sure (IIH)
history - ankylosing spondylitis
comm
pnia curb 65 -5, sudden death of his father
explain abt the management and care, daughter is angry
abdo liver transplant
resp right upper lobe collapse consolidation
cvs MR with pul hypertension and functional TR
neuro lower limb distal weakness. I gave ddx of GB and motor
.dominant peripheral neuropathy. sensory is normal

Experience of our colleague

Shawg Mohammed Ganawa
Here is my exam experience hopefully it will be useful
Maadi Military Hospital 2/6/3016 second cycle
Well organized very good atmosphere
: I started my exam with cardiology
MVR with A.FIB ,valve functioning well
Q1:causes,RHD then immediately
They ask me about management as he SOB;diuretics and
anticoagulation
 Then Q2 if patient had fever what he could have ??infective
endocarditis and what is the Target INR2.5-3.5
Then neurology station :while am examing young man i can
hear the click �he has pyramidal weakness on left side with
clonus ,and they ask d/d left sided hemiparesis stroke in
young ;then i said as i could hear click cardiac cause A.FIB and
then ask how you will decide about Anticoagulation i said
CHADS2 score other D/D demyelination then ask how you
investigate for MS I said MRI VEP and LP
Then communication station i felt i did Bad 😫😫😫elderly
with UTI and Parkinsonism which was diagnosed 3 years but
not on treatment ,now she is admitted with UTI ,her
parkinsonism become evident and started on treatment
carpidopa ,role to D/W her daughter management
My D/about that she is elderly fragile with uti her symptoms
appear
Then daughter ask about side effect of Parkinson drugs
Then i asked social history she told my father bed bound with
stroke and my mum is only care giver ,then i discuss other
modalities of treatment like deep brain stimulation
Then i told we will involve social worker if no solution then
might need to think about nursing home for your parents
Examiner ask me about treatment of Parkinsonism
Feeding i said PEG tube then i need family ,they told me to
why u need family to Discuss ;i said she might have LPA or
advance directive As she is incompetent
I felt am of point as i didn't talk much about UTI
But i score 16/16
 ; Then i moved to station 5
Cushing i asked what is your concern but I didn't answer the
concern cuz no time ,examiner ask me what is your D/D
cushing ,hypothyroidism ,then he ask me about how to
investigate and treat cushing and what is the difference
.between cushing disease and syndrom
:Second st5
years old presented with polyurea 01
,History of RTA three years concer could it be cancer
? Examiner ask what is your diagnosis
Diabetis insipidus also ask about investigation i told water
deprivation,desmopressin then examiner said more simple
.one i said urin and serum osmolality and treatment
I forgot to refer both patients to speciality,may be that is why
i score less
Then Abdomen:hepatosplenomegaly with heart failure and
also she had auidble click .gum bleeding,echemotic patch in
her hands
D/D Decompensated CLD i told hepatitis C ,then he ask
management i told referral to hepatologist and ask about
latest treatment for Hep C i told bocepravir
Chest:COPD ,with basal crepirations i told with fibrosis
examiner didn't like it he want COPD only then he ask me
about non pharmacological therapy and then pulmonary
.rehabilitation
History station:35 years old with hearing difficiency from
recurrent infections with meningitis at age 17 ,chest infection
;UTIs and came with dirrhoea and weight loss ,i told examiner
hypogammaglibulibaemia,he told me what else then HIV
,then he helped me cuz I forgot Cystic Fibrosis,till i said cystic
fibrosis 😬so am not sure what he wanted or how he will
judge me cuz i gave only hypogammaglibulibaemia and CF
after his help
Concern newly married will my children will get it then i said
Advance technologies like gene selection and IVF
02/11
‫هللا ولً التوفٌق‬
My advise is practice more than studying books

COPIED
Exam experience Kasr AlIny hospital
1211/1
first day 3rd cycle
CVS -1
prosthetic valve mitral with AF
Discussion was so long I finished my examination early he
asked me about indication for replacement , treatment, and
cause of chest pain in such case, target INR
Score 19/20
Abdomen
Pale pt with hepatosplenomegally
 DD start with hematological cause and still CLD on my list
then he asked me about common cause of CLD in egypt then
how to approach pt and treatment
02/12
Chest
Female with rt apical fibrosis and pleural effusion
Discussion was about causes and treatment but I scored bad
because I didn't exposed pt completely she asked me not to
do she was young and I respect that but examiner didn't like it
02 /2
Neuro
Peripheral neuropathy gulliam barri and discussion was about
DD and treatment when to admit pt
The funny thing in this station
That before i start i asked her if she has pain any where and if
she felt and to tell me then while am doing tone she scream of
pain I stopped immediately i told examiner i
Station 5
proximal muscle weakness wt gain -1
History everything was negative the only positive that he is on
thyroxine i asked surrogate why he is on thyroxine because i
asked about previous medical illness he said nothing he told
me I don't know
My DD at this point cushing hypothyroidsm
I examine to role in or out one of them it was hypothyroidism
diffuse goiter
Discussion was about investigation treatment
 02
middle age pt with lower limb weakness with oral ulcer -0
Hx was suggest to behecet disease i examined lower limb
neuro and for erythema nodosum,And oral ulcer
Discussion was about cause of weakness how to diagnose and
treatment
02
]10:12 02.21.11[ ,Muna Moon
]Forwarded from Muna Moon[
My exam experience gasr al3eni hospital first day 3rd cycle
CVS -1
prosthetic valve mitral with AF
Discussion was so long I finished my examination early he
asked me about indication for replacement , treatment, and
cause of chest pain in such case, target INR
Score 19/20
Abdomen
Pale pt with hepatosplenomegally
DD start with hematological cause and still CLD on my list
then he asked me about common cause of CLD in egypt then
how to approach pt and treatment
02/12
Chest
Female with rt apical fibrosis and pleural effusion
 Discussion was about causes and treatment but I scored bad
because I didn't exposed pt completely she asked me not to
do she was young and I respect that but examiner didn't like it
02 /2
Neuro
Peripheral neuropathy gulliam barri and discussion was about
DD and treatment when to admit pt
The funny thing in this station
That before i start i asked her if she has pain any where and if
she felt and to tell me then while am doing tone she scream of
pain I stopped immediately i told examiner i
Can't continue examination she is on pain he told me proceed
I thought i lost it but al7amdole ALLAH
Score 20/20
History
Pheochromocytoma men
Young pt recently diagnosed with HTN and he had panic
attack he was started on diazepam
Discussion
DD add hyperthyroidism he asked me how u will explain wt
loss in Pheochromocytoma i told him 10% can be malignant
?Why men
ve family hx+
Symptoms of hypercalcemia
02/11
Communication
 I scored bad and I didn't read scenario good
Middle age pt newly started on thiazide for HTN he was
walking on hot weather he drink water then he had fit
Na was 114
Explain to wife about conditions and prognosis
What i did i explained why he had fit and the idea of dilution
hyponatremia and the effect of thiazide and i told the wife its
provoked seizure but still we need image to role out other
causes
But this part upset examiner he said no need for further
image no need to discuss job and driving
11/2

The Experience of the Exam of our colleague

)copied from Dr. Zain group(
,,,Examined in Egypt last diet
start my exam with station 3
Cvs:it was case of shortness of breath diagnodis wasMVR with
pulmonary HTN In AF question was about AF managment , B
blocker contraindication , target INR for mitral valve
replacement
Score 19/20
 CNN case of difficulty in walking in young patient finding was
pallor, jaundice with hemiparesis lt side q was about causes of
hemiparesis how to investigate and how to ttt
Score 18/20
Station 4
yrs old lady on renal dialysis with past history of stroke 22
after which she become blind she experience wish to stop
dialysis if her condition become worse and the renal team
decide it is time to stop dialysis she is drowsy with shortness
of breath and expected to die after 3 day if dialysis is stopped
😰speak to her son about his mother condition
It was tough and I don't know how I will manage I Remember
the consequence of Dr. Zain I start with same manner after
greating and permission of note and if any relative wont to
attend , how much he know about his mother condition he
know little about it I clarify her condition and the need to stop
dialysis to her and I ask if he know that his mother she has
any wish and he know about the wish of his mother he ask to
take mother home since dialysis is stop I counsel him about
the need for her to stay in hospital for her best interest his
concern was about his mother condition and if he is able to
take her home and after how many day she will die I tell it will
shorten her life then summarize and check his understanding
� the till me still u have time I don't know what I will tell more
😓I didn't discuss about DNR
Examiner q was about issue
And why u will keep patient in the hospital and what about
😓the wish if her son
Itwas v.bad station for me
 Score 10/16
Station 1
Respiratory was case of copd with bibasal fibrosis q was about
how to investigate and how to ttt and lung function test
Score16/20
Abdomen
CLD
Q was about finding and how to investigate and how to ttt
Score 20/20
Station 5
Case of headache only complain in history she has Sheehan
syndrome and not on ttt
Concern cause of headache
Q what us the cause of headache and how to investigate and
ttt of Sheehan syndrome
Score 26/28
0
Case of lt facial weakness LMLN
No other CN affection no weakness concern if this stroke and
what is cause of it
Q what is causes of facial weakness how to ttt
Score 28/28
History role sho in medical admission unit case of CA breast
received chemotherapy and radiotherapy she can not copy at
home and insist for hospital admission 😕I was though it is
😂 communication not history
In the history she has symptoms of hypercalcaemia with bone
metastes back pain and shortness of breath her concern is the
admission and about the cause of her symptoms
Q how to treat hypercalcaemia and palliative care
Score 20/20

My exam experience first day second round new kasr el aini

hospital
Dr/yousif el malahy
Score 140
Firstly i like to share how i prepared for the exam
This was my first attempt
Not take any courses
Just listen to dr ahmed maher in you tube for communication
senarios but not for hx taking and it will be reflected by my
score in station 2
For physical examination stations i prepared for it by
collections from many books and videos and start to practise
it in my clinic with every patients
I started with station 3
First one neuro
Examine lower limbs
It was spastic paraparesis with abcent knees and upgoing
planters with no sensory impairement except for in L5
 dermatome in right side it cause me cofusion not reach
diagnosis but discussions was good i reached diagnosis only
while driving back home as pure lateral sclerosis i score 13/20
Second one cardio
Obese bad exposure
Not cooperative
Midsternotomy scar with no vein harvesting scar
Metallic sound before systol i diagnose it Prosthetic mitral
valve
No signs of infective endocarditis nor heart failure
Discussion was about investigations
I was not sure about diagnosis as while we out 2 of us say it
was mitral 1 say it was aortic because patient was tachycardic
Score20/20
Station 4
Explain diagnosis of IBS 7 for 7 years not improving little angry
want mor investigations and second opinion
I think i do it good
Dicussion was about why not do more invextigations ?may it
?be cancer
If he has the right to seek second opinion
Score13/16
Station 5
First one acromegaly
Complicated by carpal tunnel obstructive sleep apnoea visual
problems but no symptoms or signs of field problems
discussions about cause i say papilloedema or optic atrophy
Score28/28
Second one pemphigus vulgaris
Generalized erosions oral erosions
No other signs
One of concerns about complications i said im not sure
Dicussion about DD i forget steven jonson
Surprisingly i score 26/28
STATION 1
First one abdomen
Jaundice pale splenomegaly ascitis liver not felt
Discussion about DD
Score20/20
second one chest
COPD
There was crepitations but i dont mention i think there was
bronchiectasis or fibrosis also
Dicussion about investigations and treatment
Score14/20
Station 2
My nightmare
Abdominal swelling pain diarrhea
 I miss past medical disease of exised breast cancer however i
ask about family history of cancer
I miss diagnosis all my focus was about coeliac disease and
inflamatory bowel disease this was simply because i gave no
attention to abdominal swelling and didnt analysed it
Score6/20
overall grade pass
Thanks to dr ahmed maher eliwa
I share this photo because it helps me alot in practice of
physical examinations at home

kuwait 23/3 cycle 3

station 1
Abd
About 40 years man looks very well no sign of chronic liver
disease not pale or j' no av or central v catheter scar or fistula
then I notised right iliac fossa scar so I thought this will be a
case of crohn's disease butt later I found a mass below this
scar resonant can be bi manually palpable move less with
respiration . No other mass no ascites no bruit .then I
returned back searching for sign of immunosuppressins ,
infection . Volemic status . Scar or fistulla peritoneal cath scar,
this patient have very small central v cath scar in his chest .
Later on I met this patient he told me I did very well and I will
get the full mark because he have the experience to judge the
. candidate performance
 Examiner questions
Present your POSITIVE finding and diagnosis. The causes of
renal failure ,I said I couldn't find any clue helping me to know
. the cause but most likley it is dm ,htn , glomerulonephritis
? What is the immunosuppressant drugs for R trans
.?What is their side effects
?. How you know this patient have a faild renal transplant
Respiratory case
years old man dyspnic .clubbing with sings of obstructive 22
lung disease decreased cricosternal distance ,prolonged
expiration with wheezes. resonant exept the bases . Harsh
Crackles changes with cough anteriorly ,soft crackles not
change with cough in the bases . When i said that the british
examiner shocked he said to me are sure I said yes very sure,
he sked me are you sure the crackles in the base are not
change with cough i said yes and there is dullness . He said
you have to chose between bronchiectasis and fibrosis , I said
could be both fibrosis due to repeated infection, he said no
you have to choose , I said fibrosis. Then he said suppose this
?patient have bronchiectasis how are you going to investigate
What is treatment ? What is the most immportant part of non
?pharmacological treatment
Station 2
For history station if your exam at center running late like me
you have to read and practice all cases came in the other
center uk and overseas. Because of that this station was very
easy for me . I knew that this is the case of postpartum
thyroiditis. I just need to rule out the other d diagnosis of
.palpitation and other causes of hyperthyroidism
 . A lady complain of palpitation
recent delivery , weight loss. Feel warm , loose motion .
Postive familly history of heart disease her mother died due
to heart attack at age of 60 . No cardiac or p.e risk factor, no
neck lump or eyes changes , no tremor . Negative every thing
else . Past history of asthma no drugs other than sulbatamol
inhaler , no smoking, house wife , live with her husband and 2
kids satisfied financially when I asked her are you satisfied
financially she said look if you are asking about my mood I am
ok and I dont have anxiety then she laughed, me and the 2
examiner also laughed alot .when I asked her how this
problem affected your life she said I dont know and she
. looked to the examiner with big smile
? Concern :- is it heart attack like my mother
? What is my problem
? Is it treatable
. I explained to her the problem and answered her concern
Very lovely examiners British man and young lady I think she
. is a sudanese
She asked me about d diagnosis ? P p thyroiditis, pp
cardiomyopathy and h attack and arrhythmia are very
.unlikley
Investigations ? Some questions about what I expecte about
? antibodies and thyroid isotope scan result
Treatment? I said the treatment is b blocker but because this
patient have asthma I have to seek a senior advise . And close
f up of her next pregnancies because this problem may re
.occur again
Station 3
 Cardio
Berfore I enter the room I saw the patient coughing large .
amount of sputum I said most likely this patient have pulm
edema😆 . Then no right hand pulse, left hand regular large
volume collapsing , raised jvp but I wasn't sure .s 1 was soft
normal s2 loud at the pulmonary area left parasternal heave
palpable 2nd h sound . Pansystolic at the apex radiate to the
axilla but you can hear it all over the precordium but with
diffrent intensity at upper left sternal edge . And I am pretty
sure that there was a radition to the right carotid 😑. There
was also lung bases crackles and no lower limb edema . That
what I found but I said to the axaminer no right hand pulses
he asked me why ? I said catheter and clott, embolism . Then
good volume pulse I didnt mention collapsing. I said systolic
murmur radiate to axilla with different intensity I will do echo
to make sure about this . with pulm htn . He asked me
without echo how you can know if there is tricusp reg or not .
At is moment I knew that mean the jvp was raised I said to
.him sorry I forgot that the jvp was raised
. so there is tricusp reg also
When I told him that this patient have basal crackle he told
me forget about that 😑. He asked me does this patient need
?anticoagulation
?Investigation
?Treatment
after that the other examiner asked me are you sure that you
didn't hear any diastolic murmur ?😑😑 by this question I
thought that mean I missed some thing serious but I said no I
didn't hear 😑. He looked straight to my eyes and I kept silent
.
 Cns
Examine upper limbs
years old man 22
Have an amputated left leg below the knee. large right upper
arm scar with
Power zero hyptonia no reflex loss of all types of sensations in
the same side of the sacr
Normal left upper limb normal back examination, normal co
ordination . I asked can I examine the lower limb he told me I
dont think it will help you .to be honest for unknown reason I
didn't compare the 2 limb in reflexs and sensation. I didn't
😑.asses the sensation by dermatomes only by level
_: Examiner
?Your positive findings
?The cause
Nerve injury due to trauma most likely accident . Which type
?of trauma
? Which nerves
?Investigation
. Treatment? Just support
Communication
Very long scenario about 14 lines 😑. It is in d. Zain sheet but
with a little difference . I took what I thought a bad
performance in station 3 so I wasted more than 1 minute
. doing nothing
A man about 50 admitted MI found to have low HB about 110
g/l , nothing was done and they told him it is due to NSAID
.discharged on aspirin
month later his GP found his Hb about 70g/l (I am not sure 0
about those numbers ) and he did some investigations and
found nothing( here I dont know why I thought the
cardiologist was the one who did the investigation and all
returned normal) . That all I can remember, actually that all
what I knew when the bell rang. But I kept calm because I
.know I can gather all the Information from the surrogate
Then can you share with me what you know about your
problem ? He told me every thing about his case . More than
that he told me he afraid it may be a cancer and the gp told
him that he may need blood tranfusion 😑😑 . Why the
cardiologist didn't do any thing to discover this cancer as the
cause of his anemia ? He afraid of blood tranfusion because
. he think he can get hepatitis and hiv
So dealing with angery patient keep calm listen carfully allow
him to talk dont disturbe . I told him he can't do camera for at
least 6 weeks after MI . And it was wrong to be on aspirin so
we need to stop it till see the result of the investigation we
will contact the cardiologist to give you alternative
medication .And let us go for ward to know the cause of your
. low hb
. The blood is tested and he will not get Hiv or heptitis
I took quick history seerching for common causes of anemia
. and he had nothing positive
I asked him about endoscopy I found that he have alot of
information about It . Then i explained the endoscopy . Offer
 a leaflet to read and the endoscopy doctor will answer any
. questions before the procedure
I dont know what is the cut of for transfusion when using g/l
value 😑 i know it 6 when you use g/dl . So i told him we need
to involve the blood doctor and also the bowel doctor
? The patient asked me if he have a cancer
I said the cause of your low hb is not obvious so we need to
do full check up to know what is the cause it is ranging from
mild cause like diet and bleed due to aspirin to more worrying
. like cancer
_: Examiner questions
He asked my why the cardiologist didn't do anything for low
hb ?I told him he did but all normal
He told me that was the Gp . I told him sorry because of the
scenario was very long I thought the cardiologist was the one
who did that . But if that was the case there is negligence . He
asked me is it nice to expose the mistakes of our colleagues? I
. told him to be honest is the best thing
? Then he asked me about the issues in this case
What if this patient refuse the blood tranfusion? He have the
. right to refuse
.What we call that ? Patients autonomy
.Do you think this patient have cancer ? I said it is possible
Station 5
First case a man complain of joints pain
So main d diagnosis :_ 1/R arthritis 2/osteoarthritis
.3/psoriasis 4/ank spond
 Open question then
.Targeted questions to reach the diagnosis
He have symmetrical metacarpophalangeal joints, proximal
interphalangeal and both wrists some times shoulders and
knees pain . Morning stiffness . Releived by exersice.this
problem For more than 10 years . No back or neck pain . No
skin rash no eyes changes. No breathing problems . Normal
.water work normal bowel habits
P. history of viral hepatitis but have been treated many years
. ago
Drug on steroid, azathioprin , NSAID. But no great benifit
.😑 He doesn't know what is his diagnosis
IT engineer . Negative f. History . No great impacts on his daily
. life
. Normal physical examination normal hands function
Most likely r arthritis it controlable ,we need to carry out
some tests, blood and x ray . Appointment to discuss the
.result of this tests
Gruop of specialist will be involved in your management
including joints doctor who may need to change or add some
.medications physiotherapists and occupational therapist
Concern? He told me I already answered all his concern thank
you . He was very nice indian man he told me after the exam
:- actually I helped you alot 😊. I said yeah thank you so much
. And he was right because he gave me most of this
information after the opening question. And he was easily
.satisfied by my explanation
_: Examiner
 ?D diagnosis
Any relation between his liver problem and this joint pain I
.️☺ said no relation
?Inv ? And treatment
?What medication we can add
?Biological medications
Station 5
hours right side weekness 50 . years old lady .bp 150/95 0
So main d diagnosis
. TIA , complex migrane
Less likely m sclerosis antiphosphlipids syndrome. vasculitis
.and Psychological
Sudden onset right side weekness continued for 2 hours no
headache no face weekness no vision or speach problems no
.loss of consciousness. negative other cns symptoms
No palpitation no chest pain or breathing problems. No skin
. or joint problem
P history of htn no other vascular risk factor no p history of
similar condition no history of unsteadiness or bowel or
.bladder control . No p.h of migrane
F history of stroke mother at about 50 years old
. Drug :- lisinopril , no oral contraceptive
.She is a nurse . She doesn't drive nor smoke. No alcohol
.No mood problems
physical exam :_ normal pulse no carotid bruit normal uper
limbs examinatin . They stoped me doing heart auscultation
 and cranial nerves examination including fundus after I
. affored to do them
She want to know what is going on ? Is it stroke ? Will it
?happen a gain
I said it is mini stroke with explanation . Yes it may happen
again so we need to admit you and carry out some tests blood
test heart tracing and scan . Brain image and ultra sound scan
to your neck .the nerve doctor will be involved in your
.management
-: Examiner questions
What is your positive findings? Nothing
Why do you want to admitt her despite the weekness has
. resolved? Abdc2 score
?Investigations

Sharing my experience with Paces: Never give up & u will

.reach your goal
I had 4 attempts for paces, the first attempt was 2013 where i
was quite immature and had a nightmare. Went on to 2nd
attempt had a heart breaking score of 129 passed all
components but failed total mark. 3rd attempt was in Brunei
December 2015 where i scored 150 but failed in a heart
.breaking component of concern with 9 marks
Finally manage to complete my marathon in 2016 4th
:attempt
:Exam case
 Started with the station i dread the most and least well
.prepared - station 4
:Station 4
MND counseling: break bad news about the diagnosis and
)11/10( .address patients concern
:Station 5
)02/02( Thyroid eye disease with cataract
)02/01( Psoriatic arthropathy with lower limb OA
:Station 1
Respi: scleroderma with pulmonary fibrosis (obvious
sclerodactyly with mouth furrowing and unable to put in 3
fingers into mouth, bilateral fine basal crepitations with
bronchial breathing. Chemoport seen at right chest region.
Was asked about the use of chemoport & how to correlate
)with the diagnosis. I was unable to answer that.(20/20
Abdomen: Chronic liver disease with hepatosplenomegaly,
was asked what one single test you would like to do to
confirm your diagnosis? Finally was told to be liver biopsy by
)02/02( the examiner. I was surprised by the marks
:Station 2
Pulmonary fibrosis secondary to methotrexate / bronchial
asthma / bronchiolitis obliterans. Questions about bronchial
)02/12( .asthma and treatment
:Station 3
CVS: ASD with ?TR in failure. (9/20), i guess i messed up this
station and created the signs of tricuspid regurgitation.
!Perhaps there is none. Lesson learnt is not to create signs
 Neurology: Guillain barre syndrome with patchy areas of
sensory loss and bilateral lower limbs weakness (13/20), was
questioned about findings in LP for GBS. Unable to reach
management & thus affected my mood. Luckily this is my final
.station
Total score 130/172. I wish those who are going for exams
good luck & work hard. Play hard and enjoy the learning
.process too

Detailed and very useful Experience ,,, from a colleague who

appear in Brunei 10/6/2015
Brunei 10/6/2015 these is my third trial and worst trial 😁 and
the evidence for that in the trial before I get full mark in more
than 4 station but I didn't pass 😳 don't astonished that is
PACES and in the last exam I didn't get any single full mark
any station but I pass my exam, why I told all that story
because after my shocking result in the past I had wrong
believe if I didn't get full mark in most of the station I will not
😁 pass and that proved totally wrong
I started by station1 my first case is respiratory young man
looks good complaining of S.O.B I find only trachea shifted to
the RT and crepitation bilateral changed by cough I finished in
time the British examiner was the leader
He asked my did u finish your examination I started my
presentation I rich the diagnosis of bronchiectasis he asked
about investigation and management 🔔 was ringing we
moved to next case me and the local examiner and I started
 my examination for middle age man and I rich looking for the
hands and until that time the British examiner not came in the
time I started shaking because I said to my self maybe I have
bad presentation or wrong diagnosis in the respiratory and he
marked me bad 😢😢 and the local examiner also went I
become alone with pt ,the local examiner he asked the British
to come when they came I rich the face of the pt and I asked
my how they can assess me in the examination of hands and
difficult to start again because the time is already gone 😓😓 I
complete my examination and it was case of
hepatosplinomegaly I started my presentation in the end of
the discussion they asked me if we said for u the pt is stable
for long time , in that moments I feel lost and that means I
didn't rich the diagnosis and become silent for moments and
after that I don't Know why I opened my mouth and I said it
could be APKD I think the face of examiner became like 😡 and
🔔 is ringing in the same time really in that time I pray to not
hear me at least one theme because I'm sure these is case
hepatosplinomegaly I went for st2 really depressed because I
compared my previous performance in the previous exams
and got full mark really I become depressed for me be for 2
minutes I didn't looking for scenario of the history and I told
my self with full mark I didn't pass in the past how I will pass
with the bad performance and that is totally wrong I get 19
and 18
And after that I feel like I'm in dream I heard yours voice
,dr.zain and all of u , u said don't worry that is only one st u
can compensate in the next coming st really like I wake up
from sleep I tried to forget and I realized that I have very long
scenario I have ever seen in the history it's like
communication scenario
 It talk about young female with long history of uncontrolled
DM type1 and now presented with recurrent history of
hypoglycemia they written investigation and long story
😢😢😢 I feel depressed again I know the history of DM very
long also and the examiner will be so sophisticated in marking
,I enter the st I found the same surrogate of my last exam but
that time she was in st4 I remembered her she was very nice
in that time I feel relax and started asked her in these time
she become talkative and also not understand some layman
English 😳 like water system always she speak about diarrhea
and I found difficult to control her when I rich family history
they remind me for 2 minutes I feel shaky 😢😢😢 I want to
ask her for many thing I realized that I did badly managed my
time. They start to ask about her problems I said most of DM
complication prephral neuropathy and autonomic neuropathy
and retinopathy and the cause of hypoglycemia it could be
CKD or Addison and they discussed with me about
management and🔔 ringing when I rich the door I remember
that women I didn't ask her about her job and driving and I
felt that I did fatal mistake because the last exam I fail skill C I
said allhamdolilah and felt depressed again I heard your
voices and I remembered I came here to do all the exam not
only 2 st they give me 14
I refresh my self by drinking water because I feel very thirsty I
enter st 3 and I full of hope it will be very easy because I
practiced very will with imtithal by the way the history also I
practiced with her so nicely when I remembered I said to my
self ah ah ah I started by cardio meddle age it looks like COPD
pt 😳 I examined him and find nothing in cardio after I rich the
back searching about any thing even basal crepitation and I
didn't find any thing ,still I have time can u imagine I started
agin the examination of precordium only I realized that man
 has distant heart sound ,when he said tell your finding I want
to cry 😭😭 I said for him I found nothing than distant heart
sound I put deferential diagnosis they discussed the
management , in that moment I felt that my destiny not pass
that exam we went for neuro the British said to me these is
sister she will help u with your case really I asked my self what
that case need for help in his examination 😳 when we enter
the room I read the structure it written women she blurring of
vision please examine her cranial nerve 😢😢 women about 75
years old she can't understand single word of English and
sister translate for her ,the problem when I give her the order
and nurse translated for her she understood wrongly
especially in visual field and eye moving she started to
laughing with high voice because she find it difficult and the
British examiner Also laughing with her in that time I said to
my self I rich here by 3 airplane and they laughing 😭😭😭 , in
end I find only bilateral tossing , I said for him I want to
pursued he said carry on I asked to count and looking for
ceiling it was +ve and also fatiguability test is not clear I said
for him I want to examine her chest he said only from outside
also she had difficulty to release my hand and I find that
difficult to me is that from bad communication or true sign I
put deferential diagnosis myasthenia gravis and muscular
dystrophy and from discussion they want only myasthenia 🔔
they give me 16,14
In front of st 4 just I remembered your talking about istigfar
and alsal ala alnabi
I did that and I felt relaxed and starting study st4 scenario
about meddle age women she had past history of breast ca
and bronchial asthma ,she done surgery and received
chemotherapy before 2 years now she has pneumonia before
 6 weeks ago and she did x Ray now the radiological
department they found shadow and today also repeat the x
Ray with the same lesion they said talk with her and dealing
,with uncertainty
I enter relaxed she was angry at first because the delay but
when I said I will revise your file I will reported if I find any
delay she became relaxed I speak with her about the
possibility of cancer or infection and we have to further test
like ct scan and bronchoscope and I explain for about it and I
asked about allergy for dying and contrast also did she do it
before also I asked about kidney function also I check
understanding many time and make summery and closing
,they asked about the ethical issues I said ,BBN,dealing with
uncertainty,empathy and counseling about the investigation
in the last time he asked me what do you think the main issue
of these scenario, I just keep silent and after that the 🔔
ringing I went out relaxed I said to my self it will be full or 14
and I feel these is best st from start and no big difference from
my performance of my last exam and i get full mark in that
😳 time but that also is wrong feeling because I get only 10
I rich my last st and most challenging st for me because my
previous trials i lost all my scores in st 5 first scenario about
elderly man has history of Mi came for cardio clinic complain
of difficulty of walking they given normal vital ,case 2 about
young female complain of chest pain also with normal vital
when I enter I found old man with good dressing sitting in
chair beside him young lady I greet him really he masked face
but I think firstly that's normal because the old Asian looks
like these I started to ask his relative when I asked about
shaking hands she said yes he has after these point I target my
questions and examination of Parkinson's I think the most
thing cause the examiner happy I tried to exclude vascular
cause and also the examination of babinisky sign because the
he has shoes with socks I volunteer to help him because I felt
the time is running 😢😢 pt refused I did it and knee in the
ground the British examiner came near to me after that I
examined his gait and his concern about his treatment of MI
can caused the problem I reassured him and we didn't start
for him the management until the problem effected his life
they asked did you find tremor I said little bit 😁😁 Really it
was not obvious also he asked about gait I said shuffling he
said ok go for next case
I found young lady in the bed with hijab I started to take
history I found she has history of SLE after that I target my
questions about PE and also the pain increase when she
bending forward I put precarditis I complete my examination
and I finished early he asked do u want to do anything more
,during examination I found the pt has tight skin now I look
for her again and she didn't have other sign of scleroderma I
ask her to put her hand inside her mouth in that time the
British examiner laughing they ask me about investigation I
feel relax after I finish because st5 hear is only best st in the
exam and for sure its best than pervious one they give me 26
and 27
In the end my advice don't occupied your mind by any
believes ,because we are Muslim it hard to said PACES is
gambling game but it's tawfig from Allah
Dr.Telal Eltyb
 :In Liverpool , Broad green hospital . I started with station 2
A pt with long standing dm presented with swelling of both
. leg and fatigue with +++ proteinuria
:Station3
Cvs: pt has midsternotomy scar with pacemaker scar with esm
.at aortic area.no srphanous harvesting graft
.CNS: both sensory and motor neuropathy
:Station 4
A female patient has admitted with pneumonia and
developed click difficile infection. One of medical staff not
.maintain hand hygiene. Angry patient
:Station 5
BCC1: Fatigue ,; Acromegaly with OSA
BCC2: A patient has c/o not seeing well after 4pm. Retinitis
.pigmentosa
Station 1 : Abd: Rt renal transplant with Rt AV fistula and pd
.scar with hand tremor Abdul gum hypertrophy
Res: a young female with khyphosis and contracture of finger
link and thin mid thoracotomy scar _ cystic fibrosis with lung
.transplant
.Dr Mohammad Sazzad Haider
.Rustaq hospital.Oman
Keep praying for me
For those who are interested in following (Difficult) UK Exams
,,,
,,," This is a small collection of " UK Exams
Glasgow PACES -1
:Station 4
Delayed diagnosis of pheochromocytoma
Mr, jones 35 years male
Had High BP for last 5 years
Seen by psych for panic attacks
Tried many Med for HTN
But
His BP has been difficult to control
On his insistence , his GP has referred him to hypertension
clinic 2 weeks before
Results of tests now show
Urine : high metanrphrines
CT adrenal : 5 cm mass in right adrenal
Ur task is to explain the diagnosis
U don't need to know the details of further tests and further
management
Patient was concerned
Is it serious
Is it cancer
Is there a cure
 Will I require future surgery
What future tests will be done
Was the delay justified
What medicine u will give me
Examiner : repeated similar questions
Overall not too harsh patient
Satisfied at the end
Agreed follow up GP Consultsnt website address alpha
blocker beta blocker
11/11
History station at same centre
Opening : 11 points
Discussion : as under
Young female 28
Blood Diarrhoea after Cyprus visit
Started 1 day before coming back
Mixed with stool
Similar episodes for last 2 years
Took amoxicillin in Cyprus
Diarrhoea aggregated
Now last 10 days
Frequent blood a salime in still
Painless
C/ o small joints pain
 No backache
No other extra intestinal symptoms
No oral ulcers
No skin changes
No jaundice
Cousin IBD UC
Father CA colon
No blood thinners
No steroid
No warfarin
No bleeding disorder
No weight loss
Concern : cause
? Is it cancer
? What next tests
? What Med
? Need admission or not
DD: xIBD ( UC)
Infective Diarrhoea
Antibiotic associated Diarrhoea ( as patient said Diarrhoea
) aggravated by amoxicillin ( but I told least chances
Explained to patient in detail and agreed a plan
: Closing
summary
 Labs / Leaflets / NHS choices website
Agree
Examiner : just repeated all above
And
Asked
In
; History how will u rule out infective cause
Fever
Vomiting
But
He told
U will ask about symptoms to others accompanying him
Marks : 4/20
History & Communication : zero
Concerns : zero
DD : zero
Judgement : zero
In feedback : written
: History and communication
️✔PC
️✔HOPI
️✔Past Hx
️✔ Personal
 ️✔Family
️✔Drug
️✔Allergy
️✔ Treatment
️✔ : Social
️✔Occupational
️✔ Travel
️✔ Association of IBD
Used jargon : IBD ( during explanation of DD to patient )
Oral ulcer ( mouth ulcer should be used )
Didn't get more details of past episodes
Result : zero marks
DD: 1st diagnosis was IBD
But actually it was infective Diarrhoea
Result : zero marks
Concerns : though addressed adequately but remarks are he
left patient worried about the diagnosis ( serious diagnosis as
IBD)
Result : zero marks
: Clinical judgement
Question 1
: How u investigate
CBC to look For
CPR ESR
 Electrolytes
Renal functions
LFT
Stool microscopy & culture for infective Diarrhoea
Sigmoidoscopy / colonoscopy if required
Question 2
Treatment: as per diagnosis if it's UC
Then steroids and mesalazine
If infections : antibiotics
Remarks : want to give steroids though preferred diagnosis is
infective Diarrhoea
Candidates remarks : This happens in real life
Though I was expecting 100% 20/20
But
. Actual 4/20
###############################
Castle Hill Hospital-0
Station 2》
years old .DM.asthma presented 02
With recurrent chest infections for 6 months 6 times
I put DD bronchiactesis .TB
No Hx of fever .wt loss or travel or contact with pt with
chroinc cough.he has greenisg sputum..constipation..I did not
understand his accent clearly
 He continue mentioning constipation and trying to have a
baby and I totaly ignore it..his concern why I have this
recurrent infection
His diabetes and asthma are not well controled I asked about
HIV risk which up set the examiner
I forget sinusitis and examiner was angery and heampotesis as
.well
I told him we are going to do bronchoscopy..also upset the
examiner
He asked me about d ...my dd was bronchiactesis and TB
He asked about one blood test for specific for bronchiactesis
I told I do not remember
..😳 He said serum antibodies for pathogenes
😣 I was about to say immunoglins but bell rang
.CNS: Upper limb exam .3》
He has hemiparesis
I did not finish sensation
Not examin e nech
He had truma with scar in head which I did not notice even
.when examiner point it
He ask me if you notice any facial asymetry I said no..which
acutaly was present
:CVS .3》
A tall women I wasted time looking for alchol gel for scruping
and washing hands with water
 Marfan syndrom with 2 sacrs on medisternotomy scar with
metalic clikc and aother an rt subcalvicukar..no muremur but
2nd sound was loud and palpable..first was soft
My d..aortic valve replacemtn
He asked about causes of chest pain in marfan
I told ACS
And pneumothatx he asked what else which I can not answer
She had high arch palate and archenodactyly..I think by other
cause of chest pain he wants rupture anyuresm..I just
remember it now
:Communication skills :2》
Staion 4 ...80 years old patinent..Alzehimer d...was on NG
feeding and she was agreesive and agitated all the time and
use to pull it out..her doughter facing problem with feeding
and want PEG tune insertion ..speak to her doughter and
...explaine ill_terminal care and palliative care for her
I do not now mentioning DNR waa suitable or not but I have
..mention it
Examiner asked about how are you going to feed her if sh will
..😳 not take oraly no NG no PEG tube
:2》
Station 5 was diffecult
years with skin lesion over her forhead and scalp 12
Looks like morphea
Some candidate mentioned SLE
Apart from that she did not have any manifestation of scl
 ? eroderma ..her concern is it a infecious
?Is it cancer
I reassure her ..but examiner asked what could cause
morphea
Second case 62 years old ..with blurring of vision .exssive
fatiguabilty..and more blurred by the end of the day..deffintly
she had exopthalmous and opthalmobligia..diplopia on both
lateral gazes..thyrodyectomy scar and left firm thyroid
😥 nodules
Dry hard skin..fundus normal..no other manestation of
..thyroid ..no proximal myopath
I told dd
Graves opthalmopathy and
Mysthenia graves
:Station 1》
chest bilatral basal fibrosis and skin rash..I do not now what ¤
is it...some candiadte examiners told them it is
dermatomyosistis..it was not typical she had hard skin..finger
.tips ulcer as well
Abdomen...abdominal pain ¤
I could apprecaite 2 masses in rt side and one mass in left side
not liver not spleen...it was transplanted kidney ..examiner
? asked why she is going to have abdomian pain
?What about immune supression side effect
...Examiner questions was more tough than the exam
But it was nice experiance
..Keep praying for me
 #########################################
:UK PACES experience-3
I want to share my experience in Western General Hospital,
...Edinburgh 25 Feb 2016
..I started my exam by station 3 ☆
..Cardiovascular; 50 year old man complains of SOB )3
I did the exam, I appreciated a murmur in apex.. I could not
.. time it
for unknown resean I said it is diastolic murmur considering I
do believe that diastolic murmur can not be brought in
..PACES
The examiner ask me if that was diastolic murmur what will
be your differential.. at meet the patient after the exam at
( hospital gate and he told me he has AS and MR !!! I scored
) 02/2
CNS; lower limb exam.. patient was not cooperative and )3
misleading
he kept moving his lower limb during tone assessment and
giving contradicting information during sensory exam.. I could
..not formulate DD
) 02/7 ( I scored
Communication: 40 year old lady has IDDM her HbA1c 9 )2 ☆
,referred for albuminurea
I was disappointed from previous station and forget to ask her
if she does attent all foloow up appointment , does she check
??her glucose
)02/2( I scored
 BCC1: psoriatic arthritis has joint pain.. has skin rash )2 ☆
)over elbows and hair line.. I scored ( 28/28
BCC2: 70 year old lady history of loss of consciousness and )2
abnormal movement, had murmur during adulthood for
..which she does not require follow up
My DD : epilepsy and stroke
.. I could not appreciated any abnormality in exam
..I instructed her not to drive for 1 year and to inform DVLA
!!they ask me if I appreciate any murmur.. I answered No
)02/02 ( I scored
Abd: kidney and pancreas transplant , has gum )1 ☆
hyperatrophy and poor vision.. I said the cause is Type 1 DM
.as patient has vitiligo
) 02/02 ( discussion about complication of transplant
Chest: Rt upper lobe lobectomy with deviated trachea )1
discussion about indication of lobectomy and types of lung
) cancer ( 20/20
History: 55 year old male with symptomatic anemia and )0 ☆
.. melena on ibuprofen for knees pain
??His concern: Is it colon cancer
..I told him I ll request upper and lower GI scope
) 02/11( I scored
)170/132( The End Result is PASS
.. It was My first trial
I have never been to UK before .. I had course in Ealing
..Hopsital, London for 2 day ( it is excellent )
 ..Despite the bad beginning .. Still AlHamdullah I passed
..My Advice .. do not be relactant in applying to UK
My English language and accent is not perfect however they
!! consider that
################################
UK Colchester Hospital University-2
STATION 5
A.28 yrs old male admitted with diarrhoea and fever
.37.8.bloody no wt loss no other symptoms
Differential
Investigations
Management
.B 56 yrs old male complains of dryness in his eyes
.Apparent ptosis and miosis
.Lt Horner syndrome
.Left neck scar
What is a cause
How to investigate
.How to treat
?Concern is it reversible
Station 1
Abdomen
Failed kidney transplant
With AV fistula
 .Questions straightward for transplant
Chest:left side pleural effusion and with skin lesions mycosis
.fungoides
What is the diagnosis
?How to investigate
?How to manage
Station 2
yrs old male with gait difficulty.has frequent falls and 11
.difficulty in getting upstairs
Its very difficult case.till I came to the drug history.was
prescribed prochlorperazine for dizziness by his Gp the gait
difficulty came after the medicine.then I went back asking
.about parkinsonism symptoms
All questions
?What are causes of parkinsonism
?Are you going to stop the medicine
?His concern could it be brain tumour
?How do you treat parkinsonism
?Drugs and side effects
Station3
CVS: ms with SBE
?Straight forward question
CNS: examine the lower limbs in the patient with gait
.difficulty
All finding consistent with lower motor neuron.periphral
.neuropathy with features of mytonic dystrophy
 Station4
lady admitted with SLE over night all labs normal except 02
.proteinuria
.Explain diagnosis and obtain consent for renal biopsy
?Concern she is worried about renal biopsy
She refused to do it.except in last 2 minutes when checking
understanding.I reinforce that is very important because
.treatments are different to the stage.then agreed
?Questions whyneed to do biopsy
?Who will do it
?Complications
?Ethical isaues
If refused? I toldI will speak toher again after a while. if
?refused again
I will check competency if competent I have to respect
.decision
?.How to assess competency
######################################
Edinburgh -2
:station 1
andomen: hepatomegaly with? PD catheter - how are they
?related
respiratory: thoracotomy scar plus and chest tube
:station 2
 middle age man with recurrent fits in pt with esrf? no hx
stroke. pt concern unable to take care of himself if he has
epilepsy
:station 3
:cardiovascular
multiple murmurs ?aortic regurgitation with metallic 1st heart
sound. also got thoracotomy scar
neuro: PICA syndrome?/ brainstem syndrome (not really sure
about this one)
:station 4
discuss with pts father regarding bone marrow transplant. pt
(capable of making own decision) refuses but father still
insists
:station 5
optic atrophy. No INO/ RAPD ? -1
oral (i think with oesophageal) candidiasis in RVD refused -0
HAART
My fren sat the exam 1st of march 2016
Good luck 4 ALL

Royal infirmary, Glasgow

June / 2016
History
young female with frequent dizzy spell and blackout, dx was
,hocm
 Family h/o sudden cardiac death at 30
Communication
a man was intubated following anaphylaxis after eating salad,
Now ready to discharge - talk to him
Explaining about anaphylaxis and prevention
Respiratory
bibasal crepitation, d/d ;The man looked cushingoid, so I told
most probably fibrosis
But the creps was slightly coarse, Examiner said most
!probably bronchiectasis, he was not sure either
Cardio
was very difficult, there was mr, but not sure about as, I think
I messed it up, bad station
Neuro
cranial nerve examination of a young boy with slurred speech
I got bilateral palatal pulsy, discussion was about dd, not bad
Abdo
isolated splenomegaly - I think I have done well here,
examiner were happy
station 5
Bcc1- psoriatic arthropathy, but he had short 4th and 5th
metatarsal, I don't know was it important or not, he had back
pain, I said may be spondylitis or secondary arthropathy
Bcc2 - a woman with previous h/o pituitary surgery came with
headache, on fundoscopy there was papilloedema
 Exam haywood hospital
0211/1/1
St 5 ist case
osteogenesis imperfecta command was pt has recurrent
fractures, viva about genetics types etc
nd case0
elderly with arm weakness on exam no weakness only mild
rigidity at wrist diagnosis was parkinson disease (i saw that on
examiner mark sheet otherwise hard as no other features
tremors etc) qs about how to diagnose etc
station 2
young lady joint pains she gives full history about rheumatoid
arthritis at the end when asked about concerns she says yes i
get sun burns and blue hands she has sle most candidates fail
.to diagnose her as she did not volunter this info
Abdomen
.renal transplant with pd scars and gum hypertrophy
CHEST
lady has scleroderma multiple telengectasias scar at back one
side fine crackles other side normal diag was lung transplant
with ild due to sclerosis examiner were more intersted in
,telengectasias and ild
CARDIO
MR and AS examiner wants diffrence between sclerosis and
stenosis and full figures on echo about severity
Neuro
 a man with upper motor neuron signs in upper limb on right
side with strange contractures i said ms or stroke and qs were
.all regarding ms right from macdonald criteria till managment

