How I passed my PACES exam first time with 168/172
Insight into my Actual Exam (Stations 1, 3 & 5)
By this stage of the exam I was done with the bulk of the talking bits of Station 2 (History) and Station 4 (Communications) and was onto the the examinations. It was definitely feeling like a marathon at this point and you just had to keep going with the stamina.
Next was Station 3 (Cardio and Neuro)
Two friendly examiners here examining cardiology and neurology. The room was divided, and I was taken first to the Cardiology case. I was given 2 minutes to don PPE and even though I finished donning it early, the station did not start until the end of 2 minutes. This was the case for all examination stations.
Cardiology (20/20)
The gentleman was probably in his early seventies. I could hear an audible metallic click at the bedside. He was comfortable and not peripherally overloaded. He had a midline sternotomy scar. I found auscultation and timing the heart sounds a bit hard as I could barely feel the carotids, so I just hoped for the best with the timing. I though the first heart sound was metallic but coming closer to the aortic region, the second heart sound could possibly also have been metallic, but I wasn’t sure. On looking at his legs (I was running out of time at this point so couldn’t do a proper inspection) I saw there was a scar in the distribution of the long saphenous vein on the right but instead of the one long scar there were two shorter vertical scars instead.
As I wasn’t a hundred 100% sure if the second heart sounds were metallic, I didn’t want to make up findings. I presented my case as follows:
“Mr X appears comfortable at rest. A metallic click was audible at the bedside and on inspection there was a midline sternotomy scar with no evidence of bruising or ecchymoses. On auscultation, I noted the first heard sound was metallic in character with no associated murmurs. I also noted the patient had two vertical scars in the long saphenous distribution, but it is not the one long scar I would expect to find if her had undergone a coronary artery bypass graft. In conclusion, I believe the patient has a metallic valve replacement which is functioning well and there is no sign of anticoagulation related complications”
This was followed up with these questions:
- Can this patient still have had a CABG? Yes, He could have had a CABG via the internal mammary artery graft, or his long saphenous vein could have been stripped using the two vertical scars in the leg.
- Could this patient have had another valve replacement? (At this point I thought I probably was not imagining my second metallic sound so I decided to take the plunge). I believed the character of the second heart sounds changed in the aortic region and it was much louder so I do think he could have also had an aortic valve replacement. I would like to take a history and echocardiogram to confirm my finding and assess LV function
- This patient’s target INR is 3.5. Why is it that high? Patients with metallic heart valve replacements have a higher chance of clot formation and have higher INR targets than those with just aortic valve replacements.
Neurology 18/20
This was a very odd station. I still am not 100% sure what the patient actually had. An elderly patient was sat on a chair with glasses where one lens was covered with a plaster. My instructions were “This lady complain of double vision, please examine as you see fit”
I was quite thrown off by this one. I wanted my muscle memory to kick in – do my standard lower limb, upper limb or cranial nerve but now I had to piece different things together. I definitely had what felt like long pauses during my clinical – even the examiners asked me what equipment I was looking for when I kept staring at equipment trolley by the patient’s side for possibly an abnormally long time deciding what to do next.
I could see that the left lens of her glasses was covered with plaster. I started off by asking her to take off the glasses and examined the acuity in each eye in turn which was normal. On inspection, I thought she possibly had bilateral ptosis but she had no nystagmus. I checked her peripheral visual fields which were normal. On eye movement, she had no pain on eye movements, but she complained of double vision in the central field and up gaze which improved in the peripheral extremes of vision (odd, right?!). There was no convincing weakness on sustained up gaze. I didn’t note obvious nystagmus. I generally tested power and sensation in the face which was normal, her gait was normal and she wasn’t ataxic. I did the tests for myotonic dystrophy by asking her to close her hands tightly into a fist and release them and there was no evidence of myotonia. I asked her to mover her shoulder up and down a few times at which point she asked me “would you like me to do it 20 times?” (which made me think my suspicion of myasthenia was probably right”) but I didn’t note any sign of fatiguability. I didn’t have a clear idea what was going on so I tried to present it as factually as I could so here goes:
“This lady has bilateral ptosis with binocular double vision which resolves with one eye covered suggesting this has a neurological rather than ophthalmological cause. The diplopia is worse in central field and on up gaze but not in the extremities of vision as would be typically expected. As this is a complex binocular double vision, the lesion is either in the muscle, the nerves, or the brain. She had no proptosis suggestive of grave’s disease, no evidence of myotonia or fatiguability for myasthenia. But given bilateral ptosis my top differential I would like to investigate further is myasthenia gravis. I would like to test for fatiguability for a more sustained period and perform further diagnostic investigations”
He asked me what I would do investigate further for myasthenia. I replied I would like to do a mote thorough and longer examination to elicit fatiguability, bloods particularly anti-acetylcholine receptor antibodies, EMG and EEG (Slip of tongue, WHOOPS!). He asked me if I would really do an EEG and I quickly corrected myself saying nerve conduction studies and ant not EEG.
