A Conceptual Guide To MRCP (Uk) Paces Exam.: Station 2, 4 and 5. Sample

paceUrPACES Dr Tanzeel Bukhari
Page | 1
A CONCEPTUAL GUIDE TO MRCP (UK) PACES EXAM.

STATION 2, 4 AND 5.
Sample Edition.
Written and Edited by:

Dr Tanzeel Bukhari.
MBBS, MRCP(UK).
Cell No: 00923346036496
Email: drtanzeelbukhari@gmail.com
Email : drtanzeelbukhari@gmail.com Cell No: 00923346036496

Content: Page No
Case 2-1: PALPITATIONS IN A YOUNG MAN WITH FAMILY HISTORY OF SUDDEN DEATH: 3
Case 2-2: SHORTNESS OF BREATH IN A LADY OF CHILD BEARING AGE. : 7
Page | 2 Case 4-1: EXPLAINATION OF NEWLY DIAGNISED BARRETT,S ESOPHAGUS. 15
Case 4-2 : REFUSAL OF HEMODIALYSIS IS A COMPETENT PATIENT. 20
Case 5-1 : PAINFUL AND STIFF SHOULDERS IN A 50 YEAR MALE. 25

CASE 2-1
You are a SHO in GMC.
Page | 3
Mr. Smith, 23 years old has presented to you with the complaint of racing of his heart from
last 6 months.
His vitals are
BP: 120/70 mmHg
Pulse: 77 beats per minute
Temperature: 37 “C.
Please take history and address his concerns.

Be careful not to miss
History of presenting complaint:
Along with routine questions of onset, duration, progression, aggravating and relieving factors, do ask
Page | 4 1. When was the last attack?

2. Was the last attack similar to the previous one or it has changed in character?
3. What he was doing exactly at the time of attack.
4. How much time the attack remained.
5. Did it settled by his own or he has to do any maneuver?
6. Any thumping of heart.
7. Any missed beats.
8. Ask him to tap on the table to give you an idea of his rhythm during the attack.
Associated symptoms and systemic review:
Specifically ask about
1. All cardiac symptoms.

2. CNS questions specially did he ever get any numbness or weakness in any of his body part. Any
problem in his vision or speech.
3. Ask about black out if any?
Drug history:
1. Ask about certain drugs like Beta agonists, other sympathomimetics, theophylline, or certain
drugs which may cause Long QT syndrome like Quinidine, Disopyramide, TCAs etc
Family history:
1. Specifically ask about history of sudden death in the family
Social history:
1. Current mood, anxiety and any stress at home or at job.

2. Recent excessive intake of coffee and tea
3. Alcohol.
4. Use of any drugs for recreation.
5. Hobbies like swimming, football
6. Occupation patient may have to change certain jobs like pilot or army in which case we
should refer him to the respective department.
7. Driving :patient may have to stop it
Important Differentials not be missed:
1. Arrythymias due to congenital heart diseases like HOCM, Long QT Sydrome, Brugada Syndrome.

2. Thyrotoxicosis
3. Phaeochromocytoma.
4. Coffee tea excess not to be neglected as a probable cause.
5. Alcohol
6. Sometime hypoglycemia or anemia may cause palpitations.
Page | 5
Investigations not to be missed:
1. Please mention routine base line investigations like CBC, RFT, LFT
2. Thyroid function test
3. May need to investigate pheochromocytoma if there is any hint in the history
4. Chest X Ray
5. Resting and Stress ECG.
6. 24 hour Holter monitoring but it is more helpful in frequent arrythmias
7. 7 day cardiac monitoring may be needed if arrythmias are less frequent.
8. Echo
9. Cardiac doppler.
10. Cardiac MRI
11. Electrophysiological studies.
12. May need genetic testing.
Be very careful in cardiac catherization as it may provoke VT itself.
Management plan:
1. In general measures avoid the triggers like any medicine

2. Avoid strenuous exercise
3. Normalize tea coffee intake
4. Depending upon our final diagnosis we may have to teach our patient certain maneuvers like
Valsalva
5. And please do not forget cardiology referral.
6. If the patient is female in childbearing age advise her regarding the pregnancy because it may
worsen HOCM.
7. Medical treatment for HOCM may include beta blockers, calcium channel blockers, amiodarone
to control arrythmias, careful use of diuretics if the pressures are high ( diuretics may cause
hypotension which in turn may worsen HOCM ), septal myomectomy or radiofrequency
ablation. Pacing and ICD may be used
8. For Long QT syndrome, we may use beta blockers. ICD implantation or Cardiothoracic
sympathectomy may be used. In acute acquired Long QTs we may use magnesium sulfate or IV
isoprenaline which is very unlikely to appear in exam scenario.
9. Brugada syndrome usually does not respond to beta blockers and ICD is often needed for their
management.
10. In case of AF we may go for rhythm control with class 1c antiarrhythmic drugs (
Flecainide/Propafenone usually preferred in patients having no underlying heart disease ) or
class 3 antiarrhythmic drugs ( Ibutilide/Dofetilide usually used for patients with underlying
structural heart disease ), cardiac catheter ablation technique for left atrial appendicular
occlusion. Rhythm control is preferred in young patients. While we may go for rate control in

older patient and those who have permanent symptomatic arrhythmias with beta blockers or
calcium channel blockers. Pacemaker may be needed. We may need to anticoagulate the
patient after doing CHADVASC of HASBLED Scores if needed.
Page | 6 Common questions to be expected from Examiner
1. Mode of inheritance of HOCM

2. Different arrhythmias associated with HOCM.
3. Most common Echo findings in HOCM
4. Criteria for ICD insertion
5. CHADVASC or HASBLED Score
6. Driving regulations.
Please remember that Long QT Syndrome may be congenital like Jerrell Lange Nielson Syndrome
(Autosomal recessive, Long QT Plus hearing loss) 0r Romano Ward Syndrome (Autosomal dominant) but
these are extremely rare. The most common Long QT syndrome in exams is acquired usually due to
drugs. If such is the case, please stop that drug and refer the patient to the respective specialty for
change in his medicine. Corrected QT interval of more than 470 msec (in some books 500 msec) is
considered as Long QT.
Brugada syndrome is a rare syndrome having right bundle bruch block with ST elevation in Leads V1-V3
in ECG with no evidence of structural cardiac disease.