Yangon center previous Q 2016/1st Diet

Day 1 R 1&2
St 2 - 40 yr old female lung cancer with poor mobility and back
pain
St 3 - Pleural effusion; Parkinson' d/s
St 4 - talk to son, mom Alzeimer, confusion, UTI, no IV line,
concern about confusion
St 5.1 - myotonic dystrophy
St 5.2 - joint pain, thalassemia, splenectomy scar, polyuria
St 1 - COL & RIF scar; CVS - ASD
Day 1 Round 2 Yangon
Station 1 - Chronic liver disease; Dullness at left lung base
Station 2 - known case of Ca lung, previously treated with
radiotherapy last 18 month, C/O back pain
Station 3 - Parkinson's disease
Station 4 - 82 yr lady with Alzheimer's and knee OA, admitted
with confusion and UTI, can't give antibiotic
because of dislodge cannula, talked with angry son
Station 5 - myotonic dystrophy, thalassemia with
Haemochromatosis
Day 1, Round 3
 History - Three episodes of collapse within 8 months in binge
drinker
Communication - Fits occur after giving chlarithromycin in
asthma patient who takes aminophylline for a
long time
Station 1 – COL; COPD
Station 3 - MS with AF; Third nerve palsy
Station 5 - Common paroneal nerve palsy; Headache in
Takayasu
st day 3rd round1
CVS - MR AR
CNS - Ataxia with dissociated sensory loss
Resp - Collapse
Abd - HS with jaundice
H/O - collapse ?ALcohol withdrawal fit
Commu - theophylline toxicity
BCC1- Tarkayasu
BCC2 - Leprosy (Common paroneal nerve palsy )
Day 2, Round 2
Station 4
year old ex. manger with headache for 3 months, blurred 22
vision 2 weeks, with fits 2 days ago. CT scan head revealed
high graded glioma at frontal lobe. His wife worked at aboard
and will come back the next day. Breaking the bad news
Concern: Why he suffer fits? How long will he live? How to tell
?his wife as he planned vacation with his wife
 Station 5
BCC 1. Right Hemiplegia with visual problem - Right
Homonymous Hemianopia
BCC 2. Hand Pain with Acromegaly - Carpel Tunnel Syndrome
Station 1
Resp. Rt upper lobe collapse. (Axilla lymph node biopsy scar
noted)
Abd. Renal Transplant with Hirustism
Station 2
year old lady with bloody diarrhoea and abnormal LFT. 20
.History of travel last 6 months ago to Australia. Wt loss 5 kg
Concern: Is it cancer? Is it managable? I am not complete in
.concern
Station 3
CVS. AS AR
CNS. Facial Palsy with cerebellar and CP angle Tumor.
(Operated)
Day 2 R 1&2
Station 5 - Case 1. homonimus hemianopia, AF. Case 2 CT$ in
ACROMEGALY
.Station 4 - Breaking bad news. Brain tumor
Station 2 - Bloody diarrhoea
Resp - ex. pleural effusion
CVS - AR
Neuro - 7th palsy due to CP angle tumor
 Abd - hepatosplenomegaly, COL
Day 2 R 3
Pleural effusion
Renal abdomen
MVR
CN 3, 4 palsy
History - post partum thyroiditis
Comm - Medical error. Codeine given to a patient who has
allergy. No features of allergy
BCC Gout; Psoriasis
nd day 3rd round another pair0
St1. Hepatosplenomegaly probably thalassaemia
??RUZ collapse
History - the same
St3. Cranial nerve palsy due to MG
MVR, previous MS and pulmonary hypertension
Comm - the same
St5. 5.1. Psoirasis worsen by propranolol for palpitation
Gout worsen by antihypertensive therapy .2.0
nd day 3rd round0
History
postpartum thyroiditis, H/O of palpitation in previous
pregnancy.Now 4 mth after delivery of 2nd baby. palpitation 2
mth. H/O asthma. coffee 3 cups/day. H/O thyroid disease in
sister
 Communication
yr old lady with pneumonia, CURB 3, hyponatraemia, 22
hypoxia, h/o adverse effect on codeine. Daughter told that
allergy to codeine but night MO gave 3 dose of cocodamol.
.Now confuse. Talk to daughter
Concern Why happened? I previously told about this.
Antitode? Why my mom is confused? Can I see the chart for
.reason whether you note down it or not
Day 3 round 1
BCC - Systemic sclerosis
OSA -
Resp - COPD with basal crepts
Abd - COL with bilateral mastectomy scars with RIF scar
Neuro - dysarthria & examine UL - cerebellar sign(+)- MS
CVS - AS AR TR MR? Examiners ask to measure BP
St 2 - Tiredness with ED, with U/L DM & HT
St 4 - Noncardiac chest pain ?Musculoskeletal ? Functional
Day 3 R 1
Lung basal crepts - interstitial lung disease .1
Renal transplant bi fistula
Lethargy & loss libido, DM, HTN (+), gap shaving interval .0
DDx hypopituitarism; autonomic neuropathy
Metalic click I told DVR (but friend said that it is MVR) .3
--- .2
same as Hsu May Oo post --- .2
Day 3 R 3
 History - TIA+young HTN (?pheochromocytoma) -
TIA+headache+palpation+stress
Comm - UC for oral steroid counselling
BCC – 1. SLE + TB; 2. DM with ?Laser scar on fundus
Resp - 1. consolidation?/mass?, 2. pleural effusion
Cvs - MS+Pul HT+CCF+TR
Abd - 1. hepatosplenomegaly, 2. renal transplant
Neuro - 1. Myasthenia, 2.?MND
Day 3 last round
Station 1 - Right sided pleural effusion; Thalassaemia
Station 2 - TIA
Station 3 - MG; Mitral stenosis
Station 4 - Known UC, afraid to take oral steriod bcoz of side
effects, explain management plans of UC
Station 5 - Laser scar; SLE with TB
th day 2nd round2
Stat 1 - pleural effusion, Thalassaemia
Stat 2 - breathlessness in RA pt taking Methotrexate
Stat 3 - Parkinsonism , MS
Stat 4 - oseophageal perforation d/t pneumatic dilatation
Stat 5 - 1. Neurofibromatosis with H/T; 2. Vitilogo with Goiter
D 4 3rd round
History - H/T with protein & RBC on urine
Comm - Anaemia with underlying IHD with taking aspirin and
clop - task further Ix
 BCC – 1. Thyroid eye; 2. Ankylosing Spondylitis
CVS - MS
CNS - Spastic parapresis
Abd - Hepatosplenomegaly (Thalassaemia )
Day 5 R 1&2
Station4 - delay diagnosis of pheochromocytoma
Station2 - chronic headache with menorrhagia
BCC1 - RA with carpal tunnel syndrome BCC2 -hypopit, c/o
fatigue with increase weight
???CVS - double valve replacement with AF
???CNS - syringomyelia
Resp Pl effusion with or without collapse
Abdo - thalassaemia
Day 5 2nd round
History - headache for several months with menorrhgia for
treatment
in detail - tension type HA with medication induced HA.
?concern - cancer
Comm - delayed dx of pheochromocytoma explain - scenario -
missed for 5yr and confirm by urine and CT
concern - cancer? why delay? need to again mood dr and
?surgeon
CVS - AS AR with pul H/T
Resp - i don’t know think Rt upper lobe collapse
Abd - HS with jaundice (Thalassaemia)
 CNS - MND ( bilateral small muscle wasting )
BCC1- RA with CT $; BCC2- hypopit
Day 5 Last round
Station 1 - Resp - effusion & tumor?? Abdo -
??hepatosplenomegaly with CLD
Station 2 - IDA & wt loss, epigastric pain, taken Ibuprofan and
diclo for knee pain
Station 3 - Cerebellar; MS with Pul HT
Station 5 - 1. Cushings; 2. DM with CRVO

EGYPT ,,,,Cairo 8/2

St1 ,hepato+splenectomy,cha(thalasemia)
s.scl .lung fibrosis
St2; known ca prostate, PW:confusion
??St3,ms, ASD
Lt .hemiplegia
St4,young w ESRD for rrt
St5,1.hypothyroid,Cushing
Headache,optic atrophy .0
 ..Maadi exam 2/6/2016 1st carosel
..started with st 4
patient with Parkinson disease the scenario said she was
diagnosed 3 years ago and didn't take medication but it was
not clear so i thought that she was uncompliant to ttt the she
deteriorated and admitted because of uti.. the surrogate was
so nice and her concern was about her mather who is taking
care of her father and what other treatment she can be
given.. the examiner was not that nice!he asked me about
that the pt didn't start medication from the start and why u
told her she was uncompliant? i told him I'm sorry thought
she started and discontinued medication.. then he asked
about other lines of treatmen i said surgery then he asked
what else i said i can't recall.. i think it was not good not bad
!station
..Station 5
st cas was straight forward clear cushing s and complain is 1
uncontrolled BP.. the discussion about DD and investigation
!and asked me why u didn't do visual field.. i said I'm sorry
..nd case.. excessive urination for differential diagnosis0
not DM.. had history of trauma for 3 years ago but surrogate
..didn't gave any details
i said cranial diabetes insipidus and discussion about how to
diagnose diabetes insipidus.. i wasn't good on discussion
.honestly
...Station 1..abdomen
hepatosplenomegaly on a patient with mid sternotomy scar
and heart failure.. i said congestive hepatomegaly or other DD
.like cld as viral hepatitis.. it was a good station
chest.. obstructive lung disease he told me what other dd and
he wanted to hear why not bronchial asthma?.. i don't know
.my assessment for that case although i did good examination
Station 2 history of young patient with repeated chest
infections and diarrhea and on history there was hearing loss,
..weight loss and conjunctivitis
i thought it's a cystic fibrosis case but he wanted to hear
common variable immunu deficiency syndrome.. and i told
him it's a possible dd but when i was going to leave the room..
i did not bad in sloving patient concern but not good also in
!dd and invstigations
..Station 3
Cardiology case.. AVR with aortic stenosis.. valve needs to be
assesed.. discussion was about what would u do if the valve is
?restenosed
..Neurology case
left sided hemiparesis and 7th and 12th nerve palsies on same
side.. she had cerebellar signe on right side.. 1st i said it's a
clear left sided uncrossed hemiparesis with 7th and 12th
nerves palsies.. then she asked me u notice hyporeflexia on
?heplegic side how do explain it
i said it could be shock stage she said no.. i told her she has
cerebellar signs in the form of finger nose dysmetria she told
me show me i showed to her.. i told here the patient has
either MS or double stroke.. then investigation question was
.good
i think overall need Allah mercy to pass and all of people
!prayers
 Egypt
Maadi 1-6 - 2016
:Station 1
COPD with fibrosis
SM with shrunken liver
:Station 3
Double aortic valve disease with questionable MS
MS
:Station 2
Hypercalcemia from bone metastasis
:Station 4
Withdrawal of hemodialysis from terminally ill patient
:Station 5
$ Sheehan
$ Ramsey hunt

EGYPT ,,, Maadi ,,,2-6-2016

:Station 1
HSM with LNs
COPD with bronchiectasis
:Station 2
 Colieac
:Station 3
VSD with dextrocardia
Right sided hemiparesis
:Station 4
Chef had anaphylactic reaction and ventilated and u should
advise him to leave the job ( Indian examiner; very tough)
:Station5
A case of headache~
Mostly subarachnoid hge versus ICH
Thyrotoxicosis~

Egypt
Maadi cairo 31 - 5 - 2016
CVS: AVR and MVR WITH NO abnormality
CNS: MS
Hist: Recurrent pneumonia in young lady who is single and no
travel history or drug abuse
Communication : Giulian bares
ST 5: diabetic and hypertensive retinopathy with very bad,
.heroic old scope
Dermatomyositis
Chest: Lt pneumonectomy with COPD in right side
Abdomen: thalassemia with splenectomy and hepatomegaly
 Egypt - Maadi
0211-2-31
:Neuro
Left sided hemiparesis with normal reflexes
:Cardio
AVR
:Chest
COPD with bronchiectasis
:Abdomen
HM
:Station 2
Painless haematuria mostly APCKD
:Station 4
Refusal of inhaled steroid for asthma
:Station 5
with bleeding per rectum#‎Acromegaly
lesion#‎skin
Vague case may be psoriasis
 .Paces today may 30 , 2016
.University brunei Darussalam
.St 4
Elderly lady with pneumonia , complicated with c.difficile. Son
angry, as junior doctor didnt follow protocol. And what
.treatment, why isolate
St 5
Blurry vision both eye. Visual acuity until waving finger.
.Underlying dm. Had eye operation before
.😂 Funduscopy
.I see black scar at vessels, and pale optic disc
.My mx all dm retinopathy and eye specialist
.My fren said it was Retinitis Pigmentosa
St 5
.Scleroderma with fibrosis, obvious reynauld
St 1 respi
.Lobectomy with joint deformity
St 1 abdomen
.Transplanted right kidney with non functioning fistula
?Why he is abd pain
😂 .I said maybe rejection, he ask what else, I said IBD
St 2
.Breathlessness, went to thailand
.Is said copd, tb, hiv, cancer
St 3 cardio
 .Dual valve metalic. With AF
St 3 neuro
.Unilateral spastic paraparesis. With cerebellar
.I said stroke, alcohol, thyroid, phrnytoin
Examiner ask about rehab . Luckily they didnt ask where is the
.stroke. I just mention cerebellar and post stroke
😂😂..I want to go home and relax. Paces so stressfull

Brunei exam 31/5/2016

ILD:1
chronic renal disease -recent mode of replacement is
haemodialysis
.headache ..cluster headache:0
double valve replacement:3
Rt side hemiparesis
Examine the upper limb
provoked seizure (hyponatraemia) concern can it come :2
? again ? And can I drive
psoriatic arthropathy:2
Vetiligo....present with tirednes; pernicious anaemia
Adrenal insufficiency
 0211/2/32
nd carousel0
Started from station 1
Splenomegaly with normal liver
There is LNs but couldnot complete and discusiion about
..lymphoproliferative
Chest
COPD i couldnot hear bronchectic change said secretion
Discussion about copd asthma and why not asthma how to
differentiate
Ttt of copd
St2
Female with type 1 dm with loss of wt fatigue dizzy spells fh of
hypothyroidism
I did all aspect well and asked about dd inv
St3
Cardio
..Double mitral doumble aourtic with mild tricuspid regurge
.. Asked why he has angina i answered
He didnit want to ask any questions
Neuro
Spastic paraparesis
Diagnosis was primary lateral sclerosis asked me what inv to
,,do i told him it is clinical diagnosis
..What to investigae
 S4
..Idiopathic dilated cardiomyopathy with polypharmacy
Not very well
St5
SOB
Pulmonary Embolism
..DD pneumonia
Wtloss
Thyroid
On carbimazole 80mg and propranolo
Invs
..Can we raise dose i said no
, Options surgical
?Signs of activity

Cairo Exam 29/5/2016

First carousel
Station 1
Chest : acute case with ascitis ...pleural effusion ...COPD ?
Fibrosis ..didn't finish examination
Abdomen : young man with splenomegaly ...felt LN others
? didn't
 Station 2: 45 yr old man with 2 weeks headache and short
memory loss abs concentration also he has right
heminopia..he HTN and hypercolestromia ...heavy smoker
and father has a history of stoke ....DD ( remember while
walking back ) lung cancer metastasis / stroke
Station 3
Cvs : young lady with shortness of breath ....MVR with TR
Neuro: young lady with spastic para paresis with no sensory
affection ...examine lower limb only
Station 4
Relative refuses the discharge of her 84 yr old mother who
was admitted for pneumonia 5 days received antibiotics and
feels better and has capacity and can take care of herself but
tired Explain to the relative
Station 5
yr old lady with menorrhgia since menarche ... Normal 02 .1
platelets ....bruises and history of gum bleeding ... Drug
history : tenaximic acid and vit C. .... I said most likely Von
?willbrand
yr old lady with old recurrent rash ...1 week on the soles 32 .0
and palms ... History : HTN on Beta blockers and takes lithium
for a psychological problem ... None smoker ...mild pain in
fingers not bothering her.... Has lesions on the shins ... Mostly
likely psoriasis exacerbated ( medication )
..... ‫اللهم وفقنا أجمعٌن‬
 EGYPT
Today exam 29/5 Cairo
rd cycle3
Station 1
ABDOMEN: hepatomegaly +splenectomy
No ascites , pallor . Jaundice
Chest Lt pneumonectomy
Station 2
DM complaining of frequent hypoglycemia +diarrhea
Station 3
Neuro spastic paraparesis without sensory level
Cardiology mitral valve replacement
Station 4
HCOM DISCUSS SCREENING
STATION 5
Icthiosis
Benign intracranial hypertension (headache + oral
contraceptive pills)

,,,Cairo Exam 29/5/2016

)Another experience for the same previous cases(
 Started with history taking patient 45 with headache
confusion homonymous hemianopia and short term memory
loss. he is htn and hyper lipidemix and smoker all complains
there for 2 weeks. i put dd of space occupng lesion abscess
and stroke
Cvs i cant finish exam but patient having pSM gng to axilla and
parasternal heave i put MR plus PHTN
CNS spastic paraparesis no sensory level
coominucatn 50 y old lady want to go home decided by
medical team she can go home. but her daughter saying she is
weak and she should stay in hospital
station 5 psoriasis staright forward it was palmoplantar
variant of psoriasis patient had arthralgia also
station 5 15 old lady with menorrhagia woth bruises platelets
normal disaster for me i missed normal platelets given in
scenario exmanier not happy as i put ITP but it was i think von
willebrand
GIT splenomegaly pallor for DD
RESP == it was acute patient with abdominal ascites there was
dull and decreased fremitus at bases it put DD of pleural
effusin Examiner satisfd looking

Exam of LATER dates ,,, 11/3/2016

Myanmar - yangon
March 5tg day 3rd round 11
Respi - upperlobe collapse consolidation .1
Abd - hepato splenomegly +sign of chronic liver insuficiency .0
incl gynecomasia, bilateral parotid
yr old girl HMA, low iron 32 .0
Positive histroy - knee pain, takjnv NSAIDs, abd pain, wt loss,
no family histroy
CVS - MSMR,MS dominant ,AF, pul hypertension .3
b. CNS - young boy - examine gait n proceed - wide base gait, 3
bilateral cerebellee, increase knee jerk, no sensory, CN - intact
Patient wafrin for AF, stroke again, INR -1.2, missed last INR .2
clinic appoinment. Talk to grandson
a.young lady, hypertension, blood sugar high - Cushing2
b. Known DM, impair vision - CRVO2

EGYPT ,,, Cairo Exam 29/5/2016

First carousel
Station 1
Chest : acute case with ascitis ...pleural effusion ...COPD ?
Fibrosis ..didn't finish examination
Abdomen : young man with splenomegaly ...felt LN others
? didn't
Station 2: 45 yr old man with 2 weeks headache and short
memory loss abs concentration also he has right
heminopia..he HTN and hypercolestromia ...heavy smoker
 and father has a history of stoke ....DD ( remember while
walking back ) lung cancer metastasis / stroke
Station 3
Cvs : young lady with shortness of breath ....MVR with TR
Neuro: young lady with spastic para paresis with no sensory
affection ...examine lower limb only
Station 4
Relative refuses the discharge of her 84 yr old mother who
was admitted for pneumonia 5 days received antibiotics and
feels better and has capacity and can take care of herself but
tired Explain to the relative
Station 5
yr old lady with menorrhgia since menarche ... Normal 02 .1
platelets ....bruises and history of gum bleeding ... Drug
history : tenaximic acid and vit C. .... I said most likely Von
?willbrand
yr old lady with old recurrent rash ...1 week on the soles 32 .0
and palms ... History : HTN on Beta blockers and takes lithium
for a psychological problem ... None smoker ...mild pain in
fingers not bothering her.... Has lesions on the shins ... Mostly
likely psoriasis exacerbated ( medication )

Egypt,,,,Kasr Alainy
. .. Paces exam today 28 may. 2016
Station 1_ respiratory
 c.o.p.d with rt basal fibrosis
Abdomen
..Chronic liver disease. ..decompensated
Station 2...female pt 55 yrs with history of loose motion and
abdominal swelling and bloating for 2yrs. .p.H of ca breast
..with mastectomy 5y ago
Station 3..c.vs: ?? mixed mitral valve disease
C.n.s...peripheral neuropathy
Station 4....I.B.S diagnosed by consultant with normal
investigations even the sigmoidoscopy..pt concerns. .he needs
further test and he is afraid of cancer
Station 5 /acromegaly with obstructive sleep apnea
second case pemphigus vulgaris

,Dear all
As this website helped me a lot in dealing with a lot of stress
during my examination period, especially with the experience
of many candidates, I feel I should share some of my own as
well. To begin with I passed my MRCP Paces. And I am very
happy about it because so many things were at stake with this
.exam
Let's begin. Is it my first attempt? No, it's my third one. First
one was like a bad dream. I don't know why I even attempted
because I was least prepared for it. Then, second attempt: I
tried my best. Due to some personal reasons I couldn't
practise with my frens at hospital and I imagined cases at
 home and met all sorts of MRCP cases in my lil room in the
form of pillow. Fortunately, I met a wonderful fren to practise
with over the skype. We practised a lot and felt ready. I even
attended a course, given a good feed back. So, I went for it in
the UK. Well, although, I missed a diagnosis of only one neuro
case which was Right sided hemisensory loss with Carotid
endarterectomy, I thought I would pass but no. I had to have
.another 6-8 months of stress
So, this time I started in my hospital with exam in mind. I
examined most of the cases just like in the exam, everyday.
So, my examination technique improved significantly. For
instance, I could examine thyroid and extrathyroid
manifestations withing 1-2 mins. I tried to communicate just
like in the exam although in reality our traditional practice
differed in many ways. As in my hospital there was none
appearing for this test, I did my best with my eyes on the
prize. Before 4-5 months, I again started practising with my
old fren who unfortunately couldn't pass like me. But
everything happens for a reason. The practise has made me
more confident and more clinical oriented. So, I appeared for
the third time in Kolkata. I took a course there, and I failed
badly in the mock exam in the course. Got a very bad
feedback and felt very disheartened. That was the last thing I
needed before the exam. But my colleagues thought I was
.good enough, so that kept my lil flame alive
The exam day was the most stressful. I couldn't sleep the
whole night. Though I have tried to handle myself as a cool
guy throughout my life, I felt like a fool that night. I asked for
a taxi to drive me to the hospital and we got lost. There were
four hospitals with the same name, and he didn't know
neither did I. He called many people over the phone and
finally we reached there. So, I thanked him for allowing me to
 appear for the exam. He charged me double but I was in no
.mood to argue with this silly man
So, finally my exam started. I was taken to neuro case which
was stroke. Finished my examination before 1 min like in
other stations. I was asked to examine the limbs. Surrogate
was not only annoying but misinterpretating. Clearly the
patient was in pain but surrogate said no. I caused pain to the
patient. So, you can imagine what must have gone through
my mind. Question and answers were easy, which I had
practised hundred times and seen many such cases. So, easy
diagnosis but I know they are not looking only at diagnosis.
.Felt sad but got 20/20
I was taken to cardio station where I was happy to see
Midline sternotomy scar. So, I got the diagnosis and answered
as MVR, but the examiner was asking me questions like what
other treatment the patient is on beside anticoagulation. I
didn't know. He also asked me causes of displaced apex beat,
and I forgot to mention about heart failure or
.cardiomyopathy. So, got screwed. got 13/20, not bad
My weakest skill is communication. Had tried a lot but
strangely failed a lot. Confidence, I lack a lot. It was a simple
TB case where I had to assure her not to travel abroad becoz
she had active TB. I missed many points like HIV, contact
tracing, and so on. The examiner punched me with difficult
MDR TB questions and I almost fainted. Thank God, I survived.
.To my biggest surprise, I got 16/16
Station 5 was easy. Psoriatic arthropathy and stroke in young.
These cases have already been mentioned in this site, so I
don't want to talk about cases but my experience. For the first
time during the exam, I felt good because I was able to
 diagnose both cases and answer properly to the examiners,
.hence I got 24 and 26. Pretty good
As I mentioned previously I was quick with my examination, I
finished before time in both respi and abdo, and gave some
differentials for RA induced ILD, and hepatomegaly with funny
scar(or scare, never seen such in my life). Did badly with the
.examiners in abdo, but got 20 and 19 respectively
Finally, with little energy I was left with, I went to history
station. Some people outside were laughing. That was
probably the second time in my life when I hated people who
were smiling because I found it hard to focus on the task at
hand. Anyway, with fake smile and pseudo confidence I
entered the room. But there was no surrogate. I had wait
another two minutes. By this time my energy had drained and
I think I looked like a Parkinson's patient with mask like facies.
Took history for 15 minutes regarding diarrhoea which I had
practised for at least 20 times with my fren. So, it was easy
.but again with the examiners I was poor. Got 13/20
I thought I would fail after the exam. I told my family and
frens that I might not make it again. When I saw 151/172, I
.was extremely happy and called everyone I knew
My advice: Never ever give up. Keep on practising, and a time
will come, as my fren told me - "You will pass even if you
".appear the exam in a drunk state
.Thank you all for taking time to read my experience
.God bless you

,,, Exam of LATER dates

 EGYPT,,, Exam Experience
Almaadi military hospital 9/2/2016
: Station 3
:Neuro
:Findings
Spastic paraparesis+PN with stocking distribution (Rt leg)+
.sensory level on left side for DD
:Questions
DD: MS, spinocerebellar degeneration, SCD
.Investigations: spinal & brain MRI, CSF findings
Treatment:acute, chronic, pharmacologic &
nonpharmacologic
:Cardio
:Findings
.AVR & MVR
:Questions
findings, functioning valve or not, HF, IE
Investigations:routine, ECG, echo, INR
.indications for AVR in AS
?what symptomatic AS means
.Treatment: nonpharmacologic and pharmacologic
:Station 4
Elderly lady admitted to the hospital with confusion and UTI,
can’t give her the AB as she keeps pulling the IV cannula out,
 comorbidities are Alzheimer’s, knee OA, frequent admission
.to the hospital in the last few month
Task: talk to her daughter (angry), who is asking about an
.update
:I think this scenario is looking for the following
dealing with an angry relative.who also was tearing , offered
): her tissue that was on the table
Explain the need for a PICC line,draw what you are going to do
.and consent
Sort out the other comorbidities and any risks at home (stove,
shower, lost her way before, driving, the need for an
occupational and social workers and visiting nurse after
discharge)
the daughter kept saying that she wants to continue taking
care of her mom,and no way she will send her to a nursing
.home. you have to appreciate that
The daughter wants a brain CT done, because she is
confused(it must be her brain, doctor. Why you didn’t
perform at CT, you are not giving her the appropriate care)
Be patient and try to explain that it is a problem with the
.chemistry of the blood not an actual brain problems
:Concern
Why my mom is not improving after few days from
?admission
?When she wil go home
:Questions
Ethical issues in the scenario (Beneficence and
.nonmaleficence), dealing with an angry relative
 Why you didn’t do a CT as her daughter wanted (there is no
focal neurological deficits that warrant doing a CT, also there
is an explanation for her confusion), not sure if this is the
.good answer, I Would like to hear your comments
.Long term prognosis of the patient
.what do you want to offer her
What about sedation (I said it may worsen her condition, but I
heard after the exam about chemical and physical restrains), I
.leave that for the experts
:Station 5
(Ramsay Hunt $) Facial nerve LMNL (very clear) with history -1
.of ear rash few days before
Questions about DD: all causes of LMNL facial lesions (CP
angle tumours, parotid or face surgery, auditory canal
(cholesteatoma, abscess),also UMNL facial (he didn't like it,
),wanted the LMNL
Treatment(steroids, acyclovir, stomach and eye protection,
physiotherapy)
?Concern: could this be cured, how long it takes
Hypothyroidism (difficult case) -0
Presentation (fatigue , weight gain, menorrhagia, no
skin,voice or hair changes, on a treatment, she doesn’t know
the name, which turned out to be thyroxin, started a year
after a surgery in the neck (thyroidectomy))
.Examination: fine tremors, no eye signs , thyroidectomy scar
Questions about investigations, what is the single test you
want to do (TSH)
 what is the most probable cause of her thyroid problem
(Graves’s?, I am not sure if that is right, there is no eye, hand
or leg signs)
.Concern : what is the cause of the fatigue
Station 1(terrible examiners and difficult patients)
Chest: Rt upper lobectomy + obstructive lung disease+
)deviated trachea to the Rt side & left basal fibrosis
Questions: findings, he asked if the fibrosis is diffuse, I said I
couldn’t appreciate that, investigations (HRCT,sputum
C&S,PFT findings)
Treatment (nonpharmacologic and pharmacologic)
Abdomen: Very obese patient with HSM, pallor, pigmented
striae, no LNS
Questions:findings, one diagnosis only (didn’t want to hear
DD), I said Lymphoproliferative, asked about blood film
findings and other investigations, and treatment of
(: )lymphoma
:Station 2
Patient with macular rash over chest , neck back and
sometimes arms, started as vesicles that rupture after that,no
change with
sun exposure, on doxycycline for acne,no other autoimmune
disease) for DD
examiner asked about DD(they wanted photosensitivity in the
first place, he said if you pressed on him more he will say it it
increases with sun exposure, but I asked about that clearly
and about travel history to Hurghada and after spending
sometime on the beach, he denied any change in the rash)
 Other questions about investigations and ttt
....Concern: will it leave a scar, I said yes

-: Dubia ,,,, May 2016, first day , third cycle

Neuro LMNL , not sure
.MND , all sensations are normal
,CVS: systolic murmur
S1 normal, S2 accentuated so VSD vs Tricup Regurg & P.htn
Chest: pleural effusion
.With midsterontomy scar , harvesting scar rt leg & LL edema
Abdomin Kidney transplant, functioning well & AV fistula
.functioning & no recent puncture
Bcc1 : DVT with h/o travel to India , Indian female , FH of leg
.clot both mother and sister & also on OCP
Bcc2: Indian lady middle age with h/o MI 3 weeks ago &
present now with chest pain increase with deep breathing,
. Dresslor syndrome, diff pericarditis, myocarditis, pleurisy
Medication post MI ACE inhibitors, statin , clopidogrel , aspn&
.b blocker
:History
middle age male , with HTN & recent hematuria
.POlycystKD( same case in Dr Zain ) adopted ) typical case
:Communications
 Lady middle age with h/o asthma & steroid phobia becz she
.used inh steriod and her voice changed & jobe is singer

Dubai 17/5
Cardio
Prosthetic mitral valve it was clear case
Neuro spastic paraparesis without sendory level
I told DD MS .parasagital meningioma.sarcoidosis he got very
angry when i told sarcoidosis any how i continued for
investigation and managment on the right way
History taking
Patient has henoptysis .nasal block .ear block.joint pain
.hematuria and night fever and sweats .he lost 3 kg in 6 weeks
i told DD vasculitis wegner granulomatosis .r/o TB she asked
about radiological finding in wegner and managment it was
not bad
Communication case was the worst
The patient is known case of rheumatoid on methotrexate he
recently has UTI for which the Gp prescribed trimethoprim
then he developed nasal bleeding
Your role to discuss with the patient the plan to stop
methotrexate to control pancytopnia from erroronous use of
trimethoprim with methotrexate
He asked silly question
What is percentage of pancytopnia if used trimethoprim with
methotrexate
Is it absolute contraindication
He did not ask many about the ethics but he seems not happy
with my answers
I expect 4/16 in this case
Chest case was clear COPD WITH LOCALISED FIBROSIS
Abdomen jaundice anemia heoatospleenomegally -------
Thalassemia
Then she asked if not hemolytic anemia what it could be
The spleen was hugly enlarged so i told malaria .leishmania
.lymphoproliferative .i think i did well in this case
Station 5 35 years old with typical chest pain lady Smoker
Dyslipidemic with strong family h/o IHD
Brother and father on 50 age
I told admission as acute coronary syndrome
He asked if normal ecg and labs repeated over 24 hour what u
will do
I told send for stress echo or treadmell
Case 2 59 years lady with back pain since 3 days
After trauma
?????She is known case of artheritis
On prednisolone .methotrexate
For ladt 15 years
 I examined the hand there was nodule on distal
interphalangeal joint .wasted hand muscles some deformities
i did not recognize then i examined the back
He asked about hand signs and underlying disease i told
psoriatic arthropathy but it was z defirmity of rheumatoid
However DD was right osteoporosis .r/o fracture
I wishb good luck for you all

Exam experience in Dubai 16/5/2016

station 5
yrs old man with dryness of his eye he has exopthalmous 07
with neck swelling diagnosed as hyper thyroid on ttt with
carbimazole and propranolol his concern was what is the
cause of his bulging eye as people are commenting on this
yrs old woman with pain and swelling of both hands family 22
history of RA she is a secretary and on examination she has
swelling of DIP with no signs of active synovitis and fair
functional status she has also knee pain and no skin rash her
concern what is the cause of this pain and swelling could it be
RA and any treatment she can't cope with her work
Then respiratory
middle age Lady with audible wheeze and on examination
vesicular breathing with prolonged expiration most -COPD
Abdomen
hepatomegaly with palmar erythema two scars on the
abdomen one on the middle longitudinal and the other is
 transverse on rt lumbar region when icommented about the
scar the examinar told leave it
History 50 yrs lady with cough and breathing difficulty
diagnosed 6months back as having breast cancer now on
tamoxifen on history no wight loss or night sweets she has dry
cough with dyspnea and paroxysmal nocturnal dyspnea ll
oedema no travel history not on ocps husband died in
accident and on son will be graduated next year she is apart
time teacher not smoker not alcoholic and was concerned
about that she may has cancer and financial issues
Neuro
claw hand wasting of hypothenar and weakness in ulnar
distribution no scar at wrist or elbow no time for testing
sensation
Cardio
mitral and aortic valve replacement with pan systolic murmur
radiating to axilla in ayoung lady examinar asked about target
for INR and what other investigation and what about if she is
planning for pregnancy
Communication 50 yrs old male dealing with pigeon in his
business with braethlessness and cough CT chest high
resolution with allergy test to avian ptn highly positive so
diagnosis of interstitial lung disease was done and the task
was to tell him about that and to tell that he should avoid
contact with pigeon and to start corticosteroid for ttt

Myanmar ,,,Yangon
 thday 2nd round2( 11/.3/.12
)
Stat 1 - pleural effusion, Thalassaemia
Stat 2 - breathlessness in RA pt taking Methotrexate
Stat 3 - Parkinsonism , MS
Stat 4 - oseophageal perforation d/t pneumatic dilatation
Stat 5 - Neurofibromatosis with H/T
Vitiligo with Goiter

My experiences in old Yangon General Hospital, Day 4,

10.3.2016
diet1/2016
Station1
Lt Collapse Consolidation / fibrocavitory lesion
Etio TB Malignancy
Forgot to examine axillary LN
Luckily 20/20
Renal transplant AVF
DDx mass in RIF
02/02
Station2
Middle age female wheezing SOB increase in early morning ,
,night time cough, episodic
 no sputum no blood, no palpitation,no leg oedema,no
syncope
H/o RA took methotrexate 7.5mg for 6 yrs
Salbutamol inhaler, steroid inhaler, rosedronate, folic acid
DDx bronchiolitis obliterans
Lung fibrosis d/t methotrexate, RA
Pulmonary nodule
Bronchial asthma
Patient concern is it associated with drugs
Examiner asked about severity assessment, monitoring and
management of Bronchial Asthma
02/02
Station3
Middle age gentleman with difficulty in holding objects
O/E resting tremor
Bradykinesia
Rigidity ?
Dx Parkinson d/s
ddx ET
02/12
Middle age female
MS AF Pulmonary HT
02/12
Station4
yr achalasia doing oesophageal dilatation resulting 72
perforation
Previous 2 times ok
risk signed in document%2
Talk with anxious daughter
Is it Serious
Can discharge now
Want to discharge and transfer to other hospital
Further mgt
Why this happen
How to feed him
How long need to stay in hospital
She didn't want to tell him about perforation
Ethical principle
11 /11
Station5
BCC2
Skin rash with goiter in middle age female
Vitiligo+goiter m/b euthyroid
Sugar normal
No postural drop
Is it curable
Can her daughter get this
02/07
 BCC1
Skin lesion with painful in gentleman
Neurofibromatosis
Is it cancer
Can his son get this
How treatment
02/11
Fortunately I have passed
This was my 2nd time
Thank you all my parents, teachers, and study partners
Fighting and best of luck! all the candidates in the coming
diets for PACES

Oman Med J on 13/10

I started with station 5
Case 1 paget disease
.Patient with high alkaline phosphate and hearing difficulty
Paient on examination large skull typical paget disease face
have hearing aid. His main cincern was decrease hearing . Legs
were normal in examination and he did good walk . I asked
examiner that i want tunning fork to examine rennie &
webers test then one examiner give me fork from his picket :)
he deliberately hiding it from candidate to see that he asked
. for it or not
I got 28/28
Case 2 TIA with high BP RIGHT SIDED WEAKNESS AND
.DYSARTHRIA AFTER 30 MIN
BP 169/100. FEELS IMPROVED
This was simple case his ABCD2 score was high i explained him
his condition and needs of admission 28/28
Staion 1
Resp . Bronchiactasis young male . Examiner askwd me causes
of bronchiactasis in yiung patient . Then later he start viva on
immitile cilia . He asked about cilia structure thanks God that i
recalled my MBBS final tear knowledge . I told him that on
transverse section cilia is look like wheel spoke and main
defect is in demin arm where LACK of ATPase enzymes which
is nessesary fir cilia to mobile . Then he asked me how many
spokes came out from cillia which i dont know and he told me
9 i got 18/20
Abdomen . Thelesemia with tender hepatomegaly and has
splenectomy . Sec hemachromatosis as pigmented skin
Examiner asked me causes if hemachromatosis . I did nt do
well in this station missed hyperpigmentation as pt dark skin .
He had multiple abd. Scar i thought it was chron's but then
examiner give me some clue which lead me to go with correct
diagnosis 10/20
Station 2
year old female return from kenyia after spending holidays 32
started bloody diarrhea , abdomunal pain and wt loss 3 kg 1
week history . Family hx of crohn dis ( uncle )
Conern was what happen to me
02/12
Station 3 cvs MVR
Examiner asked me indication of mitral valve rep. It was
simple case i did well 20/20
Cns muscular dystrophy
Vs motor neuropathy
This was difficult case i asked pat to walk but examiner nit
allowed me to do this on examination hypireflexia hyoitonia
generalized reduced power almost 2-3/5 sensory all intact . I
told my finding and put my DD . 17/20
Station 4 young female admitted with rt. Sided weakness all
investigation normal seen by neurologist and he say its
functional . Patient known via nurse that doc. Saying its like
. this so pt. angry now . Talk to her
I explained her problem and apologuzed for that incidence .
Alsi discussed her lufe which was full of problem she is
unmarried only earning person at home unable to pay house
bills as earning nit enough . Brother addicted nit doing any
thing . She has problem at work as nurse her duty 12 hours
and she tired to do these duties . Lit of issues . I tried my best
to arranged and solve her all issues. Concern what happen to
me . What action you will take against that doctor who told
that i am lying
11/11
Alhamdolilah i passed 149/172
 Oman 11 April
I started with communication skills 29 yrs university engeneer
with ulcerative colotis on mesalazine with no improvement 6
motions per day anemia with high ESR to be started on
steroids he is refusing bc of SE as he read on
internet
Station 5 1st case 30 yrs acromegaly with bitemporal
hemianopia
nd pt with headache and blurring of vision diagnosis from hx 0
myathenia gravis
St1 chest bronchectasis
Abdomen renal tp with palpabe liver asked for single
diagnosis she has cushingoid feathers
St2 hx of patient with headache stress at work friend
diagnosed with brain tumor
St 3 cvs double valve replacement quite difficult the metallic
noise is not heard without the stethoscope I am not sure
about
Neurology as well hypotonia hyporeflxia nd depressed
sensation up to the umblicus they discussed Causes of LMNL
paraparese also I am not sure about
Plz pray for me and thank you all
 Uk ,,,, Colchester Hospital
STATION 5
A.28 yrs old male admitted with diarrhoea and fever
.37.8.bloody no wt loss no other symptoms
Differential
Investigations
Management
.B 56 yrs old male complains of dryness in his eyes
.Apparent ptosis and miosis
.Lt Horner syndrome
.Left neck scar
What is a cause
How to investigate
.How to treat
?Concern is it reversible
Station 1
Abdomen
Failed kidney transplant
With AV fistula
.Questions straightward for transplant
Chest:left side pleural effusion and with skin lesions mycosis
.fungoides
What is the diagnosis
?How to investigate
?How to manage
Station 2
yrs old male with gait difficulty.has frequent falls and 11
.difficulty in getting upstairs
Its very difficult case.till I came to the drug history.was
prescribed prochlorperazine for dizziness by his Gp the gait
difficulty came after the medicine.then I went back asking
.about parkinsonism symptoms
All questions
?What are causes of parkinsonism
?Are you going to stop the medicine
?His concern could it be brain tumour
?How do you treat parkinsonism
?Drugs and side effects
Station3
CVS: ms with SBE
?Straight forward question
CNS: examine the lower limbs in the patient with gait
.difficulty
All finding consistent with lower motor neuron.periphral
.neuropathy with features of mytonic dystrophy
Station4
lady admitted with SLE over night all labs normal except 02
.proteinuria
.Explain diagnosis and obtain consent for renal biopsy
?Concern she is worried about renal biopsy
She refused to do it.except in last 2 minutes when checking
understanding.I reinforce that is very important because
.treatments are different to the stage.then agreed
?Questions whyneed to do biopsy
?Who will do it
?Complications
?Ethical isaues
If refused? I toldI will speak toher again after a while. if
?refused again
I will check competency if competent I have to respect
.decision
?.How to assess competency