He then moved on saying now forget about myasthenia, where do you think the lesion is. And I was going with causes of bilateral ptosis so I said something like in the muscles, the neuromuscular junction, or somewhere behind in the brain which could affect the tract of either the sympathetic or oculomotor nerves. I mumbled something about superior orbital fissure and cavernous sinus syndrome and the the brainstem for ptosis ( I was thinking of ptosis associated with lateral medullary syndrome and Weber syndrome in brain stem strokes). I don’t recall ever mentioning cerebellum as I didn’t note any nystagmus.
I genuinely thought this station was a complete car crash, but I was pleasantly surprised by getting 18/20 in this one. Based on this, my greatest advise would be to say things as you see it and trust your clinical examination. If you don’t note something, don’t make up signs. In your presentation you can always say you found X but you would typically expect Y instead if this differential were true.
Station 5: Brief Clinical Consultations
I had 5 minutes to read through both the consultation briefs including glancing at the patient observations tables. This felt very time pressured! And even more time pressures if the 8 minutes given for history and examination!!
Its a very artificial way if judging your abilities and in clinical practise you need longer than this. The reverse if the the history station where you take the history for a ridiculously long 14 minutes without examining – which is unnatural. If a patient comes in with a rash – you look at the rash. In my history station the patient came in with joint pain and stiffness – I had to go against my examine not to look or examine the hand.
This will be changed in the new PACES format (which is yet to be implemented – date TBC). Stations 2 and 5 will be replaced by two 20 minute consultations with with 15 minutes for structured history and exam which is more reflective of clinical practice. But the old format is still ongoing so my station 5 was 2 10 minute stations ( 8 minutes for history, 2 minutes for viva) .
Brief Clinical Consultation 1 (26/28)
My first patient was a young lady in her late thirties. She presented with sudden onset dizziness. Her observations were stable aside for a mildly raised BP for her age – I think I was in the 160s.
I started off by taking a brief history – Onset of dizziness, what it feels likes (room spinning versus light headedness), what was she doing when it first started, if there were any other associated symptoms. She complained that she woke up this morning with dizziness. This came on suddenly and didn’t have any other symptoms of vision disturbance. She reported she had some right arms numbness but no weakness. She was a bus driver but worked part time as a yoga teacher. She had no recent infections. She denies having a headache or palpitations. She had no personal or family history of heart disease or strokes.
I did a brief clinical examination, taking her pulse to make sure it wasn’t irregular and had a quick listen to her heart for murmurs and carotids for any bruits. I examined her eye movement which were normal and she had no ptosis. I did a brief cranial nerve, upper limb and lower limb exam mainly focussing on power and sensation in each. I found that she had crossed signs with left sided facial numbness associated with right sided arm numbness. At this point I was pretty convinced she had a posterior circulation stroke. So I proceeded with tell her the diagnosis – I explained I think there is a chance this may be a stroke and we need to urgently do some investigation including blood tests and a scan of her head and the blood vessels which go up to the brain. I mentioned that she should stop driving her bus at present and we can give a letter to her employer to support her and she readily agreed to this. By this point I ran out of time.
My follow-up questions were, “So you think it is a stroke, if you had more time what other investigations would you have liked to perform”. I was definitely mumbling something along the lines of a full neuro exam but when he stared at me blankly I knew that was not the answer he was looking for exactly. I finally focussed it and said I would like to a cerebellar test including coordination and he was happy with that and moved on. He asked me what would my other differentials be and I said the differentials for sudden onset dizziness can be broad “These include vestibular causes like BPPV or labyrinthitis but the history is not consistent with this”
It was only 2 minutes for questions so that was it for this station.