CASE 2-2
You are a ST3 in Acute medical clinic.
You have been asked to see Mrs. Julia, 34 Years of age who is from Nigeria originally.
Page | 7 She has presented to the clinic with complaint of shortness of breath which is getting worse
day by day.
She is also obese.
Her vitals are:
B.P: 110/70 mmHg
Pulse: 80 beats per minute
Respiratory rate: 20 breaths per minute
SpO2: 92% at room air
Please take history and address her concerns.
Be careful not to miss

History of presenting complaint:
Along with routine questions of onset, duration, progression, aggravating and relieving factors,
do ask about
1. Exercise tolerance: whenever there is dyspnea in exam please ask about exercise
tolerance by asking
• How much can you walk now without getting breathless
• How much could you walk before without getting breathless
• Any breathlessness at rest
• Breathless while doing normal activities or changing clothes.
This will help you in quantifying the dyspnea according to the NYHA classification.
Associated symptoms
In case of Shortness of breath ask detailed questions of cardiovascular and respiratory

symptoms together. These both systems are twins and most of the times should be asked
together in station 2
The possible questions of symptoms may include
• Cardiovascular system

1. Any racing of your heart.

2. Any chest pain, if yes then when and where you get it, do complete analysis of pain in
that case.
3. Do you use any extra pillows to sleep?
Page | 8
4. Any swelling around your eyes and ankles
5. Any cough
6. Do you ever feel dizzy?
• Respiratory system:
1. Any cough
2. Any phlegm if yes then specify its amount, color, thick or thin, order and any blood
streaks
3. Ask about any difficulty in breathing
4. Any chest tightness or chest pain
5. Any chest pain while taking a deep breath in
6. Any whistling sounds from your chest
7. Did you ever cough up blood?
8. Any effect of weather change on your breath
9. If cough, then any effect of day or night timings.
Whenever you get clue of any other history of past medical condition in the stem like asthma,
hypertension, diabetes, take a break and explore it at this stage. Like in this case it is mentioned
that patient is obese so take a break and ask
• How much was your weight before?

• How much you weigh now
• So, you got ??? kg in this much time
• Diet
• Physical activity
Be very polite in asking these issues.
Please remember that whenever you get an obese patient especially old one never forget about
ischemic heart disease later on in the past medical history.
systemic review:
Do a quick systemic review. Following questions may suffice
1. Any headache or vision problem

2. Any joint pains

3. Any preference for cold or hot weather
4. Any bowel issues
5. Any problem with water works
Page | 9
6. Any numbness, tingling or weakness anywhere
By this time, hopefully, you will have a clear idea that this lady is giving history of
• Dyspnea with gradual onset and getting worse day by day. It is aggravated by exertion
and eases out in rest
• Orthopnea
• Paroxysmal nocturnal dyspnea
• May be swelling around her ankles or eyes.
• She may tell you that all this started in the last month of her pregnancy and is worsening
even after delivering the baby. She may not tell you at this stage if she is an experience
surrogate and will keep you waiting for this information till you reach the gyn & obs
history later in your scheme.
Get alarmed that this lady is trying to hint you towards heart failure and whenever you get
heart failure in a lady of childbearing age do not miss
1. Peripartum Cardiomyopathy
2. Congenital heart problems e,g mitral stenosis
3. Primary pulmonary hypertension
4. Pre-eclampsia: it may complicate and give these symptoms.
Now proceed further
Ask General Questions:
Heart failure can result in a multitude of general symptoms so ask about
• High body temperature

• Tiredness (some examiners consider fatigue as a jargon so better use word Tiredness)
• Rash
• Mood changes
• Loss of weight
• Excessive sweating
• Lumps and bumps anywhere
• Sleep issues

Past Medical History

Ask specifically about any history of hypertension or any history of hypertension in pregnancy
Allergies
Page | 10 Medicine history
Be aware that certain medicines like tocolytics when used during labor can cause peripartum
cardiomyopathy.
Hospitalization
Surgeries
Significant Family History
Specifically ask about any pregnancy issues in family
Gyn & Obs History
Ask about
• Monthly periods (do not ask about too much detail like days of bleeding, amount of
blood, tampons used etc. if it is not relevant to the case). Do not use the word
menstruation or menses please
• Birth control pills (avoid using contraceptive pills as it might be considered as a jargon by
some examiners)
• Pregnancy. If the surrogate has not told you before then this is the time she will tell you
that she has delivered a baby some days ago and her problem started in the last month
of pregnancy or in the 6 month period after deliver. Ask if the last pregnancy was
uneventful or not, ask the mode of delivery of the baby.
At this stage do not forget to ask about baby that is he/she fine.
Ask about breast feeding and mobility after delivery (long immobility is generally not
recommended after delivery now a days)
Travel History
Social History
Ask about
• Smoking if yes advise to quit in a polite way
• Alcohol if using more than limits, do CAGE questionnaire and advise to reduce. Offer
help in smoking and alcohol not being judgmental
• driving