,,,, Copied
PACES experience: was in the last day last cycle 4/4/2016 in
.Khartoum center
:Communication Skills ■
I started with station 4 the scenario about a patient who have
achalasia and underwent a pneumatic dilatation for the 3rd
.time but in this one he developed eosophageal perforation
It was mentioned that this complication can happen in 5% of
.pts and the patient was consented
You will meet his son to explain for him what has happened
and the need for admission for 14 days and any issue raised
.by him
I started by the usual introduction and then checked what he
knows about his father condition then i explained for him
.what happened in BBN pattern
He asked why this happen to his father this time he has done
this procedure twice before.I explained for him that any
procedure has a possibility of bad effects and it happens in a
few patients; in every 100 it happens in 5 patients and no one
.can predict which one will be affected
He said do my father know this? i said any procedure will not
be done unless we explain for pt the benefit and risk of it and
let him to decide which is called consent and your father was
.informed
I told him that we need to keep your father in hospital for 2
weeks but he refused. I asked why but his answer was not
clear for me but i proceed and explained to him that this cut
or perforation of his gullet will cause leak of food and fluid to
his chest and lungs and this will cause damage and
inflammation so that we need to give fluid by his veins and
medicines called antibiotics and we need to involve our
.colleagues in surgery
Also i told him if he went home he may develop complications
and deteriorate more and i am sorry to tell you that he may
die . After this he agreed to admit his father but he wants me
not to tell his father i replied to him this the right of your
.father to know about his condition
Then he kept silent and i asked him do you have any other
concern? he said no and still there is a time and i wonder how
to fill this time but fortunately while i am thinking the
examiner told 2 minutes left i summarized for him and
.checked his understanding and thanked him
?Ex: what are ethical issues
Me: BBN,dealing with angry relative(realy he wasn't), doing
.no harm and autonomy
Ex: the son don't want his father to know what do you think
?about this
Me: i think this the right of his father to know to ensure
.ethical issue of autonomy
?Ex: any other principle
Me: i think we have to be honest and tell exactly what has
.happened
?Ex: how are you going to manage him
Me: monitoring
NPO
IV fluids
IV antibiotics
surgical consultation
?Ex: why you need to keep him NPO
Me: so no more food or fluid to get to mediastinum causing
.mediastinitis and allow time for healing
 ?Ex: what do you think the surgeon will do
Me: the management may be conservative or surgical but i
.am not sure of indication of surgery
.then the bell rang
Station 5 ■
BBC 1:
young lady with deterioration of her vision in last 8 months
.her vitals were ok
I started by open question then i analysed the visual loss
which was mainly at night and there was no eye pain or
headache and the course was progressive and not episodic
then immediately i asked about family history which was
positive her elder brother is blind
I proceed immediately to fundal examination to confirm my
diagnosis and i found scattered dark pigmentation which was
clear in the rt eye also i couldn't appreciate the disc clearly
after i finished fundal examination i remembered that i didn't
assess her visual acuity i did it & was normal for finger
.counting
i returned back to the history and i asked about associations
of retinitis pigmentosa and other routine parts of history
and i asked about driving
.which she is not
then i examined again for hearing aids and weakness only bcz
i thougt other associations were excluded by history
then i asked about her concern? is she going to be blind? and
? what about job
.she was a teacher
 i told un fortuanately this is a progressive disease and till
now there no curative treatment but research are ongoing
and for her job she can continue as far as her vision can allow
.we can give some visual aids
the examiner asked about my diagnosis and the associations
.of RP
also what other areas you want to examine i said cerebellar
and peripheral neuropathy he said do u want to examine her
fingers i said yes for polydactyly.then do you need to examine
her visual field i kept silent he said what do you expect to find
.i said tunnel vision
.then he took me the next pt
Station 5:
BBC 2:
A 28 years old male with skin lesions for several years which
.are non-pruritic not painful and I expected it to be vitiligo
i started by asking its onset duration progression distribution
any starting lesion any aggravating or relieving factors and
involvement of mucous membranes which were all negative
then i request to have a look. The lesions were raised small
yellow nodules on flexural part of the elbows
there was also another large one on his lateral epicondyles
and also in his back & eyelids and when i came closer to his
.eye i saw corneal arcus
it was clear this pt has xanthomas secondary to
hyperlipidemia then i asked about his FH which was positive
for sudden young death i asked specificly about cholestrol
problem he said no. then i asked about macrovascular
complications and the secondary causes of hyperlipidemia (
 DM,Renal diseases,hypothyroidism,alcohol and primary
biliary cirrhosis) i asked about smoking and job
.then i examined his CVS which revealed AS
Lastly i asked about his concern which was is he going to die
?suddenly like his family members
I told him that these skin lesions are manifestation of high
cholesrol in his blood and this something run in family and
this high cholestrol harm your blood vessels and this can
cause heart attack and sudden death. We need to do more
blood tests and we will give you medicine to lower your
.cholestrol
Examiner asked me about my diagnosis what tests you need
.to do and how to manage him
Station 1 ■
Chest:
The pt was comfortable, peripheral examination was normal,
Trachea was deviated to the rt and rt side was depressed and
moving less the percussion wad heterogenous(dull+resonant)
auscultation there was fine end inspiratory crackles bilaterally
.but more on the right in upper zones
I presented my findings and said pt has bilateral apical fibrosis
mainly on the rt. Ex asked me about causes i said most likely
.TB +other causes of bilateral apical fibrosis
.What investigations and management
Abdomen
A female patient with finger clubbing and functioning fistula +
.gingival hypertrophy
.At this point i was expecting a renal transplant
On abdominal examination there was no renal transplant scar
there was huge hepatomegally about 14 cm bcm and
.splenomegally 4 cm
.Others normal
I presented my findings and i said the has
.hepatosplenomegaly and ESRD
?Ex: how to correlate them
Me : hepatitis on top of renal failure
?Ex(not convinced):what else
Me: amyloidosis
Ex: what else
Then i remebered the gingival hypertrophy and said
leukaemia by infiltrating the kidneys although it is rare then
the examimer seems to be convinced and asked me about
.investigations and management
Station 2 History ■
This was a difficult scenario of a young female feeling fatigue
for 2 months she went to her GP who found high BP and have
done some tests which revealed proteinuria and haematuria
.and normal RFT
I put differential of
CKD(stage 2 normal rft)
GN due to wegner's or goodpasture or post streptococcal or
IgA nephropathy
Polycystic kidney disease
Lupus nephritis
 When i entered i analysed her fatigue and high BP then i
started by renal system then enquired about cvs/resp
including haemoptysis then i asked about URT features sore
throat nasal congestion epistaxis hearing lmpairment then i
asked about musculoskeletal skin rash joint pain
All the above was negative
then i started to complete the other systems GIT and
neurology and i found that pt has loss of appetite and non-
specific headache then i asked about constitutional symptoms
.which revealed loss of wt
All
other parts of history were negative except she was taking
.OCP for menorrhagia for several years
When the ex told me 2 minutes left i have no idea what is
?diagnosis
I asked the pt about her concern she said could OCP be the
cause and i am planning to start a family does your treatment
?affect my future pregnancy
I told her i need to do more test to determine the cause of her
condion and it is unlikely for OCP to cause high BP and the
treament for your condition will depend on the cause and
there are different treatment some of them may affect your
pregnancy
.and others will not
?Then examiner asked me what is your DD
I told him about the one above
He asked me why you asked about nasal blockage i said bcz i
think of wegner's he said to me you mean vasculitis as general
i said yes but there is no skin rash or joint pain he asked me
could the high Bp be the cause of her headache i said yes if it
is malignant
he asked me how to know
i said i need to do fundal examination he said if it is normal i
said it is unlikely to be the cause of headache
he asked me what is the commonest presantation of HTN i
replied asymptomatic
?Ex: investigations
Me:CBC
Ex:what specific in CBC
Me: eosinophilia
Ex:why
Me:churg-strauss syndrome
Ex:how to manage vasculitis
Me:methylprednisolone and cyclophosphamide
Ex:is this may affect her pregnancy
Me: yes the cyclophosphamide
Ex:other anti-htn can affect pregnancy
Me: ACEI
Ex: other causes of htn
Me: endorinological like pheochromocytoma,
.....hyperparathyroidism
the bell rang
Station 3 ■
CVS:
 The pt was young all peripheral examination was normal.
Precordial examination was normal except in auscultation
there was systolic murmur allover and radiating to carotids
also there was early diastolic murmur on lt sternal edge so my
diagnosis was mixed aortic valve disease and no one is
dominant
.the examiner asked inv and management
Neurology:
The instruction was to examine the lower limbs it was
apparent that the pt has spastic paraparesis with sensory
level just below umbilicus the time finished before i examine
the back i told him i want to examine the back
.The asked about clinical diagnosis DD inv and management

Castle Hill Hospital..March 19

Station 2..chronic cough for 6 months in 25 years old male +
DM type 2+Hx of uncontroled asthms+infertilty+constipation
Station 3 cvs..marafan with 2 scars and AVR discussion about
causes of chest pain in Marfan
Cns hemiplegia due to truma
PEGTube insertion in agressive agitated Alzehimer pt used ..2
to pull NG tube
doughter want PEG tube insertion tell her it is not suitable + ..
discuess palliative care in terminal ill pt....how are you going
to feed patient
 morphea ..what is the causes of morphea.?.is it cancer??..2
..Lady with fatiguabilty and blurring of vision
Thyroid nodule +thyroidectomy scar +opthalmplegia and
exopthalmous
Station 1 .bilatral basal fibrosis +skin rash ??dermatomyositis
Abdomen..plycystic kidney +transplanted kidney + abdominal
pain
Discussion about causes of abdominal pain and immune
suppresion side effects

I am happy to say that I have passed. I took the examin in

.Castle Hill Hospital Cottingham 20th March 2016
Station 1: Respiratory; Middle aged, obese woman with fine
inspiratory crepitations more at the lung bases. I reported
that they were all over the chest as I thought so. I was asked
about differential diagnosis, investigations and what I expect
to see on HRCT and treatment. I got 11/20. Abdomen; Young
man with right hypochondrial tenderness only. Differentials
included hepatitis, cholecystitis etc. I was asked if I would
discharge him if transaminases were mildly elevated, I said
.no. I got 19/20
Station 2: A 55 year old woman with a 4-week history of
weight loss, night sweats and joint pains. If you ask only you
will get a history of a tooth extraction 2 weeks before onset of
symptoms (History which I did not get). I said Rheumatoid
arthritis, lymphoma and vasculitis. Diagnosis was Subacute
.Bacterial Endocarditis. I got 10/20
 Station 3: CVS; middle aged woman with kyphoscoliosis, high
arched palate and pes cavus. Had AVR, no murmurs. I
reported as AVR in Marfan's. No murmurs. I got 20/20.
Neurology: LL exam. Also a middle aged woman with wide-
based, high-steppage gait. Had champagne bottle sign, pes
cavus, distal muscle weakness and stocking distribution of loss
of pin prick sensation. I picked an upgoing plantar on the
right, and for some obscure reason her joint position was
intact. Differentials were CMT and other peripheral
.neuropathies. I got 20/20
Station 4: My worst station and I really messed it up. I was
worried about my neuro case that I thought did not make any
sense, I thought it was a total disaster so I did not concentrate
and fully comprehend the message I was supposed to give the
patient's relative. It was about a young man with metastatic
colonic cancer, who had massive UGB from duodenal cancer.
The team has planned arterial embolization for him but his
brother (whom I was to talk to) thought I should just let him
die. Meanwhile the patient himself wanted surgery and
lifesaving treatment. Up until now, I am not clear about what
.I was supposed to say to him. I got 4/16
Station 5: BCC1; Ankylosing spondylitis. Staightforward –
question mark sign, fletcher's sign etc. Asked about
investigation and treatment. I got 26/28. BCC2; Known
diabetic with blurring of vision. Fundoscopy showed
cottonwood spots and laser scars. I talked of a non-urgent
ophthalmology consult and tightening blood sugar control to
the patient. I was asked about screening for nephropathy and
neuropathy. I was asked if I saw hemorrhages and I said no. I
.got 26/28
Total 136/172
 My exam experience
0211/2/0
Mater di hospital
Abdomen : splenomegaly with ascites for diffrential diagnosis
Questions : DD, IX
Chest : left thoracotomy scar , aggressive shift of trachea to
. the left side, air entry is diminished only left basal
I told the examiner : this shifting of trachea is going with
pneumonectomy but the air entry is diminished only in left
. basal which might be lower lobectomy
Questions : indication of pneumenectomy , he asked in this
patient what do u think the cause ? I said may be cancer or
suppurative lung disease because of clubbing .. He said tell me
only one possibility and why ? I said cancer as the patient was
cachectic and elderly , he asked about PFT in this case : I told
him mixed as the patient might have compensatory
hyperinflation also .. I got 19
Cardio: double mitral and aortic regurge
Questions : indication of operation , echo findings
Neuron: examine upper limb
Short stature man with right upper limb deformity ,
examination of upper limb revealed some weakness in right
side , I examined lower limb showed spastic legs more in the
 right side ...at that time I had a mental block ..I considered
that the patient has hemiparesis and I told him the diffrential
diagnosis of that including stroke , he asked me about the
treatment which I answered ( stroke treatment )
I got full mark
History ; good case
younge male with family history of cardiac diseases presented
.with palpitation
Inside : father and mother died in their 70th due to heart
attack , history revealed only work stress and excessive
. caffeine intake , other possibilities I ruled out
So my impression : was HOCM is less likely , mostly it is stress
related tachycardia
Communication
female , family history of cancer colon , presented with 22
cont diarrhea for the last 2 months , she is worried about
cancer colon , task is to address her concerns
Initially I took a quick history which showed no any alarming
signs of cancer , father and brother and uncle have cancer
colon , the diarrhea mostly was due to irritable bowel
syndrome , so I assured her and I asked her about
colonoscopy before , she told me she had normal colonoscopy
8 months ago , so my message to her : cancer colon is less
likely but in presence of continues diarrhea and strong family
history repeating the clonoscopy after consulting a MDT will
be advisable ...which seemed to be wrong as the examiner
was unhappy and asked me do you think that polyps will be
formed over 8 months only ?? I told him may be , he told ..no
it needs at least one year .. So no need to another clonoscopy
 , then he asked me why you did not inform her about the
screening programme of cancer colon ?9/16
Station 5
joint pain in younge female )1
Inside psoriatic arthropathy ( asymmetrical in the most of the
joints with psoriasis rash in the elbow)
I requested to examine the lungs for possible fibrosis but he ,
told no need , I requested to examine the eye he told ok ..she
has red eyes bilaterally ( ? Uveitis) th examiner was very
happy about that
Questions : patterns of psoriatic arthropathy
Treatment
repeated chest infection in old man )0
Inside : old man , with cough, sputum , clubbing , chest
infection recurrent since childhood , I auscultation the back
D.D : bronchiactasis , he said what else could be ? I said cystic
fibrosis , he said what is the first possibility I said
, bronchiactasis again☺ , questions : causes
CT findings , treatment
Alhamdlellah I passed
My advise : extensive clinical practice , do not waste your time
in big books , cases of paces is enough for clinical stations ,
. you should have your approach for any medical complain
I would like to thank Dr Ahmed Ahmed Maher Eliwa for his
great efforts with me in history and communication before
the exam ...really I appreciated that unlimited support from
Dr. Ahmed
 Thanks
Wish you all of the best

Wolverhampton,, UK,, new cross hospital,, 12

February 2016
history, collapse,, patient on thiazide & started candisartan -1
two weeks back / Cardio, instruction pt is asymptomatic but
referred by his GP,, I heard ejection systolic murmur,,
discussion about aortic stenosis & sclerosis / neuro examine
cranial nerves,, only abnormality is diplobia on looking
outward and upward on both sides // communication,, pt
with essential tremor, carpenter diagnosed 3 years by
consultant, now concerns about Parkinsonism referred by GP
for deep Brian stimulation
station 5,,, fever in 27 year lady,, by history she had ,,
lymphoma before,,, second case diarrhea,, I noticed deformed
nose,, finally its wegners plus diarrhea after augmentin course
for sinusitis abdomin,, HSM,, NO stigmata,, plethoric. Copied

My Experience in Mater Dei Hospital Malta on 2/4/16 first

carousel
 I started with station 1
Chest : young patient with spares head hair( I Said possibly 2
to chemo later on upon discussion and actually I picked it up
as I used to see this finding a lot in my practice in oncology)
,RT side of the chest is depressed and moving less, RT
thoracotomy scar and decreased chest expansion, impaired
percussion and dec breath sounds
Diagnosis: RT pneumonectomy
DD of etiology was bronchiactssis, fibrosis,Abcess and
,malignancy
Discussion was about cancer causes in young patient (germ
cell, and Sarcoma )and workup also asked if he developed SOB
what might be the cause , I mentioned infection and
thrombosis
?How to investigate him
I got 20
Abd : middle aged male with features of CLD ( D contracture,
P erythema,thenar wasting and Tinge of jaundice) and
splenomegaly I said no asites
DD and work up
Honesty I felt that I missed hepatomegaly
I got 16
Hx: 50 years female , married , work as hospice nurse,
travelled to Kenya with her husband and came back with
nausea,vomiting, fever and upper and pain radiating to back
Heavy alcohol intake
Had 3 miscarriages at Gestational ages of 26,28,28 no
personal or Fx history of VTE
 Gp letter mentioned high bilirbin 70 and high all Liver
enzymes
? Concerned is it cancer
DD : I mentioned Alcoholic hepatitis, viral hepatitis(A) and
dengue,autoimmune hep, and malignancy
discussion was about working her up , and how to manage, I
mentioned that she needs admission, clinical assessment and
rehydration if dehydrated,pain control and fever ttt with
NSAID and avoidance of acetaminophen and teat etiology
I emphasize on alcohol cessation referral
I got 20
CVS : old male has peripheral features of AR
apex displaced
Systolic murmur all over radiates to carotid
I said AS and AR although I didn't hear the diastolic murmur , I
was not comfortable to the auscultatory findings and I felt
may be something is missing, anyway , they discussed with
me what might be the causes of systolic murmer in this age
and how to differentiate between AS and sclerosis,
investigations to do
I got 20
CNS : middle aged patient
Instruction was : this patient has problem lefting objects
I examined his upper limbs , he was sitting on a chair , he is
non English speaker however examiners helped with
instructions and I passed few instructions in Maltese my self(
most of them sounds as in Arabic)
Findings are pure proximal atrophy and weakness at shoulder
girdle and scapular muscles with defined supraclavicular and
scapular margins, no facial involvement
DD : proximal myopathy likely congenital causes as patient
has an atrophy
And I suggested scapulohumeral variant I enlisted few other
causes as well
Investigations including EMG,NCS, and muscles biopsy
He asked me about mode of inheritance I answered that I
can't recall
Management is supportive and I motioned that few Novel
therapies is under study
I got 20
Communication: speak with angry son of 70+ female admitted
initially in orthopedic ward with # femur and underwent
arthroplasty 2 weeks ago , 1 week after she felt while doing
rehabilitation, since this last fall she is on and off confused,
orthopedist assure son that this because of UTI and she is
receiving ttt for that , then patient transferred to medical
ward as her confusion continues, CT scan arranged , showed
intracerbral bleed with midline shift, neurosurgery advised to
hold enoxparin ( which was started as prophylaxis) and her
usual aspirin and stop her oral feeding until the see her
Role : speak with son about CT findings and subsequent plan
and discuss the clinical judgment when outweighing benefits
and risk of LMWH
Son was angry but I listened to hem empathetically and
reassured that I'm here to help, I broke the CT findings and
explain the role of Neurosurgery opinion, his concerns : what
 is the cause of her bleed, why giving anther blood thinner
while she is on ASA , could the fall be avoidable, why he has
?been told that she has UTI
Actually examiner's discussion revolved around whether
LMWH has caused her bleeding or not and wether there is a
way to know that I said unlikely it was the direct cause
however above therapeutic level of anti factor Xa might give a
clue that helps to reveal the uncertainty of her bleeding
.cause
I got 16
BCC 1 : old male , c/o slurred speech for 30 minutes, three
previous episodes of near fainting , during episodes he feels
. "fluttering" sensation of his heart
PMHx : HTN on amlodipine 5 mg , AF on pacemaker and
warfarin 3 mg and regular check, ranitidine for gastritis
Exam : AF with rate of 80
Discussion was about DD
,I mentioned TIA , orthostatic hypotension
How to investigate, he ask me will you change his anti
?hypertensive or not
?How do you know if pacemaker is non functioning
I got 28
BCC 2 young lady, pregnant in 18 weeks gestation with SOB
for 2/52 and cough with occasional whitish phlegm and occurs
at late night and early morning,no any other symptoms upon
discussion
 KCO bronchial asthma was controlled before pregnancy on
INH SABA & INH steroids but she stopped them both after got
,pregnant as She thought they're harmful
Examination: all clear , LL clear
I explain for her the role of inhaled Mx in controlling her
asthma and that why she got these sympx , reassure about
safety in pregnancy, adviced PFM diary and FU with GP
Discussion: DD chest infection and less likely PE
Examiner asked what've s against infection, also asked if PE
? need to be rolled out what to do
Actually I peaked my marking sheet within the examiner
hands while pill was ringing and I'm about to leave the room
with all marks in satisfactory area , I felt it was a comfort
message from Allah at the end of the exam
I got 28
Over all I scored 168
My conclusion that PACES is a MOSIAC experience, it
concludes different roles and various methods and the
probability of passing lies in practising as many as one can do
.. of these roles and methods

:My exam in Khartoum center day 2 cycle 2

Station 3 ●
:CVS •
A female é SOB. Her pulse is small volume & regullar. Loud S1
& S2. Pan systolic murmur heard all over not radiated to
.axilla
?Ex asked: what r your finding and D
I said l have DD pulmonary HTN é functional TR, or VSD ę P
.. HTN
.Ex: is the murmur go to axilla? I said no
Ex: what about MR? I said it is one of dd but the murmur not
radiating to the axilla, l added i also want to assess for MS
because of loud S1. Ex asked is there any murmur of MS? I
replied no then asked how to invx and tt and what are the
.. causes of primary pulmnary HTN
)I got 18(
:Neuro •
A male e difficulty in walking pt had wasting proximally e pus
cavus, flaccid weakness, abscent reflexs and normal
sensations. l examined the upper limbs which also shown
proximal weakness e reduced tone & no reflexs bell ran
::bell::bell
The examimer asked about +ve finding then he asked what
about coordination :grin: l told him that it is difficult to assess
in LL & in upper L time not allowed. Then asked about each
DD what with and what against ..then invx & tt when I
mention muscle biopsy he asked what do you find in the
biopsy? I dont know he smiled and said this is pathologist
..level
)got 19(
Sation 4 ●
 The senario of delayed diagnosis of pheochromocytoma. We
have done this senario e dr Imtithal
.so I was happy by getting this senario
I started as dr zein tough us e greeting pt, agreeing the agenda
.and if any one e him and ICE
The surrogates's main concern is negligence and delayed
diagnosis for 5 yrs. I said first I'm sorry for the delay
for his suffering during those yrs and the good thing now &
we know the cause and try to help him
regarding negligence l said I doesn't know the situation at that
time but I am going to check and give you feed back ..he asked
when you will give me the feedback? I told him I am not the
one who do this, I will inform my consultant and special office
in the hospital and they will check the records and sit e your
GP to know the situation, then they give you feedback ...he
agreed
then I talked about his disease and the possibility of
malignancy ..he didn't respond
I thought he did not hear me so I repeated it again, he said ok
..then we discussed the manegment plan and he asked about
the effects of high BP during those 5 yrs. l told him l can not
tell now & I need to assess him for bad effect of HTN and do
some tests then i summarized and checked his understanding
..the nice surrogate left the room
Ex asked about ethical issue , is there any negligance ,i heard
you telling him it is difficult to diagnosed why , l heard you
telling him you wont to assess for effects of HTN what did you
wont to do , i heard you telling him the surgery is high risk
why then he asked about tt ..I felt they are satisfied
 )I got 16(
Station 5 ●
BCC1: A male patient with h/o blackout all vital signs are •
.normal
I explored pre during and after the attack. So it is epilepsy.
The surrogate said also he worried about a rash in his face
.....+ve FH of epilepsy
O/E tge pt has adenoma sebaceum. I checked for focal
neurological deficit.. None. Then i checked for subungual
Fibroma +VE ex the mouth for high arch palate and bifid uvula
_ve. Abd for Palpable kidney -ve. Then I wanted to do chest &
CVS examinar said normal. I examined the fundus & it is
.. normal
He was concerned about the cause & whether it will affect his
.kids
After I answered the concerns the Ex said you still have one
min, so l council him about the driving issue and tell the plan
again ..ex ask about D & assosiations ask about what I wont to
check again ..yes i said shagreen batches and ashleaf :ok_ I got
28
BCC2 •
A 55 female e Progressive lt hand weakness. In history I asked
about duration ,progression other hand ,sensations and the LL
...i found it bilateral carpal tunnel :blush: PH of
hypothyroidism on tt I examined the hands then the thyroid
.and thyroid status
Her concerns are what is the cause & whether gonna be
paralysed ? ..again I finished 1min earlier.. so l went back and
.explained more
 :Examiner's questions
.. causes of carpal tunnel, inves & ttt
)I got 28(
Station 1 ●
Chest.. by inspection there is a scar so i hurried to reach the •
back the scar is strange i got confused. Later when i presented
my findings i said the trachea is central the ex asked me to
check it again then i said yes it is to the lt he said do u mean to
.say this from the start, i said yes
Then the DD is pneumonectomy , fibrosis , collapse
Then the rest of discussion is about fibrosis , he was not happy
...& I thought I failed this station
)I got 20(
.Abdomen. The pt has abnormal movements in her hands •
So during the general ex I kept looking for the instructions. I
presented my finding CLD there is lymph node e scar of biopsy
ex asked me to show him the node then he didn't comment &
I ignored it. Examiner asked what about the movements? l
said it could be flapping tremer he said if not? I replied
..chorea
.DD of CLD
I mentioned Wilson disease, so he said if i told you this pt has
Wilson, how are you going to investigate. Also he asked about
.. the tt
)I got 18(
Finally I ended e history station ●
 A 36 yrs female e fatigue. GP found iron dificiancy anemia
...... other tests are normal. Examination is normal
no history of blood loss in M&S she has knee joint pain D as
osteoarthritis. I asked about how she diagnosed she said by
her docter and was diagnosed .. MRI and she was on NSAID
for 2 yrs wt loss 5 kg and epegastric pain. The fatigue afectted
her job & life alot and she is concerned about fatigue. I told
her there are many causes from simple PU to serious Ca so we
need to consult the gut doctor & do upper GI endoscopy also
need to stop the NSAID and review her joint problem e joint
.doctor
I summarized then they told me 2 minutes are left.. so I
.checked understanding and summ again
The ex asked about DD what is the most likely one.. plan of tt
. & invs
during Iam Ansures the other examiner told me I heard you
telling her about other pain killer tell me about them.. he also
asked about H pylori, the best diagnostic test & why ,ttt &
follow up, the OGD finding and when we took a biopsy. Then
he asked the other ex if he wont to ask me any Q he said I
.think nothing more we finished the Qs
)I got 20(

Exam on 2/4/2016 day 2 cycle 1 in soba university hospital

I started by station 2 history
 Scenario of (35 years old lady has fatigue for 6 months her gp
did a blood test and confirmed to be iron deficiency anaemia )
I introduce my self, explain the role ask about her job ... she is
a teacher and agree the agenda
As she has fatigue I start by analysis of her fatigue and then
general symptoms and she give hx of wt loss of 5 kg when I
ask about joint pain as apart of general symptoms she tell she
has joints pain for 2 years and she had been diagnose to have
osteoarthritis by orthopaedic consultant
Then I asked if she use any medicine for that she tell she use 2
medicine ibuprofen and other NSAID the medicine was given
without PPI cover. She has hx of localised epigastric pain
made worse by eating ass with nausea but no vomiting....
some times heart burn
.there was no melena or haematemesis
No mouth ulcer
No change in her bowel habits
.No bleeding through her back passage
On bloating and no tummy pain with specific type of food (
wheat products )
Normal menstrual cycle
She take balanced diet and she give me example for her diet
.Then review of her systems was negative
Her past hx and family hx is negative
I take the drug hx as part of HPI
In social hx she is affected greatly by her fatigue and also she
can't do her hobbies as she use to run and go to gym
 She concerned about the cause of her fatigue and how can I
.help her to do her hobbies
I explained to her the likely cause of her fatigue related to
medicine which she is taking and that we need to do cammera
test and we need to stop her medicine after discussing this
with her orthopedic surgeon and if we need to continue on it
we will give PPI and we are going to give her iron replacement
and that I will reply back to her gp
Then I check the understanding
And thanks her
First examiner question
Did you ask about smoking I said no sorry
do you think it is important I sa
I said yes as pt most likely has gastritis or peptic ulcer disease
so smoking impaired the healing of the ulcer
: Then did you ask about alcohol
Again I forget
??So do you think it is important
Yes as it may cause gastritis
Then he ask why you ask about numbness and
???unsteadiness
Because if malabsorption is cause then B12 may cause
subacute combined degeneration of the cord
Then ask about DD
I put gastritis
Gastric and duodenal ulcer
 Malignancy as other has wt loss
Then coeliac disease and IBD
he asked whether NSAID CAUSE small bowel ulcers apart from
duodenum? ?? I said it is not common but if multiple then we
need to think of zollinger elisson syndrome
???How can endscopy help
Macroscopic we can see the ulcer and we can take biopsy
???What to test in biopsy
The presence of malignant cell and also H.Pylori
Any relation between NSAID and H.Pylori? ??
:sweat::sweat::sweat: I said I don't know
Then how NSAID cause peptic ulcer? ?? After explain then
?? ?again he ask any relation between NSAID and H.Pylori
I feel that he need me to say yes so I tell yes there may be a
relation
Then how you will treat H.Pylori? ?? I said triple before give
the name of triple he tell if you stop NSAID what other
medicine you will give to the pt I said paracetamol
I think they will mark me negatively as I forget important ****
part of social hx but surprisingly I got 20
Then station 3
..... CVS
young female with small volume pulse and she is pale
She has chest deformity ... active pericardium with visible
pulsation the apex is not displaced with palpable 2nd heart
sound and positive lt parasternal heave and on thrill
 There pansystolic murmur in lt para sternal border with
maximum intensity in the apex but no radiating to axilla wit
loud 2nd heart sound
I present my case as MR with pulmonary htn then the
examiner asked whether th murmur radiate to axilla or not???
I said no and the the murmur is in lt parasternal border so it is
differential of TR ,MR,VSD with pulmonary htn
Then about the causes of pulmonary htn and investigations
I got 20
.... CNS
young male with stick beside the bed
There is pes cavus and wasting of both leg with hypotonia and
weaknesses of LMNL but proximally more than disatlly
Abscend reflexs and equivocal planter
Coordination difficult as power grade 0
Intact sensation
I said the gait he tell no need
Then I examine the upper limbs with same finding
?? ?Ex what is you positive finding
??? What is your diagnosis
I said LMNL weakness either muscle problem or pure motor
PN but with pattern of weakness proximal I will go with
muscle disorder then asked about how can gait help you and
DD of pure motor neuropathy then investigation and
.management of proximal myopthy
I got 20
Station 4 communication
 Scenario of delaying a diagnosis of pheochromoctoma in
young male suffering for 5 years seeing by many doctor
including psychiatrist for panic attacks and been prescribed
diazepam and also has htn that difficult to control and on HIS
INSISTENCE the go refer him to you clinic and you are the
doctor in hypertension clinic... the tests done for him show
mass of 5 cm in his RT adrenal and urine test also positive
Your task to explain for him the diagnosis and to answer his
...concerns
I stard by
Introducing my self explain the role ask about his job and any
one he would like to invite to attend the meeting and then
agree the agenda & ask him to tell me more he was attacking
in nature... that he is suffering for 5 years and seen by many
doctors and prescribed sleeping pill but without any
improvement. I showed embathy regarding his suffering for 5
years the explain to him that the result with me now and that
unfortunately it is not as we hope then telling that it show
pheochromoctoma and whether he hear about it he say no
the if he would like to explain more .... the I explin
pheochromoctoma and telling that the good news that we
find cause for your suffering and it is curable condition in
majority... then explain the cause behind is a growth... he is
not care about the growth whether it us cancer or not but I
explain to him the possibility of cancer of 10% when I tell him
it is curable he tell how I tell surgery then he is habby an tell
OK just removed now (verbal cue) I think then I tell it is not
easy surgery we need to control you blood pressure first as I
am a doctor in hypertension clinic then I am going to involve
MDT he tell what MDT I tell sorry a team of expert people
including the gland doctor, the surgeon and anaesthetist they
will make meeting and they will decide
 ?? ?He ask when the will decide
I tell as soon as possible
Then his main concern where there is negligence or not
I tell I need to go back to your record to see what exactly done
for you. Then he tell doctor there is negligence and I will
complain against my gp....I tell it is your right to make a
...complain
The he concern where there is a damage happen to him from
HTN? ?? I tell l need to examine you and to do some test test
.see the effect off htn
...I asked any other concern
He tell no then make summary ,,, check the understanding
and telling I will reply back to your gp then offer help and
.leaflets and if he can drive alone
The British examiner
What did you think about this case???then I give summary of
the case and what I did
Why you did not tell him about risk of surgery??? I tell I just
brake bad news for him and I dose want to give him all bad
news and he will have metting with surgerical team who the
will discuss with the risk of surgery( then he smile)
???How you will treat his htn
Alpha blocker and then beta blocker
???Do you think there is negligence in this case
I give him the same answer for the surrogate then he ask is
there is any damage from his htn???I tell the same that I need
to examine him and to do fundus and investigation to see if
.he has damage
 Then he ask again any negligence??? I notice that both the
surrogate and examiner concerning about damage from htn
then I tell you pt suffering for 5 years and not diagnosed this is
not usual and if there is damage happen from his htn OF
COURSE there is a negligence (I Don't know why I said of
course )
then he ask do you think the pt is habby and he can drive
alone??? I keep silent for while then tell yes he is habby
The bell rang
The British examiner tell well done
I got 15
Station 5
BCC1
years male with blackout with normal vital signs 22
From hx blackout mainly in the morning and during sleep also
I get confuse how during sleep the a very nice surrogate he
tell he bite
His tongue and wet him self
I asked any shakes he tell no
I review CNS which is negative then asked about trauma
which is negative the about general symptoms including skin
...rash
He tell yes he has skin rash in his face for 20 years which
difficult to fade away... I look to the face and then feel relaxe
...as I catch the dignosis
Past hx of htn and on amlodipine 5 mg with no change in the
dose
Family hx of abdominal surgery in 2 of his sister and skin rash
in his brother
He is a teacher!!!! and I asked about his school performance
he tell good and he drive a private car and dose not drink
.alcohol
I examined the face for the rash and the doing pronater drift
for any weakness
Check the trunk for ash leaf spot and examine the back for
shagreen batch
Offer abdominal examination he tell normal offer chest exam
he tell normal offer to check BP tell 130/70 then offer fundus
for phakomas he smile and tell Do it
I check quickly as the pupil is not dilated I know that nothing
.well be there
The concern about what is going on ... I explain tuberous
sclerosis
...Another concern about his kids
Explain that each has 50% chance to get the disease
No other concern
The examiner tell still you have 1 minute
Then I explained the eplipsy and driving but still there is time
.then I explain the screening of family and gentic counselling
Examiner question
?? ?What is your diagnosis
Investigations and management
I got 28
BCC2
 years female with lt hand weakness 22
Before shaking pt hand it seem she is on pain so I tell sorry I
will not give you shake as you are in pain
Then surrogate give hx of both hands pain in disruption of
median nerve without any thing in the system review point to
... the cause
However in oast hx she diagnosed to have hypothyroidism
and not on follow up for tow years but using her thyroxin 100
mcg
No other significant hx
O/E
clear signs of carpal tunnel syndrome bilaterally and more in
the lt
Then I checked for thyroid status
Concern about the cause of the problem
Other concern whether her lt hand will become paralysed
I admit the 2 concern and explain the need to check her
thyroid status and regular follow up and we may need to do
surgery
The British examiner still you have 1 minute
Then again I tell the importance of regular follow up
The examiner smile still you have 30 second but no problem
.... you can regulate you thouhts
Then ask the dignosis the DD
The investigation and management
I got 28
 My last station is station 1
I start by abdomen
Young female looks ill and very pale with cannula in her RT
arm with ting of jaundice and no stigmata of CLD with
hepatosplenomagly
I examine only for one group of axillary LN as time did not
allow me
Then ask about DD
the discussion about myeloproliferative disorders
I got 19
The chest
Amiddle aged male with obvious depress lt side and moving
less with very strange scar on the lt side only the tip of scar is
seen anteriorly so I try to go fast to examine the back from
anterior the trachea deviated to lt with impaired percussion
on lt and decreased air entery on lt and vocal resonance
however there is increase vocal resonance in lt upper part and
bronchial breathing in same lt upper part
Posteriorly same finding and that scar stii confusing me it look
like long thoracotmy scar but surprisingly there area about 2
cm of normal skin
So I present my case as lt pneumenoctomy
Then he ask did hear any thing abnormal in lt side I tell
increase vocal resonance I am afraid from inventing sign so I
did not tell bronchial breathing but he is very helpful
examiner and ask me what type of breathing in lt upper zone
then confidently I tell bronchial breathing so he tell what
could be the cause again I tell this could from stump .... he
smile he tell stump can not cause this... he ask what could
 cause increase vocal resonance and bronchial breathing I tell
cavity ..... he tell yes now what could be the cause I tell
fibrocavitatory lesion ...he becomes habby and asked about
the common cause and how to investigate TB
I GOT 20

Station3 Cardiology
Young lady with heart murmur ..advised to examine with
.limited exposure
All through examination were normal. I did all possible
manuevre,but could not find any particular abnormality. So i
said i could not find any significant CVS abnormalities.
Examiner did not challenge me. Asked me suppose this lady
?has a very faint systolic murmur. What will be d/d
I replied physiological murmur. Then asked causes of it. I gave
a long lists of causes. Then any congenital heart disaease? I
replied ASD can cause flow murmur in pul. Area, vsd can
cause pan.sys.mur , but it is usually loud. Then asked any
other condition young female can go with long time without
any problem? I replied mitral valve prolapse. Now examiner
got the answer what he was wating for. Then he asked me
signs of right heart failure, signs of pulmonary hypertension,
why TR occurs in pulmonary hypertension. Then time over. At
the end of examination, i found all of us said normal cvs
 started with station 3
,,CVS- MVR- midline scar , metallic sound, MD Murmur
examiner discussed about infective endo- how present, wht
investigation
02/17
Neuro- diffic. to walk- examine neurologically-- Rt hemiplegia
with facial palsy- where lesion? invest? acute presenta--
.Alteplase
02/02
station-4
Open TB- sputum positive- wants to visit abroad mother got
stroke- adv to start treatment then after 2 wks recheck- if
negative then allow-- contact trace- did not tell side effect of
anti-TB -- 10/16

station 5
BCC1- headache with visual loss-- surrogate told bump Rt
-side
examination-- Rt Homo Hemianopia. previous unconsco
history- d/d-- ICSOL, MS, Stroke,, inves, 26/28
BCC2- Hands- Small joint pain- stiffness > 1hr, h/o Psoriasis 3
yr back, nail changes present-- Exam-- no active inflammation,
only nail change-- Examiner- nail change- d/d- psoriasis or
fungal, d/d- Psoaria or RA- Investgation of Psoriatic. 28/28
Station 01
 Abdo- anemia, jaundice, Hepatosplenomegaly-- 45 years age-
CLD with Portal HTN- D/D- lymphoproli, Malaria, Thalasse(age
not supportive)- cause CLD, Invest.-- 16/20
Respir- Rheumat hand with Fine creps- ILD-- D/D- MTX
induced ILD, investi, Rx.--- 20/20
station 02
female 30
bloody diarr 4 wks, visited Cyprus. low back pain with
years colon stiffness-no fever , no wt loss- grandfather 57
cancer-- D/D- Inflammatory(IBD) or Infective- but to exclude
i do colonoscopy, examiner asked Invest of Infection, cancer
IBD- Rx- do it on OPD basis. 20/20
Total 157/172
Thanks to all

Experience of our collegue Nagwa Mahmoud

St 1. Chest copd.clubbing Basal fibrosis . Chushing features ask
about finding. Cause of fibrosis .Inv. and management.got 16
And. HSM. QUICK. Cause inv. Ask about upper GI. Endoscopy
in this case and ttt.if the cause is HCV. Asked if it works? Bill
rang.got 20
History bloody diarrhea and arthritis .history of travel to
miraco
History of long term diarrhea and recurrent and pain relieved
with defecation. FH. Cancer colon in grand father aged 75 no
other family members has cancer colon . Cancern is it cancer
 like my grandfather. Questions DD. Infective diarrhoea. IBD.
.Asked what his risk to develop cancer colon told like others
asked if he need admetion I told I after examining and doing
basic inv. U&E we will decide asked about inv.and
management of Infective diarrhoea . got 20. St 1 neuro. Ms.
Pyramidal weakness bilateral more in line. Side loss of
sensation in rt. Side till face cerebellar signs. Time finished
befor doing deep sensations actually when he told one minute
.... remaining I did cerebellar. Told I wand to do
Discussion about DD inv. TTT. got 20. Finally cardiovascular .
Double aortic with AR. Predominant. Q. Finding . Causes. Inv
.and management got 20
I hope my exam experience help you all . My advice is to
concentrate at least 3 months befor exam and to have
studying partner for history and communicatios also to make
.study group. In yr work to see patients and discuss
Good luck for all and thanks a lot for our colleagues who
‫ و أكثروا من الدعاء‬.shared their experiences befor
+
.St4
A female pt about 70 known bronchial asthma that's difficult
to be control till recently. She was admitted with congestive
heart failure and was controlled on diuretics and ACEI. Today
one of the junior doctors prescribed bisoprolol as he thought
it is of benefit for her heart Failure & a nurse gave her the ttt.
Since 30 minuts no harm happened till now but the pharmacy
told it is harmful to her to be given bisoprolol as she is
asthmatic. So the nurse was worried and pt. feel that
. something went wrong
You are asked to speak to her and explain the condition ...very
..long scenario
After introduction I checked understanding & explained what
happened, apologised & explained what will be done incident
report, department meeting ..and put under observation for
any SE. And follow up by cardiovascular and chest team . Her
concern why happened what will happen to me what will u.
do to prevent this happening to others . Ist she was angry but
after explanation and apologies and stress on her care and
postpone discharge for one to two dayes till we are sure she is
. ok. she is satisfied
Examiners ask legal issues I told negligence but is not. It is
mistake he told any thing else told autonomy - I should tell
not to do harm also he asked why bisoprolol is harmful in BA.
We are giving small dose- he told- I told as it is non selective b
blockers asked what can we give i told carvidilol . Asked how
.u do incident report I explained . I got 13
. St 5 #
Sudden loss of vesion pt. Hypertensive By history last less -1
than one hour plus hemiplegia. She is on insulin and
bisoprolol only . Ex. Pulse AF. Carotids asked to examined
precordium examiners refuse . Examined visual aquety simply
asked for fundus they refuse asked to examine her
neurologically told ok. I checked power. Was normal . Her
concern. Is it dangerous. Why happened? Questions about
positive findings. DD. Management .got 26
St 5. 2nd case Active RA . Discussion about inv. ttt.
Components of multidisciplinary team for this case. Got 28
.St 1#
 Chest copd.clubbing Basal fibrosis . Cushingnoid features *
asked about finding. Cause of fibrosis .Inv. and
management.got 16
Abdomen. HSM. Discussion about Cause inv. Ask about *
upper GI. Endoscopy in this case and ttt.if the cause is HCV.
Asked if it works? Bill rang.got 20
History bloody diarrhea and arthritis .history of travel to #
Morocco
History of long term diarrhea and recurrent and pain relieved
with defecation. FH. Cancer colon in grand father aged 75 no
. other family members has cancer colon
.Concern is it cancer like my grandfather
Questions DD. Infective diarrhoea. IBD. .Asked what his risk to
develop cancer colon told like others. asked if he need
admission? I told I after examining and doing basic inv. U&E
we will decide asked about inv.and management of Infective
.diarrhoea . got 20
Neuro. Ms. Pyramidal weakness bilateral more in right Side #
loss of sensation in rt. Side till face cerebellar signs. Time
finished befor doing deep sensations actually when he told
.... one minute remaining I did cerebellar. Told I wand to do
Discussion about DD inv. TTT. got 20
.Finally cardiovascular . Double aortic with AR. Predominant #
Q. Finding . Causes. Inv and management got 20
.I hope my exam experience help you
My advice is to concentrate at least 3 months befor exam and
to have studying partner for history and communicatios also
.to make study group. In yr work to see patients and discuss
 Good luck for all and thanks a lot for our colleagues who
shared their experiences before

:My exam in Kuwait 23/4/2016

: Station 4
Young lady with DM since 30 yrs on insulin, she has hx of
retinopathy before and on regular visit to her GP she found to
has proteinuria and GP started her on ACEI. her HbA1c is 20..
your task is to discuss the result of this recent urine test and
..the management plan
I started my discussion with raport and i asked her to tell me
how much she know about her condition, and she start to
speak for more than 4 minutes until the point of initiation of
ACEI by the GP which she didn't take it coz she don't know
why given to her ( she said the GP not explained to her for
what this drug). So then i told her iam here today to explain
for you why this drug for.. i asked her about DM in details
when diagnosed and if she is taking her ttt regularly and
complications. I discovered that she is taking her ttt regularly
BUT the problem is the follow-up.. she is not going to clinic in
a regular basis . Now is the main issue which is the SOCIAL
Problems.. i asked her is there any thing prevent you to come
to clinic? I asked her specifically is there problem at work or at
 home that makes you busy? She was separated from her
husband recently and also she is taking care of her old bed
bound mother and her kids that why she is not following.. i
showed her some empathy and sympathy and i said it is good
to take care of others but also not forget your self.. i told her
the importance of controlling DM and consequences which
may happen if not controlled and here i explained why GP
start ACEI.. her concerns are : heart attack, stroke and if she
. .will end with renal failure and dialysis
I said to her iam not here to make you afraid but all these can
occur that why is importance of taking ACEI and to follow to
prevent all these complications. I told her i am here for help
and i will involve the social worker to help you.. then i
summarized the meeting and i checked her understanding and
..she is happy about the plan
Then the examiner asked me firstly what do you know about
autonomy ? And how to know she followed your advice? I
..told by follow-up if she came
11/11
Station 2
yrs female with Episodic weakness in Rt upper limb and 32
..last one yesterday which stayed for 10 minutes
After starting with raport ask her to tell me more.. she has 4
episodes all for less than 10 minutes.. otherwise all hx
negative including systems review.. she has past hx of HTN
during her last pregnancy and she didn't follow after and now
her BP in the referal letter is 170/100. also she is smoker.. l
asked about CVS and rheumatological hx and family hx all
negative.. no features of MS (i put this in my mind coz of
?episodic weakness ). Her concern is it brain tumor
 . Then i discussed the management plan
She asked me what about driving and i forgot the duration
exactly so i said the phrase of my friend who is faced the same
question ( iam not sure but i will go now to the book of DVLA
in my office and i will tell you 😊😊) but i said it is better to
..inform the DVLA
Examiner : investigations and management.. Also about
..ABCD2 score
.02/02
Abd: CLD pt with jaundice, ascites , splenomegally, palmar
.erythema
.Examiner : investigations and management
.02/02
Neuro : paraplegic with sensory level. 16/20
Chest : bronchectesis
02/13
CVS : AR and MS pt also has AF
02/17
Station 5 Acromegally
yrs with headache and HTN 32
..He has typical features
.02/07
nd is ankylosis0
..yrs with back pain 02
.He has morning stiffness and uvitis in the hx neck pain
..O/E.. only mild restriction of spine flexion
 02/01