Brief Clinical Consultation 2 (28/28)
This was a more straightforward case compared to first station 5. This was a gentleman with fatigue, lethargy and shortness of breath. He had occasional feeling of lightheadedness and dizziness stable. He denied any fevers or weightloss. He appeared well and his observations were stable. The symptoms of lethargy had been increasing for the last few months (probably around 3) but he wasn’t exactly sure when and but was getting more noticeable.
He had a history of a metallic heart valve (and was on warfarin) and ischaemic heart disease. He in the past had reported he had black stools which was investigated with an endoscopy. He thinks he may have had darker stool sin the preceding weeks but aren’t black. He reported he was having regular INR checks and belived this to be within range. I briefly went through the rest of the drug history and social history but there was nothing relevant of note.
I proceeded onto the examination and he had a fairly normal pulse, but with metallic heart sounds (I didn’t pay attention to which of the sound was metallic at this stage). There were no murmurs audible. He had some ecchymoses on his arms. His chest was clear and he had no signs of peripheral overload. I offered to perform a DRE which was normal.
The patient’s main concern was that there may be a problem with his heart. I explained to the patient that although with his history of ischaemic heart disease and metallic valves, we will do a jelly scan of the heart (echo) to ensure everything is ok with the heart but at present I feel that his symptoms are most likely due to anaemia. I advised that he should get a blood test done today to check things such as his haemoglobin, clotting and iron and B12 levels and we will make further plans based on what those results suggests. If his Hb is very low, he may need admission for transfusion which would improve his symptoms.
The final push, Station 1 (Resp and Abdomen)
Respiratory (20/20)
I feel like nerves were kicking in at this point and I was overwhelmed that I had already done most of the exam. This station also has the most pokerfaced examiners and appeared least friendly too. These nerves immediately translated to me messing up the donning order. I put the apron on before washing my hands and then tried to squeeze the gloves on top of my freshly washed went hands which was obviously not going to work. I ripped the first pair of gloves I tried on and had to re-dry my hands properly before trying on the next pair.
My blurb was that this gentleman is breathless please perform a respiratory examination. I had a gentleman in his seventies possible. He was very kyphotic and was clubbed. He wasn’t on any oxygen delivered via a cylinder. There was no other paraphernalia like inhalers etc by the bedside. The main finding was that he had bibasal fine end inspiratory crackles.
For the presentation and viva in this station I essentially went largely on a monologue and they let me. I presented this case as follows:
“I believe this gentleman has signs consistent with interstitial lung disease. This is evidence by clubbing and fine end-inspiratory crackles in both lung bases. The chest expansion was reduced in all directions but the percussion note was resonant. He showed no evidence of cor pulmonale. Other differentials for this presentation could include COPD but I would not expect to find clubbing unless complicated with lung cancer and bronchiectasis where I would expect the nature of the crackles to be coarser and earlier during inspiration. I could not elicit a clear cause of his interstitial lung disease in my examination for example he had no evidence of inflammatory disease such as rheumatoid arthritis in the hands. I would take a history including occupational exposure to irritants particularly asbestosis and drug history as he has a basal pattern of fibrosis. I would investigate this patient further by taking bedside observations particularly looking for respiratory rate and oxygen saturations, a CXR and am ECG to look for evidence of right heart strain. The gold standard diagnostic test would be a high-resolution CT scan looking for honeycombing of the lungs. Pulmonary function tests including a TLCO is required as I suspect his kyphosis will also contribute to a restrictive picture. This patient should be managed within a respiratory MDT where GPs, Respiratory physicians, and Respiratory clinical nurse specialists are involved. This patient may benefit from steroids and anti-fibrotics such as Pirfenidone.”
The examiner asked me “How would you manage if this patient presented breathless patient in the acute setting?”
