Great Golden Guide

Great Golden Guide12Th
**‫ وقد رشدا‬،‫مروا على جدثي يا أرشد هللا من غاز‬

ّ ‫** حتى يقال اذا‬
‫ كري َم النظر‬،ِ‫سماع‬
َّ ‫شريف ال‬،،‫طا‬
َ ‫عفيف ال ُخ‬
َ ‫الطريق‬
ِ ‫ وكن في‬$$
َّ : ‫يقولون‬،،،‫وكن رجالً إن أتوا بعده‬
$$ ‫مر وهذا األثر‬
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Guidance To PACES Success[GPS] .. By Dr. Ahmed Maher Eliwa
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The Great Golden Guide
why this specific name???
As we know ,,there are many & many sources for PACES
ALL of them are great & so helpful
Also there are many & different points of veiws regarding:
how to prepare??
how to study???
how to examin???
BUT،،،
But we need the source & the advice that paint to us the right , honest
& the nearest ROAD
At the same time we need the SHORTEST one
So ,, we give you the ( GPS ) & THE ( GGG ) The Great Golden Guide
in your hand in order to shorten your ROAD & JOURNEY to PASS PACES
PLEASE ,,read it carefully
In particular befor your FINAL REVISION
Also you can Browse it whilst you are preparing for PACES
Best wishes for ALL
good luck
Just Pray 4 me
**Alkhateeb Gaballa**
**BEBO BEBO**
Important links for PACES 👆🏻
ALL MRCP PACES MATERIALS
https://drive.google.com/…/fol…/0B1QBk81HeIymalk0cnhRYjNfMEU
Valuable & Precious MRCP PACES MATERIALS

https://www.mediafire.com/folder/2lda1a198d9ba/MRCP
Podcast and DoctorCast 38 audios

https://drive.google.com/…/fol…/0B51SmsqsUjjfZU9obHA2dWp4Zk0
**Paces**A channel contains almost all books, files and folders related to PACES.
https://telegram.me/paces
Pastest Paces Videos - By Ibrahim Elbialy
http://www.mediafire.com/download/x95c4789fg6ex32/Pastest_Paces.part01.exe
http://www.mediafire.com/download/1wal3phfu907019/Pastest_Paces.part02.rar
http://www.mediafire.com/download/9k9eljb6sa7bogt/Pastest_Paces.part03.rar
http://www.mediafire.com/download/ktcjp5g8trab953/Pastest_Paces.part04.rar
http://www.mediafire.com/download/4ro8b12z3teeby0/Pastest_Paces.part05.rar
http://www.mediafire.com/download/g4slap1il3c1dis/Pastest_Paces.part06.rar
http://www.mediafire.com/download/88v03vxbykdw1lr/Pastest_Paces.part07.rar
http://www.mediafire.com/download/4nvb3bd8cbfbe21/Pastest_Paces.part08.rar
http://www.mediafire.com/download/wpupt8y4bslzoh8/Pastest_Paces.part09.rar
Podcast and DoctorCast 38 audios
https://drive.google.com/folderview…
McLeod's clinical7osce
https://drive.google.com/…/0B51SmsqsUjjfS1NaQmxQaTUwT…/view…
Clinical skills OSCEs
https://drive.google.com/…/0B51SmsqsUjjfYzZVYlMtZWZFR…/view…
Osce at glance
https://drive.google.com/…/0B51SmsqsUjjfb3BZYWphU0ppc…/view…
Osce and clinical skills handbook
https://drive.google.com/…/0B51SmsqsUjjfX3REajhRLVNoU…/view…
PACES clinical exam vids
PACES Complete Pastest Videos
Complete Medical Masterclass pdf
HPIM 19th ed
Sure!
https://drive.google.com/…/0B51SmsqsUjjfZjBMRExGLS1oV…/view…
Kumar and Clark 9th Edition
https://drive.google.com/…/0B51SmsqsUjjfQlhoRENOTjBle…/view…
See these, 13 RCP recommended videos
McLeod's clinical examination vids
Nicholas_Talley clinical exam vids
Heart lung sounds
Gait abnormalities videos
PACES station 5 audios misc 684 mb
Physical exam pro.apk
https://drive.google.com/…/0B51SmsqsUjjfX215LWdTMjdMY…/view…
Clinical skills. Apk
https://drive.google.com/…/0B51SmsqsUjjfRmhoblcxdjlnN…/view…
Sanjay sharma book
https://drive.google.com/…/0B51SmsqsUjjfMGpoUGRhTlVXe…/view…
PACES miscellaneous exam videos
OST Gautam Mehta vol 1
https://drive.google.com/…/0B51SmsqsUjjfS2x1TmU3SFJsQ…/view…
MRCP Manual by Ali
https://drive.google.com/…/0B51SmsqsUjjfQlZlVkNlcDByY…/view…
Uptodate for offline use in mobile or desktop
The Team Work of GGG
Experience in Glasgow Golden Jubilee center
St 2 ::
Outside 22 yrs old female student with recurrent
abdominal pain her vital are normal ultrasound
done normal
inside i tell to myself (‫ ???? )شكلها متسهله‬i ask
about about DD that i consider like hereditary
angioedema and prophyria and FMF and
mesnetric vascular occlusion and i ask
specifically about facial swelling she told me
yes last 2 day and i ask about all precipitant like
pets change environment and cosmetic and
food and food allergy hay fever and pollen and
ask about stresses in family studying she was
so stressed and ask about insect pits and bee
sting very important and inhaling any fumes and
any part time job and it was shocking for me ??
that she was working as model in make up and
using different creams and i ask about oral
contraceptive pills she was taking and ask
about any medication nil she had surgery for
appendectomy to relief the pain and i ask her
what the comment of the surgeon on the
appendix did u analyze it the examiner was
laughing ???? as i know the case then ask
about family history she was adopted finally wat
ur concern she told me do i need to stop OCP i
tell i appreciate ur concern why ur minded by
ocp did u start it recently she told me one year i
tell her no need at all now and it not the reason
for that she told me so what the reason of my
tummy pain is idiopathic angioedema explain
this unknown decrease in protein that break
down the inflammatory substance leads it to
increase suddenly causing face swelling and
abdominal pain the treatment usually in the
hospital that why u should inform all people
around and keep adrenaline pen with u the
nurse with inform u how to use it is a life
threatening condition if not treated in time
should u continue my part time job
i tell we will do test to exclude that u have
allergy from such substance and we will refer
that to occupational health doctor and if u have
hypersenstivity he will reallocate u accordingly
timeeeeeeee
examiner questions
do u think u convince regarding her job ????
(‫)ده هيستورى مش مرار طافح‬
i try my best sir and i will refer her to allergy
clinic for dermal test to see it is releated or not
what if she is free i told she can
continue(????ya lamby)
tell me ur DD
idiopathic angiodema
allergic reaction
wat else ( marar tafa7) i tell prophyria he looks
happy ?? (abo shaklak)
then inx and ttt
the bell rang one examiner motivate me and
give me banana ?? i get 20/20
St3::
outside eating banana singing to amr diab walla

be7abek moot relaxing cut thinking.
cardio st patient with headache examine cvs
i see the patient with Midline sternotomy scar
and with harvesting scar with pulse slow rising
with low volume and has metallic 2nd heart
sound all my carousel tell it is not metallic
except me it was really wired and ejection
systolic murmur radiate to neck i finish in less
than 4 min and i take 15 sec to collect the data
then i go to examiner i look to his eye sir i finish
he tell me what i tell the positive sings in a
simple way then the important negatives he told
what is ur diagnosis i tell nonfunction aortic
valve replacement wth stenosis he told are u
sure yes sure sir
what investigation ??? i told i will admit him
now i i will do brain CT scan because of the
headache may be overwarfinized and had brain
hge i should exclude that he give a good smile
then what else i tell echo to exclude IE why u
will do ct head before echo i tell it is more
serious and life saving for time management.
management i tell management of bleeding if
present then go for surgical replacement ask
about u do think this valve not function well i
tell him the murmur is radiating to the neck with
peripheral signs of aortic stenosis
he told me if not fit for surgery what u will do i
tell palliative and end of life care he tell yes then
the other examiner catch my hand and send me
in other bed for neuro st
later i will tell ??? wait us
neuro station unbelievable

instruction examine upper limb only
i get alook to the patient his left food is moving
under bed cover i start examine ul and in fast
way it was completely normal tone power
reflexes (oh shit) i reach cordination it was
normal but slow i realize at that time it is a case
of parkinson i tell the examine can i go to
examin face what u will examin only glabbellar
reflex and belepherospasm it was grabbellar
positive and ask for eye movement no need and
then i ask to see lower limb for the movement i
find tremors in one side and i find apomorphine
syringe like insulin pump i do tone in left ankle
only and bradkinesia and synkinesia all are
positive in left ankle i tell him i want him to write
and ask the patient how u come here negative
both offer gait time finished (horrible)
examiner present ur finding
i tell what i see in organized way
dd parkinson disease
parkinson plus
why r telling parkinson i tell tremors cogwheel
rigidity bradykinesia and synkinesia
he told tremor in feet i told can be sir it is
regular rhythmic slow with cogwheel rigidity
yes apomorphine pump is effiecent or not i tell
him yes efficient with residual tremors and
rigidity due to disease progression
he told do think his parkinson controlled i tell i
should take history but with physical signs i see
it is minor tremors and rigidity so it is controlled
he told will u offer him investigation noooo sir
he didnot need
what treatment i told non pharmacological with
advance plan care with surgical treatement only
he discuss role of surgery and deep brain
stimulation
st4::
a 75yrs old man with cough and heamopytsis

since one week admitted in hospital 3 days ago
ct scan show a mass and pleural effusion and
bronchoscopy showed a cancer, we have talked
to the patient about that the patient turkish and
know a little english and we use interperter for
him and his daughter want to know about his
condition tell her about diagnosis and future
plan of managment
outside thinking in this strange scenrio ??????
start with asking the daughter about does she
take the permission from her father she started
to raise her voice and tell me no need for
permission i told her it is difficult to complete
without his permission
examiner told me assume she has that
permission ( ‫كنت عايز اخلص هنا واخد اربعه و ال اكلم الوليه‬
‫) المجنونه دى‬
i start to break bad news give her water tissue
bad prognosis, he may day with next few weeks
or monthes
she told me do not tell my father i tell her why
she told he is a weak man and he will be
depressed i told her we r profession in breaking
bad news to hinm and when he find us
supporting him beside him ofcourse his agony
will be relieved and start to tell her that we know
steps of reaction happen after breaking bad
news like denial and anger sadness depression
and we can deal with all of that . he has the right
to know about his condition and if he has future
plan or advanced plan he can do it i think he will
satisfied if he did that even the doctor future
plan and investigation and he will enter a
medical procedure the doctors will tell him later
about the reason of such procedure and this
break the honesty of medical staff
she stat to be angry again i told he again do u
have another reason of not telling him she told
me i am the one want to tell to him? i told he i
am afraid to tell u this completely forbidden and
this our duty and may be ur way will harm him
we have the ideal way to do that
then i told her i want to tell u one more thing
that i afraid we have already told him? oh my
god she tell she become to nervous and hitting
the table i react calm with her telling her i
appreciate ur way ur caring about ur father but
we justify for u the reason of telling is beneficial
for him and his best interest for him and we can
arrange a meeting with u and him with
interpreter to clarify all the things and reply all
concerns
i tell her about bad prognosis palliative
management involving GP macmalian nurse
social support and pain management and care
of the carer and support
social things
permorbid state
offering help
examiner question was very depressive
first thing he told me did u read scenrio well i
tell him yes sir
did u reply her concern well yes sir ‫و النعمه‬
does the patient has the right to attend meeting
of breaking bad news to the patient yes sir after
patient permission what if he did not permit
her? i will not allow her sir
if she told the patient before medical staff what
u will do? i will do my best to correct things and
i will explain to the patient with help of the
interpreter
for me i think i will get 4 as usual but
unexpectedly i got 16 what a mercy from Allah
even i see him make negative in one skill and
start to frustrate but i find it 16 how come
sobhan Allah so people do not frustrate if he
comment bad or mark u negative after the
session sometimes he change his view
according to the other examiner
station 5
BCC 1: from outside patient with eosinophilia

5000/ul with joint pains
from outside i tell to myself it is churge strauss
i enter inside i find patient obese only ask about
joint pain 2 month ago it was in right hip and
elbow with hand pain and stiffness with
morning and last 1 hr and ask about weakness i
find there were attack of weakness half the body
no mouth sores she deny any rash although
there a malar flush in here face with cushoiniod
ask about steroid she told me no ask specificaly
about period regular no abortion pills she take
ocp ask about asthma no nasal symptoms no
itching no shortness of breath yes chest pain
no, no headach or blurring of vision or fits or
DVT no hair loss, fatigue all the time with some
weight loss, urinary symptoms nil, no other
medication, she is working as pilot
on examination
hand boutonniere deformity corrected on
making fist and no rayaunds no nodule some
proximal myopathy, chest free heart no need
ask to examine other joint on clothes tell me do
what u can pick up i do only cripitation test
what is ur concern what is going wrong i tell her
u have a disease that ur defense system
become maldirected and attacking joint and
lung and cause ur blood more liable to clots like
the weakness u have before we will do scans
and run blood test to prove that for know i will
give some pain killers and refer u to MDT of
joint dr and blood , lung dr physiotherapy and
occupational therapy
2nd concern what disease specifically u can
mark it i tell although it is early to tell except
after run some test but let me share with u the
thinking we suspect SLE with antiphospholipid
and a disease called churge strause
3rd concern do i have allergy because i have
allergy cells in my blood? i tell here this cells
seen in allergy yes but also can be seen in such
diseases i mention before as reaction of
immunity it dose not mean u have allergy and u
didnot have any symptoms of allergy
i ask r u satsifed with my reply to ur concern
she told yes i ask any others concern no
examiner q tough really
ur positive signs i tell deformitiy with correction
jaccouds arthropathy type with proximal
myopathy with malar flush cusnoid face
although no steroid , chest free
ur dd
sle with antiphopholipids
next churge strauss or rhematoid or
microscopic polyangitis or wegners vasculitis
for DD
he ask is there eosinophilia in sle i told him yes
can be especially with antiphospholipid
ask what is the causes of eosinophilia here i tell
may be associated with others condtion like
parasitic infestation or hypereosinophilic
syndrom or the disase itself
he ask about investigation i tell basic & rh ana
anti dna and ANCA P&C anti ccp, coagulation,
lupus anticoagulat and anti cardiolipiden and x
ray chest over hand and affected joints, HRCT,
bone marrow biopsy if all are normal he told yes
managment
no pharamacological
pharamcological if confirmed most of the cause
we give steroid after rheaumatology referral
anticoagulant if APS confirmed
heamologist referral if investigation come
normal
he was happy got 28
all my carousel tell churge strauss and they r
severely deducted play it safe and express
things honestly and logical
than u later on other stations stay with us
BCC 2::
a26 yr lady with mild nausea

outside i make dd of local git causes like
gastritis, PUD, non ulcer dyspepsia, hepatitis or
cholecystitis pancreatitis or general cause like
renal failure or increase ICT
inside ask about the nausea in which time it is
more morning she tell me yes at that time i feel i
catch it (ICT) then ask morning headache yes
blurring of vision yes double vision
occasionally happen no the case confirmed ICT
i ask fever neck stiffness or fear from bright
light all no
about wight gain no, OCP yes she told
mouth sores or sores at private area no blood
clots , no dark urine, no lumps or pumps any
where no no weakness any parts no fits no loss
of sensation no speech problem or gait changes
family history mother has a brain tumor before
driving yes i tell her stop driving for now and
inform dvla
working as teacher
examination i go to eye acuity field movement
pupil funds all normal
i do pronotor drift and ask to do planter no need
i tell i need to make full neurological
examination no need he tell
concern what is going wrong i told u have
increase in the pressure inside the brain and the
reason may be ur pills that y u shouldn't take for
now and i will refer u to women dr to choose
another method of contraception and moreover
i will do scan for ur head and after we will take a
sample of needle from back to measure the
pressure i will refer u to brain dr for that
any other concern it can be tumor? i tell no atall
u do not have any symptoms of that and the
scan of the head will exclude that but i reassure
it is very unlikely.
examiner qs
what is ur signs it tells all are negative normal
fundus no papilloedema.
what is ur dd
idiopathic intracranial hypertension
any others i tell unlikly to be a brain tumor
i tell because no localizing symptoms like
weakness or loss of sensation or dysphesia no
other symptoms of malignancy like wight loss
or any mass
what investigation i told about brain CT scan
what u expect i tell to be normal what else
lumber puncture what u expect high pressure
with normal analysis
what else ? i tell MRV if there is sinus
thrombosis he give good smile
how u manage i tell non pharmacological stop
OCP
give acetozalmoide and repeated lumber
puncture and ventrulopertoneal shunt if need if
there is compression on optic nerve we can do
optic nerve sheathes fenestration.
station 1 tomorrow
station 1 last station

chest
positive finding
female with very faint mildline sternotomy scar
with 4 drainage scars with telengectesia on face
and with dilated vein on chest i see
tracheostomy scar and 3 cvp scars, trachea
central with right zone fine end inspiratory
crackles not changed with cough rest of
examination normal
what is u dd
i told lung transplant as there steroid cusnoid
face he has superior vena cava obstruction but i
think it is from multiple cvp canulation after
transplant
any others i tell pneunomectomy he feel upset
any othersssss???? no sir (‫)الحمد هلل على كده‬
SVC obstruction not from a cancer i tell yes if
cancer there will not be a transplant (he
smile)????
he told what is the complication of transplant
i tell him rejection and immunosuppresion
drugs abd broncholitis oblitrans then he told
broncholitis oblitrans how treated? i tell him it is
fatal condition needs icu admission patient
stabilization and plus immunosuppressive
what is the investigation to be done
i tell basic invx renal function x ray chest ct
scan drug monitoring in every investigation he
told me what u well see, i tell free on the side of
transplant with pathology in the other side
how u ttt
non pharmacological is very important with
rehabilitation program physiotherapy
frequently, smoking is forbidden
ttt regular follow up adjusment the dose of
immunosuppressive accordingly
abdomen
55 yr old man with Mercedes benz scar with
gyncomastia and scar over the Mercedes benz
on the right side the patient show me
glucometer at the end of examination ( ‫ابن حالل و‬
‫)هللا‬
what is ur dd
i tell him this a case of liver transplants as
evident by mreceds benz scar
what r the dd of mereceds benz scar i told him
liver transplant extensive diaphragmatic surgery
or gastric surgery
what u think why liver transplantation done i
told chronic liver disease as evident by
gyncomastia he told which chronic liver disease
i told him hemochromatosis i suspect because
the liver biopsy scar and glucometer
do u think graft is function i tell yes there is no
astraxsis or jaundice or ascitis
what medication did this patient taking i told
cyclosporin
as he has gum hypertrophy he told me u miss it
i told sorry sir
what the complication of liver transplant
rejection, leak biliary or thrombosis bud chairi,
portal vein, immunosuppression
investigation basic, LFT, coagulation profile ,
albumin and protein, doppler u/s on liver ct scan
if needed drug monitoring
ttt no pharmacological no alcohol
ttt mainly follow up
oh my god finished the exam it is like 2 hour
lost it is seconds
i will share sources and every thing later on
My exam centre was in Kochi-Aster Medcity
My examination started from station 2 (History

taking):
A young gentleman presented with productive
cough having diabetes mellitus on insulin. He
has previous history of Bronchial Asthma on
steroid inhalers. His cough is difficult to control.
The diagnosis was bronchiectasis possibly the
gentleman had cystic fibrosis as he had
abdominal pain suggestive of Chronic
pancreatitis. Examiners asked about causes of
bronchiectasis and whether I have tried to find
out aetiological clue like childhood viral
infections like measles etc. Did I asked about
clinical features of Kartageners syndrome in my
history or not (Nasal symptoms e,g. Running
nose etc). Then asked about managing patient
with Bronchiectasis. I told about rotational
antibiotics based on Sputum for C/S, chest
physiotherapy and surgery.
Score: 15/20
Station 3
Cardiovascular system:
My case was a middle aged gentle man having
chest pain examine the precordium. He had high
volume collapsing pulse with normal first and
second heart sound and an ejection systolic
murmur heard all over the precordium also
heard in the axilla (possibly galavardin
phenomenon). Also an early diastolic murmur of
Aortic regurgitation. I told about AS with AR
with predominant lesion being AR. I was asked
if the patient has chest pain what I am going
do? Management of Aortic regurgitation and
criteria for valve replacement.
Score: 20/20
Neurology:
I was asked to examine the lower like of a young
person who has difficulty in walking. I
asked for " can I ask the patient to walk (as
there is difficulty in walking but not unable to
walk). But the examiner asked me to it later. I
found spastic paraparesis with bilateral planter
extensor and bilater cerebellar sign. The
examiner was asking me to clarify about
unilateral or bilateral cerebellar sign? Then
asked about differentials I told about MS,
Spinocerebellar ataxia, stroke (rarely) etc.
Score: 11/20
Station 4
Communication skill:
I was talking with the daughter about a medical
error done by injecting intravenous amoxycillin
where as the patients record shows He was
allergic to amoxycillin. Which then lead to the
collapse of the patient with shock then he had
undergone resuscitation and became settle. But
the surrogate is not convinced about
acknowledgment of medical error and want
further action to be taken. I talked about
complaint manager and PALS etc. The examiner
asked me that your lawyer telling you that don't
acknowledge about error done by the team
member, what would you do? I told about telling
the truth etc. The station didn't actually not what
I expected.
Score: 8/16
Station 5
BCC 1:
A middle-aged gentle man having graves
disease having block and replacement therapy
(Carbimazole and levothyroxine). On
examination he is currently in euthyroid state.
What can be done about eye problem was the
question and signs I looked for assessing the
thyroid status. How would i investigate him
further?What are the other options of treatment
etc.
Score: 25/28
BCC2:
A young female having typical history of
migraine e,g. Unilateral headache, photophobia,
phonophobia, nausea and occasional vomiting
sometimes associated with vertigo. No history
suggestive of headache due to raised ICP, No
danger signs like no focal sign, planter flexor,
fundus normal. But she was taking abortive
therapy like paracetamol etc. I offered
preventive therapy like propranolol,
amitriptyline, topiramate etc.
Score: 28/28
Station 1
Respiratory:
My case was a middle age gentleman having
features of COPD as evidenced by
supraclavicular excavation, prominent
accessory muscles of respiration etc. But there
was scar mark on both sides of chest indicative
of previous ICT drainage. Initially I thought it
was unilateral pathology as the right sided scar
for ICT was more prominent and left side small
scar and trachea was slightly shifted to right
(Which is normal). But later examiner was
interested in guiding me to come up with
bilateral pathology . Then I told about COPD and
regarding scar actually dye to previous
pneumothorax.
Score: 16/20
Abdomen:
The case was a middle aged gentleman
with moderate splenomegaly without any
peripheral stigmata of Chronic liver disease.
No evidence of anaemia rather conjunctival
suffusion. The examiners asked about the
differential. I told about myeloproliferative
disorder e,g. PRV, Chronic Myeloid Leukaemia
and Myelofibrosis. They have asked me about
Polycythemia and it's treatment. Discussion
regarding blood lating/venesection and drug
therapy.
Score: 20/20
Total score: 143/172

Soba Teaching Hospital
Khartoum - Sudan
Day 2 Cycle 3
Started with Station 1
Station 1?
CHEST : Left Upper Lobe Fibrosis.
Abdomen : ADPKD
Station 2?
History : A Young male Knwon to have Asthma
since childhood, recently has worsening
wheezing, cough and SOB for last 3 months .
Also
has Vasculitic rash in his Leg in started 6 weeks
ago and recently started to work as a Car
mechanic. DD: Churg Strauss Syndrome.
Occupational Asthma
Station 3?
CVS : DVR
CNS: GBS
Station 4?
Esophageal perforation after dilatation talk to
son Explain the Esophageal Pneumatic
Dilatation and the perforation. Son want to take
him home. Also asked not to tell his father
about the complication because his father will
be worried. Acctually I did Bad in this Station
????????
Station 5?
BBC 1. Transient loss of vision
Was TIA and Stroke other candidate mentioned
TIA and Migraine. Patient was having headache.
Also out side her BP is 180/100.
BBC 2 : Outside Young lady with Dysphagia
inside was Systemic sclerosis also has hair fall
in questioning her. Concern what she has and
why she lost weight. I mentioned Systemic
sclerosis I forget to Say mixed Connective
tissue disease because she also has Hair fall.
Pray for your Brother to Pass this exam.

Copied from Telegram = Dr.Zain group
(UK) Experience
Wrexham hospital
Station 1: Respiratory was pulmonary fibrosis

Abdomen: RIF scar ?renal transplant and
hepatomegally
Station 2: chest pain and nocturnal reflux

symptoms
Station 3: Cardio: possibly MR or AS

Neuro: lower limb weakness and no sensory
defiict ? MND
Station 4: speak to wife of a patient who had a

large stroke, treated with thrombolysis and
developed a large brain haemorrhage. Wife was
angry and this complication wasn't explained to
her and wants to complain.
Station 5: 1st case pt with skin changes and
long standing visual loss ? Pseudoxanthoma
elasticum
2nd case: patient with chest pain with recent

travel hx from USA and recent cold symptoms.
Hx of angina. Had O2 sats of 92%. Differentials
?PE ?pneumonia ?angina
paces exam experience 29/11/2018 third
carousel
UK Dewsbury and District hospital
I started with station 2
20 year old female with skin rash and
leucopenia and anaemia
inside i checked history of rash, photosensitive
rash started during
her travel and releived by hydrocortisone cream
+ve history of joint pain, mouth ulcers, no
genital ulcers, no deformities
+ve history of miscarriage in first trimester
-ve history of mixed connective tissue disease
concern about diagnosis? SLE
what about if i want to be pregnant?
explain flares and some drugs that can not be
used in pregnancy
examiner: what is your DD? SLE, what else?
antiphospholipid ab, Behcet
and discussion what is with and against
INV? basic and autoimmune profile
ttt? Non Ph and Ph, MDT , he asked about
members of MDT
Rh, Nephrologist, Dermatologist, Hematologist,
who else Ob/gyn
+ admission, he asked why? because she is
neutropenic if after
examining her, there is risk of neutropenic
sepsis, she needs admission
U are in the clinic now, you want to talk to
anybody before admission? consultant
what simple test to do in the clinic? urine
dipstick for proteinuria
I got 20/20
Station 3
Neurology (my weak point)
i missed the case as he was acute patient and in
pain
40 year old male c/o difficult walking and using
hands
examiner instructions start UL, if you have time
go to face then LL
so i expected Myotonia
very difficult examination, i was surprised he
has hypertonia, hyporeflexia
normal sensations, abduction and adduction
equal, and the patient has baldness
tenderness in multiple points , weak hand grip, i
could not complete the examination
i realized after the exam it is Motor Neuron
disease
i got 6/20
cardiology
50 year old female c/o SOB
auscultation Aortic stenosis, with no carotid
bruits
examiner: diagnosis, DD, inv, indications of
valve replacement
i got 19/20
Station 4
30 year old female known asthmatic, not
controlled, recent admission
to ICU with respiratory failure and required
intubation and steroid inhaler
was added to her regular medications, still not
controlled
i tried to explore all the causes of difficult to
control asthma
smoking, passive smoking, job,
pets,birds,renovation,technique of inhaler
drugs,vasculitis,carcinoid, compliance
she is concerned about steroid and is not
convinced, non compliant
i explained that inhaled steroid has no systemic
side effects and even
if systemic steroids is next step i tried to solve
steroid problems
weight,BP,DM,......
she was difficult surrogate
examiner asked about did you convince her?did
u tell her that
the information she is reading in the internet
about steroids is wrong?
i got 11/16
Station 5
BCC1 20 year old female with epileptic fits
difficult to control
spot diagnosis,Tuberous sclerosis,clear
Adenoma sebaceum in face
patient is kind once i asked any other rash
showed me ash leef spots
asked about BP and fits and university
acheivement
examined face, nails,back , abd and asked for
BP, eye
drug list included antiepileptics and Evrolimus
not driving, -ve FH
concern diagnosis and contorl of fits
examiner, diagnosis, name of facial rash
did U ask about FH? yes, did U ask about
siblings? no
control of fits? we need imaging to evaluate
tubers
kidneys? cysts, angiomyolipoma
ttt MDT
i got 28/28
BCC2 79 year old male with blurring of vision

inside unilateral painless transient loss of vision
history of UL and LL weakness but resolved
history of uncontrolled RBS and BP and lipids
No history of HT disease
long drug list but i noticed apixaban
very difficult patient talking very slowly, did not
ask all eye questions
i asked snellen chart, they looked for it
hahahahahah
then examiner told me normal acuity, field,
patient is not cooperative,
i thought sup quadrantopia but could not say it,
asked for fundus no need
pulse regular, no time for carotid or ht exam
concern diagnosis and time ran out
examiner, diagnosis TIA
what is field defect? he is not cooperative i need
to do perimetry
pulse? regular but patient is on anti
SOBA TEACHING HOSPITAL - SUDAN
DAY 2 (09/12/2018)
CAROUSEL 1:-
■COMMUNICATION :
80 years female with moderate alzheimer and
immobility due to osteoarthritis. Admitted with
confusion and have UTI on antibiotic and iv
fluids. She is pulling the cannula. Talk to her
granddaughter.
Concerns:
$why she has confusion now?
$how you can calm her?
How you will give the antibiotics now?
What about feeding?
Why took too long to improve now? Frequently
admitted but she became ok faster than this
time?
She is the only carer of her and can't manage
alone at home? (I asked her from that)
Viva questions :
What are the issues?
How you will assess her swallowing?
What about the options to calm her? Examiner
looked angry when mentioned restrain as last
resort.
What are the options of feeding?
If didn't improve what do you think?
If she has recurrent UTI are you going to treat
her?
Really I think did bad.
■BCC1:
☆Stem:-
60 years old male has recurrent loss of
consciousness for the last 6 months. Vitals
normal.
●syncope for few seconds when try to catch the
bus. Recurrent. FH of sudden death 2 first
degree relatives. Other symptoms of TIA and
EPILEPSY and DRUGS negative.
Regular collapsing pulse and ejection systolic
murmur in first AA radiated to root of the neck
and early diastolic murmur in second AA.
Told the surrogate that we need to run blood
tests and tracing of the heart with jelly scan of
the heart and other tests concerning regarding
problem gates if the heart and possible heart
problems run in the family.
Viva questions :
Positive findings :as I mentioned above 👆🏻.

DD : Aortic stenosis and Aortic regurgitation.
Possible HOCM or Long QT syndrome.
Investigations )details of ECHO findings in AS
and AR).
What are the indications of aortic valve
replacement?
Which type you preferred in this patient?
Target INR.
One test to do before going to surgery?
Said coronary angiography for any ischaemia.
Station went good. I think so.
■BCC2:
Missed the case because of the surrogate
(whether he did that intentionally or not I will
leave that to ALLAH).
☆Stem:47 years female present with headache

for 3 months with fatigue all the day.
●headache with no specific character and no
symptoms of raised ICP. no significant past
history apart from rt eye cataract surgery and
now infection of the eye because of headache.
Nothing positive. Started to think about
polycythemia so asked in the beginning from
vision problem (said no) asked at the end does
she has any blurring of vision (said no despite
he told the candidate who did St 5 before me
yes and I don't know why).
Did bad disoriented shameful examination
because don't know what to do .couldn't get the
findings or solving the concerns.
Viva :
Findings (nothing)
He said if we told you hb 18 gms, told him
headache because of polycythemia.
Then I told him I saw the right eye congested.
Only one examination to do? Told him abdomen
for splenomegaly.
Investigations of polycythemia rubra Vera?
Management and complications?
Missed the case .
■CHEST:
Male with difficulty of breathing.
●Positive findings:
Finger clubbing with dry cough and small
transverse scar in the front of the chest looks
unrelated and hpopigmented skin patches in the
lower chest and abdomen.
In both lower zones :
Chest expansion is reduced .
Percussion note slightly dull.
Breath sounds and vocal resonance diminished
.
Apart from that there is fine inspiratory crackles
doesn't change with cough.
●DD:
Bibasal pulmonary fibrosis for dd.
●what is the cause in this pt?
Said idiopathic pulmonary fibrosis.
●what else?
Connective tissue disease.
Drug induced fibrosis.
Occupational lung disease.
●what else can cause clubbing and crackles.
Only give me one answer?
Said bronchiectasis.
●what is the main cause of bronchiectasis in
Sudan? Give me only one answer.
Said pulmonary TB.
●How to solve the dilemma now?only one thing.
Said high resolution CT scan.
●Give me only one thing the patient will get
benefit from it?
Said many things sir but the cornerstone is
pulmonary rehabilitation programme (postural
drainage w
ith physiotherapy and

social,psychosocial,occupational, financial
support)but there is other like stop smoking.,he
stopped me.
●what are the complications of bronchiectasis?
Said commonly come to a&e with recurrent
chest infection,also empyema and pleural
effusion and pulmonary htn and corpulmonale
and even nephrotic syndrome due to
amyloidosis.
●if pt with bronchiectasis developed stroke
what will be the cause?
Said I don't know (may be septic embolus ).
■Abdomen:
●Positive findings :
Lady has rt forward AV fistula functioning and
recently used, apart from that she has scar in
the rt side of the neck most likely from previous
site of vascular access of haemodialysis,
slightly pale, apart from that in the abdomen to
be honest with you I couldn't appreciate any
organomegally (because she is obese).
●Diagnosis:
ESRD on adequate haemodialysis most likely.
●examiner asked I saw you went back to the
hand what was you looking for?
Said for finger pin prick marks because DM is
the common cause.
●what are the other causes?
Said HTN,GN,DRUGS and POLYCYSTIC
KIDNEY DISEASE which I need to rule ou in this
patient.
●what is your work up?
Said apart from basic investigations i would like
to do US first then urinalysis and RFT and
electrolytes and investigations for the
complications.
●If she is following with you in the clinic how
you will manage her?
Said:
1/General advice regarding smoking and food
types .
2/ supplements like iron and calcium and
vitamin D and erythropoietin.
3/insure adequacy of renal replacement therapy.
●How you will treat anaemia?
Said depends on the hb and symptoms.
Iron tablets.
●what if can't tolerate?
Said iv iron.
●would you like to give blood?
Said I don't know sir. He said no transfusion do
you know why?
Said I don't know.
He told me do you have any plan in the future?
Said I will refer her for the renal transplant team.
He told me that is why they shouldn't receive
blood.
I said thank you sir this is new for me.
■History :
40 years female has headache become worse in
recent 6 months and known to be hypertensive
but controlled was on atenolol and now on
amlodipine .has menorrhagia planned to be
seen by gynaecologist.
I put:
Analgesic misuse headache .
Tension headache.
●she insisted for CT but I said no indication at
the moment but in case of anything new we will
reassess you (I felt there is trick here).
■NEURO:
O/E of this gentle man he had wasting in both
LL which start abruptly in the lower thighs, pes
cavus and trophic skin changes. In the both
lower limbs he has the positive following
findings:
Hypotonia, hyporeflexia at the knees with
areflexia at the ankles even with reinforcement,
mute planters, weakness the shape of weakness
the extensor more weaker than flexor ,the distal
more weaker than the proximal and abductor
more weaker than the adductor,apart from that
coordination intact with eye opened and slightly
impaired with eye closed, there is loss of light
touch and pinprick and vibration in stocking
distribution, lastly asked the pt to walk it was
high steppage gait.
●what's your diagnosis?
Said bilateral symmetrical peripheral
sensorimotor neuropathy for DD.
In this young patient with these features on top
is hereditary sensorimotor neuropathy.
●what others?
Said in this young patient :
Uremia.
Drugs,he stopped me, which drugs?
Said isoniazid, phenytoin,metronidazole,
vincristine and cisplatin.
Then DM and alcohol and paraprotinemia.
●How you will investigate?
Said this patient? He said yes.
Said :
Genetic test.
NCS and EMG.
NERVE BIOPSY.
FBS and HbA1c.
RFT.
TFT.
He stopped me.
●How you will treat him?
Said multi disciplinary team on top
physiotherapist and occupational therapist.
Also social worker and specialized nurse and
neurologist.
Foot care with chiropodist and special shoes.
Assess risk of fall and modifications
accordingly.
Treatment of neuropathic pain.
●what vitamin deficiency can cause peripheral
neuropathy?
Said vitamin B 12.
●is it treatable?
Said can give methylcobalamine.
●any infection can cause peripheral
neuropathy?
Said many and time off.
■CARDIO:
O/E of this gentleman there is midline
sternotomy scar and the second HS is clicky
metalic, PR around 72b/min regular of average
volume and equal in both hands ,first HS
audible, systolic murmur in MA but heard
allover the precordium.
●What's your diagnosis?
Aortic valve replacement.
●what's could be the cause?
Aortic stenosis or regurgitation.
●what is the cause of valve problem in this pt?
Rheumatic heart disease .
Congenital .
Connective tissue diseases.
Collagen vascular disease . like what? Said
marfan.
●what are the investigations? What is the target
INR?
●How you will know the valve is not
functioning?
●How you will manage.?
●which type of anticoagulant?
Said warfarin.
●Did you hear about new anticoagulant?
Said yes novel anticoagulants.
●which one of the novel anticoagulant you will
use?
Said in this patient?
He said yes.
I said no one of them.
●Any advice of this patient ?
Said drugs interaction and food.
Like what food?
Said cranberry and grapefruit.
Hope this will help.
Please pray for me I did bad and it's my last trial
MRCP PACES exam

Malta diet 3/2018
third carousel
Station 1
Chest : interstitial lung disease
Abdomen : middle aged woman with multiple
scars on the abdomen, no organomegaly, no
ascites, I said previous PD
STATION 2
Male with joint pain, fever, one episode of
sinusitis, deafness, dry cough, recent history of
travel to USA (CALIFORNIA) I SAID WAGNER
but examiner asked: Which infection can act like
vasculitis!! I said IE, Meningococcal, he said no,
in this patient
Station 3
Neurology peripheral neuropathy
Cardiology PSM, I was confused about
diagnosis whether MR OR TR OR VSD
Station 4
BBN, Brian tumor
Station 5
1-Confusing case : SOB, no cough, non smoker,
history non conclusive, he is having a hoppy of
carpeting, exam normal
2- hyperthyroidism
My Experience At North Cambridgeshire
Hospital St 1 Abdomen : old lady with Deranged
liver functions for differential Diagnosis , Chest
: A lady with SOB DD : ILD/Bronchiactasis , St 3
Cardiology : AVR + MS , Neurology : A
gentleman with LL weakness and difficulty in
walking : Bilateral wasting , LMNL, and
Stockings sensory level with a small scar @
lumbar spine . St 2 30+ yr old gentleman with
fatigue and joint pains , his labs showing low Hb
, low eGFR , High Creat and CRP , urine with
Blood and Ptn , all happened after a brief URTI
that was diagnosed as sinusitis and he Rcvd
Amoxicillin by his GP , there is Hx of recent
travel with no risky behaviour , he is married ,
no previous chest or URT complains , my top
DD was post streptococcal GN , St 4 was : talk
to the daughter of Mrs Brown who is 70 + yr old
, HTN and using ASA , had a fall at the Golf
course and broker her hip , undergone
Arthroplasty with post op LMWH , then she had
a fall during a PT session , after the fall she
became confused , Orthopedics shifted her to
Medical ward as a case of UTI , she had a CT
that revealed intracranial Hge with no midline
shift , the patient is not unconcious but
Neurology postponed her examination till she
improves , and i should discuss it with the
daughter .St 5 : Case 1 : 50 yr old gentleman
complaining of increased breast size , inside
was a gentleman with tall stature , large breasts
with no actual disc underneath the nipple , he
said that he has been like that since puberty , he
stated that he had problems conceiving and
scanty body har since he was young , a case of
Kleinfelter syndrome , Case 2 : 20 + lady with
elevated BP and pain at both hands , inside was
clear acromegaly ....Alhamdulillah passed , this
is my 2nd Attempt .

Bcc1: hemolytic anemia with gall stones
Bcc2: sob worse with exertion. Multiple risk
factors for ischemic heart disease but he had a
left upper lobe mass with facial plethora so my
first differential was svco
Station1: Adpckd with hepatomegaly and right
iliac fossa scar and renal transplant
Bibasal pulmonary fibrosis
Station 2: diabetic, hypertensive with recurrent
falls and left wrist fracture
Station 3: cns: mixed Parkinson's features with
gait abnormality and right sided foot drop due
to great saphenous venous harvest scar
CVS: mixed aortic valve disease with
predominent aortic stenosis. Dicrotic pulse on
inspection with normal volume pulse but early
diastolic murmur best heard in expiration
Station 4: severe persistent asthma, reluctant
on inhaled steroids, with occupational risk
factors
Malta cases today 7dec 2018

1st & 2nd carousels
BCC 1: recurrent hemoptysis since 2 weeks, he
had exposure as he is working as a security
guard and exposed to immigrants from Africa
viva; work up and if its broncheictasis , what

would be the findings..
BCC 1: h/ o joint pain and lower back pain.. he is
known case of RA ans h/o TB.. he had typical
findings ok ankylosing on examination..viva abt
its mamagment and rationale about biologics (
he had h/ o TB )
: cardio: AS ?? MS, investigate, what other
findings
: Neuro; lady had spastic paraperises and PN:
what other findings u would look for, ddx:
spastic paraperesis with PN, MS etc
chest: bibasal crackles with left shift of trachea,

I said left sided fibrosis with element of
obstruction, viva about managment and whats
the main pathology
GI: hepatosleenomegaly( huge spleen) ddx:

myeloproliferative etc, viva about investigations
and managment, but here examiner had masked
�💀face so not really sure
: History: 50 y/o female with h/o valvular

replacement, on wafarin having symptomatic
anemia.. she is on ferrous sulphate but still Hb
is 9.7?
concerned about GI malignancy, she gave h/o

alternating bowel habits with bloody stools
once, having hemmoroids as well, actually it
was a complex of many factors
: St 4: dealing with son of an old guy who had

femur fracture, shifted to ortho rehab, had h/o
fall there and before admission while playing
golf,, and now docs noticed that he is confused,
CT brain showed intra cranial bleeding, also he
was on LMWH ( due to h/o DVT) and ASA..
Diet 32018 Egypt

13/10/2018
Station 1 chest
bilateral fine end Inspiratory crepitations with
?mild wheezes(as I present) and clubbing
I didn't examine the trachea and lymph nodes ...
Discussion was about fibrosis 7/20.
Abd :
Palmer erythema , palor, huge spleen in middle
aged patient
examiner asked about Dx. I answered chronic
liver disease because I said shrunken liver ..
actually the case was CML then ask about
management .8/20
Station 2 :
Outside,
Fatigue and generalized
joint pain for 2years ,with anaemia ,high
creatinin , low e GFR, high crp.
He has Hx of sinusitis .for last 6 months
Inside , I analyzed the presenting c/o and
covered all aspects of Hx .
All negative except travel Hx to USA California ,
I asked about rash , insects bite ,
DD : granulomatosis with polyangitis ,
microscopic polyangitis, and I mentioned rocky
mountain spotted fever ( examiner asked me
how ? I said I don't know)
I didn't mention post streptococcal
glumerulonephritis...
Then discussion about investigations and
management .18/20
Station 3:
Neuro : Lower limb;
Lower motor neuropathy proximal more than
distal (GBS , hereditary ....etc)
Dx is Gillian Barre Syndrome
Then investigations (NC study and EMG and ,
lumbar puncture and MRI if indicated ) .
Rx , I.v steroids , I.v I.g or plasma exchange.
19/20
Cardio:
MR, AS with harsh thrill and irregular pulse (AF)
Discussion about invest. and management
(examiner asked if this Pt come with SOB what
is the management? I didn't say surgery )
18/20
Station 4:
outside :
asthmatic patient since childhood was
controlled on salbutamol inhaler , also has hey
fever , recently becomes
Uncontroled and refusing steroids because
she was given steroids before and causing
weight gain ,
The task is to convince her to use steroids
inhaler which was prescribed recently ...
Inside :
I started with introduction (my self,my role,
proof pt identity, make rapport, and ask her to
tell me more ....
Then check idea , concern and expectations)
I let her talk more and took her time then
accordingly she was concerned about sleep
disturbance, difficulty in work and daily living
activity .
I told her that steroids are magic drugs
regarding you problem , it will help v.much , and
she is going to be followed up closely in case of
any bad effects to be managed early on and are
reversible also with regard to weight gain she
can find out solutions like exercise and healthy
food , also steroids can help her to do so ...
It is important to talk about steps of
management of asthma and tell the pt that she
is at level where steroids are the preferred
choice. 16/16
Station 5:
BCC 1 : outside
Proximal myopathy with HTN
Inside : caushing disease most likely b/c of
pigmentation
Analyzed the complaint and complete the
format
Examine the hands , proximal myopathy in both
upper and lower limbs, face and neck ,
auscultate the heart and base of the lungs ,
trunk for striae , lower limb edema .....
Concern
Ask about complications of obesity like OSA ,
Carpal tunnel syndrome and osteoarthritis.
Discussion about invest. (dexamethason
suppression test in details) and outlines of
management plan .
28/28
BCC2 : outside, shortness of breath (inside ,
scleroderma with pulm htn).she has drug list .
discussion about investigations after presenting
the case
28/28.
Egypt 18/10
I started with st5 bcc1 young Male with dark
urine no other urinary symp hole urine p.h of
brain clot Ithink he mean sinus thrombosis with
blurring of vision one year ago also has
difficulty of swallowing which ICouldn't
correlate no history of other clot or f.h of clot no
jt pain , mouth sore or downward sore ex of abd
no need ex of fundus they gave me
ophthalmoscope ,back of leg no needdiagnosis
Isaid PNH.treatment,concern is it
serious.examiner q is it treatable Igot 23
Bcc2 40 yes female with neck pain ass with
back pain and hand pain, stiffness and
restriction of movement negative history of
other seronegative arthropathy ex of neck
movement and back movement and ex for
tenderness concern is it treatable bcz can't
cope at home exam q what is your diagnosis
why you examine the back investigations
treatment options.Igot 28
St1 chest signs of OLD crepitarions with
bronchial breathing Igave DDof bronchial
breathing investigations and treatment Igot 20
Abd thalasmia with splenectomy with 2ry
haemochromatosis and hypopitutrism ex q
about thalasmia investigation type of
Hb,treatment, target Hb complications of PTSD
has splenomegaly what's the diagnosis Igot 20
St2 transient lov in 40 years Male for sec history
of clot in the other eye with glaucoma and poor
vision also history of htn other history is
negative. concern is to lose vision
Diagnosis tia dd glaucoma but no pain
Migraine but no headache
TCA but age of pt against that and no pain
Q about dd investigation and treatment and If pt
has lt ventricular thrombosis what treatment u
will give I will refair him to cardiologist .
St 3 spastic paralysis without sensory level DD,
treatment examiner has different accent and
keep asking about some thing which I can't get
Igot 17
CVS vsd with ps there's pansystolic murmur all
over the pericardium. And radiated to the neck
in pul area Igot 19
St4 penicillin allergy senario medical error the
pt keep asking u will move her to other place
Ican sit beside her how u will prevent it from
happening again why still confuse is it bcz of
allergy is it serious
Ex q what type of meeting u will do and he ask
about other meeting which I don't know Igot 16
Actually Igot seat 3 wks before my exam date
but alhamdullilah allah help
MY EXAM IN CHENNIA MADRAS MEDICAL

MISSION 12NOV 2018
I begin with
st2 yong patien with asthma since chilhood 3
month resistant to treatment with rash at both
legs DD occupational asthma charus stress
CV patient with chest pain on exam
pancystolic murmur radiate to axilla also radiate
to neck DD AS MR
NS . elder patient ask fot giat examinar not
need left leg power weak tone increase
babinisk eqivocal i want exam upper limb
examinar no need i observe left hand weaknes
when ask patient for reinforsment for rt ankle
jerk diag lt hemiplagia where lesion difficult
could be i go to roung diagnosis
ST4 traxi driver with TIA explain to him
disease stop driving .
st5 cc1 lady with bilateralleg edema progress
with few days nothing in history juist in past
history DM for 20 years on exam leg edema
posative ,cataract blind diabetic nephropathy
CC2 patient with diarrhea eating outside
home3days ago concern want to traveal for
wedding her brother
Abdomen patient wiith av shunt with
hepatosplenomegaly ,
CHEST patient with sob exam left side back

decrease air entry. dullnes cores crackle
DD effusion bronchctasis examinar ask
abour pleral efusion cases diagnosis light
chriteria for pleural effusion treatment of TB
DAY 2 (09/12/2018)
CAROUSEL 1:-
?COMMUNICATION :
granddaughter.
Concerns:
What about feeding?
time?
Viva questions :
resort.
her?
?BCC1:
?Stem:-
normal.
?syncope for few seconds when try to catch the
Viva questions :
Positive findings :as I mentioned above ????.
and AR).
replacement?
Target INR.
?BCC2:
?Stem:47 years female present with headache
?headache with no specific character and no
Viva :
Findings (nothing)
for splenomegaly.
Missed the case .
?CHEST:
?Positive findings:
.
?DD:
?what is the cause in this pt?
?what else?
?what else can cause clubbing and crackles.
?what is the main cause of bronchiectasis in
Said pulmonary TB.
?How to solve the dilemma now?only one thing.
?Give me only one thing the patient will get
benefit from it?
drainage with physiotherapy and
stopped me.
?what are the complications of bronchiectasis?
amyloidosis.
?if pt with bronchiectasis developed stroke
?Abdomen:
?Positive findings :
?Diagnosis:
?examiner asked I saw you went back to the
the common cause.
?what are the other causes?
Said HTN,GN,DRUGS and POLYCYSTIC KIDNEY
DISEASE which I need to rule ou in this patient.
?what is your work up?
complications.
?If she is following with you in the clinic how
Said:
types .
?How you will treat anaemia?
Iron tablets.
?what if can't tolerate?
Said iv iron.
?would you like to give blood?
you know why?
Said I don't know.
blood.
?History :
I put:
Tension headache.
?she insisted for CT but I said no indication at
?NEURO:
findings:
high steppage gait.
?what's your diagnosis?
?what others?
Uremia.
?How you will investigate?
Said :
Genetic test.
NCS and EMG.
NERVE BIOPSY.
FBS and HbA1c.
RFT.
TFT.
He stopped me.
?How you will treat him?
neurologist.
accordingly.
?what vitamin deficiency can cause peripheral
neuropathy?
Said vitamin B 12.
?is it treatable?
?any infection can cause peripheral
neuropathy?
?CARDIO:
?What's your diagnosis?
?what's could be the cause?
?what is the cause of valve problem in this pt?
Congenital .
marfan.
?what are the investigations? What is the target
INR?
?How you will know the valve is not
functioning?
?How you will manage.?
?which type of anticoagulant?
Said warfarin.
?Did you hear about new anticoagulant?
?which one of the novel anticoagulant you will
use?
He said yes.
?Any advice of this patient ?
Like what food?
Please pray for me I did bad and it's my last
trial.
SOBA TEACHING HOSPITAL -SUDAN

Day 1 (08/12/2018)
Carousel 1 :-
#Chest :
bibasal lung fibrosis upto mid zones.
#Abdomen:
ESRD with non functioning av fistula and
rejected transplanted kidney, patient has tunnel
catheter for dialysis now.
#History:
Middle age with chest pain for 6 weeks
aggrevated by heavy meal and he is heavy
smoker. FH of sudden death at young ages.
Working as labour.
DD: IHD AND ,GERD, MUSCULAR .
#CVS:
Female with mitral regurgitation and pulmonary
hypertension.
# NEURO :
Not sure, hypertonia in both lower limbs with
hyperreflexia on the knee and areflexia on the
ankles and mute planters and pyramidal shape
weakness.
Gave MND as diagnosis and time up.
#Communication:
Elderly lady diagnosed 3 yrs ago as mild
parkinson not on medications admitted with
acute confusion with UTI and stiffness . talk to
her daughter.
Daughter asked why not given antiparkinsons 3
yrs ago?
Is she will be ok?
Who will take care of my father at home,he has
stroke and iam living faraway?
Viva :
Clinical questions of parkinson and parkinson
plus and antiparkinsons and their side effects,
no ethics at all.
#BCC1:
Middle age male with visual problem.
Retinitis pigmentosa.
#BCC2:
Middle age female with haematuria and polyuria
and high BP and her brother had kidney stone
before.
He did it as polycystic kidney disease but he
mentioned hypercalcemia for DD.
Malta cases today ??7dec 2018
1st & 2nd carousels
BCC 1: recurrent hemoptysis since 2 weeks, he

had exposure as he is working as a security
guard and exposed to immigrants from Africa
viva; work up and if its broncheictasis , what

would be the findings..
BCC 1: h/ o joint pain and lower back pain.. he is
known case of RA ans h/o TB.. he had typical
findings ok ankylosing on examination..viva abt
its mamagment and rationale about biologics (
he had h/ o TB )
: cardio: AS ?? MS, investigate, what other
findings
: Neuro; lady had spastic paraperises and PN:
what other findings u would look for, ddx:
spastic paraperesis with PN, MS etc
chest: bibasal crackles with left shift of trachea,

I said left sided fibrosis with element of
obstruction, viva about managment and whats
the main pathology
GI: hepatosleenomegaly( huge spleen) ddx:

myeloproliferative etc, viva about investigations
and managment, but here examiner had masked
????face so not really sure
: History: 50 y/o female with h/o valvular

replacement, on wafarin having symptomatic
anemia.. she is on ferrous sulphate but still Hb
is 9.7?
concerned about GI malignancy, she gave h/o

alternating bowel habits with bloody stools
once, having hemmoroids as well, actually it
was a complex of many factors
: St 4: dealing with son of an old guy who had

femur fracture, shifted to ortho rehab, had h/o
fall there and before admission while playing
golf,, and now docs noticed that he is confused,
CT brain showed intra cranial bleeding, also he
was on LMWH ( due to h/o DVT) and ASA..
PACES CHENNAI NOVEMBER 12 2018
MANDAI MEDICAL MISSION
ABDOMEN
Enlarged kidneys: APKD on hemodialysis via
Left AVF
Was asked what vaccinations ESRF patients
need
RESPIRATORY
Bronchiectasis: chesty cough, bilateral crackles
NEUROLOGY
Upper limb: old stroke hyperreflexive, increased
tone
CARDIOLOGY
ESM with slow rising pulses: Aortic Stenosis
HX TAKING
25/F come in for followup from apparent
anaphylaxis from seafood
COMMUNICATION
Speak to son RE his father with esophageal
stenosis, post esophageal dilatation #3
developed esophageal perforation.
Was asked what my plans were and if pt can go
home or not
BBC1
Seizures in a young epileptic male with HTN.
Was asked what could cause the seizures.
BBC2
Progressive Blurring of vision in 68 female with
DM HTN Hyperlipid. Saw she got cataracts, then
i didnt do well on funduscopy coz not sure
about retinal findings.
UK - Exam experience
North Cambridgeshire hospital – UK
22/11/2018
Station 2
Outsides: 30 years old female c/o fatigue and
joint pain
Positive data: bilateral small joint arthritis of
both hands with 30 min morning stiffness –
rynaud`s phenomenon – photosensitive rash –
oral ulcers – fatigue – high BP by GP for follow
up
Concern : social troubles ( difficult to bring her
children from school … )
Examiner:
DIAGNOSIS? . I put ( SLE – RA – MCTD )
INVESTIGATIONS?: mentioned all basic labs
and all immune markers
Criteria for MCTD? I TOLD HIM SOME CRITERIA
FROM SLE AND SS AND PM THEN MENTIONED
RNP-AB
CAUSE OF HTN? I SAID GN – he asked about
other causes of renal affection in SLE .. I
mentioned interstitial nephritis and drug
induced renal diseases ( was not satisfied with
this answer)
GOT 19/20
STATION 3
CARDIOLOGY CASE:
INSTRUCTION NOTE: PATIENT WITH MURMUR
FOR CVS EXAM
POSITIVE SIGNS: SYSTOLIC MURMUR HEARD
ALMOST ALLOVER THE PERICORDIUM GOING
TO THE AXILLA AND ALSO UPTO CAROTIDS (
A LITTLE BIT CONFUSED ) BUT PATIENT`S
PULSE WAS LARGE WITH WATERHUMMER
PULSE.
EXAMINER:
DIAGNOSIS: MR ( 3 out of 5 candidates said AS)
ASKED ABOUT CAUSES? MVP and
degenerative – may be acute as aresult of ant.
MI
Asked about investigations? Basic – Echo (
stopped me and asked what are u expected to
find) I said assess the severity grade of regurge
and EF and size of LV . asked why? I said to see
if the patient indicated for MVR or not.
GOT 19/20
NEURO CASE:
INSTRUCTION: 40 YEAT=RS WITH DIFFICULTY
IN WALKING
POSITIVE DATA: I started with gait ( ATAXIC
GAIT ) – bilateral LL weakness – hypotonia –
hyper reflexia – upgoing plantar – positive
cerebellar sign – intact sensation – ( I forgot to
examine pathological reflexes and clonus)
Examiner qs:
Positive findings?
Diagnosis: I said MS
How to confirm diagnosis of MS? I mentioned
basic investigations and inflammatory markers -
MRI for demyelinating lesions and plaques –
CSF for oligoclonal bands – AEP and VEP
Treatment? Acute: iv methylprednisolone –
inbetween if relapsing remitting or 2ry
progressive we can start natalizumab –
finglimod then time up
GOT 17/20
STATION 4
OUTSIDE: 65 years female patient with diabetic
foot refused amputation and she is having
capacity – talk to daughter
Inside , surrogate was angry and talking quickly
– I think I covered most of points in this
scenario (asked about permission and next of
kin - check understanding and expectation –
sympathy and empathy – explained the
condition and need for surgery but we have to
respect her decision – we can`t assume that she
doesn’t have capacity just because she refused
life saving procedure – I raised the plan by
palliative team care )
Examiners were not satisfied at the end of
discussion like I was talking about different
scenario – asked why you will not procede to
the surgery for the best intrest? Bcz patient has
autonomy the right to know and refuse the
procedure . why u say that she has capacity?
Bcz it is written in the scenario . yes but is there
any reason can make this patien lose her
capacity ? yes if she confused due to septic
shock . how u can say that patient has
capacity? I said understanding – retain –
outweight – communicate. How to check
understanding? I stopped talking. What are u
used to do in ur daily practice ? I don`t know (
was really bad discussion with pretty stupid
examiner)
GOT 10/16
STATION 5
BCC 1 patient diagnosed with asthma but not
improved on inhalers
Was straightforward TYPICAL case of
occupational asthma ( changed his job recently
to bakery and in contact with flour)
I asked everything in history (very common
case specially in this diet) – examined the chest
was normal
Concern what the cause of not improving? I
explained occupational asthma and further plan
of management and talking to occupational
health physician.
Examiner qs:
Diagnosis?
Investigation? Basic – CXR – ABG – PEFR IN
WORK DAYS AND OUTSIDE
Treatment? Change the job . what u will do if the
patient refused to leave it? Relocate him in
other position inside the same job. What else? I
said advice him to wear a mask ( he was happy)
GOT 28/28
BCC 2 50 years old with visual problem
Inside : what do u mean? Dropping in left eye lid
. I was trying to prove the case as MG for 1
minute but no history suggestive so I started to
examination of the eye .. left ptosis and miosis
so I got diagnosis of HORNER SYNDROME and I
was really happy . I asked about all neuro qs
and questions to localize the lesions ( central –
preganglionic – post ganglionic) all –ve . only
positive data IHD ( PCI 6 months back – on anti
ischemic ttt) I don’t know what is the relation!!!!
She was smoker
EXAMINER qs:
Positive findings?
Diagnosis? I told mostly pancost tumor but
need confirmation by CT ( he asked did u
examine the chest ? feel shocked, NO.
How u confirm diagnosis of horner?
Apraclonidine test
If this patient come to ER few hours ago by
Chest pain what u will do? I said CT
angiography to diagnose carotid artery
dissection
GOT 26/28
STATION 1:
ABDOMEN CASE:
POSITIVE FINDINGS: too many findings (
working AVF in rt arm – closed AVF in lt arm –
sacr of permcath in rt subclavian – thin skin and
ecchymosis in both arms – gum hypertrophy –
left iliac fossa scar and underlying kidney graft-
ballotable mass in rt ilia region , I didn’t feel it in
lt side so I was afraid to mention it)
Examiner qs:
Positive findings: I told everything except PCKD
, I didn’t even mention it in causes of primary
renal disease ( I don’t know why) .. by many
candidates , they said sure this patient had
PCKD.
Asked about causes ? medications?
If this patient come to ER at night with
abdominal pain and rising RFT , what u will do?
Consult nephrologist .. end
GOT 20/20
RESPIRATORY CASE
Positive findings ( bilateral basal crepitations –
lt thoracotomy scar – hand rheumatoid
deformities – thin skin – proximal myopathy )
EXAMINER qs:
Physical findings?
Scar? I said lobectomy . he asked what else? I
said may be biopsy or cardiac procedure.
What is the cause of fibrosis? IPF 2ry to
rheumatoid
What other causes of fibrosis ? I said
bronchiectasis but against that …
What else? Silence for few seconds then may be
pulmonary congestion but against …
END
GOT 20/20
I will write all the details of my preparation and
few tips that may be helpful for your preparation
later on but special thanks to the person who is
not just a teacher but was a friend and leader
Prof. Ahmed Maher Eliwa.
Many thanks
UK EXPERIENCE 11 / 11/ 2018
Station 1
Resp=ILD in patient with underlying CT
disease..
Abdo= b/l renal transplant with PD scar and
functional av fistula,no signs of uremia and fluid
overload
Station=2
Female with 6 months hx of vertigo mostly while
turning in bed,all CNS features were negative,no
hx of hearing loss or tinnitis .In discussion
examiner started by directly telling me that so it
is quite obvious that patient has BPV ????.so
all discussion was around BPV.but need to do a
brain scan to exlude vertebrobasillar
ischemia.In scenario it was written by GP that
patient has nystagmus,so to baffle
candidate.actually one can elicit nystagmus
during hallpike maneur??.
Station 3
CVS = DVR with AF..discussion was in AF
CNS=command was examine cranial nerves,as
patient has visual problem.on examination thr
was rt sided superior quadrantanopia.then
discussion was in stroke and management.
Station 4
Patient with long standing copd,on maximal
medical therapy was planned to discharge and
no further advance therapy agreed both by
patient and consultants.so to councel her son
regarding all the plan and to answer his
questions.
Station 5
BCC1
Ptient with SOB.Rcently treated for breast ca.
Inside patient has SS.
SO dds were given like,ILD,Dialated
cardiomyopathy 2ndry to doxarubicin,mets,and
anaemia.
Nothing significant on exam for SOB
BCC2
Typical scenario taken from ryder regarding
occupational asthma.patient compliance was
poor and also directed regarding spirometry
during work and off work.involvement of chest
physician and occupational health
department.all other allergens and drugs were
excluded.no hx of atopy.no positive findings of
churg strauss..
Please pray for me.
Oman 3/2018
Firstly, I would like to express my warmest

congratulations to our colleague Dr. Omer Imam
for his well deserved success and the
outstanding record. And to thank him for
sharing his rich PACES experience.
¤ Station 2
71-year - old man with recent hx of diearhea and
vomiting and improved from it, he get collapse
after a week and was confused,agitated and
shaky, OE was dehydrated,decreases JVP ,Na
155, mild renal impairment, other chemistry,
FBC, glucose were normal, CT brain was
normal(brain atrophy)
Task take a hx from his son and explain
diagnosis.
It's was lithium toxicity and has
polyurea,polydepsia(drink any thing he
founded) as diabetes insipedus
19/20
¤ Station 3
Cardio was AR dominant with systolic murmur
??AS
18/20
¤ Neuro was Backer with asymetical limb

weakness ,his giat was normal
20/20
¤ Station 4
Talk to angery Son
His father has done endoscopy for achalasia
dilatation complicated by esophagus
perforation ,why happened to him not the other,
I want to take him home (father was competent)
16/16
¤ Station 5
50 year old lady with HTN has recurrent fainting.
Inside very difficult surrogate Evey qs replying
by no, I'm not sure, there was recurrent collapse
since 2 years with LOC no shaking, no aura, any
how I start examination I noticed ???subungal
fibromata (I neglected it)despite that I missed
adenoma sebacum any how may be that lead
me to jump to skin exam and there was
hypopigmented skin macule, gave a diagnosis
of tuberous sclerosis Vs NF
28/28
2nd canse 28 man with HTN ,DM, kidney ds

come for follow up.
Inside a short man sitting, during checking his
medical problem stability his concern was that
mouth discomfort, has renal Tx 3 years ago any
how it was gum hypertrophy due to
ciclosporin??nifidipine
28/28
¤ Station 1
Chest, hate it, clubbing,Steroid side effects ??
RT lower chest tube scar and dullness,crackles
??discussion about is it fibrosis or
bronchiectasis
10/20
Abdomin was HSP with some submandibular
lymphadenopathy ,Thallasemia
20/20
159 Total score
Egypt 18/10
I started with st5 bcc1 young Male with dark
urine no other urinary symp hole urine p.h of
brain clot Ithink he mean sinus thrombosis with
blurring of vision one year ago also has
difficulty of swallowing which ICouldn't
correlate no history of other clot or f.h of clot no
jt pain , mouth sore or downward sore ex of abd
no need ex of fundus they gave me
ophthalmoscope ,back of leg no needdiagnosis
Isaid PNH.treatment,concern is it
serious.examiner q is it treatable Igot 23
Bcc2 40 yes female with neck pain ass with
back pain and hand pain, stiffness and
restriction of movement negative history of
other seronegative arthropathy ex of neck
movement and back movement and ex for
tenderness concern is it treatable bcz can't
cope at home exam q what is your diagnosis
why you examine the back investigations
treatment options.Igot 28
St1 chest signs of OLD crepitarions with
bronchial breathing Igave DDof bronchial
breathing investigations and treatment Igot 20
Abd thalasmia with splenectomy with 2ry
haemochromatosis and hypopitutrism ex q
about thalasmia investigation type of
Hb,treatment, target Hb complications of PTSD
has splenomegaly what's the diagnosis Igot 20
St2 transient lov in 40 years Male for sec history
of clot in the other eye with glaucoma and poor
vision also history of htn other history is
negative. concern is to lose vision
Diagnosis tia dd glaucoma but no pain
Migraine but no headache
TCA but age of pt against that and no pain
Q about dd investigation and treatment and If pt
has lt ventricular thrombosis what treatment u
will give I will refair him to cardiologist .
St 3 spastic paralysis without sensory level DD,
treatment examiner has different accent and
keep asking about some thing which I can't get
Igot 17
CVS vsd with ps there's pansystolic murmur all
over the pericardium. And radiated to the neck
in pul area Igot 19
St4 penicillin allergy senario medical error the
pt keep asking u will move her to other place
Ican sit beside her how u will prevent it from
happening again why still confuse is it bcz of
allergy is it serious
Ex q what type of meeting u will do and he ask
about other meeting which I don't know Igot 16
Actually Igot seat 3 wks before my exam date
but alhamdullilah allah help.
UK EXPERIENCE 17/11/2018
1st Carousel 17th November in Leicester UK:
Station 1:
Resp: Pneumonectomy for DD
Abdomen: Renal Transplant
Station 2: Bloody diarrhoea after return from

travel. Diagnosis: Post infective Crohns
Disease.
Station 3:
CVS: Bioprosthetic Aortic Valve Replacement.
Neuro: Spastic Paraparesis for DD
Station 4: Counsel for Post AF start of NOAC

Apixaban.
Station5:
Diplopia due to Graves Diease
Breathing Difficulty because of ILD secondary

to Mixed Conective Tissue Disease
Diet 32018 Egypt

13/10/2018
Station 1 chest
Discussion was about fibrosis 7/20.
Abd :
aged patient
management .8/20
Station 2 :
Outside,
management .18/20
Station 3:
Neuro : Lower limb;
19/20
Cardio:
18/20
Station 4:
outside :
Uncontroled and refusing steroids because she
was given steroids before and causing weight
gain ,
Inside :
tell me more ....
activity .
choice. 16/16
Station 5:
BCC 1 : outside
pigmentation
Analyzed the complaint and complete the format
Concern
management plan .
28/28
BCC2 : outside, shortness of breath (inside ,
the case
28/28.
MY EXAM IN CHENNIA MADRAS MEDICAL
MISSION
12NOV 2018
#Station2
A young patient known as bronchial asthma
since childhood.
For the last 3 months he is resistant to
treatment with rash on both legs DD
occupational asthma churg straus
#CV patient with chest pain on exam

pancystolic murmur radiates to axilla also
radiate to neck DD AS MR
#NS
An elderly patient, No need to examine the gait.
left leg power weak tone increased babinisk
eqivocal
I request to examine the upper limb examinar no
need i observe left hand weaknes when ask
patient for reinforsment for rt ankle jerk
diag lt hemiplagia where lesion difficult. Not
sure of diagnosis
#ST4
A taxi driver with Tia. Task: explain to him
disease & to stop driving
#Stn5
BCC1: A lady with BILATERAL LEG edema
progress within few days nothing in history just
in past history DM for 20 years on exam leg
edema ,cataract blind diabetic nephropathy
BCC2 patient with diarrhea eating from outside

home 3days ago concern want to travel for
brother's wedding
#Abdomen patient wiith av shunt with

hepatosplenomegaly ,
#CHEST patient with sob exam left side back
decrease air entry. dullnes & coarse crackles
DD effusion bronchctasis examinar ask abour
pleural efusion cases diagnosis light chriteria
for pleural effusion treatment of TB
#Thank you for sharing & good luck
Experience in MRCP PACES examination diet

2/2018 held on 03/07/2018 in Brunei, especially
for those who are going to have the exam there
next month.
It was my second (and LAST) trial.
I had some fears from Brunei center initially as I
did not found many feedback and the visa
process was complicated.
I received the visa 5 days before departure. It
was a long journey. The country is beautiful,
people are welcoming and the centre is well
organized.
I started with ST1. Outside I started to review
the sequence of the chest examination then the
bell rang. The examiner said this is your
abdomen case!!.. he was a young and slim
gentleman.. so l introduced myself and started
my examination by the hands and surprisingly i
found Swan neck deformity .after completing
my examination the Examiner asked what is
your finding i said he has deformities in his
hands also he is pale and joundiced, no
peripheral signs of CLD and he has
splenomegaly near the umbilicus but I didn't
found hepatomegaly i need USS to confirm. The
examiner what is your DD? I said my differential
is chronic haemolytic anemia (thalassemia)..
infection.. chronic liver disease (although no
peripheral signs of CLD) and felty syndrome.
Then asked about investigation and
management (mainly of thalassemia)
I thought i will not have good score.. I blamed
my self on missing liver and mentioning a rare
DD (felty).. surprisingly i got 20/20 (In the
feedback both examiner gave ne satisfactory in
skill B & D and mentioned swan neck deformity
and felty in there note)
ST 1 chest was a middle age lady. I noticed

some facial features of systemic sclerosis then
in hand examination her skin was tight.. chest
examination revealed lung fibrosis
Discussion about DD.. investigation and
management for lung fibrosis and systemic
sclerosis
I got 20/20
ST 2 middle age lady has difficulties in

controlling her BP.. every time her doctor
prescribe a medicine she suffer some side
effects and the doctor change it. She has no
complaints. She is concerned about why her BP
is not controlled. as there is no complaints I
started with systemic review begining with CVS
then CNS.. during history she mentioned that
she has some stress and anxiety and when I
asked more questions she mentioned this
because she is concerned why her BP is not
controlled despite being adherent to her
medicines and she affraid to have the same
thing happened to her father who was
hypertensive and died because of a heart attack.
also she mentioned headache, wt loss of 3 kg
and some sweating.. no heat intolerance or neck
swelling no palpitations.. the examiner asked
please summarize your history then asked what
is her problem? I said I think this laddy has
uncontrolled essential Hypertension because
she has difficulties with many drugs and
nothing in her history is pointing toward
secondary cause of hypertension.
Then asked for other differential? I answered
paeochromocytoma and hyperthyroidism
Investigation? I answered general investigation
is important here, RFT can help in renal causes
and investgations for other cardiovascular risk
factors ( Glucose & lipid profile) as she has
family history of cardiovascular death Then
investigation to exclude DD
(paeochromocytoma and thyrotoxicosis) then l
mentioned them.
The examiner: if those tests are negative what
are you going to do? I will reassure her and..
then the bell rang
I got 20/20
ST 3 CVS was young lady with stermotomy scar

(I was so happy when I found it ) then I complete
my examination.. (NO CLICK!! , apex difficult to
locate and I am not sure about the murmur) I
realized that I missed the case!
The examiner what is your finding? then I
mentioned the scar and systolic murmur in
aortic area then the examiner also realized that I
missed the case and he started to enjoy this.. he
asked: you mean aortic stenosis but she has
good pulse volume? (I had mental block at that
time only thinking about why she has
stermotomy scar and I didn't think about mixed
AVD and also there are no peripheral signs of
predominant AR) at the end he asked why this
patient has scar? I said don't know
They was very kind and gave me 8/20
(In the feedback they write I missed EDM so I
think the case was mixed aortic valve disease
but they didn't mention the reason behind the
scar)
ST3 CNS old gentleman sitting in the chair! ..the

instructions Examin the upper limbs
neurologically!!. I observed tremer in his left
hand and expressionless face.. I did
neurological examination of the upper limbs and
at the end i did some test for bradykinesia.. then
I said I would like to do some other tests for
Parkinsonism and Parkinson plus syndromes
but the examiner said follow the instructions!
The examiner asked: what is your finding? Then
I mentioned them and said the patient must likly
has Parkinsonism
What is your DD? I said cerebellar syndrome..
the examiner get angery and said do you think
this patient has cerebellar syndrome? I said no
because cerebellar tremer is intentional fine
kinetic and this tremer is resting coarse. Other
differential? I said essential tremor (Here the
other examiner how is not leading in this case
get angery and said do you think this is
essential tremor?) I said no because this patient
has bradykinesia and rigidity
Then the leading examiner said :if I told you this
patient is diabetic and hypertensive what do you
think? I answered it could be vascular
Parkinsonism. Others? I said it could be
pakison disease (here I understood they want to
hear the causes)
The examiner: could this be drug induced? I
answered unlikely as it's unilateral.. then asked
about investigation and management
Surprisingly they gave me 17/20
ST4 university students diagnosed recently to

have ulcerative colitis started on rectal
treatment but no improvement.. he still open his
bowel frequently and the disease affect him
significantly as he missed many classes in the
university.
The Doctor decided to give him oral steroids but
he refused and said he need more time to think.
He came to you to day to discuss this option.
After the introduction and after he told me what
he knows about his condition i explored his
thoughts about oral steroids he said he don't
want them.. i asked may i know why? He said i
read in the internet about it's side effects.. I
asked about these side effects then he told me
some of them.. then i started to explain that all
medicine has good and bad effects but here we
think the benefits is more than the side effects..
then i explained to him the side effects of
steroids and how we can minimize them and
also the expected benefits from steroid
treatment on the disease and his life specially
university performance then i asked what do
you think? He said no i don't want them!!. Then i
explained to him the sequence of his decision
on the disease and his life especially university
( i mentioned few side effects of the disease and
concentrate on daily living activities and
university) but also he refused and asked for
alternatives then i explained the steps of UC
treatment and I mentioned the alternatives and
told him they are also powerful medicine with
many serious side effects. Then he said one of
my friends with similar problem tried Chinese
herbal medicines and he is ok now i want to try
them. I asked whether his friend has the same
disease? He said i don't know but he also open
his bowel frequently. then i said he may have
different conditions and I explained to him him
that it's not approved as a treatment for UC and
there no evidence that it can cure the disease
and it may also cause some side effects for you.
Then i asked again about his thoughts he said i
don't want the steroid why not to allow me to try
Chinese herbal medicine then i explained again
as above, and again asked now what do you
think? he said I will try Chinese herbal medicine
if they fail I will take the steroids. I said you have
the right to choose but as i told you previously
it's not approved as a treatment for UC and
there no evidence that it can cure the disease.
Then I asked clearly about CONCERN but
nothing new
examiner: do you think you convinced him?
I said i tried my best and i explained the benefits
of steroids and how we can minimize the side
effects but he refused
The examiner: do you think you tell him enough
information about the sequence of his decision?
What are the Complications of UC?
I mentioned all the complication including
colectomy & colostomy to the examiner then he
said if you told him about them in details and he
knows he may undergo surgery to remove his
bowel and his stool will come out through his
tummy he may change his mind.
The examiner: I heard you telling him it's your
right to choose are you agree with Chinese
herbal medicine? I said no and i told him many
times that itis not approved as a treatment for
UC and there no evidence that it can cure the
disease. then he said you have to be firm
regarding this.
( But I thought about autonomy)
I got 9/20
ST5.
BCC1 female with neck swelling
after the introduction I asked about symptoms
of hyper and hypothyroidsm there was some
symptoms of hyperthyroidism no fever or
illness before. Then I examined the hands, the
pulse then the goiter from front and back then
asked for shortness of breath and difficulties in
swallowing and examined for retrostenal
extension then auscultate for bruit and
examined for lymph nodes and eyes for thyroid
eye disease. Then asked about past medical
history.. Family history.. Drug history and social
history. My diagnosis was thyrotoxic goiter
The examiner asked about the findings.. DD and
plan of management
Got 23/28 (in the feedback both examiner said I
missed obvious bruit in the right side.
Regarding skill D (DD) one examiner gave me
satisfactory and the other gave me borderline
and both mentioned "correct diagnosis" )
BCC2 male with skin rash

after the introduction I asked few questions then
I said can I have a look, he has scaly rash over
elbows it's psoriasis then I examined behind the
ears and the scalp then I examined the nails he
has nail changes then I asked about joint pain
and examined the joints but no arthritis. Then
asked about visual problems and looked to the
eyes. Then asked about shortness of breath and
auscultate the apices, then asked about fainting
attacks and examined pulse and auscultate the
heart then asked about heel pain and examined
Achilles tendon then asked about Past medical
history said he has Hypertension. Family history
not significant. Drug list he takes many drugs
one of them is Beta blockers. Social history I
asked about alcohol ( not drinking alcohol) job
and how much itis affect his life he said it's not
affecting my life. His concern is about the
diagnosis. Then I explained the diagnosis and I
said we need to refer you to skin doctor and we
need to review your medicine with heart doctor
as it can aggravate the condition
The examiner asked about the DD and plan of
management. He asked also what are the social
habits that can aggravate the condition I said
alcohol he said smoking also can
Got 26/28 (in the feedback both of the examiners
deducted one mark from skill C and comments
he didn't consider smoking history!!)
ALHAMDULLAH I passed the exam.
I would like to thank my family and friends who
supported me during the hard times.
Good luck for everyone.
PACES experience in Cairo/Egypt, New Kasr
Elainy on 15/10/2018..
#Station3
?CVS:
young female with AF and DVR.. i missed the
2nd click of avr said mvr with PHTN.. gave me
12/20..
?Neuro:
female with asymmeyrical wasting of the lt
LL.,with dorsiflexion deformity at lt 4th toe
,weakness grade 3 in lt.hypotonia &
hyporeflexia at the ankle b/l with hyperreflexia at
the knees b/l??planters equivocal.. sensation
was intact.. coordination intact.. so i said dd old
polio., cauda equina lesion , MND... asked about
other dd idont know.. inv. Said ncs,mri of the
back.. I got 16.. confusing case Im waiting for
the feedback..
?Station 4:
Talk to Miss Mona.,the daughter of Mrs Fatima,
about the result of investigation & expected
plan of managment
She is 70yrs referred from the GP with 3month
hx of jaundice, wt loss & anorexia.. he did for
her routine invx.. us abd. There was dilated gall
bladder and no obvious mass.. ct abd was done
confirm the same findings.. ERCP was done. To
releive the obstruction and was not conclusive..
Biobsy was taken from the gall bladder &was
_ve.. diagnosis is highly suspicious of cancer in
pancreas or cholangiocarcinoma.. but not
confirmed.. started after confirmation &
checking understanding then explanation ,tried
to use drawing to explain liver and biliary tree
and explaining the result.. breaking the bad
news .,showing empathy & sympathy.. she was
concerned about not to tell her mother about
this. Asked why.?b.cher mother is emotionaly
fragile and may feel depressed.. I highly
appreciated this and said sorry this is her right
to know every thing and i will not inforce the
information on her.other concern was what are
you going to do for her next.. i said i will return
to my consultant first.. as this will be discussed
by a team of doctors..exam. Q. Issues in the
scenario..bbn.. councelling about diagnosis of
un certainty, pt automomy..asked about my next
plan of management are you going to admit
her.I dont know how to answer this question.I
said i will return to my consultant accord.ti her
situation if she needs fluids or antibotics and
may need to repeat imaging.
I got 14..
?Station 5
5 /1. 40 yrs female with wt gain.. it was hypo
thyroidism typical hx and examination
findings..got 28
St 5/2 elderly male with confusion..has fever

from outside.. hx was typical of UTI/delerium
over 1 week.. stil asked about all dd of
confusion in eldery .. concern about Alzehimer's
disease. I got 28??
#Station1
? Chest
Chest : young male with wheeze all over.. some
fine crackles over lt base.. dd obst. Lung
disease..asthma or copd.. discussion about
asthma got 20
? abd young male pale .jaundiced,

hepatomegaly and splenectomy.. had palmar
erythema_ i missed to mention it. no other sign
of cld.. has some small lymph nodes in the
neck.. examiner asked about diagnosis and
findings I said chronic hemolytic aneamia ..
asked about other findings did you found .. i
dont know??i think he wants signs of cld then
disease mostly he got infection due to repeated
b. transfusions. Then discussion about
thalassemia types inv. Treatment.. indication of
splenectomy.. i got 16
? Station 2 ..
50 yrs male with wt loss . Breathlessness.
Fatigue and some problem in his neck.. fatigue
was at end of the day . Has difficulty swallowing
for liguids and with nasal regurgitation .. and
coughing .. sob mainly with swallowind .. loss of
wt of 2kg .no loss of app. But his food intake
reduced due to swallowing problem.. neck
problem was that he used to support his neck
by the end of the day.. has FHx of
hypothyroidism in his sister.. job ,office work..
Concern what is the cause.. said MG
Explain it.. what we need to do .. and may need
admission after assessing breathing.. other
concern is it a cancer.. said most likely no your
symptoms is going with myasthenia ?? he was
afraid that this may be a ca.. then exam. Asked
dd MG.. Lambert eaton .. said so why you dont
tell the pt that he asked you several times about
possipility of ca?? then asked what inv you
want to do to exclude GI CA? i said colonscopy
and ogd.. abd ct.. then inv for MG.. managment
and when he need icu admision... then finished
??
I got 17/20..
Thank you Dr. Eiman for the nice and detailed

feedback..
Once again Congratulations on your well
deserved success...
GUYS PLEASE FOLLOW THESE COLLEAGUES

EXAMPLE AND SHARE YOUR/YOUR FRIENDS
PACES EXPERIENCE TO HELP OTHERS.
Exam Experience on 16 November /2018 .....
Station 5:A) ankylosing spondilitis man with

short of breath...... this was his main concern....
i couldnt hear apical crackles or aortic rehurh
murmur......exam Qs were about fibrosis n
investigations
Station5:B) young lady with collapse..... no

pallor no tongue bite no TIA features no
arythmias no hypoglycemia no recreational
drugs no fam hx........exam Qs were about
causes of collapse
St:1) abdomen= left renal transplant with PD

scar n big rite hypochondrium scar...... exam Qs
were abt apkd n imunosupresion
Resp:= rite lower lobectomy.... exam Qs were
about causes of lobectomy n tests n diff from
pneumonectomy
Station 2;) pt with high BP= 156/96 , anterior
chest pain and family hx of IHD.... when asked
he said it is burning type pain with no radiation
n increases after food.... there is some sweating
aswell during pain. ... some times he feel pain
while lifting heavy things...
Exam Qs were about GERD and IHD
ST3;=> CNS= walking difficulty.... stiffnes in

both legs , hyperreflexia n metal in left knee
after surgery..... touch sensations loss upto Mid
thigh.... position sensations ok...spine ok......
viva about causes of leg stifness n MS...
CVS:) midsternotomy scar , tremors on hand
examination.... ddx of midsternotomy scar
given..... viva was about heart transplant n
imunosupresion
Station 4;) esophageal perforation on

endoscopy...talk to angry daughter.....
Daughter asked me 5 times that i want the name
of doctor who did this..... then she asked wat
will u do with my father..... she want to take his
father to another hospital....... she wants to
make complaint.....
Diet 32018 Egypt
13/10/2018
#Station1
¤ Chest
Discussion was about fibrosis
Score Only 7/20.
¤ Abd :
aged patient
management .
Score Only 8/20
THIS CANDIDATE ALMOST FAILED FROM 1ST
STATION...
AT THIS POINT CANDIDATES FOLLOW 2

PATHWAYS:
1. To evaluate & score themselves, got
depressed and go to next station/s defeated,,,
OR
2. Take PACES as (5 INDEPENDENT EXAMS) &

forget about the previous bad performance AND
GO TO THE NEXT STATIONS motivated and
increase their chances of success
LET'S SEE WHICH PATHWAY OUR FRIEND

FOLLOWS
#Station2
Outside,
management .18/20
#Station3:
Neuro : Lower limb;
19/20
#Cardio:
18/20
#Station4:
outside :
Uncontroled and refusing steroids because she
was given steroids before and causing weight
gain ,
Inside :
tell me more ....
activity .
choice. 16/16
#Station5:
¤ BCC 1 : outside
pigmentation
Analyzed the complaint and complete the format
Concern
management plan .
28/28
¤ BCC2 : outside, shortness of breath (inside ,

the case
28/28.
THANK YOU DR. AHMED FOR EXEMPLIFYING

THE FOLLOWING POINTS:
1. TO PASS PACES ONE DOESN'T NEED TO
PASS ALL STATIONS
2. YOU NEED TO SCORE THE MINIMUM
PASSING SCORE OF 130 ( +) TO ACHIEVE THE
MINIMUM PASSING SCORE FOR EACH OF 7
SKILLS
THEREFORE, TAKE EACH STATION AS AN

INDEPENDENT EXAM
CONGRATULATIONS DR. AHMED ON YOUR
WELL DESERVED SUCCESS & lots of thanks
for the detailed feedback
#Short_collection for St George's exam

experiences
#Memmories
St George's 3/1/18. Carousel 3.
Station 3. Metallic mitral valve replacement.

Neuro: Peripheral neuropathy.
Station2 : Fever, night sweats and

lymphadenopathy.
Station 1.: renal transplant and hearing aids::

alports syndrome.
Resp.: COPD on LTOT.
station 4.: ADPKD in father now on

dialysis..explain disease to son. And address
his concerns.
Station5;
Pt with raised LFTS. gay, HIV, Hepatitis.
Station5.polymyalgia rheumatica
St. George’s hospital London
Abd renal transplant Av fistula
Cns lower limb brisk reflexes sensory ataxia

asked to localise lesion
Resp lung fibrosis also had midline sternotomy

scar with harvest scar in leg
Cvs aortic stenosis

History- type 1 diabetic frequent hypoglycaemia
attacks anaemic and weight loss
Communication young female sah normal ct

needs lp wants to go home
Bcc1 diabetic peripheral neuropathy

Bcc2 headache cerebello pontine angle tumour
signs
Abd with lots of scars ( central midline

encircling the umbellicus, multiple laprascopic
scars from ports, scar at the side of the head)
no organomegaly.
Resp pul fibrosis with central sternotomy scar
St2 dyslipidaemia with new onset diabetes,

strong family history of MI.
St4 a terminally ill COPD or , she is not

responding to IV antibiotics, NIV, competent and
wants to go home and not be readmitted of she
deteriorates. Son is worried and wants her to
stay. No one to look after her, he has the LPA.
Talk to him and explain and address concern.
CVS old lady with SOB , AVR no metallic click.
Neuro young man with falls
left umn signs with cerebeller.
St5 found female with polyuria and h/o renal

stones, rbs 18.9
Young female with chest pain pericarditis
#Short_collection for Wythenshawe Hospital's

exam experiences
#Memmories
UK experiences
1- Wythenshawe Hospital 12/10/17.
Resp: Bronchiectasis with COPD features
Abdo: renal transplant and PKD
History: patient with history of colonic cancer ,
metastatic to liver and she refused
chemotherapy after discus with oncologist and
now for palliative treatment presented with
constipation and on examination no feature of
obstruction
talk to the patient.
Inside: I took history of Constipation and DD-
Opioid induced 2- Hypercalcemia 3- it’s her
terminal condition
concerns: 1- wants to enjoy her life 2- afraid
from chemotherapy side effects .
I offered her some laxatives, palliative input and
discussed chemotherapy refusal.
Cardio: 27 years female with high BMI , no
Murmurs only subclavicular device.
outside history recurren chest pain
I said it could be arrythmia or cardiomyopathy
they insist on types of Cardiomyopathy and I
think the diagnosis was viral cardiomyopathy.
Neuro : lower limbs examination shows nothing
obvious,however, I noticed from back exa that
both scapula removed
I told FSHD
communication:
neglected old patient with NG feeding and
soaked with his urine .
his daughter very angery and wanted
explanation
discussion about neglect and IR1.
BCC :
A: Psoriatic arthropathy with knee OA
B: Hypoglycemia , young patient collapsed and
history of T1DM.
other experience in this diet
communication : CPR done for a patient despite
advanced directive
communication: NHL
previous experiences
History: sudden loss of vision in Rt eye
it was IE in patient with leaky valve and recent
dental extraction.
#########################################
#################
Wythenshawe hosp
Station 1
Pulm fibrosis
Hepatomegaly jaundice, midline laparotomy
scar and right iliac scar. Couldn't find kidney..
examiners kept asking for causes of the midline
scar..is liver transplant possible? Anyways
didn't say that.
Station 2
History- spoke to pt s daughter.pt confused
found wandering in street. Pulse 56/ min.
Dementia and slowing in activities + old MI on
drugs. She said that her father kept asking to
refill her meds again, though it was refilled a
week ago. DDI said B block overdose, lewy body
dementia, sepsis
Station 3
Cardiac MR
Neuro cranial N. Very confusing..had R side
INO. L side ptosis..she has smell and hearing
defect. DD SOL, Stroke,DM
Station 4
Pt has ILD worsening.. should discuss with son
about palliative treatment. I told he might need
nursing care. But he was very furious that he
can't let him go away from him. I was not sure if
we could give him the palliative care at home..
Station 5
BCC1 IVD user ALT increased.
DD. Hepatitis, HIV autoimmune
BCC2 spo2 94% RR 25. Chest pain.known

asthmatic. No travel no clot risk factors. Had
creps B/L. DD PE, PPH.
#########################################
###################
11 oct Wythenshawe Manchester :

Hemiplegia,
AVR ? ,
Lobectomy vs single lung transplant ,
CLD.
St recurrent falls with postural hypotension &
proximal myopathy
St 4 : follow up pt , 6 weeks back admitted with
asthma , cxr had 2 uncertain opacities which
needed further imaging . Pt not told about
findings in previous admission. Also past
history of breast cancer treated with
lumpectomy chemo.
St 5 back pain + rash + joint pains dd
Ankylosing spondylitis psoriatic
St 5 headache Acromegaly
#########################################
#####################
My exam was in wythenshawe Manchester

: In station 5 my first case was on ANGINA.
instruction was like that::: middle aged lady
present with chest pain. All finding are normal
on observations. On taking history, chest
tightness for couples of months on exertion.
HTN, HYPERLIPIDEMIA, ON TREATMENT.
2nd case . Young lady present with collapse

while listening music
It was a 2nd episode, first 3month back without
warning, no chest pain or palpitation. I took
history from cardiac as well neurology point of
view. Social history was significant as she was
a bus driver. I follow the history, exam, and ask
for concern. And advise not to drive.
#########################################
########################
I started with st 1
Resp case was idiopathic pulm fibrosis with
drum stick clubbing and sob at rest pt was on
oxygen and could hardly speak. Findings of ILD
was very straightforward. Thay asked about the
DD investigations management plan
significance of pirifenidone therapy types of
oxygen therapy. I got 20/20
Abd transplanted kidney in bilat renal mass pt

my DX was ADPCKD. With functioning
transplanted kidney. They asked about
immunosuppressive ttt and its side effects
causes of impaired renal functions in FU I got
20/20
Station 2 a case of long term IBS with altered
bowel habits typical of steatorhea plus mouth
ulcers. No other positive dsta at all. Concern is
that cancer. I gave DD of malabsorption. She
told what is your 1st posdibolity I said chron's
because of oral sores. What invest. I think thr
case was cealiac. I got 16.
St 3 Cardio was rather difficult. About 40 years

old male with median sternotomy scar large lt
lat thoracotomy scar ( reaching near spine on
the back) and saphenous scar metalic 2nd HS
and pansystolic murmur all over the precorfium
more in lt 4th 5th parasternal area.
I told it is difficult to interprete and gave
possibility of blalock tussing in fallot and AVR
and CABG and may be associated lung disease
required surgury
They asked what will you do.
I told I will take history to know for what all
these durguries. What invest and plan I
answered as valve replacement case
Got 20/20
Neuro case was female about 30 years old

instruction to examine LL as she has weakness
in both ul anc LL
ON EXAM purely MOROR LMNL. I had no time to
examine 7th and 11th nerve.
I told dystrophy fascioscapulohumoral vs
becker. She told look to her face can you notice
any thing i told i need to examine. Asked about
invest and ttt and insisted that pt needs a fmily
what will you advice.
Got 18/20
St 4 meningococcal sepsis presented acutely

with shock and xhifting to icu now. Meet wife
and explain what is happening and answer her
questions.
Wasn't easy case. Most important was local
health authorities notification and track8ng all
contactd and care of his wife and kids
I made a mistake that I gave her only 2
possibilities deterioration and death and
tecovery. Long term handicappjng or other
partial recoveries not mentioned anx yhey
asked me why not mentioned. They tolx you
know how old are hos kids? Shd hax anewbofn
baby what measured needex for care.
I got 11
Bcc1 TIA fascial palsy and dysaryhtia in T1DM

HTN 41 yrs old male
Got 25
Bcc2
Peripheral sensory neuropathy in 60 yrs old
male known hemochromatosis he had ascitis
DM impotence on venesection no cardiac failure
Got 27
Overall 157 alhamdo lellah
Approach to tremor as BCC case:

Probable scenario - Mr. Williams, 50-year-old
teacher, presented with hand tremor and
difficulty writing. Please assess him.
Focused history-
1. Details about tremor: Onset, duration,
progression, which parts of body affected,
uni/bilateral, when it occurs- at rest/maintaining
a posture / during activity, aggravating and
relieving factor.
2. Associated features : slowness of movement,
difficulty walking, speech difficulty, palpitations,
heat intolerance, excessive sweating.
3. Effect of tremor on his daily activities, driving
and job.
4. Family history.
5. Medication history : Salbutamol, Theophyline,
Antipsychotic, Anticonvulsant,
Lithium,Thyroxine.
6. Personal history : Recreational drug abuse,
smoking, alcohol.
Focused examination -
1. General appearance : masked like face,
thyrotoxic face, head tremor.
2. Tell the gentleman to keep his arms on his
lap: Asymmetrical resting tremor in PD. If no
tremor, tell him to count from 20 to backwards
like 20, 19,18...(tremor of PD increases with
mental activity) If tremor present, examine for
bradykinesia, cog-wheel rigidity and upgaze
palsy.
If no tremor, do finger-nose test. If positive, do
other cerebellar tests- nystagmus,
dydiadocokinesis and gait.
If FNT is negative, examine for postural
tremor(out-stretched hands with spreading
fingers).
If positive, examine thyroid gland,pulse and
proximal myopathy.
I will look for observation chart and will do
bedside urine dipstix.
Concern: Is this Parkinson's Disease, doctor?

Suppose findings are consistent with Benign
essential tremor.
Explanation : After listening your history and

performing clinical examination what i found
that you have a condition called Benign
essential tremor which is a familial condition of
shakiness of hands and head. It partially
improves with taking alcohol, as you mentioned
and I will give you beta blocker now to ease
your symptoms. I will also arrange some blood
tests and scanning of your brain to exclude
other causes of tremor. After getting the test
results, I will refer you to nerve doctor. Thank
you.
DDs: Thyrotoxicosis, PD, Anxiety disorder.
My experiance MRCP PACES
Diet 3 Egypt alkasr ani

Start with st 5
BCC 1 fatigue; HYpothyroid. 28
BBC2 acute confusion.. I had Mental block i
didnt ask about infection, urinary symp, surgate
stress that he is living alone,, .. EXaminer,, he
lived alone is it significant? .,, again mental
block, i dont enquire about propability of
trauma. 12?
St1
Resp COPD vs OHS (obese pt). 18
ABD thalathemia major examiner DD: Other
causes of CHA, Against SCA? there was
splenectomy, other Qs inv, complications,
cutvalue for bl transf, I answered Hb7. 20
St2 History myathenia graves. Fatigue incresed

at the end of the day, wt loss mostly dt
dysphagia, SOB with mild effort., DD LEMS. I
offered admisdion, inv., bed side test?
Edrophonium test. Ttt of MG. 20
ST3
Neuro LL ex short limb with LMNL pure motor:
polio, I noticed hypereflexia of knee jerk but i
denie it during presentation, examiner ask me
what is about knee reflex so i tell hyper so, ask
me why? I respond may be ass with UMNL Like
stroke 20
CVS MVR, AVR well functioning. Qs inv,
treatment. Coag profile and warfarin is so
important (role of novel oral anticoag? no role
for novel anticoag in prothetic valve), 20
St4
Commun BBN Uncertain diagnosis , consultant
suspecting pancreatic ca vs cholangeoca after
doing ERCP and us , but still no definit
diagnosis 16
Alhamd lelah I passed ; 154
Advise
1 ‫االعتماد على هللا والتوكل عليه‬.
2. Forget the station u finished and concentrate
on the next, my 1st st BBC 2 , I know that i
forget trauma and infection so, I was sure that I'
ll fail in that station, but, i forget it and i
concentrate in the next stations
3. Self confidance is v imp
Egypt 13/10
Station 1 chest
Inspiratory crepitations with mild wheezes and
clubbing
Abd :
Palmer erythema , palor, huge spleen (normal or
shrunken liver )
Station 2 :
joint pain with anaemia ,high creatinin , low e
GFR, high cry.
He has Hx of sinusitis .
Station 3:
Neuro : Lower limb
Cardio:
MR, AS irregular pulse
Station 4:
Uncontroled asthma refusing steroids ...
Station 5:
BCC 1 :
BCC2 : shortness of breath (inside ,
scleroderma with pulm ).
Pray for me please .
: Experience of one candidate uk 7/2018

UK
Edinburgh. 10.07.18
Western General hospital
St 1 :abd : multiple abd scar : rt ileac Fossa and

transverse laperotpmy scar + AV Fistula on both
hand with scar for tunnel catheter. Pt had
bruise.
Examiner q :why bruise? I said for
immunosuppressive. He was not convinced. I
found some heoatomegaly. But other didn't say.
Respi: rt thoracotomy scar - I found everything
normal. Except obstructive feature. Asked why
scar : said lobectomy, pneumonectomy, asked
why was done, inv, rx of ILD
St 2 : hypercalcaemia : Pt had wt loss,
Dysphagia to solid, back pain, all feature of
hypercalcaemia. Gave dd of mm, malignancy
with 2ndary mets.
St 3: cvs : marfanoid feature with scoliosis and
correction scar, high arched palate,
arachnodactyle,, I said Mr, tr, with af. One said
ar. Examiner asked both
Cns: Confusing, pt had tremor, walking aid,
sensation said normal, I said Parkinson and
pps. All question was about Parkinson and
Parkinson plus.
St 4 : Pt with lung ca has mets to brain on
palliative rx. Then at home he was given
fentanyl patch for pain relief. Developed seizure.
Admitted to hosp and patch was missed.
Surrogate was wife and complaining, crying but
understood. Examiner asked lots of q... Duty of
condour specially.
St 5 : bcc1 : goitre with Thyroxin. Has increased.
Gave dd of incomplete dose, recurrence,
malignancy but rare.
BCC 2: malena... Migrain pt takes 6 ibuprofen
and no anti ulcer... Had previous episode
before. Dd: bedding dyspepsia, hht
Western general hospital Edinburgh,
18/july/2018
Started with st4
hyponatremia induced seizures
St5
Bcc1:
Old aged lady with long standing joints pain,
and sob, referred for regular follow up
inside lady with marked symmetrical hands
deformities, got worse since 6 months, with
past history of psoriasis. concern was: is it flare
up
dd: psoriatic arthritis
RA, MCTD
Bcc2:
Old aged gentelman with lethargy since 6
months, underwent pituitary surgery on 1986
inside patient with acromegaly, complaining
from lethargy and decreased libido, everything
else were negative
Examiner question what is the cause of
lethaergy?
St1
Respiratory:
Pulmonary fibrosis
Abd:
Renal transplant
LIF scare
Viva about APKD
i could not palpate polycystic kidneys
St2:
Palpitation in 55 yrs old man, more frequent
since 2weeks, an episode of palpitation for 20
min recently with lightheadedness, no risks for
ihd, no any other cardiac symptom, father
sudden cardiac death on age 42, working in
coffee shop taking 5 caps of filtered coffee per
day, h/o anxiety taking 150 mg sirtraline for, 5
yrs back same problem for which was evaluated
and only PVCs were detected and which were
not considered of clinical importance that time.
DDx:
anxiety related palpitation
Caffiene intake
LQTs
Brugada synd
IHD
St3
Cardio: slow rate AF and MS?
Neuro:
peripheral sensory neuropathy
For bcc 2 the causes of lethargy:

1- panhypopituitarism.
2- hypothyroidism.
3- obstructive sleep apnoea due to acromegaly.
exam experience in wishaw general hospital
wishaw. Glasgow centre 2nd November. I
started from station 5. 1st scenario was of a
lady with RA complaining of recent SOB and
family physician did chest xray which doesnt
show any malignancy but some scarring. She
was on methotrexate and she had pernicious
anemia too. I found right sided fine creps (i
guess left sided too) i gave diagnosis of pulm
fibrosis secondary to either RA itself or
methotrexate. Q: D/D. i missed taking h/ o
smoking and examiner asked : did she smoke. I
sa.id sorry i didn't ask, then he asked, in case.of
smoking what will be differential.
BCC2: a lady with multiple swellings in neck
and some problem in mouth (i couldn't
undesstand well about mouth features, i guess
decaying teeth. No characteristic lesions). She
had almost all neck glands palpable.
(Submandibular, parotid, cervical lymph nodes,
some drs noticed surgical scar below jaw which
i didn't notice ). She didn't have any weight loss
etc (i gave d/ d of miculicz syndrome as she had
pernicious anemia also, thinking autoimmune
process and examiner asked.what else, i said
lymphoma, he asked which is most probable, i
said she doesn't have B symptoms :-) he said u
didn't ask about it in history =-O). Which made
me nervous and i couldn't give good
management plan :'(
Station 1: abdominal examination was
hepatospelnomegaly and i guess was simple. I
didn't find any signs of CLD but now i doubt that
maybe there were spider nevi. :-P respiratory
was classic COPD case, went fine. Q: d/ d of
wheezy chest. How will u differentiate
asthma.and copd. Investigation, management
plan.
History: lady with lethargy and fatigue for 3
months. Gp started citalopram and now referred
for hyponatremia 124, history exploration
revealed weight loss and cough (gp started
managing as asthma.). She also had
diverticulosis previously and family hx of ca
colon. Was concerned about that. I gave d/d of
SIADH due to paraneoplastic syndrome,
citalopram induced hyponatremia. How will u
investigate.
Neuro : lady with.clumsiness, examine upper

limb. I found pill rolling tremor (in happiness i
missed exam routine for which they
categorically asked.. what about
reflexes...proprioception, which i missed
examining. Key is to do full scheme of
examination ). Viva: d/d. How will u differentiate
PD from parkinson plus (and asked whether u
looked for any signs, which i missed checking ).
CVS: man with midline sternotomy scar, has
sob ( i didn't concentrate on command so
missed important d/d), i gave diagnosis of
tissue valve replacement as no metallic click or
vein harvesting scar. They asked why he has
sob. and i became confused that only then i
noticed that scenario was for sob. Anyhow i
managed to answer a bit but as sob was not in
my mind so cpuldnt notice valve functioning
etc. People say he had aortic stensoaia murmur
which i didn't appreciate.
Station 4: counsel.angry son of patient. Patient
had femur fracture and she shifted to rehab
where she was started on steroids as doctor on
duty suspected giant cell arrteritis when lady
complained of headaches. After steroids she
developed psychosis and MDT thought that she
should be shifted to hospital. Son was next
of.kin and was angry why she was shifted
without informing him and why dr gave steroids
and wanted to complain. Asked about further
management and issues. I guess i did well in it.
Viva : how did this meeting went, (plz notice that
for station 4 usually examiner ask this question
that how did this neeting went). Asked about
ethical issues and what ethical issues u know.
Asked me in real life if u encounter an issue like
this how u will manage. also asked whether i
missed some issues .
exam experience glasgow 27/6 golden jubilee
hospital
Station one :
Abd: obese female , only positive finding is
Palmar erythema
DD liver cirrhosis
No ascites no organomegally
Chest :
Thoracotomy scar
Normal examination
Station 2
65 years old female with ID anaemia . I turned
out that she is taking ibuprofen for knee pain
Station 3 :
Cardio 60 years old male with light headedness .
Finding : thoracotomy scar . Bilateral
pacemaker scars
Metallic second heart sound
Neuro: examine the upper limbs of a patient
who drops thing
Parkinson's tremors
Station 4
Speak to the daughter of 93 years old lady with

dementia CKD ., heart failure ., fracture pelvis ,
admitted with pneumonia . CURB65 is 3 . DNR
decession was made . The daughter is very
angry about it .
( did it very bad as she was shouting and crying
all the time )
Station 5
Bcc 1
78 years old with sudden onset of LOC for
minutes his colour changed to grey . No
symptoms before it
Bcc 2
21 years old lady with joints pain

Denies any skin rash or ulcers
Pain is mainly in the wrists , symmetrical with
morning stiffness .
Family hx of SLE
Wolverhampton Hospital
Here are the cases :
Station 1 :
Abdomen
Splenomegaly with jaundice and Vitiligo
Respiratory :
Cushingoid patient with midline Sternotomy
scar otherwise normal examination
Station 2:
Middle aged female with previous history of
headache is referred with continuous headache
despite paracetamol and tramodol intake .
station 3:
Cardiology:
AVR
Neurology :
Stroke
Station 4:
Middle aged female with Uncontrolled DM
diabetic retinopathy has been diagnosed with
Nephropathy as noticed by protrinurea and were
given ACE inhibitors .
Task is to check compliance and counsel about
ACE as kidney protective medicines .
Station 5:
BCC1:
SOB and CHEST PAIN :
Inside scleroderma
ILD and GERD
BCC2:
Vision problem
inside she told about diplopoda
Turned out to be Myasthenia Gravis
Soba Teaching Hospital

Khartoum - Sudan
Day 2 Cycle 3
Started with Station 1
Station 1⃣
CHEST : Left Upper Lobe Fibrosis.
Abdomen : ADPKD
Station 2⃣
History : A Young male Knwon to have Asthma
since childhood, recently has worsening
wheezing, cough and SOB for last 3 months .
Also
has Vasculitic rash in his Leg in started 6
weeks ago and recently started to work as a Car
mechanic. DD: Churg Strauss Syndrome.
Occupational Asthma
Station 3⃣
CVS : DVR
CNS: GBS
Station 4⃣
Esophageal perforation after dilatation talk to
son Explain the Esophageal Pneumatic
Dilatation and the perforation. Son want to take
him home. Also asked not to tell his father
about the complication because his father will
be worried. Acctually I did Bad in this Station
😞😞😞😞
Station 5⃣
BBC 1. Transient loss of vision
Was TIA and Stroke other candidate mentioned
TIA and Migraine. Patient was having headache.
Also out side her BP is 180/100.
BBC 2 : Outside Young lady with Dysphagia
inside was Systemic sclerosis also has hair fall
in questioning her. Concern what she has and
why she lost weight. I mentioned Systemic
sclerosis I forget to Say mixed Connective
tissue disease because she also has Hair fall.
Pray for your Brother to Pass this exam.
Experience of a friend
SOBA TEACHING HOSPITAL -SUDAN
Day 1 (08/12/2018)
Carousel 1 :-
#Chest :
bibasal lung fibrosis upto mid zones.
#Abdomen:
ESRD with non functioning av fistula and
rejected transplanted kidney, patient has tunnel
catheter for dialysis now.
#History:
Middle age with chest pain for 6 weeks
aggrevated by heavy meal and he is heavy
smoker. FH of sudden death at young ages.
Working as labour.
DD: IHD AND ,GERD, MUSCULAR .
#CVS:
Female with mitral regurgitation and pulmonary
hypertension.
# NEURO :
Not sure, hypertonia in both lower limbs with
hyperreflexia on the knee and areflexia on the
ankles and mute planters and pyramidal shape
weakness.
Gave MND as diagnosis and time up.
#Communication:
Elderly lady diagnosed 3 yrs ago as mild
parkinson not on medications admitted with
acute confusion with UTI and stiffness . talk to
her daughter.
Daughter asked why not given antiparkinsons 3
yrs ago?
Is she will be ok?
Who will take care of my father at home,he has
stroke and iam living faraway?
Viva :
Clinical questions of parkinson and parkinson
plus and antiparkinsons and their side effects,
no ethics at all.
#BCC1:
Middle age male with visual problem.
Retinitis pigmentosa.
#BCC2:
Middle age female with haematuria and polyuria
and high BP and her brother had kidney stone
before.
He did it as polycystic kidney disease but he
mentioned hypercalcemia for DD.
DAY 2 (09/12/2018)
CAROUSEL 1:-
■COMMUNICATION :
granddaughter.
Concerns:
What about feeding?
time?
Viva questions :
resort.
her?
■BCC1:
☆Stem:-
normal.
●syncope for few seconds when try to catch the
Viva questions :
Positive findings :as I mentioned above 👆🏻.

and AR).
replacement?
Target INR.
■BCC2:
☆Stem:47 years female present with headache

●headache with no specific character and no
Viva :
Findings (nothing)
for splenomegaly.
Missed the case .
■CHEST:
●Positive findings:
.
●DD:
●what is the cause in this pt?
●what else?
●what else can cause clubbing and crackles.
●what is the main cause of bronchiectasis in
Said pulmonary TB.
●How to solve the dilemma now?only one thing.
●Give me only one thing the patient will get
benefit from it?
drainage w
ith physiotherapy and
stopped me.
●what are the complications of bronchiectasis?
amyloidosis.
●if pt with bronchiectasis developed stroke
■Abdomen:
●Diagnosis:
●examiner asked I saw you went back to the
the common cause.
●what are the other causes?
Said HTN,GN,DRUGS and POLYCYSTIC
KIDNEY DISEASE which I need to rule ou in this
patient.
●what is your work up?
complications.
●If she is following with you in the clinic how
Said:
types .
●How you will treat anaemia?
Iron tablets.
●what if can't tolerate?
Said iv iron.
●would you like to give blood?
you know why?
Said I don't know.
blood.
■History :
I put:
Tension headache.
●she insisted for CT but I said no indication at
■NEURO:
findings:
high steppage gait.
●what's your diagnosis?
●what others?
Uremia.
●How you will investigate?
Said :
Genetic test.
NCS and EMG.
NERVE BIOPSY.
FBS and HbA1c.
RFT.
TFT.
He stopped me.
●How you will treat him?
neurologist.
accordingly.
●what vitamin deficiency can cause peripheral
neuropathy?
Said vitamin B 12.
●is it treatable?
●any infection can cause peripheral
neuropathy?
■CARDIO:
●What's your diagnosis?
●what's could be the cause?
●what is the cause of valve problem in this pt?
Congenital .
marfan.
●what are the investigations? What is the target
INR?
●How you will know the valve is not
functioning?
●How you will manage.?
●which type of anticoagulant?
Said warfarin.
●Did you hear about new anticoagulant?
●which one of the novel anticoagulant you will
use?
He said yes.
●Any advice of this patient ?
Like what food?
Please pray for me I did bad and it's my last
trial.
Diet 32018 Egypt

13/10/2018
#Station1
¤ Chest
Discussion was about fibrosis
Score Only 7/20.
¤ Abd :
aged patient
management .
Score Only 8/20
THIS CANDIDATE ALMOST FAILED FROM 1ST

STATION...
AT THIS POINT CANDIDATES FOLLOW 2

PATHWAYS:
1. To evaluate & score themselves, got
depressed and go to next station/s defeated,,,
OR
2. Take PACES as (5 INDEPENDENT EXAMS) &
forget about the previous bad performance AND
GO TO THE NEXT STATIONS motivated and
increase their chances of success
LET'S SEE WHICH PATHWAY OUR FRIEND

FOLLOWS
#Station2
Outside,
management .18/20
#Station3:
Neuro : Lower limb;
19/20
#Cardio:
18/20
#Station4:
outside :
Uncontroled and refusing steroids because
she was given steroids before and causing
weight gain ,
Inside :
tell me more ....
activity .
choice. 16/16
#Station5:
¤ BCC 1 : outside
pigmentation
Analyzed the complaint and complete the
format
Concern
management plan .
28/28
¤ BCC2 : outside, shortness of breath (inside ,

the case
28/28.
THANK YOU DR. AHMED FOR EXEMPLIFYING

THE FOLLOWING POINTS:
1. TO PASS PACES ONE DOESN'T NEED TO
PASS ALL STATIONS
2. YOU NEED TO SCORE THE MINIMUM
PASSING SCORE OF 130 ( +) TO ACHIEVE THE
MINIMUM PASSING SCORE FOR EACH OF 7
SKILLS
THEREFORE, TAKE EACH STATION AS AN

INDEPENDENT EXAM
🔷 Diet 3 experience
✔️ Abdomen : CLD
✔️ Resp : COPD
✔️ Cardio : maybe MR
✔️ Neuro : hemiplegia
✔️ St 2 : Cystic fibrosis
✔️ St 4 : Bbn of pheochromocytoma
✔️ BCC 1 : Prolactinoma
✔️ BCC 2 : Hypothyroid
🔷Diet 3 experience
✔️ station 2 : was a case of recent exacerbation

of bronchial asthma following a new job as a car
mechanic with h/o exposure to spray
paint+smoker +he had a recent non-blanchable
purpuric rash on his left leg-which i couldn't
correlate.
✔️ CVS: s/p MVR with AF in CCF + i also heard

an ?EDM (another candidate too did hear) +Rt
leg cellulitis - - discussion went on Infective
endocarditis, valves and anticoagulation.
✔️ CNS:left hemiplegia for motor examination.
✔️ Station 4: elderly lady admitted with

uncontrolled DM & left leg cellulitis since one
month developed overnight gangrene due to
vascular occlusion and team of consultants
including vascular surgeon have decided only
below knee amputation will save her from dying
but she's not willing to undergo surgery. She's
fully aware of the risks involved but she's
suffered a lot recently & didn't want any more.
But the daughter wants the surgery done & had
to talk to her regarding her mother's decision.
There was autonomy, consent & mental
capacity didn't go very well
✔️ BCC 1: systemic sclerosis patient with

recent worsening of SOB & dry cough with Spo2
88%.
✔️ BCC 2: Rt knee gouty arthritis in a heavy

alcoholic with p/h/o HTN not on any meds
✔️ Resp : COPD with corpulmonale but also

had bibasal fine crepts, so i gave both COPD
and ILD as dd's
✔️ Abdomen : Decompensated CLD with gross

ascites and bipedal edema
🆕 Diet 3 experience
✔️Abdomen - CLD
✔️Neuro : hemiplegia
✔️ RESPI - COPD
✔️Cvs - MR+Pul HTN
✔️ St2 - Repeated fall...ramipril postural

hypotention
✔️ St4 - UTI for 2 dayz...now

confused..delerium
....h/o alzeimer+OA....bed ridden...talk to grand
daughter...palliative
✔️ BCC 1 :anti TB induced hepatitis
✔️ BCC2 2 : Malaena due to Diclofenac....
🔹Another diet 3 experience
➡️ By Paces Network
✔️Resp : copd with right lateral chest 2 scars ?

Vats ? previous chest drain
✔️ Abdo - icterus with ascites
✔️ Cvs - ejection systolic murmur heard all

over precordium but not radiating to carotids in
20-30 yo male; loud P2 and parasternal heave
✔️ Cns - left sided hemiparesis with increased
tone, upgoing left plantar but reflexes not
elicitable
✔️ Bcc1 - abdominal distension and leg

swelling in chtonic alcoholic
✔️ Bcc2 - you are in endocrinology clinic.

Patient on follow up for thyroid problem
presents with headache and redcwatery eyes x
1 month. O/e diplopia on right lateral gaze
✔️ Stn 2 - 27yo male presents with abdominal

pain and loose stools x 6 months but no blood
in stool or weight loss. No response to
mebeverine. Has nocturnal symptoms
✔️ Stn 4 - patient with parkinsons disease

admitted for fall. Today is day 3 of admisdion. Pt
very stiff, not sble to get up from chair, not able
to walk to toilet. Also pt noted to cough while
drinking and team suspecting aspiration
pneumonia. Nurses mention today morning that
cocareldopa not available since admission.
Task is to talk to concerned/angry daughter
SEP 29,2018
Whipscross
Abd: Splenectomy
Res: ILD with RA
CNS: HSMN upper limbs
CVS: AR with CABG
History: Acute confusion due to lithium toxicity

on background of acute pre-renal kidney injury
Counselling: seizure due to theophylline in

COPD patient
BCC: Headache and visual disturbance: BIH

Weight gain and fatigue: Cushing's and OSA
🆕 Sep 29, diet 3

✔️Abdo - renal transplant
✔️Resp - systemic sclerosis with pulmonary

fibrosis
✔️Neuro - weakness in shoulder movements -

not sure of diagnosis
✔️Cardio - aortic valve replacement
✔️History - weight loss in 45 year old with type

1 diabetes
✔️Comm skills - haemorrhaging stroke in

patient on warfarin.
✔️BCC1: weight loss in young patient and pale

stool - malabsorption
✔️BCC2: unilateral leg weakness in a young

patient, no improved.
with previous visual problems - had eye signs.

Suspect MS
✅ Diet 3 UK exam, 30th September
✔️Station 2: 40 year old male presented with

dysphagia
Station 3:
✔️CVS - MR,
✔️Neuro - CMT
✔️Station 4: A DNAR is being considered for a

patient (massive stroke in 80 year old with
aspiration pneumonia and now unconscious)
but not decided. Task was to speak to the
daughter to inform her of her mothers condition,
and do the relevant. Daughter wanted to not
resuscitate her mother but had to counsel that
its a health team decision that will be made in
the patients best interests.
✔️BCC1 - A young lady had facial swelling after

dental extraction.
✔️BCC2: A middle aged man with back pain

and morning stiffness
Station 1:
✔️Resp - ILD with RA on steroids.

✔️Abdomen - Abdominal swelling (I said
ascites) due to CLD (examiner asked what if the
patient had splenomegaly, although I couldn’t
feel any spleen)
🆕 experiences from diet 3
➡️ Station 4
44 y.o came to ER c/o SOB , evaluated by
cardiologist , he sees that he has TR and some
vegetations on the valve with previous hx of
on/off fever , dr noticed he has injection marks
in his both anticubital fossa , he came to a dx of
IE ,patient is stable now , cardiologist decided
conservative management, the nurse noticed
during the ER stay patient requests analgesia
for his headache he asked for pethidine please
speak to the patient regarding the high risk
behaviour and possible addiction.....
➡️ Station 2
Diabetic patient with abnormal LFT , his concern
was hand pain while playing golf
Dx is haemochromotosis
🔷October 3rd, diet 3

✔️Station 1: clubbing with bibasal fine end
inspiratory crepts.. Some said rheumatoid
hands..
So either IPF or PF secondary to rheumatoid..
✔️Abdo : splenomegaly. No other signs
✔️Cardio : metallic aortic valve replacement.

She had multiple bruises secondary to
anticoagulation
✔️Neuro : dystrophia myotonica
✔️History : myasthenia gravis
✔️Comm. skills: Alzheimer's dementia,

admitted with UTI. Still confused, pulling away
her cannulas, talk to daughter and address
concerns
✔️BCC1 : hand tremor
✔️BCC2 : diabetic sensory neuropathy, had

trophic/ ischemic ulcers in both feet, new on left
foot..
Station 1
1. Pulmonary fibrosis with right thoracotomy
scar mark
2. Renal failure with AV fistula on left arm on
dialysis
Station 2
50 years old lady with dysphagia for solids for
18 months with weight loss.
Station 3
1. Throcotomy scar with atrial fibrillation MVR
with AF
2. Upper limb examination with slow releasing
grip any myotonia- myotonica dystrophica
Station 4
An old lady with dense hemiplagia, aspiration
pneumonia and confused.speak to her daighter
who doesnt want any further treatment- discuss
the reason and answer her quries
Station 5
1. Rheumatoid Arthritis with joint pains
2. Myotonica Dystrophica presented with dizzy
spell and syncope
Today Oman
History
Unexplained Iron deficiency anemia
Communication
HOCM
Station 5
Acromegaly
Systemic sclerosis
UK today
St 1 resp copd patient distressed sitting on

chair when she saw me started to move to bed
and it took at leaset 1.5 to set in bed and also
has lobectomy
Abd renal transplant
St 2 pt with SOB and lost 3 kg with past history

of MI , PMR,smoker and on steroids job retired
and at the last end mentioned he exposed to
asbestosis
St 3 cardio pansys murmur ? TR
Neuro exam in the patient neurologically 'LL

flexes dealers than extensors more on the left
side lost sensations till the knee + urinary bag
St 4 patient with history of hip surgery 2 w and

felt in hospital 1w and became confused was on
prophyl clexan and antiplatelets and orthoteam
mentioned UTI and transfered to medical team
who did CT brain showed frontal bleeding meet
the daughter who does not know the result of
CT
St 5 patient with Graves + dizzy spells
St5 patient Turner with HTN, sternotomy scar
Oct 4 AFH Oman diet 3
Started with station 1

Bronchiectasis with clubbing and cyanosis
There course cryptatoin
Abd was spleen 4cm for dd

The discussion was about chronic liver disease
Station 2
Asthma get wors after joining a new job and pt
noticed skin rash on his legs
Dd occupational asthma and ch Strauss
Concern about his job
Station 3
Avr and mitral regurgitation
Station 3 neuro
Upper limb was Parkinson’s
Station 4 Parkinson’s admitted 2 days ago for
fall ditarurated and developed aspiration
pneumonia
U revised his files to find his medications for
Parkinson’s no written in the medication list and
he did not taken his medications for 2 days
Talk to his daughter
Was angry relative
Station 5
1 Rh arthritis with carpal tunnel
2 goiter after sore throat
Station 5 was not obvious
🔷 5th october
✔️Station 1 lobectomy d/t ca
✔️Isolated huge splenomegaly
✔️Station 2 tia in middle age female with

multiple risk factors. Complaint was dizziness
and h/o fall. D/ds bbpv, post circulation stroke,
menier 's disease.
✔️ St 3 : difficult cases
✔️Station 4 genetic screening for Hocm
✔️Bcc 1 : 3rd nerve palsy
✔️BCC 2 : Swollen limb of diabetic and

hypertensive patient
Oman,,, Royal hospital 5-1012018 2nd cycle:
Starting with station 5:

Bcc1: young lady with joint pain and skin
problem..
Inside pt. with psoriatic arthropathy
Examiner asked about findings, what's the nail
Changes that can be found, ddx, invest.
Bcc2: diabetic pt. with vision problem
Inside pt has IDDM, has problem with reading,,
has previous vision problem and on followup,
On funds exam:pt has dot hemorrhage,
maculopathy..
Examiners: summarize, what's ur findings, did u
see any neovascularization? Any laser therapy?
🙄,,, what's the management? Why u'll refer him
urgently to eye doctor? Disribe how
maculopathy looks in funduscopy?
Station 1:
Chest: bronciectasis with RT. lobectomy and
clubbing.. What's ur finding? Ddx? Invest.?
Management?
Abd: Renal transplant with small RT.
subclavicular scar and gum
hypertrophy...finding? Cause of renal
transplant?
Invest? If pt. Presented with fever,, what could
be the cause other than uti??
Station 2: 50 yrs old man, c/Oloss of vision in
RT eye..
Inside: pt suddenly lost his vision, no pain, mild
headache for 1 hr, past h/O similar cond.
Resolved spontously, pt has dm, htn,
dyslipidemia not on regular treatment or
followup,, he is smoker,, family h/O stroke and
MI in young age... Driving
Examiners: summarize? Ddx? Invest? For how
long u'll stop driving? What is the risk to
develop stroke?
Station 3:
Neuro: �♀️�♀️🏃♀️
CVS: AVR
Finding? Dx? Functioning or not? Ddx of
causes? Complication of AVR? Indication of
surgery in AS? Indication of surgery in AR?
indication for surgery in Infective endocarditis?
Station 4: 70 yrs old k/c htn and AF on warfarin,,
collapsed, found to have intracerebral
hemorrhage,,, INR:1.5 (target 2 - 3)...talk to
anger daughter....
Inside: surrogate wanted to complain the heart
doc. For giving warfarin
Examiner:summarize? What will u do next? Will
u start warfarin in the future? What other
alternatives? Advantages and disadvantages of
novel anticoagulants?
UK today

has lobectomy

asbestosis


CT
🔷 05/10/2018, 🆕diet 3
✔️Renal transplant
✔️History Iron deficiency anemia
✔️Cns Stroke
✔️Cardio MS
✔️Communication BBN CKD and missed

diagnosis
✔️Bcc1 Headache and 3rd nerve palsy ?

Pituitary apoplexy
✔️Bcc 2 TIA
royal hospital oman 3rd carousal 5/10/18
Rt renal transplant
rt lobectomy with bronchiactasis
hereditary angiooedema
AVR
spastic paraparasis
negligence iv amoxicillin in a known penicillin
allergic patient
systemic sclerosis CREST
cushing syndrome
Oman royal hospital ..6/10 first cycle

Station 1.
Abdomen..hepatomegally+splenectomy
scar+pallor( chronic haemolytic
anaemia..thalassemia)..respiratory..bronchiecta
sis with rt lobectomy upper
Station 2..cystic fibrosis
dd.Immunodeficiency
Station 3 spastic paraparesis with sensory
intact..cardio..aortic stenosis
Station 4 ..elderly with community acquired
pneumonia + hypertension on treatment
develop Delerium explain it for her daughter
and future managment..her concern about
feeding and it reversible condition
Station 5 obstructive sleep dyspnea for
differential...second polycystic ovary syndrom
🔷 🆕 diet 3 experience 6th october

St2-29 young male altered bowel habit 6
months- diarrhoea. No LOW LOA, not related to
food. Gp has prescribed mebeverine for ibs but
not improved
St4- to inform diagnosis of pheochromocytoma
and delayed of 5 years for the diagnosis. Was
under psychiatric gmc and hypertension clinic
for follow up
-u r not expected to know details of
management in the information
Bcc1 31yo 15 packs years smoking hx come
with polyuria and cough 3 months
-hypercalcemia 2’ lung cancer
Ddx; DI
BCC2- marfan patient with mvr before coming
with fever sob chest pain 1 week. History of
tooth extraction no prophylactic abx weeks
before.
Ddx: IE
MRCP 3rd diet 6th oct

Respi: bilateral MZ and LZ bronchiectasis with
ronchi
Abd: ADPKD
Neuro: bilateral LL UMNL
CVS: pacemaker/ iCD scars. No murmur,
probably HOCM.
Station 2: a young lady with palpiations. Further
hx just give birth 2 months ago. DDX: post
partum thyroiditis.
Station4: elderly gentleman admitted for CAP,
develop delirium and aggressive. Explain to the
son regarding the condition and further plan.
(son appeared to be anxious and cried at the
last 2 min)
BCC 1 : a young girl with bilateral hand
numbness. Further hx ESRF > 10 yrs. Recent
hyperparathyroidectomy few weeks ago, non
compliance to calcium. Diagnosis:
hypocalcemia.
BCC 2: middle age lady with hoarseness of
voice x 6/12. A/W difficulty and painful during
swallow. LOW 2kg. Deny neck swelling. No
cough. PMHX has arthritis on MTX. Deny
scleroderma sx. Strong fm of malignancy.
Breast and colon ca. Clinically no neck swelling.
Lungs: somebody commented bibasal crepts. I
commented clear lung field. Not sure regarding
diagnosis: ? apical lung ca
7/10/ 2018
3rd cycle .. oman SQUh
St1:
bronchiectasis
Transplanted kindey
St 2:
wt loss in IDDM
St 3:
DVR
F.ataxia
St 4:
uncontrol asthma .. concerning about side
effects of steroid inhaler
St 5:
BCC 1:
pcos (irregular cyle+wt gain
BCC2:
MEN1 (kideny stone+ hypo attacks).
2018/2 YGN IM2
Day 1 Round 1
St 4 talk to daughter of patient PCKD CKD Stage
4
Task . About mother conditions and her
concerns ... worry may happen to her , her
brothers , her childeren , about HD , Transplant
How can she reduces the risk of renal failure
Qs .. ethical n legal problems
St 2 .. angionerotic odema
St 1 resp .rt pleural effusion
Abd hepatomegaly with splenectomy scar with
haemochromatosis
St3 CVS valve replacement ( dual or single ..not
sure ) with midline sternotomy scar and
submamallary scar with PSM at mitral area
Neuro .. paraparesis with bilat EPR with
absence ankle jerk
BCC 1 DM with foot ulcer
BCC2- SOB with raynaund phe. N jt pain with
pul fibrosis
D1R1
CNS- c/o difficulty in walking
mixed LMNL & UMNL of lower limb
sensory level T 4
CVS- aortic valve replacement (dual?)
(mid line sternotomy scar & valvotomy scar)
St 4-
Talk to daugher.
ADPKD with CKD stage 4 in mother. admitted
days ago for UTI.
St5-
56 yrs man with DM c/o ulcer in lt
sole.(Neuropathic ulcer)
31yr women with SOB* 6mths(Pulmonary
fibrosis with MCTD)
St1-
Abdomen - ADPKD
Respi- Bronchiectasis
St 2- NSAID induced angiooedema
Day 2 round 1
St1. Resp=left upper mass with cervical ln
Abd= renal transplant with working AV fistula
(pt comes with fatigue)
St2. Headache and unsteadiness,N,V (DDx
Basilar Migraine, post circulation TIA)
St3. Neuro=Bell's palsy
CVS=MS with AF and pul HTN and LLO
St4. MS with GE fell to ground got #femur need
operation
St5. BCC1 pt kc DM and BMI35 HTN comes with
sob and palpitation
Inside: obese ,lower limb pitting O,?AF
snoring at night
DDX:HF,OSA
BCC2. Woman comes with hand pain
Inside:PSS
D2 last round
Station 1 - prompt —fatigue-renal transplant in
young patient
Resp- prompt —Hoarseness of voice .. COPD +
??
Another counter — bronchiectasis
Station 2-NSAID induced GI bleed and anemia

Station 3 - CVS - MSMR +AF
CNS - visual problem—6CN plasy , other 3
Nerve palsy
Station 4 - Ca colon and warfarin
Station 5
BCC1- BOV in dm
BCC2- loss of menstrual period ( inside joint
pain and skin rash -SLE )
Day3 second round
St2 young man palitation and blackout during

workout at the gym
St3 prompt breathlessness
AS MS AF PHT
Prompt - dropping of the object --UL exam--
Parkisonism
St4 MS BBN and concern
St5 prompt- Daytime sleepiness with High BP
150-90 and hyperglycemia BMI 3y
Inside Obese man , OSA history no hypothyroid
, no acromegaly feature
Dx OSA with metabolic syndrome
Prompt- Hyperglycemia
HbA1c 7.4
Inside drug induced (herbal)
Cushing syndrome with rt knee jt pain ?OA
St1 Bronchiectasis
Pallor with moderate heatomegaly and
Massive splenomegaly ( Thalassaemia)
Day 3(last round)
St2: 65,male,lethargy and tiredness for 3 mths

with low Na and Cl( past h/o
DM,Asthma,Depression inside got h/o wt
loss,cough,SOB,no fever drugs:
citalopram,metformin, inhaler)
St3: CVS - MS/ MR? with AF, Pul Hypertension
CNS- isolated 3rd Nv palsy? (pupil spared)
St 4: UC for steroids
St 5:tingling with painful jts (RA hands with CT
$)
30 yrs,female with weight loss ( Grave's )
St 1: Abd- ADPKD with AV fistula
Respi- Rt UZ consolidation?
Diet 3/ 2018
Yangon,
Station 1
Abd - Renal transplant
Resp- Lt lower collapse/ consolidation
Station 3
CVS - metallic valve replacement (mitral+ ?
Aortic)
Neuro - GBS
Communication - same
History - same
Diet 3
St2: vertigo and falls. Dd: BPPV migrain, stroke
St4: counsil sister of a person who died last
year suddenly and had HOCM .she is a flight
leuitenant .
Bcc 2 : 35yr old lady wd pain going from lumbar
area to front and then thighs. No idea abt dx
Bcc 2 - lady with blackouts for 3 wks and
palpitations but no findings.
S1- roof top scar with hepatomegaly; lung
collapse. S2 - Rt chest pain in 35Yr male. S3-
?PDA; Spastic paraparesis with sensory level
ang urinar catheter. S4 - Asthma pt for
management. S5 1.coffee ground vomitting in
young boy with backpain. 5-2 DM with dizziness
- hypoglycemia.
My experience Day2 3rd round ygn

Start with S5
BCC1. Dysphagia with hand jt pain
PSS with CREST , vitiligo also present
BCC2 . SOB 2wks with Down syndrome
On Ex, all Normal
History recurrent chest inf with 2inhalers
regular use and ?asthma
Examiner wants DDx for cardiac cause.
Station 1 COPD
Not recognize small scar between scapula and
hyperpigmentation of lt scapula
Examiner is too good that he told me and
showed me “look at this ! If it is radiation marks,
how do u think??COPD patient with radiation
mark!’’
I told him ‘malignancy’
But no support sign of malignancy such as
clubbing or lymphnodes.
Abdomen- thalassemia
(But old lady without Anaemia I think and facial
appearance not much look like thalassemic face
I think
I confuse with COL
Station 2 history
Bloody diarrhea while in Thailand trip
DDx
1.infectious diarrhea
2.IBD
3.CRC (FH +)
Station 3
CVS PDA
Neuro Lt hemiplegia with uMNL Facial palsy
Station 4
Dealing with patient ‘s son who don’t want to
shift his father to ITU For further Mx care
Pneumonia with underlying dementia
Examiner asks
If son refuses continuously,what will u do?
I answered we will do for the best interest of
patient
Decision made by medical team.
Why son refuse?
Bcoz of bad experience with his mother who
died in ICU 6mths ago.
What are criteria for shifting ICU?
They want underlying comorbidity apart from
other causes .
Hope the best for all of us!
Great good luck
Yangon experience
9 Oct 2018 D2R3
Station 2
Middle aged female with bloody diarrhoea for 10
days, which started during her stay in Thailand
on vacation. No similar attack before. She ate
only food prepared at hotel. But her husband
and the other guests who stayed at that hotel
suffered the same symptom simultaneously. Her
diarrhoea persisted although other people
relieved. She took antibiotics precribed by Dr at
hotel. Family history : Grandfather was taking
Rx for Colon cancer. Brother has ulcerative
colitis. Sister has asthma. Differential Dx are
Infectious diarrhoea, IBD, colon cancer.
Investigation : Examiners wanted to do
colonoscopy.
But I didn't do it.
Concern :
Is it cancer?
What will u do for me?
If scopy result turns out to be negative, what
should I do?
(Beware: the scenario outside described that
her bloody diarrhoea became worsening. That's
why she's here to get your assessment
urgently. But when I talked with the surrogate
inside, she said her symptoms had disappeared
a week ago. Quite confusing! Management
would be a little bit different, in my opinion.)
Station 4
70 yr old man, feeling depressed since her wife
passed away. He suffered severe CAP & was
brought by the neighbours to hospital. At the
hospital, he deteriorated with septic shock &
doctors decided to transfer him to ITU. His son
who lived away didn't want ITU care & wanted to
talk with you.
Task : explain the condition, patient needs to
transfer to ITU for central venous cannulation,
possible ventilatory support & ITU nursing care.
Inside :
Why ITU care? Why can't u give such care in ur
ordinary ward? (because his mom passed away
in ITU, although being treated with so many
catheters & machines. He didn't want his father
to suffer like this.)
Are u sure he will recover with ITU care?
Even if he recovered, how would u plan for my
father? bacause I cannot take care of him.
The son disagreed until the end.
Should ask about living will & lasting power of
attorney.
That's all about my experience today.
Although I did really bad in some stations, I
hope my experience would be helpful for the
other candidates.
Wishing you all best of luck!
Ygn 10.10.18 1st R ,

S4 CKD , Cr 600, anaemia, USG.. reduced kidney
size, explain dx and management, patient has
underlying hypertension, not on any
medications
S5..BCC1 RA with Chest pain
Ddx.. pleuritic Chest pain, IHD
History is of pleuritic pain
BCC2..Headache left sided with hypertension ,
vomiting+ Neurofibromatosis
Ddx.. SOL , migraine, hypertension
S1 thalassemia , upper lobe fibrosis, reduced
breath sd in UL.,clubbing
S2 wt loss, type 1 DM , dizziness on standing
from sitting, hypo attack 2 times recently
S3
CVS ..?AS .. not sure if other added murmur
CNS left sided UMN facial palsy
Ygn 2018 3rd diet

Day 3(10.10.18) last round
Station(1) Resp- Lt upper lobe consolidation

(?mass) + effusion
Abd- Jaundice + hepatomegaly
Station 2 - recurrent chest infection + DM +
Malabsorption + Infertility ...... cystic fibrosis
Station 3- CVS - AR+ AS (?functional ESM)
CNS- Bilateral cerebellar sign+
Station 4- Known Parkinson disease- Admit for
fall - at hospital UTI and worsening neurological
symptoms.. now improved
Explain her daughter about patient’s condition
and parkinson disease
Station 5- BCC 1- 30 yr back pain
Inside Marfan $ + chest and spine deformities
BCC 2- DM + Dizziness
H/O hypoglycaemia (whipple triad+)
Vision impaired
H/O Nephropathy+ (at follow-up)
Fundus- ? Proliferate retinopathy (+)
Lying standing BP - said to be normal
BCC1 MG with IHD, xanthelesma
BCC 2 Drug induced CS with proximal
myopathy with Underlying SLE, APS ??
Respiration... Rt Ca lung ( I am not sure )
Abd... ADPCKD
CVS... AS, AR ( AR dorminant)
Neuro... difficulty in walking found out to be Lt
hemiplegia due to CVA
History... Wegener’s G.. DDx CSS, SLE
Communication... diagnosis of uncertainty
(possible cholangiocarcinoma and Ca pancreas
) explain to pt’s daughter
Concern... don’t want to tell mom if found out to
be Ca
Yangon 11-10-2018
Day 4 Round 1
Station 1 Right upper lobe fibrosis with dullness

at RLZ
I gave differential
Old TB + DDx of dullness at lung base
Abd - J +clubbing+splenomegaly
COL with portal hypertension, DDX CML,
chronic malaria
Station 2 - sinusitis+ fever+jt pain+rash+
impaired renal function
Wegner's
DDx APSGN, AB induced interstial nephritis
CNS Rt third cranial nerve palsy,pupil dilated
I gave surgical cases first
Examiners also want medical causes
Other candidate- Left hemiplegia
CVS - AR AF with peripheral signs, other
candidate says AS also +
BCC1 outside 30 yr old lady Chest pain off and
on 1mth, inside pain was typical cardiac pain,
occular MG with known DM 1 yr
On pyridostigmine and OHA, DM control poor
Dx Angina, ACS
BCC2 weight gain and difficulty in climbing stair
Inside Cushingoid face with past history of SLE
regular taking of prednisolone +
Drug induced Cushing
Consern want to stop steroid and want to have
baby
Yangon Day 4, last round
Station 1 lt sided pleural effusion

Hepatomegly with deep jaundice
Station 2 27yrs old lady with intermittant

palpitation, wt loss, postpartum 4 mths, asthma
taking ventolin inhaler, coffee 3-4 cups/ D, mood
Ok DDx postpartum thyroiditis, drug and coffee
related but exam not happy with thyroiditis, I
think they want anxiety related, patient concern
afraid of Ht d/s b/c parents died of heart attack
Station 3 AV replacement
Lt sided hemiplegia with lt UMN facial palsy
Station 4
elderly man admitted with chest infection, was

given penicillin, develop anaphylactic shock,
resuscitation done and became stable, after that
found out that pt pen allergic on record, talk to
son, concern not to happen again, pt living far
from hospital, so want hospital to arrange for
transportation on another attack, will give FOC
or not as a compensation, also ask if there was
similar error previously in this hospital. He also
want to complain. Examiner Q- ethical principal,
negligence or not. What is the process of
incident report. I think she want it's to find out
the
cause, root cause analysis, what type of error.
Station 5 BCC1 20 yrs, man, prompt polyuria

and fatigue, high BP, high blood sugar, inside
he also had wt gain, difficulty in climbing stairs,
u/l kidney d/s taking prednisolone, abdominal
striae+, DDx drug induced Cushing, Type 1 or 2
DM
BCC 2 middle age lady, prompt reduce UO, high

BP attending rheumato clinic, inside obese lady,
also had fever, taking NSAIDs and ACEI, no
obvious physical finding. I give DDx analgesic
induced, ACEI induced nephropathy, UTI.
Last day yangon

First round
Start with st 5 gout dm hypertension ( cushing

steroid induced)
St 5 fit (hypoparathyroid ) thyroidectomy scar
St 1 resp lt pleural effision
Abd trasplant kidney
St 2 diarrhoea ibs
St3 cvs msmr af
Cns peri motor sen neuro
St 4 stroke bleeding with inr 1.5
Plz pray 4 me. I did not do well bcoz of stress
Ygn Last day round 2
St 2- diarrhea in young female, no blood, tummy

pain and bloatedness relieved by passing
motion. D.Dx- IBS, giardia, IBD, Coeliac
St4- Rt basal ganglia bleeding due to
hypertension taking warfarin for AF
St5- treated gout with DM
Inside Cushing syndrome
Dx- drug induced Cushing
Second case- first seizure
Inside thyroidectomy scar, muscle twitch,
tingling and numbness
Dx- hypo calcimia due to hypo parathyroid and
hypo thyroid after surgery
YANGOG- LAST DAY
BCC1- tingling sensation of both hands, Dr in

rheumato OPD
Dx - CTS underlying RA
BCC2- polyuria and weight loss, taken treatment
for hormonal treatment, Dr in MedOPD
Dx- Type 1DM with Grave
Station 2-?occupational asthma
Station 4- BKA for critical ischaemia left leg,
underlying left foot ulcer, type 2DM 1 month
hospitalization.
Patient not want to do BKA although after
knowing nature of operation, risks and benefits,
consequences of refusing it.
Talk to patient's daughter and manage her
concerns.
Diet 2 /2018 Brunei.

3/7/2018 cycle 1
I start with station 3
CVS..young pt with beside the bed translator
Pluse was large volume regular .there is
midline sternotomy scar which is faint and
covered with skin fold I did not see it only in
last minute so I examin percadium there is
diastolic murmor more in aortic ..iam very
confused and not sure about my finding I
present it ..when asked what's diagnosis I said
aortic regurgitation and there is sternotomy
scar but I did not hear click.
How you will investigate and time finished
...Kindly they give me 15/20
CNS..I was very stressed and confused from
cvs .
Pt was old about 60yrs .examine upper limb.
No clear tremor l examine tone there is mild
rigidity in lt. There is bradikenisa ...when I ask
him to tap for cynkinesia tremor is clear.
I present pt as brakinson disease
examiner ..how you will diagnosis .
What treatment.time finished.
I got 17/20
Station 4 ..
Was unversity student known to have
ulcerative colitis given rectal steroid not control
the plan to start him on oral steroid but he
refuse.
Inside ..
Pt has sever disease with frequent bloody
diarrhoea he doesn't want steroid as he read in
internet about S/E.
I explain to him the need of starting steroid and
the side effect and the prophylaxis for gastric
and oestoprosis..
But he insisted not to start and he want to try
chianese medicine I ask why he said his friend
try it and improved.
Pt totally refuse and I advice to arrange meeting
with consultant.
Examine. .
1/did you convense the pt I said no and I
arrange meeting with my consultant. .
2/why you did not give him chance to try
chianese medicine .i said it not approved and
not evidence Base for its use.
3/what prophylaxis for oestoprosis you will
give.
4/why you told the pt we will give steroid for
short time
5/what other treatment and any role for biologic.
I answer all..
I got 16/16.
Station 5..
First case clear psoriasis which is all over the
body with nail change onciolysis. .. I took
history of skin rash and ask for other eye .joint
.bowel .urinary symptoms all negative .
I examine skin rash in sclap. .ear .back and all
his body.
Examiner...
1/what's your diagnosis
2/what about its severity .
3/ any organ involvement
I answer no he said to me dud you examine the
joint .I said no as by history no joint
involvement.
I got 21/28
2nd pt.neck swelling.
History postive for facial flushing and plaptation
..
Pt is euothyroid by history. .i examine Thyroid
and lymph node.. I forget to check Pluse.
D/w about MEN type 2.
I got 21/28
Chest..
Scleroderma very clear with scleodicily and
Rauynaud in hand ...
Bibasal creps.
D/w what is diagnosis
How you will mange.
I got 18/20
Abdomen.
Young pt pale .jaundice.
Massive spleenomgly.
Case of hemolytic anemia.
Examiner.
1/what is diagnosis.
2/how you will investigate
3/what complications he will develop.
4/what hath at iron chatter you will give.
I answer all ..I got 20/20
My experience in Brunei
2/7/18
Start BCC 1.
Middle age guy with syncope and palpitation.
Underlying DM and HPT. (Upon ask)
BCC 2.
Acute joint pain more on left knee.
Upon asking RA for 10years.
On MTX, hydroxychloroquin,
sulfasalazine,prednisolone.
Station 1 Respiratory
Bronchiectasis
(He had MR murmur ) may come in CVS station
later.
Station 1Abdomen
CLD with mild hepatomegally.
Others candidate said normal findings.
Station 2
Middle age man with chronic headache, sudden
severe throbbing headache with unsteadiness
and vomitting.
Station 3
Cardio
MVP metalic in nature
Station 3
Neurology
Droopy eyelids, bilateral facial muscle
weakness.
MG
Station 4
Seizure, ct brain and biopsy brain highgrade
astrocytoma.
BBN + Palliative care.
Brunei 1 session 4th july 2018
Respi hard case

Clubbing, cyanosis, deviated trachea to right
Reduce chest expansion
Reduce breath sound
No crept
Midsternotomy scar
Some candidate said ddx lung transplant, right

lung collapse
17/20
Abdo young man with left renal transplant with

nonfunctioning fistula. 20/20
Hx taking 35yo man with depression, chr back

pain on mutiple meds hx of itchiness 3w with
weight loss, drenching night sweat. Neck lump.
Hx of eczema in chilhood. No food allergy.
Mother stay in nursing care with ? Outbreak of
scabies
Ddx lymphoma, drug allergy
19/20
Cvs MVR 20/20

Neuro Depressed reflex with normal sensation.
All candidate answer peripheral neuropathy
17/20
Hx taking father 80 with PD treated in hosp for

CAP, jr dc forgot to start antPD, sx of PD
worsening in ward
Daughter not satisfied with the issue and want

to bring pt home
10/16
BCC 1 graves disease 28/28
BCC 2 ocular MG precipitated by ciprofloxacin
28/28
155/172
UK
Edinburgh. 10.07.18

bruise.
with 2ndary mets.
Parkinson plus.
condour specially.

18/july/2018
Started with st4
St5
Bcc1:
up
RA, MCTD
Bcc2:
else were negative
lethaergy?
St1
Respiratory:
Pulmonary fibrosis
Abd:
Renal transplant
LIF scare
Viva about APKD
St2:
DDx:
Caffiene intake
LQTs
Brugada synd
IHD
St3
Neuro:
☝️Experience of one colleague who got full
mark in that case
Fairfield general hospital
Bury - Manchester
Saturday 14/7/2018
Stations in order:-
Station 4:
47 yrs male known case of DM and HTN and
Rheumatoid arthritis presented with progressive
dry cough and exertional dyspnoea, treated for
pneumonia and 2 weeks ago chest xray done
and interstitial pneumonitis given as diagnosis
bse of methotrexate and the consultant stoped
methotrexate and started 20 mg prednisone od
and the pt came today and a bit improved and
LFT showed restrictive pattern. Sit with him and
tell him about the test result and address his
concerns.
Conerns:-
1\the consultant didn't tell me methotrexate can
affect my lung.
2\is it reversible effects? What will happen to my
lung?
3\I don't want the steroid. I read about it's side
effect.
4\can I stop the steroid today? I don't want
them.
5\can I take the methotrexate again? . It helped
my rheumatoid a lot.
Examiner questions:
1\summarise your discussion.
2\what are the issues in this scenario?
3\are you going to stop the steroid?
4\are you going to restart the methotrexate?
Station 5:
BCC1:-
53 yrs female c/o sob progressive with increase
in her weight. Recently symptoms get worse
with palpitation and LL swelling. Vitals normal.
Inside the patient obese known COPD .
Patient in the start forget her history and forget
the clue and the examiners stared on her. I told
her it's ok .Then I checked the oedema (she said
aah despite she said no pain , I apologized to
her) the chest is clear but forget to check for
pulmonary htn despite I put it in the DD. Then
from no where something pushed me to ask her
( do you snore on sleeping) then she shouted
yes yes I remembered now . then clear
obstructive sleep apnoea.
DD:
Pickwickian syndrome
OSA alone
Heart failure
Pulmonary htn
BCC2:
57 yrs female had hoarseness of her voice for 3
months after sore throat. All vitals normal.
Surrogate patient.
Positive is weight loss but no other symptoms.
On medication verapamil concerned me.
Other medications of no significance.
A case of DD
Concern:is it cancer?
Station 1:
RESPIRATORY:-
92 yrs female very sick with sob RR 26 b/min
Did bad on it bse the pt unstable and examiner
delayed me many times on discussion even we
didn't reach the investigation and treatment
COPD with lt lower zone fibrosis. I gave also
bronchiectasis as DD
Clear swelling and deformity in PIP and MCP
joint in hands symmetrical (Rheumatoid
arthritis) examiners agreed that.
ABDOMEN:-
48 yrs female obese with RIF scar extend to rt
lumbar area in the back and lt hypochondrial
scar. No av fistula or scars in forearms or in the
neck or chest. No stigmata of CLD and no
organomegally or ballotable kidneys. No
palpable mass under the RIF scar but dull to
percussion so gave possibility of renal
transplant with peritoneal dialysis (I was honest
and I told the examiner I am really confused), he
asked me and the other scar? Told him maybe
nephrectomy for polycystic kidney or
something else or splenectomy I don't know. He
said for renal cancer. Then usual discussion.
Station 2:
46 yrs male new to the clinic and routine
investigations showed deranged LFT as follow:-
AST 50 (UPTO 31)
GGT 91 (UPTO 50)
bilirubin and albumin and alk phosphatase were
normal. GP got spider naevi and liver palpable 3
cm BCM.
Inside all the Hx negative
Ortho surgery in UK
Tattoos in UK
Forget FH😂
Examiner (did you asked from FH? I said did I? I
told him this may be bse of stress bse may be
haemochromatosis. Then he laught and said
yes . discussion on haemochromatosis.
Station 3:
CVS:-
58 yrs male
PR 64 bpm regular with large volume and
collapsed and synchronised
Apex displaced and not sure from character
(should be thrusting) 1st and 2nd heart sounds
audible and there is diastolic murmur in apex
radiate to lt upper sternal edge best heard when
pt leaning forward with expiration
I gave diagnosis of aortic regurgitation.
Examiner asked me did you hear any other
murmur ? I said no . other DD I said MS but the
1st heart sound not loud, she said what else I
said pulmonary regurgitation. Discussion
about aortic regurgitation in details.
NEURO :-
My nightmare but the strange thing is the only
station I did well on it.
My favourite case ever.
Examine gait and then upper limb.
I saw the pt and from the instruction and his
face I knew he is a parkinson disease.
So gait then upper limb for tremor and rigidity
and bradykinesia and speech with hand
writing(before leaving the hand asked for BP
lying and standing) and then upper gaze and
lateral for nystagmus and finger nose test (all
negative for parkinson plus)then power in upper
limbs was normal and reflexes normal and
sensation (fine touch and pin prick and
vibration all normal)
I did a mistake by putting the neurotip on table
and examiner said no put in the sharp then I put
with the other neurotips😂 thanks to Allah I was
the last candidate and I told the 2nd examiner
please dispose all of them😎and told the other
examiner I am sorry among all candidate I
shouldn't do this stupid mistake bse I am
working in icu but you know the stress. He said
it's ok.
Usual discussion on DD
Idiopathic parkinson
Parkinson plus but I said no evidence but need
more examination
Drug induced or vascular
What else? I knew what he want so said benign
essential tremor (he satisfied) .
Investigations:I said clinical diagnosis but ct
and MRI brain and DATSCAN.
Management:
Medications he stoped me what other
treatments rather than medications ? I told him
non pharmacological (like physiotherapy and
occupational therapy and speech and language
specialist. He said speech and language
therapist for what? I told him I read in NHS and
parkinson society in UK they have some
training and exercises bse at the end the family
will come to ask for peg tube which is not
suitable for parkinson patient. Examiner
laught😂He said yes you are right .Then asked
what do you expect from this pt? Told
unfortunately it's a progressive disease. Then
asked what is the most important complication
to put in mind? I said I am afraid mainly from
aspiration. He said yes.
BELL RANG.
In general I am not happy from my performance
and I felt if I did it again I can perform more
better but it was my first time.
My advice is keep smiling to the patients and
examiners (even that rude examiner on
respiratory station😂) specially in UK centres
bse they appreciate that.
Be relax and even if you did a big mistakes like
what I did forget about them and concentrate on
the next step (and thanks to Allah I wasn't
anxious even with the mistakes) and very
important to be honest (don't cook) and say
what you found and share this with the
examiner and if forget something tell the
examiner I am sorry I didn't use to do the same
on my daily basis practice (say this only in UK
centres😂)
At the end if I passed alhamdulillah , if not I will
fight on another day.
Please pray for me.Specially to avoid the
mistakes I did.
St 2. Middle age female has progressive

increasing SOB. Started with introduction and
elaboration of CC. She said for 3 months she
has gradually increasing SOB without any
specific time and has dry cough. no chest
tightness. Asked for GERD which was absent
and no neurological issues pointing toward MS
as in some scenarios. Did systemic review and
didn't get any positivd point.Till end of CC was
not getting obvious cause. In social history she
had pet dog since 6 years , no house dust mite,
no paint or carpet changed recently. Travell
history ,she visited Africa and willing to stay
there bcaz she loved that place without any
SOB. But when arrived back she has aggressive
shortness and cogh. This pointed toward
occupational asthma. She was working in
plastic factory since 12 years and didn't
changed any position. Was HTN and on ACEI.
No fever , lumps and bumps. Asked concern
and she told might be developing cancer.
Adressed her concern in last minute. Examiner
questions .. what is D/D , occupational asthma /
ACEI induced cough . How to diagnose ? Here
he showed me written on a paper some FeNO2
(not remember exactly )and asked me do u
know this test ..i said no.How will u investigate
and manage. Steps of BA management. After
step 1 he said how much u will wait to move to
next step which I said sorry I am not sure about
time. 20/20
Dubai 15.10.2018
Staion 2 Iron deficiency anaemia referred by gp
due to shortness of breathing for 6 months,
patient on warfarin for heart valve replaced
before 5 years, levothroxine,
bendroflurothiazied and ferus sulphate
Dubai communication BBN for chronic renal

failure patient found to have high bp before 10
years for examination. For insurance then did
not show up. U.s showed small kidneys and
blood urea and creatinine high tasks to inform
the pt that she has ch renal failure and need
medicine and may progress to dialysis.
The examiner ( young Egyptian) criticised me
for asking the surogate if she want any one to
attend this conversation. He did not agree when
I said in breaking bad news patient may find
emotional support from some one like relative
and friend but he said you have not to ask and I
saw him wrote unprofessional start of
conversation.
Station 5 25 years lady presented with 6 months
swelling of moth and limbs on and off. Currently
no attacks I gave diagnosis of angeoedema and
I offered to examined cvs, abdomen and they
told n examiner asked why not examined moth
for larngeal enema?? Even she has no attacks
Second case RA presented with carpal tunnel

syndrome
I suggest blood loss due to warfarin ,

haemolysus due to rbc destruction byl valve
replacement, anaemia of chronic illness due to
chronic illness I mentioned haemoglobinopthy
like haemosidrosis she has black stool but no
loose motion and no skin rash or joint pain I
told examiner I will consider also mesentric
ischemia and celiac disease despite no
symptoms but he insist to give more and he
looked for certain diagnosis I think 5hat I did not
mention
Egypt 13/10
Station 1 chest
clubbing
Abd :
shrunken liver )
Station 2 :
GFR, high cry.
Station 3:
Neuro : Lower limb
Cardio:
Station 4:
Station 5:
BCC 1 :
Experience at Bedford hospital,London
(7th October 2018)
Station 5
BCC1 ; elderly lady with long standing joint
deformity and Rheumatoid arthritis but no
active synovitis
Pt's concerns :do i need treatment right now?
I said no because there is no active disease but
OP and physio can help (Scored 23/28)
BCC2 ; YOUNG GENTLEMAN with palpitations

...Hx of heavy alcohol abuse and smoking
Cardiac exam normal
Fhx of sudden cardiac death
Pt's concerns: will it happen again
I said iam not sure right now but would
definitely like to rule of cardiac causes first with
Ecg and Echo and also advised to reduce the
alcohol /smoking (Scored 18/28)
Station1
Abdomen ; Renal transplant with signs of
immunosupression (Scored 13/20)
Respiratory ; COPD WITH malignancy (horners
syndrome) (Scored 8/20)
Station 2 ; young female with bloody diarrhea

Fhx ca colon + ulcerative colitis
Dx IBD (Scored 20/20)
Station 3
CVS ; Aortic Valve replacement with flow
murmer
Examiner's question : whats causing Sob and
palpitations in this patient
I said it could be either valve dehiscence or
valve stenosis Scored(20/20)
CNS ; CRANIAL NERVES EXAMINATION
Elderly lady with scar on right forehead with left
sided hemianopia and pronater drift
Dx: occipital stroke ( she had vp shunt in place

Scored 20/20)
Station 4 ; Explain the diagnosis treatment and
prognosis of polymyalgia rheumatica to an
elederly lady
Pt's concerns were regarding steroids and what
else she should be worried about (Temporal
arteritis) (Scored 10/16)
n I passed with the first attempt Allhamdullilah
😄
Tips
Must attend the FAST Paces course, which is far

far better than any other UK course,
Seriously!
All thanks to Dr Imran Babar who has been an

immense support and guidance throughout.
His Notes and Ryder was all i kept reading till
the exam day.
Stay Confident!
Its not at all a dreadful exam as we'v been
Imagining before, 😁
Just a game of mind and logic
Believe in Allah completely and luck would
always be in your hands!
UK today (4/10/2018)
has lobectomy

asbestosis


CT
chest 2m wasted by patient

In abdomen U shaped scar across the abd
In Neuro case was asked to do full neurological
examination
In st 5 do not expose the patient any more
Started with St 4 .. Patient was admitted in

Rehabilitation ward after Hemiarthroplasty
surgery and was started LMWH as DVT
prophylaxis .. was on Adpirin and
antihypertensive meds .. Had Fall and became
confused after that. Dr in Rehab ward told
daughter UTI is the cause of Confusion .. CT
Brain done showed midline bleeding with no
shifting now he is improving but still not
oriented to time and place so neurologist could
not examine properly but no sign for
neurodeficit .. doctor adviced Nil per mouth.
Please talk to daughter explain benefit and risk
of LMWH and answer her concerns
Concerns : she feel guilty that she encouraged
her mother for going to this Golf Contest when
she had this joint problem and think all
happened after that is her fault..
Why she is not eating anything or even drink

water ?
As she has UTI shouldnt be taking much fluids?
Will she become dependent after that?

Examiner questions :
What are her concerns
How did u answer?
Is Fall the cause of bleeding? Does MRI support

fall as a cause? .. they wanted as it is
intracranial mostly it is from LMWH and aspirin
but fall increased risk of bleeding
Anything in history favors bleeding? Wanted
HTN as she is taking antHTN meds!
What about Prognosis ?
What about feeding? U think we may try some

ways other than IV fluids? He wanted PEG or
NG
Fairfield general hospital
Bury - Manchester
Saturday 14/7/2018
Stations in order:-
Station 4:
47 yrs male known case of DM and HTN and
Rheumatoid arthritis presented with progressive
dry cough and exertional dyspnoea, treated for
pneumonia and 2 weeks ago chest xray done
and interstitial pneumonitis given as diagnosis
bse of methotrexate and the consultant stoped
methotrexate and started 20 mg prednisone od
and the pt came today and a bit improved and
LFT showed restrictive pattern. Sit with him and
tell him about the test result and address his
concerns.
Conerns:-
1\the consultant didn't tell me methotrexate can
affect my lung.
2\is it reversible effects? What will happen to my
lung?
3\I don't want the steroid. I read about it's side
effect.
4\can I stop the steroid today? I don't want
them.
5\can I take the methotrexate again? . It helped
my rheumatoid a lot.
Examiner questions:
1\summarise your discussion.
2\what are the issues in this scenario?
3\are you going to stop the steroid?
4\are you going to restart the methotrexate?
Station 5:
BCC1:-
53 yrs female c/o sob progressive with increase
in her weight. Recently symptoms get worse
with palpitation and LL swelling. Vitals normal.
Inside the patient obese known COPD .
Patient in the start forget her history and forget
the clue and the examiners stared on her. I told
her it's ok .Then I checked the oedema (she said
aah despite she said no pain , I apologized to
her) the chest is clear but forget to check for
pulmonary htn despite I put it in the DD. Then
from no where something pushed me to ask her
( do you snore on sleeping) then she shouted
yes yes I remembered now . then clear
obstructive sleep apnoea.
DD:
Pickwickian syndrome
OSA alone
Heart failure
Pulmonary htn
BCC2:
57 yrs female had hoarseness of her voice for 3
months after sore throat. All vitals normal.
Surrogate patient.
Positive is weight loss but no other symptoms.
On medication verapamil concerned me.
Other medications of no significance.
A case of DD
Concern:is it cancer?
Station 1:
RESPIRATORY:-
92 yrs female very sick with sob RR 26 b/min
Did bad on it bse the pt unstable and examiner
delayed me many times on discussion even we
didn't reach the investigation and treatment
COPD with lt lower zone fibrosis. I gave also
bronchiectasis as DD
Clear swelling and deformity in PIP and MCP
joint in hands symmetrical (Rheumatoid
arthritis) examiners agreed that.
ABDOMEN:-
48 yrs female obese with RIF scar extend to rt
lumbar area in the back and lt hypochondrial
scar. No av fistula or scars in forearms or in the
neck or chest. No stigmata of CLD and no
organomegally or ballotable kidneys. No
palpable mass under the RIF scar but dull to
percussion so gave possibility of renal
transplant with peritoneal dialysis (I was honest
and I told the examiner I am really confused), he
asked me and the other scar? Told him maybe
nephrectomy for polycystic kidney or
something else or splenectomy I don't know. He
said for renal cancer. Then usual discussion.
Station 2:
46 yrs male new to the clinic and routine
investigations showed deranged LFT as follow:-
AST 50 (UPTO 31)
GGT 91 (UPTO 50)
bilirubin and albumin and alk phosphatase were
normal. GP got spider naevi and liver palpable 3
cm BCM.
Inside all the Hx negative
Ortho surgery in UK
Tattoos in UK
Forget FH😂
Examiner (did you asked from FH? I said did I? I
told him this may be bse of stress bse may be
haemochromatosis. Then he laught and said
yes . discussion on haemochromatosis.
Station 3:
CVS:-
58 yrs male
PR 64 bpm regular with large volume and
collapsed and synchronised
Apex displaced and not sure from character
(should be thrusting) 1st and 2nd heart sounds
audible and there is diastolic murmur in apex
radiate to lt upper sternal edge best heard when
pt leaning forward with expiration
I gave diagnosis of aortic regurgitation.
Examiner asked me did you hear any other
murmur ? I said no . other DD I said MS but the
1st heart sound not loud, she said what else I
said pulmonary regurgitation. Discussion
NEURO :-
it's ok.
more examination
Management:
BELL RANG.
centres😂)
Please pray for me.
Egypt 13/10
Station 1 chest
clubbing
Abd :
shrunken liver )
Station 2 :
GFR, high cry.
Station 3:
Neuro : Lower limb
Cardio:
Station 4:
Station 5:
BCC 1 :
for the nuro case ..is it floppy weakness ??