Malaysia
--) 0211-2-17 (
...res -Marfanoid guy with bronchiec, abdo renal transpant
...hx was IBD with joint pain
..cvs i also donno wat....cns peripheral sensory neuropathy
...bcc was takayasu and PDR
comm phaeo late diagnosis

My exam was in Sabah hospital

I started with ST 5 BCC 1 was this pt presented with joint
...pain
He has pain in both wrist elbows some times his right knee
&swelling stiffness for half an hour..no skin changes no
photosenstivity no mouth ulcer or eye changes no muscle pain
or weakness ..his wt is some times increasing
&decreasing..systemic review is negative
 Not diagnosed before but for several years he is taking
azathioprin & steroid..no FH ..Menimal impact on the daily
..living
OE Indian surrogate with normal exam..iDid all hand exam
including hand function carpal tunnel rheumatoid nodule
.. proximal myopathy &I offer to examine knee
Examiner question what is the diagnosis..Rh.artheritis not
active as no synovitis now stiffness less than hour..how to
investigate ..what is sign in x Ray for Rh.arthritis..how would u
manage this pt..I answered all these question however I said
according to test if disease is active to add methotrexate
examiner was not happy about this I think may be because
the pt has history of hepatitis which I missed..also he told me
you didn't screen about side effects of steroids..I told him I
asked about wt and muscle problem & I examined for
proximal myopathy but he told me u should ask about the
others..I got 20/28
BCC 2
yrs old lady with rt side weaknesses..in history started 22
suddenly continued for 2 hrs then resolved..first episode..no
speach or visual problem no alter sensation..no headache ,fits
or Loc..no history of trauma..no cvs symptoms esp
..palpitations no joint pain or skin rash
Known hypertensive no other vascular risk factors..no history
of AF..negative FH..social history including impact is
.unremarkable..she is on OCP..anti hypertensive medication
OE iexamine for pulse,listen 4 carotid bruit examine conjugate
eye movements ,power in upper limb ..offer to examine cvs &
..fundus
 Examiner questions what is problem with this lady ..what are
risk factors for Tia in this lady ?isaid only hyper tension he ask
me if OCP is risk factor..isaid only if pt has thrombophilia or
connective tissue disease or history of migraine with
aura..how to investigate..how to manage..of course based on
her ABCD score..he asked me about management of stroke..I
got 28/28
It is really difficult to start with station 5 esp if this is ur first
attempt..but ithink we should try to control our nerves as this
is most imp thing& alhamdullah I gained my confidence by
second case
Station 1 Abdomen
Young man who is pale & jaundice in absence of stigmata of
CLD & prominent zygomatic bone..he has venous ulcer in rt
leg.. With scar in his back has hepatospleenomegally no ascitis
..my diagnosis was haemolytic anemia mostly thalassemia. he
asked me about what other differential how to investigate
including HB electrophoresis & bone marrow & managment..I
got 20/20
Station 1 chest.. I think itis same case as dr Mazin amale who
is excessively coughing with finger clubbing has all signs of
hyper inflation of chest including decreased cricosternal notch
hypersonant all over the chest except in rt base vesicular with
prolong exp & coarse crackles mainly in rt base with little
change by cough as pt is excessively coughing..my diagnosis
was Copd & bronchiectsis.how to investigate..what r signs of
Copd in X-ray what r signs of bronchiectsis in xRay &ct
scan..what is expected PFT & management of both
conditions..if he came acutely with sob how to manage..you
said control oxygen why.. I got 20/20
Station 2
 ..Young lady with palpitation
On taking the history exertional mainly ..with no adverse
symptoms ..started n ended suddenly ..no other cvs
symptoms her wt is decreasing with normal appetite...she feel
hot but no other symptoms of hyperthyroidism.. She just
deliver 4 month ago with amaenorrea since that time.. No
skin changes or eye changes..known asthmatic using
salbutamol inhaler..she used it once in month as her
symptoms r not so frequent ..FH of premature heart disease
her mom age 50 her brother in his 40th.. her dad also..her
sister has hypothyroidism..so here I emphasized with her n I
asked her if she checked her cholesterol as Iam concerned as
u have strong FH of heart disease so she said no so I offered
appointment for this..SH she said she is not having any
stresses in her life n taking caffeine n alcohol moderately she
is only in salbutamol...so I asked her if she had idea about the
cause she said Iam afraid itis a heart attack I told her is this ur
concern she said I have lots of concern 😅..is it a heart attack
(I clearly said itis unlikely as she has no chest pain no sob..Is it
from my salbutamol inh (it is unlikely as u r not using it so
frequent..)..what ami having... What r u going to do 4 me..I
..answered her n reply back to GP
Examiner asked about diagnosis post partum thyroiditis..
Other deferential is post partum excarbatation of graves
which is unlikely as no neck swelling no eye or skin
changes...other causes of palpitations is excluded from
history..examiner said I like the way u took history 😊...asked
about investigation & treatment.. I got 19/20
Station 3 cvs it was obese lady who refused full exposure..her
pulse is large not collapsing.. APex to be palpated..systolic
murmur all over pericardium also radiated to root of neck...I
 knew at that time pt has AS as murmur radiated to root of
neck..but pulse is large so she has regurg valve is it double
aortic but no diastolic murmur or MR..so at that time I said
iwill mention only AS I will say may be there coexistant AR..n
murmur in apex is from gallaverdine phenomenon...examiner
was angry ..he said if I heard other murmur I said no so he ask
me about cause investigation n treatment ..I knew I did bad in
this station...after exam I met the pt n I asked her about
diagnosis she told me itis MR..she has AS but not sever...I got
10/20
Cns instructions:examine this pt who has difficulty in
walking...isaid to my self if is tarted with gait I will waist my
time as he cannot walk beside bed as itis to small he will take
about 2 minutes 😰 so I started with general inspection n
started with lower limb he has a reflexia even with
reinforcement..down going planter..loss of superficial
sensation in stocking distribution..difficulty in coordination
while pt closing his eyes which may indicate sensory ataxia..I
didn't finish examinations time finish when Istart to do
vibration..😰..so I told I want to finish my examination by
examining gait...as if he was not listening examiner asked me
what is instructions why u didn't start with gait...I apologize 4
that...what is diagnosis I told peripheral sensory motor
neuropathy..what causes imentioned commonest...how to
investigate...how to treat...then British examiner said if itold u
this pt is having positive Romberg will it change ur diagnosis
...imentioned in that case it will be PN& dorsal column
affection..so most likely SACD of cord asked about treatment
...is it reversible or not... I remember the answer from dr
Ramadan...surprisingly I got 18/20
Station 4
It took me more than 2 min to control my nerves after which I
thought bad performance ....this is 50 yrs old man diabetic for
more than 20 yrs admitted before with MI under went
catheter n was put on all anti ischemic including plavix n
aspirin during hospital admission his HB was I think 9 before
that it was 11 ...it was mention clearly no action was done for
this n he wasn't given Aplan or referral regarding u were not
apart of treating team now referred by his GP with HB 7
gm...long scenario...after introduction pt immediate shout
was angry he told me he found out that his HB since
admissions is decreasing no one informing him...he was
discharged home without appointment....no plan what to
do...so I apologize n I admit negligence...n i told him
endoscopy usually will not be told only after6 wks from mi (
which is as iremembered mention by one college in the
group)...so he calm down n asked me about cause ...itold him
avarity of causes ranging from less serious one like soreness in
tummy to might be celiac disease as u have DM for long time
to more serious causes like cancer which cannot be excluded
now...so itis better to do endoscopy upper & lower...
Imentioned the details of procedure & benefit & risk which
might exclude hage esp he is on dual antipaltelet..so we need
to stop it around a week before the test... He told me that he
is having sob now he is really tired...it was verbal cue that he
is symptomatic so I offered admission for blood transfusion
esp he is recovering from recent MI we don't want to put a
load in to his heart with this anemia ... He was afraid he might
catch some infection so I assure him regarding that.. I
summarized then I asked him if he agrees about endoscopy n
... blood transfusion...he said yes
Examiner questions were what is cause of Anaemia in this
pt...is there is angligance n why... I told him usually we r not
doing endoscopy after MI only after 6 wks however the pt was
discharged without been informed about result not given
Aplan for investigation...examiner agreed...asked about
ethical issue .... When to stop aspirin n plavix before
endoscopy...asked about chances of having infection after
blood transfusion.i got 16/16

Oman 13/04
St 5
Constipation in young man, father died with cancer colon, by
history polyuria , flank pains , hypoglycemic episode , most
likely MEN1
Second case gynecomastia , by examination acromegaly vs
kleinfelter
Chest bronchiectasis
CVS mv replacement
Neuro flacid quadreplegia , no sensory affection, not sure abt
the diagnosis
Abdomen renal tx with audible graft bruit with functioning avf
History back pain and bowel incontinence in pt with h/o lung
cancer
Communication delayed diagnosis of pheochromocytoma

Oman
 Royal Hospital
0211/2/10
COPDand CLD -1
yrs old female has h/o Diarrhoea wt:loss smoker ,no 22-0
family history malignancy
young male AS & Transverse Mylitis -3
COPDpt admitted with pneumonia and he got one fit and -2
theophylline level was high and pt was on clarithromycin
Pt asked I will complain and Su it dr y not before level done at
admission time
Tuberous Sclerosis and Gynecomastia -2

Oman PACES, 14.4.2016

FROM ARMED FORCES HOSPITAL MUSCAT
Stn 4. Astrocytoma high grade to inform his wife he is #
confused decision taken for pallative menegement
.Stn 5 #
Case no 1 blurring of vision with exesive lacrimation *
discovered from history thyrotoxicosis on treatment he looks
local cause
Case no 2 uncontrolled HTN recently started on valsartan ? *
?? ?RENAL ARTERY STENOSIS
St4 1 #
COPD +lung fibrosis *
 hepatosplenomegaly+ascites *
Stn 2. TIA #
Stn 3 #
Parkinsonism (disease) *
Mixed aortic valve *

Oman,round2, Thu14/4/2016
St2: tiredness in uncontrolled DM
St3: Cvs: AS+/-MR
Cns: mixed picture of LL weakness- MS
St4: father underwent pneumatic dilatation with
.perforation.Talk to the sun
St5: scleroderma
Gynaecomastia
St1: chest:Old+bronchiectasis + Lt thoracotomy scar...very bad
case
Abdomen: hepatosplenomegally +shifting dullness+ Rt iliac
fossa mass

-- Hospital kuala lumpur, malaysia 1st cycle

 Station 1: respi : Sob , marfanoid with left lobectomy .causes
of lobectomy and treatment
Abd : hepatoslplenomegaly with no CLD features
Thalassemia / CML /ALL/infection
Management of thalaseemia
Station 2: young lady with headache and transient weakness
of upper limb ..d/d hemiplegia migraine / TIA/vasculitis of
brain
Station3: CVS : loud murmur at mitral systolic and diastolic
..apex can't feel at all as too fat lady ..There is systolic murmur
over the aortic radiates to carotid ..initlly I said mixed mitral ,
Dato chandran very nice let me listen again ..is mixed aortic
.. valve ...asked causes , manamgenrt of AS
CNS : young lady with spastic hemipareiss no sensory sign
with cerbellar florid bilateral
Diff/MS , SCA , FA
ix and management of MS
Station 4: talking to patient son as patient post hip
replacement and given anti coagulation ..fall at ward and
confused , CT scab show bleed in brain ..address concern
:Station 5
Old lady with vitiligo and presbet with dementia
Causes hypothyroidism secondary to non compliance of
Thyroxine reduced reflexes
Differential : b12 level deficient
Management : take blood and examine..help the patient with
Meds as alarm and also discuss with family members
regarding taking care of her as she lives alone
gentleman presbet with frequent fall ...DM with sensory )0
ataxia and also DM retionpathy which examiner expect us to
do fundosocpy
Having Charcot joint
Optimized sugar and refer occupational and podiatrist ..foot
ware
Refer Opthal
What is gold standard testing for sensory ataxia :
monofilament 10g and NCS
.. Noted tractional fibrosis AT eye

Cases Oman 11 April

communication skills 29 yrs university engeneer with
ulcerative colotis on mesalazine with no improvement 6
motions per day anemia with high ESR to be started on
steroids he is refusing bc of SE as he read on
internet
Station 5 1st case 30 yrs acromegaly with bitemporal
hemianopia
nd pt with headache and blurring of vision diagnosis from hx 0
myathenia gravis
 St1 chest bronchectasis
Abdomen renal tp with palpabe liver asked for single
diagnosis she has cushingoid feathers
St2 hx of patient with headache stress at work friend
diagnosed with brain tumor
St 3 cvs double valve replacement quite difficult the metallic
noise is not heard without the stethoscope I am not sure
about
Neurology as well hypotonia hyporeflxia nd depressed
sensation up to the umblicus they discussed Causes of LMNL
paraparese also I am not sure about
Plz pray for me and thank you all

---Calcutta 3rd cycle

Sta.1 - hepatospleenomegaly with anemia
.rheumatoid lung ds .
Sta.2 -conversion disorder
Sta.3- ms or ar
examinations of cranial nerve with rteye laterus rectus palsy .
with vertical diplopia and resting nystagmus in lft eye
Sta.4-- theoohyline toxicity with clarytromycin
Sta.5-- dm with lft lateral cutaneus nerve palsy
 another case lft side stroke with MVR on warferin & .
.palpitation

-- Calcutta today 3rd cycle

sta.1 - abd - CLD with ascites
resp - ILD in rhematoid hand
sta. 2 - confusion in old man with prostatic carcinoma , talk to
son
sta. 3 - cvs - MVR
neuro - spastic paraplegia
sta. 4 -rupture esophagus after pneumatic dilation for
achalesia cardia ,talk to son
sta. 5 - a ) fibrosis of lung
b) DVT

Kolkata April -2016

rd cycle3
Station 5 - MS - rt hemianopia with optic atrophy with h/o rt
sided weakness
 Station 5 - ? Ankylosing with ILD/COPD - wheezes as well as
crepts - little odd
STation 1 - Chronic MR with ?? AR - you really had to strain for
the AR murmur, no peripheral s/o AR - seem like a clear cut
MR
Abdomen - hepatosplenomegaly - likely hemoglobinopathy
Station 2 - Wegner's /PAN/Autoimmune with
Glomerulonephritis
Station 3 - Rheumatoid Lung - fixed hand deformities with
effusion vs collapse
Neuro - Rt LR palsy with rotatory nystagmus - likely brain stem
lesion ? vascular vs others
Station 4 - convincing patient regarding oral steroids for
ulcerative colitis

Oman
April 11, 2016
st 4
Communication skills
A 29 yrs university engineer with ulcerative colotis on
mesalazine with no improvement 6 motions per day anemia
with high ESR to be started on steroids he is refusing bc of SE
as he read in the internet
Station 5
 st case 30 yrs acromegaly with bitemporal hemianopia1 -
nd pt with headache and blurring of vision diagnosis from 0 -
hx myathenia gravis
Stn 1
Chest bronchectasis -
Abdomen renal tp with palpabe liver asked for single -
diagnosis she has cushingoid features
St2
Hx of patient with headache stress at work friend diagnosed
with brain tumor
St 3
CVS double valve replacement quite difficult the metallic -
noise is not heard without the stethoscope I am not sure
about
Neurology as well hypotonia hyporeflxia nd depressed -
sensation up to the umblicus they discussed Causes of LMNL
paraparese also I am not sure about

My exam cases in Kilmarnock, Glasgow college

Abd: multiple scars including liver transplant and renal
transplant plus polycystic kidney plus widespread melanoma
like lesionsplus b/l dupytrens contracture. V difficult to
palpate as pt wz markedly tender
Score 14/20
 Resp: COAD with bronchiectasis yellow thick nails
Score 20/20
Cvs: mixed aortic valve disease predominant AS
Viva went on diagnosis, severity classification(new AHA) bad
prognostic markers, ind n timing n types of surg options
Score 20/20
Cns: rt homonymous hemianopia with rt sided weakness(
command was to examine the vision)
Finished in 3 mins, offered fundo, did a quick cvs exam
including pulse n carotid n surg scar on scalp
Stil had 1 min examiner stopped me(said no more reqd)
Viva: causes, emergency management including invest,
protocol for thrombolysis according to guidelines, long term
.management
Aftrr this examiner said my Qs r finished but u still hav 7sec
left n i turned to the second examiner for further viva but he
just smiled n waited for bell
Score 20/20
In all these cases the most imp thing is our confidence in
examining, picking right signs n giving ur 1 diagnosis without
being shaky
History: 50 yr male with blackouts
Diagnosis: vasovagal syncopy
?Viva: wht makes u think of this diagnosis
I said the imp causes of syncopy in this gentleman r vasovagal
considering his presyncopal symptoms of flushing heart racing
n immediate recovery, however in background he does hav
Afib which is asymptomatic well controlled so i wil investigate
that as well
Pt also had 1 seizure like movement as well
The next Q wz on dvla
How wil u manage: addressed all social issues involved with
the risk of injury to himself in his job and at home as well
Examiner's remark while smiling: "excellent, plz can i have ur
notes" n bell rang
Score 20/20
St 4: amiodarone induced lung injury
Went v smoothly
Viva: ethics involved
Management of underlying arrhythmia? I mentioned the AHA
guidelines on stepwise approach
With few recent updates at which examiner again smiled
St 5
Bcc1: abd pain with htn
Diagnosis neurofibromatosis with pheochromocytoma
Viva: r u not surprised there is no family history, i said it can b
a new mutation but now his next generation is at risk
Next Q: u were v keen to know abt his hearing n balance u
?confirmed it twice y
Ans: i wanted to rule out central tumors in particular cp angle
schwanoma acoustic neurona meningioma
Next Q: u mentioned to him these r non cancerous then y did
he hav 3of them removed (scars were present)
 Ans: they can always increase in size, for cosmetic reasons,
impingement of underlying nerves n v v unlikely but may b
sarcomatous change
?Next Q: u offered him some scan of tummy y
Ans: for 2 reasons: NF is assoc with renal artery stenosis and
pheo which is the likely cause here
So wil get doppler mibi scan n urinary levels
He wz asking me some other Q regarding vision but bell rang i
just said the causes of eye involvement in NF in 2-3 points
Score 28/28
Bcc2: diarrhea n racing of heart
No other signs of hyperthyroid found
Complex external opthalmoplegia on exam
Past his of thyroid prob
No cause found
No AI diases present
Not driving not smoking
Concern : eye symptoms of grittiness redness
Explained him it could b ur thyroid again but ur eye prob is
persisting from ur previous thyroid issue which we can help in
several ways
?Viva: wht r ur findings? Eye findings
Apart from thyroid wht other causes can u think of
?exophthalmos
Ans: u/l causes
B/l causes
 ?How wil u manage
Ans: Thyroid
Eye
Social support
?Q) Wht can b the causes
Wht other causes u had in mind while u were asking facial
flushing n then htn
Ans: carcinoid, pheochromo anxiety but none were found n he
has obvious exopthalmos With opthalmoplaegia
Bell rang at this
Score 28/28
:Overall summary
👍Pass AH
Score 166/172
This is the exams of ur clinical skills on background of sound
medical knowledge, the ability to keep ur nerves well
controlled, all of this comes with repeated practice on ur
patients and do alot of talking practice! I mean ALOT! So that
in actual exam u keep talking to pts and examiner in a fluent
yet unhasty speed. This is a true rapid fire exam. Give it ur
best shot with adequate practice especially of ur weak points.
The exam is not difficult but tricky, mark urself on the real
marking sheets while u practice with ur friends to master ur
!skills
👍Best wishes for all
Dr Qurat ul Ain Amjad
MRCP(UK)
 Calcutta yesterday first cycle
.Had TB for communication
Station 5 had facial nerve palsy and man with small joint
.problems
Station 1 had bilateral bronchi ecstasies with rt upper lobe
consolidation mostly TB and
.man hepatomegaly with splenectomy, mostly thalassemia
Station 2 had bloody diarrhoea with recent trip to Cyprus,
.mostly infective or Ibd
.Station three had an AS and Potts paraplegia

:Khartoum PACES, Day 3 last cycle

Station1》
:Chest ☆
.Lt Apical lung fibrosis
:Abdomen ☆
..Polycystic kidney
:History》
HTN in a 25 years old female..on two occasions. .RFT normal.
...protein and blood in urine
 Station 3》
:CVS ☆
Mixed Mitral valve with P.HTN
Station 5》
Retinitis pigmentosa 1☆
Familial hyperlipedemia 0☆

,Khartoum PACES, 3rd April 2016

cycle 3
:Station 1 ■
Abd: HSM+Lympadenopathy ▪
Chest: Left u lobe fibrosis + pleural effusion ▪
Station 2 ■
.. Chronic diarrhoea + abnormal LFT ALP high (UC+ PSC)
Station 3 ■
CVS: AVR ▪
CNS: LL Examination pt. with hypotonia mute planter & ▪
hyper reflexia
Station 4 ■
BBN & Councelling female 37yrs with ESRD (the one in the
course)
Station 5 ■
yrs male with Rt arm weakness22》1
 Neurofibromatosis compresses the ulner nerve. The pt.
underwent surgury for removal of fibroma recentely
A 53yrs male with long standing arthritis present with 》1
..dysphagia
have gritten eyes (sjogren) and have bibasal lung fibrosis & is
on methotrexate

Experience of my Friend,,get his Exam in Malta

0211/2/0
Cardio double mitral
Neuro : I did bad, examine upper limb. Right side hemiplegic
posture with mild weakness of no specific pattern, left upper
limb is normal, he told me to examine lower limbs which was
spastic in right side with extensive planter , he told me that no
need to examine sensation as all are normal
For diffrential diagnosis
Communication : also was bad, 40 female with diarrhea 2
. months ago, father and brother with cancer colon
Inside: no reason for diarrhea except ? Irritable bowel, she
had normal colonoscopy 9 months ago
The examiner was tough , I said she has to do colonoscopy
again because the it was 9 months back and the diarrhea 2
month ago but he was unhappy , also he asked me why u did
.not mention cancer colon screening programme
Station v
joint pain ..inside psoriatic arthropathy )1
 recurrent chest infection : inside bronchiactasis )0
Abdomen : splenomegaly with ascites for diffrential
Chest : thoracotomy scar with deviated trachea ? But there
was some breath sound on upper and no bronchial breathing
of the stumb.. ??? Pneumenectomy
History .. Palpitation in young male with family he of cardic
... disease
Inside : the father and mother died on 70ths, no hocm, mostly
stress , caffeine related
Over all impression : I missed a lot due to my own mistakes
.but the centre and most of the examiner are helpful
‫بالتوفٌق للجمٌع‬

Experience in Malta Centre

second day , carousel 1 11/2/0
: ABD ♤
splenomegally with CLD
: Chest ♤
.Pneumonectomy in a young patient with alopecia
Hx: fever, upper abdominal pain , nausea and high LFT in a ♤
returner from Kenya
CVS: AS /AR ♤
Neuro : proximal myopathy (?congenital)♤
 :Comm ♤
A lady post Hip # and arthroplasty & on prophylactic LMWH,
fall down during physiotherapy and developed intacerbral
.bleedind
:Task
She is confusion , speak with her son (angrey😡)
:BCC 1 ♤
AF, pacemaker possibly non functioning presented with
.slurred speech for 30 minutes
:BBC 2 ♤
..A pregnant lady with SOB for 2 weeks
:Hx ♧
A 50 years female , married , works as hospice nurse, travelled
to Kenya with her husband and came back with
nausea,vomiting, fever and upper and pain radiating to back
Heavy alcohol intake
Had 3 miscarriages at Gestational ages of 26,28,28 no
personal or Fx history of VTE
Gp letter mentioned high bilirubin 70 and elevation of all Liver
..enzymes
? Concerned is it cancer
DD : I mentioned Alcoholic hepatitis, viral hepatitis(A) ,
.autoimmune hep, and malignancy
Discussion was about working her up , and how to manage, I
mentioned that she needs admission, clinical assessment and
 rehydration if dehydrated, pain control and fever ttt with
NSAID and avoidance of acetaminophen and to treat etiology
.I emphasize on alcohol cessation
:Communication ♧
Task: To speak to an angry son of a 70+ female admitted
initially in orthopedic ward with # femur and underwent
.arthroplasty 2 weeks ago
One week after she has fallen down while doing
rehabilitation. Since this fall she is on and off confused,
orthopedist assure her son that this confusion is because of
.UTI and she is receiving ttt for that
Then, the patient is transferred to the medical ward as her
confusion continues, CT scan arranged & showed intracerbral
bleed with midline shift. The neurosurgeon advised to hold
enoxparin ( which was started as prophylaxis) and her usual
.aspirin and to stop her oral feeding until the you see her
Role : To inform the son about CT findings and the subsequent
management plan and to discuss the clinical judgment when
.outweighing benefits and risk of LMWH
Son was angry but I listened to him empathetically and
reassured that I'm here to help, I broke the BN (CT findings)
,and explained the Neurosurgeon's opinion
:His concerns are
,what is the cause of her bleed *
, why giving another blood thinner while she is on ASA *
,could the fall be avoidable *
?why he have been told that she has UTI *
BCC 1 : old male , c/o slurred speech for 30 minutes, three ♧
previous episodes of near fainting , during episodes he feels
. "fluttering" sensation of his heart
PMHx : HTN on amlodipine 5 mg , AF on pacemaker and
warfarin 3 mg and regular check, ranitidine for gastritis
Exam : AF with rate of 80
Discussion was about DD
,I mentioned TIA , orthostatic hypotension
How to investigate, he ask me will you change his anti
?hypertensive or not
BCC 2 ♧
A young lady, pregnant in 18 weeks gestation with SOB for
2/52 and cough with occasional whitish phlegm and occurs at
late night and early morning, no any other symptoms upon
discussion
K/C bronchial asthma & is controlled before pregnancy on
inhaled SABA & Inhaled steroids but she stopped them both
,after got pregnant as She thought they're harmful
Examination: all clear , LL clear
I explain for her the role of inhaled Mx in controlling her
asthma and that why she got these sympx , reassure about
safety in pregnancy, adviced Peak flow diary and FU with GP
Discussion: DD chest infection and less likely PE
Examiner asked what is against infection, also asked if PE
? need to be ruled out & what to do
 Castle Hill Hospital
Station 2》
years old .DM.asthma presented 02
With recurrent chest infections for 6 months 6 times
I put DD bronchiactesis .TB
No Hx of fever .wt loss or travel or contact with pt with
chroinc cough.he has greenisg sputum..constipation..I did not
understand his accent clearly
He continue mentioning constipation and trying to have a
baby and I totaly ignore it..his concern why I have this
recurrent infection
His diabetes and asthma are not well controled I asked about
HIV risk which up set the examiner
I forget sinusitis and examiner was angery and heampotesis as
.well
I told him we are going to do bronchoscopy..also upset the
examiner
He asked me about d ...my dd was bronchiactesis and TB
He asked about one blood test for specific for bronchiactesis
I told I do not remember
..😳 He said serum antibodies for pathogenes
😣 I was about to say immunoglins but bell rang
.CNS: Upper limb exam .3》
He has hemiparesis
I did not finish sensation
 Not examin e nech
He had truma with scar in head which I did not notice even
.when examiner point it
He ask me if you notice any facial asymetry I said no..which
acutaly was present
:CVS .3》
A tall women I wasted time looking for alchol gel for scruping
and washing hands with water
Marfan syndrom with 2 sacrs on medisternotomy scar with
metalic clikc and aother an rt subcalvicukar..no muremur but
2nd sound was loud and palpable..first was soft
My d..aortic valve replacemtn
He asked about causes of chest pain in marfan
I told ACS
And pneumothatx he asked what else which I can not answer
She had high arch palate and archenodactyly..I think by other
cause of chest pain he wants rupture anyuresm..I just
remember it now
:Communication skills :2》
Staion 4 ...80 years old patinent..Alzehimer d...was on NG
feeding and she was agreesive and agitated all the time and
use to pull it out..her doughter facing problem with feeding
and want PEG tune insertion ..speak to her doughter and
...explaine ill_terminal care and palliative care for her
I do not now mentioning DNR waa suitable or not but I have
..mention it
Examiner asked about how are you going to feed her if sh will
..😳 not take oraly no NG no PEG tube
:2》
Station 5 was diffecult
years with skin lesion over her forhead and scalp 12
Looks like morphea
Some candidate mentioned SLE
Apart from that she did not have any manifestation of scl
? eroderma ..her concern is it a infecious
?Is it cancer
I reassure her ..but examiner asked what could cause
morphea
Second case 62 years old ..with blurring of vision .exssive
fatiguabilty..and more blurred by the end of the day..deffintly
she had exopthalmous and opthalmobligia..diplopia on both
lateral gazes..thyrodyectomy scar and left firm thyroid
😥 nodules
Dry hard skin..fundus normal..no other manestation of
..thyroid ..no proximal myopath
I told dd
Graves opthalmopathy and
Mysthenia graves
:Station 1》
chest bilatral basal fibrosis and skin rash..I do not now what ¤
is it...some candiadte examiners told them it is
dermatomyosistis..it was not typical she had hard skin..finger
.tips ulcer as well
Abdomen...abdominal pain ¤
I could apprecaite 2 masses in rt side and one mass in left side
not liver not spleen...it was transplanted kidney ..examiner
? asked why she is going to have abdomian pain
?What about immune supression side effect
...Examiner questions was more tough than the exam
But it was nice experiance
..Keep praying for me

weird st 4 experience uk center:( friend of mine)

task: talk to this lady who is 40 years old,she had referred by
the GP to cardiologist for complain of chest pain.her cardiac
markers,ecg,cxr,stress echo everything came out normal.your
cardiologist is not present in hospital and you as medical
registrar been asked to explain the findings to patient and tell
.her the pain is non cardiac
Hello, is this Mrs.Walker? hi Mrs.Walker ,my name is
Dr.Vincent and i am the medical registrar.i have been asked to
.speak with you regarding your test results
?first of all please tell me how are you feeling today
 is anyone accompanying you or do you want anybody to be
here while we discuss? she is like no doc,i am just wondering
!what is the problem with me
i can understand that you are bit anxious about the present
situation, please tell me what do you know so far?has anyone
?explained you about your present problem
no doc i just went to my GP few days back with this horrible
chest pain and he immediately sent me to the heart doctor
and he did bunch of tests and something called echo and i
don't know why i am having chest pain? i think its heart
!attack,what do you think doc
well,i am very sorry about that( making sad face and
concerned look ,as if i am going to get an oscar award for this
performance),let me assure you i am here to help you and i
am going to explain you what has been happening ,okay! you
have told me that you think its heart attack,do you have any
specific reason to believe this,can you share with me that
!thought
oh,you know doc ( sobs!........i am silent,offer her a
tissue,sobs....i am just waiting,suddenly crying spell is over( i
.....)feel sigh
you know doc,my mum and sis both had heart attack and died
!coz of that and i am damn sure i am also having same issue
oh Mrs.Walker ,its sad to hear that and i am very sorry that
your mum and sis had to go through this turnmoil,do you
mind telling me a bit about their health in general ,i mean did
they smoke,drank alcohol excessively or had history of high
,blood pressure
, oh yes,my mum was heavy smoker and my sis was alcoholic
and at what age you mum had heart attack ---at age of 70
 and your sis-55
.again i am sorry about that,Mrs.Walker
Mrs.walker i understand that the pain you have been having
in left side of your chest is been there from 3-4 days ,am i
.correct? oh yes dr
.and its always there? oh yes
and do you smoke and drink alcohol,no doc.i dont do any of
those and i exercise regualrly
i know we shouldnt take history but i was just confirming (
and trying to reinforce the thought before i tell her its non
.cardiac
.thank you mrs.walker
well we have done extensive blood tests as well imaging of
your heart and all tests appear to be normal and thats
!excellent news
isnt it? what do you mean doc? my tests are normal? there
?must be some mistake
Mrs. walker i understand your worry and concern ,however
the tests are thoroughly verified and it appears that the pain
you are experiencing is not because of heart attack,i am quite
!sure about that
hmmmm doc! so you think there is anything else ,any other
?test can be done to be hundred % sure
Mrs. walker ,as a doctor i can reassure that we have done
every possible and relevant test in your case,and everything
leads to this outcome that the pain is most likely due to
.muscle injury in chest
!rest assured,its not your heart
 !!!!!!!silence
also mrs walker you have been leading a very healthy life
style,you do regular exercise,stay away from all sorts of
toxins, and these factors do protect your heart from
?developing any heart ilness, are you following me
yes doc ,so thats why my GP told me to not exercise for 2
(weeks
bam!!!!! i wonder ,why the hell i didnt ask her this before but
any way she has spit this info to me ,now i am sure its
)costochondritis,but i cant take detailed history here
!yes Mrs.walker i believe so
would you mind telling me hows things at home lately !
?specially since the pain started
!well i have been feeling low! my appetite become low
hmmm! do you have nay hobby? yea i used to do gardening
but i am not doing any more from last one month! i also get
.less sleep in night
have you had any bad thoughts lately? what do u mena doc? i
.mean any thoughts of self harm........ hmm no
okay,these experiences may also be culprit in causing you the
?pain you are having? what do mean doc ,am i going nuts
No Mrs.Walker,its nothing like that,you see our body is very
complex and sometimes our brain does creates symptoms
inspite of no obvious reasons,however in your case your pain
,is real
but just to rule out any psychological reason ,i would like you
!to have a chat with our psychologist today,if you are willing
!okay,we can do that doc
so let me ask you ,can you pls tell me what we have discussed
?so far
.she summarise it briefly and appears to be okay now
okay ,at this point do you have any question for
?me,Mrs.walker
?oh yes,doc shall i resume exercise after 2 weeks
well Mrs walker i will re-asses you after a week and see how
you have progressed and then we can take it on further. does
?that sound like a plan
oh yes doc ,thanks a lot
examiners were real jerk( see i am South asian but the south
asian examiners are worst,specially the one in England)
?first question 1,how can you say its non cardiac
i feel puzzled!! i guess thats what my task is,to convey the (
message to patient in proper way that its non cardiac pain,i
)..... felt like
any way i answered him," sir ,as the all test were normal as
well she didnt have any significant risk and both her mum and
sis developed heart attack after the age of 50 which is not risk
factor,this patient has healthy life style as well the pain is
persisting from 3 days,its most likely costochondritis or
functional pain,to rule out one need detailed history however
here i am bound to stick with communication and ethical
)concern only
.nd qs0
?what are the ethical principles involved
Autonomy
beneficence
 non-maleficence
justice
,rd3
why did you tell her that you will get a psych consult? arent
!you able to deal by yourself,you are also a Doctor
i said,yes the reason why i need a psych consult is ,initial
depression screening does suggestion some element of occult
depression and its wise to get professional help,as my current
.role is cardiology registrar
Now what he does is completely insane,he tells to other
"examiner ," i think you should also ask some questions
)i am like what the ****,ideally only one examiner leads (
anyway that guy asks me ,do you think patient was
?convinced?did you resolve her all issues
yes sir,i believe she did. as she agreed upon further followup
as well she got convinced that its basically muscle pull in chest
.which causing the pain not heart attack
!okay,thank you,you may go
I felt ,atleast i will get 12-14 out of 16 in this case
????>when result came out,it was a shocker
11/3
they simply screwd me,i had 127 score overall,passed in all
!skills but st4 and communication
!story of my life
 Whipps hospital in London
I scored 150 and passed all the station and scored 9 in ♢
. patients concern.So Failed the exam
I asked about the concerns in all the stations and I don't know
.why
:My stations were
:Clinical Stations》
:CNS ¤
Scleroderma and proximal myopathy
CVS:Mixed AR and AS ¤
Abd:liver and renal transplant (PCKD) ¤
: Respiratory ¤
Apical fibrosis (Asian. Man -could be TB /and discussion
around asthma )
:Communication 》
I think we had it in the course
The old lady after hip fracture who was on aspirin and clexane
.She had a fall in the rehab ward and had a stroke .Discuss
with daughter who was angry and does not know why mother
. had scans
:History》
A 55ys old pt with anemia and malena
On Ibuprofen for knee pain
:Station 5》
Diabetic pt with visual problem ¤
 Uncontrolled hypertension in a young man ,has ¤
hepatomegaly
‫ا‬DD Pheocromocytoma /PCKD
;This candidate is very unfortunate》》
It is unbelievable, to score 150 and pass All the stations & the
Skills with high mark and to fail the exam because of One
..mark in One skill
My Advice to this (& similar candidates) is to go to the next
..exam as it is unlikely to be unlucky twice
Good luck

:Glasgow PACES today

:Station 4 ♤
Delayed diagnosis of pheochromocytoma
Mr, jones 35 years male
Had High BP for last 5 years
Seen by psych for panic attacks
Tried many Med for HTN
But
His BP has been difficult to control
On his insistence , his GP has referred him to hypertension
clinic 2 weeks before
Results of tests now show
 Urine : high metanrphrines
CT adrenal : 5 cm mass in right adrenal
Ur task is to explain the diagnosis
U don't need to know the details of further tests and further
management
Patient was concerned
Is it serious
Is it cancer
Is there a cure
Will I require future surgery
What future tests will be done
Was the delay justified
What medicine u will give me
Examiner : repeated similar questions
Overall not too harsh patient
Satisfied at the end
Agreed follow up GP Consultsnt website address alpha
blocker beta blocker
History station ♧
Young female 28
Blood Diarrhoea after Cyprus visit
Started 1 day before coming back
Mixed with stool
Similar episodes for last 2 years
 Took amoxicillin in Cyprus
Diarrhoea aggregated
Now last 10 days
Frequent blood a salime in still
Painless
C/ o small joints pain
No backache
No other extra intestinal symptoms
No oral ulcers
No skin changes
No jaundice
Cousin IBD UC
Father CA colon
No blood thinners
No steroid
No warfarin
No bleeding disorder
No weight loss
Concern : cause
? Is it cancer
? What next tests
? What Med
? Need admission or not
:DD
 IBD ( UC)
Infective Diarrhoea
Antibiotic associated Diarrhoea
Examiner : just repeated all above
And
Asked
In
; History how will u rule out infective cause
Fever
Vomiting
But
He told
U will ask about symptoms to others accompanying him
On your behalf, I thank this colleague for his detailed n ♡
comprehensive feedback And I wish him all the best and of
.course success

Chennai
nd day0
Station 2 / palpitations for 1 month. Delivered 4 month. back
... .Postpartum thyroiditis. Post partum cardeomyopathy
cns charcot Mary Toth / 3
CVS systolic murmur all over the precordium. .. VSD /MR not
sure
/1
abd ADPK
Respiratory. Fibrosis +_ cavity .old TB
non cardiac chest pain. Seeking more investigation /2
SLE c/o pluritic chest pain /2
Distal phalanx arthritis. Known case of hypertension on
.thiazide presented with lt wrist joint pain D/D gout arthritis

:Kuwait exam on 23/3

CVS:AVR
CNS:UL wkness for DD
COMMUNICATION:talk to pt's daughter>>her father CVA
.admitted to non_stroke unit> develop MRSA
BCC1:P.N for DD
BCC2:Bloody diarrhoea for DD
.CHEST:Rt pleural effusion
.Abd:HSM&Ascites
.H.T:SOB&WHEEZES
.Best luck for all

;Malta PACES
 ..The experience of another colleague
:Station 5》》
BCC1: scleroderma + lung fibrosis》
BCC2: Retinitis pigmentosa》
:CHEST》
left thoracoplasty + lobar lung collapse , right upper lobe
crackles S/p Pulmonary TB
Abdomen: ESRD w RRT in a form of left sided transplant & AV
fistula ( functional & in use currently), multiple scars for
previous tunneled catheter, peritoneal dialysis & RIF scar! I
justified the active fistula with transplant failure as patient
was uremic & hypervolemic, but couldn't justify why the
!transplant was left while it's usually done in right side
The other point I said right sided scar most likely not related
to the case & could be s/p appendectomy, later I found the
patient & he said the transplant was first in right but failed &
!redone in left side
:History》》
Deliberate self harm, paracetamol & alcohol toxicity, very
..annoying & arrogant lady
:cardio》
midline sternotomy & left lateral thoracotomy S/p Mitral
valvotomy & later MVR, was in decompensation with
thrusting displaced apex, raised JVP, loud P2 , PSM.. Metallic
click wasn't very clear, other candidates got confused with
.this case
:Neuro》
 Mixed Motor &Sensory neuropathy, Charcot joints & left foot
drop, absent reflexes & all sensory modalities distally, bedside
..orthosis
:Communication》》
Discuss brain death & organ donation with girlfriend , very
:complicated case with many legal & ethical issues
She was complaining that my consultant already discussed -
the case with her boyfriend's mother without taking her
.permission & she is No 1 in relative ranking by law
The mother agreed for organ donation & she is the -
nominated proxy w valid Lasting power of attorney accredited
by a solicitor , but the Girlfriend refused organ donation &
!was challenging the power of attorney
GF requested to explain how she can officially complaint -
!against NHS

Malta Centre
second day , carousel 1 11/2/0
: ABD ♤
splenomegally with CLD
: Chest ♤
.Pneumonectomy in a young patient with alopecia
Hx: fever, upper abdominal pain , nausea and high LFT in a ♤
returner from Kenya
CVS: AS /AR ♤
Neuro : proximal myopathy (?congenital)♤
:Comm ♤
A lady post Hip # and arthroplasty & on prophylactic LMWH,
fall down during physiotherapy and developed intacerbral
.bleedind
:Task
She is confusion , speak with her son (angrey)
:BCC 1 ♤
AF, pacemaker possibly non functioning presented with
.slurred speech for 30 minutes
:BBC 2 ♤
..A pregnant lady with SOB for 2 weeks

Experience of my Friend,,get his Exam in Malta

0211 /2/ 3
COMMUNICATION
Explain Diagnosis PHEOCHROMOCYTOMA
 Dr Ahmed Maher Eliwa discuss thi scenario with me 4 dayes
before the exam
‫جزاه هللا خٌرا‬
Hisrory
Abnormal liver enzymes(Transaminase increase 20 folde)in
young man taking Methotrexate for 8 mounth
ve sympt&signs+
epigastric pain
dark urine
pale stool
glasses of wine per night0
NEURO
Spastic paraparisi for DD
But i examiner stops me with each step ASKING can y interprt
what y r doing
eg:: hypertonia
hyperreflexia
The WHOLE time of i exam turned to ADISSCUSSION
about DDof Spastic paraparisi
?? eg:: in a young man what is the causes of Spastic paraparisi
??? in old lady&
ask about ttt of MS
Again Expectation of Dr Ahmed Maher Eliwa especially 4 me
)‫(مستشفى الحسٌن‬
CARDIO
 MR
ask about signs of Infective Endocarditis
signs of severity of MR
investig&ttt
ABDOMEN
Pallor+PALPABLE liver
span 4 fingers below i costal margin
first i told him hepatomegally,,he asked how many fingers,, I
answered 4 fingers
???he asked do think it is enlarged
I answered ok,, it is palpable NOT enlarged
ask about DD
INVESTIG
TTT
CHEST
The first=The worst=The difficult one
chest deformity ...= ...Pectus excavatum-1
Left lung = area of bronchiectasis-0
Right lung=Boncheal breath+dullness+high vocal resonance -3
Under built-2
ask about the right one
DD
INVESTIG
TTT
 STATION 5
Loose motions for eight mounth&anaemia 10.5=serrogate -1
Coeliac
Irritable bowel syndrome
Intractable dry cough for 3 mounth=serrogate-0
she has childhood asthma
has gastritis
I ask every one read this ,,, only pray 4 me
if y please
Thanks&good luck 4 all

:Khartoum PACES, second day

Day 2 Cycle 1
St 1 ●
.Bronchiectasis •
Felty's syndrome •
St 2 ●
Iron deficiency anemia •
St 3 ●
.Proxymal myopathy •
.Mitral regurgitation é pulmonary Htn •
.St 4 ●
 Delayed diagnosis of pheochromocytoma
.St 5 ●
.Tuberous Sclerosis •
.Bilateral carpal tunnel in hypothyroid a 55 yrs old lady •