• You may ask history of any recreational drugs or party drugs if appropriate but be
careful it is a very sensitive issue and your voice and word selection should be
auspicious for that.
• Her job
Page | 11 • Effect on her job and daily activities. in this case ask about help required to take care of
baby.
• Support at home or at job. Is anyone there to take care of her or not. If she is giving care
to anyone else how she is managing that with her own job and daily activities
• If needed financial support
• Offer help in the form of cessation clinics, occupational health department, occupational
health physician and social support as appropriate.
Summarize
Always tell the patient to add on any missing information or any thing he thinks is important to
him and you have missed
Explain and address concerns
Always tell the patient that you will examine him now, will run some tests to reach the final
diagnosis but listening to the history the most likely cause is XXYYZZ
Most likely you have a condition called as peri partum cardiomyopathy. There can be different
causes for it. What happens is that the heart muscle become loose and flabby and their ability
to pump blood is reduced which may result in different problems you are facing.
Tell her not to get pregnant till we do further Echo of her heart to investigate her heart status
and referral to heart specialist and woman health specialist. Tell her to always seek medical
advice before planning next pregnancy.
Important Differentials not to be missed
Considering our patient who is having symptoms of Shortness of breath starting in the last month of
pregnancy and worsening later you must keep in mind the following differentials
1. Peripartum cardiomyopathy
It is diagnosis of exclusion and the symptoms present in last month of pregnancy or with 6 months of
delivery
2. Congenital valvular heart disease like Mitral stenosis
Mitral stenosis may present for the first time in pregnancy as the hemodynamic stresses during the
pregnancy make the heart more vulnerable. However, the final diagnosis will come after investigations
3. Primary pulmonary hypertension

Final diagnosis will come after investigation
4. Pulmonary embolism
In exam scenario, most likely it will be acute. Unlikely to present with such a long history of dyspnea. It
may be associated with history of pleuritic chest pain and tachycardia. Pregnancy, no doubt is associated
Page | 12 with increased risk of thromboembolic phenomena. Investigations will help to rule out it further
5. Pulmonary edema
Patients of pulmonary edema are usually sicker than our patient. Pregnancy may be associated with
cardiogenic and non-cardiogenic pulmonary edema. As pregnancy is a state of low oncotic pressure so
when there are stressors, they can cause pulmonary edema even with normal cardiac filling pressure.
The common stressors could be infections or acute kidney injury, but these will be ruled out by asking
general questions and doing a systemic inquiry. Investigations will help to rule out it further.
6. Preeclampsia
It can get complicated and may result into these symptoms. Pre-eclampsia tends to settle down after
the delivery.
7. Alcoholic cardiomyopathy
If the patient gives history of extensive Alcohol consumption during the history while she is pregnant, it
can be good differential otherwise don’t mention it.
Investigations not to be missed
Please try to list a sensible list of investigations which may include
1. CBC
May show Anemia which is not an uncommon cause of shortness of breath in pregnancy specially in the
developing countries like Pakistan, India. It may show megaloblastic anemia if Alcohol overuse is
suspected.
2. LFT
May show abnormalities in Alcohol overuse and HELP syndrome as a complication of preeclampsia.
3. RFT
Creatinine and urea, proteinuria may be checked for to rule out pre-eclampsia
4. Cardiac markers
Creatinine phosphokinase may be elevated after normal delivery. Persistently elevated Troponin T levels
after diagnosis are related to persistent left ventricular dysfunction. Elevated BNP levels may be seen in
pre-eclampsia and peripartum cardiomyopathy.
5. ABGs may show respiratory alkalosis because patient has shortness of breath

6. D Dimers and FDP may be nonspecific near to delivery
7. ECG
Page | 13
May show nonspecific changes like sinus tachycardia, atrial fibrillation, low voltage with left ventricular
hypertrophy and nonspecific ST segment and T wave changes.it may show typical pattern for pulmonary
embolism like S1Q3T3 pattern. Please try to learn some normal ECG changes in pregnancy
8. X Ray chest
It may show increased size of the heart and signs for pulmonary edema and pulmonary hypertension
9. Echocardiography
It will show increase heart size and other valve abnormalities. Cardiac catherization may be needed to
rule out pulmonary hypertension. Meanwhile higher filling pressures are associated with peri partum
cardiomyopathy and lower filling pressures are seen in pre-eclampsia.
10. Cardiac MRI
Management plan
Considering the most likely diagnosis of heart failure in this case of peri partum cardiomyopathy
following management can be discussed with examiner
1. Admission in the hospital

2. Reduced sodium intake
3. Strict bed rest is not usually recommended after delivery now a days because of the increased
risk of thromboembolism, so patient should be appropriately mobile.
4. The treatment of heart failure is same in both the pregnant and non-pregnant patients. We may
give beta blockers e.g. carvedilol, metoprolol and if the patient has arrhythmias, we may give
sotalol. Loop diuretics may be needed. Digoxin can be added if there is abnormal ejection
fraction. For after load reduction we may use nitrates and hydralazine. ACE and ARBs are
contraindicated in pregnancy but after delivery they can be used.
5. If ejection fraction is less than 35 %, we may need to anticoagulate the patient
6. If there is increased risk of tachyarrhythmias ICD insertion may be needed
7. Cardiac transplant may be needed.
8. Do not forget referral to cardiologist and gynecologist for further pregnancy.
SOME POINTS TO REMEMBER ABOUT PERIPARTUM CARDIOMYOPATHY
1. It is the most common type of cardiomyopathy during pregnancy