BBC 1 proximal myopathy with HTN .. we can
put cushing ??
history ....pulmo renal
St 3
Myopathy?
Low tone ,reflexes, equivocal planter
Normal sensation
Normal cerebellum
Cushing
UK Queen Elizebath Hospital Glasgow

#Collection_ Experiences
Queen Elizabeth Glasgow
June 7/2018
Station 1:
Abdomen (renal transplant).
Chest (lobectomy).
Station 3:
CNS : myotonia dystrophica
CVS (CABG with MR).
STATION 5:
1\TURNER.
2\YOUNG GIRL WITH HIGH BP most likely
essential HTN.
STATION 2:
Old man with Hx of fever and wt loss and night
sweat.
STATION 4:
Nursing home resident with advanced
parkinson and recurrent aspiration pneumonia.
Discuss enteral feeding with relative (explain ng
tube and peg tube feeding but tell it also can
cause aspiration so they want to hear palliative
options like iv fluids ).
Uk 07.06.2018
Station 1 : resp- right lobectomy
Abdomen - left iliac fossa scar with renal
transplant.
Ab fistulas not recently used+ no thrill
Purpura + , tremors+
Station 2 - 71 y male, with general malaise,
weight loss, and decrease appetite
Hb 105 , ESR raised
Known asthma , hypertensive on salbutamol ,
beclomethasone
Amlodepine- controlled * 10 years
Pain over shoulder, hip and knee joints
Station 3- mitral regurgitation, with mid
sternotomy scar
Myotonia dystrophica- asked to examine upper
limbs
Station 4 - advance Parkinson's admitted with
recurrent aspiration pneumonia and dementia.
Swallowing assessment done yesterday - poor
swallowing
consultant decision of no invasive management
Discuss about enteral feed option
Station 5: lady feels she has Turner syndrome
as per internet information.
Actually she had clinical features of Turner's
but also gave history of 2 child births
Station 5/ 2 - 30 y female with no medical history
or any complaints has been referred by GP as
her bp is around 190/ 80 since last 4 weeks
👉🏻uk experience 8.6.2018
Respiratory Lobectomy??
Abdomen bilateral mass in abdomen Polycycltic
kidney or renal mass ?? Renal cell cancer??
St 2 pt had mastectomy and stop treatment 6
months back now on Tamoxifen having c/o
cough and Sob
DD cardiomyopathy, Metastasis
Neurology Hemiplagia
cardiology DD AS ??or MR
St 4 wife admit with diarrhoea , cause infection
kept in isolated room, she fell down remain on
floor 4 hour no look her and had fractured hip
joint talk to angry husband and manage the
concern and he want to make written complain
and planed for surgery now for hip fracture.
BBC 1 h/o fall pt has prostitis atorvastatina
bisoprolol , warferine and doxosin for prostrate
DD TIA, postural Htn
BBC 2 pain in hand , shoulder, and hip joints DD
psoraitic Psoriatic arthropthy, RA pt was on
methotrexate and CRP AND ESR incraesed.
👉🏻Uk 8.6.2018
st4: talk with husband abt a pt who has MS, now
develops infective diarrheoa induced delerium,
She was in side room. She fell in bathroom, 4
hrs on the floor, fracture neck of the femur.
Transferred to ortho,waiting for surgery. Very
angry surrogate
st2: cough n breathlessnness,h/0 breast ca
BCC 1 : 92 years old sudden fall
BCC 2 : 71 years old pain n swelling in hands
Resp : lobectomy
Abdomen : bilateral kidney with midline scar in
the abdomen
Neuro spastic paraperesis
Cardio : MR
👉🏻08/06/2018
Resp: bilateral lung transplant
Abdo: midline laparotomy scar and ileostomy,
Leukonychia, anaemia Dx: Crohn.
Cardio: repaired TOF
Neuro: LL examination, bilateral UMNL Dx:MS
H/o: 60 male, dry cough, heavy smoker, on
ramipril, occasional wheezy, work at car factory,
relieve on vacation. Dx: occupational asthma,
ACEi induced dry cough, concern: lung cancer?
St4: paracetamol OD, suicidal assessment &
counseling, pt want to self-discharge.
St5: (1)Horner syndrome secondary to Ca lungs
(2)Benign essential tremor
👉🏻9 June U.K
Station 1: respiratory . Clamshell scar and
bilateral cracked. Discussion was causes of
scar and bronchiectasis.
Abdomen; mid laprotomy scar and iliestomy.
For differentials and management.
Station 2: persistent cough specially at morning
for one month on ramipril. Recurrent chest
infection with only dry cough and no fever.
Normal x-ray. Travelled to South Africa . Chest
wheeze on attack. Also works in a factory.
Station 3: mid sternotomy scar /pulmonary
stenosis . TOF . Indication for surgery.
Spastic paraparesis (cervical myelopathy).
Normal sensation.
Station 4 ; paracetamol overdose. Want to
discharge himself.
BCC 1 ; essential tremor.
BCC 2 ; Typical Horner syndrome and neck scar
👉🏻09/06/18, UK
St 1 abdo polycystic kidney disease.
Resp. Dull percussion with vats scar.
St2 cough, takes ace inhibitor and diagnosed
asthma. Occupation of working in a factory with
dust and solvents.
ST3 cvs lateral thoracotomy scar on left with
?mid diastolic murmur of MS. Radio radial
delay.
Neuro sensory ataxia with fasciculations.
Reflexes present at knee and bilateral distal
weakness.
St 4 paracetamol OD. Patient wants to go home.
St5 bcc1 fundoscopy for visual loss in one eye
for past few years.
Bcc2 visual disturbance plus necrobiosis
lipoidica diabeticorum
Queen Elizabeth hospital today.
1-ild
Polycystic kidney disease
History seizures.
3 ,DVR
Myotonic dystrophy
4 advance pancreatic ca
Discussion with daughter
5 syncope
Hemoptysis
Queens elizabeth hospital, 8th March
ST 4 : IBS discuss diagnosis and consultat

advice amitriptaline.
Be aware of side effects.
St 3
Cardio AF! No clear murmur.
Neuro/bilateral weakness more in left side a n
impired sensation on left side only.
History: Female with breast cancer brought to
hospital for admission!
Going inside found to be metastatic disease
with pain and fatigue.
Discussion causes and plan.
St 1
Abd:spleno megally with wt loss.
Chest/sings pf COPD in short patient.cyctic
fibrosis!
St5
BCC 1
Lady with both hands joint pain and RT foot
pain - First metatasal.
History of cancer
BCC 2
Lady with headache.
Tension?space occuping lesion?
Exam experience of friend in queen Elizabeth
hospital, on 5/10/2017
Lung- pneumonectomy/lobectomy
Abdomen- few spider, huge splenomegale, just
palpable hepatomegale, another rt flank mass
Gave dd of CLD, ADPKD
CVS-AF with wide pulse pressure, no murmur
They asked about collapsing pulse , I said due
to fast AF I couldn't appreciate
Neuro- myotonia dystrophy, dd- I said motor
neuropathy, they wanted MND
HISTORY-38 yr collapse, described like seizures
but feeling hungry after regaining
consciousness, h/0 alcohol, work as a coffee
machine mechanic, frequent drive due to job,
concern about driving. Gave dd of
hypoglycaemia, some others but I forgot, asked
about dd, inv , mx
Communication- Talk with the wife of a newly dx
HD, concern- children & wanted to inform
children
Husband was found heterozygous on genetic
testing
Bcc1- 79 years with 2 wks fever chills & rigors,
past history of CABG & MVR
Bcc2- palpitations on 73 yrs man , on warfarin,
pulse given-150, no abnormal physical exam
Respiratory: Lt Lobectomy
Abdomen: CLD due to PBC
History: 37 yr old female with h/o T2 DM has
presented with tiredness and leg swelling 3/12.
She also gave h/o SOB for the same duration.
No h/o wt change, hot/cold intolerance. Her
creatinine was 145, Hb 8.9. Takes amlodipine,
insulin, statin.
CVS: AF, water hammer pulse, MR
Neuro: Diabetic motor & sensory neuropathy
Communication: 70-ye pt admits with
pneumonia. He also has dementia. He has given
iv antibiotic. Pt ‘s son is not happy why iv
antibiotic given without asking for his (son’s)
consent as he thinks iv route is associated with
more side effects. He also would like to talk if
any alternative treatment can be considered like
acupuncture, garlic which may help treating
pneumonia.
BCC1: Double vision in one eye for 2 weeks. No
sing of double vision found during examination,
visual acutely founds normal but has unilateral
ptosis.
BCC2: Neck swelling: Multinodular goiter.
Nothing positive found other than a visible
swelling that moves with swallowing.
Elizabeth Hospital
Glasgow college
7th june 2017
Station 2
Patient with history of knee pains presented
with fatigue and melena !
Pain associated with stiffness and improves

with walking .
Family history of RA is positive.
patient concern was do i have RA like other

family members ...!!
Station 4
Communication with a young girl who is
married and planning for kids who has been
diagnosed with RA and now on follow up visit
as she was told to start Methotrexate in her last
visit and now she is back again to discuss the
plan after reading about the therapy on internet
station 5:
BCC 1.
Man with multiple problems of

Psoriasis
Athropathy
Had shoulder dislocation few days back and
was operated
now presented again with shoulder pain with
fever.
BCC 2 :
Young male with history of crohn's disease

presented now with back and stiffness along
with pain in the neck ..
Exam from Queen Elizabeth Hospital
Glasgow centre
6th June 2017
Statio. 2
History of Rash on hands .
History of intake of Tetracycline .
Patient concern was will i get scarring after the
rash is over .??
station 4:
A chef had anaphylactic reaction to eating salad
sandwich. He was allergic to peanuts. Had
minor reactions to them before twice. Was also
asthmatic and on inhalers. As a result of
anaphylaxis was admitted into icu and
ventilated. Task was to explain seriousness of
his allergy and implication on his job
Station 5
BCC 1 :
Patient with RA presented with Backache
BCC 2:
Patient with dermatmyositis presented with
sudden hip pain
She was on steroids .
3/7/2018 cycle 1
cvs .
I got 17/20
Station 4 ..
refuse.
Inside ..
internet about S/E.
and oestoprosis..
with consultant.
Examine. .
give.
short time
I answer all..
I got 16/16.
Station 5..
his body.
Examiner...
involvement.
I got 21/28
..
I got 21/28
Chest..
Bibasal creps.
How you will mange.
I got 18/20
Abdomen.
Examiner.
Station 2.
45 yrs old pt k/C of hypertension started on
Lisinopril she develop Allergy change to Amlor
she develop L.L odema now on valsrtan and
thiazide .her BP is not controlled. ..
I ask for about compaince to medication she
take it regularly and in time ..ask about all
causes of 2ndary HTN endocrine(acromegaly.
Cushiong. Cones ) renal cause all are negative
.as about any stress he is very anxious about
her BP ..Ask about complication for high BP
from to down. (Eye .cvs.kidney .peripheral
vascular disease) all are negative.
I explain to the pt the may be essentail HTN or
gland problem I need to take more history and
to examine you to do some blood test and
images if needed and we will sit with you again
I will refer you to heart dr may need to adjust
your medication.
Examiner. .
1/what do you think the cause of high BP ..I
answer in view of negative all 2ndary causes it
can be essentail or it can be stress as pt is
anxious.
2/examiner tell if I told you this pt pay
esphyngommanmter and she check her BP at
home and it's normal .
I said that is white coat HTN.
he ask how you will mange answer reassurance.
.
I got 20/20

NEURO :-
it's ok.
more examination
Management:
BELL RANG.
centres😂)
Please pray for me.
BY DR. Zein Mahgoub
□ #New Scenario:
》 The following scenario came in the UK and

described by many colleagues as being
unusual, complicated and difficult to deal with.
》 Actually, it is not the first time to show in

PACES and I used to refer to/discuss it in my
courses.
》 It is not as difficult as we think and we can

deal satisfactorily with (and any scenarios new
to us) by wise application of logic and the
simple basic ethical and legal principles.
~~~~~~~~~~~~~~~~~~~~
□ An elderly patient presented to your hospital

in cardiac arrest with a complex medical history.
He is successfully resuscitated with return of
spontaneous circulation but remains
unconscious.
The patient moved to your city few weeks

earlier.
You are seeing his son, who is very upset with a
major concern (why my father revived although
he has an advance directive stating clearly that
he wants his last beat to be the last)..
He have a copy of his father's advanced

directive and wants to file a complaint.
Qs:
1a. How you manage/deal with the son's
concerns?
1b. Can he make a complaint?
2. What is/are the major ethical and legal issues

applicable to this case.
~~~~~~~~~~~~~~~~~~~~~~~
》 If you wish to participate in the discussion,

please answer these 2 questions.
》 My opinion and suggestions will be given at
the end after giving the chance to as many as
possible of our colleagues to contribute.
Thank you
My exam was in afternoon at James Cook
University hospital, Middlesbrough. Registrar
there told us that this is the biggest paces
centre in uk .
My exam started from station 4 .An old lady
admitted with dense hemiplegia ten days ago
now having aspiration pneumonia and is on
antibiotic. She is deteriorating but officially
code is not decided . You were discussing her
condition with one of ur colleagues and her
neighbor who was volunteer as her visitor
overheard that and conveyed that to patient s
son . You have to speak to patient son who is
very angry that why it was not discussed with
her . It was to deal with angry attendant but
examiners viva was really tough .
Next was station 5 ( a night mare)
Bcc1 a middle aged lady with blurring of vision
and diabetes and many co morbidity. Her
diabetes control was poor , history of laser
therapy in both eyes . Fundoscopy took time but
couldn’t find anything . Told them that’s it’s due
to poor diabetes control . Examiner asked did u
see the insulin pump and I was no. Because I
didn’t think of that .
Bcc2 .lady with headache . Asked all the

questions about headache but all negative. She
just told me that it’s worse in the evening but
couldn’t think of any headache that’s worse in
the evening. Then she told me that her
colleagues are also having that . She told me
her occupation but I couldn’t focus on that . Did
visual acuity, field and fundoscopy all normal .
Pt quest what’s my problem and I said it’s
carbon monoxide poisoning we wil do a blood
test and wil involve an occupational health
physician
Next station history
Young lady with chest pain, ankle swelling, rash
on shins , that’s sarcoidosis
Next . Abdomen. Renal transplant with

functioning Av fistula, multiple scar marks in
abdomen and polycystic kidneys
Respiratory. Copd with left lung collapse

examiner focus was on lung collapse n he was v
happy when I picked that
Cvs. Pt has presented for follow up please

evaluate
Multiple scars alll over body . CABG with aortic
valve replacement and Mitral regurgitation and a
pace maker. Examiner question were unusual
again
Neuro . Spastic paraparesis ,multiple sclerosis
was diagnosis. Examiner asked me would u see
ologoclonal band in blood I was astonished for
a while like what he is asking then I answered I
hv never read in any book . He started laughing
😆.19/20 .
On some station there were 3 examiner, station
5 both fundoscopy , carbon monoxide
poisoning . It was a nightmare exam and to pass
it is a miracle and my mom s prayer who never
left prayer mat until I came out of exam .Allah is
kind
I m really grateful to dr imran babar for all his

help on phone. During course and after course
he did mocks with me . He knows exactly what
are the requirements of overseas candidates n
his tips and tricks for passing exam are
awesome. He is a wonderful paces tutor
Alhamdulillah, I cleared my PACES in my first
attempt from London centre. I attended the Fast
PACES course in November 2017.I will second
what Imran Babar always mentioned during the
course, keep it simple, do not go deep. The
exam is not tough, they look for basics. Don't
go for deep stuff. It's basic knowledge
assessment. They don't want specialists or
consultant level.. It's important to keep it simple
My first case was Station 1 - Abdomen - Renal

transplant patient, simple, comment on scar and
immunosuppressive stigmata
Second was Chest - VATS scar, with dullness
on the same side base..
Station 2 - history of collapse in T1DM, with
Autonomic Neuropathy
Station 3 - CVS - AVR with CABG
CNS - Rt hemiplegia with hemiplegic gait and
scar on scalp
Station 4 - Hepatic Encephalopathy with
hepatorenal syndrome, DNR discussion with
son
Station 5 - Acromegaly and Bilateral ptosis
The examiners are literally trying to find, what
we know not to highlight what we don't know.
The issue with candidates, they tend to
complicate simple stuff. Don't go around
reading big textbooks. The notes from the
course is more than sufficient.
Don't hesitate to apply for UK, London centre
The environment they create is not at all
intimidating.
Please, first thing that is important is have faith
in your abilities. Use your stress and anxiety to
bring out the best in you. Don't let negativity of
the people around you to bring you down..
Best of luck everyone
Brunei 2nd day 2nd round (3.7.2018)
Station 3.
▪️Prosthetic heart valve
▪️Parkinsonism
Station 1.
▪️Renal abdomen with tunnelled catheter and
nonfunctioning AV fistula
▪️Bronchiectasis vs ILD
▪️Station 2. Uncontrolled hypertension with

headache(when taking atenolol) skin rash (when
taking ACEI, urticaria whole body, now relieved
)palpitation at times, sweating(menopause was
last 5years ago) and family history of MI and
hyperCHO (at 50 yrs of her father's age)
Ddx including pheo, essential hypertension with
anxiety( though no risk of metabolic $ -N
Cholesterol, non smoker, nondrinker, no
Diabetes) white coat hypertension ( ambulatory
monitoring of BP), hypothyroid(but no thyroid
symptoms)
▪️Station 4. Persuing UC patient to take oral

steroids( pt's already on enema steroids for
9months---still having diarrhoea over 6times
and anemia and ^ESR--lost in trust of taking
steroids--wanna try indigenous chinese
medicine)
Persuing tactics:
steroid SEs will be monitored and prevention
programmes; will be tapered as soon as
possible;
Promted by examiner-If not taking steroids there
could be perforation and surgery or even death;
Help from anyone to persuade him? asked by
examiner---??GP involvement and UC nurse
▪️Station 5.
1.neck swelling with BP 180 , PR 96 >>>neck
swelling is not seemed to be thyroid, no thyroid
symptoms, headache and palpitations with long
history of constipation...so thought it might be
MEN2 but there was bruit over the swelling----
afterthought is hypertension with bruit--
probably Takayasu's( but cannot explain
palpitations?)
Station 5.
2.skin rash on elderly man's arm>>>turn out to
be psoriasis whole body includ, hair line ,
extensors and back...nails have prominent
onycholysis , normal hand function, no joint
pain or back pain.
UK centres (2018/ 2nd diet)
08/06/2018
Resp: bilateral lung transplant
Abdo: midline laparotomy scar and ileostomy,
Leukonychia, anaemia Dx: Crohn.
Cardio: repaired TOF
Neuro: LL examination, bilateral UMNL Dx:MS
H/o: 60 male, dry cough, heavy smoker, on
ramipril, occasional wheezy, work at car factory,
relieve on vacation. Dx: occupational asthma,
ACEi induced dry cough, concern: lung cancer?
St4: paracetamol OD, suicidal assessment &
counseling, pt want to self-discharge.
St5: (1)Horner syndrome secondary to Ca lungs
(2)Benign essential tremor
14/06/2018
Station 4: Patient on Methotrexate for Psoriasis
and Psoriatic athritis, started on Trimethoprim
1/52 ago and now presenting with Epistaxis and
Bruising from Pancytopenia. Task Medical error.
Station 5: a)TIA/CVA. b) Lady 6/12 post
thyroidectomy, presenting with weight loss and
hypotension. Has vitiligo. ADDISON'S in
background of Polyglandular/endocrine syn.
STATION 1; Resp: pul fibrosis with bilateral
digital clubbing and peripheral cyanosi. ABD:
Lady with left colostomy and right what looks
like a refashioned urostomy with midline
laparotomy scar. Either Crohns or malignancy
STATION 2: Dx - HOCM in a 28 year old man that
collapsed in gym with family hx of defibrillator
insertion in cousin at 28yrs
STATION 3: Cardio Metallic AVR with CABG and
AF. NEURO: Spastic paraparesis, Multiple
sclerosis
10/06/2018
Resp: lobectomy
Abdo: renal transplant
CVS: MVR
Neuro: peripheral neuropathy
H/o: fever & wt loss. Dx - lymphoma
St4: MND, speak to daughter about Dx and
counseling for PEG tube
BCC:(1)headache - SAH
(2)carpel tunnel $ with acromegaly
10/06/2018(same date as above at different
center)
Resp: COPD
Abdo: Renal transplant
CNS: Myotonic dystrophy
CVS: Dextrocardia
BCC:1)RA 2)systemic sclerosis
History and communication : similar as above(
H/o: fever & wt loss. Dx-lymphoma St4: MND,
speak to daughter about Dx and counseling for
PEG tube)
17/06/2018
Station 1
Abdo: liver transplant
Resp: scleroderma/pulmn fibrosis but she’d
also had a mastectomy and had tracheal
deviation so I’m not sure whether there was
something else going on too.
Station2
40F with joint swelling, dyspnoea on exertion
and tender shins, Cxr Pt told me showed
enlarged LNs so she was worried about
cancer(Dx:Sarcoidosis)
Station 3
Cardio: metallic mvr (she actually had on a
medic alert bracelet saying she had a mvr and
was on warfarin!!) Spoke to a few other
candidates afterwards who hadn’t seen the
bracelet and said it was AVR so make sure you
read what’s on those medic alert bracelets
peeps.
Neuro: he had foot drop on one side but
bilateral distal muscle wasting and reduced
reflexes. I have NFI what he had TBH.
Station4
Had to apologise to patients son who overheard
his mom is for DNAR without any dicussion with
him. Basically explain , apologise and then
discuss DNACPR for his Mum who is
deteriorating following a stroke and will
probably die.
Station 5
1. TIA on background previous CVA and
uncontrolled hypertension
2. First Seizure on background recent CVA
17/06/2018 (same date at different center)
Station 1
Abd: hepatomegaly with CLD
Resp: left sided lobectomy with ?CA breast (she
had a scar on her left breast- not mastectomy
scar)
Station 2: (same scenario as above different
center) 40F with joint swelling, dyspnoea on
exertion and tender shins, Cxr Pt told me
showed enlarged LNs so she was worried about
cancer (Dx Sarcoidosis)
Station 3:
Cardiac- AVR
Neuro- (UL examination) - bilateral LMNL.
Diagnosis is fascio scapulo humeral dystrophy.
stop at examining sensory and ask if what do u
wanna do next apart from sensory examination.
Station 4: (same scenario as above different
center). Had to apologise to patients son for
discussing patient re should be DNACPR on the
ward such that it was overheard but patients
neighbour who had then told the son that we
weren’t treating the patient anymore. Basically
explain , apologise and then discuss DNACPR
for his Mum who is deteriorating following a
stroke and will probably die.
Station 5:
1.male, 55 with right knee pain. Turned out to be
OA
2.female, 22 with TIA, previous DVT and family
history of SLE.
22/06/2018
Pulmonary fibrosis
Renal transplant
Metallic AVR
UL bilateral LMNL
H/o 56 year old with tiredness at loss:
lymphoma
St4: Parkinson’s PEG tube counseling &
consent with family
Whippscross Hospital (2018/3)
Abd: Splenectomy scar - DX splenectomy
Res: ILD with RA & methotrexate induced
CNS: HSMN upper limbs
CVS: t AVR with AR, +/- CABG
History: Acute confusion due to lithium toxicity
on background of acute pre-renal kidney injury.
Had to get collateral from daughter- tell her dx
and Mx plan.
Ethics: seizure due to theophylline toxicity

given macrolide with theophylline in COPD pt-
duty of candour, apology and bus driver - dvla
BCC: acute Headache and visual disturbance in
young female IIH
Weight gain and fatigue: Cushings dx
Finally pass my paces from queen Elizabeth
galsgow ...want to share my exaperience .my
station 5 was bcc1 70 year old lady came with
b/l shake of hands that is affecting her daily
activities.when I entered b/l hand tremors
postural and tremors of jaw as well and family
history positive .it was essential tremors .
Bcc2 .a man admitted with redness of ball of big
toe and he is diabetic .when I entered there was
b/l charcots joint and ulcers and toe amputation.
Resp was an obses lady with clubbing and
Crepts .pulmonary fibrosis
Abdomen.myelofibrosis
Cvs :ppm scar with mvr and clamshell scar
mark .
Cns myotonic dystrophy
History was tricky :a 55 year old retired solicitor
with weight loss and dyspnea .when I entered
his first compliant was difficult to hold his neck
and dysphagia .when I explore he is very tired
more at the end of day and weight loss .it was
Myesthenia Gravis but scenario was very vague
.
Station 4 was speak to daughter whose mother
is admitted with delirium due to uti :
Best of luck to everyone and this page is very
useful and look at this page for previous exam
scenarios in ur Centre .best of luck
UK EXPERIENCE St. George’s hospital London
9-2018
Abd renal transplant Av fistula
Cns lower limb brisk reflexes sensory ataxia
asked to localise lesion
Resp lung fibrosis also had midline sternotomy
scar with harvest scar in leg
Cvs aortic stenosis
History- type 1 diabetic frequent hypoglycaemia

attacks anaemic and weight loss
Communication young female sah normal ct

needs lp wants to go home
Bcc1 diabetic peripheral neuropathy
Bcc2 headache cerebello pontine angle tumour

signs
UK EXPERIENCE
St George's 3/1/18. Carousel 3

lymphadenopathy.
alports syndrome.

his concerns.
Station5; Pt with raised LFTS. gay, HIV,

Hepatitis.
Station5. :polymyalgia rheumatica
18/july/2018
Started with st4
St5
Bcc1:
up
RA, MCTD
Bcc2:
else were negative
lethaergy?
St1
Respiratory:
Pulmonary fibrosis
Abd:
Renal transplant
LIF scare
Viva about APKD
St2:
DDx:
Caffiene intake
LQTs
Brugada synd
IHD
St3
Neuro:
For bcc 2 the causes of lethargy:

1- panhypopituitarism.
2- hypothyroidism.
3- obstructive sleep apnoea due to acromegaly.
☝️Experience of one colleague who got full
mark in that case
increasing SOB. Started with introduction and
elaboration of CC. She said
for 3 months she has gradually increasing SOB
without any specific time and has dry cough. no
chest tightness.
Asked for GERD which was absent and no

neurological issues pointing toward MS as in
some scenarios.
Did systemic review and didn't get any positivd

point.Till end of CC was not getting obvious
cause.
In social history she had pet dog since 6 years ,

no house dust mite, no paint or carpet changed
recently. Travell history ,she visited Africa and
willing to stay there bcaz she loved that place
without any SOB. But when arrived back she
has aggressive shortness and cogh. This
pointed toward occupational asthma. She was
working in plastic factory since 12 years and
didn't changed any position.
Was HTN and on ACEI. No fever , lumps and
bumps.
Asked concern and she told might be

developing cancer.
Adressed her concern in last minute. Examiner

questions .. what is D/D , occupational asthma /
ACEI induced cough . How to diagnose ? Here
he showed me written on a paper some FeNO2
(not remember exactly )and asked me do u
know this test ..i said no.
How will u investigate and manage. Steps of BA

management. After step 1 he said how much u
will wait to move to next step which I said sorry
I am not sure about time. 20/20
DEALING WITH MEDICAL MISTAKES/ERRORS
(By Dr. Zein Mahgoub) :
The word "error" is preferable to "mistakes":
📌 Nowadays, scenarios of medical

mistakes/errors are increasingly encountered in
Communication skills.
📌 First of all , from the scenario and the

gathered information from the patient/relative
▶️ you need to make your mind:
》Is there any error ?

This is usually clear by careful studying of the
scenario.
》Is it only a error or is it a case of negligence?
🚦We need to stop here to show the difference

between these two:
》Negligence is doing anything to the patient

that results in harm, suffering or any bad
consequences/outcome WITHOUT informing the
patient of the likelihood of their occurrence ..
》In medical errors, occurrence of damage or

harm is Not needed And the patient does Not
have the burden of proof of harm.
♦️ Therefore, you need to decide whether there

is harm or not.
Let's take the amoxicillin scenario as an

example:
If you give amoxicillin to a patient who is known
to have penicillin allergy:
Then,
↪️ If no adverse effects happen (No bad
consequences),
� This is a medical error
The patient can file a complaint without the
need for a proof of damage.
↪️ If the patient developed a

reaction/anaphylaxis:
� This is negligence
📌📌 Then how to deal with a medical
mistakes/error and negligence❓❓
Rule no. 1️⃣

NEVER make assumptions; use only the solid
data given to you/gathered from the patient.
Rule 2️⃣:
DON'T panic,
many people get panic and shaky when the
patient raise the issue of taking the case to the
court.
It is the patient's right to make a complaint.
Remember, you also have a legal adviser who
can advises and help you.
Rule 3️⃣:
NEVER try to hide mistakes.
You should be honest and admit mistakes
➡️ Suggested Approach ⬅️
➡️ Assess how much the patient/relative
knows (current knowledge)
➡️ if knowledge is incomplete, then step-by-

step break the bad news & deal with the
reactions (ANGER is the usual reaction)
➡️ Admit the mistake/error or negligence
➡️ Explain (exactly and in details) what had

happened
➡️ Explain the resulted consequences
➡️ Apologise in an appropriate language
➡️ Express great empathy and support
➡️ Explain: incident report, audit (I am going to

report the unfortunate incidence to the hospital
authorities who usually study all the
circumstances and take actions towards the one
who committed this error and take measures to
prevent the happening of similar incidences ) -
this just an example; you better use your own
words.
➡️ Never tell the patient to 'go & complain'

If the person wants to file a complaint:
- Tell him it is his right to do so,
- Show him the procedure
- Involve the consultant
- involve your legal advisor
➡️ In such legal issues, you need to arrange a

meeting with your consultant.
📌📌 DEALING WITH UNCERTAINTY📌📌
Scenarios of uncertainty are also common.
Examples from my course/exam:

● The patient who presented with empyemia
following chest tube insertion for relief of
pneumothorax,
● The issue of consenting the demented mother
for endoscopy,
● Delayed reporting of a lung lesion,
● Delayed investigation of post MI anemia. . 2
scenarios; one done in the group and the other
in the course manual
➡️ Suggested Approach⬅️
➡️ Never make assumptions; use only the
available information/data
➡️ Never be judgemental
➡️ Never be defensive
➡️ Empathise with the person
➡️ Admit uncertainty..
e.g. I am sorry I can't make my mind because I
have only limited information.
I need to check the medical notes, discuss other
members of the medical team and take the
opinion of my consultant
➡️ Assure that you're going, after gathering all

the details, to arrange another meeting.
➡️ Assure that you are going to be frank and

isn't going to hide any information
➡️ Arrange appointment with your consultant.
➡️ Some people misinterpret this approach for

trying to protect your colleagues...
Assure them that (I am not trying to protect
anyone, but honestly, I need to gather more
information before expressing my opinion)
BY DR. ZAIN
GENETIC TESTING
An important and confusing question is sent to
me by a colleague and I am sharing it with you
because many candidates face it in their PACES
and life..
Q:
I want to ask a question
Regarding genetic diseases
Huntington, APKD, MD.
If a pregnant lady requests for genetic testing
for her pregnancy and other kids;
Will I refer her for the genetic counselling team,

Or I should tell her that no test will be done for
them until they become adults❓
A:
My reply to her:
Good question..
◇ Genetic counselling and testing is done in

specialised centres with expert counsellors
◇ for APKD & HOCM genetic testing is NOT

recommend bcs of the mutations and because it
is very expensive..
You are advised to do US / Echo instead.
◇ For diseases where no other tests are

available (MD & Huntington), it is recommended
to offer genetic testing
◇ What about testing during pregnancy and

after delivery❓
¤ Prenatal testing is acceptable whenever it is

applicable and available.
¤ Early (< 12 weeks): the baby can be tested and

therapeutic abortion can be offered and
performed.
¤ 2nd trimester and above:
No benefits of testing and therefore Not
recommend..
If mother insists: express your opinion and refer
to your senior/ specialised councillors.
◇ Childhood and minors:

¤ Genetic testing is offered usually after the age
of 18 if no advantages of earlier age testing e.g.
APKD
¤ Earlier testing is offered Only if there are

advantages e.g. ICD or other measures to
protect life and prevent death in HOCM
In HOCM screening by Echo starts at the age of
12.. and earlier than this if there is significant +
FH of sudden death, Or if the child participates
in strenuous exercise..
◇ In APKD you need to screen for berry

aneurysm by CTA if:
1. There is high risk of fall,
2. Job involves working at high altitudes, or
3. First degree relative's death of IC bleeding..
I hope these points are going to help if you face
such complex scenarios in PACES or life.
Brunei 2/7/18 2nd carousel,
s4 explain the daughter about pckd,
BcC 1 tried ness with blurring vision, no clue
difficult case?
Bcc2 jt pain with back pain with psoriasis,
s1 Renal transplant, Ild ,
s2 wt loss with night sweat,
s3 Dvr?avr , cervical myelopathy.

pray for me.
My experience:
St4: task was to talk to sister of a patient of
hocm who died last year. She was a flight
leiutenant so had to explain implications of dx
to her and to counsil her about further
investigations. She was a very talkative n angry
lady so i kept listening n didnt interrupt her
altho i ws running outta time. N told her in
chunks about hocm n further tests n that she
will have to avoid strenuous activity. Referred
her to occup health deptt.
st3: cardio: old lady, pulse was good volume
but i could hear ESM only and was unsure about
AR so i said it can be mixed aortic valve
disease.
CNS: middle aged lady difficulty in walking but
apparently had a normal walk. Mixed periphral
neuropathy on exam .
St2: 50yr male with vertigo and falls. I gave dd
of BPPV , stroke, migrain and SOL. Examiner
asked details of Halpike manoevre.
St1: abdomen midline scar, bilateral iliac fossa
scars. Mass felt under left sided scar. So gave
dd of left sided renal transplant,
appendicectomy and previous peritoneal
dialysis OR pancreatic transplant. Resp:obvious
pnemonectomy case but very slightly deviated
trachea .
✔ Bcc 1 : 35yr old lady wd pain going from
lumbar area to front and then thighs. On exam
had absent ankle reflexes but normal sensation
. No idea abt dx
✔ Bcc 2 - lady with blackouts for 3 wks and

palpitations but no findings. Had h/o cardiac
accessory pathway ablation.
Few weeks before exam, try to examine clinical

cases under time pressure.
I took Fast Paces course a few weeks before
exam it gave a good exposure to exam related
cases.
Last Advice: Dont go after rare things!
Wish u all the best😊
Diet 2 Penang, Malaysia day 3 last carousel
Station 1 :-
Respi - patient with copd with bronchiecstasis. I
didn’t get to hear the crepitations but
generalized wheeze. Other candidate able to
hear crepitation. Only get 8/20
Abdomen - chronic liver disease. Discussed
about causes of chronic liver disease . Question
more on Wilson disease. 20/20
Station 2- a young lads presented with

numbness of the left upper limb associated left
sided headache . History of taking ocp.
Diagnosis was hemiplegic migraine. Ddx -
central venous and tia. Question more on
migraine . Examiner ask will you do a ct scan for
this patient. 20/20
station 3 :-
Cvs - an end stage renal failure on hd with
severe mr and tr. 15/20
Cns - hereditary sensory motor neuropathy. Has
reverse champagne bottle, high stoppage gait
and hammer toes. Question about Charcot
Marie tooth
))The patient has bilateral foot drop with pes

cavus. There was also s walking aid which was
behind the bed. The patient demonstrated high
steppage gait when I asked her to walk. Sensory
and muscle power was reduced bilaterally and
distally. The examiner asked about:-
1) how many types of cmt that you know of?
2) is cmt a demyelinating disease or axonopathy
mostly?
((
Station 4 -
Patient with underlying psoriasis on
methotrexate, developed pancytopenia after
given trimetoprim by Gp. Developed nose bleed
and bruises . Did my do well . Only got 7/16
Station 5:-
Bcc 1 - a lady with underlying Graves’ disease
done total thyroidectomy presented with seizure
. Missed calcium supplement. Forgot to check
chovestek sign. Got 24/28
Bcc2 - a lady complained of Haematuria for a

week. Further history noted patient has
underlying seizure on sodium valproate and
auntie also has seizure. Physical examination -
adenoma sebaceum. Has palpable and
ballotable mass over both hypochondriac
region . Right bigger than left. Dx - renal
angiomyolipoma underlying tuberous sclerosis.
Got 28/28.
Smear positive patient is admitted in your ward.
Staff asks you if there is any need of negative
pressure ventilation or contact isolation as it's
not a MDR TB. Your reply?
Patient needs to be contained in a side room if

not MDR. Negative pressure only if in a ward
with immunocompromised patients.
No need for contact isolation. Only needed
when staff has to use aerosol for the patient.
In MDR, Both negative pressure and contact
isolation needed by default
3/7/2018 cycle 1
cvs .
I got 17/20
Station 4 ..
refuse.
Inside ..
internet about S/E.
and oestoprosis..
with consultant.
Examine. .
give.
short time
I answer all..
I got 16/16.
Station 5..
his body.
Examiner...
involvement.
I got 21/28
..
I got 21/28
Chest..
Bibasal creps.
How you will mange.
I got 18/20
Abdomen.
Examiner.
2/7/18
Start BCC 1.
BCC 2.
Bronchiectasis
later.
Station 1Abdomen
Station 2
and vomitting.
Station 3
Cardio
Station 3
Neurology
weakness.
MG
Station 4
astrocytoma.
14 August 2018, Middlesbrough , UK
Exam stations :
Resp :
Isolated RT lower lobe bronchiectasis - most
likely posterior lower lobe as crackles were
localized to the posterior lower right thorax
Abdo :
Kidney transplant with a J shaped scar in RT
iliac fossa, but no transplant kidney palpated
underneath, signs of recent needle marks on AV
fistula, possible kidney ballottement but pt also
had a plantar surface foot dressing so could be
either PCKD or DM nephropathy
HX :
Night sweats and weight loss - travelled all his
life around the world for work but last 5 years
only to Africa, has been taking malaria
prophylaxis but dose not remember being
vaccinated for TB, no sinister sexual history,
committed to his wife, further probing was
found to have a dry cough for past 2 months on
a background of excess smoking for 35 + years
in the past (20 pack / year history of smoking)
Cardio :
Aortic valve replacement presented with chest
pain - examiners keen to know what will you do
for someone who has a AVR metallic
(irrespective of this pts current presentation) ,
also asked why would this pt have chest pain on
a background of AVR , whether it was a recent
AVR or old - the scar looked fresh though
Neuro :
Charcot Marie tooth syndrome
Communication:
Daughter of your pt who has presented with
stage 4 CKD and thereafter been recently
diagnosed of PCKD is worried as someone on
the ward told her mother that her condition is
hereditary and the daughter wants to know what
is her chance of getting the disease and what
will be next for her in terms of investigation, is
the condition fatal, if she starts her own family
will her kids also have PCKD, examiners keen to
know what all should be done for the pt. e.g.
genetic testing, U&E, BP....I said I would still
scan pts head and look for mitral valve prolapse
with an echo although he is not symptomatic
BCC:
HOCM (PC - 3 episodes of fainting with exertion
and after alcohol excess) family Hx - father and
brother sudden death at the age of 40 and 35
respectively. No significant clinical findings on
examination, pt concerns he will also die now.
Plan - postural BP, echo, hotter and cardiology
r.v, not to drive till diagnosis made
................Benign intracranial HTN, PC -
headache and neck pain, on examination she
had dilated pupils and an ophthalmoscope next
to her. She reported 2 months hx of headache
and 10 days hx of neck pain and bilateral
blurring of vision, otherwise fit and health but
slight elevated BMI, and on OCP for past 2
years...on examination bilateral papilledema, no
other visual field defects. LT eye had partial
linear pigmentation adjacent to optic disc which
examiners were keen to know what it was
...some candidates said that it was retinal mole
Thankfully Shared To me by one candidate
My exam experience in Qatar 🇶🇦 last day last

cycle 30/06/2018
St4 Nurse 👨⚕ came after she took Gliclazide she

came with hypoglycemia ,now she is ok and she
asked for discharge .
Sourgate was smiling beautiful lady 🙈and she

is was v.good till I said to had I need to consult
mood doctor 👨⚕ her concerns she need to go
home 🏡 I asked her Why she said that she
didn't wont any one of her colleagues to known
what happen to her
Then St3 difficult station and tough examiner 😢

When I went inside he said to me this yr first
case examine cardiovascular at that time I
became confused coz from outside I prepared
my self to go to wall and to read instructions 😔
Pt young man when I finished from
examinations he said to me present only +
findings I said to him I couldn't appreciate any
abnormality apart from loud first heart sound he
asked did u hear 👂 any murmur I said noooo
discussion was on Ms & As
When I finished cardio he said this yr neuro
case examine upper limb the mistake I did I
examin Pt as if the instructions is to examine as
a proprietary 😏😏case was Parkinson's only +ve
finding is tremer and synchaniza .
Discussion was on Parkinson's and mangment .
St2 talk to mrs fatima son .
His mother came with recurrent convulsions (
when I took history she is known epilepsy for 30
yrs days ago diagnosed to have UTI ,history of
resent trauma ) his concern he would like to
known what's happen to his mum ,why fits is
recurrent ?? It's due to medicine given for UTI?
St5 (1) headache and fatigue it was acromegaly
put in examination I didn't found any finding
every think normal no face changes suggestive
of acromegaly .
St5 (2) recurrent chest pain not known DM or
HTN or + ve family history of sudden death OE
only +ve finding is xanthelasma over Lt eye lid
diagnosis is f. Hyperlipidemia
St1 chest Lt lower lobectomy
Abdomen CLD . liver shrank I could not
appreciate any +ve shifting dullness .
Plzzz prayer 🙏 for me

Brunei center (2018/2)
2/7/18
Start BCC 1.
BCC 2.
Bronchiectasis
later.
Station 1Abdomen
Station 2
and vomitting.
Station 3
Cardio
Station 3
Neurology
weakness.
MG
Station 4
astrocytoma.
3/7/2018 cycle 1
Pluse was large volume regular .there is midline
sternotomy scar which is faint and covered with
skin fold I did not see it only in last minute so I
examin percadium there is diastolic murmor
more in aortic ..iam very confused and not sure
about my finding I present it ..when asked
what's diagnosis I said aortic regurgitation and
there is sternotomy scar but I did not hear click.
CNS..I was very stressed and confused from cvs
.
I got 17/20
Station 4 ..
Was unversity student known to have ulcerative
colitis given rectal steroid not control the plan
to start him on oral steroid but he refuse.
Inside ..
internet about S/E.
and oestoprosis..
with consultant.
Examine. .
3/what prophylaxis for oestoprosis you will give.
short time
I answer all..
I got 16/16.
Station 5..
his body.
Examiner...
involvement.
I got 21/28
..
I got 21/28
Chest..
Bibasal creps.
How you will mange.
I got 18/20
Abdomen.
Examiner.
4th july 2018 first round
Respi hard case
Reduce breath sound
No crept
Midsternotomy scar

lung collapse

nonfunctioning fistula.


scabies
Cvs MVR
Neuro hard case. Depressed reflex with normal
sensation. All candidate answer peripheral
neuropathy

worsening in ward

to bring pt home
BCC 1 graves disease

(4-7-2018) Brunei center ,

I started with history taking he is male pt 30 year
old itching 3weeks back , weight loss about 7kg
,lump in his neck , sweating and itching more at
night , he also DM, hypothyrism,on morphine
due to back pain after motor car accident ,he
has echezaema since childhood , he has stress
and take medication ssri no other allergy ,no
other suggest Prv,no PBS, I told him many
causes in your condition but I want to exclude
lymphoma first , examiner ask about DD,
investigation, treatment, how I can diagnose
scabies😁, are you sure diabetes cause itching I
told her yes if uncontrolled then time finished .
St4 angery daughter due to missed dose ,I
apologise to her and take about incident report
and all medical error action , then she told I will
be happy if he improved ,I told I can't guarantee
that he will improve complety has pneumonia
and it's added cause to his condition , asked her
about premorbid stat and his baseline before
admission, she want to meet the doctor
responsible ,I told her we working here as a
team all of us responsible in his Heath condition
June 2018 Royal Victoria Hospital Belfast UK
London College
1. History : scenario of a patient feeling dizzy

while standing up for 1 week bloods with g.p
showed raised urea and creatinine. Past hx of
ulcerative colitis and ileostomy. Inside only on
asking serrogate told high output from stoma
but no blood or fever. Also taking over the
counter NSAID for the last 1 week for back pain.
Told patient that symptoms of dizzness are
likely due to postural hypotention and
dehydration. Patient's concerns were about
kidney functions told him that can be due to
dehydration or NSAID use. Will need admission.
D.d viral gastroenteritis and ATN questions
about how to manage got 19/20
2. CVS Guy with a very small lateral

thoracotomy scar i could not pick up any
murmer. Examiner said if there is a mild ejection
systolic murmer at aortic area what would you
think. I said it might be a case of coarctation of
aorta with previous repair ass with bicuspid
aortic valve stenosis. Questions regarding
management got 10/20
3. CNS Young patient with left sided
hemiparesis spastic left leg exaggerated knee
relfex ankle clonus and complete sensory loss.
Left sided facial paresis. Examiner asked d.d
and said what is the dx if there is complete
hemisensory loss along with motor paresis in a
young patient, i said stroke migraine MS could
not say tumor and bell rang got 15/20
4. Communication tast to talk to wife a patient

that satrted cycling and due to fear of
dehydration started to drink loads of water.
Came with hyponatremia and fits. Ct brain and
all other invedtigations normal. Explained that
likely cause of fits is low sodium due over
drinking and treatment is to slowly correct it
through iv fluids. Wife's concern were if ot is
epilepsy can it happen again and what
precautions should we take. Also asked they are
flying next month is it possible i said i will
contact DVLA and ask relevant guidelines. Got
15/16
5. Station 5 known sarcoidosis patient can in

with collapse and palpitaion . Main dd cardiac
involvement and likely arythmia brief
examination of pulse cvs and resp no findings.
Pateints concerns what is the cause and how
will it be managed Examninor asked about
definative dx i said by cardiac biopsy got 27/28
6. Station 5 old man with ckd came in with joint
pain early morning started from ankles and
involved hands. Tophi visible on finger also
taking diuretics. Patients concern was how will i
treat his pain Examiner asked your top
diffrential i said chronic gout got 28/28
7. Abdomen lady with left sided fistula rt iliac

fossa scar underlying renal tenasplant.
Examinors said if any compilation of steroid use
visible i said i am not sure. Got 8/20 which
surprised me but obviously i have mis
diagnosed the case still waiting for feedback
8. Resp clubbing with peripheral cynosis

bibasal fine crackles. ILD Examiners asked
about dd and investigations said everything but
could no mention lung function studies which
the examinor pointed in the end. Got 17/20
Overall 139 cleared in my first attempt and very
releaved. All the best everyone preparing
UK center
24 June 2018
*Station 1: (Respiratory)* ILD with clubbing and

steroids Induced skin changes
(Abdomen) ESRD with failed kidney transplant
and left arm fistula, functional and active, with
another scar on left subcostal area I dunno for
what.. I mentioned pancreas transplant.. But
dunno what it was.
*Station 2* 52 yr old policeman with 5 month
history of itching all over body. Had DM and
Hypothyroidism, and backache. Now noted 7kg
wt loss and submandibular Lymph nodes.
Mother had alzheimers and is in nursing home,
was worried if its an infection.
*Station 3* _Cardiology_ mixed mitral valve
disease with atrial fibrillation.
_Neurology_ cranial nerve exam in a normal
subject, with history of intermittent diplopia
*Station 4* paracetamol poisoning, wants to self

discharge, main concerns were that she didn't
want to tell husband and GP, examiners
discussed about how would you practically deal
with her wish of not to inform husband, as he
would figure out anyways. Also, if you agree not
to tell GP, what would you write on discharge
card.
*Station 5* _BCC1_ Hereditary Hemorrhagic

Telengiectasias
_BCC2_ left homonymous hemianopsia, sudden
onset.
23/06/2018 UK exam experience
Resp-right upper lobectomy with clubbing, no
abnormal sounds
Abdo-left ballotable K/d with pain/ no scars at
all, given symptom is tiredness. Questions: Why
pain? Why tired? Causes of Uni k/d
enlargement.
History-41 female Breast cancer, completed
chemo&RT 6/12 ago, currently on tamoxifen.
Presented with 2/12 dry cough/SOB and ankle
oedema. Diagnosis is heart failure, d.dx:
pulmonary hypertension, drug induced,
chemotherapy/RT induced, concern: is the
return of cancer? & can she able to attend her
son graduation next year?
CVS -bioprosthetic AVR. AS AR with feat of
heart failure
CNS - bilateral spastic paraplegia with reduced
ankle jerks(mixed UMNL+LMNL), pes cavus +,
with left cerebellar signs> MS/MND/Fredrick
ataxia?
Communication-medical error/ talking to pt’s
husband, pt: lung ca with bone&brain Mets,
missed fetanyl patch for 5/7 despite emphasized
by husband to clerking doctors and nurses,
angry till the end despite apologies and
information about PALS
BCC
1- 69yr man with CCF, 2/52 tongue swelling and
bruising on lower eyelids(both stated by pt but
no macroglossia/no bruising on examination
?amyloidosis, ramipril induced? No feats of
acromegaly, no feat of hypothyroid. don’t know
the answer till now.
2-female 21yr with previous malignant
melanoma, 2/12 abdo pain and constipations
(given outside), (inside) occasional bloody
diarrhea, no wt loss, no extra intestinal IBD
feats, IBD/IBS? to exclude infection.
Uk centre
I passed in first attempt Alhamdulillah
Stem was deranged LFTs with fatigue and no
symptoms and no other positive history except
positive family history of liver cirhosis in father
and all brothers of father have diabatese
It was haemochromatosis
Discussion about dds investigations
I got 19/20
Station 3 CVS old age male presented with

collapse
systolic murmur throughout precordium
i missed the case
mentioned MR but it was AS
discussion about d.d and investigations and
managment
examiners were not happy
i got 8/20
CNS left sided decresed power with ankle
clonus with normal sensation and gait was
hemiplegic(could not identify because patient
walked with stick)
i could not explain findings correctly but i gave
diagnosis of stroke
when asked about gait
i said hemiplegic gait
further discussion about d.d and investigations
and managmnt
i got 19/20
Station 4
Talk about DNACPR to daughter of a patient
with multiple comorbidities
Main concerns were
1)it is my mothers wish to get resusitated
2)i want to sue the hospital fr this decision
3)can u change this decision
Discussion about ethical principles
Focussing esp on is it breech of autonomy or
not in this case
I got 13/16
Station 5
1)30 yr old male with speech problm
Inside was a surrogate who gave History of
speech prblm fr 15 minutes with headache and
left arm numnness
Known case of migraine which is controlled
Prevous history of CVA fr which thrombolyzed
Concern was about driving which i advised to
stop
There were no findings as patient was surrogate
I gave diagnosis of TIA
Discussion about d.ds and investigations and
treatment
Examiners were asking constantly what else
They wanted to hear hemiplehic migraine
I could not give this d.d and they cut marks fr
that
I got 24/28
2) old age male with essential tremors now got
worse inside was parkinsons patient .he gave
history of tremors on right side and face and
unable to roll over bed.family history positive fr
essential tremors
I performed parkinsons scheme
Concers were that should i cntinue taking
propranolol which i am taking fr essential
tremors i said v will replace it with another
medicine
Discussion about d.d and again i was not able
to give d.ds properly
Missed cerebelum as d.d and again examiners
asked what else
Further discussion about investigation and
management
I got 24/28 in this case
Station 1
Abdo
Young female presented with Fatigue and
pruritis
nothing on exam except a spider navus on
chest
i missed this finding but gave correct d.d and
investigation and management plan
this was ptimary biliary cirhossis
they gave 14/20
Resp
patient had wet cough during the exmination nd
had mixed crackes changing with coughing
there was also prolonged expiration
i gave diagnosis of bronchiectasis with copd
Discussion about investigation and
management
i got 20/20
Qatar 🇶🇦 2018
Much worse than i expected
Resp was lobectomy i said pneumonectomy
Abd was cld shrunken liver
Cardio no clue seems vsd
Neuro clear parkinson
Station 5 headach fatigue weight gain prox myo

normal visual feild i said acromegaly
Other case is chest pain with exertion relieved

by rest burning strong family history of CAD
Isaid cad vs gerd start asp and bb and ppl plus
workup
Communication
Nurse with overdose of oral antidiabetic want
discharge before psych assessment
History taking
Epileptic Elderly on phenobarbital came with
status epilepticus
Started on nitrofurrintoin
UK EXPERIENCE
8/7/2018 Luton & Dunstable Hospital- UK
St2:
35yrs gentleman
Referred by GP weight loss + lethargic +
Malaise.
FBC normal.
Thyroid Function normal.
Inside:
CVS. N
RESP. N
GIT. N apart of anorexia.
CNS. N
MSK & Skin. N
Mood very low
Lost his job 4/12
Lost his father 2 yrs with lung Ca.
Separated from his wife recently.
Looked depressed
Lack of appetite
Lack of sleep
Lack of joy
No suicidal ideation
St4:
36yrs gentleman
Seen in the general medical clinic 4 weeks after
routine bloods done by GP which showed
deranged LFT. Now liver screen negative,
Ultrasound showed cirrhotic liver and Ascites.
PMH T2DM 20yrs and obesity. He is not taking
alcohol.
Your consultant think it’s Non Alcoholic Fatty
liver disease secondary to DM & Obesity.
Concerns:
1- Is it serious, bcz my uncle died from Cirrhosis
and was very sick?
2- how I get this cirrhosis! Although I’m not
drinking Alcohol!
3- How DM do that!
4- was it developed suddenly or what’s going
on!?
5- how you’re going to treat me?!
6- is it reversible condition?!
7- I’m afraid of the future?! What will happen for
me?!
I did very bad indeed in this station. The actor

was very rude, not as part of the scenario but he
was holding his paper and talking, reading his
papers!!
Chest: ILD + Clubbing

Abd: sick pt, deeply jaundiced, most of the
discussion about the obstructive causes.
CNS: Parkinson
Cardio: metallic AVR.
BCC1: steroid induced myopathy for differential.
BCC2: k/c of scleroderma/SLE
C/o back pain, mechanical pain
Exam cases from seberang jaya, penang,
malaysia 6/7/18, 2nd carousel
Only one team in the carousel, but 2 set of pt in
station 1&3 alternating for each candidate
Station 1
Abdomen - hepatomegaly with massive
splenomegaly - myelofibrosis
Respi
1- right lower zone bronchiectasis with vats scar
and chest drainage scar on left, likely left lower
lobectomy with underlying bronchiectasis
2- pulmonary fibrosis with underlying
scleroderma
Station 2
35 yo lady recent travel to vietnam complain of
fever with bloody diarrhoea
Fever 5 days, diarrhoea 2 days after back from
vietnam, moderate amount, watery stool mixed
with blood. Loss of appetite for 1 week, loss of
weight 3kg in 2 days. History of hay fever, family
history paternal uncle has crohns disease.
Social hx unremarkable
Dx dysentry
Concerns
- could it be malaria?
- could it be crohns disease
- do I need to be admitted
Examiner question
- what is the possible microorganism
- antibiotic choice
- how u decide pt need admission - examination
and ix
- when colonoscope is indicated
- wat is the complication if perform colonoscope
now
Station 3
CNS
1- LL examination- proximal myopathy
2- LL examination- spastic paraplegia
Cvs
1- MVR
2- PS + ? MS (candiate who get this case said pt
looks syndromic)
Station 4
Break bad news - newly diagnosed MS
patient is physical education teacher, just
engaged. Admitted for cerebellar sign, resolved
spontaneously in 1 week. Mri suggest of ms
Concern
- my uncle also diagnosed with ms n now bed
bound, will I become like him?
- how shud I tell my fiancee?
- can I continue to work?
- how about my wedding plan in the end of the
year, shud I postpone?
- will my child be affected?
Station 5
Bcc 1- kco t1dm 15 years, c/o blurring vision
and frequent trip on objects
Examination showed visual acuity 6/60 both
eye, tunnelled vision both eye. Fundoscope
hard exudate over both eye macula region
Dx both eye diabetic retinopathy with
maculopathy
BCC2 40 y/o male with low grade fever, abd

pain, hematuria. Father and sister h/o ckd
required dialysis, father passed away d/t icb.
Examination bilateral ballotable kidney
Dx adpkd with infected cyst/ bleeding into cyst
UM 2 Myanmar
2018/2- day 2- round 2
Station 5
BCC -1
Middle aged man with palpitation and
brathlessness underlying Hypertension and DM
BP-160/90
Inside- obese man
History- poorly controlled hypertension with DM
Examination- AF with congestive cardiac failure-
controlled- pedal oedema present but no lung
sign
My Dx was Controlled heart failure with AF
underlying IHD with hypertension with DM
Examiner questions- How to diagnose-
ECG,Echo, Angiogram, CXR, lipid profile ,
HbA1c , UACR and creatinine.28/28
BCC-2
Middle aged lady with painful hand
Inside- History - Raynaud's phenomenon with
tightening of skin. Difficulity in swallowing and
dry cough also present.
Examination- PSS features present . Inspiratory
crackles are not sure.
Examiner question- positive findings in
examination
How to diagnose and Mx
Mx of Raynauds and PSS answered but he
asked specific treatment of PSS ?? 26/28
Station 2- History
Middle aged man presented with sudden onset
unsteadiness last night.
He got sudden onset unsteadiness with
spinning around while he was sitting while
watching TV last night associated with
headache and vomiting. History of headache
previously relieved by paracetamol. No weak
limbs , LOC , fits. History of hypertension on
Losartan and taking aspirin. He is a teacher with
some stress. He is married with 2 children. He
does not drive. His father has Stroke and
mother has hypertension.
I had no time for system review. When examiner
reminded me 2 mins left, surrogate told me his
concern is he is worried as he got stroke.
My dx was Basilar migraine.
DD are Posterior circulation stroke, Acute
vestibular failure or Benign positional vertigo.
Examiner questions- Why you did not put stroke
in first place? He had history of headache
relieved by paracetamol suggestive of Migrane.
Stroke is possible as he has hypertension and
family history but more favored of Basilar
migrane.
How to diagnose? No definitive investigation for
migrane. I will exclude other diagnosis by CT ,
Hallpike manaeuvre. Examiner said if these are
normal, what will you do?
I will give Migrane treatment with prophylaxis as
he got headache more than 3 times per month.
Examiner asked do you want to change his
antihypertensives as he is 57 years old. I
answered if BP is controlled , I will not change.
But examiner reminded me for Migrane
prophylaxis, CCB is better for him . 20/20
Station - 4
Talk to husband
His wife was admitted with confusion after losse
motion ( infective diarrhea) kept in a side room
got slip and fall and fracture leg and on the floor
for 4 hours without being noticed by the staffs.
Staffs are busy with admission and Ill patients
that night. She has underlying Multiple
sclerosis.
He was angry why she got slip and fall and got
fracture without being noticed by the staff. I
apologized and I will help to investigate what
had happened to her. As she was weak due to
loose motion, she was kept in a side room so
that she got no infection from other. Staffs are
busy with admission and I'll patients but there is
also shortage of staff. I will inform my
consultant, write down facts about what had
happened to her in hospital incident report
book. Hospital administration will investigate
the event and take action and will let you know
the result. He was concerned about finance for
surgery for fracture. They are retired
pensionists and lived in second floor. I will help
him by contacting with social worker as he will
have problem to take care at home.
Examiner questions- his concern. How to take
action for shortage of staff. Will you tell name of
staff at that night? 16/16
Station 1- Respiration- COPD with bronchiatasis
-11/20
Abdomen- Hepatosplenomegaly with pedal
oedema - Chronic haemolytic anaemia probably
beta Thalassaemia major with CCF due to
cardiomyopathy due to haemochromatosis-
Questions- Dx of Thalassemia and Mx up to
haemochromatosis. 20/20
Station-3 CVS - MR with TR with pulmonary
hypertension -15/20
CNS - Bell palsy 20/20
UK ,,experience from bishop aukland hospital
durham
Station No 1 Chest Pneumonectomy , Abdomen
Liver and Pancreas Transplant
Station No 2 ; Addison history
Station No 3 ; Prosthetic MItral valve
replacement .
NEURO ; Stroke Left side Hemiplegia .
Station No 4 Breaking Bad news .
Station No 5 SVC obstruction

and Goiter
UK ,,, experience from wastern general hospital
Edinburgh
Station 1
Renal transplant, bronchiectasis
Station 2
ACEI induced cough
Station 3
AS, Multiple sclerosis
Station 4
New diagnosis of MND, Neurologist want PEG
due to bulbar involvement. Discuss with son
Station 5
Polyarthritis-psoriatic, Goiter
Uk experience diet 2 -- 24 June
Started with st3.
Cardio- pt with sternotomy scar , left
thoracotomy scar. Both radial pulse was there.
AF with solw ventricular response .
DVR . I found a murmur in apex . But said i
would like confirm doing Echo. No features of IE
or pulmonary oedema or overt warfarinization.
DD i said may be inherited connective tissue
disease or IE ?
Neurology . Elderly man with peripheral sensory
motor neuropathy. It was an HSMN case.
St4- young pt paracetamol overdose . Blood
level still high. Pt dressed up ready to go away .
Nurse saying need 16 hrs at least to complete
acetylcystine drip. Inside pt was a pure
gentlewoman. She already got convinced as i
said about possible liver and renal involvement.
Explored why she took it. She said it was an
impulse. Will not do it again. Wanna see
husband to settle all this. Doing job ..staying in
the house very little. . Then i raised the issue of
assessment by the psychiatrist . Said . We are
very happy that u are thinking positively for the
future . That is what we want. But we need to do
a thorough check up by mind specialist just to
be 100% sure that this thing will never happen
again. It is just a regular check up by the
specialist in this sector. She was convinced. I
said if u want , i will be there with specialist.
Concerns was whether her husband and gp
need to know or not.
St 5.
Bcc1 . 82yrs old man with vertigo episodes 2
times 2 weeks back.
And also diplopia at that time. Nothing now. Did
eye movement test . Normal. Cerebelar was
problemetic . Pt couldnt do dysdiadocokonesia
test properly. Examiner said no cerebellar
problem. Did a quick walk test. Romberg test .
All ok. Forgot to see pulse and precordium :(.
Dd said BPPV and posterior cieculation stroke?.
Pt was actually BPPV .
BCC2 . Htn in 41yrs old patient. Occasional
heasache , sweating :) . Inside a case of
neurofibromatosis. History episodic headache
palpitation sweating . But may be not all of them
same time. Ask to do ophthalmoscope, urine dip
stick, did pulse and precordium, asked to do
thyroid test . No need they said.asked to do
tummy test to see any organomegaly. No need.
Concern was pain in nodules and htn
St 1
Respi right thoracotomy scar and sternotomy
scar with grafting scars . No abnormality in
auscultation apart from mild crackles in the
right.
Abdomen . I said jaundice with massive
spleenomegaly. Examiner said not proper
lighting for jaundice , no jaundice they said.
St2 was cough with SOB . Breast cancer 2yrs
back . Chemo radio done 6months back. Dd i
said heart failure . Recurrence of mets ,
pulmonary thromboembolism. Actually i think it
would be . Heart failure then pulmonary fibrosis
then chronic pulmonary embolism ?
Colombo (Sri lanka) COLLECTIONS PACES
EXPERIENCES
Colombo, Sri Lanka (2018/1 diet)
Resp : probably idiopathic Pulm fibrosis with
focal consolidation and bronchiectasis
Abdomen : B/L PCKD with active fistula and RIF
scar with no underlying renal transplant
probably appendicectomy scar..no side effects
of immuno supp
Neurology : Spastic paraparesis with normal
sensation
Cardiology : Severe MS in sinus rhythm
Loud P2
BCC 1 : recurrent collapse Severe AS and MR
BCC 2 : Haemaetemesis with moderate
splenomegally and Hx of DVT...young lady DD
Myelofibrosis with thrombocytopenia or CML..or
myelodysplasia with PNH
St 2 : Psoriasis s pondyloarthropathy or
ankylosing spodylitis
St 4 : GBS with axonal type went into resp
failure intubation and ventilated
Now weaned off with tracheostomy. .
Colombo day 2
BCC1- DROWSINESS +ACCIDENT = OSA
BCC2- headache - kidney mass = SAH + PKD
RS = patient has hemoptesis, has anemia and
right upper lobe fibrosis = TB
Abd: jaundice, i could not find other finding =
hemolytic anemia??
Neuro: left sided lower motor neron facial palsy
CV: sever Aortic stenosis
History: hyponatremia in patient with hx of HTN
and hypothyroidism = Adisson, ?paraneoplastic
syndrom
Communication= inform the angry husband of
patient who got penicillin injection and then has
SJS
Colombo , Sri Lanka, 15th March
Station 2: A 22 year old girl has collapsed and
there had been urinary incontinence. She has a
brother who was diagnosed with epilepsy.
Although this looked like a seizure initially it
was not. She did not have aura, no jerky
movements, no tongue biting, no eye rolling up,
and it lasted only for 10_15 seconds. At that
time she was standing in a queue for 30mins
and she has looked pale.during the episode. So
I took it as vasovagal syncope, but for DD I gave
seizure disorder, arrhythmias.
Station 3 CVS: AR and AS with tachycardia and
mild ankle edema. Patient had clear collapsing
pulse, Corrigan sign.
Neuro: 3rd nerve palsy with contralateral
hemiparesis
Station 4: 82 year old who was investigated for
haematemesis and vomiting, initial UGIE
duodenal ulcers, CXR, USS normal, repeat UGIE
narrowing of esophagus. CT showed
disseminated malignancy. Daughter is angry
that you are late to. diagnose her mother's
condition. Now she can't eat and NG tube
passage failed. Daughter wanted to complain
and to discuss treatment options for her
mother.
Station 5: BCC 1: 55year old male with 5 day
history of cough and fever. Has had TB 4years
ago. Examination post TB bronchiectasis.
Concern could this be TB again
BCC2: 65 year old male with headache and
proximal myopathy, jaw claudication.
Examination negative. Concern ?brain tumor,
will I get better
Station 1: RS :ILD with clubbing and cushinoid
appearance
Abdomen: Pallor with splenomegally , no
icterus. Haemolytic anemia, infections,
haematological malignancy as DD
2018/1 New Delhi
(9.02.2018)
station 5
1.40 yr old lady with pain abdomen and vomiting
since 4 days...known diabetic on insulin..sugar
was not under desired levels.. discussion was
around dka and acute cholecystitis
2..40 year old lady with diarrhoea and vomiting
..7 days had out side food.. discussion about
food poisoning and admission
Stn 1.abd.abd massive splenomegaly..
discussion about myeloproliferative disorders
and Rx
Respi..COPD
Stn 2..40 year old male with collapse..was
known DM with all pathies/htn/af/ihd
Stn 3...cardio..midline sternotomy in old lady
pace maker in situ.. discussion about MVR
mettalic
Neuro.cranial nerve exmn...young lady around
20 year.. findings..7.9.10...involved .. discussion
about icsol..
Stn 4..talk to son about mother who had
delirium following uti and developed black
ulcers on foot ( never heard in India about such
term) presumed it to be pressure ulcer and
explained ..task explain and clear concerns
Delhi
Station 1 : ?right effusion ? Ild.. . The effusion
findings were not very good. Gave DD of fluid
related crackles as well. .
Gi was cld with ascites with elevated jvp
Station 2: history regarding fatigue, fever,
cough since 3 weeks in 50 year old male.
Station 3: left hemiparesis with facial palsy
CVS was mvr with AS
Station: drug error. Asthmatic patient with HF
given bisoprolol
Station 5.
- acute onset confusion in elderly
-meningitis
18/july/2018
Started with st4
St5
Bcc1:
up
RA, MCTD
Bcc2:
else were negative
lethaergy?
St1
Respiratory:
Pulmonary fibrosis
Abd:
Renal transplant
LIF scare
Viva about APKD
St2:
DDx:
Caffiene intake
LQTs
Brugada synd
IHD
St3
Neuro:
UK,,,Edinburgh. 10.07.18
bruise.
with 2ndary mets.
Parkinson plus.
condour specially.
New Delhi
station 1
Resp: pleural effusion unilateral with av fistula
Discussion was about causes of unilateral
effusion in esrd patient...
Abdomen: gross ascites but no other signs of
cld... no organs palpable
I said could be tb peritonitis etc
But examiner asked all about cld maybe I
missed something
Station 2
Lady with breast cancer progressing on multiple
lines now wants to be admitted because family
can’t take care of her...
I got a lil stumped in this because this is not the
usual history taking...
in history got points that she is still in pain,
clinically depressed , symptoms not controlled
...
asked about pain meds she was on morphine
ibuprofen paracetamol etc
I said will admit for pain control and to find out
why having pain...
Bt examiners were still not happy...
They said you should ask individual side effects
of each med... like for morphine constipation,
for paracetamol about jaundice whether she
knows max limits and is she exceeding it etc
Screwed up this one
Cvs: young lady with bivalvular replacement
Asked why... I said rheumatic
Then he asked me why do you think she had
metallic and not bio valve
Again was stumped for a while gave pros and
cons for both types ... and said she may need
another surgery later on in life... discussion
about anti coag which I answered
Neuro: guy with muscle wasting , high arched
foot , intact sensations
Was thinking hsmn but sensations intact... gave
it as differential
Examiner asked can it be polio, then realized
maybe it was polio
St 4
Wife went to work and collapsed ... has signs of
meninogicocaal meningitis and needs icu
First part was about patient updates and that
she is sick may die...
I said we hope that she will recover because she
was brought within 4 hours started antibiotics
on time etc
second part about contact tracing- public health
issue
Can do it without his consent also (this was the
ethical issue)
In discussion examiner said you didn’t say that
disease has high mortality
Bcc 1
Long standing asthma patient on oral steroid
cane with sudden onset back pain
D/d osteoporosis fracture
She asked me what apart from these can come
suddenly with back pain i Said ovarian torsion
bt overall I did well they were happy i did slr
Bcc2 young man cane with blood in stool... on
and constipation for 8 months
Father has polyps which were benign
Gave d/d of colorectal ca, polyps, piles, fissure
Discussion was about screening guidelines
3rd carousel (9.02.2018)
St1: Abd Huge ascities with Mark for recent
paracentesis and scar in upper abd of recent
shingles. Dd CLD/Malignancy
Resp Fever with cough. Dd Pneumonia, TB
ST 2: 30Male h/o unilateral headache for 1 yr
which has increased in last 2 months. During
last 2 month he is having cocodamol qds.
Concern- what is the cause. Can it be tumour.
Diag Analgesic abuse headache in the
background of migraine.
St3: Neuro Chorea. Cardio - DVR with infective
end. Viva on IE
ST4: M45yrs having at loss enlarged liver,
Supraclav LN. CT and FNAC done. CT
suggestive of upper lobe mass with liver mets.
FNAC report is missing. Your friend who did the
FNAC is on leave. Boss is out of station. He
instructed u to talk to pt. And repeat FNAC. Very
angry surrogate. Hardly allowing to speak.
St5: BCC1- Sudden SOB for 4 hrs. On exam DVT
with PE.- Surrogate.
BCC2 - Maroon colour stool with new
constipation for 8 months. Tenderness in LIF.
Father had polyps. Had dizziness and tachy.
Was on antiplatelets- Surrogate
1st carousel.( 10.02.2018)
st 2.A 50yrs old man H/o Evening rise of
fever,Cough,SoB for last 2weeks. Haemoptysis
for 7days,Lethargy &weight loss for 3 months.
T2DM on Glargine 10 units. visited Kenya 6
months back.Smoker 10 cigarettes a day.D/D-
TB,Ca lung,Lymphoma,HIV
St3-DVR+IC drain in right side.sick
patient.Pneumonia with effusion.very sick
patients.Neuro -Upper limb-CVA. on inspection
UMN facial palsy.
St 4 long scenario.53 years old patient Asthma
plus ex smoker this time admitted with
SOB.Revealed Heart failure.Improved with
Diuretics &ACE inhibitor.Fit to discharge
tomorrow. But one of your junior prescrbed
Bisoprolol 5.Pharmacists warned nurse.that it is
contradicted in Asthma.But patient heard it.Talk
to patient
Questions -Ethical issue.Surrogate told about
negligence. I apologised & mentioned that it is
error. He is going to complain. Introduced to
PALS.
BCC1-Elderly man c/o Confusion &fall for
7days.Known Hypertensive. Taking Thiazide
.Hyponatremia
BCC2- Middle aged man having fever ,headache
,vomiting for last 5 days.Inside different
story.Known epilepsy taking Levetiracetm,
Alcoholic. Treated as a case of viral
menigitis.Discharged &again same c/o
headache, vomiting, seizure.Now in emergency.
on examination -only neck rigidly. D/D-Bacterial
menigitis,TBM,Cerebral venous sinus
thrombosis
St1-CKD with AV fistula in left hand with Right
sided pleural effusion. CLD ascites with Midline
sternotomy scar plus ?Portacaval shunt
Experience of one colleague who got full mark
in that case

increasing SOB.
Started with introduction and elaboration of CC.

She said for 3 months she has gradually
increasing SOB without any specific time and
has dry cough.
no chest tightness.
Asked for GERD which was absent and no

neurological issues pointing toward MS as in
some scenarios.
Did systemic review and didn't get any positivd

point.
Till end of CC was not getting obvious cause.
In social history she had pet dog since 6 years ,

no house dust mite, no paint or carpet changed
recently. Travell history ,she visited Africa and
willing to stay there bcaz she loved that place
without any SOB.
But when arrived back she has aggressive

shortness and cogh. This pointed toward
occupational asthma. She was working in
plastic factory since 12 years and didn't
changed any position.
Was HTN and on ACEI. No fever , lumps and

bumps. Asked concern and she told might be
developing cancer. Adressed her concern in last
minute.
Examiner questions .. what is D/D , occupational

asthma / ACEI induced cough . How to diagnose
? Here he showed me written on a paper some
FeNO2 (not remember exactly )and asked me do
u know this test ..i said no.How will u
investigate and manage. Steps of BA
management.
After step 1 he said how much u will wait to

move to next step which I said sorry I am not
sure about time. 20/20
Paces exam 9th October experience
Station 1 abdomen- weird case patient with only
mild hepatosplenomegaly mild jaundice sclera/
dirty sclera . Unsure whats the diagnosis. Give
differentials of chronic hepatittis with portal
hypertension , haematological causes.
Lung- coarse creps with a small dressing over

left axilla. Examiner guide to fnab. Likely lung
cancer??
Give diagnosis of bronchiectasis
Station 2. Patient come in with malaise for 4

weeks with frothy urine and generalized body
aches one day. On omeprazole 3 weeks ago for
gerd. Also has bilateral lower limb rashes.
Likely vasculitic rash. Give diagnosis of churg
strauss, wegerner, henouch scholein purpura,
microscopic poliangilits, drug induced nephritis
secondary to omeprazole. Seriously no clear cut
diagnosis.
Station 3 avr with mr and tr
Neuro. May be myotonic muscular distropy，

fascioscapular muscular dystrophy
Station 4 counseling on anticoagulation of
someone with af. Give the choice of noac.
Examiner ask all the medical questions like
choice of noac, bleeding risk between each
noac. No ethic questions at all.
Station 5 bcc1 patient with bloody diarrhea and

weight loss. Just come back from overseas
claim india. Give differentials of gastroenteritis,
ibd.
Bcc2. Rheumatoid arthritis. ?? Anaemia of

chronic disease, got some bruises also on the
arm. Splenomegaly 2 fb. ?? Fely syndrome
UK
Edinburgh. 10.07.18
bruise.
with 2ndary mets.
Parkinson plus.
condour specially.
Respi hard case
Reduce breath sound
No crept
Midsternotomy scar

lung collapse

nonfunctioning fistula.


scabies
Cvs MVR
Neuro hard case. Depressed reflex with normal
sensation. All candidate answer peripheral
neuropathy

worsening in ward

to bring pt home
BCC 1 graves disease

IMPORTANT NOTE BY Dr.Zein Mahgoub:
Some colleagues contacted me regarding
medications errors and negligence:
☆ Medications errors:
Defined as "any preventable event that may
cause or lead to inappropriate medication use
or patient harm while the medication is in the
control of the health care professional, patient,
or consumer. Such events may be related to
professional practice, health care products,
procedures, and systems, including prescribing,
order communication, product labeling,
packaging, and nomenclature, compounding,
dispensing, distribution, administration,
education, monitoring, and use."
☆ When an error results in 'harm' it is called

negligence.
☆ Some authorities/examiners don't like the

word negligence as they consider it as being
"judgemental"
☆ Therefore, I recommend using (preventable

events) instead.
》 Preventable events + Harm = Preventable
adverse drug events
》 Preventable events - (without) harm =

Potential adverse events
Day 1 Colombo
Resp : ILD
Abdomen : anemia , jaundice, splenomegaly ,
top dd Hemolytic anemias
Cardio : AS + AR
Neuro : 3rd nerve palsy
Bcc 1 : Bronchiectasis with old TB
BCC 2 : Giant cell arteritis
St 4 : Ca oesophagus with issues like difficulty
eating. Discussion on PEG tube etc
St 2 dizziness with dd of vasovagal , seizures
Day 1, Carousel 3, Colombo srilanka (26/10/17)

Alhamdulillah i passed,
I started with station 4...
Station.... 4
A 23 yo, young man, Hodgkin lymphoma....
newly Dx and newly married..
Task was...To explain Dx, management plan And
address pt concerns.
Pt was a smart surrogate, school teacher,
His main Concerns were fertility issues, will he
be able to continue the same job ? any risks in
job if I'm started on chemo ? Also I'm scared of
chemotherapy and central line , risks of
infections ? if started on chemotherapy
16/16
Station 5...
BCC 1... Hemoptysis,,, (Dx .. HHT)
A 60 yo pt... with H/o 3 episodes of coughing up
fresh blood.. one day Hx.
No fever, SOB, Chest pain. No bleeding
elsewhere, nor in joints,
No meds,
No past Hx
But positive family Hx of epistaxis and anemia
Pt had received treatment for anemia in past but
no Dx
On exam.... multiple telengectasis, on hands,
arms , face and Oral mucosa
I checked for anemia, did chest auscultation.
Examer asked me about the Dx and DD and Ix &
Rx
27/28
BCC 2.... a middle aged lady with bilateral leg

swelling.with peri orbital puffiness
DM , HTN, high cholesterol 15 years and on
Metformin, diamicron, Aspirin, Atorvastatin and
valsartan....
edema legs.... recently, progressive
No cough, chest pain or SOB or PND but
FROTHY URINE , and also puffiness around
eyes (which i could not see in the pt)
I checked legs,,, diabetic foot, with amputated
left little toe, and Charcot ankles
I palpated Abdomen for kidneys and liver and
spleen, and auscultated precardium
Qs were about Cause for edema legs
I told nephrotic syndrome
Examiner asked what else. Heart failure,
hypoproteinemia, liver dieases.
What investigations and Mgt
28/28
Station 1
1...Resp... an old age lady... with command to
examine the chest of this pt who has H/O cough
and SOB
in GPE.... I found sclerosis in hands but wasn't
sure so did not comment.. bilateral basal
crepitation ... didn't alter with cough.
I gave DD.... Bronchiectasis first and
thenPulmonary fibrosis. Examiners asked what
else.. I told pulmonary congestion.
Then he asked.... what signs you noted in
hands,,, I kept quiet
Okay, then he said give me one Dx... I told I'm
not sure... could be Fibrosis or bronchiectasis.
Examiners were not happy, they wanted to hear
ILD from me... as they had given some hints too
but i remained duff.
Next he ask What Ix...
what single investigation you will do to
differentiate bw the two.... HRCT I told. What will
be the suggestive features of each.
I could have done it much better but i messed
such an easy station.
8/20
2...Abd.... young pt , male
jaundice and hepatosplenomegally
No stigmata of CLD...
He asked about positive findings and Dx...
I mentioned DD.... infective hepatitis.... as i can
see multiple scars and tattoos in the fore arms (
examiner asked me, show me where are these
..., i pointed out , there were so many.
What's your other DD,,, Hemolytic Disorders like
THALASSEMIA. He asked what other possible
familial cause ... I mentioned WILSON...
Then he asked investigations ...
About Wilson and thalassemia...
We were in management,
20/20
Sation 2
Young male pt, 7 days h/o parasthesia and legs
weaknesses,,, ascending pattern
Also breathing difficulties on lying.
Recent H/o diarrhoea, but then he told, i afraid
doctor that diarrhoea was from food poisoning
No other significant history
Negative systemic review
In concerns.... he told
I'm fire fighter, I afraid I'll lose the job, what
else... yes dr i have financial problems, have
mortgaged a home, i may lose it. Any thing
else? Yes dr if you want me to admit in
hospital,,, my company will kick me out of job
I tried to address his concerns.
At the end he asked one q....
dr you saying this GBS,,, could it be MS... ( my
God.... the surrogate was i think a dr himself or
at least in med profession or a very trained
actor he was)
Examiners were happy I guess,,, they asked
about Dx, DD , and rest they asked every thing
about GBS... investigations... and Rx plan...
admission and supportive care.
Specifically they asked me about findings on
LP, NCS
AND RX ? Immunoglobulin, plasmapheresis and
respiratory support... even to alert anaesthesia
dr for intubation if requires
What's the prognosis of GBS, how much
chances of recovery, over how much time?
What else he needs... physiotherapy,
occupational
20/20
Station 3....
1..cardio.... young to middle age female pt...
hyperdynamic precordium, with thrusting and
displaced apex. Also I appreciate some thrill .
On auscultation
systolic mumurs ... for DD
There were collapsing pulse, signs of Heart
failure, (jvp, crept at bases and pedal edema)
P2 was quite loud
Murmurs were not radiating to carotid nor axilla.
I told DD.... septal defects(vsd, asd), MR, TR
Examiners asked... what will you look in echo?
What else you will do,,,, BNP and other tests,
including catherization if required.
I guess Dx was Pulm HTN as examiners spec
Colombo (Sri lanka) day 1 ... (first exam in This
country) : 2016 November
Neurology : Command examine lower limbs ,
Spastic paraparesis without sensory
involvement
(some other candidates got another patient with
command examine upper limbs : blilateral
wasting small muscles of hands)
Cardiology : Some candidates gave diagnosis
as MR and some My exam experience....
st 2+4 list for diet 3:=====
1. =============
St2 - Repeated fall scenario:
ramipril induced postural hypotention
St4 - palliative care:

UTI for 2 days ...now confused..delerium
....h/o alzeimer+OA....bed ridden...talk to grand
daughter...palliative
2:=====
Stn 2 : 27yrs male presents with abdominal
pain and loose stools for 6 months but no blood
in stool or weight loss. No response to
mebeverine. Has nocturnal symptoms
St 4 := dealing with angry daughter:=
patient with parkinsons disease admitted for
fall. Today is day 3 of admisdion. Pt very stiff,
not sble to get up from chair, not able to walk to
toilet. Also pt noted to cough while drinking and
team suspecting aspiration pneumonia. Nurses
mention today morning that cocareldopa not
available since admission. Task is to talk to
concerned/angry daughter
3:======
St 2 : Cystic fibrosis> need details.
St 4 : BBN of pheochromocytoma.
4:=====
station 2 : was a case of recent exacerbation of
bronchial asthma following a new job as a car
mechanic with h/o exposure to spray
paint+smoker +he had a recent non-blanchable
purpuric rash on his left leg-which i couldn't
correlate.
Station 4: elderly lady admitted with

uncontrolled DM & left leg cellulitis since one
month developed overnight gangrene due to
vascular occlusion and team of consultants
including vascular surgeon have decided only
below knee amputation will save her from dying
but she's not willing to undergo surgery. She's
fully aware of the risks involved but she's
suffered a lot recently & didn't want any more.
But the daughter wants the surgery done & had
to talk to her regarding her mother's decision.
There was autonomy, consent & mental
capacity didn't go very Well
DD for pt with SOB, joint pain & Skin rash
- SLE
- SS
- PSORIASIS
- DERMATOMYOITIS
- SARCOIDOSIS
Day 1, Doha centre, Dec. 8, 2017.
cycle 1/cycle 2
Abd. HSM/ADPKD
Chest ILD/Pleural thickening with apical

?cavity?fibrosis
CVS AVR/ AVR+PACEMAKER
CNS MS/CMT
HISTORY Hematuria
COMM. SKILLS MND (break bad news)
Day 2, Doha centre, Dec. 9, 2017.
cycle 1 / cycle 2
Abd. HSM/ ADPKD
CHEST LOBECTOMY/ BRONCHIECTASIS/ ILD
CVS DVR / AS,AR,MS,A FIB., HEART FAILURE
CNS Spinoverebellar Ataxia / INO
HISTORY seizure
Comm. Skills medical error
Sorry,for day 1 the Neuro station was MND not

CMT
Day 1, Carousel 3, Colombo srilanka (26/10/17)
Alhamdulillah i passed
I started with station 4...
Station.... 4
A 23 yo, young man, Hodgkin lymphoma....
newly Dx and newly married..
Task was...To explain Dx, management plan And
address pt concerns.
Pt was a smart surrogate, school teacher,
His main Concerns were fertility issues, will he
be able to continue the same job ? any risks in
job if I'm started on chemo ? Also I'm scared of
chemotherapy and central line , risks of
infections ? if started on chemotherapy
16/16
Station 5...
BCC 1... Hemoptysis,,, (Dx .. HHT)
A 60 yo pt... with H/o 3 episodes of coughing up
fresh blood.. one day Hx.
No fever, SOB, Chest pain. No bleeding
elsewhere, nor in joints,
No meds,
No past Hx
But positive family Hx of epistaxis and anemia
Pt had received treatment for anemia in past but
no Dx
On exam.... multiple telengectasis, on hands,
arms , face and Oral mucosa
I checked for anemia, did chest auscultation.
Examer asked me about the Dx and DD and Ix &
Rx
27/28
BCC 2.... a middle aged lady with bilateral leg

swelling.with peri orbital puffiness
DM , HTN, high cholesterol 15 years and on
Metformin, diamicron, Aspirin, Atorvastatin and
valsartan....
edema legs.... recently, progressive
No cough, chest pain or SOB or PND but
FROTHY URINE , and also puffiness around
eyes (which i could not see in the pt)
I checked legs,,, diabetic foot, with amputated
left little toe, and Charcot ankles
I palpated Abdomen for kidneys and liver and
spleen, and auscultated precardium
Qs were about Cause for edema legs
I told nephrotic syndrome
Examiner asked what else. Heart failure,
hypoproteinemia, liver dieases.
What investigations and Mgt
28/28
Station 1
1...Resp... an old age lady... with command to
examine the chest of this pt who has H/O cough
and SOB
in GPE.... I found sclerosis in hands but wasn't
sure so did not comment.. bilateral basal
crepitation ... didn't alter with cough.
I gave DD.... Bronchiectasis first and
thenPulmonary fibrosis. Examiners asked what
else.. I told pulmonary congestion.
Then he asked.... what signs you noted in
hands,,, I kept quiet
Okay, then he said give me one Dx... I told I'm
not sure... could be Fibrosis or bronchiectasis.
Examiners were not happy, they wanted to hear
ILD from me... as they had given some hints too
but i remained duff.
Next he ask What Ix...
what single investigation you will do to
differentiate bw the two.... HRCT I told. What will
be the suggestive features of each.
🔔 rings.
I could have done it much better but i messed
such an easy station.
8/20
2...Abd.... young pt , male

jaundice and hepatosplenomegally
No stigmata of CLD...
He asked about positive findings and Dx...
I mentioned DD.... infective hepatitis.... as i can
see multiple scars and tattoos in the fore arms (
examiner asked me, show me where are these
..., i pointed out , there were so many.
What's your other DD,,, Hemolytic Disorders like
THALASSEMIA. He asked what other possible
familial cause ... I mentioned WILSON... (🙈)
Then he asked investigations ...
About Wilson and thalassemia...
We were in management, 🔔 rings again

20/20
Sation 2
Young male pt, 7 days h/o parasthesia and legs
weaknesses,,, ascending pattern
Recent H/o diarrhoea, but then he told, i afraid
doctor that diarrhoea was from food poisoning
No other significant history
Negative systemic review
In concerns.... he told
I'm fire fighter, I afraid I'll lose the job, what
else... yes dr i have financial problems, have
mortgaged a home, i may lose it. Any thing
else? Yes dr if you want me to admit in
hospital,,, my company will kick me out of job
I tried to address his concerns.
At the end he asked one q....
dr you saying this GBS,,, could it be MS... ( my
God.... the surrogate was i think a dr himself or
at least in med profession or a very trained
actor he was)
Examiners were happy I guess,,, they asked
about Dx, DD , and rest they asked every thing
about GBS... investigations... and Rx plan...
admission and supportive care.
Specifically they asked me about findings on
LP, NCS
AND RX ? Immunoglobulin, plasmapheresis and
respiratory support... even to alert anaesthesia
dr for intubation if requires
What's the prognosis of GBS, how much
chances of recovery, over how much time?
What else he needs... physiotherapy,
occupational
20/20
Station 3....
1..cardio.... young to middle age female pt...
hyperdynamic precordium, with thrusting and
displaced apex. Also I appreciate some thrill .
On auscultation
systolic mumurs ... for DD
There were collapsing pulse, signs of Heart
failure, (jvp, crept at bases and pedal edema)
P2 was quite loud
Murmurs were not radiating to carotid nor axilla.
I told DD.... septal defects(vsd, asd), MR, TR
Examiners asked... what will you look in echo?
What else you will do,,,, BNP and other tests,
including catherization if required.
I guess Dx was Pulm HTN as examiners specas
Mixed mitral valve disease
Respiratory : ILD (clubbing with bibasal fine
crepts, character doesn't change on coughing)
Abdomen : hepatosplenomegaly
Station 5 a) SOB in longstanding RA , also on
Methotrexate
Station 5 b) Probably hypokalemic periodic
paralysis
History : Acute monoarthritis
Communication : Pacemaker malfinctioning,
needs readjustment. Patient doesnt want to stay
in hospital
Exam today in Sri Lanka
St1 basal fibrosis ,hemolytic anemia
St3 ulna nerve palsy, AR with pul Htn
St 5 lt hemiparesis AF diastolic m in mitral area
Bcc2 psoriasis got worse after taking
hydroxychloroquine
St4 pt in rehabilitation given steroid got
psychosis
St2 epilepsy
Sri lanka
26 November 2016
St5
TIA
HAEMOPTYSIS
St1
Abdom hepatosplenomegally=haemolytic
anaemia
Reapir pleural effusion
St3
SPASTIC PARAPARISIS without sensory level
Mitral regurg
St 4
DM WITH HYPOGLYCEMIC ATTACK
St2
SLE
country) : 2016 November
involvement
as MR and some as Mixed mitral valve disease
Methotrexate
paralysis
in hospital
hydroxychloroquine
psychosis
St2 epilepsy
UK exam experience diet 2
CVS: AVR - midline scar, systolic flow murmur
with loud metallic s2 with audible click - murmur
was mostly in mitral area and in aortic area its
almost silent, they asked my finding twice but i
did not change my finding .... ques was whats
my dx ... how will investigate and which echo is
preferable i said TEE - asked if pt come with sob
what will b the cause. And is it possible that this
pt have CABG, i said yes if internal mammary
harvest. Some candidate said its MVR but thank
to Allah got it right. 20/20
Neuro: Myotonic dystrophy - all typical findings
with myopathic facies .. examined upper limb
and facial muscle showing upper limb weakness
with small muscle hand wasting with sensory
intact and facial muscle weakness with bilateral
ptosis .... examiner ques was what is dx, how u
will inv, what other other organ can inv and
what test u will do and mode of inheritance.
20/20
Communication: talk to daughter and mother
with MS fell in bathroom no one came in 4 hours
.... lots of apology, sorry ... told abt incident
report and PALS. Examiner ques about PALS,
ethical issue i said negligence. Asked why u will
inform consultant and nurse manager about this
incidence .. 14/16
BBC1: RA with sob on MTX ... examiner ques
was as usual about RA and its drugs and side
effect ... asked me did you get fine creps, i said
no and they were happy. 28/28
BCC 2: LOC with cardiac family history had
palpitation before loc, no seizure sign... dx said
SVT, hocm and said will admit in hosp to
monitor ... asked abt diff of seizure and
syncope, i forgot to ask driving but examimer
ask me can she drive i said no, asked how long,
i said until get dx.he asked give me 3 ix u want
to do ... i said ecg/echo/ holter/ stress ecg ... but
ecg/ echo were fine but 3rd one do not know
probably he wanted to hear cardiac biopsy due
to hocm. 28/28.
Abdomen: kidney pancreas transplantation with
av fistula and midline abd scar extending below
umbilicus and its due to DM. I got the dx and
cause correct but missed left toe amputation
and i saw cv line and peritoneal dialysis scar
but did not mention during presentation and i
also said i did not feel transplant kidney
probably he had ballotable kidney. Ques abt
other organ involvement if pt have renal
transplant due to DM. 12/20
Respiratory : left thoracotomy scar with
wheezing. Dx gave pneumonectomy dd
lobectomy. Ques abt cause of both, i told all dd,
it was due to lung cancer. She said if he comes
with sob and now wheezing what it cud be, may
b she wanted me to tell her post
pneumonectomy syndrome that i could not tell.
Asked ix i told so. 16/20.
History: migraine related vertigo. Dd brain stem
stroke. Pt has one episode of vertigo, vomiting
with occipital headache with h/o headache for
years which is pulsatile but he did not know
name. F/h migraine. Asked abt headache before
and now and all neuro ques. He had nothing and
came up with dx. He asked is it stroke. I said no.
Its migraine related vertigo. Examiner ask what
u will do i said with med will send home and will
not do any inv except few basic blood test. He
said if u think its stroke which part brain inv, i
said brain stem. He said ct/mri which u will do, i
said mri. Asked all about migraine 20/20.
In all station there were actually more questions

but i forgot some due to exam related stress :)
Learned a lot from this group.

By the Mercy of Allah SWT passed with 158/172.
Alhamdulillah I cleared MRCP this time from
mmm hospital Chennai.
My exam experience is st 1 resp rt sided
dullness in AV fistula pt.
Gave dd of rt sided plural effusion, collapse,
thickened pleura 12/20
Abd AV fistula pt had raised JVP, generalized
black pigmentation, ascitis, hepatomegaly n
bilateral pedal edema gave dd congestive heart
failure, haemachromatosis, chronic liver
disease got 12/20
St 2 bilateral lower limbs weakness n pins n

needles for last 5 days with h/f loose motion 1 m
back now has breathlessness gave dd of GBS,
Hypokalaemic periodic paralysis. Adv to admit n
concern was is it multiple sclerosis. Got 18/20.
St 3 cvs MR with pul htn got 15/30. Neuro left

sided both upper motor n cerebellar lesion in an
elderly man gave dd rec stroke, multiple
sclerosis, paraneuplastic got 18/20
St counselling of angry son having clostridium

diffecile infection got 13/16.
St 5 bcc1 pin and tingling sensation in diabetic
pt gave dd of diabetic sensory Neuropathy,
deficiency like folate or b12 got 27/28.
Bcc2 breathlessness in sle pt had dullness in rt

lower zone gave dd of sle relapse n pleural
effusion due to other causes.
Got 28/28.
Alhamdulillah I got 143/172.
This is today exam...MALTA
#Cardio:
old pt with midsternotomy scar and VSD
#Chest:
Lt. upper lobectomy bcoz of pancoast tumor
with rt basal fibrosis.
#CNS:
spastic paraparesis weakness proximally only
with normal sensation ( all modalities),
hyperreflexia and +ve pathological reflexes. !!!!
#Abd:
Splenomegally.
#History:
palpitation in young male 26 yrs...every day for
6 months by the end of day...h\o stress,
caffeine,....
#Communication:
old pt. admitted with pneumonia, treated ,
improved and discharged...talk to grand-
daughter whose angry why disharged before 1
wk.
#Station5:
Both of them S.O.B from outside..
- BCC1: pulmonary embolism!!
- BCC2: pt with h\o CABG and 3 stents...c\o
dyspnea with minimal exersion and fainting....
PRAY 4 ME TO PASS
I started with Station 4 ,
26yrs old lady physiotherapy as st.
Working in stroke unit .admitted with flaccid
limb weakness , CT and MRI normal explain
about functional weakness . Pt was reluctant to
accept the diagnosis and wish to see
neurologist urgently don't want to see
psychiatrist .social issue about job , and
grandmother died 3 months back with
stroke.discussed about psychiatric referral and
physiotherapy .
Station 5 - 1 st case
A 30 yrs old lady with high prolactin levels and

normal TSH c/o scanty and irregular
menstruation.
2nd case- 26 yrs old lady with SLE since 6 yrs

presented with right sided pleuritic chest pain
,with fever.
Discussion about DD of chest pain.
Station 1 -- Respiratory -- lung fibrosis

Abdomen = ascites with chronic liver disease ,
jaundice, parotid swelling,flapping tremor,
spider nevi , examiner asked about if there is
fever what can be the cause and how to treat
.management of ascites .
Station 2 -
A 30 yrs old lady with facial and neck swelling

sudden onset ,adopted child , no other positive
history , concern about allergy .DD- hereditary
angioedema . Investigation and treatment .
Station 3 Neuro
right sided weakness , with proximal wasting

hypertonia, hyperreflexia ,dyddiadokokinesia
,sensory normal .
Cardio -- young lady with MS - tapping apex

sinus rhythm ,loud S1 diastolic murmur , phtn
and raised jvp
2018 New Delhi
Delhi 9 Feb :

and Rx
Respi..COPD


mettalic
about icsol..�
10th July. ,,, Delhi


CVS was mvr with AS

given bisoprolol
Station 5.
-meningitis
Both station 5 didn't have findings. Esp

confusion one.
New Delhi Center Experience
station 1

missed something
Station 2

...

why having pain...

Screwed up this one

it as differential
maybe it was polio
St 4

on time etc

issue
ethical issue)
Bcc 1



Overall... it was a very unpredictable exam...

don’t really know what they expecting and be
ready for surprises .
My exam experience glasgow 27/6 golden
jubilee hospital
Station one :
Abd: obese female , only positive finding is
Palmar erythema
DD liver cirrhosis
No ascites no organomegally
Chest :
Thoracotomy scar
Normal examination
Station 2
65 years old female with ID anaemia . I turned
out that she is taking ibuprofen for knee pain
Station 3 :
Cardio 60 years old male with light headedness .
Finding : thoracotomy scar . Bilateral
pacemaker scars
Metallic second heart sound
Neuro: examine the upper limbs of a patient
who drops thing
Parkinson's tremors
Station 4
Speak to the daughter of 93 years old lady with
dementia CKD ., heart failure ., fracture pelvis ,
admitted with pneumonia . CURB65 is 3 . DNR
decession was made . The daughter is very
angry about it .
( did it very bad as she was shouting and crying
all the time )
Station 5
Bcc 1
78 years old with sudden onset of LOC for
minutes his colour changed to grey . No
symptoms before it
Bcc 2
21 years old lady with joints pain
Denies any skin rash or ulcers
Pain is mainly in the wrists , symmetrical with
morning stiffness .
Family hx of SLE
Egypt New Qasr Elainy 5/5/18
3rd carousel
Alhamdulillah at the beginning and at the end
I know it may help someone as we learned a lot
from previous experiences
It's my last chance and I completed my marriage
24 days before the exam
I have only few days to prepare but I know it is a
matter of luck to pass , so am so calm and I said
to myself I should Do my best
I started with stn 4
Stn 4 : from outside 60 yrs old gentleman
presented with seizure for 1st time aborted by
diazepam but still confused
CT done showed mass with haemorrhage,
biopsy showed high grade astrocytoma
Consultant said he is not candidate for surgery,
chemo , or radiotherapy
Only palliative care
I started as usual , introduced myself and
agreed agenda
Do you want any one to attend this discussion
What do you know about your husband
condition so far
She said we live in peace a lone as my kids
living away , he had nothing previously, it
happened all of a sudden
I gave her warning shot then explained the
situation and what we found in CT and biopsy
and show sympathy and empathy for her
I told her his his growth is so advanced so no
way for cure
She asked me what is palliative team and what
they can do exactly because she want to take
him home
I told her what is palliative team and what they
can do and we need to make some
arrangements at home before transferring him
there
I told her about the poor prognosis of his
condition
She asked me if we can put him in mechanical
ventilation if he deteriorated
I told no way because his condition is so
advanced
She asked if she can ask her sons to come to
see him , I said yeah it's better to come and see
him because this is going to shorten his life
I asked if she needs any help , she said no
I make a summary and asked her what she got
from the discussion and time over
Examiners questions is repeating candidate
questions
What is palliative team

Why you didn't offer him mechanical ventilation
What palliative team do exactly
What things you put in consideration before
entering the room
I told pt is confused so I assumed he gave me
permission to talk to his wife in his best interest
He said in another way Why you didn't dig more
in social history
I said I asked if she needs any help but she said
no
He said this lady had cardiomyopathy and had
arrhythmia and her sons live away
I know I lost some marks and I got 11/16
Stn 5 BBC 1
60yrs gentleman presented with fever and
abdominal pain for 5 days
I know it has long list of DD , so I didn't
prepared from outside
Inside i started to analyse his fever and

abdominal pain and cover GIT , fever is
continuous high grade, the is generalised and
vague , had tummy destension
had history of HBV
I started examining the after 2 minutes and
completed the history while examining
I did full abdominalexamination
O/E signs of CLD, ascites hepatosplenkmegally
, most so I put my diagnosis SBP
His concern what is the cause and if related to
his hepatitis
They asked my findings as above
DD SBP , any infection like viral hepatitis
IBD
Investigation, basic abdominal U/S ascetic tap
ttt 3rd generation cephalosporin and quinilones
28/28
2ND case is 40yrs old lady presented with
tingling and numbness in her hands , I put my
deferential rheumatological , vascular like
renauds or CTS
Inside I analysed the pain it is in all the hand not

joint , more at night and relieved by shaking , no
joint pain or swelling, no stiffness, had past
history of operation at the hands , she looks
acromegalic so I asked about increased in ring
and she size she said yes
Any changes in her appearance, she had
sweating , blurring of vision
I don't remember if she diabetic or hypertensive
I asked about complications
OSA , bleeding per back passage,
I examined the hand neulogically which is
normal only CTS scar
Had pig hands with rough skin , all features of
acromegaly
Had bitemporal hemianopia
I offered fundoscopy he thought for a while then
said no need
She is driving and her concern what is the
cause and if these changes is reversible
I explained the diagnosis and I said am sorry to
tell you these changes is not reversible
I need confirm my diagnosis and refer you to
gland Dr
And you need to stop driving
Discussion your findings
I forgot to mention bitemporal hemianopia then
he asked how you will deferentiate between
macro and microadenoma clinically
I said by impingement of the optic nerve and by
the I forgot to mention bitemporal hemianopia
😅 he said that's why I asked you this question
Diagnosis
Investigation
Management
He asked me why you didn't asked about cycle I
said I should ask about it and all other pituitary
axes as it may affect them
Bell rang
27/28
Abdomen young man pale , jaundiced,big

laprotomy scar, hepatomegally , spleen not
palpable,
I presented my findings as above
Whatl is your deferential
most likely chronic haemolytic anaemia
In what base : pt young pale and jaundiced and
hepatomegally and laprotomy scar most likely
for spleenectomy as he had resonant splenic
bed
He said is this pig scar is usaual for
spleenectomy, I said may be huge spleen
He said if this pt had spleen what is your
deferential
I said CLD
Chronic haemolytic anaemia
Infections like schestosomiasis
Lymphoproliferative disease as he had
submandipular lymph nodes
I expect high mark but surprisingly only 15
Chest COPD straight away

HISTORY young man presented with syncope
Inside 1st time while he is running in a
marathon , LOC
Only for few seconds with brief twitching , no
tongue bitting or loss of sphincter control , he is
adopted and taking antihistamine on and off
DD HOCM
long QT syndrome
Questions why it is not epilepsy
Is tongue bitting or loss of sphincter control can
exclude epilepsy I said no
What is the things favouring cardiac cause more
than Neuro
Why you said you want to admit this pt
What investigations and management
I did well but actually I knew I will lose some
marks in justice
16/20
Cardio young pt had grade 4 clubbing , midline
sternotomy scar
In my mind this pt had congenital heart disease
When I put my stethoscope, heart sound is
metalic😳 , 1st is clear metallic, am not confident
if the 2nd is also metallic or loud only , I took
long time in it , pt had PSM in apex and TR when
I sit the pt again I took long time to see if it
metallic, finally I decided to say DVR , I
auscultate the back , and am done
He said still you have 30 seconds
I said can I you use it he said it is your time
I put my stethoscope again and now am more
confident it is DVR
Examiner present your findings
What is your deferential diagnosis
DVR but this pt had clubbing it could be ass
with congenital heart disease
Can it be explained by valve itself yeah infective
endocarditis 😅😅 I didn't think about it from the
start
Investigation and management I 20/20
Neuro young chap has pes cavus, hypotonia ,
hyperreflexia , sensation normal , had
nystagmus and slurred speech
DD MS , FA
Investigation and management 19/20
Alhamdulillah I passed with score of 156 total
and 23/24 in skill B which is my main problem in
my previous attempts , although some of them
is examiner mistakes but I learned the lessons
Don't say more than what they want and the
only things you are sure about
Hope this will help you guys
Specially those going for Qatar centre
Al the best for you and hope all you will do soon
29/6/2018 Qatar
St 5
RA on gold therapy and NSAIDs..with
proteinuria and lower limb swelling
Other case lady with bilateral tremor ..?cause
St4..explain dx of methotrxate induced
pnuemonitis to pt with RA
S2..pt with ulcerative colitis came with
AKI..causes dehydration secondary to infection
and intake of ibuprofen..
Abdomen jaudice.palar and splenomegally
Chest..I said ILD with small rt axilla scar
CVS..I said AVR..other candidate mentioned
MVR
Neuro..spastic paraparesis
Experience from Brunei
Cardio : Clubbing, cyanosed, parasternal heave
and Palpapable P2, loud systolic murmur at LSE
- ? VSD in Eisenmenger
Lungs : Scleroderma patient , with bibasal fine

crepitation
Abd : Hyperpigmented patient,

hepatosplenomegaly, frontal bossing
Neuro : Foot drop , Pes Cavus, Hypotonia ,

Absent reflex , Babinski equivocal, Sensation
patchy reduced
Hx : Young man, palpitation and collapsed in

gym, fhx of sudden death (uncle), cousin has
pacemaker
Comm skill young lady, 2nd episode of BOV,

was rv by neurologist, but pt requested to see
2nd doctor
BCC 1 RA patient, came with joint pain over
right knee
BCC 2 Young lady with right calf pain 1 week,

recent travel to India by flight, takes OCP, had 3
miscarriages
Brunei 🇧🇳 , 3/7/18
Respi : Bibasal Lung fibrosis
Out side others told she looked like systemic
sclerosis
Cardio : Was the worst 😩😩

I don’t know what is it
Pt had clubbing and peripheral
cyanosis???VSD
But with another diastolic murmur??
Station 2 : Young gentleman , palpitation and

collapse for few seconds after exercising
associated with sweating and light headedness
was worried about affection on job and driving
seems cardiac (HOCM,brugada ,long Q-T
syndrome)
?
Station 3
Abdo : Hepatosplenomegaly, Jaundice, Pallor
Neuro : peripheral sensory motor neuropathy
Station 4 : Counselling about MS ( pt met with
neurologist prior to this, but requested to meet
another doctor - to discuss more)
Station 5
BCC 1 : knees pain in patient with RA with
+effusion and crepitus differentials OA /RA or
septic
BCC 2 : Right calf pain in pt with recurrent

abortion, takes OCP, recent long journey flight
,,,diagnosis DVT 2ry to APAS
Diet 2 experience UK 2018
DATE -1/07/18
Started with sation 3
Cardio- 50years male with SOB
O/E there is midline sternotomy scar without
any venous harvesting.pulse was low
volume.could not determine regular or not.
On auscultation metallic valve sound but
confused about MVR/AVR.Also on auscultation
felt like irregular heart beat. Gave the dd of
MVR/AVR with AF?.Asked about investigations
and treatment.
Neuro- a middle aged guy.examin lower limb.
o/e there is circumduction gait on left side. With
wasting of both legs more on left.there is left
sided hypertonia with ankle clonus,upward
planter,co ordination not done properly because
of weakness.there is some loss of both fine
touch and vibration sense on both of legs. Gave
dd of left sided umn lesion with bilateral
peripheral neuropathy.asked about dd,
investigation.
St4. medical error scenario regarding
methotrexate and trimethoprim
Concerns-1. is it GPs fault..the Gp knows that i
am on methotrexate then why prescribed
trimethoprime.
2.I was well controlled on methotrexate so why
it was stopped.
Examiner question
1.do you think that methotraxte can be again
startrd on this patient?i replied
diplomatically..his blood counts are low..we will
b monitoring it..but its better not to start
again..will consult the hematologist.
2. How do you rectify the GPs fault here as he
was the one who prescribed trimethoprime
knowing fully that he was on methotrexate. I
replied that it should be mentioned on his
medical records and gp can be directly
communicated from our side about this issue.
3. Why do you apologised to the Patient?its not
your fault. i said i apologized on the behalf of
medical team because patient has suffrred and
he was angry about this error.
St5
Bcc 1- 50years old mr thomas green was on
epixaban as he has nonvalvular AF. Recently he
presented with lower G.i bleeding. Examine and
give ur valuable opinion.
History of non valvualar AF on epixaban.
History of lower G.i bleeding negative red flag
symptoms.he was diagnosed previously as a
case of diverticular disease. Histiry of death of
father due to stroke.
On examination there is regular pulse.no
purpura,heart clear,no pallor,no mass in
abdomen everything ws normal.
Ask concerns
1. Is there is a chance of stroke like my father .
2. Should i continue the medicines.
Examiner questions- how do u asses the high

risk(chad2vasc2)
Bcc 2- 25 years old female lucy archer
presented with polydipsia,polyuria for
2months.her fasting sugar was 5nm. But her
sodium was 147.
On history there was polyuria,polydipsia
without any weight loss,any fatigue,asked about
hypercalcemia,men it was negative,no histry of
any CNS symptoms,no surgury,no lumps or
bumps,no renal symptoms.history of
depression,previously was on escitalopram but
now stopped. No significant family
history.exsmination was normal. Gave the dd of
central/nephrogenic diabetes insipidus,
hypercalcemia,DM. Asked about
investigation.water deprivation test.
How to investigate for cranial diabetes
insipidus(then bell rang!!)
Station 1
Respi-clubbing with Ild(asked about new
treatment of IPF..told about
perfenidone,nintedanib
Abdomen-liver transplant
Station 2 Miss Samantha herrick 39 years

female presented with recurrent episode of
swelling of lips and eyes with itchiness.
Asked about all the trigger factors,any hay
fever,AR,Bronchial asthma,any atopy.she was
on ibuprofen for ankle pain. No family
history,worked as a hair dresser.. Depressed
because everyone mocks her..assured her that
its due to NSAIDs,called angioedema..should
always avoid this kind of medicines and other
triggers.
Asked about investigations
Treatment.told about ffp,c1 esterase if
hereditery.
✅ 29 June, Diet 2
St 2 hx abnormal liver function
,haemchromatosis
St 3 cardio pansystolic murmur +diastolic
murmur
Commnication medical error
Methotrexate +trimethoprim
Station 5 thyroid swelling patient is euthyroid
2.heamaturia+gouty tophi
Station 1
Abd hepatosplenomegaly with
lymphadenopathy
Chest fibrosis +bronchiactesis
Experience shared in what's app group3:
28/6/2018
st4:
young female recently diagnosed with SLE have
gross proteinuria explain need for biopsy i
explained abt biopsy,surrogate kept asking
reptedly abt SLE.
St5:
straight forward,,AS and hypertension with
hypokalaemia
St1
totally messed up respiratory pt compained of
cough OE i couldn,t get anything n he didn,,t
understand nither arabic nor english,sounds
like a productive cough i said bronchiectasis n
gave Copd as deffrential
St3
Abd.pt cachexic n deeply jaundiced with
hugggge spleen i fogot to mesure liver span
then i said liver is shrunken examiner got upset
Then i said sorry liver is not palpable,when i tell
abt spleen size he asked do uu mean cm or
fingers i understood zt size i gave didn,t fit what
in his mind
St3 :cardio
MR with pulmonary HTN in AF
St3:Neurology
young male with difficulty to walk hypotonic n
areflexic i examined only light touch it was
intact i gave GBS as top deffrential examiner
said okaaaaay�.
St2 :===============???????????????
Pt with anxiety disorder n hx of panic attacks on
dizepam had incidental glycosuria and had i
fight with the nurse this morning so developed
palpitations n chest discomfort ECG was normal
.
When i started to ask he said i have white coat
HTN
I asked abt flushes,wt loss,headache
UK EXPERIENCE 2018
🔸Station 4:
Nurse admiited overnight with gliclazide
overdose after quarrel with husband. No
recovered but awaiting psychiatric assessment.
Patient wants to self-discharge against advice
and your task is convince her to stay
Concerns: are you going to inform my ward
manager (very irritated when I asked about
source of gliclazide specifically when I alluded
to the possibility of her getting it from hospital)
Discussion about how to assess capacity and
what are the possible causes in my opinion the
nurse took the tablets. 10/16
Station 5
🔸BCC1 Outside: Old lady with pain in fingers

and hip
Inside: patient with psoriasis on methotrexate
and clear hand osteoarthritis
Concern: unable to manage household chores
Discussion: side effects of methotrexate.
Pattern of joint affection in psoriatic
arthropathy, characteristic lesion in
osteoarthritis. 28/28
🔸BCC2: Outside: 52 year old man with blurred

vision and difficulty walking
Inside: sudden loss of vision for 3 days – no
regressive. I had complete mind block and
wasted ages in hx. Only thing positive is hx of
valve replacement and currently on warfarin.
Examination very hurried, could identify
abnormality well but severly reduced acuity,
normal fundus, no weakness. I think he was a
surrogate and was supposed to act that he has
homonomous hemianopia. Ran out of time in at
the end of fundoscopy. 8/28
Station 1:
🔸Resp: Young man with clear bronchiectasis.

Discussion: causes and investigations.
Congenital causes? I mentioned cystic fibrosis
but they asked what else so I mentioned
immotile cilia. They asked a question that led to
me to mention Krtagner syndrome. They asked
me if this patient could have and I said possible
as I did not feel the apex beat in the left
hemithorax. 20/20
🔸Abd: Hx: Patient with abdominal pain. Renal

transplant, AV fistula, Cushing and gum
hyperplasia and left palpable kidney
Discussion: possible causes of pain (mentioned
bleeding into kidney cyst and graft rejection).
Side effects of ciclosporin. 20/20
🔸Station 2:
Acute recurrent swelling of the lips and around
the eye in a 32 year-old female. All history
negative except recent onset on taking
paracetamol and ibuprofen for ankle sprain.
Family hx negative. Discussion: DD I said
angioedema due to c4 esterase deficiency and
possibly precipitated by NSAIDs. He asked
about the likely cause and I said it’s inherited.
He was not happy and said could it be due to
NSAID and I said yes. Investigation: mentioned
the esterase assay. He asked if I know of a
blood abnormality that normalizes if she stops
the NSAIDs. I said eosinophilia but he said is
there sth more specific? Finaly he asked where
would you refer this woman? I said to
dermatology but he said what other speciality, I
said possibly immunology. 19/20
Station 3:
🔸CVS: Hx: 55 year old man with fatigue and

breathlessness. MR, severe irregular brady
cardia (HR 40). No heart failure. Discussion:
investigations. I mentioned ECG and Echo. They
said what might be the cause of symptoms, I
said the arrhythmia. Anyother investigations to
explain symtoms Isaid FBC to look for anaemia
(examiner was not very happy) but then saved
by the bell (I think in hindsight he wanted me to
say cardiac enzyme as this could be heart block
and ruptured cordae tendinae from MI) Any way
🔸CNS: Hx: patient with diffulty walking,

examine gait and any other relevant neurology.
Parkinson’s. Discussion: causes – I said most
common idiopathic but could be due to a,b,c.
What investigations, I said it’s a clinical
diagnosis and there are no findings in
examination to suggest Parkinson plus. He
asked are you going to treat without ANY
investigation? I said I might need to exclude
Wilson so he said how I said ceruloplasmin.
20/20
PACES EXPERIENCE 2018
Hx sarcoidosis
Comm angry pt
Cvs ?MS ?MR
Cns spastic paraparesis
Abd spleen +|-liver ascites
Resp Obstructive lung dx
BCC acromegaly psoriatic arthropathy
UK EXPERIENCE 6-2018
🔷Abdomen 👉
CLD with deep jaundice and massive ascities
with pedal edema
🔷Respiratory 👉 right lower lobectomy
🔷CVS 👉
MVR a fib cabg scar pedal edema
🔷Neuro 👉
Walking stick, hearing aid and glasses for both
near and far vision , command for cranial nerves
exam related to eyes
Also left sided cerebellar signs
🔷 Station 2 👉
Evaluate dry cough and breathlessness in
previous h/o radiotherapy chemotherapy for ca
breast
🔷 Station 4 👉 Paracetamol poisoning wants

lama the famous one :-)
🔸Station five
🔷 BCC 1 👉 OSA in ckd on dialysis in left
brachial fistula, also known asthmatic now on
steroids leading to Cushing syndrome
🔷 BCC 2 👉 TIA/stroke
I passed in first attempt Alhamdulillah
10-6-2018
Stem was deranged LFTs with fatigue and no
symptoms and no other positive history except
positive family history of liver cirhosis in father
and all brothers of father have diabatese
It was haemochromatosis
Discussion about dds investigations
I got 19/20
Station 3 CVS old age male presented with

collapse
systolic murmur throughout precordium
i missed the case
mentioned MR but it was AS
discussion about d.d and investigations and
managment
examiners were not happy
i got 8/20
CNS left sided decresed power with ankle
clonus with normal sensation and gait was
hemiplegic(could not identify because patient
walked with stick)
i could not explain findings correctly but i gave
diagnosis of stroke
when asked about gait
i said hemiplegic gait
further discussion about d.d and investigations
and managmnt
i got 19/20
Station 4
Talk about DNACPR to daughter of a patient
with multiple comorbidities
Main concerns were
1)it is my mothers wish to get resusitated
2)i want to sue the hospital fr this decision
3)can u change this decision
Discussion about ethical principles
Focussing esp on is it breech of autonomy or
not in this case
I got 13/16
Station 5
1)30 yr old male with speech problm
Inside was a surrogate who gave History of
speech prblm fr 15 minutes with headache and
left arm numnness
Known case of migraine which is controlled
Prevous history of CVA fr which thrombolyzed
Concern was about driving which i advised to
stop
There were no findings as patient was surrogate
I gave diagnosis of TIA
Discussion about d.ds and investigations and
treatment
Examiners were asking constantly what else
They wanted to hear hemiplehic migraine
I could not give this d.d and they cut marks fr
that
I got 24/28
2) old age male with essential tremors now got
worse inside was parkinsons patient .he gave
history of tremors on right side and face and
unable to roll over bed.family history positive fr
essential tremors
I performed parkinsons scheme
Concers were that should i cntinue taking
propranolol which i am taking fr essential
tremors i said v will replace it with another
medicine
Discussion about d.d and again i was not able
to give d.ds properly
Missed cerebelum as d.d and again examiners
asked what else
Further discussion about investigation and
management
I got 24/28 in this case
Station 1
Abdo
Young female presented with Fatigue and
pruritis
nothing on exam except a spider navus on
chest
i missed this finding but gave correct d.d and
investigation and management plan
this was ptimary biliary cirhossis
they gave 14/20
Resp
patient had wet cough during the exmination nd
had mixed crackes changing with coughing
there was also prolonged expiration
i gave diagnosis of bronchiectasis with copd
Discussion about investigation and
management
i got 20/20
🔷Experience from UK 🇬🇧 19/6
station 5
🔶Bcc1: shortness of breath with fatigue. Inside

Pt of psoriatic arthropaty on mtx have shortness
of breath for 3-4 months. ILD
Corner: Why I have this breathlessness ?
Discussion about investigations and dd
🔶Bcc2:
Palpitations with hypertension
Inside graves patient on carbimazole. H/o
palpitations and visual disturbance
Thyrotoxicosis??
Phaeochromocytoma
Anxiety
discussion on Dd investigation n management
Station 1:
🔶Abdomen: splenomegaly for Dd n
investigations
🔶Respiration: bronchiectasis Dd workup
🔶Station2:
Fatigue weight gain tiredness -3months
gave birth 18 months ago
Hypothyroidism
Sheehan’s
Dd n workup
Station3:
🔶Cvs: mr
🔶Cns: spastic para paresis

Dd workup
🔶Station 4:
Mother had adpkd, talk to daughter about her
screening about adpkd.
Concerns:
What will happen to me?
How my disease can be stopped if I’m having
genes but no signs yet
What are my chances of having the disease?

Other cases which came to few candidates
were:
Cvs: Mvr
Cns: a lady with difficulty in taking tea
But she has no problem to eat other food,
examine her neurologically.
(Cerebellar syndrome)
Abdomen: renal transplant on ADPKD
Resp: COPD
UK EXPERIENCE 20-6-2018
ST 3::
Parkinson
MR
ST1:: COPD
IBD
ST 2: back pain AS
St 4: Barrets esopahgus
St 5: Acromegaly and Benign intracranial
Hypertension
🔶Resp: lung fibrosis
🔶Abdo: transplant kidney
🔶Cvs: AVR
🔶CNS: spastic hemiparesis
🔶Comm: talk to wife of husband with fits due to

low Na
🔶BCC 1: sarcoid patient with syncope: gave

history of irregular heart beats
🔶BCC 2: joint pains for work up, DD: RA?

Gout? Seronegative?
🔸ST4: 92 year old man with background hx of

Parkinson’s disease ,Af ,HTN, was admitted with
recurrent falls , his INRVwas 4.3, has another
fall in the ward , found to have postural
hypotension , his warfarin and hypertensive
medication been stopped , was seen by
physiotherapist and deemed MFFD , one day
later had cardiac arrest and he died , break bad
new to his son
(I think the main issue is to refer to coroner to
decide about autopsy or postmortem then we
would be able to issue his death certificate
because cause of death is unknown.
ST5:
🔸BCC1 : 29 year old man with progressive

visual deterioration / was retinitispigmentosa
🔸BCC2: 48 year old man was admitted with

jaundice fever right hypocondrial pain and
derranged LFTs , inside told me he had liver
transplant one year ago .
My DD was biliary sepsis, chronic liver rejection
, viral hepatitis
OE had mild upper abdominal tenderness with
roof top scar .
🔸ST2: 42 years old lady had 3 episodes of right
arm weakness , each one resolve within 24
hours , had risk factors of smoking, FH of stroke
My DD was TIA , hemiplegic migraine , consider
MS. Was concerned about driving.
ST1:
🔸Respiratory: pulmonary fibrosis secondry to

connective tissue disease .
🔸Abdomen : APKD with left iliac fossa renal

transplant
ST3:
🔸Cardio : MVR,AVR (metallic )
🔸Neuro : HSMN/ Rt foot drop.

QEQM 16 June 2018/3 3rd carousel.
St 1
Resp: Bilateral fine end inspiratory crepts with
facial rash, either plethora or butterfly rash.
Abdo: bilateral renal enlargement with weird

drain coming out of left flank. Most likely
Peritoneal dialysis catheter.
St2. Upper gi bleed with melaena secondary to

alcohol smoking and aspirin.
St 3
Cvs. Mid sternotomy scar picc line, systolic flow
murmur. Dds tAVR or tMVR
CNS. Exam eyes. Patient had homonymous

supraquadrantanopia. Residual right sided
weakness.
St4. Breaking bad news of cirrhosis.

St5.
Bcc1 rheumatoid hands with flare up.
Bcc2 palpitations after thyroidectomy. On

thyroxine.
UK 6-2018EXPERIENCE
🔸St 1 pulmonary fibrosis + lobectomy, renal tx
🔸st2 stroke in young
🔸st3 MVR / AVR AF
🔸st 4 BBN death of father
🔸st 5 diarrhea /tia

UK 16-6-2018 EXPERIENCE
🔸St 2 : Chest pain , headache with blurred

vision, wt loss , tummy pain , constipation . She
said her mum died 1 yr back, unsupportive
husband , overburdened with work as medical
secretary . With depression symptoms &
constipation - hypothyroidism , tummy pain &
constipation - hypercalvemia , ? Men , chest
pain was dealt in detail in A&E & no cause could
be found ..the other d/d was depression.
I said I will investigate with bloods/ mri head / ct
cap- the examiner told me all where normal .
She is 50 years old & had hysterectomy at 35 &
hence did not have kids. I asked for the cause,
she did not give me any answer . So I thought in
terms of malignancy but examiner later told me
they were removed for fibroids
🔸BCC 1
Examine this lady with left heel pain . Surrogate
, no other joint symptoms / systemic symptoms
..
They agreed for plantar fasciitis . I did not
examine the foot for any myalgia :(
🔸BCC 2 : Deranged lfts with tremor in elderly

man ... inside well dressed elderly person with
both hands shaking . I asked him to walk ,
normal gait , may mild cog wheel rigidity at
wrists but couldn’t appreciate bradykinedia ,
writing was alright . No cerebellar symptoms ,
no thyroid , not on drugs that causes tremor .
So said BEnign essential tremor . Treat with
propranolol ... No alcohol history as well & he
declined deranged lfts with me .
Station 1.
🔸Resp: bronchiectasis
🔸Abdo: bilateral nephrostomy scars with renal

replacement . I think , they prompted me a lot ...
for causes of b/l nephrostomies ..
Retroperitoneal fibrosis is the answer
Station 3:
🔸Neuro MS
🔸Cardio : Bioprosthetic valve replacements

with AR I think
🔸St 4 : nut allergy - head chef by profession

UK EXP.
🔸Respi. Midsternostomy scar with cushingoid

features.
🔸Abdomen. midline laparotomy scar
🔸Neuro. Bilateral umnl lower limb
🔸Cardio. AS?
Comm skills. Steroid initiation in ulcerative
collitis.
🔸History taking. Primary immune deficiency?
🔸Bcc 1. Homonymous hemianopia
🔸Bcc 2. Tb in RA patient?
👉St1 p fibrosis and Scars of VATS
👉 Abdomen lady with fatigue and itching

No clear sings of CLD no hepatosplenomegsly
👉 St2 B asthma
👉 ST 3 cardio AVR
👉 Neuro Parkinson's with exam for upper limb
👉 ST 4 man admitted with paracetamol over

dose after fight with his wife and want to go
home refuse to stay in hospital
👉 St five first case elderly lady with collapse

she has As
👉 BCC 2 young lady with ehler danlose with

chest pain.
UK EXPER.
Station 1: Resp: Lt lower lobectomy, Abd: gross
ascitis on young female.
Station 2: angio-oedema
Station 3: Cardio: mitral regurgitate, CNS: MD
Station 4: this was very difficult one as the
scenario was about diabetic nurse who took
gliclazide OD and she want to self discharge
before being seen by psych and don’t want her
manager to know about the incidence and I the
main idea is to assess capacity, assess suicidal
risk and know how did she got the medication.
Station 5: case one was a bit odd as well as the
scenario was about young male admitted with
pyelonephritis but his main concern was
painless hematuria which being going for
couple of months and examination was normal
apart from bilateral lumbar tenderness. Case 2:
was SOB on lady with mixed connective tissue
disease and she got bilateral basal creps.
UK=New Station 2⃣ scenario
🔸Gp referral, pt had acute kidney injury.. Back

ground UC with ileostomy...
🔸Inside he was having increased output from

ileostomy from last 10 days and decreased
urine output from last 4 days... Also he had back
pain and was taking ibuprofen OTC...
🔸 Likely AKI due to dehydration and increased

stoma output.. Also NSAID induced
nephrotoxicity
St 4 scenario - Pt develops a recognized serious

side effect of a medicine e.g Amiodarone-
induced interstitial Pneumonitis. Patient tells
you that he wasn't told about this side effect
when consultant started him on this medicine
and is very angry. What we can do in this
situation
? Do we need to take any steps like incident
report , go through previous notes or talk to
consultant who started this medication ?
✔Station 1: respiratory . Clamshell scar and

bilateral cracked. Discussion was causes of
scar and bronchiectasis.
✔Abdomen; mid laprotomy scar and iliestomy.

For differentials and management.
✔Station 2: persistent cough specially at

morning for one month on ramipril. Recurrent
chest infection with only dry cough and no
fever. Normal x-ray. Travelled to South Africa .
Chest wheeze on attack. Also works in a factory.
✔Station 3: mid sternotomy scar /pulmonary

stenosis . TOF . Indication for surgery.
✔Spastic paraparesis (cervical myelopathy).

Normal sensation.
✔Station 4 ; paracetamol overdose. Want to

discharge himself.
✔ BCC 1 ; essential tremor.
✔ BCC 2 ; Typical Horner syndrome and neck

scar
Exam Experience in Emarate 15-10-2018
History : pt with valvular replacement and AF
on wafarin having IDA not respond to iron
ferritin still low
Communication: chronic kidney disease talk to
pt about management plan and need
replacement therapy in future
My expirence in PACES Maadi military hospital
Cairo 8/5/2018
Beginning with station 5
BCC1 lady with hand pain and knee pain
Inside , pain in joints of hand with morning
stiffness 30 minutes, ask for the rest of
rheumatological diseases there is only gritty
eyes and dry mouth .
Examine joints of the hands and no carpal
tunnel. Ask to examine sensation , the examiner
told me no need and eyes. And he also told me
no need for knee examination when i asked for.
He asked me about DD
I told him could be mixed connective tissue
disease , could be 1ry s'jogren.
I want to do basic investigations(cbc , kfts,
inflammatory markers)
Shrimer's test
ANA, anti RNP, anti Ro&La.
How would you like to treat?
24/28
BCC2
Outside lady with breast discharge
2 month ago
Headache (surrogate told me i am not sure
when i asked about analysis of the headache
and about visual abnormalities like pumbing the
objects at the side of her road) ,Cycles stopped
6 months ago.
No symptoms suggest acromegaly or
hypopituitarism.
Ask for the rest of MEN1 (large volume of urine,
passing stones from kidneys frequently and FH
of gland cancer) , negative.
Visual field was limited in all direction , ask for
fundus (papilledema) , ask about driving , and
advise her to stop driving.
He asked me about diagnosis , prolactinoma
Investigation , prolactin, other pituitary
hormones( TSH , short synactain test , oral
glucose tolerance with growth hormone)
MRI pit.
Then asked me what did you find in fundus , i
told him .
what did you expect the field ? I said bitemporal
hemianopia ,
Why she has constricted field? Could be due to
optic atrophy from long standing increased ICP.
Ttt surgery, dopamine agonists,
28/28
St 1
Respiratory
Gentleman with upper left lobe fibrosis with
hyperinflated lungs
Causes
TB, occupational lung disease, extrinsic allergic
alveolitis, AS.
Investigations HRCT , PFTs asked about
restrictive pattern .
Investigation for TB, occupational history ,
Ttt acc to the cause.
He asked about ttt of obstructive lung disease , i
told him bronchodilator acc to EFV1 and
possibility of LTOT.
20/20
Abdomen.
Tender hepatomegaly with splenomegaly
without ascites or stigmata of CLD.
I asked to examine Lnds he refused.
DD
Pallor and Tender hepatomegaly most probably
infection as we are in egypt 1st HCV , he told me
what else i mentioned all infections except
bilharziasis 😂😂
Myeloproliferative diseases, infeltrative disease
, autoimmune disease
Investigation and treatment.
16/20.
St2 history taking
Outside , you are the doctor in the admission
unite , see young lady with cough , fever .
Analysis of complain recurrent chest infections
I ask about traveling abroad , TB contacts , i
asked about HIV risk factors , asked about
cystic fibrosis , another infections she had
chronic diarrhoea diagnosed as giardiasis,
tonsillitis ،no meningitis or uti.
DD hypogammaglobulinemia ,
Cystic fibrosis
Or aquired immune deficiency.
Investigations. basic, cXR, inflammatory
markers.
Gamma globulin levels ,
CL sweat test, genetic for CF. HIV test.
Whould you like to admit?
Acc. To curb 65 score and her O2 saturation.
Ttt , gamma globulins infusion for life
Asked me about frequency?
I have no experience , i will refer her to the
immunologist and hematologist.
Whould you like to vaccinate her?
I think it is not benificial.
20/20
St3
CVS aortic and mitral valve replacement
Viva questions: causes, investigations,
management, causes of dyspnea?
20/20
Neuro 😢😢
Examine LL
Weaknesses all over of LMN type with intact all
modalities of sensations.
I tried to get distribution 😢 but i can't

unfortunately 😢
I told him pure motor neuropathy after i
answered all questions perfectly .
In the last few seconds before the bell .
The examiner told me look to his face , i
understand that he wanted to refer to
fascioscapulohumeral myopathy . 😢😢
Shocked 😢😢
I got 10/20.
St4
My nightmare.
Pt. After endoscopy diagnosed as Barrett's
esophagus talk with about endoscopy
surveillance .
He was angery as none explained for him
anything about his condition , i calm him and
apologize and told him i am here to explain and
answer all of your concerns , then explain with
drawing , he was angery when i told him we
need to repeat camera test in a frequent basis,
Why? that's the only way to avoid and early
detect the cancer of gallut.
Ask me about how much frequent? and for how
long we need to repeat camera test?
His concern is that will prevent cancer?
When i told him that the corner stone of his
management is life style modification and ask
about Alcohol and smoking?
He was heavy smoker, i can't stop smoking?
I did it perfectly this time.
16/16
Alhamdullah
Passed
would like to share my paces exam on egypt
diet2 7\5\ on new kaser alennai hospital first
station was chest case COPD with regular
questions especially DD of copd and
investigation like pulmonary function test what
u will find how to treat when u start steroids and
indications of LTOT abdomen case wase huge
splenomegal with pallor main discussion about
DD of massive splenomegaly i mentioned
causes i said lymphoma he asked me what type
of lymphoma i said HDJ lymphoma i got19\20
2nd station history taking 37years man o c of
low back pain it was ankylosing spondylitis
regular questions like dd, investigations
,extraarticular manifestations,treatment
igot20\20 station3 neuro case with unclear umnl
in lower limb with nystagmus igive dd of
recurrent strock ,MS, i got11\20 cardio case was
AVR with MRand AS and heart failure as raised
JVP lower limb edema and bilateral basal
crepitations i got19\20 station 4 was medical
error female patient on methotrexat her gp start
her on trimethoprim presented to Er with
epistaxis which was controlled the surrogate
was angry she was admitted as pancytopenia
with very low blood indicies her main concern
to be discharged and to c\o i apolgize for her
many times not inturrepted her to express her
anger aknowldge that we start our treatment
and incident report wad made and she shuold
be in hospital till her blood test be improved
examiner questions was about mechanism of
pancytopenia her and how let her trust her
medical team again and if she make complaint
she will win or no the bell ring but he insisted
me to answer i said yes she will i got 14\16
station5 case1 was Graves disease with sob i
forget to analyse well sob the patient was
started on cabimazole and inderal but he
stopped it i examine thyroid i find water beside
the patient discussion was about graves
disease 2nd case patient diabetic not controlled
for one year it was case of p.vulgaris it was easy
to rupture was mm involved she was started on
oral antibiotics for one week i explain to her her
condition why herDM not controlled bcz of
steroids and she will need bone prophlaxis
examiner questions was about DD i said
p.vulgaris,pemphigoid,he said what else i said
steven jonshon syndrom he asked me why she
take antibiotics i said for 2ry infection of her
skin condition i got 23\28 alhamidallah i passed
thank for any one heping me and i share that for
my friends they will sit for paces hope that they
will pass easily exam need only concentration
self confidence not panic and talk fluent not
stop infront of examiner like your regular work
and practice station 2 and 4 at least online to be
familiar any questions to me i hope i can answer
thank u
✅St 1 abdo polycystic kidney disease.
✅Resp. Dull percussion with vats scar.
✅St2 cough, takes ace inhibitor and diagnosed

asthma. Occupation of working in a factory with
dust and solvents.
✅ST3 cvs lateral thoracotomy scar on left with

?mid diastolic murmur of MS. Radio radial
delay.
✅Neuro sensory ataxia with fasciculations.

Reflexes present at knee and bilateral distal
weakness.
✅St 4 paracetamol OD. Patient wants to go

home.
✅St5 bcc1 fundoscopy for visual loss in one

eye for past few years.
✅Bcc2 visual disturbance plus necrobiosis
lipoidica diabeticorum
UK EXP.
🔶 Station 2 peripheral neuropathy in metal work

businessman. Frequent traveller with
unprotected sexual IC. Also drinks a glass
wine/day. No DM sx.
DD HIV, heavy metal. DM, alcohol
🔶Station 3
Cardio presented with collapse midline
sternotomy scar with ESM no radiation
Neuro myotonic dystrophy
🔶Station 4
MTX induced pneumonitis. Known RA. Explain
PFTs also diagnosis. Pt worried about pred,
BMs (known DM), bone density. Works as med
rep regular traveller ? Possibility of flights. Can
methotrexate be restarted. No one told about
the MTX side effects.
🔶Station 5
1, bruising and joint pains inside joint
dislocations since childhood. Family hx +ve
Ehlor's danlos DD Marfans. Pseudoxanthoma
elasticum
2, pre cholecystectomy SOB and desats, flight
5/52 grand dad death following hip surgery.
Likely PE
DD COPD, lung malignancy (current smoker)
🔶Station 1
Splenomegaly
COPD DD PE and lung malignancy as frail( SOB
with palpitations).
UK EXPER.
Started with station 5:
BCC 1 :
36 year man with 15 mins speech problem:
History:
An episode of expressive dysphasia with no
weakness in arms or legs
No loss of consciousness
Had headache but relieved now.
No brainstem or cerebellar signs or symptoms
Past history of HT and stroke thrombolysed (
same symptoms at that time )
No family history
No other risk factors
Examination he was a surrogate ( most probably
)
Concerns:
Drive I told not to drive for 4 weeks
DDs
TIA
Hemiplegic migraine
Hypoglycemia
Arrhythmia
Investigations:
All of TIA with CT BRAIN
Questions on management and investigations
BCC 2 :
67 year old chap with diagnosis of essential
tremors getting worse
DDs
Parkinsonism
Cerrebellar cause
Essential tremors
Family history of essential tremors

Examination:
Parkinson's signs
Examiners:
Management and DD
Station 2
60 year lady with deranged LFT
Same as we discussed previously
Family hisotry of hemochromatosis
Station 4:
93 year with multiple comorbiditues
For DNAR
Daughter was angry for that and she wants

resuscitation otherwise she will sue the hospital
😃😃😃
I told sorry but this is a medical decision
Went well but let see 😃😢😢

UK EXPER.
🔹st2 - 59 yrs old M with sudden unsteadiness

with headache, nsusea.vomiting for 12 hrs
🔹st 4 - Renal biopsy in SLE Pt
🔹BCC 1 - transient global amnesia
🔹BCC 2 - back pain in 85 years old lady who

had a Pacemaker 2 yrs back
🔹Abd- splenomegaly
🔹resp- Rt sided pneumonectomy/ lobectomy.
🔹Neuro- lower limb exam- weakness with

plantar ext, sensory all modality absent, Rt side
totally normal
🔹Cardio- AS with AR
UK EXPER.
🔷 st4: talk with husband abt a pt who has MS,

now develops infective diarrheoa induced
delerium, She was in side room. She fell in
bathroom, 4 hrs on the floor, fracture neck of
the femur. Transferred to ortho,waiting for
surgery. Very angry surrogate
🔷 st2: cough n breathlessnness,h/0 breast ca
🔷 BCC 1 : 92 years old sudden fall
🔷 BCC 2 : 71 years old pain n swelling in hands
🔷 Resp : lobectomy
🔷 Abdomen : bilateral kidney with midline scar

in the abdomen
🔷 Neuro spastic paraperesis
🔷 Cardio : MR
Hello everyone one Alhamdullilah I pass paces
in diet 2 2018 from EGYPT.. and here is my
detailed experience..
I started with st4 but I will write it in order..
✅St 1 abdomen case was a young male with

hepatospleenomegally and generalized
lymphadenopathy d/d infection
lymphoma..examiner asked which more favored
I said lymphoma.. which type? Answer NHL.
why ? Age! (he is 35+ ).. inv &tt I got 18
✅Chest Was male pt with obstructive lung

disease with bronchial breathing in Rt upper
&middle zones ex. asked causes of bronchial
breathing , inv &ttt I got 20
✅St 2 sarcoidosis (I totally missed the case ) pt

c/o pain& swelling in ankles also knee pain and
wrist pain .. 3wk .. she developed dry cough
&SOB vitals normal .. inside I did full analysis of
the joint pain and detailed musculoskeletal
history and full analysis of S.O.B and I took long
time in that but I didn’t conclude any thing ( in
my opinion the surrogate was not good trained
.. many times I need to repeat the questions to
get a clear answers) the pt Also have painful
rash in her leg (E.nodosum) (I got it but again I
failed to put things together! ) .. she gain some
weight and she was on water tablets given by
her GP and she improved a little on it !! Also she
take burfen for the pain .. when I run out of time
and I need to till some thing I told her I need to
examin you but I think you have condition called
nephrotic syndrome which has many causes in
your case may be because of lupus nephritis!!!!
we need to do for you some tests to confirm
that.. (All candidates in my cycle said they
reached the diagnosis from outside!! it seems
that I didn’t read the scenario well .. although I
think I did so !!) ex asked me why you think this
pt has SLE ? I answered I need to do
investigation to complete the criteria but she
has arthritis and .. he interrupted me and asked
is it arthralgia or arthritis.. ? I answered arthritis
because she has pain and swelling.. he said ok
.. I said also she has E.nodosum .. when I
mentioned that he asked me what the causes of
E.N ( l think he try to bring me back to the track
but I was not there!!) I mentioned post
streptococcal . IBD RA SLE .. he said what else..
I stuck.. ! he said what infections ? I said
Mycoplasma! He said more common than that..
? I think he need to hear TB or may be he didn’t
hear me when I mentioned post
streptococcal??! Here I think if I mentioned
Sarcoidosis as deferential of E.N may be it
would make a deference!! Then he asked in
nephrotic syn. Bp how will be? I said it can be
normal or high ! he said fair enough!! Then
asked what inv. you will do for this pt.. I said I
will CBC to look for aneamia and wbcs, RFT ..
Inflamatory marker , serology and renal biopsy ..
bell range!! I got only 7!! But l am not
surprised!! Not only because I missed the
diagnosis but also because I know they are now
giving 4 in history station easily!!
✅St 3 CVS middle age very thin lady with raised

JVP & clear LT parasternal heave .. clear
murmur of (MR AS TR ) .. ex q. Cause..? Inv? ttt
? I got 20
✅CNS male pt with lt side uncrossed hemplegia

(instruction ex this pt motor system .. ) but after
I present the findings examiner asked me what
about sensations??!! I said you asked me to
examine motor sys. He said ok ! then tell me
what do you want to examin more I told pulse
and heart and carotid .. actually pt was AF but I
didn’t examine his pulse .. !! Then he asked
about the site of the lesion and the management
and said if this pt has AF what you will do .. did
you hear about NOAC ? What is its
contraindications..? Prosthetic valves and
valvular lesions mainly MS I got 17
✅St 4 young male pt college students with UC

dignosed 9 mth ago was about to start oral
steroids after failure of rectal foams and he is
worried about the side effects and he want to go
back to his college .. after opening I asked him
how he is doing.. he said he is suffering and he
open his bowel more than 8 times .. he read
about steroids side effects in the internet.. I told
him that we will monitor you and give you
proper protection.. and if did not take this ttt his
condition will deteriorate more and he is loosing
essential minerals and other elements by this
diarrhea and although it early to said but you
may need surgical intervention.. ! Also I
mentioned to him that we need to admit him
now for fluids replacement and I.V medications
.. I thought I failed to convince him because he
keep repeating same consern and same
sentences and and when I asked him do you
have any other concern he said No and when I
was about to close he said he still doesn’t want
this ttt can I take garlic ??!! .. I said we are not
giving this in the hospital and we don’t have any
evidence about that but you can take what ever
you wants.. !! and we will not force you to take
any ttt because you own and role your body !!
discussion with examiner was very tough he
was attacking me badly and I was unable to
defend myself ! .. firstly he asked what was the
conserns of this pt I said he conserns about the
side effects of steroid and his college.. he
interrupted me and said he is not aware about
it.. ! then I surprised !! and stair on him
(because the pt told me clearly that he read it
can cause high blood pressure and diabetes
and even can change my face appearance) !!
then asked why you want to give stomach
protection ?? .. what you will give? You
mentioned surgical intervention.. what surgery?
.. what is the indications ..? you mentioned
other organs can be affected what ?? I said it
may ass with PSC , arthritis.. l thought I lost the
station and it was my start so I tried haaaardly
to forget about it.. surprisingly I got 15 !!
✅St 5.a lady with neck pain ..
Inside was a lady with neck pain , joint pain and
low back pain pt was Ankylosing Spondylitis
(spot diagnosis.. ) I did occipital wall test and
demonstrate limitations of neck and back
movement and examine for sacroiliac
tenderness asked for schober’s test no need (ex
said) looked to the eyes , mouth and auscultate
chest .. concern what the cause of my back
pain.. Ex q v classic.. inv, ttt .. l got 24 I think I
forgot to mention biological agents or maybe
missed something in the history ..
✅BCC 2 Young pt diagnosed 3mth ago with

T1DM recently he has skin lesions.. inside I
asked him to show me the lesions it was vitiligo
about 3-4 patches only in his legs .. then I asked
few questions about it.. then screening
questions for other autoimmune diseases and
about his diabetes.. it was controlled .. I saw his
eyes for the paler and palpate his abdomen ..
concern.. what is this.. ? I explain and reassure
him but we may need to do some tests to
exclude other associations .. discussion about
other autoimmune diseases When I mentioned
Addison examiner asked me.. Is this pt has
Addison?? I said No !! but I should open his
mouth to see pigmentation.. 😱 but from history
he didn’t have postural hypotension... and he
has no loose motions or tummy pain but again I
need to do investigation to exclude .. what you
will do for him .. control and follow up to his
diabetes , inv. to exclude other auto immune
referral to dermatologist.. what dermatologist
will do? He can give some camouflage.. PUVA
therapy.. what the role of puva??? It can
enhance pigmentation!! Bell rang.. I got 28 Total
score 149
That was almost what I did and Allah gave me
success.. Thanks him. Alhamdullilah
🔺 Experience of passed candidate from UAE in
diet 2 🔺
✅ Resp : lung fibrosis in systemic scelerosis
✅ Cardio : Mvr with AF
✅ Abdomen adult polycystic kidney

End stage renal disease With central catheter
✅ Neuro lower motor neuron lesion Peripheral

neuropathy, Cauda equina ?
✅St 4 : Mtx trimethoprim
✅History palpitations, Father died at 42, Anxiety

With family history of death
On serteralin and increase coffee intake
✅Bcc1 : suprarenal mass incidental finding in

ultrasound. With negative findings in
examination.Had hx of renal stone.
For differentials
got 18
✅Bcc2 : bahect disease Hx of eye sore , mouth

sores
sores in private area. Also hx of dvt - most likely
a surrogate
UK EXPER=6-6-2018
✅ St2 👉 hypercalcemia sec to

malignancy,parathyroid adenoma,multiple
myeloma,mets
✅ St 4 👉 palliative care/mesothelioma
✅ BCC 1 👉 scleroderma
✅ BCC 2 👉 chest pain /PE
✅St1 Abdomen 👉 Liver transplant
✅ Resp : B/l lung transplant
✅St 3 Cardio 👉 Mixed Aortic valve
✅ Neuro 👉 peripheral neuropathy

UK EXPER. 6-6-2018
✅ BCC 1 👉 it was hand weakness in known RA

pt. Diagnosis 👉 cts
✅ BCC 2 👉 haemoptysis. Diagnosis 👉 HHT
✅ Resp 👉 pulmonary fibrosis,
✅ Abdomen 👉splenomegaly, Liver transplant
✅ Cardio 👉 dvr
✅ Neuro 👉 MS
✅ St 4 👉 mesothelioma with palliative care
✅ St 2 👉 hypercalcemia
Wythenshaw , manchester🔺
7-6-2018
✅ Respiratory : lobectomy scar with central

trachea.resp sounds normal
✅ Abd-ascites with hepatomegaly.
✅ Cvs- sternotomy scar without venous

harvesting scar.. Confusing auscultation
feature. Some candidate said it is heart
transplant..Others valve replacement (mitral).
✅ Neuro-. Motor neuropathy.bilataral foot drop.
✅ St 2 - elderly women with fever weight loss

night sweats.
✅ St 4 - advanced Parkinson's.talk to the

daughter explaining why invasive feeding is not
going to work (peg)
✅ Bcc 1- thyroid with ophthalmoplegia
✅ Bcc 2 - OSA
UK EXPER 7-6-2018
✅History station 👉
58 year old man diagnosed with hypercalcemia.
3 months history of polydipsia and polyuria.
Calcium 3.10 phosphate 0.9. Also had wt loss of
about 3 kg and back pain with decrease appetite
and tirdness. Pt idea was it could be increase
hormones and was also concerned abt cancer
✅ St 4 👉 60 year old male came with chest pain.

X ray showed suspicious lesion and ct and
biopsy confirmed malignant mesothelioma. Pt
had no idea. History of shipyard worker and
smoker. Break bad news and discuss palliative
care plan in detailand oncology involvement. Pt
was really disturbed as nobody gave him idea
previously. Socially he was divorced and
childern vusit him occasionally. Examiner later
also discussed abt industrial injuries benefit
because of asbestos exposure as could not
discussed it with pt as he was in denial and sad
✅ BCC 1 : JOINT PAIN AND RASH INSIDE

S.SCLEROSIS AND RASH AND JOINT PAIN
✅ BCC 2 : CHEST PAIN IN ASTHMATIC

SMOKER FEMALE.D/D PNEUMOTHORAX, PE
✅ Cardio : Mixed aortic valve disease with

predom AR
✅ Neuro : HMSN
✅ Abdomen : Liver transplant
✅ Resp : Bilateral lung transplant with

wheezing
UK experience, June 7/2018
Station 1:
Abdomen (renal transplant).
Chest (lobectomy).
Station 3:
CVS (CABG with MR).
STATION 5:
1\TURNER.
2\YOUNG GIRL WITH HIGH BP most likely
essential HTN.
STATION 2:
Old man with Hx of fever and wt loss and night
sweat.
STATION 4:
Nursing home resident with advanced
parkinson and recurrent aspiration pneumonia.
Discuss enteral feeding with relative (explain ng
tube and peg tube feeding but tell it also can
cause aspiration so they want to hear palliative
options like iv fluids ).
Experience of my friend did the exam today
Pray for him and us.
Experience of Aberdeen Royal Infirmary
Clinical Skills Centre
neuro: myotonia dystrphica
Andomen: renal Transplant and peritoneal
dialysis catheter scars
Respiratory: Rheumatoid Lung disease
CVS: dual metallic valve and sometime AS.
BCC 1: OSA
BCC2: Tophaceaous Gout
These were very frequently repeated!
I’ve passed my PACES exam in UM2 (2018/2,

Yangon, Myanmar)
Let me share my experience.
👁Station1-Abdomen-Renal transplant
-Resp-Upper zone bronchiectasis and
Lower zone fibrosis
👁Station2-Young man with black out attack,

inside HOCM history with strong family history
(Always ask histories of sudden cardiac death
for ALL family members, in my case the patient
didn’t have any history of SCD in his mom and
dad but a very strong history of SCD in his
uncles and cousins) , dont forget the DDx of
Brugada
👁Station 3-CVS-MR
-Neuro-Parkinsonism without features of
Parkinson plus syndrome
👁Station 4-Breaking bad news for Multiple

sclerosis patient whose career is a PE teacher
at school
👁Station 5- BCC1-Outside patient with a history

of excessive sleepiness, BMI-increased,Spo2-
reduced, Inside- Patient with facial plethora,
polycythemia , and increased neck
circumference , no features of pulmonary
hypertension or heart failure, No cause of OSA
could be found so I said OSA due to increased
weight, Examiner questions-Investigations and
treatment
BCC2-Outside-patient with hyperglycemia only,
Inside-Cushing’s features with no diabetic
complications, when i looked for the cause of
Cushing’s, history of taking traditional medicine
was found(mayb probably liquorice) for knee
pain, there was knee swelling with some pain.
Attendance question-Do I have to stop the
medication? -Ans-We need to slowly reduce the
dose and then stop the medication. Examiner
questions-what can happen if u stop the
medication right now? Answer-Addisonism
crisis
Communication-BBN to pt’s son for sudden

death.92 yr pt was admitted for fall underlying
Parkinson,DM,hypertension,AF
Pt on warfarin.Fall may be due to postural
hypotension.Stop drugs.CT head NL
INR 4.Stop warfarin .Patient has history of MI
and CABG was done.Now pt is stable and ready
for discharge tomorrow.
At morning, Sudden unexpected death
occurred.
Explain BBN and cause of death
Refer to hospital postmortem and coroner
Concerns - cause of death of his father
- refused to do postmortem
- cause of death may be due to stopping of
warfarin?
-Why not successful CPR?
Examiners asked the most possible cause of
death
I answered recurrent attack of MI.
What about successful CPR rate in hospitalized
patients?
I gave 3-4%
Is it due to stopping of warfarin?
I answered no!!
Is warfarin suitable for such kind of pt?
I think it is not suitable for pt and told about
Newer anticoagulant drugs.
Luckly,I got 16/16
Experience of candidate who passed from UK in
diet 2 🔸
✔ Abdomen
bilateral iliac fossa scars ،malar rash
Dx:ESRD,Post renal transplant 2nd LUPUS
Either RIF appendectomy with left renal
transplant or Right renal trasplant failed then
have left renal transplant 😌
Questions about DDX, investigation and
treatment if patient had UTI
✔ Respiratory
bronchectasis or bronchial asthma
Tremor . + lateralizing sign. Prolonged
expliratory phase & wheezy
Questions all about emergency case of asthma(
ER
✔ CVS
AF + MR
Q: causes and treatment of AF,, does he need
valve replacement ,, anticoagulation types,,
✔ NEURO
EXAMIN PATIENT UPPAR LIMB ,,Parkinson with
all signs
Pill rolling tremor ,cogwheel ,lead-pipe
rigidity,synchynesia,positive glabellar
sign,shuffling gait , and ask pt to right to check
for micrographia but time out😌
✔ Station 2:
Patient with joint pain ,cough ,rash in lower limb
:Sarcoidosis
The examiner want to here possibility of cancer
as she has bilateral lymphadenopathy in X-ray
Stress on X-ray finding which pt knows but I did
not ask about finding 😭 but got diagnosis. But
low score
✔ Station 4:
talk to angry son he heard from rumors that his
mother planned for DNR FROM DOCTORS
TALKING IN CORRIDORS
✔ BCC 1 - pt with palpitation
::pheochromcytoma ,thyroid , paroxysmal
AF,arrythemia
✔ BCC 2 - pt with joint pain ,loss of vision and

come back , grittiness of eye and dental caries
:::RA + sjogren syndrome +amaurosis fugas
Day 2 ,first round ,Mandalay
History-Sarcoidosis
Pt complains painful shin ,dry cough&TOC
Relieved by NSAIDs.
GP arranged Chest X-RAY
Examiners asked diagnosis,DDx,management
as usual
I forgot to ask CxR result!
I got only 16/20
CVS-MR only with sinus rhythm

DDx,management
I got 20/20
CNS-pt with difficulty in walking

Flaccid paraparesis,areflexia with ?sensory
impairment!
I gave DDx
-GB $
-CIDP
-combined motor &sensory peripheral
neuropathy
I got 19/20
Abdomen- Massive splenomegaly

Dx Thalassemia
Examiners asked
DDx,management,complications,iron chelation
therapy
I got 19/20
Respiration-Left upper lobe Collapse

Questions-Dx,DDx &management
I got 19/20
Experience 2/2018,Mandalay
BCC2
weakness of lower leg and vital sign
stable(outside)
Inside left foot drop with underlying taking for
pulmonary TB treated for 4 months duration.
I got 20/28
Abdomen
middle age male patient with anaemia, bone
pain and huge splenomegaly no features of CLD
no lymphadenopathy Dx leukaemia Ddx h'ltic A
other causes of hugesplenomrgaly as usual Q
19/20
Respiration
LUL Collapse
19/20
History
sarcoidosis
20/20
CVS
features of MR and heard ESM at PA so I said
Dx MR with ASD (but no features of ASD)
14/20
CNS
Exam all CN
I found the diplopia on looking towards the L
side ( convergent squint) only no other abn
discuss the causes of 6th CN palsy and diplopia
and inv ( i do the all cn exam . want to fundus
exam normal (n). bp n. blood sugar n. UL exam
n) examiner Q what about pupil i exam i think n
but i didn't answer. what other abn findings.
what about L eye?
Sorry i didn't know the case
8/20
other candidate the same case MG ? but he also
same mark
Good Luck for other candidates

Day 2, first round,Mandalay Centre
BCC 1
A young lady presented with blurred vision for 3
months & history of similar attack(+)6 months
ago.
No headache,pain (+) on eye ball
movements.BMI 35, Obese lady
Vision is reduced and only finger counting (+)
On fundoscopic exam,bilateral optic atrophy
noted
No weakness & no Cerebellar signs
I asked about driving & informed to DVLA
Examiner questions - Diagnosis,DDx
Investigations & treatment
I got 28/28
BCC 2
A young man presented with difficulty in
walking.
Firstly, I asked him to walk.Fortunately,I saw
high stepping gait of the patient.
Pt has history of TB meningitis and took anti TB
treatment for 4 months.
I examined lower limb examinations as usual
and found common proneal nerve palsy (left).No
evidence of leg injury.
I gave DDx of underlying etiology
-antiTB induced
-mono neuritis multiplex
-trauma/prolonged compression
Examiners asked investigations and
management.
I got 27/28
I passed 139/172 on diet 2 Mandalay exam
centre (10.7.18).
This is 4th attempt. Start with st 4
92 yr old gentleman admitted to Hp for fall
attack with the underlying PD , DM , HT & AF. He
was Tx with warfarin. His fall attack is dt the
postural hypotension so all hypertensive drugs
were stopped. He has another fall attack at
Hospital. CT scan head done and result is
normal. INR is 4. His condition is recovery now.
He has plan to discharged on this morning after
reviewing the physiotherapist. Unfortunately he
has suddenly cardiac arrest on this morning &
cpr done but he passed away. Task explain to
his son.
First I introduce myself & explain my role.
Second how do u know about ur father
condition.He answered .....After that I want to
explain more about ur father condition he
accept so i explain his father condition ( ur
father was admitted to our hospital for fall with
underlying medical condition PD DM HT & AF.
ur father fall is dt the Bp drop so we stop the bp
lowering drug . but ur father has another fall .
why? he ask ? dt drugs? so i show empathy and
that why we are about ur father condition it can
be caused by drug may be bleeding into the
brain so we done special scan of the head it
show normal no evidence of bleeding also done
inr do u know ? he know . is it high? i appreciate
ur concern. it's higher than normal so we afraid
of bleeding but no evidence bleeding. i paused...
and i continue ur father condition stable he was
seen by physiotherapist for PD
plan to dc but ....... unfortunately ur father has
sudden cardiac arrest so we do chest
compression for the best interest of him i m
sorry to say that ...... .... ur passed away .......
why????? .......i m really sorry that ... what
happened to ur father.....why? you say my father
condition has improved and plan to dc
why?? i show sympathy and empathy repeat
sorry again i want to explain ur ft has a lot of
condition like..... that can be range of possible
.... heart attack (other candidate say pe ) rhythm
disturbance of heart or bleeding in the brain. he
accept. so oexplain about pm exam. he angry
for that why? we do not know the definite cause
of death so why we need to do this. can i get the
death certificate. sign? i can't give or issue for
that why? we don't know the cod. i dont want to
pm exam. of u dont want to do pm exam we cant
issure dc but we write the possible cod & if
coroner accept this we can issue. any concern?
so i summarise and then bell rang.
examiner Q? do u convice? i explain. why cant
give dcertifiate ? cod not know. ppssible cause
above explain ask about inr can bleed no . can
increase but not . is suitable for warfarin for this
age no why increase risk of bleeding why blood
vessele are fragile and bell rang. I got 13/16
BCC St
Bcc 1 35 yr old lady with BOV blurring of vision
2 week woth BMI 35
BIH
inside pt obese
explore the symptoms both eye affect+
eye pain +colour vision not affect no stroke
symptom no headache similar attack+ no bih
symptoms exam bilater optic atropy
Dx MS
pt concern
exam q cause findongs ivx mx
i got 26/28
Day2,Round2
St2-sarcoid, same as old question in other
centers, examiner questions -ddx, invxs, tx...
16/20
CVS-MR, examiner question -ddx of PSM, invx,
IE prophylaxis recent guide,A/B need or not...
20/20
Neuro- cranial nerve exam in vision problems, I
not found no diplopia, ptosis, I excited n
worried, examined all cr nerves, not got dx,
examiner question -dx, I can't told... 6/20(now I
think, it may be treating MG)
St4-eldarly man with multiple Co morbs, lNR
prolonged, sudden dead, explained son n
postmortem same as other centers question. I
done BBN, convince for pm exam . Examiner
questions so many, I forgot... 13/20
St5(1)blurr vision in young lady with pain in eye
mm, I done as usual in eye cases, fundoscopy I
think no OA(other candidates said bilat OA) I
give optic neuritis due to MS because of pain
and duration 2wks... 23/28
St5(2) rt foot drop, h/o of treating TB, h/o of
fever, LOC,admitted last 3mths, fits n
antiepileptic. I give common proneal palsy d/t
mononeuritis m.plex,leprosy, examiner
questions -invx, I asked NCS, bell rings... 23/28
Resp-bilal basal course crept, not altered with
cough- interstitial lung ds, examiner questions -
causes, what drugs can cause, invxs, tx... 20/20
Abd-root top scar, no other abnormalities, I give
ddx as liver or pancreas transplant, in Myanmar
most probably liver. examiner questions -invx, I
asked before invx I will review ed medical
records, examiner happy... 20/20
I passed and thanks to all
Station 4 Common Mistakes -
1.Failure To meet concerns of surrogate
2.Unable to explore hidden issues
3.Tell informations that are not written in
scenerios
4.Not Assessing the Patients social life and

impact of disease on his/her daily life.
5.Not being enough empathetic.
6. Not being technical in answering sensitive

and tricky questions like-
Is it cancer?
Am i going to die?
Is it GP's negligence?
Why you are not doing surgery and allowing
him to die!!!!
Why you are not going to resusitate him?
7.Give wrong information when you are not sure
8.Dont discussing vital issues like

DNR/LPA/Advanced
Directives/Insurence/Driving when it is indicated
9.Failing to pick up clues given by surrogate by

repeated questions.
10.Talking toooo much and poor listening.

🔷 Experience of candidate who has passed in
diet 3 from UK
My experience:
✔St4: task was to talk to sister of a patient of

hocm who died last year. She was a flight
leiutenant so had to explain implications of dx
to her and to counsil her about further
investigations. She was a very talkative n angry
lady so i kept listening n didnt interrupt her
altho i ws running outta time. N told her in
chunks about hocm n further tests n that she
will have to avoid strenuous activity. Referred
her to occup health deptt.
✔ st3: cardio: old lady, pulse was good volume

but i could hear ESM only and was unsure about
AR so i said it can be mixed aortic valve
disease.
✔CNS: middle aged lady difficulty in walking but

apparently had a normal walk. Mixed periphral
neuropathy on exam .
✔St2: 50yr male with vertigo and falls. I gave dd

of BPPV , stroke, migrain and SOL. Examiner
asked details of Halpike manoevre.
✔St1: abdomen midline scar, bilateral iliac fossa

scars. Mass felt under left sided scar. So gave
dd of left sided renal transplant,
appendicectomy and previous peritoneal
dialysis OR pancreatic transplant.
✔Resp:obvious pnemonectomy case but very

slightly deviated trachea .
✔ Bcc 1 : 35yr old lady wd pain going from

lumbar area to front and then thighs. On exam
had absent ankle reflexes but normal sensation
. No idea abt dx
✔ Bcc 2 - lady with blackouts for 3 wks and

palpitations but no findings. Had h/o cardiac
accessory pathway ablation.
🔷 Few weeks before exam, try to examine

clinical cases under time pressure.
I took Fast Paces course a few weeks before
exam it gave a good exposure to exam related
cases.
✅ Last Advice: Dont go after rare things!

Wish u all the best
2/7/18
Start BCC 1.
BCC 2.
Bronchiectasis
later.
Station 1Abdomen
Station 2
and vomitting.
Station 3
Cardio
Station 3
Neurology
weakness.
MG
Station 4
astrocytoma.
BBN + Palliative care
Respi hard case

Reduce breath sound
No crept
Midsternotomy scar

lung collapse
17/20


scabies
19/20
Cvs MVR 20/20

17/20
worsening in ward
to bring pt home
10/16
28/28
155/172
St.4
A 40year-old lady,diagnosed with
Smear negative pulmonary TB,
planned to start anti TB.
History reveals she lives with her mother who is

known to have CKD on hemodialysis.
Should I say-
you should be in isolation for 2 weeks while you
are on anti TB medication
" Doctor, can I fly? I am scheduled to fly next

week. "
Should I say-
you should wait for 2 week while you are on anti
TB medication.
BCC 1
Pituitary tumor with panhypopituitarism with bi-
temporal hemianopia
BCC 2
Elderly lady presented with diarrhoea for 4
weeks with AKI.kco of wegeners
granulomatosis
Pseudomembrenous colitis due to antibiotic
Abdomen
ADPKD, left palpable kidney,right kidney
slightly palpable with just palpable liver
Respi
Normal lung
Pt has a h/o fall in a river
Near drowning
D/D...pulmonary odema,ards
Neuro
MS with sensory impairment in both leg
Cardio
PPM,central sternotomy scar,TR with raised jvp
St 2
Hypersensitive pneumonitis
St 4
Diagnostic uncertainty of suspected malignancy
Station 2.
Station 2. Patient come in with malaise for 4
weeks with frothy urine and generalized body
aches one day. On omeprazole 3 weeks ago for
gerd. Also has bilateral lower limb rashes.
Likely vasculitic rash. Give diagnosis of churg
strauss, wegerner, henouch scholein purpura,
microscopic poliangilits, drug induced nephritis
secondary to omeprazole. Seriously no clear cut
diagnosis.
Reply from a colleague :

Possibility of renal involvement
Frothy urine ( proteinuria )
Ask about blood as well ( will differentiate
between nephrotic and nephritic syndrome )
Prodrome any URTI ( in days then IGA and if in
weeks then post streptococcus nephritic )
Other differentials
Drug induced nephritis ( omeprazole )
Churg Strauss syndrome
Wegeners
Good pasture
Microscopic polyangitis
Management admission
Bloods
Markers
Urine
USG
Biopsy
Urgent renal review
Experience From my Paces Journey...
Paces Rules:
1.Its a exam of nerves.Never Panic.Never means
Never!!
2.If you have performed a station BAD, never
think that you are going to fail because -
A.You dont know what is BAD/GOOD

performance in Paces.Many times you will get
Full Marks in your 'BAD' station and score very
poor in your 'GOOD' station.
B.Paces is format based exam.Marks are given

in segments not overall.so even if you had a bad
crossing u can easily get 18/20.
3.Dont waste your time behind lots of big

books.There are much more important task to
perform.
4.Practise and Practise.But with proper

assesment!!! Wrong practise might be
detrimental. SO YOU NEED GOOD
PARTNER/GOOD MENTOR.
5.Make Good dds of every possible finding
/history...Resonable dd making is sign of
maturity they are looking for.
6.Dont READ Disease.Read Symptoms.
7.Be swift and methodical in examination
8.Never hurt patient physically or emotionally.
9.Missing to meet concern means failing in

Paces
10.Pray To Allah....
My PACES experience
Chennai Sundaram Medical Foundation diet
3/2017
BCC1 psoriatic Arthropathy ,questions about
differential,investigation and
management...patient already on treatment with
methotrexate for psoriasis.28/28😊
Bcc2 male middle aged banker with hemoptysis
and shortness of breath one month...inside on
history taking, no fever but give history of
weight loss and is chronic smoker 40 pack
year...examination no finding Gave probable dx
as bronchogenic carcinoma but wanted to rule
out TB
Questions regarding any finding,investigations
and bell rang27/28☺️alhumdulillah
Station 1 shortness of breath,
Patient having left thoracotomy scar with
decreased breath sounds and VR in left lower
lobes question with findings and reason for
lobectomy ..gave TB as probable ...couldn't
point out cause for it 12/20😕
St1 abdo male with AV fistula left forearm
functioning with hepatomegaly (smooth)3 finger
...no scars
Gave ESRD on MHD with hepatomegaly ....
questions on reason for ESRD and for
hepatomegaly...didn't say about ADPKD
{smooth margin not cystic)😢14/20
St2 female with angioedema no
precipitant,adopted child , recurrent abdominal
pain led to appwndicectomy but pain
recurs,,this is repeated scenario also given in
Ryder ...gave provisional as hereditary
angioedema differential of anaphylaxis
questions about investigation,diagnosis ,
management and advice to patient...I thought
didn't answer
viva well but Alhumdulillah 19/20
St3 CVS my night mare...