“I would approach the patient in an A&E manner and resuscitate as necessary. I would do an arterial blood gas if the patient was hypoxic. I would require a chest X-ray and take a full set of bloods including inflammatory markers and a temperature to see if there was an infective exacerbation of ILD and cover the patient with antibiotics. I would see if the patient had any pre-discussed ceiling of care and if appropriate discuss this with him early as he might need further ventilatory support with NIV or optiflow.”
The time ran out by this point and I was moved on to abdomen. I should probably have also said something regarding seeking specialist Resp advise for steroid use but didn’t think of it at the time. At least a donned and doffed without making a fool of myself this time.
Abdomen (20/20)
I was very worried I might have failed this patient. The patient in this examination was a little elderly Indian lady who loved to have a chat. She was fully dressed in a tightfitted top and had her arms, abdomen, chest all covered. There was also a wheelchair on the bedside, and she had an ankle-foot orthoses like the one you have for foot drop for the he left foot. I did the usual introducing myself and asked her if she was in pain. She was like not at present, but I will be once you start examining me and started chatting about a bunch of other things. I had to gently steer her back to the examination. I asked her to let me know straight away if she was in pain and I would stop immediately.
I did the usual inspection, and I could see she had two J shaped scars in both the right and left iliac fossa. I began to lifer her snugly fit sleeve and she immediately told me that was painful (I was lowkey panicking at this point – surely its a fail if you supposedly caused patient pain?). I apologised for the pain caused and asked her if she wanted to lift her sleeve up and slowly watched her do this knowing I was so behind with the exam. The examiner did tell me not to worry around this time and that she would add 30 seconds to my exam time. It was worth the effort asking her to lift her sleeve as then I noted an excised AV fistula scar on the left arm. She also had a scar in the anterior chest wall possibly for a previous Tessio line for dialysis. On palpating the abdomen, I was so bogged down on really pressing down on her abdomen as I couldn’t properly feel kidneys under her scars. I was certain couldn’t feel anything under the right scar but there was maybe something under the left. I was so pre-occupied I am not sure if I remembered to look at her face during abdominal palpation.
She had no signs of itching or peripheral oedema. She had evidence of gum hypertrophy and a mild tremor but no interscapular fatpad. I presented the case as follows
“This lady has end stage renal failure and is currently receiving renal replacement therapy via a transplant which appears to be functioning well. This is evidenced by two J shaped scars in the right and left iliac fossa and she was no signs of peripheral overload or uraemia. There is also no evidence of acute rejection as there is no pain over the kidney scar, erythema or fever. She has likely received previous RRT via an AV fistula and a Vascath. She had evidence of complications with immunosuppression including a tremor and mild gum hypertrophy which is seen with tacrolimus and ciclosporin use. I could not elicit a clear aetiology of her renal failure. Given this lady is of Asian descent, diabetic nephropathy remains high on the differential list but I did not note any finger prick marks. However as she has bilateral J shaped scars, she may have had a simultaneous pancreas-kidney (SPK) transplant suggesting a diabetic aetiology”
Examiner: What are the other reasons why she may have have two scars?
Me: Its either due to a SPK transplant as I mentioned earlier or it could also be a previous renal transplant on the right which has now been removed, The scar could be used to access abdominal structures underlying it such as the uterus, ovaries or bowel for an unrelated pathology.
Examiner: What is the aetiology of kidney failure?
Me: The commonest causes include hypertension and diabetes. Other causes include glomerulonephritides such as IgA nephropathy or SLE.
Examiner: Can you think of any other causes?
I had a mind blank, I stumbled. Probably should have said adult Polycystic kidney disease but didn’t think of it at the time and time was up.
Concluding remarks, my humble tips and advice:
- Don’t do PACES because everyone is doing it. Do it at the earliest opportunity of when YOU feel is right. Your own other academic and personal life commitments like weddings, being best man or maid of honour to your best friend, trip back to the motherland are all important. So do it when you know you have at least two months of focus.
- Don’t underestimate practising how you come across. Having a nice systematic way of presenting and communicating I do believe goes a long way.
- Be the doctor you are on the exam date, not an exam candidate waiting to be scrutinised. The examiners would guide you and do want to pass you, so just take a step back and try and enjoy it. You are about to see an interesting case mix of patients in three hours so let it be at least a bit of fun. A smile around the PACES carousel goes a long way!