2. It is defined as idiopathic cardiomyopathy that presents with heart failure secondary to left
ventricular systolic dysfunction towards the end of pregnancy (last month of pregnancy) or the
months (within 6 months) after the delivery in the absence of any other cause of heart failure
3. Risk factors: age above 30, obesity, multiparity, pre-eclampsia, twin pregnancies, black race,
smoking, malnourished e.g. lacking selenium in diet and use of tocolytics during labor

4. Pathophysiology: somehow increased amount of prolactin and decreased amount of VEGF

during the end of pregnancy play role in development of peripartum cardiomyopathy. Genetics
have some role too
5. Poor prognostic factors: initial LVEF below 30 %, LV dilatation with left ventricular end diastolic
diameter greater than 60 mmHg, elevated BNP at the time of presentation and black race.
Page | 14 6. Since most of the symptoms like dyspnea, swelling around ankles etc. are common in pregnancy
so patient usually ignores her real symptoms and it is said that late diagnosis is a norm for
peripartum cardiomyopathy.
7. About 60 % patients recover from this condition however patient should be counselled that it
can be serious, and she may need admission in ICU.
8. For future pregnancies if there is persistent left ventricular dysfunction (LVEF < 50 % ) WHO
classifies it as mWHO level 4 and is an absolute contraindication for pregnancy however prior
peripartum cardiomyopathy with normal LVEF is categorized as mWHO class 3 , defined as
moderate maternal risk. The lady may go for pregnancy with close monthly surveillance and
planned delivery in specialized centers. However please remember that for exam purpose we
will tell the patient as mentioned above.
9. Use of corticosteroids may also be associated with peri partum cardiomyopathy.
10. If hemodynamically stable the mother may go for Spontaneous vaginal delivery other otherwise
C Section should be planned under specialized care.
11. Peri partum cardiomyopathy tends to worsen after 2 to 3 days of delivery.
12. Breast feeding is generally not recommended after delivery because it causes increased
metabolic stress to the mother and it may result in increased prolactin levels which may worsen
the condition
13. Complications of peri partum cardiomyopathy for mother can be premature delivery,
threatened abortions, arrythmias, thromboembolism and progressive cardiac failure while for
fetus it may result in fetal distress and growth retardation.
14. Role of Bromocriptine is being studied in prevention of further peri partum cardiomyopathies in
future pregnancy

STATION 4-1
Page | 15
CASE; 1
You are a ST3 in Gastroenterology clinic.

You have been asked by your consultant to talk to Mr. John Smith, 45 years of
age.
Mr. Smith has been suffering from heart burn from last one year. He took some
herbal medicine and certain household remedies which did not help him. His GP
prescribed him with Proton Pump Inhibitors which did not gave him significant
symptomatic relief.
Upon referral from GP an Endoscopy was suggested which show low grade
Barrett’s Esophagus.
Mr. Smith is unaware of the diagnosis.
Your task is to explain the diagnosis to him, discuss with him the future
management plan and address any concerns he may have.

Always remember:
To:
Page | 16 1. Greet the patient and introduce yourself.
2. Confirm his identity by asking his name and age.
3. Set an agenda for discussion.
4. Build a repute by asking how he is feeling today. It will be a good time to show
sympathy and empathy here. At this stage ensure him that you understand how
much he has been suffering and he has been passing through a tough time, also
tell him that you all (whole treating team) are here to help him.
5. Check his understanding by asking does he know anything about his condition
and if yes ask him to briefly tell you.
6. Now pace the discussion gradually, repeatedly check that is he following you by
asking him are you with me or are you getting me. Also show sympathy and
empathy during the discussion.
Keep in mind the following points
1. Explain Barrett,s Esophagus: Normally there is acid in food bag ( Stomach might be
considered a jargon by some examiners so be careful ) and this acid can not enter the
food pipe which transports food from mouth to the food bag because there is a tight
junction between two of them. Sometimes due to some reasons this junction loosens
and the acid flows back to the food pipe. When this happens for a long time the inner
lining of the lower part of the food pipe becomes sore and changes its nature and
becomes more like the lining of food bag which is known as Barrett,s Esophagus.
You may tell him here, very tactfully that this may progress to the cancer of the food
pipe looking at his reaction or you may wait a bit to pace on the discussion further.but
most likely you will have to tell him yourself as this might be the hidden agenda in the
scenario.
2. Common concerns asked by the patient and their probable answers
• Is it an infection: no it is not any infection , it is an irritation or soreness of the lower

part of the food pipe
• Is it serious: tell him that this may progress to the cancer however the chances are low
but there is a definite risk. Tell him that it is not a cancer itself. By the way CANCER is
not a jargon.
• How can I come to know it will progress or not: tell him we will keep him under
observation and we will do repeated Camera Test ( endoscopy ) for him. He may say

that the last endoscopy was too much painful and he can,t imagine another one , then
please ensure him that you take care that in future he is given enough pain relief , if
time allows briefly explain again about endoscopy, its complications and tell him that he
may have to sign a consent form it
Page | 17 • I have already undergone a camera test it was too painful .is there any other option or
can you do X ray or CT scan etc: tell him that for proper follow up and to better know
about his condition we need to view his food pipe lining and we may take small snips
from it and see them under microscope , this can,t be done by X ray or CT scan.
Furthermore X Ray and CT scan will put him under unnecessary exposure to radiations.
It could be difficult for him to know that he has to undergo repeated endoscopies, so at this
stage show sympathy and empathy.
• What might have caused it.