Young male ,bradycardia I thought sinus rhthym
,no scars ,no murmurs😳😳only heard loud S1
...gave dx as MS..viva on silent MS,complication
of MS ,,leading toward AF management of AF
but bell rang 10/20
CNS old gentleman looked cva..
But not cooperative ...command was to examine
him neurologically didn't read properly thought
only lower limb after motor wanted to do
sensory on lower limb examiner said no need
then gait ::circumduction gait left hemiparesis
...asked permission to examine upper limb 🙈1
min left ....{should have done only motor exam
ul and ll and cranial nerve}couldn't complete
upper limb viva on findings , investigation
choice between ct and MRi if present at 30 mins
after weakness and other investigation 17/20
St 4 case of young female physiotherapist

assistant with probable functional
weakness....variable findings in clinical exam
,CT normal,Neurologist seen and advise MRI
which is also normal {patient doesn't know
result}meanwhile a nurse told her that doctors
think she is faking it,patient angry and upset
wants to see the good neurologist who seems
to understand her😏task to speak to her about
the provisional working diagnosis of functional
weakness ,and explain further plan🙊
Spoke to her appreciating her concern that

anybody will feel bad if people think they are
faking it...she kept asking for the neurologist
explained he will b seeing her later in the
day...tried to know any precipitate events...she
has stress at work place she is physio asst in
stroke ward afraid she will end up paralysed...at
home doesn't so well with mother ,,grandmother
was close to her but she died recently ....told
what she is undergoing is distressing,doesnt
mean she is faking but given that ct ,MRI normal
it's good news and stress can cause this in
some people..explain need to speak to
behavioural psychologist ...used psychiatrist
also examiner questioned who is better
psychologist or psychiatrist said
psychologist...can she have stroke....said stroke
in young possible but not this patient as
clinically and imaging wise she is fyn and has
stress at work and home
16/16 Alhumdulillah
MashaAllah laquwwata illabillah
MRCP was a long journey Alhumdulillah
reached a milestone ....wantwd to give
back...sorry for the long posts... JazakAllah
khairan
Total score 143/172
PACES EXAM EXPERIENCE
St 1 : abdo :
ESRD on active dialysis from AV fistula ... has
large lt hypochondrial scar (?)
looks cushingoid
Chest :
ILD in cachectic patient with porta cath beneath
skin below rt clavicle + amputated fingers and
amputated leg (below knee) ... asked about DD
and what could be causing ILD.
Patient has portacath because taking IV
medications repeatedly.. why and which
medications ?
St 2 : wageners
Has upper and lower respi + nasal discharge +
dark urine + joint pains ... etc
St 3 :
Neuro : Rt upper limb weakness and hypertonia
.. discussion about stroke
CVS : double mechanical (both aortic and
mitral)
St 4 : C. Diff following pneumonia ttt in 83 y old
lady ... son angry because doctor didn't wash
hands (repeated well known scenario) and want
to complain about doctor.
BCC 1 : outside microscopic hematuria ...

Inside : joint pains and gouty arthritis .. gave DD
of uric acid stones and ibuprofen induced
interstitial nephritis
BCC 2 : fatigue and blurring of vision ... inside :

optic atrophy (?)
BCC2 May be myasthenia gravis

🔷 Dubai day 1
Station 4 55 years old patient with CKD break
the bad news.and explain to the patient that she
needs dialysis and medical management.8 years
ago she did urine routine which showed protein
and rbc and she had raised blood pressure but
she didn't care....station 5 bcc1 young 19 years
old patient simulator with recurrent attacks of
limb and facial swelling for 4 years.inside young
patient same history no similar family
history...bcc2 numbness and pain in 50 years
old patient inside rheumatoid with wrist swelling
and carpal tunnel typical history on RA
medications...history 50 years patient with
valvular heart disease and Af now with
shortness of breath and fatigue iron deficiency
anemia with dark stool history...CVS CABAG
with prosthetic valve...CNS sensory motor
neuropathy lower limb...GIT young patient with
hepatomegaly no splenomegaly probably
ascites...RSP young patient with clear chest
may be bronchiectasis he had probably(
clubbed)??hope it will help people
🔷UK experience today
✔St.1copd
✔Hsm
✔St3 ar as
✔P.neuropathy
✔St.2 wt.loss type 1diabetes
✔St4 discuss anticoagulant
✔St5 pancreatitis
✔Sickle chest crisis

My experience. September 2018
(Scored 164/172)
Station 1 Resp: COPD (17/20)

Station 1 abdomen: ascites with hepatomegaly
(17/20)
Station 2: postural hypotension ramipril induced

(20/20)
Station 3 Cardio: MR (20/20)
Station 3 CNS: Stroke (20/20)
Station 4: Speak to grand daughter regrading
advanced Dementia- grand daughter concern-
poor social support, wants full resuscitation,
wants NG feeding. (16/16)
BCC 1: NSAID induced gastric ulcer causing
malena (28/28)
BCC2: ATT induced hepatitis (26/28)
How I studied?
It took me 7-8 months of dedicated prep
I attended 2 PACES course one in Singapore at
the beginning of prep and one a week before
exam in India
I also attended PACES teaching conducted in
my hospital.
Resources I used:
For Station 1 and 3 OST oxford and ploughing

through paces.
Station 2: Ryder, knowledge of old scenario.
Taking a structured history is important. So I
have my own template which I used to follow.
Station 4: Master class notes and Ryder.
Station 5: Ryder and ploughing through paces
notes.
I prepared notes to concise different resources

and had a standard template for the talking
stations.
And I also practiced talking station with a study

partner.
Just a cut down of scores:
You can get 48 marks only by managing patient

concern and maintaining patient welfare. That’s
37% of your marks. So never forget to ask
concern and answer the concern and always be
nice/gentle.
16 marks you get by the way you communicate.

And communication skill is quite important you
need to score 11/16 (68%)- easy to fail even with
score above 130
Only 66 marks is clinical knowledge and skills.

It’s easy to say but ya it’s good to have a break
down of scoring system.
Good luck guys.

🔷 station 4 detailed experience in Diet 3.
✔ BBN for chronic renal failure. Patient found to

have high bp and abnormal urinanalysis 10
years ago on medical examination for
insurance. She was advised to follow up but she
didn't take it seriously. Recently had Ultrasound
which showed small kidneys and blood urea
and creatinine high tasks to inform the pt that
she has ch renal failure and need medicine and
may progress to dialysis.
Patient was an over actress and didn't give
candidates much to speak and kept on speaking
herself for most of the time.
Her Questions and concerns were
1. Whether i would have been saved from CKD if
i had followed 10 years back?
2. I never thought any thing serious going on.
Doctors 10 years ago should have pressed me
more at that time.
3. Did i get CKD because of HTN?
4. Why did you call me after four weeks of
taking blood test when you knew that i have
CKD?(Though she had bloods done 4 weeks
ago but she had US Kidneys one week ago)
5. How will you treat me now?
Examiner Questions
How did that go?
What were the themes of the scenario? (BBN
and delay in inv)
How should the scenario be approached?
What will you do for late appointment of patient
as patient had bloods done 4 weeks ago?
How will you give hope to the patient?
*Prayers requested for me*
🔷2nd round, Sharjah
Station 1:
Abdomen;
Spleenomegaly
Chest : bronchiectasis.
Station 2 : IBD like history with bloody diarrhea

and joint pain.
Station 3.
CVS ; MVR ( I messed up as lady was not letting
me expose well😑)
CNS ; CIDPpure motor neuropathy.
Station 4 : elderly lady with fall on enoxaprin for

arthroplasty.
Now ICH speak to daughter to tell results.
Station 5 ;
BCC1 Retinitis pisgmentosa hostory .
Tunnel vission of fileds
Bit no fundoscopy findings.
BCC2 ; I Did not get what it is .

Complain of fatigue and weight loss.
Inside no infecfion.
No signs of anemia.
But positive hostory of delivery 9 months ago
with heavy bleeding.
Still no symptoms of Hypothyroidism.
No Addison.
I saod anemia of blood loss or iron deficiecy.
Did not think of Sheyhan syndrome.
I dont know what they wanted honestly.
🔷 15 October, diet 3 - UK experience
St 1
✔ respiratory _copd with cor pulmonale
✔Abdomen _crohns disease with ileostomy n

fistula presented with abdominal pain
✔St2 drug induced interstitial nephritis

St 3
✔cardio MVR with pulm Htn
✔Neuro MS
✔St 4 elderly pt with htn n AF on warfarin

presented with intracerebral bleed, hemiplegia.
In r 1.5. Daughter thinks it's due to warfarin..
Explain her about diagnosis and management
St 5
✔Bcc1_Hereditary hemorrhagic telangectasia
✔BCC2 Diabetic retinopathy

Experience of a passed candidate from Luton,
UK
🔹 started with Cardio.MR with AF. Question

usual. dd, inv,management, which
anticoagulant? why not noacs? got 20/20
🔹 then neuro : facioscapulomuscular

dystrophy. inv, management. specifically
mentioned physio and Occupational, social
support in management. got 18/20
🔹st 4⃣ : grandfather came with stroke,now

improving. task : talk to granddaughter. explain
CT and ans concerns. concern was :
1. granddaughter did not take the gandfather in
anticoagulation clinic for INR. so ahe thinks she
is responsible. offered empathy. told her it
might happen even if on right warfarin dose.
2. garnd father wants to go home, asked why.
granddaughter replied : food is not good. told
her that we will specifically ask what he needs
and will try to artange.
examiners q : management of stroke :
replied as 1. acute and secondary mx. they
asked what will happen if patient wants to leave
hosp. I told : I will explore cause. they asked will
u assess capacity. I said yes. then asked how ,
got 16/16
St 5⃣
🔹 BCC 1⃣ : from outside : young lady with
diplopia.now improved. thought about MS, SOL,
Cranial nerve palsy,TIA.inside : she gave history
of diplopia. lasted 3 days. no other neuro
problem. explore SLE symptoms thinking about
TIA. there was none. past medical hx of
migraine. no medication. physical examination
was normal. gave dd of complicated migraine,
MS,TIA.examiner asked how u will manage
migraine. told : reassurance, painkillers,
triptans, prophylactic propranolol.
🔹 BCC 2⃣ : outside : middle aged man with

diplopia.inside a man having diplopia and facial
weakness, becomes worse on end of the day.
On examination complex opthaalmoparesis. had
sternotomy scar for thymectomy.was on
pyridostigmine.
dx : told relapse of MG. other dd : causes of
complex opthalmoplegia : thyroid eye disease,
CPEO. then asked inv of MG. and acute mx of
crisis 28/28
🔹 then comes resp : missed vats scar. was very

small on right axilla. had unilateral creps. told
dd. bronchiectasis, fibrosis. examiner asked
management of bronchiectasis. got 12/20
🔹 Abdomen was aweful! totally messed up.

young man with jaundice, hepatomegaly.
spleenectomy scar. I told also had ascites. but
he did not have it :(. got nervous. could not even
tell proper dd. told hemolytic anemia. don't
know why I did noot say myelo/
lymphoproliferative. got 9/20
🔹 then st 2⃣ history. outside 60 year lady, with

epigastric pain, inv : calcium high
so from outside dd was causes of
hypercalcemia. MEN,drugs,
hyperparathyroidism, sarcoidosis,
hypercalcemic hypocalciuria. inside she gave all
hyper calcemia symptoms, was on lithium but
on same dose for 2 years. father had kidney
stone.mather had pancreatic cancer. concern
was : is it cancer.
examiner asked dd : told lithium toxicity,
hypercalcemic hypocalciuria,
hyperparathytoidism, had no spectrum of MEN,
so thought it was unlikely at that moment. they
asked inv for these. asked for pancreatic cancer
how will u investigate. I told ct abdo. got 16/20
Dear colleagues,
I have immensely benefited from others
experiences and now that I have passed I wish
to share my experience too hoping to help
someone.
1. Respiratory: was a case of COPD with
corpalmonale and I could hear some fine
inspiratory creps on right lower base with a
small scar like VATS scar on the same side.
I gave my dx as copd with corpalmonale but
decided to avoid other potential dx of fibrosis as
I was tensed n confused. Questions were usual
on invest. Tx. Reason for breathless . Got 14.
2. Abd: icteric middle aged man with hugely
distended abd. But umbilicus was inverted and
flank full. Found moderate ascitis with a just
palpable spleen with parotid swelling . Gave dx
of cld due to alcohol . Question were cases of
cld n mx.got 20.
3. Cvs: not sure of dx. Got 10.
4. Neuro: hemiplegia with hemisensory loss
with absent ankle and mute plantar . Asked
about each finding in detail n asked about site
of lesion , mx, long term n short term. Got 18
5. History: outside scenario was repeated chest
infection in a 27 yr old man for 1 year with past
history of diabetes with poor control for 5
years.asthmatic with poor control on steroid
inhaler. Inside gave history of repeated chest
infection with productive green cough for about
5 months and has taken repeated course of
antibiotics without much help. Asthma is not
well controlled despite compliance to inhaler.
Diabetes not controlled despite taking regular
metformin.no other dm complications . Further
had fertile issues for which he was seeing doc.
Cousine too had asthma. Gave dx of cystic
fibrosis, dd of ciliary dysmotility
syndromes.questions were extensively on CF ,
bronchectesis and other primary
immunodeficiency disorders. Got 20.
6. Communication: young man dx as
pheochromocytoma after 5 yrs of visiting his GP
who had labeled his symptoms as anxiety
disorders . Task was to explain the dx .i told him
about the disease n he wanted to know why
there was a delay n if he could complain. I
suggested tht the delay could be due to
similarly in symptoms to tht of anxiety and
apologized tht it was not picked up before and
told him I would guide him if he wanted to
complain. No other issues. Very tight lipped
surrogate. I was struggling to keep the
conversation flowing for 14 mins and yet
finished 1 min early. Examiner asked about
ethical n legal issues n asked about
investigation n management of
pheochromocytoma. Got 16.
7. Bcc1. Outside , young lady with neck
swelling. Inside a beautiful lady well dressed
lady who said she had neck swelling. Gave no
positive history except swelling n I could find no
signs n not even swelling . Mother died of
thyroid cancer. I gave dd of thyroid problems
but examiner was rude and asked is there a
swelling I said no but I would do a usg to rule
out . He asked if investigations normal whts dx.
I said anxiety secondary to her mother's ca
history. He was ok with it. Got 28.
8. Bcc2: outside young lady with irregular
menstruation and investigation prolactin level
raised. Again surrogate , gave history of
headache not really pointing to any particular
type. On further probing gave history of breast
engorgement n nipple discharge. Getting
married in 3 month. Examination find normal .
Gave dx of prolactinoma. Questions were on dd
n invst n mx. And asked me if she could get
married. I said yes😬😬. Got 28.
St 2- diarrhea in young female, no blood, tummy
pain and bloatedness relieved by passing
motion. D.Dx- IBS, giardia, IBD, Coeliac
St4- Rt basal ganglia bleeding due to

hypertension taking warfarin for AF
St5- treated gout with DM

Inside Cushing syndrome
Dx- drug induced Cushing
Second case- first seizure
Inside thyroidectomy scar, muscle twitch,
tingling and numbness
Dx- hypo calcimia due to hypo parathyroid and
hypo thyroid after surgery
Yangon experience;
9 Oct 2018 D2R3
Station 2
Middle aged female with bloody diarrhoea for 10
days, which started during her stay in Thailand
on vacation. No similar attack before. She ate
only food prepared at hotel. But her husband
and the other guests who stayed at that hotel
suffered the same symptom simultaneously. Her
diarrhoea persisted although other people
relieved. She took antibiotics precribed by Dr at
hotel. Family history : Grandfather was taking
Rx for Colon cancer. Brother has ulcerative
colitis. Sister has asthma. Differential Dx are
Infectious diarrhoea, IBD, colon cancer.
Investigation : Examiners wanted to do
colonoscopy.
But I didn't do it.
Concern :
Is it cancer?
What will u do for me?
If scopy result turns out to be negative, what
should I do?
(Beware: the scenario outside described that
her bloody diarrhoea became worsening. That's
why she's here to get your assessment
urgently. But when I talked with the surrogate
inside, she said her symptoms had disappeared
a week ago. 🙄Quite confusing! Management
would be a little bit different, in my opinion.)
Station 4
70 yr old man, feeling depressed since her wife
passed away. He suffered severe CAP & was
brought by the neighbours to hospital. At the
hospital, he deteriorated with septic shock &
doctors decided to transfer him to ITU. His son
who lived away didn't want ITU care & wanted to
talk with you.
Task : explain the condition, patient needs to

transfer to ITU for central venous cannulation,
possible ventilatory support & ITU nursing care.
Inside :
Why ITU care? Why can't u give such care in ur
ordinary ward? (because his mom passed away
in ITU, although being treated with so many
catheters & machines. He didn't want his father
to suffer like this.)
Are u sure he will recover with ITU care?
Even if he recovered, how would u plan for my
father? bacause I cannot take care of him.
The son disagreed until the end.
Should ask about living will & lasting power of
attorney.
That's all about my experience today.

Although I did really bad in some stations, I
hope my experience would be helpful for the
other candidates.
Wishing you all best of luck!
UK experience ❗
Station 1:
Abdomen: ESRF
Signs: functioning left BCF, multiple PD scars,
infra umbilical Midline partial laparotomy scar ,
Hepatomegaly
Questions were regarding etiology of esrf. I was

unable to ballot both kidneys. There were no
glucose capillary prick marks. Examiner also
asked what’s the relation of hepatomegaly to
esrf. Not sure if it was polycystic kidneys and
liver cysts as I couldn’t feel the kidneys. Asked
how to differentiate between hepatomegaly and
enlarged kidney.
Respiratory: Left thoracotomy scar with midline

laparotomy scar with stoma bag.Likely left
lobectomy Questions: how to connect both
pathologies?
how to investigate if this patient came with
hemoptysis
If patient had ptb in childhood what are the
chances of reoccurrence?
Station 2:
Elderly gentleman in his 70’s complained of
transient left eye blindness. Comorbids: right
eye blindness (told that blood clot caused it),
glaucoma, hypertension
Dx: likely TIA Questions on how to workup.
What to do if ecg normal. Holter and expected
findings
Station 3:
CVS: midline sternotomy scar and harvest scar

on legs
Likely AVR with CABG
Questions: what is the significance of a
collapsing pulse in AVR?
Neuro: Left Erb’s palsy

Typical waiter tip posture
Questions around likely etiology, investigations
and management
Station 4: Speak to son of patient who has

suffered oesophageal perforation post ogds.
Patient signed consent in which risk of
perforation was stated. Son doesn’t want father
to know regarding development as worried this
will distress the father.
Questions:Ethical principles
Station 5:
1. Travellers diarrhoea- returned from Sri Lanka
24 hours ago Profuse diarrhoea. No blood in
stool. Examination normal. Likely surrogate
Questions were regarding investigations and
ddx
2. Stem was fatigue, aches and pains and

weight loss. CXR showed bilateral hilar
lymphadenopathy Young lady. Gave a history of
bruising over shins a week back (erythema
nodo
🔸 Experience of passed candidate from diet 2,
2018 🔸
My exam was in afternoon at James Cook

University hospital, Middlesbrough.
Registrar there told us that this is the biggest

paces centre in uk .
✔ My exam started from station 4 .An old lady

admitted with dense hemiplegia ten days ago
now having aspiration pneumonia and is on
antibiotic. She is deteriorating but officially
code is not decided . You were discussing her
condition with one of ur colleagues and her
neighbor who was volunteer as her visitor
overheard that and conveyed that to patient s
son . You have to speak to patient son who is
very angry that why it was not discussed with
her . It was to deal with angry attendant but
examiners viva was really tough .
Next was station 5 ( a night mare)
✔ Bcc1 a middle aged lady with blurring of

vision and diabetes and many co morbidity. Her
diabetes control was poor , history of laser
therapy in both eyes . Fundoscopy took time but
couldn’t find anything . Told them that’s it’s due
to poor diabetes control . Examiner asked did u
see the insulin pump and I was no. Because I
didn’t think of that .
✔ Bcc2 .lady with headache . Asked all the

questions about headache but all negative. She
just told me that it’s worse in the evening but
couldn’t think of any headache that’s worse in
the evening. Then she told me that her
colleagues are also having that . She told me
her occupation but I couldn’t focus on that . Did
visual acuity, field and fundoscopy all normal .
Pt quest what’s my problem and I said it’s
carbon monoxide poisoning we wil do a blood
test and wil involve an occupational health
physician
✔ Next station history

Young lady with chest pain, ankle swelling, rash
on shins , that’s sarcoidosis
✔ Next . Abdomen. Renal transplant with

functioning Av fistula, multiple scar marks in
abdomen and polycystic kidneys
✔ Respiratory. Copd with left lung collapse

examiner focus was on lung collapse n he was v
happy when I picked that
✔ Cvs. Pt has presented for follow up please

evaluate
Multiple scars alll over body . CABG with aortic
valve replacement and Mitral regurgitation and a
pace maker. Examiner question were unusual
again
✔ Neuro . Spastic paraparesis ,multiple

sclerosis was diagnosis. Examiner asked me
would u see ologoclonal band in blood I was
astonished for a while like what he is asking
then I answered I hv never read in any book . He
started laughing 😆.19/20 .
On some station there were 3 examiner, station
5 both fundoscopy , carbon monoxide
poisoning . It was a nightmare exam and to pass
it is a miracle and my mom s prayer who never
left prayer mat until I came out of exam .Allah is
kind
🔷 6/10/2018
Station 1
Respi : right lung decortication with marfan
synd
Abd: CLD with portal hypertension

Station 2
Hereditary angioedema
Station 3
CVS : HOCM
CNS LL
Prox myopathy with gower sign. Gave ddx : MG,
Beckers, SMA, polio etc
Station 4
Elderly mother with PD, not on meds, admitted
post fall with UTI. to explain patient's condt,
treatment and prognosis to daugther
Station 5
BCC 1: Scleroderma renal crisis
BCC 2: Ankylosing spondylitis
Station 4 : tramadol provoked seizure, angry

patient,
according to patient it was tramadol who
provoked
seizure because he listen from pharmacist
talking to someone.
Does tramadol provoked seizure??
yes
ST2- 50 years old Man with past history of MI 15
years ago .. fracture and DVT 10 years ago
..PMR 3 years ago .. smoking 20 /day ,now has
intermittent SOB with productive cough and wt
loss
Pt troubled with SOB mostly on climbing stairs
or digging on garden .. have no orthopnea or
chest pain or leg swelling no cough up blood or
night sweats just white phlegm sometimes
greenish .. no lumps but has wt loss with
normal appetite
Retired and taking big list of Meds ..
prednisolone , statin , aspirin. Recently reduced
dose of steroid.works as ship engineer
Experiences from diet 3
➡ Station 4
Should we proceed in this way
May I ask how far do you know

Would you like me to explain it more
You have been suffering from a condition called
IE , where the bugs has affected the heart. A
particular gateway of the heart known as valve
has been affected more and it has not been
functioning well.
( is it serious)
I am sorry to say that it is a serious thing. If left
untreated, it may give rise to a number of
complications.
I can assure you that with effective treatment,we
can control the infection.
(How have I acquired this infection)

Ok, I need to ask you a few personal questions
to get a clear idea of the whole thing.
Do you smoke
Do you drink
Do you take recreational drug
Do you take it through the blood channel
Do you share needle with others
How are your sharing partners

Are they well
We think that you have acquired through

infection through needle.
Another important thing i need to ask you

Do you have any idea about HBV,HCV,HIV
infection
If you consider your life style,have you ever

thought to check for this infection
What do you think now
Do you want to go ahead with this test
OR would you take time to think about it
If you be positive with the test,it has

implications in your life
But the good thing is that we can start the
treatment early
We need to refer you to a MDT including heart

doctor,bu specialist for proper care and
management.
What's ur thoughts on recreational drug?

If you want to stop them,we can help you.
We want to refer you to the Recreational drug
cessation clinic.
( no,I don't want to stop party drug)
Ok, We want to refer you to the Recreational
drug cessation clinic . They would show you
how to be safe , how to cut down the risks of
infection while taking drugs
I think issues here are

Offer a MDT for infection
Offer help for party drug cessation
Offer test for HBV,HCV,HIV
Ask social issues
Diet 3 experience 6th october
St2-29 young male altered bowel habit 6
months- diarrhoea. No LOW LOA, not related to
food. Gp has prescribed mebeverine for ibs but
not improved
St4- to inform diagnosis of pheochromocytoma
and delayed of 5 years for the diagnosis. Was
under psychiatric gmc and hypertension clinic
for follow up
-u r not expected to know details of
management in the information
Bcc1 31yo 15 packs years smoking hx come
with polyuria and cough 3 months
-hypercalcemia 2’ lung cancer
Ddx; DI
BCC2- marfan patient with mvr before coming
with fever sob chest pain 1 week. History of
tooth extraction no prophylactic abx weeks
before.
Ddx: IE
05/10/2018, diet 3
✔Renal transplant
✔History Iron deficiency anemia
✔Cns Stroke
✔Cardio MS
✔Communication BBN CKD and missed

diagnosis
✔Bcc1 Headache and 3rd nerve palsy ? Pituitary

apoplexy
✔Bcc 2 TIA
🔷St 2 detailed experience, diet 3
➡ 50 years old Man with past history of MI 15

years ago .. fracture and DVT 10 years ago
..PMR 3 years ago .. smoking 20 /day
.. now has intermittent SOB with productive
cough and wt loss
Pt troubled with SOB mostly on climbing stairs

or digging on garden .. have no orthopnea or
chest pain or leg swelling no cough up blood or
night sweats just white phlegm sometimes
greenish .. no lumps but has wt loss with
normal appetite
Retired and taking big list of Meds ..

prednisolone , statin , aspirin and others not
significant , cant recall
Compliant to meds but recently lowered dose of

steriod .. didnt ask why unfortunately
Not getting better on holidays

Smoking for 30 years !
No much alcohol
No FH
Again jn asking about impact .. i asked what

was your job .. he said engineer working on
ships and other things! Any exposure to
Asbestos? Yes ..
Concern : am i getting worse ?
Is it because of Asbestos .. candidates who

didnt ask about it he told Asbestos as concern
Questions DD . What is most likely ? Plan?
What more u want to ask? ! Anything about his

hobbies ? !!!! I think something rated to fibrosis
as he asked when i said about asbestos can
cause mesothelioma as well as fibrosis
➡ Station 4
➡ Station 2
Stn 4 - patient with parkinsons disease admitted
for fall. Today is day 3 of admisdion. Pt very
stiff, not sble to get up from chair, not able to
walk to toilet. Also pt noted to cough while
drinking and team suspecting aspiration
pneumonia. Nurses mention today morning that
cocareldopa not available since admission.
Task is to talk to concerned/angry daughter
I will fill up an critical incident report

I will speak with my consultant
I will speak with the nursing supervisor to
arrange medication
I can assure you that we will take measures to
avoid this type of incident in coming days
Has he ever expressed any thoughts on what

treatment he would receive or he wouldn't
Any advance directive
Any lasting power of attorney
What's ur ideas on this issue
What's the thoughts of rest of the family
members
We are considering the alternative options to

help him feeding like putting a tube down his
food pipe into the stomach OR
putting a tube directly into the stomach piercing
the tummy walls called PEG tube
The medical team in charge of his care will take

the decision what will be the best in his case
Station 4. 36 yrs old medical student present
with some neuro symptoms. Now she is
resolved. MRI showed MS features and she was
explained by neurologist about her disease.
But she requests to meet you.
After introduction, I ask her why she wants to
meet me? She said she want to know more
information. So I explained her again. She is
asking about can pregnant or not, can transmit
to kids or not, how long need to be follow up,
what will you do in follow up? I explained all .
I refer her to OT, Physio and advised leaflets
and websites. I also discussed driving and
potential of disability and she understands.
Examiner asked although she was explained by
neurologist why she wants to meet you? I said
patient wants more information and examiner
said do you think neurologist did not provide all
information? I say I am not sure. They said there
is 1 specific reason which I cannot dig out.
What's that specific reason?

Any idea?
St 4- a 60 year old gentleman, known case of
End stage liver disease due to Alcoholic
cirrhosis. Now presents with worsening
symptoms with Hepato-renal
syndrome.Consultant feels that it will not be
beneficial to do Renal Replacement Therapy &
liver transplant. Talk to son about pt's condition
& management.
What are the hidden issues here?
1.Palliative care
2.Has he ever expressed any thoughts about
what treatment he would receive and what not?
3.Any advance directive?
4.Any lasting power of attorney?
Any other OPINIONS?

St. 4
1.Father diagnosed with meningococcal
meningitis.
We need to assess wife and kids.
Who will I have to contact with - GP or Infection
control team or Health protection agency ?
2.Father diagnosed with Pulmonary TB

We need to assess wife and kids.
Who will I have to contact with - GP or Infection
3.Husband diagnosed with STD

He does not want to tell his wife of this
infection.
Explored the reason,offered help,no use,he
didn't agree to tell her.
Who will contact with his wife for STD tests
concealing husband's identity- GP or Infection
Station 4: talk to angry son he heard from
rumors that his mother planned for DNR FROM
DOCTORS TALKING IN CORRIDORS
How to approach?
Ok, I can understand your concern. We are
considering all the possibilities of his
management.
Do u have any idea about DNAR?
Would you like me to explain it?
DNAR to be successful,vital organs must be in
good health.We have been assessing his
condition whether it would be successful or
futile in his case.
Has your father ever expressed any thoughts on

this issue?
Has he made any advance directive?
Is there any lasting power of attorney?
What's ur opinion on this issue?
The medical team in charge of his care will take
the final decision.But it's our protocol to speak
with you to know your thoughts.
St.4
A 40year-old lady,diagnosed with
Smear negative pulmonary TB,
planned to start anti TB.
History reveals she lives with her mother who is
known to have CKD on hemodialysis.
Should I say-
you should be in isolation for 2 weeks while you
are on anti TB medication
" Doctor, can I fly? I am scheduled to fly next

week. "
Should I say-
you should wait for 2 week while you are on anti
TB medication.
Passed from chennae. diet 1
started with station3
CVS: teenage boy with AV fiatula in left arm
extending upto shoulders, patient tachycardic,
first heart sound loud, systolic murmur in whole
precordium difficult to differentiate from fistula
mumur, obviuos F/O pul HTN. i gave dx mixed
mitral valve disease with pul HTN. they asked
which one prominant, i said MR. questions
regarding Inv and Mx. got 20
Neuro: prompt walking difficulty. obvious Right

sided haemipaeresis with right sided UMN
seventh cranial nerve palsy. asked about Dx, inv
and mx. got 20
station 4: patient with metastatic Ca Pancreas,

palliative care team plan for ERCP. Task: talk to
daughter: daughter knows the diagnosis. i had
to explain the disease is incurable. i showed
empathyn sympathy. explain ERCP with
drawing. then MDT management plan specially
about Macmillan nurse.daughter asked about
second opinion i said they have the right
on crossing: what are the issues, what is
pallative care, from whom will you take help if
you can not convince her: senior stuff nurse, is
ca pancreas painful? why?: due to involvement
of caeliac plexus. got 16
station 5: BCC1: outside: middle aged women
with joint pain. Inside: middle aged women with
deforming hands, specially in DIP, non
inflammatory type, i noticed some nodules just
below wrist. patient has AV fistula. gave H/O
HTN on thiazde BP was high. i examine like
rheumatoid hands. counsell regarding changing
of HTN meds not to take alchohol and red meat.
MY Dx: GOUT, dd: RA, OA, Psoriatic. asked
about inv and Mx 28
BCC2: outside: young woman with Abd pain.
inside: sudden onset, at loin radiates to groin,
with dysuria but no fever, one episode of
vomiting. it was surrogate. acted like tender
abdomen. so i was cautious not loss marks in
welfare. vitals are normal.BP slightly high. my
DX: ureteric colic due to stone. asked about inv
and Mx. what advice will you give? take large
amount of water everyday. got 28
station1:
Abdomen: fistula in left arm, anaemia. bilateral
ballotable kidney.no other organomegally....Dx:
ESRD due to ADPKD. question: dd of enlarge
kidney, inv and mx. got 20
Resp: Elderly man with obvious COPD with
bilateral crepition. crepition was coarse but
inspiratory. i gave DD: COPD with ILD/
Bronchiectasis/ infective exacerbation. they
asked which one first. i said ILD . they wanted
bronchiectasis first. asked inv and Mx. got 16
station2: middle aged diabetic man with

repeated hypoglycaemia with high creatinine
with mild anaemia.
on history taking: gave history of abdominal
bloating but no other F/O autonomic
neuropathy. gave few kg weight loss. no other
micro or macro vascular complications, no
pigmentation. i gave Dd of: hypoglycaemia due
to renal failure, a nddisons as a part of APS,
autonomic neuropathy, caeliac disease. patient
was depressed, concern was why hypo and how
you will help. i said about referral to dietitian.
endocrinologist, specialist nurse. gave advice to
take frequent regular snacks to prevent hypo
and stop driving. examiners asked about Dd,
inv, which specialist review for depression. i
said clinical psychologist. got 20
Alhamdulillah i passed got 168.
thankful to this group. wish you all success in
upcoming exams. pray for me
Oman centre..Royal hospital 7th april first cycle
score
143/172
was the case of IBS .. decision was made by
consultant when all basic investigation and
malabsorption screening ..sigmodoscopy were
normal and suggest to start amitriptyline for
her..
she had stress in her life and she is suffering as
her kid has hyperactive disorder and she need
extra help I offer the social worker and she
agreed
the case went smoothly😇 concern were:

1-she afraid if it is something serious
here immediatly i asked her about alarm sign
and family history she said no..
2-she asked for further scan ..keep asking
through all station
3--side effect of amitriptyline
do you think i am mad bez this medication was
given to my mam for psychiatric illness..
3-does this medication will help me
4-am i going to be addict to this medicine??😞
examiner want to hear your advice about if she

got any alarm signs should come back to
hospital..
leader was british examiner was verrrry happy
ask me to summarize the case ask about how i
answer her concerns ..why she does not need
any further test and what is side effect of ct
scan and colonscopy
i got 16/16..
station 5
bcc1
was surrogate
she has finger pain and now came with
epigastric pain
inside only found history of long use of NSAID
for many years and history of heartburn..
concern was is it cancer???
I asked about alarm signs before and I told her
no it is not cancer bez no alarm signs and
i made the diagnosis of side effect of NSAID as
cause of her epigastric pain and i did not till the
diagnosis of CREST..
examiner asked my about diagnosis ..finding
and investigation
I got 23/28
bcc2 was pt came with dry eye

inside she is surrogate again ..gave history of
valve replacement.. joint pain only..I asked
every thing regard MCTD was negative
she had many concern..she read them from
paper�
what is cause??
am i going to be blind??
is it related to my heart problem??
what you are going to do for me?
can I watch the TV ?? �
discusion was about what is the diagnosis and
what is cause of joint pain
what investigation you would like to do
I got 22/28 dont know why �
then station 1
chest:-
was lobectomy and bronchiectsis
discusion was
what is diagnosis?? what are your finding ??
did you hear any breath sound .. i told brochial
breathing as trachea was shifted
what are investigations??
got 19/20
abdomin :-
renal trasplant and permicath ..discusion about
graft failure or not and if it is old or new graft??
asked me if he came with abd pain what would
be the cause and dd of RIF Mass and
investigation.. got 20/20
station 2
from out side I felt bad as scenario was
diabetes�
she had recurrent collapse ..
type 1 diabetes known diabetic nephropathy
..neuropathy and retinopathy.. she is known AF
and IHD ..
inside badly control diabetes ..not taking insulin
regularly as she doesnot have time she is busy
with her kids she is cycling immediatly i
stopped her from cycling and i explained to her
the risk.. also she is not following diabatic diet
not doing exersize..
had all complications and she does not aware of
hypo symptoms but never find suger low during
the collapse..
analysis of collapse was postural

hypotension..the
only symptoms were nocturnal diarrhea and
fullness
she is taking alot of medications with high
doses..
when the examiner told 2 mint left still I didnot
take social or family or gyn history 😧
concern were 2..
one what is cause of collapse ??
other what regard my social issue Iam very busy
and what about cycling
i explain the autonomic neurpathy and the
importance of controlling the diabetes and to
stop cycling
time was up without answering her concern
regard social issue �
examiner..
what is your differntial??
1-autonomic neuropathy
2-side effect of medication
he told what else i stuck here totally i forget the
addison completly 😩
then asked did you answer her second concern
i told yes..i explained for her autonomic
neuropathy
he told me second concern�
i told him i stopped her from cycling..he said
what about social issue i told i forget😔
i thought will give me 4 marks only
I got 15/20 🙏🏻
station 3
neuro straight forward
sensory motor neuropathy ..charcot marie tooth
I got 18/20
i forget to mention the pes cavus
dicussion was about differential ..investigation
and managment plan..
cardio my worst station I
was very tired and depressed bez of station 2 😔

the case was AS
very very low volume pulse..i didnot hear
murmur
he asked me the first Q did you hear murmur..
i told him no by very depressed face 😔

discussion about severe AS how to diagnose on
echo symptoms and sign of severity ..indication
of surgery..complication of surgery..what
investigation
finding in ECG
alot of Q 😕
bell rang🔔
i was verrrry depressed
british examiner was smiling he told me at least
you finished😊
got 10/20
▶️2018/2 Dubai Experiences Collection
👉🏻Dubai 2018 may 7th

Respiratory
ILD due to systemic sclerosis
Abdomen
Splenomegaly
CVS
MR or VSD
Neuro
Spastic paraparesis with L5 neuropathy
History
Drug induced angioedema
Communication
Anaphylaxis after eating nuts
Station 5
Hashimoto’s thyroiditis
Dvt
👉🏻8/5 Dubai center
Station 3 CVS: aortic regerg
CNS: CTS
Station 4 pt on methotrexate and had hx of UTI
for which her doc gave trimethoprim
Station 5:
BCC1 suprarenal nodule seen on US inside no s
or s of pheochromocytoma
BCC2 bahcet with hx of DVT
Station 1
Abdomen:abdominal mass for Dr
Chest : lung fibrosis in pt with ss
Station 2 palpitation with anxiety and familly Hx
of sudden death (her father 40yo)
👉🏻09/05 sharjah round 3
chest- copd
abdomen- splemomegaly
cns- spinocerebellar ataxia(confused)
cvs-cabg with aortic stenosis
bcc1-hemiballismus
bcc 2- periodic paralysis (familial)
history- pheochromocytoma
st4- medication error
👉🏻Dubai 7th May
neuro median nerve entrapement pt on dialysis
with fistula isaid amyloidosis he asked me any
drug can cause .
cardio aortic stenosis.
abdomen huge spleen with jandice he was
discussing haemolytic anaemia and asking
about leishmaniasis
chest pneumo ia but pt was having hiccup he
asked what is z rekstion i said no idea
history lady of 77 c of epilepsy with frequent
seizures lately talk with son
communication pt with ulcerative colitis read
you want to start steroids tabs but he read
about complication of steroids
BCC 1 thyroid with exophthalmos
BCC 2 sudden loss of vision in one eye , htn but
he is surrogate not true pt and he said if not
amurosis fugax , what else, i gave dd
👉🏻Dubai 2018 diet 2 may 7th
Respiratory
Abdomen
Splenomegaly
CVS
MR or VSD
Neuro
History
Communication
Station 5
Dvt
👉🏻dubai 8/5/2018
St. 2 palpitation , has history of palpitation
before and diagnosed as ectopic but this time
different .
Inside all negative apart from hx of anxiety
which is controlled on SSRI , FH of cardiac
death and taking much coffee , working in
coffee shop.
Cardio was not clear one candidate sayed AR ,
other colleagues had double valave replacement
.
Neuro bilateral CTS in HD patient.
St4 methotrexate and trimethoprim
BCC 1 Behcet
BCC 2 was difficult , incidental finding of
suprarenal mass 0,7 cm , inside apart from
recurrent renal stone all negatives
Abdomen HSM
Resp patient with SS pulmonary fibrosis
👉🏻Sharjah 9.5.2018 Round 1
St 1
Abdomen Splenomegaly ? Malignancy
Chest COPD: fibrosis
St 2 Recurrent TIA , high level stress job,
unhealthy diet
St 3
CVS Mitral stenosis
Neuro Friedrichs Ataxia
St 4 Husband had argument with wife had
paracetamol overdose as suicide attempt,
paracetamol level still high but wants to go
home AMA
St 5
BCC 1 Retinitis Pigmentosa and Optic Atrophy ?
BCC 2 Double vision Myasthenia Gravis
👉🏻sharjah 9th May group 3

chest- copd
abdomen- splemomegaly
cns- spinocerebellar ataxia(confused)
cvs-cabg with aortic stenosis
bcc1-hemiballismus
bcc 2- periodic paralysis (familial)
history- pheochromocytoma station 2: middle
aged man known h/o anxiety and on diazepam
off n on came with few mnths h/o chest
discomfort and palpitataions ,and incidently
found to hav glycosuria, in emquiry h/of loss,
episodic headache also
st4- medication error
👉🏻2018/02 dubai...
started my exam with
BCC1 command was young male with bilateral
eye swelling... when i entered inside , patient
was of graves ophthalmopathy. i missed scar
marks on eye lids suggestive of previous
surgery...
BCC2 was transient vision loss in right eye .. no
positive findings. i gave differentials of TIA vs
ameurosis fugax..
Abdomen - transplanted kidney ..
Resp- right lower lobe dullness with decreased
vocal resonance.
history station was old lady with history of
epilepsy . now came with status epilepticus.. h/o
fall one week back
Cardio - aortic stenosis with AR .
Neuro - bilateral CTS with AV fistula.
Station 4 - poorly controlled crohns disease ..
task was to convince patient about use of
steroids
Hello everyone Alhamdullilah I pass paces in
diet 2 2018 from EGYPT.. and here is my
St 1 abdomen case was a young male with
Chest Was male pt with obstructive lung
St 2 sarcoidosis (I totally missed the case ) pt
St 3 CVS middle age very thin lady with raised
? I got 20
CNS male pt with lt side uncrossed hemplegia
St 4 young male pt college students with UC
St 5.a lady with neck pain ..
BCC 2 Young pt diagnosed 3mth ago with T1DM
recently he has skin lesions.. inside I asked him
to show me the lesions it was vitiligo about 3-4
patches only in his legs .. then I asked few
questions about it.. then screening questions
for other autoimmune diseases and about his
diabetes.. it was controlled .. I saw his eyes for
the paler and palpate his abdomen .. concern..
what is this.. ? I explain and reassure him but
we may need to do some tests to exclude other
associations .. discussion about other
autoimmune diseases When I mentioned
score 149
2018/2 Egypt Experiences Collection
👉🏻St 1 abdomen thalassamia with splectomy

and hepatomegaly
Chest obstructive lung disease with bibasal
fibrosis
St 2 sarcoidosis
St 3 CVS DVR
CNS spastic paraparesis
St 4 pt with UC about to start steroids and he is
worried about the side effects
St 5.a lady with neck pain
Inside was a lady with joint pain ccc of RA and
low back pain
I didn't ask about steroids
Mostly she has osteoporosis and vertebral
fracture
BCC 2 Young pt with vitiligo discussion about
other autoimmune diseases
He has T1DM
👉🏻Egypt cycle 2 9/5/2018
Station 2 young female recently came from
Kenya has fever and bloody diarrhoea for
differential
Station 4 old man with many issues admitted
with fall, was fit for discharge then suddenly
had cardiac arrest and died, talk to the son
BCC 1Fibromyalgia in young female with
depression
BCC 2 Pulmonary TB in HIV pt
👉🏻Egypt New Al Kaser El Eainy
07/5/2018 Cycle 1
St 1 COPD
Splenomegaly in young male which is pale
asking about DD whic is infection..Myelo
..Lymphoproliferative ..Discusion about
Schistosomiasis and treatment..
St2 back pain..+ve increase at morning awake
him at night.. said no stiffness..there is heal
pain .. Sore eyes .. there is vomiting of blood
once.sport player mainly foot ball. FH of
Psoriasis.
DD Ankylosing Spondylitis ..Psoriatic
arthropathy..paraspinal spasm .. Mass 2ndary to
bowel malignancy and nature of pain..
Discussion about Ankylosing.
St3..
CVS MVR & AVR + AF+ PUL.HTN in failure.
Neuro: ??? Spastic paraparesis sensation
intact..Could be MS..Cerebral palsy.
St 4 Known case of Psoriasis on MTX receive
Nitrofurantoin for UTI causing epistaxis and
ecchymosisis.
Inv..pancytopenia.
Task: To stop MTX and answer her concern ..
very talkative surrogate withcalot of concerns
till the end of interview.
St5
BCC1 45y male c/o exertional dyspnea ..
Inside Thyrotoxic heart failure.. pt had features
of Graves Disease on Antithyroid and
propranolol not compliant with medication ..OE
.. AF.. 'LL edema ..bibasal crepitation.
BCC2 Out side Pt known case of DM and Skin
lesion ..
Inside Pemphigus vulgaris ..
👉🏻Egypt 5/5/18, 3rd carousel
St 4 60 yrs old gentleman presented with

seizure for 1st time aborted by diazepam but
still confused
St 5
BCC 1 60yrs gentleman presented with fever
and abdominal pain for 5 days
Inside had history of HBV
, most likely SBP
BCC2 40yrs old lady presented with tingling and
numbness in her hands
Inside had history of CTS and did surgery, she
is acromegalic
Abdomen young man pale , jaundiced,
palpable, most likely chronic haemolytic
anaemia
Chest COPD
Station 2 young man presented with syncope
marathon , LOC
DD HOCM
long QT syndrome
Cardio DVR with obvious clubbing
Neuro young man has pes cavus, hypotonia ,
hyperreflexia , sensation normal , had
nystagmus and slurred speech
DD MS , FA
👉🏻Egypt May 5. 2018, Morning

Station 2 Haemochromotosis
Station 4 Hyponatremia induced seizure
BCC 1 Systemic Sclerosis
BCC 2 Addison
Abdomen Massive splenomegaly
Respiraotory COPD / pulmonary fibrosis
Neuro CIDP / Polio
Cardio DVR
More details about St-4
2 weeks back patient was diagnosed with HTN.
His GP started hydrochorlthiazide 2.5 mg and
advised lifestyle modification. Patient cycled a
60 KM race and drank plenty of plain water
during the race. Later in the day he was
witnessed by his neighbour collapsing and
having fits. He was shifted to HDU in hospital
where he is admitted since yesterday. GCS is
14, Na is 114. Other blood investigations are
normal. CT Brain is normal.
Concerns of surrogate
If its due to low sodium why don’t you just give
him extra sodium and make it normal
My husband is Engineer and we were planning
to shift abroad. Will it be possible now ?
Concerned about his driving as important part
of his job
Examiner questions ..Can it be Epilepsy ?
Copied from Dr. Magdy Telegram Channel
👉🏻Egypt 9/5/2018
Station 2
young female recently came from Kenya has
fever and bloody diarrhoea for differential
Station 4
old man with many issues admitted with fall,
was fit for discharge then suddenly had cardiac
arrest and died, talk to the son
Station 5
Fibromyalgia in young female with depression
Pulmonary TB in HIV pt — with Ahmed Maher

Eliwa.
👉🏻Today EGYPT Round 2
St 1 abd thalassamia with splectomy and
hepatomegaly
Chest obstructive lung disease with bibasal
fibrosis
St 2 sarcoidosis
St 3 CVS DVR
CNS spastic paraparesis
St 4 pt with UC about to start steroids and he is
worried about the side effects
St 5 a lady with neck pain
Inside was a lady with joint pain ccc of RA and
low back pain
I didn't ask about steroids
Mostly she has osteoporosis and vertebral
fracture
BCC 2
Young pt with vitiligo discussion about other
autoimmune diseases
He has T1DM
👉🏻Station 1...hepatosplenomegaly with jaundice
in a female...thalacemia
Hyper resonance on percusion obliterated liver
dullness....copd
Station 2..hx was headache with glycosuria with
polyuria with rise in bp. Father had died in
young age for DD...pheochromocytoma.MEN2
Station 3... cardio ejection systolic at aortic and
pansystolic at apex murmurs with vein harvest
scar in leg.with sob and crackles in chest..
Neuro was F.A in a young female
Station 4...talk to daughter about her father
admitted with severe pneumonia now better
seen by consultant but he has hx of parkinson
disease she handed over the medications for
parkinson disease to doctor in the ER which
was not given to her father and now his
parkinsonian symptoms are worst. Apologies. I
will confirm what went wrong.ur father is in
better condition now .out of danger.we will
consult brain doctor to day. Incedent
report.cosultant knows about it.we will do the
root cause analysis and we will inform you
about its out come
bcc 1 hemiblasmus post cva and hx of dm n htn.
bcc 2 Hypokalemic periodic paralysis.
👉🏻6/5/2018
Cairo center
CNS... stroke
CVS.... AS+MR in failure
Abdomen: Hepatosplenomegaly +Ascites
Chest Penumectomy with features of
beonchiectesis
Communication
A young Chef with history of Asthma and
allergy to nuts admitted e anphylaxis to ICU
where he was ventilated . His condition
improved now . Extubated and shifted to the
general ward
The task is to speak to the pt about his serious
disease and affection of his job
History
A female with uncontrolled HTN . has history of
headache , palpitations and constipation
She has problems with ACE she now On

Atenolol and calcium ch blocker .
station 5
psoriasis precipitated by atenolol and psoriatic
arthopathy..
Uncontrolled complicated Dm e decreased
vision the Rt eye
👉🏻St 2 back pain, AS or psorriatic arthropathy

St 4 MTX and Trimethoprim causing
pancytopenia
BCC 1 Thyrotoxicosis, AF, CHF
BCC 2 Pemphigus valgaris, discuss
steven johnson syndrome
👉🏻Egypt
9/5/2018 cycle 2
Station 1: chest pneumonectomy 20/20
Abdomen: hepatomegaly with jaundice for
differential 16/20
Station 2 : 38 years old female came recently
from Kenya referred with history of fever and
bloody diarrhoea, inside 38 yrs old travelled to
Kenya 3 weeks ago came back 3 days ago,
started to have bloody diarrhoea upon return,
no mucous, more than 10 times/day, has
crampy abdominal pain that's all over more
periumbilucal, has nausea or vomiting, no
jaundice, also has fever, high grade though not
measured, associated with chills, wt loss of 1-2
kg, history of eating from outside food, no other
sick contact,
Was prescribed loperamide by GP before travel
but didn't take
No joint pain or skin rash, no mouth ulcers,
First time to have such symptoms
Systemic review negative
Past history negative
Drug history only taking OCPs
Family history positive for crohns disease in
uncle
Social:works as teacher, affected by frequent
diarrhoea, non smoker, non alcohol consumer
Concerns: what do is have is it crohns like my
uncle?
I answered from what you have told me looks
more of bug infection related to your travel and
eating from outside , crohns disease is still a
possibility, after our interview I'll examine you
fully then we will have to send for labs including
liver and kidney function and checking salts,
also we will send a stool sample for analysis to
look for evidence of any bug infection , if your
symptoms didn't improve we may need to do
camera test to look for crohns disease, checked
understanding and time over
Examiner questions summarize ur case, as
above
DD invective diarrhoea, crohns disease
Hw are you going to investigate her CBC, renal
and liver function including electrolytes, stool
analysis and culture
Will you do colonoscopy I said if there was
evidence of infection and she improved then no
colonoscopy
Then he asked whether to admit her or know, I
said if clinically dehydrated then for admission
other wise will wait for basic labs which usually
takes 1 hr 20/20
Station 3 CVS, I said AR which is obviously
wrong 10/20
CNS examine motor system, it was peripheral
motor neuropathy, I gave GBS as first DD
discussion was around it 20/20
Station 4 from outside talk to the son, his father
who's 80 yrs old has Parkinson's disease on
medications, HTN on medication, A fib on
warfarin, he was admitted 2 days ago with fall,
upon admission INR was 4.7 and warfarin
stopped case of fall was postural hypotension
and medications stopped
Next day he had a fall CT head ruled out
hemorrhage, next day he was for discharge but
early morning he collapsed and had cardiac
arrest CPR was unsuccessful and he died, no
obvious cause was found
BBN as usual (examiner said I did it good )
Said was angry and frustrated abt what
happened and why he died what's the cause
Explained everything and the option of
postmortem exam which he didn't want
Summary and checked understanding
Examiner Q; summary, then discussion was abt
coroner referral and postmortem exam which I
had no idea abt , examiner told me that any pt
who died unexpectedly within 24 hrs of
admission shud b referred to coroner for
postmortem exam, they were generous and
gave me 12/16
BCC 1 neck and buttock pain in young lady
inside she has depression, funny thing I forgot
the term fibromyalgia,
I explained everything without the name, I told
the examiner I forgot the name they were also
generous and gave me 26/28
BCC 2 fever in young gentleman , inside he has
HIV diagnosed 1 yr ago, 10 yrs ago he had RTA
which required multiple Operations and blood
transfusions
Fever with cough and hemoptysis and wt loss, it
was TB scored 26/28
👉🏻EGYPT 8/5/2018
BBC1 lady with hand pain and knee pain
Inside , pain in joints of hand with morning
stiffness 30 seconds, ask for all rheumatological
diseases there is only gritty eyes and dry mouth
.
Examine jounts of the hand and no carpal
tunnel. Ask to examine sensation , the examiner
told me no need and eyes. And also no need for
knee examination.
He asked me about DD
I told him could be mixed connective tissue
disease , could be 1ry s'jogren.
I want to do basic investigations
Shrimer's test
ANA, anti RNP, anti Ro&La.
24/28
BBC2
Outside lady with breast discharge
2 month ago
Headache ,Cycles stopped 6 months ago.
No symptoms suggest acromegaly or
hypopituitarism.
Ask for the rest of MEN1 , negative.
Visual field was limited in all direction , ask for
fundus , examiner told me no papilledema , ask
about driving , and advise her to stop driving.
He asked me about diagnosis , prolactinoma
Investigation , prolactin, other pituitary
hormones.
MRI pit.
Then asked me what did you find in fundus , i
told him he told what did you expect ? I said
bitemporal hemianopia ,
Why she has constricted field? Could be due to
optic atrophy from long standing increased ICP.
Ttt surgery, dopamine agonists,
28/28
St 1
Respiratory
Gentleman with upper left lobe fibrosis with
hyperinflated lungs
Causes
TB, occupational lung disease, extrinsic allergic
alveolitis, AS.
Investigations HRCT , PFTs asked about
restrictive pattern .
Investigation for TB, occupational history ,
Ttt acc to the cause.
He asked about ttt of obstructive lung disease , i
told him bronchodilator acc to EFV1 and
possibility of LTOT.
20/20
Abdomen.
Tender hepatomegaly with splenomegaly
without ascites or stigmata of CLD.
I asked to examine Lnds he refused.
DD
Pallor and Tender hepatomegaly most probably
infection as we are in egypt 1st HCV , he told me
what else i mentioned all infections except
bilharziasis
Myeloproliferative diseases, infeltrative disease
, autoimmune disease
Investigation and treatment.
16/20.
St2 history taking
Outside , you are the doctor in the admission
unite , see young lady with cough , fever .
Inside i found a beautiful young lady , i became
distracted for a while then i tried to concentrate
to finish the exam.
Analysis of complain recurrent chest infections
I ask about traveling abroad , TB contacts , i
asked about HIV risk factors , asked about
cystic fibrosis , another infections she had
chronic diarrhoea diagnosed as giardiasis,
tonsillitis ،no meningitis or uti.
DD hypo gamma globulin emia , Cystic fibrosis
Or aquired immune deficiency.
Investigations. basic, cXR, inflammatory
markers.Gamma globulin levels ,
CL sweat test, genetic for CF. HIV test.
Whould you like to admit?
Acc. To curb 65 score and her O2 saturation.
Ttt , gamma globulins infusion for life
Asked me about frequency?
I have no experience , i will refer her to the
immunologist and hematologist.
Whould you like to vaccinate her?
I think it is not benificial. 20/20
👉🏻Hello everyone Alhamdullilah I pass paces in
diet 2 2018 from EGYPT.. and here is my
St 1 abdomen case was a young male with
Chest Was male pt with obstructive lung
St 2 sarcoidosis (I totally missed the case ) pt
St 3 CVS middle age very thin lady with raised
? I got 20
CNS male pt with lt side uncrossed hemplegia
St 4 young male pt college students with UC
St 5.a lady with neck pain ..
BCC 2 Young pt diagnosed 3mth ago with T1DM
recently he has skin lesions.. inside I asked him
to show me the lesions it was vitiligo about 3-4
patches only in his legs .. then I asked few
questions about it.. then screening questions
for other autoimmune diseases and about his
diabetes.. it was controlled .. I saw his eyes for
the paler and palpate his abdomen .. concern..
what is this.. ? I explain and reassure him but
we may need to do some tests to exclude other
associations .. discussion about other
autoimmune diseases When I mentioned
score 149
appeared in 2018/02 dubai...

BCC1 command was young male with bilateral
eye swelling... when i entered inside , patient
was of graves ophthalmopathy. i missed scar
marks on eye lids suggestive of previous
surgery...
BCC2 was transient vision loss in right eye .. no
positive findings. i gave differentials of TIA vs
ameurosis fugax..
Abdomen - transplanted kidney ..
Resp- right lower lobe dullness with decreased
vocal resonance.
history station was old lady with history of
fall one week back
Cardio - aortic stenosis with AR .
Neuro - bilateral CTS with AV fistula.
Station 4 - poorly controlled crohns disease ..
steroids
➡️ Station 4
➡️ Station 2
Q1)If surrogate deny about IDU,what should we

do?
Q2)What is the conservative management of
IE(give Antibiotic or Not)?
Egypt cycle ⚁ 9/5/2018
Station 2 ⚁
young female recently came from Kenya has

fever and bloody diarrhoea for differential
Station 4 ⚃
old man with many issues admitted with fall,

was fit for discharge then suddenly had cardiac
arrest and died, talk to the son
Station 5 ⚄
Fibromyalgia in young female with depression

Pulmonary TB in HIV pt
Malaysia diet 1/2018 on 15th April
Station-4
young lady business woman from America,
presented with headache and meningism, SAH
suspected, CT normal,
discussion and consent for LP, then discussion
for flight travel
(I got 13/16)
Station-5.1
Acromegaly man, post-transsphenoidal surgery,
presented again with headache x 6 months, no
features of local recurrence on examination.
I said ?post-op changes, ?tumour recurrence
then investigations, management
(I got 26/28)
Station-5.2
young lady with DM 1 on insulin, c/o blurred
vision.
poor HbA1c control
When I explored, she said blurred vision off &
on, worsening after meal
normal fundoscopy
Dx- osmotic changes of lens
then discussed about investigations and
management
(I got 27/28)
Station-1
Abdo: CML, massive splenomegaly +
hepatomegaly + skin ecchymosis
(I got 20/20)
Respi: Rt. lobectomy due to lung cancer

(I got 20/20)
Station-2
young lady single, underlying DM1 with
tiredness and weight loss for poor glucose
control, because of non-compliance insulin,
broke up with her boyfriend
urinary frequency and menstrual irregularity
also noted
my D/Dx - poor DM control, hyperthyroid,
adrenal failure, depression
then discussed for investigations
(I got 19/20)
Station-3
CVS: PSM at LSE, but no radiation ?VSD, MR,
(I got 20/20)
Neuro: peripheral sensory motor neuropathy,

worse on Rt. side, sensory intact on left side
Dx- Charcot Marie Tooth
(I got 20/20)
I passed with marks 165/172.
Thanks everyone here for sharing cases,
sharing is caring. All the best for other
candidates
Experience of Dr Terence KW Lim who passed

PACES exam from Malaysia Center.
2018/1 Malaysia HTJS-IMU 16/4/18
Respi:
Left pneumonectomy
Left thoracotomy scar with fingers clubbing, left

deviation of trachea, reduced expansion,
dullness percussion, reduced breath
sounds+vocal resonance left lung.
Examiners asked differentials of underlying
pathology leading to
pneumonectomy/lobectomy, investigations,
management if patient admitted with acute
breathlessness.
Abdomen:
Chronic haemolysis, post-splenectomy and
cholecystectomy
Single long supraumbilical transverse scar from

left to right hypochondrium
Tinge of jaundice
Pale conjunctivae
No spleen, no liver, no other mass, no ascites
Examiner asked causes of chronic haemolysis

leading to splenectomy, investigations and
management of OPSI if patient admitted acutely
unwell and fever, common organisms, choice of
antibiotics.
Neuro:
Ocular myasthenia gravis
Bilateral ptosis with fatiguability, complex
ophthalmoplegia & diplopia, no bulbar
involvement, good neck muscles power
Examiner asked bedside tests, lab tests

(antiAChR, antiMuSK), thymectony, what would
you ask/assess if patient present to clinic (voice
changes, dysphagia, SOB), FVC cutoff for
ventilatory support, Mx of mysthenia crisis.
CVS
Dual valves replacement with bilateral
mastectomy scars (t-shaped scars on the chest)
Bilateral fingers clubbing, prosthetic clicks S1

S2
Examiner asked differentials needing dual valve

replacement, correlation between breast ca and
cardiac problems (doxorubicin cardiomyopathy,
radiation induced valvular ds, pericarditis), INR
target, warfarin
History:
50+ years old lady with history of depression
presented with progressive lethargy for 8
months, LOW 3-4kg in 6-7 weeks, serum sodium
130+ others unremarkable.
Examiner directed towards adrenal

insufficiency, differentials of hyponatraemia,
thyroid ds, malignancy
Communication
Breaking bad news of potential lung ca
60+ years old ex-ship yard worker, chronic &
heavy smoker with cough for 3 months,
haemoptysis, LOW, CXR right hilar mass with
associated collapse.
Tasks was to break bad news, discuss
investigations to confirm diagnosis, possible
management.
Concerns/agenda
1)Why he got lung ca but not other persons who
also smoked
2)Ix & Mx (surgery, chemo, radio)
3)How long can I live?
4)How shd I explain to my wife?
BCC 1
40+ years old, headache with blurring of vision
for 1 week
Right homonymous hemianopia, stroke
BCC 2
15 years old, tingling sensation bilateral hands
and feet
Lupus nephritis with ESRF on HD,

hypocalcaemia post-parathyroidectomy
Passed with 144/172

Copied from dr. Ahmed maher 's whatsapp
group
8/5 Dubai center;
3️⃣Station 3 CVS: aortic regerg-
CNS: CTS
4️⃣Station 4 pt on methotrexate and had hx of
UTI for which her doc gave trimethoprim
5️⃣Station 5:
BCC1 suprarenal nodule seen on US inside no s
or s of pheochromocytoma
BCC2 bahcet with hx of DVT
1️⃣Station 1
Abdomen:abdominal mass for Dr
Chest : lung fibrosis in pt with ss
2️⃣Station 2 palpitation with anxiety and familly
Hx of sudden death (her father 40yo)
Dubai 2018 diet 2 may 7th
Respiratory
Abdomen
Splenomegaly
CVS
MR or VSD
Neuro
History
Communication
Station 5
Dvt
Sudan Khartoum Soba center April 7th first
cycle
Started with st3
Neuro:patient has difficulty in walking examine

lower limbs. Greet the pt hesitate to walk the pt
first then I decided to examine .atrophied lower
limbs power G 4. Weakness more
distally.reflexes absent even with reinforcement,
coordination intact, sensation glove sensory
impairments till mid shin, for all modalities.
Time finished.
Examiner said present your finding I TOLD as
above + this pt has high arched feet. (AS ITS
NOT TYPICAL PES CAVUS) so this msn has
sensory motor peripheral neuropathy. So
examiner asked what the Dd said charcot marry
tooth. Alcohol neuropathy ,diabetic neuropathy,
but B12. He said if you got the chance to
examine the gait what will be, I said high
stepping gait.how to investigate and how to
treat.scored 18/20
Cvs: young man with sob, sternotomy scar
PULSE small volume apex in place clic in aortic
area with systolic murmur all over.I was in hurry
to finish before Bell so I did radiation to axilla
but forget radiation to neck, checked back lower
limb. Time finished, so examiner asked finding I
TOLD as above. AVR metalic . What the murmur
I said it's flow murmur he said how you know.I
said not radiate to axilla so not MR. Not radiate
to neck so not ... So he smiled and said you
didn't listen to neck. So he said then how you
explain his sob.I said this pt is not in failure, no
signs of Inf End,no regurgitant murmur no signs
of over coagulation so his sob could be due to
anaemia from the mechanical valve. So he said
how you will aprouch the pt .TOLD him cbc with
peripheral b p ,ESR CRP ECG Echo Inr.
Management warfarin regular follow up. I got
13/20
It's a female in 40 asking for discharge against

medical advice, came early with headache
suspected SAH. Imaging normal neurologist
want to do L.p..pt want discharge because she
is ok now no headache no any symptoms want
to fly home
Started with greeting what's name age. My name

and role
Asked what u know so far.and TOLD me her
story.she said no meaning to stay she has flight
to catch this evening to home US
I said we are suspecting small bleed inside your

head and it's a warning that you may have
another bigger bleed soon. The imagine was
normal but couldn't detect such small bleed so
we need to do other TEST.. the neurologist
suggest to do L.p.. do u know what this mean.
She said no.so I TOLD we will introduce a very
tiny needle through your back and take sample
from fluid covering your brain and spinal cord.
Will check this fluid for blood. We need 12 hours
from the start of your symptoms to do this
TEST.
She said no I'm pretty ok. I TOLD HER yes now
you are ok, but you may deteriorate at any time
if you bleed again and I'm afraid if this happens
will be bigger bleed with bad consequences.
She said like what ..TOLD her you may loss your
consciousness. Weakness even death. So she
kept in silence..I told her we have to make sure
is there is small bleed or no.I told her about
complication of l.p. hypotension headache small
chance of introduction of infection and fluid
leak.and how we will do our best to avoid all
these.l TOLD her she has to postpone her flight
any way even if result were negative because
we don't know if she developed bad effect.she
agreed on l.p. and I TOLD HER will come in
awhile to let her sign consent. Any questions
said no. Time finished. Examiner asked to
summarise what problem. Asked how to treat
SAH medical and surgical. Then said why I
TOLD HER to postpone her flight. If she has no
bleed can't she fly I said no..She can't fly
because she may develop csf leak up to one
week.I think he was not agreeing. So he said
what risk factors of sah.. I said
hypertension,polycystic kidney disease. Here I
realised I forget to ask about them. Then Bell
rang
Scored 12/16
St 5: 54 male with skin rash and high bp enter

the room greetings my name and role. Tell me
more...So the talk about the rash .it was
neurofibromatosis. No symptoms at all. All
examination was normal said the examiner
except of BP 170/90.Concern is it brain cancer. I
said it's associated with cancer. We need to do
imaging to brain.and we need to give you ttt for
hypertension
So examiner question what's your diagnosis
neurofibromatosis.so this pt has no
neurological finding why you will do imaging to
brain. I said associated with brain tumour.she
said what is more important than brain image I
said abd us.why ?looking for
pheochromocytoma. How you will treat him will
u give b blocker ? Said no will give alpha
blocker. If no pheochromocytoma what
medicine I said .ca chance elhamdo blocker or
Ace I.score 22/28
St 5:50 yr femal transient loss of vision while

she was driving. Headach zigzag lines then loss
of vision for awhile no every thing normal. No
significant PMH. Hx of headache in the past .
But 1st episode of loss of vision. Examination of
eye and PULSE carotid and heart were all
normal. Examiner what d TIA. Other Migrain he
said from hx what makes you think it's migraine,
TOLD him seeing zigzag lines. He said you got
it. So ask investigations and management of
TIA. Scored 24/28
Station 1.abdomen lady with no sign of cld,

compared her hands to mine was pale, when
came to eye the right eye is odematous and red,
left eye normal. Liver span normal.spleen 8 cm
below coastal margins no ascites no lower limb
odemas.when want to sit her she was in pain so
I TOLD HER no need I will examine lymph nodes
while you are lying and I did.no lymph nodes.
Time finished, examiner asked what the finding
TOLD him lady pale no signs of Cld, liver span
normal, spleen palpable 8cm, no ascites, no L
Node .What Dd, infections ,malignancy .portal
hypertension despite no signs of Cld and
normal liver. He said there is no.sign of Cld I
said yes no sign. What type of malignancy I said
myeloproliferative and lymphoproliferative.
Then he said what else did you find in this pt. I
TOLD him she has right odematous red eye,
what it could be..conjunctivitis...then I'm about
to say it could be connective tissue disease
given the red eye and splenomegally,when he
said if I said to you her HB is 17 what's your
diagnosis. I said polycythemia rupra vera .How
to investigate what complication and how to
treat. Score20/20
Then chest:gentle man with clupping. Trachea
central.normal chest expansion,normal
resonance normal air entry. Crackles and
wheeze all over mainly right chest. So finding as
above what diagnosis I gave bronchiectasis.
COBD FIBROSIS . SCORE 12/20
Now station 2: young male with loose motions

diagnosed with Irritable bowel by his Gp. On
antispasmodic no response. Father died with
colon cancer. Started with greeting what's name
age. Introduce myself and my role.tell me more.
He said loose motion just.so I said tell me more
again . Said just..So I decided to be insistent
and persistent. So kept asking in details of
motion consistency colour float or sink in
toilet,amount ...etc he was annoyed by my
questions.then blood or Melina loss of weight or
appetite. All alarm symptoms were
negative.pmh nothing just IBS. On probiotics
and antispasmodic. Family Hx father died with
colon cancer developed at 60, any body else
said uncle.any body else he said brother, Any
one else he said aunt I said any other he said
cousin , any more he said no.so I returned to
ask about their age and diagnosis one by one.
Aunt was uterine cancer ,brother,cousin and
uncle colon cancer one at age 35. So complete
the history . Concern could it be cancer.I said it
look like IBS but you have strong Family history
of colon cancer so we have to investigate you
TOLD him about colonoscopy fiscal occult
blood and even if all normal he will be followed
and screened on regular bases. Talked about
IBS management,social hx, stress in life.
Examiner asked about summary, what Dd so
IBS, IBD although no blood, CELIAC DISEASE,
COLON CANCER. WAHT INVESTIGATIONS FOR
CELIAC DISEASE what TEST given his strong
Family history said genetic. He said you forget
to ask one question??? I said yes not ask from
slim or mucous he said it's ok. Time finish. He
said leave your paper and go home. SCORE
20/20
My score was 141
Respi hard case

Reduce breath sound
No crept
Midsternotomy scar

lung collapse
17/20



scabies

19/20
Cvs MVR 20/20

17/20

worsening in ward

to bring pt home
10/16

28/28
155/172
He ask me
1.what i am having
I answer you have some sort of blood disorder.

We have to investigate 1st before reaching
conclusion
2. Did my itchiness related to my mother

scabies
Less likely
3 can it be treated
Its to early to say
We need to investigate 1st
I never mention cancer or lymphoma
Malta 🇲🇹 1-2018
Station 4
Day 1 :
Outside :
83 years old
Mrs Eric Teracy
2nd admission in 1 month with delirium
Counsel son for her condition and answer his
queries
Details ; written outside
Mrs Teracy has been admitted with urinary

sepsis twice in ur ward in 1 month . This time
she has impaired renal functions. Urea is 15
mmol and creatinine is 220u mol and she is
confused .
After admission she was started on iV fluids and
IV antibiotics and nursing staff has informed u
that she is improving after this . And also she is
less agitated as compared to admission. She
has background history of dementia , and
consultant has diagnosed delirium this time .
During course of admission, unfortunately she
has developed a black heel ulcer .
Mrs Teracy was admitted 1 month back with UTI

and delirium and after recovered fully , she was
discharged home .
Before discharge, she was assessed by
OCCUPATIONALHealth team and visited her
home for necessary arrangements .
Kindly see Mr. John , son of Mrs Eric to explain

then him latest condition & management .
Inside ;
11 points of introduction
Greet
Check identity
NOK
Introduce
Role
Agenda
Anyone with u
Want anyone to be with you for discussion
Notes taking but would be listening to u
attentively
How u came here today
&
What u do for living ?
Open Question : ICE
Idea :
What u know about condition of ur mother ?
My mother is an elderly lady 👵 u know &

She has mild Dementia but she is self caring
And cooks and clean house at her own .
She has 2nd episode of confusion in 1 month
I live at 1 hour drive from my mother house ,
and I Visit her when ever I get a chance.
I know for last some days , she was not drinking
water 💦 as much as she should & This time she
has presented with confusion and was agitated .
I was called by one of nurses as I m NOK.
I am coming straight to u
Would u please tell me what is her condition?
Thank u very much indeed for sharing this

information with us , I appreciate that.
And I am sorry that ur mother is ILL and u look
really worried for her health.
Actually she was agitated when she came in ER
, we did some tests which showed that she has
infection in water works and also her kidney are
not functioning proper. Due to this ,the waste
products which are excreted from body by
kidneys have accumulated in her body .
Also she is elderly
She has dementia
So all these things have lead to a condition
which we call as “” Delirium””
Have u heard about it ?
No dr ?
Let me tell u in simple words ?

It’s called confusion in simple words
And there are many causes for it
Which may include in ur mother case
Change in Environment like hospital
Which isn’t familiar for patient
Her Age
Infection of water works
Impaired kidney functions
Dementia
And
Sometimes some medications.
After admission ;
Our team , my consultant and all nursing staff
taking very good care of her .
&
She was given fluids in her blood channels and
started antibiotics and she improved and she is
less agitated at the moment .
What next for us and what next for u ?
Let me explain please
We will put her in s separate room

So that she isn’t disturbed by other patients
We will monitor her condition closely
Our consultant will be regularly visiting her
Nursing staff will be available round the clock
And
Treatment for infection will be continued
Fluids will continue
And we will keep u informed about her
condition.
What we request u do ? Is
U visit her more frequently if possible
Bring some familiar stuff from home , of her
choice , other hobbies she has , Which will help
her condition.
Thank u dr
That u explain me all details and u are taking
care of my mother
Can I bring books 📚 for her as she likes reading

and she like knitting .
Yes
Sure
As it will help in recovery from

This condition.
Surrogate : Dr , in corridor I met a nurse , she

told me that my mother doesn’t like hospital
food
Can I bring food from home ?
At the moment , ur mother is being given fluids

and she is confused
Once she improve more and
she demands food I will check with nurses
about her choice of food & then
Sure u can bring her favorite food .
Thank u dr .
But I have a question.
Dr, what do u think that after last admission
My mother was discharged from hosp early ?
As
That may be the reason that she is admitted
again so early
I mean this is 2 Nd time in a month
U know . Am worried . As she lives alone .
Actually
When ur mother was admitted last time
Before discharge ur mother was seen by all
teams responsible for ur mother care
My consultant
Occupational health physician
And
All other team members gave their input in
decision and occupational health department
made necessary arrangements for her at home
before she go home , only then she was sent
home &
As u also told me that she was doing good after
discharge .
So i assure u that we never discharge any
patient until And unless seen by consultant and
all
Team agrees that patient is doing good and can
manage at home .
Thank u dr .
Mr John
Another important point I want to discuss
What’s that dr ?
Actually
During hospital course this time
Ur mother has developed a black heel sore
And
She has been seen by our nurses
So
To prevent its spread further from
Heal we will do all necessary precautions and
also to prevent it getting infected
And
If needed specialist dr in this field can also see
patient .
I just wanted to inform u about it
As it may take sometime for this ulcer to heal .
But
I assure u we will do our best to prevent it on
other parts of body and treat this sore with best
possible care . I have personally talked to my
head nurse , and she will do all necessary
things .
Thank u dr I appreciate
Would of u please tell me about ur mother social

circumstances ?
As i told u dr she lives alone at her own

She was doing good
But I am worried u know as she is admitted
twice this month
I try to visit her but u know sometimes I can’t
Thank u for Sharing with me this important

information
We can arrange for social services if she agrees
but we will talk to her about it once Her infection
settles down .
Thank u dr
We have talked a lot
Let me summarize it .
But
He didn’t allow me to summarize
Rather he started to tell everything what I told
him ( I counted it as understanding )
But I summarized again
I thanked him
&
Asked him any other concerns
Any other questions
Any thing which doesn’t make sense
Any jargon , u didn’t understand
He said
No dr
U explained it very well
Examiner : 2 mins remaining

Consultation finished
But
I took a paper and pen and I wrote
Listen Mr John
I will give you leaflets
I am writing for u a website address
“”NHS choices “”
It’s very good website
U can google it
And
I am writing for you spellings of “” DELIRIUM “”
the condition your mother has
Or “” confusion”” u write any one ☝️ in this

website , u will get all information about ur
mother’s condition
What it is ?
What causes it ?
How to help Patient in this condition
How to prevent it next time
And
Another website is
Www . Patient . Co .uk
Any one u can use

And
After reading about this condition. If u have any
questions
I will be happy to answer
Thank you dr
And
I am giving u the contact number of hosp
U can contact us anytime to know about ur
mother or call for any queries.
Thank u
Mr John
U have been very kind and co operative
I appreciate that
Thanks dr
Have a good day .
Examiners : u have 1 min to collect ur thoughts
Summarize ur case:
After detail summary
1st question
🇲🇹What’s name of specialist nurse who takes

care of heel unlers ?
I forgot sir but i know, let me re call ——————
———————- he told Then ( honestly I heard 1
st time , it’s called tissue viability nurse )
🇲🇹Who decide discharge consultant ?

only with team members input
🇲🇹Who will u Involve in Patient care ?

I said team of dr .
🇲🇹What u call it
MUlti disciplinary team
🇲🇹Who are members in this team
Count 5-6 ?
Still time not finishing ?

Examiners looking at watch
He asked and explained to me some 1 word
question answers
Bell 🛎 &
I came out .
Station 5 malta 🇲🇹 day 2 mornimg

Part 1:
Outside :
70 years male
Shortness of breath 6 months
BP 150/90
Normal pulse 80/ min
RR 18 per min
Shortness of breath
Increased on exertion while taking his dog out
for mornimg walk and also going upstairs
Started gradually
Progressively increasing
Improved with rest
Aggravated with exertion
Not while sitting
Not on lying flat
Not during sleep
But
Using 2 pillows at night
Any Chest pain : not exactly pain but chest

tightness when I have shortness of breath in
centre of chest which improve on rest
No cough
No phlegm
No wheeze
Never coughed up blood
No leg swelling
No ankle swelling
No palpitations
Past history ;
HTN
Acid reflux
No admission in past
No surgeries
Medication
Taking omeprazole and antacid solution and
paracetamol for pain PRN and perimdopril 4 mg
oD
No allergies to drug or anything Else

No smoking
Alcohol 🍺: socially
Travel : 6 months back went to Ceclia but
shortness of breath and chest tightness was
same & no change in Symptoms while abroad
Job : retired teacher 👩🏫

Hobbies : spray painting
How affecting life : is concerned about it & what

s cause ?
My wife says it’s cuz of spray paintings
Is it because of spray painting ?
Same as concern !
Exam : normal except BP 150/90

Pulse good volume
Chest clear
CVS : Normal / diastolic murmur ( not sure )
faint flow murmur at aortic 2 area ( old age or
uncollected HTN )
Adresss concern as :
After listening to ur history and examining u , I
think it’s not because of spray painting or not
cuz of lungs . It’s seems as heart problem which
can be due to blood channels narrowing or a
valve of heart isn’t functioning proper
We will do some blood tests and ECG and heart
scan once results are back we will have a chat
again and we will discuss what s solution .
Any other concerns
Any Questions
No
Examiners :
Present ur findings
+ ve points in history as above pointing away
from Respiratory problem
HTN uncontrolled long standing
Clear lungs
Pulse good volume
Heart : Normal and a murmur on LSE aortic area
To confirm need to do ECG Echo

DD : AR / IHD
What may be causes of AR in this patient ?
Old age
HTN uncontrolled
Any thing else ?
IHD
Examiner happy : Yes yes
Other causes ;
Marfan syndrome
And infective endocarditis
But no features in this patient .
How will u investigate ;

ECG
CXR
Echo
Troponin to see any current silent ischemia
Angiography for IHD
and bell rang

( not sure of clinical findings )
As no peripheral signs of AR but a faint murmur
was there on leaning patient forward only
Allah knows best
Station 5
Part 2 malta 🇲🇹
Day 2 mornimg
63 years male
6 months history of abdominal pain after eating
Vitals Normal
Inside ;
Well trained surrogate
Pain abdomen
Severe 7/10
In centre of tummy
15-30 mins After eating
Going to my back
Improved a little after bending forward
Not with any specific food �
Fear of pain
Not eating much now
Weight loss 5 kg
Some Nausea
No Vomiting
No yellow discolored eyes
No mouth sores
No acid brash in mouth
No change in Bowel habits
Anything else ( no )
Past :
IHD
4 stents in 2008
CABG 2010
No other medical problems
No admissions except as above
Medication
Atorvastatin 40 HS
Clopidogrel 75 oD
Paracetamol prn
Antacid syrup
Do u take aspirin : No aspirin ;
Any other over the counter No
Any herbal No
Any painkillers No
Family history ;
No similar complaints
No disease runs in family
Smoking nil
Alcohol 🍺: daily 1 bottle of whisky � on

weekend more
Any worries or anxiety no specific
Ur mood : good
Drugs : never
Social : living with wife and kids all normal
Anything else : I think it’s coz of alcohol 🍺

should I stop 🛑 alcohol
Yes : sure alcohol may be causing this problem

Let me examine u and I will explain u
Exam :
Mid chest Scar
Left arm scar
I asked y this scar
He told they took graft for my heart from Here
Abdomen; normal
Ask about Idea : again question of alcohol

misuse ?
After taking to u
I think. Too much alcohol is causing
inflammation in pancreas and ur pain after
meals and improved on bending forward points
towards pancreas
Another point is
When ppL have heart Problem
They can have also narrowing of blood channel
in tummy (!do u have any pain while walking
which improve on resting ; no )
Okie
So
We will do some blood tests and scans and look
at pancreas and blood channels
Once results are back
We will discuss with u and explain u what to do
further
Meanwhile
U stop alcohol
And we can refer u to alcohol cessation’s clinic
Is that okie
Yes
Any other questions
Any concerns
No
Thank u
Examiners ;
Findings :
History positive points
Normal tummy
DD
Alcoholic pancreatitis ( chronic )
Mesenteric ischemia
Examimer ( 🙄)
Okie
Why u think mesenteric
Coz of history of IHD and risk factors
cholesterol for atherosclerosis
How to investigate pancreatitis ?
Do u think blood amylase will
Help
No at the moment as no symptoms
Others
Examimer was telling investigations and
CANDIADTE to tell. What u will see
USG for gall Stones and calcification and

pancreas inflammation
CT for any mass and see pancreas and any fluid

collection
ERCP for Amy stone removal
Abd x Ray for calcification
What are complications of chronic pancreatitis

DM
Malabsorption
Steatorrhoea
Bell rang
Clinical :
Station 1
ILD with SS
Pneumonectomy lobectomy
Hepatospleenomegaly DD
Dupytren s contracture only
Station 3 :
MR only
CABG with MR A fib
Pure motor Spastic paraplegic DD hereditary
Parkinson’s disease
History station:
Recurrent Lip swelling
5 episodes in a 60 years lady
DM / HTN / RA
ACEI induced Angioedeme
163/172
EGYPT ,, CAIRO 2018
St 1
Haemolytic anaemia with scar for splenectomy
and hepatomegaly
Copd with fibrosis
st 2
Collapse with fits

Hocm aAS cardiac
Less likely epilepsy
St 3
Double valve
Ms vs cp
Hypotonia with no sensory level since 6 years
St 4
Breaking bad news with palliative ttt decision
Astrocytoma
St 5
Hep b with fever abd pain

Sbb
Acromegally with carpal tunnel release with

neuropthy
Pray for me
BRUNI COLLECTIONS OF PACES

EXPERIENCES
BRUNEI BCC
▪️1 - pt came with fall - peripehral neuropathy
▪️2 - young lady with right calf pain - need tro

dvt coz hx of miscarrige n recent long haul
flight.
▪️3- psoriatic arthropathy
▪️4- Vetiligo....present with tirednes; pernicious

anaemia Adrenal insufficiency
▪️5-retinitis pigmentosa....
▪️6-ankylosing spondlytis
▪️7-Thyroid eye disease with cataract )

▪️8-Psoriatic arthropathy with lower limb OA
▪️9-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.
▪️10-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 .
▪️11-psoriasis with bloody diarrhea

lady c/o diarrahea for 1 week, bloody watery
diarrhea. pt 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
>pt with psoriasis arthropathy has hand joint
pain ..on methotrexate and adalmumab .
Concern : she has diarrhea for a month with
weight loss . What could be the cause . Answer :
drug induced . Concomitant Chron's or UC or
coeliac disease . Q:investigations . Examination
: rheumatoid hand .
▪️12-hemoptysis with systematic sclerosis

>Pt has 1 wk haemoptysis.. Has family hist of
TB( her mother) but she didn't meet her for
years. No weight loss . No Sputum production .
No fever. No symptoms of TB or Lung cancer.
Exam : has systemic sclerosis . Chest ..
examiner said clear .. not to examine. Concern :
TB . Lung cancer What other possibilities ?
Answer : all the causes of haemoptysis
including URT SOURCE. Q: investigations
▪️13-chronic LBP for last 10 yrs wjth worsening

stiffness last 2 mths - anklylosing spondylosis
(straight fwd) on bg exclusion of all redflag sx.
▪️14-45 y.o man with T2DM with biocular

blurred vision. - i offered ischaemic related (no
cherry spot, no flame shaped haemorrrhage) vs
diabetic retinopathy (more likely this). however
toward last min of pt blinking i thought i seen
some bony spicule?retinitis pigmentosa.
(excluded any previous panretinal
photocoagulation or any FHX of anyone with
blindnessat early age).
▪️15-young lady known of DM since age of 7 on

insulin and 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
▪️16-young female with transient weakness
▪️17- Middle age male diabetic with chronic

diarrhea
▪️18-The coordinator confused me with other

case. I lost 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.
▪️19-Young lady with hand deformity. She had

pain in 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.
▪️20- elderly man has history of Mi came for

cardio clinic complain of difficulty of walking
they given normal vital
▪️21- 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
▪️22-hx of short period of vertigo , nothing else

, now he is free, asked for d(we meet the guy
outside and he said i have nothing...
▪️23- skin rash , SLE but i thinks there livedo

Reticularis ? don't know
▪️24-65 yrs male with tiredness blurring of

vision O/e papilledema in one eye Optic atrophy
on t other one Dx Foster Kennedy syndrome
with panhypopituitarism
▪️25- 60 yrs male with microscopic hematuria.

O/e Gouty tophi Dx interstitial nephritis vs
asymptomatic kidney stone
After introduction I asked if he can tell more.. he
mentioned he went to t well man clinic for
annual review , did urine analysis and found out
to have blood in urine, repeated with t same
result, so he was referred , but he has no
symptoms no change in urine colour nor pain
and amount is normal. I asked of any medical
condition I should be aware of.. he said NO.. I
asked about Joint pain he said yes for t last 10
yrs in ankle and hand and there is swelling. He
denied any morning stiffness. No skin rash. No
weight changes. I asked about medications , he
replied yes he is taking NSAIDs for a long time. I
started examining t hand : gouty tophi in t
proximal IP joints of right hand and left index
trigger finger. Assessed t function and found a
scar in wrist He mentioned it was due to
removal of lumps . I asked meanwhile about
intake of meats, he mentioned no. Also asked
about smoking, alcohol and family history
which were all negative. T pt had also tophi at
ear pinna. He had two concerns: what is cause
of blood in my urine? Interstitial nephritis due to
NSAIDs Vs asymptomatic kidney stones due to
gout. T other concern: is my joint deformity
reversible?!! Examiners asked about Differential
diagnoses and investigations and management
plan
▪️26- euthyroid with goitre,
▪️27- diabetes insipidus,
▪️28.- Middle age guy with syncope and

palpitation.
Underlying DM and HPT.
▪️29- Acute joint pain more on left knee.

▪️30.-psoriasis which is all over the body with

nail change onciolysis. .. I took history of skin
rash and ask for other eye .joint .bowel .urinary
symptoms all negative .
his body.
Examiner...
involvement.
I got 21/28
▪️31.- neck swelling.

..
I got 21/28
▪️32.-graves disease
▪️33.-ocular MG precipitated by ciprofloxacin
▪️34.-RA patient, came with joint pain over right

knee
▪️35.-Young lady with right calf pain 1 week,

recent travel to India by flight, takes OCP, had 3
miscarriages
Walsall manor trust hospital 11/2/2018
Frist cycle
1-RESPIRATORY :
pulmonary fibrosis fine end inspiratory crackes
not ultered by cough
Qs:finding
DD
cause of fibrosis
Investigations
#other candidates get lobectomy for lung
cancer
ABDOMEN :
CLD liver span 8 cm spider navei no other signs
Qs:
finding ?liver span ?if you palpate liver from
below what could be the edge like ? what signs
un hand you looked for?
did you find spleen ?did you find ascites ?show
me the spider navei ?how are you sure of it ?
(Press faint then refill). Cause of CLD ?
2- St 2
Diabetic man recurrent collapse several times
during last 3 months found collapse this
morning by his wife has AF retinopathy
nephropathy neuropathy
Concern what is the cause ?is he able to drive ?
Qs: cause ?DD? what other features of
autonomic neuropathy pt has ? What features of
Addison pt.has ?investigations?investigations
for addision ?how you manage his concerns ?
3- CARDIOLOGY :middle age gentleman present
with SOB on examination his nails look strange
but I check for clubbing there was angle apart
from heart sounds were very faint and weak I
find it difficult to hear any thing I mention that
and said normal examination
Qs:findings? Normal ? Apex where ? Cause of
SOB cardiac and others ? Investigations ? Did
you notice any thing else about the nails ?
NEUROLOGY :examin LL hemiplegia
Qs:finding ?DD ? investigations?
St 4
Speak to the daughter of Mrs.Jeniffer bell 6
months ago she had cough went to GP gave her
antibiotics did not improved went back found
massive plural effusion after CT and pleural tap
adenocarcinoma spread to the lung liver bone
adrenal gland lymph nodes oncologist decide
chemotherapy withiut known the primary
unfortunately patient died before chemo 2 days
ago when collecting the death certificate
daugher want to talk to you
Her Qs why no body inform me it is definitely
cancer why not informed she is severely ill i just
called after she died did she know she was
dining did she die in pain what was the primary
site of cancer would she lived longer if started
chemo why gp gave her antibiotics
Examiner Qs.how dose the daugher feel ?how

did you react to her feeling ? What do you think
the problem was how are you going to deal with
that ? If you found there was a communication
problem are you going to tell the daughter?
what about the gp and how he treat her ? .
St. 5 man present with SOB 2 years ago was

admitted for one week Stop smoking when he
notice swelling in his body I did analysis for the
sob did not get any thing PMH whenever I ask
he said am not sure medication list warfarin anti
hypertensive and all heart failure medications
he ask for how long should i continue these
medications I said it is life long and need follow
up with your doctor when I ask about smoking
he said i stop 20 yrs ago when i get this swelling
when I ask to show me there was multiple
neurofibromas no hx of fits no hearing visual
problems no FHx. no problem with his urine ask
if there is treatment i said not refer for skin
doctor for cosmetics
Qs.
DD l said tuberous sclerosis what other i did not
mention neurofibromatosis
He ask is it familiar ?
What is the cause of sob?
I did not know?
I said I need to do echo because he has AF may
develop heart failure
What respiratory causes could it be may be
fibrosis he ask me any association I didn't know
St. 5 lady present with SOB and chest pain
yesterday analysis sharp staping from chest to
back
ask her about any pmh no medications no what
about your health in the past
Eye surgery lenses dislocation
MARFAN I did the examination
She ask what is it is it a heart attack?
Qs.what is the diagnosis? What you find to say
marfan what other signs you did not check for
for marfan (wrist and thumb signs ) cause of
chest pain ?
After I finish i found cardiology case was

dextrocardia pt has kartagner syndrome 😂
other candidate get metalic MVR
in abdomen they get renal transplant they are
not sure about neuro
Pray for me and wish me luck
Seremban, Malaysia 16/4/18
Station 2
28 years old with left hemiparesis and migraine
and black dots over vision ?
On OCP
Station 4
Speak to son
Father is chronic alcoholic with 3 admissions
with decompensation
Came in this time with similar complaint, not
responding to treatment after 1/52
Kidney is failing, but consultant thinks not a
good candidate for renal replacement not
transplant.
The nurses ask u to talk about resuscitation
status as we’ll
My exam experience 23rd march 2018,
killmernock hospital glasgow.
,The command was to examine a young boy

which had typical turner syndrome, but he was
guy and on examination there was soft p2 with
right parasternal heave and ejection systolic
murmur increasing on the inspiration. Examiner
asked , whats your dignoses? I replied, that
patient has features of turner. He asked what do
you call malr turner? I replied noonan
syndrome. Next, the viva was regarding ejection
systolic murmur.
The second case in station 3 was a young
female. The commad was to examine the vision ,
i found nothing wrong with it but nystegmas
and diplopia which was complex and was in all
directions. The patient had cerebelar sign so i
couldnt examine motor system. I intend that the
dignosesTo be multiple schlerosis.
Nextup my station was Station 5 which was
supposed to be of communication I I was
advipce to talk to son female with pneumonia
,curb 5 not for p intubaion still smoking so ltot
restriction as well ,
Concerns were regarding
Daughter marriage soon she has to go ?
Niv at home ?
How much time in recovery .?
Why not ltot ?
Is she going to die .?
I adressed each got full marks alhamdulilah
The next station was the most imp station in

exam station 5
First case was this patient presented with
headache and tumy pain .
Inside neurofibramatosis
I did all examination and history of relevant
headche
Bp was uncontrolled,headache .was
episodic,and with sweating and anxiety ..
So it was pheo causing headache .
Viva was on pheochromo.
Next case was straight farward systemic

sclerosis .
All finding were quite obvious
I explored dysphagia
Alaram signs
Git questioms.h
Addressed concern question .
Got full marks.
Next was station 1

Respo was staright farward ild
Next was abdomen with pancreatic renal
transplant
Viva was on mass dd in right ilaic fossa
How u manage if this patient come with
abdominal distension.
Last was station 2
Atypical chest pain on background of
hypercholestremia .concern
Adress was i need angigraphy .
D/d
Musculoskeletal
Angina
Cocaine induced pain
Panic attack
Malta 🇲🇹 _ 2018
Station 4
Day 1 :
Outside :
83 years old
Mrs Eric Teracy
Counsel son for her condition and answer his
queries
Details ; written outside
Mrs Teracy has been admitted with urinary

sepsis twice in ur ward in 1 month . This time
she has impaired renal functions. Urea is 15
mmol and creatinine is 220u mol and she is
confused .
After admission she was started on iV fluids and
IV antibiotics and nursing staff has informed u
that she is improving after this . And also she is
less agitated as compared to admission. She
has background history of dementia , and
consultant has diagnosed delirium this time .
During course of admission, unfortunately she
Mrs Teracy was admitted 1 month back with UTI

and delirium and after recovered fully , she was
discharged home .
OCCUPATIONALHealth team and visited her
home for necessary arrangements .
Kindly see Mr. John , son of Mrs Eric to explain

then him latest condition & management .
Inside ;
Greet
Check identity
NOK
Introduce
Role
Agenda
Anyone with u
Notes taking but would be listening to u
attentively
&
Open Question : ICE

Idea :

I live at 1 hour drive from my mother house ,
and I Visit her when ever I get a chance.
I know for last some days , she was not drinking
water 💦 as much as she should & This time she
has presented with confusion and was agitated .
Thank u very much indeed for sharing this

information with us , I appreciate that.
And I am sorry that ur mother is ILL and u look
really worried for her health.
Actually she was agitated when she came in ER
, we did some tests which showed that she has
infection in water works and also her kidney are
not functioning proper. Due to this ,the waste
products which are excreted from body by
kidneys have accumulated in her body .
Also she is elderly
She has dementia
So all these things have lead to a condition
which we call as “” Delirium””
No dr ?
Her Age
Dementia
And
After admission ;
Our team , my consultant and all nursing staff
taking very good care of her .
&
She was given fluids in her blood channels and
started antibiotics and she improved and she is
less agitated at the moment .

And
And we will keep u informed about her
condition.
Bring some familiar stuff from home , of her
choice , other hobbies she has , Which will help
her condition.
Thank u dr
That u explain me all details and u are taking
care of my mother
Can I bring books 📚 for her as she likes reading

and she like knitting .
Yes
Sure

This condition.
Surrogate : Dr , in corridor I met a nurse , she

told me that my mother doesn’t like hospital
food
At the moment , ur mother is being given fluids

and she is confused
Once she improve more and
she demands food I will check with nurses
about her choice of food & then
Thank u dr .
As
That may be the reason that she is admitted
again so early
Actually
Before discharge ur mother was seen by all
teams responsible for ur mother care
My consultant
And
All other team members gave their input in
decision and occupational health department
made necessary arrangements for her at home
before she go home , only then she was sent
home &
discharge .
So i assure u that we never discharge any
patient until And unless seen by consultant and
all
manage at home .
Thank u dr .
Mr John
What’s that dr ?
Actually
And
So
Heal we will do all necessary precautions and
also to prevent it getting infected
And
If needed specialist dr in this field can also see
patient .
But
I assure u we will do our best to prevent it on
other parts of body and treat this sore with best
possible care . I have personally talked to my
head nurse , and she will do all necessary
things .

circumstances ?

She was doing good
But I am worried u know as she is admitted
twice this month

information
We can arrange for social services if she agrees
but we will talk to her about it once Her infection
settles down .
Thank u dr

But
Rather he started to tell everything what I told
him ( I counted it as understanding )
I thanked him
&
Any other questions
He said
No dr
But
Listen Mr John
U can google it
And
I am writing for you spellings of “” DELIRIUM “”
the condition your mother has
Or “” confusion”” u write any one ☝️ in this

website , u will get all information about ur
mother’s condition
What it is ?
What causes it ?
And
Another website is
Any one u can use

And
questions
Thank you dr
And
U can contact us anytime to know about ur
mother or call for any queries.
Thank u
Mr John
I appreciate that
Thanks dr
Have a good day .
Summarize ur case:
1st question
🇲🇹What’s name of specialist nurse who takes

care of heel unlers ?
I forgot sir but i know, let me re call ——————
———————- he told Then ( honestly I heard 1
st time , it’s called tissue viability nurse )
🇲🇹Who decide discharge consultant ?

🇲🇹Who will u Involve in Patient care ?

I said team of dr .
🇲🇹What u call it
🇲🇹Who are members in this team

Count 5-6 ?

He asked and explained to me some 1 word
question answers
Bell 🛎 &
I came out
Station 5 malta 🇲🇹 day 2 mornimg

Part 1:
Outside :
70 years male
Shortness of breath 6 months
BP 150/90
Normal pulse 80/ min
RR 18 per min
Shortness of breath
Increased on exertion while taking his dog out
for mornimg walk and also going upstairs
Started gradually
Progressively increasing
Improved with rest
Aggravated with exertion
Not while sitting
Not on lying flat
Not during sleep
But
Using 2 pillows at night
Any Chest pain : not exactly pain but chest

tightness when I have shortness of breath in
centre of chest which improve on rest
No cough
No phlegm
No wheeze
Never coughed up blood
No leg swelling
No ankle swelling
No palpitations
Past history ;
HTN
Acid reflux
No admission in past
No surgeries
Medication
Taking omeprazole and antacid solution and
paracetamol for pain PRN and perimdopril 4 mg
oD
No allergies to drug or anything Else

No smoking
Alcohol 🍺: socially
Travel : 6 months back went to Ceclia but
shortness of breath and chest tightness was
same & no change in Symptoms while abroad
Job : retired teacher 👩🏫

Hobbies : spray painting
How affecting life : is concerned about it & what

s cause ?
My wife says it’s cuz of spray paintings
Is it because of spray painting ?
Same as concern !
Exam : normal except BP 150/90

Pulse good volume
Chest clear
CVS : Normal / diastolic murmur ( not sure )
faint flow murmur at aortic 2 area ( old age or
uncollected HTN )
Adresss concern as :
After listening to ur history and examining u , I
think it’s not because of spray painting or not
cuz of lungs . It’s seems as heart problem which
can be due to blood channels narrowing or a
valve of heart isn’t functioning proper
We will do some blood tests and ECG and heart
scan once results are back we will have a chat
again and we will discuss what s solution .
Any other concerns
Any Questions
No
Examiners :
Present ur findings
+ ve points in history as above pointing away
from Respiratory problem
HTN uncontrolled long standing
Clear lungs
Pulse good volume
Heart : Normal and a murmur on LSE aortic area
To confirm need to do ECG Echo
DD : AR / IHD
What may be causes of AR in this patient ?
Old age
HTN uncontrolled
Any thing else ?
IHD
Examiner happy : Yes yes
Other causes ;
Marfan syndrome
And infective endocarditis
But no features in this patient .
How will u investigate ;

ECG
CXR
Echo
Troponin to see any current silent ischemia
Angiography for IHD
and bell rang
( not sure of clinical findings )

As no peripheral signs of AR but a faint murmur
was there on leaning patient forward only
Allah knows best
Station 5
Part 2 malta 🇲🇹
Day 2 mornimg
63 years male
6 months history of abdominal pain after eating
Vitals Normal
Inside ;
Well trained surrogate
Pain abdomen
Severe 7/10
In centre of tummy
Going to my back
Fear of pain
Not eating much now
Weight loss 5 kg
Some Nausea
No Vomiting
No mouth sores
Past :
IHD
4 stents in 2008
CABG 2010
Medication
Atorvastatin 40 HS
Clopidogrel 75 oD
Paracetamol prn
Antacid syrup
Any herbal No
Any painkillers No
Family history ;
Smoking nil
Alcohol 🍺: daily 1 bottle of whisky � on

weekend more
Ur mood : good
Drugs : never
Anything else : I think it’s coz of alcohol 🍺

should I stop 🛑 alcohol

Exam :
Mid chest Scar
Left arm scar
I asked y this scar
Abdomen; normal
Ask about Idea : again question of alcohol

misuse ?
After taking to u
I think. Too much alcohol is causing
inflammation in pancreas and ur pain after
meals and improved on bending forward points
towards pancreas
Another point is
They can have also narrowing of blood channel
in tummy (!do u have any pain while walking
which improve on resting ; no )
Okie
So
We will do some blood tests and scans and look
at pancreas and blood channels
We will discuss with u and explain u what to do
further
Meanwhile
U stop alcohol
Is that okie
Yes
Any other questions
Any concerns
No
Thank u
Examiners ;
Findings :
Normal tummy
DD
Mesenteric ischemia
Examimer ( 🙄)
Okie
Why u think mesenteric
Coz of history of IHD and risk factors
cholesterol for atherosclerosis

Help
Others
Examimer was telling investigations and
CANDIADTE to tell. What u will see
USG for gall Stones and calcification and

pancreas inflammation
collection

DM
Malabsorption
Steatorrhoea
Bell rang
Clinical :
Station 1
ILD with SS
Pneumonectomy lobectomy
Hepatospleenomegaly DD
Dupytren s contracture only
Station 3 :
MR only
CABG with MR A fib
Pure motor Spastic paraplegic DD hereditary
Parkinson’s disease
History station:
Recurrent Lip swelling
5 episodes in a 60 years lady
DM / HTN / RA
ACEI induced Angioedeme
163/172
My exam experience :
18/3/18, Malta
🔹station 1:
🔻Chest: examine this lady with SOB:

pt with clubbing, raynauds, gottron papules,
helitrope rash, telengectasia and puckering of
mouth.... in chest there were fine end inspiratory
crepts that did not change on coughing
Diagnosis: ILD sec to mixed connective tissue
disease
Examiner Questions:
What are your findings
How to investigate this pt
How you will manage this pt
Got 20/20
🔻Abdomen:
Examine this lady with abdominal pain
Young lady with pallor and moderate
spleenomegaly
Diagnosis:
Lymphoproliferative/ myeloproliferative dis
Examiner Questions:
How you will investigate this pt
Any Examples of lymphoproliferative disorders
What to look for in blood film
Indications of spleenectomy
Vaccination needed after spleenectomy
Got 20/20
🔹station 2
Ramipril induced angioedema
Got 20/20
🔹station 3:
🔻cardio:
Examine this lady who presented with SOB
Middle aged lady with tapping, undisplaced
apex beat, loud P2, pansystolic murmur in the
mitral area radiating to axilla...
Diagnosis: MR
Examiner questions:
What are your findings?
How you will investigate this pt?
Did you hear any other murmur?
Criteria to assess severity?
How you will manage this pt?
What advice you will give to this pt >>>before
any dental procedure
I think i missed another murmur...
Got 16/20
🔻Neuro
Examine lower limb
It was spastic paraparesis with intact sensation
and no cerebellar signs
Examiner questions:
What are your d/d>> hereditary spastic
paraparesis, MS, cerebral palsy
Viva about hereditary spastic paraparesis
How you will manage this pt plus counseling
Got 20/20
🔹station 4:
Talk to son of Mrs Greck, 70 yrs old lady, living
alone at home, admitted 2 days back with
delerium and UTI, started on iv fluids and
antibiotics, responding well, initially the RFTs
were derranged with raised urea and creatinine
but improving now... nurses have noticed that
she is less agitated now... pt was admitted 2
months back with similar complaints made full
recovery and discharged.... during this
admission she also developed a black heel
ulcer...
Assume that you have permission of mrs greck
to talk to her son about her condition....
Very nice surrogate....
Concerns:
1:how is her condition.....
2:My mother was diagnosed with early
dementia.... i think she is not drinking enough
water .... is this the reason she is getting this
infection......
3: i am worried because she lives alone... if she
doesn’t take care of her self she can develop
this infection again....
4: is this negligence of nurses that she
developed black heel ulcer
5: one of the nurses told her that she might
need to be admitted in geriatric care.... she
doesn’t want that.... what can be done for her...
6: what you will do for this black heel ulcer...
Examiner questions:
Could you please summarize your discussion ?
What ethics were involved ?
The nurses for taking care of such ulcers....
what are they called? ...tissue viability nurse.
How you will explain the prognosis of this pt to
his son...
Got 16/16
🔹station 5
🔻BCC1
Outside scenario: 65 yrs old male with SOB,
hypertensive ....
On history: exertional SOB with some chest
discomfort improves with rest...
No orth
I did not pick any findings on examination
Examiner questions
What are your findings? 🙁

What are your d/d
Got 13/28
🔻BCC2
50 yrs old male, with abdominal pain 1-2 hrs
after taking food, improves on leaning forward,
alcoholic....
Concern:,is it because of my drinking habits
Examiner questions
What is your diagnosis: alcoholic pancreatitis
Got 27/28
Alhamdulillah passed with score of 152/172
✅ Special thanks to Dr Imran Baber for his

efforts and hardwork... I attended his fast paces
course twice before appearing in paces.... Also i
did online mocks with him.... and it helped me
alot.....his notes are more than enough to pass
paces....
passed my PACES exam in 1st diet in 2018
from Chennai, India with 159/172. My cases are
as follows:
Station 1: Respiratory.... consolidation in left
lung in patient of COPD. Question was about TB
and anti TB drugs. Got 20.
Abdomen....Hug hepatomegaly in ESRD patient
on MHD. Question was about CLD. Got 20.
Station 2: Young female known case of IBS with
history suggestive of malabsorption. D/D was
Coeliac disease, pancreatic insufficiency,
Giardiasis. Question was about investigation,
management. Got 20.
Station 3: CVS.... Missed it, I said MS, got 13.
Nervous system.... Left hemiparesis. Examine

both upper and lower limb, precordium, pulse,
carotids. Got 20.
Station 4: Penicillin induced Steven Jhonson
syndrome in young female after NVD. talk with
patient's husband. I practiced it before my exam
with my colleagues and got 16
Station 5: Recurrent LOC in Diabetic patient: I
said D/D: cardiac syncope, hypoglycemia,
vasovagal syncope. Dummy case. Got 28.
Another one is Visual disturbance in diabetic
patient: it was diabetic retinopathy. I forgot to
tell cataract as differential as media was
hazy.Got 22.
Got 22.
Alhamdullillah I passed, thanks everyone in this
group for the support. Take care.
My experience today 30-3-18 in Adan hospital

Kuwait
Station1 : chest case was right lobectomy + lt
bronchiectasis ... deviated trachea ?? ...
examiner was asking about causes of
lobectomy and interstitial lung disease ... was it
the case ??
Abdominal : CLD , cirrhotic liver- jaundice-
splenomegaly ... I told hepatomegally but the
examiner asked me to repeat hepatic
examination as it was clear shrunken liver by
percussion ... discussion was about causes and
investigations and management
St. 2 : 52 years old lady - fever of unknown
cause - wt less- lymphadenopathy- dry cough-
fatigue : I said fever for unknown and gave dd of
sarcoidosis and blood malignancy + hidden
infection
St.3: was the worst for me
Cardio patient I suspected ms+ AR examiner
was attacking and asked me about the apical
caracter and site of it also I was not shoure
about the AF as pt was little bet bradycardic .... i
think it was double aorta ??
Neuro case was pt has loss of coordination and
ataxic gate and diminished all reflexes and
hypotonia ..... dd I told ms and cerebellar
infarction also I told him about LMNL could be
due to associated neuropathy but he was not
happy about this ... discussion was about MS
Station 4 : explain for a lady that her has and
has septic meningitis ... discussion was about
prophylaxis and examiner also was in happy as
I about the complications and because I told her
his condition is serious but I did not till her he
will die
Station 5 : case 1 50 years old lady with
Recurrent PE , recurrent miscarage and on
steroid ... normal examination ... no history of
any joint pain ... my diagnosis was
antiphospholipid syndrome
2nd case 30 years. DM with blurred vision in one
eye fundoscopy showed optic atrophy ...
discussion about causes embolus and hge
treatment she wanted to here good control of
DM+ ophthalmology referral
Good luck for all friends and colleagues ❤️
passed my exam in Chennai no diet 1 2018

..159/172 my exam experience as follow :
Start with
station 2 :
young age female with type one DM present.
With weight loss and tiredness
Examiner ask about DDx ..
DDx : Hyperthyroid ism , Addison disease ,
celiac disease got 20/20 .
Station3 :
Cardiology . Mitral valve replacement .. ask
about causes of sob in this patient ... got 20/20
Neurology : Left sided hemiplegia .. ask
diagnosis and management got 20/20
Station 4:
Worst station : talk to son about his father
condition present last week with SBP and
hepatic encephalopathy got 7/16
Station 5 :
BCC1 .. neck mass .. ask about DDx and
BCC2.. fever for 1 month duration .. Ask about
Diagnosis and investigations got 24/28
Station 1 :
Respiratory: Old pulmonary TB .. ask about DDX
Abdomen : ESKD with Renal transplant .....
Asked about DDX and management got 20/20
Khartoum
soba
7/4/2018 cycle 3
station 1bronechtasis
APCKD
staion2 sob contact with parrot for 6 month
station3 periphral sensory motor neuroapthy
p .htn
station 4
pt on warfain developed strock
station 5 heart failure
syncope
Sudan
Khartoum 8/4/2018
Cycle 1
Respiratory. Lt lobectomy
Abd :transplanted kidney
St 2:uncontrolled DM/depression
St:3AR??
Peripheral neuropathy edorsal column affection
st 4:young lady developed Steven Johnson
syndrome after receiving penicillin for treatment
of streptococcal vaginal infection. She
deteriorate d and developed liver failure and
renal failure for icu admission and may
necesceiate ventilation. Talk to her husband.
St5:1:history of chronic diarrhea. Inside young
man e scar and evidence of steroid use
IBD
2/recurrent loss of conciousness
Khartoum 3rd day 2nd cycle
St4
IBS angry pt same sinario
St5
1.pt complain of head headache and itchy hand
and feet . It was polycythemia in Pt with renal
mass
2. Dysphagia in young lady

It was S'S
St 1
Abd : massive ascites with cirrhotic liver
And nephrotic as a D
Chest rt side lung fibrosis (TB)
ST2
Pt presesnt with hx of collapse once
for dd
There is hx of lymphoma ttt
Long standing cough TB
DD b/w cardiac and neural
Mostly 1st convulsion
St3
Cardiovascular v. I'll pt seem just brought from
surgery unit newly admitted and not helping
I said MR + AF and the examiner help me to add
AS
Neuro
Flaccid para. With
level stocking distribution
I present the case as UMNL because planter
were upper
Other said LMN
Examiners are not that toxic as my colleagues

said
Regard Sudan centre
Really time pass fast

And I don't know how I did
Pray for me
Thanks for all
passed PACES Exam from Colombo, Sri Lanka.
I will update my experience here.
1. I started from the communication station [2].

It was about a patient with RCC and terminal
heart failure. It was mainly on discussion further
care of the patient and breaking bad news. I
explained details slowly and never interrupted
the client. Examiners asked if the patient will
benefit from chemo. I said RCC is mostly chemo
resistant and with heart failure it may be
contraindicated and biologics may have a place
with optimum palliative care. [16/16]
2. Station [3] CVS case was mixed aortic valve

disease with dominant AR. [20/20]
CNS: Upper limbs with peripheral motor
sensory neuropathy. They asked about causes
and how to investigate [20/20]
3. Station [4] was taking history from a patient
with diarrhea and family history of bowel
cancer. [18/20]
4. Station [5] BCC 1: Haemochromatosis patient

with liver signs. [23/28]
BCC 2: Graves disease. I forgot family history
[23/28]
5. Station [1]: RS patient with widespread B/L

wheezing and clubbing. It is bronchiectasis. But
I told COPD as the first diagnosis due to
prominent wheezing. [15/20]
Abdomen: This was a difficult case. Extended

left subcostal scar and scar at RIF. No masses
were palpable except left kidney. Which could
be normal in a thin person. Functioning AV
fistula was present. No signs of CKD. It was
probably renal transplant due to PCKD and the
right kidney removed. [10/20].
If you approach systematically you can easily

pass. Thanks for I passed PACES Exam from
Colombo, Sri Lanka. I will update my experience
here.
1. I started from the communication station [2].
It was about a patient with RCC and terminal
heart failure. It was mainly on discussion further
care of the patient and breaking bad news. I
explained details slowly and never interrupted
the client. Examiners asked if the patient will
benefit from chemo. I said RCC is mostly chemo
resistant and with heart failure it may be
contraindicated and biologics may have a place
with optimum palliative care. [16/16]
2. Station [3] CVS case was mixed aortic valve

disease with dominant AR. [20/20]
CNS: Upper limbs with peripheral motor
sensory neuropathy. They asked about causes
and how to investigate [20/20]
3. Station [4] was taking history from a patient

with diarrhea and family history of bowel
cancer. [18/20]
4. Station [5] BCC 1: Haemochromatosis patient

with liver signs. [23/28]
BCC 2: Graves disease. I forgot family history
[23/28]
5. Station [1]: RS patient with widespread B/L
wheezing and clubbing. It is bronchiectasis. But
I told COPD as the first diagnosis due to
prominent wheezing. [15/20]
Abdomen: This was a difficult case. Extended

left subcostal scar and scar at RIF. No masses
were palpable except left kidney. Which could
be normal in a thin person. Functioning AV
fistula was present. No signs of CKD. It was
probably renal transplant due to PCKD and the
right kidney removed. [10/20].
If you approach systematically you can easily

pass. Thanks for all who shared experiences
and Dr AME. If you have specific questions. Let
me know. I used Metha MRCP book, one PDF for
ethics, PASS test 208 videos. Believe me I did
not see a single patient for the purpose of the
exam and did not practice with friends. I
attended one day course and a mock. However,
I advise to see enough patients if you have not
seen enough in the previous years.
Oman 7/4/3rd cycle
Bcc1dry eye
Young female e charcot arthopathy
Ph : heart attach on warfarin
Dignosis sjogrin syndrom 2ndry sle,/apl
Bcc2
See this lady bcs co of upper abd pain recently
also had recurrent finger 6months
Dignosis crest syndrom
Ask about dd of abd pain in ss
Eosphageal dismotality and gastritis 2dry to
NSAID
Chest
Upper lobe lopectomy 2dry to bronchactesis
In yong male
One dd kartagner syndrom
Abd
Renal transplant
Cns
Chrcot mari tooth
Cvs
I think
Doble valve
St2
Collapse in konw lady with dm 1
Complecated by retinopathy neropathy
nephropathy
Also AF on warfarin puse 58
Also hth
Fh of heart attach in father 45
Dissection about dd
St4
Pt her consultant desid dignose IBS based on
normal blood test and coelic test and
colonscopy test
He dicide to start amitriptyline as het anti
spasmodic not work
She has sress in her life as her son hyper active
deficit
She ask me lneed to do CT
And repeated sevseral time
And the examiner ask is ther any harm to do ct
Good luk for all
Khartoum 7th april
Cycle 1
Stn 1 abd APKD
Chest ILD
Stn 2 IBS with F.H of colonic cancer.
Stn 3 cvs mixed aortic and mitral valve ds.
Stn 4 pt suspected SAH ct brain normal need

L.P ask for self discharge.
Stn 5 transient loss of vission
Skin rash with high BP it was NF

passed my exam from India Bangalore Center
(15.3.2018)
Let me share my exam experience.
Passed with overall marks 156/172.
Start with bcc

Multiple jt pain and back pain in 62 yrs old man .
Previous history of psoriasis present.
Inside.. normal surrogate. Jt pain including DIP.
Dx.. psoriatic arthropathy(20/28)
Another bcc
Outside.. progressive SOB and dry cough in
50yrs old man
Inside.. progressive SOB exertion and rest and
dry cough started last 2 mths ago. Can lie flat
but need 2 pillows to sleep. Underlying RA and
taking methotrexate. Smoking history present.
Examination.. normal
I gave SOB due to methotrexate and RA
examiner told me how about with smoking..i
said copd.
Then ask invx (28/28)
Resp... cough with expectoration

Couldn’t elicit any signs apart from prolonged
expiration and expiratory wheeze. I heard
wheeze before examination.
Ask invx, mgt , chronic mgt for COPD and
LTOT.(18/20)
Abd...
Hearing aid present, AVF present which is
function with thrill and bruit
Massive ascities, flank fullness, everted
umbilicus, pedal oedema present.
Cannot elicit any hepatomegaly or
splenomegaly.
I told that i didn’t find apart from ascities and
examiner said i appreciate u cannot get any
organomegaly bcos of massive ascities.
But she lead me what organomegaly do u
expect... i said kidney or liver. She told that lets
assume liver. How do u correlate?
I said ADPKD with vol overload
Dialysis related infectious hepatitis.
She said me invx about VH and times up for
mgt.20/20)
History...
know type 1 DM pt with recurrent hypo attack
within 6 months. Wt loss 3-4kg. Tiredness.
Retinopathy and nephropathy present. Hb ..
normal but low side, Cr raised, eGFR.. 38,
HBA1C raised.
Inside... recurrent hypo attack glucose at the
attack 2mmol/L, need to take sweets, need
assistant by wife. Wt loss but appetite good,
tired and weak. No hyper pigmentation, no n&v,
no temi pain, no postural hypotension.
Bloating present. GP said anemia present but
no symptoms suggestive of anemia.
No lipodystrophy, no malabsorption symptom,
no autonomic neuropathy symptoms, no
exercise, no diet change, no water work
symptoms, no liver disease symptoms.
Smoking and alcohol, driving stopped.
Hypertension present taking ramipril.
Surrogate deny eye problem and kidney
problem.
I gave ddx.. hypoglycemia in know type 1 DM
patient
Addison, autonomic neuropathy , CKD.
Examiner asked addison invx.
How will u know his CKD is because of DM.. i
said check URE and look for proteinuria.
What advice do u want to give.(20/20)
Neuro
Complaint... pt has weakness of the limbs.
Examine motor system.
Found that flexor and dystonic posturing in lt
UL. Power 0. Lower limb.. extensor posturing
and tone increased, ankle jerk increased,
extensor planter.
Lt sided facial weakness UMN type.
Dx.. Lt sided hemiplegia
Ex Q: causes.
How will u differentiate vascular cause and
SOL?
Acute mgt of stroke and chronic mgt for
secondary prevention.(20/20)
Cvs
Complaint... SOB
Examination... AF present, click heard.
On examination click coincide with 1st ht
sound.
I miss pulmonary hypertension.
I also heard murmur but dont know what
murmur is and didnt mention. Pt has both LL
varicose vein.
Ex asked: dx, invx and mgt.(14/20)
Communication
32 yrs old lady come with excruciating
headache also spread to back of head, neck
stiffness present, vomitting present at
admission. CT done.. normal. Consult with
neuro surgeon and arrange to do LP after
knowing CT scan normal to exclue small SAH.
Pt want do discharge against medical advice
and want to go back home. She is visiting from
USA.
Task: explain condition CT normal and need to
do LP to exclude other causes of headache.
Concern: want to discharge. CT normal.No
family here and no one can help here.
Can she fly back ?
Want to know how to do LP. ( task doesnt
mention for explain LP but i explain a bit bcos
the pt want to know.)
She afraid of complication.
What will happen if LP result positive and
negative.(16/16)
Oman
5/4/2018
Station ⚄
Thyroid
Psoriatic arthropathy
Station ⚃
Malignant melanoma
Station ⚂
AR &
spastic paraparesis
Station 2 ⚁
Type 1dm came with wt loss and fatigue
Station 1 ⚀
CHR. LIVER DISEASE
Bronchiectasis
Alhamdulillah, I cleared my PACES in my first
attempt from London centre. I attended the Fast
PACES course in November 2017.I will second
what Imran Babar always mentioned during the
course, keep it simple, do not go deep. The
exam is not tough, they look for basics. Don't
go for deep stuff. It's basic knowledge
assessment. They don't want specialists or
consultant level.. It's important to keep it simple
My first case was Station 1 - Abdomen - Renal
transplant patient, simple, comment on scar and
immunosuppressive stigmata
Second was Chest - VATS scar, with dullness
on the same side base..
Station 2 - history of collapse in T1DM, with
Autonomic Neuropathy
Station 3 - CVS - AVR with CABG
CNS - Rt hemiplegia with hemiplegic gait and
scar on scalp
Station 4 - Hepatic Encephalopathy with
hepatorenal syndrome, DNR discussion with
son
Station 5 - Acromegaly and Bilateral ptosis
The examiners are literally trying to find, what
we know not to highlight what we don't know.
The issue with candidates, they tend to
complicate simple stuff. Don't go around
reading big textbooks. The notes from the
course is more than sufficient.
Don't hesitate to apply for UK, London centre

The environment they create is not at all
intimidating.
Please, first thing that is important is have faith

in your abilities. Use your stress and anxiety to
bring out the best in you. Don't let negativity of
the people around you to bring you down..
Best of luck everyone.
Alhamdullilah I pass paces in diet 2 2018 from

EGYPT.. and here is my detailed experience..
✅St 1 abdomen case was a young male with
✅Chest Was male pt with obstructive lung

✅St 2 sarcoidosis (I totally missed the case ) pt

✅St 3 CVS middle age very thin lady with raised

? I got 20
✅CNS male pt with lt side uncrossed hemplegia

✅St 4 young male pt college students with UC

✅St 5.a lady with neck pain ..

✅BCC 2 Young pt diagnosed 3mth ago with

T1DM recently he has skin lesions.. inside I
asked him to show me the lesions it was vitiligo
about 3-4 patches only in his legs .. then I asked
few questions about it.. then screening
questions for other autoimmune diseases and
about his diabetes.. it was controlled .. I saw his
eyes for the paler and palpate his abdomen ..
concern.. what is this.. ? I explain and reassure
him but we may need to do some tests to
exclude other associations .. discussion about
other autoimmune diseases When I mentioned
score 149
appeared in 2018/02 dubai...

✅ BCC1 command was young male with

bilateral eye swelling... when i entered inside ,
patient was of graves ophthalmopathy. i missed
scar marks on eye lids suggestive of previous
surgery...
✅ BCC2 was transient vision loss in right eye ..

no positive findings. i gave differentials of TIA
vs ameurosis fugax..
✅Abdomen - transplanted kidney ..
✅ Resp- right lower lobe dullness with

decreased vocal resonance.
✅ history station was old lady with history of

fall one week back
✅ Cardio - aortic stenosis with AR .
✅ Neuro - bilateral CTS with AV fistula.
✅ Station 4 - poorly controlled crohns disease ..

steroids
Egypt diet 2
9/5/2018, cycle 2
✅Station 1: chest pneumonectomy 20/20

Abdomen: hepatomegaly with jaundice for
differential 16/20
✅Station 2 : 38 years old female came recently

from Kenya referred with history of fever and
bloody diarrhoea, inside 38 yrs old travelled to
Kenya 3 weeks ago came back 3 days ago,
started to have bloody diarrhoea upon return,
no mucous, more than 10 times/day, has
crampy abdominal pain that's all over more
periumbilucal, has nausea or vomiting, no
jaundice, also has fever, high grade though not
measured, associated with chills, wt loss of 1-2
kg, history of eating from outside food, no other
sick contact,
Was prescribed loperamide by GP before travel
but didn't take
No joint pain or skin rash, no mouth ulcers,
First time to have such symptoms
Systemic review negative
Past history negative
Drug history only taking OCPs
Family history positive for crohns disease in
uncle
Social:works as teacher, affected by frequent
diarrhoea, non smoker, non alcohol consumer
Concerns: what do is have is it crohns like my
uncle?
I answered from what you have told me looks
more of bug infection related to your travel and
eating from outside , crohns disease is still a
possibility, after our interview I'll examine you
fully then we will have to send for labs including
liver and kidney function and checking salts,
also we will send a stool sample for analysis to
look for evidence of any bug infection , if your
symptoms didn't improve we may need to do
camera test to look for crohns disease, checked
understanding and time over
Examiner questions summarize ur case, as
above
DD invective diarrhoea, crohns disease
Hw are you going to investigate her CBC, renal
and liver function including electrolytes, stool
analysis and culture
Will you do colonoscopy I said if there was
evidence of infection and she improved then no
colonoscopy
Then he asked whether to admit her or know, I
said if clinically dehydrated then for admission
other wise will wait for basic labs which usually
takes 1 hr 20/20
✅Station 3 CVS, I said AR which is obviously

wrong 10/20
CNS examine motor system, it was peripheral
motor neuropathy, I gave GBS as first DD
discussion was around it 20/20
✅Station 4 from outside talk to the son, his

father who's 80 yrs old has Parkinson's disease
on medications, HTN on medication, A fib on
warfarin, he was admitted 2 days ago with fall,
upon admission INR was 4.7 and warfarin
stopped case of fall was postural hypotension
and medications stopped
Next day he had a fall CT head ruled out
hemorrhage, next day he was for discharge but
early morning he collapsed and had cardiac
arrest CPR was unsuccessful and he died, no
obvious cause was found
BBN as usual (examiner said I did it good 😅)

Said was angry and frustrated abt what
happened and why he died what's the cause
Explained everything and the option of
postmortem exam which he didn't want
Summary and checked understanding
Examiner Q; summary, then discussion was abt
coroner referral and postmortem exam which I
had no idea abt , examiner told me that any pt
who died unexpectedly within 24 hrs of
admission shud b referred to coroner for
postmortem exam, they were generous and
gave me 12/16
✅BCC 1 neck and buttock pain in young lady

inside she has depression, funny thing I forgot
the term fibromyalgia, 😂
I explained everything without the name, I told
the examiner I forgot the name they were also
generous and gave me 26/28 😊
✅BCC 2 fever in young gentleman , inside he

has HIV diagnosed 1 yr ago, 10 yrs ago he had
RTA which required multiple Operations and
blood transfusions
Fever with cough and hemoptysis and wt loss, it
was TB scored 26/28
Station 1...hepatosplenomegaly with jaundice in

a female...thalacemia
Hyper resonance on percusion obliterated liver
dullness....copd
✅ Station 2..hx was headache with glycosuria

with polyuria with rise in bp. Father had died in
young age for DD...pheochromocytoma.MEN2
✅Station 3... cardio ejection systolic at aortic

and pansystolic at apex murmurs with vein
harvest scar in leg.with sob and crackles in
chest..
✅Neuro was F.A in a young female
✅Station 4...talk to daughter about her father

admitted with severe pneumonia now better
seen by consultant but he has hx of parkinson
disease she handed over the medications for
parkinson disease to doctor in the ER which
was not given to her father and now his
parkinsonian symptoms are worst. Apologies. I
will confirm what went wrong.ur father is in
better condition now .out of danger.we will
consult brain doctor to day. Incedent
report.cosultant knows about it.we will do the
root cause analysis and we will inform you
about its out come
✅ bcc 1 hemiblasmus post cva and hx of dm n

htn.
✅ bcc 2 Hypokalemic periodic paralysis.

Malaysia diet 1/2018 on 15th April
Station-4
young lady business woman from America,
presented with headache and meningism, SAH
suspected, CT normal,
discussion and consent for LP, then discussion
for flight travel
(I got 13/16)
Station-5.1
Acromegaly man, post-transsphenoidal surgery,
presented again with headache x 6 months, no
features of local recurrence on examination.
I said ?post-op changes, ?tumour recurrence
then investigations, management
(I got 26/28)
Station-5.2
young lady with DM 1 on insulin, c/o blurred
vision.
poor HbA1c control
When I explored, she said blurred vision off &
on, worsening after meal
normal fundoscopy
Dx- osmotic changes of lens
then discussed about investigations and
management
(I got 27/28)
Station-1
Abdo: CML, massive splenomegaly +
hepatomegaly + skin ecchymosis
(I got 20/20)
Respi: Rt. lobectomy due to lung cancer

(I got 20/20)
Station-2
young lady single, underlying DM1 with
tiredness and weight loss for poor glucose
control, because of non-compliance insulin,
broke up with her boyfriend
urinary frequency and menstrual irregularity
also noted
my D/Dx - poor DM control, hyperthyroid,
adrenal failure, depression
then discussed for investigations
(I got 19/20)
Station-3
CVS: PSM at LSE, but no radiation ?VSD, MR,
(I got 20/20)
Neuro: peripheral sensory motor neuropathy,

worse on Rt. side, sensory intact on left side
Dx- Charcot Marie Tooth
(I got 20/20)
I passed with marks 165/172.

Thanks everyone here for sharing cases,
sharing is caring. All the best for other
candidates-
Oman SQUH 08/04/18 1st carousal
station -1 (abdomen)
1.) middle aged male
case- Right sided renal transplant.
Findings- No Av fistula, there is gum
hyperplasia, no anemia, multiple small scar in
the right upper chest most probably due to
previous central venous catheter, In abdomen
two scar. One right iliac fossa oblique scar,
another in lower left paramedian scar. Below the
right iliac fossa scar, smooth non tender mass
(transplanted kidney), no signs of fluid
overload, no signs of steriod use.
Examiner ques- *Causes of renal failure in this
patient, *Management of post transplant patient.
* Causes of transplant failure. *How to
investigate transplant failure. *What is the
probable cause for left paramedian scar (may be
splenectomy for splenic cyst in ADPKD or scar
for previous transplant failure. - got 19/20
station 1 (Respiratory)
1.) young male
Case- left sided Bronchiectasis (cystic fibrosis)
Findings- no clubbing, signs of hyperinfiltration
of chest present, vesicular with prolong
expiration, not tachypnic, no ronchi, small area
of coarse crepetation on right lower zone which
change in character with cough, trachea central,
crico sternal distance reduced.
Examiner ques- *What is the case. *What are the
positive findings. *Apart from chest examination
have you concentrate on his CVS (I said no).
*What would you like to examine more. (I said I
would like to do urine dipstick for glucose and
examine CVS for dextrocardia). Then examiner
said did you see the apex beat in the right side (I
said no). So what is the case( I said cystic
fibrosis with karetagener's syndrome). Then
asked about causes of Bronchiectasis.
Management of bronchiectasis got- 17/20
station 2 (History)
* 25 years male k/c/o IBS since 6 year, relatively
well with antispasmodic since 6 weeks
worsening of his symptoms. His father recently
diagnosed CA colon 3 months back.
*On history- No alarming red flags for Ca colon,
caeliac, IBD. No significant drug history, no
travel history, recently stressed for his father
news. On asking many of his family member
having cancer.
*patient concern: 1. What is my problem 2. Is it
cancer? 3. What you are going to do for my
problem. (I said your problem is due to a
condition IBS then I explained IBS, it is recently
worsen by your anxiety, nothing in your history
suggestive of cancer. However you meet the
criteria for screening for Ca colon as you have
positive family history. Screening will be in the
form of colonoscopy and genetic test. For your
recent worsening of symptoms we will refer you
to the psychiatry to start anti depressant then
patient asked why anti depressant.
Examiner asked- 1. What did you find in the
history 2.What are the differentials 3.If I asked
you to say only 2 d/d what will you say ( I said
IBS and Ca colon), Examiner said why you put
Ca colon in second number, he don't have any
warning symptoms. (I said he had strong family
history of cancer). Examiner asked about
investigation, also asked about the criteria for
screening of Ca colon- Got 20/20
station 3 (Cardiology)
Case- Dual Valve replacement with MR
Findings- High volume pulse, midline
sternostomy scar. no AF, pansystolic murmur in
the apex radiation to the right axilla, also
function erection systolic murmur in the aortic
are with no radiation to neck 1st and 2nd heart
sound clicky metalic.
Examiner question:- 1.What is the positive
finding 2.Causes for dual valve failure. 3
Management of patient after valve surgery. 4.
Expected INR 5.Advice for patient getting
warfarin
- Got 20/20
station 3 (Neurology)
case- lower limb examination proximal
myopathy-muscular dystrophy
Findings- Healthy young male, muscle bulk
preserved b/l, B/L hypotonia, areflexia, B/L
muscle weakness in lower motor neuron
distribution in the pattern of proximal myopathy,
proximal weaker than distal, adductor weaker
than adbuctor. Extensor weaker than flexor,
coordination intact. All modalities of sensory
intact, B/L planter equivocal. There is a scar
mark in the left thigh most probably previous
muscle biopsy.
Examiner asked-- What is your positive finding,
what is the diagnosis. (I said lower motor
neuron type of weakness in the form of PM-
most probably muscular dystrophy. I would like
to complete my examination by examining gait,
examine the facial muscle and examine the back
for winging of scapula.
Examiner asked--what type of muscular
dystrophy (I said as the patient have good
muscle bulk and also facial muscle looks not
hypoplastic most probably it is Becker)
-What are the other types of MD then
investigation -Got 20/20
station 4 (Communication)
-Husband wants to know about his wife, who is
recently delivered a baby boy. She was found to
have B hemolytic streptococcus, for that given
penicilline. But she developed steven jhonson
syndrome which is very advantage stage,
involving organ damage,kidney, liver, now need
to shift to ICU and need intubate- Got 16/16
station 5
BCC-I
Case- young female weight loss since 6 months.
Inside: -6 kg weight loss since 3 years, no
features of hyperthyroidism except tremor, no
goiter, vitiligo, no eye signs. I missed to asked
about menstrual history and also forgot to see
pre tibial myxoedema (although it was not
present). But the examiner was unhappy.
Examiner asked:- Positive finding
Asked it is multinodular or diffuse. (I said
diffuse as i feel like that, also as it associated
with vitiligo. So I thought maybe autoimmune
graves. Also asked what are the disease can be
associated then investigation, management- Got
19/28
BCC-2
case- young male right knee joint pain and
swelling since 3 days.
Inside: - no morning stiffness, worsen by
activity also having pain some other joint like
elbow, left knee. Family h/o blood disease on
examination.- there was subconjunctival
hemorrhage, effusion right joint.
Examiner asked--What is your diagnosis?(I said
Hemarthrosis due to hemophilia). Would you
like to aspirate the joint fluid. (I said it is
contraindicated. D/Ds, Inv, Mx- Got 26/28
Hospital Selayang (Kuala Lumpur, Malaysia)
Diet 1 carousel 1
Station 1
🔺Abdomen - hepatomegaly with signs of

chronic liver disease (spider naevi, clubbing) in
decompensation (ascites, peripheral edema,
jaundiced). Multiple tattoo marks on both arms
(17/20)
🔺Respi -? Collapse consolidation right LZ?

Noted needle puncture scar on anterior lower
chest wall possibly CT guided biopsy mark.
Failed this station (11/20)
🔺Station 2
Outside - man in 50s with right knee pain
Inside - monoarticular joint pain 3 episodes past
year over right knee. Also has IBD on
azathioprine, but no bowel symptoms. BhtNeed
alot of probing but once elicited hx of
precipitating factor (seafood), the rest is pretty
easy. Also has hx of right big toe pain few years
back
Concerns - can this be cured? What is it?
Viva - azathioprine allopurinol interaction. Side
effects. Precautions (19/20)
Station 3
🔺CVS - moderate aortic regurgitation

(collapsing pulse, shifted apex beat) not in
failure (20/20)
🔺Neuro - old polio. Man with hypoplastic right

LL exhibiting LMN signs. However left quads
also wasted with power 3/5 for hip flexion.
Unable to explain. Be safe gave dx as "pt exhibit
LMN weakness of right LL then give ddx polio
and plexopathy" (17/20)
🔺Station 4
Scenario - 78 year old man with comorbids of
COPD and hypertension admitted with
pneumonia with CURB score 5. He was admitted
to surgical ward as medical ward was full.
Condition deteriorated in surgical ward and
patient was intubated and sent to HDU. There
was also a few hours delay in giving antibiotics
due to dislodged IV cannula. Pt subsequently
sadly deteriorated and passed away
Role - HDU medical officer
Task - daughter is unhappy with management.
Talk to daughter
Issues/concerns -
I want to talk to consultant
Why is father admitted to surgical ward?
Are surgical staff incompetent?
Any wrong doing of ward staff that cause my
father deteriorated?
Is the delay in antibiotics cause my father's life?
What could have been done differently?
Should he be in HDU/ICU in the first place?
Should he be intubated in the first place?
(16/16)
Station 5
🔺BCC 1
Outside - CKD patient with anemia of 9.3
(normochromic normocytic)
Inside - 60 year old man with ESRD post renal
transplant. When asked what's your complaint.
Pt says "I have no complaints. I'm fine. They ask
me to come for exam" was taken aback. Then
tried to ask if any discomfort or pain. Pt
complaints of joint pain both knees. Ask about
meds. No NSAIDS. Only immunosuppressives
and some hematinics. Asked about failure
symptoms. Anemia symptoms. Causes of
anemia such as bleeding etc. None. Ask about
concerns. Pt says joint pain. After examine the
LL I told patient it may be OA. After that pt
suddenly remembered he has to fulfill his task.
So he said "why u think I have anemia? Can it
be cured". Then I said can be due to many
possibilities including occult GI bleed or
myelosuppresion. Need to further Ix and treat
the cause.
Examiners - did you check renal function? Is
transplanted kidney functioning well? No I didn't
check. But I did ask for overload symptoms and
uremic symptoms which were absent
Did you ask about altered bowel habit? No
Basically examiners looking for approach to
anemia. The joint pain part doesn't matter.
Which threw me off course awhile
(23/28)
🔺BCC 2
Outside - 68 year old with joint pain over the
hands
Inside - lady complained of pain over b/l hands
past year. Pain is constant and after use. Hx
tried to rule all all causes of joint pain (RA, SLE,
enteropathic, psoriatic, everything).
Examination shows Heberden nodes and
Bouchard's nodes both hands. Knees also genu
varus with crepitus
Diagnosis is OA
Ddx I gave burnt out RA
Concerns - diagnosis, treatment
Discussion - Ix and management including non
pharmacological and pharmacological
(28/28)
.....................
✅ Before my exam I received a message of

advice from one of my consultants :
👉 Have full confidence but not being cocky. Be

humble with full respect to patients and
examiners. But do not be too humble. Majority
of the examiners do not know you. During that
few minutes, you must let them feel that you are
at the level of their peers. Then, you shall pass
👌
Exam date 22nd april 2018

Centre kolkata india
Alhamdulillah i have passed my paces
Station 1: respiratory: ILD with rheumatoid
hand.
Abdomen: hepatospleenomegaly with anaemia
and jaundice.
St 2: young female with one episode of loss of
consciousness with seizure and loss of urinary
control.she had family history of epilepsy.it was
vaso vagal attack.concern about drving.
St 3:cardio: AS with AR with MS.difficult one.
Neuro: spastic paraparesis with absent ankle
jerk with intact sensory.
St 4: steveven johnson syn in wife who got
penicillin during NVD.baby is ok.talk to
husband.task explain it and tell him that she will
be shifted to ICU and may require ventillation.
I started with asking about the family support,
condition of the baby and any need of financial
help.then explained the grave condition of the
wife in simple words.his concern was why this
happened,will she survive or not,what to do
about the baby.
Bcc1:female patient known diabetic for many
years came with vision problem.
On fundoscopy there was grade 3 hypertensive
retinopathy.patient was not aware of her
hypertension.
Bcc 2: male pt with DM.came with pain in the
thigh.on examination there was loss of
sensation over the lateral
aspect of thigh.i said Meralgia parasthetica due
to damage of lateral cutaneous nerve of
thigh.sor asked about D/d
Diabetic neuropathy,radiculopathy,any form of
myositis.
paased MRCP PACES from kolkata,India,
My exam started with history taking it was vago

vagal syncope,
Abdomen hepatosplenomegaly, jaundice with

anemia probably hemolytic anemia,
CVS....Mitral valve replacement,
Respiratory RA with ILD,

Neurology Spastic paraplegia without sensory
impairment with scar mark in thoracic spine
area,
communication drug reaction,
BCC1 DM with retinopathy,
BCC2 DM with meralgic perasthetica
Egypt 🇪🇬 today, May 5. 2018,
🔺 Station 2 👉 Haemochromotosis
🔺 Station 4 👉 Hyponatremia induced seizure
🔺 BCC 1 👉 Systemic Sclerosis
🔺 BCC 2 👉 Addison
🔺Abdomen 👉 Massive splenomegaly
🔺Respiraotory 👉 COPD / pulmonary fibrosis

🔺 Neuro 👉 CIDP / Polio
🔺 Cardio 👉🔺 DVR
Egypt 5/5/18, 3rd carousel 🔺
🔺 St 4 👉 60 yrs old gentleman presented with

seizure for 1st time aborted by diazepam but
still confused
🔺 St 5
🔺 BCC 1 👉 60yrs gentleman presented with

fever and abdominal pain for 5 days
Inside had history of HBV
, most likely SBP
🔺 BCC2 👉 40yrs old lady presented with

tingling and numbness in her hands
Inside had history of CTS and did surgery, she
is acromegalic
🔺 Abdomen 👉 young man pale , jaundiced,

palpable, most likely chronic haemolytic
anaemia
🔺 Chest 👉 COPD
🔺 Station 2 👉 young man presented with

syncope
marathon , LOC
DD HOCM
long QT syndrome
🔺 Cardio 👉 DVR with obvious clubbing
🔺 Neuro 👉 young man has pes cavus,

hypotonia , hyperreflexia , sensation normal ,
had nystagmus and slurred speech
DD MS , FA
passed my exam from Oman royal hospital
scored 153
🔺 I started with St3
🔺 Cardiology: Avr 20/20
🔺 Neurology: Becker dystrophy 20/20
🔺 St 4
APKD 25 years of age came to her gp after she
did Ultrasound which showed she has pkd .
Because her father has pkd , on dialysis
complicated with pretonitis and he has
miserable life
Pt plans to start family in 3 months.
Your task is to explain about disease and that
there is no chance for genetic testing for her
children. Will offer Ultrasound for children only
at age of 18-20
Pt concerned about her future and will she end
up like her father ?
She wants to prevent her future any chance to
prevent future children?
If pt refused to tell her fiance are you going to
tell him ? What is the legal issue here
Are you going to screen her brother 15?
Are u going to offer test when he reached age of
18 years? Score : 15/16
🔺 St 5
🔺 Bcc1
Diabetic retinopathy 23/28
🔺 Bcc 2
Diabetic with post 24/28 prandial
hypoglycemia(autonomic neuropathy)
🔺 St 1
🔺 Abdomen : renal transplant 20/20
🔺 Chest : Lobectomy with other scar in his

abd? 15/20
🔺 St 2
45 years male c/o left knee swelling and pain for
the last 2month he have 2 attack go for gp give
him naproxen his pain improve put gp reluctant
to continue on nsad as pt has hx of ischemic
heart disease .inside pt has this 2attak of pain
and swlling e limitation of movements .i ask
about other joint involvement he didn't mention
asking although he mentioned to other
candidates one attack of big toe pain before not
going for Dr (could be b/c I didn't ask specific
question) ph of ihd and on atenolol aspirin and
simvastain and also he has hx of uc several
years put well control on azthioprine .
Pt concern about this pain and he want other
pain killer Bec of heart attack?
What is cause of my symptoms?
Ex qu
Dd/ investigation
I mentioned first d/d extra intestinal
manifestation of uc although her Uc well control
2nd d/d crystal arthropathy then causes of
monoarthritis
Routine investigation
X-rays
Aspirations.. Examiner asked when you could
perform aspiration (during attack or after
resolution of symptoms)
Examiner ask about relationships of rft and gout
Relation between medications he is on and gout
I mentioned low dose aspirin and gout but lately
I remembered
azthioprine and allouprinole interaction.16/20
I hope that to be of benefit
Thank for all those who help me hoping success
for all
started with station 4. Before I started I read ‫رب‬
‫أشرح لي صدري ويسر لي أمري واحلل عقدة من لساني يفقهو قولي‬
Out side scenario 25yr old female was
diagnosed as having B . streptococcus vaginal
infection delivered vaginally and started on
penicillin. Then developed Steven Johnson
syndrome. She deteriorated developed renal
failure and liver failure plan for icu admission
and intubation
Task :talk to her husband. So it is breaking bad
news and I have to be sympathetic and
empathic. I entered the station said hello. ami
talking to Mrs. ... husband. He said yes. I am Dr.
Omar I am one of the team taking care of your
wife. How can I call you. He said ahmed. I said
OK Mr ahmed how far u know about ur wife
condition. he said she has bug infection and
received treatment .developed skin rash and
she is ill now and will referred her to icu. So I
said OK I am sorry for what had happened to
your wife. She had developed condition called
Steven Johnson it is immune reaction to certain
conditions as u know immune system
responsible for attaking bugs,germs but in your
wife condition it attack her body her skin. This
reaction is trigger by drugs. By certain germs in
your wife this is probably the cause. Are you
following me Mr ahmed he said yes. I would like
to tell you that she is deriorating her kidneys.
Her liver not working well. Her condition now is
very serious that why we need to admit her to
icu and her concious level now is not good so
we need to put her in a machine for breathing
called mechanical ventilator do you hear about
this before .he said no then I explained to him
what is mechanical ventilation. He asked me is
this happend to her because of medicine given
to her . I said yes the medicine is responsible
for this reaction. But also the bug infection
could be responsible also. He said why you give
this medicine for her. I said it was the suitable
medicine to treat her bug infection and she is
unfortunate to develop this reaction this not
happen usually. He said now her condition is
serious and she is going to die .I said I am so
sorry to tell you that her condition is so serious
and she might die. Moments of silence so I said
are you OK Mr ahmed. Could we continue.
Could I do anything for you. He said no. So I
said but we will do our best we will give her the
maximum medical care that she need. We will
do everything to safe her .he said OK. So Mr
ahmed where is the baby. And how is he? He
said he is fine but crying all the time be cause
he is hungry. I said I am sorry but any one to
help you or to look after him. He said no. So I
will call the child doctor to assess him and I will
offer social worker help. He said OK
Any thing concerning you. He said no. Any think
you want to ask. He said no. OK what message
you take from my talk. He summarised
And I sumarised and I said I know it is difficult
time for you. But we will do everything we can
to save her. Examiner said u have 2 min. I went
back to surrogate do you have any queries. He
said no any concern he said no so I wait in
silence. Prepair my self to questions examiner
Qs was do you think the child at risk to develop
infection I said yes as his mother developed
infection before delivery and mode of delivery
was vaginal. In this period who will take care of
baby I said nurses in nursery why u talk about
social services. I said if baby is OK we will not
keep him in hospital as our practice here. The
examiner said OK. Why u said Steven Johnson
could be due to her infection. I said b/c b
streptococcus can precipitate it . the bell rang I
got 14/16
🔺 I moved to ST 5. BCC 1 : the scenario was

young boy with history of abd pain and
diarrhoea. His vital stable .inside I started as
usual introduced my self. My role and asked
surrogate to tell me more about her relative
diarrhoea she said he has abd pain 😳I said OK
tell me more. It is colicky in all abd no relieving
or aggregating factors not associated to certain
type of food. I asked again does he has
diarrhoea she said yes 7times per day not
containing mucus or blood no mouth ulcer
health in the past she said he is fine. I asked her
again did he entered hospital before she said
yes 1yr ago for tummy surgery. What type of
surgery she don't know
Isit bowel resection she don't know. Is it normal
surgery she don't know
I would like to examine. He is young boy email
rounded face. Hirsutism. Not pale or j no signs
of dehydration. No mouth ulcer. Abd there was
scar and straie. Back to surrogate any changes
in wt. Losing weight 😳.isaidto my self despite
this cushinoid feature.what medicine he used
prednisolone 20 mg. I explored all side effects
of steroid. F.H. SH which negative what is
concern. Is it recurrent appendicitis. I said no it
is codition called IBD and I explain it in a simple
way and I told her we need to join tummy doctor
for further test. And discuss to reduce medicine
use and use of another medicine. Any other
concern. She said is it treatable. I said no but
controlable .the examiner said still you have
40sec. Ijust kept silent. Examiner Q :what is
your diagnosis IBD
How to investigate I said cbc lft looking for any
evidence of sclerosing cholangitis .colonscopy.
rft and electrolytes.and inflammatory marker. I
got 28/28
🔺 BCC 2 was 60yr old male with history of loss

of conciousness vital stable. Inside midle age
male short with opvious unilateral leg swelling.
😳😳😳tell me more about his symptoms .she
said it occurs with exercise. No presyncopal
warning. No loss of conciousness he just falling
down. No post attack symptoms. So it went with
cardiac syncope .so I asked about other
symptoms of cvs which is negative. F.H of
sudden death no .high BP no high blood sugar
no. High cholesterol: not sure.lwould like to
examine. Pulse is regular. He has raised jvp.
Chest deformity. Murmur of AS. I did DVT
measures it was not . It was lymph edema. At
that time I couldn't connect this findings
together. But the only thing can explain
syncopal attack was As. The examiner said 2
min left I asked about concern: what is going
with him isaid he has tideness in one of his
heart gate which responsible for giving blood to
body organ and brain that is why with exercise
he developed this loss of conciousness we
need to involve heart doctor to scan his heart.
To trace it. And also may need to involve
surgeon as may need to change this gate.
Examiner Q. What is your findings isaid ejection
systolic murmur and evidence of pulmonary
HTN. What is this evidence. Isaid loud p2 and
raised jvp. The examiner said show me this
raised JVP we back to pt and show him. He said
OK . WHAT dd.isaid neurological and it was
stupid answer. What investigation. ECG. CXR.
Echo. Finding in ECG lt ventricular hypertrophy.
Arrhythmia. The bell is rang .I felt that I didn't do
well here and after I left the st I realised that I
should say hocm as differential I spend around
2 min thinking of this then I decided to forget
that and enjoy the rest of exam I got 24/28
St 1.started with chest midle age male clubbed.
Lt thoracotomy scar. Central trachea .
decreased chest movement in the Lt Variable
percussion note
Bronchial breathing above the scar . Examiner
Q. What is the findings I said above what is your
clinical diagnosis :LT Lobectomy mostly due to
bronchiectasis. Investigation and treatment.
What sputum test to do apart from AFB. I said
culture. What else ADTA. If pt developed chest
infection what causative organism I said
streptococcal and if recurrent pseudmonus.
What treatment in recurrent : Quinolones I got
19/20
🔺Abdomen . Lady eout stigmata of CLD. She

has fistula which is non functioning
Previous tunel cath scar in neck. Abd scar
overlying amass which is dull in percussion. No
bruit. No hepatomegaly or splenomegaly. No
ascetes. There is purpura no cyclosporin
toxicity. Qs:what is your diagnosis :trasplanted
kidney. Investigations :basic investigation and
rft Abd u/so and drug level. What medicine u
suspect pt on :steroid. Cyclosporin. Mmf .what
could be the cause of transplant :pt is young
chronic pyelonephritis
Glomerulonephritis due to vasculitis or sle. The
bell rang I got 20/20.
🔺 St 2
30 year old lady with diabetes on insulin.
Presented with loss of weight. I can't remember
the rest of scenario .inside .she has diabetes for
10 years. On insulin long acting at bed time .
ultrashort premeal. She didn't take it regularly
coz loss of interest to take medicines to go to
follow up. Has low mood coz her relationship
with her fiance was ended. Not on well dietary
control. No exercise
I explored all diabetes complications which
negative. No symptoms of Addison;
hypothyroidism
She has oligomenorrhea and significant loss of
wt Q :what is your diagnosis. Isaid uncontrolled
DM due to irregular doses of insulin .what is
plan of management :referring to
endocrinologist to control. Psychological
assessment and help regard her depression.
Actually I said this also to surrogate in plan of
management.
Why did u explore for DM complications : coz
her DM not controlled
Why this pt has oligomenorrhea I said coz has
loss of wt due to poor contol DM and this affect
the hormones .how treat her depression :
psychological referral, cpt. What medicines ssri
and tricyclic antidepressants
I got 19/20
🔺 St 3
🔺 Neuro:young man for ll examination :his
power reduced distaly hypotonia areflexia even
with reinforcement stocking distribution loss of
pinprick the striking thing it is in one limb.😳
Loss of joint sense. gait high stepage. Positive
romburge sign I decided to tell this peripheral
neuropathy with post. Column affection Qs
about dd. Investigation and treatment igot19/20
🔺 CVS:midle age man no signs of infective

endocarditis . normal volume, regular pulse
corrigon sign. Apex in place thrusting in nature
loud s1. Diastolic murmur heard all over
pericardium with maximum intensity in 2nd
aortic area with peripheral signs so this AR for
me. Examiner asked me do hear any murmur in
mitral area I denied and said I didn't apreciate
murmur but s1 is loud I would like to do echo
looking ms
Qs about investigation and treatment and
treatment of heart failure I felt I didn't Do well
signs confused me. I got 18/20
I passed with score 161 /172 allhamdullah
Ninewells hospital Dundee , Edinburgh, Feb diet
1, 2018
steal syndrome
retinitis pigmentosa)
neuropathy
transplant and pancreatic transplant
History nausea and vomiting in , patient

diagnosed case of stomach , cancer took
chemotherapy and radiotherapy for pain and on
morphine tablets with no any alarm signs of any
thing
Concerns
She told me had recent Ct chest abdomen and
showed progression of cancer
What’s next
Spoken to her about palliave team review
DDx :
Progression of cancer
Or post radiotherapy gastritis
Also examiner asked about hypercalcaemia in
this case and it’s differential diagnosis and how
you would manage it
meningitis. Talk to wife

was asking about her kids and is he dying or
not ?
Can I see him in ITU ?
Shall I speak to public health authorities or you
will do that ?
So relatives can't visit him right due to risk of
transmission ?
Yes ,can see through glass from away
and advised children not visit due risk of
infection and due to stressful condition for them
And children can go to school & wife can return
to work after receiving prophylaxis provided no
symptoms
☑ Station 2 - 24 year old lady DM on insulin with
tiredness n wt. loss. Low mood after break up
with bf n don't go out. Lost 13 kg in 12 months.
No joint pain. Polyuria present
☑ Station 3 : Neuro, spastic paraparesis with no

sensory involvement. Increased reflexes with
extensor plantor in middle age lady
☑ Station 3 : CVS. Middle age male with SOB.

Bradycardia with pacemaker.? Systolic murmur
on left sternal edge
☑ Station 4 : pt. came with urosepsis n started

on genta. Has CKD but stable, on ACEI for HT
but continue in hospital. Now develop AKI due
to genta. didn't check genta level before. Renal
team think no need for HD now. Talk to angry
son
☑ Station 5- BCC 1 : Haematuria on MVR pt.

Took analgesic 5 days ago
☑ Station 5 BCC 2 : SOB in pt. with RA
☑ Station 1 Resp : ILD on RA
☑ Station 1 GI : mild hepatomegaly on middle

age male with no sign of CLD
Experience in PACES diet 1/2018, Egypt
8/2/2018 Maadi military hospital
ST 2 : 37 male with back pack pain ( outside )
inside : lower back and buttocks pain more in

morning with 2 hours stiffness, pain improve
with moving - no family history as he is adopted
- no drug hx - hx of on and off behind ear rash-
no other joints affected and no other symptoms
-work as cleaner - concern about cause of that
pain.
my DD:
Ankylosing S
Psoriatic arthritis
Discussion :
what your DD?
investigations ?
Treatment?
complications?
is it inherited ?
Got 20/20
ST 4:( outside ) 27 y female recently diagnosed

ADPKD by ultrasound, normal KFT and BP ,
father has renal failure and feel miserable , she
will marry in 3 months.
task: explain disease and that no need for
genitic testing for future kids as no benefits to
know early but screening with US at age of 18.
concerns :what about my brothers 16 and 20

years ? we will screen the older but US but the
younger when become 18
can protect my future kids from disease ? I'm

sorry nothing can be done for this issue
any treatment now to prevent renal failure ?

your BP is normal and so KFT so we ll following
you up regularly, if your BP elivated we ll give
you treatment do dely but not prevent the
progress of the disease
shall i till my future husband? yes it is
preferable ( examiner asked me is there other
option than she told him, i said the better to
arrange another meeting for couple with my
consultant to inform husband, examiner said
excellent. )
discussion about how and who will follow up

her? i said GP and nephrologist by BP ,KFT
any benefit from intrauterine screening.? i said,
no need
Got 15/16
BCC1 : female 47 y with long hx of RA

presented with SOB for 3 months.
inside : hx of progressive cough and sometime

productive with no diurnal variations and
exertional dyspnea, all RA hand features with
diffuse crakles and wheezing all over chest and
LL edema, on steroid and methotrexate for 5
years.
DD:
fibrosis with bronchilotis oblitrans
drug inducd fibrosis
infectiondue to immunosuppressive drugs
examiner ask is she in heart failure? i said yes

cor pulmonal
investigations ? Treatment?
Got 26/28
BCC2 : 27 Y male with dark urine.
inside : hx of dark urine mainly in morning and

when i ask only morning or ny time else, side
only , no drug hx, hx of blood clots and blurring
of vision and abdominal pain , father with renal
failure
examination (face, abdomen, calf, pulse,

capillary filling) was normal (surrogate ),.
examiner ask DD:

PNH
ADPKD
why examine abdomen, i said to exclude
ADPKD
urin contain HB or myoglobin ? i said HB
ask me what is the cause of blurring? i said
thromboembolism.
will you admit him? i said if CBC shows anemia
i ll admit for blood transfusion
Surprisingly got 17/28 😢😢
Cardio
40 y female
MR, AV prosthesis with ejection systolic
murmur
Examiner Q: cause? I said rheumatic heart
Investigations?
Echo, ECG, CBC, INR
Cause of systolic AV murmur?
mismatch, flow murmur, pannus
Would you use ACEI?
According to ECHO finding but mostly yes for
remodling
Got 19/20
NEURO:
flacid paraparesis with sensory level and
upgoing planter reflex in 30 y male with back
scar
Q: causes? Trauma, tumor, TB, Disc
Why positive planter reflex?
May be in shock stage, what else?? I don't know
😢
Investigations?MRI spine, Urgent bladder and
bowel assessment , what else?? LP??
I siad for infection yes but trnasvers myelitis in
the bottom of DD list due to scar 😆
Treatment? non ph ( physiotherapy, bladder,
bowel, bed care, social & psychological support
) and ph, Refer to neurology clinic for surgical
option
Got 20/20 😄
Chest:
45 y male with shortness of breath.
Bilateral basal crakls more on Rt side and
bilateral basal dullness (?? Stony)
Bilateral LL edema
Q:
Finding?
DD? Pul fibrosis with ? pleural effusion
May be core pulmonal due to LL edema
Investigations?
Other than basic investigations i ll do
Pul function test, Chest X ray, high resolution
CT chest , CBC, ECG , ABG, ECHO
treatment?
According to the cause of PF , diuretics for
edema, o2 therapy if needed
Got 19/20
Abdomen:
50 y male with abd discomfort
No evidence of CLD or hemolytic anemia 😭😭

Hardly paplable liver 3 fingers Rt lobe and 5
fingers Lt lobe, palpable spleen 3 fingers when
patient turned right 😢
Q:
Findings?
Splenomegaly with palpable liver
Any sign of CLD ?
NO
DD?
early viral hepatitis
Drug
Infection TB
Infiltration
Investigations?
LFT,CBC, KFT, VIRAL SEROLOGY, SONAR
(each with finding)
Complications of CLD?
Chirrosis, hepatorenal, ascitis, varices, cancer
Treatment of varices?
Acute
Chronic
Treatment of viral hepatitis?
Got 18/20
Thanks god for total score of 154/170
Many thanks for my dear friend and great prof

Dr Ahmed Maher, the expert of PACES.
Egypt
🔹st 2 👉 status epilepticus
🔹st 4 👉 depressed nurse took oral

hypoglycemic tabs
🔹BCC 1 👉 hypertension in neurofubromatosis
🔹BCC 2 👉 steroid induced proximal myopathy
passed from Kolkata Centre, 21st April, second

carousel 🔺
✔ Station.2
👉 - Analgesic misuse HA with underlying

migraine + family problem.
✔ Station.4
👉 – Hepatic encephalopathy, alcoholic,

developed hepato-renal $. Consultant decided
not to do transplant. Talk to son about this and
also discuss resuscitation status.
✔ BCC 1
👉 – Young man c/o joint pain. Has congenital

heart disease. Gout precipitated by diuretics.
✔ BCC 2
👉 – c/o SOB. Inside : ankylosing spondylitis.

✔ CVS
👉 - c/o SOB. Mitral valve replacement.
✔ CNS
👉 - c/o difficulty in walking. Lt sided hemiplegia

(+Lt. facial palsy)
✔ Resp
👉 – Rheumatoid lung
✔ Abdomen
👉 – jaundice with ascites.