##############################################
##############

PART 1
Today with us A very exciting and inspiring experience
She's a friend of mine
Tested the in Muscat, Oman April 2014
On the personal level I have benefited a lot from it
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Abdomen was thalassemia it was clear ..scar in abdomen and
hepatomegaly ... ....and the question about hemolytic
......anemia
....... Chest was copd with bronchectasis
Also questions were about copd ABG and long time oxygen
therapy and ventilation
Cardiovascular I don't know what was the diagnosis. ...I did so
bad ...it was scar ....prosthetic valve ??? Ms.....and collapsing
.... pulse and pulsating carotid and murmure??? AR
.... Anyway I don't know what was the diagnosis
Neuro young pt ...left sid hemiplegia and cerebellar
..... .syndrome
 ..... Also I missed the case
Station 5....The first was neurofibroma. ...70 years with
.... .recently deaf
It was clear but the examiner asked me alot of questions
about why you didn't do weber and rinne ......even I didnt
realize that the fork in the table and why ....I thought for
...neuro
He asked me alot of questions about brain tumor I can't even
...... remember the name
The second one was young like 15 years history of double
vision
On history was recurrent mouth and genitals and this double
vision and taking steroid for that but family doesn't know
why.....on examination was so tight the place and he is not
talking English not following you ....and for fundoscopy I
asked the examiner for the light in room he said didn't switch
off .....Anyway it was optic atrophy in right eye was clear in
left I'm not sure ......The question was how to confirm optic
? ?atrophy
And about behcet disease and he was not happy because
....asked me you ll not reply gp
Alot of small mistake ....but really because of short time I
...... missed so silly things
History was 52 history of migrain and high blood pressure and
....3 weeks sob
... .years surgery on his legs for artery 12
.... .sister dead 40 years heart disease
Discussion was about left heart failure .....The time finish
befor finishing the management plan
 ... Comunication was long scenario .....My last station
The angry daughter want to see you because of her father
who was admitted 3 weeks because of cva ....He developed
pressure ulcers and swap show Mrca but clinical no signs of
.. .infection
The team in stroke unit refuse to admit him because no place
....
In side the daughter was fighting the nurse not taking care of
...... him anytime we ask her for help she is busy
Then what this infection and why and what to treat and so
.. .many questions about mrca
Then about stroke unit why didn't admit him there ......then at
.... home no one to help him
.... All the world s problem was in her mind
For me I missed alot of things even her name and if father or
mother the one in ward and also even I didnt red in the
sinario that he supposed to go to stroke unit .....Anyway the
examiner was asking about mrca
.... This was my fantastic exam
.... Alhamdllelah
I wish the best for all of you
##############################################
#########

PART 2 = Feedback
Today with us A very exciting and inspiring experience
She's a friend of mine
 Tested the in Muscat, Oman April 2014
On the personal level I have benefited a lot from it
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
..... .Good morning everyone
I'll send my feedback as I received because I want to make
things a little bit clear that to fail in one or two station or
.....three even still you can pass
In the exam you don't know what is going on in examiner
..... mind.....Anyway I'll comment on every station
First in cardiovascular and neurology I did soo bad as I wrote
...to you after exam and I didn't expect more than this
I missed the clinical findings so I didn't reach the DD and
... judgments
In chest and abdomen I did well but also I missed few things
especially in chest but in general I expect to get 18 or 20
In history I despite case was easy and because was first
station I was so confused and really after exam I was
.depressed because the case was easy and I was soo clumsy
For comunication ...I did alot of mistakes because the scenario
was soo long ... like forget who's the sick ...The pt
name...even it written in scenario that the pt didn't admit to
icu because no bed and daughter asking me why and I'm just
looking at her without answer ....Also I finish befor one
minute and was just sitting without talking
I thought I did soo bad ..but still got full mark.....
In short station also the tow scenario which I took I red the
first and the second also I forgot who send the pt and again pt
.... .name and if pt in clinic or hospital
 Again in behcet disease he wanted foundscopy so i was so
stressed when i saw the ophthamoscope in table because I'm
not familiar with that .....Anyway the optic atrophy was soo
clear and asked me two questions like how to diagnose
behcet and how to confirm the optic atrophy i answered
wrong. ..and asked me you want to reply anyone ...i was
... looking to the scenario ...without answer
But still i got 25 more than i expect
In neurofibroma ......it was spot diagnosis but in examination I
examined just the lesions without looking for frickling or
other criteria for neurofibroma...I rememberd the criteria
...after the exam
And the most important thing was he kept fork on the fir
hearing examination but I didn't realize that but he asked me
to look at the table. ...I was shocked because I forgot even the
name for the test..and asked me then how to treat also I
didn't answer well
For welfare. ....I forget to wash my hand .....Every stations the
examiner was asking me please dr wash your hand
:......:persevere
This is my feedback ......I know my score not high but I sent it
to everyone just to be optimistic and do your maximum and
.... leave the things for our God
See that in judgments i got 18
And my score just 133
But what I want to say that I studied tooo much ....and I was
trying to go to teaching hospital after finishing my 12 hr duty
...
 And many times the nurses not allowed to me to examine pt
because I'm from other hospital
Many times I back crying .... .........The only space for studying
was in work ....despite last tow months I'm doing 27 duty per
...... months because two of our colleagues on leave
.. But still i was trying ....my best
And every day I was praying and ask God to be with me in the
...... exam
##############################################
##################

--UK on 25th Cumbria

started with station 5
Lady with MS coming with frequent UTI andurinary .1
.incontinence
.On history also told she had uterine and rectal prolapse
Was confused what to examine and then the examiners told
me to examine the abdomen only.discussed possibility of
worsening MS and prolapse related problems
Got 28/28
.0
.Lady with pain in hand joints
.She had systemi sclerosis
 Forgot to take swallowing history and didn't listen to lung
bases in order to ask her concerns bu5 in discussion explained
.thqt I will take swallowing history
.They asked my diagnosis
Said SSc. Asked what physical examination will u do if allowed
.to have extra time
I forgot to tell respiratory exan and remembered qfter coming
.out
.Got 27/28
Station 1
.Respiratory was COPD
I said fibrosis but they directed me to COPD and gave a good
.discussion how we differentiate them
.02/12
Abdo
.I thought Chronic liver disease and ascites
.Got 8/20
!!.So I was wrong
Station 3
Cardio
Was pan systolic murmur at apex radiating to axilla amd
.midline sternotomy scar without any other scar
.Said MR and MVp as lady was in 30s
.They said what else
I said VSD and then we discussed endocarditis management
02/12
 Neuro
.Left sided Hemiplegia
.Couldn't complete examination
.Discussion messed up
.02/10
Station 4
.Lady with diabetis coming with proteinuria
.Explain
Went in she was very angry.calm her down and explained
.relationship between diabetes and proteinuria
.examiner gave me 8 other gave me 0 1
11/2
sta-2 - tremor , was simple got 20/20
result -- pass

last round Chennai 12.3.0211

Station 5 loose motion for 3 months
Bilateral knee pain
Station 1 Respiration COPD Bronchiectasis
Abdomen. APKD
Station 2. Headache with menorrhagia
Station 3 CVS MVR
 CNS Facial palsy
Station 4 Type 1 DM with proteinuria
Poor drug compliance

Kuwait 24/3
Station 1: Copd.... renal dyalisis pt with left A-V fistula
Station 2: headache
Station3: MR .... GB
Station 4: breaking bad news for a lady whos husband had
meningiococal sepsis
Station5 : DM macular edema .... hypopituitarism

This feedback from a colleague who appeared in last PACES. .

..Whipps hospital in London
I scored 150 and passed all the station and scored 9 in ♢
. patients concern. So Failed the exam
I asked about the concerns in all the stations and I don't know
.why
:My stations were
:Clinical Stations》
:CNS ¤
Scleroderma and proximal myopathy
 CVS: Mixed AR and AS ¤
Abd: liver and renal transplant (PCKD) ¤
: Respiratory ¤
Apical fibrosis (Asian. Man -could be TB /and discussion
around asthma )
:Communication 》
I think we had it in the course
The old lady after hip fracture who was on aspirin and clexane
.She had a fall in the rehab ward and had a stroke .Discuss
with daughter who was angry and does not know why mother
. had scans
:History》
A 55ys old pt with anemia and melena
On Ibuprofen for knee pain
:Station 5》
Diabetic pt with visual problem ¤
Uncontrolled hypertension in a young man ,has ¤
hepatomegaly
‫ا‬DD Pheocromocytoma /PCKD
;This candidate is very unfortunate》》
It is unbelievable, to score 150 and pass All the stations & the
Skills with high mark and to fail the exam because of One
..mark in One skill
My Advice to this (& similar candidates) is to go to the next
..exam as it is unlikely to be unlucky twice
Good luck
 -- exam in Kuwait yesterday
Neuro. GB
Card. Mr
Coum. PT with uncertain diagnosis for discussion with
.relative
St5 diarrhea 4 year. With iron deficiency Celiac
.St 5 leg swelling
.Chest - lung fibrosis

Yangon centre day3 round 1

BCC- systemic sclerosis
OSA -
Respi-COPD with basal crepts
Abd-COL with bilateral mastectomy scars with RIF scar
Neuro-dysarthria & examine UL- cerebellar sign(+)- MS
?CVS - AS AR TR MR
Examiners ask to measure BP
St 2- Tiredness with ED
with U/L DM & HT
 St 4- noncardiac chest pain
Musculoskeletal ? Functional?

-- exam today in Kuwait yesterday

Station 5
Acromegally
Ankylosis spond
Hx TIA
.Communication.. uncontrolled DM with proteinuria
Abd: CLD
Chest: bronchectesis
CVS:Ms and AR
.Neuro : paraplegic with sensory level

.exam 20-3-2016,Castle Hill hospital cottingham

Started with station 5 back pain increasing , my Dx Ankylosing
Spondylitis ,next progressive visual deterioration,diabetic
..... ,,pdr
Station 1, RS persistent cough,couldn't diagnose put as ILD
...abdo acut pain abdo with tatoo tender right
..hypochondrium....discussions about it
 tation 2 malaise,loss of appetite fever night sweat wt $
loss.....discussion put DD as cancer ,TB,asked anything else I
forgot sexual Hx 55 yr old women....told may b HIV,,
,connective tissue diseases
Station 3 CVS sternotomy scar no murmur look like valve
replacement aortic later examiner diverted to causes of AR I
told a few Marfan's ....later saw patient has kyphoscoliosis
missed while presenting
,CNS HMSN
Communication: patient had disseminated bowel cancer
presented with bleeding ulcer talk to brother who says his
brother is dying any how why we are doing any procedure
....brother has consent patient has capacity I told his choice to
get treatment or refuse no one can force him

Chennai 18/3./2016
last round
Station 5 loose motion for 3 months
Bilateral knee pain
Station 1 Respiration COPD Bronchiectasis
Abdomen. APKD
Station 2. Headache with menorrhagia
Station 3 CVS MVR
CNS Facial palsy
Station 4 Type 1 DM with proteinuria
 Poor drug compliance

Examinations of LATER dates

I HAD MY PACES IN ONE OF THE OVERSEAS CENTERS AND
HERE IS MY EXPERIENCE
STARTED IN STATION 3
NEURO
REQUEST WAS TO EXAMINE MOTOR SYSTEM
THE PATEINT HAS GLOBAL APHASIA(I DON'T KNOW HOW DID
THEY CONSENT HIM FOR THE EXAM) WITH RIGHT SIDED
WEAKNESS THE PT WAS NOT RESPONDING TO MY
COMMANDS AN HIS UPPER LIMB WAS PAINFUL TO TOUCH, I
DID TONE AND REFLEXES AND I STRUGGLED A LOT
TECHNICALLY THE DISCUSSION WAS ABOUT CVA AND
MANAGEMENT
CARDIO
THE TIME WAS VERY SHORT AND I AUSCULTATED ONLY FOR
ONE MINUTE THE CASE WAS DIFFICULT (COMBINED MITRAL
VALVE DISEASE AND PULM HTN) MY PRESENTATION WAS
BAD I WENT THROUGH MANY VALVE LESIONS BEFORE I SAID
COMBINED MVD THERE WAS NO TIME FOR DICUSSION
STATION 4
COMMUNICATIONS
A GIRL WHO HAD HER FATHER DIAGNOSED WITH SUP VENA
CAVA OBST AND ADVANCED LUNG CANCER AND SHE WAS
CRYING AND CRYING TO DEAL WITH HER
STATION 5
SKIN : NEUROFIBROMATOSIS 1
MSK: OSTEOARTHRITIS OF THE HANDS
ENDO: GOITER WITH OPHTHALMOPATHY DEFINE THYROID
STATUS
OPHTHALMOLOGY:(NO IDEA) I SO OPTIC ATROPHY AS A
DOMINANT SIGN AND THERE WAS SOME HARD EXUDATE??
DM+ISCHEMIC OPTIC ATROPHY
STATION 1
ABD
CHRONIC LIVER DISEASE WITH ASCITIS
THE EXAMINER DIDNT GIVE ME THE CHANCE TO COMPLETE
MY PRESENTATION AND HE TOOK THE ROLE
CHEST
COPD AND BRONCHIECTASIS( LOCALIZED)
STATION 2
A GUY WITH HEMOPTYSIS AND NIGHT SWEATS
OVERALL THE CASES WAS NOT SO DIFFICULT
THE BRITISH EXAMINER WILL LET YOU TALK AND EXPRESS
YOURSELF WITHOUT INTERUPTION
WHILE THE OVERSEAS' THEY ARE UNBELEIVABLY RUDE AND
THEY KEEP ON INTERRUPTING AS IF THEY ARE EXAMINING A
MEDICAL STUDENT
 THE TIME WILL PASS VERY QUICKLY
THE SIX MINUTE IS VERY SHORT FOR THE HEART STATION
THE NEUROLOGY CASE WAS UNFAIR AND THE GUY WAS SICK
AND NOT A CASE FOR THE EXAM
I DONT KNOW WHAT WILL HAPPEN BUT I KNOW ONE THING,
IF I SHOULD DO A SECOND ATTEPT I WILL DEFINETLY DO IT IN
THE UK
BEST OF LUCK EVERY BODY

Examinations of LATER dates

ABDOMEN WAS YOUNG MAN WITH JUST PALPABLEEN ,PALE
WITH FINGER CLUBBING ALL FINGERS AND TOES
CHEST CASE THE SENARIO WAS PT WITH PRODUCTIVE COUGH
AND HEMOPTYSIS MALL AREA OF DULLNESS IN RT LOWER
LOBE IN THE AXILLA AND FEW SCATTERED CRACKLES(NO
COMMENT)
STATION 2
YEARS OLD WITH ABDOMINAL SWELLING -ASCITES AND 11
SMALL PLEURAL EFFUSION ON RT LUNG --TALK TO HIM
STATION3
YOUNG LADY WTH TENDON XANTHOMAS XANTHELASM EYE
LIDS ARCUS SENILIS MEDISN STERNOTOMY SCAR---
MICOMPETENCE AORTIC STENOSIS NO MECHANICAL VALVE
SOUNDS
CNS
YOUNG MASPASTIC PARAPLEGIA KNEE REFLEXES EXAGERATES
ANKLES LOST NO SENSORY LOSS AT ALL ALSO PES CAVUS
STATION 4
ANGN OF 71YEARS MAN WHO WAS INVESTIGATED 6 MONTHS
AGO BEFORE CABG --HE WAS ANEMIC GIVEOOD
TRANSFUSION AND PERFORMED CABG AND NOIS ADMITTED
FOR INVESTIGATION OF SUSPECTED GI MALIGNANCY--HIS
SON GRY FOR THE DELAY OF DIAGNOSIS OF HIS FATHER
MALIGNANCY ALL THIS TIME
STATION5
ENDOCRINE SIMPLE GOITRE WITH NO HYPO OR
HYPERACTIVITY
LOCOMR
RA
EYE
YOUNG LADY WITH DILATED RT EYE PUPIL NOT REACTIVE TO
LIGHT BLIND CAN NOT MOVE LATERALLY UPWARD OR
DOWNWARDS LT EYE OK---NIGHTMARE CASE
SKIN
PSORIASIS
THE PT WAS YOUNG WITH CLUBBING OF ALL FINGERS OF
BOTH HANDS AND FEET WAS PALE JUST PALPABLE SPLEEN
WHAT ARE YOUR FINDINGS? I SAID THOSE--WHAT IS YOUR
DD?MYEL-LYMPHOPROLIFERATIVES.LIVER SCHIRROSIS WITH
PH.CONGENITAL HEMOLYTIC ANEMIA---WHAT DO YOU THINK
THE CAUSE OF FINGER CLUBBING IN ABDOMINAL CASE?LIVER
CICHROSIS-PBC-IBD
 ARE THESE DISEASES IN YOUR CASE? NO WHAT ELSE CAN
CAUSE CLUBBING IN THIS CASE? HEREDITARY ----WHAT
QUESTIONS COULD YOU ASK THE PT?---DO YOU HAVE THIS
CLUBBING SINCE BIRTH? ANY MEMBER OF YOUR FAMILY HAS
?THE SAME CHANGES LIKE YUORS
WHAT OTHER CAUSES OF CLUBBING?HOW DID YOU KNOW
?THAT THIS WAS SPLEEN
THE YOUNG ASIAN LADY IN HER 20S HAS GENERALIZED ---
TENDON XANTHOMATA XANTHELASMATA ON HER EYE LIDS
ARCUS ON CORNEA WITH MEDLINE STERNOTOMY SCAR ---
APEX WAS NOT PALBABLE -NO RAISING OF JVP --MR
MURMUR AND AORTIC STENOSIS MURMER ----WHAT ARE THE
FINDINGS?I SAID ALL OF THAT ---WHAT IS YOUR DD FOR AS---I
SAID AORTIC SCLEROSIS AS THE MURMER WAS NOT WELL
PROPAGATED TO CAROTIDS----WHAT IS THE CAUSE OF ALL
THESE FINDINGS?I SAID -HEREDITARY COMBINED
HYPERLIPIDEMIA --WHAT IS THE MODE OF
INHERITANCE?AUTOSOMAL DOMINANT WHAT IS THE TTT-
STATINS AND FIBRATES---FROM WHAT YOU FEAR FRO
THIINATIONS OF DRUGS? MYOPATHY

Hi
I took PACES in LONDON
S1
RS: COPD -Chronic Bronchirtis(I couldn't finish the back
examination so I did just auscultation) asked me how to
confirm my diagnosis I said PFT FEV1 <70 and ration <80 and
 the reverse is correct(FEV1<80 and ratio <70) The time realy
.went veey quickly
:Abdo
the patient elderly and was cold!!! so I exposed his abdo just
till mid chest
and chachectic with huge asites ,duptryn's contrcture
,Jaundice
I present it ok but I mention the most likely diagnsis is
Malignancy but I didn't find LAP and he asked what else may
be the cause I said Cardiac failure but(I seaid ) he is lying down
on bed without SOB ,what else? said TB pertonitis.asked can
cause cachexia? I siad Yes.then ask me about the IXs I said bl,
U/E, US ,then tap for exudate ,transudate,.... he daid what do
u concern about this pt. I said SBP and asked how to diagnose
this?I said Tap if more than 250 cell then postive .he said
thank u
S2
about 34 y man present with syncopal attack
He had had 1 episode of syncop??as he said 14 y ago and he
didn't loss his consciousness but his wife shout to him but he
didn't able to reply this for 1 min ,but last 8 months it
happens 3 times the last one i lost my consciousness .father
died from ICH and mother RTA he didn't went to see dr at 1st
one because he thought it was trivial accident ,he is driver
and he concers about his work and as u know(he said)now
adays the financial crisis and it's very unlikely to get work
.rapidly
 I asked about the all format like PMH,FH,drug H, Personal
smoking , alcohol, recreational drugs , ROS off course about
..... the nature of the coma and witness and
finally I didn't summarize or get his expectations about the
.illness becuase the time was very short as well
they ask me about the problem list I said either Idiopathis
epileps or secondary epilepsy , he described abcense siezure
(actuly I think it was focal epilepsy then trun to secondary
generalize epilepsy . He asked me how to Ix I said EEG ECG
Blood , U/E, he then asked me what u have to told to him : I
siad I am sorry to tell u that but u are banned from driving and
u need to contact DVLA and your Insurance company.The
examiner surprizly says But he is driver his whole life depends
.on it? I said I'll tell him I am sorry but this is the law
) Realy I don't know if this is good or not(
S3
NS
y man LL examination 32
I saw faciculation (he wears jens rised it just bove the knees
Itried to roll up it but just small part of the lower part of the
thigh was appear) then there was wasting , and hypertonia
(spasticilty bilateral) so spastic paraesis pop up to my mind
and asked him to move his legs he couldn't almost power in
both legs was 0-1 and went directly to light touch (iI siad to
him I'll gonna to touch your leg by this swap of cotton plz if
you feel it as same as this(and try to touch it to the
sternum)say yes he said actually i didn't feel it dr.can do it on
my ckeeks !!what great offer!I said ohh yes then he felt it
when I begun to test it he was talking i didn't pay attention to
him then he opened his eyes !OOOOOOOOOOOOOOffff I
 again said to plz If u feel it as same as u felt it on your cheek
plz say yes
and then change it to the lf leg he lost his sense till
T5?????????? and again whith vibration he lost till the Knee
without sensation so I told the examiners I need to put it on
ASIS but it was covered by his Jense so I used the lower edge
of the rebs???he felt the vibration(I don't know if this is
correct or not)any way the time is over without seeing the
back
I presented my findings and said this is combined UML and
LML so my most likely dx is MND????? I haven't to say that
but it just pop up .and asked me what goes with LML? then
how to IX then I mentioned one of the test is EMG he asked
!!me and what u 'll find in EMG?I said I don't know
then Asked me :u said MND does it fit with the senseory level
u found? I pursed my lips and said no it doesn't .Thank me and
CVS
He typically was Mrafan but I didn't find the Apex beat??? I
thought it Dextrocardia but it wasn't then went through all
examination but without lean him forward I found early
diastolic murmur in apex area and the time
over!!!!!!!!!!!!!!!!!!!!!! I gave them my findings suggest most
likely this AR due to Marfan and the murmur high intensity in
apex area!! (I don't know if this will make me fail this station
or not because it doesn't fit with AR but I am sure it was AR)
they asked me about IX then causes I mentioned all causes
but I also said IHD he asked me and how this can cause AR ?I
said may by degenration of the valves!!(I didn't know the
relation)
S4
 IBS the pt wants to see consultant (not me!!) and about -ve
and +ve of Ixs because she wants more IXs to find out why her
symptoms contnue inspite of using medications 3 months
..and then seek second opinion
I don't know I was ok but u can't know that till u receive the
. result
They asked me what u will do for here I said may change the
medication .then asked :who will change it?I said the
consultant asked:and how the consultant will know ?I said I'll
explained to him and see her notes and contact her GP asked
me if this will not be useful what else u 'll do? refer her to
.Psychatrist
S5
psoriatic arthropathy .(do u think she has synovitis before I
said yes ?how do u know? because her left index finger was
deformed what else? he accompanied me back to the pt but i
!!didn't see anything else
Thyroid status with neck scar
Neurofibromatosis
Fudo: The left eye was abnoraml may be old choroiditis I don't
?know
And the test over
The examiners were very nice and the cases all predicted all in
.Ryder no time for theory no time for perfect examination
Thanks
Hope all pass
 Chennai 3rd day 1st round
Copied
????cvs... MR/VSD/TR
CNS....HEMIPLEGIA
Abd... Acities alone
Resp.... underlying copd with fibrocavitatory or fibrosis
History.... confusion with underlying CA prostate
Comm... amiodarone taking patient got lung fibrosis
BCC.... OSA

Exam experience Chennai

nd day0
Station 2 / palpitations for 1 month. Delivered 4 month. back
... .Postpartum thyroiditis. Post partum cardeomyopathy
cns charcot Mary Toth / 3
CVS systolic murmur all over the precordium. .. VSD /MR not
sure
/1
abd ADPK
Respiratory. Fibrosis +_ cavity .old TB
non cardiac chest pain. Seeking more investigation /2
 SLE c/o pluritic chest pain /2
Distal phalanx arthritis. Known case of hypertension on
.thiazide presented with lt wrist joint pain D/D gout arthritis

EXCITING Experience from your colleague Mohamed Kawari

I want to share my experience in Western General Hospital,
...Edinburgh 25 Feb 2016
..I started my exam by station 3
..Cardiovascular; 50 year old man complains of SOB )3
I did the exam, I appreciated a murmur in apex.. I could not
.. time it
for unknown resean I said it is diastolic murmur considering I
do believe that diastolic murmur can not be brought in
..PACES
The examiner ask me if that was diastolic murmur what will
be your differential.. at meet the patient after the exam at
( hospital gate and he told me he has AS and MR !!! I scored
) 02/2
CNS; lower limb exam.. patient was not cooperative and )3
misleading
he kept moving his lower limb during tone assessment and
giving contradicting information during sensory exam.. I could
..not formulate DD
) 02/7 ( I scored
Communication: 40 year old lady has IDDM her HbA1c 9 )2
,referred for albuminurea
I was disappointed from previous station and forget to ask her
if she does attent all foloow up appointment , does she check
??her glucose
)02/2( I scored
BCC1: psoriatic arthritis has joint pain.. has skin rash over )2
)elbows and hair line.. I scored ( 28/28
BCC2: 70 year old lady history of loss of consciousness and )2
abnormal movement, had murmur during adulthood for
..which she does not require follow up
My DD : epilepsy and stroke
.. I could not appreciated any abnormality in exam
..I instructed her not to drive for 1 year and to inform DVLA
!!they ask me if I appreciate any murmur.. I answered No
)02/02 ( I scored
Abd: kidney and pancreas transplant , has gum )1
hyperatrophy and poor vision.. I said the cause is Type 1 DM
.as patient has vitiligo
) 02/02 ( discussion about complication of transplant
Chest: Rt upper lobe lobectomy with deviated trachea )1
discussion about indication of lobectomy and types of lung
) cancer ( 20/20
History: 55 year old male with symptomatic anemia and )0
.. melena on ibuprofen for knees pain
??His concern: Is it colon cancer
..I told him I ll request upper and lower GI scope
) 02/11( I scored
)170/132( The End Result is PASS
 .. It was My first trial
I have never been to UK before .. I had course in Ealing
..Hopsital, London for 2 day ( it is excellent )
..Despite the bad beginning .. Still AlHamdullah I passed
..My Advice .. do not be relactant in applying to UK
My English language and accent is not perfect however they
!! consider that
..Good Luck for All

Station respiratry pulmonary fibrosis secondary to drug

induced, Cvs AVR, Abdomen renal transplant Sec to APKD,CNS
, brown Seward syndrome
Station 2 young teacher with two children complain of
palpitation n two year baby
Station 4 dealing with angry pt n explaining management
And elderly tiredness and headache and previous surgery of
tumor in head. Panhypopituatrism
One of my frnd exam in uk

Myanmar
,Day 1 Round 2 Yangon
 Station 1 - Chronic liver disease, Dullness at Lt lung base
Station 2 - known case of Ca lung, previously treated with
radiotherapy last 18 month, complaint of back pain
Station 3 - Parkinson's disease
Station 4 - 82 yr lady with Alzheimer's and knee OA, admitted
with confusion and UTI, can't give antibiotic because of
dislodge cannula, talked with angry son
Station 5 - myotonic dystrophy, thalassemia with
Haemochromatosis

Chennai 1st day 3rd cycle

BCC... 1. persistent htn with knee pain. 2. Frequent headache
.within 2-3mths and impact on job
History.... 25yr old lady with hypertension and URE shows RBC
.and protein
Communication.... 25 yr old lady come to yesterday ED with
haemoptysis and fever and done CXR show bilateral apical
fibrocavitatory lession and sputum show lots of AFB positive
bacilli. Pt discharge from hospital without the result. ED ph
her to come to hospital for result and pt is reluctant to come
.to hosp but today come to hosp
Task... explain the risk to the pt herself and others and advice
.to protect of spred of infection to others
 CVS... restenosis MS with AF. Complaint... SOB
CNS... Hemiplegia, only examine LL. Complaint... difficulty in
.walking
RESP.... complaint... SOB. lt upper lobe fibrocavitatory lession
.and lt lower lobe pleural effusion
Abd.... complaint... abd discomfort. Lt arm AV fistula
functioning and recent puncture mark present with
.hepatomegaly
.That's all. Good luck to all

Examinations of LATER dates

STATION 1
RESP COPD FINDING,LOBECTOMY,EXAMINER WANTED TO
KNOW MOST LIKELY CAUSE WHICH WAS NOT OBVIOUS
GIT
POLYCYSTIC KIDNEYS,RT TRANSPLANT ,NO FISTULA SOME
GUM HYPERTROPHY
STATION 2
HISTORY....40 F ARTHRITIS,TAKE HISTORY
STATION 3CNS DEREBELLAR SIGNS BOTH LIMBS BUT SOME
HYPERTONIA N SOME SENSORY LOSS LT LEG,PROBABLLY
SPINOCEREBELLER BUT COULD NOY GET SPINAL
HALF,EXAMINER WERE OK ON CEREBELLAR SIGNS
 STATION 4
WORSE ONE FOR ME,ANGRY MAN FATHER CAME TO
DAYWARD FOR PROCEDURE ,ESOPHAGEAL DILATION,ENDED
UP IN ESOPHAGEAL RUPTURE,HE WANTS HIM TO TAKE HIM
.HOME,BLAMING CONSULTANT,,I COULD NOT CONTRL HIM
CAN ANY ONE SAY CLEAR FAIL IN THIS STATIO MEANS FAIL AS
?A WHOLE
STATIO 5
NO.1
SCLERODERMA WITH ONLY SOME SKIN TIGHTNESS AND FEW
TALENCIECTASI ON FACE,EVERY ONE TRIED THEIR BEST TO
MAKE IT SCLERODERMA INCLUDING EXAMINER
NO.2
ANKYLOSING SPONDYLITIS WITH MILD PSORIASIS

Examinations of LATER dates

CASE 1
ABD MULTIPLE SCARS,TRANSPLANT
RESP COPD
CASE 2
HISTORY TAKING POSSIBLE RA
CASE 3
CVS AORTIC REPLACEMENT
 CNS PERIPHERAL NEUROPATHY
ETHICS
RELATIVE NOT HAPPY WITH TREATMENT,BLAMING NURSES
I THINK I FAILD THIS BADLY
STATION5
PSORIASIS
DIABETIC EYE,I COULD NOT MAKE SENSE OF
IT?LASER?CHORITIS
OA
RASH OD UNKNOWN ORIGION?DRUG INDUCED

Myanmar 9/3 /2016 last round

--Station1
rt sided pleural eff
thalassemia
Station2--TIA
--Station3
Myath.Grav
Mitr.Stenos
--Station4
known case UC, afraid to take oral steriod bcoz of side effects,
explain management plans of UC
--Station5
 laser scar
SLE with TB

Myanmar 11/3/2016 last round

station1
??respi- effusion n tumor
??Abdo- hepato splenomegaly with CLD
Ststion 2
IDA n wt loss , epigastric pain , take Ibuprofan and diclo for
knee pain
Station 3- cerebellum, MS e pul H/T
Station 5 - Cushing . DM with CRVO

Experience of my colleague
I have finished my exam today
Myanmar 11 /3 /2016
nd round0
H/o - headache for several months with menorrhgia for
treatment
in detail - tension type HA with medication induced HA
? concern- cancer
 commu - delayed dx of pheochromocytoma explain
scenrio - missed for 5yr and confirm by urine and CT
concern - cancer ? why delay ? need to again mood dr and
? surgeon
CVS - AS AR with pul H/T
Resp - i dont know think Rt upper lobe collapse
Abd -HS with jaudice (Thal)
CNS - MND ( bilatral small muscle wasting )
$ BCC1- RA with CT
BCC2- hypopit

.Sharjah center 10/02/2016

Cardio- double valve replacement
Resp- right sided pulmonary fibrosis
Abdomen- polycystic kidney disease+ functioning left av
fistula+ascitis+ heptomegaly= Dialysis related amyloidosis
Neuro- Examine upper limb 16 years old boy has proximal
myopathy+ cerebellar signs+ UMN signs, sensation
!intact=friedricks ataxia as per examiner
 History= 56 years old male long standing diabetes coming
with episodic vomiting and diarrhea, has also postural
hypotension = Autonomic dysfunction, discussion about
investigation and management
Communication skills= 35 years old female with history of
chest pain, has family history of ischemic heart disease at a
young age among her father and brother.all cardiac
investigations are normal. Cardiologist asked you to tell her
that this is most likely functional and further investigations
are not waranted shes concerned about her symptoms, got
pissed when told its functional and shes asking for
Angiography, all u need to do is REASSURE REASSURE
.REASSURE and address her fears
Station 5
Case 1- young lady coming with red eye for differentials-
nothing on physical exam as shes a normal actor and not a
patient. Diagnosis is thyroid eye disease
Case 2- old man coming with facial swelling. ESRD has
brachiocephalic fistula that was recently changed because it
was clotted. Diagnosis superior vena cava obstruction
The first case was a young lady arround the age of 35
complains of both red eye for few months duration
There is no pain, discharges or headahche
No h/o of trauma or bleeding and systemic review is
otherwise normal
Pmh is insignficant
I did complete eye examination including fundoscopy and it
was normal
Examiner asked me wuts ur differential
 I said keratitis episcleritis keratoconjuctivities
Chemosis
He said if its chemosis wut else would u look for on physical
?exam
I said exophthalmos opthalmoplegia and i will do cimplete
thyroid exam
I got 25/28
The 2nd case
Old man end stage renal disease
Has functioning left brachiocephalic fistula
Got obstructed 2 weeks ago
It wad removed a new one inserted
Then later on pstient presented with facial swelling
Sob
And neck engorgment
Which gets worse when raising arm and hands above head
Is the case clear to pickup
On examination there is no obvious finding to pick up
Examiner asked wuts differential
I said superior vena cava obstruction
Investigation Ct Chest
Treatment anticoagulation
Goodluck to all
 .Sharjah center 10/02/2016
Cardio- double valve replacement
Resp- right sided pulmonary fibrosis
Abdomen- polycystic kidney disease+ functioning left av
fistula+ascitis+ heptomegaly= Dialysis related amyloidosis
Neuro- Examine upper limb 16 years old boy has proximal
myopathy+ cerebellar signs+ UMN signs, sensation
!intact=friedricks ataxia as per examiner
History= 56 years old male long standing diabetes coming
with episodic vomiting and diarrhea, has also postural
hypotension = Autonomic dysfunction, discussion about
investigation and management
Communication skills= 35 years old female with history of
chest pain, has family history of ischemic heart disease at a
young age among her father and brother.all cardiac
investigations are normal. Cardiologist asked you to tell her
that this is most likely functional and further investigations
are not waranted shes concerned about her symptoms, got
pissed when told its functional and shes asking for
Angiography, all u need to do is REASSURE REASSURE
.REASSURE and address her fears
Station 5
 Case 1- young lady coming with red eye for differentials-
nothing on physical exam as shes a normal actor and not a
patient. Diagnosis is thyroid eye disease
Case 2- old man coming with facial swelling. ESRD has
brachiocephalic fistula that was recently changed because it
was clotted. Diagnosis superior vena cava obstruction
.Goodluck to all

MYANMAR
ygn d3 r1
lung basal crepts iasked itisitial lg ds.1
renal transplt bi fistula
lethargy loss libido dm nht +…gap shaving interval . igive .0
hypopit n auto neuropathy
metalic click igive dvr but friend said that it is mvr .3
--- .2
same as Hsu May Oo post --- .2
good luck

cases exams edinburgh

:station 1
 andomen: hepatomegaly with? PD catheter - how are they
?related
respiratory: thoracotomy scar plus and chest tube
:station 2
middle age man with recurrent fits in pt with esrf? no hx
stroke. pt concern unable to take care of himself if he has
epilepsy
:station 3
:cardiovascular
multiple murmurs ?aortic regurgitation with metallic 1st heart
sound. also got thoracotomy scar
neuro: PICA syndrome?/ brainstem syndrome (not really sure
about this one)
:station 4
discuss with pts father regarding bone marrow transplant. pt
(capable of making own decision) refuses but father still
insists
:station 5
optic atrophy. No INO/ RAPD ? -1
oral (i think with oesophageal) candidiasis in RVD refused -0
HAART
My fren sat the exam 1st of march 2016

Myanmar centre, Day 1, Round 3

History - Three episodes of collapse within 8 months in binge
drinker
Communication - Fits occur after giving clarithromycin in
asthma patient who takes aminophylline for a long time

Myanmar 8-3-2016
Yangon 2nd day 3rd round
st 2
post partum thyroiditis H/o of palpitation in previous preg
.Now 4 mth after delivery of 2nd baby. palpitation 2 mth. Ho
asthma. coffee 3 cups/day H/o thyroid ds in sister
Communication
yr old lady e pnia, CURB 3, hyponatraemia,hypoxia, h/o 22
adverse eff on codein. Daughter tell that allergy to coedin but
nigt mo gave 3 dose of cocodamol. Now confuse. Talk to
.daughter
Concern Why happened?I previously told about this.
Antitode?Why my mon is confused? Can i see the chart for
.reason whether you note down it or not

,Myanmar, Yangon Center

,New Yangon General Hospital
 Day 2, Round 2
:Station 4
year old ex.manger with headache for 3 months, blurred 22
vision 2 weeks, with fits 2 days ago. CT scan head revealed
high graded glioma at frontal lobe. His wife worked at aboard
.and will come back the next day. Breaking the bad news
?Concern.. Why he suffer fits
?How long will he live
.How to tell his wife as he planned vacation with his wife
.Station 5
BCC 1. Rt Hemiplegia with visual problem. Rt Homonymous
Hemianopia
.BCC 2. Hand Pain with Acromegaly. Carpel Tunnel Syndrome
.Station 1
Resp. Rt upper lobe collapse. (Axilla lymph node biopsy scar
noted)
Abd. Renal Transplant with Hirustism
.Station 2
year old lady with bloody diarrhoea and abnormal LFT. 20
.History of travel last 6 months ago to Australia. Wt loss..5 kg
?Concern. Is it cancer
?Is it managable
.I am not complete in concern
.Station 3
CVS. AS AR
 CNS. Facial Palsy with cerebellar and CP Angle Tumor.
(Operated)
.Pray for me please
.Wish you all best of luck

Myanmar centre, Day 1, Round 3

History - Three episodes of collapse within 8 months in binge
drinker
Communication - Fits occur after giving clarithromycin in
asthma patient who takes aminophylline for a long time

Cairo 2/ 2016
.St4
A female pt about 70 known bronchial asthma that's difficult
to be control till recently. She was admitted with congestive
heart failure and was controlled on diuretics and ACEI. Today
one of the junior doctors prescribed bisoprolol as he thought
it is of benefit for her heart Failure & a nurse gave her the ttt.
Since 30 minuts no harm happened till now but the pharmacy
told it is harmful to her to be given bisoprolol as she is
asthmatic. So the nurse was worried and pt. feel that
. something went wrong
You are asked to speak to her and explain the condition ...very
..long scenario
After introduction I checked understanding & explained what
happened, apologised & explained what will be done incident
report, department meeting ..and put under observation for
any SE. And follow up by cardiovascular and chest team . Her
concern why happened what will happen to me what will u.
do to prevent this happening to others . Ist she was angry but
after explanation and apologies and stress on her care and
postpone discharge for one to two dayes till we are sure she is
. ok. she is satisfied
Examiners ask legal issues I told negligence but is not. It is
mistake he told any thing else told autonomy - I should tell
not to do harm also he asked why bisoprolol is harmful in BA.
We are giving small dose- he told- I told as it is non selective b
blockers asked what can we give i told carvidilol . Asked how
.u do incident report I explained . I got 13
. St 5 #
Sudden loss of vesion pt. Hypertensive By history last less -1
than one hour plus hemiplegia. She is on insulin and
bisoprolol only . Ex. Pulse AF. Carotids asked to examined
precordium examiners refuse . Examined visual aquety simply
asked for fundus they refuse asked to examine her
neurologically told ok. I checked power. Was normal . Her
concern. Is it dangerous. Why happened? Questions about
positive findings. DD. Management .got 26
St 5. 2nd case Active RA . Discussion about inv. ttt.
Components of multidisciplinary team for this case. Got 28
.1 #‎St
 Chest copd.clubbing Basal fibrosis . Cushingnoid features *
asked about finding. Cause of fibrosis .Inv. and
management.got 16
Abdomen. HSM. Discussion about Cause inv. Ask about *
upper GI. Endoscopy in this case and ttt.if the cause is HCV.
Asked if it works? Bill rang.got 20
History bloody diarrhea and arthritis .history of travel to #
Morocco
History of long term diarrhea and recurrent and pain relieved
with defecation. FH. Cancer colon in grand father aged 75 no
. other family members has cancer colon
.Concern is it cancer like my grandfather
Questions DD. Infective diarrhoea. IBD. .Asked what his risk to
develop cancer colon told like others. asked if he need
admission? I told I after examining and doing basic inv. U&E
we will decide asked about inv.and management of Infective
.diarrhoea . got 20
Neuro. Ms. Pyramidal weakness bilateral more in right Side #
loss of sensation in rt. Side till face cerebellar signs. Time
finished befor doing deep sensations actually when he told
.... one minute remaining I did cerebellar. Told I wand to do
Discussion about DD inv. TTT. got 20
.Finally cardiovascular . Double aortic with AR. Predominant #
Q. Finding . Causes. Inv and management got 20
.I hope my exam experience help you
My advice is to concentrate at least 3 months befor exam and
to have studying partner for history and communicatios also
.to make study group. In yr work to see patients and discuss
 Good luck for all and thanks a lot for our colleagues who
shared their experiences before

Exam in Glasgow 2016

: New scanerio
:Station 4
Delayed diagnosis of pheochromocytoma
Mr, jones 35 years male
Had High BP for last 5 years
Seen by psych for panic attacks
Tried many Med for HTN
But
His BP has been difficult to control
On his insistence , his GP has referred him to hypertension
clinic 2 weeks before
Results of tests now show
Urine : high metanrphrines
CT adrenal : 5 cm mass in right adrenal
Ur task is to explain the diagnosis
U don't need to know the details of further tests and further
management
Patient was concerned
Is it serious
Is it cancer
 Is there a cure
Will I require future surgery
What future tests will be done
Was the delay justified
What medicine u will give me
Examiner : repeated similar questions
Overall not too harsh patient
Satisfied at the end
Agreed follow up GP Consultsnt website address alpha
blocker beta blocker
History station
Young female 28
Blood Diarrhoea after Cyprus visit
Started 1 day before coming back
Mixed with stool
Similar episodes for last 2 years
Took amoxicillin in Cyprus
Diarrhoea aggregated
Now last 10 days
Frequent blood a salime in still
Painless
C/ o small joints pain
No backache
No other extra intestinal symptoms
 No oral ulcers
No skin changes
No jaundice
Cousin IBD UC
Father CA colon
No blood thinners
No steroid
No warfarin
No bleeding disorder
No weight loss
Concern : cause
? Is it cancer
? What next tests
? What Med
? Need admission or not
:DD
IBD ( UC)
Infective Diarrhoea
Antibiotic associated Diarrhoea
Examiner : just repeated all above
And
Asked
In
; History how will u rule out infective cause
 Fever
Vomit
But
He told
U will ask about symptoms to others accompanying him

Birmingham City hospital ....9/11

I started with station 3 : neurology was examining upper limb
..... it was proximal muscle weakness with no sensory
affection or incordination ...... the discussion was about
.possible DD diagnosis and investigations
Station 4 was breaking the diagnosis of MS in Young female
which an episode of unsteadiness ..... MRI confirms the
disease ...... discuss with her ttt options and her main concern
was her wedding was after few weeks ..... to tell her husband
or not ..... she a teacher what about her job ? ...... concerns
......about driving
Station 5 a was a young male with rash 2 hrs. after eating a
food ...... the rash subsides now ..... he has shortness of
breath little
b was a female with collapse ..... after history taking was 2
postural hypotension
St 1 abdomen was APCKD ..... chest lung fibrosis with
corpulmonale
 st.2-It was afemale 68 years with shoulder stiffness and hand
stiffness ...... normocytic normochromic anemia .... tiredness
.....weight loss.... but she gave a history of cough on last years
which still present ....... the GP is afraid of starting
corticosteroids because she is osteoporotic on vit D .... Ca ....
bisphosphonates .Polymyalgia rheumatica is the diagnosis i
think but I rash into the cough as may be lung cancer and this
. is Para neoplastic