• He may want to know about any treatment options.
POINTS NOT TO BE MISSED DURING DISCUSSION

During the discussion please don,t miss to tell these points:
1. Explain the Barrett,s esophagus.
2. Focus about the uncertainty of the condition. It is highly associated with cancer but we
can,t predict that he will get cancer or not.
3. Follow up endoscopy.
4. General measures to avoid GERD which may further worsen his condition e,g meals at
time, taking dinner early, walk after dinner, sleep atleast 2 hours after dinner, raise the
head side of the bed,
5. Diet issue: he should avoid fast food, fried food, chocolates, coffee, beverages.
6. He should not take pain killers without consulting his GP as they can worsen his
condition.
7. Weight control as it is associated with central obesity.
8. Social history: most likely he will be a shift worker and will be having erratic eating
habits. You have to address it properly, not being judgmental. Do consider smoking
cessation and reduction in alcohol intake ( if patient is using )at this stage.
9. Referrals: a referral to dietitian may be expected to guide him about his eating habits.
ETHICAL PRINCIPLES AND HOW THEY CAN BE APPLIED

1. Autonomy : patient is competent and he has the autonomy which means that he has
the right to know every detail about his condition and then he can himself decide which
one he opts or rejects.

2. Beneficence : every thing which we do for the patient benefit comes under this
heading.in this scenario the beneficence will involve
• Prescription of PPIs by his GP
• Endoscopy done by consultant.
Page | 18 • Future endoscopies.
• Addressing smoking and alcohol
• Referral to dietitian.
3. Non maleficence: it means do not do harm to the patient so everything which we do to
prevent him from harm comes under this heading. In this scenario non maleficence may
be
• Avoiding unnecessary investigations like x rays and CT.
• Avoiding complications of the last and the future endoscopies.
• Prescribing exact doses of PPIs to prevent him from the side effects of
PPIs
4. Justice: it means he has the right to be treated irrespective of his age, sex, ethnicity,
religious and political beliefs.
LEGAL ISSUES IN THS SCENARIO

1. The consent for the previous endoscopy
2. The consents for the future endoscopies may come under this heading.
FEWS POINTS WHICH MIGHT HELP DURING THE DISCUSSION WITH THE PATIENT AND THE
EXAMINER
1. Risk factors for Barrett,s Esophagus : White race, old age, central obesity, family history
of barrett,s esophagus. 15 percent of the people having chronic GERD may have it, while
it may occur without underlying reflex symptoms. It may be associated with hiatus
hernia.
2. There is 0.5 to 1 % increased risk of esophageal adenocarcinoma in patients of Barret,s
and the annual incidence of adenocarcinoma in these patients is 0.2 to 0.5 %.
3. Diagnosed by endoscopy and biopsy
4. We can give long term PPIs for symptom relief of GERD. PPIs do not regress Barrett,s
Esophagus but they reduce the risk of cancer in these patients.
5. For patients of Barrett,s Esophagus in which dysplasia is lacking ,we do endoscopy
annually, if two consecutive endoscopies show no disease progression we may go for
future endoscopy after 3 years.
6. Patients with persistent low-grade dysplasia should undergo surveillance endoscopy
every 6 months, if no disease progression is noted in 2 consecutive endoscopies the

surveillance period may be extended to 1 yearly follow up. Some studies have shown
that Radiofrequency ablation in low grade dysplasia may be helpful and may reduce the
risk of development of adenomacarcinoma. Since this may become a legal issue later if
he develops cancer, it will be wiser at this stage to discuss with the patient about RFA
Page | 19
with explanation of all pros and cons. RFA may cause chest discomfort, esophageal
strictures, and bleeding.
7. For patients with high grade dysplasia, considering patient’s individual health status we
may go for radiofrequency ablation, surgical resection etc. but surgical procedures of
esophageal cancer are associated with high morbidity and mortality.

STATION 4-2
SCENARIO:
You are SHO in nephrology clinic

Page | 20
Mr. Adams , 67 years of age has been in your care from the last 3 years. He was
diagnosed as End Stage Renal failure and is undergoing hemodialysis for three
years. He is currently visiting hospital twice a week. He is known hypertensive
and diabetic and is undergoing regular follow up for his medical condition to the
medical clinics. Recently his diabetes and hypertension has worsened. On last
visit your consultant suspected that he might be having ischemic heart disease
and suggested a cardiology opinion.
Today he has another dialysis session and after the session he asked the nurse
that he wants to talk to the duty doctor. Nurse told you that Mr. Adams seems
depressed and is waiting for you in the room.
Your task is to talk with Mr. Adams and address his concerns.
You are not supposed to take history and examine the patient.

Always remember:
To:
1. Greet the patient and introduce yourself.
Page | 21 2. Confirm his identity by asking his name and age.
3. Set an agenda for discussion.
4. Build a repute by asking how he is feeling today. It will be a good time to show sympathy
and empathy here. At this stage ensure him that you understand how much he has been
suffering and he has been passing through a tough time, also tell him that you all (whole
treating team) are here to help him.
5. In this scenario you may have to ask him why he wanted to see you since it is very
clearly written in the stem that he requested for the meeting.
6. In between step 4 and 5 try to use information given and ask him how diabetes and
hypertension has been, tell him that you are seriously concerned to know worsening of
his diabetes and your consultant suggested a cardiology opinion in the last visit. Ask him
how the cardiology visit went for him. All this will help you in building a close relation
with hm.
7. Check his understanding by asking does he has any idea what might be the happening
with his health and if yes ask him to briefly tell you.
8. Now pace the discussion gradually, repeatedly checking that is he following you by
asking him are you with me or are you getting me. Also show sympathy and empathy
during the discussion.
Keep in mind the following points
1. Explain End Stage Renal Failure: Tell him that kidneys are very important body organs
and they are responsible for cleansing the blood from various harmful materials. So
normally our kidneys function 24/7/365 to clean or filter the blood from these harmful
materials. Sometimes due to some reasons e,g. high blood sugars , high blood pressures
certain bug infection etc , the kidney are damaged and cannot function properly. This
damage may be permanent in some cases like unfortunately in his case. So when this
happens kidneys can not filter the harmful materials from the blood and they
accumulate and thus harm the body.
2. Explain Hemodialysis: Tell him that when the kidneys can not function properly, we
must do dialysis. This is a process in which the human body is connected to a machine
which acts like kidneys and then whole blood in the body is made to pass through this
machine which filters it from the harmful materials.
3. Remember: never assume that this patient is an old patient so he might have been
counselled for end stage renal disease and hemodialysis. Always touch these topics even
he knows them in advance. However, to avoid time you can shorten them. But these are
very important aspects of clinical communication. Please do not indulge in more details
of dialysis as it is not a scenario of explanation of hemodialysis.
Common concerns asked by the patient and their probable answers