Oman April 2018 🔺
🔺 I started with st5⃣ 🔹 BCC 1 👉 middle age man

c/o numbness in both lower limbs inside when
took history he was diabetic for long period
of time o/e he has flexor deformities nd healed
ulcer but all sensations intact normal power dx
is diabetic neuropathy examiner asked about
dd( I told him peripheral vascular disease)
investigations Mx
got 28
🔹BCC 2 st5⃣ 👉 male with headache it was

acromegaly viva dd ,investigation Mx
got 28
🔺st 1⃣
🔹Respiratory 👉 bronchiectasis vs L fibrosis 20
🔹Abd 👉 renal transplant 20
🔺st 2⃣ 👉 34 y old female with headache for

6month inside she has every day headache
more in the night for 6month she had history of
migraine she was using paracetamol nd
tramadol almost every day she was repeatedly
asking what is the cause, the headache affects
her life I showed her some empathy ,,,no
alarming signs , concern is it a tumor can you
do imaging for me, explained to her it is
analgesic headache tumor is unlikely but need
to exclude it by examining you no need for
imaging told her you need to stop all analgesics
right now she said I will not 😳,examiner
questions what you are going to do if she
doesn't stop analgesics? dd? Mx got 20
🔺st 3⃣
🔹Neuro 👉 proximal myopathy ;male with LL

weakness sensation intact LMNL I didn't
perform well got 11/20
🔹 CVS 👉 AVR viva what is the targeted INR ?,

what u r going to do if he will go for dental
operation tomorrow?
got 17
🔺St 4⃣ 👉 mother in rehabilitation department

develop headache rehabilitation doctor
diagnosed her as GCA gave her steroid then
she developed psychosis later seen by
rheumatologist and he excluded GCA talk to
daughter she was angry I explained to her what
is GCA nd that steroid given to her mother was
the best of interest as there was a risk of
blindness, the psychosis is reversible and she
will be fine, Concern why you gave my mother
this bad medicine ?when she will be ok ? Viva
do you think you convinced her? I told if I found
time will explain to her more.
what u r going to do if she said she want to talk
to the doctor who gave the steroid? I told it Is
better not make patients or relatives in this
situation talk directly to the treating doctor nd I
will make appointment with my consultant ,
what u r going to do if you discovere that yr
colleague make a mistake I told incidence report
and we need to inform risk management team i
got 15/16
Alhamdolelah I passed with score of 159
my advice you need to pray to Allah first, and
you need to practice even you are rejected
many times don't give up just continue
practicing and preparing, , previous exam
experiences very important also
best of luck
Dr. Ismael Alnawrany
My exam experience
Egypt New Kasr Alainy
Feb 03/02/2018
1st-day 2nd cycle.
BBC1
Assess this 35 years lady complaining of
weakness in her shoulder with weight gain.
Inside female with cushingoid features sitting
on the bed.. greeting introduction permission
Analysis of weight gain
Asking about the proximal weakness any
problems combing her hair or standing from
sitting position, inquire about other differentials
symptoms, hypothyroid symptoms...
PMH HTN & DM diagnosed recently
Examination:
General exam and demonstration of cushing
signs ,Asking about BP examiner told me it is
140/90.
Looking for thyroid,
Auscultation of the heart
Checking LL edema just touch her leg before
pressing she make a sound of pain with a
smiley face😳.
I apologize to her,
Finish my examination
Asking and addressing her concerns
What I have doctor?
Explanation without jargon
Plan of management including referral to gland
doctor.
Viva:
Diagnosis .. Cushing syndrome
Other differentials
Hypothyroidism
Acromegaly....
........
Investigations
Basic
Specific
Treatment ..
medical surgical
Asking about medical.. bell rang he took me to
the next case... 25/28
BCC2
ASSESS this 42 years old man who complaining
of skin rash.
Patient lying on the bed..
Greeting introduction permission.
I asked him directly..
(I understand that you are troubled by skin rash)
Can you show me plz where it is?
It was in the dorsum of both hands and feet
Then analysis of rash
Eye symptoms and signs and mouth ulcerations
which were negative
No joint pain
On digging more it is related to his recent work
on a detergent factory
Asking about concerns
Explained diagnosis and plan of management
and considering job change..
Viva
Your diagnosis?
Contact dermatitis
other differentials
Which type? Irritant type
Why not allergic?.
I kept silent�...
Ok, how are you going to investigate?
Skin batch
I heard you telling the patient that he must
change his job.
(I said yes because it is related to his problem)
Asked me about treatment
Including drugs and referral to a dermatologist.
Walking towards the door
He asked me again
You still want to change his job?
I told him yes, 😄

(Later I knew that he has to be relocated to the
factory
To avoid exposure to the irritant factor)...
I got 24/28
Station 1
Female patient
Not pale, not jaundiced
There are no stigmata of CLD
hepatomegaly with splenectomy scar
Viva
Your fiding
Differential
Causes of hepatomegaly in hemolytic anemias
(Extramedullary hemopoiesis)
A common cause of liver cirrhosis in Egypt..i
got 20/20
Chest
Middle age man complaining of SOB
Diagnosis OPD with right-sided lung fibrosis
Viva about investigations
And investigations findings
Differences between COPD
and ASTHMA
I got 20/20
Station 2 History
Young male patient referred by his G.P with a
history of abdominal pain bloating and diarrhea
, his father died of colonic cancer recently ..
I explored his symptoms accordingly enquired
about the red flag 🚩which was not present
Surrogate correlated his symptoms to the stress
in his life due to his father death and work... And
he is worried about the possibility of cancer...
I reassured him the cancer is unlikely in his
condition and this is functional bowel disease
called in medical term irritable bowel
syndrome..
Explanation
Plan of management
Adress his concerns
Summarize
Patient recap
disclosure...
I got 8/20 😳
I think the case is about
The possibility of familial polyposis coli (familial
adenomatous polyposis FAP) Which I missed
(http://www.netdoctor.co.uk/…/familial-
polyposis-coli-famil…/ )
Station 3
Cardiovascular
Mitral valve replacement with signs of heart
failure
Raised JVP basal creps
No LL Edema
Viva about
Diagnosis
Causes of mitral stenosis
Investigations
Target INR
Signs of infective endocarditis..
i got 20 /20
Neurological case
Young Female with difficulty walking for three
months
The examination was flaccid paraparesis with
hyperthesia in her soles
I forgot to do planter reflex
Viva about
Diagnosis
Gillian Barre syndrome
With consideration of other differentials..
Examiner asked me why didn't you do planter
reflex?
I told because of pain.
(He told: you have to request
To do it)
Then we will tell you to do it gently) 😬

Investigations
I got 17/20
Station 4
Middle age man was complaining of a headache
and dizziness fall at work with a body rash
Diagnosed as meningococcal septicemia with
imminent ICU admission.
Role: to discuss his condition with his worried
wife...
Started by greeting introduction agree agenda
Am dr...Medical officer in the admission unit..
Are you Mis....wife of Mr...?
Well to day we are here to discuss your
husband's medical condition and what we can
do further, ok)
Mis... Can you tell me what do you know about
his condition) checking her insight...
And break the bad news gradually with silence
gap between warning shot..
Showing empathy
Explained the disease in layman language
Plan of management
Her concerns
Will he go to die?
What about the children
And there's school?
Discuss the seriousness of the disease and the
high possibility of death
And even if he improved there might be
possibility of disability like loss of hearing
Although some people recovered completely
and I hope your husband will be one of them...
Discuss contact tracing
Prophylaxis
Isolation
And they can visit him during short time with
taking full precautions
Like wearing face mask..etc
Discuss social issues as he is the only family
supporter
Summarise
But I forgot checking her understanding...�
Viva
Ethical issues?
You don't want to notify?
What prophylaxis you will offer to her children...
I got 15/16
Overall score 149/172
Alhmdu llah finished the long journey of MRCP
..
And this success attained
because of God's grace,
And then
(‫)من ال يشكر الناس ال يشكر هللا‬
(My family' mother father mother-in-law and
lovely wife 🌹and kids .. precious friends
For the continued support and Doaa).
Dr. Ahmed Mahir Eleoa the great teacher🌹

Dr. Elrasheed Yousif (King Faisal hospital)
Dr. Zain Mahgoup
Dr. Mariam (guide me through history and
communications)
MRCP PACES 101
Malta diet 1, March 18, 3rd carousal

Scenario.
62 year old male post CABG 10 YEARS, HTN not
DM presented with sudden onset of
collapse(lost consciousness) while he was in
the garden. No post collapse headache,
confusion. Hisnleft arm is hurting because of
fall.
Vital were stables excellent HR was 58.
D/D
Cardiac syncope
Neurological ( vasovagal) ( epilepsy)
Meds induced syncope
LEAST Situational ( was not doing anything)
Went inside
Introduction
Confirmation of identity
Presented agenda, & his understanding (why we
are here)
Allowed him to explain what happened
Asked warning any signs
Do u remember fall?
What was u doing when u felt collapse?
Who was beside u?
He told me his wife was in kitchen lookin into
garden.. She told u fall and lost consciousness
for less than 20 sec, ur color was pale, mild
twitches, no loss of sphincter..... Collateral
history
Post collapse
How did u feel after fall?
Headache
Difficulty in focusing the things
Weakness in any part of body?
How u r feeling now?
Past medical history (mentioned in scenerio)
Surgical history
Hospital admissions ( reason, course,
diagnosis)
Medication history
Valsartan 180mg
Bisoprolol 5
Esoleprazol 40
Paracetamol 500mg ( recently added)
I took systemic review here... Then
Social History
Non smoker
Non Alcoholic
No illicit drugs
Family
None
Occupational
Retired needs no financial support
Psychological effects
IDEA CONCERN EXPECTATION
1.......WHAT HAPPENED TO ME....
2....... CAN I DRIVE.....
3.......I HAVE BOOKED FLIGHTS FOR AMERICA
AFTER 2 WEEKS.. WILL. I. BE ABLE TO
TRAVEL
NOW EXAMINER QUESTION
WHAT IS UR DIFFERENTIAL
WHY IT IS CARDIAC...
WHY NOT NEUROLOGICAL...
WHY NOT EPILEPSY....
WHAT INVESTIGATIONS
WHAT IS BEDSIDE TEST TO CONFIRM
SYNCOPE....
BELL RANG
failure
Differential.... Investigation.... Treatment
sensation and spastic gait

Differential..... Treatment
75 year old lady ESRD on dialysis presented

with acute confusion. Hemorrhage stroke 2
months ago. Left her blind and broken d ridden.
Reviewd by dialysis team. They decided to stop
dialysis.
Talk to son about her condition who wants to
take her home as he is recently retired and
wants to server her monther. 😔
Introduction
Agenda
Took her idea about her mother condition
( she has infection, she will be OK after
antibiotics and will go home)
Did u meet her today? No
Has anyone talk to u earlier about ur mother..
No
What do u expect from today visit.... He said she
has infection, he thinks she will improve after
antibiotics and can go home...
I said sorry, things are difficult at the moment,
as u know she is not well.....
Explain led her condition
He started to cry
Offerd water, tissue
Further discussion
Finally Offerd palliative
And appointment to nephrology consultation
Agreed... Thanked..
Final understanding of relative
Any further questions
Examiner
What is this case?
Why he wants to take her home?
What is palliative care?
What ethical principles are involved?
68 year old.... Headache one month ... Wt loss...

Night sweats...
Vital stable.
Made diagnosis of lymphoma, tuberculoma, or
SOL
BUT inside it was PMR.... Because he told he
has stiffed leg.
It was temporal arteritis with PMR.... Got at the
end �
Examiner.....
What is ur Differential...
How will u Investigate...
What is ur Treatment...
52 year old.... Difficulty in swallowing... For 3
months... No wt loss... Intact epettite
Inside it was pill esophagitis
She was taking alendronate, paracetamol,
naproxen sodium
Concerns.
What is happening to me?
Can I stop meds?
Examiner....
What is ur differential diagnosis?

What is treatment?
What test u ll do?
If upper GI endoscopy is normal what will u do?
Station 1.....

Only flanks were full. Noting else finding
differential.... Investigation... And treatment
What precautions u ll do in this patient...?
ILD.... IDIOPATHIC
Finding......
Differential......
Treatment
.....
kuwait 3/2018
Station 5
First case hypothyroidism got 24/28
Second case i didn't know diagnosis but from
outside facial swelling inside normal looking
patient history of ulcerative colitis , i didn't do
well 12/28
Abdomen CLD no signs except for palmer

erythema 20/20
Chest ILD clear case 20/20
History mild hyponatremia and fatigue.no

positive from history except depression
stopped treatment long time
I gave differential of depression and
hypothyroidism although denied any other
symptom 16/20
Neurology spastic paraparesis MS 20/20
Cardiology MS +MR only mentioned MS got

14/20
Communication End stage Copd patient not for
invasive ventilatiom treatment options to be
explained to daughter patinet conscious and
competent got 14
Alhamdolelah i passed good luck for all
april 21
☑ BCC1: 24 yr old man with congenital ht

disease complaint with big toe swelling
Dx Gouty artritis ppt by diuretics with
underlying (ASD with Eissenmenger?)
☑ BCC2: 72 yr old man with SOB with back pain

Dx AS with RLD
☑ Resp: Rheumatoid lung
☑ Abdomen : C/o abdominal discomfort:

Jaundice with ascites
☑ St 2- Analgesic misuse HA
☑ CVS -c/o SOB :MVR

☑ CNS -c/o difficulty in walking- Lt sided
hemiplegia
☑ St 4- End stage liver disease due to Alcoholic

cirrhosis. worsening symptoms with HR $ .
Consultant feels no beneficial to do RRT & liver
transplant. Talk to son about pt's condition &
management plan & resuscitation status
Kuala Lumpur, Malaysia. 1st carousel
🔺 St 1-
Respi: long thoracotomy scar at the back ?
Lobectomy
Abdo: hepatosplenomegaly with massive
spleen. Ddx myeloproliferative dz.
🔺 St 2 : Diabetic defaulted past 1.5year after

break up with boyfriend. Weight loss 13kg, low
apetite, oligomenorrhea but no other sxs to
suggest AIP syndrome or malignancy. Likely
depression.
🔺 St 3 (😩)
Cvs: systolic murmur with no radiation neither
to carotids nor apex ?as vs mr. Corrigan sign
present but no diastolic murmur or collapsing
pulse. Viva on MR.
Neuro: lower limb examination but pt hard of
hearing, difficult to give commands. Few of
candidates thought flaccid paraparesis, others
thot foot drop frm common peroneal nerve
palsy. We all got different signs frm t pt 😒
🔺 St 4: 30 yo lady wanting to go AMA. Admitted

with headache ct brain normal. Neurosurgeon
suggested to do LP. Task to convince her to do
LP.
🔺 BCC 1: 25 yo headache with HTN.

Acromegaly. Previous transphenoidal surgery 2
yrs ago. Qn on prolactinoma.
🔺 BCC2: 30 yo diabetic with blurry vision post

hi carb meal. Offered to do fundoscopy but
examiner said no need cos its normal (phew).
No other signs. Also gave hx of weight loss and
increased apetite.
April 2018, Malaysia
Station 1
Respi - left pleural effusion
Abdomen - Thalassemia with
hepatosplenomegaly
Station 2 - Type 1 DM, frequent hypoglycemia,

CKD. Suspect MEN 1, Zollinger Ellison
syndrome
Station 3
CVS mixed mitral regurgitation and Aortic
regurgitation
Neuro - bilateral leg spastic paresis but less of
sensation over whole of left leg
Station 4
Breaking bad news and angry patient
History of melanoma 9 yrs ago, wide local
excision, stage 1. Now has abdomen pain, US
abd showed multiple liver metastasis and para
Aortic Lymph nodes.
Station 5
BCC1 - jaundice, hepatomegaly, possible viral
hepatitis
BCC2 - tuberous sclerosis with worsening
seizures, ?new brain tumors
16 April, Seremban, Malaysia. Carousel 3
✔ Respi :right pleural effusion with right lateral

thoracotomy scar, discussion on right pleural
effusion. After exam only realized it could be
decorticating lung
✔ Abdomen : man with renal transplant with

functioning left AVF, no recent puncture mark,
parathyroidectomy scar, tenchkoff scar, a scar
at right hypochondrium possibly liver surgery,
discussion on renal transplant and
hyperparathyroidism and graft rejection.
✔ CVS : Mitral stenosis, in sinus rhythm, not in

failure.
✔ Neuro: UML left facial nerve palsy with left UL

and LL weakness and increase tone and left
claw hands and left foot drop, Cushingoid face,
dx is young stroke 2 APLS 2 SLE.
✔ Hx taking: hemiplegic migraine, discussion

on how I ruled out epileptic hemiplegia, TIA
(young), cerebral venous thrombosis, patient is
taking OCP, also on how to treat and prevent
migraine, patient has Asthma so cannot give
propranolol.
✔ Communication skills : BBN to son for

advanced chronic liver disease with hepatic
enceph and hepatorenal synd. Consultants
think patient will not get benefits from RRT or
liver transplant. To talk about resuscitation
status.
✔ BCC 1 : thyrotoxicosis 2 Graves’ disease with

pretibial myxedema, not in failure
✔ BCC 2: scleroderma, patient is piano lesson

teacher
Experience of candidate who passed with

excellent marks in diet 1, UK
🔺 Golden Jubilee (Glasgow)
🔹 Started with St 4: talk to husband.. wife had

NVD 3 days ago, found streptococcus +ve ..
given penicillin.. developed Stevens-Johnson..
deteriorating and need ITU admission..
Checked the husband understanding and what
he knows so far, explained everything about
Stevens-Johnson ( slowly and in a simple way)
.. explained that it’s very serious and made it
clear that we are not sure about out come and
she might die.. told him about ITU and
reassured him that we will do our best for his
wife and we’re always around if he needed any
help.. his concerns were, prognosis and his
baby! Gave him vague answer regarding
prognosis and regarding baby I told him baby
doctor will assess him..
✔ Qs: what difficulty did you find in this

scenario?! Didn’t know what he meant exactly..
so told him what do you mean!? He said have
you come across such a case? I told him yes
and patient passed away so it’s grave diagnosis
and I found it difficult not to give husband any
hope.. then he asked about issues!?
Beneficence vs maleficence and justice.. 16/16
🔹 BCC1: RA presented with cold hands..

on examination her hand were red with minimal
deformity.. did the usual in RA case .. hand plus
chest exam ..
Patient concern was what’s the diagnosis? Said
Raynaud .. what’s the treatment?! I said the
protective measures plus tablets she said I
don’t want tablets so encouraged her about the
protective measures again and told her we can
consider tabletsin the future..
✔ Qs:
Whats your diagnosis?! I said Raynaud due to
RA .. what Are positive signs?! I mentioned
minimal deformity so he asked me to look at the
hands again .. didn’t notice anything..
So Examiner asked about other causes?!
Mentioned secondary causes listing SS first, he
asked me what do you mean about SS I said
CREST , examiner was happy and started to ask
about SS. What treatment of Raynaud?
Thought I missed diagnosis of CREST but got
28/28
🔹 BCC 2 was challenging for me as no

complaint mentioned form out side..
Scenario was lady who had nephrectomy and
adrenalectomy due to RCC and adrenal tumor ..
just waited out side and didn’t know what was
the scenario about..
inside lady looks cushioned on prednisolone
30mg with other long list of medication..
examiner mentioned them very quickly.,
To be honest I didn’t even know how to start the
scenario so I just started by asking how she is
after operation .. on further questioning she has
wt loss, fatigue, night sweating ( patient didn’t
say until I asked about them) ..
I was thinking of cushing from her appearance
but she didn’t have myopathy and her
symptoms were against that..
her BP was 128/70 her pulse was normal, asked
for abdo exam examiner said no need
I became confused so told the patient I would
like to R/O recurrence of tumor 😥 .. the kind
patient gave me strange look and as if she’s
surprised.. then suddenly Addison came to my
mind so I told her it might be Addison.. her
concern was should I continue on
prednisolone? I said yes it’s very important and
she was already planned for a follow up scan in
a week time so also told her that it’s important
to make sure no recurrence ..
✔ examiner asked about Addison’s, how to

diagnose?! Bed side examination? Lying and
standing BP ( needed time to say it as I was still
confused and can’t gather my thoughts)
He said BP is 128/70 lying and standing is
117/60 .. told him no postural drop but still
doesn’t role out Addison’s .. I thought I will get
20 but got 28/28
🔹 Abdomen : rt sided rooftop scar..

Patient looked marfanoid but didn’t mention that
.. I only mentioned the scar and said no signs of
CLD,
✔ examiner asked whats you differential!? I said

may be liver transplant but I would expect
Mercedes Benz scar , it could be other type of
hepatobiliary surgery but didn’t specify .. then
examiner asked me about transplant.. got 11/20
I saw similar case before in Edinburgh and it
was polycystic liver ..
🔹 Resp: sterntomy scar, patient had proptosis
and looked cushioned.. dullness on percussion
lt side minimal crackles rt side .. wasn’t sure
about anything mentioned possible lung
transplant, needed some prompting to list all
the positive signs as I wasn’t really sure of
anything and I didn’t want to invent signs...
✔ Examiner asked me about transplant and

repeated the same Qs from the previous case so
it felt strange because I was repeating my self ..
Yeah and patient had Bilateral lower limb
Oedema so examiner asked me if she’s in HF? I
said no as JVP not raised and no bibasal
crackles.. he said whats the cause then I said
steroids, he said what else I kept silent but I
think I should have said amoldepine for HTN
due to tacrolimus .. got 15/20
🔹 St2 : 27 years male history of lower back

pain.. pain for 3 weeks worse in the morning
and improves toward the day.. no other joint
pain no symptoms of connective tissue disease,
no urinary symptoms, patient was adopted so
not sure if any family history of same.. the only
other positive thing was small patch of rash the
comes and goes behind his ears..
I told him about ankylosing and also psoriasis,
explained my plan in detail..
✔ examiner Qs:
What’s your D diagnosis?
gave dd of sero negative arthropathy including
reactive arthritis ( I immediately mentioned to
him that he didn’t have urinary symptoms but
given his age I should’ve asked about sexual
history) he said that’s alright
Then he asked me more DD I said disc prolapse
so he started to ask me how I will investigate it ..
I said xray he said what else I said MRI, asked
what I will see in MRI ? Can’t even remember my
answer because I was really confused and
worried that I missed the case😣😣😣
Got 19/20 😂
🔹 Cardio : ESM all over pericardium +

sterntomy scar no harvest
✔ Gave diagnosis of AS + sterntomy scar either

due to LMA bypass or tissue valve
replacement.. examiners were very nice and
kept nodding there head and that was
reassuring 😂
Asked me usual Qs of AS and IE plus
indications for prophylaxis 20/20..
🔹 Neuro: Parkinson ( straight forward case)

Patient had tremors very obvious in the right
had .. did full upper limb exam, checked for
cerebellar signs and Parkinson’s targeted exam
.. checked eyes for nystagmus and PSP ..
✔ Examiner Q:
Diagnosis? Treatment? Mentioned the list of
medications .. asked me what is the best in his
case I said selegiline .. examiner seemed very
happy and gave me big smile the bell rang .. got
20/20
I was very dizzy didn’t even realize that exam
has finished..
Had long journey with PACES indeed.. but

honestly wouldn’t have made it with out this
group not only because I improved and my
knowledge grew in this group but because of
the emotional support and the good friends that
I came to know ..
Seremban, Malaysia
🔺 Station 1 :
1. Thalassemia with splenectomy
2. Bronchiectasis
🔺 Station 2 :
55y.o female .
Wt loss. Fatigue and low na.
Inside menses reduced and irregular
and depression
🔺Station 3
Neurology
Spastic paralysis
sca
Cvs
mvr
🔺 St 4.
50 y.o gentlemen with hemopthysis and cough.
Cxr right lung mass eith collapse
Counsell and mx.
Inside claustrophobia.
How to tell my wife about it.(question as 3x)
🔺 Bcc 1
Headache with possible OSA, Hypothyroidism
🔺 BCC 2 :
Transplant pt with tinggling sensation of bilater
hand and feet
Dx : hypocalcemia ?
16 April, Sremban, Malysia, carousel 3
Station 1
Abdo : underlying esrf with multiple scars neck ,
newly done fistula, abdomen ascites
Resp : left pleural effusion
St2 hemiplegic migraine

St3 cvs mix mitral valve disease
Neuro peripheral neuropathy
St 4 end stage liver disease

Discuss regarding resuscitation and not for RRT
and liver transplant
St
Bcc 1 psoariatic spondlyoarthopathy
Bcc2 systemic sclerosis

Experience in history and communication in
Khartoum soba centre on 9th April 🔺
🔺 Station 2 🔺
✔ from outside young male refer from GP

because of loss of conscious associated with
jerky movement once episode occur before 1
week and GP mentionined he is considering
epilepsy but not start treatment yet for your kind
care
✔ inside I start by confirming pt ID and ask him

open Q about his condition then ask about pre
during after episode
he lost his concious for about 15 min and had
focal jerky movement in his left side according
to wittness and injured his elbow no warning
sign or aura didnt wet himself or bite tongue he
regain his conscious spontaneously and stay
confuse for about 2 hs ,
✔ no headache or weakness post attack, other

CNS negative
✔ systemic review : cough for 3 months not

respond to simple antibiotics like
amoxicillin.constituional symptoma negative
except feeling tired for the last 3 months .
✔ PMH :history of hodkign lymphoma finish

treatment before 10 years and stop follow up by
doctor .mther had heatt attack at age of 50 other
siblings and father are ok. hobby
swiming not driving not smoker or alcohol
consumer , job engineer no night shift .
✔ Concerns ❗ too many Qs

- why i have it ?,
- can it recur ?
- is it serious ?
- can you start treatment now?
✔ my diagnosis was space occupying lesion

causing epileptic seizures
✔ examiner questions ❓
- what SOL you are concerned of : I said could
be mets or tuberculosis in the view of Ch cough
or toxoplasmosis snd could be idiopathic
epilepsy as well.
- what DD others than epilepsy : i said
vasovagal and cardiac and hypoglycemia
although no symptoms going with them.
- what investigation : I said basic and specific
EEG and MRI and CXR.
- then examiner ask about details of guideline
for driving in private car and HGL although pt
not driving 😕.then finished
⤵
🔺 Station 4 🔺
✔ IBS for ampitrypiline as decided by the

consultant, all investigation normal
✔ inside pt expecting consultant not me she

was angry i calm her then we start she has a lot
of stress Single mother husband died 2 ys
before taking care about hyperactive son ,
depressed mother on amitryptiline , stress in
Job working as Secretary
✔ I addressed her the stress she is facing and

give her some solutions in the form of involving
social worker , occuptional health worker .want
further investigation itold her no because of risk
. she doesn't want to start ampitryline because
she know it as medication for mad people and
also afraid of addiction
✔ I gave some advice regarding diet water tea

and coffee intake .not smoker or alcoholic ;
assessed mood no depression.
✔ finally she agreed to take it but also wanted to

see my consultant .I summarize and checked
understanding and promised to arrange for
meeting with consultant.
✔ examiner questions ❓
- why not to do further investigation what is the
detalis side effect of CT or colonscopy .
- what if she refuse to take drug ? her right
...autonomy what def how to make sure pt is
comptent ?
- what othe modality of Rt cogntive therapy ....
do you thing you mange to confessed her? yes
..what is the dis you exclude by investigation?
ceiac and IBD
- to whom you want to refer her son and mother
❗ like 10 examiner Q, then finish 😣

My exam feedback: Diet 1,Colombo
I started my exam with station 4
Outside the scenario was a new one. 58 years
old lady with iron deficiency anaemia with
history of chronic analgesic intake due to
arthritis. Though the likely cause of anaemia is
analgesic induced peptic ulcer bleeding; but
consultant wants to do a complete work up. My
task is to convince the patient for appropriate
investigations and manage her concerns.
Reading the scenario, I thought it was upper GI
endoscopy they were trying to mean. So I draw
the picture of endoscopy from outside. Then
started talking with her, told her about the
possible causes of anaemia, need and benefits
of upper GI endoscopy; also the risks
associated with it.Also told a 2nd line
investigation will be colonoscopy; but did not
elaborate that much. Tried to address her
concerns and at the end, she seemed to be
convinced with the idea of endoscopy.
Crossing: Why didnt you emphasize on lower GI
endoscopy?
I told patient had a long history of analgesic
intake, so likely that findings will be there and
also I didnt omit the idea of colonoscopy; I told
its a 2nd line investigation.
Nevertheless; they gave me full marks here, but
I beleive they were expecting councelling for
both upper and lower GI endiscopy at the same
setting.
BCC 1: Patient came with resistant hypertension

Inside, it was a clear cut case of Acromegaly.
BCC 2: Patient with h/o childhood epilepsy

came with recent recurrent seizure
Inside, it was a patient of tuberous sclerosis.

Had a pneumonia recently treated with co-
amoxyclav and theophylline which precipitated
the seizure.
St 3: resp case still not sure what it was.

Trachea obviously deviated to right; breath
sound and vocal resonance diminished over
right upper zone, percussion note dull,
scattered fine end inspiratory crepitations all
over the lung field.
Gave differentials of Right upper lobe
fibrosis/collapse.
But I got only 9 in this station; so likely that dx
was not right.
Abd- Hereditary hemolytic anaemia
among the differentials, they were particularly
looking for primary hemochromatosis.
St 2: type 1 diabetic patient came with recurrent

hypo attacks.
This was a common case which we have seen in
previous feedbacks. Went smooth AL HAMDU
LILLAH.
St 1: CVS-Mitral regurgitation with atrial
fibrillation
Neuro: again a bit confusing case
prompt was patient has difficulty in gripping
objects.
Inside he had unilateral distal wasting with a
scar mark ( possibly due to trauma) over medial
dorsal aspect of hand. Reflexes on that limb
were all diminished.
All modilities of sensation was impaired along
the medial border of hand upto 2 inch above the
wrist. Co ordination was intact.
I gave differentials of radiculopathy/
plexopathy/peripheral neuropathy
Got 16/20
Another candidate mentioned traumatic ulnar
nerve palsy and got full marks.
At the end of the day, I passed AL HAMDU

LILLAH with a score of 152
Sudan, 10th April
Station 2
40 yrs old man with H/O LOC followed by fits
while he was in shopping.
When I asked him .
There is no h o tongue biting . No loss of sph.
Control . No frothy secretion
but he was drowsy for about 2 hrs after the
attack ,
He had H/O headache 5 to 7 in grade it was
more in the morning .
No F.H of epilepsy
No drug hist
He had H.O Lymphoma 20 yrs ago and received
chemo.and radio
No hx of hypoglycaemia
No h.o brain cancer or bleeding
No h.o trauma
No h.o brain cancer or bleeding
No h.o trauma
No fever . No wt loss
No cardiac hx
he was drowsy for 2 hrs
I put the space occupying Lesion first
as he had h o early morning headache 5 to 7 in
severity
then epilepsy
Vasovagal
Arrhythmia
Hypoglycaemia
Endocrine
He asked about relationship between h.o
lymphoma
Yes ,but put it in the bottom
Oman SQUH 8th April
🎈Station 2:
29years female with transite loss of
consciousness for 15 seconds while standing in
a queue with jerkness and loss of urine control.
She was pale and sweaty. No post ictal state. No
cardic risk factors
Family history of epilepsy.
Concern: is it seizure and wants to start
learning to drive.
🎈station 3:
Cvs; metal mitral valve.
Viva indication of valve replacement. Causes of
MR. Indication of presence of murmur in metalic
valve. Diagnosis of IE. Complications of metal
valve. Target INR in mitral valve
CNS: Proximal myopathy. Wasting of face

muscle.
Myotonia dystrophic vs fascioscapulohumeral.
Viva; Differential of proximal myopathy
Investigation. Management.
🎈Station 4
Talk to daughter of 72yr male with severe COPD
exacerbation (PFT 6month ago) On NIV
contnious now. Team decided not for
intubation.
Pt want to travel for grand daughter wedding in
3 month time. He was previously uncertain to
use NIV at home.
Concerns: Will he be better. Why is he not for
intubation. How will manage the NIV at home
Viva: how's decision not to intubate family or
doctor. If daughter want intubation and pt
dosent want, who to decide. How to prevent co-
patients complaining later if patient died.
🎈Station 5
A. Painful swallowing for 10 day. History of UTI
conpletelty recovered 1 month ago.
Not a pt a surrogate no findings
Differential; esophagitis, candida, thyroiditis.
Viva in thyroiditis investigation
B. Severe headache and nausea for 1 day.
Background history for 2 month worse in one
day with projectile vomiting. Loss of side vision.
No features of functioning adenoma.
Viva in differential (non functioning pituitary
adenoma) and investigation of pituitary
adenoma. Apoplexy.
Urgency of CT brain.
Management surgical and medical.
🎈Station 1
Chest bronchectaisis with clubbing cavity on
lower Rt lung and drain scars.
Viva differential and management
Abdomen.
Rt renal tansplanat.
Viva differential of Rt iliac mass.
Investigation and follow up in renal transplanat.
april 2018 SQUH , oman
St 2... fever with 3 wks , dry cough for 1 month ,

weight loss , lump in groin
I put t.b ,, sarcodosis ,, carcinoma , hiv ,,, but
examiner was angry as tb at top
St 3 ,,, aortic valva replacement ,, charcot marie
tooth
St 4 ,,, pt want go lama c/o headache and neck
stifness and ct was normal and counsel about lp
as sah ,, pt well fly to america after 3 days ,,,
concern about if she done lp and its ok can fly
by plane after 3 days
St5
1. Obesity , failure to concieve for 5 year ,,, pcos
2. Retinitis pegmintosa ,,, concern is this poor
vision due to brain tumour
St 1😰😰😰
Chest .. dont know may be bronchiactasis but i
said fibrosis and copd
Abdomen ,,, kidney transplant ,, but their is
hepatosplenomegaly
Sandwell hospital, UK
✅ Resp : left thoracotomy scar..dds for

lobectomy
✅ Abdomen : normal patient had only few

spider naevi...asked about causes of spider
naevi and treatment...thumbs up by examiner
✅ Station 2
Daibetic with fatigue
Long hx..
Examiner satisfied
✅ Cardio= Mid line sternotomy scar,mvr
✅ Neuro= spastic paraplagia with normal

sensations,asked about ďds and Management
✅ Station 4
90 yr old female,anemic,refused
colonoscopy,now presented with massive ant
wall MI..task was to convince her son to manage
via drugs not fot PCI and any other intervention
due to poor prognosis.
✅ BCC 1
Post graves thyroidectomy.now with weight
gain and lethargy
✅ BCC 2
20 yr old male with ulcerative colitis presented
with chest pain....
My exam experience :
18/3/18, Malta
🔹station 1:
🔻Chest: examine this lady with SOB:

pt with clubbing, raynauds, gottron papules,
helitrope rash, telengectasia and puckering of
mouth.... in chest there were fine end inspiratory
crepts that did not change on coughing
Diagnosis: ILD sec to mixed connective tissue
disease
Examiner Questions:
How you will manage this pt
Got 20/20
🔻Abdomen:
Examine this lady with abdominal pain
Young lady with pallor and moderate
spleenomegaly
Diagnosis:
Lymphoproliferative/ myeloproliferative dis
Examiner Questions:
Any Examples of lymphoproliferative disorders
What to look for in blood film
Indications of spleenectomy
Vaccination needed after spleenectomy
Got 20/20
🔹station 2
Ramipril induced angioedema
Got 20/20
🔹station 3:
🔻cardio:
Examine this lady who presented with SOB
Middle aged lady with tapping, undisplaced
apex beat, loud P2, pansystolic murmur in the
mitral area radiating to axilla...
Diagnosis: MR
Examiner questions:
What are your findings?
How you will investigate this pt?
Did you hear any other murmur?
Criteria to assess severity?
How you will manage this pt?
What advice you will give to this pt >>>before
any dental procedure
I think i missed another murmur...
Got 16/20
🔻Neuro
Examine lower limb
It was spastic paraparesis with intact sensation
and no cerebellar signs
Examiner questions:
What are your d/d>> hereditary spastic
paraparesis, MS, cerebral palsy
Viva about hereditary spastic paraparesis
How you will manage this pt plus counseling
Got 20/20
🔹station 4:
Talk to son of Mrs Greck, 70 yrs old lady, living
alone at home, admitted 2 days back with
delerium and UTI, started on iv fluids and
antibiotics, responding well, initially the RFTs
were derranged with raised urea and creatinine
but improving now... nurses have noticed that
she is less agitated now... pt was admitted 2
months back with similar complaints made full
recovery and discharged.... during this
admission she also developed a black heel
ulcer...
Assume that you have permission of mrs greck
to talk to her son about her condition....
Very nice surrogate....
Concerns:
1:how is her condition.....
2:My mother was diagnosed with early
dementia.... i think she is not drinking enough
water .... is this the reason she is getting this
infection......
3: i am worried because she lives alone... if she
doesn’t take care of her self she can develop
this infection again....
4: is this negligence of nurses that she
developed black heel ulcer
5: one of the nurses told her that she might
need to be admitted in geriatric care.... she
doesn’t want that.... what can be done for her...
6: what you will do for this black heel ulcer...
Examiner questions:
Could you please summarize your discussion ?
What ethics were involved ?
The nurses for taking care of such ulcers....
what are they called? ...tissue viability nurse.
How you will explain the prognosis of this pt to
his son...
Got 16/16
🔹station 5
🔻BCC1
Outside scenario: 65 yrs old male with SOB,
hypertensive ....
On history: exertional SOB with some chest
discomfort improves with rest...
No orth
I did not pick any findings on examination
Examiner questions
What are your findings? 🙁

What are your d/d
Got 13/28
🔻BCC2
50 yrs old male, with abdominal pain 1-2 hrs
after taking food, improves on leaning forward,
alcoholic....
Concern:,is it because of my drinking habits
Examiner questions
What is your diagnosis: alcoholic pancreatitis
Got 27/28
Alhamdulillah passed with score of 152/172
Khartoum 8/4/2018
Station 1
- splenomegaly
- Lung fibrosis (trachea deviated to opposite
site😳
Statin 2:
30 years old female known DM for 15 years
came with fatiguability and weight loss .
Station 3:
- spastic paraparesis without sensory loss
-
- Communication
- Female with who developed Steven Johnson
syndrome after delivery following iv antibiotic
talk to the husband.
Station 5:
BCC 1: Middle age male chronic diarrhea with
old laparotomy scare .
- BCC 2 : Elderly male with history of syncope (
cardiac-) with murmur and left ankle swelling
oman 8 april, 2nd carousal 🔺
🔺Station 1
Resp : Rt upper lobe fibrosis
Abdomen : Renal transplant with spleenectomy
🔺Station 3
Cardio : Marfan and AR MR
Neuro : MS
🔺 Station 4 : drug allergy
🔺 Station 2 : IBS father recent ca colon
🔺Station 5
BCC 1 : hyperthyroid with vitiligo
BCC 2 : hemarthosis due to haemophilia🔹
passed from Manipal Hospital,Bangalore with a

score of 152/172.
my exam started with st 5.Bcc 1-young women
with wt loss and shaking of hands.vitals were
given to be normal on the quest paper.there was
a young woman with no visible thyroid on
swallowing ...examinar asked about bruit I found
no bruit .pt also had amenorrhea.. dd
thyrotoxicosis..scored 28/28.
bcc 2- elderly man with forgetfulness with

difficulty in communication...no pt ..talk to his
wife...dd ..parkinsons,alzheimers,parkinson
plus..score 27/28..
st 2-young woman with tiredness..cbc shows

Anemia... she has loose stool,pisitive travel
history..I thought I did good ..told dd of celiac,
IBD..examinar asked ..then I told abt
giardiasis..got 10/20.:(
st 4 : talk to angry son of a mother who

developed steroid induced psychosis due to
suspected GCAand was not informed about
transfer of his mother .his concern was wht u r
thinking about the headache ...I told tht if it was
gca it would have responded ..as it is still there
..we r going to observe and if needed we can
consult brain doctor regarding his
management.got 16/16..
8th April, Oman diet 1
Station 4 : speak to daughter her father

presented with type 2 respiratory failure now
developed chest infection on NIVentelitation
difficult to weaned from this at night also had
lower limb edema onantibiotic &lasix the icu
doctor decide his prognosis is poor and not for
invasive ventelition
BCC 1 : Raised intracranial hypertension with

hx of chronic headache increased today with
vomitting
BCC 2 : Pt with difficulty in swallowing &pain 10
days she had hx of uti 1 month treated with
antibiotics my DD thyroiditis simple throat
infection & candidiasis
Station 1 :
Abdomen : post renal transplant
Resp : copd with bronchiectasis
Station 2 : Vasovagal syncope
Station 3 :
Neuro : proximal myopathy
Cardio : Valve replacement
7th of april diet 1 Oman

Chest bronchectasis with lobectomy
Abdomen renal transplant
Station 2
Diabetic with triopathy and af came with
recurrent attacks of LOC
Cvs AS
Neurology PNS HSMN
STAtion 4
IBS explain diagnosis and start amytriptalin
Station 5
1. PAINFUL HANDS
2. DRY EYES
Khartoum 8/4/2018 , Cycle 1
Respiratory. Lt lobectomy
Abd :transplanted kidney
St 2:uncontrolled DM/depression
St:3AR??
Peripheral neuropathy edorsal column affection

st 4:young lady developed Steven Johnson
syndrome after receiving penicillin for treatment
of streptococcal vaginal infection. She
deteriorate d and developed liver failure and
renal failure for icu admission and may
necesceiate ventilation. Talk to her husband.
St5:1:history of chronic diarrhea. Inside young

man e scar and evidence of steroid use
IBD
2/recurrent loss of conciousness
Oman , Squh cycle 2🔺
🔹 Station 1
thalassemia
Transplanted Kidney
🔹 Station 2
Ibs with family history of ca colon father.
Brother. Grandfather
🔹 Station 3
Cns????
Cvs ar
🔹 Station 4
Steven johnson
🔹 Station 5
Heamarthrosis
Toxic multinodular goiter
passed from chennae. diet 1
started with station3
CVS: teenage boy with AV fiatula in left arm
extending upto shoulders, patient tachycardic,
first heart sound loud, systolic murmur in whole
precordium difficult to differentiate from fistula
mumur, obviuos F/O pul HTN. i gave dx mixed
mitral valve disease with pul HTN. they asked
which one prominant, i said MR. questions
regarding Inv and Mx. got 20
Neuro: prompt walking difficulty. obvious Right

sided haemipaeresis with right sided UMN
seventh cranial nerve palsy. asked about Dx, inv
and mx. got 20
station 4: patient with metastatic Ca Pancreas,

palliative care team plan for ERCP. Task: talk to
daughter: daughter knows the diagnosis. i had
to explain the disease is incurable. i showed
empathyn sympathy. explain ERCP with
drawing. then MDT management plan specially
about Macmillan nurse.daughter asked about
second opinion i said they have the right
on crossing: what are the issues, what is
pallative care, from whom will you take help if
you can not convince her: senior stuff nurse, is
ca pancreas painful? why?: due to involvement
of caeliac plexus. got 16
station 5: BCC1: outside: middle aged women
with joint pain. Inside: middle aged women with
deforming hands, specially in DIP, non
inflammatory type, i noticed some nodules just
below wrist. patient has AV fistula. gave H/O
HTN on thiazde BP was high. i examine like
rheumatoid hands. counsell regarding changing
of HTN meds not to take alchohol and red meat.
MY Dx: GOUT, dd: RA, OA, Psoriatic. asked
about inv and Mx 28
BCC2: outside: young woman with Abd pain.
inside: sudden onset, at loin radiates to groin,
with dysuria but no fever, one episode of
vomiting. it was surrogate. acted like tender
abdomen. so i was cautious not loss marks in
welfare. vitals are normal.BP slightly high. my
DX: ureteric colic due to stone. asked about inv
and Mx. what advice will you give? take large
amount of water everyday. got 28
station1:
Abdomen: fistula in left arm, anaemia. bilateral
ballotable kidney.no other organomegally....Dx:
ESRD due to ADPKD. question: dd of enlarge
kidney, inv and mx. got 20
Resp: Elderly man with obvious COPD with
bilateral crepition. crepition was coarse but
inspiratory. i gave DD: COPD with ILD/
Bronchiectasis/ infective exacerbation. they
asked which one first. i said ILD . they wanted
bronchiectasis first. asked inv and Mx. got 16
station2: middle aged diabetic man with

repeated hypoglycaemia with high creatinine
with mild anaemia.
on history taking: gave history of abdominal
bloating but no other F/O autonomic
neuropathy. gave few kg weight loss. no other
micro or macro vascular complications, no
pigmentation. i gave Dd of: hypoglycaemia due
to renal failure, a nddisons as a part of APS,
autonomic neuropathy, caeliac disease. patient
was depressed, concern was why hypo and how
you will help. i said about referral to dietitian.
endocrinologist, specialist nurse. gave advice to
take frequent regular snacks to prevent hypo
and stop driving. examiners asked about Dd,
inv, which specialist review for depression. i
said clinical psychologist. got 20
Alhamdulillah i passed got 168.

Oman 6th April
🔺 Started with station2 45 years male c/o left

knee swelling and pain for the last 2month he
have 2 attack go for gp give him naproxen his
pain improve put gp reluctant to continue on
nsad as pt has hx of ischemic heart disease
.inside pt has this 2attak of pain and swlling e
limitation of movements .on asking also he has
attack of big toe pain before not going for Dr ph
of ihd and on atenolol aspirin and simvastain
.also he has hx of uc several years put control
on azthioprine .
Pt concern about this pain and he want other
pain killer Bec of heart attack?
What is cause of my symptoms?
Ex qu
Dd/ investigation
Image other than x-ray can help in diagnosis
Any Relation between uc and gout? I think he
mean azthioprine and allouprinole interaction.
Ask also about alternative medication for long
term management..
🔺 St3 cns sensory motor polyneuropathy
🔺 CVS AVR
🔺 St4 APKD 25 years f come to gp do us which

show she has pkd Bec her father have pkd on
dialysis complicated by pretonitis and he is I'm
mesirable condition pt plan to start family e in 3
month
Your task explain about disease and no chance
for genetic testing for her children will offer only
us at age of 18-20
Pt concern about her future and she will end like
her father ?
She want to prevent her future kids from
disease?
How she will tell her fiance ?
Ex qu
Same qu of surrogate discussion about any
chance to prevent future children?
If pt want you tell her fiance do you will tell him
about every things about disease?
Also pt has on brother 15 and he is minor but
you will make sure he will be contacted and
offer test when he will reach 18 years?
🔺 Bcc1 diabetic retinopathy
🔺 Bcc2 recurrent hypoglycemia .autonomic

neuropathy
🔺 St 1 chest bronchectasis with lobectomy
🔺 Abd renal transplant

Chennai :Sundaram Medical Foundation Diet
2018/01 2nd Day 2nd Carousal
Started with BCC1: outside: Skin rash with joint
pain
Inside:Psoriasis with Psoriatic Arthritis with nail
changes.Hypertensive getting ACEi.
Qus:
Diagnosis,Investigations,Management,Prognosi
s.
Got :28/28
BCC 2: Outside: Young male with abdominal
pain and loose motion for 3 month
Inside: wt loss,no relationship with food,milk,no
joint pain, red eye,painful eye,no travel
history.watery diarrhohea,no blood,no
slime.Positive history for multiple sexual
partners,no sore throat,lymphadenopathy,no
oro genital ulcer,no urethral
discharge,tenderness in right iliac fossa.wt loss
2 kg in 3 month.no history of antibiotic use,or
contact with TB person,no postural drop.I gave
DD: HIV enteropathy,IBD,CD & other
malabsorption. qus: 1.What stool
examinations?2. If you find ulcer in
colonoscopy then what you will do? 3. How you
test for HIV? 4. If HIV serology is positive will
you start HAART?
Got:28/28.
Abdomen: ESRD,Active Fistula,ADPKD
,Anaemia. qus was : Investigations,Cause of
Anaemia,Treatment of Anaemia,Dose of EPO
and how to administer. Got 18/20(May i didnt
mention about enlarged cystic liver)
Respiratoty: Bronciectasis with COPD .Qus:
Positive findings,Investigation,Management,If
the pt comes with massive hemoptysis what
you will do?I said I will admit the pt in
ICU,urgent Blood grouping and cross matching
and involvement of respiratory team and
management of ABC.Got 20/20.
Station 2: young female with history of fall and
urinary incontinence and positive family history
for epilepsy.Diagnosis: Vasovagal syncope,DD:
Cardiac
syncope,TIA,Hypoglycaemia,Seizure.Concern:
Driving.
Qus: Inv and management .Got 20/20.
Cardio: Middle aged female.Positive findings:

AF in rate control,mitral vulvuloplasty scar,loud
S1 with variable intesity,bipedal edema.Lady
was fat so didnt mention about apex beat.Plus
there was no audible murmur .Qus was around
MS,Investigations,management .Got 20/20.
Neuro: to me it was UMN type of VII the nerve
palsy as the lady can frown and close her eyes
tightly and lower half of face was involved.No
scar mark no vesicles,no long tract sign,no
cerebellar signs. Qus was around both UMN &
LMN type lesion. Got: 8/20 (It was KMN type).
Station 4: young female recently diagnosed with

ADPKD,Father has ADPKD on MHD,poor quality
of life.Planning to get married.Worried about
future kids,brothers,whether to tell her
fiance,will she need dialysis and lead a
miserable life like father. Got 16/16.
Alhamdulillah Passed in the first attempt with

158/172.
By the grace of Almighty Allah I've passed
PACES on my 1st attempt in 2018/1 diet from
Chennai Madras Medical Mission Hospital...
Started with st 2: middle aged man presented
with recurrent collapse. Known case of T1 DM
with all microvascular complications and all
features of autonomic neuropathy..history was
not so typical of hypoglycemia..past history and
drug history revealed he was on multiple
medications like beta blocker, ACEI, diuretics,
warfarin, insulin,..my D/Ds were hypoglycemia
due to diabetic autonomic neuropathy,
cardiogenic syncope, postural hypotension due
to drugs and autonomic neuropathy,
hypoadrenalism..
Concerns were about driving, family planning as
he had erectile dysfunction
Crossing was on management, investigations,
consequences of syncope in his case and
causes, DVLA rules,
Got 20/20 ☺
St 3: cardio was ms+mr+af+pulmonary
hypertension
Crossing was on inv, mx, af, anticoagulation,
complications
Got 20/20☺
Neuro was hemiparesis with umn 7th.. went
smooth. Patient had aphasia and walking aid
besides his bed
Crossing on dd, inv, mx, thrombolysis,
thrombectomy, young stroke..
Got 20/20 ☺
St was to convince a lady for lp who wants to
travel to usa..I was able to convince her
partially.. offered 2nd opinion
Got 16/16☺
Bcc 1: neck lump, euthyroid, lump increasing in
size..
Concern was about possibility of cancer..
Crossing was on d/d, inv, mx, MEN 2
Got 28/28☺
Bcc 2: young lady with right loin pain with
features suggestive of UTI..excluded stone,
cysts..Concerns were about possibility of
ectopic pregnancy..menstrual history did not
suggest that so i told it's unlikely..
Crossing was on Dr, inv,mx, ectopic
pregnancy!!
Got 27/28😕
St 1: respi: I gave dd as copd with infective
execerbation/ bronchiectasis
Crossing was on every details of dd, inv, mx,
complications
Got 20/20 ☺
Abd: Esrd with adpkd on HD..
Crossing was on esrd, adpkd, dd, mx,
Got 20/20
Passed with 171 Alhamdulillah..
Edinburgh Border general hospital diet 1
I started with station 2-
outside paper read 54 yr old lady with chronic

fatigue and wt loss..gp did bloods normal Hb,
normal TFT, normal renal function, normal LFT.
Inside history was wt loss fatigue for 6
months..no other red fkag except nausea, PMH
hypothyroidism, FH aunt had bowel ca,
daughter is T1DM..social and personal hist
nothng sig except has been in lot if stress due
to work and caring for daughter.
Main concern: is it cancer and what are we

going to do
Viva: DD, inv, bit on MEN
Station 3- cardio was metallic AVR with AR

Viva: how would you knw clinicaly it is sig AR,
investigations, echo criterias of severe AR
NEURO: i ahve no idea about diag. Task was
examine UL. Findings proximal weakness, no
sensory deficit, no cerebellar signs. I said
proximal myopathy.
Viva: inv, then he asked what do I think the

cause is..I said am unsure..he asked me to
check this persons neck and he had weak neck
flexion..he again asked me whats diagnosis now
I said I dont knw...he laughed and said thats
alright
Station 4-
82 yr old lady had NSTEMI, ckd4 refused angio

talk to daughter.
Her concerns were shld we frce mum for
angio...is it that she is nt requiring adequate
treatment..long term issues..she thinks mum
might nkt understand the importance if the
procedure.
Station 5
-BCC1 outside lady with hand pain

examine..inside reynaulds, hist of indigestiom,
on examination reynaulds, calcinosis
Concerns: what is it..wht will we do for hand
pain
BCC2 - outside gentleman refered from pre op

clinic of cholecystectomy because of neck
swelling
Inside : no positive hist, BG HTN , on
examination multinodular goitre and euthyroid
Viva: diagnosis, inv
Staion 1 Resp: idiopathic pulmonary fibrosis

only finding was bibasal crackled
Abdomen: liver transplant, thre ws a separate
horizontal scar at his umbilical levek examiner
asked what it is..i said might be drain sites or
some bladder procedure separate from the
transplant. Viva: kings college criteria,
immunosuppresants and side effects
Oman 7 April
Station 2: Dm.. htn complain of recurrent

dizziness
Station 3:peripheral neuropathy...Aortic

stenosis
Station 4 Ibs for amitriptylin
Station 5:_ epigastric pain due to nsaid for joint

RA
_dry eye and dry mouth
Station 1:upper lobectomy...renal:rt iliac fossa

scar and mass+permicath catheter
passed from Madras Medical Mission Hospital,
Chennai in 2018/01 diet with the score of
154/172.
My exam started with Station 5
BCC1- 40 yrs old lady came with fatigue, CBC

showed low Hb.
She gave history of menorrhagia only, I asked
her about features of hypothyroidism, all
bleeding disorders, family h/o, drug h/o,
occupational h/o,details menstrual and obs h/o
but there was no clue. Only h/o wt loss.
General examination , skin survey were
normal.Abdomen was a little distended but no
organomegaly.
My dx was fatigue due to anaemia as a result of
menorrhagia possibly due to gynaecological
malignancy.
Question were on inv , mx and referral to Gynae
and obs.
Score 27/28
BCC2- 40 yrs old lady, known case of epilepsy

for 12 yrs came with one attack of seizure
I took h/o to establish true seizure, there was h/
o party the night before attack, also had h/o
vomiting and missed a dose of phenytoin.No h/o
recent fever,no other h/o precipitating coz for
seizrure, no h/o low IQ or skin lesion, no h/o
symptoms suggestive of ICSOL
Examination revealed no abnormality
Questions was coz of attack, inv , mx
They asked me whether I have checked side
effects of phenytoin, I didn't do it.
Score 22/28
Station-1
Abdomen: ESRD due to ADPKD with renal
transplant with av fistula.I thought there were
multiple av fistula but in reality there was one
fistula which got engorged in 3 different sites ,
examiner was kind of rude and wasn't helpful.
Score 11/20
Respiratory: Rt sided upper lobe fibrosis with
Obstructive Airway Disease
Questions were about inv, mx, how to manage
him if he gets admitted with SOB, steroid can be
given or not in this case if it is post TB fibrosis
Score:20/20
Station 2
Young male presented with low back pain....
Gave positive h/o inflammatory back pain, one
skin rash behind ear and had issues regarding
job as he was a cleaner. Bowel habit was
normal.no h/o exposure, uti , no h/o exra
articular manifestation of Sero negative
arthropathy.
My d/d Psoriatic spondyloarthopathy,
Ank.spondilytis
Questions about Inv, Mx.
Score 20/20
Station 3
CVS: Mixed Mitral valve ds with predominant

MR with AF with pulmonary HTN
Question about inv, Mx ,Newer anticoagulants
name, whether they can be given in this case or
not
Score 18/20
CNS: Young male has come with walking
difficulty, examine his LL. On examination he
was a case of lt sided Hemiplegia.
Question about possible cause of hemiplegia, if
it is stroke which area is involved, how to inv
and mx
Score20/20
Station 4
Talk to angry son whose mother was diagnosed
with GCA on the basis of severe headache when
she was at a rehabilitation centre after surgical
treatment of femur fracture, was given high
dose steroid and developed psychosis.Later he
was tranferred to hospital and it was found that
she wasn't a case of GCA and steroid was
stopped.
Score 16/16
I was really upset about the unusual cases of

station 5 and also examiner wasn’t happy at all
at Abdomen station.But the Almighty ALLAH
blessed me and I passed the exam in 1st
chance.
So ALHAMDULILLAH!!
Chennai Diet 1 2018 Madras Medical Mission
St 4 70 yo F admitted for hip surgery and
recovering well in rehabilitation unit suddenly
had Headache. Attending doctor started her on
steroids suspecting GCA, after which she
developed steroid psychosis. She was taken in
the main hospital building under medical team
and the son was not informed. Task was to talk
to angry son.
Cross was about whether it was negligence.
Complaints procedure.
St 5 BCC1
40 yo F came to AE feeling faint. Her GP did
some test which revealed Hbs 7.8( roughly can't
remember the exact number)
MCV 65
Inside I found only menstrual abnormality which
I didn't probe further , as I was hurrying to
exclude other DDs. Pt had no anaemia.
Gave DD of possible causes of anaemia
including gynecological problem.
Cross was with inv, mx.
BCC2
45 yo F with seizure and diarrhea for last 1 day
Known case of epilepsy , forgot to take
medicine due to illness. Diahorrea for 4 days
which showed no co relation with seizure or
drug.
St1
Middle aged male ESRD or with renal transplant
and AV fistula.
I was confused with liver as I thought I found
hepatomegaly.
Cross was on why hepatomegaly , Inv, mx.
Resp
It was a very confusing case for me. A middle
aged F , found only rhonchi, and crepts at both
bases which were not typical bronchiectasis .
Gave dd of asthma, copd with IE , bronchi
Cross was on inv, mcg.
St2.
30 yo M with fatigue and back pain.
Inside was sspA psoriatic.
Cross was in on DD, inv, mx.
St3
MS with pul htn with AF
Usual cross on inv finds, complications, mx
HSMN
Cross on dd, inv, Mx.
Got full marks in st2, 4,3, bcc 2.
St1 and bcc 1 was not smooth and lost marks.
Alhamdulillah passed.
Oman 6 april , first cycle🔹
➡ Station 1
🔹bronchiactasis
🔹transplanted kidney
➡ station 2
🔹 gout
➡ station 3
🔹 AVR
🔹 neuro ???
➡ St 4
🔹 ADPkD
➡ Bcc 1
🔹 fundus Dm retinopathy
➡ Bcc 2
🔹 Dm with recurrent hypoglycemia
Oman 5th April Cycle 3🔺
➡ Station 1
🔹 Abdomen : Polycystic kidney
🔹 Respiratory : bronchiectasis
➡ Station 2
➡ Station 3
🔹 Cardio : AVR + MS
🔹 Neuro : Sturge Weber - Hemiparesis

➡ Station 4
89 year old, k/c of A. Fib and past Hx of TIA ,
nowadmitted with Stroke, missed his last
appointment at INR clinic. INR on admission
was 1.2. Task is talk to the daughter and explain
act Scan findings, need for patient to be
admitted in hospital
➡ Station 5
🔹 BCC 1
Systmic sclerosis
🔹 BCC 2
Acromegally
Mandalay diet 1 last day first round
I statred with station 1 abd , pt have only
moderate splenomegaly and jaundice only
I told DDX hemilytic anaemia , CML and COL
with PTH
examiner questions are causes of COL and How
to investigate and manage , I got 20/20
Resp station - middle age lady with DOE and dry

cough for 3 months
PE showed bilateral fine basal crept and o2
inhalation , I said ILD and I give DDX of ILD for
that lady , examiner questions are causes of ILD
and How to diagnose and manage . I got 20/20
Station 2 History
25 lady with Hypertension and Fatigue and
Urine RE showed protein and RBC at outside
Detail history she has hypertension, muscle
pain and fever 2 wk ago and weight loss for 6
months and menorrhagia and taking OC pill for
that . Plan to marriage and to get pregnancy
soon .
I explored secondary cause of HTN and features
of SLE
I said DX -GN secondary to connective tissue ds
SLE ,DDX primary or other secondary GN or
other vasculitis like Takayarsu
Concern - How about pregnancy - I said to early
to say we have to confirm DX if it is SLE you
must take treatment and pregnancy should be
avoid at that time ,
Can I continue OCPill - No , we discuss OG
doctor and will change another method
Examiner question- DX and how to investigate- I
said investigations for SLE and GN and to
exclude 2 cause of hypertension
Aorto gram for Takaryarsu
How to treatment- if it is SLE confirmed
Immunosuppressive and ACEI or ARB for BP
control
They asked Why ACEI I said renoprotective and
to reduced proteinuria
I got 20/20
Statins 3
Started with cvs
Patient is young age and has cyanosis clubbing
and pansystolic mur all over area and more in
pul area and no lord p2 but parasternal heaving
+
I said DDX TOF and essemenger syndrome of
VSD and ASD
Examination questions are how to investigate
and MX
I got 19/20 .loss 1 mark in PE method
(CNS station )- young boy with spastic

paraparesis and post column involvement ,
bilateral cerbeller involvement, but no sensory
level
I give DDX of MS, Cervical myelopathy ,tropical
spastic paraparesis , SCDS, Taboparesis
Examiner asked he is very young what about
another DX , they expected hereditary spastic
paraparesis but I didn’t know
And then they asked how to investigate and mx
I said about MS so MRI and LP and serology and
B12, folic acid level but they r not happy
I got 16/20 actually I loss DDX and clinical

judgement skill 2 marks each .
Station 4
Talking with son
Patient is decompensated liver disease due to
alcohol and repeated admission with alcoholic
liver problem ,he continued drinking
Now admitted with Hepatic encephalopathy,
SBP, HRS and unconscious
Consultant decision just conservative and not
for RRT/HD and liver transplant
Intro and asked son for his prior knowledge
He think his father condition is same with
previous admission and so I explain detail like
BBN
He request liver transplant and I explained
transplant is not best interest because of
surgical risk and his recent condition and his
best interest is just supportive
Task is explain update condition of patient and
DNR so I explain About DNR also
Finally he agreed .
Examiner question what is ethical and legal
issue
For DNR what you should explore
I said patient wish regarding this condition and
living will
I got 16/16
Station 5
Bcc1 outside 50 female patient with SOB and
tiredness
She has joint diseases since 10 years ago
Inside patient is RA and PE showed bilateral
lung crepes no anaemia
Drugs chat showed MTX and NSAID
I want to examine abd they not allowed
I explained you have lung fibrosis may be
disease itself or drugs induced
I want to do CT chest and some blood test and
consult with bone and joint dr we will change
another appropriate drugs
Concern - it is cure ? I am not sure but some are
cure ,some are not , but we have so many
supportive to control symptoms and we give
care with multidisciplinary team including lung
doctors , rheumatologist, physicians and
special nurse and physiotherapist.
Another concern is is it due to drugs ? I said
may be and will review with rheumatologist
Examiner asked what are finding I said
symmetrical deforming arthropathy no active
inflammation and well preserved functions and
ILD due to RA itself or MTX induced
That asked how to treat and I said change the
MTX and HRCT and lung function test and
Blood tests for disease activities and refer to
multidisciplinary team .
I got 28/28
BCC2 outside 75 female with tingling and

numberless of left side of body off and on
Inside history recurrent tingling and numbers of
left side of body , no motor and others CNS
symptoms
Recovers 2 to 3 hours
So taking traditional medicine , she has t2DM,
HTN , chronic smoker not taking treatment
regularly, and she is driving care
She didn’t show drugs chat and not tell which
medicine she is taking
PE showed AF only no motor weakness and
murmur no carotid bruit ,
Concern how I can help ?
I said you have mini stroke due to above risk
factors and urgent arrange to meet neurologist
because higher risk for stroke and should stop
smoking, and traditional drug, will review status
of DM and medicine for control and Need to
admit
Can she suffer stroke ? I said she is higher risk
for stroke and so we want urgently assess and
treat her to prevent stroke
Mean while not to drive .
Examiner asked what your findings- AF only
How to DX - CT head , full cardiac assessment

and carotid Doppler and CVD risk factor like CP
, lipid profile and base line liver and kidney
function
They asked how to treat- Aspilet and statin and
for AF consider warfarin
I got 28/28
I passed with 167/172

29 March, Wishaw, UK 🔺
🔹 Station 2⃣ : SOB & fever in known IVDU
🔹 Station 4⃣ : Mother is fit to be discharged but

daughter wants her to stay in hospital
🔹 Abdomen : Renal transplant
🔹 Resp : ILD
🔹 Neuro : Peripheral neuropathy
🔹 Cardio : AS/MR
🔹 BCC 1⃣ : Cushing sec to steroids for Wegener
🔹 BCC 2⃣ : Benign essential tremors
Oman 5th April, cycle 1 🔺
🔹Station 5
Thyroid
🔹 Station 4
Malignant melanoma
🔹 Station 3
Ar & spastic paraparesis
🔹 Station 2
Type 1dm came with wt loss and fatigue
🔹 Station 1
Cld +bronchiectasis
27 March Queen Elizebeth hospital Birmingham
🔺
Station 1⃣
✅ Resp: Patient with lateral thoracotomy scars.

On examination bilateral basal fine crackles. For
differential diagnosis
✅ Abdomen: 35 year-old gentleman with

midline laporatomy scar and peritoneal dialysis
scars. It was pancreatic and renal transplant
✅ Station 2⃣
56 female referred by her GP due to abnormal
LFT mainly transaminases 5 times more than
upper normal. Mentioned in stem that she is on
methotrexate for 2 years. Taking the history she
has no significant symptoms apart from mild
lethargy and indigestion. She has RA for many
years and using mtx for 2 years without any
problem. She is on PPIs, and folic acid. The only
positive points in hx that she had 1 unprotected
sex with her boyfriend who lives in Turkey. Also
she drinks alcohol more than the recommended
amount.
Her concern was why I am in hospital despite I
am feeling well in myself. Is this due to
methotrexate?
Station 3:
✅ Cardio: Aortic stenosis
✅ Neuro: young man with spastic paraparesis
✅ Station 4:
Talk to Ms Bradley, a daughter of Mrs Wilson
who is 65 years old. The daughter was unhappy
about the management of her mother.
She is a lady with severe COPD. She was
presented with RUQ pain and admitted to
surgical ward as acute cholecystitis and started
on antibiotics. The next day Xray showed right
basal pneumonia and she was shifted to
antibiotics as per hospital policy.
She was referred to medical team. She needs
oxygen to maintain her oxygen saturation. She
has been seen by consultant who thinks it was
inappropriate to be admitted to ICU and needs
ward base management. She had pneumonia
before 18 months abd needed ITU admission
with intubation and was difficult to extubate her.
Since then her activities declined but still enjoys
life with friends visiting her.
The concerns were: why she was not diagnosed
correctly from the beginning? Was there delay
in management? Does she need admission to
ITU?
Station 5
✅ BCC 1⃣
75 year old gentleman with SOB.
Found to have rheumatoid arthritis and on
examination of his chest: bilateral fine
crepitation. Dx was ILD secondary to RA
✅ BCC 2⃣
21 year old lady with iron deficiency anaemia.
On hx has recurrent epistaxis since childhood.
FH of epistaxis. On examination: Telangiectasia.
Dx was HHT
My experience in diet 1 Yangon on 6.3.18
I started with St 4. It was young lady with severe
headache suspected of SAH who want to be self
discharged. CT head was normal. My tasks were
explain abt disease and consent for LP. Inside I
explored nature of headache with few questions
and family history of stroke and renal problem.
Then I explained abt possible diagnosis but
patient deny the whole time because CT was
normal. I had a chance to explain abt LP when 2
min left. But she didn't give consent. Then
time's up. Ex questions were abt autonomy and
treatment of SAH.I got 13/16.
Then St 5
BCC1 lady with multiple hand swellings
presented with haematemesis and melaena. I
considered abt causes of upper GI bleeding.
Inside I was shocked when I saw the patient. I
have never seen such swelling in the hand in
my life. But I tried to calm down and started
questions.hand swelling is only on the right
hand not in other part. It has been for 10 years.
No history of bleeding or pain. Got H n M 7days
back. Non alcoholic, no analgesic misuse, took
paracetamol for back pain. FH Nil. O/E multiple
swellings seems like gouti tophi or
neurofibromas but not typical. At the tips of
fingers there were haemangiomas. I explained
her H n M may be associated with some
vascular abnormalities. Exam Q: most common
causes of H n M in Myanmar. I got 27/28
BCC 2 acromegaly e Hypertension. Routine

questions. I got 28/28
St 1 Resp COPD with right pleural effusion.Ex

Q: investigation and Mx. I got 20/20
St 1 abd transplanted kidney e drug side effects.
I got 10/20
St 2 back pain e rash DDx psoriatic arthropathy

ANkylosong spondylitis. Patient main concern
waere abt his work, cleaner in supermarket, and
his hobby, gym exercises and football playing. I
told him I will refer him to occupational therapist
for job rearrangement. For hobby I suggest to
do light exercise and swimming. got 20/20
St 3. CVS young man e diastolic thrill over the

precordium. I heard murmurs both systolic n
diastolic phase. Radiate to back. . I gave Dx
PDA. Ex Q: management of PDA
Got 11/20
St 3 CNS. Parkinsonism young patient. Ex Q:
investigation and management. Got 20/20
Mandalay 2018/1
1st day 1st round
Station 1
Pleural effusion
Splenomegaly
Station 2
know type1 DM presenting with collapse most
likely hypoglycaemia
Station 3
Cauda equina syndrome
? MR with pulmonary hypertension
Station 4
Meningococcal septicaemia
Station 5
Systemic sclerosis
Psoriasis arthropahy
Day 1 last round

Station 1
Upper lobe fibrosis and bronchiectasis
Station 2
OP due to coeliac disease
Station 3
MR
Common peroneal nerve
Station 4
CURB65
Station 5
NF
IBD, Malignancy, TB abdomen
1st day 3rd round

Station-3
CVS- MR TR AF Pulmonary hypertension
CNS- Common peroneal nerve plasy
Staion-2
Female, Fatigue Lethargic
Hb- 10.5 MCV-75
Menorrhagia, Thyroid function test- Normal
Patient said fatigue lethargic

No fever
Loose motion for 6 months
LOW inspite of good appetite
Travelling to Thailand present
She also feels easily asleep during reading!
i forgot to take back pain, Snoring

But she didn’t feel early morning headache
IDA due to Coeliac

Any differential
I forgot to tell worms infestations
Staion-1
Respiration- Rt Upperlobe collpse ? COPD?
Abdomen- ADPKD, BP-160/100
BCC-1
Sanario- Female Blood and mucous in stool
All vital signs are normal
Fever
Tenesmus
LOW inspecite of good appetite
Family hisory of bowel cancer
Examination - NAD
Dx- IBD
D/Dx- CRC, Ameobiasis, TB
BCC-2 Sanario
24 yr male, Headache for few days, BP-160/100
PR-60/min
all others are normal
Headache - No aura, Last 15 minutes, Not

precipitated by Coughing, No mornind
headache, associated with vomiting , Blurred
vision present
IQ- Learning difficulties
Onexamination- Pupil equal

Fudus normal
Neurofibromatosis
Cafe auit lait
Cerebellar, 7 , 8 cranial nerves normal
I didn’t diagnosis for headache

last minutes, Does anything makes headache
worsen?
Suurogate said loud noise
i also asked last question- do you feel relieved
by quiet and dark place?
Suurogate said it is better place for me to
relieve headache!
Dx- Basilar migraine

Examiner asked what serious condition do you
want to exclude?
I said bilateral shwunoma at CP angle,
Mandalay day1 round3

i start with station 1
abd -bilat polycystic kidney
resp-bronchiectasis and others said rt collapse
n consolidation also present i didnt get it.
history-pt come with tiredness n lethargic
*6month outside lab test MCV 75,menorrhogia+
past IBS history +..inside pt loose motion off n
on ..malabsorption
CNS -lt common peroneal nerve lesion ? weak lt
ankle dorsiflexion,also lt big toe dorsiflexion
,SLT -, sensation loss in dorsum aspect of foot
,but both knee jerks seen to be increased n
exam asked what do u think about that ?
CVS-MR with AF
comm-CURB 65 pt die,task explain about
management n care done to patient n also
answer patient's daughter concerns
BCC1-headache 3days inside
neurofibromatosis
BCC2- blood n mucous stool 6month with large
joint pain.also past hostory of TB n father has
ca colon
Day 2 Round 1 in Mandalay

I start with BCC...
BCC 1... collapse due to postural Hypotension
due to H&M
BCC2... 37 yrs old man with HBsAg(+) on
Antiviral Medication c/o difficulty in walking
(can’t get any clue outside)... Inside, a case of
bilateral peripheral neuropathy with footdrop,
stocking distribution.. chronic alcoholic ... give
DDx for that...
Station 1... I got Hepatomegaly with Cervical LN
& Anaemia (the others got
Hepatosplenomegaly)
For Resp... A case of Rt Upper Lobe Collapse (
there may be some other findings bcoz
examiner keep asking anything else)
Station 2 .... Fever, Wt Loss, Night sweats, Dry
Cough, Inguinal Lymphadenopathy... DDx...
Lymphoma, TB, HIV
Station 3.... CVS.... Very difficult case... Young
male patient abt 200-250 lb... can’t even get apex
beat... Very difficult to hear Heart sound at the
apex.... Only systolic M2 at Upper left sternal
edge... give DDx for that
CNS.... look at the face & proceed... Rt Ptosis..
3rd,4th,6th, 5th, 8th with ? Cerebellum...give
DDx for these
Station 4.... patient with CKD want to stop
dialysis bcoz of poor QOL.. explain to son...
Day 2 round3
i start with station 3
CVS MR AR( i just said VSD or MR)
CNS MG (look at the face and proceed)
station 4
talk to son about father 's prognosis, critical
condition , address concern
(father , underlying COPD, worsen 5days .admit
to hospital and give antibiotic ,nebuliser,
corticosteroid . got swollen ankle and give
diuretic.
he already receive NIV at night time.
comsultant decide not to give mechanical
ventilation and just give NIV at night time. he
want to go to grand daughter wedding next
3mth)
nursing staff told his son want to talk about
father condition .( u got the perssion from father
to talk about his condition) i got to tell this .
Examiner Q. Did u got the permession from
father??Did u explain well? how do u
understand the consent? ethical principle? how
about the mechanical ventilation? if his son has
LPA , do u give the mechanical ventilation? how
about the day time ventilation?
station 5
old lady with weakness of lt arm for 1mth
underlying DM,hypertension
inside ask
lt sided weakness while eating ,2-3min, recover
spontaneously
Past history of similar attack 3-4time
history of headache (band like and vomiting)
DM and hypertension present (no treatment)
examination - no neurological deficit , no eye
sign ,no AF, no murmur, just rt carotid bruit
Ex Q,DDx,physical sign,Mx
BCC1
middle age lady c/o intermittent fever off n on
for 10days
inside just fever and can't find the infection
source
just give joint pain at young age
no sore throat
physical ex-MDM and AF
i give IE
Examiner Q: Dx,DDx, Mx
station 1
respiration
c/o productive cough
no clubbing
lt lower lobe - coarse crept
other 4 said bronchiectasis
but i said rt upper lobe collapse consolidation
and lt lower lobe bronchiectasis( i got trachea
shift ,BBS and increased vocal resonance😩😩)
Ex Q ask about bronchiectasis
station 1
abd
c/o tiredness
Anaemia and splenomegaly (just 3cm)
DDx ,ask inv and Mx about CML
station 2
cough and SOB for 8mth
non smoker ,PEFR normal
not improve with antibiotic
dry cough,SOB,fever, LOW 10lb, appetite good
work at dusty place(construction)and printing
area
got perrot for 1yr (present of daughter)
give EAA,TB,occupational asthma,Ca lung
(other person said Dx is occupational asthma
,they write down on the paper)😩
Mandalay Centre
Last Day, 2nd round
I started with St2

Hypertension with haematuria and proteinuria
Inside- increase T, muscle pain, menorrhagia

,on OC pills
Concern..she has plan to be married soon.
I gave DDx
St 3- CVS - TOF
Bilateral fingers and toes clubbing, central n
peripheral cyanosis
ESM at pulmonary area and PSM at left sternal
edge
Discussion -Dx
What other cyanotic congenital
heart disease.
Mx of TOF- Medical n surgical

Complications of TOF
Signs of Pul Hypertension and Rx
Features of IE
St3 CNS - teenager boy with spastic paraparesis

No sensory involvement
Causes n Mx
What cause may be at this age?

I forgot to say Hereditary spastic paraparesis. I
remember at outside . 😞
St4- Confused pt, end stage liver disease with

SBP, renal failure.
Explain disease , poor prognosis, discuss about

resuscitation status.
St 5 - fatigue ,tiredness for 2 mths with 15 years
history of hands jt pain.
Inside- RA hands with pulmonary fibrosis
No pallor but indigestion and uppet tummy pain

sometimes present
On methotrexate, ibuprofen,CQ
Dx- pulmonary fibrosis

due to methotrexate or disease itself
Anaemia due to occult GI bleeding on NSAIDs
BCC 2
Intermittent left sided weakbess
Insided- only lt upper limb and lt upper body

Associated with transient vision loss
Lasts only ? hr and recover.

Similar history 4 times.
DM and HT h/o +
But no Rx list for that, only vitamins taken
On exam, AF +
Dx - TIA
Diff- Hemiplegic migraine
Mx multidisciplinary approach
I will admit the patient.
Examiner asked up Rx of AF and INR target.
St 1 Abd..Anaemia e Massive Splenomegaly
Examiner asked do u think this is kidney. "NO"

Any liver palpable.. I said No
Cause of A abd Splenomegaly

Rx of myelofibrosis
St 1 Resp
About 35 yrs old lady with productive cough.
Bilateral finger clubbing.

Coarse crepitations over both lungs fields
(which alter with cough)
Dx- bronchiectasis
Causes of bronchiectasis
Had u found that any features of COPD.
My experience 30-3-18 in Adan hospital Kuwait

Station1 : chest case was right lobectomy + lt
bronchiectasis ... deviated trachea ?? ...
examiner was asking about causes of
lobectomy and interstitial lung disease ... was it
the case ??
Abdominal : CLD , cirrhotic liver- jaundice-
splenomegaly ... I told hepatomegally but the
examiner asked me to repeat hepatic
examination as it was clear shrunken liver by
percussion ... discussion was about causes and
St. 2 : 52 years old lady - fever of unknown
cause - wt less- lymphadenopathy- dry cough-
fatigue : I said fever for unknown and gave dd of
sarcoidosis and blood malignancy + hidden
infection
St.3: was the worst for me
Cardio patient I suspected ms+ AR examiner
was attacking and asked me about the apical
caracter and site of it also I was not shoure
about the AF as pt was little bet bradycardic .... i
think it was double aorta ??
Neuro case was pt has loss of coordination and
ataxic gate and diminished all reflexes and
hypotonia ..... dd I told ms and cerebellar
infarction also I told him about LMNL could be
due to associated neuropathy but he was not
happy about this ... discussion was about MS
Station 4 : explain for a lady that her has and
has septic meningitis ... discussion was about
prophylaxis and examiner also was in happy as
I about the complications and because I told her
his condition is serious but I did not till her he
will die
Station 5 : case 1 50 years old lady with
Recurrent PE , recurrent miscarage and on
steroid ... normal examination ... no history of
any joint pain ... my diagnosis was
antiphospholipid syndrome
2nd case 30 years. DM with blurred vision in one
eye fundoscopy showed optic atrophy ...
discussion about causes embolus and hge
treatment she wanted to here good control of
DM+ ophthalmology referral
Good luck for all friends and colleagues ❤️

🔺 Kuwait 28/3/2018 , Alsabah hospital 🔺
🔹station 3
✔ neuro : middle aged male on folleys cath with

flaccid paralysis of both lower libs and scar on
his back
✔ cardio : MR with sinus rhythm
🔹station 4⃣
✔ Communication : 82 year old lady admitted

with vomiting and hematemesis endoscopy
done, mild gastritis and oespgagitis improved
on ppi after one month vomiting again, cxr, us
abdomen normal, endoscopy again showed
oesphgeal narrowing biopsy taken normal CT
abdomen and chest showed cancer oesphegus
with mets for palliative care, her son angry for
delayed diagnosis and why ct not done from the
start
🔹station 5⃣
✔ BCC 1⃣ 57 male with bilateral lower limb

numbness and sob his bp is uncontrolled inside
obese DM and bilateral crackles with peripheral
sensory neuropathy
✔ BCC 2⃣ 53 with lethargy and ankle swelling

one month back but now resolved,inside obese
with short neck, night snoring and
apnea,morning headache working as
accountant and has private car
🔹station 1⃣
✔ abdomen kidney transplant
✔ chest bronchiectasis with obstructive air way

disease
🔹station 2⃣
✔ Hx - 45 year old lady well controlled diabetes

and hypertension became confused while she
was at restaurant with her friends and the took
her home no palpitation no loc no sweating
during the 3 hours of confusion she was
repeating who i am where i am and she became
ok spontaneously after 3 hours
Pray for me
7.3.2018 Yangon Center, First Round.
Station 2- Question: Middle age male Type 1DM

for 15 years. now come with recurrent
hypoglycaemia attack. Hb reduced, KFT
abnormal, weight loss.
Inside: Patient complaint many hypo attacks

previously showing hypo symptoms. but
recently recurrent collapse but no hypo
symptoms (He keep saying that for abt 4/5 times
whichever Qs i asked). checked sugar at the
time of collapse and relieved by taking sweets.
In Qs, renal function tests abnormal but when i
asked abt that, he did not know it n deny any
renal features. Feeling bloating, indigestion
present but no increased sweating when eating/
full with small meal. No other complications.
Weight loss present, he couldnt mention how
much kg loss and duration. Haemoglobin was
given reduced but he didnt recognize any pallor.
He denied any abd symptoms related to any
particular food. no change in bowel habit.
No features of postural hypotension. No heart
problems at the time of collapse.
(One candidate said lipoatrophy present at the
site of insulin injection. I missed to ask that).
I gv Dx. Top: Collapse due to Recurrent hypo

and loss of awarenessof hypo attacks related to
DM nephropathy, N Gastroparesis. D.Dx:
Postural hypotension (Saying less likely as no
symptoms suggesting postural hyptension) due
to drugs/ ANS/ Addison. and Asso autoimmune:
Coeliac.
Examiner asking me why these happens. i

answer above reasons and explain as i know
but he said these r theories and keep saying
"Tell me mechanisms". I dunno what he wants.
Then he ask Mx. When i start to say Invx, he
emphasize on Coeliac Invx.
(I got 20/20)
Station 3- CVS AS.AR.

I thought i could picked up almost all findings
but in examiner Qs, i ans so bad. I didnt even
remember what is Quincke's sign. On Mx, i
could only say basic tests (ECG, CXR) and
time's up. (20/20)
CNS. Spastic para.
When i exam sensory, no sensory level but
dorsal.column affected and ankle jerk loss on
one side. I gv D.Dx of Spastic para esp with
Dorsal column and ankle jerk loss. Time's up at
the start of Invx.
(20/20)
Station 4- 89 yr old male comes with stroke, AF

present. missed appointment for INR recheck.
now INR 1.5. Task: explain his grandson abt CT
scan result & need for admission to stroke unit
n address the attendant's concern.
No problem to break bad news and CT result. He

has some problems to accompany and look
after to admit his grandfather. I tried to suggest
him to ask help fr relatives or neighbours but he
said none of them available. I advised abt social
workers who could take care to some extent
during his working hours. He agreed to admit
then. N feeling guilty as he missed for
appointment. I conforted him. explained missing
on appointment may or may not b the only
reason. many reasons possible for increased
INR. addressed other difficulties(He's a busy
person. and forgot so to keep some kinda
reminder). Then i checked his background
knowledge abt disease and warfarin. Warfarin
S.Es and things to take care (explained drug
interactions). he asked abt alternative. i
explained DOACs but warfarin wd b preferred
for gis grandpa.
Examiner's Qs: What r his concern n how i

solved?
Why i say warfarin over DOACs. (only one
available here and at the time of overdose.
antidote is so expensive and hard to find)
What r CI for DOACs?(mental disorder patient.,
renal problem)
(15/16)
Benefits? (no need INR monitor.,no need
overlap with heparin).
Station 5 - Young female Pain n numbness in

hands n feet for 1 mth referred by OG.
Inside: SLE lupus parient with 3 times abortion

history. mouth ulcer history. Anti-TB with B6
history completed last 6 mths ago. Qs shows
RBS 190mg. but pt deny bld sugar problem.
Taking prednisolone., Ibupofen.,
hdroxychloroquine. Non-Vegan. Cushing face.
Exam: peripheral neuro. bilat. both hands n
feets. No mouth ulcer.
I didn't hear Examiner's warning abt 2mins left.

So missed to asked *all Patient Concerns :( . I
was so shocked and didnt remember what i had
answered exminer's Qs.
The last Q is asking abt what Antibody i wd like
to test. i ans APL Ab.
N he asked what skin lesion I wd like to look
for? I hv no idea. He said if I checked
Livedoreticularis on feet. I missed to check.
(15/28)
BCC 2- SOB for 2mths. Already Dx- Mytonic

dystrophy patient.
Young male, On admission, leg swelling

present. But now no features oedema, lungs
and heart clear. I exam some features of
myotonic dystrophy. Choking history present
but no other features of GERD.
Also in this BCC, examiner warns only 1min left
for patient concern :(
I gv D.Dx- Heart failure or Resp Tract
infection(though no fever, n no suggestive
features), GERD. Asked abt Mx, I ans Invx n
time's up.
(20/28)
Station 1- Resp: Right Upper Lobe Collapse with

effusion (I thought underlying COPD present
cos obviously hyperresonant but I forgot to
mention that). After saying abt findings, time's
up.
(20/20)
GI- Hepatosplenomegaly.
(16/20)
Total- 146/172.
Concern score is 11. So lucky.
I thought I failed as I missed concern in BCC1 &

could not answer examiner's Qs in all exam
stations. N also can't answer mechanisms that
examiner asked in history.
It was all luck and thankful to teachers n all
patients.
Kuwait/Mubarak/carousel 3
Station 1 chest COPD
Station 1 abdomen Acromegally with
hepatospleenomegally and bilateral LL edema
Station 2 back pain 3 months not responding to
pain killers associated with diarrea and mouth
ulcer it was diagnosed as osteoprosis with loss
of 6kg over 18 months with + family history of
breast cancer and osteoprosis. Also patient had
history of BA since age of 14 and patient on
blue and Brown buffs and 45 years old
Station 3 Neuro flaccid paraparisis with
weakness proximal than distal with waddling
gait and normal coordination and sensation.
Station 3 cardiology Ms and AF
Station 4 IBS for amitryptaline
Station 5 /1 Dm and HTN with blurring of vision
for fundus
Station 5/2 sob and dry cough
SLE causing PF .Also patient had history of skin
rash and history of blood clot after cs
Diet 1, 4th day, round 3, NYGH Yangon
*I started with station 4

Angry patient, her father had COPD, now CURB
65 score is 5, no beds at medical ward, pt
admitted to surgical ward, cannula dislodge,
miss one dose of antibiotic
I explain routinely
But i forgot to mention about the mortality rate
of patient with CURB 65 SCORE 5
and i didn't mention incident report
Examiner question (1) why didn't u mention
about the mortality rate
I answer yes, i forgot to mention the mortality
rate, but i explained to daughter that her father's
condition is very severe so the score got 5
(2) why you didn't talk about incident report?
I explain to her why there's no bed available at
that time, i'll ask to the nurse incharge and let
her know
And daughter agree with it. So, i didn't talk
about the incident report form
I got 13/16
*Station 5 BCC 1
Young lady, difficulty in walking, history of joint
pain for 3 years
Vitals are normal, RBS - 180 mg/dl
Inside - Cushingoid features
I asked about complaints, underlying joint pain,
drug history detail
Examination - Striae at thigh
I tried to differentiated proximal myopathy vs
neuropathy, but examiner said neurological
exam is normal
Joint - normal
No deformity
Dx- drug induced cushing syndrome
Concern - what happened to her? I said drug
induced problems
she wants a baby, i refer her to rheumatologist
becaues she took hydroxychloroquine too
Examiner question - investigation to confim ur
dx?
I said she is under high dose steroid, so gradual
tail off with steroid replacement therapy is
needed
Investigation to confirm cushing syndrome
can't do at this time because she took high dose
steroid till now.
I got 28/28
BCC 2 - 40 year man, vision problem for two
weeks
Underlying back pain for 10 years
Inside - ask about vision which is gradual, no
neuroophthalmic symptoms and signs, i ask
fundus, examiner said normal, then ask about
back pain, looks like ankylosing spondylosis,
perform Schober's test, lumbar spine movement
Concern about his vision, can return back to
normal, i said yes.
I also ask about driving
Social history
But time's up so didn't examine AR, Archilles
tendonitis, apical fibrosis
Exminer question - dx?- ante: uveitis underlying
ankylosing spondylosis
Points for dx - i mentioned the points that i
found in examination and also talk about the
signs that i wanted to find if i've more time
I got 28/28
Thanks god
*Station 1 Abdo - hepatomegaly with
splenectomy scar, i forgot to examine the
kidney 'cause i got the dx
Examiner ask dx - i said hepatomegaly with
splenectomy scar, most likely thalassaemia, but
examiner didn't happy 'cause he wanted to
answer thalassaemia major straightly
Ask about prevention in splenectomy patient
Vaccination
Pen v
Wihch organism can infect mostly - capsulated
I got 16/20
Respiration - trachea shift, crepitation
I heard BBS but other candidates didn't heard
I got only 8/20 😢😢😢😢😢
Sttaion 2 - 40 year man, opsteoporotic fractures

Inside - diarrhoea, 18 months
No blood and mucus
No bowel change
Fogot to ask family history in detail - father has
cancer
Ddx - malabsorption
Coeliac
TB
Cancer
I got only 12/20
Station 1 neuro - parkin got 20/20

CVS - mitral valve replacement, got 19/20
Overall 144/172
I pass
Thank this group(PEC) for sharing experience
#St_5_Collections
BANGALORE BCC
1.copd with sudden breathing difficulty and rt

sided chest pain..
o/e Dec breath sound.rt mid.dd was ptx,pul
embolism, ,pneumonia. It was good
2.female was increase weight,,increase bp,,,and

proximal myopathy, ,o e no thyroid
abnormalities, ,some rash,,and proximal
myopathy,,features of osteoarthritis, ,knee jt,leg
oedema, ,
dd,was cushing, ,hypothyroidism, metabolic
syndrome, ,discuss was on cushing. .
Dx—-> hypothyroidism
H/O… cold intolerance, constipation, infertility
O/E… Normal (Surrogate)
3.1st case 30 yrs old lady with high prolactin

levels and normal TSH c/o scanty and irregular
menstruation.
outside 38 yr female with irregular menses, pain
in thighs, and wt gain, high BP, oxygen
saturation 92%...inside obese pt with pitting
oedema + bibasal crepts , proximal myopathy,
wt gain, OSAS , diagnosed as PCOS.....concerns
;: is it bcz of hormonal problems?
Crossing: ddx: PCOS with cushing,
hypothyroidism, metabolic syndrome, with
OSAS, ix and Mx of each...got 27/28
weight gain
Patient is surrogate . No abnormal finding on
o/e
History- generalized weight gain with normal
appetite, irregular menstruation and nad
4. 26 yrs old lady with SLE since 6 yrs presented

with right sided pleuritic chest pain ,with fever.
Discussion about DD of chest pain.
outside 28 yr female with chest pain radiating to

lft arm.....inside typical History of ACS,
diagnosed as SLE (pt do not want to say....said
after lots of hammering) taking prednisolone
and hydroxychloroquine for SLE...concern: is it
serious?
Crossing: ddx...ACS, GERD, PE, esophageal
spasm.
Ix and Mx of ACS, risk factors of DVT...what if
troponins are raised?
Cause of ACS?...got 26/28
SLE with chest pain

Not real patient
No signs at all
At that day I got fever and can't concentrate.
I examined only at chair
Actually Pt is sitting in front of examiner . I
examined over the clothes .
18/28
chest pain
History- left sided sharp chest pain,1 hour
duration, radiation ( dont remember) underlying
SLE
They want AC$ as first then ddx
Middle age lady
Wt gain and feeling low
Apart from that no signs
Not real patient
She also sitting in front of examiner.
I examined at there also😔

23/28
5. known hypothyroid taking medications come

with fatigue
hypothyroid symptoms again
Dx: ? Recurrence of hypothyroid due to drug
noncompliance
6. fatigue for 1yr

RTA history present and CT head normal
Seen psychiatrist and take medications but not
relieve
Family history of fatigue also present
Dx: chronic fatigue syndrome.
7. epigastric pain, epigastric lump, wt loss,
ascites
Pt was very sick. Her sister gave History.
8.
ank spond patient on biologics got fever and
cough for 2 weeks.
Clinically no signs of ank spond or pneumonia.
9. chronic headache ? Due to sinusitis. No red

flag sign
10.Know hypothyroid for 3 years with

progressive headache.
11. young female with palpitation. Her father had

palpitation and heart attack.
Pt is normal. Sinus tachycardia only.
Concern.. ht attack?
Dx.. SVT???
12. known COPD pt comes to you with
palpitation. Taking inhaler.
Dx... palpitation due to inhaler SE
13. 60 yrs old gentleman comes with multiple

joint pain and back pain. He had previous
history of psoriasis.
Dx… psoriatic arthropathy. Normal surrogate.
14. 50yrs old man come with progressive SOB

and dry cough.
RA history present and taking methotrexate
Chronic smoker.
Normal surrogate. No signs.
Gave Ddx.
Sharjah today 23/2/2017
St1 Abd splenomegaly with liver cirrhosis
Chest COPD
St2 history Dizzy spells in Dm .. history of Mi
DVT .. AF .. family history of DVT .on Ramipril.
St.3 CVS MR + TR
CNS spastic paraparesis without sensory
involvement
St4 pt with arrhythmia on amiodarone
developed lung fibrosis .. speak to the daughter
St.5 a.. HYPOKALEMIC PERIODIC PARALYSIS
B .. Dizzy spells (again ) IN pt with DM.and on
ramipril
Exam Experience
》Station 2
25 years old .DM.asthma presented

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 😣
》3. CNS: Upper limb exam.

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
》3. CVS:
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
》4: Communication skills:

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 😳..
》5:
Station 5 was diffecult
60 years with skin lesion over her forhead and
scalp
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..
I appeared in diet 1 2018 at Edinburgh western

general hospital on 27-2-2018.
Alhamdulillah passed with 142/172
Started with
station 5
BCC1 - middle aged lady with c/o black tarrey
stools and h/o malena in past. Endoscopy and
colonoscopy done before were normal and she
was given oral iron.On further enquiry she told
about recurrent epistaxis and her brother Also
suffers from recurrent epistaxis.
She was also taking OTC ibuprofen
.— HHS/ NSAIDS induced
gastropathy got 21/28
BCC2– it was a nightmare
Make Pt with c/o dyspnea , facial swelling and
early morning headache with normal urine
examination. He underwent renal transplant and
examination showed facial flushing, pupura, few
bruises and visible veins over trunk.
I was totally confused could not reach to
diagnosis.......
It was SVC obstruction got 11/28
Station 1
1- kidney transplant 20/20
2- lobectomy + COPD 20/20
Station 2
55 yrs old male presented with c/0 retrosternal
chest pain since 2 weeks, mild to moderate in
intensity, aggravated with food and mostly while
lying, h/o smoking in past, DM with no evidence
of TOD, h/o premature CAtD in 1st degree
relatives, mechanic my profession.h/o taking
NSAIDS OTC
DD
Ischemic chest pain
GERD/ esophagitis
Mechanical pain
History strongly suggestive of GERD/
esophagitis .
Key was to prioritize ischemic chest pain
considering risk factors and strong family
history.
20/20
Station 3
1- CNS myotonic dystrophy
Female patient —-
19/20
2- CVS
CABG +- bioprosthetic valve replacement, ESM,
18/20
Station 4
Task was to speak to the daughter of elderly

lady diagnosed with metastatic carcinoma with
unknown primary and symptoms started as
dysphasia , endoscopy done twicely came
normal and CT scan showed mass compressing
esophagus and evidence of metastasis.
Concerns
1- doctors are incompetent who could not
diagnose my mother
2- delay in diagnosis resulted in point of no
cure.
3- doctors neglected my mother because of her
age.
4-why CT scan not done earlier on?
5- what next? About palliative care
6- can I speak to your senior?
Examiner’s questions about
Ethical issues,
Differential diagnosis
Role of biopsy
Components of palliative care
13/16
—————————
Preparation —- cases for paces for station 5, 1,3
And Ryder for station 2, and station 4 .
Conclusion : never lose hope after 1 bad station
like what happened with me in station 5 and I
started with station 5.
Regards
Good luck for all
Dr tahir iqbal
Malta 🇲🇹 Exam Experience
St. 2 ⚁
recurrent hypoglycemic attacks in type 1 d.m.
with deranged renal function test and
autonomic neuropathy
St ⚂
M.R. A.f. pulsus trigemini.. there may be
associated m.s. but not sure... forget to do water
hammer pulse.
Neuro..
partial claw hand in ulner nerve distribution

unilat.
The examiner was asking did you find any thing

else.. �
St4 ⚃
explain and convince female with anaemia and
prufen abuse to do endoscopy
St. 5⚄
acromegally
The second case was epilepsy recently
uncontrolled... I missed this case as other
candidate sayed it was tuberous sclerosis
St. 1 chest copd with fibrosis and possible

cavity
Abd. Jaundice with hepatosplenomegally .

Prominent zygoma ..my d.d. C.L.D. And H.L.A
This is my exam experience in New kasr Elainy
on 3/2/2018
I started with station 4 a case of 50 year old man
with heart failure on maximum treatment in spite
of this has shortness of breath, he discovered
cervical lymph node and biopsy and abdominal
ctscan and bone scan show that he has
advance cancer of kidney with metastasis to the
vertebra and liver your task talk to the patient
regarding palliative treatment including
macmallian nurse and answer his concerns.
Ìstarted with greeting the patient check the
identity and check his knowledge about his
condition ,actually he has no idea about the
result of test I give him shout that I am sorry to
tell you that the result of test as not good as we
hope .....you have a kidney cancer and am afraid
to tell you that it is in advance stage it spread in
to your liver and your back bone with great
sympathy and empathy he ask about the
treatment any cure I told him if the cancer on
early stage usually the treatment and cure is
surgery but in your condition and with spread of
cancer cell there will be no role of surgery but
we will do our best to treat your symptoms we
called palliative treatment. Do you ever heard
about it ?and I explained for him all about
palliative treatment and the palliative treatment
team I told him will not let you suffering will
make your life more easier ,I didn't talk about
DNR because it is not one of the task he was
concerned regarding how to inform his wife and
I told him if you wish I will help you and arrange
meeting to talk with her and she will be good
support for him, he was concerned regarding
travelling I inform him that i appreciate your
feeling and you have the right to travel but I am
afraid with this heart disease it could be danger
for your life that why I will refer you to heart
specialist to assess your fitness for travelling
he has 3rd concern regarding dealing with
heavy objects as he works as mechanics I
appetite his concern and I inform him that
carring heavy object me put him in a risk of
fracture that why better to avoid and refer him to
social worker and occupational health
worker,he ask me to give him estimation
regarding his life span ,I inform him this is
difficult question to answer and with great
sympathy ì told him that I am sorry but with this
advance stage of cancer it will short your life it
may be period of months rather than years.
After finishing and great sympathy and empathy
the senario end with summary and check
understanding.� then move to examiner
Questions😐
The questions was regarding what ethical

issues applied in the senario I started with
breaking bad news the examiner ask me does
breaking bad news is one of the ethical issues?
I said no 😥 Autonomy the right of the patient to
know about his kidney cancer and it is advance
stage ,beneficence to manage the patient with
palliative treatment and non malfescience in
that no role for surgery her or chemotherapy
because he will suffer from bad effects and he
ask me about travelling I told him that better not
travel with this heart failure and need to be
assess with cardiologist alhamdellah I got 16
.then station 5 first one was weight gain with
proximal myopathy when I enter the room I
found a lady and when I want to put the paper I
found cup of water and hammer😉 so that I
diagnosed hypo thyrodism by the surrounding
the positive thing was weight gain allover
constipation , proximal myopathy ,low
mood,heavy cycle screen for other hypos was
negative screen for the cause also no thing
significant ask about the impact who is support
her and smoking alchol medication list like
amidaron,lithium ,steroid ,statin examination
start from hand for dryness of skin ,carpal
tunnel,pulse ,BP sitting and standing ,proximal
myopathy, pallor ,macroglossia,neck for scar
and ask her to drink water for neck swelling
examine basal crept, osteoarthritis in
knee,lower limb edema and ankle jerk,the
patient concern was about what is the cause
and it is reversible?the answer was it is due to
under activity of gland in your neck called
thyroid causing this symptoms we need to do
blood test in order to confirm diagnosis and
refer you to gland doctor,if it confirmed we will
start for you medication called thyroxin need to
be taken regular and to be follow up with the
gland doctor and it is reversible after starting
treatment. Then examiner question1- what is
your diagnosis? Primary hypothyroidism.
2_how you will manage?
3-what will be the thyroid function test?
4-differential diagnosis of proximal myopathy?
Alhamdellah I got 28
Next case was 35 years old male with dimnution
of vision inside the positive thing gradual
blurring of vision and no variation between day
and night he has oral ulcer and genital ulcer
recurrent painful , history of knee pain،history
of leg clot there is some times pain and redness
in eye ask about ,impaction,driving and social
issues examiner question what is your
diagnosis?behcet disease.
What is differential diagnosis for anterior
uveitis? How you will diagnose ?HLAB51 and
pathergy test.alhamdellalh I got 28. Then move
to station 1 I started with abdomen the case was
anemia with splenomegally but actually I was
hesitant and was thinking that may be ì miss the
liver and ascites😫so that I was not
concentrated in discussion also it is common
question they ask about differential diagnosis I
forgot infection🙈 and about clinical judgment I
didn't request any ct scan or bone marrow
examination so this was my worst station I got
13,
Chest station female with OLD with basal
fibrosis actually the patient was coughing and I
was stress examiner ask about dd. and
Management of COPD criteria for long term
oxygen therapy I got 18.
Move to station 2 from outside was written 35
years old female present with left side weakness
for one hour.
Inside I found this is the first time complete
recovery she was on hairdresser associated
with headache typical migraine with visual aura
she has sleep disturbance recently drink a lot of
coffee no other risk factors for stroke in young
she is on oral contraceptive pill no neck pain or
neck swelling she has history of bronchial
asthma social history was not significant.
Concerns it is stoke I told her because of
complete recovery it is not stroke ,it could be
ministroke or related to your headache and now
present with Unusual presentation .she asked it
could reoccur again I told her it could be
especially you are in oral contraceptive pill I
advice you to stop and refer you to women
doctor to change to other methods of
contraception and I will admit you to do for you
blood tests,heart tracing ,imaging to brain scan
to heart and treat your headache involved
neurologist. Also advice regarding have good
sleep and decrease coffee in take.
Examiner questions what is your differential
diagnosis?
Hemiplegic migraine
TIA
Carotid dissection
How you will investigate?
CBC ,ESR,inflammatory markers ,thrompophilia
screening,autoimmune screening ,ECG Echo
carotid doppler brain ct scan and MRI
He told me why MRI
I told to check if there is any area affected by
posterior circulation. Another question about
migraine management and proflaxis.
My last station was station 3😥 started with CVS

examination she was very ill patient severe pale
I couldn't assess the pluse well if it is regular or
not then I thought I will check by stethscope she
was ill and tachypneoic with midline sternotomy
scar she has ascites also I think because so
distended abdomen with raised jvp the
auscultation was so difficult she has double
valve replacement with left parasternal heave
and pulmonary htn ,there is murmur every
where😱😱😱😱 I forgot about the pulse at that
time and try to concentrate on murmur I found
MR and TR she has also lower limb edema then
after that the examiner told me to say positive
finding I told double valve replacement with
phtn and right side heart failure with MR and TR
he told me did you hear another murmur I told
am not sure because the patient is pale may be
hemic murmur I think there is aortic stenosis
but I didn't mentioned then ask about how you
will manage I told admission and involvement of
cardiologist ECG Echo CBC inflammatory
markers coagulation profile he ask me what you
will find in ECG I told him about rt ventricular
hypertrophy then told me what about rhythm
what about pulse😱😱😱 at that time I remember
that am not sure of the pulse if it is regular or
not then suddenly I told him irregular he told me
are you sure then I told yes I don't know why I
said this🙈 and I felt guilty feeling and I thought I
lost the case and also regardingMR I was
thinking may be not true because such case will
not come in exam. I was think I will get 6 but Al
hamdullelah I got 19😊the neuro station was
more tough young male examine lower limb he
has severe pain in his rt lower limb and there is
wide difference when I start to examine the tone
the patient was shouting that he has pain then I
stopped and told the examiner the patient in
severe pain he told me continue but gently I get
panic and I couldn't assess the tone well the left
leg looks normal and he is an able to move the
rt leg because of pain ,reflexes knee present
absent ankle extensor planter sensation I start
with pain and touch sensation when reach the
knee he told he feel now when I move around
the knee he told it is not similar some area are
more some are less I lost a lot of time in
sensation😥 when I start test vibration test I
didn't complete time was over 😢 and I got more
depressed I thought I fail the exam😥 then the
British examiner was the leader and he was nice
he told me forget about the vibration and
position sense what is your finding? I told him
this gentle man has monoplegia and it seem to
be not hemiplegia because the patient was
moving upper limb normally ,and not cortical
lesion because he is conscious,tone difficult to
assess well because of pain😔knee reflex intact
absent ankle reflex with extensor planter
regarding sensation it seem to be patchy
sensory loss😞 he told me so what is your DD?
I told with this patchy sensory loss could be
cauda equina
Multiple sclerosis then the whole discussion
was about multiple sclerosis how you will
investigate and manage. Then bell ring and the
exam was end I was think that I did very bad
especially in this station and may be I will fail
the exam. It seem to be appeared in my face that
I am depressed the British examiner told me be
happy already you finish the exam enjoy your
life, actually he seem to be a nice examiner I
told him actually I did very bad and left the
room😥 then I was surprised that I got 20😊
Alhamdellah I passed the exam with score 162
my advice doaaa ;doaaa and doaaa it is
matter of tofig and don't panic inside exam and
when you move to new station forget about the
previous one because you don't know how the
examiner will evaluate you.
Good luck for all of you and I hope all of you to
pass exam .
My experience from Nottingham university
Hospital UK on 3rd March 2018
Station 1
Respiration:
clear crepitations in right lung from middle to
lower zones.
Posterior Thoracotomy scar on back on left
side.
Signs of immunosuppression like fine tremors
and bruises and plethoric face.
Trachea was little deviated to right.
It was left lung transplant with ILD on right side.
Got 20/20
Abdomen: Renal transplant with scar on

abdomen and previous hemodialysis and
peritoneal dialysis. Signs of
immunosuppression and artificial dentures.
Got 20/20
CVS: metallic mitral valve replacement with very

loud systolic murmur all over the precordium.
Metallic click was audible to ear unaided but
difficult to listen and time with murmur as it was
very loud. And murmur i gave differential of MR
and AS as both increase with expiration and MR
murmur means valve is not working well. Later
one candidate told that it was MVP with
replacement. I did not hear the click of Prolapse
Got 15/20
CNS: it was typical Charcot marie tooth disease

with command to examine lower limb. HSMN.
High steppage gait and vibration sense was
decreased. Power 4/5 in ankle dorsiflexion.
Got 20/20
Station 5: female with h/o SOB.Nothing other

positive in history and no chest pain.
In past medical history she has Systemic
Sclerosis since last 10yrs and on no
medications except for omeprazole. Her mother
have history of systemic sclerosis too.Chest
examination was clear. No signs of pulmonary
hypertension too.Hands were bit bluish, i asked
for mixed CT disease but negative and all other
normal examination. Viva also went good and
her concerns that what is this?? And do i need
home oxygen??
Got 24/28
I finished 2 minutes before, and then keep
talking more and more to kill the time and
discussed plan with HRCT to see if early
changes and not obvious clinically on
auscultation, PFTs, autoimmune profile for
mixed CT disease, echo.
Other young girl with recurrent history of

Epistaxis.H/O cousins also having it.
Normal examination for me, one candidate told
that she had telengiectasias on her back upper
chest, i did not look there.
HHT with other few differentials in discussion
like ITP, bleeding disorders and simple
investigations like Platelets, coagulation profile
and then genetic testing for HHT.
Her concern: what is it?
Will i transfer it to my children?
All went good and finished 1 min before with
silence for 1 min here. Got 25/28
History: young female with h/o weakness of

right side of her body while at hair dresser while
washing her hairs completely resolved now. TIA
and Hemiplegic Migraine in final differentials.
She has h/o headaches since last 6 months with
black spots in eyes. But this time headache was
more severe and weakness was 1st time. I
explained it can be TIA or it can be type of
migraine but i want to rule out TIA 1st by doing
scan of your brain, heart scan and scan of
vessels in neck. But examiner in discussion
said it was migraine. And nothing of these tests
can diffrentiate between TIA and migraine. I said
if i will find any positive thing that will support
TIA like stenosis in carotids and any cardiac
pathology.
Things i missed
She was on OCP, so i need to tell her to go to
progesterone only pill, she drink too much
coffee, i must advice her to cut down, and her
concern was can i drive back home and i got
time finished😔
This all only in discussion with examiner.
Got 11/20
It was hemiplegic migraine,
Examiner asked what prophylaxis treatment for
hemiplegic migraine, i told propranolol later i
read that it is not given in hemiplegic migraine
Patient also reacted tooo much that dr u are
saying i had mini stroke????
For communication scenario:

It was COPD pt and u have to talk to his
daughter about home NIV and patient is not
appropriate for intubation and now on NIV but
you suggest daughter to take him home rather
in hospital.And see response and plan further
care and answer any concerns
Got 15/16
Patient was heavy smoker and did not stop

smoking ever
So started with dr understanding of his disease

and proceded to his life style and limitations coz
of SOB.
Told her that intubation is not a good option as

he is not going to get improved, and long
hospital stay with NIV he will have many
chances of hospital acquired infections.
Daughter was quite understanding, kept
checking her understandings. Told her that not
to intubate is medical team decision and not
hers but she is really important too.
Patient wanted to go for grand daughter’s

wedding, told her that it is not possible to travel
my air in this condition.
Daughter start crying, gave her tissue and told

her that i dont want to give you any false hope
and i told u ur father condition in detail. You can
discuss with rest of family too and if any further
concerns you can ask nurse to call me to
discuss them again.
Viva went easy and simple too.

Alhamdullilah passed with 150/172 marks
Experience of my Dear friend
Pray for him please 🙏🙏🙏

My experience in ‫مالطا‬
BCC 1
Fifty years woman
SOB 1yr exertional
Difficult for station five time
DM HTN 5yr
Clue ejection systolic murmur ...........
BCC 2
25 years old woman complaining of joint pain
Inside
since one year in knees elbows and Shoulders
mechanical type of not inflammatory
the clue that was admission for spinal surgery
2 admission for Pneumothorax
make wrist test
make thumb test
pinch your skin
can examine your chest and heart
DD
Ehler Danlis
Marfan
Hx
Bach pain
Dx psoriasis arthropathy
Communication
SJS due to penicillin
it was given for the best interest for the baby

not the for the mother
this was the big mistake and big issue

Her husband is caring about the wife and the
baby have a lot of concern
time finished fast
I did not check understanding
Chest
IPF
Others told bronchiectasis
Neuro
PN
I told LMNL describe .....

with stocking anaesthesia till ....
Cardio
V v v obese
I cannot hear the heart
I cannot make timing
only thing is midline scar with evident click
my diagnosis mitral valve replacement
the examiner ask it is mitral or aortic
discussion was about complication of valve
replacement
I am the only candidate for examines is patient
Abd
renal transplant as it is multiple scars AVF (not
working) in both arms and the scars in the neck
there was rt iliac scar hidden
I told there is a mass but actually I did feel it
I think there is a kidney but it was very soft to

comment about
Even not ballotable
Candidate Experience
*Date:* 16/03/2018
*Location:* Colombo, Sri Lanka.
*ST3*
*CVS* - Young man. Mid-diastolic murmur. It

was MS. I think I missed to pick up pulmonary
hypertension.
Examiners:
- Tell me the positive findings
- What is your diagnosis or DD?
- How to investigate?
- How to manage?
*Neurology* – Middle-aged female. Examine the

lower limbs. Spasticity. Pyramidal weakness.
KJ-brisk, AJ-diminished. B/L plantar-extension.
Pain and fine touch intact. Vibration impaired up
to iliac bones. JPS-patient was giving
conflicting answers. Heel-knee-shin test –
patient could not do probably due to weakness
and spasticity. Gait – the examiners did not
allow me to check. I presented as B/L spastic
paraparesis. I think it was Friedrich’s Ataxia.
Examiners:
- What are your DDs?
- How do you investigate?
- How to manage?
*ST4* - 62 years old male diagnosed with GBS.

On ventilator and feeding through NG tube.
Earlier told to the wife that the prognosis likely
to be good. But 2 weeks later the Neurologist
has seen and said that this is an axonal form of
GBS and likely to be left with permanent
disability. Discuss with the wife about poor
prognosis.
Wife’s question:
- Why they said that he will become better and
now telling me that he is going to be disabled?
- Did doctors misdiagnose?
- Her only support was husband and needs
social and financial support.
Examiners:
- What are the problems in this case?
- What are you going to do for long-term
feeding?
- Why the prognosis was said to be better and
later changed to be bad?
*ST5*
*BCC1* – 34 years, female. Presented with

sudden haematemesis. PR 100, BP 100/60,
Inside- I spoke to the surrogate and examined

the patient. Sudden massive haematemesis. H/O
DVT 6 months ago. Self-discontinued
anticoagulation. Had heartburn symptoms and
taken PPI. Examination – Pale, splenomegaly
~8cm, No evidence of current DVT.
Examiners:
- Tell me the positive findings
- What do you think the reason for
heamatemesis?
- How do you manage?
I think this is portal vein thrombosis. Discussed

about the emergency management as well.
*BCC2* – 70 year old lady. Collapsed twice with

past few days. Had exertional chest pain while
climbing stairs. PR 60, BP 100/80
Inside – Collapsed while standing and with

exertions. History negative for seizures.
Examination – Low volume pulse, ejection-
systolic murmur at aortic area, radiating to
carotid.
Examiners:
- What is the cause of her collapse?
- If the eco shows tight AS, what is your
management plan?
*ST1*
*Abd* – Middle-aged male, Cushingoid
appearance, gum hypertrophy, multiple
puncture scars in the neck, no finger prick
marks (of glucose testing). AVF with thrill in the
left brachial region – not used recently. Abd –
faint scar in the RIF. Mass under the scar. No
other organomegaly. Transplanted kidney with
evidence of immunosuppression. No obvious
cause for CKD is found.
Examiner:
- Can the mass be something else rather than a
kidney? I said the clinical picture is suggestive
of a transplanted kidney.
- What is the cause? I said no obvious
identifiable cause. Diabetes is the commonest
cause worldwide. Other causes ADPKD, there is
an epidemic of CKD of unknown aetiology in the
North-Central part of Sri Lanka.
- The patient is having abdominal pain. How do
you manage? I said need to take a detailed
history and do test. Could be UTI or graft
failure…..
*RS* – Male in his late 40s. Coughing while

entering the room. Clubbing, B/L basal
crepitation changing with cough. There was a
sputum cup kept beside the bed. (probably the
examiner did no see before me. When I said
sputum pot, he asked me where is it?)
Examiners:
- What do you think the patient has? I said
bronchiectasis.
- He kept asking anything else? I said ILD.
- How to investigate?
- How to differentiate bronchiectasis from ILD in
HRCT?
- How to manage?
*ST2* – Young male, 20 yrs. Back pain for past

few months, recently worsening. There is
morning stiffness, rashes behind the ears and
itchy scalp. No trauma, no nail changes
. No recent weight loss or anorexia. Difficult to

continue his job as a cleaner. DD-Ankylosing
Spondylitis, Psoriatic arthropathy.
It was like a nightmare ☹️☹️☹️

Cairo exam 3rd of February
st 2 history taking
45 yr old man has IBS + abdominal distension
go & answer any concern.
inside exam room pt was suffering for the last yr
of IBS and seek medical advice & received anti
spasmodic but not response. he has diarrhoea
increase frequency not bloody. no alarm sign.
last 6 months his symptom increase b/c his
father diagnosis by Ca of colon so he has stress
condition and i asked him about family history
he has his uncle & aunt also diagnosis at age 39

yr his father at 60. he works as a bank
accounter.not smoker or alcoholic drinkers.
surrogates ask me what does i have. i explain to
him what IBS as written in ryder 😜😜😜
examiner ask me does we need to investigate
him i said it diseases of exclusion . when we
need to screen him for Ca colon
i got very bad score 12/20
st 4 45 old male has Meningococcal septacemia

his GCS 7 .ICU dr descided to shift him to ICU
go and talk to his wife . believe me his wife
wants to sleep during all conversion she
�� but i still keep talking with her as i need
to BBD and explain the disease in simple way
and be empathy & sympathy as the same one
we did with Dr Zain . talk about contact tracing
his colleagues in factory and his kids. social
support B/c she has 3 kids . 2 in school and 1
baby . also contact infection control
and believe me i was so upset to her husband

more than her so i think the examiner give me
high score 15/16 😜😜😜😜
st 5 . 50 yr old lady has difficult to standing has

high BP .
inside exam room an obese female i asked
surrogate for how long has this proximal
myopathy said for 1 yr + increase weight no
increase in diet never used steroid. difficult to
control her bp . on examination she has
proximal myopathy she couldn't stand up when
i want to do upper limb the surogate stop me b/c
she is in pain so i stop immediately because
wellfare if pt.abdominal distension with full flank
+ straie .
examiner want dd.
1. cushing syndrome
asked how to investigate
i got 28/28
st 5 34 yr old male has skin lesion .

inside room skin lesion inboth dorsum in his
feet start suddenly on last 3 weeks is itching
tips here about his job he works chemical
factory when i asked in timing he also start his
job 3 weeks ago . i remembered when i enter
exam room i was so depress because i couldn't
recognise wt this skin lesion but from history i
reach diagnosis is contact dermatitis
when examiner asked me ti describes the lesion
i couldn't say it in proper way b/c the lesion
cover by full cream only i said erythematosus
rash cover by cream��.
i advice pt to change his position the examiner
jumb to my face and told me we have ecnomic
crisis in our Country😡😡😡😡😷so i decided to
cover his foot by 👢👢
i got 27/28
2018/1: Chennai, SMF. 16 March 2nd carousel:
St-2: collapse for 1 min but urinated. No aura,

no convulsion, no post ictal confusion. Pt on
queue in a bank in a hot day. Family hx of
epilepsy (brother). Dx: vasovagal. Dd: 1st attack
of epilepsy. Cardiac syncope.
Hidden issue: Pt planning to get driving license
shortly.
Ques: how to prevent vasovagal. Brain scan
needed? What inv for vasovagal? Advice for
driving as epilepsy is a dd.
St3: Cardio: morbidly obese oedematous female

very low volume pulse, impalpable apex beat
with AF with diastolic murmur in mitral area.
Severe MS e AF e Rt heart failure. But took too
much time for pulse n apex beat. Didnt notice
valvotomy scar under the left breast. (Ques: dx,
mx of MS, AF, anticoagulation)
Neuro: cranial nerve examination in a "pt with

speech difficulty". Dx: Lt Bells palsy. Some said
UMN as pt could tighty close lt eye. But wrinkles
were absent. Probably partially treated. (Ques:
everything about facial nerve, course, origin,
lesions. Causes n mx of Bells)
St:4: counsel a 26 yr old female with usg

showing Apkd e normal U & E. Father has ckd
on dialysis having peritonitis. Also counsel
about availability of genetic testing which is not
of use but could be done for 16-21 yrs (very
confusing statement) Pt going to marry in 3
months. Task is to inform all this.
(Actor was apathetic. Hardly asks anything
except how to tell her fiance. I had to do all the
queries and ans them)
Ques: what were her concerns, how did u meet
them? Role of genetic testing in pkd.
Complications of pkd. Will u do cerebral
angiogram? How to hault progression to ckd.
St5:
Bcc1: psoriasis with joint pain not relieved by
pain killers (sign: arthritis of DIP in Rt ring
finger. Forgot to mention nail changes. Plaque
like psoriatic rash all over the body) Drug
history : enalapril MTX amlodipine still
hypertensive. Dx: psoriatic arthritis. Dd :
psoriasis e 2ndary gout (ques: dx, inv, mx, role
of biologics)
Bcc2: 34 yr male e loose motion for 3 months.
2kg lost. Watery. No change e food. No fever. No
family history. No travel. On query: multiple
sexual partners without safe sex. O/e: no
anaemia/osteoporosis. Rt iliac fossa tender. Dd:
IBD, HIV related (HIV enteritis/cryptosporidium),
Coeliac, told infective diarrhoea too (ques: dd,
inv , mx)
St1: Respiratory: DISASTER most probably. I

only found BS diminished left lower zone, dull
percussion. I told pleural effusion. Dd: pleural
thickening. Raised hemidiaphragm.
I checked for scar but found none. But someone
else said there was lateral thoracotomy scar. If it
is so, then thats lt lower lobectomy and i am
doomed. (Pt had an amputed rt ring finger:
traumatic n unrelated)
Abdomen: left hand matured AV fistula, B/l

palpable kidney, huge hepatomegaly. I thought
there was spleen too but didnt tell as
insinuation could be done. (ADPKD e
hepatomegaly)
Ques: findings. Inv, mx, causes of
hepatomegaly in pkd (told hepatic cysts,
infective, amylodosis).
(Lessons: 1. Lots of repeats from recent
scenerios in St 4.
2. Lots of repeats of same/similar pt too in same
centre.
3. Cool head is needed more than knowledge.
4. Examiners were trying to help all the way. Its
only me who let me down.
5. Scars r the easiest things to miss :( )
Lei
https://www.facebook.com/profile.php?id=10001
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location=group_dialog
These questions are collected from all of the

exam candidates’ experiences. U can share
freely but one thing is that pls pray for them to
pass the exam or to be successful in their future
career.
KOCHI BCC collection

1.Long standing RA, taking MTX, Leflunomide,
prednisolone for 10yr, ongoing pain.
2.67 male with palpitation and SOB.

Hyperthyroid symptoms with goitre. Past
history of asthma on ventolin inhaler
3.Young lady . Tiredness and Short stature.

Pt denied every symptom .
Apart from tiredness does not have any positive
symptom of hypothyroid. Addison or chronic
disease.
No past med h/o . No family h/0. All family
memeber are short.
4.old man with hand pain

5.Start with middle age man presenting with

seizure 2 times this morning. H/O AGE
yesterday and headache for 3 months. Patient
can speak english but he told me different
information (seizure 1 time and yesterday, not
today), no abnormality on examination. Not
allow to do ophthalmoscope. No neurological
symptoms. (Dx according to feedback is drug
induced headache and electrolyte imbalance).
6.70 yrs old man with thyroid operation last

week now complaining SOB and palpitation.
They gave his vitals showing tachycardia. I did
not check pulse again and I am stuck. Only
thing I found out is anaemia and SOB. He
cannot answer but surrgoate answer question.
So I gave Dx of anaemia and heart failure as he
is on heart failure medications. Concern is need
to continue this medications? Question on
differential and any possiblity of thyroid
reminant after operation? I fail to examine neck
properly. The feedback showed hyperthyroid. I
got very low marks in station 5.
7.lady with T2DM came with sudden onset facial

drooping and unsteadiness which resolved after
1hr, unremarkable physical exam. Give Dx as
TIA
:TIA with family hx of stroke
: stroke in young.
8.RA
9.Blurred vision in right eye × few weeks in a

patient on insulin statins and antihypertensives.
Not sure of fundus findings. So this case was a
disaster for me.
10.an elderly asthmatic lady with tiredness. Hb

7. Dd ocult Gi bleed due to aspirin, malignancy,
nutritional def
11.psoriatic arthritis
12.first episode of seizure in 55 years old man

13.pt 35 year old lady fever high grade 10 days
with skin rash.
14.patient 65 year lady with palpitations had

right sided multinodular goitre.
15.30yr old lady with skin lesions and blisters

for 6months..
16.76 yr old gentleman with recent onset of

weight gain
17.back pain for 12 years . Nocturnal pain,

stiffness, progressive in nature. Dx.. Ankylosing
Spondylitis
18.treated Psoriasis dark coloured patches..???
19.intermittent fever for 6 months with unilateral

LL swelling
20.transient collapse with recent change in dose
of antihypertensive , patient is on Insulin
21.Oligoarthritis with joint pain
22.tingling and numbness of hand with

thyroidectomy scar.numbness on hands and
feet, scar (+)at neck. H/O renal stone (+).
Dx-Hypocalcaemia?
23.Rash and arthralgia after medications. H/O

fever 1 week before symptoms.
24.confusion with Cough,hemoptysis and wt

loss
25.diabetic patient with reduce vision

Fundoscopy normal
Discussion about diabetic eye
26.syncope in elderly women with DM. she had

AS,palpitations + PR 50/ min. Inside- thyroid
enlargement.No hyper/hypothyroid
symptoms.she was on multiple drugs for
hypertension.
Cairo exam 3rd of February
st 2 history taking
45 yr old man has IBS + abdominal distension
go & answer any concern.
inside exam room pt was suffering for the last yr
of IBS and seek medical advice & received anti
spasmodic but not response. he has diarrhoea
increase frequency not bloody. no alarm sign.
last 6 months his symptom increase b/c his
father diagnosis by Ca of colon so he has stress
condition and i asked him about family history
he has his uncle & aunt also diagnosis at age 39

yr his father at 60. he works as a bank
accounter.not smoker or alcoholic drinkers.
surrogates ask me what does i have. i explain to
him what IBS as written in ryder 😜😜😜
examiner ask me does we need to investigate
him i said it diseases of exclusion . when we
need to screen him for Ca colon
i got very bad score 12/20
st 4
a 45 old male has Meningococcal septacemia
his GCS 7 .ICU dr descided to shift him to ICU
go and talk to his wife . believe me his wife
wants to sleep during all conversion she
�� but i still keep talking with her as i need
to BBD and explain the disease in simple way
and be empathy & sympathy as the same one
we did with Dr Zain . talk about contact tracing
his colleagues in factory and his kids. social
support B/c she has 3 kids . 2 in school and 1
baby . also contact infection control
and believe me i was so upset to her husband

more than her so i think the examiner give me
high score 15/16 😜😜😜😜
st 5
. a50 yr old lady has difficult to standing has

high BP .
inside exam room an obese female i asked
surrogate for how long has this proximal
myopathy said for 1 yr + increase weight no
increase in diet never used steroid. difficult to
control her bp . on examination she has
proximal myopathy she couldn't stand up when
i want to do upper limb the surogate stop me b/c
she is in pain so i stop immediately because
wellfare if pt.abdominal distension with full flank
+ straie .
examiner want dd.
1. cushing syndrome
asked how to investigate
i got 28/28
st 5
a34 yr old male has skin lesion .

inside room skin lesion inboth dorsum in his
feet start suddenly on last 3 weeks is itching
tips here about his job he works chemical
factory when i asked in timing he also start his
job 3 weeks ago . i remembered when i enter
exam room i was so depress because i couldn't
recognise wt this skin lesion but from history i
reach diagnosis is contact dermatitis
when examiner asked me ti describes the lesion
i couldn't say it in proper way b/c the lesion
cover by full cream only i said erythematosus
rash cover by cream��.
i advice pt to change his position the examiner
jumb to my face and told me we have ecnomic
crisis in our Country😡😡😡😡😷so i decided to
cover his foot by 👢👢
EGYPT ..Cairo
This is my exam experience in New kasr Elainy
on 3/2/2018
I started with station 4 a case of 50 year old man

with heart failure on maximum treatment in spite
of this has shortness of breath, he discovered
cervical lymph node and biopsy and abdominal
ctscan and bone scan show that he has
advance cancer of kidney with metastasis to the
vertebra and liver your task talk to the patient
regarding palliative treatment including
Ìstarted with greeting the patient check the
identity and check his knowledge about his
condition ,actually he has no idea about the
result of test I give him shout that I am sorry to
tell you that the result of test as not good as we
hope .....you have a kidney cancer and am afraid
to tell you that it is in advance stage it spread in
to your liver and your back bone with great
sympathy and empathy he ask about the
treatment any cure I told him if the cancer on
early stage usually the treatment and cure is
surgery but in your condition and with spread of
cancer cell there will be no role of surgery but
we will do our best to treat your symptoms we
called palliative treatment. Do you ever heard
about it ?and I explained for him all about
palliative treatment and the palliative treatment
team I told him will not let you suffering will
make your life more easier ,I didn't talk about
DNR because it is not one of the task he was
concerned regarding how to inform his wife and
I told him if you wish I will help you and arrange
meeting to talk with her and she will be good
support for him, he was concerned regarding
travelling I inform him that i appreciate your
feeling and you have the right to travel but I am
afraid with this heart disease it could be danger
for your life that why I will refer you to heart
specialist to assess your fitness for travelling
he has 3rd concern regarding dealing with
heavy objects as he works as mechanics I
appetite his concern and I inform him that
carring heavy object me put him in a risk of
fracture that why better to avoid and refer him to
social worker and occupational health
worker,he ask me to give him estimation
regarding his life span ,I inform him this is
difficult question to answer and with great
sympathy ì told him that I am sorry but with this
advance stage of cancer it will short your life it
may be period of months rather than years.
After finishing and great sympathy and empathy
the senario end with summary and check
understanding.� then move to examiner
Questions😐
The questions was regarding what ethical

issues applied in the senario I started with
breaking bad news the examiner ask me does
breaking bad news is one of the ethical issues?
I said no 😥 Autonomy the right of the patient to
know about his kidney cancer and it is advance
stage ,beneficence to manage the patient with
palliative treatment and non malfescience in
that no role for surgery her or chemotherapy
because he will suffer from bad effects and he
ask me about travelling I told him that better not
travel with this heart failure and need to be
assess with cardiologist alhamdellah I got 16 .
then station 5
first one was weight gain with proximal

myopathy when I enter the room I found a lady
and when I want to put the paper I found cup of
water and hammer😉 so that I diagnosed hypo
thyrodism by the surrounding the positive thing
was weight gain allover constipation , proximal
myopathy ,low mood,heavy cycle screen for
other hypos was negative screen for the cause
also no thing significant ask about the impact
who is support her and smoking alchol
medication list like amidaron,lithium ,steroid
,statin examination start from hand for dryness
of skin ,carpal tunnel,pulse ,BP sitting and
standing ,proximal myopathy, pallor
,macroglossia,neck for scar and ask her to drink
water for neck swelling examine basal crept,
osteoarthritis in knee,lower limb edema and
ankle jerk,the patient concern was about what is
the cause and it is reversible?the answer was it
is due to under activity of gland in your neck
called thyroid causing this symptoms we need
to do blood test in order to confirm diagnosis
and refer you to gland doctor,if it confirmed we
will start for you medication called thyroxin
need to be taken regular and to be follow up
with the gland doctor and it is reversible after
starting treatment. Then examiner question1-
what is your diagnosis? Primary
hypothyroidism.
Next case
was 35 years old male with dimnution of vision

inside the positive thing gradual blurring of
vision and no variation between day and night
he has oral ulcer and genital ulcer recurrent
painful , history of knee pain،history of leg clot
there is some times pain and redness in eye ask
about ,impaction,driving and social issues
examiner question what is your
What is differential diagnosis for anterior
uveitis? How you will diagnose ?HLAB51 and
pathergy test.alhamdellalh I got 28.
Then move to station 1
I started with abdomen the case was anemia

with splenomegally but actually I was hesitant
and was thinking that may be ì miss the liver
and ascites😫so that I was not concentrated in
discussion also it is common question they ask
about differential diagnosis I forgot infection🙈
and about clinical judgment I didn't request any
ct scan or bone marrow examination so this was
my worst station I got 13,
Chest station female with OLD with basal
fibrosis actually the patient was coughing and I
was stress examiner ask about dd. and
Management of COPD criteria for long term
oxygen therapy I got 18.
Move to station 2
from outside was written 35 years old female

present with left side weakness for one hour.
Inside I found this is the first time complete
recovery she was on hairdresser associated
with headache typical migraine with visual aura
she has sleep disturbance recently drink a lot of
coffee no other risk factors for stroke in young
she is on oral contraceptive pill no neck pain or
neck swelling she has history of bronchial
asthma social history was not significant.
Concerns it is stoke I told her because of
complete recovery it is not stroke ,it could be
ministroke or related to your headache and now
present with Unusual presentation .she asked it
could reoccur again I told her it could be
especially you are in oral contraceptive pill I
advice you to stop and refer you to women
doctor to change to other methods of
contraception and I will admit you to do for you
blood tests,heart tracing ,ima
ging to brain scan to heart and treat your
headache involved neurologist. Also advice
regarding have good sleep and decrease coffee
in take.
Examiner questions what is your differential
diagnosis?
Hemiplegic migraine
TIA
Carotid dissection
screening,autoimmune screening ,ECG Echo
carotid doppler brain ct scan and MRI
He told me why MRI
I told to check if there is any area affected by
posterior circulation. Another question about
migraine management and proflaxis.
My last station was station 3😥
started with CVS examination she was very ill

patient severe pale I couldn't assess the pluse
well if it is regular or not then I thought I will
check by stethscope she was ill and
tachypneoic with midline sternotomy scar she
has ascites also I think because so distended
abdomen with raised jvp the auscultation was
so difficult she has double valve replacement
with left parasternal heave and pulmonary htn
,there is murmur every where😱😱😱😱 I forgot
about the pulse at that time and try to
concentrate on murmur I found MR and TR she
has also lower limb edema then after that the
examiner told me to say positive finding I told
double valve replacement with phtn and right
side heart failure with MR and TR he told me did
you hear another murmur I told am not sure
because the patient is pale may be hemic
murmur I think there is aortic stenosis but I
didn't mentioned then ask about how you will
manage I told admission and involvement of
cardiologist ECG Echo CBC inflammatory
markers coagulation profile he ask me what you
will find in ECG I told him about rt ventricular
hypertrophy then told me what about rhythm
what about pulse😱😱😱 at that time I remember
that am not sure of the pulse if it is regular or
not then suddenly I told him irregular he told me
are you sure then I told yes I don't know why I
said this🙈 and I felt guilty feeling and I thought I
lost the case and also regardingMR I was
thinking may be not true because such case will
not come in exam. I was think I will get 6 but Al
hamdullelah I got 19😊the neuro station was
more tough young male examine lower limb he
has severe pain in his rt lower limb and there is
wide difference when I start to examine the tone
the patient was shouting that he has pain then I
stopped and told the examiner the patient in
severe pain he told me continue but gently I get
panic and I couldn't assess the tone well the left
leg looks normal and he is an able to move the
rt leg because of pain ,reflexes knee present
absent ankle extensor planter sensation I start
with pain and touch sensation when reach the
knee he told he feel now when I move around
the knee he told it is not similar some area are
more some are less I lost a lot of time in
sensation😥 when I start test vibration test I
didn't complete time was over 😢 and I got more
depressed I thought I fail the exam😥 then the
British examiner was the leader and he was nice
he told me forget about the vibration and
position sense what is your finding? I told him
this gentle man has monoplegia and it seem to
be not hemiplegia because the patient was
moving upper limb normally ,and not cortical
lesion because he is conscious,tone difficult to
assess well because of pain😔knee reflex intact
absent ankle reflex with extensor planter
regarding sensation it seem to be patchy
sensory loss😞 he told me so what is your DD?
I told with this patchy sensory loss could be
cauda equina
Multiple sclerosis then the whole discussion
was about multiple sclerosis how you will
investigate and manage. Then bell ring and the
exam was end I was think that I did very bad
especially in this station and may be I will fail
the exam. It seem to be appeared in my face that
I am depressed the British examiner told me be
happy already you finish the exam enjoy your
life, actually he seem to be a nice examiner I
told him actually I did very bad and left the
room😥 then I was surprised that I got 20😊
Alhamdellah I passed the exam with score 162

my advice doaaa ;doaaa and doaaa it is
matter of tofig and don't panic inside exam and

when you move to new station forget about the
previous one because you don't know how the
examiner will evaluate you.
Good luck for all of you and I hope all of you to
pass exam .
Halem Hussein
I would like to share my exam experience .....
Egypt 🇪🇬....
5 of February New Kasr Aainy Hospital .3rd day ,
second cycle ......
�start with station 3️⃣
❣️cardio :
Young pt with sob
By examination i found large volumes
collapsing pulse
As, Ar , mr
Examiner qs:
Present your case..??
I told him about positive findings and said As ,
Ar
And i was not sure about mr..so i don't told
about it
He asked any thing else ...
I told him yes 😊... I could also appreciate

pansystolic murmur at apex radiate to axilla
So
In conclusion:
AS, AR, MR
Then asked
What r investigations??
And expected findings in Echo , Ecg
Then what is your management plan????
I answered
. Non pharmacological
. Pharma
Then asked me
Indications of valve replacement
Got ✅ 20/20 😊
................................................:::::::::::::::::::::::::::::
:::::::::::::::::::
• Neuro :
26 ys lady with difficult in walking since 16 ys
😇( you have to read instructions carfuly)
Exam lower limb....
Start by asking any pain in ur legs.. she told yes
in my rt knee ... i told here don't worry i will do
my best not hurt you... patient not cooperative,
and not comfortable but i try to say sorry and
explain what I will do in every step.....
I found spastic paraparasis with intact
sensation in both legs
( pyramidal + clonus+ upgoing planter +positive
pathological reflexes)
.. Examiner qs:
Present ur case
What r dd ?
I told him could be ms 🙈
He told : do u read the paper in the wall 😇

I told yes
It could be also
Hereditary or tropical spastic paraparasis ( so i
need to take family and travel history 😎)
Told me what else ????
I told Could be parasagital meningioma
Could b cp but less likely
Then asked me
What r investigations???
What u suspect to find ????
I answered basic and spesific lp + mri
What r findings in MRI
I told may be peri ventricular plaques
What else???
Brain atophy
What else???
parasagital meningioma
He agreed 👍🏻
What r ur management plan ???
Answered by
Nonpharm and
Pharma
Start to explain what r non pharma
Then time finished
I got ✅ 20/20 😊
................................................
::::::::::::::::::::::::::::::::::::::::::::::::
• station 4️⃣
Senario about old man 80 ys
With obstructive jaundice .. ct confirmed he has
pancreatic cancer, cancer invades adjacent
blood vessels and organ...
Technically not for surgy and also not for
chemotherapey ...
And just for palliative care and for stent by
ERCP
.............
Really i read the senario rapidly not carfuly
And told myself it is easy and I practice it many
times before... I don't think at that time it will be
the worst station and difficult examiner in my
exam at all☹️☹️.....
Inside I meet the daughter she is soon coming
from 🇺🇸 usa
....
I introduced my self , my role
Asked r u NOK
R u comfortable in this room...
She started talking... very talkative 😏

Take about 2 minutes .....
I let her to finished without any interruption..... I
asked what r u suspect and wishes ...
I promise i will do my best to help ur father and
explain everything for ur
She thanked me ...
I told here ur father came to our hospital with
fatigue and jaundice... some investigations done
for him one is ct over his tummy..
The result now in my hands
And sorry not as we hope
I break bad news .. let here to express her
feelings...
And start to drawing some figures to explain
where is the cancer and what cause of
jaundice.....
She told me plz remove it by surgery 🙃

I told here am sorry surgery not option here bcz
mass spread to nearst organ and blood
conduits.....and very difficult to remove it.....
So give him chemo 😡

I told here sorry again chemo also not option
and if we blanced benifits and hazards of chemo
in ur father condition... hazard will be more.....
Now she told me
I know u don't need to treat my father bcz he is
old man 😤😤....
I told here
Definitely not right.. we don't deal with our
patients like that .. we try to help our patients
regardless any discrimination ( age , sex
,.......)and we will do our best to help ur father
But surgery and chemo not the best intery for
him.....
We will help by inserting stent by procedure and
drawing in paper 📋this stent will help to relieve
jaundice....
And he is for palliative care.....start to explain
what it is ...
Palliative team group of specialized doctors and
nurses... help ur father and family at hospital
and home ( free of pain , nutrition, spiritual,
social.,,,,,,)
Now i asked with whom ur father is living...
She told me alone
Am the only daughter...
An afraid how can he take care of him
self....after return back to 🇺🇸
Am sorry we will include social, occupational
workers.... to visit his home and may change
some facilities to help or social worker arrange
some visits to help....
( i add as volunteer😡😡 may be arrange for

nursing home... I don't know why I offered this
option)
She told me can help by 24 hours nurse... i told
if u have the ability to do ...
it will be ok ...
I don't say directly it is private care...
She asked my father will die????
I told her am sorry it will shorten his life but no
one can predict when exactly what will hay in
future 🙃.....
I told here about DNR
Advanced directives
Concerns
No time for summary
Time finished.......
Now examiner qs.....😤😤😤

Examiner was very very tough not only with me
but with all other candidates...
Asked me :
What r this daughter concerned about????
I told him.. she is asking what is going wrong
with her father..??
Told me that is mean what is the
diagnosis!!!!!!!�
What else ....
I told also asked why not for surgery, chemo ?
Told me ... that is mean what is management
plan ..!!!
��
I told yes 😇
What else???
I told
Asked also how can we help his father at home
bcz he is living alone
Told me .. also this mean management plan...!!!
��
At that time i told myself
My exam lost 🙈🙈
Told me
You told here about nursing home.... what r the
indications of referring patients to it ????
I told patients with chronic illness need special
care, no one cares about him in home...he told
so do u think the man for nursing home ��??
I told no😤😤😤
Told me.. you offered 24hs nurse
And you don't told her it is private not from your
MDT
Here i lost my comfort and my nerves...
Told him ..
I told here if u have tha ability to offer it .. will be
good
..
Also why u don't told about ERCP
complications 😡😡
Time finished
While he looking at me by strange look ☹️☹️
Igot only ✳️ 6/16

( other candidates same cycle marks 4 , 4 , 5 , 8 )
.............................................:::::::::::::::::::::::::::::::
::::::::::::::
station 5️⃣
After st4 I think my exam lost
But told my self I have to forget and consider
every station separate exam ... ✋️
.First case :Bcc1🔘

Male 50 yrs old with tiredness 6 months.....
By history lost 10 kg wight
Lost appetite. Constipation with bleeding per
rectum...
Family history of cancer colon
Using ibuprofen frequently for knee
pain....recived blood transfusion 2 days back
bcz anemia ( hgb 8.5 )
Start to examine him just exame hands and eye
for pallor and jaundice
Examiner told 2 minutes remain..🙈🙈🙈

At that time felt lost concern is very important ..
(Concern vs examination) . i told to examiner I
would like to examine abd .. told me ok examine
it 😁😁
Rapidly superficial palpitation while asking what
is his concern...??
And told the examiner i want to examine LN
Start to answer concern (what is the problem)??
I appreciate ur concern there r Some
possibilities for the anemia and wt lost need to
exclude cancer colon
We will admit him
Doing some investigations
Colonscopy
Ct ,...........
MDT
Any other concern ??? No
Time .....
Examiner qs:
What is ur case and findings????
What investigations
Why u suspect cancer colon..
What dd
I don't find positive except pallor
And I think for that reason he cuts some marks
I got ☑️19/28 😇
..................
Second case Bcc2 :🔘

Female with headach 3 months..
Case of acromegaly with inc ict
Asked
About OSA , cancer colon
Driving , social , alchol,smoking
Examined hand , pm
Neck face
Start to examine eye
He told me what u need to examine
I told acuity, field, funds
He told me normal ✋️😁

I would like to examine
Heart , abd
Told me no need 😇
Concern .. what is the cause of her
headache???
I answered in details
Time still 45 seconds
You need to do or asked any question..???
Then examiner qs....
Findings
Dd
Investigations
Mangment
I got
✅ 26/28 😊
............................................
:::::::::::::::::::::::::::::::::::::::::::::
Station 1️⃣
♻️Abdomen:
Pallor , deputren contructure , vitiligo, inserted
canula , shranked right lobe of liver, left lobe felf
6 cm...
Spleen 16 cm
Also ascites , dilated portal veins
Mild leg oedema
No LN
.......
Dd
Cld ( viral, bilharzial, alchol....)
Investigations
Management plan?
How to ttt ascites?
How to ttt portal hypertension ?
Examiner was very happy 😊
I got ✅ 20/20
..............
❇️ Chest :
Male looks very well
About 35 ys
With sob
Copd
With bilatera basal fibrosis
.....
Examiner qs:
Present ur findings
What causes???
Which is prominent copd or fibrosis ?
I told fibrosis
He told me if ur investigations confirmed it not
fibrosis
What ur opinion??
I told bronchectasis but will b coarse crackles
Investigations
Told me one specific investigation
I told HRCT
Mangment ( non pharma + pharma)
Got ✅ 19/20 😊
.............................................:::::::::::::::::::::::::::::::
::::::::::::::
Station 2️⃣
( last station)
40 years old man with DM since 30 years.....
recurrent collapse in last 3 months .. last one
today morning......
I started to analysis the complaint .. then
directed asked do you drive 😎...
He told me yes .. i told you have to stop ✋

driving
For your safety, and the others...
He agreed
And examiner was very happy 😊

...
By history many problems ( nephropathy,
retinopathy, neuropathy..... automatic
neuropathy)
Any problem in intimate relationship.. yes
Asked about drug list ... He gives me paper 📝

list of medications
( insulin lantus , mixed, enalapril , pisoprolol ,
warfarin 😳, diuretic, statin, aspirin)
I don't asked him why warfarin And bb🙈🙈🙈

I told him we will discuss with ur doctor to
change some medication ( bb , diuretic , adjust
ur insulin dose )
Asked about PMH
FH... any heart problems, sudden death ???
No.....
Then social.. told me am a teacher and i lost my
conscious in front of my students am shaming
of that......
No alcohol or smoking..
3 Concerns:
What is cause of my collapse???
How can you help me ???
Is it serious?????
.....
Examiner qs:
What your dd ??
Autonomic neuropathy
Postural hypotension
Side effects of ttt
Associated Addison
Vasovagal
How to investigate autonomic neuropathy
And vasovagal
How to ttt
Any special ttt
I got ✅ 20/20 😊
...........
✳️❇️ Alhamdullelah 🙏
I passed
With score 150
First attempt
Thanks to all my friends, all groups , for
everyone who shared his/her experience before
and helped me alot 🌹🌹
Hope my details helped you
And sorry for this long experience 😊😊✋️
✳️ Thanks to my great prof dr Ahmed Maher

Eliwa
For great support ❤️❤️
🙏😎😎🙏
My exam experience
Cairo New Elkasr Elainy hospital
3 February 2018
1st day third cycle

Abdomen was old man around 70 years old.. the
positive findings were he had pallor, infra
midline scar with no mass under it,
splenomegaly around 8 cm.
Actually i couldn't complete examining the

groups of lymph nodes in the axilla as the
patient was talkative speaking alot interrupted
me too much and the local examiner was trying
to calm him....
Discussion was about the findings.. I said my

positive findings as above..
DD I said to him the first possibility is infection

and because we are in Egypt I have to consider
bilharsiasis firstly, other infections also should
be considered like chronic malaria,
leishmaniasis...
Other DD will be CLD but against that the
absence of stigmata of CLD..
he asked what else I said it could be malignancy

he said like what?
Here i stucked😳 and I didn't know what to say..

I said could be primary or secondary.. he asked
secondary like what I said like Mets from liver or
peritoneal cancer� (actually at that moment I
became frozen minded on the causes of
secondaries in spleen rather than saying myelo
and lymphoproliferative diseases 🙈 )
He asked oki what investigation you will do? I

said apart from basic investigation in the form
of CBC, ESR,CRP, LFT,RFT I would like to do
abdominal ultrasound to confirm my finding..
then specific investigations accordingly..
He said ok what will be the cause of anemia in

this patient?
I said could be due to hypersplenism that is why
I need to do CBC to check for pancytopenia ..
and also anemia could be due to hematemesis
secondary to oesphageal varieces if he had
CLD..
Then he asked me again what will be the type of

malignancy in such old patient 😩
And again I was doing like this� forgetting to
say myelo and lymphoproliferative diseases.. he
said ok let us go to the second case..
after the exam I remembered the lympho and

myeloproliferative disease �and I knew that I
will loose 4 degrees in DD and clinical
judgments skills
But I got only 12 �
Respiratory
was also around 65 to 70 years old lady she was
very ill and wears alot of clothes in which i lost
much of my time.
So I started by General examinations she was
dyspnic and had exessive dry cough then i
asked her to sit. I examined the trachea which
was central and she had decreased cricosternal
notch distance with tracheal Tug..
Then i examined the back which showed
decreased expansion bilaterally and there was
resonant percussion note with dullness
bibasally..
auscultation revealed wide spread rhonci with
vesicular breathing with prolonged expiration
and bibasal crackles (I couldn't detect whether it
is changing with cough or not because the pt
was coughing too much and she was talking
alot through all my examination and the
examiner was trying to calm her... which
disturbed me too much😩😩) when I was
checking for vocal resonance in the back the
examiner said you have only one minute left😳
So I asked her to lie down.. again some time lost

in undressing her so I checked only chest
expansion and percussion from the front...
they asked me present your positive findings.. I

said as above (and the summary was features of
obstructive lung disease with bibasal crackles
mostly due to bibasal fibrosis )
so he asked me about the features of OLD? I
said it again... and he said to me oki what will be
the cause of crackles here other than fibrosis? I
said could be due to bronchiectasis... he
became happy and asked me what is going with
bronchiectasis here?
I said the features of OLD.. but he asked what
else? I didn't find what to say as she had no
clubbing.. not cachexic and no productive
cough..
Then asked me about investigation and details

of what you expect to find in CXR in OLD and
bronchiectasis ...
Then asked me about findings in HRCT in both

bronchiectasis and ILD... and asked what other
important tests I said pulmonary function test
looking for obstructive features and sputum for
Culture and Sensitivity and sputum for alcohol
and acid fast bacilli.. the bell rang and I get 16
Station 2
The scenario out side was 35 years lady
complain of left sided weakness lasted for 3
hours today morning..
So I wrote in my paper my DD of all causes of
hemiplegia in the young..
Entered inside after greeting the surrogate and

aggreed the agenda i asked her about her job (
she was shop assistant)
I analysed all the presenting complaint fully and

asked about all the CNS symptoms and then
asked about all my DD list then brief systemic
review to the related symptoms only then PMH
and medication history ...
the positive information was left sided

weakness lasted for three hours and completely
recovered now... it happened while she was in
the hair dresser.. and her neck was extended
there...
No facial weakness no problem in vision no loss
of control over her water and bowel motions...
She had severe headache continuous till now..

mainly in the back of her head.. I asked about all
patterns of aura in details it was associated with
flashes of light only.. she didn't sleep well for
the last 2 days with excessive drinking of coffee
in the last few days..
she had some stresses in her life...

the headache started before the weakness and
continued till now...
she had headache for long times but it was
coming in mild attacks except the current attack
is the most severe one.. she was not sure of the
nature of the current attack...
And she didn't seek medical advise about her
headache in the past because it was mild..
All the other causes of hemiplegia in the young

were negative....
PMH was only mild asthma not on medications..
and I asked about all risk factors of TIA which
were negative..
Drug history only revealed she is using
combined oral contraceptive pills..
I started to ask about the stresses in her life, at

that time the examiner said two minutes left😳
So I run 🏃🏻♂🏃🏻♂ to ask about family history
which was negative.. and smoking and alcohol
which were negative..
Asked her what is your concern she gave me 4

or five concerns at once😩
What is the wrong with me?
Is it stroke?
Will it happen again?
And what is the treatment?
I told her I appreciate your concerns and i need

to examine you but most likely you have
condition called Hemiplegic migraine with brief
explanation..
and I need to admit you to hospital and you will

be seen by MDT mainly by the brain doctor and
appointment with the mood doctor regarding
her stresses...
And replied to her concern is it stroke by saying

it is less likely to be stroke because you
recoverd now.. but still there is possibility of
mini stroke that is why we will do for you some
blood test and imaging for your brain and
tracing for your heart... and told her the
treatment will be planned mainly by the brain
doctor.. and i advised her to stop the women
pills and we will give her another safer
contraceptive after consulting the woman
doctor...
Most likely I forgot to answer the concern of will

it rehappen again because it was many
concerns and I replied to it with explaining the
plan of management so I had to cover alot of
issues in short time �
The examiner asked me how did you manage

her concern� 😳
I said yes and repeated all my answers as I
replied to the surrogate ...
Then he asked me will it rehappen again? I said

yes since it happened it can happen again..
Then he asked what is your DD?
I said in order:
Hemiplegic migraine
TIA
Carotid artery dissection
Stroke very less likely..
And he agreed..
He asked about plan of management. I replied

the diagnosis of migraine is mainly clinical
diagnosis but I need to exclude TIA by doing
ECG, Echocardiography, Carotid doppler
ultrasound, CT Brain... and all secondary
causes of TIA should be checked as BP, Blood
sugar, complete lipid profile, coagulation
screening and vasculitic screening...
and if we found any risk factor we should
control it...
Then he asked me about the management of

acute attack of migraine and what medications
used to prevent it.
And the bell rang 🛎
I got 18😉
Station 3
CVS
the patient was around 60 years old lady
tachypnic the pulse is regular very weak even
difficult to palpate it the patient is pale, JVP is
elevated and had bilateral lower limb edema..
Also she had hugely distended Abdomen

obviously tense ascites... she had midline
sternotomy scar, the apex beat is thrusting in
nature and had parasternal heave and second
palpable heart Sound and also there was thrill
over the aortic area..
In auscultation the first heart is clicky metallic,

second heart is also clicky metallic, she had
pansystolic murmur at the mitral area radiate to
the axilla, and also another systolic area
increased with inspiration at the left sternal
border most likely tricuspid regurgitation..
Also She had ejection systolic murmur at the
aortic area radiate to the neck...
The examiner asked me present your positive

findings I said as above.. but I decided not to
comment about pulmonary hypertension fearing
from inventing sign🙃
He asked me about basic and specific
investigation especially the INR and findings of
Echo in details...
then asked me about type of anticoagulant I will

give? I said warfarin... he asked me any place
for NOAC I said no..
Time finish I got 18 �
CNS
it was my most difficult station in the exam..
examine the lower limb of gentle man around 40
years...
He was unable to raise his right leg and it was

externally rotated and there was small wounds
over the leg.. the other leg was normal..
I found hypotonia and hyporeflexia in the right

knee.. some college said it is normal tone�
I couldn't examine the right leg because there

was pain and the examiner told me to be careful
about it...
The pattern of weakness was equal power of
flexors and extensors around the hip and knee...
abductor weaker than adductor... distal weaker
than proximal...
The planter was up going in the affected side...

mute on the other side...
Coordination was difficult to interpret because

the patient was able to do it well till the mid of
shin then becomes impaired, I repeated it again
with the same finding � the coordination was
normal in the other leg during both opened and
closed eyes...
All modalities of sensations are lost till the knee

going with peripheral neuropathy...
I asked to examine the gait he said pt can't

walk...
Asked to examine the cerebellar in upper limbs
the examiner said it is lower limb only...
So asked me present your positive findings I

replied as above... and in summary there is
features of pyramidal weakness with peripheral
neuropathy for DD
He asked about my DD (Till that time I couldn't

find suitable Picture explaining my findings 😕)
so I said the first possibility in the presence of
peripheral neuropathy is subacute combined
degeneration of the cord but against it it is
unilateral rather than bilaterall...
He said what else I said it could be multiple

sclerosis supported by the bizarre asymmetrical
presentation but against it the presence of
peripheral neuropathy...
He said how you are going to investigate him if

it was MS I said by MRI Brain and spine looking
for plaques.. lumbar puncture looking for
oligoclonal bands...
And delayed visual evoked potentials..
He asked what is your treatment for acute

attacks I said admission and IV steroids..
And in chronic cases the treatment is by oral
fongolimod and beta interferon if there is
indication..
I got 12
Station 4
Very long scenario about 50 years old male
known case of end stage heart failure on
maximum anti failure management and the
cardiologist says this is maximum treatment he
can give..
He had abdominal pain... on examination they
found that he had abdominal mass... CT
abdomen done and it showed results very likely
to be left kidney cancer and they found Mets in
lungs and... vertebrae and lymph nodes...
Lymph nodes biopsy confirmed lymph node
Mets due to left kidney cancer..
The oncologist said the prognosis is very poor
and he is only for palliative treatment...
I entered inside, after greeting the surrogate and

aggreed the agenda... I asked him would he like
to invite any one to attend the meeting? he said
actually his wife is outside but he is not willing
her to attend because he would like to know
firstly by himself what is going on with him then
he will see what to do next...
I asked him what do you know about your
condition?
He said I have only heart failure and I am
struggling with it...
I said yes you are right, and also you had

tummy pain and we did for you imaging to your
tummy, do you expect any thing in particular or
do you have any idea what could be the cause?
he said yes they told me there is some

abnormalities but I think it is due to heart
failure...
I said yah Mr ramy I am afraid to tell you are not

right... and I am sorry to tell you that the results
is not as we hope then great silence �
He cut the rope of silence and said what is there

doctor?
I said I am deeply sorry to tell you that it showed

you have nasty growth in your left kidney..
again great silence �
He said sadly and with wondering face: doctor
how is that I had only heart failure how is
that...😢
I said to him with empathy I can feel how these

news are shocking for you.. and I know it is very
hard to absorb it.. but I am so sorry to tell you
that we are sure about the diagnosis... and i
gave him time to ventilate more...
And then said I am sorry again to tell you that

the cancer had spread to other parts of your
body as your lungs and lymph glands and back
bones... and brief silence then alot of empathy
and sympathy...
He asked doctor when I will die?

I said it is difficult question because different
types of cancer behave differently from patient
to patient but definitely it will shorten your life..
sorry again.
He asked again when will I die?

Here i said it will be months rather than years...
He asked is there any treatment?
I said sorry because your cancer had already
spread the cancer doctor said there is no
curative treatment just we are going to treat you
by palliative treatment, have you any idea about
it? He said no..
I explained palliative in details with examples of

symptoms that can be controlled by palliative...
and told him about the team of palliative one by
one including the McMillan nurse and cancer
doctor and pain control team and community
palliative team and spiritual support and social
worker and heart doctor as well...
and i reassured him you are not alone in this

and you will be always under our eyes... and to
keep you comfortable is our goal be sure about
this👍🏻
do you have any concern right now?
He said I love to do building and l love to take

heavy objects...
I said I highly appreciate your hobbies but I am
concerned about your health, now your back
bones are already weak and fragile, may be if
you lift heavy objects you may get fracture, so it
is better to think again about this. He agreed...
He asked again that he loves travelling around

the world' Can He continue this?
I Advised him that you had heart failure and now

your lungs is also affected by the cancer... so I
advised it is better to avoid traveling by air
plane but if you insist you have to consult your
GP to assess your condition before travelling .
He agreed...
Here the examiner said two minutes left
I said what is your concern?
He said he can't tell his wife..

I told yes I can understand this, may be because
she is caring about you, and you are afraid of
telling her this news, so if you don't mind bring
her with you next meeting and we will tell her in
good way don't worry. he agreed..
Then I asked about job and smoking...
and Said To Him We had alot of talk today would

you like to tell me the main points you got from
our meeting and checked understanding and
offered help and support...
Examiner questions were about ethical issues

and some details about palliative treatment. and
step ladder medications used to control pain
especially morphine and I said that also it can
help him to relief pulmonary edema ... and how
he can travel other than by air plane? I said by
car...
I got 16 out of 16 ��
Station 5
BCC 1
Was middle age female complain of weight gain
and muscle weakness...
I entered inside it was weight gain for the last
year with normal appetite and no change in
food, the weight gain is allover her body, no
cold intolerance, she had constipation,
menorrhagia, difficult to stand from sitting
position, falling of hair... dryness in skin... there
was no symptoms of Cushing or acromegaly..
I didn't find any cause of secondary

hypothyroidism as thyroidectomy or
amiodarone treatment.. no symptoms of
subacute thyroiditis, no postpartum thyroiditis
as the last delivery was before 6 years...
No hx suggestive of hashimoto thyroiditis as

there was no neck swelling nor hx of
autoimmune diseases nor family hx of
autoimmune diseases...
I examined pulse... skin and nails.. offered Bp

and Bs check... proximal Myopathy... neck for
goiter and scar... eyes... tongue for
macroglossia... hair for falling... Abdomen for
striae... lower limb for edema and rash.... I did
also ankle reflexes...and examined for carpal
tunnel syndrome and offered chest and CVS
examinations...
The only positive findings were proximal
Myopathy and abdominal straie...
Concerns were about the diagnosis and whether

it is treatable or not... I replied it is most likely
primary hypothyroidism and explained it and
said it is controllable by thyroxine
replacement....etc
Examiner questions about investigations and

causes of uncontrolled hypothyroidism
although of medications...
And how you are going to follow the pt and
every how long... etc
I got 27�
BCC2
was 40 years male had diminution of vision..
It was for the last year with intermittent

symptoms of vision problems of gradual onset
in both eyes associated with pain in eye
movement and redness. He had mouth ulcers
and genital ulcers... hx of recurrent blood clots..
and lower limb red rash but now fade away..
No headache, no shortness of breathing, no
chest pain...
No abdominal pain..no loose motions . he had
right knee pain... I asked briefly about SLE and
pemphigus vulgaris..
Drug hx.. many drugs containing prednisolone

and azathioprine...
Fhx nilly
Social hx not significant
Not driving no smoking and no alcohol...
I examined visual acuity, visual field, offered

fudoscopy but the examiner told me it is
normal...
I examined the eyes and mouth... did
auscultation of the chest... examined radial
pulse and offered Bp check... examined the
knee...
And I asked for tape to check DVT he said you
can examine it without tape... examined
peripheral pulses in lower limbs... offered
examining for genital ulcers also but they said
no need..
Actually there were no positive findings...
The pt concerns were many😳

What is the cause? Is it treatable? Is it
infectious? Is it hereditary?
I answered all his concerns, and explained to

him about behcet disease and it is clinical
diagnosis but there is some suggestive test..
and told him about ttt and MDT and offered
social help..
Examiner asked about the other DD of mouth

ulcers I said SLE and pemphigus vulgaris...and
what is difference between them and behcet...
Investigation I said it is clinical.. but we can use

pathergy test..
He asked me is it diagnostic?
I said no is only suggestive...
He asked any more test ?
I said yes HLA B51
The bell rang 🛎

I got 28��
Alhamdolillah I passed with total score 147
I hope that my exam experience can help you

wishing for all you pass in paces...
And my great thanks for dr. Salah and Dr.

Ramadan
And this group for sharing their experiences in
the great golden book which helped mr too
much
W alhamdolillah Awlan w akhiran

Egypt New Kasr Alainy
Feb 03/02/2018
1st-day 2nd cycle.
BBC1
Assess this 35 years lady complaining of
weakness in her shoulder with weight gain.
Inside female with cushingoid features sitting
on the bed.. greeting introduction permission
Analysis of weight gain
Asking about the proximal weakness any
problems combing her hair or standing from
sitting position, inquire about other differentials
symptoms, hypothyroid symptoms...
PMH HTN & DM diagnosed recently
Examination:
General exam and demonstration of cushing
signs ,Asking about BP examiner told me it is
140/90.
Looking for thyroid,
Auscultation of the heart
Checking LL edema just touch her leg before
pressing she make a sound of pain with a
smiley face😳.
I apologize to her,
Finish my examination
Asking and addressing her concerns
What I have doctor?
Explanation without jargon
Plan of management including referral to gland
doctor.
Viva:
Diagnosis .. Cushing syndrome
Other differentials
Hypothyroidism
Acromegaly....
........
Investigations
Basic
Specific
Treatment ..
medical surgical
Asking about medical.. bell rang he took me to
the next case... 25/28
BCC2
ASSESS this 42 years old man who complaining
of skin rash.
Patient lying on the bed..
Greeting introduction permission.
I asked him directly..
(I understand that you are troubled by skin rash)
Can you show me plz where it is?
It was in the dorsum of both hands and feet
Then analysis of rash
Eye symptoms and signs and mouth ulcerations
which were negative
No joint pain
On digging more it is related to his recent work
on a detergent factory
Asking about concerns
Explained diagnosis and plan of management
and considering job change..
Viva
Your diagnosis?
Contact dermatitis
other differentials
Which type? Irritant type
Why not allergic?.
I kept silent�...
Ok, how are you going to investigate?
Skin batch
I heard you telling the patient that he must
change his job.
(I said yes because it is related to his problem)
Asked me about treatment
Including drugs and referral to a dermatologist.
Walking towards the door
He asked me again
You still want to change his job?
I told him yes, 😄

(Later I knew that he has to be relocated to the
factory
To avoid exposure to the irritant factor)...
I got 24/28
Station 1
Female patient
Not pale, not jaundiced
There are no stigmata of CLD
Viva
Your fiding
Differential
Causes of hepatomegaly in hemolytic anemias
(Extramedullary hemopoiesis)
A common cause of liver cirrhosis in Egypt..i
got 20/20
Chest
Middle age man complaining of SOB
Diagnosis OPD with right-sided lung fibrosis
Viva about investigations
And investigations findings
Differences between COPD
and ASTHMA
I got 20/20
Station 2 History
Young male patient referred by his G.P with a
history of abdominal pain bloating and diarrhea
, his father died of colonic cancer recently ..
I explored his symptoms accordingly enquired
about the red flag 🚩which was not present
Surrogate correlated his symptoms to the stress
in his life due to his father death and work... And
he is worried about the possibility of cancer...
I reassured him the cancer is unlikely in his
condition and this is functional bowel disease
called in medical term irritable bowel
syndrome..
Explanation
Plan of management
Adress his concerns
Summarize
Patient recap
disclosure...
I got 8/20 😳
I think the case is about
The possibility of familial polyposis coli (familial
adenomatous polyposis FAP) Which I missed
(http://www.netdoctor.co.uk/…/familial-
polyposis-coli-famil…/ )
Station 3
Cardiovascular
Mitral valve replacement with signs of heart
failure
Raised JVP basal creps
No LL Edema
Viva about
Diagnosis
Causes of mitral stenosis
Investigations
Target INR
Signs of infective endocarditis..
i got 20 /20
Neurological case
Young Female with difficulty walking for three
months
The examination was flaccid paraparesis with
hyperthesia in her soles
I forgot to do planter reflex
Viva about
Diagnosis
Gillian Barre syndrome
With consideration of other differentials..
Examiner asked me why didn't you do planter
reflex?
I told because of pain.
(He told: you have to request
To do it)
Then we will tell you to do it gently) 😬

Investigations
I got 17/20
Station 4
Middle age man was complaining of a headache
and dizziness fall at work with a body rash
Diagnosed as meningococcal septicemia with
imminent ICU admission.
Role: to discuss his condition with his worried
wife...
Started by greeting introduction agree agenda
Am dr...Medical officer in the admission unit..
Are you Mis....wife of Mr...?
Well to day we are here to discuss your
husband's medical condition and what we can
do further, ok)
Mis... Can you tell me what do you know about
his condition) checking her insight...
And break the bad news gradually with silence
gap between warning shot..
Showing empathy
Explained the disease in layman language
Plan of management
Her concerns
Will he go to die?
What about the children
And there's school?
Discuss the seriousness of the disease and the
high possibility of death
And even if he improved there might be
possibility of disability like loss of hearing
Although some people recovered completely
and I hope your husband will be one of them...
Discuss contact tracing
Prophylaxis
Isolation
And they can visit him during short time with
taking full precautions
Like wearing face mask..etc
Discuss social issues as he is the only family
supporter
Summarise
But I forgot checking her understanding...�
Viva
Ethical issues?
You don't want to notify?
What prophylaxis you will offer to her children...
I got 15/16
Alhmdu llah finished the long journey of MRCP
..
And this success attained
because of God's grace,
And then
(‫)من ال يشكر الناس ال يشكر هللا‬
BANGALORE BCC
1.copd with sudden breathing difficulty and rt

sided chest pain..
o/e Dec breath sound.rt mid.dd was ptx,pul
embolism, ,pneumonia. It was good
2.female was increase weight,,increase bp,,,and

proximal myopathy, ,o e no thyroid
myopathy,,features of osteoarthritis, ,knee
jt,leg oedema, ,
dd,was cushing, ,hypothyroidism, metabolic
syndrome, ,discuss was on cushing. .
Dx—-> hypothyroidism
H/O… cold intolerance, constipation, infertility
O/E… Normal (Surrogate)
3.1st case 30 yrs old lady with high prolactin

levels and normal TSH c/o scanty and
irregular menstruation.
outside 38 yr female with irregular menses, pain

in thighs, and wt gain, high BP, oxygen
saturation 92%...inside obese pt with pitting
oedema + bibasal crepts , proximal
myopathy, wt gain, OSAS , diagnosed as
PCOS.....concerns ;: is it bcz of hormonal
problems?
OSAS, ix
and Mx of each...got 27/28
weight gain
Patient is surrogate . No abnormal finding on
o/e
History- generalized weight gain with normal
appetite, irregular menstruation and nad
4. 26 yrs old lady with SLE since 6 yrs presented

with right sided pleuritic chest pain
,with fever. Discussion about DD of chest pain.
outside 28 yr female with chest pain radiating to

lft arm.....inside typical History of ACS,
diagnosed as SLE (pt do not want to say....said
after lots of hammering) taking
prednisolone and hydroxychloroquine for
SLE...concern: is it serious?
spasm.
Ix and Mx of ACS, risk factors of DVT...what if
SLE with chest pain

Not real patient
No signs at all
At that day I got fever and can't concentrate.
I examined only at chair
Actually Pt is sitting in front of examiner . I
examined over the clothes .
18/28
chest pain
History- left sided sharp chest pain,1 hour
duration, radiation ( dont remember)
underlying SLE
They want AC$ as first then ddx
Middle age lady

Wt gain and feeling low
Apart from that no signs
Not real patient
She also sitting in front of examiner.
I examined at there also
23/28
5. known hypothyroid taking medications come

with fatigue
hypothyroid symptoms again
Dx: ? Recurrence of hypothyroid due to drug
noncompliance
6. fatigue for 1yr
RTA history present and CT head normal
Seen psychiatrist and take medications but not
relieve
Family history of fatigue also present
Dx: chronic fatigue syndrome.
7. epigastric pain, epigastric lump, wt loss,

ascites
Pt was very sick. Her sister gave History.
8.
ank spond patient on biologics got fever and
cough for 2 weeks.
Clinically no signs of ank spond or pneumonia.
9. chronic headache ? Due to sinusitis. No red

flag sign
10.Know hypothyroid for 3 years with

progressive headache.
11. young female with palpitation. Her father had
palpitation and heart attack.
Pt is normal. Sinus tachycardia only.
Dx.. SVT???
12. known COPD pt comes to you with

palpitation. Taking inhaler.
Dx... palpitation due to inhaler SE
13. 60 yrs old gentleman comes with multiple

joint pain and back pain. He had previous
history of psoriasis.
Dx… psoriatic arthropathy. Normal surrogate.
14. 50yrs old man come with progressive SOB

and dry cough.
RA history present and taking methotrexate
Chronic smoker.
Normal surrogate. No signs.
Gave Ddx.
15. Hyperthyroid
16. Loss of memory

Ddx for dementia.
KOLKATA BCC COLLECTION
1.30yr old gentleman with uncontrolled

hypertension.
Uncontrollable BP for 1 year with enalapril,
atenolol, water pills. Wt -60kg. No hyperthyroid
symptoms. No renal/CVS/CNS symptoms.
Smoked previously for 10yrs. Drink alcohol.
Mother
has hypertension.
No AF, murmur. Unequal pulse +. No renal bruit.
Dx… Takayasu's arteritis.
2. 28 yes old lady, regular attender in asthma
clinic. Today presented with acute
breathlessness.
Salbutamol inhaler for asthma. Pain in lt calf.
Travel to Switzerland 12 hrs flight last week. OC
pills +. DVT + in mother. No history of
miscarriage.
Physical examination normal.
Dx.. PE
Ex: dx. Invx. Which blood test will you do in
suspected PE? Can you exclude PE if Doppler is
negative.
3.60yr old gentleman had dyspnoea for five

months. He had back pain for 3 years.
Ankylosing spondylitis patient taking celecoxib
and ibuprofen comes with SOB for 5 months.
Smoking +.
AS features +. Chest wall expansion reduced. Ht
and lungs normal.
Concern: what's wrong? Come back to normal?
Dx: chest wall deformity and reduction in chest
wall expansion in AS patient
Ex: findings in lungs and heart? Causes of SOB
in AS patient? Invx? Mgt?
4. Know RA patient comes with SOB.