Station ( 5 ) October 2015

Dubai
Station 5 ●
DVT /1
Amurosis fugax /0
Station 5 ●
Pt has SOB: Then found to have Wt loss, diarrhoea, thyroid /1
.nodule & neck scar
.ALSO SOB: progressive then found to have RA on MTX /0
Station 5 ●
hypertension newly diagnosed with fatigue and dizziness /1
on telmesartan,o/e had postural hypotension
Young female with depression one day Hx of epigastric pain /0
and vomiting?? she took 16 Tabs panadol intermittently
Sharjah
Station 5 ●
 year old young man presented with excessive thirst 07 /1
year old abdominal pain ..flatulence ...lethargic ..family 00 /0
history of thyroid ..coeliac disease
Station 5 ●
A young lady with 4 attacks of hypoglycaemia not diabetic /1
her 2 siblings have DM on insulin
yrs old lady with gradual loss of vision with symptoms 12 /0
of increased intracranial pressure
Cairo
Station 5 ●
A 30 yrs old male with tiredness & feeling hot vital signs all /1
.normal except temp 37.8
Inside the exam: fever e sweating not profuse & there is Wt
loss, no difference bw day & night. No Hx of cough joint
problem GI CVS CNS MSK or GUS symptoms & no risk factors
for HIV. NO PH or DH of note but FH father had TB & there is
.contact with him
OE No pallor there is generalized LNpathy involving Cx axillary
& epitrochlear time not allowed for inguinal or
hepatosplenomegaly. Alcohol cause pain in these glands.
Concern is it TB like father contagious can be transmitted to
.his kids?. DD Lymphoma TB others also but less likely
Adult female e HCV infection just recently started IFN & /0
.now came e skin rash
Inside rash typically of plaque psoriasis but only started after
IFN. PH DH FH SH & SR were negative. Concern to stop IFN is it
the cause for rash? Answered by that she has psoriasis that
can be exacerbated by IFN but HCV if not ttt could be serious
so to arrange e both liver & skin doctor regarding what is best
 for her: changing to other HCV ttt or continue IFN under
supervision of both of them
Station 5 ●
Gravis disease /1
Diabetic maculopathy /0
Station 5 ●
Pt e visual distunance /1
Had optic atrophy and spastic paraparesis ... MS
old lady e features of hypothyroidism and tender thyroid ... /0
Thyroiditis
Station 5 ●
.yr male c/o headache, blurring of vision 32 /1
Normal bp and labs
Case was acromegaly, with no field defects, had numbness as
well with no carpal tunnel sign on exam. Discussion about
acromegaly management
yrs male with HTN, SKIN RASH 22 /0
,IT INVOLVED THE ORAL CAVITY
CASE WAS PEMPHIGUS vulgaris, discussion about differential,
management and relation to anti htn(amlodepine, acei)
Station 5 ●
Systemic Sclrosis. Lady with SOB and skin problem.. /1
yr old male with sudden left side chest pain with SO2: 02.. /0
88 and BP: 110/60….PE
Station 5 ●
 osteoarthritis /1
Small joints of the hand and knee with heberden's nodes
fundus /0
DM and Hypertension
Blurring of vision
Station 5 ●
Chest pain ( ischemia ) /1
Unstable angina or mi
Pain in both hands RA /0
Oman
Station 5 ●
Man with history of lithotripsy for renal stones comes with /1
excessive hunger and hypoglycemia
Normal blood pressure no findings in the neck
?MEN
Typical history of breast discharge and mentrrual problems /0
and came with head ache and blurring of vision
On history bitemporal hemianopia
On examination TUNNEL VISION : surrogate killed me
I checked three times
Did fundus examination normal
Asked dd
I said intracranial tumor
Then said prolactinoma
 Said wud like to do MRI and refer to ophthalmologist
Messed this up
Station 5 ●
young lady c/o irregular cycle ,headache & abnormal vision /1
-----> Prolactinoma
male with h/o renal stone ..presented with hypoglycaemic /0
attack -----> MEN1
Station 5 ●
.young female e polyuria polydipsia and lethargy /1
.Pt in history e DM uncontrolled
.In exam faint hyperpigmenation
.Pt e hemochromatosis
. Abd exam with many scars
.So thalassemia is the case most likely
.Young e headache and facial pain /0
.Acromegally but unless you look to pt many times
Station 5 ●
male 60 years old did routine blood check up , all normal , /1
high alkaline phosphate. . C/o decrease hearing over years ...
.Clinically has sensory impairment ..? Paget disease
male of 50 years presented with weaknesses for Rt side for /0
30 min .. he has DM on metformin ,HTN on lisinopril not well
compliance for his medications , BP 150/100 mmHg ..thought
due that weakness due to hypoglycaemia inspite no
symptoms suggested to that , he used juce , RBS on arrival 9
mmol/L , CT BRAIN NORMAL ... Clinically : NAD . ... CVA ..
Discussion about CVA , diagnosis and management
 Station 5 ●
Obese man with headache last 2 month /1
From history. Pt known htn on lisinopril. No other past
medical history
Last 2 month gain weight
Snoring
Day time semulance
Taxy driver
RTA
Obstructive sleep apnoea ???
Young female /0
Complaints of headache
All history going with migraine
Pt concern. Need ct scan because feer of ca brain
Station 5 ●
acromegally /1
.Angioedema complicating ACEI /0
Station 5 ●
paget disease /1
Patient with high alkaline phosphate and hearing difficulty
TIA with high BP RIGHT SIDED WEAKNESS AND /0
DYSARTHRIA AFTER 30 MIN FEELS IMPROVED
 -- exam in uk ...14/2/16
Station 1 : pt coming with SOb and has Rt thoracotomy scar ,
trachea deviated to Rt and decrease air entry on bases with
dull percusion ..other side some coarse crepts ..what is
?differential
Abdomen : no signs of chronic liver disease , abdomen
:hepatosplenomegaly and cervical lymphadenopathy, after I
finished they said u still have 1 min , in which I picked axillary
?LN..what is diagnosis
Station 2 :pt referred from GP with bloody diarrhea and
deranged LFTs (if anyone wanna be a candidate ?!!)
Station 3: cardio : pt coming with SOB ,I thought he was in SR ,
one other candidate said so and 2 others said AF ..pansystolic
murmur at the apex radiates to axilla , differential and how
?are u gonna manage
Neuro: examine LL limb
Normal gait , didn't finish examination , loss of sensation up
to mid shin and loss of joint position, I thought there is loss of
ankle reflexes as well and planters down going ..ppwer 5/5
Diagnosis ? What could be the cause in this gentleman ? And
what rarer causes? These are the questions asked by
examiner
Station 4 : Mrs X coming with rash, GCS 8 and you suspecting
meningiococcal septicemia ...explain to husband and address
his concerns
 Station 5
Lady had Stent inserted 3 weeks ago on dual therapy coming
with GI bleed ...hypotensive and tachycardic ....INR 5 proceed
yrs old girl presenting with headache , obs stable 30
...proceed

An Experience by our colleague

Tomadir Tag Eldin
My exsm was 11/2 Sharjah center
statio2 Hx
Problem, difficult mobility.. diagnosed with lung cancer 10
,month back, recieved radiotherapy
on quetsioning, problem started with back pain 10 days ago,
lower limb weakness today, loss of sphincter control,
diagnosis acute cord compression due to mets, examiner
asked about management of acute cord compression
including pain management options, this was my first station,
I was so tense didn't notice time, but overall I did well in this
station
Station 3
cardio case, young guy, systolic murmur all over pericordium
radiating even to axilla and root of the neck, not audible in
carotids, I presented my findings well but diagnosis I said MR!
Don't know why I said so! Examiner was not happy, he said do
you want to change your mind at this point, I said yes! It is AS
 discussion was about AS causes in young pt, ‫ رمز تعبٌري‬smile
indications for valve repplacement
I scored 14/20
Neuro, peripheral motor neuropathy, sensations intact, scars
over the ankle and knee, diagnosis
HSMN, discussion about causes of
isolated peripheral motor
neuropathy and how do you
,manage this patient
I scored 20/20
Station 4, I did very bad, scenario was very common I knew it
before, did it with Dr. Ahmed Maher Eliwa
but for some reason I did bad
Problem: pt eith stroke admitted to general ward becos no
bed available in stroke unit, developed bed sores in hospital(
which I didn't see at all, I thought ot happened at home! ) and
MRSA, ur task is to talk to daughter and explain the situation
and plans of management , I kept explaining the MRSA and
the management, precautions, when 2 min were remaining I
asked about concern, she said am concerned about my father
sitation, he developed bed sores in your hospital and I didn' t
hear even apology from your side! !! I got shocked really! How
did I miss this! ! I said am really sorry for this and I opologize
on behalf of the whole team, and we already issued incident
,report and we started investigations, she wanted to complain
Examiner asked me do you think you adressed this patient
concern? Why you didn't admit the possibility of negligence
!!frankly
 !It was terrible Station , scored 12/16 , i thought I had failed
Station 5a, female 16 yrs with recurrent attacks of stiffness
and shaking movements on Rt. Side of the body, there was
rashes over face, diagnosis tuberous sclerosis, discussion,
what is this type of abnormal movements, what investigations
?you will do, CT brain findings, what brain lesions
I got 28/28
Station 5b
Young man with polydipsia, and polyuria, otherwise nothing
in Hx, examination totally normal
Discussion about causes of polyuria and polydipsia, what
investigations
Station 1
chest, patient with midsternotomy scar, venous harvest scar,
3 AV fistula, one is functioning and newly dressed! !! This was
my chest patient! Chest examination I couldn't pick any
!abnormality apart from mild crepitation basally
my diagnosis was pulmonary fibrosis Vs pulmonary edema,
but I think it is well controlled COPD
I got 10/20 only
!Abdomen was another disaster
Female with cushinoid features, fistula again functioning well
and newly dressed! Abdomen, big RIF scar but no palple
kidney under it! ! Big hepatomegaly, I said there is spleen also
but there was no spleen, examiner catched me on this spleen,
he kept asking what could be the cause of
hepatosplenomegaly in this patient, I kept saying this is CKD
most probably due to APKD, I couldn't explain the spleen, I
 was sure there is no spleen, but I said it, and he cann't forget
it! !! I got 15/20
This was my worst station
Over all I passed thanks to Allah
-------------------------------------—----------
The lesson I got from this experience, exam is not easy yet not
impossible to pass very easily, what is needed is to organise
yourself, you need to but your own approach to each station,
what you will say and what you shouldn't say! Think very well
before you talk or present your findings, remain calm, remain
calm, remain CALM,no matter what happens, don't argue
with the examiner at all, prepare your self by good course,
study, but exam is not about knowledge only, study
moderately, last week before exam stop reading books and
organise yourself and but schemes and ur approach for the
! possible cases
Lastly again remain calm before the exam, during the exam
and between stations forget the previous station, stress will
not help you, I was so much stressed and this really affected
.my performance and thinking
Lastly you don't know what is going on inside the examiners
mind, so don't be affected by their attitude towards you and
remain calm, the one who are smiling to you could be giving
!you very bad marks and you are totally off point
------------------------------------------------------—
Best of luck to everyone
 Dont know if exam in uk is gonna be useful for u guys
...14/2/16
Station 1 : pt coming with SOb and has Rt thoracotomy scar ,
trachea deviated to Rt and decrease air entry on bases with
dull percusion ..other side some coarse crepts ..what is
?differential
Abdomen : no signos of chronic liver disease , abdomen
:hepatosplenomegaly and cervical lymphadenopathy, after I
finished they said u still have 1 min , in which I picked axillary
?LN..what is diagnosis
Station 2 :pt referred from GP with bloody diarrhea and
deranged LFTs (if anyone wanna be a candidate ?!!)
Station 3: cardio : pt coming with SOB ,I thought he was in SR ,
one other candidate said so and 2 others said AF ..pansystolic
murmur at the apex radiates to axilla , differential and how
?are u gonna manage
Neuro: examine LL limb
Normal gait , didn't finish examination , loss of sensation up
to mid shin and loss of joint position, I thought there is loss of
ankle reflexes as well and planters down going ..ppwer 5/5
Diagnosis ? What could be the cause in this gentleman ? And
what rarer causes? These are the questions asked by
examiner
Station 4 : Mrs X coming with rash, GCS 8 and you suspecting
meningiococcal septicemia ...explain to husband and address
his concerns
Station 5
Lady had Stent inserted 3 weeks ago on dual therapy coming
with GI bleed ...hypotensive and tachycardic ....INR 5 proceed
 yrs old girl presenting with headache , obs stable 30
...proceed

Experience of our collegue Mohamed Alama

My exam experience
Almaadi military hospital 9/2/2016
: Station 3
:Neuro
:Findings
Spastic paraparesis+PN with stocking distribution (Rt leg)+
.sensory level on left side for DD
:Questions
DD: MS, spinocerebellar degeneration, SCD
.Investigations: spinal & brain MRI, CSF findings
Treatment:acute, chronic, pharmacologic &
nonpharmacologic
:Cardio
:Findings
.AVR & MVR
:Questions
findings, functioning valve or not, HF, IE
Investigations:routine, ECG, echo, INR
.indications for AVR in AS
 ?what symptomatic AS means
.Treatment: nonpharmacologic and pharmacologic
:Station 4
Elderly lady admitted to the hospital with confusion and UTI,
can’t give her the AB as she keeps pulling the IV cannula out,
comorbidities are Alzheimer’s, knee OA, frequent admission
.to the hospital in the last few month
Task: talk to her daughter (angry), who is asking about an
.update
:I think this scenario is looking for the following
dealing with an angry relative.who also was tearing , offered
‫ رمز تعبٌري‬her tissue that was on the table smile
Explain the need for a PICC line,draw what you are going to do
.and consent
Sort out the other comorbidities and any risks at home (stove,
shower, lost her way before, driving, the need for an
occupational and social workers and visiting nurse after
discharge)
the daughter kept saying that she wants to continue taking
care of her mom,and no way she will send her to a nursing
.home. you have to appreciate that
The daughter wants a brain CT done, because she is
confused(it must be her brain, doctor. Why you didn’t
perform at CT, you are not giving her the appropriate care)
Be patient and try to explain that it is a problem with the
.chemistry of the blood not an actual brain problems
:Concern
 Why my mom is not improving after few days from
?admission
?When she wil go home
:Questions
Ethical issues in the scenario (Beneficence and
.nonmaleficence), dealing with an angry relative
Why you didn’t do a CT as her daughter wanted (there is no
focal neurological deficits that warrant doing a CT, also there
is an explanation for her confusion), not sure if this is the
.good answer, I Would like to hear your comments
.Long term prognosis of the patient
.what do you want to offer her
What about sedation (I said it may worsen her condition, but I
heard after the exam about chemical and physical restrains), I
.leave that for the experts
:Station 5
(Ramsay Hunt $) Facial nerve LMNL (very clear) with history -1
.of ear rash few days before
Questions about DD: all causes of LMNL facial lesions (CP
angle tumours, parotid or face surgery, auditory canal
(cholesteatoma, abscess),also UMNL facial (he didn't like it,
),wanted the LMNL
Treatment(steroids, acyclovir, stomach and eye protection,
physiotherapy)
?Concern: could this be cured, how long it takes
Hypothyroidism (difficult case) -0
 Presentation (fatigue , weight gain, menorrhagia, no
skin,voice or hair changes, on a treatment, she doesn’t know
the name, which turned out to be thyroxin, started a year
after a surgery in the neck (thyroidectomy))
.Examination: fine tremors, no eye signs , thyroidectomy scar
Questions about investigations, what is the single test you
want to do (TSH)
what is the most probable cause of her thyroid problem
(Graves’s?, I am not sure if that is right, there is no eye, hand
or leg signs)
.Concern : what is the cause of the fatigue
Station 1(terrible examiners and difficult patients)
Chest: Rt upper lobectomy + obstructive lung disease+
)deviated trachea to the Rt side & left basal fibrosis
Questions: findings, he asked if the fibrosis is diffuse, I said I
couldn’t appreciate that, investigations (HRCT,sputum
C&S,PFT findings)
Treatment (nonpharmacologic and pharmacologic)
Abdomen: Very obese patient with HSM, pallor, pigmented
striae, no LNS
Questions:findings, one diagnosis only (didn’t want to hear
DD), I said Lymphoproliferative, asked about blood film
findings and other investigations, and treatment of
)lymphoma
:Station 2
Patient with macular rash over chest , neck back and
sometimes arms, started as vesicles that rupture after that,no
 change with sun exposure, on doxycycline for acne,no other
autoimmune disease) for DD
examiner asked about DD(they wanted photosensitivity in the
first place, he said if you pressed on him more he will say it it
increases with sun exposure, but I asked about that clearly
and about travel history to Hurghada and after spending
sometime on the beach, he denied any change in the rash)
Other questions about investigations and ttt
.Concern: will it leave a scar, I said yes

Examinations of later Dates

Brunei Exam 11/6/2014
) my friend exam (:
Hx: fatige and microcytic anemia
.
Communication: BBN methiselioma
.
Neuro: weakness and hypotonia upper limb and normal
power and upgoing planter lower limb
Cardio aortic stenosis-+ sclerosis and-+ MR
Abdomen anemia +jaundice+hepatomegaly,no spleen
Chest basal fibrosis
 .
St 5 young female with transient weakness
Middle age male diabetic with chronic diarrhea

.Sharjah center 10/02/2016

Cardio- double valve replacement
Resp- right sided pulmonary fibrosis
Abdomen- polycystic kidney disease+ functioning left av
fistula+ascitis+ heptomegaly= Dialysis related amyloidosis
Neuro- Examine upper limb 16 years old boy has proximal
myopathy+ cerebellar signs+ UMN signs, sensation
!intact=friedricks ataxia as per examiner
History= 56 years old male long standing diabetes coming
with episodic vomiting and diarrhea, has also postural
hypotension = Autonomic dysfunction, discussion about
investigation and management
Communication skills= 35 years old female with history of
chest pain, has family history of ischemic heart disease at a
young age among her father and brother.all cardiac
investigations are normal. Cardiologist asked you to tell her
that this is most likely functional and further investigations
are not waranted shes concerned about her symptoms, got
pissed when told its functional and shes asking for
Angiography, all u need to do is REASSURE REASSURE
.REASSURE and address her fears
 Station 5
Case 1- young lady coming with red eye for differentials-
nothing on physical exam as shes a normal actor and not a
patient. Diagnosis is thyroid eye disease
Case 2- old man coming with facial swelling. ESRD has
brachiocephalic fistula that was recently changed because it
was clotted. Diagnosis superior vena cava obstruction

Cochin ( Kochi ) Kerala, India, 26 Feb 2016

station 5
.pt 35 year old lady fever high grade 10 days with skin rash
Second patient 65 year lady with palpitations had right sided
.multinodular goitre
Station 1
.Resp case
.examine the chest. Left oblique scar posteriorly
Abdomen
young man. Left forearm av fistula. Two scars in both iliac
fossae with a palpable transplanted kidney. No signs of any
.immunosuppression
Station 2
Palpitaions of one month in a 35 year old lady
Station 3
Cardio
 .HOCM vs Aortic stenosis
Neuro
lower limb examination. Peripheral neuropathy
Station 4
You are Dr in out patient clinic. Lady 27 year old came to ER
yesterday with hemoptysis, h/o low grade fever. Sputum AFB
full of bacilli. CXR bilateral apical fibro cavitary lesions. TB.
She left ED yesterday. Today she was called to the clinic for
admission but she refuses. She was reluctant on phone even
.to come to the clinic. Talk to her
.They kept two more cases. Abd -spleenomegaly
.CNS - Bells palsy
.Alternating between candidates

..Cochin India ..11/0/02

station 1
..Abdomen..CLD
..respiratory.. ?bronchiectasis
Station 2.. 29 yr old gentleman with Episodic Skin rashes on
and off from 3 months and recent onset blisters on forearm
Station3 ..
CVS 2 cases were kept.. Few guys faced HOCM and other ...
MVR.. CNS: i faced peripheral neuropathy and for few others
..myopathy
 Station 4: talk to the son of the patient who underwent
pneumatic dilatation of esophagus complicated wid
..perforation
station 5: 30yr old lady with skin lesions and blisters for
..6months
And one more case 76 yr old gentleman with recent onset of
..weight gain

My experience for PACES in Tameside hospital near

Manchester 6 Feb 2016
Station 1
:Abdomen
Young male with fine tremors on outstretched hand and skin
warts. On abdominal examination: there was a left iliac fossa
scar with a mass under it, also there were multiple abdominal
scars. My diagnosis was left renal transplant with previous
peritoneal dialysis history, Patient is mostly on tacrolimus or
cyclosporine. Discussion was about causes I said commonly
it's diabetes but for the patient's age can be ADPCK, GN,
obstructive or reflux uropathy. I scored 20/20
:Respiratory
About 50 years old male, on general inspection there's
peripheral cyanosis, also plethoric face with multiple
telangiectasia. On chest ex: bilateral fine inspiratory creps
that didn't change with cough. My diagnosis was Interstitial
lung disease; patient may be on steroids. discussion was
about causes. I scored 20/20
 ====
Station 2: History
Young female presented with 3 episodes of rash on sun
exposed areas, last one associated with blisters on both arms.
On history taking: Patient mentioned going to the beach
before last episode, no symptoms for rheumatological,
connective tissue disease or abdominal complaints. Past
history of acne for which she is taking doxycycline prescribed
by GP. My diagnosis was drug eruption caused
photosensitivity rash accentuated by sun exposure, my
differential was porphyria cutana tarda, dermatitis
herptiforum and pemphigoid. Discussion was about the
management: investigations ANA, TTG, eosinophilia, stopping
the offending drug. I scored 19/20
====
Station 3
:CVS
More than 60 years old female, peripheral examination was
with in normal, heart revealed systolic murmur on the aortic
area radiating all over the pericardium, also soft S1. My dx
was Aortic stenosis, the presence of soft S1 make associated
Mitral regurgitation is possible, Discussion was about the
difference between Sclerosis and stenosis. Plan of action and
indications of surgery. I scored 20/20
:Neuro
Young male with spastic posture on general inspection, on
Examination: Hypertonia and hyperreflexia with no clonus,
there is some cerebellar involvement, no sensory
involvement, I finished examination early so I had time so
preceded to examine the eye which revealed bilateral
 nystagmus, isolated left 6th cranial palsy. My diagnosis was
MS. Discussion was about my differential if no eye
examination was performed. Management plan for MS
including investigations, ttt of acute, progressive ds and
symptomatic ttt. Score was 19/20
====
:Station 4: Communication skills
Patient admitted with stroke, there was no places in stroke
ward so admitted in surgical ward. There was no
improvement in his condition, he developed bed sores,
.isolated swab revealed MRSA. I had to speak with his son
I divided the case into 3 sections: 1st one regarding the
admission, then explained bed sores and care about it, then I
explained regarding MRSA infection. Initially the relative was
angry but after calming him down and explaining the situation
and what we will do he was cooperative. I scored 16/16
====
Station 5 was quite unexpected to me as there was no
physical findings at all
:BCC1
years old female presented with melena on and off over 3 12
years duration. On history taking there was no positive data
toward a specific diagnosis. No history of epigastric pain, liver
disease, no NSAIDs, no alcohol or steroid use. On examination
also nothing was appearing, I examined the abdomen, aortic
area for AS, looked for signs of pallor, mentioned the need for
BP and digital rectal examination. Explained the need for
further blood investigations, OGD as outpatient and may be
colonoscopy according to the results. Discussion was about
the causes, management plan. I didn't feel good at this case. I
scored 22/28
:BCC2
years old female presented with history of Loss of 03
consciousness and jerky hands and leg movements. No tongue
biting, no incontinence, no frothing. CT brain done is normal,
electrolytes and initial investigations with in normal. Had mild
chest discomfort before it. No attacks previously. History of
occasional palpitation attacks. I examined the heart, pulse,
carotids for bruit, upper limbs power (just grip and shoulder
abduction), planters and did fundus examination. All came
normal. I explained that it mostly a seizure or cardiac
arrhythmia. Plan: Holter, EEG, stop driving. Discussion was
about driving restrictions and further management. I also
didn't feel much comfortable with what I've done. but I
.scored 24/28
======
Overall Pass: 160/172
==========================
Advice for the exam preparation as requested on my inbox
)this wasn't my 1st trial(
:Books for study
OST for clinical examination (Book 1)
Ryder for station 5 (only the section with the real case
simulation)
Ryder for History and communication (extreme value
especially if your going for UK)
There's also notes done by some one named Fady (last minute
revision for PACES) of very good value
for revision can use Cases for PACES book
:Duration of study
years after 2nd Part 0-1
:Duration needed for clinical experience
years or more will be perfect (seen people passed without 0
hospital work)
:Courses
Preparatory course: any course in Egypt will be enough for
intial preparation
For UK: I went for PACESahead course which was really good,
it was more than 100 cases full of findings, but you have to be
very well prepared before attending it as it's more of an exam
simulation for each case, you have only 7 minutes to examine
the case and few minutes for discussion. It will be a perfect
exam simulation especially if done few days before the exam.
My advice is not to attend it too early before the actual exam
as you lose the main advantage of it which is making you be at
.the exam mood
Other courses in UK with good reputation: PassPaces but it
only accepts UK trainee, PasTest, ealingPaces (I really can't
give an opinion about them)
:Tips
You need to see many cases, and examine them like you are -
.in the exam
Practice with other exam candidated for CS, HT, Station 5 -
 Work on your presentation to be focused, concise and -
.smart
When practicing how to present your case, you should be -
able to mention the following in less than 2 minutes (Positive
signs, releavent Labs, Imaging, TTT: General measures, specific
measures, disposal for Station 2, 5). I know it's difficult but
believe me it will make you score all the station marks in less
.than 2 minutes of discussion

Examinations of later Dates

By Dr.Mohamed Gohar
:Brunei Test, Monday 8 June, third cycle
:Station 1
RESP: Man with depressed right lung base and small scar on
right side and deviated trachea to right, expansion limited on
right base and dull percussion. air entry diminished in right
base. Breathing vesicular with area of bronchial breathing in
right upper and middle zones "over shifted trachea" with
increase VR and WP in these areas" for DD
ABD: Man with jaundice, median sternotomy scar and
massive HSM. Most probably infiltrative dieses
:Station 2
years old man with two weeks history of headache, 22
confusion, impaired short term memory and exam showed
right homonymous hemianopia, known HTN, and heavy
smoker. DD mainly of space occupying lesion either primary
 or secondary from lung cancer, how ever pt denies cough or
chest symptoms
:Station 3
Neuro: woman with difficulty in walking, lower limb shows
increase tone bilat more on right and exaggerated knee reflex
but no ankle reflex and equivocal planter and pyramidal
weakness around hip and knee. intact coordination and intact
superficial and deep sensation. I said DD MND or spastic
"paraparesis "no back scars
CARDIO: Man with median sternotomy scar and audible click,
and lower limb edema, metallic first heart sound and irregular
pulse, bibasal lung crackles and sacral edema and jaundice, no
murmurs. There might have been increased JVP and Loud P2
..but i missed that
:Station 4
Young Man work as a chef and known asthmatic for long time
and also some episode of allergic reaction to nuts. came to ER
with anaphylactic shock after eating mixed salad and had to
be ventilated for a while now he is fine. He works as a chef. to
explain condition and seriousness and impact on work
:Station 5
lady c/o diarrahea for 1 week, bloody watery diarrhea. pt :1
known pf psoriasis on adalimumaba and methotrexate and
has also vitiigio, and only other finding is right hypochondrial
pain and tenderness. I said DD either IBD or Infection mainly
TB given her immunosuppresion
young lady known of DM since age of 7 on insulin and :0
Graves disease since age of 11 on carbimazole, c/o of attacks
of hypoglycemia, also has vitiligo and postural hypotension. I
said DD addison's disease
Good luck to all still taking the exam and pray for us who took
it already

Wolverhampton,, UK,, new cross hospital,, 12 February 2016

history, collapse,, patient on thiazide & started candisartan -1
two weeks back / Cardio, instruction pt is asymptomatic but
referred by his GP,, I heard ejection systolic murmur,,
discussion about aortic stenosis & sclerosis / neuro examine
cranial nerves,, only abnormality is diplobia on looking
outward and upward on both sides // communication,, pt
with essential tremor, carpenter diagnosed 3 years by
consultant, now concerns about Parkinsonism referred by GP
for deep Brian stimulation
station 5,,, fever in 27 year lady,, by history she had ,,
lymphoma before,,, second case diarrhea,, I noticed deformed
nose,, finally its wegners plus diarrhea after augmentin course
for sinusitis abdomin,, HSM,, NO stigmata,, plethoric

Thursday 11 feb 2016 maadi military cairo

Station 5
Carpal tunnel with background of acromegaly
Asked about investigations for complaint and causes and ttt of
acromegaly
 Joint pains bith hands and knees with morning stiffness 15
mins
...Osteoarthritis
Asked why not RA
ttt lines of osteoarthritis
Station 1
Obstructive airway disease
With bibasal crackles...was not sure bronchiectasis or fibrosis
Asked about investigations and ttt
HSM was huge spleen
Asked about infectious causes of large spleen and asked about
malaria investigations and ttt and bilharziases
..investigations.....was tough station
Station 2
Story of syncopal attack for 1 min
Vasovagal vs drug induced postural hypotension due to
recently added candesartan..asked about investigstions and
ttt and necessary admission or not
Station 3
Bilateral UMNL with bilateral cerebellar and normal sensation
???Asked most likely i told MS...WAS NOT HAPPY
asked about investigations and ttt asked about new drug.i
?told fingolimod
AVR mechanical with malfunction due to radiated murmur
over neck
Asked about investigation ..ttt...other ways to replace AV
 STATION 4
IHD prescribed ASA and plavix
After 6 weeks HB drop to 7
Task to eplain causes of anemia and management
Concern
Blood transfusion
??Is it cancer doctor
I told unlikely but needs to be ruled out as he denied any
ALARM features
Seems he didnt like my concern answer

EGYPT==CAIRO,,,last cycle
St1
Abdomen HSM with Lymphnodes
Chest. Lobectomy with lung fibrosis
St 2
Occupational Asthma
St 3
Cardio
PMV PAV
Neuro
 Hemiparesis
St 4
She had obstructive jaundice and probably has cancer speak
with the daughter
St5
Gravies ophthalmopathy
After getting UTI she developed confusion

An Important EXPERIENCE from my dear friend (M.A) who

examined in Brunei last diet = December 2015
N.B. He is my GUIDE in paces
Station 1
Chest pul fibrosis in sleep patient actually mixed CTD
HE ASK ABOUT IVESTIGATION management ipf
:Abd
Huge splenomegaly in young lady with anaemia in feed back I
missed also jaundice
He ask about DD investigation. Management
Station 2 iron Def anaemia in middle age lady with mech MVR
and hypothyroidism not respond to oral iron no bleeding from
body orifices I missed to ask about menses.no alcohol intake
or malnutrition.woried about colonoscopy as she was planned
to have before but developed presyncopy .ask about DD I
mention over coagulation or under coagulation. Haemolysis
.from valve.coeliac disease .also about management
 :Station 3
.Cvs MR &AR with displaced apex
Neuro: spastic paraparesis with planters down on one leg and
equivocal on the other with loss only of pain and touch up to
mid calf on Rt leg only .joint sense normal. In feed back
transverse myelitis. I don't know how? It was difficult
.case.they ask about DD .management
:Station 4
Lady admitted with CHB .PPM inserted but lead discovered
dislodged during programming next day.needs lead
repositioning. She is angry and want to be discharged .want to
change her cardiologist. I apologise. Ask about consent she
signed before what she was told about complications? Explain
this complications can happen but rare.canot be discharged
till repositioning of the lead other wise threatening her
.life.she agree for repositioning at last
Examiner ask about consent informed or written?reply
written as this invasive procedure. She can change her
physician through him.if she insist to go DAMA? Reply I will do
my best to convince her ,consultant appointment, still insist
?she is competent and has the right to refuse ttt even if if life
.threatening but after explanation of all the risk
:Station 5
A-35 lady with 2NDRY amenorrhoea. Only with hand sweating
and headache no more symp.it was acromegaly. There was
spade hands .hirsutism. macroglossia and skin tags.i present
the case as pituitary tumour and I need to R/of acromegaly
.but they were Un satisfied
B-young lady with MCT with chest pain concerned about heart
.attack.hx of ll swelling but no DVT SIGNS .spot 98% HR 88
 They ask about DD .mention myocarditis, pericarditis.
Vasculitis.could be due to pul htn (she had accentuated 2nd
PUL SOUND) .less likely PE IN feed back they down grade me
.bacause not Menston PE
.I hope will be beneficial for preparation
Good luck

Sharjah
0211/0/12
Station 2 : diabetic autonomic neuropathy
Station 3 : double valve replacement , spinothalamic
degeneration
Station 4 : chest pain , young women , all cardiac workup
normal , reassure her no more tests required
Station 5 : requrent red painful eye ( most likely thyroid case)
nd case : svc obstruction ( senario facial swelling )0
Station 1 : obstructive lung disease
Polycystic kidney with massive ascites and
😊😊 tenderhepatomegaly with functiong fistula

EGYPT 10-2-2016
Almaadi
 St 1 . Lung consolidation with fibrosis. Abd : hsm
St 2: collapse due to postural hpot caused by acei
St 3 : neuro ms, Freidrech ataxia cardio : aortic VR with AS
St4: pt with aneamia after taking asp and clopidogrel for his
IHD concern is it cancer
St 5: osteo arthriris . Acromegally with carbal tunnel syndrom

: Dubai paces
Station 1 : lobectomy - HSM with inginal LNs
: Station 2
Post streptococcal GN
: Station 3
Mitral regurgitation
Combined ulner and median nerve palsy
:Station 4
BBN : meningitis comatosed pt
: Station 5
Cushing
Scleroderma present with reynauds

0212 12 02
 University malaya ..malaysia
St 5 ..my first
Bcc1 thyroid cardiomyopathy with icd...big mistake not
exposed fully
With overwarfarinisation
Bcc2
Diabetic retinopathy post laser
Respi unsure
Stem..c.o sob
Coad..might b right upper lobe fibrosis as tracheal to right?
I missed the fine crepts may b
Cardio
No murmur
Clubbing with polycythaemic
Asd with esseimenger
Abdo
Renal transplant
Cns
Fascioscapula humeral
St 2 radiation proctitis
St 4 addision poor adherence to steroid
 Maadi hospital 10/2/2016
) Egypt (
Cardio ms +mixed aorta
Neuro charot
Abdomen hepatomegaly hemolytic anemia
Respiratory cobd fibrosis
Comuication diabetic patient have all complications refuse to
take insulin
station 2- Post partumthyroiditis
Station 5 antiphospholid syndrome
Optic atrophy 2nd case

Cairo 10/2
Hepato splenomegally
Copd+ bilat basal fibrosis
History : bloody diarrhea
Double aortic + double mitral
??? Ms+ stroke
Communi: medical error
Sudden painless transient loss of visin
Hand pain in rheumatoid carbal tunnel
 Cairo 9/2/2016
rd carousel3
Abd
Thalassemia
Chest
COPD with fibrosis
Neuro
Cervical myelopathy
Cardio
Double Aortic
Communication
Medical error
Hx
Iron deficiency anemia in 40ys old lady with OA & weight loss
Station 5
??? Mallory weis syndrome
Short stature

Exam Experience of Dr. Noha Attia

 EGYPT 6/2l2016
my exam today kasr al3eny cairo first cycle
st 1 abd young pt wz large spleenomegally
chest :- lt lung fibrosis wz OLD
q how to investigate what treatment of fibrosis
st 4 motor neurons dis
concern what if symptoms aspiration and weakness is m living
alone
recure no one to help me iforget z beg tail
st3 neuro pt wz LMNL & down going planter asymm weakness
loss of sensation ididnt finish examination idid very bady dont
know what was diagnosis
st 2 diarrhea 3month
difficult to flush and smelly 3times per day more wz fatty food
wt loss 5kg in 3 month good appetite history of pneumonia
received amoxicillin 4 months ago for 1wk concern is it cancer
st 5 knee pain in acromegally pt ididnt do visual field was
asked by examiner
case 2 tirdeness
history anaemia melena epistaxis loss of wt not know how
much examin pallor
they didn't allow abd examination and red spots on z tongue
concern is it
serious
overall im not happy wish
u all good luck
 Egypt Cairo 7/2/2016. 2nd cycle
Copird from ** Paces uk study group** On Telegram
St2 @
.Mr. Youssef 40yrs M -
.On call doctor in medical admission unit -
C/O poor mobility -
He has been diagnosed of lung ca 18 months ago, Has a back
.pain, received radiotherapy 10 days ago
?Concern::: is it related to ca
?Am I going to walk again
St4 @
.A doctor in cardiology clinic
Mrs Noran 40yrs Female
Problem : non cardiac chest pain
Pt waiting for the result. Which showed normal lipid profile,
.normal ECG& normal stress ECHO
The COSULTANT decision that the pain non cardiac and no
.need for further test
.Manage the pt concern, reassure her accordingly
the pt keep asking for further test. And asked do u think ::::
?doctor I have to be seen by chest physician
.she has Fhx of heart attacks ( father55, bro 55) ::::
 why I need to be seen by psychiatrist ? Do u think I'm ::::
?😡😡mad
St1 @
.Abd :: HSM + multiple Abd scars & masses. For DD -
.Chest :: pt was distressed COPD + lt basal fibrosis -
St3 @
Cardio :: severe AS -
Neuro :: pt c/o difficulty in walking. O/E asymmetrical UMNL -
.+ PC + CEREBELLAR ::::: MS
St5 @
yr M hx of loss of wt 3 month, loss of appetite , diarrhea , 22 -
.lumps
.O/E cachexic , pale , Generalized lymphadenopathy ::::: DD
.yrs M with recurrent oral ulcer22 -
Hx of knee pain , sore eyes, painful skin rash over the shin. :::
b
.Behčet D + DD

Examinations of later Dates

th april 2015 oman paces1
Station 5a 55yrs old lady with mechanical type back ache post
menupausal
b. 30yrs old lady with skin lesions neurofibromatosis 2
neurofibromas and cafe aulait spots
 Station 1 abdomen ascites with positive shifting dullness
discussion around cld
Resp: 60 yrs old man with copd
Station 2: 35yrs old gentleman 6yrs history of RA on
methotrexate having breathlessness night cough and
wheezes. Discussion went around br asthma
Station 3 neuro: guillain barre synd ardflexia and inability to
walk
Cardio: MR with AS discussion around MR management
Station 4 breaking bad news to wife whose husband admitted
with seizures controlled with diazepam CT showed frontal
tumor Biopsy confirmed grade 4 astrocytoma. Experts advised
.palliative treatment

EGYPT 6/2/2016
St 3
Motor neurone disease
Wasting fasciculations,Extensor planter
)DISCUSSED IN THE COURCE OF Dr.Ahmed Maher Eliwa(
Cardiology
!! Mitral stenosis
St 4
years old lady 72
While she was on physiotherapy due to fracture neck femur
she fallen down Developed confusion but no neurological
deficit
Ct showed minimal cerebral haemorrahge
Speak with her son
)DISCUSSED IN THE COURCE OF Dr.Ahmed Maher Eliwa(
St5
Skin disease with s o b
It was scleroderma with lung fibrosis and pulm.hypertension
)DISCUSSED IN THE COURCE OF Dr.Ahmed Maher Eliwa(
At5
Blurring of vision in a diabetic patient
Fundus uncooperative patient
St 1
Abdomen
Hepatomegly with no signs of CLD
Chest
Obstructive airway disease
Pulmonary fibrosis
St 2
Fever rash loss of weight
X ray lung cavitation consolidation+GN & Nasal blockage
==Wegenar granuloma==
)DISCUSSED IN THE COURCE OF Dr.Ahmed Maher Eliwa(
 I start my exam with station 3
Cvs:it was case of shortness of breath diagnodis wasMVR
with pulmonary HTN In AF question was about AF managment
, B blocker contraindication , target INR for mitral valve
replacement
Score 19/20
CNN case of difficulty in walking in young patient finding was
pallor, jaundice with hemiparesis lt side q was about causes of
hemiparesis how to investigate and how to ttt
Score 18/20
Station 4
yrs old lady on renal dialysis with past history of stroke 22
after which she become blind she experience wish to stop
dialysis if her condition become worse and the renal team
decide it is time to stop dialysis she is drowsy with shortness
of breath and expected to die after 3 day if dialysis is stopped
😰speak to her son about his mother condition
It was tough and I don't know how I will manage I Remember
the consequence of Dr. Zain I start with same manner after
greating and permission of note and if any relative wont to
attend , how much he know about his mother condition he
know little about it I clarify her condition and the need to stop
dialysis to her and I ask if he know that his mother she has
any wish and he know about the wish of his mother he ask to
take mother home since dialysis is stop I counsel him about
the need for her to stay in hospital for her best interest his
 concern was about his mother condition and if he is able to
take her home and after how many day she will die I tell it will
shorten her life then summarize and check his understanding
� the till me still u have time I don't know what I will tell more
😓I didn't discuss about DNR
Examiner q was about issue
And why u will keep patient in the hospital and what about
😓the wish if her son
Itwas v.bad station for me
Score 10/16

Manchester pacess exam

S1
Abd renal transplant on tacrolimus
Chest IPF
S2 drug photosensitivity (doxycycline)
S3
Cardio AS
Neuro spastic paraplegia with cranial nerve (MS)
S4 stroke pt admitted in surgical ward developed bed sore
infected with MRSA
to speak with his daughter
S5
A
 st time seizure no obvious cause1
B
Black stool for 3yrs no obvious cause

Dubai exam 8/2/2016

Station 1
Respiratory.. Pulmonary fibrosis
Abdomen.. Transplanted kidney
Station 2. Bloody diarrhea with skin rash and history of joint
pain and mouth ulcer
Station 3
Cvs.. Young female with mid sternotomy scar and MR and
...xanthelasma and tuberous xanthoma
Cns.. Spastic paraparesis with normal sensation
Station 4 pt with post hip surgery and on heparin plus aspirin
felt during session of physiotherapy and develop intracerbral
hemorrhage... Discuss the situation with Her son
Station 5
st case... Pt with proximal mypoathy and morning stiffness... 1
Dd. Polymyalgia rheumatica.. Polymylitis
nd... Neck swelling with dysphagia.. Solitary thyroid nodule. 0
No lymphadnopathy.no symptoms of hyperthyroidism. Wt
loss
 EGYPT 8/2/2018
Station 1
..splenomegally( HC)
station 2
young girl with HTN and protein and RBCS in urine my
.diagnosis was Igm neph. Which was appreciated by examiner
.
station 3
.. ms with PHT and opening snap..+ spastic paparesis
stat. 4 stroke for telling the relative
. stat. 5 hyperthyroidism +pemphigus v

EGYPT TODAY 7/2/2016

Station 4
Pt with haemorrhage and inoperable shewanoma bbn deal
with wife concern (from the source <<<BUT Dr.Ahmed Ahmed
Maher Eliwa CORRECT that by :: The case of communication
was astrocytoma not shewanoma)
Station 5 first short stature
Second psoriasis exacerbated by b blockers
Station 1 jau and huge acities with vitiligo
 Chest cold with fibrosis
Station 2
headache with menorrhagia
Station 3
Neuro : lower stroke in yong pt
Cardio : arortic stenosis with aortic regair

EGYPT-kasr alaany -- cairo 6-2-2016 first cycle

st 1 abd young pt wz large splenomegaly
chest :- lt lung fibrosis wz OLD
q how to investigate what treatment of fibrosis
st 4 motor neurons dis
concern what if symptoms aspiration and weakness , m living
alone
recure no one to help me
st3 neuro pt wz LMNL & down going planter a symm
weakness loss of sensation ididnt finish examination
st 2 diarrhea 3month
difficult to flush and smelly 3times per day more wz fatty food
wt loss 5kg in 3 month good appetite history of pneumonia
received amoxicillin 4 months ago for 1wk concern is it cancer
 st 5 knee pain in acromegaly pt i didn't do visual field was
asked by examiner
case 2 tiredness
history anemia melena epistaxis loss of wt not know how
much examine pallor
they didn't allow abd examination and red spots on tongue
concern is it
serious
also there was young pt wz malar flush no one heard murmur
but she had pulmonary hypertension

Glasgow PACES March 3, 2015

:Station 4 ♤

Delayed diagnosis of pheochromocytoma

Mr, jones 35 years male

Had High BP for last 5 years

Seen by psych for panic attacks
Tried many Med for HTN
But
 His BP has been difficult to control

On his insistence , his GP has referred him to hypertension

clinic 2 weeks before

Results of tests now show

Urine : high metanrphrines
CT adrenal : 5 cm mass in right adrenal

Ur task is to explain the diagnosis

U don't need to know the details of further tests and further
management

Patient was concerned

Is it serious
Is it cancer
Is there a cure
Will I require future surgery
What future tests will be done
Was the delay justified
What medicine u will give me

Examiner : repeated similar questions

Overall not too harsh patient

 Satisfied at the end
Agreed follow up GP Consultsnt website address alpha
blocker beta blocker

11/11

History station at same centre ♧

Opening : 11 points

Discussion : as under

Young female 28

Blood Diarrhoea after Cyprus visit

Started 1 day before coming back
Mixed with stool
Similar episodes for last 2 years
Took amoxicillin in Cyprus
Diarrhoea aggregated
Now last 10 days
Frequent blood a salime in still
Painless
C/ o small joints pain
 No backache
No other extra intestinal symptoms
No oral ulcers
No skin changes
No jaundice
Cousin IBD UC
Father CA colon
No blood thinners
No steroid
No warfarin
No bleeding disorder
No weight loss