Most likely this will be the case of refusal of treatment. Surrogate will insist that he is in great
trouble and he is extremely uncomfortable in visiting hospital for dialysis and follow ups for
other chronic conditions. He may ask you the following concerns
Page | 22
1. I am fed up and I do not want to have dialysis: probe what are the reasons. Ask about
the behavior of hospital staff I,e. does he has any complain from them, if yes ensure
him that you will discuss with ward manager and arrange new staff for him. Ask about
transport problems i.e is he having any problems visiting hospital , in this case offer him
help from social support. Most likely he will not accept any help and will keep on
insisting that he is fed up of visiting hospitals and this is ruining his life , he may say he is
not interested in this sort of handicapped life. Do not panic, respect his wishes but
again tell him in a very polite way that if he will not go for dialysis this can be dangerous
for his health and he may even die. Most likely he will say that his kidneys are damaged
so he is going to die later or sooner. Show sympathy at this stage. Offer meeting with
consultant again. At this stage offer him dialysis at home ( peritoneal dialysis ) and try
to coerce him for this.
2. If I refuse dialysis, will you still help me: ensure him that yes even he refuses
treatment he is still your patient and you will help him by all possible means. This may
be discussed as an ethical issue later.
3. What other treatment options, can you offer me if I refuse hemodialysis: tell him
about peritoneal dialysis and renal transplant team.
• Peritoneal dialysis: It is done through your tummy.it uses the lining of your
tummy to clean your blood. Surgeon will put a small tube in your tummy a
couple of weeks before starting ( 3 to 4 )and it is usually put below the belly
button.it is usually inserted some time before the start of dialysis so that the
wound can heal, it is not a major operation but can have complications. And we
will provide you with bags containing special type of fluid. The advantage of
peritoneal dialysis is that you can do it at home. So when you are ready for this
you will attach the bag to the tube and the fluid will move into your tummy. it
will circulate around the lining of your tummy and will remove the waste
products. At this stage you can remove that bag and put a clamp on the other
end of tube. Now you can do your daily activities. after a couple of hours (
4to6)you can tie the bag again with the tube, now the fluid will drain back in the
bag. You can waste the bag. You may have to repeat this process four times a
day. Some people feel perfectly alright when this fluid is inside their tummy
however some may feel bloating and their tummy may feel enlarged.
Advantages of peritoneal dialysis are that you can do it at home, you do not
need to visit hospital again and again , you can do your daily activities and with
some arrangement ( with the help of a small machine) you can even sleep while
dialysis is going on. Disadvantages are this is not as effective as hemodialysis. It
involves the risk of infection of the area of the tube entry, tube may get
dislodged. The content of your tummy may protrude out of the site of tube
insertion ( hernia) though the chances are very low.and you may gain a bit of
weight. Tell him he must take care of insertion site and must keep it clean and
Page | 23
dry. And whenever he feels any redness over there, he immediately has to
notify his GP. As for all patients of renal failure suggest him to be careful about
his diet and use of medication. You can refer to dietitian to get an idea about
low calories, low sodium and low potassium diet if he has not going there
already, tell him to take extra care while travelling because he may need extra
bags of fluid or may have to inform his transport company. Tell him that he
should do it in a neat clean room and tell him that one of your nurses will teach
him how to do it until he is fully trained to do it himself at home, you can also
tell that if he wants you can also train some of his family members in case he
needs help. Tell him that though this does not demand frequent visits , he may
have to visit the hospital once a month for some investigations to check the
functioning of dialysis. Tell him about the red flags of peritonitis like fever,
redness at the side, pain in tummy and till him to report immediately if any one
of them develops. In the end tell him that peritoneal dialysis gradually loses its
efficacy but for that you will follow him up regularly. Tell him he will have to sign
a consent for tube insertion. Please tell him that it will help him in improving his
quality of life but it is not a cure for his nonfunctioning kidneys in a very decent
way.
• Renal transplant team: though this patient seems unsuitable for transplantation
we will stick to our limitations and will tell him that we will refer you to the renal
transplant team which will discuss further options with you. he may resist for
immediate renal transplant, but we will not cross our limits.
POINTS NOT TO BE MISSED DURING DISCUSSION
During the discussion please don,t miss to tell these points:
1. Explain end stage renal disease briefly
2. Explain hemodialysis briefly
3. Probe why he is not willing to come to hospital and offer help to coerce him. Involve
consultant.
4. Explain peritoneal dialysis with complications and follow up care
5. Refer to the renal transplant team
6. Probe about medications specially pain relief medications and diet suitable for renal
patients. Guide if he is not following the recommendations.
7. Take a detailed social history , how is he coping with the disease, how he visits to the
hospital, how he manages is daily activities, financial issues
8. Address smoking and alcohol. And if appropriate offer reduction