RA hand deformity +. Lungs basal crepts +.
Dx: pulmonary fibrosis
5. 23 yrs old lady with weakness of rt side of

body.
Weakness of rt side of body and slurred speech
comes suddenly while having breakfast. 30
mins last. Blurred vision +. Facial weakness +.
Claudication pain + when using arm repeatedly.
BP 140/90 rt arm, 130/80 Lt arm. Taking
amlodipine for hypertension.
Dx: Takayasu arteritis.
6. 40 yrs old gentleman comes with sudden

weakness of rt half of body.
Transient weakness of rt side of body, cardiac
operation done 5 yrs ago for coronary
angioplasty. Very slow AF+.
Dx: TIA.
7. DM patient presenting with Loss of vision and
Rt sided weakness.
8. 70yrs old man with Ht problem presenting

with weakness of lt side of body with slurred
speech and completely recover at 10 mins. AF+.
MDM+.
9. 26 yrs old lady with painful legs.

Wt gain +. Missed period for 2-3 months.
Concern: serious? Curable?
Dx: Meralgia paresthetica
10. 50 yrs old gentleman comes to you with

episodic diarrhoea.
Flushing +. Wheezing +. Diarrhoea +.
Dx: Carcinoid syndrome.
11. Know DM patient presenting with weight

loss.
Dx: Thyrotoxicosis.
12. Known asthma patient presenting with
palpitation.
Rt eye exophthalmos ? Thyrotoxicosis.
13. 57 yrs old lady referred from DM clinic for

difficult control of blood sugar level.
Topical steroid use for skin infection. Herbal
medicine for 4 months.
Concern: why sugar level difficult to control.
Dx: Cushing syndrome.
14. 54 yrs old gentleman who is a regular

attender in diabetes clinic for 20 yrs. He was
referred
for tingling sensation of both hands.
Dx: carpal tunnel syndrome with goiter.
15. 38 yrs old lady complaint of painful hands.

Dx: Peripheral neuropathy
16. ℅ Hand Pain

Dx: RA
17. 60 yrs old lady in surgical ward admitted for

hemorrhoids now complaining of joint pain of
forehands and back pain.
Deforming polyarthropathy with back pain
No skin rash. Fever present for months.
Concern: infection? Disease activity?
18. Outside. 35 years old female vision problem

and headache
Inside. Bumping into Rt side.
No blurring. No double vision
Headache. Generalized. No photpphobia.no
lacrimation.no wt changes. No OC pills. No
ICP.no
acromegaly feature. No past medical and
surgical.no similar attack
No symptom of GCA.no pit tumor
O/E. Pronator normal.v acuity normal. V.field.rt
HH .Fundus normal
Ex asked finding and lesion side
I said optic tract. Optic radiation.occipital
19. Outside progressive SOB and swallowing

difficulty
Inside . Systemic sclerosis
No LOW.no Loa. No dysphagia. Only got
heartburn
Surrogate didn't tell medical history
But i asked medication . She said PPI.
Cyclosporin. Prednisolone
Lung .clear
20. sudden loss of vision in rt Eye kco bicuspid

aortic valve
21.an elderly gentleman who had sudden loss of

vision of his right eye. K/c/o HTn under
Amlodipine. Had CABG scar on chest and leg
scars too. Did ask all relevant questions and
examination. Looked at fundus. Found it very
red. When I asked ‘Do you have any concerns?’
he didn’t understand. He was an old Bengali
man. The examiners gave him some clues and
he
asked me “Questions?” I said ‘Yes’. He said
‘Yes Yes. I have questions for you. Number 1.
What is wrong? Number 2 Is it permanent? No 3
What can you do?’ Said Vitreous Hemorrhage
or retinal detachment. Missed to say CRVO.
Was so so so tensed there.
22.There was an English patient with swelling of

his Left lower limbs. Was a DVT. It was
unprovoked and he was on Aspirin. No h/o any
surgeries or travel. No features of malignancies.
He was a priest. They asked normal questions
on DVT.
23.MS - rt hemianopia with optic atrophy with

h/o rt sided weakness
24.? Ankylosing with ILD/COPD - wheezes as

well as crepts - little odd
25.psoriatic arthritis
26.first episode of seizure in 55 years old

man.
ALHAMDULILLAH, I have passed MRCP paces
from glasgow royal infirmiry on 22nd feb, 2018
with 141/172
started with
BCC1: 75 YR old man with h/o colitis comes

with tremor and slowing of movement..on
history he had foot scruffing on floow, slowing
of movement..had blepheroclonus, monotonus
speech, cogwheel rigidity, small steps..dx was
parkinsons disease..got22/28
BCC2: 75 yr old lady with epistaxis and fatigue

had h/o anemia: inside she had melena, had
tenalgiectasia on tonge , lips..dx:hht, advised
for endoscopy to rule out gi
tenalgiectasia..got25/28
Resp: hyperinflated chest, tracheal tug, reduced

cricosternal distance, productive cough, creps
mostly unilateral..dd- copd, bronchiectasis..got
17/20
Abdomen: had renal transplant with ballotable
kidney, inactive avfistula, parathyrpidectomy
scar, - dx wad esrd with renal transplant, told pt
may be on ciclosporin as i thought there was
gum hypertrophy..got 20/20
Cvs: elderly man with esm alover

precordium.radiating to carotids..had radiation
to apex as well..i told as..other candidates told
as with mr..i dont know what i missed..got15/20
Neuro- this gentle man had weaknes in bizarre

distribution, but reflex was absent, sensory loss
in stalikng distributipn- dd- mixed motorsensory
polyneuropathy due to dm, alcohol,
uremia..examinal pointed to proximal wasting it
was gbs..got12/20
St2: pt h/o ibs for 2 yrs had worsening of

symtoms for last 6 wks as father was dx with ca
colon...had no weight loss..or feature of
malabsorbtion or blood...bt the trick was he has
family history of bowel cancer, father at age 60,
grand father, uncle at 45, and aunt had
endometrial cancer..told it most likely ibs,
however he fits the criteria for HNPCC referred
for genetic testing, and colonoscopic
surveilance...i think i missed something..got
16/20
St4: lady with hemoptysis and loss of weight ,
she had ct scan showed mass in upperlobe of
left lunfs, hilar lymph node, and liver mets. Fnac
was done and sample lost..inside..break bad
news however dont tell its definjtely cancer, say
its mostlikely cancer, apologise for lost fnac
report, told abt incident reporting, counsel for
further fnac, she was concerned delay might
affect prognosis , i told its already advanced by
i will definitel try to make sure its done as soom
as possible, asked abt prognosis, told its too
early to say, bt definitely will end ur life, asked
abt mx: told its early to discuss, once fnac is
done we can discuss the mx in mdt
meeting..showed empathy, pause at appropiate
moment..got 14/16
i recommend ost for history and clinical

station..for station 5 i have read ryder, MRCP
PACES manual and MRCP paces 180 clinical
cases..for station 4 i had some previous bad
experience i would recommend ryder, tim hall
and studying previous cases..had courses in
ealing and pastest
Experience of our colleague appear in Dubai
last diet
Alhamdullelah I passed my exam in Dubai 12/2
3rd cycle 161/172
U are Sho in medical clinic
Ms Zakaria 40yrs male
He had back pain for the last 3months seen his
GP and diagnosed of osteoporosis investigation
and X-rays showed collapsed at D9-10 please sit
with him and answres his concerns
Inside after greeting confirming the agenda he
has back pain started when he start walking and
in mid back localized no history if trauma no
neurological symptoms
No redflags like increasing with coughing or
sneezing
Not related to movement or rest
Its v severe scoring is 7to 8 isaid sorry
No other joint pain
No skin rashes and even with son exposure
No eye pain no sore in-his mouth no neck pain
No SOB
No dysuria
No abdominal pain
Pt has loose motion for the last 3 months
difficult to flush not releated to food no blood in
stool
No tummy pain mild loss of wt
Pt is not diabetic or hypertensive
X smoker for 1year after developing 1 attck of
asthma received blue and brown inhaler for
once
Only on pain killers for back pain no FH
Not drinking alcohol no contact with animal
history of recerrent travel to Egypt and once for
usa last year
He working as solicitor in firm company and the
pain is bothering him too much he cannot take
sick leave
His concerns why i have osteoporosis i know
this is for elderly people i answered it u have
this diarrhea and causing malabsorption for
some nutrients and this is causing osteoporosis
Time is finished I forget to ask about impotence
Examiner questions
Summarise ur case
Whats ur diff?
Malabsorption diarrhea causing osteoporosis
Other rheumatological but negative
Endocrine negative
Others like lack of testosterone but i forget to
about it 😔
I got 12/20 and know it after finish it i did it badly
but no choice i should complete the exam
Statin 3
Cardio young lady complain of SOB
Ms with AF and Loud S2
Whats ur finding ?
Whats ur diagnosis ?
Whats ur INV ? And why
Whats ur management ?
Got 20/20
Neuro examine UL neurological complain of
pain
Bilateral carpel tunnel syndrome more in right
Pt has right side AV fistula for HD
Whats ur finding ?
How to confirm ?
Whats the case in this pt ?Amyloidosis how to
confirm it ? What the treatment for CTS ? Whats
the treatment of amyloidosis
Igot 20/20
Station 4
U are doctor in the ward
Talk to Mr Raed son of Mrs mona
Mrs Mona 70 years old had fracture neck of
femur 3weeks back and operation done
successfully and pt on rehabilitation ward and
she developed headache and dr on ghe ward
suspected GCA and started steriod 40mg per
day unfortunately pt developed psychosis pt
transferred to the general ward late night and
assed by our consultant and rule out the GCA
and steroid was stopped
Talk to her son and answer his concerns
After greeting
Confirm identify Nok ?
Agenda
Son is v angry about shifting his mother with
telling him and no one call him yesterday
I said we are sorry for mis communication
happened yesterday and will check-it and ask
him what do u know about ur mother condition
he said she is ok untill one dr assess her and
give some medicine and she behave abnormally
after that i explain for him what GCA and
treatment and why we should give treatment to
ovoid eye complication like blindness
Then again become angry he said this bad
hospital and practice no one call me u give bad
drug upon suspicion at that time i apology for
what happen and explain more about
complication and this is medication is best
interest for his mother then he asked why my no
one consult us about treatment i said ur mothe
is competant at initiating treatment then i want
my mother to be shift again to Rehab ward i
asked why he said becused she is now under
close follow up and we need to check other side
effect of steriod and treated accordingly a and
after that my consultant with rehab team they
will assess her and decided when will be shifted
again i asked him deoed ur mother have any
memory problem or any fever constipation or
urinary problem he denied it . Summary and
aplogy again
Examiner question
Whats ethical point here ?
Angry relative
Dealing with incompetent pt
Privacy
Regarding his concern no one call him
Why u didinot inform them about treatment
When u will shif pt to rehab ward
I got 16/16
Station 5
BCC 1 45years male with history of MI
5weeks back and present with dizziness
Inside post MI fatigue last 1 week
Postural hypotenstion due to change dose of
ACE
Bblockers indiced fatigue
Aspirin indued GI blood loss
Statin induced myopathy
I offer BP sitting and standing
Pulse exam
Eye for pallor
Chest for basal crackles pls LL
I got 25/28
BCC2 35years with difficulty of swallowing
SS
Crest syndrome clear finding
I eamine chest for basal crackles
S2
Ofer BP
Hand exam
Concern whats wrong with me
do ihave cancer?
Is it reversible?
Examier exam whats ur diagnosis ?
Whats Crest ?
Investigation ?
If u have time what system u will wxam i said
abdomen
I got 28/28
Station 1 last station 😊

Chest
Letf lower lobectomy
Whats ur finding ?
Diagonsis
Investiong in this pt specifically?
I got 20/20
Abdomen
Huge splenomegaly with anaemia
Finding ?
Investigation
Management ?
I got 20/20
‫الحمدهلل رب العالمين‬
Thanks god becuse i attend the course with Dr

Ahmed Maher Eliwa maestro of paces tutor he
teach us how to be good doctor before passing
paces
Its my pleasure
Maadi military hospital Cairo Egypt
St2
History for 35 years old man complaining of
headache that getting worse
By history he gave history suggestive of
migraine
Examiners discussion about why migraine what
DD , why not cluster why not SAH
Why patients in not improving on analgesics
As he was using 2 tables 4 times daily for last 2
month
History of headache stated 1 year and getting
worse
Mainly on rt side throbbing pain and with
potosenstivity
Pt concern is it brain tumour
What you will do for me
Taking many offs and has fear to loose job
Examiners also ask about ttt of migraine and

why is it not brain tumour
They asked also about the character of
hemiplegic migraine
St 4 was very long scenario for angry relative

her mother admitted with heamatemesis and
getting worse
They did many times upper endoscopy that
revealed only gastritis and ulcer but patient
deteriorated they took biopsy came negative
Only after CT they discovered mass encircled
oes around carina
Or now is receiving if fluids failed to put NG
tube
They did dilalation
Relative concern
Why late diagnosis
Doctors are not good that is why they did not
catch diagnosis
You neglected her as she is old and we are in

governmental hospital
What will do for her now
I explained everything started by BBN that it is

extensive nasty growth spread to lymph nodes
and spleen
Explain that delay due to uncommon
presentation
Dr already did upper endoscopy many times
even snip negative
We discussed issue of justice that any of at her

situation will have same protocol of
manangment
Drs keep searching tell they find that the rare

diagnosis
Delay is not affecting ttt as already no cure at
that stage
Only palliative
Explained what palliative who are palliative team

and role of mcmalian nurse
Discovered if she needs any help after

discharge and how she will f/u with team
Discussed also what about nutrition and

possibly of peg tube
Examiner questions
What the ethical issues
Role of palliative team
Who are team member
Role of Macmillan nurse
Will you allow pt to stay in hospital if she want

Did you convince relative
Did the next of kin can interfere plan of

mangment
St 5
Bbc1
38 years old with severe abdominal pain
Inside gentleman with attacks of abd pain

mainly epigastric related to food comes on
attacks for 2 months
No H/o fever travel jaundice or blood
transfusion
He is diabetic and alcoholic
Examination all abd tender especially
epigastrium
P/h cholecystectomy
DD
Alcoholic pancreatitis
Alcoholic gastritis
What you will do for him

How pancreatitis will affect diabetes
BBC 2
Again abdominal pain with diarrhoea
Inside male pt with abd pain and loose motions

sometimes with blood
No fever
With loss of weight
Joint pain
By exam
Psoriatic arthritis and back pain
No abnormality in Abd exam
He is on steroid and methotrexate
Examiner questions
Dd
IBD with psoriasis
How you will investigate and treat

What is the next step here in ttt of psoriatic
arthropathy
Discussion about biological ttt
UK EXPERIENCE=MARCH 2018
Station 1::
Resp: Patient with lateral thoracotomy scars.
On examination bilateral basal fine crackles. For
Abdomen: 35 year-old gentleman with midline
laporatomy scar and peritoneal dialysis scars. It
was pancreatic and renal transplant
Station 2::
56 female referred by her GP due to abnormal
LFT mainly transaminases 5 times more than
upper normal. Mentioned in stem that she is on
methotrexate for 2 years. Taking the history she
has no significant symptoms apart from mild
lethargy and indigestion. She has RA for many
years and using mtx for 2 years without any
problem. She is on PPIs, and folic acid. The only
positive points in hx that she had 1 unprotected
sex with her boyfriend who lives in Turkey. Also
she drinks alcohol more than the recommended
amount.
Her concern was why I am in hospital despite I
am feeling well in myself. Is this due to
methotrexate?
Station 3:
Cardio: Aortic stenosis
Neuro: young man with spastic paraparesis
Station 4:
Talk to Ms Bradley, a daughter of Mrs Wilson
who is 65 years old. The daughter was unhappy
about the management of her mother.
She is a lady with severe COPD. She was
presented with RUQ pain and admitted to
surgical ward as acute cholecystitis and started
on antibiotics. The next day Xray showed right
basal pneumonia and she was shifted to
antibiotics as per hospital policy.
She was referred to medical team. She needs
oxygen to maintain her oxygen saturation. She
has been seen by consultant who thinks it was
inappropriate to be admitted to ICU and needs
ward base management. She had pneumonia
before 18 months abd needed ITU admission
with intubation and was difficult to extubate her.
Since then her activities declined but still enjoys
life with friends visiting her.
The concerns were: why she was not diagnosed
correctly from the beginning? Was there delay
in management? Does she need admission to
ITU?
Station 5
BCC 1::
75 year old gentleman with SOB.
Found to have rheumatoid arthritis and on
examination of his chest: bilateral fine
crepitation. Dx was ILD secondary to RA
BCC 2::
21 year old lady with iron deficiency anaemia.
On hx has recurrent epistaxis since childhood.
FH of epistaxis. On examination: Telangiectasia.
Dx was HHT
UK EXPERIENCE
Station 2⃣ : SOB & fever in known IVDU

Station 4⃣ : Mother is fit to be discharged but
Abdomen : Renal transplant
Resp : ILD
Neuro : Peripheral neuropathy
Cardio : AS/MR
BCC 1⃣ : Cushing sec to steroids for Wegener
BCC 2⃣ : Benign essential tremors
Exam date : 7/2/2018 , third carousel

Al- Maadi hospital , Cairo
I started with station 1 :
Chest : COPD patient with pulm fibrosis ( score
18/20 ) , i forget to comment on PHT 😰
Abdomen : chronic haemolytic anaemia with
splenectomy scar ( 20/20)
Station 2 :
50 years old female c/o : SOB and cough 6
months ago
It was EAA ( Bird received 6 months ago )
(20/20)
Station 3:
Neuro : acute flaccid paraplegia with sensory
level ( TM) , I developed mental block in this
station I don’t know why and I remembered the
DD once the bill is ring 😡(14/20)
Cardio : mixed AR and AS (18/20)
Station 4:
BBN with uncertainty?? Patient with history of
malignant melanoma 10 years ago well treated
with follow up 5 years discharged , then recently
with wt loss , U/S abd revealed liver metastasis
and para aortic LN
I was confused outside how can I BBN with
uncertainty of the diagnosis , I break bad news
with cancer for further investigations and
biopsy ( 14/16) , Examiners were happy from
performance but they said give hope most
probably cancer but may be other DD .
Station 5:
First one : difficult in walking and inside
Ankylosing spondylitis ( 28/28 )
2nd one : blurring of vision inside diabetic
retinopathy (28/28 )
Finally I pass with score of 160/172
Really I don’t know how I made it , it was my 3rd
attempts and I was very depressed before and
after exam , my expectation was for 3rd big fail .
Alhamdullellah , I want to give my thanks to
prof. Zein and the group members.
Myanmar.. Yangon
1st round 5.3.18 NYGH
S1 Pleural effusion
ADPKD
S2 Analgesic misuse headache with Underlying

Migraine
S3 3,4,6 Opthalmoplegia +5
V1involvement(Mulitple cranial nerve palsy)
Lone MS
S4 S J Syndrome in recent delivery

S5 Neurofibromatosis with Uncontrolled
Hypertension
Hyperthyroid with Wt loss and Polyuria
BEST OF LUCK to u all!!!Keep calm and Victory

will be urs!!!FIGHTING!!
*Egypt - Maadi*
Military Medical Academy
*08/02/2018*
Cycle 2
*Station 2*
History taking :
Young male complaining of back pain for the

last months ..
*from out side* I wrote the patient name and age
, my role .. then *SOCRATES* followed by *Red
Flag*
I divided my paper into two parts , then I wrote :
1- *inflammatory* , seronegative arthropathy [
psoriasis , ankylosing , behcet , enteropathic
and reactive arthritis ]
2- *mechanical* [ 4 T : Trauma , T.B , Tumour ,
Thinning of bone ]
Then the headline of history scheme , followed

by *impaction on his job , daily activities and
mood*
Inside ..
Inflammatory back pain
with some rash behind the ear ,
I asked about all DD .. there was history of skin
rash behind the ears ..
I explained the possible diagnosis , what we

need to do , referral to MDT involving joint
doctor , skin doctor and physiotherapist .
*Examiner :*
present your case , what is your diagnosis ?
other possible causes ?
then keep asking about ankylosing , features ,
how to diagnose , management ..!
*18/20*
*Station 3 :*
*Neurology :*
very confusing ,
pyramidal weakness in both lower limbs more in
right side , flexor deformity of right upper limb
sensation very difficult , the patient is elderly
can not concentrate and not helping at all ..
I didn't do well in this station !
*11/20*
*Cardiovascular :*
young male with clubbing , central cyanosis ,
large volume pulse collapsing , hyperdynamic
displaced apex .. I couldn't appreciate any
murmur .. I put DD of congenital Heart Disease (
VSD with eisenmienger ) , also I mentioned AR ..
discussion about investigations and
management .. I did well and answered all
questions .. surprisingly I got only *11/20*
*Station 4*
clear easy scenario ..
*APCKD* newly diagnosed , normal kidney

function , concerned about her coming
pregnancy and afraid to tell her fiance , also
concerned about testing her brothers age 16
and 20 years ..
I explained her condition in simple language ,
symptoms and possible complications ..
I asked about headache , and took brief
neurological history , asked about history if
brain bleed in family , death in young or sudden
death ..
then I answered all her concerns , gave her
important advice , going deep in social , then
summary , understanding and offer support ..
*14/16*
*Station 5 :*
*BCC 1:*
Known case of Rh.A came with SOB ..
findings :
bibasal fibrosis , obstructive air way disease ,
P.HTN ..
Discussion about cause of her SOB ,
*26/28*
*BCC 2:*
Young male with history of dark urine ..
inside proved to be early morning , +ve history
of previous clots , FH of stroke .. had transient
loss of vision recently ..
no findings ( surrogate !)
diagnosis was PNH ,
discussion about investigations and
management .
*23/28*
*Station 1 :*
*Respiratory :*
Lt sided Pneumonectomy with Rt sided

hyperinflation ( compensatory , COPD ) with
clubbing of finger ..
present your findings

Possible causes ? investigation ?
management ?
*20/20*
*Abdomen :*
Hepatosplenomegaly , no signs of CLD , No
lymph nodes , no pallor or jaundice ..
present your findings

DD : infection , CLD , infiltration
Investigations ? management of hepatitis C
virus ?
*20/20*
Finally .. passed with score 143
Alhamdulellah ..
Many thanks t *Dr Ahmed Maher*Ahmed Maher

Eliwa .. you helped me much and the corner
stone in my paces journey was through your
valuable course and continues support ..
Hi everyone would like to share my exam

experience 😊
Egypt 5 of February New Kasr Aainy Hospital
.3rd day , second cycle
I Started with st2

Outside a man 30 years old complain of
recurrent collapse and he was known case of
type1 DM for 15 years also have atrial fibrillation
on warfarin his current pulse was 56
Inside when I asked open Question he didn't
give me anything so I asked ( before during and
after ) and pt have dizziness when stand from
sitting position no sweating no tanning on his
skin and no hunger pain and no other
symptoms like raising of heart or sweating or
weakness or change in color all negative and
this collapse not happened with exercise and no
tongue pitting or loss of sphincter
Other positive symptoms pt have fullness in his
stomach with small meal and also have problem
with his intimate relationship and impotence
and all symptom of autonomic neuropathy
Then I went to the rest of history he was known
case of hypertension on multiple anti
hypertensive medication and beta blocker
Pt also have atrial fibrillation but controlled and

no symptom of anaemia
Pt have all complication of DM and have poor
control and no regular follow up
Also he lost the awareness of Hypoglycemia
Pt on insulin and many antihypertensive and
beta blocker
There was family history of death but the
sorugate did not tell any thing
I ask at what age ?? He didn't know
Sudden death or not??
Also didn't know
Any diagnosis to the cause of death? ? He
didn't know
At this point examiner said 2 minutes left and I
don't ask about smoking and alcohol and
driving
So quickly ask him did you smoke or drink
alcohol he said no
OK what your concern?
He give me 4 concern 😭
1- what is causing my problems
2-is it serious
3- treatable or not😰
4- what about my driving 😰
So I addressed his concerns put I have no time

to tackle the driving issue and definitely they
cut a mark from this point
Question of examiners are typically of DD
I give
autonomic neuropathy as complication of
diabetes
Postural hypotension due to medication
Cardiac cause as he has atrial fibrillation but
less likely
Also Addison and anemia but less likely
How to investigate and how to manage

I got 15
Station 3
Cardio
Young pt complain of shortness of breath
This pt have large volume pulse but for me it's
not collapsing regular
There are ejection systolic murmur in aortic
area radiate to carotid and all over the
pericordium
So it's mixed aortic valve
Question about the cause
Actually no time to ask more
I got 20
Neuro
Young female examing her legs
It's spastic paraparisis with normal sensation
I gave DD of heridetory spastic paraparisis
Tropical spastic paraparisis
Ms
Parasagital meningioma ad cerebral palsy
Question about how to investigate and how to

manage
Got 20
Station 4
Pt 80 year old male came to hospital with
obstructive jaundice
And did CT scan and pt diagnosed and confirm
to have pancreatic cancer and this cancer
invade the adjacent organ
The plan of management is by only paliative
treatment and by place a stent by ERCP
Oncologist decide this pt is not for
chemotherapy and the treatment after doing the
ERCP should be in the community
I went inside
Introduce myself and my role
Agree agenda of meeting

And ask the daughter what she know about her
father
She said don't know much so I have to break
the bad news and give her time to express her
feeling
And I explained the situation and this cancer is
inoperable and treatment is by control the
symptoms what is called palliative ttt and let
him comfortable
And in your father case we do this by what is
called ERCP
And she didn't have any idea about that . So I
explained what it means and it's camera test
and so on....... and need to sign a concent
Then she start to ask some concern
When my father will die??
I respond to her concern by it will shorting his
life ( but the examiner want to Said it months
rather than years )
other concern to give her father chemotherapy
and I expla
ined to
her this is not going to help him and have many

bad effects and the growth doctor decided not
to start chemo and she agree
Other concern is she need her father to stay in

hospital and I asked why? ?
She said he live alone and no one visit him and
she worry for that
I explained after doing ERCP and his symptoms
improve and the jaundice disappear we have to
discharge him and we can help him alot by our
social services and palliative teams
At the community and also there was option of
hospice care
She agree
And I didn't talked about complication of ERCP
and the first examiner questions why didn't
talked about this issue
After this point 2 minutes left ask any other

concern she didn't have
Summaries and check understanding
Offer help and thanks her
Examiner ask why not talk about complication

of ERCP
How you respond to her concerns one by one
And also ask about hospice and the role of
social warker
Examiner didn't ask the typical questions
Got 8 only 😕
Station 5
Bcc 1
Man present complain of tiredness
In side man about 50 years have tiredness all
the time mainly with exercise and exertion
Have good balanced diet and pt have bleeding
per rectum and constipation and also family
history of colon cancer
On examination
Pt have canula in right forearm
Severly pale and splenomegaly about 10 cm and
hepatomegaly about 4cm no other abdominal
mass
Examiner ask about deferential

I said colonic cancer
Other DD mayeloproliferative vs
lympoproliverative especially CML he agree and
asked about investigation and ttt
Got 26
BCC2
Female 30 years with temporal headache
Inside it's clear case of acromegaly with all of
the features
Got 27
Station 1
Abdomin
Young male with
Splenomegaly about 4 cm only
Question about DD I said infection
Hematological cause like hemolytic anaemia
others are mayeloproliferative and
lympoproliverative
Other DD infiltration and others
investigation and management
Got19
Chest
About 40 years male have COPD
With all features of hyperinflation of lung
Question about finding
Got 20
Alhamdulellah I pass with score 155
I hope this experience is going to help other
candidiates
Ahmed Wadaltom
Yangon first day last round
H/O : underlying IBS with abd pain and altered

bowel habit
CVS : valve replacement

CNS : spastic paraplegia( only motor
examination) + cerebeller signs
Abd : Hepatomegaly + ? Ascites

Resp : bilateral lower lobe fibrosis with
??clubbing ( Examiner lead to ipf )
Communication : Meningococcal septicaemia
Bcc 1 Vitiligo + MG
Bcc 2 chest pain( with underlying jt problem )-->

Aortic stenosis
A small collection for the PACES exam

experiences that were held in Castle Hill
Hospital
( A gift to my BROTHER Ahmed Zanata)
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
it is my first attempt. I was very lucky

alhamdullah because I do not practice in the UK.
This group( PACES EXAM CASES=PEC) helped
me alot thats why I gave feedback
I went to PACESAHEAD course in UK. I read

guatam mehta for station 1, 3 and 5. Ryder n Mir
for station 2 and 4, and some of 5. I had a
discussion group for station 2, 4 and 5 from the
said books. I found that pretend presentations
and role playing were very very helpful for the
exam.
We also practiced station 1 and 3 with

presentation of the 5 commonest cases in each
station. That is exam findings, differentials-,
treatment of aortic stenosis, mitral stenosis,
MVR etc.
Castle Hill Hospital
》Station 2
25 years old .DM.asthma presented
With recurrent chest infections for 6 months 6
times
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
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
bronchiactesis
He said serum antibodies for pathogenes 😳..
I was about to say immunoglins but bell rang 😣
》3. CNS: Upper limb exam.

He has hemiparesis
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
》3. CVS:
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
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
》4: Communication skills:
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 😳..
》5:
60 years with skin lesion over her forhead and
scalp
Looks like morphea
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
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..
,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
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
4..PEGTube insertion in agressive agitated
Alzehimer pt used 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
5..??morphea ..what is the causes of

morphea.?.is it cancer
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
UK Experience
9/ 2 / 2018
Feb 9 Bournemouth hospital PACES experience
Resp: Pulmonary Fibrosis. 20/20
Cardio: metallic AVR, AF and PPM. 20/20
Abdo: Renal transplant with polycystic liver.

10/20
Neuro: cranial nerves- 6th nerve palsy.

Discussion about causes of mononeuritis
multiplex. 20/20
History: Chest pain with recent normal stress

test. Father died of MI age 45. Exacerbated with
lifting boxes, worked in a supermarket. Also,
using cocaine. Only divulged this info when
specifically asked. DD- MSK pain, coronary
vasospasm. 20/20
Ethics: discuss prognosis and further

management with wife of a pt recently admitted
in ITU with SAH. Has been extubated but no
response. 16/16
BCC1: Bilateral carpal tunnel- Acromegaly.

28/28
BCC2: Pins and needles in median nerve

distribution. Recent rash- on an antibiotic
course. Recent tick bite- Lyme’s disease. 28/28
UK Experience
22 february glasgow royal infirmiry:

parkinsons disease

for endoscopy to rule out gi tenalgiectasia
mostly unilateral..dd- copd, bronchiectasis

gum hypertrophy

as with mr

neuropathy due to dm, alcohol,
was gbs

surveilance

moment
UK EXPERIENCE
Royal Victoria Hospital, Belfast
On 27th of February
Station 1
Pulmonary fibrosis
Renal transplantation
Station 2 :
IHD
Station 3 :
AVR
Spastic paraparesiss with sensory level
Station 4 :
Long scenario
Lady of 82 years Delay of diagnosis of
oesophageal cancer .
Upper GI endoscopy normal
Station 5
1-Rheumatoid arthritis
Treatment and indications of biological therapy
2-MS with Optic atrophy

(UK) Experience
Wrexham hospital
Station 1: Respiratory was pulmonary fibrosis

Abdomen: RIF scar ?renal transplant and
hepatomegally
Station 2: chest pain and nocturnal reflux

symptoms
Station 3: Cardio: possibly MR or AS

Neuro: lower limb weakness and no sensory
defiict ? MND
Station 4: speak to wife of a patient who had a

large stroke, treated with thrombolysis and
developed a large brain haemorrhage. Wife was
angry and this complication wasn't explained to
her and wants to complain.
Station 5: 1st case pt with skin changes and

long standing visual loss ? Pseudoxanthoma
elasticum
2nd case: patient with chest pain with recent
travel hx from USA and recent cold symptoms.
Hx of angina. Had O2 sats of 92%. Differentials
?PE ?pneumonia ?angina
Station 1
Hepatomoegaly
?copd ? Pulmonary fibrosis ( other found
crepitation I didn't)
Cardio
AS ?
Neuro
Pure motor neuropathy cause ??
History
Gerd and to rule out acs
Station 4
Breaking bad news post thrombolysis ic bleed
( surrogate was not listening to me ) I said sorry
sorry 100 times but why did you thrombolysed
😅😅😅😅
Station 5
Giant cell arteTitus

Pneumothorax
Unpredictable
Don't know whether I will pass or not ( mostly

fail )
Needs more more more practice

It requires sharp mind body and quick decision
making
Station 5 can't do if cases are unpredictable
My paces experience
Before I post my experience I would like to
thank my dear mentor Dr Ahmed Maher Eliwa.
Besides his outstanding experience in MRCP
paces and medicine, he is the best person I met
in my life. He supports us in every stage of
paces preparation and I am sure that if I was in
early contact with him in my first attempt, I
would have passed easily. I am not shy to
mention that I have learnt basic techniques of
history taking , communication and clinical
examination in the right way for the first time in
my medical carrer and every word he said had
its impact on my daily medical work. No words
can express my gratitude to Dr Ahmed.
I started paces preparation in 2013 and had
many mistakes in my way so I donot you all to
repeat this.
My advices
1Take course with dr Ahmed 😊(essential)

2.Limit your study sources as possible.
For example study history and communication
from ryder,
Clinical stations from cases for paces
Station 5 from ryder.
3. Develop your approach and stick to it.
4.make your notes including questions and
answers.
5. Practice history and communication with a
friend or a group (essential).
6.Don't ever miss acute cases like pulmonary
embolism, TIA.
7. Follow dr Sadek Al-Rokh group for live
videos.
8. In the exam donot ever panic. Follow ur
approach and ignore examiners.
9. Study common diseases from patient uk
website.
10. Study the recent edition of golden guide.
I again thank my brother and mentor Dr Ahmed,
May allah bless you and make all your dreams
true.
kochi (21.2.2018)
✔️st 4- talk to son of the patient who is in rehab

ward c/o headache, no biopsy taken given
steroid for GCA .hallucination developes and
shift to main hospital. Son is angry because she
was shifted without telling him.
✔️st 2-young female with fatigue - 6 months,

the IDA, underlying IBS. No bleeding
manifestation except menorrhagia, thyroid
function is normal..Traveling history - 6 months
ago. Clear history of malabsorption Wt loss +
7kg. Family HO type1 DM in brother
✔️St 5- syncope in elderly women with DM. she

had AS,palpitations + PR 50/ min. Inside- thyroid
enlargement.No hyper/hypothyroid
symptoms.she was on multiple drugs for
hypertension.
St5-
back pain for 12 years . Nocturnal pain,
stiffness, progressive in nature.
Ankylosing spondylitis
2018/1 UK
✔️station 4.
Task was to talk to the daughter . Her father had
died after 2 days of admission to hospital ,he
was a case of COPD admitted with CURB
score5. He was admitted in surgical ward
because of no beds and cannula got dislodged
and he missed dose of antibiotic .patient
arrested and shifted to HDU and later died.
✔️Station2 47 yr old came with history of dry

cough and sob for 6 months . He had no other
history later I explored that he had got a pigeon
for her daughter as birthday gift. It was extrinsic
allergic allveolites.
✔️Station 5
Outside it was written 47 yr old patient
presented with join dislocations since
childhood.
It was Ehler danlos disease
Other case 80 yr old with painful hands
Inside old lady with rheumatoid hands with
tendon transfer scars and ulnar deformity and at
elbow multiple rheumatoid nodules. It was burnt
out arthirits
Today exam in India
Station 5
1- Diplopia duo to Thyrotoxicosis
2- Palpitation
Station 2
Female 25 y recent diagnosed HTN
UK EXAM EXPERIENCE
JANUARY 2018
Station 5
childhood.

out arthirits .
station 4.
Station2
47 yr old came with history of dry cough and

sob for 6 months . He had no other history later
I explored that he had got a pigeon for her
daughter as birthday gift. It was extrinsic
Egypt 2018/1
Cairo (3.2.2018) 1st round
Abdomen
Hepatomegaly with splenectomy no other
findings
CLD
Indication of splenectomy
Chest
Basal fibrosis with COPD
Neurology
guillain barre syndrome
Cardiology
MVR
Station 5
Cushing syndrome
Contact dermatitis
History
IBS with family history of cancer
Communication
Meningococcal septicemia
Clue in contact dermatitis he was working in
factory
After stress of candidate about kind of job
Factory of detergent
Meningeococcal septicemia
Concerns were :
When pt will be discharged
What about kids , can they go to school
3 February 2018
Cairo new alkasr Alainy 3rd cycle
Station 1
Abdomen old man splenomegaly with
infraumblical scar
Pale... jaundiced?
No stigmata of ClD
For DD
Chest
Old lady had exessive cough
She had some features of OLD plus bibasal
crackles
I gave summary of OLD with bibasal fibrosis but
the examiner was interested in bronchiectasis
Station 2 was young lady had left sided

weakness when she was on hair dresser lasted
for one hour only.. she had severe headache till
now associated with visual aura.. the headache
was for long times not diagnosed and it was not
severe like this.. she is known case of mild
asthma not on treatment she take oral
contraceptive pills
DD
Hemiplegic migraine
TIA
Station 3
Double valve replacement plus mitral
regurgitation plus aortic stenosis
CNS was very difficult hypotonia in one limb
plus hyporeflexia plus up going planter
coordination is difficult to assess
All modalities of sensation are lost in stocking
distribution
My DD was
SACD
FA
MS
examiner was interested in MS�
Station 4
50 years male known case of end stage heart
failure.. had abdominal mass suspicious to be
left kidney cancer and Mets in lungs and
vertebrae and lymph nodes... biopsy confirmed
lymph Mets due to kidney cancer.. for palliative..
Direct case of BBN plus palliative..
Main concern how to tell his wife and he loves
travelling all over the world..
Station five
Iady with weight gain and muscle weakness it
was hypothyroidism
Second case was young male with diminution of
vision it was behcet disease
Walsall manor trust hospital 11/2/2018

Frist cycle
1-RESPIRATORY :
Qs:finding
DD
cause of fibrosis
Investigations
cancer
ABDOMEN :
Qs:
2- St 2
St 4


Qs.
I did not know?
St. 5 lady present with SOB and chest pain
yesterday analysis sharp staping from chest to
back
ask her about any pmh no medications no what
about your health in the past
Eye surgery lenses dislocation
MARFAN I did the examination
She ask what is it is it a heart attack?
Qs.what is the diagnosis? What you find to say
marfan what other signs you did not check for
for marfan (wrist and thumb signs ) cause of
chest pain ?
After I finish i found cardiology case was

dextrocardia pt has kartagner syndrome 😂
other candidate get metalic MVR
in abdomen they get renal transplant they are
not sure about neuro
Pray for me and wish me luck
Diet 1 : Cairo 4/2/2018 day 2
Second cycle
I start with st 1
Chest examin this gentle man who have SOB
Case COPD
Examner quz how to investegate
/managment/how to diffrentiate b/w COPD
&asthma
Abd :examine this man c/o fatigubilaty
Finding bilateral subcostal scar /pt pale /jundice
promenant zygomatic bone with hepatomegally
Examner quz :
DD
Witch type of heamolytic anamia
How to confirm thalaseamia
Cause of hepatomegally in this pt
Station 2 (catastrofic 🙈)
45 lady with history of DM type 2 on oral
hypoglycmic medication /and HTN
While she was in resturant with her frinds she
suddunly become confuse for 2 to 3 hrs then
she become ok
Hypoglysemia symptoms negative
no sweating or hunger but she did not check
her blood sugar
When ask the pt what happen and what they tell
you she said suddunly im looking in resturant
Menu i become confused ant not aware about
the surrounding and become aggitated, No LOC
No weakness or numness, No jerky movement,
concern of the pt is it stroke ?
Station 3
CVS examin this lady c/o SOB im not sure about
my finding
Neuro :examin this lady with diffecult in walking
for one year
Finding was prephreal motor neuropayhy
(painfull )the pt all examnation time she feel
pain 😫even i ask examner shall i continue or
stop bcz of pain they tell me continue but be
gentel 😐
Station 4 long senario
78 yrs lady with CKD hypertensive on ramipril
admited 5 dayes coz of uroseipses start on
amoxicclin &gentamycin first her kidney
function normal
Then they shift her other word they miss follow
up and found gentamycin level high and
develop AKI she is confused (the medication
stoped )
Nephrologest assess her descide no need for
renal replacment therpy and started on IV fluids
Task speak to her son explain to him her
condition (the son was angery and had alot of
concern (why you give her toxic drug
Why she is confused ?
How responsiple about what happen ?
Do you well addmit her to ICU ?
When she well recover
Does she well retuern bach to her base activity
😩😩
Examner quz :whey the son is angery how did
you respond to his anger
What is the issue in this senario
What is the errorr is it wrong priscription or
missed follow up
How you well help the son regarding the
complain ?what is the PALS well respond to son
😐
How you well prevent something like this not to
happen again
St 5 Bcc1 pt c/o palpitation /SOB (graves
disease )on ask him he was on carpamazol &b
blocker
Examner ask what is yr finding ?how to
investegat
Bcc2 27 ys man has chest infection and
recoverd from it but he concern about his skin
lesion since 2 years
The pt was severly ill with skin lesion all over
the body with oral ulcers the lesion stared as
blisters rupterd easly
He has long list of medication i remember
(methylepredinsolon /mycophenolate mofetel
I give diagnose of blister skin lesion like PV
/polus pemphgoid
Cairo 5/2/2018
Station 4 pancreatic cancer for palliative care
and ERCP
Task explain diagnosis and plan of management
.doutgher ask from hospice care
S2 collapse in diabetic pts with history of AF
St5 headache acromegly
Lower GI bleeding
Today cases Almaadi hospital Egypt

ST 2 malabsorption due to celiac vs Giardiasis
ST 4 steriod given for ? GCA then pt.developed
psychosis and GCA was worng diagnosis
BCC 1 prolactinoma vs hypothyroidism
BCC2 SLE MCT APL
Cairo - Maadi 6/2/17 Carousel 1
St 5
BCC 1 : 65 old man complaining of muscle pain.
On history the surrogate gave history of
working in a glass history and the doctor told
him he has a lung disease (silicosis) and on a
direct question about steroid use he said yes
the patient on prednisone.
The case was proximal myopathy and the
patient has occupational lung disease.
The examiner asked about DD:
Steroid use, Lung cancer. And to ruke out
others like cushing, hypothyroid.
BCC 2:55 Lady with joint pains.
On taking history she had joint pains on hands
and knees but didn't have any signs and
symptoms of RA or SLE
And DD was osteoarthritis and ruling out sle
and RA.
-ST 1
Chest : lt sided fibrosis (most probably post TB)
and obstructive lung disease.
Abdomen :Hepatosplenomegaly fo dd (most
probably CLD).
ST 2 : HISTORY
Young man with right knee pain (very tough
examiners and misleading surrogate)
The surrogate gave history of only rt knee pain
and from history septic arthritis, haemirthrosis
excluded.
He gave history of ulcerative colitis and on
azathioprine.
He has IHD on atenolol, simvastatin and aspirin
The examiner didn't like my lust of DD starting
from reactive arthritis of the UC and i didn't find
any precipitation of gout but he told me that the
surrogate told u that he had toe pain and u
threw it out but actually the surrogate didn't tell
me that and i didn't argue with the examiner and
said I'm sorry.
The examiner wanted Gout as the main dd and
asked a lot about it what is the precipitating
factor.. I forgot the aspirin and said atenolol
which is not. And finally he asked about
investigation of gout then the bell rang.
-St 3:
Cardio :AVR with signs of AR the examiner
asked me what are the causes of the signs of
AR in AVR i told him signs may stay longer time
after AVR but I'm sure not sure is it right answer
or not but i forgot abou valve dehisenc.
Neuro: young patient (uncooperative) with Lt LL
UMNL for DD and the questions about dd a i
said MS, stroke, vasculitis but he didn't like
vasculitis then what else i said i don't know he
said do u think carotid dissection can be a
cause i said yes may be then he asked about
investigation of carotid dissection
St 4
The scenario is 45 years old gentlemen
suddenly collapsed at work and transfered to
the hospital and found to have major cerebral
bleed and the neurosurgery team decided that
surgical operation is useless.
He developed pneumonia and was put on
ventilation and antibiotics then his pneumonia
improved then weened from ventilation and now
vitally stable but still on icu.but the medical
team is pessimistic regarding his survival.
Talk to the wife about his condition and future
management.
I started with greating her then asked the wife
about her knowledge about her husband
condition then she started to talk and attak
early!
I explained the condition as breaking bad news
scenario but the surrogate reaction was very
unprofessional act as if he is not her husband! i
expected that she was going to cry and give he
the tissue and i did already but she looked to
me and to the tissue strangely!
Then she kept on repeating that her husband is
vitally stable and he's going to recover again
but i insisted that her husband condition is
unlikely to improve with repeating i appreciate
that a hard situation then she interrupted me
please doctor i know that u appreciate and
consider and.... the she asked me for another
openion and i told her that she has the right to
ask for another openion but I'm the one here
representing the medical team and any member
of the team will speak the same language.
She kept on arguing about her husband
condition and i kept on telling her unlikely!
The the time finished and the examiner put me
on the corner and started hitting!
He asked me what will be the future plan i told
him palliative care like nursing care and
gastrostomy tube the he asked me when will u
do the gastrostomy i said anytime.
He asked about why u didn't discuss DNR i said
it's not the suitable time for discussing DNR
now.
He asked me again and again about
gastrostomy tube the I'm fed up and i told him
I'll not put gastrostomy! He said now u changed
ur openion i said yes!
The the bell rang!
I feel that i didn't do well on this station because
i said on my explanation that his pneumonia
worsened his condition and the examiner
blamed me for that.
Also i didn't take good social history about what
she's working and financial support and the
most important i didn't ask about who will help
her at hope if her husband discharged home
and i think the examiner wanted to hear that
from me but i forgot it and he discussed this
issue with my other candidates on the same
carrousel.
Finally i dunno right i didn't discuss DNR on this
scenario or no.
Egypt
St 2,EAA
St4,dealing with uncertainty,liver cancer
St 3AVR,MR
Hemiplegia v taught Indian examiner
St 1Rt lung fibrosis for DD
Thalassemia
In Maadi military hospital Cairo Egypt

St2

migraine
month
worse
potosenstivity

hemiplegic migraine
Station 4 case.
Egypt center 6-2-2018
A 45 man collapsed suddenly and found to have

extensive subdural hge not operable as
decuded by neuro surgery team.
He devoloped pneumonia and was put under
ventilation and was given antibiotics and he
improved and weaned from the ventilation.
The team is pessimistic regarding his survival.
Discuss with his wife his condition and the
future management.
Egypt - Maadi
08/02/2018
Cycle 2
started from station 2

History taking :
with some rash behind the ear
I asked about all other seronegative .. all
negative ..
examiner keep asking about ankylosing ..!
Station 3 :
Neurology :
very confusing ,
Cardiovascular :
young male with clubbing , diagnosis , large
volume pulse , hyperdynamic apex , I couldn't
appreciate any murmur .. I put DD of congenital
Heart Disease ( VSD with eisenmilenger ) , also I
mentioned AR ..
Station 4
APCKD , new diagnosis , normal kidney
and 20 years ..
Station 5 :
A-
Known case of Rh.A came with SOB
B - Young male with history of dark urine ,

of previous clots , FH of stroke .. diagnosis PNH
Station 1 :
Respiratory :
clubbing of finger
Abdomen :
lymph nodes
I think it was good exam but can't have any
expectations ☹️
Don't forget to pray for me ..

Need your Duaa please ..
good luck for all colleagues and many thanks

for the great and continues efforts ..
Experience. Maadi Egypt 8/2/2018.
Stat 1 lobectomy u lobe. Heptosplenomelly. 2
back pain psoriasis verse ankylosis spondy. In
22year. Cleaner. Issue social.
3. Transverse myelitis. Aortic stenosis mr
prosthetic mitral.
4 Pckd. Want to get pregnant.
5. Pnh. Investigation treatment Rheumatoid
arthritis came with sob. Heart failure versus
broccoli ‘tis obliterans
Egypt, 8 Feb
ST 2 : 37 male with back pack pain
pain.
my DD:
Ankylosing S
Psoriatic arthritis
Discussion :
what your DD?
investigations ?
Treatment?
complications?
is it inherited ?
ST 4:( outside ) 27 y female recently diagnosed

ADPKD by ultrasound, normal KFT and BP ,
father has renal failure and feel miserable , she
will marry in 3 months.
task: explain disease and that no need for
genitic testing for future kids as no benefits to
know early but screening with US at age of 18.
concerns :what about my brothers 16 and 20

years ? we will screen the older but US but the
younger when become 18
can protect my future kids from disease ? I'm

sorry nothing can be done for this issue
any treatment now to prevent renal failure ?

your BP is normal and so KFT so we ll following
you up regularly, if your BP elivated we ll give
you treatment do dely but not prevent the
progress of the disease
shall i till my future husband? yes it is

preferable ( examiner asked me is there other
option than she told him, i said the better to
arrange another meeting for couple with my
consultant to inform husband, examiner said
excellent. )
discussion about how and who will follow up

her? i said GP and nephrologist by BP ,KFT
any benefit from intrauterine screening.? i said,
no need
BCC1 : female 47 y with long hx of RA

presented with SOB for 3 months.
inside : hx of progressive cough and sometime

productive with no diurnal variations and
exertional dyspnea, all RA hand features with
diffuse crakles and wheezing all over chest and
LL edema, on steroid and methotrexate for 5
years.
DD:
fibrosis with bronchilotis oblitrans
drug inducd fibrosis
infectiondue to immunosuppressive drugs
examiner ask is she in heart failure? i said yes

cor pulmonal
investigations ? Treatment?
BCC2 : 27 Y male with dark urine.
inside : hx of dark urine mainly in morning and

when i ask only morning or ny time else, side
only , no drug hx, hx of blood clots and blurring
of vision and abdominal pain , father with renal
failure
examination (face, abdomen, calf, pulse,

capillary filling) was normal (surrogate ),.
examiner ask DD:

PNH
ADPKD
why examine abdomen, i said to exclude
ADPKD
urin contain HB or myoglobin ? i said HB
ask me what is the cause of blurring? i said
thromboembolism.
will you admit him? i said if CBC shows anemia
i ll admit for blood transfusion
UK EXPERIENCE
University Hospital North Tees

54 years male with backache since 3 months
Diagnosed with osteoporosis by GP
On xRay collapse of T6 and T10
Take history and manage concerns
In history there was diarrhoea and weight loss

also
Examiners asked about IBD and Ca colon
Station 3
Metallic mitral valve replacement without any

complication
Viva on anticoagulation and cardiac
rehabilitation
CNS was
Examine the upper limbs
Cerebellar signs, loss of posterior column and
internuclear ophthaloplegia present
MS diagnosis
Examiners took viva on MS
Station 4
62 yr female with poorly controlled Diabetes
mellitus
Neuropathy, Nephropathy, opthalmopathy,
Smoker 20 cigarettes/day
Advise on lifestyle and manage concerns
Station 5
Pleuritic chest pain with SLE
Viva on PE investigation and management
BCC2
Painful hands
Proximal IP joints but also distal early morning
stiffness and nail changes also
So gave DD of
RA. Psoriatic and osteoarthritis
Examiners asked about investigations
Station 1
Resp
Dyspnic patient with oxygen nasal cannula
Left thoracostomy scar
Spine deformity
Trachea central
Right sided fine inspiratory crepts
Lobectomy,pneumonectomy and lung
transplant with lung fibrosis
Viva on ILD investigation and management
Abdomen with rooftop incision scar plus scar in
right Iliac region plus scar just right side of
umbilicus
Asked about how many scars Dd and

management
I told liver transplant
Then asked why Iliac?
Told may be renal transplant also but couldn't
palpate kidney
Examiners asked any condition needs
simultaneously both transplants
I said hepatorenal
Then asked viva on hepatorenal and it's types
and management
Also asked about indications of liver transplant
Cochin ,1st carousel
Station 4 : Diagnosis of IBS, to explain patient

and to start amitryptline, patient is stressful for
her son diagnosed as hyperactive. Patient
concerns are want more test, why stress can
cause my symptoms and side effects of
amitryptline.
Station 2 : DM patient, confusion while she was

sitting in restaurant with her friend. H/O of
migraine not on treatment. Dx TGA. Examiner
wants to know asaociation between mugraine
and TGA.
BCC1 : Rash and arthralgia after medications.

H/O fever 1 week before symptoms.
BCC 2 : numbness on hands and feet, scar (+)at

neck. H/O renal stone (+)
Station 1 : COPD with crepts at LLZ, I have Dx of
COPD and broncheictasis
Another patient rt lobectomy
Station 3 : CVS MR + AS
Another case MVR
Neuro rt sided facial palsy
6 Feb almaadi, Egypt

St3 copd+bronchictesis or lung fibrosis
Hepatomegaly jaundice and lymphadenopthy
St2 iron def anaemia with Ibs diahrea changed
recently travel to Caribbean diagnosis celiac vs
traveller diahrea
St3 cns monoplegia
CVS double valve replacement
St4 steroid psychosis
Bcc1sle with aPL
Bcc2galactorea with headache
Dubai 12 Feb
History
Female fatigue depression low NA levels
Complaint of weight loss and fatigue
Dubai 13 Feb, Diet 1

Respiratory :
Lobectomy
Abdomen :
Hepatosplenomegaly
Station 2 :
A young lady with history of transient loss of
consciousness. Brother has history of epilepsy .
It was Vasovagal syncope . Concern was
epilepsy and driving.
Neurology :
Cerebellar syndrome
Cardiology :
Mitral valve replacement
Station 4 :
The daughter whose father was admitted with
curb 5, in that case apology was required as he
was the candidate for hdu from the beginning ,
that's what the examiner told me.
The point for coummunication station should be
noted
All candidates including me did it wrong
Though
In the communication scenario it was not given
On the bases of curb score
They mentioned should be admitted
So apology was required at beginning
BCC 1 :
Female with fatigue. Inside proximal muscle
weakness and tenderness. History of overian
cancer
BCC 2 :
History of pituitary surgery, now again with
headache
One point I must mention here

Don't go on station 5 scenarios from outside
and make d/ds
Just need to read. Otherwise one become
preoccupied
Just go inside and decide there
Dubai
BCC 1 : 42 years gentleman with blood in urine
since 3 months family history father died of
kidney problem and brother on CRF also had
one episode of seizure 2months back
Bcc 2 : 32 year lady previous throidectomy for
hyperthyroidism now came with swelling in
front of neck with Signs of hyperthyroidism
Station 4 case of GB syndrome talk to wife that
he is in Icu since 4 weeks and tracheostomized
neurologist has seen the Patient and task was
to explain wife about possible poor prognosis
and minimal chances of recovery , initially she
was told that chances of recovery will be good
Station 2 :
History of abdominal pain associated with
erratic bowl habits in a 32 years gentleman,
aggreviated by stress. Father has cancer and
his concern was does he has cancer
CVS MR
CNS peripheral mixed neuropathy
Chest left lobectomy
Abdomen hepatosplenomegaly
Today Paces in dubai 13/2/2018 at 12 pm

Started with bbc1
42 years old with hematuria 3 months
Family hi istory of kidney disease
D iagnosisAPCkd
2 ND Bcc2
Neck swelling
Nodular toxic goiter recurrent after
thyroidectomy
Station 1
Rt lower lt lobectomy
APCkd on hemodialysis
Station 2
35 years old with recurrent diarrhea no loss of

wt diagnosis before Irritable colon
With strong family history of
cancer colon
Station 3
AR replacement with diastolic murmur
Neuro
39 years old with difficulty of walking few days
ago
Gb syndrome
Stataion 4
Communication
Speak to wife her husband admited with GPS
admitted 4 weeks ago
On admission some body informed her we will
be ok and walk
But he was on Mv then extubated on on

tracheostomy with poor prognosis as decided
by neurologist
Sharjah 3rd cycle
St 2:
fever 40 yrs old female
Further in history, fever for 3 weeks, wt. loss of
3 kg during this time and decreased appetite.
Also noticed lumps in inguinal area.
Slight dry cough
Took 2 courses of antibiotics, no improvement
in fever.
Neuro:
young male
Spastic paraparesis
Discussion about MS
Cardio:
? MS
St 4:
Talk to son of 80 yrs old lady, end stage kidney
disease on dialysis for 3 years, also had stoke
and bed ridden for 3 years, admitted now from
nursing home with increasing SOB and
drowsiness.
Earlier she had wished to stop dialysis Incase
she deteriorates so now the doctors think the
time has come to withdraw dialysis.
On stopping dialysis, she’ll become more
drowsy and might die in few days.
So talk to son ,explain her mother’s condition
and address concerns.
BCC 1:
20 yrs female with bloating and flatulence.
On inquiring further, has anaemia, tiredness ,
stool frequency increased to twice daily, not
very loose, not being able to put on weight,
although didn’t lose.
Mother has done thyroid problem
BCC 2:
65 yrs old male , came for routine assessment
of HTN.
BP controlled, also DM
Now had headache for 2 weeks.
Mainly on left side, goes down to left face, more
on jaw movement.
No visual impairment.
Glasgow Royal Infirmiry

parkinsons disease

for endoscopy to rule out gi tenalgiectasia

mostly unilateral..dd- copd, bronchiectasis

gum hypertrophy
as with mr

neuropathy due to dm, alcohol,
was gbs
surveilance
moment
Cairo 3rd feb
✔️St 1 chest,,
Finding hyperresonant percussion bilterally
,,wheezes all over trachea is central
Examiner qu
What are positive finding?
DD
How to investigate him?
Mangement
How to differentiate between asthma and copd ?
✔️St 2
Male pt about 35 yrs of age has bloating losse
motion refered by Gp who thinks about Ibs
Sit with him and answer his conserns
Inside:
All symptoms for last 4yrs going with
IBS.,exaggerted recently when his father
daignosed byca colon
No wt loss.,,no symptoms of malabsorption...No
hx of recent travelling abroad...
Drug hx ,..buscopan ,me
His consern,,,,is it ca colon like my father..
Examiner qu:
Did you reassure this pt?
DD?
Is he need clonoscopy or not?
Plan of mangement
✔️St3
Cardio.,.
Young femal
Has mid sternotomy scar
S1 metalic.,
Pr regular
Not in faliure no signs of IE
Mitral v replacement..
Examiner:
Present positive finding
Invs
Mangement
Neurology:
Also young femal with inability to walk
In pain iget confuse 😑how to start

Idid the screening test she can raise her upper
limbs but never move her legs
Hypotonia.,areflexia even with reinforcment
Iamnot sure about power distrubution because
she was in pain when Iwant to do planter reflex
the examiner ask me donot do beacuse has sole
pain 😳
When ireach the sensation the time finish
Examiner :
Clincal diagnosis?
Itold him ididnot complete the exsmination and
planter reflex is very important for me to reach
the diagnosis? He told me is down going‫الحمدهلل‬
Isaid for him so this flacid paraparisis for dd
What are Dd?
Invs
He consentrate on GB
Mangement
✔️St 4:
You are doctor on in the ward
Mr x brought from his work with high temp skin
rash
Temp 39 GCS 7
Menengiococsemia was confirmed,prepared to
be shifted to ITU
Talk to his wife and explain to her the diagnosis.
Wife conserns?
When will be discharge?
Will improve?
For how long will be admitted?
What about my children?
Examiner :
Did you tell this wife about the possiblity of her
husbund death?
Did you discuss with her ventilation?
What are the sort of dissablities he can get it if
recover?
What you will do for her children?
He asked me as if he never hear the
conversation between us
Never ask me about ethical issues
✔️St 5
Femal pt with diffuclty to go upstair
All vital signs are normal apart of high
bp160/100
Inside:
Obese femal with round face
Trunkal obesity
Abd strae thin legs
Other signs with every step the examiner ask
me not to do no need,what you want to see!
When iask her relative?
Hx of easy brusing....wt gain...recent DM,,HTN...
Consern about of diffuclty to go upstair
BBC2:
YOUNG male with skin rash
Normal vital signs
Inside: fit man with scaly skin rah with mild
redness at his dorsum of both foot..no other
area involved
Iasked about how started first?
Incrasing decrasing factors?
Other areas invloved?
No joint pain no hx of eye redness all hx not
sure or NO
At last minute iasked about the job he is
working at detergent factory snd all these
symotoms came after working at factory and
consern about his job because he has no other
job
Examiner :
What is the diagnosis and DD
Mangement and what about is his job...
Pray for me ,,reasonable cases but when will be
under stress even your name diffuclt to
memorize it😇
Exminer questions at Bbc2,,
Finding.,
Dignosis
Invs and how to localize the cause
Mangement
Drug hx.,,never used steroid.
Sharjah
Neuro : fasciso scapulo humeral dystrophh
Cardio : old sick patient who was breathless
and not following commands. infective
endocarditis signs witl lvf .. could not find the
murmer
RESP : copd
Abd ( hepatomegally ) .
Station 2 : young male with dm -1 and weigh
loss .. reason was poor compliance with insulin
due to breakup with fiance Communication :
BBN of cancer
BCC 1 : toxic nodular goiter
BCC2 :axial plus pain in all large n small joints..
symmetrical ... with no rash from past 5 years ..
morning stiffness with difficulty in writing (
concern of the patient ) . i gave differential of RA
vs ankylosing sp
2018/1 UK
station 4.
station4) *Task was to talk to the daughter . Her
father had died after 2 days of admission to
hospital ,he was a case of COPD admitted with
CURB score5. He was admitted in surgical ward
arrested and shifted to HDU and later died*
Station2 47 yr old came with history of dry

cough and sob for 6 months . He had no other
history later I explored that he had got a pigeon
for her daughter as birthday gift. It was extrinsic
Station 5
childhood.

out arthirits .
Experience from UK
Diet 1/2018
diet 1 victoria hospital Edinburgh
St 4:
Patient know case of ADPKD for 2 years.
Diagnosed recently with ESRD and on renal
consultant plan for haemodialysis. A-V vistula
inserted and first cycle started after patient
consent.
Patient request to see you because she think
she doesn't want dialysis anymore.
St 2:
Syncope for DDx
collapse likely seizure or cardiovascular
syncope
Station 4 new diagnosis od ADPKD , counsel
Station 5: 1 diarrhoea in a immunocompromised
patient
2 GCA
New uk experience :
Communication skills : was about an 80 year old
lady brought to hospital with syncope and
reason was diuretic drug which we stopped she
was fit to discharge but daughter don't want to
take her home and we had to counsel her.
History station : was young man with diarrhea
and abdominal pain diagnosis was irritable
bowel syndrome .
BCC 1 : patient operated for subarachnoid
haemorrhage shunt was placed comes with
headache and blurred vision
BCC 2 : second scenario was rheumatoid
arthritis patient with breathlessness.
Cardiology : I think mitral regurgitation but d/d
aortic stenosis
respiratory case : left pneumonactomy
Neuro : motor sensory peripheral neuropathy
and
Abdominal case : hepatospleenomegaly
New uk experience :
St 2; 65 yrs lady had a blackout, concerned
about driving and traveling to USA
st 4: explain APKD to a daughter of a diagnosed

patient
BCC 1 : lady known lymphoma admitted with

sepsis on antibiotic. Review her for diarrhea
BCC 2 ; lady with headache started on the

occiptal region with raised ESR, gave history of
GCA. Mistake - failed to rule out fracture spine
Cvs: tissue valve
Neuro;bilateral cerebellar syndrome

Abdomen: renal transplant with hepatomegaly
Resp: pul fibrosis in systemic sclerosis
St 2 blackout 45 year old with background HTN

and CABG 8 years back on ramipril furosemide
bisoprolol and aspirin ,amlodipine stoped 2
years back cz of low BP
No recent change in meds
No dizziness on standing up from sitting
Blackout without warning while cleaning leaves
in backward (doing this for last 15-20min)lasted
for 30second wife noticed some jerking
,regained consciousness spontaneously
Injured elbow
No wetting tongue biting or postictal confusion
Father died at 50 with some heart disease
Hx of racing of heart 2 months back
Underlying SOB with good excercise tolerance
Smoker
Vitals given pulse 50
BP 110:60
I put cardiac syncope arrythmia as first dx
Contributing factor low BP
St 4
28 year old lady after vaginal delivery ,positive
strep B vaginal swab
Given IV b pen>developed rash then shifted to
medical now confused RFTs LFTS deranged
and plan is to shift her to ITU
Task :speak to husband and tell ur plan to shift
to ICU and possible intubation
He already knew that she is sick after reaction
and drowsy now not talking to him
He asked is she dying
I’m sorry she is critical and may die soon
We are trying best ....crying.....offers him water
and giving call to family
We are shifting him to ICU and possibly put tube
down her throat to help her breath
Will she be in pain and awake
No we ll give med to calm her and tolerate this
tube
Is baby fine
I said yes (was written in scenario that baby is
fine )
But if u r concerned I will get him checked by
baby dr
He said how Łl I feed him he was on breast feed
I said I’m sorry to hear this I understand it’s
difficult
Any family member who can help u
Yes my parents are on way
Bottle feed is only option at the moment
I asked about understanding and he said I gave
him infection and now she is dying
Why I Think like this do u have any symptoms
We don’t know how she caught infection
Examiner Q st 4
Q.What made him cry
She may die
Q.Any other way to covey
I tried to be clear
Q.whos changing baby nappy
I didn’t ask
Q.did u discuss DNR
No he was already not taking in given info
Q.what if he comes tomorrow and find his wife
died in night
Silent �♀
Q.what u ll do if baby become sick
Baby dr
No after going
No after d
Recent uk cases : st 2 syncope - most likely

cardiac + other dd , st 4 - steven johnson
syndrome after being given IV benzyl penicillin
for vaginal infection after delivery. BCC 1 : most
likely surrogate with hx of confusion & no
collateral hx available BCC 2 : surrogate - fever
in pt returning from Bangladesh
5/2/18
Station 1
Abd: renal transplant due to apckd
Resp:pul fibrosis sec to scleroderma
Station 2
54 male with back pain for 5 months . X-ray
collapse of t6 to t10 due to osteoporosis.
Granny had concern was osteoporosis at 60 yrs
of age and became wheelchair bound.
History of diarrhea on taking systemic review.
D/d
MalAbsorption syndrome ,celiac,
What other dd. How would you manage
osteoporosis.
Station3
Cvs: mitral valve replace
Cns. Spastic paresis😟

Some had Marie tooth charcot.
Station4.
90 female present to ed with sob. Hb 6 . Was
transfused. But denied any further work Up for
Ida. Had capacity at that time. Now 3 days later
present with and wall mi. Decided for ward level
management. Now tAlk to the daughter.
Bbn
Explain further palliative approach.
Station 5
68 male with diplopia.
Inside was graves opthalmopathy.was on
carbimazole with levothyroxine
5b
25 male with weight loss and inc sweating.
Thyroid normal.
Bp 158/90
On lisinopril
No positive s/s
No positive history.
Except for off headaches
Dd.
Lymphoma
Pheochromocytoma
Men
UK experience
St 4 : meningitis. Talk to wife
Neurology : rt foot drop common peroneal
Cardio : metallic valve replacement
resp : systemic sclerosis with plu.fibrosis
Abdomen : nephrectomy scar with renal
transplant
Bcc 1 : Tia
Bcc 2 : blurring vision in elderly woman
History nausea and vomiting in , patient
diagnosed case of stomach , cancer took
chemotherapy and radiotherapy for pain and on
morphine tablets with no any alarm signs of any
thing
Hypercalcemia
Immunosupression caused by chemo leading to
secondary infection, gastric ca obstructing the
outlet
uk experience
Today
Station 3
CABG with AVR

Peripheral neuropathy / Myopathy
Viva was about neuropathy
Station 1
Right lower Lobectomy with telangiectasias +
upper abdominal scar
Lower abdominal scar + multiple scars in

abdomen left arm fistula active and used
recently
Couldn’t palpate the kidney
Hepatomegaly was there
Station 5
Sob in lady with joint pain

Parkinsons patient with dizziness and falls on
standing
Didn’t ask about medicine compliance which
examiner mentioned
Station 2
Lips swelling from 3 months
It was drug induced due to Ramipril
St George's 3/1/18. Carousel 3.

lymphadenopathy.
alports syndrome.
his concerns.
Station5;
Pt with raised LFTS. gay, HIV, Hepatitis.
Station5.polymyalgia rheumatica.
UK
St 2 was..55 year old male with chest pain..DM
htn..heavy smoker drinker..it wz APD..with knee
pain taking paracetamol and aspirin..
st 4 was 65 yr old male presented with ischemic
stroke TPA was given now pt got intracerebral
bleed gcs7 poor prognosis..DNAR already
signed..talk to Angy wife..
st 5 was known case of PD not taking medicine
regularly and presented with postural drop...
2nd BCc was 45 year old female presented with
fatigue from last 6 months with deranged lfts
and pruritis heavy drinker....
st 1 was lobectomy and APKd with
hepatosplenomegaly with active fistula...
st 3 was CABG with AVR and displaced apex
beat..sensory motor neuropathy with
predominantly proximal weakness
UK
St 4 was very long scenario for angry relative
getting worse
oes around carina
tube
They did dilalation
Relative concern
Why late diagnosis
catch diagnosis


and spleen
presentation
even snip negative

manangment

diagnosis
that stage
Only palliative



UK
Cardio - young lady with ESM
Neuro -. Do neurology examination ( it was PD)
Station 4, talk to the daughter who's mother was
admitted with haematemesis , OGD plus biopsy
negative , latter CT showed mass compressing
the Oesophagus
Station 5 , 1 - young girl tiredness for 3months ,
proximal muscle weakness , difficulty combing
the hair
2- 70 years old female presented with cardiac
murmur and back pain,
Latter she said sacroiliac pain. No signs of
Ankylosing spondylitis, gives the history of
arthritis
Resp - Bronchiectasis
Abdomen - 20 years of female admitted with
weight loss , o/E Bilateral thoracotomy scars ,
Port-a-Cath , PEG tube , ? Cystic fibrosis
History - 3months history of intermittent lip
swelling and she was on Ramipril
Today in UK :
BCC 1 : blurred vision acromegaly
BCC 2 : lady on dialysis have postural
hypotension
St 4 : 40 y old man with probable liver
metastasis and lymp metastasis
uncertain need more investigation as per
senario
concern : am i going to die
examiner asking could it be any thing beside
cancer give me diffrential very difficult
discussion is he going to die
St 2 45 y old lady with fatigue, loss of weight
and depression..many family problems.... could
be cancer, chronic fatigue or depression
Dr rasheed group
Wolverhampton exam experience on 9th

February 2018, 2nd carousel.
Station 1:
Splenomegaly
Left Lobectomy.
Station 2:
Youngman with recurrent chest pains more on
moving the boxes during his warehouse job.
Family history of father and grandfather's death
with MI. On his story: Smoker, cocaine, high
holestrol. Concern about IHD.
Station 3:
AS
?Stroke
Station 4:
Talk to wife of the patient admitted with major
cerebral bleed with poor prognosis.
Station 5:
Known case of Crohn's Disease with acute flare
up. Concerns about Steroids use.
Young lady with fever. History of travel to

Africa. Didn't take proper prophylactic
medication in its full course. Malaria with
splenomegaly.
UK 8.2.18
Harrogate hospital
Neuro : hypotonia,hyporeflexia cerebellar signs
+ve, up going planter - MS , discussion about
MS & FA
Cardi : MVR , discussion why he had sob
Communication: long scenario
Wife of man has GBS , informed earlier that he
has good prognosis, now deteriorated, needed
NG tube & tracheostomy, neurologist opinion is
sever axonal type with very bad prognosis
She became very furious after BBN
Main concern : why they told her he has good
prognosis
Is he getting better
I want to take him home
But I don’t know how to take care of him there (
so talkative lady )
Station 5
BCC1 : 45 male with h/o DM & angina has
syncope , mostly cardiac ( no symptoms of
Addison, autonomic neuropathy, renal failure ) .,
no change in medication
BCC2 : 73 male DM with deterioration of vision
Diabetic retinopathy with photo coagulation
Respiratory (disaster)
Obese lady with small scar over rt anterior
upper chest wall , no other findings (VAT , chest
tube �)
Abdomen: thin man with mass about 6cm over
left side of abdomen ( kidney or spleen )
Discussion about if it’s spleen
History:
40 female, DM type 1 c/o tiredness & loss of wt
Uncontrolled DM , otherwise all negative :
Addison’s, coeliac , cancer , renal
failure,panhypopitutarism ,thyroid, . Her mood
is low
Uk experience 9 Feb
Station 1 : Resp was weird. Unilateral creps, no
added signs, no scars, looked well. I said
consolidation/bronchiectasis/ILD, belt and
braces approach. Abdomen was CLD/abdominal
malignancy. Quite an unwell pt with ascites and
bruising but not much else. Didn’t say abdo
malignancy high up so could have been sharper
there
Station 2 : 49m with chest pain when lifting but
strong CVS risk factors w recent negative ETT. I
said CTCA +OGD +manage risk factors, with
probable MSK pain in small print. Probs wrong
way round.
Station 3 : Prosthetic aortic valve. Upper limb
exam, stroke
Station 4 : 45m 10 days after extensive
intracranial bleed, in ICU speaking to wife. Brain
death. He had an organ donor card so tissue
harvest and I said autopsy.
BCC 1 : Bell’s palsy
BCC 2 : Systemic sclerosis.
My experience liverpool
station 1 Abdomen patient with livertransplant
scar and multiple spider navi.
Chest : straight forward COPD
2 History straight forward migraine patient
concerned if it is tumor bcz its increasing in
severity and frequency
3 CVS MVR
neuro lower limb examination patient with hyper
reflexia and hypertonia in knee joint and
hyporeflexia in ankle 😃
also sensation is impaired in gloves distribution
(pt was not so helpfull) so I give DD of lesions
which can give UMN + LMN
station 4 senario of patient came to hospital e
flu like symptoms recieved treatment 4 hrs later
he came again febrile e skin rash developed
convulsions now stablized and initial diagnosis
of meningeococcal sepsis was made now
waiting to be transfered to icu ... GCS 7 explain
to wife his condition
She will ask about her children and she will ask
if she can c him ...u have to explain her the
disease it self ... and what will be done for the
patient ... she will ask about if he will be ok
U have to admit it is serious and some patients
may develop complications ... u have to tell her
that patient needs isolation at least 24 hrs bcz
its infectious through respiratory droplet. And
we need to tell health authority bcz this is
notifiable in turn a specialized team will contact
u to determine who is in risk and they may give
prophylaxis and vaccine... for her children she
will ask if she needs to keep them at home ... no
need
Ofcourse throughout the conversation u need to
show empathy bcz it was sudden and patient
was not ill
also u need to ask some questions about who
was in close contact to patient to determine risk
Uk experience 8 Feb
St 4- communication with wife of patient with
severe form of gbs, patients family was
informed that patient is going to regain full
function but now neurologist view is different
and says no function in both lower limbs. V
difficult case as surrogate angry and just kept
talking and talking and screaming, I couldn’t
speak to her Nd she kept talking throughout
St5- a) diabetic come in with dizziness
B) diabetic visual blurring fundoscopy
St 1- rs- no idea absolutely normal chest

couldn’t find anything
Abdo- isolated spleen
St2- diabetic with weight loss and tiredness
St3- cns- upper limbs- very odd no idea what the

diagnosis was- I found umn??? Signs bilaterally
but legs looked normal??? Not sure what it was
i said ms
Cvs- aortic regurg
UK , Walsall manor trust hospital 11/2/2018

Frist cycle
1-RESPIRATORY :
Qs:finding
DD
cause of fibrosis
Investigations
cancer
ABDOMEN :
Qs:
2- St 2
St 4


Qs.
I did not know?
India
Delhi 9 Feb :

and Rx
Respi..COPD


mettalic
about icsol..�
10th July.
Delhi


CVS was mvr with AS

given bisoprolol
Station 5.
-meningitis
Both station 5 didn't have findings. Esp

confusion one.
New Delhi Center Experience

station 1
missed something
Station 2

...

why having pain...
Screwed up this one


it as differential
maybe it was polio
St 4

on time etc

issue
ethical issue)

Bcc 1




ready for surprises ...
wish me luck and wish you all luck also
Delhi 9th
Feb 3rd carousel:
St1: Abd Huge ascities with Mark for recent
paracentesis and scar in upper abd of recent
shingles. Dd CLD/Malignancy
Resp Fever with cough. Dd Pneumonia, TB
ST 2: 30Male h/o unilateral headache for 1 yr
which has increased in last 2 months. During
last 2 month he is having cocodamol qds.
Concern- what is the cause. Can it be tumour.
St3: Neuro Chorea. Cardio - DVR with infective
end. Viva on IE
ST4: M45yrs having at loss enlarged liver,
Supraclav LN. CT and FNAC done. CT
suggestive of upper lobe mass with liver mets.
FNAC report is missing. Your friend who did the
FNAC is on leave. Boss is out of station. He
instructed u to talk to pt. And repeat FNAC. Very
angry surrogate. Hardly allowing to speak.
St5: BCC1- Sudden SOB for 4 hrs. On exam DVT
with PE.- Surrogate.
BCC2 - Maroon colour stool with new
constipation for 8 months. Tenderness in LIF.
Father had polyps. Had dizziness and tachy.
Was on antiplatelets- Surrogate
10/2/2018.
New Delhi 1st carousel.
st 2.A 50yrs old man H/o Evening rise of
St3-DVR+IC drain in right side.sick
patients.Neuro -Upper limb-CVA. on inspection
UMN facial palsy.
St 4 long scenario.53 years old patient Asthma
Bisoprolol 5.Pharmacists warned nurse.that it is
contradicted in Asthma.But patient heard it.Talk
to patient
PALS.
BCC1-Elderly man c/o Confusion &fall for
.Hyponatremia
BCC2- Middle aged man having fever ,headache
,vomiting for last 5 days.Inside different
story.Known epilepsy taking Levetiracetm,
Alcoholic. Treated as a case of viral
menigitis.Discharged &again same c/o
thrombosis
St1-CKD with AV fistula in left hand with Right
sided pleural effusion. CLD ascites with Midline
sternotomy scar plus ?Portacaval shunt
I am from Myanmar. I have passed PACES

168/172 on 7th March 2017, 1st diet , my exam
center is new YGH, Yangon, Myanmar
I started with St 2
St 2 wt gain fatigue , amenorrhea, 18 mths post
partum ho of PPH blood 4 units given
Dx hypopit due to shee han
DDx Hypothyroid most probably due to post
partum thyroiditis
I got 18/20
St 3
A middle age lady presenting with SOB
MS with AF
Examiner asked what's your findings, Dx, DDx,
how would you manage, if the pt has vegetation
in echo, can it affect the INR target?
I got 20/20
Neuro station
A young lady presented with difficulty in
walking, plz examine her neurological system
Pt has ryles tube and urinary cathether inserted
Dx- Lt sided hemiplegia due to cardio embolic
stroke
I got 20/20
St 4 angry pt with esrd

Scenario given was the pt had history of high
blood pressure since 5 yrs ago which was found
out when he got accident. He didn't take any
medication nor any follow up since then. Now
he suffered SOB and saw his GP , done blood
test showing eGFR < 15, Hb 6.5, Potassium 5.3,
USG showing bilateral contracted kidney. He is
now seeing you what happens to him.
Task - discuss his current condition and further
management plan as appropriate.
I got 16/16
St 5 BCC1 a young lady presented with SOB
SpO2 88%
dx diffuse systemic sclerosis with pul fibrosis
Examiner ask Dx, DDx for SOB in this pt,
Management
I got 26/28
BCC 2
A 54 yr old lady presented with chest pain
Dx Unstable angina(ACS) with hypothyroidism
Hidden agenda here was to refer to hormone
specialist to reduce her thyroxine dose
I got 28/28
St 1
Abdominal examination
Hepatomegaly
Dx Thalassaemia
Examiner asked Dx, points for Dx, DDx,
infectious causes of HSM, treatment of
Thalassemia
I got 20/20
Respiratory system examination
Rt sided moderate pleural effusion
Examiner asked Dx, points for Dx, DDx of
dullness at base of lung, Ix, Mx, what would you
consider if this pt is working in shipyard?
I got 20/20
Thanks a lot PEC group! I may not get this

achievement without your help.
Cairo 3rd feb
✔️St 1 chest,,
Finding hyperresonant percussion bilterally
,,wheezes all over trachea is central
Examiner qu
DD
Mangement
✔️St 2
Male pt about 35 yrs of age has bloating losse
motion refered by Gp who thinks about Ibs
Inside:
All symptoms for last 4yrs going with
IBS.,exaggerted recently when his father
daignosed byca colon
No wt loss.,,no symptoms of malabsorption...
No hx of recent travelling abroad...
Examiner qu:
DD?
Plan of mangement
✔️St3
Cardio.,.
Young femal
S1 metalic.,
Pr regular
Examiner:
Invs
Mangement
Neurology:

Idid the screening test she can raise her upper
limbs but never move her legs
Iamnot sure about power distrubution because
she was in pain when Iwant to do planter reflex
the examiner ask me donot do beacuse has sole
pain 😳
Examiner :
Clincal diagnosis?
planter reflex is very important for me to reach
the diagnosis? He told me is down going‫الحمدهلل‬
What are Dd?
Invs
Mangement
✔️St 4:
Mr x brought from his work with high temp skin
rash
Temp 39 GCS 7
Menengiococsemia was confirmed,prepared to
be shifted to ITU
Wife conserns?
Will improve?
Examiner :
husbund death?
recover?
He asked me as if he never hear the
conversation between us
✔️St 5
All vital signs are normal apart of high
bp160/100
Inside:
Trunkal obesity
Abd strae thin legs
Other signs with every step the examiner ask
me not to do no need,what you want to see!
BBC2:
Normal vital signs
Inside: fit man with scaly skin rah with mild
redness at his dorsum of both foot..no other
area involved
No joint pain no hx of eye redness all hx not
sure or NO
At last minute iasked about the job he is
working at detergent factory snd all these
symotoms came after working at factory and
consern about his job because he has no other
job
Examiner :
Pray for me ,,reasonable cases but when will be
under stress even your name diffuclt to
memorize it😇
Finding.,
Dignosis
Mangement
Drug hx.,,never used steroid.
Dubai 13/2/2018
Started with bbc1

42 years old with hematuria 3 months
Family hi istory of kidney disease
D iagnosisAPCkd
2 ND Bcc2
Neck swelling
Nodular toxic goiter recurrent after
thyroidectomy
Station 1
Rt lower lt lobectomy
APCkd on hemodialysis
Station 2

cancer colon
Station 3
AR replacement with diastolic murmur
Neuro
39 years old with difficulty of walking few days
ago
Gb syndrome
Stataion 4
Communication
Speak to wife her husband admited with GPS
admitted 4 weeks ago
On admission some body informed her we will
be ok and walk
But he was on Mv then extubated on on

tracheostomy with poor prognosis as decided
by neurologist
Exam is easy but need good concentration
sleep early day before exam
Egypt ,, Cairo
Maadi military hospital
St2

migraine
month
worse
potosenstivity

hemiplegic migraine
- St 4 was very long scenario for angry relative
getting worse
oes around carina
tube
They did dilalation
Relative concern
Why late diagnosis
catch diagnosis


and spleen
presentation
even snip negative

manangment

diagnosis
that stage
Only palliative


Examiner questions

Who are team member

mangment
St 5
Bbc1
38 years old with severe abdominal pain
Inside gentleman with attacks of abd pain

mainly epigastric related to food comes on
attacks for 2 months
No H/o fever travel jaundice or blood
transfusion
He is diabetic and alcoholic
Examination all abd tender especially

epigastrium
P/h cholecystectomy
DD
Alcoholic pancreatitis
Alcoholic gastritis
What you will do for him

How pancreatitis will affect diabetes
- BBC 2
Again abdominal pain with diarrhoea
Inside male pt with abd pain and loose motions

sometimes with blood
No fever
With loss of weight
Joint pain
By exam
Psoriatic arthritis and back pain
No abnormality in Abd exam
He is on steroid and methotrexate
Examiner questions
Dd
IBD with psoriasis
How you will investigate and treat
What is the next step here in ttt of psoriatic
arthropathy
Discussion about biological ttt
Wishaw, UK
🔹 Station 2 : SOB & fever in known IVDU
🔹 Station 4 : Mother is fit to be discharged but

Station 1
🔹 Abdomen : Renal transplant
🔹 Resp : ILD
Station 3
🔹 Neuro : Peripheral neuropathy
🔹 Cardio : AS/MR
🔹 BCC 1 : Cushing sec to steroids for Wegener
🔹 BCC 2 : Benign essential tremors

Station 4
St 4 :scenario : alcoholic Encephalopathy with
hepatorenal syndrome, not considered for Liver
Transplant and discuss DNR..discussion with
Son
I started with if he is the son and NOK (

verify)what he knows, has anyone discussed
the condition of the patient with the son, What is
the meeting about (agenda setting)..then BBN
gradually. Then telling him that he has been
seen by the consultants and that he is not
considered to be a candidate for liver
transplant. The surrogate resisted, explained
him why he is not considered to be a candidate
for liver transplant, poor abstinence history,
consultant decision, discussed DNR (mentioned
in the scenario), as it is the consultant decision
( treating team's decision), however he will
continue to receive optimal treatment.
Throughout sympathetic and empathetic
My experience in diet 1 Yangon on 6.3.18

I started with St 4. It was young lady with severe
headache suspected of SAH who want to be self
discharged. CT head was normal. My tasks were
explain abt disease and consent for LP. Inside I
explored nature of headache with few questions
and family history of stroke and renal problem.
Then I explained abt possible diagnosis but
patient deny the whole time because CT was
normal. I had a chance to explain abt LP when 2
min left. But she didn't give consent. Then
time's up. Ex questions were abt autonomy and
treatment of SAH.I got 13/16.
Then St 5
BCC1 lady with multiple hand swellings
presented with haematemesis and melaena. I
considered abt causes of upper GI bleeding.
Inside I was shocked when I saw the patient. I
have never seen such swelling in the hand in
my life. But I tried to calm down and started
questions.hand swelling is only on the right
hand not in other part. It has been for 10 years.
No history of bleeding or pain. Got H n M 7days
back. Non alcoholic, no analgesic misuse, took
paracetamol for back pain. FH Nil. O/E multiple
swellings seems like gouti tophi or
neurofibromas but not typical. At the tips of
fingers there were haemangiomas. I explained
her H n M may be associated with some
vascular abnormalities. Exam Q: most common
causes of H n M in Myanmar. I got 27/28
BCC 2 acromegaly e Hypertension. Routine
questions. I got 28/28
St 1 Resp COPD with right pleural effusion.Ex

Q: investigation and Mx. I got 20/20
St 1 abd transplanted kidney e drug side effects.
I got 10/20
St 2 back pain e rash DDx psoriatic arthropathy

Ankylosong spondylitis. Patient main concern
waere abt his work, cleaner in supermarket, and
his hobby, gym exercises and football playing. I
told him I will refer him to occupational therapist
for job rearrangement. For hobby I suggest to
do light exercise and swimming. got 20/20
St 3. CVS young man e diastolic thrill over the

precordium. I heard murmurs both systolic n
diastolic phase. Radiate to back. . I gave Dx
PDA. Ex Q: management of PDA
Got 11/20
St 3 CNS. Parkinsonism young patient. Ex Q:

investigation and management. Got 20/20
UK Experience
Exam experience on 15 March :
🔹I started with st 2
Outside 55yr old DM ,HTN has chest pain 3
weeks
I made GERD diagnosis but family history was
very strong early death due to cardiac problem
therefore plan was to rule out IHD
🔹 St 3
Cardio : Midline sternotmy scar I could not
appreciate metallic click
CABG to LIMA
Tissue valve replacement
Viva was on tissue valve
Neuro : Stroke
🔹 St 4
✔ Pt admitted with severe headache ct brain

normal now talk to Pt for LP
🔹St 5
✔ BCC 1: SVCO with lobectomy
✔ BCC 2 : Goitre
🔹 St 1
✔ Resp : Pneumonectomy
✔ Abdomen : APKD
Kuwait 27/03/2018, Al amiri hospital
Station 5
Bcc 1⃣ 40year old female sports instructor
20weeks pregnant with h/o asthma developing
nocturnal wheeze &cough since 2weeks..no
chest findings...
Bcc 2 bells palsy
Station 1
Respiratory bronchiectasis with left lateral
thoracotomy scar
Abdomen..renal mass
Station 2⃣ ...... 40 yr female with h/o IBS

presenting with tiredness n lethargy iron
deficiency anemia menorrhagia TFT normal &all
routine tests normal... since 6months.
Station 3
Cardio. MR
Neuro:spastic paraparesis lower limbs
Station 4 .... Middle aged female on business

tour developed headache neck stiffness n
vomiting...admitted to hospital..CT scan
normal...now proceeding for LP to rule out small
subarachnoid bleed.patient is angry as to y this
new procedure when scan is normal..wants
discharge against medical advice...my task to
convince her for LP.
Experience on 8.3.18
(Diet 1/2018,Yangon, MYANMAR)

BCC 1
Prompt : 30 year old lady, complaint of walking
difficulty for four weeks, history of joint pain
Vitals are normal, RBS - 180 mg/dl
Inside - Cushingoid features
History:
gradual onset proximal weakness of both UL
and LL without fatigibility
previous history of hand Joints pain been on
medicine (she didn’t mention the name),no
statin, weight gain, miscarriage two times, mood
: depressed about miscarriages, no symptoms
of hypothyroid or hypopiturisim
Examination:
gait appeared normal, striae in both thighs,
bilateral LL proximal weakness of 4/5, normal
reflexes, examiners stopped me not to do
sensory,
Face -Cushingoid faces, hirsutism, increased
intrasacpular pad of fat
Joint - no inflammatory arthritis without
deformity
No features of SLE flare
No bitemporal hemianopia : to exclude Pituitary
cause of Cushing disease
No abdominal mass : to exclude adrenal cause
Dx- drug induced Cushing syndrome with
background of SLE with secondary APLS
DDx : Cushing disease, Adrenal adenoma,
Adrenal carcinoma
Concern - she wants a baby, explain about the
risk of miscarriage need to do joint case with
rheumatologist and OG, may need lifelong
blood thinner
Investigation to comfim ur dx?
To tapered the steroid, to do the screening test
for Cushing
I said I would referr her to the MDT
(Rheumatologist, OG, endocrinologist,
haematologist, SLE specialist nurse, PT, OT)
I got 26/28
BCC 2 - 40 year man, vision problem for two

weeks, back pain for 10 years
Inside -patient is sitting, I noticed the
protuberant abdomen
History:
Explore the vision problem: gradual onset
progressive of bilateral painful red eyes with
reduced near vision without affecting color
vision without trauma without other
neurological deficit, he sometimes drives
Explore the joint symptoms: gradual onset
inflammatory low back pain with morning
stiffness affecting daily activity, been on long
term low dose steroid with NSAID on and off,
exclude the other possible seronegative
arthropathy
Examination:
Vision assessment: reduced near and far vision,
color vision : normal, no visual field defect, no
opthlamoplegia, Examiner said funds was
normal
Back pain assessment: question mark posture,
increase wall-occiput distance, reduced chest
wall movement, limitation of neck and back
movement, no sacroiliac tenderness, positive
Schober's test, no archilles tendonitis, I mention
I would proceed CVS and Respiratory
examination to exclude AR and Apical fibrosis,
examiners said no need
Concern about his vision, is it reversible, I said
he needs to be assessed by the eye specialist
and will get back to with the results, asked to
stop driving at the moment
Dx: Anterior Uveitis with background of
ankylosing spondylosis
DDx: Conjunctivits, scleritis, may be cataract
Investigation: detailed vision assessment by the
ophthalmologist, Xray (thoracic and lumber,
SIJ), HLA B 27, ESR, Creatinine
Management: MDT approach ( Ophthalmologist,
Rheumatologist, PT, OT, SpA specialist nurse)
I got 28/28
Station 1
Respiration - old man cachectic looking with
features of vitamin deficiency, clubbing,
respiratory dress, trachea shift to left side, left
upper zone: dull on percussion and BBS with
crepitation on auscultation, rhonchi on other
lung field
I gave only DDx: Collapse consolidation of left
upper zone due to
1) CA lungs
2) TB
With background of COPD
Management : the examiners mainly focus on
Nutrition Support first then usual Mx on CA
lungs
I got 19/20
Abdoman - young man with facial features of

chronic hemolytic anaemia, tanning of skin,
I gave Dx: Chronic hemolytic anemia most
probably thalassemia
DDx: causes of hepatomegaly
Investigation: Blood film features of
splenectomy
Management: Vaccination, Pen v
I got 19/20
Station 2 - 40 year man, referred by GP for

osteoporotic fractures of thoracic spine
presenting with back pain
I analyzed the nature of back pain, gradual
onset, mechanical pain with nocturnal attacks,
no previous trauma, no fall, no neurological and
autonomic problems
Red flag sign: Significant weight loss with Loss
of appetite
Associated systemic symptoms: watery
diarrhoea for18 months, no steatorrhoea, no
gluten food related
father has colon cancer, mother has breast
cancer, grand mother has osteoporosis
Frequent travel to Thailand no extramarital
affairs, no TB history no TB contact
Risk of Osteroporosis: apart from family history,
nothing detected: no alcohol, no steroid, no
symptoms suggested of thyrotoxicosis, no
dietary restriction, no hypogonadism
I gave Ddx for back pain with diarrhea
1) Ca colon with secondary metastasis to spine
in view of family Ca history
2) Osteoporotic fracture spine due to
malabsorption due to Tropical infection like TB,
HIV, tropical spure, or Coeliac
Investigation: Blood test and imaging which
cover my DDx
Management mainly focus on my first dx of Ca
Colon with secondary mets to spine
I got 18/20
Station 3
Neuro - prompts: examine the patient hands
a middle age man, when I looked at the hand, no
abnormality detected
So I started with the pronator drift, luckily I saw
right hand got tremors and I got the clue
Proceed the tone and got lead pipe rigidity on
right hand then proceed the examination for
extrapyramidal signs, exclude the cerebellum,
pyramidal signs, supra nuclear palsy,
Dx: Parkinson disease in view of the unilateral
involvement
DDx: Parkinsonisim
Investigation and Mx as usual questions
I got 20/20
CVS - patient coming with the SOB
a middle age lady with collapsing pulse with
wide pulse pressure
Displaced apex beat, heaving in nature, EDM at
the left sternal edge, ESM at the aortic area
radiate to carotids, pisto shot murmur at the
femoral
No argyrobisin pupil, no features of Marfan, no
CTD feature
Dx: AS, AR
DDx: EDM: AR, PR
ESM: AS, PS
Examiner question: how would you clinically
differentiate these DDx
Investigation and Mx as usual questions
I got 20/20
Statoin 4
Angry patient, her father had COPD, now CURB
65 score is 5, no beds at medical ward, pt
admitted to surgical ward, cannula dislodge,
miss one dose of antibiotic
The daughter’s main target was the cause of
death of her father, any relationship with the
management failure throughout the hospital
stay, any negligence.
The examiner mainly focused on how I
convinced the daughter regarding the main
cause of death of the father as he came in
initially with the very sever pneumonia
evidenced by CURB 65 score of 5. They wanted
me to deal each and every concern of the angry
daughter with the sympathy and reasonable
answer.
I got 13/16
I passed with overalls 163/172
Kuwait 28/3/2018 , Alsabah hospital
🔹station 3
✔ neuro : middle aged male on folleys cath with

flaccid paralysis of both lower libs and scar on
his back
✔ cardio : MR with sinus rhythm

🔹station 4
✔ Communication : 82 year old lady admitted

with vomiting and hematemesis endoscopy
done, mild gastritis and ospgagitis improved on
ppi after one month vomiting again, cxr, us
abdomen normal, endoscopy again showed
osphgeal narrowing biopsy taken normal CT
abdomen and chest showed cancer osphegus
with mets for palliative care, her son angry for
delayed diagnosis and why ct not done from the
start
🔹station 5
✔ BCC 1 :: 57 male with bilateral lower limb

numbness and sob his bp is uncontrolled inside
obese DM and bilateral crackles with peripheral
sensory neuropathy
✔ BCC 2 ::53 with lethargy and ankle swelling

one month back but now resolved,inside obese
with short neck, night snoring and
apnea,morning headache working as
accountant and has private car
🔹station 1
✔ abdomen kidney transplant
✔ chest bronchiectasis with obstructive air way

disease
🔹station 2
✔ Hx - 45 year old lady well controlled diabetes
and hypertension became confused while she
was at restaurant with her friends and the took
her home no palpitation no loc no sweating
during the 3 hours of confusion she was
repeating who i am where i am and she became
ok spontaneously after 3 hours
Yangon, 9.3.2018
I started with station 1 Resp
It was middle age man, left pleural effusion and
no other physical findings. Discussion as usual
investigation and causes and treatment plan.
20/20
Station1 Abd
Moderate hepatosplenomegaly in middle age
male with no anaemia and jundice.
Gave DDx. CML, thalassaemia, chronic malaria.
Discussion mainly about thalassaemia. 20/20
Station 2 history
Fatigue and weigh loss. Loose motion (*needs
detailed history of stool and diet history* that
where i lost some marks) Microcytic anaemia.
With background history of IBS.
Depression.social problem about her husband
losing job and her busy working hours.
Travelling to thai 3 months ago.
Concern ..what happen to her?
Other concern cant remember.DDx coeliac,
giadia, ...
Not happy .dont know Why. 9/20
Station 3 CVS
MR AR with ?MS pul hypertension and AF with
mitral vulvotomy scar. I sincerely said i think
there may be MS but i didnt hear MDM. Ques as
usual inv and treatment.
If pt is dyspnoeic, what are possible causes in
this pt? 17/20
Station3 CNS
Proximal myopathy with depressed jerks
What are possible cause?
I said polymyositis. Why depressed jerks?
Due to severe weakness.
20/20
Station 4
Steroid induced psychosis with femur #
Concern..
Why the doctor in rehab ward prescribed
steroids?
Headache is not due to GCA and why his father
was given steroids without telling him?
His father was still confused and he want to
know confusion will be ok?
He was angry cause he dont know his father
was transferd to main med ward this morning!
What will you do to his father for his femur
#after GCA was excluded ?
When will he transfer back to rehab ward?
13/16
Station 5
BCC1 complaint - newly diagnosed DM, taking
prednisolone for months for gout.
Drug induced cushing 28/28
BCC 2
Middle age obese lady,Knee jt pain ( OA knee)
with Hypothroid , no goiter , no other physical
signs 28/28.
Total 155/172.
Golden Jubilee (Glasgow)
🔹 Started with St 4: talk to husband.. wife had

NVD 3 days ago, found streptococcus +ve ..
given penicillin.. developed Stevens-Johnson..
deteriorating and need ITU admission..
Checked the husband understanding and what
he knows so far, explained everything about
Stevens-Johnson ( slowly and in a simple way)
.. explained that it’s very serious and made it
clear that we are not sure about out come and
she might die.. told him about ITU and
reassured him that we will do our best for his
wife and we’re always around if he needed any
help.. his concerns were, prognosis and his
baby! Gave him vague answer regarding
prognosis and regarding baby I told him baby
doctor will assess him..
✔ Qs: what difficulty did you find in this

scenario?! Didn’t know what he meant exactly..
so told him what do you mean!? He said have
you come across such a case? I told him yes
and patient passed away so it’s grave diagnosis
and I found it difficult not to give husband any
hope.. then he asked about issues!?
Beneficence vs maleficence and justice.. 16/16
🔹 BCC1: RA presented with cold hands..
on examination her hand were red with minimal
deformity.. did the usual in RA case .. hand plus
chest exam ..
Patient concern was what’s the diagnosis? Said
Raynaud .. what’s the treatment?! I said the
protective measures plus tablets she said I
don’t want tablets so encouraged her about the
protective measures again and told her we can
consider tabletsin the future..
✔ Qs:
Whats your diagnosis?! I said Raynaud due to
RA .. what Are positive signs?! I mentioned
minimal deformity so he asked me to look at the
hands again .. didn’t notice anything..
So Examiner asked about other causes?!
Mentioned secondary causes listing SS first, he
asked me what do you mean about SS I said
CREST , examiner was happy and started to ask
about SS. What treatment of Raynaud?
Thought I missed diagnosis of CREST but got
28/28
🔹 BCC 2 was challenging for me as no

complaint mentioned form out side..
Scenario was lady who had nephrectomy and
adrenalectomy due to RCC and adrenal tumor ..
just waited out side and didn’t know what was
the scenario about..
inside lady looks cushioned on prednisolone
30mg with other long list of medication..
examiner mentioned them very quickly.,
To be honest I didn’t even know how to start the
scenario so I just started by asking how she is
after operation .. on further questioning she has
wt loss, fatigue, night sweating ( patient didn’t
say until I asked about them) ..
I was thinking of cushing from her appearance
but she didn’t have myopathy and her
symptoms were against that..
her BP was 128/70 her pulse was normal, asked
for abdo exam examiner said no need
I became confused so told the patient I would
like to R/O recurrence of tumor 😥 .. the kind
patient gave me strange look and as if she’s
surprised.. then suddenly Addison came to my
mind so I told her it might be Addison.. her
concern was should I continue on
prednisolone? I said yes it’s very important and
she was already planned for a follow up scan in
a week time so also told her that it’s important
to make sure no recurrence ..
✔ examiner asked about Addison’s, how to

diagnose?! Bed side examination? Lying and
standing BP ( needed time to say it as I was still
confused and can’t gather my thoughts)
He said BP is 128/70 lying and standing is
117/60 .. told him no postural drop but still
doesn’t role out Addison’s .. I thought I will get
20 but got 28/28
🔹 Abdomen : rt sided rooftop scar..

Patient looked marfanoid but didn’t mention that
.. I only mentioned the scar and said no signs of
CLD,
✔ examiner asked whats you differential!? I said

may be liver transplant but I would expect
Mercedes Benz scar , it could be other type of
hepatobiliary surgery but didn’t specify .. then
examiner asked me about transplant.. got 11/20
I saw similar case before in Edinburgh and it
was polycystic liver ..
🔹 Resp: sterntomy scar, patient had proptosis

and looked cushioned.. dullness on percussion
lt side minimal crackles rt side .. wasn’t sure
about anything mentioned possible lung
transplant, needed some prompting to list all
the positive signs as I wasn’t really sure of
anything and I didn’t want to invent signs...
✔ Examiner asked me about transplant and

repeated the same Qs from the previous case so
it felt strange because I was repeating my self ..
Yeah and patient had Bilateral lower limb
Oedema so examiner asked me if she’s in HF? I
said no as JVP not raised and no bibasal
crackles.. he said whats the cause then I said
steroids, he said what else I kept silent but I
think I should have said amoldepine for HTN
due to tacrolimus .. got 15/20
🔹 St2 : 27 years male history of lower back

pain.. pain for 3 weeks worse in the morning
and improves toward the day.. no other joint
pain no symptoms of connective tissue disease,
no urinary symptoms, patient was adopted so
not sure if any family history of same.. the only
other positive thing was small patch of rash the
comes and goes behind his ears..
I told him about ankylosing and also psoriasis,
explained my plan in detail..
✔ examiner Qs:
What’s your D diagnosis?
gave dd of sero negative arthropathy including
reactive arthritis ( I immediately mentioned to
him that he didn’t have urinary symptoms but
given his age I should’ve asked about sexual
history) he said that’s alright
Then he asked me more DD I said disc prolapse
so he started to ask me how I will investigate it ..
I said xray he said what else I said MRI, asked
what I will see in MRI ? Can’t even remember my
answer because I was really confused and
worried that I missed the case😣😣😣
Got 19/20 😂
🔹 Cardio : ESM all over pericardium +
sterntomy scar no harvest
✔ Gave diagnosis of AS + sterntomy scar either

due to LMA bypass or tissue valve
replacement.. examiners were very nice and
kept nodding there head and that was
reassuring 😂
Asked me usual Qs of AS and IE plus
indications for prophylaxis 20/20..
🔹 Neuro: Parkinson ( straight forward case)

Patient had tremors very obvious in the right
had .. did full upper limb exam, checked for
cerebellar signs and Parkinson’s targeted exam
.. checked eyes for nystagmus and PSP ..
✔ Examiner Q:
Diagnosis? Treatment? Mentioned the list of
medications .. asked me what is the best in his
case I said selegiline .. examiner seemed very
happy and gave me big smile the bell rang .. got
20/20
I was very dizzy didn’t even realize that exam
has finished..
Queen Elizabeth hospital/ Birmingham
st 1- IPF / mAVR
st2- palpitation
st3 - kidney transplant / Hemiplegia
st4- discussions of NG feeding and PEG feeding

to the son of the patient who had got
Parkinson’s diseases and early dementia , who
is not tolerating food and pulling out the
cannula on the ward
st5- tuberous sclerosis / HHT
Golden Jubilee, Glasgow college

UK
16th March, 2018
➡ Station 2
26 year old young man with back pain and hx of
psoriasis.
➡ Station 4
SJS secondary to penicillin reaction explain the
diagnosis and management of care to the
husband. Mother had normal SVD and healthy
son, diagnosed to have Group B strept and as
part of standard treatment she was given
Penicillin and on the 3rd day the mother reacted
with rashes on the face and body and on the
5thday she was diagnosed to have SJS with
multiple organ insufficiency-Kidney, Liver and
she requires ventilator for breathing, she is
transfered to ICU for Intubation. Please explain
the diagnosis and plan for management to the
husband and answer his questions and
concerns
➡ BCC 1
65 year old with RA, Undiagnosed
hypertension169/120, complaining of painful
fingers in the cold-Reynaud’s
➡ BCC 2
68 year with radical right nephrectomy, left
partial nephrectomy and adrenectomy
complaining of nausea and tiredness
➡ Abdomen
Liver transplant, findings tremors,
hepatomegaly and tinge of jaundice
➡ Resp
Midsternotomy scar with reduced chest
expansion on the right reduced/ transmitted
breath sounds/ on the right-I said single left
lung transplant with right pneumonectomy, and
features suggestive of steroid use.
➡ Cardio : aortic valve replacement with flow

murmur.
➡ Neuro : Idiopathic Parkinson’s examine upper

limbs-(both examiners asking questions in turn)
Kilmarnock, Glasgow diet 1

🔹 BCC 1 Neurofibramtosis
🔹 BCC 2 Systemic sclerosis
🔹 St 2 : Chest pain, hypercholestremia
🔹 St 4 : COPD for palliative care
🔹 Resp : ILD
🔹 Abdomen : Kidney pancreas transplant
🔹 Cardio : Pulmonary stenosis with Noonan
🔹 Neuro : mixed cranial palsies

Barnet General Hospital: 08/03/18
🔺 Station 1:➡
✔ Respiratory
Middle age Asian lady - bilateral fine inspiratory

crackles not changing with coughing
Diagnosis Interstitial Lung Disease
Viva about investigations and management of
ILD
Scored 19/20
✔ Abdominal :
Middle aged caucasian man

Had hepatomegaly , 4-5 finger breadths below
costal margin, no signs of CLD
i also said that there is shifting dullness
Viva about causes of hepatomegaly and how
would i investigate this patient
Examiner asked me to demonstrate shifting
dullness again , he said it doesn't sound dull i
agreed with him, probably i went to lateral
initially
Scored 8/20 ( probably they marked me down on
finding shifting dullness when it wasn't there)
kilmarnock, UK
🔹 St 2 : 60 year old with 3 month hx of wt loss

cough n fever, t2dm, recent visit to kenya , 40
YR smoking hx TB/lung ca/malignancy
🔹 BCC 1 : palpitations n diarrhea- inside was

thyroid
🔹BCC 2 : young male episodic haematuria-

PNH/GN
🔹 St4 : 85 yr old dialysis pt , decision to stop

dialysis , talk to daughter- palliative dscussion,
hospice, symtom control etc
🔹 CVS : MR/AS Middle aged man
🔹 Cns : cerebellar syndrome L sided
🔹 Resp : lobectomy bronchiectasis
🔹 Abdomen : renal transplant

Kilmarnock UK
✔ Station 2 : Knee Pain ; DDX - Gout,

Pseudogout, Septic Arthritis
✔ Station 4 : Mother fit and well after falls due to

postural drop. Assessed by physiotherapist.
Medically fit for discharge
Discuss with her daughter
✔ BCC 1 :: Headache +Abdominal pain looked

like Neurofibromas
✔ BCC 2:: LEG ulcer + Chronic bloody diarrhoea
✔ Resp : COPD/ Bronchiectasis
✔ Abdomen : Hepatic Transplant

✔ Neuro : Parkinson’s
✔ Cardio : MVR
Kilmarnock, UK
🔹Hx: Wt. Loss+Cough for 3 months
🔹Comm Skills+Ethics:
Speak to daughter of a lady on Hemodialysis for
ESRD. Discuss stopping dialysis because there
is no improvement with Dialysis.
🔹BCC1: Proptosis+Diarrhoea
🔹BCC2: Young man with Blood in urine++++,

No proteinuria, Normal Creatinine.
🔹station 1 & 3 : Parkinson’s , CLD+Hepatic,

Transplant, IPF, AS+ Congenital problem in a
male patient with small stature and Pectus
excavatum.
Station 2⃣
History , around 50 yrs old male c/o recurrent
chest pain for few months
He said pain in middle of the chest squeezing in
nature no aggravating or reliving factor apart
from heavy and spicy meal mainly at night , no
radiation no SOB or other sign of heart failure, I
asked about alarm symptoms such as wt loss
haematmesis, black stool all were negative ,
He is Hypertensive and diabetic for many years
and both well controlled.
Strong family history of IHD his father had heart
attack in 50 and his uncle as well .
EX smoker quit smoking about 1 yrs ago used
to be heavy smoker ,
Heavy drinker mainly in weekend. He is obese
And he put on wt recently
🔹 Very concerned about heart attack .
🔹 Examiner ask me about my DD in order I said

:
✅ first is Peptic ulcer disease such as GERD ,
gastritis and Gastric ulcer.
✅ Second I need to exclude IHD because he is

diabetic and hypertensive and have strong
family history.
🔹 and he asked me about how to investigate for

IHD I said ECG cardiac enzymes, he said what if
it is negative any other test I said EST , and
echo he agreed ..
🔹 Then he asked me about mangement of his

condition I said life style modifications, reduce
wt , cut down alcohol, small frequent meal and
medication like PPI
I scored 18 in this station ✔
☑ Station 4⃣
Communication station, long senario about
elderly lady diagnose recently with oesophageal
cancer with metastasis for pallitive mangement ,
she admitted with haematmesis and she had
two OGD with biopsy since admission and both
of them were negative , consultant advise Ct
which shows oesophageal cancer (I think
periampulary or something like that i can't
remember but I understand that cancer is out
side the oesophageal lumen) .
🔹 I started as usual asking about what she
knows about her mother medical condition, she
was fully informed about every thing and she
has some questions for me I said , surely u can
ask what you want ..
🔹 She said I think there is delay in diagnosis,

and why we didn't do Ct from the start , I said
there is no delay and the best test for every
patient who vomt blood is endoscopy and
usually itis very useful test because it show us
the gullet and stomach clearly , but in your
mother condition she had rare type of cancer
and un usual presentation all this make
diagnosis difficult from the start .
🔹 Then regarding why we didn't do Ct from start

, we have protocols and guidelines and we have
to follow them in your mother we should start
with OGD and then followed by Ct.
🔹2/ in think you I gnore my mam because she is

elderly
I reassured her we are not descrimniate
between our patient and we treat them equally
regardless there age , and your mom received
the best mangement and every patient with
same presentation will investigate him in the
same way.
🔹 3/ what is the plan any cure ?

I am afraid no cure her cancer is so advanced
and spreading to other organ so our aim is to
make her comfortable free of pain . And pallitive
team will look after ..
🔹 4/ tell me about pallitive team ?

A group of expert , specialists and nurses will
look after your mother very closely and support
her psychologically , there main role is making
sure she is not feeling any pain or distress .
Are you familiar with macmillan nurse ? She
said yes
🔹5/ what about feeding any tube ?

I said we tried twice and wasn't successful
(written in scenario NG tube failed twice)so we
will not try again will ask SALT to give her small
amount of soft food , (comfort feeding).
🔹 6/ am not convinced can I see your

consultant?
Of course you can I will arrange meeting to see
him as soon as possible.
Summary.
🔹Examiner keep repeating surrogate questions

and I reply the same
I scored 16/16 ✔
UK Experience
8/2/2018
Harrogate hospital
Neuro : hypotonia,hyporeflexia cerebellar signs
+ve, up going planter - MS , discussion about
MS & FA
Cardi : MVR , discussion why he had sob
Communication: long scenario
Wife of man has GBS , informed earlier that he
has good prognosis, now deteriorated, needed
NG tube & tracheostomy, neurologist opinion is
sever axonal type with very bad prognosis
She became very furious after BBN
Main concern : why they told her he has good
prognosis
Is he getting better
I want to take him home
But I don’t know how to take care of him there (
so talkative lady )
Station 5
BCC1 : 45 male with h/o DM & angina has
syncope , mostly cardiac ( no symptoms of
Addison, autonomic neuropathy, renal failure ) .,
no change in medication
BCC2 : 73 male DM with deterioration of vision
Diabetic retinopathy with photo coagulation
Respiratory (disaster)
Obese lady with small scar over rt anterior
upper chest wall , no other findings (VAT , chest
tube �)
Abdomen: thin man with mass about 6cm over
left side of abdomen ( kidney or spleen )
Discussion about if it’s spleen
History:
40 female, DM type 1 c/o tiredness & loss of wt
Uncontrolled DM , otherwise all negative :
failure,panhypopitutarism ,thyroid, . Her mood
is low
List of available Diet 1 st 4 cases 2018
1) communication with wife of patient with

severe form of gbs, patients family was
informed that patient is going to regain full
function but now neurologist view is different
and says no function in both lower limbs. V
difficult case as surrogate angry and just kept
talking and talking and screaming, I couldn’t
speak to her Nd she kept talking throughout
2)Task was to talk to the daughter . Her father

had died after 2 days of admission to hospital
,he was a case of COPD admitted with CURB
3)*Talk to wife of the patient admitted with major

cerebral bleed with poor prognosis.
*was 65 yr old male presented with ischemic

stroke TPA was given now pt got intracerebral
bleed gcs7 poor prognosis..DNAR already
signed..talk to Angy wife
4)*Pckd. Want to get pregnant

*APCKD , new diagnosis , normal kidney
and 20 years ..
*ADPKD in father now on dialysis..explain

disease to son. And address his concerns.
*explain APKD to a daughter for a known Us

showed few
*Patient know case of ADPKD for 2 years.

Diagnosed recently with ESRD and on renal
consultant plan for haemodialysis. A-V vistula
inserted and first cycle started after patient
consent.
Patient request to see you because she think
she doesn't want dialysis
5)40 y old man with probable liver metastasis

and lymp metastasis
uncertain need more investigation as per
senario
concern : am i going to die
examiner asking could it be any thing beside
cancer give me diffrential very difficult
discussion is he going to die
6) Benzyl Penicillin Steven johnson syndrome

Marks 16/16Instruction: speak to husband about
wife condition, recent delivered vaginal, 1st
baby, next day infection below given penicillin
developed Steven Johnson now deteriorated
has multiple organ failure, I think confused,
transferred to ICU today & expected to need
ventilator.I showed empathy, checked how
much he know, BBN in usual way, explained
current condition, poor prognosis, we will do
our best.Surrogate had many Q:Why u give this
bad medication?, Was there anyway to predict
this reaction?, Could u hav given better drug?
What if she had allergy & u don’t know?. What
ttt will u give her now?, how will she be well if u
dont give medicines now? Asked repeatedly will
she be OK?I explained its not bad it was
suitable drug for her at that time, all medicines
have good & bad effects & it was given in her
best interest. Said I wasn’t there at time if
admission but she didn’t have allergy before
bec if she did it would be clearly instructed in
her file not to receive this antibiotic. I told him
hospital protocol that when any pt admitted
standard forms r filled by doctors & nurses &
one of the important question a pt is asked is
allergy to drugs especially antibiotics so she
was probably asked & if given by mistake this is
taken very seriously by hospital & wouldnt hide
it we would be very honest about it & he would
be informed, but this isnt the case here.I
explained no specific ttt to reverse condition,
best is support that we r doing now but there a
number of options not proven very useful & it
will be decided further by icu team how she will
be managed, I assured him we will keep up to
date & can arrange meeting to speak to icu
specialist.After he calmed down I asked how is
baby? Where is baby? Anyone to take care of
him? He said no, I offered to arrange help.
Examiner Q: ethical issues, other issues, he
said any issue of confidentiality, didnt know at
first but he explained u speak to husband why, I
told him mentioned in scenario that I can, he
said yes it was given. Many Qs about steven
Johnson & management options, why
pt has poor prognosis?, Many Qs about how

husband felt with each piece of news & how he
took it all.
7) Meningeococcal sepsis explain to patient wife

and u have to tell he its notifiable, also she has
kids prophylaxis... contact tracing etc
8)90 female present to ed with sob. Hb 6 . Was
transfused. But denied any further work Up for
Ida. Had capacity at that time. Now 3 days later
present with and wall mi. Decided for ward level
Bbn Explain further palliative approach.
9)Communication skills : was about an 80 year

old lady brought to hospital with syncope and
reason was diuretic drug which we stopped she
was fit to discharge but daughter don't want to
take her home and we had to counsel her.
10)long senario
78 yrs lady with CKD hypertensive on ramipril
admited 5 dayes coz of uroseipses start on
amoxicclin &gentamycin first her kidney
function normal
Then they shift her other word they miss follow
up and found gentamycin level high and
develop AKI she is confused (the medication
stoped )
Nephrologest assess her descide no need for
renal replacment therpy and started on IV fluids
Task speak to her son explain to him her
condition (the son was angery and had alot of
concern (why you give her toxic drug
Why she is confused ?
How responsiple about what happen ?
Do you well addmit her to ICU ?
When she well recover
Does she well retuern bach to her base activity
😩😩
Examner quz :whey the son is angery how did
you respond to his anger
What is the issue in this senario
What is the errorr is it wrong priscription or
missed follow up
How you well help the son regarding the
complain ?what is the PALS well respond to son
😐
How you well prevent something like this not to
happen again
11)50 years male known case of end stage heart

failure.. had abdominal mass suspicious to be
left kidney cancer and Mets in lungs and
vertebrae and lymph nodes... biopsy confirmed
lymph Mets due to kidney cancer.. for palliative..
Direct case of BBN plus palliative..
Main concern how to tell his wife and he loves
travelling all over the world.
12)50 yrs old female diagnosed as case of

melanoma plan for wide surgical excision
Your task explain the diagnosis plan of
managment
Concern
Does it leave scar ?
Can it come again ?
What is prognosis?
Some one told me surgical intervention can
increased spread of cancer is it right.?
13) it is an old scenario.

An old lady had fracture hip on rehabilitation
programme fall down. Few days later she had
severe headache seen in the A/E and physician
start for her steroid because he was concerned
about GCA. Patient got psychosis as a side
effect. Later the diagnosis of GCA has been role
out. Talk with son
14) very long scenario for angry relative her
mother admitted with heamatemesis and getting
worse
oes around carina
tube
They did dilalation
Relative concern
Why late diagnosis
catch diagnosis


and spleen
presentation
even snip negative

manangment

diagnosis
that stage
Only palliative


Examiner questions

Who are team member

mangment
15)talk to son about mother who had delirium

following uti and developed black ulcers on foot
( never heard in India about such term)
presumed it to be pressure ulcer and explained
..task explain and clear
16) 45m 10 days after extensive intracranial
bleed, in ICU speaking to wife. Brain death. He
had an organ donor card so tissue harvest and I
said autopsy.
Alhamdulilah I have passed PACES; got 159/172

my exam experience Glasgow Feb 2017..
I started by st 3
Cardio
Pt e SOB; O/E; mid sternotomy scar, metallic
click , no murmur , my D; MVR, viva inv &
manag + valve types!!, why no saphenous
scar?! got 20/20
Neuro; pt with falls; examine his neurological
system; I started as regular greeted the pt and
asked to walk; Parkinsonian gait, I examined
tone then tried Parkinson approach as Ealing
vedio but no tremor evident, then I was stuck
and don’t know what to do more, I tried power,
reflexes and bulbar ex and time out, viva about
Parkinson, I thought I performed bad, 20/20
st 4
syncope due to OHG overdose in depressed
nurse, who denies the act but confirmed inv and
previously told about insulinoma, task to
communicate D and manage concerns;
concern: confidentiality, financial troubles &
support, I missed in scenario from where she
got the OHG, thought she was D then corrected
myself (looked not good)
viva; what ethics here, from where she got the
OHG and if from hospital any implications, what
kind of support! And how about psychiatry
assessment
I got 11/16
BBC1
Systemic sclerosis with swallowing problems,
straight forward, concern; is it curable?! I don’t
know what I missed, 26/28
BBC2
young man with Visible Haematuria with normal
Ex and history, concern is it cancer, I missed a
good DD and plan of management , EX were
upset , got 22/28
st 1
Abdomen
Scar of liver transplant + drum stick clubbing,
viva abt possible D and Inv , transplant
medications and SEs, got 20/20
chest
COPD with bronchiectasis, viva causes and inv
and management, got 20/20
st 2
Dizzy spells , postural hypotention and tachy, in
AF + DM+IDH+HTN+DVT, gave DD uncontrolled
AF / Drug / Autonomic neuropathy, viva inv and
management, got 20/20
I hope this helps

Paces is a very tough but amusing experience, I
passed from 3rd trial all in UK, done courses in
Ealing, Hammersmith in London and paces 4 u
in Manch, got 110 in 1st trial and 117 in 2nd ,
now 159 praise and favour to Allah
Try to study hard 50% and try to practice in your
real life 150% and in shaa Allah you will Pass
Hope the best for you all, much thanks to this
group and all colleagues, your experiences were
so helpful
Have a nice day…
History and Comm collection Made by PEC team
2018/1 DIET HISTORY
1.47 yr old came with history of dry cough and

sob for 6 months . He had no other history later
I explored that he had got a pigeon for her
daughter as birthday gift. It was extrinsic
allergic alveolitis. (UK)(Egypt)
2. Syncope for DDx

collapse likely seizure or cardiovascular (UK)
65 yrs lady had a blackout, concerned about

driving and traveling to USA (UK)
hx of 65 yrs lady had a blackout while cleaning
the leaves
She had extensive cardiac Concerned about
driving and traveling to USA
blackout 45 year old with background HTN and

CABG 8 years back (UK)
on ramipril furosemide bisoprolol and aspirin
,amlodipine stopped 2 years back cz of low BP
No recent change in meds
No dizziness on standing up from sitting
Blackout without warning while cleaning leaves
in backward (doing this for last 15-20 min)lasted
for 30 second wife noticed some jerking
,regained consciousness spontaneously
Injured elbow
No wetting tongue biting or postictal confusion
Father died at 50 with some heart disease
Hx of racing of heart 2 months back
Underlying SOB with good exercise tolerance
Smoker
Vitals given pulse 50
BP 110:60
I put cardiac syncope arrhythmia as first dx
Contributing factor low BP
3. young man with diarrhea and abdominal pain

diagnosis was irritable bowel syndrome . (UK)
IBS with family history of cancer (EGYPT)
History of abdominal pain associated with

erratic bowel habits in a 32 years gentleman,
(Dubai)
aggravated by stress. Father has cancer and his
concern was does he has cancer

cancer colon(Dubai)
4. young lady had left sided weakness (Egypt)

when she was on hair dresser lasted for one
hour only.. she had severe headache till now
associated with visual aura.. the headache was
for long times not diagnosed and it was not
severe like this.. she is known case of mild
asthma not on treatment she take oral
contraceptive pills
DD
Hemiplegic migraine
TIA
5. 45 lady with history of DM type 2 on oral

hypoglycemic medication /and HTN
While she was in restaurant with her friends she
suddenly become confused for 2 to 3 hrs then
she become ok ( EGYPT)
Hypoglycemia symptoms negative
no sweating or hunger but she did not check
her blood sugar
When ask the pt what happen and what they tell
you she said suddenly i'm looking in restaurant
Menu i become confused and not aware about
the surrounding and become agitated, No LOC
No weakness or numbness, No jerky movement,
concern of the pt is it stroke ?
6.collapse in diabetic pts with history of AF
(EGYPT)
40 year old male with collapse..was known DM

with all pathies/htn/af/ihd ( Delhi)
7. nausea and vomiting in , patient diagnosed

case of stomach , cancer took chemotherapy
and radiotherapy for pain and on morphine
tablets with no any alarm signs of anything.
(UK)
Dx: Hypercalcemia
Immunosuppression caused by chemo leading
to secondary infection, gastric ca obstructing
the outlet
8. Lips swelling from 3 months

(UK) 3 months history of intermittent lip
swelling
It was drug induced due to Ramipril
Facial swelling:
exact description:
🔹how does it started,
🔹over how long
🔹involvement of eyes, lips, tongue ( swelling

around the eyes? Lips? tongue? Or if the
tongue was numb and heavy?
🔹duration; how long did it last?
🔹any pain?
🔹Is there any swelling elsewhere in the body?

Like ankle swelling?( to see if it is part of
generalized oedema )
🔷Urticarial rash(weals)
so ask about skin rash, distribution, colour,
shape, itchy?! over how long does it resolved?
does it leave any scars?! (urticarial rash is itchy,
erythematous, discrete rash, when recover
leave no any skin abnormality or scars
🔷Any systemic symptoms: fever, flushing,

arthralgia? fatigue?
🔷Symptoms suggestive of systemic

involvement
🔹stridor(laryngeal oedema)- dyspnoea
🔹wheeze(bronchoconstriction)
🔹diarrhoea- abdominal pain(gastrointestinal

mucosal oedema)
🔷any previous similar attacks? Compare

between the attacks are th
ey similar? Did he need hospital admission for

any of the attacks? Or ICU admission ?
🔷what ttt was she given? response of the

symptoms to antihistamine and steroids if given
with any of the attacks, over how long the
symptoms recovered after ttt?
🔷Any trigger /precipitant: have you any idea

about what could be the cause or the triggers?
Give examples; food, perfume, jewellery,
.............................
trauma??
emotional stress
cold/ heat??
Was there any common or shared trigger
between the attacks if more than one attack?
🔷Medication: ACEi, NSAID, aspirin, penicillins,

if any, ask when was started? Before or after the
attacks?
🔷Known history of allergy: eczema, atopy,

asthma........
🔷Family history of angioedema ( similar attacks

)
🔷Any known medical condition : (Angioedema

can present with lymphoma , SLE ,
🔷 screen other systems
🔷 deal with any concern does the pt

have.
🔷 Closure;
🔹🔹explain the likely cause Mention first the
likely cause and the DDs according to the data
obtained from discussion with the pt explain
what is with/ against ;
🔹Urticaria
🔹Angioedema; could be hereditary

Angioedema, secondary to drug, or secondary
to systemic disease
🔹Systemic mastocytosis
🔹any others?? Urticaria pigmentosa ..........
🔹🔹Answer his concerns
🔹🔹The plan: including investigations going to

be carried out..
🔹🔹Explain to the patient the importance of

avoiding the trigger if it is known and that he
needs to notice if he developed any other attack
what triggered them
🔹🔹Tell him if he felt breathless if he developed

an attack , to go immediately to the nearest
hospital as it may be life - threatening (with
empathy )..
🔹🔹tell him about adrenaline auto injector for

self injection at home if he developed life
threatening attack in cases of anaphylaxis. .
***************************
🔷The examiner may ask you; is it Urticaria or

hereditary Angioedema??
🔹Urticaria:
🔸presence of weals always suggest urticaria

more than hereditary angioedema
🔸facial, lip & tongue swelling can occur with

Urticaria , and can occasionally cause
respiratory, GI symptoms, but generally visceral
oedema ( respiratory and GI symptoms ) is more
common in hereditary Angioedema but can still
occur in Urticaria
🔸there may be a clear allergen/ trigger from the

history in Urticaria.. hereditary Angioedema
might be triggered by emotional stress , trauma,
extreme cold and heat. .
🔸early response to steroids and antihistamine

goes more with anaphylaxis.. the response is
late in angioedema.
🔸positive family history suggest Hereditary
Angioedema but still negative family history
doesn't it .. some cases are sporadic. .
in the scenarios came before , when you ask
about F.H the surrogate usually tells you that he
is adopted..
9.
Fever, night sweats and lymphadenopathy.
(UK)
Q: fatigue, fever, cough since 3 weeks in 50 year

old male. (Delhi)
Q: A 50yrs old man H/o Evening rise of

fever,Cough,SoB for last 2 weeks. Haemoptysis
for 7 days,Lethargy weight loss for 3 months.
TB,Ca lung,Lymphoma,HIV (Delhi)
10. malabsorption due to celiac vs Giardiasis

(Egypt)
Q:
iron def anaemia with Ibs diarrhea changed
recently travel to Caribbean diagnosis celiac vs
traveller diarrhea(Egypt)
11. History for 35 years old man complaining of

(Egypt)

migraine
DDx, why not cluster why not SAH
month
worse
Mainly on right side throbbing pain and with
photosensitivity
Taking many offs and has fear to lose job

hemiplegic migraine
Q: straight forward migraine patient(UK)

concerned if it is tumor bcz its increasing in
severity and frequency.
12. 30 Male h/o unilateral headache for 1 yr

which has increased in last 2 months. (Delhi)
During last 2 month he is having co codamol
qds. Concern- what is the cause. Can it be
tumour.
13. Inflammatory back pain

( Egypt)
negative ..
Q: back pain psoriasis verse ankylosing

spondy. In 22 year. Cleaner. Issue social.(Egypt)
Q: 37 male with back pain (Egypt)

pain.
my DD:
Ankylosing S
Psoriatic arthritis
Discussion :
what your DD?
investigations ?
Treatment?
complications?
is it inherited ?
14. 55 year old male with chest pain.(UK)
.DM htn..heavy smoker drinker..it wzGORD..with

knee pain taking paracetamol and aspirin..
15. Young Man with recurrent chest pains more

on moving the boxes during his warehouse job.
(UK)
Family history of father and grandfather's death

with MI. On his story: Smoker, cocaine, high
cholesterol. Concern about IHD.
16. 49 male with chest pain when lifting but

strong CVD risk factors with recent negative
ETT. (UK)
I said CTCA +OGD +manage risk factors, with

probable MSK pain in small print. Probs wrong
way round.
17. 45 y old lady with fatigue, loss of weight and
depression..many family problems.... (UK)
could be cancer, chronic fatigue or depression
Q:58 year lady, Mrs Watson, retired

Complains of generalized pains and tiredness
for 6 months.
Your task is to take a relevant history and
assess pt concerns
In above scenario Hb was 9 g/dl and CRP 20
(normal was given
< 10)
18. 40 female, DM type 1 c/o tiredness & loss of

wt
Uncontrolled DM , otherwise all negative : (UK)

failure,panhypopituitarism ,thyroid, . Her mood
is low
Q: diabetic with weight loss and tiredness (UK)

Q: Diabetic man recurrent collapse several
times during last 3 months found collapse this
nephropathy neuropathy (UK)
19. Lady with breast cancer progressing on

multiple lines now wants to be admitted
because family can’t take care of her...
(Delhi)

...

why having pain...

Screwed up this one
20. Female fatigue depression low NA levels

Complaint of weight loss and fatigue (Dubai)
21. A young lady with history of transient loss of

consciousness. Brother has history of epilepsy .
(Dubai)
It was Vasovagal syncope . Concern was
epilepsy and driving.
New Delhi =10/2/2018
#st 2.
A 50yrs old man H/o Evening rise of
#St3-DVR+IC drain in right side.sick

patients.
#Neuro -Upper limb-CVA. on inspection UMN

facial palsy.
#St 4 long scenario.53 years old patient Asthma

Bisoprolol 5, Pharmacists warned nurse.that it
is contradicted in Asthma.But patient heard
it.Talk to patient

PALS.
#BCC1-Elderly man c/o Confusion &fall for
.Hyponatremia
#BCC2- Middle aged man having fever

,headache ,vomiting for last 5 days.Inside
different story.Known epilepsy taking
Levetiracetm, Alcoholic. Treated as a case of
viral menigitis.Discharged &again same c/o
thrombosis
#St1
#CKD with AV fistula in left hand with Right
sided pleural effusion.
#CLD ascites with Midline sternotomy scar plus
?Portacaval shunt
New Delhi Experience=FEBRUARY2018

#station1
#Resp: pleural effusion unilateral with av fistula
#Abdomen: gross ascites but no other signs of

missed something
#Station 2

...
why having pain...

Screwed up this one
#Cvs: young lady with bivalvular replacement

#Neuro: guy with muscle wasting , high arched

it as differential
maybe it was polio
#St 4

on time etc

issue
ethical issue)

#Bcc 1

#Bcc2 young man cane with blood in stool... on



ready for surprises ...
wish me luck and wish you all luck also
Egypt - Maadi
08/02/2018
Cycle 2
started from station 2

History taking :

negative ..
Station 3 :
Neurology :
very confusing ,
Cardiovascular :
young male with clubbing , cyanosis , large
volume pulse , hyperdynamic apex , I couldn't
appreciate any murmur .. I put DD of congenital
Heart Disease ( VSD with eisenmilenger ) , also I
mentioned AR ..
Station 4
APCKD , new diagnosis , normal kidney
and 20 years ..
Station 5 :
A-
Known case of Rh.A came with SOB
B - Young male with history of dark urine ,

of previous clots , FH of stroke .. diagnosis PNH
Station 1 :
Respiratory :
clubbing of finger
Abdomen :
lymph nodes
I think it was good exam but can't have any

expectations ☹
Don't forget to pray for me ..

Need your Duaa please ..
good luck for all colleagues and many thanks

for the great and continues efforts ..
Brunei 5 Dec 2017
Station 1: pulmonary fibrosis

Thalassemia
Station2: Wegner's granulomatosis
Station3:
Charcot Marie Tooth
Double valve replacement+Afib
Station4:
Relative of Cl.difficile pt want to complain
against doctor who didn't wash his hands
Station5:
A. 65 yrs male e tiredness+ blurring of vision
O/e papilledema in one eye
Optic atrophy on t other one
Dx Foster Kennidy syndrome with
panhypopituitarism
B. 60 yrs male with microscopic hematuria.

O/e Gouty tophi
Dx interstitial nephritis vs asymptomatic kidney
stone
Regarding station 5 B:
After introduction I asked if he can tell more.. he
mentioned he went to t well man clinic for
annual review , did urine analysis and found out
to have blood in urine, repeated with t same
result, so he was referred , but he has no
symptoms no change in urine colour nor pain
and amount is normal. I asked of any medical
condition I should be aware of.. he said NO.. I
asked about Joint pain he said yes for t last 10
yrs in ankle and hand and there is swelling. He
denied any morning stiffness. No skin rash. No
weight changes. I asked about mefications , he
replied yes he is taking NSAIDs for a long time. I
started examining t hand : gouty tophi in t
proimal IP joints of right hand and left index
trigger finger. Assessed t function and found a
scar in wrist He mentioned it was due to
removal of lumps . I asked menwhile about
intake of meats, he mentioned no. Also asked
about smoking, alcohol and family history
which were all negative. T pt had also tophi at
ear pinna. He had two concerns: wht is cause of
blood in my urine? Interstitial nephritis due to
NSAIDs Vs asymptomatic kidney stones due to
gout. T other concern: is my joint deformity
reversible?!! Examiners asked about Diffrential
diagnoses and investigations and management
plan
I just want to share my experiences
8.11.2017 second round Yangon
I started with BCC
5.1. Young lady with c/o weight gain & fatigue
Inside H/o - Grave ds on ATD
no regular F/U
O/E ophthalamopathy with delay relaxation of
ankle jerk
Dx drug induced Hypothyroid
Q- dx Mx plan
I got 27/28
5.2 Middle age man h/o gout now c/ o weight

gain & fatigue
O/ E cushingnoid Feature with purple striae &
Hypertension
Dx drug induced Cushing $
Q- Inx Mx plan
I got 27/28
St 1-
Resp- Lf pleural effusion
Q/ dx ddx Inx Mx
I thought i was not ok with examiner
But I got 19/20
Abdo - Simple case Thalassemia with
splenectomy scar but i described Spleen cos I
thought I felt it
So I got 9/20
St 2
T1DM with wt loss & poor DM control
Dx APS
Q- Ddx , test for Autonomic Function
20/20
St 3
CVS AR with peripheral Sign
Q- how about mitral valve? ddx Inx
I said I 'm not sure
12/20
CNS flaccid paraparesis
Q- dx ddx inx
17/20
St 4
Angry Pt ' son about his father condition for
diarrhoea after A/B for COPD
Q - how about the autonomy in this case
Actually I had conflict with local examiner !!
But got 16/16
Total 147/172
Luckily I passed
Thanks
Good Luck to u all

(I think I was lucky to start with this station as it
wasn’t so difficult case and helped me reduce
the pre exam stress)
Old age 80s lady admitted for treatment of
pneumonia, after 5 days she asked to go home
and the medical team agreed that she is doing
well. She has history of DM, HTN, and
osteoporosis.
Her daughter is angry about our decision to let
her go.
My approach:
Explained that her mom is competent and
capable of making her own decisions.
Explained the benefits of going home early and
possible complications that might happen.
Asked her if she has other reasons to let her
mom stay ... she answered yes (old lady, can’t
help herself, and daughter is busy at work) I
tried to help her with social worker.
Finished 1 minute early
Discussion about Daughter’s concerns and my
approach, final question (if this lady still has
fever would you let her go) I answered it
depends on the organism that she has and the
possible implications on the community.
Got 14/16
Station 5: (very stressful.. one small room with 2
cases)
1st case: scenario: female pt 36 ys with
Artharlgia (surrogate)
My approach:
Asked about pain, stiffness and possible
associated symptoms (she had malar flush and
mouth sores) my DD SLE, psoriatic arthropathy.
Discussion about DD, Ix and treatment options
for SLE
Got 28/28
2nd case: scenario Female pt 38 ys C/O loss of
wt, Lab high AKP (surrogate)
I needed sometime to remember the scenario,
and to construct a DD for this case.
I asked her about all Bone symptoms, jaundice,
skin lesions, hypercalcemia and almost all
general symptoms. Answer always No. then she
added I have fatigue also (I thought
“seriously!!?”)
I got mental block, I moved to examine the
Thyroid and examined the chest for Malignancy
(normal)
Concern: is it cancer? I answered: Unfortunately
this is one of the possibilities because you have
alarming symptoms suggesting this diagnosis,
however in order to prove it we have to do IX
and imaging. Examiner told me you still have 30
sec, I kept silent.
Discussion about DD (hyperthyroid, bone
malignancy, hyperparathyroidism) if this is
cancer where it would be? What else would you
like to examine?
I don’t remember my answers because I didn’t
have a solid diagnosis in mind. And I wasn’t
happy about it.
Retrograde I would have considered 1ry biliary
cirrhosis (I am not sure I asked about itching) I
surprisingly got 26/28
Station 1:
Abd Male pt C/O of abdominal pain
Exam (Av fistula.. active, obese pt, stria rubra,
proximal myopathy and thin skin) my diagnosis
:ESRD on HD through active AV fistula, this
patient has signs suggestive of steroid use
questions : any mass is there? I said no, why
this pt has ESRD? I enumerated DM, ADPKD,
HTN, drugs, she said in this patient? I said I am
not sure. Why this pt is on steroids (I am not
sure), why this pt has abd pain? Gave her some
bla blah, mentiond ADPKD as a cause of pain
(she raised one eye brow denoting she is not
happy.
Retrograde I think this pt has CT disease,
possible SLE, and abd pain due to steroid
induced gastritis. I got 12/20
Chest case:
COPD+ Bronchiectasis straight forward case
with clubbing, Dx about Ix and ttt of
bronchiectasis.
I felt back on track again.
Station 2
C/o headache
Mentioned in the scenario that she is already on
SSri and analgesics but it is not working. (I
forgot about this point by the end of the
station.)
My Dx is cluster headache.
Concern is it nasty growth? How to manage it?
1- It doesn’t seem like a nasty growth,
2- I said O2 therapy+ NSAIDs during the attack
and SSRis as a prophylaxis
Discussion: about DD, Ix (stress on need for
imaging ... I said no unless there is a warning
signs on exam) He asked what was the pt
concern. How would you manage her? I
repeated what I told the pt.
He said but she is already on these meds, what
else would you do? I said I am not sure. (RING)
with sigh of relief
got 13/20
Station 3:
Cardio
Female pt shy, couldn’t expose her chest, I
examined her as much as she allowed.
Couldn’t hear any murmur, but 1st and 2nd
heart sounds were loud plus she had a malar
flush. My Diagnosis RHD, MS, with Pulm HTN.
Got 20/20 Neuro:
Male pt kuwiti (weired thing)
Examine upper limb (wasn’t happy)
He had hypotonia and bilateral weakness with
preserved reflexes (I was confused at this point)
Sensation 1 minute left, so I went with fine
touch and vibration only. (He felt vibration less)
questions about findings and DD (cervical
myelopathy, MND) and I told her I would like to
complete my exam by inspection of the back
and complete sensory exam.
She asked what do you think is his reflexes (I
panicked, cause I felt this a trick) told her
hyporeflexia, she said are you sure, I told her no
he has preserved reflexes (I don’t even know
what that means in the case)
Then she moved to causes of cervical
myelopathy I got 19/20
Eventually I passed with score 152
if I went back I would have been more focused
and less hesitant,
Station 5 is the corner stone of this exam, if you
do it well, mostly you will do well in station 2
and 4.
My PACES experience, Queen Elizabeth

Hospital Gateshead (Newcastle), Diet 2017/03,
Date: 25/10/17
Started with station 1a, Respiratory.
Middle aged female sitting on chair looked
breathless. Asked her to lie on the bed,
examiner asked me to do so in sitting position.
Had mild expiratory wheeze with a prolonged
expiratory phase, peripheral brusing (likely due
to steroid use) and peripheral edema. Said likely
COPD exacerbation and in view of edema it
would be Cor pulmonale. (gave d/ds of asthma
and very reluctantly said bronchiectasis as
there were no crackles)
Viva was on management of COPD exacerbation
and Co rpulmonale and how to differentiate b/w
IECOPD and NIECOPD
Scored 20/20
Station 1b: Abdomen
Middle aged male with Mercedes Benz (roof top
incision scar), with a large incisional hernia at
the junction which was soft and reducible. Other
positive findings were multiple spider naevi and
thin skin due to steroid use. Also had palmar
erythema (which I didn’t mention). There were
no other positive findings (no organomegaly).
Diagnosis was Liver transplant due to CLD.
Viva was on causes of CLD and how to manage
and follow up a patient with liver transplant.
Following link maybe
helpful:https://ptpaces.wordpress.com/abdomin
al/liver-transplant/
Scored 20/20
Station 2: History Taking
Young man had 3 episodes of collapse in a year.
It was told that his ECG is normal, B.M of 4.8
and MCV was 102. Took full detailed history of
the collapse. Long story short, driving was main
part of his occupation, hence had to stop
driving. Was worried as last collapse was at the
office. Was profoundly alcoholic drinking
around 2 to 3 pints everyday (cant remember
the exact number).
Main diagnosis was hypoglycaemic episodes
due to ETOH excess. Was falsely reassured by a
normal B.M where as it would have definitely
have been low during an attack/collpase. Also
did’t mention that high MCV was due to alcohol
intake and did’t advice MUCH about alcohol
cessation. Had to explain clearly to patient that
alcohol is the main reason but you would also
do other tests such as CT head, ECHO, 24hour
ECG tape, EEG if approriate. Hence did loose
marks.
A good history taking template for Collapse can
be found here
: https://www.medicaleducationleeds.com/paces
/collapse/
Scored 13/20
Station 3a: Neuro
Male with Parkinson’s disease. Bear in mind,
there was no tremor. Stem said patient
presented with falls and reduced mobility.
Ignored everything and only did full focused PD
examination. When time was left, checked
reflexes.
My way of examining patients with PD.
Inspection
Speech
Tremor (by both distraction and also look for
reemerging tremor)
Gait (when asking them to stand up, ask
specifically for dizziness to rule out orthostatic
hypotension due to MSA)
Tone (look for both cog wheel and lead pipe
rigidity and synkinesis)
Bradykinesia (hands or feet)
Eye movements (to rule out PSP)
Cerebellar signs (to rule out MSA)
Writing
Standard viva on PD management and how to
diagnose it and when to start medication i.e we
normally delay in starting PD medications due
to on-off effect
Scored: 20/20
Station 3b: Cardio
Young male with slow AF and systolic murmur
loudest at apex radiating to axilla. Hence
diagnosis was MR. Standard viva on MR causes
and how to manage and its symptoms.
Amongst causes examiner especially wanted
MV prolapse and hypertrophic cardiomyopathy.
Scored 20/20
Station 4: Communications
Discharge planning in an elderly lady having
been treated with pneumonia for 5/7, now
discharged by OT/PT, to discuss with angry
daughter. Lost marks as didn’t mention the
risks of unnecessary prolonged stay in hospital
such as HAP, UTI and risk of falls in time.
Patient had capacity. Also you had to involve
post discharge services who ensure patient is
safe at home. Please remember whenever there
is difference of opinion between patient and
relatives such as patient wanting to go home
but son/daughter not happy, always advice to
sit together with the patient ideally in a quiet
room in the presence of son/daughter and with
a nurse/sister/OT/PT to explore further concerns
to come to a conclusion. Its actually a very
common scenario in real life.
Scored: 12/16
Station 5: BCC1
I must say both of them were tricky ones. Will
just mention the salient features. Old male with
pruritis and back pain. LFTs were deranged with
ALP higher than ALT, bili was normal. All
special tests were normal such as ANA, AMA.
Anyhow pruritis was longstanding and
mentioned himself that backpain was due to AS.
Had surgery in the past i.e colostomy (with a
stoma bag) due to colitis. Examined for CLD
quickly. Had a midline sternotomy scar also for
previous CABG due to MI.
Linked things together, pruritis + AS + UC with a
cholestatic picture, gave a unifying diagnosis of
PSC and differential of PBC. Also mentioned to
stop statins. Viva was on management of CLD.
Scored 28/28
BCC 2:
Middle aged female presented with headaches
and palpitations and had some skin lesions
excised in the past. Had some investigations
which were normal. Vitals were normal.
Took quick focused history. Mentioned mother
also had similar skin lesions. Also had
splenectomy and part of pancreas removed due
to aneurysms. Mentioned to her that likely she
has Neurofibromatosis and it was causing
pheochromocytoma (occurs in 5% of the
population with NF). Concern was if she has
aneurysm in the brain which was causing
headaches. Mentioned clearly its not my area of
expertise and will refer to neurologists for
further evaluation and that she will need a CT
head.
Examiner asked about bedside test for NF, so it
would be fundoscopy for retinal haemartomas
and a bedside test for pheochromocytoma
which would be lying/standing B.P to look for
orthostatic hypotension. Also mentioned to stop
bisoprolol which patient was on as it can cause
reflux HTN in patients with pheochromocytoma.
Lost marks as didn’t examine the back for
neurofibromas and café au lait spots.
Scored: 27/28
Alhamdolillah Passed with a score of 160/172.