Concern : cause
? Is it cancer
? What next tests
? What Med
? Need admission or not

DD: xIBD ( UC)

Infective Diarrhoea
Antibiotic associated Diarrhoea ( as patient said Diarrhoea
) aggravated by amoxicillin ( but I told least chances
 Explained to patient in detail and agreed a plan

: Closing
summary

Labs / Leaflets / NHS choices website

Agree

Examiner : just repeated all above

And
Asked
In
; History how will u rule out infective cause
Fever
Vomiting

But
He told
U will ask about symptoms to others accompanying him

Marks : 4/20
 History & Communication : zero
Concerns : zero
DD : zero
Judgement : zero

In feedback : written

: History and communication

️✔PC
️✔HOPI
️✔Past Hx
️✔ Personal
️✔Family
️✔Drug
️✔Allergy
️✔ Treatment
️✔ : Social
️✔Occupational
️✔ Travel
️✔ Association of IBD

Used jargon : IBD ( during explanation of DD to patient )

Oral ulcer ( mouth ulcer should be used )
 Didn't get more details of past episodes

Result : zero marks

DD: 1st diagnosis was IBD

But actually it was infective Diarrhoea

Result : zero marks

Concerns : though addressed adequately but remarks are he

left patient worried about the diagnosis ( serious diagnosis as
IBD)

Result : zero marks

: Clinical judgement

Question 1
: How u investigate
CBC to look For
CPR ESR
Electrolytes
Renal functions
LFT
 Stool microscopy & culture for infective Diarrhoea
Sigmoidoscopy / colonoscopy if required

Question 2
Treatment: as per diagnosis if it's UC
Then steroids and mesalazine

If infections : antibiotics

Remarks : want to give steroids though preferred diagnosis is

infective Diarrhoea

Candidates remarks : This happens in real life

Though I was expecting 100% 20/20
But
. Actual 4/20

:UK PACES experience

I want to share my experience in Western General Hospital,

...Edinburgh 25 Feb 2016
 ..I started my exam by station 3 ☆
..Cardiovascular; 50 year old man complains of SOB )3
I did the exam, I appreciated a murmur in apex.. I could not
.. time it
for unknown resean I said it is diastolic murmur considering I
do believe that diastolic murmur can not be brought in
..PACES
The examiner ask me if that was diastolic murmur what will
be your differential.. at meet the patient after the exam at
( hospital gate and he told me he has AS and MR !!! I scored
) 02/2

CNS; lower limb exam.. patient was not cooperative and )3

misleading
he kept moving his lower limb during tone assessment and
giving contradicting information during sensory exam.. I could
..not formulate DD
) 02/7 ( I scored

Communication: 40 year old lady has IDDM her HbA1c 9 )2 ☆

,referred for albuminurea
I was disappointed from previous station and forget to ask her
if she does attent all foloow up appointment , does she check
??her glucose
)02/2( I scored
 BCC1: psoriatic arthritis has joint pain.. has skin rash )2 ☆
)over elbows and hair line.. I scored ( 28/28

BCC2: 70 year old lady history of loss of consciousness and )2

abnormal movement, had murmur during adulthood for
..which she does not require follow up
My DD : epilepsy and stroke
.. I could not appreciated any abnormality in exam
..I instructed her not to drive for 1 year and to inform DVLA
!!they ask me if I appreciate any murmur.. I answered No
)02/02 ( I scored

Abd: kidney and pancreas transplant , has gum )1 ☆

hyperatrophy and poor vision.. I said the cause is Type 1 DM
.as patient has vitiligo
) 02/02 ( discussion about complication of transplant

Chest: Rt upper lobe lobectomy with deviated trachea )1

discussion about indication of lobectomy and types of lung
) cancer ( 20/20

History: 55 year old male with symptomatic anemia and )0 ☆

.. melena on ibuprofen for knees pain
??His concern: Is it colon cancer
..I told him I ll request upper and lower GI scope
) 02/11( I scored
 )170/132( The End Result is PASS

.. It was My first trial

I have never been to UK before .. I had course in Ealing
..Hopsital, London for 2 day ( it is excellent )
..Despite the bad beginning .. Still AlHamdullah I passed

..My Advice .. do not be relactant in applying to UK

My English language and accent is not perfect however they
!! consider that

:UK experience of one colleague

🏽👇🏽👇

Castle Hill Hospital ً‫الٌوم امتحنت ف‬

.. ‫ واللغة ما كانت ساهلة‬tough ‫االمتحان كان‬
...
‫حاكتب تجربتً ودعواتكم‬

Station 2》
years old .DM.asthma presented 02
With recurrent chest infections for 6 months 6 times
 I put DD bronchiactesis .TB
No Hx of fever .wt loss or travel or contact with pt with
chroinc cough.he has greenisg sputum..constipation..I did not
understand his accent clearly
He continue mentioning constipation and trying to have a
baby and I totaly ignore it..his concern why I have this
recurrent infection
His diabetes and asthma are not well controled I asked about
HIV risk which up set the examiner
I forget sinusitis and examiner was angery and heampotesis as
.well
I told him we are going to do bronchoscopy..also upset the
examiner
He asked me about d ...my dd was bronchiactesis and TB
He asked about one blood test for specific for bronchiactesis
I told I do not remember
..😳 He said serum antibodies for pathogenes
😣 I was about to say immunoglins but bell rang

.CNS: Upper limb exam .3》

He has hemiparesis
I did not finish sensation
Not examin e nech
He had truma with scar in head which I did not notice even
.when examiner point it
 He ask me if you notice any facial asymetry I said no..which
acutaly was present

:CVS .3》
A tall women I wasted time looking for alchol gel for scruping
and washing hands with water

Marfan syndrom with 2 sacrs on medisternotomy scar with

metalic clikc and aother an rt subcalvicukar..no muremur but
2nd sound was loud and palpable..first was soft
My d..aortic valve replacemtn
He asked about causes of chest pain in marfan
I told ACS
And pneumothatx he asked what else which I can not answer

She had high arch palate and archenodactyly..I think by other

cause of chest pain he wants rupture anyuresm..I just
remember it now

:Communication skills :2》

Staion 4 ...80 years old patinent..Alzehimer d...was on NG
feeding and she was agreesive and agitated all the time and
use to pull it out..her doughter facing problem with feeding
and want PEG tune insertion ..speak to her doughter and
...explaine ill_terminal care and palliative care for her
I do not now mentioning DNR waa suitable or not but I have
..mention it
Examiner asked about how are you going to feed her if sh will
..😳 not take oraly no NG no PEG tube

:2》
Station 5 was diffecult
years with skin lesion over her forhead and scalp 12
Looks like morphea
Some candidate mentioned SLE
Apart from that she did not have any manifestation of scl
? eroderma ..her concern is it a infecious
?Is it cancer
I reassure her ..but examiner asked what could cause
morphea

Second case 62 years old ..with blurring of vision .exssive

fatiguabilty..and more blurred by the end of the day..deffintly
she had exopthalmous and opthalmobligia..diplopia on both
lateral gazes..thyrodyectomy scar and left firm thyroid
😥 nodules
Dry hard skin..fundus normal..no other manestation of
..thyroid ..no proximal myopath
I told dd
Graves opthalmopathy and
Mysthenia graves

:Station 1》
chest bilatral basal fibrosis and skin rash..I do not now what ¤
is it...some candiadte examiners told them it is
dermatomyosistis..it was not typical she had hard skin..finger
.tips ulcer as well

Abdomen...abdominal pain ¤
I could apprecaite 2 masses in rt side and one mass in left side
not liver not spleen...it was transplanted kidney ..examiner
? asked why she is going to have abdomian pain

?What about immune supression side effect

...Examiner questions was more tough than the exam

But it was nice experiance
..Keep praying for me

Examined in Egypt last diet

My experience in paces exam in cairo 3rd day 2nd carosl

score 154/172
Dr.faisal hemeda 2016
I started with station 3 neuro
first was a case of spastic paraparsis without sensory level
 I finish my examination before the time by one and half
minute :D
and the examiner told me if you wish we can start the
discussion now i told him NOOOO :D i not finish yet i would
.. like to examine the gate to waste the remaing time
DISCUSSION
? what ur DD
MND.1
Hereditary spastic paraparsis.0
i told him i want to take travel H to exclude tropical spastic .3
paraparsis
MS (he asked me what against MS i told the age and the .2
symmetry of the symptoms )
? what ur inv
.... Basic
= specific
EMG and NCS
MRI to exclude MS
? what ur ttt
according to the cause
he asked me about the planter response i told it was not
upgoing he asked what we call it ? i answered eqivocal
the examiner was stasfied
score 20/20
nd caseCARDIO was a disaster for me :D0
 my college in the same carosel who know the pt told that he
has douple mitral and mixed aortic and P HTN
» I SAID ONLY MR WITH P HTN
discussion was not satisfactory for me rather than the
examiner
any way I score 19/20
station 4 cmmunication was ctastrophic
explain to this gentlman about dailated cardiomypathy
)\ i did not know any single useful info about this dis(
i follow the instruction of dr.@Ahmed Maher Eliwa i start by
def and cl/p and causes and compl and mangement
I keep telling the surrogate you have to take ur RX
he asked me about the surgical ttt for his condition i told him
we have protocol to start with the medical ttt first and
according to ur response and the MDT team decision cuz i
!! didnot know the answer
the surrogate was a young man 25 y but in the scenario he is
55 years and have 2 child so i got a little shocked when he told
!! me that he has 2 kids one them is 15 years
i made summary and checked the understanding
DISCUSSION
examiner have a strong english accent i did not get him in
every qs
he asked me 1.how you dare to tell the pt that he have to take
RX ?did not you know about AUTONMY and the pt has the rt
to refuse any ttt ..SHOKED ..SWEATY .. PALPITATION ... I FELT
!! he told me i give u chance to repeat ur phrase again
 then he asked me about the surgical ttt for cardiomyopathy
drug ttt for it and the role of every medication in the
mangemet
‫ حاله الرعب‬score 10/16
sation 5
case was young pt with chest pain start this moring stabbing .1
with history of leg swelling last weak
score 26/28
neck swelling.0
the discussion was good but i did 2 stupid things
first one i pretended to be calculting the pulse while i was not
and i told him there is tachy he told me howmuch ? i told did
not calculate
i told that there is bruit but here was not and that was my .0
last word before bell
rest of discussion was Ok
score 24/28
Station 1
abdomen
splenomegly bout to cross the medline
? DD
? signs of portal HTN
what other dd ? CML
no ascitis no LN pt under built
discussion was good
 score 20/20
chest
i found the pt have COPD Basasl fibrosis and area of
!!!! brochiectasis on the rt side ... i was sure
the examiner shoked told me 3 finding !! are u sure
i told him yes that what i found and discussion about inv and
ttt
when i mentioned postural drainage he told me if there is
!! brochiectasis
i was sure but it seem that there was not any way i insist
Score 17/20
station 2
history
] patient with DM 1 with wt loss
actually my dd before entering the room was
addison.1
malaborsption like.0
coiliac.3
inflammtory bowel UC.2
autonmic diarrhea.2
panhypopitiurism.2
the discussion was going was postive dizzy spell but no abd
pain or hyperpigmention to support addison and no PN or
Diarrhea or frothy urine to support autonomic !! any way i
answered the concern as addison
 examiner asked me why not TB i told him there is no fever
and no chest symptoms and the concern of the pt was why
? not cnacer
score 20/20

I had my exam in Brunei on the last day in second schedule.

Exam was tough with some atypical cases, but
ALHAMDULILLAH (All praise to Allah), I passed it. It was my
first attempt. My sincere thanks to PACES EXAM CASES and all
it's contributors, esp. Bebo bebo and Mahiuddin. I had been a
silent observer here. Dr Mahiuddin gave a lot of useful tips
here which really helped me. I also thank to my all teachers
esp Dr Abdulfattah, who taught me the basics of this exam in
.a very simple way. I would like to share my cases here
Respiration: Young short lady, with SOB. Patient could not .1
lie down, so all examination in sitting position. No clubbing,
central trachea, B/L basal crackles not fine but doesn't change
with cough as well. My diagnosis Pulmonary fibrosis, Other
DD Brochiectasis. Examiner asked about diagnosis and
different causes. British lady examiner was very cooperative
and she sensed my nervousness as it was my first ever PACES
station, that also respiratory (time taking) and plus young
.lady
.I got full marks
Abdomen: Obese man, round face, and abdominal striae; .0
with active fistula at left wrist. Few scars in the neck, left
subcostal scar with few scars beside it. No
hepatosplenomegaly. I felt some fluid hitting my hand when
 patient turned his body. It was a very difficult palpation. I got
shifting dullness as well (??). My diagnosis- Patient with end
stage renal disease on haemodialysis, most probably on
steroids, cause could be due to Glomerulonephritis. Examiner
asked me why he had ascites. I said due to volume overload
(uraemic). Then why not pedal edema? I told may be partially
treated. He asked for any other reason for this ascites in renal
patient. I told he might have peritoneal dialysis, which could
be reason for fluid. He asked me for any proof? I showed him
the scars on abdomen. He said it could be due to surgical
drainage. I said it could be. Then he repeated the question,
any other reason for ascites in renal patient. I was very
.nervous and couldn't answer further and the bell rang
History: Middle aged man with SOB and leg swelling and .3
past history of recurrent chest infection. I finished before
time. Examiner asked me about diagnosis. My diagnosis
Bronchiectasis with cor pulmonale (right heart failure). He
asked me of any other possibility. I could not get it. He asked
me about complications of bronchiectasis, I said local and
systemic. He asked further about systemic. When I told
amyloidosis, he asked, "could it affect kidney" . I told yes, it
can cause Nephrotic syndrome and that is one of the
possibility in this case. He was very happy to hear this from
.me and he gave me thumbs up
Nervous system: Middle aged lady lying down with her .2
right hand near body and wrist looks dropped. I asked her to
put her hands in front and turn the hands up. Initially the right
wrist was dropped but slowly she raised it. That added to my
confusion. I immediately started typical upper limb
examination. Power 4/5 in the right upper limb. Tone -
normal, reflexes - absent bilaterally with negative Hoffmann.
Sensations - I checked pain and vibration only, due to
 shortage of time. And both were reduced on the right side.
There was no obvious facial deviation. I was fully confused. I
went for common thing first and said it could be stroke in
spinal shock. British examiner asked me the proof to support
my diagnosis. I told it is difficult to say without examining the
lower limbs and cranial nerves. But the typical pyramidal
pattern of weakness with unilateral sensation loss of all
modalities could be the clue. She asked what did it mean by
pyramidal weakness, I said "even though it is more typical in
lower limb here I can see that abductors of shoulder and
extensors of elbow and wrist are weaker, giving the typical
".posture
I got full marks ( I can't believe, I am still not sure about
.diagnosis)

CVS : Middle aged man, with midline sternotomy scar. Dual .2

valve replacement with MR, AR and AS, with chest congestion
but no pedal edema. I forgot to check thrills. British examiner
did not agree with my apex finding, which I immediately
accepted. He asked me about diagnosis and complication. It
.was a typical station
Communication skills: Young man from military was .1
referred by GP for further check up as his brother died of
HOCM last year. His ECG done by GP was normal. He had
appointment for Echo after 2 weeks but still couldn't get
appointment for genetic studies. He was not eager for further
tests and had concern that his life would be disturbed and he
might lose job if it came out to be positive. He started
aggressively, Alhamdulillah, I tamed him and convinced him.
My MRCGP skill helped me. Examiner asked some typical
questions and also what would I do if he didn't turn up for
 further investigation. I told I would take the help of GP or
employer to trace him back. Chief examination coordinator
.was present during this consultation
.I got full marks
BCC1: The coordinator confused me with other case. I lost .7
some time in confirmation. Young lady with decreased vision
of sudden onset in both eyes for 2 days. Diabetic for 6
months, not following up, not controlled. Father had
glaucoma. Past history of gestational DM. She could only read
the top line of chart. Field normal. Before I started
fundoscopy, examiner informed that two minutes were left. I
looked in the right eye, there were black pigments suggesting
retinitis pigmentosa. I had no time to look at optic disc or
macula. I told I would like to refer her urgently to
Ophthalmologist and also check her blood sugar. Examiner
asked me about diagnosis. I said it could be due to osmotic
changes in the eye due her uncontrolled sugar. She asked me
about anterior chamber. I said I could not examine due to
shortage of time. As there is no pain the chances of glaucoma
is less. As it is acute and bilateral, Retinitis pigmentosa can't
explain this. She asked me about complications of DM, I
answered everything except Retinopathy (funny? I felt very
depressed that how I forgot this... Exam tension). I am still not
.sure about diagnosis
BCC2: Young lady with hand deformity. She had pain in .2
hand joints and backache. Fingers were deformed just like
rheumatoid arthritis. Nails were normal. On asking I got to
know she had rashes over elbows which were well hidden
with clothes. Alhamdulillah I got it. I examined her properly. I
managed the time very well here. Examiner asked me about
diagnosis I said Psoriatic arthritis. Then he asked about type of
 deformities, signs of activity of disease, chest findings and
.management
.I got full marks
Alhamdulillah, I passed the examination comfortably. All
.praise to Allah

My experience for PACES in Tameside hospital near

Manchester 6 Feb 2016
Station 1
:Abdomen
Young male with fine tremors on outstretched hand and skin
warts. On abdominal examination: there was a left iliac fossa
scar with a mass under it, also there were multiple abdominal
scars. My diagnosis was left renal transplant with previous
peritoneal dialysis history, Patient is mostly on tacrolimus or
cyclosporine. Discussion was about causes I said normally it's
diabetes but for the patient' age can be ADPCK, GN,
obstructive or reflux uropathy. I scored 20/20
:Respiratory
About 50 years old male, on general inspection there's
peripheral cyanosis, also plethoric face with multiple
telangiectasia. On chest ex: bilateral fine inspiratory creps
that didn't change with cough. My diagnosis was Interstitial
lung disease; patient may be on steroids. discussion was
about causes. I scored 20/20
====
 Station 2: History
Young female presented with 3 episodes of rash on sun
exposed areas, last one associated with blisters on both arms.
On history taking: Patient mentioned going to the beach
before last episode, no symptoms for rheumatological,
connective tissue disease or abdominal complaints. Past
history of acne for which she is taking doxycycline prescribed
by GP. My diagnosis was drug eruption caused
photosensitivity rash accentuated by sun exposure, my
differential was porphyria cutana tarda, dermatitis
herptiforum and pemphigoid. Discussion was about the
management: investigations ANA, TTG, eosinophilia, stopping
the offending drug. I scored 19/20
====
Station 3
:CVS
More than 60 years old female, peripheral examination was
with in normal, heart revealed systolic murmur on the aortic
area radiating all over the pericardium, also soft S1. My dx
was Aortic stenosis, the presence of soft S1 make associated
Mitral regurgitation is possible, Discussion was about the
difference between Sclerosis and stenosis. Plan of action and
indications of surgery. I scored 20/20
:Neuro
Young male with spastic posture on general inspection, on
Examination: Hypertonia and hyperreflexia with no clonus,
there is some cerebellar involvement, no sensory
involvement, I finished examination early so I had time so
preceded to examine the eye which revealed bilateral
nystagmus, isolated left 6th cranial palsy. My diagnosis was
 MS. Discussion was about my differential if no eye
examination was performed. Management plan for MS
including investigations, ttt of acute, progressive ds and
symptomatic ttt. Score was 19/20
====
:Station 4: Communication skills
Patient admitted with stroke, there was no places in stroke
ward so admitted in surgical ward. There was no
improvement in his condition, he developed bed sores,
.isolated swab revealed MRSA. I had to speak with his son
I divided the case into 3 sections: 1st one regarding the
admission, then explained bed sores and care about it, then I
explained regarding MRSA infection. Initially the relative was
angry but after calming him down and explaining the situation
and we will do he calmed down. I scored 16/16
====
Station 5 was quite unexpected to me as there was no
physical findings at all
:BCC1
years old female presented with melena on and off over 3 12
years duration. On history taking there was no positive data
toward a specific diagnosis. No history of epigastric pain, liver
use. On ‫ى‬disease, no NSAIDs, no alcohol or steroid
examination also nothing was appearing, I examined the
abdomen, aortic area for AS, looked for signs of pallor,
mentioned the need for BP and digital rectal examination.
Explained the need for further blood investigations, OGD as
outpatient and may be colonoscopy according to the results.
Discussion was about the causes, management plan. I didn't
feel good at this case. I scored 22/28
 :BCC2
years old female presented with history of Loss of 03
consciousness and jerky hands and leg movements. No tongue
biting, no incontinence, no frothing. CT brain done is normal,
electrolytes and initial investigations with in normal. Had mild
chest discomfort before it. No attacks previously. Hi

General western hospital edinbrough 6/7/2016

History station fever for dd (mostly lymphoma)
Neuro parkinsonism
Cvs: i couldnt get a clue intially but the examiner asked me to
feel the pericardium and it was pacemaker/ ICD
Abdomen: bilateral kidney transplant
Chest: copd
Communication: missed FNAC result and breaking bad news
of uncertain diagnosis of cancer
Stat 5 : pulmonary embolism
Ank spond. With new diagnosis of parkinsonism

) passed PACES IN UK (

Here is one of New PACES scanerio

 Glasgow college
0211/0
July 3 , 2016
Manchester

A 37 years old patient accountant has been found to be

hypertensive , his ABPM confirmed BP 160-170/110-100
He lives an active life style
. With daily exercise and plays tennis three times a week
His renal functions , CBC and liver functions are normal
His total cholesterol is high 6.0 mmol

Your consultant wants to rule out secondary hypertension and

planned for CT scan of abdomen and 24 hours urine collection
.test and Doppler USG

Kindly discuss with patient about the diagnosis , and further

. management and address his concerns

Good morning
Introduce
Relax patient
Agenda
Rapport
 Anyone with u
Anyone to attend the session
Notes taking

? What patient knows

!Then explained diagnosis

Of high blood pressure
Life style
Diet ( salt / fats / vegetables / fruits / meat)
Walk
Exercise
Smoking
Alcohol
Drugs
Job
Avoid tension / anxiety
Home blood pressure monitoring

Smoker 5 cigarette per day

Family h/o premature Heart disease
Father died with MI 49
Mother healthy
Brother had Angina at age <45
 Alcohol
Tension at job / busy schedule but still manage to go walk /
exercise and play tennis
Married
kids 0
All healthy
Discussed smoking cessation 1 word
Dietician referral 1word only

? Explained the need for further testing

? High risk for cardiovascular disease
So
Need to stop smoking

Blood pressure medication ( amlodipine )

? Patient was asking Side effects
? What Diet
!
? Any further tests
? How u will perform these test
? Do I need to be admitted

Explained further tests ( by making a picture of kidneys /

adrenal / kidney vessel )
hour collection of urine for urine metanrphrines 02
 Doppler to see blood vessels
CT scan to see adrenal and for possible Pheo / conns

That's it

Any other concerns

Satisfied patient

Check understandings
Closure
Leaflets
NHS choices websites
Wrote spellings for Hypertension / pheochromocytoma and
told patient to read on website before next appointment
Sothat if any questions
We can discuss

Thank you

Examiner asked each point

That did u discuss this

Did u discuss this
What tests
? Y u do these tests
 ? Y Doppler
? Y urine test
? Y CT scan
Did u told patient about side effects
? Of amlodipine
? Y u didn't give ACE inhibitors
? Y not beta blockers
? Can we give thiazides in this patient

Result : 16/16

History was also new for me ( will send later to u)

I have passed my PACES exam in Mandalay center

recently.Thanks to Dr Bebo Bebo and other friends in this
group for sharing invaluable experiences.I w'd like to share
.my experiences
Abdomen.heptosplenomegaly w .1
anemia.Q.finding,dx,ddx,mx.14/20
Resp.moderate pleural effusion.w tracheal shift-
Q.finding,dx,ddx,mx.18/20
.History.0
unilateral Headache.in female 30 yr.not relieved by simple
.analgesics,pizotifen and sumatryptan
 Pt have used OC pill for 6 mth then GP asked to stop.not
related to OC pills and not improved by stopping it.no
features of migraine.cluster.increased ICP.stress present at
.work and related to HA
.I said tension HA and migraine as DDx
Q.how to invest.to differentiate.I said clinically and by
.response to drugs
Q.how to manage.I said I want to do full neuro.exam and trial
of other analgesics like ibuprofen,diclo. and reduce stress and
.follow up for new symptoms
.Q.how to reduce stress .l said biofeedback and CBT
It is not fit to typical history of any paticular HA and I think
examiners want discussions about possible ddx.18/20
CVS.MS with valvotomy scar with AF .3
Q.finding,dx,ddx,mx.simple case 15/20
CNS.examine the lower limbs neurologically
. flaccid paraparesis with indwelling catheter
I examined tone.power.reflexes,planter.pinprick and joint
position sense in time.Forget and do not have time to
.examine the spine
. DDx.cauda equina and peripheral neuropathies
I said cauda equina and ddx are peripheral neuropathies like
.lead poisoning,porphyria,DM
Examiner asked about pattern of neurological deficit in each
d.dx,then mx.I said CT or MRI spine,bowel and bladder
care..treatment of underlying cause.20/20
.Station4-medical error
 pt with psoriatic arthropathy taking methotrexate was given
.trimethoprim for a UTI
.pt was admitted for nosebleed with pancytopenia
I apologize very early after taking rapport and checking pt's
prior knowledge about her condition,I said we shouldd't have
given that combination as it have led to serious damage to
you.Surrogate show only little anger and with repeated
apology ,she accepted.Ask if she can conplain,I said yes and
.explain I will help her to write conplaint to PALS
Concern.if she can get recovery and when will she can restart
methotrexate or not.I said it depends on recovery of her
blood cells and I will ask my consultant and if necessary will
get opinion of joint specialists.when can she go home.? It
depends on her codition and I will let her know after checking
her recovery.Then I summerize and check pt's understanding
and say thank you.finished early and we have to sit in silence
for 5 mins!Examiner warned me to say something to pt but
we have not much to say at that time.What ethical issues,?I
said truth telling about our mistake,.non.maleficience,
beneficience 14/16
My BCC cases are interesting and I got dx only in last 2
!minutes somewhat luckily
BCC 1.a 25 yr old man with repeated blood transfusions since
5 yrs of age ,presented with fever.,high colour urine ,tiredness
.Examination show moderate splenomegaly and pallor
Pt's concern.what is his problem?I said thalassemia
?intermedia.Why he has fever
l said UTI or malaria or other sort of infection and I will do
blood tests.How can you help me to reduce transfusion
?,interval
I said you have a big spleen ..that is why it destruct your blood
cells and U need blood transfusion.You need operation to
.remove spleen to reduce transfusion interval
Examiner ask finding .dx.Why he has fever.?I said UTI or other
infection.not satisfied.Why fever in this pt with
?.,splenomegaly
I thought long way and said he may have hemochromatosis
leading to diabetes leading to immune suppression and
infection.Any other pissibility.? I said hypersplenism leading
to pancytopenia leading to infection.Examiner was very happy
to hear it.How to mx,,,? I said neutropenic regime.not
satisfied.What is definitive mx,?I said
!splenectomy.Examiner.happy
?.what will u do before splenectomy
I said vaccination.For what? for encapsulated bacteria.Time
.was up
02/02

BCC.2.50yr old smoker present with cough for 2 weeks not

responding to 2 courses of antibiotics.pt said cough worse on
lying down but no other symptoms.I ask other chest and CVS
symptoms and did chest examination and found no
abnormality.Pt asked what is his problem and I didn't know
!dx
I replied it will be chest infection or heart problem and I can't
tell exactly at this stage and I will do some blood tests and
imaging of chest .Is it serious?is it cancer? I said he has no sign
of cancer at this stage although it is still a possibility as he
 smoked heavily.I will do tests to make sure that everything is
OK.Then.I thought that this pt must have some signs to be in
exam and it appeared in my mind that he had a
hyperresonant percussion and reduced BS. I quickly said to
the pt that he has a condition called COPD and I will give him
inhalers and some tablets.pt quickly asked is it related to
smoking and I said yes and advised to quit smoking.Time left
.only 2 min for discussion
Examiner asked my findings and accepted.Any other sign that
show other specific dx?I said no.He accepted.As my dx is
COPD any other ddx?I said asthma but no wheezing and
rhonchi.Any other ddx?HF but no other CVS
symptoms.accepted.Any other dx for cough worsen by lying
?down
I said GERD and examiner was very happy to hear.What
advice will U give to pt?I said high pillows and to avoid food at
bed time.Time was up. 23/28
There are 2 types of candidates.The first one is very bright
,smart ,lucky and they can easily passed exam after studying 2
to 3 months.The second type is majority of candidates and
they have to work very hard and take a year or more of
studying time to pass.I am the second type and have to study
a long time waiting to get a seat in Myanmar for about 3
.years.This is my first attempt
.Exam luck is also an important factor
?Then,can we improve our exam luck
As for me,yes.I shared my knowledge to others and shared
some books and mp3 podcasts in this group by my another
account.I had also helped other candidates with their study
 and practice so that my exam luck can be good.I have met
!with good natured examiners
In the exam,some candidates said they have time only to
.discuss ddx.They will lose marks for judgements
As for me,I have my own note of common causes,inv,mx and I
memorized them so I can discuss fluently in 2 to 4 minutes of
discussion time and I reached to management in every station
.and passed every station
!Best of luck to all future candidates

Here is the feedback of Dr. Munzir Al Gadi, who passed his

.PACES in the first run of Malta Centre
Thank you Dr. Munzir for the detailed feedback and
.congratulations again on the well deserved success

My Experience in Mater Dei Hospital Malta on 2/4/16 first

carousel

Station 1 □
: Chest ☆
A young patient with spares head hair( I Said possibly 2° to
chemo later on upon discussion and actually I picked it up as I
used to see this finding a lot in my practice in oncology).. RT
side of the chest is depressed and moving less, RT
 thoracotomy scar and decreased chest expansion, impaired
percussion and dec breath sounds
Diagnosis: RT pneumonectomy
DD of etiology was bronchiactssis, fibrosis, Abcess and
,malignancy
Discussion was about cancer causes in young patient (germ
cell, and Satcoma ) and workup also asked if he developed
SOB what might be the cause , I mentioned infection and
thrombosis PE
?How to investigate him
)I got 20(

: Abdomen ☆
A middle aged male with features of CLD (D contracture, P
erythema, thenar wasting and Tinge of jaundice) and
splenomegaly I said no ascites
DD and work up
Honesty I felt that I missed hepatomegaly
)I got 16(

:History □
A 50 years female , married , works as hospice nurse, travelled
to Kenya with her husband and came back with
nausea,vomiting, fever and upper and pain radiating to back
Heavy alcohol intake
Had 3 miscarriages at Gestational ages of 26,28,28 no
personal or Fx history of VTE
 Gp letter mentioned high T bilirubin 70 and high all Liver
enzymes
? Concerned is it cancer
DD : I mentioned Alcoholic hepatitis, viral hepatitis(A) and
dengue, autoimmune hep, and malignancy
discussion was about working her up , and how to manage, I
mentioned that she needs admission, clinical assessment and
rehydration if dehydrated, pain control and fever ttt with
NSAID and avoidance of acetaminophen and teat etiology
I emphasize on alcohol cessation referral
)I got 20(

:Station 3 □
CVS: old male has peripheral features of AR ☆
apex displaced
Systolic murmur all over radiates to carotid
I said AS and AR although I didn't hear the diastolic murmur , I
was not comfortable to the auscultatory findings and I felt
may be something is missing, anyway , they discussed with
me what might be the causes of systolic murmer in this age
and how to differentiate between AS and sclerosis,
investigations to do
)I got 20(

: CNS ☆
A middle aged patient
Instruction was : this patient has problem lifting objects
 I examined his upper limbs , he was sitting on a chair , he is
non English speaker however examiners helped with
instructions and I passed few instructions in Maltese my self(
most of them sounds as in Arabic)
Findings are pure proximal atrophy and weakness at shoulder
girdle and scapular muscles with defined supraclavicular and
scapular margins, no facial involvement

DD : proximal myopathy likely congenital causes as patient

has an atrophy
And I suggested scapulohumeral variant I enlisted few other
causes as well
Investigations including EMG,NCS, and muscles biopsy
He asked me about mode of inheritance I answered that I
can't recall
Management is supportive and I motioned that few Novel
therapies is under study
)I got 20(

:Communication □
Speak to an angry son of 70+ female admitted initially in
orthopedic ward with # femur and underwent arthroplasty 2
weeks ago , 1 week after she felt while doing rehabilitation,
since this last fall she is on and off confused, orthopedist
assure son that this because of UTI and she is receiving ttt for
that , then patient transferred to medical ward as her
confusion continues, CT scan arranged , showed intracerbral
bleed with midline shift, neurosurgery advised to hold
 enoxparin ( which was started as prophylaxis) and her usual
.aspirin and stop her oral feeding until he see her
Role : speak with son about CT findings and subsequent plan
and discuss the clinical judgment when outweighing benefits
.and risk of LMWH

Son was angry but I listened to him empathetically and

reassured that I'm here to help, I broke the news of the CT
findings and explain the role of Neurosurgery opinion, his
concerns : what is the cause of her bleed, why giving anther
blood thinner while she is on ASA , could the fall be avoidable,
?why he has been told that she has UTI
Actually examiner's discussion revolved around whether
LMWH has caused her bleeding or not and wether there is a
way to know that I said unlikely it was the direct cause
however above therapeutic level of anti factor Xa might give a
clue that helps to reveal the uncertainty of her bleeding
.cause
)I got 16(

Station 5 □
: BCC1 ☆
An old male , c/o slurred speech for 30 minutes, three
previous episodes of near fainting , during episodes he feels
. "fluttering" sensation of his heart
PMHx : HTN on amlodipine 5 mg , AF on pacemaker and
warfarin 3 mg and regular check, ranitidine for gastritis
Exam : AF with rate of 80
 Discussion was about DD
,I mentioned TIA , orthostatic hypotension
How to investigate, he ask me will you change his anti
?hypertensive or not
?How do you know if the pacemaker is non functioning
)I got 28(

BCC 2 ☆
A young lady, pregnant in 18 weeks gestation with SOB for
2/52 and cough with occasional whitish phlegm and occurs at
late night and early morning,no any other symptoms upon
discussion
KCO bronchial asthma was controlled before pregnancy on
INH SABA & INH steroids but she stopped them both after got
,pregnant as she thought they're harmful
Examination: all clear , LL clear
I explain for her the role of inhaled Mx in controlling her
asthma and that why she got these sympx , reassure about
safety in pregnancy, adviced PFM diary and FU with GP
Discussion: DD chest infection and less likely PE
Examiner asked what've s against infection, also asked if PE
? need to be rolled out what to do

Actually I peaked my marking sheet within the examiner

hands while pill was ringing and I'm about to leave the room
 with all marks in satisfactory area , I felt it was a comfort
😃 message from Allah at the end of the exam
)I got 28(

Over all I scored 168/172》》

My conclusion that PACES is a MOSIAC experience, it 》

concludes different roles and various methods and the
probability of passing lies in practising as many as one can do
.. of these roles and methods
Inhance your best qualities and fill your defects and as Prof
Zein says eliminate your chance of failure by avoiding the
.failing practice

Thanks Dr Zain again and again for your support and effort
. and may Allah grace you with health and serenity

Thanks all members of the group for the endless effort that 》
.helped me and others, may Allah bless you all

Dr Munzir Algadi

exam experience gasr al3eni hospital first day 3rd cycle

CVS -1
prosthetic valve mitral with AF
 Discussion was so long I finished my examination early he
asked me about indication for replacement , treatment, and
cause of chest pain in such case, target INR
Score 19/20
Abdomen
Pale pt with hepatosplenomegally
DD start with hematological cause and still CLD on my list
then he asked me about common cause of CLD in egypt then
how to approach pt and treatment
02/12
Chest
Female with rt apical fibrosis and pleural effusion
Discussion was about causes and treatment but I scored bad
because I didn't exposed pt completely she asked me not to
do she was young and I respect that but examiner didn't like it
02 /2
Neuro
Peripheral neuropathy gulliam barri and discussion was about
DD and treatment when to admit pt
The funny thing in this station
That before i start i asked her if she has pain any where and if
she felt and to tell me then while am doing tone she scream of
pain I stopped immediately i told examiner i
Can't continue examination she is on pain he told me proceed
I thought i lost it but al7amdole ALLAH
Score 20/20
History
 Pheochromocytoma men
Young pt recently diagnosed with HTN and he had panic
attack he was started on diazepam
Discussion
DD add hyperthyroidism he asked me how u will explain wt
loss in Pheochromocytoma i told him 10% can be malignant
?Why men
ve family hx+
Symptoms of hypercalcemia
02/11
Communication
I scored bad and I didn't read scenario good
Middle age pt newly started on thiazide for HTN he was
walking on hot weather he drink water then he had fit
Na was 114
Explain to wife about conditions and prognosis
What i did i explained why he had fit and the idea of dilution
hyponatremia and the effect of thiazide and i told the wife its
provoked seizure but still we need image to role out other
causes
But this part upset examiner he said no need for further
image no need to discuss job and driving
11/2
Station 5
proximal muscle weakness wt gain -1
History everything was negative the only positive that he is on
thyroxine i asked surrogate why he is on thyroxine because i
asked about previous medical illness he said nothing he told
me I don't know
My DD at this point cushing hypothyroidsm
I examine to role in or out one of them it was hypothyroidism
diffuse goiter
Discussion was about investigation treatment
02
middle age pt with lower limb weakness with oral ulcer -0
Hx was suggest to behecet disease i examined lower limb
neuro and for erythema nodosum,And oral ulcer
Discussion was about cause of weakness how to diagnose and
treatment
02
I attended dr zain course for history and communication
And for clinical stations dr ahmad maher mock course
‫اللهم لك الحمد والمنة‬

This is Dr. Abubakr who passed PACES at Khartoum centre

..(Soba university hospital) with a score of 170
My exam on 2/4/2016 day 2 cycle 1 in soba university hospital
Station 2 history ♤
Scenario of (35 years old lady has fatigue for 6 months her gp
did a blood test and confirmed to be iron deficiency anaemia )
 I introduced my self, explained my role asked about her job
(she is a teacher) and agreed the agenda
As she has fatigue I started by analysing her fatigue and then
general symptoms and she gave hx of wt loss of 5 kg.. When I
asked about joint pain as apart of general symptoms she
answered that she had joints pain for 2 years and she had
been diagnosed to have osteoarthritis by orthopaedic
.consultant
Then I asked if she use any medicines for that she said she
uses 2 medicines ibuprofen and another NSAID. These
medicines were given without prophylactic PPI. She has hx of
localised epigastric pain made worse by eating ass with
nausea but no vomiting.... some times heart burn
.there was no melena or haematemesis
No mouth ulcer
No change in her bowel habits
.No bleeding through her back passage
There is no bloating and no tummy pain with specific type of
food (wheat products)
Normal menstrual cycle
She takes balanced diet and she gave me example of her usual
.diet
.Then review of her systems was negative
.Her past hx and family hx are negative
I take the drug hx as part of HPI
In social hx she is affected greatly by her fatigue and also she
can't do her hobbies as she used previously to run and go to
.gym
She is concerned about the cause of her fatigue and how can I
.help her to continue her hobbies
I explained to her the likely cause of her fatigue is related to
the joint medicines and that we need to do a cammera test
and we need to stop her medicines after discussing this with
her orthopedic surgeon and if we need to continue on it we
will give PPI and we are going to give her iron replacement
.and after that I will reply back to her gp
.Then I check her understanding and thanked her
First examiner question
.Did you ask about smoking 😨😨😨 I said no sorry
Do you think it is important? I said yes as pt most likely has
gastritis or peptic ulcer disease so smoking impairs the healing
.of the ulcer
?😨😨 Then did you ask about alcohol
Again I forget
??So do you think it is important
.Yes as it may cause gastritis
Then he ask why you ask about numbness and
???unsteadiness
Because if malabsorption is the cause then B12 may cause
subacute combined degeneration of the cord
Then ask about DD
I put gastritis
Gastric and duodenal ulcer
Malignancy because of the wt loss
 Then coeliac disease and IBD
He asked whether NSAID can CAUSE small bowel ulcers apart
from duodenum? ?? I said it is not common but if multiple
then we need to think of Zollinger Elisson syndrome
???How can endscopy help
Macroscopic we can see if there is the ulcer and we can take
biopsy
???What to test in biopsy
The presence of malignant cell and also H.Pylori
Any relation between NSAID and H.Pylori? ?? 😓😓😓 I said I
don't know
Then how NSAID cause peptic ulcer? ?? After explain then
?? ?again he ask any relation between NSAID and H.Pylori
I feel that he need me to say yes so I tell yes there may be a
relation
Then how you will treat H.Pylori? ?? I said triple before give
the name of triple he tell if you stop NSAID what other
medicine you will give to the pt I said paracetamol
I think they will mark me negatively as I forget important ****
part of social hx but surprisingly I got 20
Then station 3 ♤
..... CVS ♡
A young female with small volume pulse and she is pale
She has chest deformity ... active pericardium with visible
pulsations. The apex is not displaced with palpable 2nd heart
.sound and positive lt parasternal heave and on thrill
 There is a pansystolic murmur in lt parasternal border with
maximum intensity in the apex but no radiating to axilla with
loud 2nd heart sound

I present my case as MR with pulmonary htn then the

examiner asked whether the murmur radiate to axilla or
not??? I said no and the murmur is in Lt sternal border so its
.differential is TR , MR, VSD with pulmonary htn
Then asked about the causes of pulmonary htn and
investigations
)I got 20(
.... CNS ♢
A young male with stick beside the bed.. Examine the lower
.limbs
There is pes cavus and wasting of both leg with hypotonia and
weaknesses of LMNL but proximally more than disatlly
.Absent reflexs and equivocal planter
Coordination difficult as power grade 0
.Intact sensations
I wanted to examine the gait but he tell no need
Then I examine the upper limbs with same finding
?? ?Ex what is you positive finding
??? What is your diagnosis
I said LMNL weakness either muscle problem or pure motor
PN but with pattern of weakness proximal I will go with
muscle disorder then asked about how can gait help you and
 DD of pure motor neuropathy then investigation and
.management of proximal myopthy
)I got 20(
Station 4 communication ♤
Scenario of delayed diagnosis of pheochromoctoma in a
young male suffering for 5 years. He was seen by many
doctors including a psychiatrist for panic attacks and have
been prescribed diazepam and also has htn that was difficult
to control and on HIS INSISTENCE the gp referred him to your
clinic. You are the doctor in hypertension clinic... the tests
done for him show a mass of 5 cm in his RT adrenal and urine
.test also positive
Your task is to explain for him the diagnosis and to answer his
...concerns
;I stard as Dr zein taught us
Introduced my self, explained my role, asked about his job
and if there is any one he would like to invite to attend the
meeting and then agreed the agenda & asked him to tell me
more. He was attacking in nature... feels that he is suffering
for 5 years and seen by many doctors and prescribed sleeping
.pills but without any improvement
I showed empathy regarding his suffering for 5 years the
explained to him that the results are with me now and that
unfortunately it is not as we hope then telling that it show
pheochromoctoma and whether he heard about it he say no
then i asked if he would like me to explain more .... the I
explin pheochromoctoma and that the good news are that we
found the cause of his suffering and it is curable condition in
the majority... then i explained that it is a growth... he asked
whether it is cancer or not. I explained to him the possibility
 of cancer is 10% when I told him it is curable he asked how? I
told him surgery then he is habby and said OK just removed it
now (verbal cue).. I told him it is not easy surgery, we need to
control your blood pressure first as I am a doctor in
hypertension clinic then I am going to involve MDT. He asked
what MDT? I apologised and then explained it is a team of
expert people including the gland doctor, the surgeon and
anaesthetist and they will make a meeting to decide the way
.to manage him
?? ?He asked when they will decide
.I replied as soon as possible
Then his main concern whether there is negligence or not
😓😓😓😓😓
I answered I need to go back to your records to see what
exactly done for you. Then he said doctor there is negligence
and I will complain against my gp....I told him it is your right to
...make a complaint
The he brought another concern about any damage happen to
?? ?him from HTN
I told him l need to examine him and to do some tests to see
.the effects of htn
...I asked any other concern
..He replied no
Then i made a summary ,,, checked the understanding and
told I will reply back to the gp, and offered help and leaflets
.and if he can drive alone
The British examiner
 What do you think about this case???then I give summary of
.the case and my plan
???Why you did not tell him about risks of surgery
I answered I just broke the bad news for him and I don't want
to give him all bad news at one time since he will have a
metting with the surgical team who is going to discuss the
risks of surgery( then he smiled)
???How you will treat his htn
Alpha blocker and then beta blocker

