An Aid to the MRCP PACES, Volume 2: Stations 2 and 4

This new edition of An Aid to the MRCP Paces Volume 2: Stations 2 and 4 has been fully revised and updated, and reflects feedback from PACES candidates as to which cases frequently appear in each station.

The cases and scenarios have been written in accordance with the latest examining and marking schemes used for the exam providing an invaluable training and revision aid for all MRCP PACES candidates.

Preface, ix

Introduction, xiii

Section D: History–Taking Skills, 1

Station 2, History–Taking Skills, 7

1 Abdominal swelling, 8

2 Ankle swelling, 10

3 Asymptomatic hypertension, 13

4 Back pain, 16

5 Breathlessness, 19

6 Burning of the feet, 23

7 Chest pain, 26

8 Cold and painful fingers, 28

9 Collapse? cause, 30

10 Confusion, 32

11 Cough, 35

12 Diabetic feet, 37

13 Diffi culty in walking, 40

14 Dizziness and feeling faint, 43

15 Double vision, 45

16 Dysphagia, 48

17 Epigastric pain and nausea, 50

18 Facial swelling, 52

19 Funny turns, 55

20 Haemoptysis, 58

21 Headache, 60

22 Hoarse voice, 63

23 Hypercalcaemia, 65

24 Hyperlipidaemia, 67

25 Jaundice, 70

26 Joint pains, 73

27 Loin pain, 76

28 Loss of weight, 78

29 Lower gastrointestinal haemorrhage, 80

30 Macrocytic anaemia, 82

31 Neck lump, 85

32 Painful shins, 87

33 Painful shoulders, 89

34 Palpitations, 91

35 Personality change, 93

36 Pins and needles, 96

37 Polyuria, 98

38 Pruritus, 100

39 Purpuric rash, 102

40 Pyrexia, 104

41 Renal colic and haematuria, 107

42 Tiredness, 109

43 Tremor, 112

44 Visual disturbances, 114

45 Vomiting, 117

46 Vomiting and forgetfulness, 120

47 Weakness of the right arm, 123

48 Weight gain, 126

49 Weight loss and chronic diarrhoea, 129

50 Wheeze, 131

Section E: Communication Skills and Ethics, 135

Station 4, Communication Skills and Ethics, 145

Category 1: Informed Consent

1 Consent for a lumbar puncture, 147

2 Consent for oesophagogastroduodenoscopy (OGD), 150

3 Emergency surgery under principles of best interests , 154

4 A competent patient s refusal of treatment, 157

Category 2: Diagnoses and Management Advice

5 Obesity management, 160

6 Side–effects of cardiac medication, 163

7 Presentation of a fi rst seizure, 166

8 Rheumatoid arthritis, 169

9 Valvular heart disease in a young woman, 172

10 Air travel with chronic obstructive pulmonary disease, 175

11 Polypharmacy, 178

12 Blood transfusion, 181

13 Hormone replacement therapy, 183

14 Lifestyle adjustments after a myocardial infarction, 186

15 Smoking cessation, 189

16 Starting insulin therapy, 192

17 Refusal of analgesia, 194

Category 3: General Clinical Issues

18 Human immunodefi ciency virus testing, 196

19 Communication of a human immunodeficiency virus–positive result, 200

20 New diagnosis of tuberculosis, 204

21 Non–compliance with anti–tuberculous treatment, 208

22 Multidrug–resistant tuberculosis, 211

23 Hospital superbug 1 (Clostridium diffi cile), 215

24 Hospital superbug 2 (methicillin–resistant Staphylococcus aureus), 219

25 Assessing suicide risk, 223

26 Genetic counselling, 226

27 Fitness for anaesthesia/surgery, 230

28 Screening for prostate cancer, 232

Category 4: Breaking Bad News

29 Malignancy in a young patient, 235

30 A chronic illness, 238

Category 5: Ethical and Legal Issues

31 A patient with a functional illness, 240

32 Brainstem death testing and organ transplantation, 243

33 Hospital postmortem, 248

34 Coroner s postmortem, 253

35 Do not attempt resuscitation decisions, 257

36 Withholding information from patients, 262

37 Maintaining patient confi dentiality, 266

38 Advance care decisions, 270

39 Healthcare decisions for a patient who lacks mental capacity, 274