In my examination stations I only mentioned the
positive findings rather than using the rote
approach given in textbooks. Say what you ‘see’
or ‘feel’, please don’t make up physical
findings.
Find a good study partner and practice with
someone who mocks at you really hard. Do
specifically practice for station 5 with proper
timing as it carries 1/3rd of the marks. You can
find numerous station 5 scenarios on this
group.
Anyone who is working abroad and planning to
give/ or preferably booked his/her PACES here
in UK, I am more than happy to give advice
depending on where your centre will be. Only
genuine candidates can email me at
fanwar360@gmail.com and I would try to help
as much as I can.
Kind regards and good luck everyone.
My experience in day 1 round 1 in Nov 2017 at

Mandalay centre
I passed with 161/172
started with station 1 Respiration
a middle aged lady, not dyspnoeic, no clubbing,
teachea shifted to left, chest expension reduced
on left, chest wall is depressed on left, dullness
in left upper zone, BBS on left upper zone,
coarse creptations in left lower zone, I didn't
have time to examine the lymph nodes. Dx ?- I
said left upper lobe collapse with lower zone
bronchiectasis. BBS may be because of shifted
trachea. Cause?- Tuberculosis, compression by
a tumour or lymph nodes. then investigation?-
CXR, sputum examination, CT, bronchoscopy if
there is a tumour, baseline blood tests. I got
18/20.
Abdomen
Middle aged man, no anaemia, no features of
chronic liver insufficiency except for mild
jaundice, no hepatomegaly, there is moderate
splenomegaly, no ascites, no edema
Dx?- moderate splenomegaly with jaundice
most likely haematological malignancy such as
CML, CLL, Myelofibrosis
D/Dx?- I said COL, the examiner didn't like it and
asked me whether the patient had features of
CLI, I said no. Then I gave haemolytic anaemia
like thalassemia, She accepted. Then,
investigation and Mx. She asked me any other
D/Dx. I answered malaria when the bell rang. I
got 19/20.
Station 2
middle aged lady came with left sided weakness
which recovered a few minutes later
When I asked. she had occipital headache
before weakness. She had similar occipital
headache with visual aura in the past ( need to
ask specifically). She was taking OC pills. No
risk factors for CVA. Dx?- Hemiplegic migraine. I
advised her to stop OC pills and consult with
OG for an alternative. concern? - Stroke? D/Dx?-
carotid artery dissection ( but I forgot to asked
about neck pain and massage) , focal epilepsy,
TIA
Investigations?- I said migraine is clinical
diagnosis. But I would like to do CT and blood
tests to exclude other sinister causes. Then Mx.
I got 20/20
Station 3
An invigilator told me to sit in front of CVS
station room and to take CVS first. When I got in
there was no examiner. The examiner came out
of CNS room and called me. I felt a little bit
panic.
CNS - patient came with vision problem. She
was sitting. There was complete ptosis with
dilated pupil in right eye. Ophthalmoplegia was
not obvious. No other signs. Dx?- Rt third nerve
palsy. Causes.?- causes of mono neuritis
multiplex like DM, vasculitis, I forgot to describe
PCA aneurysm. But I gave it when the examiner
asked me what I consider if she had headache. I
got 19/20.
CVS- obese lady, everything seemed to be
normal in inspection. There was tapping
undisplaced apex beat and MDM. Dx- mitral
stenosis with AF but no pulmonary
hypertension, no heart failure, no IE. Then
Causes, investigations, Mx. I got 20/20.
Station 4
a middle aged man presented with pleural
effusion, cytology showed malignant cells,
Unknown primary. Task is to explain Dx and
manage concern. I made a good introduction,
explored what he understand and his
expectation. At first he got denial and asked for
testing again. Concerns - how can it be possible
at such young age with no history of smoking?
curable or not? prognosis? how do he tell his
wife? who is going to take care of two young
children?
I gave him sympathy and empathy. I explained
him sometimes people get cancer without any
obvious risk factors. I told that probably the
staging of tumour was high as it had already
spread and couldn't tell exactly about prognosis
and type of treatment because of unknown
origin. I would help him to tell his wife. I gave
hope by describing the advance of treatment,
care and support groups. Then I arranged next
appointment with him and his wife. I got 16/16.
Station 5
BCC1- an elderly lady with known Parkinson
presented with abnormal movement. Parkinson
for five years, on regular levodopa for five
years, dose was increased a few weeks ago
because of worsening Parkinson's symptoms (
she won't tell if you don't ask specifically) , I
examined for gait, rigidity, bradykinesia. I also
examined for signs of chorea, but they were
absent. I explained the patient that abnormal
movement might be dyskinesia as a result of
increased dose and dose adjustment was
needed. But I was not sure about my Dx. I gave
the Dx as chorea ( with lack of confidence) when
the examiner asked. He raised his eyebrows and
asked me what I had just explained the patient.
Then I told him dyskinesia. Then he asked the
cause, management of dyskinesia in Parkinson
(Honestly, I didn't know what medication to give
for dyskinesia . So I was mute. ) Then he asked
what features of PK she had. I got 21/28.
BCC2- a middle aged lady presented with
gradual onset of blurred vision in both eyes, she
had history of similar problem a few years back
which resolved spontaneously. her medications
included anti platelet and statin. Visual acuity
was severely reduced. Other cranial nerves are
OK, bilateral OA in fundoscopic examination, no
pyramidal sign, no cerebellar sign. Dx?-
Bilateral OA due to MS. Concern? - vision will
recover or not? Stroke? Mx? I got 28/28
That's all I remember. Best of luck!
My experience..i think that will help other.i have

passed from diet 3..Kolkata centre's
Exam started with St 2:
APS 2
Most horrible part of my exam bcz I appear 1st
time with 1st station.
St3
Cvs:
MVR with AF with pAH
Examiner was very happy with my performance
he thumb up &said best of luck Dr for exam
I was inspired
20/20
CNS:
Spastic para paresis
Dx,mx.inx.rx
19/20
St 4:
Mx of angry son due penicillin allergy
12/16
St 5
Bccc1
RA with ILD
Got 28/28
Bcc 2
Gout
28/28
St 1
Abdomen
CLD with Hepatomegaly
Examiner ask lots of questions
Got 19/20
Respiratory
ILD
Inv.mx.rx.dd
16/20
Grateful to ALLAH..
I am going to write about my paces experience I

passed from 2nd trial Sharjah 2017
Paces exam is very easy to pass but easier to

fail . My advice is to keep practicing practicing
practicing
I started with st 1 - chest COPD straightforward
ex. Qu. What is yr +ve finding .?dx?
Investigation ? Management plan ?Rx of acute
exacerbation ? Complications?
Abdomen -young man , very thin hair with

alopecia
ESRD with hepatomegaly _ not pale and for me

congested so I invented polycystic kidney ex.
Qu. +ve finding _ common causes of renal
failure , rare causes , main causes in young &
mainly about APKD very long discussion I got
13
St. 2 young male in his 40s referred with

hematuria previously had episode of uti e.coli
grown ic c/s after received Rx _ microscopic
hematuria persisting BP high creatinine
elevated
Inside young 3 episodes of hematuria

throughout the urine , Painless with occusional
abdominal discomfort all other hx _ ve no other
symptoms I asked by dd not by systemic review
Fhx adopted knows his biological parents father
died at 35 cause unknown 2 younger brothers
on dialysis
Has 2 sons 9 &12 well and healthy - his concern

cause of hematuria _ I said most likely u have d
called apkd explained all symptoms
complications - other concerns will he end in
dialysis _ is it treatable and what about his kids
his job - ex. Got angry why only I gave him dx
of Pk I should mention all dd then asked about
dd & INV for hematuria & management plan and
what u will advise him
St 3
Cardio really I don't know the case but i will

post my finding
Young male very pale cushingoid face with

central line
Pulse large volume tachycardic jvp not raised

apex slightly displaced s3 audible with bilateral
crackles no lower limb edema
Ex specially asked about p. Rate volume
character ,apex & heart sounds I made dx of
HF &AR then he asked about INV & mgt I only
talked about hr failure how to investigate & how
to treat he asked me about condition can case
ESRD & AR said don't know Surprisingly I got
19
Cns periphral neuropathy usual qus.
St 4 elderly with chest infection confused

allergic to penicillin despite that given to him
developed anaphylactic shock rx initiated BP
improved but still confused talk to his daughter
her concern I informed them why given ? I kept
apologizing apologizing apologizing I said it
should not be given this is error , and we
immediately stopped the drug and rx given to
counteract allergy and good thing he is
responding and BP maintained -- then said I
already informed my consultant & risk
management team and meeting will be there to
know how and why it happened - 2nd concern
what u will give him now
I said his chest inf still not treated as this 1st

dose we need to give again abs . She said he
will develop allergy again _ I said all drugs has
bad and good effect and no grantee that the new
abc will not cause allergy but well do allergy
test and incase he developed allergy again will
treat vigorously _ then she said how you will
prevent it from happing to others
Again I repeated phrase up and said like dr Zein

incident like this with show us the weak points
in our system & allow us to study it so it can be
prevented _ I said we will but that this pt is
allergic on top of his file and hand band or
specific color to be known to the staff _ then
she raised social issues like he is living alone
No hx of confusion before
I said conf. Most likely from infec. After treating

it we will assess him again and then we will
decide whether can be discharged to home or
nursing home but it's too early to decide now
No other concerns I checked understanding and

then summarized Ex same qs me same an. He
asked about ethical issues.
St 5 from outside lady with blackout vitals

normal
Very nice surrogate she gave all hx with in 1
min. It was postural hy. She has fatigue loss of
wt tanning of the skin for few months her
mother on thyroxine and father diabetic
By hx I excluded all causes of collapse all other

autoimmune d. Concern what is the problem I
explained Addison’ disease what
Kasr Alainy, Cairo, 14/10/17
■ Station 4:
Medication error , lengthy scenario of a geriatric
diabetic pt who admitted in the hospital because
of lower respiratory tract infection , still
confused , after 2 days of admission , found by
the pharmacist that the admitting dr prescribe
Humalog 15 bid , but the pt was supposed to be
on Humalog mix 15 bid as he checked with the
family dr,, the pt suffered from 1 episode of
hypoglycemia in the hospital and managed by
sugary drink
Your task is to Talk to the daughter and explain

this error
Inside i explained the mistake and apologised ..

we are so sorry that happened to ur mom , and
mention it is under investigation with an
incidence report authority called OVR , and it is
ur right if u want to complain, she mention
something about discharge i told her it will be
discussed upon discharge the whole plan and
multidisciplinary team plah plah plah
The examiners asked what is the medication

error here?! i said she received wrong type of
insulin , he asked type or dose!? i said type he
asked r u sure?! I insist and said TYPE not
dose😑
Then he asked So explain the type of error , i
said she suppose to receive mix with
intermediate but she received only short acting
what made her hypoglycemic, he asked but after
2 days ?! Rapid insulin causing hypoglycemia
after 2days?!
Then i had a little mental block, but i said we are
managing her infection probably with iv fluid
and dextrose maybe thats why😭,, then the
discussion was all about dealing with this type
of medication ?! He literally pushed me to say
(high alert medications) finally when i said it he
was happy for a moment, then he was v tough
about the precise details �, how it suppose to
be checked (i said double check and labelled
but he was not happy) ,, what is ur role as a
doctor ?! where are u gonna complain ?! I said
the quality department ,, how urgent u r gonna
do this ?? I explained the types of OVR .
And lastly he said dr she was asking u about the
plan of discharge but u didn't address her
concern i don't know what he was referring to
exactly, other than the multidisciplinary team .
Hx was about 35 yrs old man , with Hemoptysis

cough,,General fatigue and wt loss and on/off
ear pain , Later in the systemic review he
mention dark urine looks bloody sometimes
It was wegener granulomatosis
passed PACES from Mandalay center

(22.11.2017)
CVS - MS/MR( MS dominant)
Examiner question. DDx of MS, rare causes of
MS, Mx of Acute condition
(Difficult to understand examiner’s question
️) 16/20
CNS - parapresis with pes cavus and scoliosis (
long duration)
No sensory/sphincter involvement
(Difficult case for me to give ddx) 😭12/20
Station 4
Pneumonia pt responding to treatment and
planned to be discharged.
OT & physiatrist already assessed the pt and
agree to be discharged.
Talk to pt’s attendant who worries about his
mom and angry to be discharged as he was said
that his mom need to be admitted for one week
when he arrived at the hospital.
got 16/16 😁
Station 5
BCC 1 - nightmare 😰
Difficult to walk for ?2mths
When I asked reasons, he said due to pain in
calf muscle (typical claudication pain)
No DM/HTN/IHD
Heavy smoker
Both Lower limbs are black color,cold
edematous and pulse less on rt side
reduced pulse on lt side.
I said chronic peripheral arterial disease and
need further investigation to confirm the
diagnosis & explains to attendant that it was
related to smoking and suggested to stop
smoking .
Examiner asked for cause of edema.
I don’t know but said might be also associated
with venous insufficiency and will see at color
doppler 😅
He smiled and said ok. 18/28
BCC-2
Transient loss of vision with underlying DM&
HTN
Almost all DM complications are present 😪
h/o Laser therapy to both eyes (+)
Poor drug compliance & loss follow up for
social problems!
Visual field - peripheral field constriction on
both eyes
Fundus- photo coagulation scars & pre
proliferated DR( pupils are not dilated 😰)
Dx TIA/ DR
Examiner asked manangement plan
got 28/28 😁
Station 1
Resp- Rt upper lobe collapse& consolidation
Ask about causes,ddx and manangement
got 18/20
Abdomen
Splenomegaly in pt with vitiligo
Causes, ddx and mx
Discuss about autoimmune hepatitis.
got 20/20 😁
Station 2
35 year old lady with known h/o type I DM on
insulin therapy and IDA on iron supplement with
fatigue
(Hb 11%)
I feel relief as the cause may be one of the
components of APS 1 or 2.
My ddx are .....coeliac disease/ CKD / chronic
bleeding/ nutritional problems/worms/
hypothyroidism/ pernicious anaemia/
hypogonadism/
But pt denied any symptoms of above ddx 😰
No other symptoms apart from fatigue. I also
feel fatigue ️as I got no clue
I asked if there’s any other symptoms......and
she replied “which symptoms sir?” (in very
lovely smile) 😖
She is attending regular follow up with good
compliance and no symptoms of DM
complications esp CKD.
Fortunately I asked about Mood and she
admitted about low mood, difficult to sleep
without any reason ❗️ but no early morning
waking, no social /familial problem.
Now, time’s up and she asked me what’s her
problem and I sincerely told I don’t know ️♀️
It might be due to your low mood and we need
some inv to exclude serious causes of fatigue in
your case
Examiner asked me ddx &mx
I said ddx for IDA & fatigue (as above)
He was satisfied with my answer but keep
asking if all inv are normal, what is your dx? ⁉
️ 😖 😫
Fortunately I remember chronic fatigue
syndrome ‼️
He said Yesss 😁 and continue to ask
manangement plan & prognosis of CF$
I said graded exercise, consulting with
psychiatric, clinical psychologist
And prognosis is poor as they didn’t respond to
tx and symptoms continue.
He asked how many pt have I ever seen such pt
in my life and what’s about the response. (I
think he was very interested in CF$ 😁)
I answered his question and luckily the bell
rang.
He said this is your last section and Goo Luck
😍
Got 18/20
Best of luck to all.
Very thank to this PEC group.
All the praises and thanks be to the Almighty
Allah
I passed paces in Mandalay center
Sorry for late post
Thanks PEC
Started with
BCC1 left sided hemiplegia with Left homonymous
hemianopia 28/28
BCC2 systemic sclerosis 21/28
(Couldn’t answer why patient got dyphagia, forgot to
ask about calcinosis, no time to examine lung)
Respi - broncheatasis 18/20
(Couldn’t give good differentials)
Abdomen - massive hepatosplenomegaly + anaemia
17/20
(Examiners asked Tx of Chronic malaria. I answered
“splenectomy” 🙈 🙈 🙈 🙈)
History - Worsening asthma due to beta blocker to
reduce anxiety 17/20
(Couldn’t answer how to manage anxiety)
CVS - MS 9/20
(I thought ASD 🙈 🙈 🙈)
CNS - left small muscles of hand wasting without
sensory involvement 12/20
(Allah just saved me)
Comm - son angry about doctor didn’t wash hand
and wear glove before touching his father 16/16
(I said sorry all the time. Both examiners laugh at me
during my explanation about C-deff. I don’t know
why I got full marks at this station)
Thanks Allah for passing paces in one stroke.
Today first carousel in Egypt
1) lt lobectomy for DD
Splenomegaly for DD
2)diarrhea &vomiting in DM with RRT
3) mitral valvotomy scar in patient with SOB
Rt lower limb monoparesis with intact
sensation
4) functional disorder, the surrogate denies all
stresses!! ️
5) fatigue in pallor transfusion jaundice
splenectomy
Glasgow Royal infirmary today

Station 5 bcc1 psoriatic arthropathy
Bcc2: gca/PMR
HISTORY ;iron deficiency anaemia on nsaids for
OA with weight loss
In history my differential were PUD
Gastritis
Malignancy
Examiner asked you were asking about family
anything to do with
I said HHT
he looked fine he said what else I said I will rule
out celiac
Communication : patient resuscitated with a
DNAR in place but hospital didn’t receive it. And
no discussion took place in 2 days , patient
brought with collapse b/c of prolonged qt
secondary to antidepressants > speak to his
son whose father died, DNR decided before
admission
I asked about anyone else in family he
mentioned he has a sister but he is NOK
I said I’m sorry for your loss
Then he brought up why was he resuscitated
and why GP didn’t send his details
And even if not this why discussion didn’t
happen for resuscitation as he might have told
that he doesn’t want that
I apologised and said it should have happened
and patient confirmed he was competent till
yesterday when he last saw him
Other thing why he was given antidepressant
from gp which led to prolonged qt
Patient lost his wife about 18 months ago and
was depressed
So he started to have a go at gp
I mentioned incident as well as contacting gp
after speaking to my seniors
Resp: lobectomy with nicotine stains ,
undernourished
Abdomen ; roof top scar with multiple other
scars iliostomy in situ
Cardio: AS/ Ar ? Unsure
Neuro: difficulty walking examine neurological
system ? MS As with weakness more on left
with reduced pinprick and impaired heel shin
and dysmetria on left no. Nystagmus broad
based gait
PACES experience:
25th october, Northern General Hospital,
Sheffield under College of London
Started with station 2: a 35 year old male with
recurrent syncope for 3 episodes for last 8
months with dizziness for 20 years..there was
no past history of any illness..the positive
findings were syncope improved with taking
sugar..but his RBS was normal, never checked
RBS during attack...he had mood disorders with
depressive illness in wife, stress at work he was
alcoholic and his mcv was increased..my d/d
was spontaneous hypoglycemia, paroxysmal
cardiac arrhythmia..but they kept on
questioning d/d..must have missed smthing..got
12/20
st 3. Cardio. AS with pacemaker
implantation..there was a scar in chest i had no
clue...also over both thighs and paraumbilical
region..kept on asking if AS was severe..got
10/20..
Neuro. cranial nerve exam: left sided mono
ocular blindness with right temporal field loss
with RAPD with left complete 3rd nerve palsy
with left 7 th nerve palsy...asked where is the
lesion..pathways...got 16/20
st4. 80 year women admitted with pneumonia,
improved in 5 days..now ok to b discharged,
occuptional & physiotherapy team cleared..pt
also keen to go home..but pt's daughter was
angry..task was counselling with the daughter
..got 16/16
st 5. bcc1. 40 year old lady with eye puffiness,
dx thyroid eye disease with complx
ophthalmoplegia..got 25/28
bcc2. 25 year old female with intermittent
palpitations and dizziness..dx thyrotoxicosis /
autoimmune polyendocrine syndrome..got 25/28
st 1. Abdomen : ESRD with rt sided transplanted
kidney with nephectomy on left side with AV
fistula with PD scars with cyclosporin
toxicity..got 20/20
Resp..Bilatelal basal pulmonary fibrosis with
steroid toxicity..got 20/20..total mark was
144/172.. Alhamdulillah...it was my second
attempt..did courses in Hammersmith & Ealing
which helped me a lot..I am grateful to this
group & its group members..
(I think I was lucky to start with this station as it
wasn’t so difficult case and helped me reduce
the pre exam stress)
Old age 80s lady admitted for treatment of
pneumonia, after 5 days she asked to go home
and the medical team agreed that she is doing
well. She has history of DM, HTN, and
osteoporosis.
Her daughter is angry about our decision to let
her go.
My approach:
Explained that her mom is competent and
capable of making her own decisions.
Explained the benefits of going home early and
possible complications that might happen.
Asked her if she has other reasons to let her
mom stay ... she answered yes (old lady, can’t
help herself, and daughter is busy at work) I
tried to help her with social worker.
Finished 1 minute early
Discussion about Daughter’s concerns and my
approach, final question (if this lady still has
fever would you let her go) I answered it
depends on the organism that she has and the
possible implications on the community.
Got 14/16
Station 5: (very stressful.. one small room with 2
cases)
1st case: scenario: female pt 36 ys with
Artharlgia (surrogate)
My approach:
Asked about pain, stiffness and possible
associated symptoms (she had malar flush and
mouth sores) my DD SLE, psoriatic arthropathy.
Discussion about DD, Ix and treatment options
for SLE
Got 28/28
2nd case: scenario Female pt 38 ys C/O loss of
wt, Lab high AKP (surrogate)
I needed sometime to remember the scenario,
and to construct a DD for this case.
I asked her about all Bone symptoms, jaundice,
skin lesions, hypercalcemia and almost all
general symptoms. Answer always No. then she
added I have fatigue also (I thought
“seriously!!?”)
I got mental block, I moved to examine the
Thyroid and examined the chest for Malignancy
(normal)
Concern: is it cancer? I answered: Unfortunately
this is one of the possibilities because you have
alarming symptoms suggesting this diagnosis,
however in order to prove it we have to do IX
and imaging. Examiner told me you still have 30
sec, I kept silent.
Discussion about DD (hyperthyroid, bone
malignancy, hyperparathyroidism) if this is
cancer where it would be? What else would you
like to examine?
I don’t remember my answers because I didn’t
have a solid diagnosis in mind. And I wasn’t
happy about it.
Retrograde I would have considered 1ry biliary
cirrhosis (I am not sure I asked about itching) I
surprisingly got 26/28
Station 1:
Abd Male pt C/O of abdominal pain
Exam (Av fistula.. active, obese pt, stria rubra,
proximal myopathy and thin skin) my diagnosis
:ESRD on HD through active AV fistula, this
patient has signs suggestive of steroid use
questions : any mass is there? I said no, why
this pt has ESRD? I enumerated DM, ADPKD,
HTN, drugs, she said in this patient? I said I am
not sure. Why this pt is on steroids (I am not
sure), why this pt has abd pain? Gave her some
bla blah, mentiond ADPKD as a cause of pain
(she raised one eye brow denoting she is not
happy.
Retrograde I think this pt has CT disease,
possible SLE, and abd pain due to steroid
induced gastritis. I got 12/20
Chest case:
COPD+ Bronchiectasis straight forward case
with clubbing, Dx about Ix and ttt of
bronchiectasis.
I felt back on track again.
Station 2
C/o headache
Mentioned in the scenario that she is already on
SSri and analgesics but it is not working. (I
forgot about this point by the end of the
station.)
My Dx is cluster headache.
Concern is it nasty growth? How to manage it?
1- It doesn’t seem like a nasty growth,
2- I said O2 therapy+ NSAIDs during the attack
and SSRis as a prophylaxis
Discussion: about DD, Ix (stress on need for
imaging ... I said no unless there is a warning
signs on exam) He asked what was the pt
concern. How would you manage her? I
repeated what I told the pt.
He said but she is already on these meds, what
else would you do? I said I am not sure. (RING)
with sigh of relief
got 13/20
Station 3:
Cardio
Female pt shy, couldn’t expose her chest, I
examined her as much as she allowed.
Couldn’t hear any murmur, but 1st and 2nd
heart sounds were loud plus she had a malar
flush. My Diagnosis RHD, MS, with Pulm HTN.
Got 20/20 Neuro:
Male pt kuwiti (weired thing)
Examine upper limb (wasn’t happy)
He had hypotonia and bilateral weakness with
preserved reflexes (I was confused at this point)
Sensation 1 minute left, so I went with fine
touch and vibration only. (He felt vibration less)
questions about findings and DD (cervical
myelopathy, MND) and I told her I would like to
complete my exam by inspection of the back
and complete sensory exam.
She asked what do you think is his reflexes (I
panicked, cause I felt this a trick) told her
hyporeflexia, she said are you sure, I told her no
he has preserved reflexes (I don’t even know
what that means in the case)
Then she moved to causes of cervical
myelopathy I got 19/20
Eventually I passed with score 152
if I went back I would have been more focused
and less hesitant,
Station 5 is the corner stone of this exam, if you
do it well, mostly you will do well in station 2
and 4.
Walsall Manor Hospital 07/10/2017

CVS: AVR withb CABG
CNS: examine LL, Rt sided spastic weakness
with loss of sensation to all modalities.
Examiner Q DD, I mentioned MS, stroke, cord
compression.. Qs about MS
Communication: 18 years male coming with
recurrent collapse. Seen by cardiologist and
said only vasovagal, talk to father and answer
his concerns
BCC1: Neurofibromatosis with SOB
BCC2: sever headache .. DD Subarachnoid or
Migraine.. absolutely missed this one up..
Respiratory: Lobectomy
Abdomen: kidney transplant
History: 55 years old lady with lower back pain. on
history has background of coeliac.. examiner Qs
Whats your diagnosis I answered osteoporosis asked
me to justify, work up and plan
My exam experience at the Golden Jubilee
Hospital, Glasgow on 17/11/16
Abdominal - renal transplant functioning well
with old capd scars. No fistula,no neck catheter
scars. Questions on management,
immunosuppression 20/20
Respi - right lower lobe lobectomy, as trachea
central and apex not displaced. Questions on
causes, and then went on to sx ix and mx of PE
20/20
History - stem: collapse. Patient had focal seizure
with generalization, hx of breast ca on anastrozole, no
other sx. Questions on ddx, immediate ix and mx. dx:
seizure sec possible brain mets
20/20
CVs: irregularly irregular pulse, otherwise all
normal. Mistakenly said loud S1 thinking it's MS but
examiners not happy. In the end questions all about
AF only, who needs warfarin, what new drugs for
anticoagulation, mx in emergency. 11/20
Neuro : complain of double vision, eyes all normal (no
overt ophthalmoplegia)except worsening diplopia on
sustained uPgaze and also involving UL. has midline
sternotomy scar. Dx is MG. Questions about
pathophysiology, other ddx (lems, other myopathies)
ix of choice and mx. Was also asked about congenial
MG but said I don't know. 20/20 :p
Comms: break bad news: skin mole turned out to be
stage 1 malignant melanoma. Surrogate was
concerned her fruqent tanning caused it. 15/16
Bcc1: c/o bl LL skin itchiness and rash. On
examination looks like diabetic dermopathy, ddx is
venous insufficiency. Examiners asked about dm,
ddx, mx 27/28
Bcc 2: this one weird: stem was headache and bp
140/90. On hx headache wakes him at night, morning,
had some accident. On examination of eyes no visual
field defect. Funduscope shows grade 2 htn
retinopahty, didn't see papilloedema. Presented
findings but not sure, ddx was intracranial lesion. Ix
CT scan no time to discuss other. Examiners not too
happy 16/28
Praise God is passed.
Khartoum cycle 1:
St 2 : hemiplegia in a young patient
St 4: C.difficile after ABX for chest infection.
Relative already knows everything about
c.difficile and stopped candidate from
explaining about it. The only concern he saw
one of the doctors giving medications without
wearing gloves. He wants to raise a complain..
his mother is competent
St 5: 1. retinintis pigmentosa
2. Pt found wetting his bed every morning
I just want to share my experiences
8.11.2017 second round Yangon
I started with BCC
5.1. Young lady with c/o weight gain & fatigue
Inside H/o - Grave ds on ATD
no regular F/U
O/E ophthalamopathy with delay relaxation of ankle
jerk
Dx drug induced Hypothyroid
Q- dx Mx plan
I got 27/28
5.2 Middle age man h/o gout now c/ o weight gain &
fatigue
O/ E cushingnoid Feature with purple striae &
Hypertension
Dx drug induced Cushing $
Q- Inx Mx plan
I got 27/28
St 1-
Resp- Lf pleural effusion
Q/ dx ddx Inx Mx
I thought i was not ok with examiner
But I got 19/20
Abdo - Simple case Thalassemia with splenectomy
scar but i described Spleen cos I thought I felt it
So I got 9/20
St 2
T1DM with wt loss & poor DM control
Dx APS
Q- Ddx , test for Autonomic Function
20/20
St 3
CVS AR with peripheral Sign
Q- how about mitral valve? ddx Inx
I said I 'm not sure
12/20
CNS flaccid paraparesis
Q- dx ddx inx
17/20
St 4
Angry Pt ' son about his father condition for
diarrhoea after A/B for COPD
Q - how about the autonomy in this case
Actually I had conflict with local examiner !!
But got 16/16
Total 147/172
Luckily I passed
Thanks
Good Luck to u all
My exam at madras medical mission, chennai

It's my 1st attempt, luckily i have passed paces
with total 151 marks
1st of all , starts with
Station 1 Respi - COPD with chest infection
without respi faliure and corpulmonalae
Examiner Q - dx, ddx, management
Got 20/20
Abd - massive splenomegaly with pallor
Examiner Q - Ddx, how will u investigate to get
dx
Got 18/20
Station 2 SOB, cough for few mths
Inside gave history of asthma since childhood
no excerbation history, no history of
hospitalization, ppt factors taking b blocker
from husband bcoz of anxiety, pets cats since
few mths ago, and also gave history of GORD
like heartburn, acid taste in mouth, dry cough
esp: at night
Family h/o asthma in her mother and sister,
married 2 childrens
Taking regular steriods inhalers and
bronchodilator prn
Concerns - what's wrong and how about anxiety
Examiner Q - dx, ddx, how will u do for ppt
factors, how about cats, asthma inherited or
not, how about anxeity
Got 20/20
Station 3 CVS - I didnt get Dx, only heard
systolic murmur at apex
Only gave Ddx
Got 10/20
CNS - left sided stroke
Examiner Q - dx and management
Got 13/20 I dont know what's wrong
Station 4 councelling hungtinton disease to pt's
wife
Concerns - what wrongs with my husband,
curable or not, can it occurs sudden onset,
effects my child or not, surrogate didnt ask
about genetic test
Examiners Q - ethical principle, how u solve
concerns, Mx of hungtinton
Got 14/16
Station 5 BCC1 young lady with palpitation, all
vital are stable
Inside - two episodes last 2weeks ago only lasts
few secs, not taking coffee and tea before
attack, no syms of thyroid, phaeochromo, she is
under stressful conditions, one children 1yr old,
normal mens period, no syms of anaemia
P/E all normal
Concerns - what's wrong with me
Examiner Q - Ddx - SVT, anxiety, anaemia,
investigation, Mx
Got 28/28
BCC2 - old age gentleman ClO difficulty in
vision with history of HT and DM for 13yrs BP
170/100
Inside - history of cannot read small prints last
one yr ago
Now reduced vision, forget to ask about detailed
vision history, no other Cx of DM, FBS 240 or
250, not know HbA1c, regular kideny function
check up
On fundus exam, cotton wool spots and hard
exudate
Treatment taken - glimepride, b blocker,
nefidipine
No time to ask about detailed HT history
Concerns - how about my vision, can it be blind
Examiner Q - Dx - preproliferative diabetes
retinopathy
How will u manage
How about glimepride - want to change to
metformin and others if renal functions good
after discussing with diabetic specialist
Did pt well controlled with HT - i said no , BP is
170/100 and pt has HT and DM so I want to
change to ACEI
Got 28/28
Thanks God,
6.11.17 Yangon
3rd round
St.1.Deep J with hepatosplenomegaly ascites
Q. Are you sure of splenomegaly?
Resp: rt pleural effusion
No time for lymph node
Investigations told
Pleural biopsy left
St 2: 40 yr male, hematuria 2 times within 6 month,
back pain
Adopted, found family recently
Younger brother has kidney problem and HD, father
sudden death at 35, cause unknown
Dx PCKD
Will u admit?
Any differential
St 3: CVS young male, apex displaced,sys thrill over
mitral, LSE, aortic
PSM in mitral radiate to axilla, PSM loudest in LSE
? EDM in LSE
?VSD , AR
?MR, AR
It is so odd of telling AR with normal BP and no
peripheral signs.
Please aware of not to tell uncertain signs .
It cause making up the sign. :(
CNS, young male with left hemiplegia Forget to
examine AF and heart.
St 4. Young lady, flight attendant, explain about UC,
plan to marry, afraid of job
Haven't told about her disease severity which is mild
to moderate
What other Investigation u want to do apart from
colonoscopy and biopsy
If she use OC pill , what will be the important.
How you will write about disease to job,
Will take consent from her
Will u show the letter to her
I will tell her what is involve in the letter
St5, 40 yr male vitiligo MG taking pyridostigmine,
has ophthalmoplegia
52 yr male wt gain and slowing of movement, chest
pain and hypothyroid taking thyroxine, hypertension,
hypercholestrolemia
He has xantheleama, jerks are normal
Reduce thyroxine dose
What did u see in pt face
Cannot answer
? Discoloration due to amiodarone
Cases are not difficult except CVS
But performance is not good due to exam fright.
I would like to add my pass marks.
Just to share.These are like a dream bec I didn't
expect due to poor performance.
I was extremely lucky.
Thanks to this group.PEC
Exam Experience:
UK, Royal College of Edinburgh.
University Hospital of North Tees.
Stockton.
13th October, 2017.
Station 1:
Abdomen: patient with mild hepatomegaly,
splenomegaly and positive shifting dullness on
abdominal examination. Jaundiced, with evidence of
tacrolimus use (fine tremor, skin tumour resection
over forehead and viral warts).
Most likely dx: CLD secondary to Autoimmune
hepatitis.
Score: 18/20
Respiratory: patient with COPD. Examiner asked
about d/dx so I mentioned bronchiectasis bcz patient
had inspiratory sqwaks as well as expiratory crackles.
Examiner asked,, Bronchiectasis and bilateral?? I
said usually it is unilateral but can be bilateral. Then
he asked,,,is there any clubbing? I said ‘no’. He
basically wanted to tell me that bilateral chest
findings without clubbing do not favour
bronchiectasis, (though it’s not necessary for clubbing
to be present in 100% of the cases of bronchiectasis).
Score: 9/20
Station 2: patient with hx of hemoptysis and
hematuria with vasculitis and nasal crusting. Dx:
wegener’s granulomatosis.
Score: 20/20
Station 3:
CVS: Aortic stenosis
Score: 20/20
CNS: Multiple sclerosis
Score: 20/20
Station 4:
Counsel the daughter of an old dementic nursing
home resident about her father having chest infection
and admitted to hospital for that. Secondly, he was
confused and wandering in the ward so given
lorazepam following which he went into resp arrest.
He was resuscitated and was stable afterwards but
daughter had to be counselled regarding all that had
happened.
Score: 16/16
BCC1:
diabetic patient with 3 month hx of visual
deterioration.
Patient had laser photocoagulation and mononeuritis
multiplex.
Examiner asked about examination findings and
whether he could drive or not?
Score: 23/28
BCC2:
patient with headache and visual deterioration over
few days.
Patient gave hx typical of GCA and PMR. I ruled out
SOL, migraine etc but forgot to mention trigeminal
neuralgia as d/dx. Fundoscopy was difficult here.
Both BCCs involved fundoscopy and other relevant
examination which was quite time consuming.
Score: 18/28
Alhamdolillah I have passed, securing 144 marks.
Thank you to all those who have been sharing their
experiences and guiding us all. Best of luck
everyone!! 👍
I used gautam mehta for examinations and station 5,
ryder mir for hx taking and communication skills and
pastest videos for general concept of examinations
and the actual exam. Cases for paces for final
revision.
would like to share my PACES experience in Yangon

Centre .
this group has been a great help for me ^^ thank you!
I had to start with the Station 3

CNS - the instruction notes said examine the motor
system of this patient, but the examiner told me not to
read this instruction, but instead he said the patient
has right sided weakness and to examine the cranial
nerves of this patient.
so i told the examiner i would like to ask the patient to
sit up, he said the patient couldn't sit, so i had to
examine the cranial nerves in lying positing. when i
started to examine, the patient was only able to
mumble instead of full communication.
i was so nervous and fed up...
the patient had multiple cranial nerve palsies and
right sided hemiplegia... i even made the gross
mistakes in discussion due to my nervousness...
asked abt D.Dx, management plan
it was a nightmare for me, got only ( 13/20 )
CVS - as soon as i started to examine the precordium,

i could not palpate the apex beat and it took me a
while to look for it. the patient had atrial fibrillation
and AS. i could not detect any other ( other
candidates said AS+AR / MS+AR )
discussion was on investigation, management plan,
what are the important points to look for in this
patient for the severity?
i got ( 12/20 )
Station 4 ( 16/16 )
it was couselling to the patient's son abt the palliative
treatment in an advanced interstitial lung disease
with frequent hospitalisation and poor diabetic
control due to the steroid treatment for his lung
disease. the patient had already agreed to it and the
son also agreed.
the questions were " can i bring my father back to my
house? how many days left for him? are u sure
nothing works?
during discussion, i was asked are u going to let the
patient go home?
how many days do u think left for this patient? i said
in the scenario, it was given the prognosis was bad,
but in my task, it was given to explain the longterm
mgt of the palliative care, so i told him it could be a
few days to a few weeks.
Station 5
1. RA hands with fatigue , deformity and anemia
present. on MTX for years, family history of CA
colon present
concerns - do i have cancer? is it related to my joint
problem? can i go back to work? ( 28/28 )
2. 35 yo female with off and on chest pain with PMH
of myasthenia gravis , i examined the CVS and MG
and during discussion, i was asked D.Dx, mgt and
why i was percussing over the upper sternum which i
answered thymoma could also present with chest pain
( 28/28 )
Station 1
resp - COPD with clubbing
i could not find crackles or mass features
so only gave D.Dx ( 18/20 )
abd - splenomegaly with anaemia
D.Dx and management plan
( 20/20 )
Station 2 ( 20/20 )
history of cluster headache. the surrogate didn't give
the typical features of cluster headche at first, only
gave when i asked her the exact features, taking many
drugs for the headache but not relieved.
concerns were - was it a brain tumour? can i get
pregnant?
discussion was on D.Dx, treatment, prevention.
the total score was 155/172
clearly, BCC compensates all my mistakes in station
3.
best best best of luck to all the candidates.
New yangon general hospital 3/2017.9.11.2017

second round.
I want to share my exam experience.This is my
2nd attempt. 1st attempt is 3/2016 mandalay. I
failed badly in score as well as skills. So, I
requested for PACES feedback from rcp.It took
2 months.I had known my weakness (spoke
quietly. Difficult to listen what surrogate told
even good english.cannot understand what i
told).I had known that examiners were looking
carefully every step of performance and
behaviour.It took time to correct my weakness.
My second attempt started with station 2.
Genetic counselling at Hungtington' disease
(wife) task.....talked with her husband with 3
children (eldest is 17 . I try to explain benefits
and risks of genetic testing in his children.I
forgot his wife' job.I cannot solve the
problem.Will I quit my job to care of children.I
got 7/16.
Station 5.1. 45 yrs old female with joint pain
presented with reduced urine output.I tried to
find out pre-renal, renal and post.no fluid loss.,
blood loss.She also complainted of dizzy in
toilet but no malaena. Drug taking of xicam by
herself.examination .... overweigt with
OA.exclude septic. Systolic murmur aortic
area(no radiation).Dx drug induced interstitial
nephritis with OA.need to find out aortic.I got
26/28
5.2 50 yrs old lady (DM with tingling and
numbness in lower limbs.I tried to find out
sugar control, macro and microvascular
complication.She said no.drug anti TB for 1
month.diet vegetarian.Examination absent jerk
only.I ask to do fundus .exminer said it is ok.Dx.
anti TB induced neuropathy.I got 28/28.
Station 1 left sided consolidation with
effusion.only got 9/20.? invented signs.
Abdomen.-PCkD I got 20/20.
Station2. 30 yrs old lady with painful oral
ulcer.exclude other SLE criteria.She had DVD.
exlude APLS.She said she had bloating and
indigestion.exclude coeliac.nearly time up, I told
surrogate summary .At that time, i remembered
to ask genital ulcer and conjunctivitis(i thought
it is examiner'examiners were alert to mark
score sheet.Dx Behcet' disease.I got 20/20.
Station3. YOUNG MALE Motor examination only.
left hemiparesis.I ask examiner to do cvs.he had
AF. times up.DX LEFT HEMIPARESIS underlying
cardioembolic.I got 18/20.
Cvs.apex beat displaced.RVH.JVP
raised.prominant carotid pulsation.systolic
murmur radiate to axilla. EDM left sternal edge.
Systolic murmur at pulmonary area.I told MR
,AR,AS. Examiner showed me senerio pt
dyspnoeic since young. Other candidate told me
PDA.I got only 13/20.
Finally, I PASSED with 141/172.Thanks for all
including PEC and my teachers and my friends
who supported and guided. me.
Alhamdulillah have passed MRCP PACES from

chennai india in diet 3 2017. My experience:
respiratory station 1- COPD with bibasal
inspiratory creps. I told COPD with ILD. Q was
on management inv and spirometry finding of
mixed airway disease. Got 16/20. Abdomen PKD
with fistula with hepatomegaly with anemia . I
was not sure about hepatomegaly so did not
tell. Got 14/20. Q was on causes of abdominal
discomfort here?
Would like to thank the group members for all

the sharing of experiences which were very
helpful in my paces preparation. Mine was in
Reading, UK (Royal Berkshire). 1st attempt was
in UMMC failed last year. I attended Ealing
paces.
St 1 Abdo - stem - abdo distension. 2 kidney
transplants in each iliac fossa, pd catheter and
avf with no recent puncture mark. Was too
anxious probably as it was 1st patient, slow to
digest findings and said esrf currently rrt is
transplant. Not happy, examiner asked me what
is the pd catheter doing? Then only i said oh,
maybe currently using pd cath, transplant
failure. Examiners sighed n moved on is there
ascites, i said shifting was -ve. He asked twice
but i didnt change my answer. Nt sure actually.
Other questions on ix and follow up clinic. I
thought i flunk the case completely but
surprisingly got 16.
St 1 respi. RA hands with basal crepts. Less
anxious now so able to present well. Said it was
pulm fib due to Ra or mtx. Examiner ask why
not bronchiectasis. I said crepts didnt change
with cough (actually in exam I completely loss
my hearing ability to distinguish
fine/crepts/early/late LOL). Further questions on
how to confirm by ix - hrct, lung fx and mx.
Scored 20.
St 2 history - 35 yr old, hemoptysis. Went tru hx
as usual. Systemic review - hematuria. Didnt
prepare well for this (too engrossed with short
cases n bcc) Told pt not able to link all his sx
together but need to rule out tb, ix for
autoimmune n blood disorders. Examiner grilled
on many parts of history (didnt ask hiv risk,
didnt ask previous occupation - examiner said
maybe he was asbestos seller before becoming
car salesman). Thought i would lose alot of
marks but surprising scored 20.
St 3 CVS - blind elderly man, wheelchair, midline
sterno no leg scar, tried to listen to click, all i
heard was the wall clock just next to patient!!
Auscultate - never heard such heart sound +
systolic murmur at aortic no radiation to
carotids. I think they didnt stopped me after
6mins coz presentation time was very short. I m
not sure what the pt has, mumbled hocm. Asked
me why hocm, bell went. No surprise - got 8.
St 3 Neuro - chatty man, walking stick. Rt foot
drop, weak rt dorsiflex otherwise everything
else normal. I think ankle jerk was depressed.
Not allowed to do gait. No spine scar. At the
heat of exam, i cant rmb inversion vs eversion
to differentiate L5 rad vs common peroneal so i
didnt bother to do. Went through my findings
and ddx - lower motor lesion - above. Asked
how to ix - ncs. Further mx. My think the
exchanges with examiner was ok, scored 18.
St 4 - speak to asian daughter abt father's
terminal liver ca not for further treatment in
oncologist opinion. Daughter not keen to tell
father but father seems to all as someone who
wants to know. Went well. Got 20.
St 5 bcc1 - stem headache. Went in left ptosis,
surgical 3rd nerve. Straightforward. Got 26
sob. Went in to a sclerderma pt. Too engrossed
with the scleroderma, asked all the systemic
sclerosis sx which were all present. Forgot to
explore other ddx of sob. Examine the lungs
was stopped and told normal. Didnt listen to
heart. Examiner asked to why pt having
sob...cant giv other ddx. Other candidate said
loud Esm murmur. Oh my god.. I thought heck, i
am going to do paces exam again :(
Score out 12 only.
But total up I scored less than my first attempt
but I passed, learnt that uk cases were not as
limited, chronic and standard as I expected.
Surgical 3rd nerve in an exam!!!! Examiner's
expressions were difficult to judge therefore
best ignored!!! If unfortunately failed, do not
wait too long before reattempt. I waited a year
and restarting preparation after a year is very
painful. Good luck people, it is all about luck on
that day!
Khartoum exam yesterday

2/12/2017..
St3
CVS.. mixed aortic valve dis !!
CNS,.Charcot Marie tooth
ST4.. uncertainity (X-ray 2shadows)... pt recently
diagnosed asthma ,. Past history ca breast
underwent lumpectomy . concerns.. is it
recurrence? Why not informed? My sister died
of ca breast I thought Iam cured.dud the delay
worsen my fond ?? ......I informed her Iam not
sure about the delay but Iam going to check
records and if no reason then we can make
incidence report
examiner: what factors considering the X-ray
findings. X ray for any asthma pt? (He means
that should she really been informed earlier??
).. is it real asthma? What are other
possibilities?? What further management?
St 5: 1- SOB in joint dis was on methotrexate
2- tiredness in vitiligo
St 1: PKD.... bronchiectasis
St 2: Wagner.. what are thedifferentials? How to
manage? Focused on admission
Kilmarnock UK
Station 2 : Knee Pain ; DDX - Gout, Pseudogout, Septic
Arthritis
Station 4 : Mother fit and well after falls due to

postural drop. Assessed by physiotherapist. Medically
fit for discharge
Discuss with her daughter
BCC 1Headache +Abdominal pain looked like

Neurofibromas
BCC 2 ::LEG ulcer + Chronic bloody diarrhoea
Resp : COPD/ Bronchiectasis

Abdomen : Hepatic Transplant
Neuro : Parkinson’s
Cardio : MVR
Malta experience
Station 2
hx of blackout in the garden for old man with history of

CABG
Differential diagnosis were cardiac syncope and drug
induced as he is taking ramipril and frusemide. No
symptoms of epilepsy
Station 4 about an elderly lady with multiple

comorbids , her wish for dialysis withdrawal and the
medical team have the same opinion as she is blind
previous stroke cardio and esrd
Role to talk with her son who was crying , concerned
about if she would die soon
BCC 1::headache in old gentleman plus weight loss and

appetite loss , inside complain also of thigh weakness
on early morning, dignosis would be PMR then Sol
BCC 2 : difficulty swallowing in old lady , with weight

loss
appeared in diet 1 2018 at Edinburgh western general

hospital on 27-2-2018.
Alhamdulillah passed with 142/172
Started with
station 5
BCC1 - middle aged lady with c/o black tarrey stools
and h/o malena in past. Endoscopy and colonoscopy
done before were normal and she was given oral
iron.On further enquiry she told about recurrent
epistaxis and her brother Also suffers from recurrent
epistaxis.
She was also taking OTC ibuprofen
.— HHS/ NSAIDS induced
gastropathy got 21/28
BCC2– it was a nightmare
Make Pt with c/o dyspnea , facial swelling and early
morning headache with normal urine examination. He
underwent renal transplant and examination showed
facial flushing, pupura, few bruises and visible veins
over trunk.
I was totally confused could not reach to diagnosis.......
It was SVC obstruction got 11/28
Station 1
1- kidney transplant 20/20
2- lobectomy + COPD 20/20
Station 2
55 yrs old male presented with c/0 retrosternal chest
pain since 2 weeks, mild to moderate in intensity,
aggravated with food and mostly while lying, h/o
smoking in past, DM with no evidence of TOD, h/o
premature CAtD in 1st degree relatives, mechanic my
profession.h/o taking NSAIDS OTC
DD
Ischemic chest pain
GERD/ esophagitis
Mechanical pain
History strongly suggestive of GERD/ esophagitis .
Key was to prioritize ischemic chest pain considering
risk factors and strong family history.
20/20
Station 3
1- CNS myotonic dystrophy
Female patient —-
19/20
2- CVS
CABG +- bioprosthetic valve replacement, ESM,
18/20
Station 4
Task was to speak to the daughter of elderly lady

diagnosed with metastatic carcinoma with unknown
primary and symptoms started as dysphasia ,
endoscopy done twicely came normal and CT scan
showed mass compressing esophagus and evidence of
metastasis.
Concerns
1- doctors are incompetent who could not diagnose my
mother
2- delay in diagnosis resulted in point of no cure.
3- doctors neglected my mother because of her age.
4-why CT scan not done earlier on?
5- what next? About palliative care
6- can I speak to your senior?
Examiner’s questions about
Ethical issues,
Differential diagnosis
Role of biopsy
Components of palliative care
13/16
—————————
Preparation —- cases for paces for station 5, 1,3
And Ryder for station 2, and station 4 .
Conclusion : never lose hope after 1 bad station like
what happened with me in station 5 and I started with
station 5.
Regards
Good luck for all
Malta Experience
Station 5 detailed experience of a candidate

outside : 63 male , with 6 months history of abdominal
pain after eating. Vitals Normal
Inside ;
Well trained surrogate ❗
Pain abdomen
Severe 7/10
In centre of tummy
Going to my back
Fear of pain
Not eating much now
Weight loss 5 kg
Some Nausea
No Vomiting
No mouth sores
Past :
IHD
4 stents in 2008
CABG 2010
Medication
Atorvastatin 40 HS
Clopidogrel 75 oD
Paracetamol prn
Antacid syrup
Any herbal No
Any painkillers No
Family history ;
Smoking nil
Alcohol 🍺: daily 1 bottle of whisky � on weekend more
Ur mood : good
Drugs : never
Anything else : I think it’s coz of alcohol 🍺 should I
stop 🛑 alcohol

Exam :
Mid chest Scar
Left arm scar
I asked y this scar
Abdomen; normal
Ask about Idea : again question of alcohol misuse ?
After taking to u
I think. Too much alcohol is causing inflammation in
pancreas and ur pain after meals and improved on
bending forward points towards pancreas
Another point is
They can have also narrowing of blood channel in
tummy (!do u have any pain while walking which
improve on resting ; no )
Okie
So
We will do some blood tests and scans and look at
pancreas and blood channels
We will discuss with u and explain u what to do further
Meanwhile
U stop alcohol
Is that okie
Yes
Any other questions
Any concerns
No
Thank u
Examiners ;
Findings :
Normal tummy
DD
Mesenteric ischemia
Examimer ( 🙄)
Okie
We u think mesenteric
Coz of history of IHD and risk factors cholesterol for
atherosclerosis

Help
Others
Examimer was telling investigations and CANDIADTE to
tell. What u will see
USG for gall Stones and calcification and pancreas

inflammation

collection

DM
Malabsorption
Steatorrhoea
Bell rang
station 4 experience=MALTA
80 years old Mrs Smith
Counsel son for her condition and answer his queries
Mrs Teracy has been admitted with urinary sepsis
twice in ur ward in 1 month . This time she has
impaired renal functions. Urea is 15 mmol and
creatinine is 220u mol and she is confused .
After admission she was started on iV fluids and IV
antibiotics and nursing staff has informed u that she is
improving after this . And also she is less agitated as
compared to admission. She has background history of
dementia , and consultant has diagnosed delirium this
time . During course of admission, unfortunately she
Mrs Smith was admitted 1 month back with UTI and

delirium and after recovered fully , she was discharged
home .
OCCUPATIONALHealth team and visited her home for
necessary arrangements .
Kindly see Mr. John , son of Mrs Smith to explain then

him latest condition & management .
Approach by candidate Inside ;

Greet
Check identity
NOK
Introduce
Role
Agenda
Anyone with u
Notes taking but would be listening to u attentively
&
Open Question : ICE

Idea :
I live at 1 hour drive from my mother house , and I Visit
her when ever I get a chance.
I know for last some days , she was not drinking water
💦 as much as she should & This time she has
presented with confusion and was agitated .
Thank u very much indeed for sharing this information
with us , I appreciate that.
And I am sorry that ur mother is ILL and u look really
worried for her health.
Actually she was agitated when she came in ER , we did
some tests which showed that she has infection in
water works and also her kidney are not functioning
proper. Due to this ,the waste products which are
excreted from body by kidneys have accumulated in
her body .
Also she is elderly
She has dementia
So all these things have lead to a condition which we
call as “” Delirium””
No dr ?

Her Age
Dementia
And
After admission ;
Our team , my consultant and all nursing staff taking
very good care of her .
&
She was given fluids in her blood channels and started
antibiotics and she improved and she is less agitated at
the moment .

And
And we will keep u informed about her condition.
Bring some familiar stuff from home , of her choice ,
other hobbies she has , Which will help her condition.
Thank u dr
That u explain me all details and u are taking care of
my mother
Can I bring books 📚 for her as she likes reading and
she like knitting .
Yes
Sure

This condition.
🔺 Surrogate : Dr , in corridor I met a nurse , she told

me that my mother doesn’t like hospital food
At the moment , ur mother is being given fluids and

she is confused
Once she improve more and she demands food I will
check with nurses about her choice of food & then
Thank u dr .
As
That may be the reason that she is admitted again so
early
Actually
Before discharge ur mother was seen by all teams
responsible for ur mother care
My consultant
And
All other team members gave their input in decision
and occupational health department made necessary
arrangements for her at home before she go home ,
only then she was sent home &
discharge .
So i assure u that we never discharge any patient until
And unless seen by consultant and all
manage at home .
Thank u dr .
Mr John
What’s that dr ?
Actually
And
So
Heal we will do all necessary precautions and also to
prevent it getting infected
And
If needed specialist dr in this field can also see patient .
But
I assure u we will do our best to prevent it on other
parts of body and treat this sore with best possible
care . I have personally talked to my head nurse , and
she will do all necessary things .
circumstances ?

She was doing good
But I am worried u know as she is admitted twice this
month

information
We can arrange for social services if she agrees but we
will talk to her about it once Her infection settles down
.
Thank u dr

But
Rather he started to tell everything what I told him ( I
counted it as understanding )
I thanked him
&
Any other questions
He said
No dr
But
Listen Mr John
U can google it
And
I am writing for you spellings of “” DELIRIUM “” the
condition your mother has
Or “” confusion”” u write any one ☝ in this website , u
will get all information about ur mother’s condition
What it is ?
What causes it ?
And
Another website is
Any one u can use

And
questions
Thank you dr
And
U can contact us anytime to know about ur mother or
call for any queries.
Thank u

I appreciate that
Thanks dr
Have a good day .
Summarize ur case:
1st question
What’s name of specialist nurse who takes care of heel
unlers ?
I forgot sir but i know, let me re call —he told Then (
honestly I heard 1 st time , it’s called tissue viability
nurse )
Who decide discharge consultant ?
Who will u Involve in Patient care ?
I said team of dr .
What u call it
Who are members in this team

Count 5-6 ?

He asked and explained to me some 1 word question
answers
Castle hill , UK
BCC 1 : ocular myasthenia

BCC 2 : rheumatoid arthritis
Abdomen : pckd on dialysis with active av fistula

Resp : ILD
Station 2 : postural syncope
Neurology : cpa syndrome with 5 6 7 8 cranial nerves

affected
Cardio : Mvr with AF
Station 4 : talk to the relative of end station hepatic

cell failure because of alcohol addiction. Didn't talk
about don’t cpr because it was not written in the
scenario..Examiner asked why you did not talk about
dnr
Malta Experience
History ; recurrent lip swelling in 76 years old lady in

Ramipil 4 years
Station 4 :
83 years lady
Dementia
Admitted with uti and impaired renal functions plus
delirium and black heel ulcer ( repeated case )
BCC 1
Old man with shortness of breath
In walking and going upstairs with chest pain and
tightness
HTN
Uncontrolled BP
Non smoker
No alcohol
DD
Cardiac
IHD
AR
HTN
( vs respiratory )
BCC 2
Other abdominal pain after 15-30 mins of meals heavy
alcohol use , and IGD 4 stents CABG
was
Lalcoholic pancreatitis
Mesencteric ischemia DD
Resp
Pul fibrosis with SS
Lobecomy
Abdomen
Hepatospleenomegaly
Other was
Dupytren contracture only
Cardio
MR only
Other was
CABG with MR
Neuro
Spastic hereditary paraplegia DD
Russels hall hospital
St2 : is for collapse with incontinnce

Fh of epilepsy
Concern was epilepsy ans driving
It happened while she on bank queue
St 4 : Pt with IDA transfused and refused endoscopy.

Now mi with pallitive care. For pallitive care. Daughter
concern was if she agree for endoscopy, will you give
her active Rx
BCC 1 : Vth, 7th nerve palsy ???, spinal surgery 1 years

back, LL numbness and weakness 2 wks ago
BCC2 : grave with thyroid eye disesas. Diplopia
Concern: work and Rx
Cardio : CABG WITH AVR

Neuro : friedriech ataxia ????ms
Abdomen : transplant kidney

Resp : Pulmonary fibrosis
Sandwell hospital, UK
Resp : left thoracotomy scar..dds for lobectomy

Abdomen : normal patient had only few spider
naevi...asked about causes of spider naevi and
treatment...thumbs up by examiner
Station 2
Daibetic with fatigue
Long hx..
Examiner satisfied
Cardio= Mid line sternotomy scar,mvr

Neuro= spastic paraplagia with normal
sensations,asked about ďds and Management
Station 4
90 yr old female,anemic,refused colonoscopy,now
presented with massive ant wall MI..task was to
convince her son to manage via drugs not fot PCI and
any other intervention due to poor prognosis.
BCC 1
Post graves thyroidectomy.now with weight gain and
lethargy
BCC 2
20 yr old male with ulcerative colitis presented with
chest pain....
Colombo, Sri Lanka , diet 1
Resp : probably idiopathic Pulm fibrosis with focal

consolidation and bronchiectasis
Abdomen : B/L PCKD with active fistula and RIF scar
with no underlying renal transplant probably
appendicectomy scar..no side effects of immuno supp
Neurology : Spastic paraparesis with normal sensation

Cardiology : Severe MS in sinus rhythm
Loud P2
BCC 1 : recurrent collapse Severe AS and MR
BCC 2 : Haemaetemesis with moderate splenomegally
and Hx of DVT...young lady DD Myelofibrosis with
thrombocytopenia or CML..or myelodysplasia with
PNH
St 2 : Psoriasis spondyloarthropathy or ankylosing

spodylitis
St 4 : GBS with axonal type went into resp failure

intubation and ventilated
Now weaned off with tracheostomy.
Bangalore 17 March
St2-fever with weight loss and night sweats -

tb,lymphoma
St4-pt with COPD exacerbation on non invasive
ventilation ,spo2-88,explain bad prognosis to the
attender
.st 5
BCC 1 : pt with numbness and headache -tia,SAH , q
were about SAH
BCC 2 : pt with knee joint pain and high uric acid..q
about gout
st 3
cvs-holosystolic murmur not sure about radiation
cns-rgt sided hemiplegia
St 1:
abd-cirrhosis with jaundice no ascitis
resp-bronchiectasis
Chennai, sundaram medical foundation, 16th march

2018
station 2
A 28yr male patient qith histoy of intermittent
abdominal pain and erractic bowel habits foe several
years, worsened sine 6 weks. Father recemtky
diagnosed with ca colon.
station 3 cardio...prosthetic mitral valve replacement

Neurology...parkinsons
Station 4... nightmare...familiar scenario....talk to

daughter whose father died a day before. 75yr male
patient was admitted with pneumonia, curb 65 was
less than 5, patient admitted to surgical ward. Patient
suddenly deteriorated. Staff arranging to shit to hdu
meanwhile patiend died. Also staff missed dose of
antibiotic because cannula got dislodged and they
were busy arranging to move him to HDU. The
daughter didnot allow to talk at all...didnt even allow
me to introduce myself properly and reconfirm
identity. As soon j said, i am one of the doctors
here..she atarted bombarding... my father died, why
did he die, i was told my father was fine and will
recover in 2 to 3 days then how can he die. why did u
put him in surgicL ward and not in icu. Why was the
medicines missed. Why was i not informed about his
critical consition. I met him last evening and he was
doing fine,. How can he die. U people have killed him.
She didnot allow me to give even a singke explanation.
I just kwot saying sorry n apologising, she said ur sorry
is not the answer. Ur sorry will not bring back my
father. Finally, i suggested eeting with consultant for
which she agreed and she expresses wish to complaint.
I said i will introduce her to PALS. till the end she was
not convinced. After coming out, the other candidates
also shared the same experience in this station.
Probably she was told to be that way i guess. Examiner
questions routine...what was the main issue here,
what are the medical and legal issues, is there any
difference of care in surgical ward and medical ward.
station 5 bcc 1 50yr female with difficulty in walking

and pain in knees whike walking. Has had 2 episodes of
fall over last 2 weeks bcoz of pain. DD osteoarthritis,
seronegative arthritis
Bcc 2....50yr lady with history of breathelssness on

minimal exertion and palpitations. On elicitibg history,
gives history of some cardiac surgey 10yrs previously
but doenot know the details. She ws nkt on any
medications aslo, no blood thinners nothing.
Diagnosed with hypertension 2 yrs back and
prwscrived some medicines but not taking it. Very poor
compliance. On examination, obese lady, could not get
anyy findings. I really dont know what the diagnosis is.
I gave the dd of IHD, Hypertension, Thyroid.
station 1 reapiratory...clollapse left lung

Abdomen...ascites with AV fistula in left hand. Obess
male with grossly distensdsd abdomen. I could not feel
for kidneys on ballotment...dont know if i missed
adpkd.
15 March, Sundram medical foundation, chennai
St 1: obstructive airway disease

Adpkd, another 1 renal transplant
St 2: 28 yr female dm type1 for 15 years, comes with

fatigue and wt loss
St 3: MVR
Left sided hemiparesis

St 4: decompensated alcohol liver disease patient
admitted with sbp and hepatorenal syndrome,
consultant feels not to liver transplant and renal
transplant, discuss about not to resuscitate
St 5: neck sweeling: goiter

Fever for 1 month and 2 times rti during 1 mnt, wt loss
Colombo =2018
BCC1- DROWSINESS +ACCIDENT = OSA

BCC2- headach - kidney mass = SAH + PKD
RS = patient has hemoptesis, has anemia and right

upper lobe fibrosis = TB
Abd: jaundice, i could not find other finding =

hemolytic anemia??
Neuro: left sided lower motor neron facial palsy
CV: sever Aortic stenosis
History: hyponatremia in patient with hx of HTN and

hypothyroidism = Adisson, ?paraneoplastic syndrom
Communication= inform the angry husband of patient

who got penicillin injection and then has SJS
Colombo , Sri Lanka

Station 2: A 22 year old girl has collapsed and there had
been urinary incontinence. She has a brother who was
diagnosed with epilepsy.
Although this looked like a seizure initially it was not.
She did not have aura, no jerky movements, no tongue
biting, no eye rolling up, and it lasted only for 10_15
seconds. At that time she was standing in a queue for
30mins and she has looked pale.during the episode. So
I took it as vasovagal syncope, but for DD I gave seizure
disorder, arrhythmias.
Station 3 🔹CVS: AR and AS with tachycardia and mild

ankle edema. Patient had clear collapsing pulse,
Corrigan sign.
🔹Neuro: 3rd nerve palsy with contralateral
hemiparesis
🔹 Station 4: 82 year old who was investigated for

haematemesis and vomiting, initial UGIE duodenal
ulcers, CXR, USS normal, repeat UGIE narrowing of
esophagus. CT showed disseminated malignancy.
Daughter is angry that you are late to. diagnose her
mother's condition. Now she can't eat and NG tube
passage failed. Daughter wanted to complain and to
discuss treatment options for her mother.
Station 5: 🔹 BCC 1: 55year old male with 5 day history
of cough and fever. Has had TB 4years ago.
Examination post TB bronchiectasis. Concern could this
be TB again
🔹 BCC2: 65 year old male with headache and proximal
myopathy, jaw claudication. Examination negative.
Concern ?brain tumor, will I get better
Station 1: 🔹 RS :ILD with clubbing and cushinoid

appearance
🔹 Abdomen: Pallor with splenomegally , no icterus.
Haemolytic anemia, infections, haematological
malignancy as DD
Bangalore ,,, 2018
Station 2 : was recurring hypoglycemia in type 1 dm

with weight loss anaemia , preproliferative retinopathy
, Nephro pathy, and bloating of abd
Station 4 : SAH refusing LP and wanting self discharge

BCC 1 : joint pain in a patient with diagnosed
psoriasis... he had back pain n dip joint... very strange
surrogate . Talking in muffled voice. Examination
finding very very normal
BCC 2 : was sob n dry cough in a ra patient on

methotrexate n whos work exposes him to asbestos
and is a smoker
Resp : COPD
Abdomen > Ckd with ascitis with fistula... some
candidate found hepatomegally . Was asking dd of
hepatomegally in ckd pt
Cardio : Mvr with pht with af with heart failure

Neuro : Hemiplegia
Sundaram = UK =2018
St 4 ADPKD..
ST 5 bcc1.. psoriasis e psoriatic arthropathy bcc 2

diarrhoea and weight loss
St 1..respi copd e bronchiectasis..
Abdomen..ADPKD
St 2.. vasovagal syncope..
St 3..left 7th facial nerve

AF e MS
Mandalay
St 1 bilateral pleural effusion

Bronchectasis
Splenomegaly
St 2 frequent collapse in type1 DM
St 3 ? GB or MND
MVR
St 4 meningococcal septicaemia
St 5
1 Systemis sclerosis
2 psoriasis
Castle hill , UK
BCC 1 : ocular myasthenia

BCC 2 : rheumatoid arthritis
Abdomen : pckd on dialysis with active av fistula

Resp : ILD
Station 2 : postural syncope
Neurology : cpa syndrome with 5 6 7 8 cranial nerves

affected
Cardio : Mvr with af
Station 4 : talk to the relative of end station hepatic

cell failure because of alcohol addiction. Didn't talk
about don’t cpr because it was not written in the
scenario..Examiner asked why you did not talk about
dnr
Dubai
Station 2
Lady Presented with loss of weight and appetite
Lab test revealed hyponatremia
Family history of thyroid
dd Addison
Hidden agenda : concern of cancer
Station 4
Medical error
I met son of old patient who admitted and recive
gentamycin for some reason it's level not checked lead
to renal impairment but no other side effect
Explain to the son what happened
Apologize , incident report, what you will do if no
improvement
BCC 1
Back pain
Osteoporosis on Steroid patient hav lower Back pain
after falling down from the bed
BCC 2
Neck swelling for long time
Simple goiter
Patient concern about cancer
Chest
Upper lobectomy
Scar in left thorax
Neuro
Biltral carpal tannel
Presence of scars biltarlly
Patient on hemodaylisis
Abdomen
Kidney transplant with fistula
Examiner ask about signs of rejection .
Cvs
prosthetic valve replacement
Examiner ask about manegement and follow up for this
patient
UK Experience
Experience at western general hospital Edinburgh
✔ I started with station one........
🔹 Respiratory .......
Lady initially presented with weight loss....
Around 50 yr lady lying comfortably .....clubbing ...rt
side of chest depressed...trachea shifted to Rt ...Rt
thoracotomy scar at back.....bronchial breathing at
rt..percussion note dull ...decrease vocal resonance.....
I told pneumonectomy ....
Dd I said lobectomy ....
Examiner ask cause ...
I said tumour / chronic infection TB...
Work up....routine labs...inflammatory markers
X ray..
CT...
BRONCOSCOPY ...biopsy.
Treatment as per cause
He asked me is patient cyanosed it was extreme cold at
that day ....I said no ...
Got 20/20 ❗
🔹 Abdomen
.....middle aged lady.... Presented with disturbed
biochemistry examine her....
Multiple scar marks of fistula on both upper limb only
one functional not active .....scar mark in neck found
with difficulty ...I said throid/ parathyroid surgery..scar
marks upped chest of previous lines...
One scar in Rt iliac fossa...I could not appreciate
transplant kidney below it she was fatty lady ...an
other horizontal scar below umblicus...
Thin skin with purpuRa...I forgot to focus on gum
hypertrophy....
So examiners ask finding...I mention all above and told
only one fistula functional but not marks of needle...
So I said EsRd with current mode of replacement
transplant kidney....on steroids possibly on calceneurin
inhibitors....
She ask how you will investigate...I said urine
analysis.....abd USg..routine labs...
She said what advise you will give this patient ...I said
to be closely follow in transplant clinic...overt
infections and compliance to medications...she ask
what else you will advise o can't judge...so I ask
examiner regarding what she said me if she is on
steroids what advise you will give...I said bone and
stomach protection bell rang...
20/20 ❗
✔ Station 2 History
🔹... 50 year Lady with recurrent lip swelling ...
I made in my mindhereditary angioedema....
I start history took details regarding episode rule out
any other associated involvement like laryngeal
enema...abdominal pain...any triggers stress
alcohol.family history ..allergies to nuts ...food ...hay
fever ..asthma..urticaria insect bite she denied all ...5
episode in last 3 months last one settled after 24 hours
...
So in past history ...she told my HTN...was on
bendruflunethuaxide ..and Ramipril 10mg I GOT it
😊..RA for which taking paracetamol and salfasalazine
for 18 years...then I focus on medicine only when
episode started 3 no the but she was taking Ramipril
for 18 months ....no change in dose....no over the
counter ...
So at end I told it is by medicine Ramipril we hve yo
stop and shift to other ....patient but it is very good for
my BP😡 I said I understand but now we have good
alternatives...I also offer referral to local allergy clinics
to rule out any allergy ....
Examiner ..summarize your case ...
Diagnosis ...Ramipril induced anhioedema....
Dd Allergy ...
Hereditary down the list .He said how will you manage
..
I said I will educate patient a big😡😡😡 Laugh I don't
no why ..he said about what I said her episode mayget
worse involving airways so in case immediate seek
help....we have to monitor her BPas we are going to
change her medication...He asked me you will reduce
dose or stop ...
I said I will STOP...
Then else I told him epipen might be not helpful in her
case.
Blood test I said C4 and C1 easterase inhibitor level to
rule out hereditay
Allhamdullilah bell rang😷😷
Got 20/20 ❗
still thinking why examiner laugh ...
✔ Station 3...
🔹 Cardio....55 female with shortness of breath ....
Scar mark with generator left inflaclavicular area...
AS MURMER but I don't know it was radiating to axilla
as well
I said As and MR...
Examiner how will you proceed
ECG.
Xray .
ECHO ...then manage accordingly...
Indications for surgery....symptoms/ Lv dimensions or
EF ..
I got 14/20 I think it was only AS plus pacemaker
🔹 Neuro
I totally mess up all ... Difficulty in walking middle age
...I think he had broad base walk...difficult to talk step
but couldn't fit any where ..
Tone was increased. Knee jerk u thing
exaggerated...ankle absent ...plantar dowing going
...sensation..coordation normal...
I said pyramidal signs with absent ankle ...gave dd of
subacute degeneration ...tabes paresis...cervical
myelopathy with peripheral neuropathy ...examiner
not happy ...they are asking to see me some on feet of
patient I could not appreciate bell rang ..8/20 ... I think
it was myotonic dystrophica and I mess up
things😑😑😑.....
✔ Station 4 Communication :
🔹 Council the wife of mr peatre who's husband
admitted with meningococcal septicemia...went to
office in morning ...from where he recovered in
collapsed state with a seizure ...GCS 7 ...impending
admission to ICU...
So I start with same protocol ..
Confirm all
Understanding of wife about situation...
Then tell sypmathically that at moment your husband
is in serious condition might need admission
inICu..explain about ventilation and vasopressors need
in future...
Explain prognosis ...mention clearly that he might die
in this situation ...but we all are here to give best
possible treatment to your husband ...we have already
started him on best treatment ...we have to closely
monitor his situation ...we will keep you updated
.....then I move to next step regarding contact tracing
ask about kids .. there ages ...vaccinations ...then o told
her we need prophlaxis for you and your kids ...2 kids
are in school one with grand mother...I tell her our
team will go and assess your kids and give them
prophylaxis....we have to inform public health
department they will trace contact it is not your
responsibility ....then at end I again offer for any help
with promise to see her soon to update also I told her
your husband is in isolation with special protections so
but will not spread ....
Examiner .....
So brief your case I start with same story ...
Then suddenly he ask what us your differential
diagnosis 😲😨😨😨
I really was not prepared ...then I think for moment
then said it might be septimecia due to other reason
involving brain ...even the other examiner look at her
colleague on this question ...😁😁
I mention during discussion that patient has GCS 7 SO
prognosis can be worse ...examiner suddenly stop and
check on his paper that GCS 7 ...😉😉.
Then he tell me it might be post ictal state after seizure
..I said might be as they didn't mention how much time
passed since fit ..usually it is for 2 hours then he said ok
....
How will you manage ...same multidisciplinary team
..workk up urgent LP CT ....start antibiotic
beforexdelaying because it reduce mortality ...contact
tracing ...prophylaxis ..he ask me option .I told
rifampicin .cipro ..
He ask first you told to patient wife that our team will
take your kid to hospital and give then prophylaxis
then you told her they will pick assess them and
giveprophlyaxix at home ...so which one is right option
...I said should be kept at home as risk of infection
spread and observe for any symptoms...
Finally kids should be isolated how long I really don't
know exact so I give ans by hit and trial ...48 hours
allhamdullilah bell rang finally ...
16/16 ❗
✔ Station 5
🔹 BCC1...
50 year lady with regular palpitations ...spontaneously
stopped ....had history of 1st loss and palpitations
before 6months ...refereed from GP but she lost follow
up ..
Pulse now 76...BP 130/80 ..
No need to examine eyes...
I went inside middle age lady ..
I first ask this palpitaion ...
Any chset pain..SOB...dizziness...syncope or black out
she denied all...
Then I ask general ....she sai yes swelling in neck ....
Ok then temp tolerance yes I prefer cold ...then I ask
about wt loss and palpitations before ..
She said I have good appetite start examine ...
Examine hands....rheumatoid hands😠😠😨😨 I ask
immediately about joint pain she smile yes I have joint
problems but it is not my active issue ...
So I give her water...confirm thyroid...then examiner 2
min left ....I left rest of examination and ask concern
..why I have palpitations ..I told it is related to over
active gland in your neck ...we have to run some blood
test ..scan of neck ...
Patient Dr this have treatment I said yes but first we
have to do test ..then will decided..but I said I will start
tablet for your palpitations ....beta blocker ...also she
was HTN...on thiazide...
Examiner what is your diagnosis ...I said thyroid
adenoma overactive stat...he ask what signs in patient
at the moment for overactivity�� I said I could not
found any but history suggestive wt loss with good
appetite..palpitations..heat intolerance..
What test you will do ...
Thyroid profile..Antibodies..
Usg ..radioactive scan ...
Management ...beta blocker...abtutyroid ..radioactive
iodine .surgery bell rang ..
Got 22/28 ... I think I should auscultate heart as case of
palpitations bit I was short of time ...I mention
examiner that I want to do cardiac examination.
🔹 BCC2......
I forget age but around 60 with ...with difficulty in walk
and recurrent falls ...
Man lying comfortably on bed lower limb exposed with
all things ready for neurological examination.....
I ask history about fall ...rule out syncope loss of
consciousness...rule out serious injuries with fall...
Numbness and tingling yes I have ..only in legs or
hands also....no in legs only ...up to which level up to
knee joint ....
Balance yes I have balance problem....in darkness
worse ...
I ask briefly about diabetes control HBA1c...diabetes
for 30 years eyes and kidney status ....start
examination ask patient to walk ....one of examiner pls
don't do romberg☺ ok high steppage....power
decrease distally...but on pinprick he confused said I'm
feeling equal on both sides as at chest😩😩 so I leave
check coordination...vibration was impaired ...
I told him management plan...
Multidisciplinary team ...physiotherapist...occupational
therapist ..Will give him support then prevent fall
...diabetic clinic...some test ....medications for
neuropathy ....I ask about alcohol and thyroid and
vitaminB12 as well ...
Examiner ..diagnosis ...peripheral sensory motor
neuropathy .
Cause ...possibly diabetes . I rule out alcohol...vitamin
B 12 thyroid .medications .
DD ...I stuck 😑😑😑😑 peripheral polyrediculopathy
🙄🙄 .ok
HOW will you manage ..
Blood test .HBa1c...vitamin b12..thyroid....NCS
Same multidisciplinary team..
Physio occupational health and...diabetes control
...diabetic clinic.....foot care....medications for sensory
neuropathy ...
Finally bell rang ..
25/28 .....
chennia center 14\march second arousal

adbome case polysystic kidney with av shunt no kidney
transplant
resp case patient heavy smoker nicotine staning with
av shunt with SOB
lt side pleral effusion
nerology case lt sideb hemiplegia
cvs cases ms plus patient ductus arteriosis
st 5 c1
middle age leady with epilepsy for 6 yearswith treat(
no fit) .
today presented with fit .she had vomiting and
diarrhea for 2 days before fit
histoy i ask sourrigate about desicription of fit tonic
clonic fit with tonge bite with post fit confusion.
she stop take anti epileptic drugs due to vomiting
diarrhea settled
exam for upper limb for tone power for tod parralysis
concern of sourrigate why get fit
my answer because stop treatment
can i change tratment
my answear send to doctor of brain
examinar ask how you investigate her
basic investigation cbc esr blood sugar serum
electrolite Ct scan for brian
serum level for drugs
advice here for stop drive
your opinion about my job in this case .i think i am not
good
is need to do fundoscopy
this case in cheenia center in india in 14 march 2018
st5 c 2
elderly patient with tirdness present with nearly faint
investigation HB70gm/ microcytic
because microcytic anemia i concentrat for iron
deficency anemia
history of heavy menses every 15\days
history for operation in uterus
history of peptic ulcear operated on
no hitory of vomiting blood or passing blood with stool
no history of nsaid ingestion
exam pale white nail
abdomen mass large about 16-10 cm hard intra
abdominal suprapubic area
scar in suprabubic area for operation
no lymph node enlarge
surrogiate ask cause of tirdness
answer anemia due to blood loss
surrigate what can do for her
answer adission see by MDT doctor of women doctor
of abdomen. need blood transfusion
social and occupational support she is teacher
examinar ask mass from uterus or ovary i answer
diplomatic after us known sourse of mass
investigation cbc esr
us ct abdomen
seen by MD
chennai caurosal 2
St 1: obstructive airway disease

Adpkd, another 1 renal transplant
St 2: 28 yr female dm type1 for 15 years, comes with

fatigue and wt loss
St 3: MVR
Left sided hemiparesis
St 4: decompensated alcohol liver disease patient

admitted with sbp and hepatorenal syndrome,
consultant feels not to liver transplant and renal
transplant, discuss about not to resuscitate
St 5: neck sweeling: goiter

Fever for 1 month and 2 times rti during 1 mnt, wt loss
Colombo
Resp : ILD
Abdomen : anemia , jaundice, splenomegaly , top dd
Hemolytic anemias
Cardio : AS + AR
Neuro : 3rd nerve palsy
Bcc 1 : Bronchiectasis with old TB

BCC 2 : Giant cell arteritis
St 4 : Ca oesophagus with issues like difficulty eating.

Discussion on PEG tube etc
St 2 dizziness with dd of vasovagal , seizures
Chennai 14th March
- st 2 : seronagative arthritis
- st 4 : Steroid psychosis
- BCC 1 : microcytic anemia + dysfunctional uterine
bleeding
- BCC 2 : seizure in a known epileptic after developing
diarhea & vomiting (missed dose)
- st 1 : renal transplant, ILD
- some candidates get hepatosplenomegaly, Br Asthma
- st 3 : MS with AF, Hereditary motor neuropathy
- some get ASD, Flaccid paraparesis
Whittington hospital,UK,
- BCC1 syncope in old age AS

- BCC2 60 year femle with itching for dd examiner not
want primary biliary cirrhosis and not want abd exam
pt has wt loss may be lymphoma or PRV
- Station 2 : recurrent hypoglycemia
- Station 4 : Son angry - his mother admitted with

pneumonia and discovered black ulcer in her leg
- station 1
- Respiratory : pulm fibrosis with corpulmonale, on o2
- Abdomen : Liver tx + POLYCYSTICKIDNEY not sure.
- Neuro : examine LL mostly cerebellar syndrome but i

said LMNL i want to examine UL for cerebellum i said
motor PN
- Cardio pacemaker with MS and AF
Mandalay second round last day
BCC 1 Pulmonary fibrosis RA

BCC 2 TIA
St 4 Breaking bad news end stage Liver disease &

discussion of resuscitation
St 2 tiredness and wt loss fever haematuria, GN

Cardio : TOF
Abdomen : splenomegaly with jaundice, gynecomastia

Resp : PF with systemic sclerosis
Neuro : spastic paraparesis without sensory
Western general hospital,UK
St 4 : meningococcal septicaemia
St 2 : ramipril induced angioedema
BCC 1 : Old lady with palpitations ...was a case of

thyrotoxicosis due to graves
BCC 2 : Recurrent falls in a diabetic patient...peripheral
neuropathy
Resp : ( we told bronchiectasis , might be ILD as well)

Abdomen : right subcostal scar (probably due to liver
cysts removal , didn't feel any kidneysthough )
Neuro : myotomic dystrophy

Cardio : AS
Chennai 12th March
St 4 :
🔶 Patient has severe COPD which improved slightly
after 5days of hospital admission and NIV. Patient wish
to attend his granddaughter wedding in 3 mths time.
He's undecided for long term NIV. Your consultant has
discussed with intensivist and their opinion is not for
invasive ventilation. You have permission to speak to
his daughter. Task is to:
1) explain regarding his condition
2) explain about no invasive ventilation
3) talk about further treatment plans
4) prognosis
Bcc 1:
🔶 CKD patient with 2/12 swelling on the face and
tiredness. Saw swelling on the left cheek. Noted that it
extend to left hard palate. Pt has some weight loss.
Inadequacy of dialysis as well
Ddx:
1)malignancy
2) renal osteodystrophy (I got severely prompted
before coming out with this dx)
Mx:
1) investigate for electrolytes and parathyroid
adenoma
2) adequate dialysis
Bcc 2:
🔶 Patient presented with migraine like headache for a
month. Noted sbp: 180, and urine normal from the
notes outside. Asked for secondary hypertension, but
couldn't find. Asked for fundoscopy, was told that he
has grade 2 Hypertensive retinopathy. Asked what's
the diagnosis?
I said hypertension headache with ddx of migraine.
Would like to investigate for secondary causes.
Ix:
Ultrasound doppler kub
Catecholamines
Electrolytes
Examiner asked: have you heard of renalvascular
causes? How to investigate?
I didn't know and didn't have time to answer. Didn't
reach management
Station 1:
🔶 Abdomen
ADPKD on HD with recent venepuncture. Noted pallor.
Case is straightforward.
🔶 Respiratory:
Slightly breathless young boy with recent left
pneumonectomy/lobectomy. Right lung was normal.
No clubbing. Tracheal shifted to right. Asked about why
tracheal is right when there is left lobectomy. I
answered probable apical fibrosis which I might have
missed. I would like to do cxr to confirm.
Asked why is he breathless?
I answered maybe pneumonia or atelactasis post
surgery.
Station 2:
🔶 Patient, 40yrs old, had 1st episode left sided
witnessed seizure last week. Came today for
treatment. Asked about epilepsy in family, drugs,
hypoglycaemia, meningitis, electrolytes imbalance-
none. He revealed dry cough for a mth on my systemic
review. Asked about malignancy, lost of weight and
appetite- none. Asked about tb contact and travelling-
none. Asked about sexual history and hobbies too.
Examiner claimed that I didn't ask past medical history.
I just apologised.
Discussion was about why I asked sexual history, why I
asked hobby, why I didn't ask for trauma.
Then what is my investigation? I said ct brain and eeg. I
would like to also do cxr and induce sputum.
Not quite satisfied on this one. If I argue with
examiners, I would lose time and marks,right?
Station 3
🔶 CVS
I think I got eisenmenger secondary to vsd. Patient had

mild clubbing. I can't appreciate central cyanosis as I
have colour weakness. Raised JVP and bilateral pitting.
I said vsd with eisenmenger and ddx is TR. All my
colleagues said that's AS. �
🔶 Neurology:
Examine UL. Confirm LMN presentation, with
hypotonia, hyperreflexia, bilateral Distal wasting and
some proximal weakness. Check sensory. Patient had
language barrier. I asked the chaperon to translate, but
the chaperon too, had no idea what I was talking.
Finally she told me there is some sensory loss on the
right palmar only.
Provisional dx: root lesion (most likely dermatomal
sensory loss)
Discussion was about what's the cause and how to
investigate
Mandalay
✔ BCC 1 ... collapse due to postural Hypotension due to

H&M
✔ BCC 2 ... 37 yrs old man with HBsAg(+) on Antiviral
Medication c/o difficulty in walking (can’t get any clue
outside)... Inside, a case of bilateral peripheral
neuropathy with footdrop, stocking distribution..
chronic alcoholic ... give DDx for that...
✔ Station 1... I got Hepatomegaly with Cervical LN &

Anaemia (the others got Hepatosplenomegaly)
For Resp... A case of Rt Upper Lobe Collapse ( there
may be some other findings bcoz examiner keep asking
anything else)
✔ Station 2 .... Fever, Wt Loss, Night sweats, Dry

Cough, Inguinal Lymphadenopathy... DDx...
Lymphoma, TB, HIV
✔ Station 3.... CVS.... Very difficult case... Young male
patient abt 200-250 lb... can’t even get apex beat...
Very difficult to hear Heart sound at the apex.... Only
systolic M2 at Upper left sternal edge... give DDx for
that
CNS.... look at the face & proceed... Rt Ptosis..

3rd,4th,6th, 5th, 8th with ? Cerebellum...give DDx for
these
Station 4.... patient with CKD want to stop dialysis bcoz

of poor QOL.. explain to son...
Mandalay center
🔹Station 3
CNS- common paroneal nerve palsy
CVS- MR with ?AS AR AF pul hypertension
🔹 Station 2
20 yr old lady with tiredness and lethargy for 6 mths
IDA on IVx
TFT nl
H/O menorrhogia also (+)
She had H/O IBS 2 yrs ago on Meveberine with little
help
She gave all symptoms of malabsorption but
No association with food
Wt loss 15 kg
Quite stressful as her husband lost his job recently and
her symptoms giving so much trouble on her job as a
school teacher
No children although tried
FH of T1 DM in her brother but no other features of
APS
Travelled to Thailand 6 mths ago
Examiner asked causes of malabsorption
IVx for coeliac d/s
🔹 Station 1
Resp: RUL collapse with bronchiectasis
Abd: PKD
🔹 Station 4
Talk to daughter whose father has died recently with
pneumonia with CURB 65- 5
🔹 Station 5
✔ BCC1- 47 yr old lady with blood & mucus stool for 6
mths and wt loss and jt pain and FH of Ca colon
Past h/o TB 20 yrs ago
DDx- IBD, TB, Malignancy
✔ BBC2- 25 yr old man with headache,
Inside Neurofibromatosis
He gave headache suggestive of migraine
No features of raise ICP
Fundus NAD
other neurological exam: NL
H/O Hypertension which is controlled with Amlodipine
No renal bruit, no features of phaeochromocytoma
DDx: migraine, SOL, Hypertension
New kasr Elainy on 3/2/2018

I started with station 4 a case of 50 year old man with
heart failure on maximum treatment in spite of this
has shortness of breath, he discovered cervical lymph
node and biopsy and abdominal ctscan and bone scan
show that he has advance cancer of kidney with
metastasis to the vertebra and liver your task talk to
the patient regarding palliative treatment including
Ìstarted with greeting the patient check the identity
and check his knowledge about his condition ,actually
he has no idea about the result of test I give him shout
that I am sorry to tell you that the result of test as not
good as we hope .....you have a kidney cancer and am
afraid to tell you that it is in advance stage it spread in
to your liver and your back bone with great sympathy
and empathy he ask about the treatment any cure I
told him if the cancer on early stage usually the
treatment and cure is surgery but in your condition and
with spread of cancer cell there will be no role of
surgery but we will do our best to treat your symptoms
we called palliative treatment. Do you ever heard
about it ?and I explained for him all about palliative
treatment and the palliative treatment team I told him
will not let you suffering will make your life more
easier ,I didn't talk about DNR because it is not one of
the task he was concerned regarding how to inform his
wife and I told him if you wish I will help you and
arrange meeting to talk with her and she will be good
support for him, he was concerned regarding travelling
I inform him that i appreciate your feeling and you
have the right to travel but I am afraid with this heart
disease it could be danger for your life that why I will
refer you to heart specialist to assess your fitness for
travelling he has 3rd concern regarding dealing with
heavy objects as he works as mechanics I appetite his
concern and I inform him that carring heavy object me
put him in a risk of fracture that why better to avoid
and refer him to social worker and occupational health
worker,he ask me to give him estimation regarding his
life span ,I inform him this is difficult question to
answer and with great sympathy ì told him that I am
sorry but with this advance stage of cancer it will short
your life it may be period of months rather than years.
After finishing and great sympathy and empathy the
senario end with summary and check understanding.�
then move to examiner Questions😐
The questions was regarding what ethical issues

applied in the senario I started with breaking bad news
the examiner ask me does breaking bad news is one of
the ethical issues? I said no 😥 Autonomy the right of
the patient to know about his kidney cancer and it is
advance stage ,beneficence to manage the patient with
palliative treatment and non malfescience in that no
role for surgery her or chemotherapy because he will
suffer from bad effects and he ask me about travelling I
told him that better not travel with this heart failure
and need to be assess with cardiologist alhamdellah I
got 16 .then station 5 first one was weight gain with
proximal myopathy when I enter the room I found a
lady and when I want to put the paper I found cup of
water and hammer😉 so that I diagnosed hypo
thyrodism by the surrounding the positive thing was
weight gain allover constipation , proximal myopathy
,low mood,heavy cycle screen for other hypos was
negative screen for the cause also no thing significant
ask about the impact who is support her and smoking
alchol medication list like amidaron,lithium ,steroid
,statin examination start from hand for dryness of skin
,carpal tunnel,pulse ,BP sitting and standing ,proximal
myopathy, pallor ,macroglossia,neck for scar and ask
her to drink water for neck swelling examine basal
crept, osteoarthritis in knee,lower limb edema and
ankle jerk,the patient concern was about what is the
cause and it is reversible?the answer was it is due to
under activity of gland in your neck called thyroid
causing this symptoms we need to do blood test in
order to confirm diagnosis and refer you to gland
doctor,if it confirmed we will start for you medication
called thyroxin need to be taken regular and to be
follow up with the gland doctor and it is reversible
after starting treatment. Then examiner question1-
what is your diagnosis? Primary hypothyroidism.
Next case was 35 years old male with dimnution of
vision inside the positive thing gradual blurring of
vision and no variation between day and night he has
oral ulcer and genital ulcer recurrent painful , history of
knee pain،history of leg clot there is some times pain
and redness in eye ask about ,impaction,driving and
social issues examiner question what is your
What is differential diagnosis for anterior uveitis? How
you will diagnose ?HLAB51 and pathergy
test.alhamdellalh I got 28. Then move to station 1 I
started with abdomen the case was anemia with
splenomegally but actually I was hesitant and was
thinking that may be ì miss the liver and ascites😫so
that I was not concentrated in discussion also it is
common question they ask about differential diagnosis
I forgot infection🙈 and about clinical judgment I didn't
request any ct scan or bone marrow examination so
this was my worst station I got 13,
Chest station female with OLD with basal fibrosis
actually the patient was coughing and I was stress
examiner ask about dd. and Management of COPD
criteria for long term oxygen therapy I got 18.
Move to station 2 from outside was written 35 years
old female present with left side weakness for one
hour.
Inside I found this is the first time complete recovery
she was on hairdresser associated with headache
typical migraine with visual aura she has sleep
disturbance recently drink a lot of coffee no other risk
factors for stroke in young she is on oral contraceptive
pill no neck pain or neck swelling she has history of
bronchial asthma social history was not significant.
Concerns it is stoke I told her because of complete
recovery it is not stroke ,it could be ministroke or
related to your headache and now present with
Unusual presentation .she asked it could reoccur again
I told her it could be especially you are in oral
contraceptive pill I advice you to stop and refer you to
women doctor to change to other methods of
contraception and I will admit you to do for you blood
tests,heart tracing ,ima
ging to brain scan to heart and treat your headache
involved neurologist. Also advice regarding have good
sleep and decrease coffee in take.
Examiner questions what is your differential diagnosis?
Hemiplegic migraine
TIA
Carotid dissection
screening,autoimmune screening ,ECG Echo carotid
doppler brain ct scan and MRI
He told me why MRI
I told to check if there is any area affected by posterior
circulation. Another question about migraine
management and proflaxis.
My last station was station 3😥 started with CVS
examination she was very ill patient severe pale I
couldn't assess the pluse well if it is regular or not then
I thought I will check by stethscope she was ill and
tachypneoic with midline sternotomy scar she has
ascites also I think because so distended abdomen with
raised jvp the auscultation was so difficult she has
double valve replacement with left parasternal heave
and pulmonary htn ,there is murmur every
where😱😱😱😱 I forgot about the pulse at that time
and try to concentrate on murmur I found MR and TR
she has also lower limb edema then after that the
examiner told me to say positive finding I told double
valve replacement with phtn and right side heart
failure with MR and TR he told me did you hear
another murmur I told am not sure because the patient
is pale may be hemic murmur I think there is aortic
stenosis but I didn't mentioned then ask about how
you will manage I told admission and involvement of
cardiologist ECG Echo CBC inflammatory markers
coagulation profile he ask me what you will find in ECG
I told him about rt ventricular hypertrophy then told
me what about rhythm what about pulse😱😱😱 at
that time I remember that am not sure of the pulse if it
is regular or not then suddenly I told him irregular he
told me are you sure then I told yes I don't know why I
said this🙈 and I felt guilty feeling and I thought I lost
the case and also regardingMR I was thinking may be
not true because such case will not come in exam. I
was think I will get 6 but Al hamdullelah I got 19😊the
neuro station was more tough young male examine
lower limb he has severe pain in his rt lower limb and
there is wide difference when I start to examine the
tone the patient was shouting that he has pain then I
stopped and told the examiner the patient in severe
pain he told me continue but gently I get panic and I
couldn't assess the tone well the left leg looks normal
and he is an able to move the rt leg because of pain
,reflexes knee present absent ankle extensor planter
sensation I start with pain and touch sensation when
reach the knee he told he feel now when I move
around the knee he told it is not similar some area are
more some are less I lost a lot of time in sensation😥
when I start test vibration test I didn't complete time
was over 😢 and I got more depressed I thought I fail
the exam😥 then the British examiner was the leader
and he was nice he told me forget about the vibration
and position sense what is your finding? I told him this
gentle man has monoplegia and it seem to be not
hemiplegia because the patient was moving upper limb
normally ,and not cortical lesion because he is
conscious,tone difficult to assess well because of
pain😔knee reflex intact absent ankle reflex with
extensor planter regarding sensation it seem to be
patchy sensory loss😞 he told me so what is your DD?
I told with this patchy sensory loss could be cauda
equina
Multiple sclerosis then the whole discussion was about
multiple sclerosis how you will investigate and
manage. Then bell ring and the exam was end I was
think that I did very bad especially in this station and
may be I will fail the exam. It seem to be appeared in
my face that I am depressed the British examiner told
me be happy already you finish the exam enjoy your
life, actually he seem to be a nice examiner I told him
actually I did very bad and left the room😥 then I was
surprised that I got 20😊
Alhamdellah I passed the exam with score 162 my
advice doaaa ;doaaa and doaaa it is
matter of tofig and don't panic inside exam and when
you move to new station forget about the previous one
because you don't know how the examiner will
evaluate you.
Good luck for all of you and I hope all of you to pass
exam .
Chennai 12 March, diet 1
St 1
Abdomen : ascites with renal failure
Resp : Pulmonary fibrosis
St 2 : Diarrhoea with abdominal pain 6 months
St 3
Neuro : Cerebellar signs with sensory involvement
Cardio : MS/ MR
St 4 : talk to husband regarding wife for icu admission
and intubation who developed SJS after penicillin
injection.
St 5
BCC 1 : recurrent hypoglycemia after adding additional
tab of diabetis
BCC 2 : blurring of vision in a diabetic patient.diabetic
retinopathy with cataract.
Dubai 12/2 3rd cycle 161/172
U are Sho in medical clinic
Ms Zakaria 40yrs male
He had back pain for the last 3months seen his GP and
diagnosed of osteoporosis investigation and X-rays
showed collapsed at D9-10 please sit with him and
answres his concerns
Inside after greeting confirming the agenda he has back
pain started when he start walking and in mid back
localized no history if trauma no neurological
symptoms
No redflags like increasing with coughing or sneezing
Not related to movement or rest
Its v severe scoring is 7to 8 isaid sorry
No other joint pain
No skin rashes and even with son exposure
No eye pain no sore in-his mouth no neck pain
No SOB
No dysuria
No abdominal pain
Pt has loose motion for the last 3 months difficult to
flush not releated to food no blood in stool
No tummy pain mild loss of wt
Pt is not diabetic or hypertensive
X smoker for 1year after developing 1 attck of asthma
received blue and brown inhaler for once
Only on pain killers for back pain no FH
Not drinking alcohol no contact with animal history of
recerrent travel to Egypt and once for usa last year
He working as solicitor in firm company and the pain is
bothering him too much he cannot take sick leave his
diet is v good
His concerns why i have osteoporosis i know this is for
elderly people i answered it u have this diarrhea and
causing malabsorption for some nutrients and this is
causing osteoporosis
Time is finished I forget to ask about impotence
Examiner questions
Summarise ur case
Whats ur diff?
Malabsorption diarrhea causing osteoporosis
Other rheumatological but negative
Endocrine negative
Others like lack of testosterone but i forget to ask
about it 😔
I got 12/20 and know it after finish it i did it badly but
no choice i should complete the exam
Statin 3
Cardio young lady complain of SOB
Ms with AF and Loud S2
Whats ur finding ?
Whats ur INV ? And why
Whats ur management ?
Got 20/20
Neuro examine UL neurological complain of pain
Bilateral carpel tunnel syndrome more in right
Pt has right side AV fistula for HD
Whats ur finding ?
How to confirm ?
Whats the case in this pt ?Amyloidosis how to confirm
it ? What the treatment for CTS ? Whats the treatment
of amyloidosis
Igot 20/20
Station 4
U are doctor in the ward
Talk to Mr Raed son of Mrs mona
Mrs Mona 70 years old had fracture neck of femur
3weeks back and operation done successfully and pt on
rehabilitation ward and she developed headache and
dr on ghe ward suspected GCA and started steriod
40mg per day unfortunately pt developed psychosis pt
transferred to the general ward late night and assed by
our consultant and rule out the GCA and steroid was
stopped
Talk to her son and answer his concerns
After greeting
Confirm identify Nok ?
Agenda
Son is v angry about shifting his mother with telling
him and no one call him yesterday
I said we are sorry for mis communication happened
yesterday and will check-it and ask him what do u
know about ur mother condition he said she is ok untill
one dr assess her and give some medicine and she
behave abnormally after that i explain for him what
GCA and treatment and why we should give treatment
to ovoid eye complication like blindness
Then again become angry he said this bad hospital and
practice no one call me u give bad drug upon suspicion
at that time i apology for what happen and explain
more about complication and this is medication is best
interest for his mother then he asked why my no one
consult us about treatment i said ur mothe is
competant at initiating treatment then i want my
mother to be shift again to Rehab ward i asked why he
said becused she is now under close follow up and we
need to check other side effect of steriod and treated
accordingly a and after that my consultant with rehab
team they will assess her and decided when will be
shifted again i asked him deoed ur mother have any
memory problem or any fever constipation or urinary
problem he denied it . Summary and aplogy again
Examiner question
Whats ethical point here ?
Angry relative
Dealing with incompetent pt
Privacy
Regarding his concern no one call him
Why u didinot inform them about treatment
When u will shif pt to rehab ward
I got 16/16
Station 5
BCC 1 45years male with history of MI
5weeks back and present with dizziness
Inside post MI fatigue last 1 week
Postural hypotenstion due to change dose of ACE
Bblockers indiced fatigue
Aspirin indued GI blood loss
Statin induced myopathy
I offer BP sitting and standing
Pulse exam
Eye for pallor
Chest for basal crackles pls LL
I got 25/28
BCC2 35years with difficulty of swallowing
SS
Crest syndrome clear finding
I eamine chest for basal crackles
S2
Ofer BP
Hand exam
Concern whats wrong with me
do ihave cancer?
Is it reversible?
Examier exam whats ur diagnosis ?
Whats Crest ?
Investigation ?
If u have time what system u will wxam i said abdomen
I got 28/28
Station 1 last station 😊
Chest
Letf lower lobectomy
Whats ur finding ?
Diagonsis
Investiong in this pt specifically?
I got 20/20
Abdomen
Huge splenomegaly with anaemia
Finding ?
Investigation
Management ?
I got 20/20
‫الحمدهلل رب العالمين‬
Kolkata (India)
🔹Station 1
✔ Resp
RA hand with COPD
Pleural effusion
✔ Abdomen
Alcoholic Liver Disease with Ascites
Upper abdominal scar (Thalassaemia+Splenectomy)
🔹 Station 2
Swelling of face and tongue (Angioedema)
✔ Station 3
🔹 CVS
CABG with MR
? Normal Heart
🔹 CNS
Spastic paraparesis with scar at back
Right homonymous hemianopia (Stroke)
🔹 Station 4
Young lady presents with Seizure and Right Temporal
abnormality on CT head, Neurosurgeon wants to do
MRI for confirmation
(Epilepsy)
Explain about uncertainty of diagnosis and MRI
✔ Station 5
🔹 BCC 1 : RA with ILD
🔹 BCC 2 : Sudden loss of vision (CRAO) with Biscuspid
aortic valve disease
Whittington Hospital, London
Started with st 5️⃣

BCC 1: Lady with RA flare
BCC 2: Obstructive sleep apnea with high BP high BMI
(recent central weight gain) , no features of
hypothyroidism/ Acromegaly
Only positive was mood changes
Had mild abdo striae (not typical)
CV risk factors: nil
DDx : OSA sec to Cushings
St 1️⃣
Abdomen - huge hepatosplenomegaly life likely sec to
myeloproliferative diseases
Respi - COPD on oxygen
St 2️⃣
Headache x 1 yr, has photophobia, taking high dose of
Cocomadol, all other symptoms were negative DDx:
Migraine, medication overuse headache, pt is worried
about CA brain
St 3️⃣
CVS: MS with AF
Neuro: spinocerebellar ataxia
St 4️⃣:
Talk to the angry son, mother was admitted for
fracture NOF s/p surgery, was transferred to rehab
ward and doing well. She got a headache while in
rehab and prednisolone was started suspecting
temporal arteritis. Temporal artery biopsy was not
done. Now she is having steroid imduced psychosis and
was transferred to main hospital. Today morning
consultant felt that it is unlikely to be temporal
arteritis and steroids was stopped.
Son’s concerns:
1. Why nobody has updated me about what’s going
on?
2. Why my mom can’t recognise me?
3. Will she get better? Is it reversible?
4. Why they started predni in rehab if it can cause
serious side effects?
5. I want to complain against the doctors in rehab
about this.
Luton, UK.
🔹 started with Cardio.MR with AF. Question usual. dd,

inv,management, which anticoagulant? why not
noacs? got 20/20
🔹 then neuro : facioscapulomuscular dystrophy. inv,
management. specifically mentioned physio and
Occupational, social support in management. got 18/20
🔹st 4⃣ : grandfather came with stroke,now improving.

task : talk to granddaughter. explain CT and ans
concerns. concern was :
1. granddaughter did not take the gandfather in
anticoagulation clinic for INR. so ahe thinks she is
responsible. offered empathy. told her it might happen
even if on right warfarin dose.
2. garnd father wants to go home, asked why.
granddaughter replied : food is not good. told her that
we will specifically ask what he needs and will try to
artange.
examiners q : management of stroke :
replied as 1. acute and secondary mx. they asked what
will happen if patient wants to leave hosp. I told : I will
explore cause. they asked will u assess capacity. I said
yes. then asked how , got 16/16
St 5⃣
🔹 BCC 1⃣ : from outside : young lady with diplopia.now
improved. thought about MS, SOL, Cranial nerve
palsy,TIA.inside : she gave history of diplopia. lasted 3
days. no other neuro problem. explore SLE symptoms
thinking about TIA. there was none. past medical hx of
migraine. no medication. physical examination was
normal. gave dd of complicated migraine,
MS,TIA.examiner asked how u will manage migraine.
told : reassurance, painkillers, triptans, prophylactic
propranolol.
🔹 BCC 2⃣ : outside : middle aged man with
diplopia.inside a man having diplopia and facial
weakness, becomes
worse on end of the day. On examination complex

opthaalmoparesis. had sternotomy scar for
thymectomy.was on pyridostigmine.
dx : told relapse of MG. other dd : causes of complex
opthalmoplegia : thyroid eye disease, CPEO. then
asked inv of MG. and acute mx of crisis 28/28
🔹 then comes resp : missed vats scar. was very small
on right axilla. had unilateral creps. told dd.
bronchiectasis, fibrosis. examiner asked management
of bronchiectasis. got 12/20
🔹 Abdomen was aweful! totally messed up. young

man with jaundice, hepatomegaly. spleenectomy scar.
I told also had ascites. but he did not have it :(. got
nervous. could not even tell proper dd. told hemolytic
anemia. don't know why I did noot say myelo/
lymphoproliferative. got 9/20
🔹 then st 2⃣ history. outside 60 year lady, with

epigastric pain, inv : calcium high
so from outside dd was causes of hypercalcemia.
MEN,drugs, hyperparathyroidism, sarcoidosis,
hypercalcemic hypocalciuria. inside she gave all hyper
calcemia symptoms, was on lithium but on same dose
for 2 years. father had kidney stone.mather had
pancreatic cancer. concern was : is it cancer.
examiner asked dd : told lithium toxicity,
hypercalcemic hypocalciuria, hyperparathytoidism, had
no spectrum of MEN, so thought it was unlikely at that
moment. they asked inv for these. asked for pancreatic
cancer how will u investigate. I told ct abdo. got 16/20
Yangon
St 1 🔹Resp : Lt pleural effusion

🔹 Abdomen : Hepatosplenomegaly
St 2 🔹 TIA or Hemiplegic migrane
St 3 🔹 CVS DVR
🔹 CNS Hemipresis with AF
St 4 🔹 IBS with plan to start Amnitrypyline
BCC 1 🔹 Poor control of type 2 DM with autonomic

neuropathy
BCC 2 🔹 Addison with Generalised MG
My Paces experience, diet 1 2018, Sharjah
Role: doctor in Acute medical unit
40 years old female, presented with fever for 3 weeks,

received treatment for urosepsis with a course of
antibiotic, but fever didn’t settle, so she was given
another course of antibiotic.
Her condition didn’t improve.
Now presented for assessment and management
accordingly
Outside I made a vast list of differentials for fever, but

since there was not much information given to indicate
a cause, so I decided to go by systemic review.
Inside, the opening question also gave me the same

information ONLY which was given outside and pt.
showed concern that she’s very worried why my fever
is not settling.
I told her that I appreciate that u must be upset since u
r not feeling better, so I’ll try my best to sort out the
problem and will manage as best as possible. So let me
ask u in detail so that I can reach the cause.
So I started with each n every detail of Fever first. It
was never touching baseline, no particular pattern, no
evening rise, mild chills but no profuse sweating.
Then I asked about general symptoms:she had lost
weight ( almost 4kg in these 3 months), and appetite is
poor as well.
At this point, I started thinking of tuberculosis ( she

was of Indian origin), lymphoma mainly ( other
malignancies less likely considering the age)
She had mild dry cough, and had noticed a lump in the
inguinal area ( had to ask specifically about any lump
she has noticed)
Apart from that all history was negative.

She had completed the courses of antibiotics
No joint pains, no rash, no travel, nothing in social.
Non smoker
Works as a baby sitter for a local family.
When I summarized and asked “ do u want to add

anything else which we might have missed?”
She said, u can ask me doctor, may be I have
something else 😳🙄
What I remember, I could not think of asking anything

else, and neither the time was left.
At 2 minutes left, I asked about concern
She said, what’s happening to me ? Is it some
infection?
Why fever is not settling?
Im worried, I’ll lose my job if I continue to be absent
from work. She wasted time by repeatedly asking same
questions and not letting me open mouth.
I told her that I can see that u r very upset.

there could be few possibilities and the significant wt.
loss is a cause of concern for me, so we need to do
more tests to find out exactly what’s going on.
She said, like what doctor?
I said, one of the possibility could be , what we call
lymphoma, which is a type of cancer
She was like WHAttt 😳😳😳 CAncer ??
( I thought may be I made a mistake)
So I emphasized, that it’s just 1 of the many causes. We
can’t say with confirmation until we go further tests...
In telling this much, time finished and I couldn’t
address her concern of job.
( I thought I lost, because I couldn’t answer concern)
Examiner:
Summarize, then differentials
1: lymphoma
based on no responsive fever with wt loss, low
appetite and inguinal lump, however she didn’t have
night sweats
2: sarcoidosis based on dry cough, inguinal lump,

although she didn’t have any joint pains, any rash
Then examiner said, what else?

I said, further I can think of viral fevers as EB virus,
infectious mononucleosis etc.
Then further down the list could be some other

malignancy, although I didn’t get any positive
symptoms and no significant family history.
She accepted
Then she asked what were her concerns? And did u

address them?
I told, that she is understandably worried about the

fever not improving n wants to know what’s the cause.
And she’s worried about losing job, I told if I would
have more time, I would have told her that I’ll give her
sick leave etc.
Then time finished 😓

I felt bad after coming out, because I couldn’t address
the concerns completely.
Got 17/ 20
stn 1:
Abdomen:
Pt. with tiredness , examin abdomen
Intro, Consent, exposed, told first I’ll have a general

look at u, so Inspected from bed end
Young male , in 20s, thalassemic facies and tanned

skin.
No abdominal scars
Came back and covered him again and then started

examining from hands, nails, flap, arms for any fistula,
tattoos, prick marks etc n up to eyes.
Had a slight tinge of jaundice and pallor
While checking JVP, mentioned that I would ideally like

to check jvp at 45 degrees, examiner said it’s alright.
Checked chest for any scars, spider naevi

Axillary hair n gynaecomastia
Before palpating abdomen, I kneeled down and rubbed

my palms, told the pt that my hands might be little
cold, plz excuse me for that.
Light palpation revealed a mass in left upper quadrant,

non tender.
Deep palpation
Organ palpation : right n left lobes of liver, liver span,

spleen n kidneys
Shifting dullness etc
He had splenomegaly, approx 8 finger breadths below

costal margin and hepatomegaly with liver edge
palpable approx 2 finger breadths below CM
After auscultation, made him sit and checked for lymph

nodes from behind, then auscultated lung bases and
checked for sacral edema,
Finally checked for lower limb edema.
Covered and thanked him.

Turned to examiner and said I would like to complete
my examination by checking the hernial orifices,
genitalia and DRE etc
Examiner said, u can check hernial orifices u still have
time 😳
I realized that I finished earlier
Anyway he smiled and said leave it, so tell us the
findings.
Told as above
Based on these findings my diagnosis is that this
gentleman has chronic haemolytic anaemia
Examiner said which one?

Told most likely thalassemia
What could be the cause of hepatomegaly I. This pt?

1) sec. haemochromatosis which is very likely here
since pt has hyperpigmentation.
2) extra medullary hematopoeisis
3) viral hepatitis as a complication of blood transfusion
Then asked about investigations:
CBC looking for hb level and therefore severity of

anaemia
Blood film , asked what u’ll find in blood film, told

hypochromic microcytic rbcs, anisocytosis
Hb electrophoresis
LDH, haptoglobin, retics count for haemolysis
Then USg abdomen to assess liver n spleen
Inv for complications like haemochromatosis ( ferritin

levels , iron studies)and so on
Examiner asked, which test u’ll do periodically for this

pt?
I couldn’t make out at that time
He told, ferritin levels so as to monitor for sec.
haemochromatosis
Then treatment
General , specific
Asked the target hb level, told 10
Scored 20/20 Alhamdulillah
Abdominal exam revealed mass in Lt upper quadrant

on light palpating.
Stn 5:
BCC 1:
20 yrs female with bloating and flatulence.
Outside, I put dd of IBS mainly, malabsorption and

remotely gall stones.
Inside, a young lady of thin built , has these symptoms

for few months. She feels tired, No tummy pain , stool
frequency increased to twice daily, not very loose.
Asked about wt. she said she’s not being able to put on
weight, despite eating everything. No wt. loss
however.
So at this point I shifted my thoughts towards

thyrotoxicosis, asked about few other symptoms but
she denied.
In past hx she said she was told by a doctor that she is

anaemic. ( so here I considered celiac and asked few
more questions about it )
Family hx
Mother has some thyroid problem
While talking to her, I noticed a lump infront of neck

which was not very obvious
I started examination early, stated with thyroid
because I noticed a small water bottle on the bedside
table. So whole thyroid exam including hands for
tremors, nails, pulse proximal myopathy, eyes
proptosis, lid lag etc, heart auscultation
Checked for anaemia for celiac, and offered to do

abdominal examination
Apart from a small diffuse thyroid swelling, no other

positive findings
I told the possibilities of hyper functioning thyroid and

Coeliac disease to the pt. and the need to do the tests
etc
Examiner asked about diagnosis, told the same,

1) hyperthyroidism
2) coeliac disease
Investigations And management
Got 26/28
BCC 2:
65 yrs old male , came for routine assessment of HTN.
BP controlled, also DM
Now having headache for 2 weeks.
Mainly on left side, goes down to left face, more on
jaw movement, not sure about nature of pain, said
may be throbbing. Also has slight scalp tenderness.
No visual impairment.
Examination:
Started by a generalized look, checked for temporal
tenderness which was mildly present, palpated TMJ
while opening n closing of jaw, asked about any other
joint pain, denied.
Then checked visual acuity, asked for snellen’s chart,

examiner said u can do without it.
So checked by fingers
Then checked for visual field
Offered fundoscopy because earlier I noticed it on the

table. Examiner said it’s normal.
So gave diagnosis of temporal arteritis based on

unilateral headache with temporal tenderness and
increasing pain on chewing.
Other differential: TMJ arthritis because pain more on

chewing, although no Hx of other joint involvement
Examiner asked about Inv. for temporal arteritis: ESR ,
temporal artery biopsy to confirm
Mx: I’ll start steroids before discharging the pt. and

Neuro and ophthalmology referral as well.
27/28
Cardio:
I forgot what was written on the wall, may be pt. with
SOB,
I examined and presented in this way 👇
Middle aged male, comfortably lying in bed.

(From bed end, no abnormality, no scar. But this I
didn’t say in presentation, I avoided telling negatives
first)
Pulse... irregular ( rate around 80, had to pay much

attention to make out that it’s irregular, confirmed on
auscultation )
Venous pressure not elevated,
Precordial exsmination revealed apex beat

undisplaced, apart from that I didn’t appreciate any
parasternal heave or thrill.
On auscultation, there’s a faint diastolic murmur in the
mitral area.
Apart from that I couldn’t appreciate any other

murmur and there r no peripheral signs of infective
endocarditis, pulmonary htn or heart failure.
So based on these findings, my diagnosis is that this

gentleman has mitral stenosis with an irregular pulse.
Examiner asked: whether he is in AF? I told i would like

to do a bedside ecg to confirm if he is in AF.
She said but what do u think is he in sinus rhythm or AF
😳
I told, I could appreciate that the pulse is irregular
which is more obvious on auscultation but I’m not sure
if he’s in AF or these are PVCs or PACs
She said is it regularly irregular or irregularly irregular?

😳
I told I’m not sure. However if I’m considering the
diagnosis of Mitral valve pathology so it is possible that
he has AF and probably on rate control therapy since
the pulse is in approximately in 80s
Then she was satisfied 🙄

Then she said what about the nature of apex beat ? 🙄
I said honestly I’m not sure, but keeping in with mitral
stenosis it could possibly be tapping. 😖
Then she said, the how would u manage this pt.

Started with 12 lead ECG to confirm the rhythm
abnormality, echo to confirm the valve lesion and
other parameters as chamber size, plum htn etc.
Then she asked about treatment of AF

I told pharma ( rate control or rythm control) and non
pharma.
Then bell rang
Got 20/20
Stn4:
80 yrs old lady, with end stage kidney disease on

dialysis for 3 years, had stroke and bed ridden for 3
years, also got blind after CVA, got admitted now from
nursing home with increasing SOB and drowsiness.
Earlier she had wished to stop dialysis Incase she
deteriorates so now the doctors think that the time has
come to withdraw dialysis.
On stopping dialysis, she’ll become more drowsy and
might die in FEW days.
So talk to her son ,explain his mother’s condition and
address concerns.
Assume that the son has the permission to discuss his
mother’s condition.
After reading the scenario, I was not sure whether this

is pt’s wish ( autonomy) or the medical decision to
withdraw dialysis.
So I went inside with a confused state of mind, not

knowing exactly what I have to convey.
Anyway, started with the usual greeting, intro, role,

confirming identity, building rapport etc.
Checked his understanding about his mother’s

condition by asking what he knows so far?
He told, actually I’m not living with my mother, I’m far

away due to my business, so my mother has been in a
nursing home since she got stroke and is bed ridden for
around 3 years. Also she has been on dialysis for long
time.
So I started off by saying that as u mentioned, she has

been on dialysis and now she is admitted from nursing
home due to increasing shortness of breath and
drowsiness.
Unfortunately, her condition is not improving.
Then I asked, does he have any idea about his mother’s

wish to stop dialysis?
He said , yes I know my mother has been distressed

and suffered a lot and she doesn’t like to continue
dialysis.
So I said, that now the treating doctor’s think that we

need to stop dialysis ( I tried to repeat the same words
as written in scenario, because I didn’t want to add
anything from my side)
So I continued, that by stopping dialysis, she’ll become

more drowsy and I’m sorry to say that she’ll die soon.
Surrogate was very calm, didn’t show much

expressions
Asked how long will she live ?
I told, I can’t say with certainty, but probably we r
talking about few days rather than weeks or months.
He said, but r u doing this because it’s my mother’s

wish , because she doesn’t want to suffer more?
( I knew this is probably the tricky part.... about which I

was not sure.... that whether it was the pt’s wish that
the doctors are respecting or the medical so decision
because pt. is not improving.... or both factors lead to
this decision...�� so I really didn’t know what I should
say exactly........
So , I told honestly, that “ I’m not very sure that on

which grounds the decision has been made, whether
there is a medical reason behind this or because of ur
mother’s wish, however I will clarify this with my
senior and will get back to u, after our meeting today
😓
( I felt myself very silly in saying this.... that I’m not

sure and I’ll discuss with my senior, but I didn’t have
any other option , I got very depressed at this point
and felt I lost the exam, but instantly tried to compose
myself, further strengthen my voice to mask the
underlying worry and moved on)
He said, can u do me a favor, plz don’t stop dialysis

now, continue for few more months so that I can spent
more time with my mother, because earlier I have
been busy with my business...
(Here, I got the feeling that I should not accept his

request)
So I told, I appreciate ur feelings, but I’m afraid we
can’t continue dialysis against ur mother’s wish , we
have to respect her decision
He said , if my mother agrees then?😳
I said, let me discuss the matter with my consultant as I

mentioned, because if it’s for the medical reason, I’m
sorry to say that we won’t continue dialysis because it
won’t benefit her and will prolong her suffering.
However, if it’s because of us mother’s wish, and if she
is able to take a decision on her own ( competent) we
can sit with her and talk about it.
( in the given scenario, even it was not clear whether

pt. is competent or not, because on one hand it was
written admitted with drowsiness, but in the other
hand, written that son has got permission to talk (
which is usually from a competent pt.)
Anyway, he agreed to it.
Then he said, will my mother suffer when u stop

dialysis?
Here, I mentioned all about palliative care, that she’ll
be taken care of by a special team of experts which we
call as palliative care team, to provide pain relief etc
etc. to keep her comfortable etc etc
Then he said, I want to take my mother home.
Is it possible?
( there was nothing mentioned about it in scenario and

I didn’t want to create something from myself, do I
remained diplomatic again)
I told, let me discuss with my senior about the

discharge plan and will let u know
However , it’s possible to provide palliative care at

home, which can be arranged with involvement of Gp
as well.
He said, do u can arrange a nurse at home, because I’m

busy
I said, we can arrange for community nurse for home

visits and other social support.
I asked about any other concerns, any financial issues?

He said, no, all fine.
So, I checked understanding

Again told him about the plan, that I’ll discuss with my
senior and will get back to u before u leave the
hospital, will arrange social services as discussed etc
and closed the meeting.
Examiner: what do u think, should we continue dialysis
in this lady?
I said, we need to respect pt’s decision based on the
principle of autonomy or if it’s a medical decision , we
must follow ( best interest)
However, I told him that from the given scenario, I was
not sure about it, so I would like to further clarify with
my consultant before conveying it to the relative.
He said, ok it’s not very clear, but what will u do in this

situation, would u continue dialysis for an 80 years old
lady who is bed ridden and blind ,
I said, I will not continue dialysis
He said, yes !!
Then he said, it’s good that u talked about palliative

care.... and u mentioned about home palliative care ,
which definitely can be provided
He asked, do u have any idea about Liverpool end of

life care ?
I told, no
He said, it’s fine , it’s just an end of life care pathway
which provides care at home.
And finally the bell rang

I came out extremely depressed but surprisingly got
15/ 16 Alhamdulillah
Stn 3:
Neuro: young man with difficulty walking

Examin lower limbs neurologically and focus more on
motor system.
Young male, lying in bed

After greeting, intro and consent, went to bed end to
have a general look, looked around , saw wheel chair
partially hidden behind the curtain, no other obvious
abnormality
Exposed lower limbs, no wasting, no abnormal
posturing, looked for any pes caves or hammertoes,
looked for any scars, then checked for fasciculations.
Not there.
Tone was near normal, but clonus was positive, power

was 1/ 5 b/l
Exaggerated reflexes and upgoing planters.
Tried to check for cerebellum by heel shin but couldn’t

do due to weakness, offered to check in upper limbs,
examiner said leave it.
Then Sensations: vague findings, randomly decreased
to pin point at a few points, otherwise normal,
vibration intact and position sense as well, so I ignored
the sensory abnormality.
Offered to check back for any scar, examiner said leave

it.
Then time finished
Examiner: ur findings?
Presented; on examination of this young gentleman,
who presented with difficulty walking, I found that he’s
lying comfortably in the bed and I can see there’s a
wheel chair, so probably his walking ability is
significantly affected.
On neurological examination of lower limbs, I found

upper motor neuron type of weakness as evidenced by
obvious clonus, hyperreflexia and upgoing planters.
So considering these findings in a young pt. I would

consider multiple sclerosis as the most likely diagnosis.
Other differentials;
Freidrich’s ataxia, but there is no pes cavus or

hammertoes and no dorsal column involvement
Spinal cord lesion
Further questions about investigations of MS and

treatment.
Told MRI brain n SC to see plaques , visual evoked
potentials, he asked what other than MRI, told LP to
see oligoclonal bands.
Treatment: General mx by a multidisciplinary team

approach involving neurologist, physiotherapist,
occupational therapist to provide walking aids or other
adjustments to optimize his ability to carry out
activities of daily life and psychosocial support.
Specific treatment, mentioned about interferon if

fulfills the criteria, fingolod ( the oral therapy), and
other 2 drugs which now can’t recall , I think
Natalizumab and 1 more.
Got 20/20 Alhamdulillah
respiratory Pt. with sob, examin chest
A young pt, in 30s, comfortable at rest, had an AV

fistula in left arm.
After bed end inspection, started with hands, nails, fine
tremors ( beta agonist) and flapping tremors etc.
Palpated left arm AV fistula, functioning.
Eyes, face tongue etc
JVP
Had small scars in upper chest ( possibly for central

census access for dialysis)
After inspection of chest, I made him sit upright and e
amines trachea and cricoid notch distance.
Then went behind and examined lymph nodes and

then whole back
Had reduced breath sounds in right lower zone, dull

percussion note and decreased vocal resonance.
No sacral edema
Then completed front examination
Diagnosis: right pleural effusion possibly secondary to

renal failure as evidence by the renal replacement
therapy in the form of haemodialysis through
functional AV fistula.
other differentials ?
Differentials for dull percussion note;
1) pleural thickening but there I would not expect
reduced air entry
2) consolidation but I couldn’t find any other
supportive finding as crackles or bronchial breathing
3) fibrosis but no crackles
4) raised hemidiaphragm
Then investigations n management

Particularly asked in detail about pleural fluid tests
Scored 20/ 20 Alhamdulillah
Total was 165/ 172 Alhamdulillah
Things which helped me in exam, I don’t know how but

I was very calm and remained very confident, fluent
examination and presentations.
Kept talking to pt. during examination, even in stn 5, I

started examination early and asked questions while
examining.
For example, when looking at thyroid I asked do u ever
feel any differently in breathing or swallowing
When reached hands, asked do u ever noticed ur hands
being shaky or ur palms being sweaty etc.
So this helped me in time management in stn 5 and it
seemed to be a natural doctor pt. encounter
I didn’t think much of stn which went bad, like I was

very upset about stn 4.
I didn’t mention any sign which was subtle, unless

examiner asked, and even then I honestly told I’m not
sure, however I’ll do this n this to confirm or I expect it
to be this etc
##############################################
##########################
Glasgow Royal Infirmiry

started with
🔷 BCC1: 75 YR old man with h/o colitis comes with
tremor and slowing of movement..on history he had
foot scruffing on floow, slowing of movement..had
blepheroclonus, monotonus speech, cogwheel rigidity,
small steps..dx was parkinsons disease..got22/28
🔷 BCC2: 75 yr old lady with epistaxis and fatigue had

h/o anemia: inside she had melena, had tenalgiectasia
on tonge , lips..dx:hht, advised for endoscopy to rule
out gi tenalgiectasia..got25/28
🔷 Resp: hyperinflated chest, tracheal tug, reduced
cricosternal distance, productive cough, creps mostly
unilateral..dd- copd, bronchiectasis..got 17/20
🔷 Abdomen: had renal transplant with ballotable

kidney, inactive avfistula, parathyrpidectomy scar, - dx
wad esrd with renal transplant, told pt may be on
ciclosporin as i thought there was gum
hypertrophy..got 20/20
🔷 Cvs: elderly man with esm alover

precordium.radiating to carotids..had radiation to apex
as well..i told as..other candidates told as with mr..i
dont know what i missed..got15/20
🔷 Neuro- this gentle man had weaknes in bizarre

distribution, but reflex was absent, sensory loss in
stalikng distributipn- dd- mixed motorsensory
polyneuropathy due to dm, alcohol, uremia..examinal
pointed to proximal wasting it was gbs..got12/20
🔷 St2 : pt h/o ibs for 2 yrs had worsening of symtoms

for last 6 wks as father was dx with ca colon...had no
weight loss..or feature of malabsorbtion or blood...bt
the trick was he has family history of bowel cancer,
father at age 60, grand father, uncle at 45, and aunt
had endometrial cancer..told it most likely ibs,
however he fits the criteria for HNPCC referred for
genetic testing, and colonoscopic surveilance...i think i
missed something..got 16/20
🔷 St 4 : lady with hemoptysis and loss of weight , she

had ct scan showed mass in upperlobe of left lunfs,
hilar lymph node, and liver mets. Fnac was done and
sample lost..inside..break bad news however dont tell
its definjtely cancer, say its mostlikely cancer,
apologise for lost fnac report, told abt incident
reporting, counsel for further fnac, she was concerned
delay might affect prognosis , i told its already
advanced by i will definitel try to make sure its done as
soom as possible, asked abt prognosis, told its too
early to say, bt definitely will end ur life, asked abt mx:
told its early to discuss, once fnac is done we can
discuss the mx in mdt meeting..showed empathy,
pause at appropiate moment..got 14/16
✔ i recommend ost for history and clinical station..for

station 5 i have read ryder, MRCP PACES manual and
MRCP paces 180 clinical cases..for station 4 i had some
previous bad experience i would recommend ryder, tim
hall and studying previous cases..had courses in ealing
and pastest
Yangon
🔺 Day 1 3rd round
Started with st 3 neuro.c/o difficult in holding object .
O/E..small hand m/s wasting with exgerrated jerk n
+ve hoffmann with sensory normal. cerebellar sign +ve.
Dx MND MS n examiner asked abt MS Invx n Rx.
CVS..PSM in LSE..Dx VSD
✔St 4..meningoccal septicemia
Pt was well apart from some minor illness like common
cold in early morning.then he suffered headache n sign
of meningism n collapse at work.condition was high
fever with GCS7 with rash..gave IV AB n fluid n plan to
shift to ICU.
Explain Dx n manage concerns of wife.
concerns. Outcome(ask several time)., how should she
do to her children.
Examiner ques. Why u say so serious? Contact tracing n
notify communicable ds centre.
I forgot to let her notify to centre.😩
✔St 5..refer to skin clinic from neuro clinic qith
hypopigmented lesion. Inside..vitiligo. with u/l MG
with 6th CN palsy.
Another case.. c/o chest discomfort with H/T with
strong FH of HT n Ht ds. O/E. ESM radiated to neck.
Dx..AS but i put the 1st dx of IHD. 😭😭😭
✔St1..respiration...Bilateral basal crept with hand jt
deformity n clubbing.i put the Dx of PF with UL RA.
Examiner asked abt causes of PF n also ask abt causes
of EAA.n Invx for PF.
Abdomen.. hepatosplenomegaly(but not obvious for
me 😭😭) with UL thalassemia..
i missed liver. Asked abt Invx n Rx.
✔St2.. crampy lower abd pain for years worsen within
these days precipitated by stress with frequent loose
stool with no red flag sign. Strong fam history of bowel
cancer in granpa n uncle.
Dx..IBS.ddx..Bowel cancer n other causes of abd pain n
LM.
Pt concern.. is it bowel cancer?
Any particular drugs do i need to avoid.do i need
regular camera test.n ask abt Invx n Rx.
Examiner ques..drugs which can cause diarrhoea.
Could u tell me which kind of bowel cancer? I said Ca
colon. Asked again..i said carcinoid tumor.then the
nodded head n smile.
Other causes of chronic diarrhoea n bloody diarrhoea.
Will u do the scopy by urself?i said i ll refer him to Gut
specialist. Examiner told me i should explain more abt
colonoscopy.
🔺 Day 3 round 3
station 1
abd : chronic hemolytic anemia
resp : left lung collapse ?
combined collapse with
effusion
station 2
young female with hypertension discuss about
secondary cause of young hypertension.
station 3
CVS MVR
CNS cerebellar syndrome
Station 4
PCKD
Station 5
1) Down syndrome with DOE 2 wks
2) RA with peripheral neuropathy
🔺 Day 2 round 1
History
Back pain: Ankylosing spondylitis vs psoriatic
arthropathy
Comms
SAH want to discharge and go back to Australia
BCC 1 multiple swelling at right upper limb with H&M
???AV Malformation
BCC 2 Uncontrolled HTN with Acromegaly
CVS :
MS +AF+ pul: HTN
PDA?/AR?
Neuro :
Young Parkinson
?Mixed motor and sensory peri neuro
Resp:
Lt Pleural effusion
Dullness at the right base
Abd:
Transplant kidney
Hepatosplenomegaly with Jaundice
🔺 3rd day first round
BCC1 - young lady come with tingling and numbness

hands and feet, refer by OG.
She has cushing face, glove and stocking peripheral
neuropathy, underlying joint disease taking
prednisolone, ibuprofen, hydroxychloroquine. History
of mouth ulcer,skin rash,repeated abortion, taking
antiTB 1year ago.
BCC2- young male, known case of dystrophia
myotonica come with SOB.
He has symptom suggestive of heart failure, recurrent
choking.
Com- 89yr old underlying AF, TIA, come with stroke.
Miss INR appointment and INR 1.2 explain to grandson
and further management plan.
History- type 1DM with recurrent hypo attack, with wt
loss,fatigue, anemia, retinopathy, nephropathy
Abd- hepatosplenomegaly haemolytic anemia?
Neuro - Rt eye ptosis, ?MG. Examiner ask about MG.
But in last second why you dont think horner syndrome
and time up
Resp - collapse, effusion,copd but i only got
effusion😭😭
CVS -Nightmare😥midline scar but no click. AF,
gynaecomastia?, PSM radiate to axilla,also systolic
murmur in LSE.
🔺 3rd day round 2
BCC1 - young lady come with tingling and numbness

hands and feet, refer by OG.
She has glove and stocking peripheral neuropathy,
underlying lupus, APLS with recurrent abortions, taking
prednisolone, ibuprofen, hydroxychloroquine. took
antiTB with b6 1year ago.i failed to ask diet h'o.
BCC2- young male, known case of dystrophia
myotonica come with SOB.
He has symptom suggestive of heart failure, recurrent
choking.
Examiner asked about swallowing tests? I dunno 🙁.
st4- 89yr old underlying AF, TIA, come with stroke.

Miss INR appointment and INR 1.2 explain to grandson
and further management plan.
what they want is DOAC.
St2- type 1DM with recurrent hypo attack,with wt
loss,fatigue, anemia, retinopathy, nephropathy.
i excluded polyglanular. ddx autonomic N: gastric
stasis, ckD. 1 ddx they still want.
Abd- hepatosplenomegaly with anaemia, tinge of J, dx

thalassaemia
Neuro - Rt eye ptosis, ?MG. i gave 4 ddx: ps 3rd nerve

palsy, M.gravis, horner, myot D
Resp - collapse, effusion,copd. Forgot to mention COPD
CVS - AS, AR, MR, but i only got AS.
🔺 2nd day last round

St 2 : Uncontrolled type 1 DM with wt loss & tiredness
BCC 1 : SOB with Hb 9 with Graves
BCC 2 : tingling & numbness sensation with
pseudohypoparathyroidism
St 4 : Malignant melanoma with liver metastasis
Queen Elizabeth hospital.
✔ Station 1
🔹 Resp : ILD
🔹 Abdomen : Poly cystic kidney disease
✔ Station 2 : History of seizures
✔ Station 3
🔹 Cardio : DVR
🔹 Neuro : Myotonic dystrophy
✔ Station 4 : advance pancreatic ca
Discussion with daughter
✔ Station 5
🔹BCC 1 : Syncope
🔹BCC 2 : Hemoptysis
Egypt 5 of February New Kasr Aainy Hospital .3rd day ,

second cycle
✅ Station 2⃣
I Started with st2
Outside a man 30 years old complain of recurrent
collapse and he was known case of type1 DM for 15
years also have atrial fibrillation on warfarin his
current pulse was 56
Inside when I asked open Question he didn't give me
anything so I asked ( before during and after ) and pt
have dizziness when stand from sitting position no
sweating no tanning on his skin and no hunger pain
and no other symptoms like raising of heart or
sweating or weakness or change in color all negative
and this collapse not happened with exercise and no
stomach with small meal and also have problem with
his intimate relationship and impotence and all
symptom of autonomic neuropathy
Then I went to the rest of history he was known case of
hypertension on multiple anti hypertensive medication
and beta blocker
Pt also have atrial fibrillation but controlled and no

symptom of anaemia
Pt have all complication of DM and have poor control
and no regular follow up
Pt on insulin and many antihypertensive and beta
blocker
There was family history of death but the sorugate did
not tell any thing
Also didn't know
Any diagnosis to the cause of death? ? He didn't know
At this point examiner said 2 minutes left and I don't
ask about smoking and alcohol and driving
So quickly ask him did you smoke or drink alcohol he
said no
2-is it serious
So I addressed his concerns put I have no time to tackle

the driving issue and definitely they cut a mark from
this point

I give
autonomic neuropathy as complication of diabetes
Cardiac cause as he has atrial fibrillation but less likely

I got 15
✅ Station 3⃣
☑Cardio
This pt have large volume pulse but for me it's not
collapsing regular
There are ejection systolic murmur in aortic area
radiate to carotid and all over the pericordium
I got 20
☑ Neuro
Ms
Question about how to investigate and how to manage

Got 20
✅ Station 4⃣
Pt 80 year old male came to hospital with obstructive
jaundice
And did CT scan and pt diagnosed and confirm to have
pancreatic cancer and this cancer invade the adjacent
organ
The plan of management is by only paliative treatment
and by place a stent by ERCP
Oncologist decide this pt is not for chemotherapy and
the treatment after doing the ERCP should be in the
community
I went inside

And ask the daughter what she know about her father
She said don't know much so I have to break the bad
news and give her time to express her feeling
inoperable and treatment is by control the symptoms
what is called palliative ttt and let him comfortable
And in your father case we do this by what is called
ERCP
explained what it means and it's camera test and so
on....... and need to sign a concent

I respond to her concern by it will shorting his life ( but
the examiner want to Said it months rather than years
)
other concern to give her father chemotherapy and I
expla
ined to
her this is not going to help him and have many bad
effects and the growth doctor decided not to start
chemo and she agree
Other concern is she need her father to stay in hospital

and I asked why? ?
She said he live alone and no one visit him and she
worry for that
discharge him and we can help him alot by our social
services and palliative teams
At the community and also there was option of hospice
care
She agree
And I didn't talked about complication of ERCP and the
first examiner questions why didn't talked about this
issue
After this point 2 minutes left ask any other concern

she didn't have
Examiner ask why not talk about complication of ERCP

And also ask about hospice and the role of social
warker
Got 8 only 😕
✅ Station 5⃣
☑ Bcc 1⃣
In side man about 50 years have tiredness all the time
mainly with exercise and exertion
Have good balanced diet and pt have bleeding per
rectum and constipation and also family history of
colon cancer
On examination
hepatomegaly about 4cm no other abdominal mass

Other DD mayeloproliferative vs lympoproliverative
especially CML he agree and asked about investigation
and ttt
Got 26
☑ BCC 2⃣
Inside it's clear case of acromegaly with all of the
features
Got 27
✅ Station 1⃣
☑ Abdomen
Young male with
Hematological cause like hemolytic anaemia others are
mayeloproliferative and lympoproliverative
Got19
☑ Respiratory
Got 20
I hope this experience is going to help other candidates
UK EXPERIENCE
Station 4: patient with malignant melonama 10 year

back removed completely and then discharge back to
GP after 5 yr followup now with RHC discomfort not
responding to PPI. LFT cholestatic and US showed
multiple lesion. Explain diagnosis and plan further
investigations.
Too many questions:
R u sure its cancer
Is it back from melanoma
Would it had changed outcome if picked up earlier as
GP delayed it.
What further test
How biopsy is going to perform.
When CT will be done.
Can i do my job. He new about mcmlon nurses as he
wife died 5 yr back of cancer.
Viva around possible primary source.
Social and community support as he lives alone.
☑ Station 2 : type 2 diabetic hypertensive female on
oral hypoglycemics and good glycemic control with
confusion at lunch at a restaurant with a friend. No fall.
No vasovagal. No fits. According to patient her friend
told that She just standed and said where i am and
what is going on here. She said she was fine after 2
hours. She didnt recall what had happened between
these two hours.
Concerns: is it stroke. Is it epilepsy. Can i drive.
Viva on differentials. And investigations. I said hypo vs
epilepsy but I was not able to hit the right one.
Examiner told me it was transient global amnesia.
☑ BCC 1: SOB
?sarcoid as he gave H/O erythema nodosum over shin
that vanished itself and crepts in exam. I was concernd
about weight loss so mentioned malignancy. Viva on
investigstions.
☑ BCC2. Renal transplant with SOB. i was blank as no
clue on history or exam for anemia chest or cvs
problem. He was obese so i checked for myopathy as
wel considering cushing. No tremors. Lungs clear. I
couldnt hit that. Missed to say possible infection in
viva as he was on immunosuppressive. He had av
fistula in left cubital fosa but he said its not being used
for last 3 year but there was a thrill over it.
☑ CNS: LMN type lower limb weakness diminished
reflexes. Peripheral sensory loss stocking patern. I
couldnt go beyond light touch. Time ended. Viva on
causes and investigations.
☑ CVS: Midline sternotomy scar, irregular pulse,
pansystolic murmur more on expiration but no
radiation, loud S2. I was confused if its mitral replaced
or aortic replaced. Mild crepts at bases too. Viva on AF.
☑ Chest: left side crepts with wheeze. Cough full of
secretion. Viva on bronchiectasis.
☑ Abdomen: RIF scar with palpable kidney. Viva on
differentials other than renal transplant for scar/lump
in RIF and also if its renal transplant and this patient
comes with pain what investigations will you do.
whipps cross, UK
✔ St 4⃣ talk to wife of pt with GBS who was initially told

that he will recover but now neurologist revied and
said it's axonal neuropathy so minimal recovery is
expected pt was on mechanical ventilation but
tracheostomy done now and off vent on NG tube
St 5⃣ ✔ BCC 1⃣ : pt had wkness of upper limb and speech
problems recovered now
✔ BCC 2⃣ : young female found collapse in washroom in
a pool of urine
St 1⃣ ✔ Respiratory : obese pt they gave hx of sob pt
had prominent veins in upper torso with full blown
features of Copd nasal canula
✔ Abdomen : young male hx of chronic diarrhoea
abdomen had multiple scar (small) give diagnosis of
Crohn's disease viva causes of these scar, about IBD
and chronic diarrhoea also asked if there is another
scar in lower abdomen transverse what it cud be in
Crohn's pt ( I didn't knew that)
✔ St 2⃣ Hx sob and cough
Gave differentials of EAA ( had a bird at home wt loss
fever ) sarcoidosis tuberculosis and malignancy
St 3⃣ ✔ Cardio : pt with Afib midline scar and harvesting
scar heart failure symptoms and I gave diagnosis AVR
viva about 💓 failure management
✔ Neuro: examine hands and lower limbs
There was Dupuytren's contracture and lower limbs
there was sensor y loss to all modalities of sensation
with downgoing planters viva on causes
That was all
Whipps cross hospital
🔷 CVS - MS scar bioprosthetic valve replacement

(unsure mitral or aortic) with flow murmur
🔷 CNS- UL unilateral hyperreflexia otherwise NAD
🔷 Communication - GBS post ITU, d/w wife poor
prognosis, long term plans
🔷Respiratory - tachypnea on O2, crackles on the left
not clearing post cough, no wheeze
🔷Abdomen - renal transplant
🔷 St 2 Hx - cough, wt loss for 6 months- extrinsic
allergic alveolitis
🔷 BCC1- fever and sore throat - HIV
🔷 BCC2 – TIA
Cairo New Elkasr Elainy hospital
3 February 2018
1st day third cycle

Abdomen was old man around 70 years old.. the
positive findings were he had pallor, infra midline scar
with no mass under it, splenomegaly around 8 cm.
Actually i couldn't complete examining the groups of

lymph nodes in the axilla as the patient was talkative
speaking alot interrupted me too much and the local
examiner was trying to calm him....
Discussion was about the findings.. I said my positive

findings as above..
DD I said to him the first possibility is infection and

because we are in Egypt I have to consider bilharsiasis
firstly, other infections also should be considered like
chronic malaria, leishmaniasis...
Other DD will be CLD but against that the absence of
stigmata of CLD..
he asked what else I said it could be malignancy he said

like what?
Here i stucked😳 and I didn't know what to say.. I said
could be primary or secondary.. he asked secondary
like what I said like Mets from liver or peritoneal
cancer� (actually at that moment I became frozen
minded on the causes of secondaries in spleen rather
than saying myelo and lymphoproliferative diseases 🙈
)
He asked oki what investigation you will do? I said

apart from basic investigation in the form of CBC,
ESR,CRP, LFT,RFT I would like to do abdominal
ultrasound to confirm my finding.. then specific
investigations accordingly..
He said ok what will be the cause of anemia in this

patient?
I said could be due to hypersplenism that is why I need
to do CBC to check for pancytopenia ..
and also anemia could be due to hematemesis
secondary to oesphageal varieces if he had CLD..
Then he asked me again what will be the type of

malignancy in such old patient 😩
And again I was doing like this� forgetting to say myelo
and lymphoproliferative diseases.. he said ok let us go
to the second case..
after the exam I remembered the lympho and

myeloproliferative disease �and I knew that I will loose
4 degrees in DD and clinical judgments skills
But I got only 12 �
Respiratory
was also around 65 to 70 years old lady she was very ill
and wears alot of clothes in which i lost much of my
time.
So I started by General examinations she was dyspnic

and had exessive dry cough then i asked her to sit. I
examined the trachea which was central and she had
decreased cricosternal notch distance with tracheal
Tug..
Then i examined the back which showed decreased
expansion bilaterally and there was resonant
percussion note with dullness bibasally..
auscultation revealed wide spread rhonci with
vesicular breathing with prolonged expiration and
bibasal crackles (I couldn't detect whether it is
changing with cough or not because the pt was
coughing too much and she was talking alot through all
my examination and the examiner was trying to calm
her... which disturbed me too much😩😩) when I was
checking for vocal resonance in the back the examiner
said you have only one minute left😳
So I asked her to lie down.. again some time lost in

undressing her so I checked only chest expansion and
percussion from the front...
they asked me present your positive findings.. I said as
above (and the summary was features of obstructive
lung disease with bibasal crackles mostly due to bibasal
fibrosis )
so he asked me about the features of OLD? I said it

again... and he said to me oki what will be the cause of
crackles here other than fibrosis? I said could be due to
bronchiectasis... he became happy and asked me what
is going with bronchiectasis here?
I said the features of OLD.. but he asked what else? I
didn't find what to say as she had no clubbing.. not
cachexic and no productive cough..
Then asked me about investigation and details of what

you expect to find in CXR in OLD and bronchiectasis ...
Then asked me about findings in HRCT in both

bronchiectasis and ILD... and asked what other
important tests I said pulmonary function test looking
for obstructive features and sputum for Culture and
Sensitivity and sputum for alcohol and acid fast bacilli..
the bell rang and I get 16
Station 2
The scenario out side was 35 years lady complain of
left sided weakness lasted for 3 hours today morning..
So I wrote in my paper my DD of all causes of
hemiplegia in the young..
Entered out side after greeting the surrogate and

aggreed the agenda i asked her about her job ( she was
shop assistant)
I analysed all the presenting complaint fully and asked

about all the CNS symptoms and then asked about all
my DD list then brief systemic review to the related
symptoms only then PMH and medication history ...
the positive information was left sided weakness

lasted for three hours and completely recovered now...
it happened while she was in the hair dresser.. and her
neck was extended there...
No facial weakness no problem in vision no loss of
control over her water and bowel motions...
She had severe headache continuous till now.. mainly

in the back of her head.. I asked about all patterns of
aura in details it was associated with flashes of light
only.. she didn't sleep well for the last 2 days with
excessive drinking of coffee in the last few days..
she had some stresses in her life...

the headache started before the weakness and
continued till now...
she had headache for long times but it was coming in
mild attacks except the current attack is the most
severe one.. she was not sure of the nature of the
current attack...
And she didn't seek medical advise about her headache
in the past because it was mild..
All the other causes of hemiplegia in the young were

negative....
PMH was only mild asthma not on medications.. and I
asked about all risk factors of TIA which were
negative..
Drug history only revealed she is using combined oral
contraceptive pills..
I started to ask about the stresses in her life, at that

time the examiner said two minutes left😳
So I run 🏃🏻♂🏃🏻♂ to ask about family history which
was negative.. and smoking and alcohol which were
negative..
Asked her what is your concern she gave me 4 or five

concerns at once😩
What is the wrong with me?
Is it stroke?
Will it happen again?
And what is the treatment?
I told her I appreciate your concerns and i need to
examine you but most likely you have condition called
Hemiplegic migraine with brief explanation..
and I need to admit you to hospital and you will be

seen by MDT mainly by the brain doctor and
appointment with the mood doctor regarding her
stresses...
And replied to her concern is it stroke by saying it is

less likely to be stroke because you recoverd now.. but
still there is possibility of mini stroke that is why we
will do for you some blood test and imaging for your
brain and tracing for your heart... and told her the
treatment will be planned mainly by the brain doctor..
and i advised her to stop the women pills and we will
give her another safer contraceptive after consulting
the woman doctor...
Most likely I forgot to answer the concern of will it

rehappen again because it was many concerns and I
replied to it with explaining the plan of management
so I had to cover alot of issues in short time �
The examiner asked me how did you manage her

concern� 😳
I said yes and repeated all my answers as I replied to
the surrogate ...
Then he asked me will it rehappen again? I said yes
since it happened it can happen again..
Then he asked what is your DD?
I said in order:
Hemiplegic migraine
TIA
Stroke very less likely..
And he agreed..
He asked about plan of management. I replied the

diagnosis of migraine is mainly clinical diagnosis but I
need to exclude TIA by doing ECG, Echocardiography,
Carotid doppler ultrasound, CT Brain... and all
secondary causes of TIA should be checked as BP,
Blood sugar, complete lipid profile, coagulation
screening and vasculitic screening...
and if we found any risk factor we should control it...
Then he asked me about the management of acute

attack of migraine and what medications used to
prevent it.
I got 18😉
Station 3
CVS
the patient was around 60 years old lady tachypnic the
pulse is regular very weak even difficult to palpate it
the patient is pale, JVP is elevated and had bilateral
lower limb edema..
Also she had hugely distended Abdomen obviously

tense ascites... she had midline sternotomy scar, the
apex beat is thrusting in nature and had parasternal
heave and second palpable heart Sound and also there
was thrill over the aortic area..
In auscultation the first heart is clicky metallic, second

heart is also clicky metallic, she had pansystolic
murmur at the mitral area radiate to the axilla, and
also another systolic area increased with inspiration at
the left sternal border most likely tricuspid
regurgitation..
Also She had ejection systolic murmur at the aortic
area radiate to the neck...
The examiner asked me present your positive findings I

said as above.. but I decided not to comment about
pulmonary hypertension fearing from inventing sign🙃
He asked me about basic and specific investigation

especially the INR and findings of Echo in details...
then asked me about type of anticoagulant I will give? I
said warfarin... he asked me any place for NOAC I said
no..
Time finish I got 18 �
CNS
it was my most difficult station in the exam.. examine
the lower limb of gentle man around 40 years...
He was unable to raise his right leg and it was

externally rotated and there was small wounds over
the leg.. the other leg was normal..
I found hypotonia and hyporeflexia in the right knee..

some college said it is normal tone�
I couldn't examine the right leg because there was pain

and the examiner told be to be careful about it...
The pattern of weakness was equal power of flexors
and extensors around the hip and knee... abductor
weaker than adductor... distal weaker than proximal...
The planter was up going in the affected side... mute

on the other side...
Coordination was difficult to interpret because the

patient was able to do it well till the mid of shin then
becomes impaired, I repeated it again with the same
finding � the coordination was normal in the other leg
during both opened and closed eyes...
All modalities of sensations are lost till the knee going

with peripheral neuropathy...
I asked to examine the gait he said pt can't walk...

Asked to examine the cerebellar in upper limbs the
examiner said it is lower limb only...
So asked me present your positive findings I replied as

above... and in summary there is features of pyramidal
weakness with peripheral neuropathy for DD
He asked about my DD (Till that time I couldn't find

suitable Picture explaining my findings 😕) so I said the
first possibility in the presence of peripheral
neuropathy is subacute combined degeneration of the
cord but against it it is unilateral rather than
bilaterall...
He said what else I said it could be multiple sclerosis

supported by the bizarre asymmetrical presentation
but against it the presence of peripheral neuropathy...
He said how you are going to investigate him if it was

MS I said by MRI Brain and spine looking for plaques..
lumbar puncture looking for oligoclonal bands...
And delayed visual evoked potentials..
He asked what is your treatment for acute attacks I
said admission and IV steroids..
And in chronic cases the treatment is by oral
fongolimod and beta interferon if there is indication..

I got 12
Station 4
Very long scenario about 50 years old male known case
of end stage heart failure on maximum anti failure
management and the cardiologist says this is maximum
treatment he can give..
He had abdominal pain... on examination they found
that he had abdominal mass... CT abdomen done and it
showed results very likely to be left kidney cancer and
they found Mets in lungs and... vertebrae and lymph
nodes... Lymph nodes biopsy confirmed lymph node
Mets due to left kidney cancer..
The oncologist said the prognosis is very poor and he is
only for palliative treatment...
I entered inside, after greeting the surrogate and

aggreed the agenda... I asked him would he like to
invite any one to attend the meeting? he said actually
his wife is outside but he is not willing her to attend
because he would like to know firstly by himself what
is going on with him then he will see what to do next...
I asked him what do you know about your condition?
He said I have only heart failure and I am struggling
with it...
I said yes you are right, and also you had tummy pain
and we did for you imaging to your tummy, do you
expect any thing in particular or do you have any idea
what could be the cause?
he said yes they told me there is some abnormalities

but I think it is due to heart failure...
I said yah Mr ramy I am afraid to tell you are not right...

and I am sorry to tell you that the results is not as we
hope then great silence �
He cut the rope of silence and said what is there

doctor?
I said I am deeply sorry to tell you that it showed you

have nasty growth in your left kidney.. again great
silence �
He said sadly and with wondering face: doctor how is

that I had only heart failure how is that...😢
I said to him with empathy I can feel how these news
are shocking for you.. and I know it is very hard to
absorb it.. but I am so sorry to tell you that we are sure
about the diagnosis... and i gave him time to ventilate
more...
And then said I am sorry again to tell you that the

cancer had spread to other parts of your body as your
lungs and lymph glands and back bones... and brief
silence then alot of empathy and sympathy...
He asked doctor when I will die?

I said it is difficult question because different types of
cancer behave differently from patient to patient but
definitely it will shorten your life.. sorry again.
He asked again when will I die?

Here i said it will be months rather than years...
He asked is there any treatment?

I said sorry because your cancer had already spread the
cancer doctor said there is no curative treatment just
we are going to treat you by palliative treatment, have
you any idea about it? He said no..
I explained palliative in details with examples of

symptoms that can be controlled by palliative... and
told him about the team of palliative one by one
including the McMillan nurse and cancer doctor and
pain control team and community palliative team and
spiritual support and social worker and heart doctor as
well...
and i reassured him you are not alone in this and you
will be always under our eyes... and to keep you
comfortable is our goal be sure about this👍🏻
do you have any concern right now?
He said I love to do building and l love to take heavy

objects...
I said I highly appreciate your hobbies but I am

concerned about your health, now your back bones are
already weak and fragile, may be if you lift heavy
objects you may get fracture, so it is better to think
again about this. He agreed...
He asked again that he loves travelling around the

world' Can He continue this?
I Advised him that you had heart failure and now your
lungs is also affected by the cancer... so I advised it is
better to avoid traveling by air plane but if you insist
you have to consult your GP to assess your condition
before travelling . He agreed...
Here the examiner said two minutes left

I said what is your concern?
He said he can't tell his wife..

I told yes I can understand this, may be because she is
caring about you, and you are afraid of telling her this
news, so if you don't mind bring her with you next
meeting and we will tell her in good way don't worry.
he agreed..
Then I asked about job and smoking...
and Said To Him We had alot of talk today would you

like to tell me the main points you got from our
meeting and checked understanding and offered help
and support...
Examiner questions were about ethical issues and

some details about palliative treatment. and step
ladder medications used to control pain especially
morphine and I said that also it can help him to relief
pulmonary edema ... and how he can travel other than
by air plane? I said by car...
I got 16 out of 16 ��
Station 5
BCC 1
Was middle age female complain of weight gain and
muscle weakness...
I entered inside it was weight gain for the last year

with normal appetite and no change in food, the
weight gain is allover her body, no cold intolerance,
she had constipation, menorrhagia, difficult to stand
from sitting position, falling of hair... dryness in skin...
there was no symptoms of Cushing or acromegaly..
I didn't find any cause of secondary hypothyroidism as

thyroidectomy or amiodarone treatment.. no
symptoms of subacute thyroiditis, no postpartum
thyroiditis as the last delivery was before 6 years...
No hx suggestive of hashimoto thyroiditis as there was

no neck swelling nor hx of autoimmune diseases nor
family hx of autoimmune diseases...
I examined pulse... skin and nails.. offered Bp and Bs

check... proximal Myopathy... neck for goiter and
scar... eyes... tongue for macroglossia... hair for
falling... Abdomen for striae... lower limb for edema
and rash.... I did also ankle reflexes...and examined for
carpal tunnel syndrome and offered chest and CVS
examinations...
The only positive findings were proximal Myopathy

and abdominal straie...
Concerns were about the diagnosis and whether it is
treatable or not... I replied it is most likely primary
hypothyroidism and explained it and said it is
controllable by thyroxine replacement....etc
Examiner questions about investigations and causes of

uncontrolled hypothyroidism although of
medications...
And how you are going to follow the pt and every how
long... etc
I got 27�
BCC2
was 40 years male had diminution of vision..
It was for the last year with intermittent symptoms of

vision problems of gradual onset in both eyes
associated with pain in eye movement and redness. He
had mouth ulcers and genital ulcers... hx of recurrent
blood clots.. and lower limb red rash but now fade
away..
No headache, no shortness of breathing, no chest
pain...
No abdominal pain..no loose motions . he had right
knee pain... I asked briefly about SLE and pemphigus
vulgaris..
Drug hx.. many drugs containing prednisone and
azathioprine...
Fhx nilly
Social hx not significant
Not driving no smoking and no alcohol...
I examined visual acuity, visual field, offered fudoscopy

but the examiner told me it is normal...
I examined the eyes and mouth... did auscultation of
the chest... examined radial pulse and offered Bp
check... examined the knee...
And I asked for tape to check DVT he said you can
examine it without tape... examined peripheral pulses
in lower limbs... offered examining for genital ulcers
also but they said no need..
Actually there were no positive findings...
The pt concerns were many😳

What is the cause? Is it treatable? Is it infectious? Is it
hereditary?
I answered all his concerns, and explained to him about

behcet disease and it is clinical diagnosis but there is
some suggestive test.. and told him about ttt and MDT
and offered social help..
Examiner asked about the other DD of mouth ulcers I
said SLE and pemphigus vulgaris...and what is
difference between them and behcet...
Investigation I said it is clinical.. but we can use

pathergy test..
He asked me is it diagnostic?
I said no is only suggestive...
He asked any more test ?
I said yes HLA B51
The bell rang 🛎

I got 28��
Alhamdolillah I passed with total score 147

Yangon Myanmar
🔹 Station 1
Resp Bronchiectasis u COPD
Abdo : col (Cirrhosis of liver)
🔹 Station 2 medications overused headache u
migraine
🔹Station 3
cvs asd
Cns cervical myelopathy;bilateral small muscle wasting
of hands
🔹Station 4 : SJ$ after delivery
🔹Station 5
bcc 1 neurofibromasis : difficultly to control his
hypertension
Bcc2 grave n type 1 dm ; pt present with polyuria n
weight loss
Myanmar, diet 1
St 1⃣
✔ Resp : Pleural effusion ✔ Abdomen : ADPKD
✔St 2⃣ Analgesic misuse headache with Underlying
Migraine
✔ St 3⃣ : ✔Neuro : 3,4,6 Opthalmoplegia +5
V1involvement(Mulitple cranial nerve palsy)
✔ Cardio : Lone MS
✔ St 4⃣ S J Syndrome in recent delivery
St 5⃣
✔ BCC 1⃣ : Neurofibromatosis with Uncontrolled
Hypertension
✔ BCC 2⃣ : Hyperthyroid with Wt loss and Polyuria
BEST OF LUCK to u all!!Keep calm and Victory will be
urs!!!FIGHTING!!
Egypt 5 of February New Kasr Aainy Hospital .3rd day ,

second cycle
I Started with st2

Outside a man 30 years old complain of recurrent
collapse and he was known case of type1 DM for 15
years also have atrial fibrillation on warfarin his
current pulse was 56
Inside when I asked open Question he didn't give me
anything so I asked ( before during and after ) and pt
have dizziness when stand from sitting position no
sweating no tanning on his skin and no hunger pain
and no other symptoms like raising of heart or
sweating or weakness or change in color all negative
and this collapse not happened with exercise and no
stomach with small meal and also have problem with
his intimate relationship and impotence and all
symptom of autonomic neuropathy
Then I went to the rest of history he was known case of
hypertension on multiple anti hypertensive medication
and beta blocker
Pt also have atrial fibrillation but controlled and no

symptom of anaemia
Pt have all complication of DM and have poor control
and no regular follow up
Pt on insulin and many antihypertensive and beta
blocker
There was family history of death but the sorugate did
not tell any thing
Also didn't know
Any diagnosis to the cause of death? ? He didn't know
At this point examiner said 2 minutes left and I don't
ask about smoking and alcohol and driving
So quickly ask him did you smoke or drink alcohol he
said no
2-is it serious
So I addressed his concerns put I have no time to tackle

the driving issue and definitely they cut a mark from
this point

I give
autonomic neuropathy as complication of diabetes
Cardiac cause as he has atrial fibrillation but less likely

I got 15
Station 3
Cardio
This pt have large volume pulse but for me it's not
collapsing regular
There are ejection systolic murmur in aortic area
radiate to carotid and all over the pericordium
I got 20
Neuro
Ms
Question about how to investigate and how to manage

Got 20
Station 4
Pt 80 year old male came to hospital with obstructive
jaundice
And did CT scan and pt diagnosed and confirm to have
pancreatic cancer and this cancer invade the adjacent
organ
The plan of management is by only paliative treatment
and by place a stent by ERCP
Oncologist decide this pt is not for chemotherapy and
the treatment after doing the ERCP should be in the
community
I went inside

And ask the daughter what she know about her father
She said don't know much so I have to break the bad
news and give her time to express her feeling
inoperable and treatment is by control the symptoms
what is called palliative ttt and let him comfortable
And in your father case we do this by what is called
ERCP
explained what it means and it's camera test and so
on....... and need to sign a concent

I respond to her concern by it will shorting his life ( but
the examiner want to Said it months rather than years
)
other concern to give her father chemotherapy and I
expla
ined to
her this is not going to help him and have many bad
effects and the growth doctor decided not to start
chemo and she agree
Other concern is she need her father to stay in hospital

and I asked why? ?
She said he live alone and no one visit him and she
worry for that
discharge him and we can help him alot by our social
services and palliative teams
At the community and also there was option of hospice
care
She agree
And I didn't talked about complication of ERCP and the
first examiner questions why didn't talked about this
issue
After this point 2 minutes left ask any other concern

she didn't have
Examiner ask why not talk about complication of ERCP

And also ask about hospice and the role of social
warker
Got 8 only 😕
Station 5
Bcc 1
In side man about 50 years have tiredness all the time
mainly with exercise and exertion
Have good balanced diet and pt have bleeding per
rectum and constipation and also family history of
colon cancer
On examination
hepatomegaly about 4cm no other abdominal mass

Other DD mayeloproliferative vs lympoproliverative
especially CML he agree and asked about investigation
and ttt
Got 26
BCC2
Inside it's clear case of acromegaly with all of the
features
Got 27
Station 1
Abdomin
Young male with
Hematological cause like hemolytic anaemia others are
mayeloproliferative and lympoproliverative
Got19
Chest
Got 20
I hope this experience is going to help other candidates
UK EXPERIENCE
Station 1⃣
☑ Resp: kartaganers
☑ Abdo: splenomegaly +/- hepatomegaly
Station 2⃣
☑ History: medication overuse headache
Station 3⃣
☑ Cardio: AVR with dextrocardia
☑ Neuro: CMT
Station 4⃣
☑ Comm skills: son of COPD patient not for ITU and
consider home NIV
Station 5⃣
☑ BCC 1 : GCA
☑ BCC 2 : gastroparesis in T1DMHistory: medication
overuse headache
India
St2 : young male with backache with stiffness ,worried
about job & life
St 4 : female with pckd
Abdomen : CLD with portal hypertension
Resp: Lobectomy
Cardio : Vsd
Neuro : spastic paraparesis
Bcc1 : treated Psoriasis dark coloured patches..??
Bcc2 : Goitre with palpitation.
St 2⃣ : was backache with osteoporosis

Viva was about osteoporosis
✅ St 4⃣ : about diabetes compliance issue with
medicines including anti hypertensive, aspirin + issues
like diet ,smoking,alcohol
✅ BCC 1⃣ : 55 years female came with sudden vision
loss with background dm , had to do fundoscopy
✅ BCC 2⃣ : headache,with blurring of vision,acromegaly
diagonosis
UK EXPERIENCE
Station 1
☑ Resp : not sure
Reduced breath sound and vocal resonance on left
side, DDx Pleural effusion, Pleural thickening
☑ Abdo: Renal Transplant
☑ Station 2 Recurrent Hypoglycemia
Station 3
☑ CVS: Metallic MVR and PSM
☑ Neuro: peripheral Sensory motor neuropathy
☑ Station 4
85 years old lady
ESRF on dialysis, recent ICH
SOB and drowsiness
Patient wish not to dialysis if condition deteriorating,
Renal reviewed and said not for dialysis
Task to explain to patient son
Station 5
☑ BCC 1: irregular menstruation for 6/12
DDx: PCOS, Hypothyroid and hyperthyroidism,
pituitary causes
☑ BCC 2: Diabetic Retinopathy
UK EXPERIENCE
✔ Bcc1 Carpal tunnel on a pt with acromegaly

✔ Bcc2 was very unclear. Female with tiredness
lethargy for 3 months. Weight loss also. No symptoms
at all. Couldn’t examine properly but all were normal.
Depression like symptoms present. Asked about
possible differential diagnosis. People were telling that
it is a hiv case. I think I missed that
✔ Resp case bi basal crepitations in a patient with ? L/
pancoast tumour
✔ Abdomen patient with midline laparotomy scar and
ileostomy like thing, others were telling it is an ileal
conduit. I’m not sure what it is.
✔ History taking is young female with recently
worsening IBS with father recently diagnosed bowel
carcinoma.
✔ Neuro this gentleman presented with difficulty
walking, examine upperlimbs. Bilateral cerebellar
signs. Nothing to suggest aetiology.
✔ Cvs young male with midline sternotomy and
bilateral thoracotomy scars and mechanical ht sounds.
Not sure what it is. High arch palate also.
✔ St 4 : patient presented with stroke thrombolysed
and now GCS dropping. Large ICH. No neurosurgical
intervention. Explain to the wife. Breaking bad news to
angry relative.
Queen Elizabeth
✔ Station 1⃣ : spleenomegaly ,ILD

✔ Station 2⃣ : collapse
✔ Station 3⃣ : peripherals neuropathy ,systolic murmur
✔ Station 4⃣ : explanation to daughter regarding mom
whose having pneumonia ,high curb score
Discuss managements
✔ BCC 1⃣ : headache likely tension ,
✔ BCC 2⃣ : Dymennorhea took 16 tabs of cocodamol
Queens elizabeth hospital, 8th March

✔ ST 4 : IBS discuss diagnosis and consultat advice
amitriptaline.
Be aware of side effects.
✔ St 3
Cardio AF! No clear murmur.
Neuro/bilateral weakness more in left side a n impired
sensation on left side only.
✔ History: Female with breast cancer brought to
hospital for admission!
Going inside found to be metastatic disease with pain
and fatigue.
Discussion causes and plan.
✔ St 1
Abd:spleno megally with wt loss.
Chest/sings pf COPD in short patient.cyctic fibrosis!
✔ St5
✔BCC 1
Lady with both hands joint pain and RT foot pain - First
metatasal.
History of cancer
✔ BCC 2
Lady with headache.
Tension?space occuping lesion?
UK EXPERIENCE
St 1⃣
CKD with multiple scars and active fistula. No mass
beneath scar in RIF. Multiple scars for PD
Idiopathic ILF
St 2⃣
40 year female with lower backache and fatigue
ongoing for few months.
History showed inflammatory arthritis with psoriasis
St 3⃣
B/L classical cerebellar signs
Offered D/D
AR/MR
Examiner was not happy
St 4⃣
Counsel husband re poor prognosis for hemorrhage
into infarct (patient is his wife) following thrombolysis.
St 5⃣
BCC 1⃣ Psoriatic Arthropathy with lung Fibrosis.
Patient was on prednisone for 13 years with no bone
protection.
BCC 2⃣
58 year female with fall. ED doctor said it is trip but
patient disclosed some visual issues. On probing to
history she said she had problem while seeing
upwards. PSP came into my mind but no features for
PD. She was also on thyroxine but clinically euthyroid.
Offered thyroid eye disease and PSP in D/D
UK EXPERIENCE
St 2⃣ :chest pain ,4 episodes ,,elder dm, HTN pt

St 4⃣: delay diagnosis of advance malignancy ...pt has
repeate endoscopy, cxr,abdo us, then after 1month Ct
chest done
Station 5⃣ :
BCC 1⃣ :lethargy ,weakness in young lady post delivery
BCC 2⃣ : back pain in 39 lady with history of radiation
and surgery pituitary gland on hydrocortisone
St 1⃣
Abdomen : ADPKD
Resp : Bronchectasis
St 3⃣
Neurology : diabetic pt with unilateral pes cavus..loss
of refexes..wasting leg muscle ...loss of joint position
and vibration only ??
Cardiology : not sure of diagnosis
Galsgow, diet 1
✔ History : Chest Pain, typical of GORD

✔ Communication- : Lady with Barrett's oesophagus
,two OGD were normal and CAT showed malignancy
scanerio
✔ BCC1_ Lady on levothyroxin presented with neck
swelling - enlarged thyroid
✔ BCC2- Diabetic man presented with blurring in Right
eye for one week, fundoscopy showed laser
photocoagulation,
✔ Abdomen - Renal transplant with midline
laparotomy scar
✔ Resp- ILD with clubbing
✔ Cardio- AS with MR
✔ Neuro- Homonymous quadrantanopia
Sudan .. Khartoum exams
Day 2 cycle 1
St. 1 . lobectomy .. hep splenomegally +J @A
St.2 APKD
S.3 AVR + Muscular dystrophy
St. 4 MD
S. 5 Transient v. loss + bilateral hip pain + J @A
My MRCP PACES experience , Yangon , Diet

3/2017 Date 10.11.2017
Started with station 2 , A case of 24 year old
lady present with recurrent headache off and on
for 2 year duration, surrogate clearly gave
typical features of cluster headache, concern
was is it a brain tumor? Planning for pregnancy,
possible drug effects on my baby? I was asked
about DDx, management plan, possible drug
effects on pregnancy?? Got (18/20)
Station 3
CVS , it was a case of AS, asked about DDx,
severity and management plan, Got (15/20)
Neuro , it was a case of multiple cranial nerve
palsy , there were 3rd N, 6th N, 5th N, 7th N 9,
10, 12 CrN palsy with hemiparesis , asked about
DDx, and management plan. (Got 19/20)
Station 4 Communication and ethics
It was a case of counseling son about the
palliative treatment for Advance interstitial lung
disease of his father. Respiratory team have
suggested palliation to which father
agrees.Asked about ethical principles of the
case. (Got 16/16)
Station 5
BCC 1 RA with anemia (Got 28/28)
BCC 2 DDx of chest pain in 35 year old Lady,
patient have xanthelasma above her eyelids
with strong family history of premature CVD. （
Got 28/28)
Station 1
Respiration , it was a case of COPD with
bronchiectasis, on examination, there was
obvious features of COPD with coarse
crepitations on Right upper and middle zones.
Asked about DDx, and management plan ( Got
20/20)
Abdomen , it was a case of jaundice with
splenomagaly, I could only give DDx coz there
were no sign of chronic liver insufficiency and
features of chronic hemolytic anemia. (Got
16/20) Luckily, I passed with (160/172) Best of
luck to all candidates who are going to sit for
PACES in the future. 😊
Rest experience about other station in chennai:
station 4 functional weakness. Examiner wanted
clinical psychologist not psychiatrist. Got
15/16.Station 5: psoriasis with hand joint pain.
D/d was psoriatic arthritis , RA,osteoarthritis,
gouT and pseudogout . Got 28. Case 2 was
hemoptysis in a man of 60 yrs. D/d was ca lung,
TB, Pneumonia and vasculitis and blood
coagulation problem. Got 28. Advised about
smoking stop
My experience about other stations in chennai:
station 2: hereditary angioedema. Asked details
about precipitating factors of angioedema
including dental extraction. And about
danazol.18/20 Station 3 was pure Mitral stenosis
and neuro was hemiplegia.got 20/20 in each.
Staion 4: functional weakness in a
physiotherapist. Apologised first because
everybody was telling that she was facking.
my experience kolkata on 24.11.17. st5) pt with

SOB for 6 months, inside I found pt with RA with
hand deformity taking MTx for 5yrs. I got
bilateral basal creps, anaemia, lots of concerns
to answer st5) pt with sudden loss of vision for
last 3days with a pt with congenital bicuspid
aortic valve, inside rt sided complete loss of
vision with mydriasis, pale optic disc. I said
could be clot in the vessel, dd was MS, st1)
bilateral basal creps with rheumatoid hand
asked dd ild, heart failure, bronchiectasis st1)
cld with tattoo, flapping tremor,rigid abdomen
asked lot about investigation st2) hereditary
angioedema, asked about dd st3) CABG,
saphenous vein graft scar with systolic murmur,
splitted 2nd HS, I said ASD but may be MR st3)
Cranial nerve examination, I found rt sided
homonymous hemianopia, asked about causes
:stroke,MS, ICSOL I told wanted to know detail
about interpretation of visual evoked potential
test st4) explining about the uncertainty of CT
report with a pt with seizure. need further MRI.
this was very easy but I didn't read the scenerio
throughly as it was long and I was exhausted. I
just told you have brain tumor and need MRI to
confirm that. ...... examiners were very angry
about my communication. I will get 0 in this
station. . . ALLAH IS KIND, ALMIGHTY. if he
wants, i will pass only.
Diet 3 2017 wishaw general hospital glasgow
I began from station 2: middle aged male with
cholestatic pattern of LFT ,4 week history of
sudden onset ,started after use of co amox for
recent chest infection
All viva on causes of cholestatic jaundice
20/20
Station 3
Cardio : MR with AF 20/20
Neuro: left sided hemilaresis with distal muscle
atrophy and some sensory signs ,upgoing plantar with
absent reflexes
I thought i messed this station but got 20/20
Station 4 : counsel son about his father health
Father has advanced IPF poor prognosis resp team
have suggested palliation to which father agrees 16/16
Station 5 :
Bcc1 uncontrolled hypertension for last 3 months past
history of wegeners
Clinically gynecomastia , distended abdomen with
stria
Cushing syndrome ,all discussion with examiners
about sec causes of hypertension
28/28
Bcc2 : GP letter (assess this lady with jaw pain and
swelling)
.clinically patient had enlarged submand ,post
cervical lymph nodes
No B symtomes,no resp signs
Discussion on differentials
23/28
Station 1
Resp :elderly lady with left sided scar mark on chest
with crackles at bases
I struggled to give plausable differetial for lobectomy
10/20
Abdomen : lady with gross jaundice ,palmar
erythema ,bruises ,spider nevi and hepatomegaly
All discussion on causes of jaundice in the setting of
chronic liver disease
15/20
ALHUMDULIAH i passed
Pass paces london course prior to exam was really
helpful ,but practice as much as possible prior to
exam and be confident on exam day
Dont argue with examiners and give reasonable
differentials
My exam experience
SQUH Oman 15/10/2017 ,, carousel 3 :
Station one : Bronchiectasis 20/20 , Renal
transplant 20/20
Station two : SLE ( with antiphospholipid $
)19/20
Station three : Double valve replacement 20/20 ,
neurology : Muscular Dystrophy (mostly Becker 😉)
20/20
Station four : medical error of chest infection
presented with confusion and given amoxicillin, he is
penicillin allergic and it was noted in his previous
notes and also his daughter told the doctor at
presentation, he collapsed , he was given epinephrine
and corticosteroids and his hypotension improved ,
but still confused. 15/16
Station 5 : BCC1: optic atrophy in epileptic pt taking
phenytoin , he was prescribed ethambutol and
rifampicin for TB 6 weeks ago and since then he has
color vision problem more on right eye. 28/28
BCC2: MEN1 , pt presented with recurrent
hypoglycemic episodes he was operated for lithotripsy
6weeks ago and his sister also has done lithotripsy. (
one of my colleagues said he has also acromegaly
although I asked him and he has no acromegalic
features and has normal visual field ) 28/28
Pass 170/172
I can’t say how much I am grateful to my teacher Dr
Ahmed Maher Eliwa for his support throughout this
difficult journey.
I want to thank also my brothers Dr Khaled Magdy ,
Eslam Zahran and Ashareif Ahmed for their great
efforts and their prayers for me.
My paces experience...
Addenbrooke's hospital, Cambridge UK...
Station 3 Lady having a routine checkup, gp
found a murmur and referred, there was a
sternotomy scar with no graft scars, a
pansystolic murmur, AF, edema...MR with Post
CABG with AF
Station 3 Man having difficulty in walking,
peripheral neuropathy, questions regarding
causes, investigations
Station 4 A dental nurse having sputum positive
tb, having some risk factors about exposure,
Task was to explain and give Mx plan for tb and take
consent for hiv testing
Station 5 A man with abdo pain, from outside there
were features of shock, inside he has a diagnosis of
ADPKD with functioning fistula, h/o haematuria, I
gave a dx of clot retention and colic, examiners not
happy
Station 5 A 25 yr old female with blackout, dx case of
epilepsy for 6 yrs, I couldn't find the cause, I didn't
do the neuro examination, examiners not happy
Station 1 A man with huge hepatomegaly, ascites,
edema, no spleenomegaly, Chronic liver disease,
Examiners wanted me to say it was NASH, I couldn't
Station 1 A man with cough and breathlessness,
Bilateral fine crepts, ILD
Station 2 A man with headache for 2 wks, on query a
bit clumsy recently, forgetfulness, I gave dx of
Normal pressure hydrocephalus
Overall average exam with bad station 5s...
Rest depends on ALLAH...
Mdy day 3 first round

Bcc 1 left sided weakness left sided
homonymous hemianopia
Bcc 2 systemic sclerosis
Station 1 massive splenomegaly +
hepatomegaly
(Other Obstructive Jaundice)
Bronchiataxis
Station 2 known Asthma worsening
(Beta blocker + cat?)
Station 3 ASD?MS?
(Other Ms+ Ar)
Station 4 angry relative - C. Defficil moved to
side room.
Son angry about doctor didn’t wear glove
doctor. Dont want to know about why moved to
side room
Started from st 2 pt complaining of SOB and
tiredness pacemaker insertion 1 year back last check
up was six months ago HB 108 MCV 85.
Also have long

St 4 lady complaining of weakness of leg and arm all
examination are normal ct normal
Station 4 lady concern that one of nurse told her that
she is faking for her symptoms
st 5 graves opthalmopathy
Ulnar and median nerve palsy
EGYPT .. Cairo 2017

Station 4
Scenario Noora is 64yrs old lady é history of COPD
and recurrent hospital admissions admitted few days
back è an exacerbation received antibiotics and
developed diarrhea . She had been diagnosed è
c.difficle infection given the appropriate antibiotics
for that but regarding her chest condition she is not
improving and even deteriorating . Her daughter
want to discuss her condition with a doctor and the
nurse warned u that she is angry.
Inter the room greeted introduced made a rapport(
job), r u the NOK ,agreed the agenda , she
immediately attacked me saying i know that the
doctors and the nurses her get bored of my mother
due to her repeated admission i answer no we never
get bored of our pt . Then i asked what due know so
far about her condition she answered she is
deteriorating and even she developed that diarrhoea
and i had been informed that she have some bug
called c.difficle i explained it to her that this is
friendly bug found in our guts but when some one
gets certain antibiotics the balance between those
bugs disturb and this bug can cause diarrhoea some
times dilation of our gut and rarely can cause a hole.
She said but i red in the internet that bug can come to
the hospital admitted pt may be from other pt and i
think she gots it from yr hospital i answered her yes
this us possibility and the bug can be transmitted by
direct contact but this is unlikely because our hospital
have a very strict guidelines and rules and we have a
specialized team to manage such issues she convinced
and her anger decreased , then she asked what u will
do for her i said antibiotics to treat the bugs were
already started with some fluids and close monitoring
. Then she said i want to stay è her i said sorry this is
not possible because will spread the infection and also
we are going to move yr mam to srperate room until
she clears the bug . She said can i visit her i said yes
but è certain precautions the nurse will explain for u
later on such as hand washing after direct contact .
She said can i get the infection my self i said it is
possible because u r young and healthy and not
taking any medecine it is unlikely.
She said and regarding her asthma she is
deteriorating what u will do i answered does she have
any advance directive because the next few days will
be difficult and vital decisions should be made
regarding her health she answered no she doesnt
have my mother is very optimistic life loving lady she
looked sad and teary i empathized è her i asked her
about job early she is a teacher and she can not
handle the matter a lone i offer social worker help she
seems satisfied . I asked any other concerns. Check
understanding summarized offered availability
The britich examiner ques : why u think she is angry i

said just she needs explanation empathy more time all
this after checking the level of her understanding and
the source of her information . He asked about ttt and
inv for c. Difficle and further management of her
COPD he kept asking waiting to me mention help
from the microbiologist .16/16
Station 5
Headache è visual problem inside pt with a surrogate
to take history with very few signs of acromegaly with
no bitemporal hemianopea . His height is about 150 to
160 cm only big hands and foots and prominent
supraorbital ridge and interdental separation
examiner asked frankly about field defect and
macroglossia i said no they
r not present .inv, treatment options 27/28
Bcc2
Shoulder joint in a diabetic
Ask about the usual history of a joint pain plus any
trauma any other joints skin rash and dont forget
about DM for how long , medecation , complications
macro and micro , whether he is following with the
diabetic nurse
Examined the shoulder
Diff.diagnosis is adhesive capsulitis and charcot joint
ques about inves and management of the former one
28/28
Station 5
Headache è visual problem inside pt with a surrogate
to take history with very few signs of acromegaly with
no bitemporal hemianopea . His height is about 150 to
160 cm only big hands and foots and prominent
supraorbital ridge and interdental separation
examiner asked frankly about field defect and
macroglossia i said no they
r not present .inv, treatment options 27/28
Bcc2
Shoulder joint pain in a diabetic
Ask about the usual history of a joint pain plus any
trauma any other joints skin rash and dont forget
about DM for how long , medecation , complications
macro and micro , whether he is following with the
diabetic nurse
Examined the shoulder
Diff.diagnosis is adhesive capsulitis and charcot joint
ques about inves and management of the former one
28/28
EGYPT ,,October 2017
Station 4:
I start with greeting son , introduces myself and
confirm that he is the son and ask him if he want
someone to attend this meeting and then ask him how
much he knows about his father condition and if he
wants to know everything ,, and explain for him y we
are here ,,,, then I explain for him more that his
father has scaring of some part of his lung and this
the cause of he recurrent chest infection and usually
treated by steroids and it was given to your father but
unfortunately his blood sugar became uncontrolled
because this steroid also caused of high blood sugar
that's y we stopped steroids
and
all these decrease his defense system and more
infection
Then I explain for him the current situation ,, ur

father this time admitted with chest infection and we
treat him he is improved but his previous lung
condition now getting worse Iam so sorry for that and
the chest team looking for him decide that there is
nothing can be do to improve his lung condition but
we keep care for him to avoid more infection and
make him comfortable as much as we can ,
Then discuss the needs of oxygen also at home and we
can arrange this and help him with the occupation
worker and social worker and also discuss with him
the home conditions and the precautions such as stop
smoking ,, keep fire far ,,, and if anyone has infection
or even flu to be far from father because he can get
infection easily and because of his lung condition it
will be more severe,,,
I asked him his concern at the middle he said want to
know what going on his father
Also at the end I asked him if he has any other
concern
The son was angry but I tried to clam him and I keep
saying to him we are here to help u and ur father
Also I told him it's great thing that u r looking for
him and I keep to tell him that I appreciate yours
worries regarding your father condition and so on
From same colleague:
Station 5 BCC:
First one :
30 years old male with left side vision loss
Inside his sister with him I took information from her
I analyze the Vision loss and and neurological
symptoms ,, no other symptoms
Past history of similar condition on same eye 2 years
ago improved after 3 weeks
Then I ask the permission to examine while talking
history
Start with visual acuity, field and then fundoscopy ,,,
optic atrophy
I complete history while doing this then ask concern
Explain for him his problem
Then discussion about finding and diagnosis I said

MS because of past history of similar condition and
age and relapse and remitting
Scored 24/28
2 : history of weight gain and fatigue

Start by analyzing weight gain and appetite and so
history going with hypothyroidism I exclude briefly
other causes of weight gain
Then start to do examination while asking rest of
history
Start from hand , proximal myopathy, neck , knee ,
delayed ankle reflex examination was normal
And then ask concern explain for her that most
probably gland problem and so ,,
Discussion about diagnosis , investigation and

treatment
Scored 28/28
It is just a bad luck..