9. Referrals: a referral to dietitian may be expected to guide him about his eating habits.
Referral to renal transplant team must not be forgotten.
10. Give him leaflets and brochures about peritoneal dialysis, diet in kidney disease and
renal transplant etc
Page | 24 ETHICAL PRINCIPLES AND HOW THEY CAN BE APPLIED
1. Autonomy : patient is competent and he has the autonomy which means that he has
the right to know every detail about his condition and then he can himself decide which
one he opts or rejects. He still has autonomy even if his decision seems stupid or life
threatening to other. In this case he has the right to refuse hemodialysis if he does not
want . we will respect is decision.
2. Beneficence : everything which we do for the patient benefit comes under this
heading.in this scenario the beneficence will involve
• Hemodialysis for his poor kidney function
• Follow up for DM and HTN
• Referral to cardiology
• Offering peritoneal dialysis
• Offer meeting with renal transplant team
• Follow up after start of peritoneal dialysis
3. Non maleficence: it means do not do harm to the patient so everything which we do to
prevent him from harm comes under this heading. In this scenario non maleficence may
be
• Preventing from complications of hemodialysis like fluid abnormalities or
electrolyte imbalance
• Prevention of complications of catheter insertion
• In this case if the renal team decides against the transplant and the insists for
transplant, we will refuse as per his non maleficence,
4. Justice: it means he has the right to be treated irrespective of his age, sex, ethnicity,
religious and political beliefs. In this case if the patient refuses hemodialysis we will still
offer him peritoneal dialysis and further management plan as per justice.
LEGAL ISSUES IN THS SCENARIO
1. Patient autonomy is the legal issue in this case
2. Consent for hemodialysis
3. Consent for catheter insertion for peritoneal dialysis
4. If needed consent for renal transplant.

STATION 5--1
SCENARIO
You are a SHO in Rheumatology clinic.
Page | 25
You Have been asked to see Mr. Albert, 50 years of age. He is Having difficulty in combing his
hairs from the last 6 months.
He is vitally stable at the moment.
Please take a brief history, do focused examination and address any concerns he may have.

IMPORTANT POINTS IN HISTORY OF PRESENTING COMPLAINTS:

1. Introduction:
Keep your introduction short in station 5 , it will save your time. You can say Hello Mr. ABC I
Page | 26 am Dr. XYZ and I have been asked to talk to you and examine you, is it fine with you. Patient
will say yes then ask the next question: please let me know what brings you to the hospital.
Show sympathy and empathy by saying that you are sorry for his suffering and you will try
your best to help him out.
2. Specify any vague symptom by asking what exactly he means by that.
In this case you should ask him what he means exactly by difficulty in combing. Most probably
he will say he has pain in his arms and shoulders due to which he has difficulty in combing. If so
then:
3. Ask about stiffness
Most likely he will give history of stiffness, more than thirty minutes in the morning.
4. Now ask about pain questions in detail:
• Location, he will most likely say that he has pain in his arms and shoulders. Ask
about unilateral or on both sides, if on both sides ask about equal on both sides or
not.
• Onset sudden or gradual, he will most probably say that his pain was sudden in
onset.
• Quality give examples for quality by asking how the pain sounds to him like burning,
dull ache, gripping etc. it will be most likely dull ache.
• Intensity of pain by asking him to grade the pain from 0 to 10, 0 being no pain at all
and 10 being the severe pain he ever had.
• Radiation, his pain may be radiating towards neck.
• Aggravating factors: most likely he will say that his pain worsens by inactivity known
as Gel Phenomenon.
• Relieving factors: patient may say that his pain is relieved by doing some activity.
5. Ask about any pain anywhere else: he may have pain in his hips and lower back.
6. Ask him about any pain, stiffness, swelling, deformity in any other joints like hands.
7. Specifically ask him about pain around temples and loss of vision.
In station 5 after doing history of presenting complaints ask about past medical history. It can
give you important clues in the start and will save your time.
ASK ABOUT YOUR DIFFRENTIALS:
In station 5, please ask one or two specific symptoms to rule out your differentials. It will save
your time and will help you to show examiners that you are trying to rule out your differentials.

Considering this 50 year old man who has pain and stiffness in his shoulders with stiffness
lasting more than 30 minutes in the morning you might think about the following differentials
• Polymyalgia rheumatica
• Polymyositis
Page | 27 • Dermatomyositis
• Fibromyalgia
• Cervical spondylosis
• myopathy
• Frozen shoulder (frozen shoulder is usually unilateral while polymyalgia is usually
bilateral )
Keeping in view the above-mentioned differentials you may ask the following questions quickly
1. Ask about the general symptoms like fever, fatigue, loss of weight, loss of appetite,
lumps and bumps, rash,sweating and issues in sleep. Polymyalgia Rheumatica is usually
associated with some of the general symptoms. By asking these questions you will also
rule out polymyositis and dermatomyositis, the later may be associated with
malignancy.
2. Ask specifically about weakness in shoulders, this will help you in differentiating
polymyalgia rheumatica from polymyositis and dermatomyositis. The former is
associated more with pain and stiffness and the later is more commonly associated with
weakness.
3. Ask about any rash specially around knuckles, it will rule out dermatomyositis (
Gottron,s Papules ).
4. Ask about tenderness or body aches anywhere else to rule out fibromyalgia.
5. Ask about tingling sensations in arms and neck which will rule out cervical spondylosis.
6. Frozen shoulder is usually unliteral but it can be bilateral
7. Myopathy is usually not associated with pain or stiffness.
8. Sometimes Polymyalgia may be associated with polyarthralgia of hands, in that case
rheumatoid arthritis can be discussed as one of the differentials.
COMPLETE YOUR HISTORY
1. Ask about family history
2. Ask about medicine or drug history
3. Ask about smoking if he smokes advise to stop smoking
4. Ask about Alcohol if excessive advice to reduce
5. Ask about driving if relevant
6. Ask about job
7. Ask about the impact of his disease on his daily life and job, if affected show sympathy
and offer help involve occupational health physician, social worker or occupation health
therapist as appropriate.