Do you think there is negligence in this case??? 😰😰😰 I give

him the same answer for the surrogate then he asked is there
???any damage from his htn
I gave the same answer given to the patient, that I need to
examine him and to do fundoscopy and investigations to see
.if he has damage
???Then he asked again if there is any negligence
I noticed that both the surrogate and examiner are concerned
about damage from htn, then I told him the pt is suffering for
5 years and not diagnosed this is not usual and if there is
damage happen from his htn OF COURSE there is a negligence
(I Don't know why I said of course )
Then he asked me do you think the pt is happy and he can
???drive alone
.I kept silent for a while then said yes he is happy
The bell rang
.The British examiner saidwell done
 )I got 15(
Station 5 ♤
BCC 1 ♢
..A 55 years old female with Lt hand weakness
Before shaking the pt hand it seem she is in pain so I
.apologised for not shaking hands bcs of the pain
Then surrogate gave a hx of both hands pain in disruption of
median nerve without any thing in the systemic review giving
... clue to the cause
However in the PMH she was diagnosed to have
hypothyroidism and not on follow up for two years but using
.her thyroxin 100 mcg
No other significant hx
O/E
Clear signs of carpal tunnel syndrome bilaterally and more in
.the lt
.Then I checked for thyroid status
Concerned about the cause of her problem
Other concern whether her lt hand will become paralysed
I responded to the 2 concerns and explained the need to
check her thyroid status and regular follow up and we may
.need to do surgery
The British examiner said still you have 1 minute
.Then again I explained the importance of regular follow up
The examiner smiled & said still you have 30 second but no
.... problem you can review your thouhts
 Then ask the diagnosis and the DD
The investigation and management
)I got 28(
BCC 2♢
.A 50 years old male with blackout and normal vital signs
From hx blackout mainly in the morning and during sleep also
!!I got confused how during sleep
He is a very nice surrogate he told me he bits his tongue and
.wets himself
.I asked any shakes he replied no
I reviewed the CNS and it is negative. then asked about
trauma which is negative, then about general symptoms
...including skin rash
He said yes he have skin rash in his face for 20 years which
difficult to fade away... I looked to the face and then felt
...relaxed as I catch the dignosis
Past hx of htn and on amlodipine 5 mg with no change in the
.dose
Family hx of abdominal surgery in 2 of his sister and skin rash
.in his brother
He is a teacher!!!! and I asked about his school performance
he said it is good and he drive a private car and do not drink
.alcohol
I examined the face for the rash and the the pronater drift for
.any weakness
Checked the trunk for ash leaf spot and examine the back for
.shagreen batch
 Offer abdominal examination but examiner said normal.
Offered chest exam again he said normal. Offered to check BP
and he said130/70. Offered fundus for phakomas he smiled
😬😬😬😬😬😬 and said Do it
I check quickly as the pupil is not dilated I know that nothing
.will be there
... The patient is concerned about what is going on
I explained tuberous sclerosis
...Another concern about his kids
.Explain that each has 50% chance to get the disease
No other concern
.The examiner: still you have 1 minute
Then I explained the epilepsy and driving but still there is time
then I explained the screening of family and gentic
.counselling
Examiner question
?? ?What is your diagnosis
Investigations and management
)I got 28(
Station 1 ♤
Abdomen ♢
Young female looks ill and very pale with cannula in her RT
arm with ting of jaundice, hepatosplenomagly and absent
.stigmata of CLD
I examined only for one group of axillary LN because time
.didn't allow more than that
 .Then asked about DD
The discussion about myeloproliferative disorders
)I got 19(
Chest ♢
A middle aged male with obviously depressed lt side of the
chest which was moving less, and a very strange scar on the lt
side only the tip of scar is seen anteriorly so I tried to go fast
to examine the back from anterior. The trachea deviated to lt
with impaired percussion on lt and decreased air entery on lt
and vocal resonance. However there is increased vocal
resonance in lt upper part and bronchial breathing in same lt
.upper zone
Posteriorly same finding and that scar (still confusing me it
look like long thoracotmy scar but surprisingly there area
about 2 cm of normal skin)
.So I presented my case as Lt pneumenoctomy
Then the examiner asked did hear any thing abnormal in lt
side I replied increase vocal resonance. I was afraid of
inventing signs, so I did not mentioned bronchial breathing
but he is very helpful examiner and asked me what type of
breathing in lt upper zone then confidently I tell bronchial
breathing. Then he asked what could be the cause again I said
this could be from stump .... he smiled & said stump can not
cause this? he asked what could cause increase vocal
resonance and bronchial breathing I said cavity ..... he said yes
now what could be the cause? I mentioned fibrocavitatory
lesion ...he looked satisfied and asked about the commonest
cause and how to investigate..TB
)I GOT 20(
 Dr. Mohammed A Mutalab (who scored 171 in Khartoum)
:PACES experience
My exam was in the last day last cycle 4/4/2016 in Soba
.centre, Khartoum
:Communication Skills ■
I started with station 4 the scenario about a patient who have
achalasia and underwent a pneumatic dilatation for the 3rd
.time but in this one he developed eosophageal perforation
It was mentioned that this complication can happen in 5% of
.pts and the patient was consented
You will meet his son to explain for him what has happened
and the need for admission for 14 days and any issue raised
.by him
I started by the usual introduction and then checked what he
knows about his father condition then i explained for him
.what happened in BBN pattern
He asked why this happen to his father this time he has done
this procedure twice before.I explained for him that any
procedure has a possibility of bad effects and it happens in a
few patients; in every 100 it happens in 5 patients and no one
.can predict which one will be affected
He said do my father know this? i said any procedure will not
be done unless we explain for pt the benefit and risk of it and
 let him to decide which is called consent and your father was
.informed
I told him that we need to keep your father in hospital for 2
weeks but he refused. I asked why but his answer was not
clear for me but i proceed and explained to him that this cut
or perforation of his gullet will cause leak of food and fluid to
his chest and lungs and this will cause damage and
inflammation so that we need to give fluid by his veins and
medicines called antibiotics and we need to involve our
.colleagues in surgery
Also i told him if he went home he may develop complications
and deteriorate more and i am sorry to tell you that he may
die . After this he agreed to admit his father but he wants me
not to tell his father i replied to him this the right of your
.father to know about his condition
Then he kept silent and i asked him do you have any other
concern? he said no and still there is a time and i wonder how
to fill this time but fortunately while i am thinking the
examiner told 2 minutes left i summarized for him and
.checked his understanding and thanked him
?Ex: what are ethical issues
Me: BBN,dealing with angry relative(realy he wasn't), doing
.no harm and autonomy
Ex: the son don't want his father to know what do you think
?about this
Me: i think this the right of his father to know to ensure
.ethical issue of autonomy
?Ex: any other principle
 Me: i think we have to be honest and tell exactly what has
.happened
?Ex: how are you going to manage him
Me: monitoring
NPO
IV fluids
IV antibiotics
surgical consultation
?Ex: why you need to keep him NPO
Me: so no more food or fluid to get to mediastinum causing
.mediastinitis and allow time for healing
?Ex: what do you think the surgeon will do
Me: the management may be conservative or surgical but i
.am not sure of indication of surgery
.then the bell rang
Station 5 ■
BBC 1️▪
young lady with deterioration of her vision in last 8 months
.her vitals were ok
I started by open question then i analysed the visual loss
which was mainly at night and there was no eye pain or
headache and the course was progressive and not episodic
then immediately i asked about family history which was
positive her elder brother is blind
I proceed immediately to fundal examination to confirm my
diagnosis and i found scattered dark pigmentation which was
clear in the rt eye also i couldn't appreciate the disc clearly
after i finished fundal examination i remembered that i didn't
assess her visual acuity i did it & was normal for finger
.counting
i returned back to the history and i asked about associations
of retinitis pigmentosa and other routine parts of history
and i asked about driving
.which she is not
then i examined again for hearing aids and weakness only bcz
i thougt other associations were excluded by history
then i asked about her concern? is she going to be blind? and
? what about job
.she was a teacher

i told unfortuanately this is a progressive disease and till now

there no curative treatment but research are ongoing and for
her job she can continue as far as her vision can allow we can
.give some visual aids
the examiner asked about my diagnosis and the associations
.of RP
also what other areas you want to examine i said cerebellar
and peripheral neuropathy he said do u want to examine her
fingers i said yes for polydactyly.then do you need to examine
her visual field i kept silent he said what do you expect to find
.i said tunnel vision
.then he took me the next pt
BBC 2️▪
A 28 years old male with skin lesions for several years which
.are non-pruritic not painful and I expected it to be vitiligo
i started by asking its onset duration progression distribution
any starting lesion any aggravating or relieving factors and
involvement of mucous membranes which were all negative
then i request to have a look. The lesions were raised small
yellow nodules on flexural part of the elbows
there was also another large one on his lateral epicondyles
and also in his back & eyelids and when i came closer to his
.eye i saw corneal arcus
it was clear this pt has xanthomas secondary to
hyperlipidemia then i asked about his FH which was positive
for sudden young death i asked specificly about cholestrol
problem he said no. then i asked about macrovascular
complications and the secondary causes of hyperlipidemia (
DM,Renal diseases,hypothyroidism,alcohol and primary
biliary cirrhosis) i asked about smoking and job
.then i examined his CVS which revealed AS
Lastly i asked about his concern which was is he going to die
?suddenly like his family members
I told him that these skin lesions are manifestation of high
cholesrol in his blood and this something run in family and
this high cholestrol harm your blood vessels and this can
cause heart attack and sudden death. We need to do more
blood tests and we will give you medicine to lower your
.cholestrol
Examiner asked me about my diagnosis what tests you need
.to do and how to manage him
Station 1 ■
 Chest️▪
The pt was comfortable, peripheral examination was normal,
Trachea was deviated to the rt and rt side was depressed and
moving less the percussion wad heterogenous(dull+resonant)
auscultation there was fine end inspiratory crackles bilaterally
.but more on the right in upper zones
I presented my findings and said pt has bilateral apical fibrosis
mainly on the rt. Ex asked me about causes i said most likely
.TB +other causes of bilateral apical fibrosis
.What investigations and management
Abdomen️▪
A female patient with finger clubbing and functioning fistula +
.gingival hypertrophy
.At this point i was expecting a renal transplant
On abdominal examination there was no renal transplant scar
there was huge hepatomegally about 14 cm bcm and
.splenomegally 4 cm
.Others normal
I presented my findings and i said the has
.hepatosplenomegaly and ESRD
?Ex: how to correlate them
Me : hepatitis on top of renal failure
?Ex(not convinced):what else
Me: amyloidosis
Ex: what else
Then i remebered the gingival hypertrophy and said
leukaemia by infiltrating the kidneys although it is rare then
 the examimer seems to be convinced and asked me about
.investigations and management
Station 2 History ■
This was a difficult scenario of a young female feeling fatigue
for 2 months she went to her GP who found high BP and have
done some tests which revealed proteinuria and haematuria
.and normal RFT
I put differential of
CKD(stage 2 normal rft)
GN due to wegner's or goodpasture or post streptococcal or
IgA nephropathy
Polycystic kidney disease
Lupus nephritis
When i entered i analysed her fatigue and high BP then i
started by renal system then enquired about cvs/resp
including haemoptysis then i asked about URT features sore
throat nasal congestion epistaxis hearing lmpairment then i
asked about musculoskeletal skin rash joint pain
All the above was negative

then i started to complete the other systems GIT and

neurology and i found that pt has loss of appetite and non-
specific headache then i asked about constitutional symptoms
.which revealed loss of wt
All other parts of history were negative except she was taking
.OCP for menorrhagia for several years
When the ex told me 2 minutes left i have no idea what is
?diagnosis
 I asked the pt about her concern she said could OCP be the
cause and i am planning to start a family does your treatment
?affect my future pregnancy
I told her i need to do more test to determine the cause of her
condion and it is unlikely for OCP to cause high BP and the
treament for your condition will depend on the cause and
there are different treatment some of them may affect your
pregnancy
.and others will not
?Then examiner asked me what is your DD
I told him about the one above
He asked me why you asked about nasal blockage i said bcz i
think of wegner's he said to me you mean vasculitis as general
i said yes but there is no skin rash or joint pain he asked me
could the high Bp be the cause of her headache i said yes if it
is malignant
he asked me how to know
i said i need to do fundal examination he said if it is normal i
said it is unlikely to be the cause of headache
he asked me what is the commonest presantation of HTN i
replied asymptomatic
?Ex: investigations
Me:CBC
Ex:what specific in CBC
Me: eosinophilia
Ex:why
Me:churg-strauss syndrome
 Ex:how to manage vasculitis
Me:methylprednisolone and cyclophosphamide
Ex:is this may affect her pregnancy
Me: yes the cyclophosphamide
Ex:other anti-htn can affect pregnancy
Me: ACEI
Ex: other causes of htn
Me: endorinological like pheochromocytoma,
.....hyperparathyroidism
the bell rang
Station 3 ■
CVS️▪
The pt was young all peripheral examination was normal.
Precordial examination was normal except in auscultation
there was systolic murmur allover and radiating to carotids
also there was early diastolic murmur on lt sternal edge so my
diagnosis was mixed aortic valve disease and no one is
dominant
.the examiner asked inv and management
Neurology️▪
The instruction was to examine the lower limbs it was
apparent that the pt has spastic paraparesis with sensory
level just below umbilicus the time finished before i examine
the back i told him i want to examine the back
.The asked about clinical diagnosis DD inv and management
This is my paces exam experience in eygpt,it was a tough one
.,but al7mdolellah kathiran i passed
I started with station 1
Chest: Copd+bilateral lung fibrosis+ some brochiectetic
.changes on z right side
I took 5 mins examining the pt generally and the ant chest
,the examiner told me that i have just 1 min left ,so i
.examined z pt back and lymph nodes and sacral oedema
?the examiners ,asked me for z positive findings
i told her there are obst changes with end insp crackles
bilaterally ,and medium sized crackels littly changed by cough
,so there r brocheictatic changes
She asked me what type of crackels again,what invs you want
? to do for him
when i told her lung f test and it will be obst changes she
. asked me just that, i said mixed
why he has these changes i told her pcoz he may have
,repeated infections on top of copd
like the usual bacterial inf ,she asked me what other inf i told
TB
what management ,i told pharmaclogical and non ,
. pharmaclogical ,and i told her all till steriod
I got 19/20
abdominal station
 D: decompensated chronic liver disease +huge splenomegaly
+ascites
They asked me what the cause,then what other infections
cause huge spleen i told kalzar and shcistosoma, what invs i
told all till i came to ascitic tapping ,she said for even small
.ascites i told her according to US
when i said check serum albumin she asked why you want to
? do it
What mangement ?accordingly to dd,complications
?she asked when you want to give antibiotics
? Why is he decompensated i said j+ ascites,she asked is he j
02/02
Station 2
History: it was advanced breast ca + hypercalcemia
The scenario was tough they just told us she has breast ca and
she was treated with chemo and radio ,she feels unwell pls
.asses her
So i couldnt figured what is happening and i thought that i am
.going to talk to z daughter
r u z ,So when i entered i shaked hands i was blank,i greet her
daughter of ms.maha, she said no i am ms maha,so i
surpreised and said sorry,then i told her would you just tell
me about your condition,she told me the story ,she feels
drowsy and unwell recently ,i said may be brain matestsis ,so i
asked about all cns system,then i didnt get anything i said may
be dermatomyositis ,but nothing ,then i asked her about the
treatment ,what she was given and for how long,i thought it
may be tamoxifen induced cardiomyopathy ,but no hf .just
 sob on moving to bath ,or may be adrenal metastasis,causing
addison disease,but not typical
. Till i came to z water system ,she has ploy uria at night
and she is so depressed ,i was lost,then i told her i want to
reherse what i get from her ,i said you have increase water
frequency +depression+ constipation (i think it may be from
morpheine)+ abd pain+back pain (metastasis)
The examiner told me u have just 2 mins left ,so iasked about
smoking,alchohol,impact & drug history ,then concern,i told
her i want to admitt you and do some imaging n blood tests
,may be you have some metastasis,and i want to ask the
phsycatry to asses you and give you some nuritional support
and fluides then time finish
examiner asked me what do you think,and why you want to
?admitt her
i told him i want to give her nutritional support + iv fluides+
.do imaging
Asked why you want to give her iv fluides i said pcoz she is not
.eating,and dehydrated,i want to asess her first
?then what else
she is dehyderated
And has polyuria and polydepsia,so it may be hyponitremia
,then the examiner told me so z pt has
😱😱😱polyuria,depression,abd pain ,what do you think
😒 i siad hypercalcaemia
What is z management?Rehydration + calcitonin ,he asked
what else ?i forgot z besphosphonate totally 😔so replied i
.couldnt remember
 Then asked me what other speciality you want to
.consult,apart from the psychatrist ,i said z oncologist
?Finally what z dd o her sob on moving
I said PE, or metastasis or pleural effusion ,n i will do imaging
.,but i think he was looking for anaemia
What is z cause of her abd pain ? I said could obst or
metatsis,he said could z hypercalcamia
I said yes ,lastly he asked what abour her social issues

I said i am so sorry i couldnt ask her with whome she lives ,he
asked is it important i said sure because if i want to admitt her
,she may have some issues to be solved.(lives with her
.daughter who travelling now
I got 10 /20
:Station 3
Cvs :As+Ar with dominant AR
?They asked me what is d?what you want to do for him
What is cause? In this young pt bicusbed aortic valve or
.rhuamtic heart disease
What about his pulse rate? large volume collapsing and
.regular
What you want to see in echo? What r signs o severity on
?echo
then what else?what about complications ?IE,but he is not
.febrile and has no signs
 What management? Accordingly,duretics if he present in
Hf,asked me is he in hf ? No,i couldnt appreciate any crackles
.or ll oedema
then ACEI ,examiner even with this AS,i said according to ECO
.if is it significant or not
Then surgical,aortic valve replacement most probabely
.metalic pcoz he is young
02/02
Neuro: Rt hemiparesis((upper motor neuron lesion+cerbellar
signs))
DD:(Ms or multiple strocks or spino cerbellar degeneration)
.The instructions was examine z motor system
I started by the LL,then UL finally the face i examine for
.horzintal nystagmus, facial nerve and hypoglossal nerve
pt has rt hemiparesis,has cerbellar signs in form of
dysdyadokinsia ,rebound phenomenon,finger nose test,all
.evident on the rt upper limb plus horzintal nystagmus
In addition he has UMN signs in form of upgoing planter in the
Rt side , the refelexes r normal in the LL but increased in UL on
.the rt side
?want to examine his gait and speech (what type of speech
? examiner asked
. what about the Lt side i said it was normal
.what about z tone ? hyptonia
.asked why ?due to cerbellar lesion
?What diagnosis?DD
What investigations? MRi brain looking for plaques of ms,Ncs
? (he asked what do you see
Lumbar puncture(looking for what ? Oligoclonal band (what is
? it
? What management
Pharmaclogical and non pharmaclogical
Staion 4: the senario was about an elderly lady which had
multiple strocks and recent brain heamorrhage,known DM
and ESRD on regular heamodialysis ,now she is deteriorating
,and her wishes was to stop the dialysis if she is getting
deteriorating,and the treating team decided to follow her
.wishes
My task was to inform her son about her wishes and the team
.decision
I started by asking the son ,is he z next of ken,does he want
anyone to attend this meeting with us,did he see his mother
?recently and what does he know about her condition
Then i told him unfortantely her condition is deteriorating as
he told me ,and about her wishes,and that our team decided
. to respect her wishes
?Surrogate: if you stop dialysis what will happen
?S: is she going to die?and when
S: ok if so ,let me to take her home ,i will bring a nurse to stay
?with her
Me : i apprecite your feeling ,i know yr keen about your
beloved mother,but it is difficult to be managed at home,pcoz
we need to ,there is substance called k ,it is going to be high
monitor her closely. to give her the proper
....management,etc
 ?S: what about her Dm and other things
Me: i assure you ,we are going to treat her respectfuly and
with diginty, taking care about all her needs and manage her
blood sugar.only the dialysis was stopped
?S : i am afriad she is feeling pain
.Me : she is not aware about her surroundings most probabley
?Do u want me to call any one for you
What about you? Who was taking care of your mother at
?home ? And with whome she was living
S :i am a business man,was so busy recently ,i couldnt stay
with her,i hired a nurse for her, i have no siblings or other
.family member
Me: i can understand how is difficult for you,and appreciat yr
. feelings
? Do you want us to offer any social support for you
?What is concerning u more about her
S : ok thanks dr, i jusr want to be sure that she is not feeling
.pain,and to stay with her for now
Me :your more than welcome ,if u want i can arranged a
meeting with my consultant ,and the kidney consultant to
.discuss with them.and your welcome to visit her at any time
. Only 2 min was left

Me : did your mother has any advance directive or did she tell
?you about her wishes ? Or anyone told you about that
S : no she didnt
 .Then i summarize for him and he agreed
?Examiner asked me? What z issues in this senario
.Bbn, empathy,autonomy of z pt ,advance care of ill pt
? What z issues of her son
?How do you konw this is rt decision
Me : i trusted z senario & my team so most probabely they r
.sure that z pt was competent when she decided
?E : how do u know z pt is competent
Me : that she can understand z information ,recall
E : no there r 4 componenets of it�
Me : recall and weight benifits and risks and no one inforce
.her
😁E :not recalling it is retaining
😫😫😫Me :yes that what i mean
? E :what ethical issues in it
Me : autonomy ,empathy
E : empathy isnt an ethical issues
? Me : benfecience (what is it
Malefecience (what is it )
.😰😰😰 Finally finished
11/11
: Station 5
:1
Female 40 ,came with headache
I was totally exhuasted and it was my last station,when i read
.i suppose it was a male and i put different dd
So when i entered the room,examiner told let us start with
😱😱 female pt ,i was shocked
she has headache for 2 months,no signs of ICP ,no fever or
symptoms of manangism,no trauma,no cns symptons,no
.aura,i felt i was lost .no drug history
Till asked about her period ,she have just gave birth to her
.baby 2 month ago,period stopped from that time
, asked did she bled a lot,she said yes
? what happen,asked about lactation
.she couldnt lactate her baby since that time
).it is shehan syndrome(
asked about symptoms of panhypopitutrism.she is
depressed,feeling hot ,fatigue,etc
:examination
Started by hands ,checking PR,rough skin,i asked to do bp
standing and sitting.examiner told me it is written behinde
😫😫you in z wall
I asked to examine her neck,gave her water to drink for
,thyroid examination
to check her for breast atrophy and examine the axilae( for
hair distribution). Examine abdomen (for straie) ,back for
. interscapular fat, examiner told me no need
.to do fundoscopy ,examiner told no need
. I forgot to do visual field
Then i answered concern, the need for urgent admission,give
.iv fluides.do some imaging and blood tests
?Examiner asked what is d
pitutary apoplexy due to post partum haemmorrahage
.causing panhypopiturism
iv fluides ,iv ,What management? Urgent Admission
.steriods,thyroxin
What investigations?MRI brain for pitutary and blood
tests,etc
?What dd
.I said migrane but there was no a typical aura
.Infection but no fever
I think they r were looking for bengin ICP,and pitutary tumor i
.forget to say
02/01
:Bcc2
yrs male with facial weakness,vitals r normal 22
He has rt facial weakness for 1 week ,no other cns symptoms
,when came to hearing problem,surrogate told me he has rt
.ear vesicles 1 week before with ear pain
.Also he is a heavy smoker
I examined facial nerve,rough examination for hearing ,asked
for torch to examine the mouth for 9th crn.examiner told no
.need
.Examine the ear for rash
.Examine arms for pronator driift
 Asked to examine for upgoing planter,speech and walking.
.and to do chest examination ,examiner told all r normal
.Concern was what z d? Is it strock?does he need admittion
I said it facial nerve affection most probably due to recent
viral infection, no need for anti viral pcoz it is not active now
.it is unlikely to be strock because he has no signs of cva or
weakness ,but we need to refer him to nerve dr ,do MRI brian
as out pt ,to be sure there is no lesion in z brain,esp he is a
.heavy smoker
.I adviced regarding to stop smoking
We will gave him drugs called steriods,he should cover his eye
.and eat gums to move his mouth
We will give him refreshing eye drops and refer him to
.physiotherapist
?Then examiner asked: what z d
Is it strock? I said it is unlikely pcoz most probably it will be in
.the brain stem,has weakness and more ill
😅He said but it could be strock .i said may be
?Asked what invst
Brain MRi to be sure there is cerebellopontine lesion esp he is
.a heavy smoker
.Then basic invt
.I replied the same managment i said to surrogate

What complications ? Eye keratitis

What speciallity dr you need to ask him to see the pt a part of
?the nerologist ,ENt,physiotherapist
 Opthalmologist
?What abou his speech
02/02

Maadi Military Hospital 2/6/3016

Well organized very good atmosphere
: I started my exam with cardiology
MVR with A.FIB ,valve functioning well
Q1:causes,RHD then immediately
They ask me about management as he SOB;diuretics and
anticoagulation
Then Q2 if patient had fever what he could have ??infective
endocarditis and what is the Target INR2.5-3.5
I score 20/20
Then neurology station :while am examing young man i can
hear the click �he has pyramidal weakness on left side with
clonus ,and they ask d/d left sided hemiparesis stroke in
young ;then i said as i could hear click cardiac cause A.FIB and
then ask how you will decide about Anticoagulation i said
CHADS2 score other D/D demyelination then ask how you
investigate for MS I said MRI VEP and LP
02/02
Then communication station i felt i did Bad 😫😫😫elderly
with UTI and Parkinsonism which was diagnosed 3 years but
not on treatment ,now she is admitted with UTI ,her
 parkinsonism become evident and started on treatment
carpidopa ,role to D/W her daughter msmagement
My D/about that she is elderly fragile with uti her symptoms
appear
Then daughter ask about side effect of Parkinson drugs
Then i asked social history she told my father bed bound with
stroke and my mum is only care giver ,then i discuss other
modalities of treatment like deep brain stimulation
Then i told we will involve social worker if no solution then
might need to think about nursing home for your parents
Examiner ask me about treatment of Parkinsonism
Feeding i said PEG tube then i need family ,they told me to
why u need family to Discuss ;i said she might have LPA or
advance directive As she is incompetent
I felt am of point as i didn't talk much about UTI
But i score 16/16
; Then i moved to station 5
Cushing i asked what is your concern but I didn't answer the
concern cuz no time ,examiner ask me what is your D/D
cushing ,hypothyroidism ,then he ask me about how to
investigate and treat cushing and what is the difference
.between cushing disease and syndrom
02/02
:Second st5
years old presented with polyurea 01
,History of RTA three years concer could it be cancer
? Examiner ask what is your diagnosis
 Diabetis insipidus also ask about investigation i told water
deprivation,desmopressin then examiner said more simple
.one i said urin and serum osmolality and treatment
I forgot to refer both patients to speciality,may be that is why
i score less
02/02
Then Abdomen:hepatosplenomegaly with heart failure and
also she had auidble click .gum bleeding,echemotic patch in
her hands
D/D Decompensated CLD i told hepatitis C ,then he ask
management i told referral to hepatologist and ask about
latest treatment for Hep C i told bocepravir
02/12
Chest:COPD ,with basal crepirations i told with fibrosis
examiner didn't like it he want COPD only then he ask me
about non pharmacological therapy and then pulmonary
.rehabilitation
02/17
History station:35 years old with hearing difficiency from
recurrent infections with meningitis at age 17 ,chest infection
;UTIs and came with dirrhoea and weight loss ,i told examiner
hypogammaglibulibaemia,he told me what else then HIV
,then he helped me cuz I forgot Cystic Fibrosis,till i said cystic
fibrosis 😬so am not sure what he wanted or how he will
judge me cuz i gave only hypogammaglibulibaemia and CF
after his help
02/11
‫هللا ولً التوفٌق‬
My PACES experience in Golden Jubilee Hospital, Glasgow, UK
in June 2016

:Station 1
Respi: A elderly man with obvious pectus excavatum.
However, the chest signs were subtle. I got left LZ crepitations
with reduced breath sounds, giving the diagnosis of pectus
excavatum with left LZ bronchiectasis. Another candidate got
right LZ crepitations, the 3rd candidate got bilateral LZ
crepitations. Turned out the answer was right LZ
.bronchiectasis. Lost all marks in physical signs component
)02/10(

Abdomen: Another station with subtle clinical findings. Stem:

this man has abdominal pain; please examine and find out
why. This middle aged man has very subtle hepatomegaly.
Discussion on causes and management. Another candidate
reported hepatosplenomegaly, and the 3rd candidate
reported normal findings. The answer was hepatomegaly, but
I missed the gynecomastia, so identifying physical signs marks
were deducted. Gave the correct DDX of alcoholic liver
)02/12( .disease

:Station 2
A middle aged lady with prolonged fever, symptoms persisted
despite admission and treatment for UTI. Further hx revealed
 prolonged fever with weight loss. She will also mention a
lump in the inguinal area. DDX given was lymphoma, occult
malignancy, CTD, TB, IE. Concern: What is causing my
symptoms? Spent a lot of time explaining diagnosis, the need
for biopsy, admissions, further tests. Need to explore how the
)02/11(.fever has affected her daily life and offer solutions

:Station 3
Neurology: Stem: this lady complained of double vision.
Please examine her. A case of Myasthenia gravis with
thymectomy. The only sign was double vision with
.fatiguability and thymectomy scar. Questions were standard
)02/02(

CVS: An elderly man with central sternotomy scar, vein

harvest scar, and MR. Got panicked and gave the wrong
)02/12( .diagnosis of AS. Did badly overall

:Station 4
A elderly man was admitted for pneumonia with confusion.
Given amoxicillin in ward and developed anapylaxis. He
recovered but still remained confused. Talk to the daughter
and address her concern. Need to elicit the fact that the
daughter mentioned to a doctor regarding patient's allergy to
penicillin. Thus, this is a case of error of drug administration.
Need to apologize profusely. Lodge critical incident reporting.
Need to address her concern and reassure her in every way
this will not happen again, and provide her the example how
you intend to avoid this from happening again. She will have a
lot of concerns and anger and you need to apologize,
 reassure, offer solutions and answers to her concern. I didnt
mention about PALS as she never mentioned lodging a
complaint but if she did, offer her ways to lodge a
)11/11(.complain

:Station 5
BCC1: A elderly lady with dark pigmentations over her shins.
Further hx: long standing DM on OHA, long standing
pigmentation for years, not causing symptoms apart from
itchiness. It is a case of necrobiosis lipoidica diabeticorum
(most likely healed lesions). Given differentials of chronic
.venous insufficiency with stasis eczema, diabetic dermopathy
)02/02(

BCC2: A case of a young man with headache. A challenging

station as there is a lot to get from history and to examine,
and all need to be done within 8 minutes. Further history
revealed symptoms of headache worse in morning and with
sneezing, vomiting and blurring of vision. Examinations were
normal. Didn't perform fundoscopy but did mention it.
Concern: Is it brain tumor? My mom had brain tumor at age of
40. DDX: headache due to raised ICP, e.g. IIH, less likely SOL,
)02/02( .migraine. Mx: Offer urgent CT brain

Overall: 148/172 (PASS)

:Personal opinion
 Exam case in UK are generally fair. It has tendency to put up
cases with subtle clinical findings esp. BCC. Normal surrogates
are frequently used in BCC, with scenarios like headache,
.syncope, fever etc being not uncommon

The examiners were rather strict and particular about

identifying correct physical signs. This is the component that
scared me the most. This applies to PACES everywhere

My PACES experience in Golden Jubilee Hospital, Glasgow, UK

in June 2016

:Station 1
Respi: A elderly man with obvious pectus excavatum.
However, the chest signs were subtle. I got left LZ crepitations
with reduced breath sounds, giving the diagnosis of pectus
excavatum with left LZ bronchiectasis. Another candidate got
right LZ crepitations, the 3rd candidate got bilateral LZ
crepitations. Turned out the answer was right LZ
.bronchiectasis. Lost all marks in physical signs component
)02/10(
 Abdomen: Another station with subtle clinical findings. Stem:
this man has abdominal pain; please examine and find out
why. This middle aged man has very subtle hepatomegaly.
Discussion on causes and management. Another candidate
reported hepatosplenomegaly, and the 3rd candidate
reported normal findings. The answer was hepatomegaly, but
I missed the gynecomastia, so identifying physical signs marks
were deducted. Gave the correct DDX of alcoholic liver
)02/12( .disease

:Station 2
A middle aged lady with prolonged fever, symptoms persisted
despite admission and treatment for UTI. Further hx revealed
prolonged fever with weight loss. She will also mention a
lump in the inguinal area. DDX given was lymphoma, occult
malignancy, CTD, TB, IE. Concern: What is causing my
symptoms? Spent a lot of time explaining diagnosis, the need
for biopsy, admissions, further tests. Need to explore how the
)02/11(.fever has affected her daily life and offer solutions

:Station 3
Neurology: Stem: this lady complained of double vision.
Please examine her. A case of Myasthenia gravis with
thymectomy. The only sign was double vision with
.fatiguability and thymectomy scar. Questions were standard
)02/02(

CVS: An elderly man with central sternotomy scar, vein

harvest scar, and MR. Got panicked and gave the wrong
)02/12( .diagnosis of AS. Did badly overall
 :Station 4
A elderly man was admitted for pneumonia with confusion.
Given amoxicillin in ward and developed anapylaxis. He
recovered but still remained confused. Talk to the daughter
and address her concern. Need to elicit the fact that the
daughter mentioned to a doctor regarding patient's allergy to
penicillin. Thus, this is a case of error of drug administration.
Need to apologize profusely. Lodge critical incident reporting.
Need to address her concern and reassure her in every way
this will not happen again, and provide her the example how
you intend to avoid this from happening again. She will have a
lot of concerns and anger and you need to apologize,
reassure, offer solutions and answers to her concern. I didnt
mention about PALS as she never mentioned lodging a
complaint but if she did, offer her ways to lodge a
)11/11(.complain

:Station 5
BCC1: A elderly lady with dark pigmentations over her shins.
Further hx: long standing DM on OHA, long standing
pigmentation for years, not causing symptoms apart from
itchiness. It is a case of necrobiosis lipoidica diabeticorum
(most likely healed lesions). Given differentials of chronic
.venous insufficiency with stasis eczema, diabetic dermopathy
)02/02(

BCC2: A case of a young man with headache. A challenging

station as there is a lot to get from history and to examine,
and all need to be done within 8 minutes. Further history
 revealed symptoms of headache worse in morning and with
sneezing, vomiting and blurring of vision. Examinations were
normal. Didn't perform fundoscopy but did mention it.
Concern: Is it brain tumor? My mom had brain tumor at age of
40. DDX: headache due to raised ICP, e.g. IIH, less likely SOL,
)02/02( .migraine. Mx: Offer urgent CT brain

Overall: 148/172 (PASS)

:Personal opinion

Exam case in UK are generally fair. It has tendency to put up

cases with subtle clinical findings esp. BCC. Normal surrogates
are frequently used in BCC, with scenarios like headache,
.syncope, fever etc being not uncommon

The examiners were rather strict and particular about

identifying correct physical signs. This is the component that
scared me the most. This applies to PACES everywhere and a
lot of practice is required to be able to pick up subt

.le signs. Never create signs as this is really fatal

Station 4 is very unpredictable. Cases can be easy or complex

with multiple agendas. Suggest to review all the cases posted
up here previously and practise them. Need to have some
knowledge regarding DVLA, Mx of meningococcal ds and
 prophylaxis etc... Need to really elicit the concerns, and offer
.solutions/answer as much as you can

.Good luck and all the best

Station 1
Abdomen: Lady around 50y.o with cushingoid features,
Perma cath, scar on the Right iliac fossa ( failed renal
transplant) and multiple scars around the umbilicus ( previous
Peritoneal dialysis)
The examiner asked about the complications ( esp. bone
complications and he asked about dietary restriction
{Shappati} as the pt and examiners are Indian)

Respiratory: Male pt around 55y.o well- nourished with right

thoracotomy scar on the back+ end-insp crackles. No clubbing,
no cyanosis, no signs of pulmonary HTN
Dx ILD, the scar is for lung biopsy ( I said to the examiner it's
for lobectomy but he asked me what else it could be for, I said
for lung biopsy then he agree with me)

Station 2
Lady aged 55y.o heavy smoker with 3months h/o SOB,
coughing blood and loss of weight. She sought medical advice
 recently and given antibiotic ( she doesn't know the name of
it) by GP who diagnosed her as acute bronchitis, but no
improvement. One week ago she developed dysphagia for
solid food. No h/o fever, no vasculitis symptoms, no other GI
.symptoms

Station3
Cardio: young lady with mid-sternotomy scar and palmar
erythema. No signs of pericarditis. S1 is metalic. No murmurs
or additional heart sounds. No signs of pulm HTN or pulm
cngestion
Dx Mitral valve replacement ( metalic)

Neuro: instruction: examine lower limbs

old man with walking aids beside him, indwelling Foley's cath.
Perioheral neuropathy for DD. I mensioned them specifically
paraneoplastic syndrome ( ? Prostatic cancer)

Station 4
Middle age lady diagnosed to have bird fancier lung disease.
She presented today to know the result ( BBN) and to discuss
with her the need for corticosteroid treatment and to avoid
exposure to pigeon ( she's breeding pigeon and she's famous
in her region )
She resisted first to take the steroid but when I explained to
her its benefits and risks ( including osteoporosis) and the
prophylaxis for the side effects she accepted. Also she got
 angry when I suggested to her to avoid exposure to pigeon.. I
appreciated her upset and I explained that she will not get
better unless she avoids exposure. I suggested to wear mask
in case she has to see her pigeon or to train somebody to feed
them. She said her son may help her in taking care of the
.pigeon finally agreed

Station5
Case 1
y.o. Lady presents with fever (39.5) and diarrhea. She 02
admitted eating from restaurant. When I asked about travel
she said she came from Thailand. I asked about insect bite
including mosquitos she said yes. Then I asked about malaria
prophylaxis before during and after travel she said yes. I also
.asked about HIV risks
O/E : no signs (surrogate)

Case 2
y.o male with headache, high blood pressure (180/100) 32
and urine dipstick showing proteinuria and microscopic
hematuria. He had h/o childhood chest infection and family
.h/o SLE
O/E no signs
There is ophthalmoscope on the table. I noticed it late. I said "
"): I would like to do fundoscopy but no time
Dx AkI ( Glomerulonephritis needed kidney biopsy and
Autoimmune profile+ Renal US)
 UK EXPERIENCE

I started with station 5

young female recurrent abdominal pain. Refered from .1
.surgerical team.scan normal
.On history she had rash,mild headache and some joints pain
.I made differential of vasculitis and porphyria
.Examiner ask about investigation of porphyria
young gentle man with collapse. History goes with seizures . 0
. grossly no neurological deficit . I explained about diagnosis,
,ask about driving

.My experience at whipps cross hospital 31/8/2016

Started with station 5
young female referred from surgical department due to .1
.recurrent abdominal pain
.History was negative, no diarrhoea, no loss of weight
.No relieving or aggravating factors
Systemic review showed rash at forearm, mild headache and
some joints pain. No weight loss
Periods normal
Examination; no jaundice, abdomen soft nontender and no
viscromagely
 ;Concerns
what is the cause.1
.why ultrasound normal.0
.I explained likely vasculitis or porphyria
. Needs other blood and urine test to confirm
Examiner asked about differential i said as above and the next
question was investigation of porphyria
years old university student with collapse. I started what 0.02
.happened he told he passed out while watching movie
I ask if happen before, Pt told 3 weeks ago while he was
working on computer in library. I started with prodormal
symptoms, they were none.i ask any friends observed jerky
.movements, Pt told yes
Than history goes on with incontinence and fatigue after
.recovery
I ask about any thing unusual a night before (lack of sleep ),Pt
told no . then asked about driving, drugs, and hobbies (keen
swimmer).grossly examine tone power in both limbs,gait and
.ask for fundus. (Examiner refuse)
Concerns 1.what is my problem
.what you will do (scan +eeg).0
.Consouil about driving and any attendant while he swims
Examiner ask! What will be finding in ct? I told him likely to be
normal as there is no neurological deficit but would like to
have com

.Complete neurological examination

 .Is it possible to have any cardiac problem to this patient
I explained possible but less likely as both events occur while
.Pt was sitting, however tacyarrthmias can be possible
Would you start treatment. I said refereed to seizure clinic
and neurologists will decide

Abdomen# young female with central larotomy

scar,subclavian

Dialysis catheter and right palpable kidney. Not sure about

larotomy scar (which was the main question by
examiner),other question was about causes of fatigue in this
patient 😁I told him uremia, possibility of underlying
hypothyroidism, anemia and infection. Overall not very good
Respiratory # young female, no rheumatological
manifestations, wheezing from bedside. Minimal basal
.crepetations
Indian examiner started with respiratory rate (forget😳)
Next question was jvp findings (😁),followed by did this
.patient had loud P2 (�)
I said sorry for above 3 questions
.Than he ask differential i told him copd /fibrosis
He ask which will be your priority diagnosis, I told copd due to
prominent wheezing than investigation of copd with xray
findings and pulmonary function test. Overall it was tough
 History ##50 years old women complaints of abdominal
.discomfort and bloating
I started with usual pattern of pain,location, bowel changes,
all none. Nonspecific pain not related to any thing . half stone
weight loss. Than I asked any tummy distension, she said yes
her trouser are tighter and she is using large size from before.
I switch to orthopnea, pnd, negative. No lower leg swelling no
periorbital swelling no problems with water. No signs of liver
disease. Clueless I proceed to past history which was
significant for mastectomy secondary to malignancy. Family
history positive for ca breast in sister . mild low feeling due to
recent mother died because of ca breast.post menopausal (no
.dysparunia/break through bleeding)
Concern 1. What is cause of tummy distension. I explained
likely that some tumour cell spread .2. Is it too late as I have
symptoms since 3 months. I told her we have to investigate
and don't worry we will do your test on priority
.Examiner ask# diagnosis i told him metastasis
He ask if Pt don't have distension than what do you think. I
told I consider irritable bowel as recent death of her mother
.and only half stone of weight loss
What other possibilty I told ca ovaries. Then tumour markers
of ca ovary. What do you do? Scan ct . any investigation
would you like to offer while she was in opd. I don't have any
.answer. He told chest xray
What measures you told to other sisters and daughters. I told
repeated manual breast examination and after 40 years of age
mammogram. Got full marks
 Cvs # 75 years old male with sob . murmer of AR. I checked
.collapsing pulse
.Routine questions about causes
Causes of acute AR (dissection of aorta, endocarditis and
ruptured sinus of valsulva)
Type of valve

Cns# 50 years old gentle man with difficulty in walking please

😳 examine upper limbs

It was parkinsonism. I mentioned to check sitting and standing

BP, micographia and gaze palsy

.Examiner ask about causes

Treatment
New treatment, mention deep brain stimulation and
.dopamine containg implants
.Who will be involve in management of this patient #MDT
😳She asks what occupational therapist will do

I told occupational therapist will visit the home and arrange

.some rails and support to prevent patient from falling
Alhamdillah went well. Got 19 in both

Communication # spoke to wife, husband in icu. Keen cycle

rider and went for long marathon and take extra fluids to
prevent dehydration. At home he also drink water continously
till he was found to seize in garden and brought by
.neighbours. CT and all other labs normal. Sodium 114
Better but still confused with gcs 15 . two weeks ago started
on bendrafluthiazide for htn (Pt age 45)

I started with wife with sympathy, what she Knows so far

.regarding husband
Gave good news that scan is normal. Likely seizure due to low
.salt in body
She asks why salt become low. I explained . she asks why still
confused I told her take time to correct sodium slowly . she
.asks about discharge.,explains it will take coupleof days
She asked they are moving to dubai, so he can do cycle ride
there. Its will happen again 😳😁like little puzzle with this
question but told her that chances are low but instead of
taking plane water if he took carbonated water it contains
.!!some salt
She asked about BP medication attributing. I told possible.
She asks continue bendrafluthiazide. I told we ask cardiology
.colleges

Came back to driving and profession .Pt was enginer but not
.exposed to heavy machine. I told dvla
She asks follow up for how long as they are moving to dubai. I
told we don't need long term follow up as prognosis is good
and we're will gave detail medical report to be shown to
.doctors in dubai
 Last concern where he will ride cycle in dubai as it is very hot
there ��

I just mention i am not sure But in dubai you may find indoor
cycling track as most of the activities there are indoor even ski

Examiner ask why Pt confused I told still sodium is not correct.

He ask other reason I told him possible cerebral edema due to
.seizure and low sodium
He ask at what rate you will correct sodium. I told 5 -8
meq/day . then he ask what happens with rapid correction. I
answered. He ask at what sodium level you are happy to
discharge. I told him 135 -140. He ask what about cycle riding
.rules after seizures in uk
I told him I have no idea, but advisable not to do in early few
months . last question is bendrafluthiazide was a good choice
of anti hypertension for this patient. I told no as patient ids
less than 55 an ACEI should be considered. Alhamdillah Got
full marks

Overall experience of exam in uk was good . there is no

problem of understanding of English with surrogate in station
.2 and 4
.Thanks for this group
.Thanks to Dr zain
Best of luck and good wishes to all my friends in this group