Pray with me for this candidate success in the next
diet
Station 2 :
Type 1 diabetic on insulin C/O fatigue
Analysis of all other autoimmune diseases but no
other symptoms
Family history mother Rheumatoid Arthritis
Discussion on other autoimmune disease cause fatigue

If not what , I said also chronic fatigue syndrome ,
fibromyalgia
Respiratory case
PACES Exam;
55 year old male with nicotine stain, clubbing
and unilateral coarse crepitations on right lower
base.
No weight loss or any other sign suggestive of
malignancy. Afebrile. No sputum pot.
Qs; What did you find?
Ans: Based on my above findings, possibilities
are;
1.Bronchiectasis
2.Infection
3.Cancer
Qs; What is your diagnosis ?
And; As patient is not having fever etc infection
is less likely. As there are no other signs
suggestive of cancer such as Cachexia,
lymphadenopathy, wasting of small muscles of
hands, Horner, or lymphadenopathy etc,
malignancy though a D/D seems less likely. So
first possibility is Bronchiectasis.
Qs: There is no sputum, how it can be
bronchiectasis?
Ans; There is an entity of bronchiectasis called
Dry Bronchiectasis, so that may be possibility.
Qs: So you think it's not a cancer ?
Ans; It's a possibility but not my first diagnosis
based on the clinical clues.
Qs: How will you proceed
Ans; I need detailed history. The need to
examine rest of the systems too, such as
abdomen for any clues of Amyloidosis.
Then labs tests including inflammatory clues,
chest X-ray, PFTs and HRCT.
Qs: If it's a cancer, which one is more likely?
Ans: Smoking stains favour SCC or Small cell.
But given the fact that small cell is mostly
metastatic, so that is less likely given this
patients clinical findings. So if it's a cancer,
which I think isn't the case, it's likely to be SCC.
Bell rings. You apply the gel and move
PACES Abdomen Case
45 year old male with facial plethora, reddish
congested conjuctiva, massive
SPLEENOMEGALLY till umbilicus and Mercedes
Benz scar in upper abdomen.
Examiner stops you while you say "Oh" when
you detected spleen & asks
1. what's your diagnosis?
Ans; likely Polycythemia Rubera Vera based on
above mentioned signs.
2. Why there is a scar?
Ans; possible liver surgery which may be transplant.
3 Why he would need liver transplant ?
Ans; he may have had Budd Chiari with acute liver
failure ending up in transplant.
4. Anyother reason for scar?
Ans; there may have been anyother reason for
hepatobiliary surgery which may not be related to
PCRV.
5. How confident you are about PCRV
Ans; that's one of the most likely possiblity based on
the signs. Will like to look at tests which have been
done such as Hct, ABG,Epo, RBC mass etc.
Bell rings. That was a true exam scenario. Passed
with full marks.
2017/3 Mandalay Day 1 2nd Cycle

Station 1
Respiratory
Bronchiectasis
Abdomen
COL
Station 2
Hemiplegic Migraine
Station 3
Upper limb Examination
Cervical Myelopathy
CVS
MS with AF
Station 4
BBN about Adenocarcinoma of Pleural Fluid with
uncertain origin
Station 5
1
New abnormal movement in Parkinson disease
2
Patient presents with Blurred Vision
Fundus Bilateral Optic Atrophy
thanks for all of your help. I have eventually

passed my MRCP.
It wasn't a smooth journey as I only passed at
my third attempt, all three attempts in 2017.
But one thing I can be sure is: never give up.
=)
Diet 1: Eastbourn Hospital, England
Station 1a Respi: bronchiectasis.
experience:
My dx was collapsed consolidation: reduced
breath sound over left LZ with dullness on
percussion.
trachea deviated to the left.
The whole experience was horrible. The patient
was tachypneic with RR 28bpm, I can't see
oxygen around and the patient felt too
exhausted to take a deep breath for me to
assess breath sound quality and nor to listen
for any adventitial sound.
He can't even mentioned ninety-nine properly
because of SOB.
Examiner's comment: finding sign that was not
presence. Their marking scheme only expect b/l
crepitation with the diagnosis of bronchiectasis
(but i confirmed with other candidate, they DID
appreciate tracheal shift and reduced lung
expansion one sided).
The patient anyhow has bronchiectasis, thus
collapsed lung can happen which I am not
surprised. If you are doing respi round, the respi
finding change from hour to hour esp for patient
with chronic lung.
My score: 8/20
1b Abdomen: hepatosplenomegaly
Very straight forward but the leader of examiner
just minus 2 marks WITHOUT any reason
written as opposed to College's instruction's to
examiner.
The co-examiner minus a lot of marks here and
there (the reason was i didn't examine lymph
nodes). Also marks was deducted for
discussion session for vague reasons.
I just barely pass the station.
Frankly, I felt it was a bias based on my
previous performance in respi.
My score: 13/20
Station 2: History
young guy with murmur and presyncopal
attack.
My diff: HOCM, bicuspid valve with AS (as he is
put on ACEi)
Examiner's comment: not clear about DVLA part
for pre-syncopal attack (minus two marks for
adress patient's concern)
My score: 18/20
Station 3A CVS: CABG with AVR
i didn't know what I was doing. I missed the
scar. I missed the metallic click. Which I
couldn't forgive myself
I have no arguement.
My score: 8/20
Station 3B Neuro: Friedeich's ataxia.
First time in my life seeing this. My bad.
I picked up mixed UMNL and LMNL, but i missed
cerebellar signs.
I offered those unlikely diagnosis like MND and
syringomyelia.
Fumbling the whole sessions. Dropped the
tendon hammer, the pin. The whole examination
was uncollected and unorganized.
i have no arguement.
My score: 6/20
Station 4: comm skill -
To counsel for prophylactic colectomy for a
middle age guy with chron's syndrome who
remain asymptomatic for 20 years.
Surveilance scope and biopsy revealed high
grade dysplasia.
Examiner comment: poor listener, did not
adress patient's concern whether repeat biopsy
is needed. Did not explain enough that the
surgery is really needed (which i think i did).
My score: 14/16
Station 5A (BCC1): DM retinopathy
Another not realistic station that I felt unfair.
Scenario: a 50 yo lady with u/l DM c/o blurring of
vision, I was asked to assess.
My experience:
history i got: BOV for past 9 years, laser to the
both eye was done. At the same time he also got
"increased eye pressure" which is painless, was
put on eye drops.
She was under regular ophtalmologist follow-up
and her vision was better compared to first
presentation 9 years ago. The scheduled follow-
up appointment was the next day.
DM control has been good. HbA1C all the while
within range.
I asked her, if this is all about her visual
problem, why she need to see me today for
blurring of vision? As she was already well
taken care.
She said she was here to review blood result:
ANCA test.
I was stunned. I could only tell her her result
was still pending (not mentioned anywhere in
the stem)
Examiner comment:
Didn't check visual field (my bad), didn't
perform fundoscopy (I tried but i can't, her eye
can't be dilated because of glaucoma. It is really
difficult to do fundoscope on undilated pupils).
The whole feedback form didn't mention a
single word about ANCA. The answer was DM
retinopathy.
But my viva session was to offer diagnosis if
ANCA positive.
Seriously, the whole questions VS patient's
script and marking scheme wasn't tailored.
My score: 14/28
Station 5B (BCC2): Malaria
Scenario: a ward sister p/w fever for 1 week with
some bowel symptoms.
Further history revealed travelling to Africa for
hols, didnt take doxycylin as instructed.
I am from an endemic country and malaria is my
bread and butter. Nth goes wrong for this.
My score: 28/28
Generally, i failed the exam badly. Major
problem is from my own insufficiency esp CVS
and neuro station, that I have no excuse.
But I still think that the respi (putting an ill
patient), abd (minus marks without solid reason
written) and BCC1 (patient didn't give the
tailored scenario) were sth out of my control.
Diet 2 Raigmore District Hospital, Inverness
Station 1A Respi: Interstitial Lung Disease
I gave prov diagnosis of bronchiectasis
Examiner comment:
slow and didn't complete all examination (minus
3 marks for examination),
didn't consider ILD for the first diagnosis,
although i mentioned in differential (minus 2
marks)
My score: 15/20
Station 1B Abdomen: Alcoholic liver disease
My finding: hepatosplenomegaly with chronic
liver stigmata
Examiner comment:
slow (minus 1 mark)
no hepatomegaly but only splenomegaly (minus
3 marks)
brief management plan (minus 1 mark)
my score: 15/20
Station 2: Hitory (late onset ashtma)
Scenario: A elderly lady with underlying RA on
MTX, presented with on-and-off SOB relieved
with bronchodilator.
patient concern: is the MTX made her suffer
from all this? I said possible, need ix and need
rheumato opinion.
She was freaked out and said her joint pain rely
so much on MTX and if stopped, she coudn't
cope.
The whole session turned out to be like another
com skill station =/
My diff: pulmonary fibrosis either due to RA or
MTX
Ddx: COPD due to partially reversible symptoms
with inhaler
Examiner comment:
-didn't consider asthma (surprisingly only
minus one mark!)
-Appeared unpractised and not systematic
about history taking (minus one mark)
-Clinical judgement (minus 1 mark, sorry I can't
read what he wrote exactly)
my score: 17/20
Station 3A: Mixed aortic valve disease
my finding: systolic and diastolic murmur
everywhere with irregular pulse.
i gv diagnosis of mixed mital valve disease with
AF
examiner comment: basically saying that every
sign i found was wrong.
A bad failed, have nth to say.
my score: 10/20
Station 3B: inclusion body myositis-
asked to examine the limbs as patient has
difficulty to perform daily task (didn't specify UL
or LL)
However, the patient's LL looks grossly
abnormal.
Given the question, I had dilemma but opted to
examine the UL first, as time running out, i
skipped sensation and check LL.
Examiner comments:
-poor time management (minus one mark for
examination)
-didn't check sensation, difficulty in
presentation (I was hesitating what to say),
couldn't pick up all sign (minus 2 marks)
-ddx given was peripheral neuropathy, an
acceptable differential but didnt thought about
muscle pathology (minus 2 marks)
-no time to discuss ix and mx, need to be
prompted (minus 2 marks)
my score: 13/20
Station 4 Comm skills
OGDS revealed sth highly suspicious of
maglinant ulcer. biopsy taken.
my task was to counsel for CT-TAP for early
staging before establish the diagnosis of
malignancy.
Examiner's comment:
-too fast to talk about metastasis (minus one
mark for patient's concern)
-didn't recognize urgency of repeat biopsy if
initial biopsy doesn't find evidence of
malignancy (minus one mark for clinical
judgement)
My score: 14/16
Station 5A BCC1: post stroke syndrome
Scenario: a middle aged gentleman with
spontaneous abnormal movement of left UL.
Past history of ischaemic stroke, DM, HPT
I didn't examine properly the neurology system
and took it for granted as the diagnosis was
obvious.
And, apparently, this is very very wrong thing to
do in exam =(
Examiner comments:
didn't asked about DM control, asked a lot of
irrelevant qs, wasted time
didn't check reflex to show UMNL etc
didn't address patient's concern about driving
despite multiple time of asking (I didn't realize i
didnt answer him)
general comment from examiner: generally have
a good idea what he is dealing but appeard
unfocused, need to spend valuable time to what
is relevant to the case
First time ever, I spotted the diagnosis, and
scored so so badly,
my score: 10/28
Station 5B BCC2: coeliac disease
young lady with hx of DM type 1, family history
of pernicious anaemia,
p/w chronic diarrhea
I offered all DM related complications, TB gut,
IBD
i ever thought of coeliac, scrutinized hard but
failed to get relevant diet history.
And I failed badly as I didn't mention coeliac the
whole scenario.
My bad, during theory we are always taught to
considered coeliac regardless of diet history as
some patients couldn't colerrate their
symptoms well with food ingested.
AND I did this mistake in PACEs.
my score: 13/28
Generally this is a fair exam. I found nth wrong
with the organizer and definitely all were my
shortcoming.
My advice: BCC is so so so important that if you
failed BCC, you failed the whole exam.
Diet 3: Sungai Buloh Hospital, Malaysia (no
formal feedback yet)
Station 1A Respi:
my finding: young cachexic guy with finger
clubbing,
very reduced a/e at right lung, with dullness on
percussion, increased vocal resonance and
fremitus
BUT trachea deviated to the LEFT.
I heard bronchial breath sound at the left lung
but forgot to mention
I can't tell a diagnosis. I said collapsed
consolidation, ddx included lung mass,
pneumonia
I didnt mention TB and the examiner wasn't
happy. The whole discussion focus on TB and I
knew i missed sth important
my score: 13/20
station 1B: massive hepatosplenomegaly
without chronic liver stigmata
a smooth station.
focus of viva: MDS and malaria,
I was also asked about mx of Kalaazaa disease
since i mentioned it, and i said I dont know but
will consult ID physician.
my score: 20/20
Station 2 History
A weird station. It was exactly like another
communicaton skills.
An elderly with metastatic colon CA refused
chemo/surgery, on high dose morphine and
codeine.
P/W chronic constipation but no abd pain and
able to pass flatus.
My task is to identify the problem, and identify
the problem from patient's point of view.
Clearly is side effect of opiates.
Yes, it turned out to be another com skill.
Differential: progression of CA with subacute
intestinal obstruction.
my score:20/20
Station 3A CVS: ?? Loud murmur
A middle age gentleman.
During 5 minutes waiting, The offier incharge
actually rush out from the room to get s/l GTN!
In station 3, i was asked to examine neuro first
while awaiting patient to settle down the chest
pain.
During examination, i can only heard loud
murmur at LSE.
I can't time the murmur properly, the heart rate
is fast!
I said systolic and it was wrong!
I offered diagnosis of AR due to peripheral
signs.
the examiner ain't happy with my physical
finding.
my score: 11/20
Station 3B neuro: likely friedreich Ataxia
A young guy with b/l cerebellar sign.
After prompting only i was able to tell there's
hypertonia and reduced reflexes.
Diff includes metabolic/drug causes and
congenital causes and NPC
The examiner hinted me for B12 deficiency as a
cause as well (what other metabolic cause? how
about vitamin?)
my score 19/20 (I failed so badly for Friedreich
Ataxia during first attempt hahaha)
Station 4 com skills
scenario: a young fireman who has been
working for 7 years,
recently diagnosed to have BA.
In fear of losing job and reluctant to tell his
superior and fiancee.
A lot of shortcoming:
- I forgot about stop smoking,
- forgot about occupational specialist (until I got
hinted during discussion: who else you need to
refer, who else, who else x3??)
- I mentioned that he couldn't get fired just
because of BA as he was protected by labor law
against discrimination. The examiner asked me
which law and i said i don't know.
The shook their head.
surprisingly my score: 16/16 (what? they made
me felt so bad in exam)
Station 5A BCC1: seronegative arthropathy
young guy with underlying IBD post subtotal
colectomy with ileostomy,
presented with migratory big joint pain and
(resolved) eye redness
Checked the joints: all looks fine. not
inflammed. No skin rashes.
Stoma site normal.
Diff: all seronegative arthropathy. They stopped
me for checking ankylosing spondylitis and said
"definitely normal, don't waste time."
Mx: symptomatic, control the u/l disease.
Ensure his IBD is also ok.
Viva: more focus on IBD and stoma
surprisingly.
My score: 28/28
Station 5B BCC2: anaemia likely UGIH
an elderly with ESRF secondary to one sided
nephrectomy post trauma (I know it is not logic.
He should have normal renal function with one
kidney).
P/W lethargic and HCMC anaemia.
further history revealed epigastric pain after
ingestion of analgesia for mechanical joint
pain,
also history dark stool (he coudn't differentiate
malaenic stool or hematenic stool).
examination:
right iliac fossa has a well healed scar with
weird feeling underneath.
Initially i told that is a vague mass, differental
included anaemia TRO ascending colon CA
Apparently the examiner wasn't agree with me
that there's a mass. She hinted "since there's a
scar, what else could it be, for the vague mass
you felt at RIF"?
I said could be only scarring tissue underneath
and she nodded.
my score: 27/28
Overall i passed.
I didn't think I wasn't good enough. But I could
feel my improvement throughout these three
diet. =)
Some advice from two times of failure:
1) Practice physical examination and be really
fast (and accurate).
2) In station 5, even you spotted the diagnosis,
do routine things, don't skipped!
3) Don't wait for prompting during presentation.
Don't stop talking unless you are stopped. i got
minus one mark just for "needprompting"
4) Choose centres that you can communicate
well with patients. I got deducted mark for "poor
listener".
5) DVLA, DVLA and DVLA
6) Try only mention things that you know well.
Chance is they will ask further based on what
you say. But.....
7) It's ok that we don't know certain thing that is
too subspecialized, but we need to know to
consult which party (and volunteer about that)
8) BCC aka Station 5 is so so so important that,
if you failed both BCC, then you consider failed
the whole exam.
If you passed both BCC nicely, you can
compensate a lot of loss mark from other
stations. INVEST IN BCC.
Thanks for reading. Good luck to all who are
sitting for exam.
Thanks to all who have shared your knowledge
and experience that helped me pass the
exam. =) appreciated.
PACES Neurology Case:
67 male with long standing type II diabetes and
BPH, now admitted with weight loss, night
sweats and Bilateral leg weakness and urinary &
bladder disturbance- examine and proceed.
Findings detected by the candidate, on exam:
Urinary catheter
Reduced sensations uptill mid abdomen
Weakness with reduced tendons reflexes including
ankle and knee
Upgoing planters bilaterally
Cachexia
Rest of exam couldn't be done due to shortage of
time.
Qs;
What's diagnosis or D/D
How would you justify your diagnosis
Investigations
How to manage ?
Kochi 15/11/17
3rd Carousel
#CVS - Metallic aortic valve
#Neuro - hemiplegia
#Resp - right upper zone crepts. ? Consolidation
#Abdo - Renal transplant
#History - 29 male, diarrhoea for 6months since
returning from Himalaya, chronic sinusitis for 2 yr.
Past history of meningitis and knee infection.
#Communication - talk to son. Father who has
dementia, admitted with pneumonia, started on
antibiotic. Son not happy and keen on alternative
therapy.
#BCC1 - Long standing RA, taking MTX,
Leflunomide, prednisolone for 10yr, ongoing pain.
#BCC2 - 67 male with palpitation and SOB.
Hyperthyroid symptoms with goitre. Past history of
asthma on ventolin inhaler
Kochi 16 November
#St1.
ILD.
Splenomegaly/ Ascities. Portal hypertensionChronic
liver disease
#St2
Young lady with Tiredness. Type 1 DM.
In the station . Pt has hypothyroid symptom
hypogonadism
Likely APS2
#St3
PSM . I think it is MR
Parkinson
#St4
Med error.
Pt admitted for pneumonia . Has good recovery.
Given wrong type of insulin nd hs hypoglycemia
#St5
Young lady . Tiredness and Short stature.
Pt denied every symptom .
Apart from tiredness does not have any positive
symptom of hypothyroid. Addison or chronic disease.
No past med h/o . No family h/0. All family memeber
are short.
St 5 old man with hand pain
Alhamdulillah, I passed my exam in Golden

Jubilee National Hospital, Glasgow on 18th
November 2016.
Station 2: Painful right knee in a patient with
ESRF on regular HD, AF on warfarin.
Cardio: MR in AF with CABG scar.
Neuro: UMN signs in bilateral lower limb- MS
Station 4: Breaking bad news- multiple sclerosis.
BCC1: multiple joint pain- osteoarthritis
BCC2: light headedness and sob in a 52 year old man
with history of UGIB. On examination he has MR
(likely MVP) in AF.
Respi: left Lung transplant, right lung fibrosis,
underlying psoriasis.
Abdomen: Tinge of jaundice in middle age man.
otherwise no other signs. Diagnosis: likely
autoimmune chronic liver disease.
first of all thanks almighty Allah for passing

paces exam in kings mill hospital Sutton.
station 5
bcc1 young lady with shortness of breath, chest
pain, no history of hemoptysis,green
sputum,fever, weight loss,joint pain and
deformities,rash, no scars both front and
back,pansystolic murmur throughout
precordium,dds vsd,mr,tr but no other signs
suggestive of alternative diagnosis,so i said vsd
most probable diagnosis, i did ask about
concern during history taking but forget after
finishing exam. examiner specifically ask did u
adress her concern .got 25
bcc 2
old lady with bloody diarrhoea,history revealed
2 weeks duration, weight loss,no drug history,
on examination deforming arthropathy both
hands,no eye signs,no previous history of
bloody diarrhoea. concern was cancer.i
explained the need for camera test.examiner
asked about diagnosis, gave dds ibd, infectious
diarrhoea,carcinoma colon.examiner asked
what infections. forgot salmonella,shigella etc
😣.got 25
station 1 chest young obese lady lying
comfortably in bed.examination of back no
scars.very fine crackles at right lung base .rest
of exam normal. examiner asked about
diagnosis. interstitial disease. examiner asked
did u notice any sign? I said only fine crackles.
he then showed me tacrolimus.i said may be pt
has renal or liver transplant. forgot about
double lung transplant 😣 😣 😣 got only 4
abdomen
middle aged overweight lady with xanthelasmas
around eyes no other signs .examiner asked
about diagnosis. dds pbc ,psc.examiner how
would you investigate .anti mitochondrial
antibodies, alp, lung biopsy. got 19/20
station 2
young man with history of recurrent skin and
sinuses infections since childhood. now loose
motions for 4 months after visiting Himalaya.
too extensive history including hiv
exclusion,warm infestations, celiac, cystic
fibrosis,ciliary diskinesia.examiner asked about
management. referal to infectious diseases unit
for thorough work up including genetic testing
after stabilising pt.got 17/20
station 3
cardiology metallic aortic valve prosthesis ,no
murmur. examiner asked why pt is getting tired
easily. mechanical destruction of rbcs leading
to anemia.got 16/20
neurology
peripheral neuropathy. straightforward.
examiner..cause
diabetes,alcohol,drugs,vitamins, 20/20
station 4
talk to the son of an old lady admitted with
pulmonary edema secondary to lvf. concern
was cardiac transplant. i explained generally
about transplant and arrange meeting with
transplant coordinator. explained about futile
outcome. got 13/16
got 139/172
Good evening every body ,I will share my experience

in exam last diet on october in New kasr Aliny
hospital
I started with ST2 instruction is that 35 yrs old female
c/o joint pain for the last 6 months, investigation wise
shown lymphopenia, inside she has hands pain in
both proximal &distal with stiffness more than one
hour, no other joint pain &no back pain,no rhynod's
phenomenon, no skin rash or rash on exposure to the
sun ,no mouth sore or sore in private area,no hair
falling, no skin tightness or difficulty in swollening, no
difficulty in combing hair or standing from sitting
position,no fever or change in body wt,she took
ibuprofen with no benefits, she has two episodes of
miscarriages (at age of 13&15 wks),has
hypothyroidism since 5 yrs on thyroxine125mcg &she
compliant to her medication &her peroid regular
&on OCP,no children, has positive FH of RA (her
mother)she working as secretory ,other systemic
review were negative, her concerns she affraid to
have RA like her mother &difficulty to cope with her
job&want to be pregnant,I told her that your
symptoms didn't look like RA ,you have a condition
which called APLS leading to your symptoms, so we
should do some blood test to confirm it &referring
you to occupatinal physicians to help regarding your
job &Obs&gyne to solve your pregnant issue.
Examiner asked me what's your diagnosis, I told
APLS,he said what's positive findings guide you to
that I said recurrent miscarriages &lymphopenia,he
said how to investigate, I said lupus anticoagulant,
ANA,ADSDNA,Anti smith ab&forget anti cardiolipin
Ab, he said what's simple test to diagnosed SLE I said
couldn't remind now , he asked about medication
used before been pregnant i said Asprin &S/C
heparin,then asked would you give the pt another
NSAID for pain I said no ,I will give according to
slepladder controls for pain he said like what, I I said
opioid then bell rang
I got 20
Will continue others stations in comming post.
Station1
Respiration: COPD & bronchiectasis
Abdomen: splenomegaly (Thalassaemia)
Station2
joint pain & fatigue for 2 weeks,
H/o of mouth ulcers
inside: knee & ankle joint pain
diarrhorea & H/O of DVT
Bechet's disease
Station3
CVS: MS ?MR
Neuro: left sided hemiplegia (young stroke)
Station 4: Hungtinton's disease
Station 5
BCC1: reduced urine output for 2 weeks, H/O of
knee pain
BCC2: pain& tingling sensation for one month,
H/O of DM for 7 years,not taking regular
treatment
inside: H/O of anti TB for 1 month & vegan for 5
years
Yangon (10.11.17) Second Round

Station 1 a.COPD with bronchiectasis
b.Left sided pleural effusion Ca lung
Anemia with splenomagaly DDx
Station 2 Cluster headache
Station 3 a.AS
b.MS MR Pulmonary hypertension
a.Multiple cranial nerve palsy
b.Proximal myopathy
Station 4
Talk to son about palliative management of
advanced ILD
Station 5
BCC 1 RA with NSAID induced anemia
BCC 2 DDx of chest pain in 35 year old Lady
Best of luck to you all!!!
Chennai 10.11.2017
Functional disorder
Weakness, physiotherapist assistant)
(Examiner don't like me referring to psychiatrist, he
wants clinical psychologist)
Station 5
(Skin problem for 2 years, taking treatment, hand
joint pain 3mths, rt ring finger swollen 3 days)
I put DD of gout, dactylitis, septic
2nd BCC
Hemoptysis
LOW LOA (+) no fever significant smoker
I gave DD Lung cancer and TB
I heard reduced VBS in RUZ
others said normal
asked me tb treatment and investigations
Station 1
RESP RUL consolidation with pleural effusion with
underlying copd
Gave DD of consolidation
ABD- AVF+ hepatomegaly
(Others said there's also single ballotable kidney, I
didn't get)
Station 2
Facial swelling and lip swelling relieved 2-3 days after
injection of burmeton and steroids
On asking no itchiness, no breathing problems. H/o
recurrent abd pain, one time removed appendix but
biopsy came bk as normal. Asked details about
allergy and env change all negative.
I gave DD as HAE and allergic reaction
He asked specific investigations.
What if C1 inhibitor level normal and raised C5?
What are precipitations?
Cardio - pure MS
NEURO- hemiplegia
(Prompt is difficult walking so I asked to patient to
walk, it took so long)
chennai 3rd day 1st carousel

[08/11, 16:53] : Today was my exam. Start from
St 1 : ADPKD with hepatomegaly. went very
well. Respiratory case couldn't complete
properly even they didn't give me any warning
just dirrectly tols finished. case was as I found
left side lower lobe crackles. I put DD : Lower
lobe localized fibrosis, Localized
Bronchiactesis. Bt seems examiner not happy. It
may be Pleurisy bt I don't know. St 2: Senerio 30
years old man present with Cough, Malaise and
haemoptysis. History goes favour of Wageners
granulomatosis. Looks examiners agree
[08/11, 16:53] : St 3 : Night mare for me specially
CVS. Middle aged man comolain of Chr
breathlessness examine CVS. Pain Rt wirst I
asked want to check collapsing pulse told no
need. Found apex just let. to midclavicular line
and thr was diastolic murmur. which rediate to
axilla. Also found Diastolic murmur at Tricuapid
area. I was confused. For me no PTH. Than I told
MS bt I told apex Normal 😭. Than examiner
asked u r telling MS bt apex shifted than I told It
might be associated with MR. Then seems bit
happy to examiner bt I m confused 😭
[08/11, 16:54] : Neuro case. Near 30 years female
examine lower limb. Pes cavius. Walking with
toes and high steping gate ( for me) . Muscle
wasting no jerk. Planter Rt extensor and Lt
equivocal. All sensory normal except vibration
impaired on Lt side upto knee. I put DD : FA,
SCD, MS. couldn't understand anything seems
they were not happy. They asked me NCS
findings of FA. I told sorry sir I don't know.
[08/11, 16:54] : St 4 : Communication : Cl.
Difficile infection. Talked to daughter of 62 years
lady. Went smooth. Bt examiner asked why u
didn't asked regarding DNR. I told DNR is
consultant deciaion not mine. In senerio it was
not mentioned regarding DNR issue. Couldn't
understand anything
[08/11, 16:54] : St 5. Outside senerio 30 years
old female CKD on dialysis came woth complain
of widening of teeth space also malalingment of
tethe and change face. Inside There was
swelling Lt sided face which involve lower jaw.
Roof of oral cavity and maxilla. ano bleed. non
tender. gave DD. Osteoma, Naso pharyngial
carcinoma.
[08/11, 16:54] : BCC2. Lower limd swelling. H/ O
DM and HTN. rediced urine output. Not regular
folloq up. Cataract both eyes. No sensory
impairement. . lungs clear. Gave DD: DN. at the
same time want rule out other causes seems
they are happy.
Yangon Day 4 round 3

Station 1 Resp. L lower effusion or
consolidation with crepts in LUZ and LMZ
Abd. Renal transplant with hirsuitism
Station 2 38 yr old lady with IDA, basic invx and
thyroid function normal. History of nsaid use
due to OA both knees, abd pain present. Wt loss
5 kg. Dx NSAID induced gastric erosion, PU
Station 3 CNS bilateral cerebellar syndrome with
ryles tube
CVS mitral valvotomy with restenosis ( only
loud 1st ht sound, no murmur, low volume
pulse)
Station 4 angry son dut to c difficile infection
after AB therapy for pneumonia and sepsis
Station 5 bcc 1 uncontrolled hypertension with
RBS 200 mg/dl. Inside neurofibromatosis with
phaeochromocytoma DD renal artery stenosis
BCC2 DM with hypertension, fever with Left loin
pain for 1 week. Ho of vision problem, ho of
laser therapy lt eye. Fundus not sure Rt
exudate, Lt laser scar with exudate??
Kuwait experience
Sabah hospital 8/11. Third carousel
St1: splenomegaly
St1: bilat basal fine creps maybe associated
with something else. Not sure.
Examiners kept asking what else
St2: 35yrs female with IDDM since 7yrs of age.
History of IDA received ferrous sulphate.
Last Hba1c and Hb normal.
St3: ?MR with MS
St3: spastic paraparesis + cerebellum. pt
uncooperative couldn't appreciate sensation.
St4 : you are CMT in general medical clinic. Theme :
dealing with situation of uncertainty. Mrs Smith is 42
ys old. Today she is on follow up visit in your clinic. 6
weeks back she was admitted in hospital with
breathing difficulty. she was diagnosed & treated for
asthma and was discharged after 5 days of admission.
During that admission she had a chest xray which
showed 2 white opacities. Radiologist had reviwed
xray and concluded xray findings were very
uncertain & further imaging is needed. However pt
was not informed about these findings of xray. Today
before coming to ur clinic, she had a repeat chest xray
and those white opacities persist. Her past history
includes Ca Breast which was very well treated with
Lumpectomy & chemo. Your task is to explain
condition of patient & need for further imaging.
St5: female with headache and blurring of vision.
?papilledema.
St5: male with painful joints.
? Hcv related vs RA
James Cook University hospital Middlesbrough

2 Nov morning
Station 1.
Abdomen: renal transplant with scars from
previous PD, no fistula or tunneled line scars
Resp : left side lobectomy, also had long scars on
anterior aspect of shoulders bilaterally (I couldn't
make out what they were)
Station 2. Middle aged lady with 2 falls in last few
months, diabetes, hypertension, atrial fibrillation...
Diagnosis postural hypotension? Drugs? Diabetic
autonomic neuropathy. Hypoglycemia not present,
patient concerns : afraid this might recur
Station 3: CVS. Prosthetic aortic valve with atrial
fibrillation, no heat failure, valve ok
Neuro was confusing, distal wasting, weakness and
Areflexia bilaterally in upper limbs, also had
intention tremor on left side (not very sure about
right side, so did not comment). He also has a long
vertical scar in back of neck? Spine / cord surgery,,,,,
examiner asked if all can fit into one diagnosis
Station 4. Middle aged lady with new diagnosis of
polymyalgia rheumatica, task was to explain the
diagnosis, talk about treatment plan as well as
associations / complications. Concerns : does not want
steroids because of side effects, wants to get back to
work asap. Also wants to know if it is totally curable
and how long steroids are required
Sta 5
Bcc1,,, 40 female comes with weakness 2 months.
When I saw her she said she was having paraesthesias
in distal extremeties and periorally, some cold
intolerance, known to have barretts esophagus, on
omeprazole. Her concerns was paraesthesias only.
Didn't give much info on history
Examiner asked if there is a link between symptoms
and medications
Bcc2. Lady with diabetes 16 years, progressive
weakness in vision bilaterally, past history of laser
treatment lt eye, dense cataract Rt eye ,,, concerns
will she get any better
Yangon, Myanmar
8.11.17 Round 2
Station 1
Resp. ILD with scleroderma
Abd. Transplanted Kidney
Station 2
Long standing DM on basal bolus
Poor control
Hypoglycaemia
Thyroxine replacement for years
weight loss, postural dizziness, bloating
Dx. Polyglandular
Gastroparesis/ Autonormic
Nephropathy
Station 3
CNS. GB$
CVS. AR, ?AS. Collapsing pulse, wide pulse pressure.
Station 4
Infective exacerbation of COPD last 10days
Give co-amoxiclav and clarithro
Pt better
last 72 hour, diarrhoea
found to be C. diff
Now, pt extremily ill but not consider palliative
treatment at the moment
Now on oral vancomycin
His pre-morbid condition was good with LTOT.
Talk to his son.
Station 5
(1) Gout on steroid and NSAIDs
Drug induced Cushing
(2) Weight gain
Carbimazole for underlying Grave
Hypothyroid
Yangon 3rd day last round
Cvs: MR, IE
CNS: hemiplegia
Resp: Bronchiectasis/ fibrosing alveolitis
Abd: Thalassemia
History: young female with one sided
weakness... hemiplegic migraine
Comm: explain functional illness
BCC1. Steroid side effects with nausea and
vomiting????
BCC2: poorly controlled type2 DM with skin
lession???
Royal Infirmmary Glasgow

St5
1. Acromegaly
2. Parkinson
St4
Incapictant old aged with dementia , admitted due to
pneumonia
Son doesnt agree with ABx , wants traditional
treatment
St3
CVS
Prosthetic valve
Double? AVR?
middle aged man with upper and lower finger
deformities and absent rt radial pulse
Neuro:
Bilateral tremor at rest, PD?
St2
37 yrs old lady diabetic since she was 7 yrs old on
insulin and history of IDA and was prescribed ferrous
sulfate
Fatigue and malaise since 9 months, + f/h
hypothyroidism but nothing in history about
hypothyroidism
Maybe. Dx was non compliance with iron pill
St1
Respiratory : confused ( first station)
Abdomen left iliac fossa scare with underlying mass
Kuwait 🇰🇼
November 7/2017
#Station 1
Resp IPF
Abdomen splenomegaly and jaundice no
stigmata of liver dx
#Station 2
History of erratic sugar control hypo and hyper
ddx gastroparesis, addisons, hypothyroid,
lipodystropht
#Station 3
Cardio metalic mitral, ms, As
Neuro spastic paraparesis wth PN
#Station 4
Huntigton dx
Talk to the wife and address her concern, and
genetic testing to her kids
#Station 5
BCC1:Ankylosing spondylitis wth diarrhea,,?
IBD
BCC2:Hypertensive emergency wth
papilloedema
Yangon 7.11.17
St1 splenomegaly
Rt pleural effusion
St2 joint pain + ho of abortion
?aps /fibromyalgia
St3 AS AR
Bilateral wasted hands with UMNL features
St4 dementia chest infection and confusion
restelessness . Lorazepam given and then resp
arrest. But can resuscitate.
St5 systemic sclerosis
Pseudohypoparathyroidism
Kuwait 🇰🇼 November 2017

‫خلصت اليوم‬
Station 1
Resp IPF
Abdomen splenomegaly and jaundice no
stigmata of liver dx
Station 2
History of erratic sugar control hypo and hyper ddx
gastroparesis, addisons, hypothyroid, lipodystropht
Station 3
Cardio metalic mitral, ms, As
Neuro spastic paraparesis wth PN
Station 4
Huntigton dx
Talk to the wife and address her concern, and genetic
testing to her kids
Station 5
Ankylosing spondylitis wth diarrhea,,? IBD
Hypertensive emergency wth papilloedema
Yangon 7-11-2017 Day2 round 2

Station 1
Respiratory- Clubbing + CxLN
Dullness rt lower zone
VBS reduced in RLZ
Trachea midline
Dx Rt lower lobe collapse, Ca lung
Abdomen - Lt ballotable kidney
Station 2 History - haemoptysis+ nasal stiffing+ black
urine
Dx Wegener's granulomatosis
Station3
CVS - MS AR AF
CNS - spastic paraparesis dt cord compression
Station 4
Mother of 4mth-old child with Myotonic dystrophy
Concern - abt herself, her eldest child(7yrold), her
sister, her nephews
Task- explain Dx, inheritance nature, future
pregnancy, worry for her newborn 4mth old child
BCC1 Down $ with chest infection
BCC2 Acromegaly with CT$
Good luck for all!
Chennai centre experience of a candidate 2nd

day last round
i satrted with stn 1
patient with av fistula,huge ascitis with
hepatomegaly and slight icterus..there are no
fearures of CLD..gave the dds as ccf,cld,bud
chiary..examiner wanted to heard tb..i gave it to
them..asked about investigations and
management
then respi
60 yeears male with a big sternotomy scar..i
thought i am in the wrong station..then read the
stem..pt came with breathlessness...on
examination there is b/l rhonchi in front..and in
the back there is creps..gave the dd of copd
with ild
i missed the clubbing..it was not gross but
still..examnr askwd about investigation..then
askd if he came into emergency what is the first
test u will do..i said chest xray ..then pulse
oxumrtry,abg..then told me he has po2 of 6.5pka
what will u do..i said oxygen therapy...he asked
me about the saturation level..i said not more
than 90-92..then bell rang
st2..same as uk..recurent diarhoea,chest
infection,sinusitis,weight loss..on futhur histiry
there is evidences of recurent history of admssn
due to meningitis,knee infection,pneumonia...no
other history except travel to himalayas...dds
was
immunodeffiency..civd;,hypogamaglobunemia,i
ga defffirncy,along with other like cystic
fibrosis,pcd,kartageners..regarding cause of
diaarheoa..exsminer more interested to listen
about coeliac disease as dd 😂 😂
stion 3 nightmare..first neuro..55year lady with
difficulty in walking..on inspection there is
gross pes cavus with hammer toe..walk
highbsteping..couldnot understand
cerebellar.on exaniation confused
findings..knee jerk on left was depressed..no
atrphy or wasting tone was ok..ankle jerkrk
absent..planter left side upward..rt side
equivocal..she could do the heel shin with
difficulty..sensory loss both ant and post
column distaaly..weakness also in the distal
limb bilateral..more on left..totly confused..gv
the dd of fredriechs,ms..asked about
investigations..talked about lumber
puncture..how to manage..bell rang..and my
heart goes bang 😭
cardio...again sternotomy scar..lady comes with
palpittions..no venous harvesting..pulse was
regular 😱..on examintion mettalic click with
s1..tthere is also psm in the lowet left sternal
edge..gv the dd of mvr with tr,vsd..and lastly
came in my mind about regurgitant
murmur!!..asked about investigations and
management..also how to differentiate vsd,tr
st4..again repeat fron uk..elderly with lorazepam
inj..goes well surrogate is very weak with no
response!!worked very hard to extend the
discussion ..she even never tslked about
complaint or medical negligence!!..exsminer
asked about the salient point..asked abou tthe
prognosis..i said as he is better previously with
no histry of chest disease the prognosis was
good..also it was mentioned in the stem that the
patient was intubated..so again said that i need
to ask the icu consultant abou t the
condition..thn ethical issue..wht should be done
for to prevent any future ocuurence..it is very
difficult for the csndidate if there any untrained
surrogate like this..bell rang
st5...
bcc1-50years lady with htn and joint pain..inside
there was a lady again with av fistula!..both
hands are deformed..at the dip joints..there was
some swelling in the wrist..history of thiazide
intake..so gave the dd of osteoarthritis and
gout..but i have never seen such gouty arthritis
with bilateral symmtrical deformity of the dip
joints..also problem with knee..nails were ok..no
skin rash..no historu of inflammatiry
arthritis..examiner more happy to talk about
gouty arthritis..gave also the dd of
psoriatic..asked about the inv and treatment
bcc2
38 year male with acute onset vomitting and
loose stools for 1day..some paremeters was
mentioned like bp-100/60,temp-
37.5,tachycardia..took the histry..gave the
history of simple infective diaarehea without
any evidence of blood or slime..explore all other
history all normal..no other family member
affected..have some outside food..told him it
may the case of infecftive diarrheoa or may the
first presentation of any other disease but i hve
to admit him and keep him for fluid replacemnt
and to prevent aki..asked also about the urine
output..also examine the toungue and capillary
refill..didnot do the skin pinch test...examiner
question mainly why need to admit..how to
treat..he wants to know about aki nad also
clinical evaluation of dehydration..told me i
NEED NOT to take all the other history for
diarhhear like ibs,ibd,hiv.as it is a case of acute
diarrhea for 1day only.. then bell rang..i came
outside and open my mrcp.uk to see for the next
uk opening date as i have not got a seat in india
in 2018/1... 😭 😭 best of luck for all... i think
st2 and st4 cases are repeated..so u have to
prepare all for new diet 3 cases..that we have
discussed in this group
To all candidates who want chennai questions

2017/1 diet Chennai
Chennai (3.4.2017) 1st round
History loose motion 6 months GP IBS.
Communication delay Dx phaeochromocytoma.
Bcc.Abdominal pain for 2 days, fever and
oligiuria known DM. ddx
Visual impairment in DM pt... dx: cataract
CNS: Lt hemiplegia
CVS: systolic murmur with AVF machinery mur
mur
Resp: LL BBS+crep ddx think lower zone
fibrosis or consolidation
Abd: Ascities+AVF think ESRD with (RRT) fluid
overload.
Resp: bronchiectasis/pneumonia.
CVS: Systolic murmer: PS/ASD/ WITH MS.
CNS:STROKE WITH PERIPHERAL
NEUROPATHY.
ABD: ASCITES WITH FISTULA
Chennai Day 1 11.45 am cases
Pheochromocytoma telling the diagnosis to
patient station 4.
Bcc 1 diabetes and UTI, bcc2 diabetes and loss
of vision - funds examination.
Abdomen ckd with HSM. Resp left upper lobe
fibrosis. History 6 months altered bowels and
abdominal pain. Cardioloy AS / HOCM ?
Associated MR also. Neuro b/l cerebellar signs
with absent reflexes .. best of luck to all of you
Chennai (3.4.2017) 3rd round
history. Cough for 6 mts SOB. Bird fancier
lungs.
Com. SLE renal biopsy.
BCC1 seizures.
BCC 2. knee joint pain OA!
(Copied) My exam experience in chennai today
3/4/17
Station 2
History taking of cough and shortness of breath
for 6 months. She has fever on and off but no
night sweating weight loss of 6 kg within 6
Months. No wheezing she works in printing
company and her colleagues have also cough
which she is thinking due to printing materials
they use all cardiovascular history is negative.
No history of TB contact no HIV risk factors. she
receive many antibiotics without improvement.
I put differential of TB and lymphoma and
asthma. During childhood she has asthma
which improved. Not smoker or drinker. But
unfortunately the diagnosis was extrinsic
allergies alveolitis. I miss birds at home.
Station 3
Mitral stenosis with AF it was clear.
Neuro
Is parkinson plus CVA. Rigidity only on
distraction so I put parkinsonism plus CVA
reflexes was exaggerated on the right upper
limb only no tremor.
Stations 4
Easy case explain renal biopsy for SLE patient.
Station 5
Difficult young on phenytoin developed seizures
yesterday after history of vomiting once and
loose bowel four times.
I don't know the case.
Second case history of bilateral knee pain with
stiffness less than 10 minutes. It was
osteoarthritis no other significant history of skin
rashes or other joint problem except back pain
occasionally.
Stations one
Polycystic kidney and clear function fistula on
dialysis. Polycystic kidney is common in
chennai take care it mimics
hepatosplenomegaly..
Chest I don't know it.
Chennai 2nd day 1st round(4.4.2017)
st2 cocaine induce chest pain
St4 - bowel cancer with bleeing for embolization
i think old que
��Station 1.. Young male with functional AVF,
elderly lady with bronchial breath sounds and
crepitation... Worst station for me.��Station
2... Best... Chest pain... Cocaine
induced.��Station 3... Young male with
diastolic murmur.. With loud p2, MS��Neuro...
Hemiplegia... Stroke with pn��Station 4...
Explain to sister of patient about condition...
Metastatic bowel cancer... Now presented with
bleeding. Endoscopy shows bleeding ulcer.
Surgeons will not operate and decision for
embolism.��Issues were sister wants
conservative management, but parents and
patient wants active management.��Station
5... Bcc1 pt with ankylosing spondylitis... Now
presents with back pain... Bcc2 pt present to
gynecologist with menorragia... Now
gynecologist wants expert medical opinion. Pt
known thyroid... Newly diagnosed DM
Chennai 2nd day 3rd round (4.4.2017)
Ho hypopit due to sheehan
Comm subtherapeutic inr with wafarin come
with stroke
Talk to grandson
Examination .
Abdomen hepatosplenomegaly
Respi collapse consoli
Cvs MR AS
Neuro small muscle wasting
Bcc 1 fever for 4 weeks
Bcc 2 burning sensation of both legs PN
Day 2 round 3 ( chennai) �Station 2 - Sheehan
�Staion4 - stroke ( ischaemic ) with inr- 1.2 on
warfarin . examiner not satisfied with ischaemic
stroke explanation �Bcc 1- fever ( puo def
asked ) Tb? Chest infection? ( didn't allow to
examine ) �Bcc 2- pn ( vegan ) examination not
allowed �Bcc2-
Station 1�Abd �Hepatomegalay with AVF
�Respi- I can't�Pigeon chest deformity with
crepts, rhonchi, with AVF ( I said IlD forget to
tell rhonchi ) �Neuro�Small muscle wasting
with thicken nerve with sensory intact, joint
sense intact, cerebellum intact( I said
CMT,CIDP, leprosy)�CVS- i can't �Come with
palpitations �Apex displaced 6th ICS outside
midclavicular line, thrusting, I don't know
murmur I said I think Diastolic
murmur.�History- Hypertension with Urine
blood, protein positive, headache, fever, wt loss,
LOA muscle fatigue �I give diff ( GN,
Vasculitis)�Comms �UC, convincing for
steroids �Patient has severe UC (admit)�BCC
1 CKD left leg swelling (Diff _ lymphodema,
Thrombosis, Elephanteasis) �BCC 2 Left leg
swelling with reduce urine on nefidepine
Chennai (7.4.2017) first round
Cases - Station 1 - CLD ? Malignancy. RS-
COPD. Station 2- microcytic anem ia on
diclofenac. Station 3- Case of probably mitral
stenosis (I said ASD)..CNS had asymmetrical
LMN signs with pes cavus and positive
Rhomberg's with sensory loss over L3, L4, L5
and S1 dermatomes. Peripheral neuropathy -
?CMT... I said radiculopathy as differential
also..station4 - explaining diagnosis of
CKD..station 5- middle aged female with weight
gain, irregular periods and weakness- ?
Hypothyroidism, ? Cushings..other one was
COPD with sudden onset chest pain - ?
Pneumothorax, ? Pulmonary embolism..
Chennai Sundaram Medical Centre 07.04.17
Station 1
Respi: COPD
Abdomen: Right transplanted kidney due to
ESRF likely secondary to APKD, differentials for
other possible causes of transplant were asked
as well.
Station 2
Dysentery - infective diarrhoea
Discussion also around IBD
Station 3
CVS: MS ? Unsure if it was AR with Austin Flint.
CNS: Spastic quadriparesis Discussion around
it.
Station 4
Explaining to patient regarding diagnosis of
PTB, need for treatment. Concerns: I have to fly
to see my mom who is now admitted in ICU in
the UK.
Can I have my meds at home and not be
admitted and isolated.
Station 5
BCC 1: Known case of psoriasis, new onset of
right ring finger joint pain
BCC 2: Young gentleman, known case of SLE
on treatment. Disease well controlled. Came in
with sudden onset of right sided chest pain and
SOB while jogging in the morning.
All the best guys!
Copied ,,,
Firstly I want to share that after a long journey I
have cleared PACES from Chennai. My score is
159/172. I am thankful to all teachers, mentors,
members of this wonderful group, my family,
friends and well wishers who have encouraged
me during my dark days of failure. It was my
third attempt and making mind for this was not
easy.
Anyway, coming to this diet,
Abdomen- Large Liver with fullness of flanks. I
was not confident of PKD and hesitated a bit.
11/20
Respi- Middle aged lady with diffuse polyphonic
wheeze. Trachea was deviated to right and there
was supraclavicular hollowing at right side.
When asked about the diagnosis I said
obstructive airway disease with possible
fibrosis or fibrocavitary lesion. I was forbidden
to exam the front , so I said I would expect a
bronchial BS or Crackels at right side. Then
about investigation and management was very
smooth. 20/20
History: 35yr old male with recurrent chest
infection. Infertility and malabsorption. I did
explore all social and familial issues including
economic. D/D -Cystic fibrosis, cartegeners
Syndrome. Questions came regarding
investigation and management. 20/20
Cardio- MS with PAH in sinus rhythm 20/20
Neuro- Command was middle aged man with
difficulty walking. Examine the neurological
system. Initially I thought but parkinsons. When
asked to exam gait, the patient took 1min to
stand and adjust his dresss. I got panicked due
to ongoing time loss. Anyway when I saw a
circumduction gait, I got relieved. Hemiplegia ,
questions on investigation , localization of
stroke, management etc.20/20.
Communication: 26 yr old Advocate, diagnosed
with ESRD. 5 yr back he was seen a blood
donation program when his BP was high. No
follow up. Now task is to discuss the diagnosis
and treatment options. I started in BBN style
then focused on the disease and effect of ESRD
on different systems of our body. Then focused
on management options- general and specific.
Transplant, Hemodialysis, Two varieties of
Peritoneal dialysis. The surrogate repeatedly
asked whether the doctor who saw him initially
is negligent? Questions came more on
treatment than ethical issues. 16/16.
BCC1: TIA, a middle aged man with active AV
fistula. I forgot to ask history of smiking and
alcohol and did a sketchy neuro exam which the
examiner did not like. He was expecting a more
detailed exam. 25/28
BCC2: Middle aged lady with fatigue. Large
goiter, clinically hypothyroid. I forgot to exam
ankle jerk. Questions came on investigation and
management. 27/28.
My first attempt (Kochi February 2016) was
underprepared one but surprisingly I scored
very high 153/172 and lost in skill B by 1 mark.
In second attempt ( Kolkata Nov 2016) I again
started 2.5month before the exam. I tried hard to
make it through by concentrating on station 5,
but was not confident in clinical stations. I lost
the diet 132/172 , 4 mark short in skill B. While
preparing I applied for the third attempt in
Chennai ( April 2017). After the second failure I
started rapidly and this time I tried to form a
group, so I was shifted to rented house and
some of my other exam gong friends actively
participated in group discussion and seeing
cases together. This actually helped a lot and I
regained my confidence.
I have noticed in my previous attempts that
examiners ask only few questions in clinical
stations and they expect a quick systematic
answer. I have prepared timed answers ( 30 -40
sec) for investigations and managements for
most of the common cases and practiced it
repeatedly with friends, juniors and even mirror.
In reality these have made a difference which I
felt this time. I did not have to think when I was
answering the common questions.
I suggest all fellow comrades to prepare their
own notes and rehearsal beforehand so that
everything becomes smooth during the exams.
For understanding I shall share my notes after
few corrections soon.
Lastly, I can surely say that even if it took me 3
attempts to clear PACES, but it enhanced my
clinical skill significantly and made me a better
doctor. Thanks you all again.
6.4.2017 ( 1st round) Sundaram
Resp: c/o: SOB
rt lower lobe bronchietasis
Abd: C/O: abd discomfort
AV fistula with hepatomegaly
CVS.. MR: apex beat not displaced heaving,
systolic murmur at mitral area
Complaint.. chest pain
CNS: C/O: difficulty in walking examine
neurological system
Parkinson
History: chest pain: vauge pain, st worse with
meal but cant relieve with antacid. SOB+.
Strong family history of ht attack in father and
brother. Ex smoker. Hypercholesterolemia +.
Comm: BBN meningococcemia
Bcc: neck swelling.. simple goitre euthyroid
: hypertension, temi pain and hamaturia: PKD. (
pt: normal).
Yangon D2 R1
�Respiratory Rt Pl Effusion�Abd renal
transplant�Station 2 �30yrs old man C/O
haemotypsis,haematuria,nasal
blockage�Station 3�CVS? VSD not
sure�Young lady with clubbing, PSM,JVP
raised�CNS multiple cranial nerve
palsy�Station 4 �27 yrs old lay with 4mths old
baby Dx as myotonic dystrophy,her mother has
cataract surgery at 52yrs,her sister has 2
children.Her 7yrs old child elder was good
health.task is explain diagnosis,inheritance of
disease,family members for genetic
implementation�Station 5�24yrs old man with
SOB �Inside pt is down's $,examination is
normal�55yrs old lady with tingling of
hands�Inside pt is acromegaly
Chennai 1st day
Chennai 6/11.
Stn 1..abd ..adpkd with jaundice
Respi..apical fibrosis
Stn 3 ..neuro .. Fredricks ataxia
Cardio..Mr+ar
Stn 4 .angry son c difficle infection
Stn2.acute ascending
weakness..dd..gbs.botulism.hypokalemic
paralysis
Stn5..bcc1..old sle with right chest
pain..pleurisy
Bcc2..dm with sensory motor neuropathy..but
patient was interested in B12 deficiency as
patient was on metformin and vegan
Myanmar Day1 round 2

St 1-
Respiration.
lt sided Horner syndrome.
with rt sided cervical L/N
Pancoast tumor
Abdomen
ADPKD (bilateral)
with AR
Station 2
35 yr feamale
complaint of maliase and fatigue
DM type 1 since age 9 no hypoglycaemic
symptom
menorrhragia for 1 yr
taking ferrous sulphate for IDA
pt is in low mood .dry skin.brittle hair.
Station 3
CVS. MR. AS. AR?
CNS difficulty in walking
ll. ? LMNL. ll
St 4 Hodgkin lymphoma withHickmanline
St5- Chest pain with hypertension with DM. HR
100/min
brief episode of loss of consciousness for 1 day
now recovered!
5th Nov. 2017

Experience in Kilmarnock, Glasgow, UK.
CVS: Murmur present all over precardium,
radiating to axilla.
? Mitral Regurgitation or AR. Not sure
CNS: Hereditary Motor Sensory Neuropathy
Station 4: patient on Hemodialysis for 3 years, not
getting better for last 5 months. Wants to stop
Dialysis and die with better quality of life.
Station 5: 1
Raynauds with features of Scleroderma as a cause
Station 5: 2
Transient weakness of both legs, visual impairment
and headache. Causes: TIA/ Stroke.
Resp: ILD
Abdomen: Ascites
Station 2
Patient complains of both lower legs weakness
ascending upward for 5 days, now with start of
breathing difficulty for one day
Diagnosis: GBS
Overall my experience was good with few mistake
because of exam stress. Minute details will be shared
on getting my result or feedback from the examiners.
Wish you all the best.
UK experience today
St1: chest... apical lung fibrosis for dd
Abdo: renal transplant + hearing aid=alport
St2:generalized joint pain+fatigue for 6
months...in hx attack of chest pain and 2
miscarriages...SLE
St3: cardio....PSM left sternal border for dd
HOCM?PS?VSD?
Neuro... cerbellar syndrome ..MS?
St4:breaking bad news .. pleural fluid aspiration
showed adenocarcinoma + plan of
management
St5: Bcc1...25 yr male with bloody diarrhea.
...IBD
Bcc2.... pt with ankylosing spondylitis
complaining of cough and expectoration and
fever for 3 weeks...in hx on infliximab and
travelled to india 2 month ago ....TB
Recent cases from Glasgow

AR with marfan
Peripheral neuropathy
Talk to Pt present with fit now she has temporal lobe
mass
Bcc1 peripheral neuropathy
Bcc2 hyperthyroidism
History tiredness with deranged Lfts
Resp diaphragm paralysis
Abdomen renal transplant
Today cases from U.K. By one of our candidate
Good luck 👍
31.10.2017 Middlesbrough
1. Station 1 CNS - Myotonic dystrophy examine
upper limbs
2. Station 1 Cvs- Aortic stenosis...some said it
was Coarctation
3. Station 2- History taking man with
breathlessness cough Xray with consolidation
and cavity urine RBC and protein + Diagnosis
Wegeners Granulomatosis
4. Station 3- Resp Copd Emphysema with
bronchial breathing ? Consolidation
5. Station 3- Git Renal transplant with PCKD
6. Station 4- talk to daughter of father with
dementia brought from nursing home with more
confusion than normal diagnosed with Chest
infection started on antibiotics, kept wandering
at night without taking medicines so gave
lorazepam went into resp arrest and
resuscitated after giving Flumazenil, to explain
what happened to daughter
7.BCC1- ankylosing spondylitis with pulmonary
fibrosis
8.BCC2- woman with AF with abdominal pain
after meals alternating constipation diarrhoea
blood in stools and lost weight
D/d they led me into were Mesentric ischemia,
bowel cancer, ibd
Good luck all..hoping and praying to get
through this hurdle!
31.10.2017 middlesborough uk
Station4- myotonic dystrophy in 4 month old
baby. Mom has some signs of myotonia with
stiffness of hand. Older child 7 year old is fine.
No history of neurological deficit in family.
Sister has 2 children n they r ok. Talk to mother.
Station 5- BCC.1) dysphaiga and wt. loss in 55
year old man with heavy smoking. Dysphagia
previouly to solid now both solid n liquid
Station 1-Resp. Middle age man with clubbing n
cyanosis with difficulty in breathing
Abd.middle age man with abd. pain. On exam.
Bilat ballotable kidney
Station 2- 55 year old lady with 2 attacks of
blackouts. No eye witness during attack. Both
occur during strenous exercise. Dad n brother
died sudden while playing football
Station 3-CVS- 23 year old young man with
sternotomy scar, bilateral thoracotomy scar n
laproscopic scar on left upper body with
systolic murmur on left sternal edge
CNS- Diabetic man with weakness in lower limb.
Atrophic lower limb in rt. Leg with loss of
vibration on both legs
Experience in UK in Aberdeen 25 October
communication :- to talk to angery daughter
refusing discharge of her mother who was
about 77 years old admitted sience 5 days dt
pneumonia and seen by occupational therpeist
and physiotherapist and decided that pt is
independent. pt is diabetic and has capacity
chest station was lobectomy
abdominal case was a lady with AV fistula
working and recently used and pt has
heptomegally rt and left lobe (most probably
ADPKD with polycystic liver ) I told only about
AV FISTULA and heptomegally .no time for
acitis no time for lymph nodes palpation as 1st
2 mints was for make the bed flat and expose pt
.
st 5 1st case the scinario from outside was a
lady complaining of tiredness had history of MI
sience 5 weeks inside she was very nice lady I
took a history then I ask her for medication list
she was on asprin and lisinopril 10 mg that
recently changed by GP she has dizziness on
standing from sitting position so I told her that
we will return the 5 mg again and I ask for cbc
the examiner qs was about the cause of
tiredness I told her dt anemia dt asprin other
case was hand pain dt carpopedal spasm dt
thyroidectomy she stope the treatment sience 5
days as the consultant told her
cns was acase of left upper limb monoparess
(may be brachial plexus injery )I miss this case
and also Cardio case I miss it
history case the scinario from outside was pt
complaining of LOC syncope MCV is high with
normal vital b12
Colombo, Srilanka... day 1 , 3rd round

[10/26, 3:44 PM] +971 50 314 7067: Station.... 4
Hodgkin lymphoma.... newly Dx and newly
married..
To explain Dx, management plan And address
pt concerns.
Concerns were fertility issues, job issues,
scared of chemotherapy and central line , risks
of infections if started on chemotherapy
Station 5...
1... HHT
2.... bilateral leg edema, with peri orbital puffiness
Station 1
1...Resp... bilateral basal crepitation
2...Abd.... young pt with jaundice and
hepatosplenomegally
Sation 2
7 days h/o parasthesia and legs weaknesses,,,
ascending pattern
Station 3....
1..cardio.... systolic mumurs ... for DD
There were collapsing pulse, signs of Heart failure,
(jvp, crept at bases and pedal edema)
P2 was quite loud
2... Neuro.... pyramidal leg weakness, more on left
side... with signs of hyperreflexia, tonia,
Dorsal column ok
Touch sensation diminshed , left side only,,, but pain
prick okay
Surrogate was there, so could not illicit signs well‫ا‬
31/10/2017, 19:21:56: Dr Babita: Todays exam at

James cook
History- cough and breathless like TB.
Neuro- upper limb like lower motor neurons.
Cvs-coartation of aorta
Communication -given lorazepam to dementia
or got respiratory arrest d/w daughter.
At 5- double vision
5- epigastric pain
Abdomen -mass don't know what
Respiratory -bronchiectasis.
Best of luck.
UMMC KL Msia 24/10/17

Respi - Right lower zone mass
Abd - Hepatomegaly with CLD stigmata
Station 2 - 65 year old with Hx of pacemaker
insertion came with anaemia and lethargy.
Further Hx got fever and night sweats, constitutional
sx - infective endocarditis
CVS - Double valve replacement with pulmonary
HTN and AF
Neuro - Bilateral cerebellar syndrome on wheelchair.
SCA
Comms - 60 year male.ESRF for 3 years on HD.
Wants to stop dialysis. Speak to patient .
BCC 1 . Bleeding tendencies.( Menorrhagia and gum
bleeding) Underlying SLE on MMF.
BCC 2 stem cough with hemoptysis
Underlying AS on biologics.
Some UK experiences
obstruction
terminal condition
I told FSHD
communication:
explanation
BCC :
history of T1DM.
advanced directive
communication: NHL
dental extraction.
Basildon hospital UK
13/10/2017
St 1
Respiratory : female of 45 yrs she is restless
with fine end enspiratory crackles and
thoractomy scar she has feature of sc
I said lung fibrosis due sc ( iam not sure about the
cause of scar either lobectomy or transplanted lung
idont have enough time to diffrentiate)
Examiner ask me how u know its due to systemic
sclerosis ? Isaid she has afeature of telangectasia and
raynaud +pinsh nose . Then asked about inv and RX
and some Q of sc
Abdomen:
Pt 40 male obese presented with abd pain and loose
motion
On exam there is midline labrotomy scar and scar in
Lt lumber and other in Rt iliac fossa there is mass
under it inform of crhon disease may be but i didnt
get it.
Q: inv and Rx How to follow and whats is the cause of
scars.
St 2 pt with dizzy spell female about 50 yrs old it
come 4 times in last 6m while she running for
marathon there is + FH of brother sudden death her
son playing foot ball
She concern about marathon
I said that i want to exclude cardic syncopy.
St3:
Cvs: female 50 yrs with infraclavicler scar of
pacemaker and thoracotomy scar i heared systolic
murmur allover radiate to axilla and to the neck she
has clubbing and cyanosis
I said fallot tetrology partially corrected with VSD or
MR and pacemaker
The pulse in rt hand is obviously diminshed.
Neuro : LMNL of upper limbs sensations are intact.
St 4 :female has baby discoverd that he has congenital
Myotonia dystrohy and she has similar problem
Her concern about her child.
St 5:
60 yrs man with knee pain . Inside i found that he has
ehler danlons
65 yrs man with headache and blurring of vision he
has acromegally.
Some UK experiences
obstruction
terminal condition
I told FSHD
communication:
explanation
BCC :
history of T1DM.
advanced directive
communication: NHL
dental extraction.
station 1
non alcoholic ascitis ...TB
st upper love area of bronchial breathing
station2
sacrolilac pain
station3
3rd cranial nerve palsy
mitral valve prolapse
station 4
explain celiac disease
station 5
retinitis pigementosa
poly arteries nodosa
MRCP Paces Serdang Hospital 22/10/17

Station 2
—�—�—�—�
32 yo gentleman, headache for 2 weeks. Early
morning headache, tends to bump into things..
poor concentration, no blurring of vision...
Smoker, HPT and dyslipidemia.
History of Ankylosing spondylitis ( claimed not on
biologics)
No history of IVDU/ promiscuity. Plan to travel to
India in 2 weeks time... can i travel or not?
Differential diagnosis:
1. SOL ( pressure symptom)
2. Stroke ( risk factors)
3. Infection
Station 3
—�—�—�—�
CVS : Dual Valves replacement with bruised. Ask
why patient has chest pain?
Possible anemia induced. Hemodynamically stable
not in failure.
CNS: Stem examine this patient lower limb. From far
can see loss of left nasolabial folds, contracture of left
foot and elbow flex posture. UMN weakness left sided.
No sensory or cerebellar involvement. Diff: Stroke,
Demyelination.. I forgot to put vasculitis.
Station 4
—�—�—�—�-
Functional Hemiparesis
A 25 yo female physiotherapist in a stroke unit having
right sided body weakness. CT/ MRI brain normal.
Due see by neurologist. Said somebody talk behind
him she’s faking up her symptoms. Work in stress
environment and taking care of mum whom is
bedbound alone. Financial issue. Poor coping
mechanism.
Station 5
—�—�—�—�
BCC 1 Stem this 74yo patient presented with bilateral
hands and feet numbness. Background history of DM
(HbA1c 6.1%) . Noted amputation of hand and feet
with trophic ulcer, saddle nose deformity ( thought
initially relapsing polychondritis but ear lobe normal
appearance). History treated for 1 yr in Sungai Buloh
many years ago. No raynauds.
Current meds: Metformin & Neurobion
Diagnosis:
Hansen Disease approach for peripheral neuropathy
causes sensory PN ( DM, Drugs and leprosy
BCC 2 Hemangioma/ PWS of left UL
Differentials: Sturge Weber, Osler Weber Rendu
Station 1
—�—�—�—�-
Respiratory: Right UL lobectomy with
bronchiectasis.
Findings: trachea deviated to the right
reduced breath sounds with bronchial breathing, dull
to percussion, right lateral thoracotomy scar. Left
lower zone coarse inspiratory creps which change
with coughing.
Examiner guide towards post TB bromchiectasis.
Abdomen: hepatosplenomegaly thalassemia
intermedia, tinge jaundice, pallor with RIF transverse
scar ( appendicectomy scar, even examiner didn’t
even bother to ask)
Differentials: Hemoglobinopathies,
Myeloproliferative, Lymphoproliferative, CLD with
PHT, CTD and infiltrative)
Examiner guide towards Thalassemia.
UMMC Malaysia, Diet 3 carousel 3

St 5
Bcc 1 systemic sclerosis with possible bacterial
overgrowth, abdo no mass felt, no scars
present, concerns is cancer possible? ddx ibd,
ibs, infective age
Bcc 2 pcm overdose with fainting episode (took
10 g of pcm, found fainted by boyfriend with
vomitus), hx of absence seizure, last attack 10
years ago not on treatment, physical exam
normal, concerns long term damage and alcohol
dependence, ddx cardiac, endocrine, vasovagal
causes of loc, mx of pcm overdose, ix of loc
St 1
Respi
Right upper lobectomy with ipsilateral chest tube
scar, patient cachectic, finger clubbing present,
trachea deviated to the right, chest expansion reduces
over right, bronchial breathing with dull on
percussion over anterior right upper zone,? Collapse
consolidation over right upper zone
ddx ca, tb, bronchec, abscess
Abdo
ESRD with right renal transplant, with left ballotable
kidney (adpkd), right ijc and subclavian scar, no avf,
not cushingoid, no signs of ciclosporin toxicity
Ddx esrd with ballotable kidney, obstructive
uropathy
St 2
35 yo with recurrent sinusitis, conjunctivitis, loss of
weight, productive cough, and prolonged diarrhea
x6/12
Concerns, why still not recovering with prolonged
repeated antibiotics, and possibility of cancer
Ddx hypogammaglobulinemia, primary cilliary
dyskinesia, alpha antitrypsin deficiency, aids with?
Postinfectious diarrhea (hx of travel to himalayas,
eating local food)
St 3
Neuro
Flaccid paraparesis (distal weakness and atrophy)
with high stepping gait, sensation normal in pin-
prick, light touch, and proprioception, diminished
reflexes, plantar bilaterally equivocal
Ddx cidp, mmfn with cd, mnd
CVS
AVR with possible mitral valvuloplasty or repair,
median sternotomy and left thoracotomy scar, no
venous harvest scar, metallic S2 click with systolic
flow murmur, BP given 120/70, pulse not collapsing,
no signs of overanticoagulation.
ST 4
Angry son whose mother was taken blood without
consent and proper hygiene, mother was admitted for
cap with c-dif infection, son wants to complain,
concerns regarding infection control in hospital
university malaya 24/10/17

st 1
abd: left internal jugular catheter and palpable
left kidney
Respi: lung fibrosis and systemic sclerosis
features
St 2: history taking, inflammatory joint pain of
hand/toe with recurrent abortion. Had history of
chest pain 2 years ago.?sle and apla
St 3:
Cvs: dual valve replacement
Neuro: bilateral cerebellar and brisk reflex at
knee but normal reflex at ankle and downgoing
barbinski. No muscle weakness. Sensory intact.
?ms/sca
St 4:
Talk to an angry daughter, her mother had
pneumonia and mistakenly given codein for
backpain which she had history of allergic
reaction to and now she is confused.
St 5:
1: uncontrolled hypertension secondary to
acromegaly 😆
2: osteoarthritis of hands, heberton node of
distal dip. She got nail fungal infection. Had skin
lesion before but now no more.
UM 25/10/2017
History
Uncontrolled type 1 DM with frequent hypo
Got hypo thyroid
Ddx poor insulin technique/education
Polyglandular, hypoadrenalism
Worsening kidney profile
CVS
Aortic Valve replacement
Neuro
Parkinson disease
Com
Medical error
Wrong insulin
Angry patient
Abdo
Renal transplant with 3 scar
Respi
Collapse consolidation (I think)
BCC
DM retinopathy and phantom limbs
Headache, Evan syndrome..
Carousel 2 PPUM Kuala Lumpur 24/10/17

St 4: angry daughter. Her mother admitted for
pneumonia curb 3, low na, urea high, hypoxia.
Had history adverse reacrion to codeine,
however doctor give her mother codeine pcm
for back pain.
Bcc 1: joint pain. OA
Bcc 2: Uncontrol HTN, acromegaly
Abd: Young man ESRD, peripheral sign+, abd nad
Respy: pulmonary fibrosis ul scleroderma
Cvs DVR, apex dislaced, AF with collapsing n
corrigan
Neuro UMN bilateral LL with foot drop, normal
sensory n coordination
Hospital Serdang 21/10/17 first carousel

CVS: dual heart valve replacment. Not in failure.
But got signs of bruises
Neuro: right hemiparesis but got bilaterally
small muscle wasting of hands - its a stroke.
Dds MS
Respi: left lobectomy unsure cause cause cant hear
anything
Abdomen: hepatosplenomgelay with anaemia: ddx:
thalassaemia, myeloproliferative disorder
History: headache, poor concentration, bumping into
things, memory impairment
Ddx: intracranial tumour, pituitary mass, stroke
Comm: explain functional weakness, pt angry
because one of the staff nurse
(This one should be ok)
BCC1: stem is bilateral numbness.
Pt is on wheelchair, with autoamputation of fingers
and toes, deformed joints,
Positive family history
And a nose deformity (so angry that i couldnt work
out what it was)
Answer is leprosy..
I gave Charcot marie tooth
BCC: skin discoloration of left arm
Ddx. Port wine stain
Hospital serdang 3rd carousel

St 1 .. right sided chest deformity.. i heard fine
creps.. others gt bronchial brething , course
creps, rhonchi aso sum heard.. unsure of dx
Abdo - hepatospleno
St 2 - colon ca decided not for op with nausea,
vomiting , constipation
St 3 - i heard AR/MR.. Others MR only, MR/TR
Neuro- unsure of dx, positive cerebellar
St 4- asthma couselling, he is a firefighter,
whether nid to inform his workplace or not
St 5-
1.IBD with backpain and shoulder pain
2. Anemia in CKD
Grimsby Oct 7 Uk Diet 3 Cycle 3

I started with station 1.
Abdomen: A young male with two scars in the
iliac fossa was lying propped up. Had to ask
permission from examiners to flatten him.
When carefully inspected i saw striae, some
were pink, some purplish on sides of abdomen
and back. He also had fine tremors on extension
of hands. On palpation i found transplanted
kidney and a mass in right lumber region. I gave
transplanted kidney in a patient with pckd as my
dx with stigmatas of immunosuppression. Usual
questions followed. Both examiners asked
questions till the bell rang. I had pointed out a
scar for vascular route in femoral region.
Examiners were surprised to hear about it and
checked dubiously to find it there.
20/20
Respiratory: A middle aged man with tattoos all
over his torso lay comfortably. He had clubbing
and fine inspiratory crepts at bases. I said
pulmonary fibrosis. And gave d/d. Both
examiners asked questions till bell rang. Some
candidates said he had joint deformities. I did
note very subtle changes but chose to ignore in
my presentation however mentioned in causes.
20/20
Station 2: Lady with back pain. Scenario had 2.2
calcium and raised ALP..
On history she told she had been diagnosed
with celiac 10 years ago. There were no red
flags for back pain. Had history consistent with
osteoporosis. Had many risk factors. Her
concerns were she didnt like gluten free diet,
will she need dexa scan, what is causing back
pain. Offered managment plan.
Viva was tricky! ️Asked what u made of
biochemical markers outside. Why not ALP
raised because of liver as she is taking
Paracetamol. Did u ask how much she
excercise? ( i forgot.. 😣) What tests to confirm
liver as a cause of raised ALP. Then a tiring
confusing discussion about gamma GT in which
examiner wasnt comprehending what test it
was.. ️
Bell rang..i thanked God and came out..
20/20
Station 3:
Neurology: Command was to examine Pt. Who
has difficulty managing his tasks. I asked him to
close eyes. There was blepharospasm. Did all
the tests to elicit parkinson disease and
presented as such. Examiners asked how were
the reflexes and sensory system.. 😓 I didnt do
it as it wasnt an upper limb exam. command. I
explained that. Questions were about the
investigations and specific indication for these
investigation. Both examiners asked question
and didnt stop pulling my legs till the bell rang.
17/20
Cardiology: Command Patient presented with
SOB. Findings were of A fib, AVR, ICD mid line
sternotomy scar extending upto umblicus and
scar hernia in abdomen. There was a systolic
murmur as well. Viva was on the flow murmur
and cause of SOB in this patient. Examiners
pushed me to tell whether JVP was raised or not
and how u can be sure that it is ICD..
I played safe and explained that there is
ambiguity would like to confirm by
investigations.
17/20
Station 4: Nightmare
Address concerns of mother whose son
presented with recurrent vasovagal syncope.
Mother was furious, defiant, adamant and what
not. She kept trampling my explanations and
settled on seeking second opinion. All the major
time was wasted on explaining her that it is
concerning but not serious. With quite difficulty
i manage to discuss social issues related to that
and then bell rang. Painful viva with examiners
about different things i said to mother to
console her. However i made sure to explain it
to examiners what important safety issues were
and needed to be told to mother and plan for
follow up.
12/16
BCC 1 : Vague scenario outside with no name
and just vitals and complaint of pain in joints.
Surrogate was lousy. Only told what was asked.
Told in random fashion. Pain was in wrists,
elbows and knees. No stifness. History of
thyroidectomy, on thyroxine. I ruled out all d/d
and couldnt nail the dx till end. To add to my
confusion just 1 minute before end of interview
she told me she was using MTX for her arthritis.
And i was like why didnt u tell earlier when i
asked abouts meds and PMH.
Addressed the issues hastily and give vi
vas on D/D..She also had myxedemic look and
subtle scar of thyroidectomy.
Thought had lost the station but Alhumdulillah
27/28
BCC 2: Again no names, just age, vitals and
pain in joints with SOB.
Lousy surrogate again, had to grill everything to
narrow dx. Felt like station 2. Surrogate didnt
led anywhere, told only what asked. I was
confused till i listened to lung bases and found
fine crepts. Had malar rash as well and
cyanosed fingers. So again gave d/d.
Viva on Systemic sclerosis.
28/28..
Maadi military hospital ..19th Oct 2017 ....the

second carousel ...
started with history ... 55 years old male with
tiredness .. Hx of prothetc valve ... drop in Hb ....
he is on warfarin 4 mg .... i go through history ...i
forget to ask family history which known later
during discussion as he has family history of
cancer colon ... i miss that ... very tricky to me ...
only adviced investigations for heamolysis
ignoring the cancer colon history ..
CVS ... prothetic mitral valve with congested
neck viens and ejection systolic murmur,very
fine AF ..
Neuro .... peripheral neuropathy.
chest ... left lung fibrosis.
abdomen .... HSM for DD.
Communicatio ....... newly diagnosed liver mets
of unknown primary, daughter refuse to tell her
father ....daughter keep asking if he gonna die ...
i only mention that he has the right to know his
disease and i can not predict his death.
Station 5 ...
1.acute chest pain .... family history of
hypercoagulable state, COpD ... dd
pneumothorax, PE
2.pain , tenderness over back, sholders,
buttocks, history of IBS, menstural irrigularities,
depressiin on fluxietin .... i said it is fibromylgia
rheumatics but i forget to examine joints
involved.
i didnot dp so well this time ...
Cairo 19/2017
First station abdominal case chronic hepatic
diseases has rash on his hand ulcer mouth loss
of body hair with yellowish with huge
splenomegaly and mild ascitis. On shift test the
examiner ask me what ur. Diagnosis cld. Due
auloi. Immune disease. Ask. An other hepatitis.
B. C. Infiltrative. Disease. Like sarciidosis. An
other how do u investigate.
Respiratory case
Patient with copd. With right inspirtory.
Criptation examiner. How. To. Investigate
this. Case. I. Started. Mansion several
investigation. But the examiner. Ask me one
iinvestigation I told him hrct.
Stecion. 2.patient has aortic. Valve replacement
before 9 month now present. With anemia mcv.
69.hb.low has short breathing on exertion fx.
Father. Was. Diagnosis with. Colon. Cancer..
I tell him about warfarin. And valve hemolysis.
And. Should. Be. Investigate colon. Cancer. The
examiner ask. Me what investigation I
said.i.n.r.and camera. For. Upper. And. Lower.
Gastrointestinal. Tract. He. Ask. Me. What. First.
I. Told. Him. Colonoscopy
Station 3 p. N. Investigation.
Cardio. Ms
Station.4.Patient his wife die from Brest cancer
2 years ago and now he present with CT
multiple metastatic lesion on his liver the
scenario speak with her daughter because she
refuse that her father know about his condition
will affect him and no benefit
Station 5 short breathing
On he. Exam. Patient has varicose veins and
cold. The sob started suddly yestardy diag.
Pulmonary thrombo.embolism.dd.pnumotorax
station. 5confused. Case. Joung fat lady with
back and neck pain on hx. Pain on his right leg
some college told me ask everything negative
only use antidepressants when I examined her
there. Is pain. In her. Right. Leg. The. Calf. And.
On dorsofelexin. Of foot. I told.
May.this.case.fibromyalgia.rehumatic fever. Sle.
Ra.....
Today in egypt
Station 5 fibromyalgia complaint neck pain
buttock pain
Station 5 shortness of breath pe or
pneumothorax
Family history of blood clot and rectal bleeding
Pt smoker
Station 4 copd 70 y cancer liver of unknown source
Palliative ..concern didnt tell pt about diagnosis
Station 2 iron anemia with avr fatigue
s2 history :uncontrolled asthma due to pt by new cat
to his son and he also used his wife propranolol for
anxiety
s4 communication : explain polymyelgia rheumatica
to pt and ass and prognosis and answer any concern
s5 BBC1 female with shortness of breath ; inside she
having RA
BBC2 male with headache ; inside acromegaly
s1 respiratory left lobectomy
abdomen spleenomegaly with jaundice no signs of
chronic liver disease
s3 cardio DVR
neuro sensory motor prepheral neuropathy for DD
Cairo,Alkaser El Ainy 16/10/2017

1st Carousel
#Station 3
-Cardio MR TR possible AR
-NEURO lt hemiplegia
#STN 4 vasovagal attack
#STN 5
BCC1-Ankylosing spondylitis
BCC2-Hyperthyroidism
#Station 1
-Abdomen CML
-Chest pneomonectomy
#Station 2
History :45 yrs business man came from trip to Dubai
had SOB
Egypt PACES. 14/10/17
Cycle 3
St 4:
Hodgkin lymphoma.. Aiming for cure, the team is
planning to start chemotherapy through Hickman
line (as in the course)
St5
1) female with menorrahgia
2) young male..LL swelling ..nephrotic syndrome
DD>> minimal change GN in details
St2:
A 35 yrs atheletic .. blackouts recurrent ..vasovagal vs
HOCM
St3 :
Abd: massive splenomegally
Chest: SS sclerodyctyly ..microstomia..BL lung
fibrosis more on the lt
Investigations all even Lung function test in details
..plan of ttt in details even ttt of idiopathic
St 3:
Neuro : LL ..Rt leg hypotonia ..lt was normal ..all
sensation normal..weakness of upper limb..carotid
negative & no murmur.. Stroke ..ABC ..CT infarction
..discussion when to thrombolysis & investigations in
details .. stroke in young
CVS:
A young male ..median sterniotomy scar..S1
normal..S2 clicky..ESM..AVR for evaluation
Cairo, Alkaser El Ainy 15/10/2017
1st Carousel
#Station 1
-COPD
-Deep Jaundice
#Station 4
Long senario Counselling pt have anemia with past
Hx of angioplasty on aspirin and plavix !!! 😐
#Station 3
-Spastic paraplegia without sensory level
-Cardiovascular
AVR +??
#Station 2
Back pain and diarrhea
Celiac and osteoporosis
#Station 5
-Psoriasis recited interferon
-Gouty arthritis on thiazide
My experience sharjah 18/10/2017

St2 .... 35 year old female with transient Lt side
weakness and numbness for 2 hrs ... headach...
St3.... CVS .... MR and hear failure .... Neuro ...
Freidrich ataxia
St4 ... son of old man who was admitted with
COPD and pneumonia and get complication
pseudomembranous colitis
St5 .... BC1 36 y old female with Rt trigeminal
neuralgia and lt hand numbness for 1 month....
BC 2 tuberous sclerosis
St1 .... COPD ... splenamoegally and I said there
is hepatomegally and ascitis but other in group
told me only splenomegally ... I am not sure
UK PACES
October 2017
St 2:
scenario v simple case of tiredness GP checked
blood>> picture of iron def anaemia
49 yrs lady with 6 month hx of tiredness . Seen her
GP who found Hb & MCV low..
Was on ibuprofen and diclofenac for Mild OA
Periods ok
Epigastric pain
No GI bleed or other bld loss.
Lost 11 pounds in 3 month.
DD
PUD
NSAID GASTRITIS
IBD
UPPER OR LOEER GI MALIGNANCY
Celiac disease etc
CONCERNS
IS Z TIREDNESS GOING TO RESOLVE AND
PRACTICE HER GYM
WHAT IS Z CAUSE OF HER EPIGADTRIC PAIN
Resp:
A case of clubbing and bilateral fine insp crackles
And case of thoracotomy scar
Cardio
Marfans with AVR
MVR
Communication: BBN of bowel cancer
Neuro PD Parkinson's
As you can see, all are easy and simple.
Dubai 17/5/2016
PACES……………………………………..
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: case #1: 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
Station 5: Case #2: 59 years lady with back pain
since 3 days
After trauma
She is known case of artheritis?????
On prednisolone .methotrexate
For last 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
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.
Station 5: Case #1: Bcc1 : DVT with h/o travel to
India , Indian female , FH of leg clot both mother
and sister & also on OCP.
Station 5: Case #2: 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 inhaled steriod and her
voice changed & occupation is singer.
Cairo PACES on 29 may
○ Hstory taking
A 45 yrs old patient presented with headache
confusion homonymous hemianopia and short
term memory loss. he is htn and hyper lipidemic
and smoker. All complains are 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
○ Communication:
A 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 shud stay
in hospital
○ Station 5a
° Psoriasis staright forward it was palmoplantar
variant of psoriasis patient had arthralgia as
well.
° Station 5b
A 15 old lady with menorrhagia with 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 Willbrand
° Abdomen:
Splenomegaly pallor for DD
°RESP it was acute patient with ascites there is
dullness and decreased fremitus at bases I put
DD of pleural effusin Examiner looks satisfied
Cairo PACES 28th May'16
#Station 1
* Respiratory
COPD with rt basal fibrosis
* Abdomen
Chronic liver disease. ..decompensated
#Station 2...
A 55 yrs old female presented with history of
loose motions and abdominal swelling and
bloating for 2yrs. .PMH of CA breast with
mastectomy 5y ago..
#Station 3..
*CVS ?? mixed mitral valve disease
* CNS..peripheral neuropathy
#Station 4....
I.B.S diagnosed by consultant with normal
investigations even the sigmoidoscopy..pt
concerns. .he needs further tests and he is
afraid of cancer
#Station 5
* Acromegaly with obstructive sleep apnea
* Pemphigus vulgaris
Brunei exam 31/5/2016
1: Lung: ILD
Abdo: chronic renal disease -recent mode of
replacement is haemodialysis
2:headache ..cluster headache.
3:Cardio: double valve replacement
Neuro: Rt side hemiparesis, Examine the upper
limb
4: Coomunication: provoked seizure
(hyponatraemia) concern can it come again ?
And can I drive ?
5:psoriatic arthropathy
Vetiligo....present with tirednes; pernicious
anaemia
Adrenal insufficiency
5- diabetic pt..fundoscopy ..laser burn mark and

exduate ...—/
2-..pt had pituitary surgery 1993and MS ...now
confusion ..cant ans much ...i have d/d of hypo
pituitarism ....b/c NA ..123..b.p low ........sation
2..h/o pacemaker working well complain of
tiredness and anemia...c/o loss of wt .night
sweat...d/d CA ..TB..Lymphoma..
4... breaking bad new adenocarinoma in lung
with palliative care to pt ...
1- ..hepatomegaly with palmer erythema...d/d
..2..ILD ..
station no 3..AR...
neuro ...UML weakness with sensory level ..D/D
Station 5
Osteoporosis
Bulls
Station 4
MND
Station 3
AS AR
HSP
Station 2
Cluster
Station 1
Thalassemia
COPD with basal fibrosis
My exam was in st Georges hospital.

Respiratory - lung fibrosis
Abdomen- patient had pain Abdomen and had
tenderness all over but more in right .
Midline scar and transverse scar above
umblicus.
CVS- MR and As
Neurology- sensory neuropathy
History- pt had swelling in tongue and lips -
Angioedema
Station 5 Asthma and Analgesic overuse
headache.
Communication had relative of patient with C
.difficile who was upset with another doctor
because he didnt take proper contact
precautions and was not well dressed.relative
was very angry with that doctor and wanted
immediate action
UK 🇬🇧 Experience
October 2017
Communication 4 mytonia
History 2 dizzy spells
Cardio 3.fallot + pacemaker
Neuro LMNL of Ul
Station 5.
Ehler danlons
ACROMEGALLY
Chest 1 fibrosis +SS + thoractomy scar idont konow
why scar
Abdomen Laprotomy scar of IBD
Al Maady 1st carousel

1 patient with chest pain
resonant percussion note
Increased AP chest diameter
Some left basal secretion cleared with cough
Vesicular breath with prolonged expiration
OLD
Examiner what is causes chest pain
Pneumothorax ?
What else
PE ?
Abdomen
HSM
Lymphadenopathy
Distended abdominal veins
Ascitis
Pallor
Jaundice
DD lymphoproliferative disorder
CLD
2 ) 50 y old man with SOB
+ 1blood cells in urine
+1 protein
Cough
Blotches of skin rash not sure about sites & sun
exposure
Veterinarian
Generalized boney aches
Weight loss few kgs
Intact appetite
Examiner asked diagnosis
I started by brucellosis
What else
Pulmonary renal syndrome
Like what ?
Wegener
Goodpasture
Microscopic polyangitis
Examiner what about SLE ?
Yes sir it could be but surrogate did not give me a
clue 😌
How to be sure about wegener
ANCA
How to ask about
Nasal stuffiness & crusting but sorry I forget to ask
😔
How to investigate SLE
ANA & Double stranded ab
3)
AVR
Ejection systolic murmur for Echo
MR
How to Inx
What is simple procedure to do before Echo
CXR for cardiomegly
Inability to walk
Umnls
Hypo or normal reflexes
Clonus
Ex planter
D.C.
Intact cerebellum
Intact superficial
Asked for gate
Unsteady
What is your DD
Umnls
D.C.
Romberg
MS
Taboparesis
SCD
How to inx
Spinal & brain MRI
What else
LP
4
Explain diagnosis & mangemet of UC
5 my nightmare
25 y with abdominal pain
Arthralgia
Cough
Chest scar but not sure why
The Indian examiner DD
I said FMF
What is the genetic test
I thought he needs cystic fibrosis
😀
I said yes there is genetic test for cystic fibrosis
Forget about cystic fibrosis
I mean FMF
I mean cystic fibrosis sir forget about FMF 😀
second case 30 y old male with 2 months fever
History of blood transfusion 4 years ago after RTA
Cough with phlegm & blood
What is your DD
I need to rule out HIV
What else
TB
How
Sputum culture & CXR
Is there any sensitive test for TB
PCR for mycobacterium
How to be done
Is it a blood test
Yeah 😳 😳
What else
Community acquired infection like pneumonia or
staph 😳
Then the bell rang
I feel lost
It was my last trial
Thanks for everyone who helped me
Hope the best for you all
Exam Experience Oct 15 2017 MUSCAT SQUH

ST 1 Resp : young patient with clubbing, small
scars on the sternum in lat chest, coarse crepts
at bases... Bronchietasis
Abdomen : young to middle aged male
complains of tiredness old scar marks on the
left arm over wrist and cubital fossa, no bruit
underneath, scar mark on RIF with slightly
tender mass, gum hypertrophy,... Renal
Transplant
St2 : young lady with 3 months history of joint
pains and tiredness, CRP normal, counts
normal just lymphonoenia, no improvement with
paracetamol and NSAIDS, past HO thyroidism
well controlled on thyroxin 125mcg, last TFTSs
a months normal, feels tired all the day, no
mouth ulcer no rash no hair loss, no joint
tenderness swelling or Stiffness, but wakes up
unfresh and feels stiff in general almost
throughout the day,no tummy pains periods
regular, past history of two abortions one on
23weeks orthet not sure but also in 2nd
trimester, one past history of chest pain went to
drs but they told nothing serious mother has
RA
Non smoker no alcohol not very happy in
marital life because no kids, otherwise no
stresses at work, had ro take few times sick
leave from work
Concern do I have RA like my mother
Will this condition will affect my chances of
becoming mother.
DD APLA, Chronic fatigue syndrome
Examiners wanted APLA, I think
St 3. Mid line sternotomy scar, small scar near
apex area.. Two Metallic sounds?? DD MVR/DVR
viva on management, indications of MVR,
advice after MVR , warfarin advice about
warfarin, If pt alcoholic, complications of Valve
replcement, if pt needs dental procedure,
endocaritis prophylaxis
Neuro : obese young gentleman, commands
examine LIMBS, I asked sir upper or lower, both,
after finishing motor of lower limbs, generalized
weakness, depressed reflexes even with
reinforcement, examiner, notging in sensations,
proceed I started UL.. Weakness again bilateral
more proximally, cerebellum intact
Finding, DD, ( ️ ️confusing I started CIDP,
GBS, Lead, botulism,dystrophies examiner
asked was weakness more proximal or distal, I
said sir more pronounced proximally and favors
towrds muscular dystrophy
Becker dystrophy 😇 😇, viva on it Becker, if pt
was veryyoung I said Duchene
I told its X linked receive so his mother was
carrier, he asked about gene, that time I forgot
after coming out from examination hall I recalled
its Dystrophin 😅, any treatments, I said
supportive, I told all about non pharm as PE,
OT,etc I said any treatment specific that can
help, I sir I don't member
St4. : 74 old man admitted two days back with
Pneumonia sick since last few days with some
cough fever , IV amoxicilin given, allergic
reaction, hypo tension happened, seen by you
given steroids epinephrine, BP improved still
little confused..
Amox allergy was mentioned in pt previous
records
Talk to angry daughter, that polite Oman girl
👧 guess didn't know how to become angry 👊,
it went nicely, I told her what happened ,
apologized, gave reasons, told how situation
was handled, concern what measures will you
take so this don't happens, so root call analysis,
involving consultant and risk management
team,
Concern will this allergic reaction effect my
father in long run, will he be okay, how will you
prevent it
St 5 BCC 1:
Epileptic since 6 years on medications, having
visual problems, I had in mind it could be some
drug related or Optic atrophy or DM retinopathy,
inside middle aged Omani with translated,
explored visual problem it was color vision
problem, explored about any medical condition
or illnesses I should know off, she said taking
some medications for cough, I asked which
medication she said Rifampicin and ethambutol
other she don't remember, but I took a sigh or
relief, I ruled out any Lima weakness headache
DM social smoking alcohol.
Examination visual acuity, low on right bang
✋, I m not good at fundoacopy at all, at all, but I
knew by far from history and this little exam that
I just have ti find pale clear marfined disc on
right fundus ️
Gave diagnosis of Optic Atrophy , explained the
pt, concern will it become okay
Viva on OPTIC ATROPHY,
Other causes optic Atrophy said told them the
list 😉
What investigation I said OCT, one examiner
was like 😯, I was not sure, but I knew this was
some scan of eye (orbital CT) was not sure
though, this ia done or not just in the flow in
mentioned
One examiner question was you told to the
translator that it may recover, I told I'm not fully
sure but drug related conditions may recover
some time, but eye dr will be in better position
to answer, she asked with this much optic
atrophy on eye is it still possible I said not sure
BCC2 32 years Mr Philip 5 years back lithotripsy
done for renal stones, has complains of
sweating dizziness and palipations, vitals given
all normals basic labs normal glucose 2.8 mmol/
So I put DD as MEN1 and Insulinoma
asked about symptoms, improvement with
sweats, any severe attacks needing
hoapitlizations, asked about black stools, lumps
bumps, weight changes, headache and visual
problems all no active
Examined hands face neck proximal muscles
Examiner positive, do yiu think pt has features
of Acromeglay on examination, I said sir just
broad palms, he asked jaw,
Told pt about possibly need scans of head and
tummy, examiner asked how to examine told
him about supervised fasting inauline C peptide
scan of head and scan of tummy,
Sorry guys for writing too much details
Good luck to all of you
Please remember in your prayers
Exam experience muscat royal hospital 14

.10.2017.
st 4 husband diagnosed with hungtington
disease found heterozygous wife wants to know
about husband and children
st 5 bcc1 graves disease
bcc2 lady complaing blurring of vision dm
fundus hard exudate cotton wool spot new
vessels dm retinopathy
st 1 resp lobectomy with bronchiectasis abd
was confusing ? hepatomegaly ascites ?
splenomegaly examiner qs on splenomegaly
station 2 cluster headaches
station 3 cvs AS ex question any other i said
systolic murmur could b gallverdin
phenomenon or MR neuro v confusing young
lady with some hypotonia and depressed
reflexes power coordination normal it was mess
in this station
Exam Experience Oct 15 2017 MUSCAT SQUH

ST 1 Resp : young patient with clubbing, small
scars on the sternum in lat chest, coarse crepts
at bases... Bronchietasis
Abdomen : young to middle aged male
complains of tiredness old scar marks on the
left arm over wrist and cubital fossa, no bruit
underneath, scar mark on RIF with slightly
tender mass, gum hypertrophy,... Renal
Transplant
St2 : young lady with 3 months history of joint
pains and tiredness, CRP normal, counts
normal just lymphonoenia, no improvement with
paracetamol and NSAIDS, past HO thyroidism
well controlled on thyroxin 125mcg, last TFTSs
a months normal, feels tired all the day, no
mouth ulcer no rash no hair loss, no joint
tenderness swelling or Stiffness, but wakes up
unfresh and feels stiff in general almost
throughout the day,no tummy pains periods
regular, past history of two abortions one on
23weeks orthet not sure but also in 2nd
trimester, one past history of chest pain went to
drs but they told nothing serious mother has
RA
Non smoker no alcohol not very happy in
marital life because no kids, otherwise no
stresses at work, had ro take few times sick
leave from work
Concern do I have RA like my mother
Will this condition will affect my chances of
becoming mother.
DD APLA, Chronic fatigue syndrome
Examiners wanted APLA, I think
St 3. Mid line sternotomy scar, small scar near
apex area.. Two Metallic sounds?? DD MVR/DVR
viva on management, indications of MVR,
advice after MVR , warfarin advice about
warfarin, If pt alcoholic, complications of Valve
replcement, if pt needs dental procedure,
endocaritis prophylaxis
Neuro : obese young gentleman, commands
examine LIMBS, I asked sir upper or lower, both,
after finishing motor of lower limbs, generalized
weakness, depressed reflexes even with
reinforcement, examiner, notging in sensations,
proceed I started UL.. Weakness again bilateral
more proximally, cerebellum intact
Finding, DD, ( ️ ️confusing I started CIDP,
GBS, Lead, botulism,dystrophies examiner
asked was weakness more proximal or distal, I
said sir more pronounced proximally and favors
towrds muscular dystrophy
Becker dystrophy 😇 😇, viva on it Becker, if pt
was veryyoung I said Duchene
I told its X linked receive so his mother was
carrier, he asked about gene, that time I forgot
after coming out from examination hall I recalled
its Dystrophin 😅, any treatments, I said
supportive, I told all about non pharm as PE,
OT,etc I said any treatment specific that can
help, I sir I don't member
St4. : 74 old man admitted two days back with
Pneumonia sick since last few days with some
cough fever , IV amoxicilin given, allergic
reaction, hypo tension happened, seen by you
given steroids epinephrine, BP improved still
little confused..
Amox allergy was mentioned in pt previous
records
Talk to angry daughter, that polite Oman girl
👧 guess didn't know how to become angry 👊,
it went nicely, I told her what happened ,
apologized, gave reasons, told how situation
was handled, concern what measures will you
take so this don't happens, so root call analysis,
involving consultant and risk management
team,
Concern will this allergic reaction effect my
father in long run, will he be okay, how will you
prevent it
St 5 BCC 1:
Epileptic since 6 years on medications, having
visual problems, I had in mind it could be some
drug related or Optic atrophy or DM retinopathy,
inside middle aged Omani with translated,
explored visual problem it was color vision
problem, explored about any medical condition
or illnesses I should know off, she said taking
some medications for cough, I asked which
medication she said Rifampicin and ethambutol
other she don't remember, but I took a sigh or
relief, I ruled out any Lima weakness headache
DM social smoking alcohol.
Examination visual acuity, low on right bang
✋, I m not good at fundoacopy at all, at all, but I
knew by far from history and this little exam that
I just have ti find pale clear marfined disc on
right fundus ️
Gave diagnosis of Optic Atrophy , explained the
pt, concern will it become okay
Viva on OPTIC ATROPHY,
Other causes optic Atrophy said told them the
list 😉
What investigation I said OCT, one examiner
was like 😯, I was not sure, but I knew this was
some scan of eye (orbital CT) was not sure
though, this ia done or not just in the flow in
mentioned
One examiner question was you told to the
translator that it may recover, I told I'm not fully
sure but drug related conditions may recover
some time, but eye dr will be in better position
to answer, she asked with this much optic
atrophy on eye is it still possible I said not sure
BCC2 32 years Mr Philip 5 years back lithotripsy
done for renal stones, has complains of
sweating dizziness and palipations, vitals given
all normals basic labs normal glucose 2.8 mmol/
So I put DD as MEN1 and Insulinoma
asked about symptoms, improvement with
sweats, any severe attacks needing
hoapitlizations, asked about black stools, lumps
bumps, weight changes, headache and visual
problems all no active
Examined hands face neck proximal muscles
Examiner positive, do yiu think pt has features
of Acromeglay on examination, I said sir just
broad palms, he asked jaw,
Told pt about possibly need scans of head and
tummy, examiner asked how to examine told
him about supervised fasting inauline C peptide
scan of head and scan
11 oct Wythenshawe Manchester :

Hemiplegia,
AVR ? ,
Lobectomy vs single lung transplant ,
CLD.
St recurrent falls with postural hypotension &
proximal myopathy
St 4 : follow up pt , 6 weeks back admitted with
asthma , cxr had 2 uncertain opacities which
needed further imaging . Pt not told about
findings in previous admission. Also past
history of breast cancer treated with
lumpectomy chemo.
St 5 back pain + rash + joint pains dd
Ankylosing spondylitis psoriatic
St 5 headache Acromegaly
Egypt 🇪🇬 14/10/2017 carousel 2

BCC
Hypothyroidism
SS
Communication
Medical error wrong insulin dose
History
Wagner granulomatosis
Station 1
HSM with LN
COPD with basal fibrosis
Station 3
GBS
MVR with AS and PH
Cairo today 15/10/2017

Station 1
Hepatomegaly with LN and left subcostal scar
COPD with Rt. Basal crackles
Station 2
Back pain
Station 3
Spastic paraparesis with intact sensation
AVR
Station 4
Anemia after MI
Station 5
Gout
Psoriasis
OMAN PACES EXAM EXPERIENCE

OCTOBER 2017
Diet 3 Muscat
Station 1
Chest moving les on the rt side
Chest soracotomy scar rot side
Dull on percussion over the right lower part
Cryptations bilateral basal Inspiratory and
expiratory
( I said expiratory)
DD pulmonary fibrosis
Bronchiactesis (I forget to say)
And pale with ascitis no organomegaly
Dd
Station 2
Headache was cluster with mode affection
Station 3
As and mr
I said only AS
Neuro
Was lower limps flaced weakness
With intact sensation for defrintial
Station 5 was gravis disease very obvious
Other case visual disturbance
On ex there is acromegaly signs
Eye examinations maculopathy
Diabetic retinopathy
St 4 Huntington disease
Respiratory: Lt Lobectomy
Abdomen: CLD due to PBC
History: 37 yr old female with h/o T2 DM has
presented with tiredness and leg swelling 3/12.
She also gave h/o SOB for the same duration.
No h/o wt change, hot/cold intolerance. Her
creatinine was 145, Hb 8.9. Takes amlodipine,
insulin, statin.
CVS: AF, water hammer pulse, MR
Neuro: Diabetic motor & sensory neuropathy
Communication: 70-ye pt admits with
pneumonia. He also has dementia. He has given
iv antibiotic. Pt ‘s son is not happy why iv
antibiotic given without asking for his (son’s)
consent as he thinks iv route is associated with
more side effects. He also would like to talk if
any alternative treatment can be considered like
acupuncture, garlic which may help treating
pneumonia.
BCC1: Double vision in one eye for 2 weeks. No
sing of double vision found during examination,
visual acutely founds normal but has unilateral
ptosis.
BCC2: Neck swelling: Multinodular goiter.
Nothing positive found other than a visible
swelling that moves with swallowing.
Oman (13.10.2017)
Neuro-spastic parapResis with sensory level
Cardio double valve replacement
Abdomen -real transplant cushioned face
previous fistula
Communication _BBN colisterdia defecalis after
the for pneumonia
Hx uncontrolled DM Auto immune poly
glandular type 2
Station 1
Pulm fibrosis
Hepatomegaly jaundice, midline laparotomy
scar and right iliac scar. Couldn't find kidney..
examiners kept asking for causes of the midline
scar..is liver transplant possible? Anyways
didn't say that.
Station 2
History- spoke to pt s daughter.pt confused found
wandering in street. Pulse 56/ min. Dementia and
slowing in activities + old MI on drugs. She said that
her father kept asking to refill her meds again,
though it was refilled a week ago. DDI said B block
overdose, lewy body dementia, sepsis
Station 3
Cardiac MR
Neuro cranial N. Very confusing..had R side INO. L
side ptosis..she has smell and hearing defect. DD SOL,
Stroke,DM
Station 4
Pt has ILD worsening.. should discuss with son about
palliative treatment. I told he might need nursing
care. But he was very furious that he can't let him go
away from him. I was not sure if we could give him
the palliative care at home..
Station 5
BCC1 IVD user ALT increased.
DD. Hepatitis, HIV autoimmune
BCC2 spo2 94% RR 25. Chest pain.known asthmatic.
No travel no clot risk factors. Had creps B/L. DD PE,
PPH.
I think these were probable diagnosis according
to stations ,
Cvs : 1) Leaky aortic and mitral valve repair : pt
complaints DOE
CNS : 2) hemiparesis
RS : lobectomy with permanent pace maker
insertion
Abdo: chronic liver disease
Station : 2 ) lady with dm htn with history of falls
twice in 2weeks on getting up from sitting
position, Bp is 98:60
Station 4 : BA Patient two rounded opacities on
previous discharge x rays but no opacities now
I’m routine follow up , past history of breast ca
and lumpectomy done with chemotherapy
Station 5 : ankylosing spondylitis with crohn
with pyoderma gangrosum
3rd oct 2017

UK experience at
Queen Elizabeth University Hospital - Glasgow-
UK
St-2
Hypoglycemia attacks pt known DM.
Inside: nausea, vomiting, dizziness and wt loss
in type 1 DM. Past hx hypothyroidism.
Examiner questions: you checked the weight? I
said yes there was wt loss. He said how much? I
realised that I didn't asked how much over how
2 years 😳 🙈
She was on insulin? Yes which types? One
Long acting and short acting three time a day.
The name of the types? I didn't asked.
🙉 ☹ 🙄
DDX: Addison
Autonomic dysfunction
Gastroparesis
Autoimmune Poly glandular
Inv. ttt
St -4
Hodgkin Lymphoma
I approached it as Dr. Zain teach us. I put
outside three points:
1st/ explain the disease, symptoms,
complications and prognosis
2nd/ explain central line, its preperation with
potential complications and consent.
3rd point/ chemotherapy with bad effects and
how we will overcome it.
I started the conversation by I am sorry for your
recent medical condition but I believe you are
strong man and you can fight it. You are so
brave bcoz only yesterday the diagnosis had
been made and .......etc.
Did you slept well last night? How do you feel.
What is your job? Teacher. It is great job and
help the coming generation for.... etc.
How far do you know about your condition?
Then the three steps which prepared from
outside.
Main Concern was infertility which was
expected concern and its answer was already
prepared.
Other concerns
1- sick leave
2- how can I tell my wife? Can you help me in
that? I said be open tell her everything in detail
and I will help you if needed. and here there was
a long conversation with the examiner. I insist
the main issue is patient confidentiality versus
the wife interest. The wife may interest in
children while the chemotherapeutic agents
could cause infertility and freezing of sperm
backup may not help. I already had informed the
pt even after sperm freezing you may not have
children in future, no one grantee the
possibility. I involved the consultant.
St- 1
Abdomen: enlarged spleen with brusis in leg. I
finished early and I used the remaining time to
check for lymph node enlargement (femoral
cervical and axillary) all are not enlarged.
Respiratory: lobectomy for ddx.
St -3
CVS:
Large volume collapsed pulse displaced apex
with systolic murmur radiates to apex my Dx MR
Neuro:
Distal wasting scars of frequent injuries with
flaccid paralysis. All Sensory modalities lost. My
Dx Charcot Mary tooth, other differential DM and
Alcohol Cidp if GBS but wasting against that
DDX inv ttt.
St 5 -1
Patient is short stature,
Inside she has squent and she has symptoms of
hypothyroidism. Hair distribution was low
therefore I gave the cause is weeb neck. She
has children. I put diagnosis as turner. But the
negative was that the absence of primary
amenorrhea and pt has children. I took too long
history therefore I couldn't do proper
cardiovascular examinations, the examiner ask
me what your cvs findings, I said I need time to
do it properly.
St 5 - 2
Pt has arthalgia and htn
Inside there is wt gain change in face feature
macroglosia and all the feature of acromegaly.
diet 3 uk experience of a colleague

St :systolic murmur for Dd
Abd liver transplant functioning well
viva about ttt investigation in OPD
Chest :looectemy
Lt thoractomy scar fo dd (lung reduction
surgery
History :37yr dm1 insulin hba1c normal.pMH of
anemia now corrected..co fatigubty and
tiredness..only +ve dry skin
No symptom of hypothyroidism.addison-
mythenia gravis -no bleeding wt loss fever no
medication-diet not vegetarian but restricted
duo to DM.anemia duo to menorragia in the
past-no hypoglycemic symptoms
Viva DD Addison-hypothyroidism-automatic-
diet
Did you ask about mood?? Noooo
U think it's related I said yes
She taking her ferrous tt!!
What r cause of anemia?? Could b
ckd..restrictions of diet
How do investigate andtt
Pt concern :after I explain possibility of Addison
and hypothyroidism if life long I said yes and we
will dissuss after test result I suggest meeting
today
Neuro :LLhypertonia absent reflex peripheral
sensory neuropathy high stocking distribution
DD :ms .cord compression
DM
BBC1: night mares 😰 😰very talkative
surrogate may be give hx for 3 minutes 😩 😩(
u will fail me goshhh 😑
man co black stool +ve only epigastric pain and
Asprin (no indication for aspirin)He did
endoscopy came -ve many times
Hx -ve no wt loss bleeding from other site no
traveling or fever no hypermoblity joint
Examiner came close and tell him 2 minutes
remaining if you want any q (really 😳iam the
candidate by the way not him 😂 😂 😂)
Concerns want to travel
I advise to stop aspirin and need admission and
endscopy
I suggest peptic ulcer disease
He doesn't want endoscopy again I offer
capsule endoscopy and ct abd he agreed
Viva ask same q
BBC2 :thyroid nodule
Examiner saied I agree with you and all viva
about that
Communication:dissuss with daughter mother
condition kc DM OS admitted with pneumonia
Assume permission taken
And Pt ready for discharge assessment done
with occupational and phythiotherpist
Daughter live far away
Concerns not be discharge she affaid she will
be deterioted
and if OT had assess her for making cup of tea
I calm her by we asses her
Keep asking if will uble to mange
I suggested meeeting with OT
and offer contact and availability
Viva never ask about ethical issues
All about role of OT and safety issue I offer
inveroment carpet cutlery and alarm
And how I address concern daughter if mother
deteriorate
I answer contact
Ask me what u will do in real practice
I suggest my contact number
He laughed tooo much
And said Her GP
Ask me this usually do this in real practice??-I
said pneumonia receive tt she might not
deteriorate
He said yes bell rang.
whoops cross hospital UK, (2017/3) diet

St 4: Breaking bad news lung cancer and
delayed diagnosis,
History was 40 years old with recurrent chest
infections ,diarrhoea and wt L
oss
CVS-? MR(because iam not sure of any of the
diagnosis)
Resp-normal chest with haemoptysis and
recurrent infections
Abd-splenectomy scar
Neuro-diabetes or with headache
Station 5_straight forward Ank spond,type 1 DM
PACES Neurology Clues:

PES cavus + Absent ankle reflexes & down
going plantars is Charcot Marie
PES cavus + Absent ankle reflexes & up going
plantars is a Fredrick's Ataxia
Lower motor leg weakness with no wasting and no
sphincter involvement is acute GB (AIDP).
Lower motor leg weakness with wasting and
sphincter sparing is CIDP or neuropathy.
Neuropathy usually has mixed sensory and motor
signs and follows rule of length which means that by
the time it reaches close to knee, it starts involving
hands.
Lower motor leg weakness with sphincter
involvement is Cauda Equina (patchy sensory and
motor deficit which is L2 -S4) or Lumbar spinal cord
pathology due to necrotising myelitis.
Spastic legs with normal upper limbs is thoracic cord.
Spastic legs with Flaccid upper limbs is cervical cord.
Spastic legs and spastic upper limbs is cervical cord
above C5 or brain stem.
Spastic legs, spastic upper limbs and Flaccid tongue is
medulla
Spastic legs, spastic upper limbs and spastic tongue is
pons or above and (Exaggerated jaw jerk would
means lesion above pons).
My experience of Passing Paces from Banglore,
India, 5th august....
Started with St1 :
Respi : man with resting dyspnoea, prominent
resp. accesory muscles, barrel shsped chest, I/v
cannula, bedside oxygen nasal cannula, palmar
erythema, peripheral cysnosis, bounding pulse.
Resp examination consistent with COPD.
Dx: acute infective exaxerbation of copd.
crossing : dx, ix, mx, what wud i do if this man
came to casualty with breathlessness.......got
20/20
Abdomen : a very obese ,middle aged man with
HUGE ascites, gross generalised pigmentation,
i/v cannula, scar in RIF consistent with ascitic
tap, peripheral odema, deep jaundice and
umblical hernia.
Dx : decompensated CLD with portal htn.
Crossing : any organomegaly? I said i could not
appreciate due to huge ascites.
Single cause of cld in this sp.pt? I wanted to say
chr viral hepatitis but i decided to be practical
so i said, as becz pt is having elevated BMI so
most likely NASH or ALD.
Why pherp odema nd basal creps? Said maybe
volume overload due to persistent aldosterone
activation due to underfilling of circulation or
due to concomitant CKD as pt is slso
hyperpigmrnted.
Ix And Mx. Got 20/20
St2: a 28 yr old man with dudden onset rt knee
swelling and lft ankle swelling.
Pt gives vague history...describes pain to be
mechanical...on further query admitted an
episode of food poisoning, brother with
psoriasis..rest sll history negative. There was no
dysuria nd pt is umnarried....so here made the
mistake of not taking sexual history as i thot no
need of it....also did not take drug allergy
history.
crossing : ddx: psoriatic arthritis, reactive
arthritis,enteropathic..
What things u ruled out? Said,male SLE, gout,
pseudogout, septic arthritis, sarcoidosis
What are assos systemuc disease? Said ,
sarcoidosis...examiner pinpointed me that i
missed serum sickness arthritis as dint take
allergy history nd also sexual history....then
asked abt ix , mx, how to rule out gout nd
poseudogout. Got 12/20
St3.....cardio:
Young man seemed to be drowsy, pulse normal,
apex beat in the 4rth ICS (made me confused)
signs of Pulm HTN present, with PSM with
radiation to axilla
Crossing: dx: severe MR with PHTN.
Then examiner asked me to show where i got Rt
parasternal heave (i got scared) and thrn he
checked himself.
What might be other assos lesion? I said
possible MS ..need to find out by echo
Ddx: VSD , MVP
Y not VSD: said rad to axilla
Ix....details about each nd every Ix findings....got
20/20
Neuro: young man with compaints of dropping
things from hand..exsmine UL
Rt hand flexed with fingers flexed in typical
stoke pisition....ex consistent with pyramidal
pattern of wasting nd weakness snd UMNL in rt
with loss of all modalities of sensation except
joint position...left limb normal.
Crossing : dx: left sided stroke eith rt
hrmiparesis
Ddx: all of a sudden i blacked out nd ssid
nothing.
Details of Ix and Mx.
Long term mx ? Said cvs risk factor mx and
phisiothersphy...got 19/20
St4: 84 yr lady with fall csme to casualty..test
revealed UTI...later pt is confused...started
approp antibiitic..pt now improved also there is
some resting tremor..so diagonosed as idio
parkinsons nd given careldopa..she was having
mild tremor since 3 yrs but never attented
medical advice...only daughter came from
abroad to discuss.
Many issues: pt is only carer of husbsnd who is
having stroke., pt is living alone, one son but
reluctant to look after, pt's hobby is
painting...so pt is sad she cant paint due to
tremor...y confusion? Is this true that slowly she
will start to forget things? Why she was not
started on parkinson Rx earlier? How can she
take care of her mother? Any Rx avsilable ?
Crossing: what issues did i come across?
Why not started Rx earlier?is there any harm to
pt for not starting Rx earlier?
Details abt ix and mx with mode of action and
side effects of each drug, surgical Rx? Got
16/16
St5 ...a) outside 38 yr female eith irregular
menses, pain in thighs, nd wt gain, high BP,
oxygrn saturation 92%...inside obese pt with
pitting odrma + bibasal creps , proximal
myopathy, wt gain, OSAS , diagonosed as
PCOS.....concerns ;: is it bcz of hormonal
problems?
OSAS, ix and Mx of each...got 27/28
B) outside 28 yr female with chedt pain radiating
to lft arm.....inside typicsl History of ACS,
diagonosed as SLE (pt do not want to say....said
after lots of hammering) taking prednisolone
snd hydroxychlorowuine for SLE...concern: is it
serious?
spasm.
Ix nd Mx of ACS, risk factors of DVT...ehat if
ALHAMDULILLAH passed with a total score of
160...
Thanks to this page and all the doctors for i
have learnt much by remaining active on this
page....i hope my experience will help the
upcoming candidates. Good luck !
My exam experiences in 4th of July, 2017 at

Mandalay General Hospital.
Station 1
Respiration - Left lung collapse, I dun know
what I missed. 17/20
Abdomen - Hepatomegaly with huge
splenomegaly 20/20
Station 2
20 years old female dance instructor, persistent
diarrhoea for 4 months, LOW (+), Travelling history
to Thailand before diarrhoea episode. Full blood
count, ESR, CRP, Stool culture all normal. Family
history of CA Colon in grandma. GP think of IBS. Dx
- IBS
DDX- Thyrotoxicosis, Coeliac disease, Malabsorption
syndrome, IBD, Giardiasis.
19/20
Station 3
Neuro - Look at the eye and proceed.
Dx Occular myasthenia 20/20
CVS - Mitral stenosis, Aortic regurgitation with Afib
no features of IE, no features of heart failure. 20/20
Station 4
Talk to the daughter about his father condition.
Recently got stroke and now got MRSA infection at
pressure sores of both heels, no signs of clinical
infection.
13/16
Station 5
1) 55 years old female constipation for 3 years
without red flag signs, but mild hypertension on
Thiazides diuretic. No other features of
hypercalcaemia. On examination, no features of
hypothyroid and hypopit, lower midline scar for child
delivery 17 years ago(+) no features of intestinal
obstruction. Family history of CA colon in mother.
Dx hypercalcaemia due to thiazide or primary
hyperparathyroidism
I gave general advice for constipation and refer for
colonoscopy for CA colon screening.
28/28
2) 63 years old lady Uncontrolled diabestes and
hypertension, underlying bronchial asthma on
inhalers, develop white skin patches in lower limbs
and she is taking OTC medications for two weeks for
skin problem. On examination, no physical features
of Cushing's Syndrome, widespread rhonchi (+) on
auscultation of the chest. White patches looks like
Vitiligo.
Dx Uncontrolled diabetes is multifactorial but most
likely because of? Steroid medication
Mx I said Multidisplinary team approach
28/28
Thanks for all in this group. I passed with 165/172.
UK EXPERIENCE
,Glasgow college.
Exam was on 16th july, and fortunately I passed
it.It was excruciating experience to go through
the tormenting phase of PACES prep however in
the end it is very rewarding.
My cases were
St 1
VSD AND PARKINSONISM
14/16
I don't know why I have not received good score in
these two case coz both were straightforward cases
St2
Confusion in a known prostate carcinoma patient; I
gave a differential of
Hypercalcemia,metastasis,delerium
Resp and abd st were ILD and liver transplant
respectively 16/15
St4 convincing a young female for steroid inhaler
St 5 Raynauds phenomena and transient ischemic
attack 27 /27
The key of the exam is to be fluent,must not fumble
and be confident.they often try to check that whether
you are stick with your findings or not and if you are
keep changing your opinion ,that may be proven
detrimental.
I am not going to tell you anything extraordinary,the
most of the things you already know.
during exam we do feel nervous but just trust your
instincts.you have invested so much time and finances
to reach in this state .you can not just screw up
everything by silly mistakes.
accept your limitations,when diagnosis is not obvious
just state it loud and give best possible differentials.
Exam doesn't want you to be sherlock holmes ,just act
as Med registrar,you dont have to be a consultant for
this exam
Thanks this group.

My experiance , mandalay, first day last round
Start with history
25 years old man with recurrent headache,
hypertension, this morning he got glycosuria++.
So came to consult, while waiting , he argued
with nurse n got palpitation, nurse took ECG-
normal. He has history of anxiety n taking dz.
Take history.
In the room, serogate didn't tell more than that
except recurrent sweating. Drug- taking high
dose vit C.
Explain- gland problem . Need to confirm.
Is it curable?-depends on cause. DM?- no.
Examiner- dx- pheo, hyperthyroid, anxiety
Points for pheo?- not sure. Any asso: problem-
no. DM?- no. Why glucosuria?- vit C high dose.
May be anxiety but need to exclufe pheo
I got 20/20
Diet 2 Penang Hospital Malaysia

This group has given much help for the
preparation of PACES. These are my cases
My advice is FOR HISTORY AND COM SKILLS
-try to share out to our fellow frens the
important points in the scenario as
cases are repeating (easier to prepare with
concrete info)
As for short cases, identifying physical signs is
important and comes to a unifying
diagnosis based on findings u get
Station 5
scenario 1- middle aged lady with long standing
rheumatoid arthritis comes with
foot weakness
Scenario 2- 48 year old lady presented with
tremors
Scenario 1
One quick glance: gross deformity of hands, left
foot drop
Hx: weakness over left foot-2-3
months,worsening, loss of sensation over
lateral side of leg
RA for 30 years, no recent
history of trauma
on T methotrexate 15mg/weekly, T prednisolone
10mg OD (meds taken for 2 years)
no osmotic symptoms
staying with daughter, quickly assess home
environment
Physical signs
-walking frame by bedside
-wasting of distal muscles of bilateral lower
limbs
-wasting of small muscles of hand with
Boutoneirre,swan neck,Z deformity,ulnar
deviation
-left lower motor neuron foot drop
-claw toes
-right ankle:Charcot joint (all movements of
ankle restricted,deformed)
-no scars
-unable to invert and evert left foot
-hip flexors and hip adductors power 5/5
-sensation intact
-proprioception loss
-mention want for gait )-stopped by examiners
concern: what is wrong with me?
discussion: how to determine level of lesion in
foot drop, differential diagnosis
I gave: mononeuritis multiplex (due to RA, can
be due to DM-steroid induced, vasculitis),
CIDP, mx-multidisciplinary
Scenario 2
Hx- tremor of hand, left side only, usually at
rest, disappears during action,
no symptoms of hyperthyroid, no improved with
alcohol
no frequent falls
no giddiness upon postural change
no constipation
drug history : antihypertensives only
no family history
working as clerk
Physical signs
-mask liked facies
-resting tremor over left hand
-cogwheel rigidity
-signs more prominent upon distraction
-bradykinesia
-shuffling gait,absence of arm swing
-writing-micrographia
-no cerebellar signs, no pyrimidal signs,no gaze
palsy
-mention to check BP for postural drop
concern: what am i having
impression: idiopathic parkinson disease,Yahrs
grade 1, in view of asymmetrical findings
lack of other signs
* but also want to investigate for other causes of
Parkinsonism in view of her age still
young
questions from examiner- ix for Parkinsons
disease,mx
Abdomen
young lady
inverted J shaped scar over abdomen -->likely
to be renal transplant
non functioning AVF over right arm
multiple previous puncture marks at neck
pink
no Cushingnoid appearance,no gum
hypertrophy
mass about 5x5 cm beneath the scar at the right
iliac fossa,firm,mobile,non tender
able to get above,no bruit
no other organomegaly
no ascites
no pedal oedema
lungs clear
no dextrostix marks, no alopecia,no malar
rashes
requested for BP during end of examination
impression
end stage renal disease,current mode of renal
replacement therapy is right renal
transplant which is functioning well, previous
mode of RRT is hemodialysis
clinically not overloaded and pink.Likely cause
for ESRD would be glomerulonephritis
in view of the age
Questions from examiner- ix and mx
Respiratory
young gentleman
Respiratory rate 20 under nasal prong oxygen
clubbing of fingers
tattoo all over arms and body
thoracotomy scar and previous chest tube scar
over right hemithorax
trachea central
reduced chest expansion right mid and lower
zone
dull percussion right mid and lower zone
bronchial breathing right upper zone with
increased vocal resonance
coarse crepts left lower zone
impression
features of consolidation right upper
zone,bronchiectasis left lower zone,
and right lower lobe lobectomy/decortication
unifying diagnosis considering the geographical
area would be pulmonary TB
questions: ix and mx
History taking(i only write out important points)
30 years old gentleman presented with sudden
loss of vision over right eye
lasted for few seconds only
no other neurological symptoms
no symptoms of connective tissue disease
history of having 'blood clot in the vessel of left
eye' few years back-presented with
loss of vision also
hypertension diagnosed at few years back ( so
rule out all causes of young HPT)
significant family history of stroke
no one in family having recurrent
miscarriages,thrombosis
drug history- started on aspirin few years back-
compliant
smoker-stopped few years ago
driving
Impression
amourosis fugax
Ix
CT brain TRO stroke,ECG for AF, ECHO for LA
size,thrombus, as well as patent foramen ovale
USG doppler carotid
fasting glucose and lipids
Hb to look for polycythemia
thrombophilia screening
Mx
extended release dypridamole/ clopidogrel
warfarin if AF or thrombophilia
advise for driving precaution
CVS
middle age gentleman with SOB
slow rising pulse,low volume
apex beat not deviated
ESM radiating to carotid and apex
no other murmurs
no signs of IE or failure
mention to check for BP
impression -severe AS with Gallavardin
phenomenon
questions on ix and mx
Neuro
middle age gentleman with blurring of vision
left complete ptosis
3rd nerve palsy
pupils dilated
other CN intact
no pyrimidal signs
no dextrostix marks
mention to check BP and ask for any headache
Impression - left surgical third nerve
palsy,lesion -PCOM aneurysm
questions on ix and mx
Com skills
56 years old gentleman came for UGIB and
endoscopy done showed malignant looking
ulcer. Task is to explain findings to patient and
counsel for CT
questions asked by surrogate
Is it cancer?
Am I going to die? how long do I have to live?
straightforward scenario, cant find any hidden
agenda
2/2017 Mandalay General Hospital, Myanmar.

5 July 2nd round
Station 4
24 years old lady history of recent
thyroidectomy for medullary carcinoma of
thyroid and hoarseness of voice after post-op
but recovered completely. Tested MEN 2a gene
which is positive. It's autosomal dominant &
chance of phaeochromocytoma for 50% and
hyperparathyroidism for 30%. No family history
of cancer. Planning to marry soon.
Task- counsel about genetic and family planning.
Concerns - how should she tell her husband?
What about her children future?
How about her parents? Do they need to screen?
Examiner Q:
What does this disease like?
How will the genetic counsellor explain this disease to
this patient?
Does she need to tell her husband?
Station 5 - 1
Old-aged gentleman, arthritis for 3 days.
Inside - Big toe inflammation, tophi present on big
toe, fingers, no fever. History of similar attack last
year but no consultation and no treatment. History
hypertension and Diabetes.
Dx- acute on chronic gout most likely due to
metabolic syndrome.
Station 5 - 2
Young lady, polyarthralgia and low grade fever for 1
month.
Inside- no fever now, history of butterfly rash, oral
ulcers and painful rash on palms last 3 months. No
consultation and treatment taken. Now pregnant and
5-month. No significant signs apart from systolic
murmur.
Station 1
Chest - left lung collapse
Abdo - hepatosplenomegaly with ascites
Station 2
24 years old gentleman with fever and cough for 3
days. On examination BBS is heard in rt lower zone.
History of repeated chest infection.
Inside - features of pneumonia, repeated chest
infection last 3 years, history of tonsillectomy at the
age of ten. History diarrhoea last year diagnosed as
giardiasis. No history of pancreatic insufficiency . No
family history.
Dx - lower respiratory tract infection most propably
due to primary immune deficiency like
hypogammaglobulinaemia and CVID.
DDx - cystic fibrosis, immotile ciliary syndrome,HIV,
bronchiectasis
Station 3
CVS - ?valvular heart disease
CNS - mixed motor and sensory peripheral
neuropathy.
Thanks a lot to this group for sharing experiences. It
does give a great help for me to pass PACES. 😊 😊
😊
Copied from Dr ZAIN group

Thanks GOD for passing paces ,,,, don't loose hope if
delayed accepetance and continous rejection it will
come to be true one day Inshallah.
One advise I will give what I was doing is studying my
colleagues experience , no time for reading books in
and out with heavy duties
Egypt 2017/May 23 Almaadi Military Hospital
I started with station 2#
While waiting i asked myself why they put station 2
my first ststion , if it went bad every thing will go bad
,,, ok i will try to forget about it however it finishes
A 35 yrs old male presented with cough , past medical
history he has multiple sclerosis ,, vitals are stable
I started with opening and history of present
complaint ; cough for the last 1 month ,dry , diurnal
variation? all the day but mostly at night , no wheeze ,
sob ,chest pain ,orthopneae, pnd,leg swelling or
haemoptysis,
any thing that increase it , i gave all allergy risks
negative including pets , relives it ?only partialy
relived by gavascon.no improvement at weekends or
vaccation. May be GORD? So i went to GI questions
all negative except mild heart burn.
I was asking my self why they brought it directly
GORD ,, it came around my mind GORD ass with
weight gain zI directly asked did u gsin any weight?
Surprisingly he said yes ,, non intentional ,no specific
distribution, no Hypothyroid or cushing symptoms,
no proximal myopthy , so why weight gain , i said
leave it time will finish.
I screened other systems , when reached
muscloskletal any weakness right now ( he has MS)
he said no but 2 month back he had weakness , I said
was it MS attack ? he said yes and voulantry told he
was admitted there and apon discharge the doc
changed his medicine to Methylpredinsone tabs 5
days a week
Aha ,,,, and did he give u any medicine for stomach , i
dont remember his answer ,,
,I finished reaching drug history nothing ,, affecting
him badly in job but job not related to cough. 2 min
remaining i was still taking history they remind me
again
CONCERN : do l have aspiration pneumonia? I read
in internet MS causes it am so afraid and soo much
worried he was talkative ,,, i paniced I cant stop him
now
I remebered dont answer concern with managment
plan so I answered NO its not aspiration pneumonia ,
good you dont have sob, fever, etc ,,, I told him breifly
the tabs given for MS caused u weight gain and it
relaxed the stomach opening this why stomach acid
goes up irritate you ,,,,didnt give him mang plan time
finished
1 min reflection : i read wat i wrote in my paper
Examiner questions :
whats his problem : ended with GORd , how? Relax
of sphincter
Why you think its not pneumonia
Investigstion : basic ,,, any thing specific ,,,i was
blocked he said like invasive I said you mean
endoscopy? he said something to confirm , i said
esoph manometry , for what? To check acidity , Then
he asked if this man came to you in ER will you not
do for him CXR ,,,, i realized i forget I said yes but
really i said why CXR! After exam i remembered
chronic cough
DD i listed all starting with GORD , other dd and
what is against
No time for treatment
I got 20
Station 3 # CVS :
Double aortic ,,, with possible mitral regurgitation
Questions:
Findings
Investigations
managment including indications for replacment
1 got 19
#Station 4
From outside long scenario : A young lady with long
standing history bronchail asthma well controlled on
brochodilator had an attack of srver astha wranted
ICU admission and intubation 4 days discharged on
steroid inhaler but her symptoms are uncontrolled
since disharge. The GP sent you the patient because
he feels she is not compliant to inhaler ,,, she also has
eczema since childhood
I started by the opeing as Dr zein taught us , she is a
teacher , no one with her , how she feels now, she has
all symptoms day and night ? And how much she
knows about her condition , she knows everything
,she left nothing to add, , so told you are right and am
sorry for the unfortinate event(icu intubation) i know
it was a hard experience but happy
that you are out of it snd I hope it want happen
again.she said thanks.
So what about the tabs given to you to control your
symptoms , she said no one gave me tabs , 🙆 i asked
mo one gave you steriod tabs ? she said no ,,, 😂 i
looked at the paper coz I prepared my self as
councling for steroid tabs ,, they gave her inhaler ,,,,
so i said the doc prescribed steroid inhaler , she said
yes again I repeated no one wrote for you tabs coz i
was preoccupied by tabs ,, so every thing is changed
now ....
So do you have any problem with the inhaler you take
, any difficulty with technique ,,,I didnt want to say
GP told you are uncomplient ,,, she said am not
taking it ? Any thing nothering you with it? Then she
talked too much about worriness of side effects she
said all side effects ,,, I said i appreciate your
worriness but i want to calm you that inhalers are not
like tabs and this side effects dont happen unless with
long time use , the most thing that happens is throat
infection for which you need to wash mouth after
each use , and the inhelr is important to controll
symptoms and not having a bed experience like
before. I went far that without controlling asthma an
attack may lead to DEATH.
She asked repeatedly of side effects and i told the
same.
Then she said any other ttt thsn this? I said in asthma
we follow a step up method we give simple ttt then
add more potent ,,,, i said if not controlled you may
need to be given higher dose inhaler or steroid tablets
which will have more side effects ,,,,
I asked how do you think about using the inhaler?
She said i will think because you told no side effects
with it ,, i said it can happen minimally with long time
use but they are important to controll symptoms.
She is a teacher lives with her husband who is
supporting her financially ,many sickleaves and her
husband leaves the room at night coz of her coughing
,,, I appreciated this and empathized for that ,,, then i
asked sny other concern : she said no you answered
all concerns ( she asked many questions)
Then I summerized check understanding and closed
,,,, and again said you agreed to take them she said
yes . and advised sgsin on compliance and regular
follow.
They told one & half minute remaining
Ok i will talk about any thing , i told do you have
kids? She said no ,, i told i hope you will get kids
soon 😂 😂 😂
This is non sense , Then asked you have symptoms
right now , she said all the time , i said I will asses you
and check your oxygen and wether you need
emergency ttt right now . She agreed .and we kept
silent waiting for bell.
Examiner question :
Whats her problem
What are ethical issue : autonomy,councling,
empathy
What are her concerns
Did you convince her , i said she told she will use it
If she came to you next time and didnt use inhaler
what you will do? I said I will council her again , if
not?I said I will send her to gp and talk to her
husband!! He said you will talk to her husband? I
said after taikng her permission , and do you think he
will help her? I said yes I forgot he leaves the room at
night,, he asked and how he will help her? 😥I said
he will tell she is important for him 😇 I forgot she
told me that he leaves the room for her at night.
Then he said what else? I said GP , do you think GP
will convince her? I said yes gp is the family doctor
and their relation is strong with patients ,,,( i worked
as family doc before) what else? Bell rang ,,, he
wanted to hear consultant and specialised nurse I
think
got 14/16
# BCC1 : A 35 yrs old lady presented with SOB for 1
month or more ,,, All her vitals are given normal
when I entered I great examiners , patient and
surrogate ,, looked at the pt to see if spot diagnosis in
face nothing ,,,
I asked all questions regard SOB it was exertional
now at rest , No symptoms of anaemia, H failure or
other chest symptoms ,,, i was taking a look at the pt
every time when I realised her skin on dorsum of
hands is shiny ? may be scleroderma ,,, fingers were
in slight flexion position ,,, I said i would like to
exsmine ,they said proceed , ehen standing b
eside her I rememberd risk for Pulmonary embolism
all negative
Hands skin was tight dorsum only , fingers were blue
, slightly flexed but not deformed,function good, I
asked about Raynaud , other connective tissues (
mixed, overlap) all negative ,proximal weakness, in
the face normal skin normal mouth opening she can
introduce 3 fingers , i examined the back crackles on
right side only dont change with cough , the examiner
put his stethoscope at the same place I did and said
continue, I checked pulmonary area for PHTN
couldnt hear loud P2 , i finished history, dhe is a
house wife , sob affecting her soo much , I said that is
hard with empathy
CONCERN : will she get back to her normal status
like before? I said am afraid to tell that she will not
return to normal as before , because the SOB is due to
scarring of her lungs ,,, and this related to the change
in her hand skin and also causing the( raynaud) all a
condition called scleroderma ,,, but some medicine
can help to improve her symptoms .... I completed she
needs some test and images and more assesment
better as inpatient
Ex questions : patient problem
Diagnosis , limited SS complicated
What did u find in exam: i said limited skin changes
to dorsum hand , mild sclerodactly , calcinosis ( no
cslcinosis actually) he said look at her fingers they
were cyanosed
Do you want to examine her legs i said no , I should
have checked for skin and pitting edema
Investigations : all
Bell rang got 26/28
BCC2 :
Skin rash macular scaly itchy on the arms, it started
in abdomen i took a look red scally , no joint,nail
affection , no back pain, no ppreceeding sore throat,,
I asked for every thing negative, , I jumped to PMH,
drug history ,HIV risks, social all negative ,then silent
for around a minute , i didnt know what to ask , then
I
Asked any loss of wt blindly,
Surprisingly Pt had weight loss 5 kgs non Intentional,
fever and night sweats
Others negative( searched quickly for infection and
malignancy source as no time),,,I asked to examine
chest they said proceed nothing in chest , I want to
examine lymph node I examined right submandibular
, they said no lymphadenopthy ,,bell rang , 2 min
remaining , I said I would like to examine,abdomen
for hepatospleenomegly ,they said again 2 min
remaining .
Concern : will this rash disappear and improve?
I said am afraid it may not disappear bacause am
thinking of serious cause like growth , i hope its not
the case , we csn give something to help with itching
and need to do some blood test and may go for some
scans to rule out growth.
Examiner q:
Whats his problem?
What is your d or dd ? I said in presence of wt loss ,
fever sweats and this rash I put infection , malignancy
he asked what type of malignancy answered (
haematological & solid) what infection I said like TB
although not sure .
Investigations : no time
I got 28/28
got28/28
Station 1 # Chest : pneumonectomy 20/20
Diagnosis
Causes
Investigations
Treatment , they discussed LOTOT indications
# Abdomen : hepatosplenomegaly , ascites ,signs of
CLD
CLD for differential 20/20
BCC2 raelly i couldnt reach diagnosis coz if not
following the previous feedback from colleagues it
came before as icthyosis with underlying malignancy
,,,
I would like to thank dr.zein Zein Mahgoub for his
great ,unlimited support and the group he created
where all previous feedbacks are shared beside
continuos disccusion ,,, Thanks for all colleagues and
good luck.
Copied from Dr. Zain group

Experience in paces in maadi hospital in
May(EGYPT)2017
◇ Station 5..
1_from out side pt 50 yrs complain of loss of
vision.. Inside she is diabetic and hypertensive.
History going with TIA.. I examined the pulse
and the carotids. I asked to do fundus exam and
cardiovascular the examiner said normal. I
asked about driving not driving..concerned
about is it stroke..I got 21
2_about 60 years male complain of loss of wt.
Inside there is significant wt loss no any other
GIT symptoms..pH of bowel resection and on
replacement for vit B12. On examination midline
laprotomy scar.. Concerned is it cancer igot 18
😓..
◇ Station 1..
▪️ Chest.. Lt sided pleural effusion..
Discussion about causes differential
investigation then bell 🔔 rang..
I got 20/20
▪️Abdomen.. hepatosplenomegally for
18/20
◇ Station3..
▪️ CVS .. mitral regurgitation with pulmonary
hypertension and atrial fibrillation.. Discussion
about investigation and management
20/20
▪️ Neurology.. Amiddle age male.. Instruction
to examine the lower limbs and tell the positive
findings..there was monoparesis with hyper
reflxia and the planter was equivocal for me.. I
put ms and they ask about the investigations
and the 🔔 rang..
20/20
◇ Communication.
A young male.. Admitted to the hospital
because of pneumonia. And started to improve
but suddenly developed convulsions.. When
you revised his notes,he is a known epileptic
but not given his medications since the
admission...
Inside.. I introduced my self. I ask how is he
feeling today.. He said IAM not fine.. I said IAM
sorry for that and directly I asked him what he
knows about his condition so far.. He replied
that I was fine.. And admitted to your hospital
because of cough but today I developed
convulsions l don't know why.. Because IAM
compliant to my medicine even in the day of the
admission in the morning I took my medicine
and for the last 7years it didn't happen... I
listened to his story then I replied yes u are right
and directly I said lam sorry to tell that that
happened because it seems that u didn't receive
your medicine because the medical team have
to give you but that didn't happen..he start to
shout how is that.. IAM coming here to be cured
and u r causing me more problem..this is not
acceptable at all..I tried to stay calm and make
him to show his anger.. I said you are right in
every thing u r telling.. And this is our mistake
and I will be thankfull if u accept my apologies
and on the behalf of all the team I repeat the
apology and I hope to accept that.. 😢 and I
told him already we wrote something called
incident report and we inform our senior and we
will discuss this in the doctors meeting.. After
repeating more apology he started to show me
his concern which was that he want to make
acomplain.. I replied that your right and will
direct u to the authorized place to make your
complain.. The other concern was the driving
and. When he can drive and that we make the
mistake and at the moment he wants acar with
the driver to to be able to go to his work place
as ( I can not remember but seems something
important). I replied IAM sorry to tell you that u
are adviced to stop driving and to inform the
DVLA.. he asked for how long l said it is months
rather than days 😀 I was not sure for how long
exactly.. And regarding the private driver lsaid I
will inform the social worker he will do his best
to help you.. He asked he will give me the car
and the driver l told IAM not sure exactly if
possible to do so but I am sure that he will do
his best to help..Finally he looked convinced.. I
ask him what he get from our talk he replied I
want to complain 😀...I thank him and
apologized again.. The examiners asked about
the ethical issues and if it is mistake or not..I
replied yes it is.. They ask who is responsible..
Isaid the admitting team of doctors.. And what u
want to do to prevent such event.i repeated
same what I said to the pt...then the 🔔 rang
😀
I got16/16
◇ History station..
A young female known diabetic present with wt
loss..her Dm is well controlled.. Inside history
going with Addison disease.. Discussion about
differential and investigations and management
of Addisons
And alhamdolellah before and after.. And thanks
again to Dr. Zein and everybody in the group
UK EXPERIENCE
experience Fairfield Hospital, Buay, Manchester:
station 5 - 1: 35 YO F c/o palpitaion and
dizziness with history of dislocated hip joint
inside: symptoms in attacks and occurs during
standing or any exertion: no chest pain no sob,
palpitation is regular. +ve all hyperextended jts.
my diagnosis EDS with anaemia for DD. qs:
criteria to diagnose EDS and causes of anaemia
how to investigate.
Station 5-2: 72 YO Male, c/o SOB and x-ray shows
pleural plaques. inside midsternotomy scar, decrease
air entry bibasal posteriorly. qs: why this scar, I said
it is tissue valve replacement vs CABG as no click no
vien harvesting which may from internal mammary
artery. causes of SOB I said heart failure but no LL
oedema or increased JVP, pleural effusion, lung
fibrosis. causes of lung fibrosis and effusion.
Abdomen: hemeplegic bed ridden 75 YO man, with
upper midline scar, has SOB. no HSM, no ascites, no
Heart failure. Qs.: why this scar, why he is
hemeplegic, why SOB. I mentioned general causes
like cancer stomach or bleeding gut, one of the
examiners insiste about what is the simplist
investigation if he has acute abdomen.
unfortunately I forget to mention brown frecklings
under his tongue which may be the key diagnosis as
Peutz J disease.
Chest: Lung fibrosis bilateral bibasal, causes of
fibrosis investigations how to treat.
Neurology: Parkinsonism, what is the DD of this
tremors.
CVS: AVR with sob, causes of SOB the examiner was
happy when I told him warfarin complication.
History: attacks of anexiety and palpitation MEN
syndrome i forgot the smoking and alcohol but I
covered every thing else, the problem is that the
serrogate keeps asking about his job what is the
causes is it stroke and so on not give me any space to
talk.
Communication: patient with asthma admitted with
excerpation treated well and on the day of discharge
given wronge treatment to other patient shared her
last name, asprin, steroid, BB and ACEI. very angry
and annoying surrogate. she didnt give me any space
to talk keeping shoting and didnt want to listen to me
even I tried to apologize, aknowledge her feeling,
asking about social problem, but without response
from her. finally, I stopped her and informed her that
this is only one dose we will keep you for 24 hours for
observation. the examiner accept my behaviour and
he said that she is a real actress dont worry.
PACES EXAM 3 July 2017 Mandalay General

Hospital
Station 3 CVS
Pt come to OPD for breathlessness
Middle age lady with submammillary
scar?Previous mitral valvotomy scar.
Pulse AF present.
Apex beat 5th ICS over mid axillary line and
diastolic thrill.
MA loud 1st sound MDM grade 4/6 loudest at the
end of expiration with the bell of stethoscope
Other NAD
DX This lady has MS with AF no sign of pul
hypertension ,no sign of IE and no sign of heart
failure.Possibly from restenosis of previous
mitral valvotomy and aeitiology is possible
rheumatic origin.
How will u manage?Firstly ECG for AF.Echo for
severity of MS,valve area,gradient and EF.Also
thrombus in LA.
She may benefic from anticoagulation treatment
with warfarin,and cardiologist referral.
Which investigation would you like to do?
I answered cardiac cath.
I got 19/20
Copied ,,,
easy.
11/20
smooth. 20/20
management. 27/28.
PACES 3 July 2017 Mandalay General Hospital

Station 4 Communication Skill
Patient record full paper about joint
pain,morning stiffness,lab results.
25 yr old lady with symmetrical joints pain
,morning stiffness duration about 3months.CP
auto Hb 10.5,RA positive,anti CCP titre
raised.U&C normal,LFTs normal.
Your tasks explains results,your consultant
want to start methotrexate and explains patient
concerns.Patient wants to start family planning
comming soon.
Firstly,introduce to patient.
Do you come alone.Do you want any coffee or
tea.How about your joint pain.
Patient said well and fine.I said Good.What
wrong my result dr.I makes like BBN style.I had
your blood results in my hands,I sorry the result
is not good.What?I sorry,you had serious
disease.I makes like PACES CS idol in PACES
video like multiple sclerosis explanation.
RA.Do you heared about it.Joint problem?Yes it
is long standing and deforming joint problem
without treatment.Not only joint but also it
damages your lung & kidney.I carry patient to
the darkness.But I give hope.But there is a
special drug which delay these problem.Called
methotrexate .My consultant want to give you
these special drug.
Pt ,now I am good,may I need these drug.
For long term,it is beneficial for you.
Pt,it has many side effect?It is true dr?
You are right,methotrexate has many side effect
but it is manageble and we can detect early and
we can stop timing.
What are the SE dr?
MTX has effect on your blood count,lung and
liver.Some inflammation of your lung and
liver.But if the drug stopped they recovery to
normal.
Pt,I am planning for family,it is ok?
Oh,it is very important.At least 4 months we
may stop methotrexate before pregnancy.
Why dr?It had bad effect on your baby.
What means dr?Your baby has some body
structural and organ dysfunction.
So what can I do?
Don`t worry.We may give you joint care with
lady O&G dr and joint specialist.
If mtx stopped my joint problem will be serious?
Don`t worry.Jt specialist will give some
alternative.Ofcourse your baby is precious not
only for you but also for me.
By the way,do you smoke?
May be 2 cigarettes ocasionally.
You must stop smoking to improve your
health.If you have some problem,I will refer you
smoking cessation clinic.
Do you drink?No.It is good.
What are you doing for living?School teacher.
Great your job is important.Any impact on your
jog.Because of joint pain some difficulty .I will
refer you to social worker to solve this problem.
How about your family?
Fine but my father has also RA.I sorry to hear
that.
Bell ring
Examiner asked me why you said serious
problem to patient.I shocked.Actually I expectes
what are ethical issues in this cases.
I explain 1,for compliance 2,for long term
complication of RA.
Examiner asked me why you didn`t make
another follow up with patient and her husband
with your consultant.
I shocked.
It is very important,I sorry,sir.
Finished....
After CS ,I believe I will preare for another
attempt.I depressed .I think this time is not for
me:-)
I prayed to the Buddha .
I read MAHAPATHAN Bible and I makes due
respect and pray to all examiners every night.
After 20 days,the result come out.
I pass.155/170.My station 4 is 8/
16.I happy.
Special thanks and due respect to Prof Col Khin
Phyu Pyar.Very thanks and respect to AP Dr U
Sein Win,AP Dr U Moe Naing and Dr U Phyo Thi
Ha.Thanks to Lt Col Aung Moe Myint,Maj Hlawn
Moe Han,Capt Nyi Min Han,Maj Pyae Nyein
Maung,Maj Thet Aung Zaw Myint,Maj Nyein
Chan Aung,Capt Han Myint Oo,Lt Col Aung
Myo.Finally but not the least ,Dr AhMed Maher
Aliwa,Dr Bal S Jhar. for very good and effective
web site and information.Thanks to all PACES
members.Never surrender .Fighting.
PACES Mandalay 3 July 2017 Day 1
Station2
35yr old female with joint pain
On analysis of joint pain,non specific
polyarthralgia,moring stiffness is minimal and
nonspecific,involing small and large joints,no
functional deficit,pain is increased by
movement and reduced by rest and
para.Associated with cough.I reviewed about
cough,mostly dry cough,associated with TOC
and ocasionally noisy breathing.Weight loss
present.Reviewing of JOSEPH joint ,occular,
skin lesion ,esophagus,photosensitivity and
hair loss.I explore skin lesion on leg.I
happy.Skin lesion suggestive of E
nodosum.Patient has low grade fever off and on
present.Past medical history of cough and CXR
done by GP showed some swelling of gland?I
so happy.
No urinary,bowel problem and no private part
sores.No relevant drug history.
I explains to pt,You had problem called
sarcoidosis.It is due to your overactive defense
mechanism,attacked on your jt,skin,lymph
gland and your lungs.
Patient concerns it is serious?
No,it is manageable and you must take regular
medication and follow up.
May I need admission?
No,we can do some blood test and imaging to
your chest as out patient.I will refer you to gland
specialist,joint specialist and lung doctor.Now I
will give you some pain killer.Do you have any
concerns? No.
Examiner asked me ,what is your
dx?Sarcoidosis
What is your DDx?
RA SLE
How will you manage this pt?Firstly,CP for
anaemia of chronic disease.ESR may
raised.Serum Ca and ACE level.auto immune
screening and rheumatology profile for
DDx.CXR and CT chest for lymphadenopathy
and pul fibrosis.Lung function test for restricted
lung disease.
Symptomatic Tx NSAID with GI cover PPI for
joint pain,mucolytic agent for chest
symptoms.Specific Tx she may benefic from
immunosuppressive Tx.I will consult with
rheumatologist and chest physician.What for?
Bronchoscopy and lymph node biopsy.
Which infection similar to this presentation?
I answered TB.
I got 18/20.
PACES Exam 3 July 2017
Station 3 CNS
Examine this patient and proceed neurological
exanmination
Young lady was sitting and smiling.Her left arm
was moving.At first,I think chorea but not sure.I
decided to walk and examine her gait.I so
happy,there is mild hemiplegic gait.I examine
upper limb and lower limb motor ,sensory and
cerebellar thoroughly and quickly.After that I
request pulse for AF,Heart sound for
MDM,Carotid bruit and fundus for OA.
My PDx is UMNL left hemiparesis most probably
young stroke with cerebral infarction or
vasculitis or MS.
Examiner asked me causes of young stroke.
I got 18/20
Station3
CVS- sinus rhythm, apex -not shift, PSM at apex,
ESM at aortic area, radiation+,
Dx- MR,AS- examiner not satisfy- AS murmur
can heard at apex. Which is more likely? Why?
AS- normal apex , sinus rhythm
I got17/20
C
Neuro
I'm not sure whethet scitica or CPN
Only9/20
Station 4
35 year old man with recurrent palpitation. His
father died at 40 . His brothet dx cardiac
disease, now on ICD. His ECG n Echo- HOCM
Task- ivx results, dx, concerns n
electrophysiological study.
Serogate- consult due to his brother's doctor
advice, he refuse to seek medical attention
when his dad died. IT expert, doing gym,
strenguous exercises, he has a son.
Concern- sure? Am i die like my dad?-sorry,
progressive disease, but will treat any symptom,
is it late dx?-no. Not change tx. Explain all tx
avaliables up to heart transplant. How about his
son,2 year old, - take him, ivx n regular follow
up. Exercise- warned not to do strenguous
exercises, sings to seek attention.
Examiner- ethical? Inheretant of HOCM, chance
of the son? Is it late dx? How to mx his son?
Regular follow up. Not satisfy- genetic
screening-ok
I got16/16
PACES EXAM 3 July 2017 Mandalay General
Hospital
I started with BCC 1 Station 5
40 yr old male with headache and BP 150/90.On
quick analysis of headache,chronic headache
with suggestive of raised ICP,early morning and
vomiting.On reviewing patient,all features of
neurofibromatosis.I examine CN 3 4 6 7 8and
pronator drip.Fundus NAD.I explained to
patient,headache may be associated with skin
growth,there may be nusty growth in brain.Need
special imaging CT Head.May be needed
to referral to brain dr and brain surgeon.I will
give some pain killer and some injection to
relieve pain.At present,importance of stop
driving.
Examiner`s questions
What is your diagnosis?
Why you say neurofibromatosis to these patient
?
What are possible causes of brain tumour in
these patient?
How will u manage?
I got 28/28
BCC 2 25 yr old lady with secondary
amenorrhoea for 6 yr
Positive symptom ,amenorrhoea and weight
gain.On quick examination ,obese lady,no
hirsutism,cn 2346 normal,no goitre nor
hypothyroid sign.
Mood normal.Libido normal.
I explained to patient,there may be female gland
problem and cystic formation.Need imaging
study ,blood test for hormone study,referral to
lady doctor,O&G,gland doctor,need hormone
treatment.Weight reduction.
Examiner`s Questions
What is your Dx?
What is your DDx?
How will u manage this pt?
I got 24/28
Station 1
Respiration
35 yr old man with breathlessness
Trachea shift to right,dullness on right upper
zone,VR increase and some crept
Dx Collapse Consolidation RUL/Fibrocavitating
lesion TB
Ddx Malignancy
I got 20/20
Station5 BCC1
C/o back pain - patient is a mook, got clue from
measuring talpe on the bed. Found ? posture
only when walk, did all measurements. Explain
dx, tx n occupational n physiotherapy.
Got28/28
BCC 2
C/o-fatigue. History of blindness+
Cushing patient. Recurrent blind on pregnancy
period, got headache on preg n blind , brain doctor
gave tx n releived. Now on tx. No drug chart. Lt eye
blind totally. Fundus- found nothing.
Dx- drug induced cushing. Ivx- no need blood test. To
do slow drug reduction
Got 26/28
Station1
Respi- stridor-with lt upper lobe collapse
Got-20/20
Abd- hepatosplenomagly with palmar erythema
Ddx-
Got- 16/20
Sat for the paces exam on 7th july, 2017 in
Aberdeen Royal Infirmary under Royal College
of Physicians, Edinburgh.
Station 1:
Respiratory: Left Lobectomy(probably lower
lobectomy). findings: thoracotomy scar on left,
and reduced breath sound, reduced vocal
resonance in left lower lung field. cant
remember
if percussion note was reduced in lower left
lung field as well. No other findings.
Was asked about the causes of lobectomy.
What inv to do in obstructive lung disease?
What
to expect in spirometry in obstructive lung
disease. What to do if the patient with
lobectomy
comes with breathlessness.
Got 20/20
Abdomen: CLD with hepatomegaly. Stigmata of
CLD like spider naevi, palmar erythema and
gynaecomastia
was present. Clubbing +/- so decided to ignore.
There was tender hepatomegaly, abdominal
flanks was full
but shifting dullness was not present so sed
there was no ascites. But people around me told
there was ascites.
Forgot to assess fluid thrill. It was written that
patient was suffering from weight loss.
Was asked about the causes: i told HCC on top
of CLD. Also sed CLD due to alcoholic liver
disease/non alcoholic fatty liver disease.
Was asked what else could cause the CLD. Then
sed this could be HCC on top of CLD due to all
the other causes. Was asked how to investigate
the case.
Got 20/20
Station 2:
Prompt was that patient has been suffering from
shortness of breath and wheezing for last 3
months. Previously he was completely fine. No
h/o allergy, chest
clear, x ray clear.
While interviewing the patient, it became evident
that the patient has been suffering from
exertional breathlessness, waking him up at
night, some degree
of orthopnoea, some dry cough and
breathlessness more in the weekends. Patient
works as a spray painter. Does not use the
mask regularly. During this period, went on a
holiday to spain
during which he was completely fine. Was also
a heavy smoker but gave up 10 years ago after
smoking for around maybe 25 years. Daughter
had h/o eczema.
Suggested to him that it might be occupational
asthma so made a plan of measuring his peak
flow regularly both in the
week days and in the weekends and arranged a
follow up. Told him to inform the occupational
health department but he sed there was none.
So told he might
have to give up his job, but he was shocked at
this.
Examiner asked diagnosis. I gave the
differentials of occupational asthma, late onset
asthma, copd and also wanted to rule out
ccf(but there was no h/o
chest pain, claudication, past h/o stroke or mi,
no dm, no htn, no high cholesterol but still told
abt ruling ccf out bcos of orhopnoea and
nocturnal dyspnoea)
How to investigate. How to treat. what other can
be the trigger? the exercise itself(this was
suggested by the examiner himself to which i
completely agreed)
Examiner picked up my mistake on bringing up
the issue of giving up job too early and
suggested that i cud have simply told him to
use the mask more regularly
and wait for the peak flow readings. What was
against COPD in this case?
Got 20/20
Station 3:
Cardiology:
A man with Atrial Fibrillation(rate controlled)
with signs of over anticoagulation. Patient had
kyphoscoliosis, a midsternotomy scar, no
corresponding vein
harvest scars and a very loud second heart
sound(seemed metallic to me).
Gave the cause as avr(metallic) with af with over
anticoagulation. the fact that he has
kyphoscoliosis might mean he has an
underlying connective tissue
disorder. Was asked if this patient comes with
breathlessness, what to do? Criteria for
anticoagulation
Got 19/20
Neurology:
It was a disaster. Was asked to examine arms.
Patient was lying down. Started with gait but
was denied by examiners. Power was reduced
in the left side, with
diminished reflexes and some wasting over left
deltoid and sensory loss in dermatomal pattern.
Examined the patient with him lying down trying
to maintain
the welfare but that turned into a disaster cos it
was so difficult to examine upper limbs with him
lying down and hence wasted a lot of time,
messed up the
examination technique in panic and could not
complete properly. Did not notice properly if
power in left side was lost proximally or distally.
Did not try
to reinforce the reduced reflexes. Did not find
out properly which dermatomes the sensations
were lost, just the distal dermatomes.
presented as radiculopathy/brachial plexopathy.
was asked what else could cause. I told
mononeuritis multiplex. what else. Sed Stroke
with spinal shock. Examiner
dint seem to be satisfied and asked if i noticed
any pattern in his power loss. Asked about the
reflexes, asked if it is a lower motor type of
lesion.
Asked how to investigate?
Got 18/20.
Station 4:
Breaking Bad news. Old Lady had h/o ca lung
which was operated two years back. felt bit bad
for the last 2 weeks and had sudden spastic
paraparesis from yesterday.
presented to the emergency department and mri
showed spinal mets. now on catheter.
Asked permission to drag the chair near her.
Then slowly broke the bad news cautiously after
assessing understanding of current and past
conditions and giving
warning shot. She cried, offered her tissues.
Gave her time. She was first in denial but then
started to accept. She asked what now from
here? told her abt
involving the oncologists, the macmillan
nurses, and maybe the physiotherapists for her
paralysis. Tole her that further investigations
will
be needed to assess how far it has spread.
Focussed on doing all these urgently. Asked
about home support. Her husband takes care of
her
but he goes to office in the morning so offereed
social workers. She was uncomfortable about
the catheter so gave her hope that with proper
medicines(steroids)
and radiotherapy things will improve so at one
point catheter wont be necessary. Woman was
very nice and cooperative.
Examiners were nice too. Summarised the case
to them. they asked what stages of grief the
patient went through. Asked what to do abt the
catheter, i also
suggested intermittent self catheter to them.
They liked the idea. How to treat? I Brought up
the palliative care team in the discussion with
examiners.
The examiner asked what will i do if patient
refuses treatment due to side effects of anti
cancer treatment which she experienced 2 yrs
back. TOld that will
counsel her abt newer better meds. What if she
still refuses. Respect autonomy. What are the
ethical principals involved in any case?
Got 16/16
Station 5:
BCC1: Abdominal bloating and discomfort in
young lady with BMI 19.
Entering the room found a cheerful relatively
healthy young lady whose BMI was certainly not
19 so immediatly understood this is a dummy
case.
history also revealed loose stool. no alarm
symptoms, not much wt. loss, no family h/o
bowel cancer, no symptoms of thyroid
problems.
Gave differentials mainly of coeliac, ibs and
infections like giardiasis. How to investigate?
when told esr, crp, examiner asked whY? I told
bcos of
ruling out IBD so examaminer asked if it was
one of the d/d. I sed it can be but less likely due
to no reasons given above.
Got 26/28
BCC2: Shortness of breath and painful fingers.
Middle aged man with raynaud's, h/o finger
ulcer. no joint pain, no other signs of sys.
sclerosis. had past h/o lung cancer and bowel
cancer resection.
Examination revealed no signs of sys. sclerosis
except telengiectasia on the face which the
patient commented that these are usual for him
from before.
Chest had bilateral thoracotomy scars which the
patient sed was due to lobectomy on one side
and removal of a lump on the other. There was
also probly
abdominal scar. Fine creps in right lower lung
field.
Gave diagnosis of sys sclerosis with pulmonary
fibrosis. What findings? Told the findings found
including telengiectasias and scars. How to
investigate
and treat?
Got 22/28.
In total got 161/172. Alhamdulillah
Did the Ealing course. Found it okayish as a
whole but for me it was also kinda life saving
bcos it wud have been probly suicidal to sit for
uk exam
without doing any course at all. Scottish accent
is impossible to understand at times but
thankfully, this was not a problem in the exam
cos almost all of the
surrogates and patients had very
understandable accent. Examiners were largely
very kind and well behaved.
I would like to share my exam experience with
you. Special thanks to all this group admins and
their members... it has been so benificial to me.
The exam was in Grantham and district hospital
in UK on june 2017.
First was station 4: 30 years patient dx with
testicular cancer 3m ago complained of
dysphagia ct done showed advanced
esophageal metastisis... your task is to explain
the management that the consultants reached
which is either esophageal stent or
radiotherapy... went inside introduced my self and
task... asked about patient previous knowladge of
condition... explained the result to ptn. and available
managements and their quick side effects... ptn
concerns were I want to live my life with no
constrains... and am I going to die... examiners q.
were if ptn refused both managements what to do, I
said tpn, peg tube, ngt., they said if he refused those??
I said inform my consultant... they said have u heard
about cancer teams... I got (16/16).
Next was st5.
Ptn after thyroidectomy complaining from tingling
and fatigue... inside he said he had carpo-pedal
spasms, those symptoms happenex only after
surgery... he had collar scar... I checked thyroid
function quickly then did chovestic and Traussaue
signs which were negative.... q. were what is dx?
Iatrogenic hypocalcemia... management? Ca. Level,
mg. Pth. Level.... ttt. Give Ca and vitD. (28/28).
Other st5 .young Ptn complaining of deminution of
vision for 2 years... had +fh his sister has simillar
symptoms however milder, did visual acuity...the
visual field testing which was constiricted then
fundus... it was retinitis pigmentosa... questions...
about management... occupational therapist,
opthalmologist... what else? They wanted refferal to
genetisist... mode of inheritance.. syndromatic Rp.
Also were asked about... got (28/28).
St1. Abd. Patient with Rif scar and mass also below
umbellicus scar.... Q. Dx? Renal
transplant...Management? Got (20/20).
Chest. This one I didnt do well in she was a female
with a small scar in left axillary reigon and basal left
crackles... they kept asking do u notice any thing in
her eyes?.... my colleagues said she had left horner
syndrome... got (9/20).
St2. Ptn has type 1 dm. Complaining of fatigue and
dizziness.... dx. Addisons disease... Q. Dx.?
Investigations? Management? (20/20).
Stn 3. Cardio... bilateral mitral anf Aortic valve
replacement... Dx? Investigations? What if he had
fever what u will be worried about? Prophylaxsis for
infective endocarditis?(20/20)
Neuro. Old lady has bilateral gloves and stalkings LL.
Sensory loss and left sided LL weakness. Dx. P.
Neuropathy with possible left sided weakness CVA?
wasnt sure about this station... however thank God
got (20/20).
Total 161/172... it was only with Gods bless.... it
wasn't my first experience.
A big thank you for the admins of this page it was so
benificial to all of us.
Advice: dont give up continue. Cheers.
UK EXPERIENCE
Exam Experience was in grantham and district
hospital glasgow n my exam cases were
I started with respiratory station command was
this patient has presented with recurrent
pleuritic chest pain
A middle age Lady with a scar on back of left
lung field n left horner's rest of examination was
normal
Scar was thoracotomy scar n examiner asked
about possible cause of horner syndrome
investigations n treatment 11/20
Next was abdomen
Faint scar in right illiac fossa n no other scar i
can
Found so i gave my diagnosia as functioning
renal transplant n gave differentials for renal
failure as in goutam mehta it is given as causes
of renal failure viva was about the most possible
cause i said diabetes n then how ll u investigate
if this pt comes to u in emergency with
abdominal pain n about treatment with
immunosuppressants 20/20
Then my next station was history that was
young patient with history of weight loss n
diabetes mellitus
In the start of history he told about postural
hypotension then weight loss for about 1 year n
recurrent hypoglycaemia for the last few weeks
even no change in his current diabetic regime n
family history of thyroid problem so my most
likely diagnosis was addisons n differentials
was autonomic dysfunction due to DM he asked
me about else for weight loss in young patients
i said i would like to assess for coeliac n thyroid
then viva about addisons investigations n
treatment 20/20
Then cardio
A man with midline sternotomy scar n audible
metallic click coincides with second heart
sound n ejection syatolic murmur so that was
AVR with AS
Viva was about investigation n management
how ll u follow up this patient
He also asked me either valve is functioning
well or not if well then what r the signs of not
functioning well then signs of cardiac failure
In neurology a lady with vericose veins charcoat
joints at ankle bilaterally on inspection then i
asked for walk in start her romberg sign was
positive n there was reduced power 4/5 with
hyporeflexia but hypertonia in left knee
surprisingly n sensory loss in stocking
distribution so i gave my most likely diagnosis
as peripheral sensori motor neuropathy viva
was about differentials which i told about
causes of sensorimotor neuropathy as given in
goutam mehta n investigation n treatment
17/20
Station 4 was about
A young patient with dysphagia due to
metastatic testicular carcinoma got multiple
treatments in pasr n now offer him about
palliative care n for dysphagia give him 2
options
Stent placement
Radiotherapy
I followed the scheme n as he already knew
about his disease n treament failure so his main
concern was about to live an independent life so
i told him about that options their pros n cons n
that we respect his wishes n 2 points were imp
in this scenerio
1.advance directive or LPA 2. Palliative care
team referral at the end he agreed upon stent
placement 16/16
Now the last station was station 5
First scenerio was a young patients
complaining of abnormal sensations in legs
after thyroidectomy n all vitals r normal i
thought about tetany n peripheral neuropathy
due to hypothyroid or it might be any other
diagnosis by keeping my mind open for all
options i went inside the room in the start he
told me its actually carpopedal spasm when i
asked what exactly happens n then i asked
about recent surgery cause n current thyroid
status n rule out other causes of hypocalcaemia
diet,renal,malabsorption
Examination was about chvostek n trosseu sign
n thyroid scar with palpation n looking for
tremors n sensations even these signs were
negative but still history was typically about
hypocalcaemia so i gave my diagnosis with
cause is parathyroidectomy with thyroidectomy
Then investigation n treatment
27/28
The next station was this patient has gradual
loss of vision...young patient who gave me
history of nyctalopia on exploring typical
history of retinitis pigmentosa n no associations
with other syndromes
N family history positive I examined visual
acuity perimetry n fundoscopy n looking for
general appearance he was thin lean so no
association with lawrence moon
Then explained to patient
Viva was about diagnosis fundoscopy findings
n what r the syndromes associated with RP n
what referrals r imp i said 2
Low vision clinic n genetic counseller 27/28
UK EXPERIENCE
Experience in oxford centre
Station 1
Respiratory patient with dilated veins on chest
with clubbing bilateral lobectomy scar and has
bronchiectasis
Abdomen renal transplantation with old
peritoneal dialysis with ascitis
Station 2
History of left knee and right ankle swelling and
pain with last month food poisoning it was
reactive arthritis reiter syndrom
Station 3
Cardio aortic stenosis with mitral incompetence
Neuro
Eye examination only i find visual acuity
diminished in both sides with POF in left
Visual field on right revealed temporal
hemianopia with movement revealed
internuclear ophthalmoloplegia with fundus
bilateral optic atrophy more at left
My diagnosis was MS
Station 4 uncertainty for cancer stomach with
further management plan
Station 5
1-Graves eye with thyroidectomy scar with
acropathy and peritipial myxedema patient has
typically hypothyroidism and non complaint to
medication
2- patient with collapse with no witnesses he
start amilodipin recently 3 weeks and collapsed
on driving and there ejection systolic murmur i
tell aortic stenosis appears when he takes
vasodilator and stop driving is mandatory
Pray for me plzzzzz
My experience in Victoria hospital, kirckadly