EXAMINATION:
Do not miss to
Page | 28 1. Complete general physical examination
2. Look at the knuckles, neck.
3. Feel tenderness in shoulder after taking proper permission from the patient.
4. Check power, in polymyalgia rheumatica there is no weakness. Some books mention
that the patient may feel or give history of subjective weakness as he is not able to use
his arms properly and thinks his arms are weak but when examined careful it will
become clear that patient is not weak and is unable to use his arms due to pain , not
due to weakness of his muscles.
5. Feel temples for tenderness.
6. Quickly check visual acuity. Steps 4 and 5 to rule out GCA.
7. Check active and passive movements of shoulders: in polymyalgia rheumatica active
range of movements is reduced while in frozen shoulder both active and passive range
of movement are reduced.
ASK CONCENS AND EXPLAIN THE DISEASE
1. What I have doc ?
Most likely you have a condition called as polymyalgia rheumatica. It is soreness of the tissue
surrounding the joints and lining the inner surface of joints ( polymyalgia rheumatica is not a
myositis, it is inflammation of the bursa and synovium that is the reason muscle enzymes are
normal in the Labs ) this can result in painful arms and shoulders. There is one concerning issue
which I want to discuss with you. Sometimes this condition can be associated with vision loss
and I will like to tell you that if you ever feel problem in your vision, immediately seek medical
advice.
Tell the patient that there is very good medicine available called as steroids, but he has to take
steroids for one year or so and we will add stomach and bone protection with them.
EXAMINER QUESTIONS :
INVESTIGATIONS :
1. CBC will show normochromic normcytic anemia.
2. Inflammatory markers e.g ESR , CRP which will be raised. Other markers of acute
inflammation like gamma glutamyl transferase and alkaline phosphatase may be raised.
3. Muscle enzymes which will be normal.
4. Baseline bone profile.

5. Blood glucose levels. Investigations no 4 and 5 will be needed before starting steroids.
6. If any suspicion of GCA then go for temporal artery biopsy.
7. Radiological investigations are USG and MRI. MRI is more specific investigation for
bursitis.
Page | 29
TREATMENT
Steroids are the treatment of choice. The starting dose is from 10-15 mg in a single dose in
morning. The dose may be adjusted according to the clinical response.
Polymyalgia rheumatica shows dramatic response to steroids and if there is no improvement in
patient condition the diagnosis should be reconsidered.
The dose can be tapered down once symptoms seem improving, however most of the patients
may need to take steroids for more than a year ( 12-18 months). Flare up of the disease may
occur while tapering down, in that condition addition of Methotrexate has shown reduction in
flare ups
Calcium, Vit D supplements and stomach protection should be added along with steroids.
Follow-up is with clinical response i,e improvement of symptoms and ESR.
And if in the scenario you are given a role in general medical clinic, please don’t forget to refer
the patient to joint doctor.

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paceUrPACES Dr Tanzeel Bukhari

A CONCEPTUAL GUIDE TO MRCP (UK) PACES EXAM.

Written and Edited by:

Email : drtanzeelbukhari@gmail.com Cell No: 00923346036496

Email : drtanzeelbukhari@gmail.com Cell No: 00923346036496

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Be careful not to miss

History of presenting complaint:

Page | 4 1. When was the last attack?

Associated symptoms and systemic review:

Specifically ask about

1. All cardiac symptoms.

1. Specifically ask about history of sudden death in the family

1. Current mood, anxiety and any stress at home or at job.

Important Differentials not be missed:

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Be very careful in cardiac catherization as it may provoke VT itself.

1. In general measures avoid the triggers like any medicine

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Page | 6 Common questions to be expected from Examiner

1. Mode of inheritance of HOCM

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Be careful not to miss

In case of Shortness of breath ask detailed questions of cardiovascular and respiratory

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1. Any racing of your heart.

• How much was your weight before?

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2. Any joint pains

• High body temperature

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Past Medical History

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Important Differentials not to be missed

2. Congenital valvular heart disease like Mitral stenosis

3. Primary pulmonary hypertension

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Final diagnosis will come after investigation

Investigations not to be missed

Please try to list a sensible list of investigations which may include

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6. D Dimers and FDP may be nonspecific near to delivery

10. Cardiac MRI

1. Admission in the hospital

SOME POINTS TO REMEMBER ABOUT PERIPARTUM CARDIOMYOPATHY

1. It is the most common type of cardiomyopathy during pregnancy

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4. Pathophysiology: somehow increased amount of prolactin and decreased amount of VEGF

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You are a ST3 in Gastroenterology clinic.

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2. Common concerns asked by the patient and their probable answers

• Is it an infection: no it is not any infection , it is an irritation or soreness of the lower

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• What might have caused it.

POINTS NOT TO BE MISSED DURING DISCUSSION

ETHICAL PRINCIPLES AND HOW THEY CAN BE APPLIED

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LEGAL ISSUES IN THS SCENARIO

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You are SHO in nephrology clinic

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