40 Care of the vulnerable adult, 278

41 Blood transfusion for a Jehovah s Witness, 282

42 Eligibility for major surgery, 285

43 Postponement of an investigation, 287

44 Clinical error in drug administration, 289

45 Fitness to drive, 292

46 Limits of treatment in end–stage disease, 295

47 Withdrawing treatment, 298

48 Enrolling a patient in a clinical trial, 301

49 Industrial Injuries Disablement Benefit, 304

50 Internet therapy, 306

51 Unrelated live donor transplant, 309

Category 6: Dealing with Difficult Patients/Relatives

52 A patient desperate for a diagnosis, 311

53 A missed tumour, 315

54 An unhappy inpatient, 319

55 Delay in investigation, 322

56 A patient wanting to self–discharge, 324

Category 7: Professional Issues and Communication with Colleagues

57 Major incident exercise, 327

58 A struggling team of doctors, 330

59 A colleague with hepatitis B infection, 334

60 A colleague with a needlestick injury, 337

61 The improper doctor, 340

62 The incompetent doctor, 343

63 The sick doctor, 345

64 Consent for medical examination, 347

65 Submitting an audit project, 350

66 Treating a prisoner, 353

67 A violent and abusive patient, 355

68 Withdrawing treatment in intensive care, 357

Section F: Experiences, Anecdotes, Tips, Quotations, 359

Full PACES experiences in the first person (since 2009), 367

Full PACES experiences in the first person (before 2009), 389

Additional Station 2 experiences, 427

Additional Station 4 experiences, 431

Invigilators diaries Stations 2 and 4, 435

Some anecdotes from our most recent surveys, 435

Experiences, 437

The power and range of the candidate s observations, 439

The candidate s examination technique, 441

The clinical competence of the candidate, 443

Common errors, 444

Look first, 444

Double pathology, 445

Tell them of the expert that told you, 445

Apologies accepted, 445

Even though I didn t mean to say it I did , 446

Invigilator s diaries, 446

Fly on the wall complete accounts, 448

Ungentlemanly clinical methods, 452

Miscellaneous pass experiences, 452

You never know you ve failed until the list is published, 464

Survivors of the storm, 466

Some fail experiences, 470

Downward spirals, 475

Anecdotes, 477

Some anecdotes in the fi rst person, 480

Miscellaneous, 483

Useful tips, 483

Quotations, 484

Adopt good bedside manners, 485

Practise clinical examination and presentation, 485

Get it right, 486

Listen, obey and do not stray, 486

One wrong does not make one fail, 487

If you say less they want more, 487

Humility is more persuasive than self–righteousness, 487

Keep cool: agitation generates aggression, 488

Simple explanations raise simple questions, 488

Think straight, look smart and speak convincingly, 488

You have seen it all before, 489

Use your eyes fi rst and most, 489

Doing and forgetting, 489

Examiners are different, 489

Additional comments and quotes from candidates, 490

Appendices, 491

1 Website links, 493

2 Abbreviations, 495

Index, 497

Dev Banerjee Department of Medicine, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust and City Hospital, Birmingham

N. Sukumar Department of Medicine, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust and City Hospital, Birmingham

Robert E.J. Ryder is Consultant Physician and Clinical IT Lead at City Hospital NHS Trust, Birmingham, and Honorary Senior Lecturer in Medicine at the University of Birmingham.

Dr M. Afzal Mir is Senior Lecturer and Consultant Physician at University Hospital of Wales, Cardiff

Dr Anne Freeman is Consultant Physician at Royal Gwent Hospital, Newport, and Clinical Adviser and Chairwoman of the Welsh Stroke Alliance