Edinbrugh, UK
July 2017
Station one
Chest : about 60 y old pt co SOB
Pt had clubbing , insp crepitations all over the
chest
ILF
Examiner asked about inv &ttt
Abdomen
Pt had mild hepatomegally
Huge spleen
Midline labarotomy scar
RIF scar
No signs of CLD, or anaemia
I talked about hepatosplenomegaly DD
Examiner was not happy
Station 2
Young lady , k/c IDDM
History of wt loss &dizziness
No skin pigmentation or GIT symptoms
Few hypoglycaemic attacks
D. Addisson's dis
DD hyperthyroidism
Celiac dis
Examiner asked about inv for addisson &ttt
Station three
Cardio
Pt had mid sternotomy scar & venous harvest
scar
No metallic clicks
Waterhammer pulse
Murmurs of AS &AR
D. Mixed AoVD
With CABG
Discussion about predominant lesion AR or AS
Indications of valve replacement
Neuro
Examine upper limb
Pt is sitting on chair
When I asked about pain he said he had pain in
rt shoulder & elbow 😱 😱
When I tried to examine tone I could not then
examiner told me to take care as pt has pain in
rt arm
I examined tone and power around wrist only
Reflexes normal
Sensation normal except vibration
Pt could do test for coordination I asked the
examiner to test for nystagmus to assess
cerebellar function but he refused
Presentation I said i could not examen him dt
pain but he had weakness more in flexors and
loss of vibration
DD Cervical myelopathy
MS
He said if pt had hyper extension trauma to
shoulder what do you suspect
Discussion was about brachial plexus injury
&frozen shoulder
Station 4
Communication
Pt admitted with wt loss, CT abdomen results
shows suspected cancer colon with liver
metastases.radiologist suggested meeting with
treating consultant &oncologist to confirm D.
Her daughter is angry as she is in the ward for 3
hours & nobody informed her about her
mother's condition. She requested to see the
doctor. You did not see the pt before but you
checked the file before talking to the daughter.
Assume that pt gave permission to discuss her
condition with the daughter.
After greeting and confirming the relation I
apologized for the delay, then agreed the
agenda
Breaking bad news
Mostly she had nasty growth but we need to
wait for MDT meeting to confirm D &put
management plan
She did not show any feelings
Concern Staying in hosp for long time
Living alone: options
Her father died with cancer :sympathy
Guilty about delay in D: I will discuss the history
with her mother, usually difficult for old people
to pick symptoms early , but I will check if there
is delay
I finished early and examiner was not happy &
told there is 2 minutes
I offered a drive &
A near aptt to discuss more
Discussion about autonomy
Why u did not discuss management?
D not confirmed, she did not ask
He said u should volunteer
I told it is better not to discuss it in same
Meeting after BBN & I gave near aptt in same
day
Then he accepted
Station 5
BCC1
Young lady with back pain
Pain is more in the morning & improve with
exercise
PH anterior uveitis
I examined neck movements
Then lumbar
I asked to do shoeber test surprisingly he said
yes
So I did it without putting marks
The wall was far so i did not do occiput wall to
save time
I examined lung apices & ht
Then concern & plan
Ankylosing Sp
Discussion about ass condition , management
BCC2
Pt admitted with MI 4 days ago & co chest pain
Long history to exclude relation with effort and
food
Compare with pain if Previous MI
No LL pain
One attack fever
No cough
I ex LL & chest quickly
Concern is it another stroke
Plan of management
Examiner asked about positive findings
No positive findings
DD dressler sy
PE
P eumonia
Gerd
Inv , ECG in pericarditis
In general all examiners donot allow u to
present ur finding or complete ur sentences. All
the time asking rapid question &distracting
It was my First trial
Alhumdullelah I passed
UK EXPERIENCE JULY 2017
Oxford diet 2 UK .
st 1 renal transplant n hepatospleenomegaly
with laprotomy scar n incisional hernia , fistula
not active,astrexis present
St 2 bronchial asthma
St 3 cardio median sternotomy n syncope
Neuro peripheral motor sensory neuropathy with b/l
pescavus , spasticity+, power decreased in left lower
limb, reflexes diminished .heel shin test intact.high
stepping gate.
St 5 bronchiactasis
St5 frozen shoulder
St 4 MRSA positive
St 3 resp pul fibrosis secondary to scleroderma
I would like to share with you what I have learnt

from my PACES experiences. This group has
been very helpful in my preparations and I
thought I would contribute in terms of the
lessons I have learnt. Here are a few of them
1) Understand that PACES is a entry exam into
Specialty training in the UK. So it requires you
to be able to make sound judgement and also
be competent in managing patients welfare and
concerns. You will rarely get something out of
the ordinary. Common things are common. This
is not an exam to test only your knowledge. It
has been tested in Part 1 and 2. This exam is to
test your showmanship. Show that you know
your stuff! Do not be overconfident . Do not
fumble and look unsure either.
2) Pertaining Station 1 and 3. You should aim to
get full marks for your Abdo station. The types
of cases that you can get is very limited! The
key to abdo stations are your peripheral
findings. The other station that you should do
well in is your respiratory station. The list of
cases that may turn up is standard.
3) Always..always take a step back and look at
your patient in Stations 1/3/5. Take about 10-20
sec just to do that. In previous attempts I
realised I was so focussed on the diagnosis that
I forgot to look at the patient in entirety. The
diagnosis would have been more evident. That
20 seconds you spend may give you an obvious
finding that may help you spot a diagnosis!
4) Be VERY polished in your physical exam. It
has to be mint. It has to be second nature. I
know you have read this like a thousand times.
But the logic here is, you dont want to be
thinking of what to examine after tone in a neuro
exam. What you want to be doing is interpreting
the signs to come up with a diagnosis.
5) When you are in a communication station, try
to establish - What kind of station is this? Is this
a breaking bad news station? Is this an angry
patient station? That will help you set out a
template on what to say exactly. Be familiar with
concepts like - capacity, DVLA rulings, Mental
Health Act, Human Tissue Transplant Act and
the four principles of ethics. When you discuss
with your examiner, you must tell them how
does
beneficience/maleficience/autonomy/justice
apply in this particular scenario.
6) It really doesnt make sense to work on skills
that you are already good at. Work on things
that you dont like. I hated fundoscopy! So when
I was at my shifts I ended up doing almost 5-7
fundoscopies a day. At the end of the day,
eventhough I had a lazy left eye, fundoscopy
wasnt a difficult thing.
7) Station 5 carries the MOST marks in the
exam. On top of the usual cases that you may
find in the books, station 5 are becoming more
relevant to Acute Medicine these days. One of
the stations I had was a patient with lung cancer
. And another was a cluster headache.
Remember ...common things are common.
8) Sometimes it is rather tough to get people to
watch you examine. Use your smartphone! I
dressed up my pillow with my shirt and
recorded myself examining it. You will be
surprised how much you can learn and improve
with just doing this!!
Hope this helps!! All the best!!
MRCP - An exam that teaches more than tests!
UK EXPERIENCE
Exam EXPERIENCE was in grantham and
district hospital glasgow n my exam cases were
I started with respiratory station command was
this patient has presented with recurrent
pleuritic chest pain
A middle age Lady with a scar on back of left
lung field n left horner's rest of examination was
normal
Scar was thoracotomy scar n examiner asked
about possible cause of horner syndrome
investigations n treatment 11/20
Next was abdomen
Faint scar in right illiac fossa n no other scar i
can
Found so i gave my diagnosia as functioning
renal transplant n gave differentials for renal
failure as in goutam mehta it is given as causes
of renal failure viva was about the most possible
cause i said diabetes n then how ll u investigate
if this pt comes to u in emergency with
abdominal pain n about treatment with
immunosuppressants 20/20
Then my next station was history that was
young patient with history of weight loss n
diabetes mellitus
In the start of history he told about postural
hypotension then weight loss for about 1 year n
recurrent hypoglycaemia for the last few weeks
even no change in his current diabetic regime n
family history of thyroid problem so my most
likely diagnosis was addisons n differentials
was autonomic dysfunction due to DM he asked
me about else for weight loss in young patients
i said i would like to assess for coeliac n thyroid
then viva about addisons investigations n
treatment 20/20
Then cardio
A man with midline sternotomy scar n audible
metallic click coincides with second heart
sound n ejection syatolic murmur so that was
AVR with AS
Viva was about investigation n management
how ll u follow up this patient
He also asked me either valve is functioning
well or not if well then what r the signs of not
functioning well then signs of cardiac failure
In neurology a lady with vericose veins charcoat
joints at ankle bilaterally on inspection then i
asked for walk in start her romberg sign was
positive n there was reduced power 4/5 with
hyporeflexia but hypertonia in left knee
surprisingly n sensory loss in stocking
distribution so i gave my most likely diagnosis
as peripheral sensori motor neuropathy viva
was about differentials which i told about
causes of sensorimotor neuropathy as given in
goutam mehta n investigation n treatment
17/20
Station 4 was about
A young patient with dysphagia due to
metastatic testicular carcinoma got multiple
treatments in pasr n now offer him about
palliative care n for dysphagia give him 2
options
Stent placement
Radiotherapy
I followed the scheme n as he already knew
about his disease n treament failure so his main
concern was about to live an independent life so
i told him about that options their pros n cons n
that we respect his wishes n 2 points were imp
in this scenerio
1.advance directive or LPA 2. Palliative care
team referral at the end he agreed upon stent
placement 16/16
Now the last station was station 5
First scenerio was a young patients
complaining of abnormal sensations in legs
after thyroidectomy n all vitals r normal i
thought about tetany n peripheral neuropathy
due to hypothyroid or it might be any other
diagnosis by keeping my mind open for all
options i went inside the room in the start he
told me its actually carpopedal spasm when i
asked what exactly happens n then i asked
about recent surgery cause n current thyroid
status n rule out other causes of hypocalcaemia
diet,renal,malabsorption
Examination was about chvostek n trosseu sign
n thyroid scar with palpation n looking for
tremors n sensations even these signs were
negative but still history was typically about
hypocalcaemia so i gave my diagnosis with
cause is parathyroidectomy with thyroidectomy
Then investigation n treatment
27/28
The next station was this patient has gradual
loss of vision...young patient who gave me
history of nyctalopia on exploring typical
history of retinitis pigmentosa n no associations
with other syndromes
N family history positive I examined visual
acuity perimetry n fundoscopy n looking for
general appearance he was thin lean so no
association with lawrence moon
Then explained to patient
Viva was about diagnosis fundoscopy findings
n what r the syndromes associated with RP n
what referrals r imp i said 2
Low vision clinic n genetic counseller 27/28
UK EXPERIENCE
Experience of Pilgrim hospital Boston
Station 1: Abdomen:
Very elderly female, on couch wearing full
sleeves shirt, fully dressed
O/E hepatosplenomegaly with ascites, palmar
erythema, unstable and can not roll for shifting
dullness so examiner said it's okay, pedal
odema with very bad superficial big ulcers on
both legs with oozing of transparent secretions.
She took one minute to make her arms above to
have a look at arms and don't like helping her
for exposing.
I request complete exposure to examiners
before starting examination and they said talk to
patient. Discussion on myeloproliferative and
lymphoproliferative disorders and I said I will
put differential of CLD with portal hypertension.
After finishing examiner asked me patient can't
roll for shifting dullness so y u did not do fluid
thrill. I hardly finished in time coz of this me
already wasted by patient. There were no
abdominal scars at all
Respiratory station
45 yrs old male with marked clubbing and
pursing of lips, reduced cricosternal distance
and crepitations in upper lobes bilaterally, with
normal vocal resonance
I give ILD, COPD as differentials but did not
mention bronchiectasis with COPD
In discussion examiner ask y u would like to see
sputum pot, no sputum in pot, then.
I said I will proceed further, asking findings of
CXR in COPD and then ILD and when I tell him
one by one he said u will find in all cases these
findings, I said not in all pts
History station
was 40 yrs old male with backache after lifting
something heavy and he lives alone at home,
information outside the room
On history he gave positive history of weight
loss 5 kgs in last 2 months and have pain in ribs
2 sites on right side too, and fell down at home
3 times in last 2 months jus standing coz of
sudden weakness of lower limbs which later
recover and no sensory symptoms and no
urinary or bowel incontinence
In diffrentials list Malignancy was at the top and
spinal cord compression to be ruled out by
urgent MRI and involvement of Orthopaeds
team , primary Malignancy symptoms not
evident in history with an system
Examiner was satisfied and happy and also the
patient, I said I will not discharge u and will do
urgent MRI spine and will see u again to make
further plan. Coz u are alone at home also so we
will discuss about it further in more detail and
will try to help u at home maximum by involving
ur GP and occupational health therapist. But
currently urgently thing is to rule out
compression of ur back
Cvs: young female with pansystolic parasternal
murmur not affected with inspiration or
expiration so I told VSD
It was very clear, and apex beat was displaced.
Visa went on NICE guidelines of prophylaxis
before dental extraction and then before
colonoscopy
Went the best station 😀
CNS: lower limb examination
After inspection started with gait, broad based
ataxic gait, Romberg test not done as pt cannot
stand with feet together
Motor, sensory normal, he managed to do heel
chin test but badly, went to upper limb for
cerebellar signs and time finished
Patient also had clear nystagmus
Viva on causes and how to investigate
cerebellar disease causes, examiner said well
done at the end 👍🏻
Communication was young 26 yrs female
diagnosed as RA and started on methotrexate
and she did not start treatment as she is going
to get married in 2 months time and had heard
about side effects
Patient was alcoholic too, and planning not to
be pregnant for 2 yrs after marriage
Went really good with explanation for RA, then
how methotrexate works, what are benefits and
what are side effects and patient agreed.
Station 5 1st: hyperthyroidism with all
symptoms and small neck swelling and diplopia
in multiple directions
So Graves' disease, not on any treatment
2nd: young male with h/o ischemic gut removed
1 year ago and had complain of chronic diarrhea
for last 1 year not improved with anti-diarrheal
And on rivaxoxaban 20 mg OD since 1 year
Inside the room he said his last part of small
intestine was removed and has clot in his heart.
No family history of any illness or clots
anywhere in other organs.
I did abdominal examination and laparotomy
scar only, nothing else.
And this went really bad and scored badly too
I discuss about malabsorption and b12
deficiency
Patient asked should I keep taking rivarxaban, I
said yes to keep taking as he has clot in heart
and we will consult heart drs for it too.
Central Middlesex hospital 8/July /2017

St5
Chronic cough(GORD/EAA/drug induced)
TIA
Abdomen ascites/leuconechia/+_ telengiectasia for
differential
Chest basal crackles with clubbing
Neuro Parkinson with PSP
Cardio AVR( not sure if it's mechanical or
biological)/pacemaker
St 2
Back pain metastatic
St4
Daughter angry why her father not on dialysis, her
father capacity was intact to refuse after explanation
India( Bengaluru)
Station 4 , 26yrs old lady physiotherapy as st.
Working in stroke unit .admitted with flaccid
limb weakness , CT and MRI normal explain
about functional weakness . Pt was reluctant to
accept the diagnosis and wish to see
neurologist urgently don't want to see
psychiatrist .social issue about job , and
grandmother died 3 months back with
stroke.discussed about psychiatric referral and
physiotherapy . Station 5 - 1 st case 30 yrs old
lady with high prolactin levels and normal TSH c/o
scanty and irregular menstruation. 2nd case- 26 yrs
old lady with SLE since 6 yrs presented with right
sided pleuritic chest pain ,with fever. Discussion
about DD of chest pain. Station 1 -- Respiratory --
lung fibrosis Abdomen = ascites with chronic liver
disease , jaundice, parotid swelling,flapping tremor,
spider nevi , examiner asked about if there is fever
what can be the cause and how to treat .management
of ascites . Station 2 - 30 yrs old lady with facial and
neck swelling sudden onset ,adopted child , no other
positive history , concern about allergy .DD-
hereditary angioedema . Investigation and treatment .
Station 3 Neuro - right sided weakness , with
proximal wasting hypertonia, hyperreflexia
,dyddiadokokinesia ,sensory normal . Cardio -- young
lady with MS - tapping apex sinus rhythm ,loud S1
diastolic murmur , phtn and raised jvp .
bangalore. Manipal ..7/4/17
Started with st2...Anaemia (MHA.) H/o ibs 6 yrs on
peppermint oil,occasion leg swelling,ho rta and nsaids
,father died of cancer colon,mother taking inj.3
monthly for anaemia,so many issues, ,DD was so
many issues..coeliac..nsaids, ,ulcer
St3,cardio MS,,neuro..patient was very un
cooperative, not following me,,actually language
barrier was prob. I didn't understand what he told
about sensation, ,planter was very confusing, ,Indian
examiner didn't tell anything! !
St.4 esrd bbn and plan of mx
St5,,copd with sudden breathing difficulty and rt
sided chest pain.. o/e Dec breath sound.rt mid.dd was
ptx,pul embolism, ,pneumonia. It was good
St5 female was increase weight,,increase bp,,,and
proximal myopathy, ,o e no thyroid abnormalities,
,some rash,,and proximal myopathy,,features of
osteoarthritis, ,knee jt,leg oedema, ,dd,was cushing,
,hypothyroidism, metabolic syndrome, ,discuss was
on cushing. .
UK EXPERIENCE
Royal preston hospital lancashire
06-07-17
Station 1
Resp.. left lobectomy
Abd...renal and liver transplant
Station 2
Pt diagnosed as asthmatic since childhood well
controlled with sos basis salbutamol now for 3 months
his cough,wheez,sob is worsening
During history he told that he had dry cough and 6
weeks ago he developed rash on legs
Diagnosis was churg strauss syndrom
Station 3
CVS...AVR,pt was marfan syndrom
CNS...sensory motor neuropathy
Viva about causes management
Station 4
Pt known case of psoriatic arthropathy on
methotrexate
She had UTI and GP started her on trimethoprin and
as a result she developed pancytopenia
Presented in hospital with nose bleed and bruises
Explain the medical error to her
Her concerns
Am I going to die
Complain about GP
What about methotrexate I dont want to discontinue
as iam well controled with it
Station 5
Evalaute pt with abdominal pain and fever
Inside lady with left wrist av fistula and she told she
has renal transplant for 12 years doing well
3 days history of lower abdominal pain and smell in
urine
No vomiting haematuria on examination she has
tenderness on suprapubic area
She was taking tacrolimus,steroids,
Questions
Daignosis
Cystitis,uti
Management
Station5
2nd pt
Young guy presented with fatigue out side given
TSH,T3,t4 low
Inside an actor
Gave hiatory of fatigue all time had severe headache
1 month ago and now also developed visual problem
Asked about dizziness when stand he tell yes every
time and when asked he tell he is feeling loss of libido
also
On exam
He had bitemporal hemianopia(pretending)
No blackening of skin
Concern was what is happening
He ask me to give me thyroxin as my thyroid profile
is deranged
I advised labs and trestment after
Advise about stop deriving,some medicine for erectile
dysfunction etc
Copied from telegram group

Glasgow, today cases
1) Respi - right lobectomy , some said right
pneumonectomy because in btw right lung
there's an area of bronchial breathing. However
, I still think right lung lobectomy coz trachea
Nor deviated.
Examiner asked about if suspected recurrent mitotic
lesion of lungs ... and CT- date pending ... what
investigation to get other than cxr
2)Abdomen- everyone said normal abdomen but I felt
minimal enlarge hepatomegaly.
She is an obese lady with palmar erythema and 3
spider naevi.
I gave diff diagnosis of PBC/ autoimmune hepatitis /
Hep B / hep C / NASH
Examiner questioned about PBC clinical finding ... I
said pruritus / scratching mark / jaundice ... he wants
more then bell rang
3) Neuro - a 50 yo gentleman with normal finding ...
he was given L-dopa kaw kaw ... then I only managed
based on the clue from the stem ... there written
frequent fall. Noted subtle sign of Bradykinesia, then
divert him to tap his lap then noted very subtle
cogwheel rigidity ( not sure whether I created sign
onot ). Checked for psp and request to do mmse/ Bp/
mocrographia.
Examiner asked about Parkinson treatment / ix/
causes
4) Cardio- MR+ AF + HF + grade 2 finger clubbing +
peripheral cyanosis
Some heard purely AF
1 said MS
Examiner asked about MR , how to manage , how to
diagnose , warfarin therapy
History
Back pain , 50 yo , sudden onset
Managed to get history of LOW 6kg, constipation ,
urinary retention, nocturia, no red flag
Given whole bunch of DD but examiner further
discussed bout mets to bone 2 prostate Ca/ lung CA/
GIT Ca
When I came out only realised that it's actually
multiple myeloma. Didn't get a chance to discus with
examiner
Comm skills
40yo gentleman u/l epilepsy 10 years fits free 7 years
admitted to ward for pneumonia. Forgot to prescribe
AEM for him in ward. So in ward 36h developed
seizure
BCC
1) 45yo gentleman c/o headache for 4/52
Generalised headache
BP 145/90
Normal pt
Given DD - migraine / Raised intracranial pressure /
tro SOL/ tension headache / cluster headache and
mentioned also want to rule out young hpt-
phaechromo
BCc 2
Pt came with anemia
Further h/o renal transplant + Dual valve
replacement + latest INR 4
Given
1) UGIB
2) valve hemolysis
3) kidney graft failure
UK EXPERIENCE
Colchester today Under London College
I stared first with station 5
BCC1: 5 days h/o diarrhoea with signs of
dehydration not on patient but mention the
scenario
BCC2: Goitre with weight loss and hyperthyroid
status
Resp: Brochiectasis typical case
Abdomen: mass in the lumber region with scar on it
viva was about Polycystic kidney and differentials
CVS: Aortic stenosis n viva wa related to it
CNS: examine the lower limb and do relevant and it
was typical case of myotonic dystrophy
Communication:
Breast cancer with mets to hilar lymph nodes and
pressing on esophagus and MDT team offered
palliative radiotherapy and esophageal stenting
Talk to the patient
History station:
DM Type1 weight loss and dizzy spell and very good
control of diabetes
I made diagnosis of Addison disease and forgot to ask
about autonomic neuropathy and viva was on
Addison disease
Good luck every one
UK exam experience (2017/2) diet
Royal infirmary Glasgow
22-06-17
History was unusual so going to share
Young girl has presented with Recurrent
abdominal Pain and recurrent vomiting for last 9
Months.
She was operated for Adenomyosis 3 years
back ...
Diagnosis is subacute intestinal obstruction
New lister building
Glasgow
22 june 2016
Station 2.
40 years old man
smoker
had advanced Lung cancer and mass in left side
but not metastasized diagnosed 3 months back
and was treated with chemotherapy
has now presented with Pain
( 3 types of pain , Backache,left sided chest pain
( severe not responding to strong analgesics) ,
Right sided chest pain .
Station 4:
Old man
known hypertensive on medicine and aspirin
Had a fracture of femur and admitted in
Orthopaedic ward and on investigations was
found to have UTI as patient was unconscious .
Then consulted with doctors of medical floor
and despite treatment did not respond so brain
scan done which showed Frontal lobe
hematoma.
patient was also given Heparin in orthopaedic
department for prophylaxis of DVT .
Talk to son about the situation
GOLDEN JUBILEE NATIONAL HOSPITAL
15th June 2017
Station 2:
History
Middle aged lady having Multiple sclerosis and
on regular follow ups has presented with cough.
it was dry cough more on lying flat with burning
in the chest
No other chest or heart symptoms
patient concern was
is that Aspiration pneumonia ???
diagnosis : GERD
STATION 4:
83 year old man has End Stage Renal Disease
with underlying DM and HTN .
was admitted with Pneumonia and herat failure
1 month back and recovered.
was advised Dialysis which he refused at that
time .
Now talk to the son who is insisting for Dialysis
as he says his father says yes to him but
refuses when doctors talk to him about dialysis.
Assume the permission was given by the father
to talk to the son about his condition.
( Father concern was that he lives alone and can
not manage to go to hospital regularly for the
Dialysis )
STATION 5:
BCC 1:
Man presented with weight loss and palpitations
.
concern was why i get lot of sweating .
BCC2:
Man with previous history of Aortic valve
replacement now presented with joint pains
including hands and Knee !!
history was suggestive of RA with acut flare.
viva was also about Hyperuricrmia?
Concern was will it affect golf which i play since
long?
Can you settle my Deformities?
8th june 2017
station 2:
Middle aged female
with Type 1 DM
well controlled ( on history)
Now presented with Fatigue and Weight Loss
Station 4:
Old Lady with advanced CA breast
encroaching upon esophagus causing
dysphagia
Break bad news
Discuss about treatment options
including Stenting and Radiotherapy
Station 5:
BCC1
Old male
presented with Collapse
inside Parkinson Disease
concern : will i get better
BCC2:
Man with Rheumatoid arthritis
presented with Fever
inside told about night sweat
weight loss and
cough
visited india few months back
taking new medicine for RA with much relief (
Infliximab)
concer: Will you stop my medicine as i am
feeling much better after this medicine
irrespective of TB or else ( Lymphoma)
9Th june
Here are the cases :
Station 1 :
Abdomen
Splenomegaly with jaundice and Vitiligo
Respiratory :
Cushingoid patient with midline Sternotomy
scar otherwise normal examination
Station 2:
Middle aged female with previous history of
headache is referred with continuous headache
despite paracetamol and tramodol intake .
station 3:
Cardiology:
AVR
Neurology :
Stroke
Station 4:
Middle aged female with Uncontrolled DM
diabetic retinopathy has been diagnosed with
Nephropathy as noticed by protrinurea and were
given ACE inhibitors .
Task is to check compliance and counsel about
ACE as kidney protective medicines .
Station 5:
BCC1:
SOB and CHEST PAIN :
Inside scleroderma
ILD and GERD
BCC2:
Vision problem
inside she told about diplopoda
Turned out to be Myasthenia Gravis
Queen Elizabeth Hospital
Glasgow college
7th june 2017
Station 2
Patient with history of knee pains presented
with fatigue and melena !
Pain associated with stiffness and improves
with walking .
Family history of RA is positive.
patient concern was do i have RA like other
family members ...!!
Station 4
Communication with a young girl who is
married and planning for kids who has been
diagnosed with RA and now on follow up visit
as she was told to start Methotrexate in her last
visit and now she is back again to discuss the
station 5:
BCC 1.
Man with multiple problems of
Psoriasis
Athropathy
Had shoulder dislocation few days back and
was operated
now presented again with shoulder pain with
fever.
BCC 2 :
Young male with history of crohn's disease
presented now with back and stiffness along
with pain in the neck ..
Exam from Queen Elizabeth Hospital
Glasgow centre
6th June 2017
Statio. 2
History of Rash on hands .
History of intake of Tetracycline .
Patient concern was will i get scarring after the
rash is over .??
station 4:
A chef had anaphylactic reaction to eating salad
sandwich. He was allergic to peanuts. Had
minor reactions to them before twice. Was also
asthmatic and on inhalers. As a result of
anaphylaxis was admitted into icu and
ventilated. Task was to explain seriousness of
his allergy and implication on his job
Station 5 :
BCC 1 :
Patient with RA presented with Backache
BCC 2:
Patient with dermatmyositis presented with
sudden hip pain
She was on steroids .
Barnsley Hospital , Glasgow on 3rd of June
Station 1
Chest ILD with cushing
Abdomen Left Lumbar Mass(Renal ?)
Station 3
Neurology. Bilateral cerebellar Syndrome
Heart. Dextrocardia ( No clues , Notmal pulse,
apex beat not detectable , muffled heart sounds
.... must check other side to rule out
dextrocardia).
station 2. Joint pains and Colour changes of
fingers
Station 4.
Talk to daughter about the condition of her
father who is confuse after injury and fracture of
tibia and mild hematoma without midline shift (
on CT Brain ) .
He had atrial fibrillation and was on Warfarin
with Normal INR currently .
Daughter's concern were:
she was it being updated about the progress of
her father?
Will he become alright ?
Station 5 :
BCC1
Old lady presented with collapse after episode
of melena.
Pulse 110/minute
Postural Drop evident ( Given)
In history she told about NSAIDs use because of
OA
She was also on Warfarin because of previous
pulmonary embolism with Normal INR currently
BCC 2 :
Old aged male with stiffness and weakness of
muscles ( proximal as patient told inside)
ESR 85
Station 1
Resp.Cryptogenic fibrosing alveolits
Abd, massive spleenomegaly
Station2
Paroxysmal asthma, not taking inhalers
properly,
Was on MTX for RA for 8 years.
Station 3
Cardio aortic stenosis
Neuro
Wasting of small muscles of hand
Station 4
Presented with harmatemesis, malignant
looking ulcer on OGD, breaking bad news and
inform reg CT TAP
Station 5
Stroke 3yrs ago, now on/off involuntary jerky
movements left arm for last 3months
2nd, type 1diabetic presented with crampy abd
pain 6 months and weight loss 1 stone.
Yesterday exam at Reigmore center
UK Experience ,,,
The Exam in West general hospital in
Edinburgh,,, 6 / 2017..
{ copied from Dr. Zain group}
□ Station 2:
Outside information :
Fatigue pt with high createnin level discovered
accidentally during follow up.
Inside there is skin rash, joint pain, and sinusitis (it
will not be given unless you asked direct)
DD: I give wegner granum, goodpature , and SLE
examiners were so happy.
Qs: Investigation and ttt
□ Station 4:
Pt is a known parkinsonism , has UTI which result in
deterioration of her symptoms, but her baseline were
not that good , plan to talk about prognosis ..
Concerns Inside:
Prognosis? I said prognosis is variable, but your
condition will become worse (progressive disease)
-how many years until she will die: I said it difficult to
predict,
- dementia : she have a risk of dementia (mood,
memory,...etc)
-ttt: MDT: neurologist and memory clinic, refered
her for social worker, environmental and
occupational therapy.
Main concern : when she will die? I said
unpredictable she repeat it several time and I was
calm as Dr. Zain teach us and said no one can know,
difficult to predict surely the disease will shorten her
live , bad lifestyle but no one knows when she will die
□ Cardio:
Aortic and mitral metallic valve replacement
□Neuro:
Cranial nerve examination (5th, 7th and 8th) cranial
nerve palsy .. I asked to do cerebellum.. one of the
examiner said ok .. I started to examine , the other
examiner said is it part of cranial nerve.. I said no , he
said please follow the instruction .. however at this
stage I already got cerebellum impairment,
□ Abdomen:
hepatosplenomegaly
□ Chest:
End inspiratory cracks with hyper inflation, and
clubbing, I said creptogenic fibrosis and
bronchoectasis
□ Station 5 :
1- pt has palpitation, inside the station pt has feature
of thyroid
2- pt present with blurred vision, in hx she has DM, I
took quick hx of DM, then V acuity and spent all the
remaining time in fundus examination: there was
laser scars and preproliferative changes
👍🏼 It seems very fair exam.
Please join me wishing our colleague a good luck &
success
UK Experience ,,,
Royal infirmary hospital abeerdeen ,,, 20 - 6 -
2017
Station 1
Hepatomegaly in female
Chest female with clubbing
Telangectasia
crepitation
Fibrosis vs bronchiactesis
I missed scar ?? Bikini scar
Station 2
Knee pain
Ankle pain
By asking
Loose motion
Red eye
His brother have psoriasis
Reactive arhritis
Septic
Station 3
Cardio
Midsternotomy scar in female
MVR
AF
murmur but I didn't mention it
Neuro
LL exam in male
UMNL with cerebellar manifestation
Nystagmus
Not sure because at the end the patient looks like
myotonia dystrophy
???
St4
Highly suspected cancer stomach by endoscopy after
haematemisis
Need to do CT chest and abdomen for staging
Task explain endoscopy result and the need to do CT
Chest and abdomen
I missed this scenario because I went more with that
diagnosis is cancer not highly suspected cancer
This was the trick ..
St5
Headache for 6 month
History of brain surgery before with the same
headache
She is taking analgesic for 6 month twice daily
No feature of acromegaly
No blurred of vision
Examine visual field and movement and field
Didn't complete examination for acromegaly feature
..
I think examiner wanted me to look for large toungue
..
St5
Palpitations in female
No CHEST or cardiac or stress no excessive smoking
no sweating no gland problem
Examination I found irregular plus
I said maybe arrhythmia AF
Examined heart and carotid ..
UK Experience *** Glasgow***Queen Elizabith
Hozpital 7th june 2017
St_2
pt w hx of knee pains presented w fatigue &
melena
pain associated w stiffness & improves w
walking
family hx of RA is positive
concern ::do i have RA like my family members???
St_4
communication w young girl who is married &
planning 4 kids who has been diag. w RA &now on
follow up visit as she was told to start Methotrexate in
her last visit & now she is back again to discuss the
St_5
BCC1
Man w multiple problems of Psoriasis Arthropathy
he had shoulder dislocation few dayes back & was
operated
Now presented again w shoulder pain & fever
BCC2
Young male w hx of crohns disease preasented now w
back & stiffness along w pain in the neck
################
Unfortunately that is ALL ??!!
UK Experience 6 / 2017
Hx
Known pt with DM, HTN, IHD,
C/o - lethargy & wkness for 6/12 , CBC - normal
On questioning -
Not following regularly
HbA1c 6m back 9 ,
MI 2 yrs back
on BB, statin, aspirin, ACEi, metformin, Isophane
insulin
Importance
Problem @ work deu to poor concentration
Mouth becomes dry frequently
Stopped smoking 2yrs back
Those were the only positive symptoms he gave & all
other questions were answered as no no no....
I was unable to come to a unified diagnosis
D/D
Uncontrolled DM ,
Renal failure,
psychological impact of importance
Questions
D/Ds
How you will manage?
20/20
3)
CVS -
Young male pt with VSD
Que
Positive findings
Investigations
14/20
CNS -
Ulnar nerve palsy - trauma scar present
Positive findings
Investigations
Management
17/20
4)
Parkinson's disease
Diagnosed 3y back
Not started Rx at diagnosis
This time came for UTI started on trimithopim &
responded well
Now the patient started on carbidopa before her
discharge from the hospital.
Explain to daughter regarding diagnosis, prognosis,
management , future plans
16/16
Hidden agendas
Hobby - drawing
Husband CVA bed ridden & only carer - do not
willing to give institutional care for him.
5)
BCC 1
Collapsed while walking with his wife
On questioning
Had a MI & fitted with pacemaker 15y back
Not on any medicine / regular follow up
Diag - Pacemaker dysfunction
How you will investigate ?
17/28
BCC 2
KT
On regular medicine & follow up
Derangement of renal function
On questioning
Recent use of NSAIDs for 1wk for mechanical
backpain after lifting a wt
28/28
St 1
RS
ILD / Bronchiectasis
Positive findings
How you will differentiate clinically?
Investigations
Management
19/20
Abd
Thalassemia with splenectomy scar & Hepatomegaly
Positive findings
Investigations
Complications
Causes of abd pain in this patient
18/20
UK Experience 6 / 2017
Hull Royal Infirmary Hospital
Cardio
valve replacement ? Mvr vs Avr with LL edema
viva about pro bnp and negative predictive
value
Andomin Renal trasplant
Neurology examine upper limb ‫ ؟‬myotonia
dystrophica
Chest left lower pleural effusion
Station 5
1 Reumatoid artharitis
2 acromegally with carpal tunnel
History
reactive artharitis
Comunication
a 55 yr f with hematamesis found to have ulcer on
endoscopy looks like malignant and biopsy a waiting
ur consultant want to do ct scan abdomin and chest to
r/o metastesis please to to her and explain the need of
ct scan
UK Experience 6 /2017
Station 2
Wagner granulamatosis
Renal impairment given out side .. and pt present
with fatigue
Inside I got sinusitis
Joint pain
Skin rash
Urine frothy and red
Station 5 :
1st: palpitation
In the analysis I realized it is thyroid
I asked in detail about thyroid
I asked in detail about thyroid
I examined thyroid gland
Eye
Tibial mexodema
Other station 5 was diabetic
Present with blurred vision
I took he in quick, visual acuity and the remain of
time I spent in fundus
Preproliferative with laser therapy marks
Cardiovascular
was easy also
I had dual valve replacement
Neuro:
cranial nurve ex
7, 8, and 5
Cerebropontine angle lesion
Abdomen : HSM
Respiratory there was end inspiratory crack and also
hyper inflation
St 4:
Parkinson's with uti
To explain the prognosis
UK Experience
GOLDEN JUBILEE NATIONAL HOSPITAL
15th June 2017
Station 2:
History
Middle aged lady having Multiple sclerosis and on
regular follow ups has presented with cough.
it was dry cough more on lying flat with burning in
the chest
No other chest or heart symptoms
patient concern was
is that Aspiration pneumonia ???
diagnosis : GERD
STATION 4:
83 year old man has End Stage Renal Disease with
underlying DM and HTN .
was admitted with Pneumonia and herat failure 1
month back and recovered.
was advised Dialysis which he refused at that time .
Now talk to the son who is insisting for Dialysis as he
says his father says yes to him but refuses when
doctors talk to him about dialysis.
Assume the permission was given by the father to talk
to the son about his condition.
( Father concern was that he lives alone and can not
manage to go to hospital regularly for the Dialysis )
STATION 5:
BCC 1:
Man presented with weight loss and palpitations .
concern was why i get lot of sweating .
BCC2:
Man with previous history of Aortic valve
replacement now presented with joint pains including
hands and Knee !!
history was suggestive of RA with acut flare.
viva was also about Hyperuricrmia?
Concern was will it affect golf which i play since long?
Can you settle my Deformities?
copied from Dr. Zain group
sharjah experience on may 17th , al qasmi
hospital, sharjah,3rd cycle
I started by station 4 , 38 years old lady , she is
diabetic for 22 years, on insulin, speak to her
and explain the importance of proteinuria ,
discovered
by her Gp,and the importance of adhenence to
control ,that is the task. she has diabetic
retinopathy also, she born tow pre mature baby
before.long scenario
I introduce my self to her, confirm identity,
agreed agenda, I asked if she want any one to
attend, shae said no.I asked her tell me more,
she told I have aprotein in urine and i am afrid
am I going to dialysis? i told her I am her to help
you, let us to think how to control your sugar,
she told how doctor, every doctor tell me do
that and that, and go there and there ,and i am
busy with my kids and my sick mother
here I showed empathy , i told her i will help in
this issue , i will refer you to social worker.
about your sugar , you need to follow some
restrictions regarding your diet, exercise, and
follwo up,
and I will refer you to dietician , he will help
more
also I will refer you to gland doctor, and eye
doctor for regular check up , here i asked her do
you have other problems, she told like what?
I told nerve problems, she told no, I forgot to
ask about macro complication
her concerns:
end in dialysis? I will be blind ? I told her this
will depend on control of your sugar, if the
sugar controlled and you follow diabetic diet ,
with regular follow up we can prevent
further deterioratin in kidney function, and
vision problem, and if the sugar not controlled ,
this will lead to more deterioration in kidney
function, and might you go to dialysis,
I hope this will not happened to you.I
summarized to her, check understanding,
agrred plan : referral to specialities as above,
offer help , contact number , leaflets , web sites
she told me I conviced doctor, then thank her
Examiner questions: did you think you
convinced her? confidently I said yes. he asked
why , I answered , because at the end she told
me I conviced
he asked me , did you bleive her, I replied yes.
he asked what important thing confirm that she
convinced and she can follow your plan? he
told me , if she agreed to come to follow up, and
you did not ask her for follow up
what ethical issue in this scenario? I told
autonomy
what is the cause of complication in diabetes?
he told I mean pathophysiology , I answered
microvasular complication.
why you refer her to social worker? I answered
to help her , because of her mother is sick.I got
11/16
station five:
BCC1 : 38 years old lady has neck swelling for
five years, all vital sings not avilable N/A.this is
the scenario. I think about thyroid problems.
BCC 2: 18 years old has spasm and shaking of
her right side of body. this only in scenario,
from outside I put d/d of myotonic epilepsy,
wilson disease, hemiballismus , because these
are common in station 5 in sharjah centre.
when I entered the room they told me your first
case on left, I saw young lady on the rigt side
with clear adenoma sebaceum on her face, so I
confirmed my second case is tuberus sclerosis
BCC 1: after introduction and greeting , can you
tell me more about this swelling, I asked her
about symptoms of hypo hper and pressure
symptoms, she has only constipation, family
history of similar problem in her sister, I asked
her about other auto immne diseases, are
negative, durg history , she is taking thyroxine,
her concerns is it curable? it will affect my kids?
i told her yes it is curable,regarding to your
kids, you have some we call it auto immune
thyroiditis , it is not inhereted , but your kids
have more chance to get a disease,
examination: smooth diffuse goitre, no eye
signs, no retrosternal extention, no proximal
myopathy, no pretibial myxedema, no lower
limb edema, I asked to do ankle reflex ( not
allowed )
examiner questions:
what is your diagnosis? hashimoto thyroditis.
whatis your findings ? diffuse smooth goitre.
clinically what her thyroid status? euthyroid
what other d/d than hashimoto ? It could be
simple goitre. what investigations you want to
do ? A: thyroid funtion tests, thyroid ultrasound,
thyroid Abs. what test use for follow up ? A ;
TSH. also asked about frequency of follow up.
what treatment? I will refer her to
endocrinologist and to continue on thyroxin
time finished, I got 28/28
BCC2 :
as scenario above, there is young lady and
surrogate beside her, after greeting and
introduction, I asked her tell me about that
shaking , she gave description of tonic clonic
seizure, I asked about performance at school,
she told me low performance, I asked about
rash in face since when ? she told since
childhood. any other rash , she told no
i asked about respiratory symptoms, GIT
symptoms, eye symptoms all are negative. I
asked about similar problem in family , No. drug
history : she is taking two anticonvulsants , one
is topiramate , other I dont remember
no significant past medical history.I examined
the rash on face , rash in distribution of butterfly
, adenoma sebaceum, I asked to examine the
back for shagreen patch, not there, I asked to
examine the trunk for other rash , they told
leave it, I examined the eyes by torch light,
nothing
concerns: is it curable ? I explained to her she
has some we call tuberus sclerosis , it run in
family , it is not curable but we can control it , as
she taking this medication to prevent fits.other
concern : that medication is correct medications
and if she can continue on them ? I told her I
will refer her to nerve doctor , who will check
that medicines and who will decide to continue
or to change.
I told her disease can affect respiratory , gastro
or eyes , IF any symptoms we will refer her to
specific specialty.
examiner questionS
what is your diagnosis? A : tuberus sclerosis .
do you think the rash related to her fits ? A : yes
, both are features of tuberus sclerosis. do you
think she taking correct medicatins ? A: yes but
I think not correct medications, because
examiner told me you did not ask about
frequency of fit , she has two attacks last week,
so I think she need to change anticonvulsants.
what investigations? A : ct brain. what you will
find in CT? A: tuber and calcification time
finished I got 23/28
station one : abdomen : scenario , examine the
abdomen of this pt , who came for follow up
young boy, pale , jaundiced, no signs of CLD ,
palpable spleen about 5 cm below costal
margin, liver: right lobe 4cm bellow costal
margin,liver span is 12 cm, left lobe about 5 cm ,
no ascites, there is tanned face
examiner questions
what is your positive findings? A: as above
what is your diagnosis? chronic hemolytic
anemia . what exactly ? A: thalssemia
what is D/D? A: I told myeloproliferative , she
told me myeloproliferative in this young patient
??, then I told infiltrative disease, she is not
happy also, I told chronic liver disease,
accepted, what aganist it ? no stigmata of CLD,
what investigations ? A : u/s abdomen,
complete blood count, HB electrophoresis,
blood film, and investigations for complications.
what complicatin? secondary hemochromatosis
from repeated transfusin, how you treat this
complication ? A; iron chelating agent like
desferoxamine .
what is cause of death in those patients ? A :
cardiomyopathy I got 20/20
chest : scenario is examine chest of this patient
who has shortness of breath
elderly male with cannula on his left arm,
anterior chest examination , for me normal at
this point
back examination: wide spread ronchi and
creps , I recalled from anterior examination,
percussion seem like hyper-resonant
examiner questions: what are positive findings?
A : as above
what is your diagnosis ? obstructive airway
disease most probably is COPD with acute
exacerbation.
what is clue in his hand for COPD ? A: I did not
find, I think he mean tar staining .
what are investigations? cxr , pulmonary
function test , CBC .
what is treatment for acute exacerbation ? A :
admission , i.v steroids , B2 neublization ,
antibiotics , oxygen.
what is treatment for COPD ? none
pharmacological and pharmacological in
details.
what are the indications for long term oxygen
therapy ?
I got 19/20
station 2 :
scenario: 35 years old , tody discovered at Gp
clinic , he has glucosuria , he has history of
uncontrolled hypertension , anxiety , chest pain.
in the history : no syptoms of DM, other positive
findings are sweating , headache , palpitation ,
family history of death of his father due to
kidney problems, no symptoms of MEN 2, no
symptoms of other causes of seconadry
hypertension, I put diagnosis of
phaeochromocytoma, I explained to patient the
diagnosis and treatment
his concerns is about diagnosis and is it
curable , I told him it is curable.
examiner questions ? what do you think about
cause of glucosuria ? A: related to his
phaeochromocytoma
what are the causes of false positive glucosuria
?
what is your diagnosis & D/D? A:
phaeochromocytoma on top, D/D , other causes
of seconadry hypertensin, anxiety
what are the investigations?
why you did not assure the patient?
I got 10/20
station 3:
cardio: scenario, examine the heart of this lady
who has shortness of breath.
pakistani lady, look in thirties, with other young
lady for translation
low volume pulse, midsternotomy scar, no
harvesting scar, palpable second heat sound,
loud second heartsound.I did not hear any click
sounds
what are your finndings ? as above
what is the diagnosis ? A: mitral vave
replacement , I guess it because pt is young, I
am not sure but I mentioned It.
do you think she is in failure ? A: no
what investigatios ? A: echo, ecg. cxr, INR
what target ranges for MVR?
I got 7/20. for me the case is not clear and I
know other two candidates got 7 , one put AVR,
and other DVR.
neuro:
examine the lower limbs of this patient
middle age male , he has hemiplegic flexion of
his left upper arm
normal examination on right lower limb
hypertonia, weakness , hyperreflexia , up going
planter on left lower limb.
examiner questions:
what are the finding? A: as above
what is your diagnosis ? left sided hemiplegia
given his flexion of his left upper limb.
where is the lesion ? A: internal capsule. what is
the side? A: right side
what investigations ? A: CT brain in acute stage
to exclude haemorrhage
what is mangement ? A: in acute stage , I will
refer him to stroke unit, what is treatment right
now ? A : seconadry preventions: control of BP
if hypertensive, mangement of DM, and
hyperlipidemia and other risks.
I got 20/20
thanks god I passed the exam
Am one of the silent observer here, just want to

share my recent exam experience in brunei.
Alhamdulillah, i've passed the exam.
PACES Brunei May 2017
St 2- 48 yo lady with abdo pain n constipation.
Concern - father died of colon cancer. Further hx,
back pain, polyuria, polydypsia, reduced
concentration, hx of kidney stone. Previous hx of
breast ca. DD - hypercalcaemia, hypothyroid
St 3
CVS - pulmonary stenosis
CNS - MG (bilateral ptosis, bilateral 7th CN LMN,
nasal speech, fatiguability of eye n UL)
St 4 - elderly lady with moderate alzheimer n OA
with fall at home, recurrent hospital admission.
Admitted again for UTI n become more confused in
hospital. Speak to daughter. Daughter concern why
more confused n demand ct brain. Ethical issue,
autonomy, do good, do no harm. Hidden agenda, need
to discuss on DNR and advanced directive, referral to
palliative team.
St 5
BCC 1 - pt came with fall - peripehral neuropathy
BCC 2 - young lady with right calf pain - need tro dvt
coz hx of miscarrige n recent long haul flight.
St 1
Respi - right pneumonectomy
Abdo - thalasaemia with splenectomy (pallor,
jaundice, hepatomegaly, splenectomy scar)
Exam Experience {My sister} ... Egypt May 2017
metalic mitral valve
neuro : ulnar n palsy
Resp not sure
abdomen hepatosplenomegaly
Station 4: medical error, administered trimethoprim
for a patient on methotrexate fir psoriasis so she had
bone marrow suppression, discussion about the
mechanism by which they have caused it
Hx taking : poorly controlled asthma, likely
occupational Vs churg Strauss
Station 5: proximal myopathy due to
hyperthyroidism and goiter ,
frequent seizure in known previously controlled
epileptic y likely drug interactions as he was given
clarthomycin recently
I passed PACES from dubai. Thanks to this

group for the support!
Cases to my concern ️ ️
Station 4. Task was talk to the daughter( NOK)
about the diagnosis of her father who is 70 yrs
Known AF and HTN and was on warfarin. Now
got brain haemorrhage, confirmed on CT brain.
INR was below threshold level. Bp well
controlled
Q why this happened to my father?
Q was it due to medicine ?
Q should he continue that medicine
Q what will happen now
Q I want to complain
Concern. I am the only daughter , my husband
supports me
I asked the cardiologist not to start this
medicine but....
My answers 😜... medicine is not the cause.
... team will take care of him and will decide
what is better for him . Meanwhile we will stop
that medicine
Examiners Qs
1) what are the ethical issue here?
I told autonomy .. examiner not happy
Then I told BBN .....examiner was totally not
agreed
Then he asked me what is malfience ?
I answered it
Q what do u think that was right decision to
start with warfarin for this patient? I said yes as
he was with AF. But he was not happy
Q what will u do now ? U will start warfarin or
not? When u will restart?
I said sorry I will ask for opinion from senior and
examiner smiled and said what is yours
opinion? I said at the moment warfarin will be
hold.
I missed to guide her to make complaint as she
made bombardment of another concern as she
is alone .... I told examiner there was no time but
if I had time will guide her.....score 11/16
Statition 2 : 45 yrs old with transient loss of
unilateral vision .
Past h/o blindness in other eye 5 yrs back due
to retinal vein thrombosis. Family h/0 stroke and
heart Attack.
Medications list was there.
Diagnosis. Transient ischemic attack(
amarousis fugax)
Examiner Qs
1) what is the cause ?
2) investigations
3) management
Concern:
Driving
Would I need admission? Got 20/20 ( amazing)
Station 1 : respiratory case
Examiner command : this lady has some
shortness of breath . Examine her back of
chest....
it broke my scheme as Pt was total blind when I
told her please can you make yours hands like
this 😇 😇 😇 😇
I did not do proper general examination and
findings at the back were scattered all over
chest but more over left lower zone.... confused
crackles... not clear about diagnosis ..not clear
work up and same management ....11/20
CVS:; very interesting case ️
When I entered the room , Pt was angry to the
examiner as he wants to go home. I tried to
make him relax that I am the last dr to check you
as that was last station of the cycle...he became
relaxed . Thanks to him. Then I read the case.
"THIS PATIENT IS POST CARDIAC CATH......"
Findings. Unequal radial pulses ....left radial
pulse was not palpable.
There was thrill over RT radial pulse and I told
irregular....
Precordium .... nothing found even heart sounds
were muffled...
Examiner asked wat is diagnosis??
I said unequal pulses and iatrogenic AV fistula
post cardiac cath 😜
Examiner asked on which side cardiac cath was
done..... I was lost because RT and left radial
pulses both were with findings.... I said may be
repeated both sides....not happy. Investigation
and management.... examiner asked be
specific..... I felt this case also misssed as
respiratory case but I got 17/20 ( awaiting for the
correct diagnosis)
Good luck 👍
Dubai Paces exam. 15/5/2017

Station 4:
A pt. with COPD with frequent exacerbations
and hospital admission on Theophylline and
monitoring serum level regularly admitted by
chest infection and clarithromycin given for him
causing Fits. He is a taxi driver.
I address the problem, apologize and ask him to
tell DVLA.
Examiner asked is this medical error I said yes.
Station5:
1st:Neck swelling:Throidectomy scar.
I took a brieve history and DD symptoms of
hypo and hyperthyroidism and concern.i did
examionation for thyroid,hand and visual field
of eyes,lymph nodes.
Nothing except thyroidectomy scar. Examiner
ask about investigations.
2nd: Young Pt. complaining of dizziness and
lightheadness when standing from sitting
position. Type 2 DM on insulin and metformin
uncontrolled.She has abdominal fullness .Data
given BP supine 135/90 and standing 115/70 like
that.
I took history excluding the causes,address the
concern.No physical findings, I asked to
examine the heart he told me no need…because
she is normal….
Asked me what is your diagnosis:Postural
hypotension,autonomic neuropathy.
Other causes:Fits,hypoglycemia,cardiac
arrhythmia.
Asked me about investigations and
management,,,the bill ringing.
Station 1: Male with abdominal discomfort.
Abdomen:Renal tx,no functioning,tender,many
AV fistulas one of them is working and recent
punctures there.
She asked me what is your
diagnosis,nonfunctioning renal tx,how did you
know.Complications of medications
physically:striae ,cushingoid face.
She asked me what is in mouth, I told her my
gingival hyperplasia,she did you check I told her
I am not sure really…
Investigations :urine, C&S,cbc,ca ph,PTH.
Chest:Pt. with dyspnea…lt. pleural effusion.
Asked about finding,investigations.
Station 2: History taking
Femal pt. around 45 y complaining of recurrent
central abdominal pain,diarrhea,no bloody
diarrhea,no loss of wt. no NSAIDS.
History systematic,concern about the
diagnosis,cancer,admission or not I said less
likely to be cancer,no need for hospital
admission.
Examiner for DD and analysis.
Station 3:
Neurology:Young male about 35 y. with
difficulty waling.
Neurological ex:Hpotonia,loss of joint
reflexes,power normal.Sensation fine touch and
pinprick impaired,heel shine test intact,no time
for deep sensation.
UK examiner:I was hesitated about the
weakness at first then I told him there is
hypotonia,abscent joint reflexes ,impaired
sensation,the he told me whatis your diagnosis I
told peripheral neuropathy…DM,vit. B12 def he
repeated vit. B12 are you sure I told yes.
Investigations:NCS,EMG,Blood
sugar,HbA1c….ringing bell thanks God.
Cardiology:
Pt with neurological insult for cardiology
exam.Pt. has hemiparesis.
I did general exam… pulse irregular.
Local inspection no thing,palpation no
thing,Auscultation no murmur…..i am surprised
…no murmur???
I forgot to check carotid and auscultate the pt.
sitting for AR??
Final minut:I checked bach chest bilateral fine
crep. Basally.
LL edema ++,sacral edema.
what is your diagnosis…I told her no signs of IE
,pulse irregular she asked which irregularity I
told irregular irregularity AF.
Really I couldn’t detect any murmur?? The
looked for me I said yes.
What is your diagnosis I tod them congestive
heart failure.what is the cause I told may be the
same causing cerebral stroke,IHD,mycordial
infarction.
Investigations:I told searching for risk factors
ECG,ECHO,lipids,blood sugar,BP.
Management:For AF formal anticoagulation ,she
asked how you decide I told CHAD VASC score
,diuretics.
UK doctor ask me you did not check carotids
???
I told him yes I have to check and doing carotid
doupler for internal carotid stenosis,he said
GOOD…I feel bad to forget carotid and sitting
the pt. and hear aortic area but it is very
distressing during exam. Short time.
Your comments are highly appreciated.
Firstly, Thanks Allah, for his inspiration and

Tawfiq. I passed from the FIRST ATTEMPT. Till
now I'm surprised by this happy news and I
hope all success to all of you.
Thanks to all my teachers, mentors, members of
this wonderful group, my family and my friends.
I will tell you my PACES story in details hoping
that it will be beneficial to you.
◇ Station 1:
》I started with Station 1, I was very afraid about
the exam at that time. I remembered some
prayers at the time and read it. Then, I prepared
myself as I will start with the Chest Station.
The bell rang. "Okay this is your abdomen case,
start doctor" the examiner said. I got stressed at
this moment because I'm preparing as I'm
entering a Chest case. On the board patient is
asymptomatic. I started. There is fistula in the
left forearm, which is not working. Patient is
mildly pale. There is right iliac fossa scar with
mass under it. I concluded that, this gentleman
has renal transplant which is working well, with
mild pallor. Examiner kept asking about pallor
"Are you sure ???" more than 3 times. I'm afraid
about inventing signs. He said: "what else ?" I
said: "maybe the patient has gum hypertrophy I
didn't concentrate on it, I would like to examine
if you give me a chance 😓". He said: "if the
patient has RIF pain, what did you think about
?" I said maybe graft failure". "How you will
follow ?" "Renal function, vital signs and urine
outpt". "What other differential diagnosis ?"
"Maybe infection". "If the patient develop
glomerulonephritis, what is the best
investigation to confirm the diagnosis ?" "Renal
biopsy". Bell rang. My impression is that I did
very bad in this station. I got 20/20.
》 Next case, Chest. Young male with SOB on
Oxygen with nasal cannula. I started my
examinaton. Cachexic patient with Clubbing.
Patient is tachypnic. There is left thoracotomy
scar. Chest move better in the other side !!!
Variable percussion note. Bronchial breathing at
left upper lobe. Crepitations all over, change
with coughing, with scattered wheeze. Trachea
is central.
1 minute left and even I didn't start examination
from the back. Time finished. I concluded that,
patient has bronchiectesis evidence by the
previous signs. He kept asking "what is the
cause of thoracotomy scar ?" I gave a
differential diagnosis of upper lobectomy and
other types and what with and what aganist. He
kept asking me what else, what else about the
differential diagnosis and the causes of
thoracotomy scar until the end of the station. I
felt completely lost 😰. I got 19/20
◇ Station 2:
I moved to station 2, with a feeling of
depression. History of young man, 28 year old
who lost his consciousness for 2 minutes while
he was playing football after feeling some
palpitation. This is the first time to him to lose
his consciousness. He got tonic clonic
convulsions, without eye rooling up, without
tongue pitting and without loss of sphincter
control. He waked up completely well, and went
home. He had previous history of palpitations
13 years back. He is adopted. Nothing more.
I gave a differential diagnosis of Vasovagal
attack, Epilepsy, Cardiac causes
(Arrhythmias/HOCM) and Hypoglycemia. He
discussed with me to put it again in order. After
that I put cardiac causes firstly. He asked me
about each one' investigations. Then the bell
rang. I got 13/20.
◇ Station 3.
At this time, I remembered what Dr. Zein said to
us: "Take every station as an independent
exam. Don't be bother about your performance
in one station. Forget about it and move on".
》Cardiac case. It was straightforward. MVR. He
asked me about investigations and the causes
with some discussion about the prophylaxis. I
got 19/20
》Neuro case. Middle age man with difficulty in
walking. Examine the lower limbs. Examiner
adviced me to start with the gait. Mmmmm I
think for a while and then I start with it. Wide
base gait. Patient has cerebellar signs in both
legs with loss of superfecial sensation in the left
leg up to the inguinal region. Examiner didn
't allow me to move more. I concluded that this
paK A'Rahman Ageeb:
tient has cerebellar signs with superfrcial
sensation loss for Differential diagnosis. I said
MS, and then I had brain block 😯. I couldn't
remember any Differential diagnosis 😷 and he
was waiting. Then he asked me about the
investigations and the treatment. I got 14/20
◇ Station 4 about 60 year old man, hypertensive
for 8 years on treatment. He got DVT before 6
weeks, and started warfarin. He came yesterday
to the hospital with loss of consciousness. His
Blood Pressure at admission was 190/110 and
INR was 4.0. CT brain showed brain
haemorrhage (I think they didn't tell more than
this). One day after, the patient deteriorated
more, desaturated, intubated and admitted to
ICU. Neurosurgery opinion, they said they can't
interfer because of the condition of the patient.
Your task is to speak to the wife to tell her about
the condition, the prognosis and the plan.
After opening and After taking her idea about
her husband' condition, I explained to her
everything about his condition. She asked:
"what is the cause of the haemorhage ?" I said:
"maybe his high blood pressure, maybe from
the warfarin that he takes, but his INR at
admission was 4, and maybe other causes. She
said: "Is this the fault of the GP that prescribed
the Warfarin ?" I said: "it is unlikely, because
your husband take the warfarin now for almost 6
weeks and before he didn't have any problem
with it. She said: "Then any thing to be done to
him ?" I said: "we will do other best, we will give
him his feeding and antibiotics that he need and
close observing his vital signs but unfortunately
his condition is not good". She said "Any
surgery ?" "The opinion of our neurosurgery is
that, he can't not interfer with your husband
case because of his condition". "Will he die
soon and when?" "I can't say to you when, but
unfortunately he may die at any time". "Will I
call my son to see him ?" "Yes, please as early
as possible". Then, she kept to ask me, any
more help, any surgery to my husband, and
transfere to another hospital until the end of the
station. I forgot to give her another chance to sit
with my consultant if she want.
Examiner asked me "Did you think she is happy
about the plan ?" I said "no". "What you will do,
then ?" "I will give her chance to sit with my
consultant if she want". "Okay, nice, what is the
cause of this brain haemorrhage" I said: "may
be his high blood pressure, maybe from the
warfarin that he takes but his INR at admission
is 4, and maybe other causes like berry
aneurysm associated with polycystic kidney
although she denied any previous history of
renal problem or family history". "Is these
Differential diagnosis written FRANKLY in the
letter ?" No. "Then, don't say what is not
written" ..... 😐 "What is the percentage of
survival from his condition" "What is the
percentage of survival from cerebral
haemorrhage in general" and questions like
this. I got 5/16 😐
◇ Station 5
》1st one is 28 year old female presented with
headache for the last 6 months, increased in the
4 weeks. She said it is mainly unilateral,
throbbing in nature, relieved by ibuprofen,
associated with nausea, no vomiting, more at
morning, with positive family history of same
condition. All other history are clear (no history
of clots, no skin rash, no joint pain, no
weakness, no ulcers, no symptoms of anemia,
no eye symptoms, no local symptoms, no
medicines or OCP). All vital signs are normal.
Brain block happened 😲. I don't know what to
examine. I didn't do fundoscopy or offer it.
"Doctor do I need to do CT for my brain ? I'm
afraid It maybe cancer" "No need for the
moment, it is most probably Migraine. We will
refer you to the neurologist and after medication
if no improvement may be we will need CT
brain". Examiner questions: "What is your
Differential diagnosis ?" "Most probably it will
go with migraine, I can put medication over use
headache, although I forget to ask about it".
"Will you do CT brain ?" No need for the
moment, it is most probably Migraine. I will refer
her to the neurologist and if
needed we will do CT later". I got 18/28
》 2nd case: around 60 year old gentleman
presented with loss of vision. His all vital signs
are normal. He has history of brain surgery
(Hypophysectomy) 2 years back, and he usually
takes his medications. He has gradual loss of
vision over weeks to months. No eye pain or
headache. No other symptoms at all. He has
acromegalic feartures. He has bitemporal
haemonepia. When I start to do fundoscopy, 2
minutes remaining and another brain block
happened 😧. I think there is papilledema but
I'm not sure. Examiner asked "what is your
diagnosis ?" "Most probably recurrence" "What
did you see in the fundus" By mistake I said
optic atrophy, and I didn't want to return to say
papilledema because I'm not sure. His face
changed. Then he asked: "what else ?" I said
"silver wiring". He said "What is the best
investigation that you will do ?" I said "MRI
brain". I got 24/28.
My total score was 132/172.
GOOD LUCK.
Egypt / May /2017

Regarding exam today 3rd carousel
St 5 first case is inability to walk
nd one is inability to lactate post delivery2
Chest pneumonectomy
Abdomen thalasemia
Neuro paraplegia with level
Cardio mitral valve replacement
Hist back pain in a women post menauposal with
mastictomy 15 years back
Communication suspected cancer stomach waiting
investigation
Sharjah exam today =17 / 5 / 2017

Cvs;
Cabg scar , av fistula, systolic murmer on apex
with radiation
Cns;
Motor neuropathy
Resp;
Right side pleural effusion in ckd patient and
bibasal crepts
Abd
Renal translant
St 5;
1.excessive hair growth
2.gradual visual loss 5 yrs now blind
St 2;
Female with ankle swelling, joint pains , dysnea
and cough
St 4
Anaphylaxis in chef for discussion with
seriousness of disease and job implication and
treatment
Exam Experience Egypt May 2017

Cairo today
St 1
CLD with ascitis
COaD with possibility of Rt up lobe fibrosis
St 2"
Bronchial asthma
Ca bronch
St 3
Mixed mitral valve
AR
Spastic paraplegia
St 4
Unawareness of hypoglycemia
St 5
Behcet disease. V vasculitis
Polyglandular failure
Anaphylaxis scenario.. {Copied from Dr .Zain
group}
Communication station:
Middle age man work as a chef in a restaurant.
He's known allergic to peach and peanuts.
Brought to the casualty after collapsing at work
just after eating a pear
He doesn't have known allergy to it before. He is also
asthmatic. In ER he was in anaphylatic shock for
which given ttt then admitted to icu. After 2 days
become more stable
🔹 🔹Patient concerns: 🔹1.This my only job what
I will do, advice to change his job in the same
resturant but not in the area that he will expose to
substance that patient is allergic to like casher and we
can talk to occupation therapy
🔹2. What abou my kids? This allergy can run in
family ,we need to involve specialist DR to test your
kids and to see if they allergic to common substance
🔹3. Can I die: Death is one of possibilities, we need
to do some protective/ preventive measure like we will
give you small pen contain substance called
epinephrine in case of allergy you can use it
🔹4. Can this allergy occur again: Yes if your are
not avoid the substance that you are allergic to.
From the discussion patient: he changed his house, I
asked him whether the allergy start when he transfer
to new house he said no
👉 Reagarding concern 3: I have advised him that
we will give a medical alert card in your poket
💢 💢Examiner's Qs 💢 💢
》Q1: What if patient collapsed at home alone: We
can arrange teaching scessions for his wife and if his
alone he can use EPI pen & call the ambulance.
》Q2: What you will write on the card that you will
give to patient? The substance that he is allergic to,
treatment that patient should recive, take me quickly
to hospital
》Q3. Any other possibility of something else that can
lead to this patieny allergy?
The new house but unlikely because the allergy
started after he ate the pear
👋 👋 He got 16/16
Sharjah cycle 1 & 2 May / 2017

History : pain in wrist and knee joint for month ,
sob, pain in shins for 3 wks, ,female 52
,sarcoidisis
communication: anaphylaxis in a chef ,allergic
to salad, talk to him regarding to diagnosis , job
, treatment
Sta 5 : hirsutism for dd , cushing ,pcos
bcc 2 : deterioration of vision , esstential intracranial
htn, optic atrophy
Dubai - May 2017
The first cycle 15/5
History: sudden blindness ( amurosis Fugaus )
Comm:- pt elderly with AF on warfarin.
Develop left sided weakness & INR = 1.5 .. possible
hypert hage bleed ::: discuss with his daughter.
Station5
1- post-MI came with lethargy
On lisinooril . Statin , bisoprol & aspirin
?? Postural hypotension , statin se,
Anemia
2- elderly lady 60yr came c/o back pain, k/c
osteoporosis on treat
Temp 39
DD: fracture ،discitis
Alhamdulillah i have passed paces

First attempt in Royal Hospital Oman held on
8th April 2017
Scored 146 😁
Well before i share my experience I would like to
thank dr Ali Hameed
Dr Ali Raza
And all Mypaces team for their generous
support and a very special thank to Dr Abdul
Fateh
I learnt alot from his course and it really helped
me all through preparation 😄 especially
Neurology which was the big elephant 🐘 for
me since final year MBBS
I got my result a little later then my other
colleagues which made me think 😒 Mera
Faisala bhi Mehfooz ho gaya hai (my Pakistani
colleagues can relate to this joke 😤)
Down below is my experience (i was very sure i
failed because I didn't follow my scheme during
exam that i had made while preparing for the
Exam but they say miracles do happen 😇)
Started with station 4 delayed diagnosis of
pheochromocytoma
Surrogate was not aware of the diagnosis which
i had to break and give him reasons for delay in
diagnosis
Dont know what i did wrong got 3/16 😲
Station 5 BCC1 frozen left shoulder in Diabetic
pt
In the d/d I didn't mention Frozen joint at all and
kept beating around the bush ️ got 25/28
BCC2 was Toxic Goiter staright forward got
26/28
Station 1 😩 😩 unsure of the actual diagnosis
of Resp case but i diagnosed as COPD with Bi
Basal Fibrosis/bronchiectesis (i know doesn't
make sense ) pt didn't have tht wet type of
cough but crepts were course and didn't change
with cough
Viva was usual on management of the pt and
investgations got 18/20
Abdomen was Renal Transplant due to Apkd
,well here also the examiner pulled diagnosis
out of stomach 🙄 as i was again not telling
the actual diagnosis in my presentation ,and i
also failed to identify the transplanted kidney(i
said may be he had some abdominal surgery for
some infection 😧 ,what was I thinking 😳still
got 17/20
Station 2 coelic disease (lady with fatigue ankle
swelling and Microcytic Anemia) Viva was about
the investigations specifically asked me the
Antibodies and management of coelic got 18/20
Station 3 (my most feared but the best station
️)
Cardio was young male around 25 yrs with AVR
no murmur at all,though he had Afib,viva on
management of replaced valve pts ,I mentioned
all the usual with diet and medicine care, he
asked me which is the most common medicine
interfering with INR ,i said Antibiotics 😎 got
20/20
Neurology was young 25 to 30 yrs probably with
involvement of post columns and PYrmidal type
weakness in L/L left then right
Reflexes exaggerated in right diminished in
left(appeared with reinforcement) i gave D/D of
MS ,syringomelia,Friedrch with MS on top due
to patchy involvement ( remembered a line by
my hubby when nothing makes sense its MS
️)
Viva was usual on investigation and
management of MS got 19/20
So now my advice to all preparing
Have a study partner
Think simple in exam
Do loads of prayers (as i did 😎)
Allah make things easier for all of you
Ameen
Thanks again to all my teachers who taught me
my parents my in laws they were huge support
to all my whining and self speculations of
failure
❤ ❤
Dubai 17/May 2017

{Copied from Dr .Zain group}
station 4
Conunseelling about proteniuria, adherent to
medication
Station 5
BCC1: Hypothyroidism, goitre
BCC2:tubeus sclerosis
Abdomen, thalassemia
Copd chest
Station 2
phaeochromocytoma
Cardio: valve replacemet
Neuro, hemiplegia
Dubai - May 2017

History :
recurrent chest infection
Communication:
Hypoglycemia unawareness
Examiner asked about the cause of Unawareness,
B blocker is written in the scenario
#####################
Dubai - May 2017

First day 15/5 third cycle :-
History:-Diarhoea with FH of Cancer.
Communication :-
Theophylline toxicity after give clarthomycin &
developed seizure
Jobe: taxi driver
ClNS :-Caw hand
Chest :- Pleural effusion
Abdomin:- chronic liver disease
Cvs:- CABG with murmur & AS
Dubai /May 2017

{Copied from Dr .Zain group}
St_3
metalic aortic valve,
neuro : ulnar n palsy
St_1
Resp not sure,
abdomen hepatosplenomegaly
St_4
Station 4: medical error, administered trimethoprim
for a patient on methotrexate so she had bone
marrow suppression, discussion about the mechanism
by which they have caused it
St_2
Hx: poorly controlled asthma, likely occupational Vs
churg Strauss
St_5
Station 5: goiter, frequent seizure in known epilepsy
likely drug interactions as he was given clarthomycin
recently
Exam experience in Glasgow in Golden Jubilee

Hospital 23/3/2017
I passed alhomdellah with 148/172
This is my first trial in PACES but i had the
sense that i know what to expect in the exam
from the experience that had been shared from
other colleges so i would like to thank
everybody who share his experience.
I started with station5 and when i knew that i
panicked because i thought if i messed it up i
will fail but then i said to my self just do what
you can and forget about it in that room don not
take it to other stations.
The first case was a lady with weight loss and
type 1 DM so i put from outside grave' s disease
and coeliac disease and when i entered the
room it is obvious that it is Grave' s so i started
by shaking hands with the patient and then she
gave history of gritty eyes and weight loss with
good appetite and diarrhea and then i started
the examination by checking the eyes she has
led lag and retraction and ophthalmoplegia and
proptosis and then i asked her to take a sip of
water she does not have goiter but i examined
the neck and there is no finding and in the
beginning i checked the pulse and it is regular.
She has positive family history of type 1 dm and
she is on b blocker and no smoking history and
not drinking alcohol and her concern was what
is my problem so i explained the grave, s and i
refer her to endocrinologist.
The examiner questions were what is the
diagnosis and what you find in the eyes and
what is the investigations and the bell rang and i
did not finish the discussion and i forgot to see
the legs for pretibial myxedema and the
proximal myopathy and i knew that i will lose
marks and i got 23/28
The second case was systemic sclerosis
I became calm and confident in this case
because i found that there is nothing to worry
about it went fine the first case. The scenario
was a man came with discoloration in his
fingers and pain so i went inside the room and
the patient has obvious talengectasia. I started
taking the history and the patient has rynaude '
s with dysphagia and shortness of breath and
he is a builder so i examined him i saw the
talengectasia and i saw his hands he has ulcer
in his finger and the skin also he has lung
fibrosis with fine crackles and then i asked the
examiner about patient BP to exclude the renal
problem and the examiner was happy. The
patient concern was what i have and then i
explained tge disease and i told him that i will
refer him to rheumatologist and i advised him to
keep his hands warm and to avoid vibrating
tools.the discussion was on diagnosis, finding
and investigation and treatment and i knew that
i will have full mark and i have it 28/28
Station 1 :
The abdomen case was liver transplantation,
patient with Mercedes Benz scar so i started the
examination and the secret is to be fluent do not
think about what you want to do next, the
examiner wil Will have good impression
The scenario was patient cane with abdominal
discomfort.the discussion was about what is
your finding ? The patient has tinge of jaundice
and the scar and the liver is palpable six cm
below the costal margin and no signs of chronic
liver disease so my diagnosis is that the patient
has liver transplantation and the discomfort
could be due to rejection or portal vein
thrombosis or hepatic vein thrombosis and i
should say biliary stenosis but i forgot.
Then he asked about what might be the cause of
transplantation.
What the think you will do before you send the
patient to the liver unit for transplantation and
what are the side effects of immunosuppression
medications.
I got 17/20
The respiratory case was an easy one but i
messed it up. Patient came with shortness of
breath. On examination he has right side
thoracotomy scar and crackles so it is
bronchiectasis. I presented my finding and then
i said fibrosis i don not know why i said it even
he said is it bronchiectasis or fibrosis and then i
said bronchiectasis but i became confused so i
forget to lung function test in investigation and i
forgot postural drainage in treatment. I knew i
will have 10 and it is i got 10/20
Station2:
The scenario was patient 36 years old male with
type 1 DM came with recurrent hypoglycemia
and weight loss and anemia he has renal
impairment the GFR was 38 and he has
retinopathy.
So i started by asking open questions and the
patient answered by himself all my questions
from the first 5 minutes.
He has recurrent episodes but he has
awareness of hypoglycemia only two times he
needed help from his wife and he is an IT and he
is driving his car but now he stopped so i told
him that is good and i appreciate that you
stopped driving.
He also has abdominal pain and recently
discovered that he has renal problem.
Not smoker.
His concern was what i have.
So i explained that he has an autoimmune
disease which is type 1DM and there are others
and now he may have Addison and i explained
what is it and it could be due to the renal
problem and he may need to the
endocrinologist to decrease his insulin dose but
idid not say to the patient coeliac disease. The
examiner question what is your differential
So i put addison, coeliac and due to renal
problem and then he asked why he has anemia i
said it could be due to the chronic kidney
disease so he asked what GFR can cause
anemia i said 30 and then he said why he has
anemia i said pernicious.
Second questions was what investigations and
then he asked the patient is on ramipril what
you will do i said he will continue on it because t
is protective he said excellent answer i got 16/20
Actually it was nice experience and the
examiners was good
Station 3:
The cardio was an old patient with regular pulse
and on examination he has pansystolic murmur
radiating to the axilla
Examiner asked what is your finding
And he was so happy about my presentation
I said that the patient has regular pulse 70 per
minute and he has pansystolic murmur
radiating to axilla and my impression is that the
patient has mitral regurgitation and the
differential is Tricuspid regurgitation but the
things that against are no hepatomegaly and
raised JVP and the other differential is VSD and
the age of the patient against that.
The examiner agreed
And then what are the causes of mitral
regurgitation
What investigations
What are the treatment
I said replacement and then he asked about the
indication for it
Then he asked me about the medical treatment
and i said vasodilators and diuretics
I got 20/20
The neuro was old patient with mask face
The instruction was to examine this patient
I started doing the parkinson disease
examination
I asked the patient a question how he came to
the hospital
And then i examined him for tremor
And then i did the tone in hands
And the examination for bradykinesia
In upper and lower limbs
Then i asked him to walk
And the finger nose test
Just i forget to test the supra nuclear palsy
But the examiners were so happy and he said
you still have time but i said i don not have
anything to do else and then he said what about
the eyes then i remembered and i told him how i
will do it and he said ok no need to do it
In discussion
What is your diagnosis
What is the differential
I said parkinson plus and the drugs induced
What investigation
I said it is a clinical diagnosis but if in doubt we
can do CT and MRI and SPECT scan
What treatment
I said all the medication with their side effects
He asked what this patient at risk of
I said fall
He said what you will do
I said multidisciplinary with physio and
occupational to adjust the house and also the
social worker for benefits i got 20/20
Station 4
The scenario was 54 old patient with congestive
heart failure and he is at maximum treatment
and the cardiologist said no more added
treatment then he complained of lump in his
neck and biopsy was taken and CT abdomen
revealed that the patient has primary kidney
cancer which is spread all over his body
The task was to break that news and to tell the
patient that he is for palliative treatment and the
role of specialist nurse.
I started by asking him if he wants some one to
attend with him and he said no body
Then i asked him what he knows about his
condition and he said everything about his
cardiac condition and he knows what the
cardiologist said
And he said that he has a lump and a biopsy
was taken and he wants to know the result
So i asked what do you think the cause and he
said am afraid of the worst so i told him am
afraid you are right and then i told him the result
if the biopsy and the CT
Then i kept silent and i let him speak and he
took his time then i said can you tell me what is
going in your mind and then he said he is
shocked so i show empathy and i gave him time
again then i asked him do you want me to
proceed
He said yes and then i told him about the
palliative treatment and i told him that we will
provide support to him and his family and he is
wondering how to tell his family so i offered to
him to bring them in the upcoming meeting and
i will tell them
Then he asked about how long he will live and
empathetically i said i don not know then i
proceed and told him about the specialist nurse
and i asked him again for more questions he
said he can not think now so i told him to write
every question come to his mind and we will
discuss in the upcoming meeting and then he
repeat the question again about how long tine
he has
And again i said i don not know and i explained
that no body can tell
Time finished and the surrogate while he is
going out he told me verygood
I got 14/16
The discussion was about why you did not
specify time
the examiner wants me to tell the patient that he
has months to live so as to prepare his living
will
And then she asked me about the ethical issues
I said breaking bad news
And beneficence vs malfecience
Both examiners were happy
And the. She asked what websites you want him
to search on and what you don not want to
search
I told her that i don not want him to search for
hope while there is no and treatment will harm
him more and his functional level already
impaired
By the cardiac problem
And during my discussion with the patient i
advised him to go to support group and that is
why she asked about the benefits if the support
group so o told her the benefits are for the
patient and his carers
I finished the exam with score 148/172
Sorry i forgot also i told him about the role of
the specialist nurse and how she will help him
and his family
UK Exam Experience ,,,wirral university

teaching hospital
May 2017
St_1
chest ,,,,COPD
Abdomen ,,,Liver + kidney Transplant
with left hypochondrial mass
St_2
History
abnormal creepy sensation since 4 month
DD. RESTLESSLEG SYNDROME
hypocalcemia
neuropathy
St_3
cadio..... can NOT diagnosed
I am NOT sure
Neuro,,,,spastic paraparesis=MS
St_4
COMM
acase of open TB
start on ttt 1 week back
specialist nurse informed that he hadnot pick up his
ttt
yr task :: manage concern & implications of the dis
St_5
1= frequent falls
come out due to frequent joint dislocation
it is Ehler Danlos synd
2=pins & needles
in hands
it was Raynauds phenom. with scleroderma
Thanks everyone here sharing cases . I benefit

much from this group.
Finally I passed in Malaysia , selayang
diet2017/01.
Station 1
Resp:right upper zone collapse consolidation
Ddx: mitotic, tb
Abdomen:
Hepatospleenomegaly , pallor
Ddx: myeloproliferative , lymphoproliferative
Station 2: recurrent chest infection , infertile , sx of
malabsorption underlying DM on insulin
Ddx: cystic fibrosis, chronic lung disease,
hypogammaglobulinamia
Station 3:
Cns : right 5,67,8,12 cranial n palsy, left 3,6 nerve
palsy, big occipital scar hidden underneath hair . No
pydramidal involvement
Ddx : cns lymphoma , NPC
Cvs: 2 big scar . Midline sternotomy scar , no harvest
vein , another big scar from below left nipple extend
till upset border left scapula( I x sure wat the scar for
n correlation with midline scar), metallic click with
first heart sound , TR murmur with raise JVP ,
bilateral pedal ordered ascites . Loud P2 ,AF
Communication skill:
Angry relative . Daughter of a old lady with
underlying advanced heart failure on digoxin .
Currently kinday failure . Digoxin accidentally serve
and pt developed Brady and died .
? Drug error causing death .. explain
Bcc1:
Stem : young lady with joint pain
Hx: typical SLE sx
Sign: RA type involvement joint deformity
Ddx SLE with jaccoub arthopathy , MCTD
Bcc2:
stem:heart murmur detected while applying job
Hx : udenerlying thyrotoxicosis treated , then
Recently postpartum having ? Toxic sx
Clinically euthyroid plus Psm loud at LSE
Ddx: thyrotoxicosis dilated cardiomyopathy , VSD
All the best to everyone !
I want to share them the success ; happiness; and the

the exam cases
St 1
Chest: young male clupped , changing crepts with
cough (cystic fibrosis )
Abd : middle aged female with RIF scar (kidney
transplant dt ADPKD)
ST 2
young female with weight gain 15 month post partum
hit of post partum hemorrhage (hashimoto ; post
partum thyroiditis ;Sheehan synd)
St3
Cardiology
Middle aged male with AR and MR
Neuro
Young male with cereballar signs PC
Hypotonia in patchy distribution (MS)
ST 4 Communication
Young male with CRF
Break the bad news and explain the options of
mangement
St5
BCC1 young male with Neurofibromatosis with
Pheochromocytoma
BCC2 young male with weight loss and exophthalos
(grave's)
I passed with score of 156 out of 172
Thanks a lot
Exam Experiences(of my Dear Brother) -Kolkata

- India April 2017
St2 changle in bowel habbit for 6 months gp
prescribed mebeverine no improvement.
Analysis of complaint large volume diarrhea
500ml for 5 times(small intestine pathology) no
blood no slim no relation to food no
improvement after fasting awake him at night
with urge to move bowel vague abdminal pain
,wt loss not significant.
Pmh of joint surgery,
Travel history last year.
What is your dx?ibd
Your dd ibs , caeliac,tropical sprue,cancer,hiv .
Invs?basic,stool,antibodies screen,faecal
calprotectin,endoscopy ,cancer markers?
Which antibodies to order?iga,ttg,ema
St3
Cardio
Mid sternotomy scar ,harvest graft ,no metallic
,systolic murmur at apex.
Dx MR,PHT
Invs,ttt
Neurology examine cranial nerves
Right Homonymous Hemianopia
Causes?leasion beyond chiasma tract
,radiation,occipital lobe,pisterior cerebral artery
occlusion,internal capsule.
Causes?invs?
St4 SAH on warfarin inr 4 with large onfarcts
specialist see no benefit from surgery talk to wife
BBN?
Qs what percentage can recover?why not ask about
organ donation?
BCC1 female bilateral arm pain
My dd was muscular vs rheumatological vs vasculitis
Postove finding pain with exertion absent pulse no
systemic symptoms other criteria of takayasau
absent
First dd was takayasu
What is your dd?other vasculitis, GCA,PMR,FM
One onvestigation to order?angiography
BCC2 hematemsis
Positive data nsaids tds last week ,pmh of colitis and
on pentasa and moderate alcohol no finding no
organomegaly no persistent vomiting or liver
cirrhosus ridk or hepatitis
DD? PU vs Crohns VS MWS
Others varices ,malignancy
St1
Abdomen
Dark coloured patient with chevron scar no stigmata
of cld no spleen with normal span liver, maxillary
bossing ,no LNs, No ascites,
DD? Thalassemia major, HHC ,aih,psc,infiltration.
If this HHC what operation for this scar?
Hepatecomy,transplant
Chest
Patient with rheumatoid hand
COPD with bilateral basal crackles
Dx?OLD with ILD
Forget the rheumatoid what is other dx ? COPD
invs?
TTT?.
Muscat,Oman hoping my brothers will have a

benefit from my experience .
I started with station 4:
This lady diagnosed with SLE 3 days ago. And
her urine showed protein. Please explain to the
need for renal biopsy and manage her concern
I started with do u want anyone of ur family to
attend our meeting. She Saied no.
how much u know about ur health, surprisingly
she doesn’t know anything
so I explained to her
then unfortunately ur kidneys were affected and
in order to know to witch level ur kidneys
affected we need to do one more test wish is
renal biopsy. Then I explained to her renal
biopsy. and I draw for her the kidneys and how
we will do the procedure
her concern is it by general anesthesia . I said
no but with local and sometimes we might just
let u sleep but it is not general.
She asked me will it affect my university. I told
her we are here to help u, we will do our best ,
we need to involve MDT to give u a proper
management and if it so u will live a nearly
normal life but us should under regular follow
up
then she asked me will it affect me if I want to
get pregnancy. I told her it should be planned
whenever It is planned and under close monitor
, it will not affect u
Then I told her there is a consent she has to
sign
she asked me If she doesn’t like to do the
biopsy. Will it affect me.
I told her we do not know to witch extend ur
kidneys affected so we can not give u a proper
management.
Then she agreed and accepted to sign the
consent
examiner q :
do u think u convinced her.
I Saied yes
what is the ethical issues :
do u think renal biopsy is important for her.
I told absolutely, why , I answered the same
answer above
at what stage of lupus nephritis u think this lady
is :
I Saied wt least stage 3
What is the modalities of manager. He asked
about the drugs
I Saied im not sure but methotroxate is one of
drugs plus other immunosuppressant like
azathio.
did u answered her concern about pregnancy > I
Saied yes
then he told me did u speak about methotroxate
during pregnancy
I told him no but I have to
ok thank u
Station 5:
1.Young male with presented with diarrhea for
days after using antibiotics
for ur kind care :
when I entered the room 50 years male
I started with tell me about ur health
he said diarrhea now settled down . so what’s ur
problem now> he said this skin rash with hand
pain
I asked to see the rash It was not looks like
psoriasis . so I stunted show me ur hand. There
were in rt hand only
ulnar deviation at metacarbophalengial joint
the left hand is normal
then I analyzed the pain and he said morning
stiffness for more than one hour
I asked all CTD anakysis from hair till symptoms
of myathenai qravis
then I asked him to see his elbow no rash
his back no rash
then finally where else u suffered he told me in
my scalp
yes this is psoriasis although no typical rash
but I Saied this is psoriatic arthropathy
I explained to him . and asked him how this
affect his daily activity and job. He answered a
lot.
then I managed his concern and I will refer him
to multidisciplinary team including joint and
skin doctor and they will provide agood plan of
management for him
is it treatable. Unfortunately but controllable
2. this lady co difficulty in swallowing . for ur
kind care.
I thought I will find systemic sclerosis but when
I went to room I found no evidence of SS. But
she has peaked nose  strangely
I analyzed the symptoms which was toward
solid
no loss of weight , lymphadenopathy , sweating
nor alarm signs
I asked her to see her neck
the I found smaaaaaal goiter
then I started to analyze the thyroid symptoms
which was negative
social drug and past medical history non
significant.
I examined her thyroid and no retro sterna
extension
I asked her what is ur concern
she Saied what is going on with me
I explained to her every thing
is it treatable
I told her thankfully no alarm signs but we need
to exclude serious condition but from her
history no alarm symptoms
we need to do upper GI endoscopy
examiner q:
how u will investigate
how u will mange:
do u think this thyroid is the cause for her
symptoms
I Saied no that’s why we need to do upped GI
endoscopy
Clinical stations :they asked about whats ur DD,
investigation and how u will manage this
patient.
Station 1:
1. Abdomen:
Please examine this gentleman :
When I saw the patient he is a young male
I do not know if he is overpigmented or not but
he looks so
then I took inspection then after finishing
examination the examiner asked me to present
my findings
then I was shocked but I saied I will present
what I found
This is my pleasure to examine this gentleman
who is lying comfortable with an average build
the patient is not pale jaundices or cyanosed .he
has gum hypertrophy with good oral hyagine
there is no evidence of CLD
this gentleman has mild fine termer
this gentleman has mid laboratomy scan with
some drainage scars
he has hepato-splenomegally
liver span is 10 cm and spleen is 10 cm below
the costal margin
No evidence of ascites and there is no evidence
of lymphadenopathy
I would like to complete my examination by
doing DRE and examination for gentalia.
Examiner q :
What is ur diagnosis?
I said in the presence of gum hyperplasia and
mild fine termer , hepatosplenomegally and mid
laboratomy scan I will put liver transplant at the
top of my DD
although there is no evidence of CLD but I
cannot exclude CLD with portal hypertension
How do u this the cause of CLD in the man?
I saied alcohol , infective like hepatitis,
infiltrative and autoimmune like autoimmune
hepatitis, PBC and PSC
hemochromatosis.
How u will invewstigate this pt ?
I will start with baseline investigation in form of
CBC , urea and electrolyte.
LFT
autoimmune antibody and viral screening
Iron study and copper study
Then I will go for abdominal ultrasound and I
maight need liver biopsy
How u will manage this pt?
Non pharmacological and
pharmacological………
2. Chest: bronchiactasis with left lower
lobectomy
Station 2:
a 38 years old male presented with recurrent
chest infection since long time. All labs were
normal. for you kind care.
During analysis he has recurrent ear pain(Otitis
media) and sometimes loose motion. sometimes
he has burning in micturition.
He is smoker and alcohol consumer.
No other symptoms
I have to exclude HIV( sexual history) in a
sensitive way.
Social and family history
it affect his job and has recurrent absence from
work.
no significant drug history apart from recent
antibiotic usage
So examiner q:
what is ur dd
common variable immunodeficiency vs cystic
fibrosis vs HIV vs hypogamaglobulinemia
how u will investigate this gentleman:
baseline investigation in form of CBC
chemistry…….
xray
immunoglobulin
sputum for culture and sensitivity . for gram
staining and acid fast bacilli
Na sweat test
how u will manage this pt:
pharmacological and non pharmacological
last q : do u think this pt has CF> I said I ahave
to exclude but for me unlikely
so this gentleman diagnosed with CF> what do
u think. I said wrong diagnosis
Station 3:
CNS:
Neuro case :
Please examine this gentleman:
It is my pleasure to examine this gentleman who
is lying comfortable with an average build
by inspection there is no deformity , scars or
wasting
This gentleman has weakness in a pyramidal
distribution in witch flexar is weaker than
extensor, abductor is weaker than adductor and
distal is weaker than proximal.
The weakness is more in left lower limb than RT
There is loss of sensation up to amblicus to pin
prick (strange finding)
posterior column modalities of sensation in
form of joint position and vibration are intact
He has an evidence of cerebellar signs evident
by impairment of heel shin test
I would like to complete by examining the upper
limb, eye looking for nystagmus , gait looking
for wide ataxic gait
then the eaxaminer told me just forget about
sensiation.
What is ur diagnosis:
I told him this gentelman has cerebellar
syndrome
Whats ur DD?
I told him I couldn’t get ur Q
He said what are the causes of cerebellar
syndrome?
I said demylination like MS, degenerative and
dierty , infective, vascular like stroke,
inflammatory , neaoplasm, vit b12 dif and
hypothyroidism.
Whisch cause can be reversible after
treatment?(I thought he mean reversible
completely)
I said Iam not sure
How u will investigate this pt :
MRI of spinal cord and posterior fossa
CSF analysis, VEP
Vit b12 level, THT
How u will manage this pt? Pharmacological
and non-pharmacological
Cardio: Double valve replacement
Wish you all the very best of luck
UK exam exerience, Hull (18 March, 2017).

..I started with station 5, my first case was an
old lady with a skin rash. As soon as I set my
eyes on her, I quickly figured out that she had
extensive scaly maculopapular rash affecting
her head, face and trunk. Hx>>>Long standing
for almost 20 years, Worse on exposure to
sunlight, no itching or pain, now getting worse,
drinks alcohol. I examined her elbows and back
of the years as well as examined for
arthropathy. Viva questions were about
diagnosis, differential diagnosis and
management. I got 15/28 😳 Next ST5 second
case was a lady in her fifties who had elevated
ALT on routine examination and had some
painful periods. Nothing else of note. No
findings on examination. Questions were about
diagnosis, differential and management. I told
them that it's most likely Non-alcoholic fatty
liver disease, other differentials were alcoholic
liver disease but I told the examiner that in that
case, I expect AST to be higher than ALT as well
as high GGT. Other differential I said could be
autoimmune hepatitis. She asked what
investigations....? ASMA....I got 14/28 😳 😳
😳 Next I went for respiratory st. An old man,
actually there were no significant findings on
auscultation. But thanks to Dr. Magdy, I was
thorough in clinical examination, therefore I
missed the diagnosis but still got 9/20. It was
COPD but don't know how, (perhaps in exam
pressure) I said Interstitial lung disease. My viva
was about causes and managment of ILD. Next I
went to Abdomen. Patient had gum
hypertrophy, Tremors, PD catheter mark and as
scar in Rt. iliac fossa with a nontender
underlying mass. My diagnosis was a kidney
transplant. Viva questions were about what
modality of dialysis was he on, I said PD. Then
what meds he could be taking, I said
Cyclosporin because he has tremors and gum
hypertrophy. He asked are these side effects
only because of cyclosporin. I said they are a
common side effects of any calcineurin
inhibitors. Then, he asked me if this pt came
with fever and abdominal pain, what could be
the possibilities? I said Infections., UTI etc etc.
He asked me could he be rejecting? I said yes,
but in that case the graft will be tender. How will
you investigate rejection? again, thanks to Dr.
Magdy, I said blood works, including routine
CBC, renal profile etc, special such as
cyclosporine levels and imaging Renal US and
possibly a kidney Bx...I got 19/20 Next was
History, a man in his 40s, on multiple meds, had
A.Fib on warfarin and a number of other meds
including simvastatin, IHD, c/o difficulty
walking. Initially I thought, it was ?Stroke, but
he had difficulty climbing up stairs as well as
coming down, generalized body pains,
shoulders, legs etc. I thought of Polymyalgia
rheumatica but his age was against it. I thought
of proximal myopathy, Cushings,
hypothyroidism but no features to suggest
them. I could not tell a unifying diagnosis, and
forgot to stop his statin. But I told the examiner
that he needs physio, stop statin and
investigate for the above causes. I got 10/20
☺️ Next I had neuro: Again messed up. A
freightening case, a lady sitting in a wheelchair
with short hands and lax skin, having right
sided weakness of all muscle groups and
depressed reflexes but no sensory affection. I
said MND 😔 But when he asked me what's
against MND, I said unilateral signs. He said
where is the lesion, by that time I had realized
what mistake I had made. I said cervical
spine...Examiner was looking at me, then he
asked me if I had seen the back of the neck, I
said no. He asked me to do so. AND......
There was a scar at the back of the neck..... 😔
😔Got 10/20 Next cardio, Here I would advise
candidates who think in UK, an old white man
>>>thnink of aortic valve, young female
>>>mitral ....THIS CONCEPT IS WRONG and
Decieving....It was an old white male, but his
first heart sound was metallic with central
sternotomy scan. No murmurs. Thanks to Dr.
Magdy for giving us an excellent opportunity of
cardiology practice. Exam questions were:
Diagnosis, MVR. Valve functioning well? Yes,
management, anticoagulation. Indications? Got
19/20 Last, I had ST4. Task was to talk to the
son of a patient who was started on Amiodarone
for V. Tach and now admitted with pulmonary
fibosis. He was insisting why it was started if it
could harm him. I showed empathy, told him
that I can completely understand his feelings,
and he is feeling so because of his love and
care for his father. Let me tell you that when the
drug was started, it was given to him in his best
interest as the other alternates are not as
effective as this drug is. He said my GP never
informed us of the S/E. I said I was not part of
the team when it was started, so don't know
exactly what happened. Will look at the charts
and get back to you. Let's look forward now and
see how we can help your father. I asked his
whether his father's bedroom is on ground floor
or he has to climb up the stairs, who lives with
him, how he used to manage his activities of
daily living prior to admission, and offered him
all the social support. I got 16/16 My overall
score was 112.
Didn't pass this time and I think my actual
problem was station 5.
my pleasure to share my experience in

up
sign
management.
consent
examiner q :
I Saied yes
answer above
is :
about the drugs
azathio.
Saied yes
during pregnancy
ok thank u
Station 5:
for ur kind care :
pain
of myathenai qravis
his back no rash
my scalp
lot.
management for him
kind care.
solid
nor alarm signs
which was negative
significant.
extension
is it treatable
examiner q:
how u will mange:
symptoms
endoscopy
patient.
Station 1:
1. Abdomen:
he looks so
my findings
what I found
some drainage scars
the costal margin
of lymphadenopathy
Examiner q :
top of my DD
hemochromatosis.
LFT
lobectomy
Station 2:
No other symptoms
sensitive way.
work.
antibiotic usage
So examiner q:
what is ur dd
chemistry…….
xray
immunoglobulin
Na sweat test
Station 3:
CNS:
Neuro case :
wasting
sensiation.
syndrome
Whats ur DD?
syndrome?
hypothyroidism.
completely)
I said Iam not sure
CSF analysis, VEP
Vit b12 level, THT
my experience in after passing the PACES exam

at MALTA center 1/2017, excuse me if little long
but just trying to benefit all my dear colleagues.
-
Starting by telling about the examiners all of
them are British and local examiners from Malta
really all of them are very supporting,
encouraging meaning that it was wonderfull
exam environment
- The sources in terms of books I used Ryder for
history and communication and station 5 But
take care books are only good guide ultimately
you have to have your own approach after
acquiring the experience
In the beginning I like to mention about those
people that are leaders from whom I got benefit.
I attended the first clinical course long time ago
with Prof Dr Abdulfattah Arafa. And Prof Dr
Magdy Mohamed Abbas as a team .
The second course with Prof Dr Ramadan Zaki
All od them are wonderful team in teaching
PACES very sincere and encouraging with
marvellous experience, doing the maximum
efforts for their colleagues.
. THERE are great people you can tell Angeles
that I didn't meet till the moment. from their
videos and publications and online Internet
activities were wonderful source and motivating
materials. Even it was free help reflecting how
much it was for the sake of humanity only ,
cuurently a number of them doing training
coursed Thanksa lot for all of them those great
people are profs Drs Sadek Al-Rokh Ahmed
Maher Eliwa Nashwa Aboamera Shiny Moon
The cases :
- Communication ; to discuss with the wife
whose husband is 45 years old gentleman who
suffered from headache and rapid deterioration
of the general condition within few hours (while
being at work) bought to the hospital and final
diagnosis is meningococcal meningitis ,GCS
ONLY 7 and the plan to shift him to ICU .
After the usual introduction almost she knew
nothing about his condition, I explained
everything about meningococcal meningitis
with the help of a paper to draw something
about the brain and surrounding meninges,
I explained about the expected outcomes
considering the GCS ONLY 7 and the plan to
shift him to ICU and the prognosis is guarded,
Of course contact tracing and related issues.
She was to much concerned about her heath
and her son are there any risk they might got
the infection. I explained about infection control
department in contact tracing and MDT, offered
all forms of support.
Finally I asked if there is anybody to drop her
home
-She was understanding appreciatiating
everything. I got 16/16
-
- BCC1: Elderly PT with Ankylosing spondylitis.
Has low back pain. With history of treated
breast Ca. Chrons dis. Multiple abd scars. DD.
1_Active AS for optimisation of treatment
2_recurrence of breast Ca with metastases 3-
osteoporotic frature, what are the
investigations. I got 28/28
- BCC2; YOUNG LADY known to have bronchial
asthma has worsening cough for the last three
months. Examining her she has expiratory
wheeze otherwise normal concern again about
the cause DD Exacerbation of bronchial asthma.
When I mentioned people as she is using oops
the examiners didnot agree (no tachycardia or
leg swelling) I think I missed asthma mimics as I
went deeply in thinking Unnecessarily I got
19/28
-
-Station 1 Chest
:bilateral basal pulmonary fibrosis. Discussion
about the causes and investigations and
management. I answered all only forget to
mention drug induced among the causes.
Scored 19/20.
Excuse me all , So sorry I will comlete later
because of time constraints,
Many thanks and all the best.
MALTA Center 1/2017
Communication ; to discuss with the wife whose
husband is 45 years old gentleman who
suffered from headache and rapid deterioration
of the general condition within few hours (while
being at work) bought to the hospital and final
diagnosis is meningococcal meningitis ,GCS
ONLY 7 and the plan to shift him to ICU .
After the usual introduction almost she knew
nothing about his condition, I explained
everything about meningococcal meningitis
with the help of a paper to draw something
about the brain and surrounding meninges,
I explained about the expected outcomes
considering the GCS ONLY 7 and the plan to
shift him to ICU and the prognosis is guarded,
She was to much concerned about her heath
and her son are there any risk they might got
the infection. I explained about infection control
department in contact tracing and MDT, offered
all forms of support.
Finally I asked if there is anybody to drop her
home
-She was understanding appreciatiating
everything. I got 16/16
-
- BCC1: Elderly PT with Ankylosing spondylitis.
Has low back pain. With history of treated
breast Ca. Chrons dis. Multiple abd scars. DD.
1_Active AS for optimisation of treatment
2_recurrence of breast Ca with metastases 3-
osteoporotic frature, what are the
months. Examining her she has expiratory
wheeze otherwise normal concern again about
the cause DD Exacerbation of bronchial asthma.
When I mentioned people as she is using oops
the examiners didnot agree (no tachycardia or
leg swelling) I think I missed asthma mimics as I
went deeply in thinking Unnecessarily I got
19/28
-
-Station 1 Chest
:bilateral basal pulmonary fibrosis. Discussion
about the causes and investigations and
management. I answered all only forget to
mention drug induced among the causes.
Scored 19/20.
NEUROLOGY ;SPASTIC PARAPLEGIA
WITHOUT SENSORY LEVEL, discussion as
usual around DD, investigations (20/20)
Cardiology; an adult pt, with PSM over the apex
mostly MR ,discussion around DD,
investigations,echo FINIDING (15/20)
Abdomen ; left hypochondrial mass for DD
mostly spleen , DD, plan, no features of CLD ,no
lymphadenopathy , no facial plethora, 12/20,
WAITING FOR THE FEEDBACK TO SEE WHY
THIS MARK
HISTORY; adult pt. with migraine developed
sever headache (7/10) at the occipital area with
gait unsteadiness since three days ,
unsteadiness improving partially ,no wakness ,
no sensory abnormality, no visual problem, no
fits, I did not ask about vertigo , NO FEVER , NO
NECK STIFFNESS
DD I mentioned storke , SAH (THAT THE
EXAMINERS DID NOT LIKE) WORSENING OF
MIRAINE
.DISCUSSION ABOUT workup , why not
meningitis , I got 14/20
FINALLY PASS 143/172
Wishing all the best for all of you, the exam
needs reasonable preparation, good practice
Malta centr 2 April 2017

Started with abdomen
Left hypochondrial mass said spleen
Pneumonectomy straightforward.
S2
Young gentleman 24 year while running a marathoon
(after 8 klm) lost consciousness with jerking , brief
concerned is it epilepsy.
PHx similar episodes but no loss of consciousness.
No DM NO epilepsy or other illness no trauma .
Drug Hx
eczema on antihistamine the examiner said it was
significant and i should have taken more details ' I
think they wanted you to think about prolonged QT .
FHx adopted
Social negative
Concern is it epilepsy .
S3 Don't know other candidate said aortic
regurgitation.
Examine lower limb upper motor findings in one leg
gait hemipligic with walking aid
S4
Speak to Mr ...son of mrs ....80 year old lady admitted
3 days with pneumonia and developed delerium task
explain mangement and answer concern.
Discussion about treatment and prognosis of delerium
.
S5
Repeated lady after back surgery came with pain and
fever
Discussion how to cover staph aureus .
...........
Other case
12 years post CABG presented with chest symptoms
and faint concern is it heart attack .
Discussion about beta blockers side effects
Sudan 2017
1.RT
1.Left.lower lobectomy
2.cystic fibrosis.
3.MVR. FLASID PP
4.Renal biopsy in SLE.
5.BCC1Peripheral neuropathy due to anti TB.
BBC2.Familial hypercholestrolemia
Exam experience in bradford royal infirmary on

27 march 2017.
BCC1:
lady comes with tiredness fatigue and sob, with
previous hx of some brain surgery
(hypophysectomy and she was on steroids,
levothyroxine and GH) hx looks like OSAS. It
didn't clicked to my mind that she is acromegaly
and OSAS is due to acromegaly itself. I gave
differential of hypothyroidism and cushing
being cause of her OSAS. Exam findings were
nil for anything :-( she repeatedly gave me
clue why she is sleepless and i kept on beating
about the bush, same as viva.
BCC2: RA with sob and GP mentioned nodules
in xray.
I couldn't find any abnormalities on chest
auscultation:-( and gave d/d if rhenatoid lung
and they asked about any d/d of pulmonary
nodules, i said neoplastic. Next qs about invx
and mx.
4:
Deal with annoyed son who is NIK and his
mother was admitted yesterday with acute
confusional state due to UTI and AKI (brought
by ex husband who claims to be taking care for
her) son seems to be away and less caring but
he was annoyed why his father (who left his
mother when she needed) is around and he
demanded that his father shouldn't be around
and why the son was not called by the hospital.
And he semanded that when she will be
discharged he doesn't want his father to be
around. (Being next of kin he demanded that he
has the right to decide about his mother) i
inquired about power of attorneyband advance
directive which son said he has no idea and
repeated that he is NIK.
Questions were about rights of next of kin.
and if son claims that his father is using mother
to get financial benefits and he is responsible
for her ill health then what should be your
stance. Will u ignore it, where to report it.(I had
no idea)
In case there is no legal report where you will
get guidance (i said hospital legal advisor,
examiner asked who else, i said ex husband. He
asked who else..then he told my by himself that
GP can be contacted)
then he asked if she gets improved then how
will u manage the issue. I said if she is proven
competent upon recovery then she should
decide (autonomy).
3:
Cvs:
lady with palpitations,,,
Midline sternotomy, audible click with 1st heart
sound. Pacemaker scar. I gave MVR and
functioning well. Other candidates told there
was ejection systolic murmur of aortic which i
didn't find:-(
Questions were typical.
Neuro : examine lower limb of lady who has
weakness.
Examination showed power 3/5 both lower
limbs. absent ankle jerks, downgoing plantars.
Stocking sensory loss of all modalities. I gave
d/d of peripheral sensorimotor neuropathy but
examiner was interested in spinal causes and
spinal level.
Asked me to give specific investigations only.
2:
40 Yrs lady with multiple visits with sob and
wheeze, smoker. GP found wheeze at
exanination. And no DVT Further hx
Cat at home. Hx of sob at cold exposure.
CONCERN : is it cardiac.
( No suggestions of cardiac). I gave dd of
asthma copd churg strauss etc. I am still
confused whether there was any trick in case.
1:
Abd:
male with night sweats.
HSM with no lymph nodes, gave dd of
lymphoproliferative and myeloprolifetive
disorders viva about invx and management.
Respiratory : subtle findings. I found wheeze,
examiner was interested in clubbing (though not
apparent, he wanted clear answer whether there
is clubbing or not. Viva about invx and
management.
Common scenario=Station 4
Young male with ulcerative colitis un controlled
with mesalazine
With inc diarrhea and weight loss
Council pt regarding steroid
Started with open questions
Then pt afraid. From steroid as he read about
side effects
Then I filled the gaps
Then every complication how we might mange
Involved the GP
Conserns
1) for how long you will use steroid
Ans
Until we control the disease the dec dose till we
reach remission with minimal dose
2) I want to use herbs 🌿
Ans
Sorry but I can't be sure what will be the effect
on 🌿 on the disease course or how it may
interact with steroid
If u choose to use herbs 🌿 plz inform ur GP
( DR.zain advice never say no to stupid thing pt
want to do just smile and give all options to him
and then till him ultimately you may hurt your
self)
Discussion
What is ethical issues
What are the complications of ulcerative colitis
1)anemia
Which type
All type
Norm normo (of chronic disease)
Megaloblastis ( fe + b12 malabsorption)
Iron deficiency ( due to blood loss)
2) colorectal Ca
This what he want to hear
3) what kind of diet you will give him
I tried to be smart ️ ️ ️ I will refers to
dietitian
Then agin what diet
I told him high fiber diet 😆 😆 😆
He asked me ru sure 😅 😅 😅
I said with smile of ignorance
Yes sure
I got 20/20
My exam experience in kolkata

st 4 pt non compliant to take steroid, kc
Addison. Husband pt of MS
St 5 (1)RA
LOC(2)
St (1)hepatosplenomegaly wth jaundice
ILD wth systemic sclerosis
St 2)return traveller bloody diarrhoea grandfather ca
colon dx at age 78, 2nd cousin having UC.
St 3 1)mixed mvd with af with hf, 2)spastic paraplegia
traumatic.
Exam experience of PACES=MALTA= 01.04.2017

I started with station 2 : 24yrs old lady c/o
fatigue and headaches found to have high BP
160/98 on different occasions. No family hx , no
complications.....examiners asked would you
start treatment...i said not now if secondary
causes r/o including white coat htn then yes.
Discussion about secondary causes of htn and
investigation.
Got 20/20
Station 3: cardio VSD/TR pansystolic murmur in
tricuspid area. Discussion about investigations and
management.
Got 16/20
Neuro; middle age with walker reflexes with re
inforcement rigid limbs throughout....planters
equivocal no cerebellar signs ...out of time could not
check sensory system....made dx of spastic
paraparesis....asked of causes got 11/20
Station 4: talk to the wife of 50years man known
MND recurrent admissions for pneumonia. This time
admitted with aspiration pneumonia not responding
to anti biotics and confused. Discuss with her his
management and condition. I explained to her that he
is in advance stage....and any invasive procedure like
intubation is futile. We will give him palliative
treatment only and keep him comfortable. Examiner
told that i did not told about NIV when the wife
asked. Got 15/16
Station 5: first case young lady with joint pain...i was
happy will be from common causes. When i entered
took hx all joints pain including hand joints.
Surrogate told she was told by GP that she has double
joints. I was more confused...asked what u mean
double joint she said i dont know gp told me that and
he was not sure.i examined no sign of inflammation.
Raised skin dorsum of hand elastic . Checked
functions. Found high arched palate. Joints
hyperextensible.arm lenght normal. Gave diff of
marfans pseudoxanthoma elasticum forgot to tell
ehlers danlos syndrome. Examiner asked were there
marfanoid features i said no. I wanted to examine
chest they stopped me asked what u want to see i said
AR....they said normal. Asked how you investigate
joints in general...started with inflam marker RA
factor ACCP...time finished got 28/28
2nd cast st.5: believe me i totally forgot....got 23/28
Station 1: abdomen; lady in 50 has pruritis and abd
pain.....i neglected pruritis....no signs of CLD or
immuno suppression...distended abdomen tender all
over mid line laprotomy scar below umbilicus.
Shifting dullness+ could not appreciate any
organomegaly or mass due to tenderness. Differential
...causes of ascites asked about causes of transudative
ascitic fluid....got 8/20
Respiratory: c/o of Sob pneumonoctomy scar left side
trachea deviated to left no breath sounds left
......asked about investigation ....told so many still
asking was happy when told sputum analysis and c/s
and AFB ....infection as cause of Sob
Got 20/20
Wish success for all you going for PACES......my
advice is to perform during exam in relaxed way,
smile and forget about any station where you did not
perform well.
Oman 9/4/2017
Day 4 Cycle 2
My case a lady of 35 years old present
complaining of fatigue and weight gain 3 Kh in
the last 6 months , she gave history of typical
hypothyroidism
I ask about other hypos no other symptoms
apart from amenorrhea ( hypogonadism ) .
She had family history of thyroid problem ( her
mother )and her any is using regular vitamin
injection but she is not sure what is it .
Her last delivery about
18 months ago and was eventful, she had been
transfused much amount of blood , but against
Sheehan's syndrome she is lactating for more
than one year.
No PMH and not on any medications.
Examiner question what is your DD :
Postpartum thyroditis ( he ask why you think
about it ) I told him because her symptoms
started after delivery )
Autoimmune poly glandular syndrome (family
history of endocrine disease)
Sheehan's syndrome .( against it no symptoms
suggesting hypoadrenalism and she is lactating
for one year .
Other questions :
Investigations and treatment.
At the end he asked about Addison disease
How do will treat patient with Addison disease ?
I stared if he came in emergency I will stared
with IV fluid normal saline
Before I answer hydrocortisone bell rang
Station 3
*Cardiology*
Examine this patient and present your findings .
First and second heart sound are metallic clic
MVR + AVR
Questions:
Investigations
Echo , What is single blood test you want to do
(*He want INR*)
Other question can you prescribe for him new
oral anticoagulant ? I told him up to date it's not
license in patient with metallic valve
(*Neurology*)
Strange case :
Young patient with lower limbs weakness.
On examination LMN weakness (proximal
myopathy)+ loss of vibration sense with intact
joint position in the left side ).
Most probably the patient had Becker ( I could
not match the things together )
I told him proximal myopathy for DD but against
that the loss of vibration sense in the left side
He ask me forget about vibration sense , what
could be the cause of his weakness ? How are
you going to investigate him
Bell rang
*Station 4*
29 years old Omani male he is complianing of
fatigue and dizziness for the last 6 months ,
today he had been call by his GP because he
has abnormal renal function , your role to
explain to him his condition.
BP : 160/105
K : 5.2
High creatinine
High Urea .
High creatinine .
During discussion he told me I have cut wound
in my hand 5 years before could it be related ?
My BP was high since that time and the Dr.at
that time did not bother him self .
What is final treatment ?
I explain to him what chronic renal failure , what
is complications and what are option of
treatment including renal replacement therapy (
dialysis).
*Examiners Questions*:
You mention to this gentleman that you want to
admit him , why ? During the discussion the
patient mentioned that he has shortness of
breathing , consequently I told him you might
need dialysis after I full examined you and doing
CXR ( fluid overload ).
As he is lower what mode of dialysis you will
over him ? I told him haemodialysis is better (
less chance of complications).
Then he asked me what is problem of high
serum K ? Do you think 5.2 need dialysis?
*Station 5*
*BCC 1*
35 years old male complaining of attacks of
headache, sweating and palpitations .
When I went inside I'm asking about course,
onset and duration of symptoms.
I asked also about aggravating and decreasing
factors (none)
Loss of weight , fever night sweating , analysis
of headache , analysis of palpitations
Mean while am asking I told the surrogate I will
examine the patient meanwhile I will ask some
questions
It was clear neurofibromatosis
After that I ask about PMH , family history ( he
had family history of similar condition).
Medications history .
I ask about the concerns. She ask me what the
is cause for his problem ?
How he can be treated ?
How skin lesions be treated ?
I ask I want to examine BP , they told me no
need
I examine the back of the patient looking for
cafe auilt spots
Auscultation of heart sound .
Bell rang.
Examiner Questions:
What is your diagnosis?
DD
Management.
Time finished .
*BCC2*
38 years old male with history of loss of weight
and fatigue .
Hyperthyroidism
Graves' disease.
Dear all,
Thank you so much for sharing your knowledge.
I finally passed paces!
First attempt at Bangalore India 2017/1
Cvs
Very loud MR with displaced apex and thrill.
Otherwise not in failure. But also noted ar and tr.
Collapsing pulse
Asked about how to ascertain cause of mr- echo and
angiography
Respi
Left pleural effusion
Asked about lights criteria
History
Young woman overtly hypothyroid post partum. No
other features of hypopituitarism. History of pph with
massive transfusion. Still able to breastfeed. Ddx
Sheehan , postpartum thyroiditis
Neuro
Old CVA with left hemiparesis, left umn facial nerve
palsy
Asked about mx for acute and chronic stroke ie rehab
Abdo
Cld, cachexia with ascites
Asked about peritoneal tap
Communication
Elderly lady with obstructive jaundice suspecting ca.
All investigations negative. To convey the uncertainty.
BBN. Advise next step. Concern is what if daughter
wants to keep the news from mother.
Bcc1 ank spon patient on biologics got fever and
cough. Clinically no signs of ank spon or pneumonia.
Bcc 2 chronic headache ? Due to sinusitis. No red flag
sign
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.
1. Respiration: Young short lady, with SOB.
Patient could not 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.
2. Abdomen: Obese man, round face, and
abdominal striae; 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.
3.History: Middle aged man with SOB and leg
swelling and 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.
4. Nervous system: Middle aged lady lying down
with her 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).
5. CVS : Middle aged man, with midline
sternotomy scar. Dual 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.
6. Communication skills: Young man from
military was 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.
7. BCC1: The coordinator confused me with
other case. I lost 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.
8. BCC2: Young lady with hand deformity. She
had pain in 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.
Mohamed Khalid Albasha

‫الحمد هلل الذي بنعمته تتم الصالحات‬
‫من ال يشكر الناس ال يشكر هللا‬
‫ وواجب علي اشكر‬Ahmed Maher Eliwa... ‫علي اي حاجة عملها‬
‫فلك مني يا رائع كل الشكر والتقدير‬
‫انت سبب رئيسي في نجاحي بعد هللا و دعم اصدقائي‬
‫وقروبك سبب رئيسي في نجاحي‬
‫جزاك هللا خير ونفع بك‬
‫يا ريت لو في ايدي حاجة عشان اجازيك بيها‬
Mahade Hassan
By the Grace of Almighty Allah..Passed PACES..in
1st attempt
My gratitude to my sir.. Ahmed Maher Eliwa...
kuwait 1/5/2017
1st day 3rd cycle kuwait centre
Mobarak alkabeer hospital
started with station 5 bcc1 young lady c/o
difficult swallowing and wt loss goitre (signs of
hyperthyroidism)
bcc2 old lady c/o SOB with exertion it was
systemic sclerosis
station 1 abd. rt iliac scar with mass(renal

transplant)
resp. confused not sure about the case
station 2 40yrs lady c/o SOB and cough for

6months
positive thing in history contact with bird the
examiner want extrinsic allergic alviolitis,
station 3 cardio mitral valve replacement and

early diastolic murmur seem to be aortic
regurgitation
CNS flaccid paraparesis with normal sensation
I put differential of MND and I think examiner
want gullian barre
station 4 discuss about side effect of

amiodarone pt developed SOB CT confirmed
lung fibrosis
discuss with the daughter the finding and she

concerned about why the cardiologist not
mention this SE and also concerned about
other option if amiodarone stopped.
Actually the communication scenario was long I
didn't concentrate what is exact cardiac
problem for which the cardiologist start
amiodarone. ISaid to surrogate that her father
need admition with follow up with chest and
heart physician.
The examiner ask me again what is substitute
for amiodarone I answered with the same that
we need cardiologist and chest physician then
he asked me and what is your role 😕
some candidate said outside ICD
the indication mentioned in the scenario and I

miss it.
My advice that every one should read the
scenario well
paces exam experience at indian centre for

2017/01 diet.....
my second attempt. first attempt at 2016/03 diet
at golden jubilee glasgow in nov 2016. failed.
though scored 136....failed in physical signs
skill by 2 marks. desperately wants to finish
mrcp so applied for international centre in oct
2016 for 2017/01 diet. got indian centre for exam
in first week of april 2017. ..
started with station 3
Cardio: 60 year lady, left al thoracotomy scar
indicative of previous closed mitral valvotomy,
severe mitral restenosis, sinus rhythm, in
congestive cardiac failure, no evidence of ie or
thromboembolic manifestations...routine
standard questions...missed oral
anticoagulation in management .....got 18/20
Neuro:60 year lady...right lower motor neuron
facial palsy...passive...routine standard
questions.....got 19/20
station 4: 25 lady..working in .it sector....came
yesterday to er with cough
...fever..hemoptysis....left against medical
advice...now diagnosed with sputum positive
pulmonary tb showing multiple infiltrates in
bilateral lungs on chest x ray..called back to opd
today...discusss...explore and manage
concerns....went well ...got 14/16.
BCC1:50 year gentle man...bilateral joint
pains......diagnosed to have...psoriasis...skin
changes...hand changes...nail
changes....checked spine movement....on
methotrexate since 2 years... so examined
hands...checked for anemia...oral
ulcers..auscultated bilateral lung
bases...palpated abdomen for
liver..then...standard routine questions.....got
27/28
BCC2;27 year man...acute onset of chest pain
and sob since morning....explored....known
lupus on steroids since 1 year...had knee joint
injury 6 weeks back...cast removed
recently...examined...eyes..oral
cavity..hands..pulse...complete respiratory
system...neck vein...auscultated heart
sounds..checked knees...legs...given
differential.. as...pulmonary
thromboembolism.....sle pleuritis....atypical
pneumonia....and management
accordingly.....got 27/28..
Resp: 70 year man....median sternotomy
scar..left posterolatral and anterolateral
thoracotomy scars, bilateral leg vein harvesting
scars....decreased movements on left
hemithorax...trachea deviated to left...dull ness
left bases...bronchial breath in apical area.....so
my diagnosis...post cabg...post left lobectomy
or left pneumonectomy....then standard
questioning and answers...got 18/20..
Abdomen: 50 year man....functioning right
radiocephalic fistula....grossly anemic...bilateral
pitting pedal edema...distended neck
veins....bilateral ballotable kidneys,....palpable
hepatomegaly....ascites....my
diagnosis....APKD...with anemia...with fluid
overload...with multiple cystic liver...with
functioning fistula....standard questionnaire and
answering.....got 20/20....
History: 30 year lady....fever...abdominal
pain...bloody diarrhoea...since 1 week ..after
returning from a trip from kenya..gone well...got
19/20.
finally got ..162/172...goodscore and pass ..
my experience:
1. focus...focus...focus...last one week...more on
physical examination...should be thoroughly
rehearsed....rest ...we have time in
examination...we can get back to them even if
miss....but physical examination....should be
flawless...and is in our hands..
2. never ever create physical signs that are not
there. we may miss physical signs that are
there...but never ever create physical signs that
are not there..if we do...sure shot of failure.
3. come exactly at the reporting time mentioned
on admission usually one hour before start of
actual exam..relieves lot of stress..
4. i have written just my initials rather than my
full name on answer sheets.
5. no verbal roughness with examiners or with
patients.
Edinburgh - centre =April 2017

Glan Clwyd Hospital in Rhyl – Wales
1.a) Abdo- multiple abdominal scars which

looked like renal transplant scars but no kidney
underneath palpable. AV fistula which was
buzzing and looked like had been recently
needled. Could feel a retro peritoneal mass- said
it might be a polycystic kidney. Also had
parathyroidectomy scar. Was asked for Mx. Said
U&E , Doppler US of abdomen. Then bell rang. I
thought this station was a disaster and would
fail. 16/20
1 b) Resp- 65 yr old man reading newspaper.
Only finding was some crackles R>L and
perhaps a dull left lung base. My DD's were ILD,
Bronchiectasis and pleural effusion. Said would
start with CXR then HRCT. Examiner directed
discussion towards dull lung base. Reasons,
lights criteria and cut of of pH for empyema.
Thought I had failed this as well as was not sure
about the dull lung base and this obviously was
the diagnosis. 18/20
3 a) Neuro. Elderly lady in wheelchair. Examine
LL. Asked if I could see her walk. Examiner said
not needed. B/L increased tone L>R, B/L
Proximal weakness in pyramidal distribution.
Knee jerk increased. Ankles N. plantars
equivocal, coordination N. Sensation N. asked
to check coordination in upper limb as pt was
having problems lifting legs. Examiner said its
LL examination. Anyway when i was presenting
my findings he started asking me questions
about reasons for cerebelar dysfunction. Did
not give me chance to give my diagnosis which
most likely was spastic paraparesis. Was not
sure how i had done. Got 13/20
3.b) metallic MVR with AF. Pt tachycardic. Was
expecting atleast 18/20. Questions- if this pt
came With SOB- what would your dd's be. Got
14/20
2. Hx. 30 yr old female with palpitations.
Recently had a baby. Fx hx of some auto
immune condition. Dx- post partum thyroiditis.
Was expecting 20/20. Got 16/20
4) communication skills: elderly lady with end
stage heart failure and new renal failure who
has just died. While going through notes you
notice that she was earlier on digoxin which
was stopped due to renal failure and new
bradycardia. However this was inadvertently
started by the on call team. Tell this to pts
daughter. I told her what had happened.
Apologised for mistake. Told her would do
incident report and RCA. Try to ensure this
doesn't happen again. She asked if the digoxin
could have killed her mother. I told her that this
might have been the immediate cause although
her heart was already in a bad way. Told her
would inform coroner about this. Key point -
apologise, be honest about drug error possibly
being the cause of death. Got 14/16
5 a) 60 yr man with weakness and pain in L hand
. Worried if it could be TIA. I did not have a clue
till I started examining. By fluke, I felt pulse in
both hands and noted absent radial pulse in L
hand. Went up and absent brachial as well. Told
DD as Takayasu's and examiner frowned and
asked what else. Said subclavian steal
syndrome and he gave me the thumbs up. 28/28
5 b) Gp referral for pt with dizziness. BP 130/80.
Hx of diet controlled diabetes. On asking pt
gives hx of postural hypotension. And if you ask
about standing BP , examiner tells you its 90/60.
If you check medications, then on 4 anti
hypertensives. Acei, bisoprolol, alpha blocker
and calcium channel blocker as well. So told pt
will stop both alpha and calcium channel
blocker as pt also had ankle swelling. 28/28
Thank you so much for sharing your knowledge.

I finally passed paces!
First attempt at Bangalore India 2017/1
Cvs
Very loud MR with displaced apex and thrill.
Otherwise not in failure. But also noted ar and tr.
Collapsing pulse
Asked about how to ascertain cause of mr- echo and
angiography
Respi
Left pleural effusion
Asked about lights criteria
History
Young woman overtly hypothyroid post partum. No
other features of hypopituitarism. History of pph with
massive transfusion. Still able to breastfeed. Ddx
Sheehan , postpartum thyroiditis
Neuro
Old CVA with left hemiparesis, left umn facial nerve
palsy
Asked about mx for acute and chronic stroke ie rehab
Abdo
Cld, cachexia with ascites
Asked about peritoneal tap
Communication
Elderly lady with obstructive jaundice suspecting ca.
All investigations negative. To convey the uncertainty.
BBN. Advise next step. Concern is what if daughter
wants to keep the news from mother.
Bcc1 ank spon patient on biologics got fever and
cough. Clinically no signs of ank spon or pneumonia.
Bcc 2 chronic headache ? Due to sinusitis. No red flag
sign
Hi all,I would like to share my station

Day 5 round 2 Yangon
Station 1
Resp - Rt.sided pleural effusion with Lt crepts
and rhonchi
Abd- Hepatosplenomegaly (Thalassaemia)
Station 2
20yrs old lady with hypertension
GP did urine dipstick show proteinuria and
haematuria. Pt also c/o fatigue for 6mths and fever
for 3weeks ago.
Station 3
CNS- MND
CVS- MVR with vulvotomy scar
Station 4
Talk with granddaughter about 89yrs old rt. sided
weakness. PMH - TIA and AF with wafarin ,fail to
follow up at wafarin clinic ,
INR 1.2,CT - infarct stroke and no bleed
Task - explain about CT result and refer to stroke
unit
Station 5
BCC1 - H&M due to NSAID and prednisolone
overdose with low back pain and ankylosing
spondylitis
BCC2 - Peripheral neuropathy with DM and also
taking anti -TB and diet -vegetatrian
My one and only PACES experience

Alhamdulillah .
Appeared from Glasgow College.
STATION 2: (Both examiners British)
40-year-old female, presented with complaint of
fatigue, Hb 8 and MCV 70. She also has
complaint of mild ankle edema. Her father had
colon cancer. Abdominal examination was
normal.
Both the examiners were smiling and seemed
nice when I went inside which boosted my
confidence a bit since it was my first station. .
When I started with history, the patient told me
about this fatigue which she had from the last 3
months. Along with that she said she had
complaint of palpitations and shortness of
breath. She was a fitness instructor. She said
she had no other complaints. I went on with my
questioning. When I asked her about her bowel
works, she said “more or less my bowel habits
are okay”. I then specifically asked if she had
any diarrhea or constipation? She said she had
complaint of diarrhea and bloating from the last
9 years!!!!!!! Next I asked her if she felt it was
associated with any specific kind of food, and
she said yes to that. She had injured her back
and was taking Diclofenac off and on for it.
Her concerns:
1. Do I have colon cancer like my Dad?
2. Can this be due to the peppermint
supplement that I am taking? (I said I am not
sure what you are taking but I can look it up and
get back to you with the information)
3. Why the mild ankle swelling? (I replied that it
might be due to the Diclofenac that you are
taking as it can cause fluid retention but we will
get the necessary tests done today and
hopefully find out)
My Diagnosis: Coeliac Disease
Examiner Questions:
DD? Diagnosis of Coeliac disease? Why not
colon cancer? (I said that I had inquired about
all the alarm symptoms which were negative).
They seemed happy, one of the examiners even
said “Well done”
Score: 15/20
STATION 3: (Both examiners British)
CVS - “Please examine the cardiovascular
system of this patient”
Elderly female with mid-sternotomy scar. No
harvesting scar and no clicks audible. I could
appreciate and ejection systolic murmur which
radiated to the carotids.
My Diagnosis: AVR with bi-prosthetic valve/
AVR with CABG with internal mammary graft
(Examiner said fair enough)
Examiner Questions:
Please tell me ONLY your positive findings?
Why ejection systolic murmur still there after
AVR? (I said that the murmur does sometimes
pre-exist despite of valve replacement)
Criteria for diagnosis of AS?
Criteria for Aortic valve replacement?
If patient has bi-prosthetic valve, how will you
manage further?
Score: 18/20
CNS - “This patient had difficulty in walking.
Please examine”
As soon as I introduced my self to the patient
who was an elderly male, I asked him to walk. I
expected him to have difficulty doing that, but
her was up and running in a second. No
problem at all. I actually asked him to walk twice
. On inspection there was a slight twitch in just
his right foot, which I initially could not
interpret. It seemed more like voluntary
movement!
No other abnormality in lower limbs. Anyway, I
was always advised by seniors to proceed
methodically and to stick to my scheme, which I
did. Examined the power, tone, reflexes,
planters and even sensation in the lower limb
(NOTHING). I was lost. Just then the examiner
said, “one-minute left”. I resigned to the fact
that I had totally lost this case… Then out of
nowhere a thought occurred to me that the case
was Parkinsonism. I immediately asked him to
sit facing me and asked him to close his eyes
and there it was “blepharoclonus”. Then I
immediately checked the tone of his limbs first
without and then with synkinesis. Then time
was up
My Diagnosis:
Idiopathic Parkinsonism
Examiner Questions:
Diagnosis?
Differential diagnosis of tremors? Types of
tremors? Why not cerebellar? (I said gait was
fine and no ataxia)
Drugs causing parkinsonism?
How would you help this patient besides
medical management? (I said physiotherapist,
occupational therapist)
If he has a problem opening jars, who would
you said him to? Occupational or
Physiotherapist? Choose one? (I said
occupational. Examiner seemed happy)
Score: 19/20
STATION 4: (Both examiners were Asian)
You have to talk to Mr. Glass who is the son of
Mrs. Glass. She was admitted in the ward 3 days
back with community acquired pneumonia and
was being treated with IV antibiotics. No other
medication is being given to her. Today, she has
gone into a state of delirium, and is abusing the
nurses in the ward. She did not get her self
checked by you when you went to see her
today. She is refusing to take any medications
and is not eating anything thinking that the staff
is going to poison her. Your task is to talk to her
son and explain the delirium and further
management plan.
After reading that scenario, I though definitely
this is going down. Anyway, I went in and
started talking to the patient’s son. Explained
that his mother was in delirium, cause of which
might be the recent illness which she is going
through. Elderly people do sometimes behave
this way.
Concerns:
1. What is the cause? (I said it can be just due to
the illness, or something else like salt
imbalance in the body)
2. Can she go home? (I said it would be best if
she stayed at the hospital till she is all well as
her health is our first priority)
3. Is this Alzheimer’s Dementia?
Well……. Guess what? I was done with the
scenario, the son seemed very satisfied. I asked
him twice if he had any more concerns or any
thoughts? He said, no doctor, I am happy that
she is being looked after well by you. and the
examiner told me I had 4 more minutes!!!!!!! We
sat in silence!
I finished this scenario 4 minutes
early!!!!!!!!!!!!!!!
Examiner questions:
Explain briefly what the scenario was and how it
went?
What is delirium? Please explain to me in
layman terms as if I not am not a doctor?
What one test you would like to do? (I said
Serum Electrolytes. He was happy)
Will you put the patient to sleep? I said
definitely not, I will just give her something to
calm her down.
The patient is mentally incapable now, what will
be your plan regarding this patient? Will the son
decide? (I said, no, it is the doctor’s
responsibility to decide but it is very very
important to get the relatives on board)
How will you judge mental incapacity?
What ethical laws apply to this scenario? (I said
beneficence, and non maleficence. He smiled)
Score: 16/16
STATION 5 (The one I was most scared of!!!)
Both examiners were British
BCC 1:
This 66 year old female has presented with
complaint of swelling of fingers.
Went inside and it was a spot diagnosis of
Acromegaly.
Examiner questions:
Diagnosis? Investigations? Management?
Score:28/28
BCC 2:
This 50-year-old male presented with painful
and cold fingers.
My Diagnosis: Limited systemic sclerosis with
ILD.
On history there were all features positive of
CREST syndrome, in addition he had bilateral
velcro crackles. Again, it was a very obvious
diagnosis. Sclerodactyly, Teleangectasis,
Pinched nose, puckered mouth.
Examiner questions:
Diagnosis? Investigations? Management?
Score: 28/28
STATION 1 (One examiner was Asian and one
was British)
RESP: “This gentleman presented with
complaint of exertional breathlessness. Please
examine”
There was a nebulizer next to the patient’s bed
which I didn’t see till the end that too when the
examiner pointed out. He was breathless at
rest.
The patient appeared pink with bilateral ronchi
and left sided basal crepts which changed on
coughing.
My Diagnosis: COPD with Bronchiactasis
Examiner Questions:
Diagnosis? Investigations? Management of
COPD? Causes of Bronchiactasis?
Score: 19/20
GIT: “This gentleman has had multiple
admissions in the hospital in the past. Please
examine his abdomen”
The patient was all covered up, I thought that as
soon as he would remove his sheet there would
be multiple scars on it. But it was all clean. No
marks, no ascites. I saw nicotine staining on his
hands and just a single spider angioma on his
chest. Then on palpation of his abdomen I could
not feel anything massive. I told the examiner
hepatomegaly, because I felt it was very slightly
enlarged. I finished one minute early!!!!!
I forgot to auscultate the abdomen
My Diagnosis: CLD
Examiner questions:
Diagnosis? Differential? He had multiple
admissions for ascites. If he comes back with
massive ascites what would be your
management plan.
Score: 19/20
Total score:162/172
Alhamdulillah, I cannot thank Allah enough. I
have tried to write down my experience as
detailed as possible so that it can help
everyone. I did not attend at courses in UK. I
attended the two courses available in Lahore
where I live. I have been following this group
regularly and has been of immense help to
me. :). Thank you and Good Luck!
kochi
st 4- talk to son of the patient who is in rehab ward
c/o headache, no biopsy taken given steroid for GCA
.hallucination developes and shift to main hospital. Son
.is angry because she was shifted without telling him
st.2 - history - patient presents with fatigue - 6 months,
the IDA, menorrhagia, thyroid function is normal.
underlying IBS. Travelling history - 6 months ago. Wt
loss + 7kg. Family HO type1 DM in brother
st 5 - syncope in elderly women with DM. No DM
retino/ nephro/ neuropathy. palpitations + PR 50/ min.
.Inside - goitre. No hyper/hypothyroid symptoms
st 5- AS back pain for 12 years . Nocturnal pain,
.stiffness, progressive in nature
st 1 - bronchiectasis?? clubbing with crepts
Abd - splenomegaly
st 3- CVS- AVR
Neuro- Stroke
st Feb kochi 21
Station 1
Git -chronic of liver ds with portal htn decompensated
/ hemochromatosis is a possible dd as pt was
hyperpigmented
Resp -ILD with scleroderma

: Station 2
young female with IDA in the background of IBD. Clear
history of malabsorption .past history of travel to
lakshadweep ..No bleeding manifestation except
menorrhagia
...Could be coliac ds,tropical sprue i guess
Station 3
CVS:Elderly man with atypical chest pain
esm in aortic area / high volume pulse / collapsing/ bp
was normal /no wide pulse pressure ..not sure wat
exact diagnosis is...discussion of case was on As vs
aortic sclerosis
Cns -both upper limb bilateral lmn signs..severe

flaccidity wasting .Power was zero in both limbs .No
sensory signs with? fasicualtion(some flickering at
infraclavicualr area was there.).... Discussion was on
progressive muscular atrophy and muscle disorder like
..myotonic dystrophy
Station 4-angry relative -speak to son whose mother

developed steroid induced psychosis after starting
steroids for GCA
Station 5
Ankylosing spondylitis-
Dizziness - she had AS, had thyroid enlargement , -

orthostatic hypotension and possible drug induced
dizziness as she was on multiple drugs for htn
My exam experience in bradford royal infirmary on 27
march 2017
:BCC1
previous hx of some brain surgery (hypophysectomy
and she was on steroids, levothyroxine and GH) hx
looks like OSAS. It didn't clicked to my mind that she is
acromegaly and OSAS is due to acromegaly itself. I
gave differential of hypothyroidism and cushing being
cause of her OSAS. Exam findings were nil for anything
:-( she repeatedly gave me clue why she is sleepless
.and i kept on beating about the bush, same as viva
.BCC2: RA with sob and GP mentioned nodules in xray
auscultation:-( and gave d/d if rhenatoid lung and they
asked about any d/d of pulmonary nodules, i said
.neoplastic. Next qs about invx and mx
:4
Deal with annoyed son who is NIK and his mother was
admitted yesterday with acute confusional state due to
UTI and AKI (brought by ex husband who claims to be
taking care for her) son seems to be away and less
caring but he was annoyed why his father (who left his
mother when she needed) is around and he demanded
that his father shouldn't be around and why the son
was not called by the hospital. And he semanded that
when she will be discharged he doesn't want his father
to be around. (Being next of kin he demanded that he
has the right to decide about his mother) i inquired
about power of attorneyband advance directive which
.son said he has no idea and repeated that he is NIK
.Questions were about rights of next of kin
and if son claims that his father is using mother to get
financial benefits and he is responsible for her ill health
then what should be your stance. Will u ignore it,
)where to report it.(I had no idea
In case there is no legal report where you will get
guidance (i said hospital legal advisor, examiner asked
who else, i said ex husband. He asked who else..then
)he told my by himself that GP can be contacted
then he asked if she gets improved then how will u
manage the issue. I said if she is proven competent
.)upon recovery then she should decide (autonomy
:3
:Cvs
،،،lady with palpitations
Midline sternotomy, audible click with 1st heart sound.
Pacemaker scar. I gave MVR and functioning well.
Other candidates told there was ejection systolic
(-:murmur of aortic which i didn't find
.Questions were typical
.Neuro : examine lower limb of lady who has weakness
Examination showed power 3/5 both lower limbs.
.absent ankle jerks, downgoing plantars
Stocking sensory loss of all modalities. I gave d/d of
peripheral sensorimotor neuropathy but examiner was
.interested in spinal causes and spinal level
.Asked me to give specific investigations only
:2
Yrs lady with multiple visits with sob and wheeze, 40
smoker. GP found wheeze at exanination. And no DVT
Further hx
Cat at home. Hx of sob at cold exposure. CONCERN : is
.it cardiac
No suggestions of cardiac). I gave dd of asthma copd (
churg strauss etc. I am still confused whether there
.was any trick in case
:1
:Abd
.male with night sweats
lymphoproliferative and myeloprolifetive disorders
.viva about invx and management
Respiratory : subtle findings. I found wheeze, examiner
was interested in clubbing (though not apparent, he
wanted clear answer whether there is clubbing or not.
.Viva about invx and management
My exam experience in chennai today 3/4/17

Station 2
History taking of cough and shortness of breath for 6
months. She has fever on and off but no night sweating
weight loss of 6 kg within 6
Months. No wheezing she works in printing company
and her colleagues have also cough which she is
thinking due to printing materials they use all
cardiovascular history is negative. No history of TB
contact no HIV risk factors. she receive many
.antibiotics without improvement
I put differential of TB and lymphoma and asthma.
During childhood she has asthma which improved. Not
smoker or drinker. But unfortunately the diagnosis was
.extrinsic allergies alveolitis. I miss birds at home
Station 3
.Mitral stenosis with AF it was clear
Neuro
Is parkinson plus CVA. Rigidity only on distraction so I
put parkinsonism plus CVA reflexes was exaggerated
.on the right upper limb only no tremor
Stations 4
.Easy case explain renal biopsy for SLE patient
Station 5
yesterday after history of vomiting once and loose
.bowel four times
.I don't know the case
Second case history of bilateral knee pain with stiffness
less than 10 minutes. It was osteoarthritis no other
significant history of skin rashes or other joint problem
.except back pain occasionally
Stations one
Polycystic kidney and clear function fistula on dialysis.
Polycystic kidney is common in chennai take care it
..mimics hepatosplenomegaly
.Chest I don't know it
pray for all candidates in chennai please
easy.
11/20
smooth. 20/20
management. 27/28.
My exam first cycle dubai 20/2

I start with history Yong patient complain of chest pain
with family history father died at 45 years IHD and they
gave that his cholesterol is high upper normal started
by grating the patient introduce my self as Dr told us
then I asked about the pain dull aching not radiated no
any other symptoms
He is smoker
his work as something inthe bulding carrying object
that what I understand and he was seen by other
doctor and stress done for him 9 month back
Then his concerns what is the cause of the pain I said
we need to rule out ischemic cause first as he had
strong family history and smocker and his cholesterol is
high but he is not happy then I said we need to do echo
and possible coranery angio then
I closed by checking understanding
Discussion with examiner's what could be the cause
I said ischaemia. And mention many differential but he
is not happy at the end I said muscular
Then he told me what will be your first diagnosis then
I said ischemic then muscular time finshed i am not
happy they gave me 12
Station 3 first
Cardilogy aortic stenosis with classic murmur but large
volume pulse collapsing and neck vein pulsation
Pulse regular
Discussion what is your finding
Diagnosis
AS and possibly AR but I could not heard the murmur
who you confirm ur diagnosis
echo looking for 1234
Management
Education and counselling avoid exercise
Valve replacement then at end what other i said TAVI
I got 20
Neur examin hands of the patient
No obvious deformity I start with inspection then I
examin ulnar median and redial she had lt hand
median palsy
Discussion what could be the cause investigation
I got 20
station 4 Communication
Bdn of uncertain malignancy
Long scenario female 80 ys presented e
vomiting,obstructive jaundice loss 20 kg of body
weight but still obese for 2 m u/s and CT no mass no
lymph node Stent inserted in common bile duct no
malignant cells in biliary fluid but still malignancy is
suspected
Task inform her daughter and answer her queries l
started as Dr zain taught us identify myself my role,
check relative identity, ask if she want any body to
attend meeting said no I inform her about reason of
meeting, then I ask her about what she knows about
her mother condition she started to talk for about 3
minutes telling the story of her mother so I explain to
her the result of investigation and told her that we are
still suspecting that her mother bad growth she said
what do mean I told her mean malignancy she get the
phases bad news reaction l left her to express herself,
and after becoming calm asked what happened after I
told her we need to take tissue sinp from suspected
area, she told please don't tell mama I answer as in
doctor zain course I handle thus issue gently if your
mam wants to know we will inform her we will not
enforce information to her and this will help her to talk
decision about management plan and if hide
information she might know and then she loose trust
in medical team. and accepted. Another concern want
to take her mama I said now we need to do some test
and I need to consult my senior and oncologist then if
she remain stable after she can be discharged then
discussion was about ethical issues, why you will
inform the pt I answered as said to daughter and the
autonomy of pt as she is competent. as about elment
of competence he asked about involving the senior
I got 16
.St 1
Resp. Middle aged lady with COPD and -
.fibrocavitatory lesion
Qs: causes of COPD, what are the possible cause of the
lesion (old TB, ABPS), what investigations to do and
how would you manage. When I was presenting my
findings I got confused and forgot to mention the
bronchial breathing and VR over the cavitatory lesion.
15/20
Abdomen. Young male with functioning AV fistula -

and HSP, no signs of CLD. I wasn't sure exactly how to
link all findings together when asked. I suggested 2ry
amyloidosis or CTD leading to ESRD. Also asked what
investigations would u do for him. 19/20
.St 2
Young male known to have asthma with worsening
symptoms over 4 months. The key point in history was
a new pet cat he purchased 3 months ago. His concern
.was losing his job because of recurrent absence
Examiner asked me about differential diagnosis, tests
to be done. I said skin allergen test then he asked
about the latest test -> RAST. he asked about the
method of RAST test which I didn't know then he went
on to ask about the difference between atopy and
anaphylaxis but thankfully time was up. 19/20
.St 3
Neuro. Young lady with cerebellar syndrome and pes
.cavus
Qs: what is pes cavus associated with? Differential
diagnosis for this case (FA, MS, vascular, tumor) What
sensory findings to expect if she had friedrich's ataxia -
> peripheral neuropathy. What Investigations? 20/20
Cardio. Confusing case. Lady with midsternotomy scar,

palpable S2, LPH. I couldn't hear any prosthetic valve
clicks or murmurs. S2 was split. I gave differentail
diagnosis of ASD with previous corrective surgery or
pulmonic valve disease and pulmonary HTN. Examiner
asked about investigations only. And surprisingly I got
20/20
.St 4
yr old lady with diabetes was admitted to the 25
hospital with pneumonia and while she was admitted
ahe received the wrong type of insulin when compared
to her GP notes and developed only 1 episode of mild
hypoglycemia. Task was to explain the error to a
."somewhat" angry patient
Concern was having another hypoglycemic attacks at
home. Examiner asked who was responsible for the
error I said it was a medical team responsibility as
there are multiple factors leading to it. While the
doctor was overwhelmed in the emergency room his
senior or the nurse could have contacted the GP for the
medication list. Examiner seemed happy with that
response and asked what could have been done to
avoid it. I suggested a double signature system for
medications and a pharmacy policy to review GP
records of long term medications before prescribing.
16/16
.St 5
Case 1. Middle aged female with worsening exertional
dyspnea and ankle swelling. From history she said she
was hypertensive for 2 years but didn't take any
medications for it. On examination she had an
inframammary scar, raised jvp and bibasal crackles as
well as lower limb edema up to the knees. I couldn't
hear any murmur probably because she was a little
obese and I was rushing to address the concerns. I said
the pt was in heart failure, the scar suggests mitral
valve disease that was repaired and probably recured.
The other possibility is untreated HTN. Examiner asked
about management of heart failure and hypertension.
23/28
Case 2. 30 yr old male with uncontrolled high BP

.170/100
History was only positive for similar problem in his
father who had high BP and developed an intracranial
hemorrhage. Examination was negative but I forgot to
check for radiofemoral delay so of course the examiner
asked about coarctation of the aorta, what were the
other diffentials (APKD, phaeochromocytoma) and if I
would admit him. 24/28
Overall it was a tough exam but I passed with the

.praise of Allah
Chennai-Nov 16
Communication station in cochin
years lady diagnosed with obstructive jaundice 75
relieved by stenting and now the pt well ,the team not
found the cause despite full investigations
But the team think that the cause either small
pancreatic cA or cholangiocarcinoma
The pt give you a consent to discuss with her daughter
her condition
Task to explain mother condition and inform relative
about uncertainity of diagnosis
:Daughter cocerns
What could be the cause
May she go to die
Why the team not find the cause yet
What can we do for her
Can we hide this information from her
The examiner appeared not satisfied when i told her

that if she asked to know about her health i will inform
her as she is competent and has all the right to know
,and he asked about prons and cons of telling the
patient the posdibility of CA
Also he asked:Do you think this patient need palliative

care and still the diagnosis not reached ? I told him
palliativr care isnot only for cancer and obstructive
jaundice in this age mean advance stage of spreading
of growth
Also he was not happy about term of stent coz hr
thought this is jargon
Oman 6/4/2017
S2
Postpartum thyroiditis-
Female 55 yrs complains of intermittent early -
morning headache+vomiting having pmhx of
hemiplegia CT done was normal and depression
.+anxiety on FU with psych
Her headache sounds to be due to SOL
Tension headache less likely
I think CT needs to explore whether done with contrast
.or not
St 4
.Pt with UC to be convinced for steroid recently came-
Pt with nsemi underwent ptca started on dual -
antiplatelet and other medication told by her gp that
she is allergic to aspirin but that wasn't in her record
.Given aspirin and developed epigastric pain
Your role is to speak to her husband to persuade her
.for compliance
I would like to convey my experience for paces April

2017
Station 3
Cardio aortic valve replacement
Neuro paraplagia
Station 4
Late diagnosis of pheochromocytoma
Breaking bad news plus negligence
Station 5
Shoulder pain in diabetic patient - 1
Adhesive capsulitis
Weight loss -2
Thyrotoxicosis plus goiter
Abd
Right iliac fossa scar without transplanted kidney
Left iliac fossa big scar with a mass under it
Possible kidney transplant with possible poly cystic
kidney
Chest
Copd with clubbing
.Possible interstitial lung disease or bronchiectasis
History
Anaemia in young female using diclofenac for back
، pain with history of bilateral ankle swelling
Family history of colon cancer in her father
My colleague exam today

Oman 10/4, 3rd cycle
:St 1
.)Chest: Bronchiectesis + Thoracotomy (? Bullectomy
.Abd: Renal transplant
:St 2
.)Patient came with collapse (most probably HOCM
:St 3
Cardio: MVR
Neuro: Cerebeller syndrome + unilateral hypothesia
.with persevered dorsal column for DD
:St 4
BBN about patient known HTN on treatment, not
controlled, and he has DVT on warfarin with INR 4 and
developed Large SAH who is ventilated and admitted
.to ICU
St 5
.)BCC 1: Young female with headache (Migrain
BCC 2: Patient with previous hypophysectomy on
treatment developed gradual loss of vision (?
.)Recurrence
Oman exam 8/4

St 5
lt shoulder pain ?? Frozen shoulder 1
toxic goiter 2
St 1
Transplanted polycystic kid d having fistula
Chest: bronchiatisis
St 2
Fatigue with family history of colon cancer
?? Her mother taking iv drug every 3 months
She was taking also diclofinac for 6 months
St 3
All candidates said AVR
St 4
Delayed phychromocytoma diagnosis
Oman 3rd cycle 8/4
Station 1 seems polycystic kidney

Bronchiectasis due to cystic fibrosis
Cardiology AS. MS
Neuro. Charcot marry tooth
Station 4 headache and fatique
all investigations are normal they asked you to tell her
about the results
Conversion disorder
Station 2 back pain inflammatory type
With family history of rash
Station 5 essential tremors and psoriatic arthropathy
oman 4/7
Cycle 3
St 1
Congenital bronchiectasis kartegeners syndrome
Renal Tx
St 2
Cough and SOB for 6 months
St 3
Spastic paraparesis with intact sensation for DD
AS
St 4
Elderly known advanced bladder cancer and bed ridden
admitted with obstructive uropathy and deterioration
of consciousness for discussion with his son about need
for nephrostomy and future treatment
St 5
Reduced visual acuity in a young (33 yrs) with
background HTN and DM
valve replacement came for follow up and c/o dry eye

for few month
Cycle 1&2
Kartegners syndrome with lobectomy
.DVR. AR
Transplant kidney. Chronic h anemia with splenectomy
Charcot marytooth. Spastic paraplregia without
sensory level
Lung fibrosis due to amiodarone
History. Pt with familial hyperlipidemai presented for
chest pain
Oman exam 9/4 cycle 1-2

History postpartum thyroiditis
Communication CKD
Chest bronchiatisis + copd
CVS DVR
Abdomen Thalassemia with HSM
Neuro Charcot marry tooth
Ct5 Neurofibromatosis. Thyroid
Oman exam 10/4

Cycle 1&2
??St 1 bronchiatisis + liver transplant
St 2 common variable immunodeficiency vs hiv vs CF
vs hypogamaglobulinemia
St 3 DVR. Cerebellar syn
St 4 SLE for reanal biopsy
St5 simmple goiter + psoriatic arthropathy
.Oman 10/4- 2nd group
information:following in medical clinic for abd -1-5
problem, dirrhore few days. Vitals normal. Some nail
changes treated by GP as fungal inf, no benefit
Inside: it was AB induced dirrhore,lasted 3 days,
settled now without treatment, Actual problem was lt
wrist, ltMPJ Arthritis,Rt normal, brown rash macules all
over body , lower half of legs are all brown, said no
treatment taken ever, long lasting - deliberately hided.
Nail only flat, one nail only slight onycholysis, only one
side. Later same patient gave us lift and told us he have
.psoriasis, treated, only one hand arthritis
f, Dysphagia to solids for one month, no other 50 -2
positive Hx, ex only small central thyroid nodule, no
.،other finding or Hx
Abd: bilateral IF scars, RIF mass, Rt chest and neck -1
.CVLine scars, some gum hypertrophy
Resp: Yong male, Lt Lower half coarse crackles,
..rhonchi
Hx: recurrent chest infection in a Yong male, is DM on
.insulin, Asthma on Symbicort
Recurrent chest infection since child hood, poorly
controlled DM, constipation, infertility - immobile cilia,
.CF and others as you said
Resp: localised bronchiectasis, I mentioned all
.posibilities
CVS- long midsternotomy scar, extending to -3
umbilical, collapsing pulse, Double metallic clicks, AR
murmur, apex 5th ICS, lateral to mid MCL. Double valve
.with AR
CNS: LL-- Examiners didn't allow to check gate, back,
said normal. Bilateral cerebellar signs, lt LL lmn
weakness with decreased sensations, dorsal column
.ok- it was confusing, I said MS
SLE and Renal biopsy -4
I would like to share my experience which was in 23/3

in Glasgow in Golden Jubilee Hospital
I passed alhomdellah with 148/172
This is my first trial in PACES but i had the sense that i
know what to expect in the exam from the experience
that had been shared from other colleges so i would
.like to thank everybody who share his experience
I started with station5 and when i knew that i panicked
because i thought if i messed it up i will fail but then i
said to my self just do what you can and forget about it
.in that room don not take it to other stations
The first case was a lady with weight loss and type 1
DM so i put from outside grave' s disease and coeliac
disease and when i entered the room it is obvious that
it is Grave' s so i started by shaking hands with the
patient and then she gave history of gritty eyes and
weight loss with good appetite and diarrhea and then i
started the examination by checking the eyes she has
led lag and retraction and ophthalmoplegia and
proptosis and then i asked her to take a sip of water
she does not have goiter but i examined the neck and
there is no finding and in the beginning i checked the
.pulse and it is regular
She has positive family history of type 1 dm and she is
on b blocker and no smoking history and not drinking
alcohol and her concern was what is my problem so i
explained the grave, s and i refer her to
.endocrinologist
The examiner questions were what is the diagnosis and
what you find in the eyes and what is the
investigations and the bell rang and i did not finish the
discussion and i forgot to see the legs for pretibial
myxedema and the proximal myopathy and i knew that
i will lose marks and i got 23/28
The second case was systemic sclerosis
I became calm and confident in this case because i
found that there is nothing to worry about it went fine
the first case. The scenario was a man came with
discoloration in his fingers and pain so i went inside the
room and the patient has obvious talengectasia. I
started taking the history and the patient has rynaude '
s with dysphagia and shortness of breath and he is a
builder so i examined him i saw the talengectasia and i
saw his hands he has ulcer in his finger and the skin
also he has lung fibrosis with fine crackles and then i
asked the examiner about patient BP to exclude the
renal problem and the examiner was happy. The
patient concern was what i have and then i explained
tge disease and i told him that i will refer him to
rheumatologist and i advised him to keep his hands
warm and to avoid vibrating tools.the discussion was
on diagnosis, finding and investigation and treatment
and i knew that i will have full mark and i have it 28/28
: Station 1
The abdomen case was liver transplantation, patient
with Mercedes Benz scar so i started the examination
and the secret is to be fluent do not think about what
you want to do next, the examiner wil Will have good
impression
The scenario was patient cane with abdominal
discomfort.the discussion was about what is your
finding ? The patient has tinge of jaundice and the scar
and the liver is palpable six cm below the costal margin
and no signs of chronic liver disease so my diagnosis is
that the patient has liver transplantation and the
discomfort could be due to rejection or portal vein
thrombosis or hepatic vein thrombosis and i should say
.biliary stenosis but i forgot
Then he asked about what might be the cause of
.transplantation
What the think you will do before you send the patient
to the liver unit for transplantation and what are the
.side effects of immunosuppression medications
I got 17/20
The respiratory case was an easy one but i messed it
up. Patient came with shortness of breath. On
examination he has right side thoracotomy scar and
crackles so it is bronchiectasis. I presented my finding
and then i said fibrosis i don not know why i said it
even he said is it bronchiectasis or fibrosis and then i
said bronchiectasis but i became confused so i forget to
lung function test in investigation and i forgot postural
drainage in treatment. I knew i will have 10 and it is i
got 10/20
:Station2
The scenario was patient 36 years old male with type 1
DM came with recurrent hypoglycemia and weight loss
and anemia he has renal impairment the GFR was 38
.and he has retinopathy
So i started by asking open questions and the patient
answered by himself all my questions from the first 5
.minutes
He has recurrent episodes but he has awareness of
hypoglycemia only two times he needed help from his
wife and he is an IT and he is driving his car but now he
stopped so i told him that is good and i appreciate that
.you stopped driving
He also has abdominal pain and recently discovered
.that he has renal problem
.Not smoker
.His concern was what i have
So i explained that he has an autoimmune disease
which is type 1DM and there are others and now he
may have Addison and i explained what is it and it
could be due to the renal problem and he may need to
the endocrinologist to decrease his insulin dose but
idid not say to the patient coeliac disease. The
examiner question what is your differential
So i put addison, coeliac and due to renal problem and
then he asked why he has anemia i said it could be due
to the chronic kidney disease so he asked what GFR can
cause anemia i said 30 and then he said why he has
.anemia i said pernicious
Second questions was what investigations and then he
asked the patient is on ramipril what you will do i said
he will continue on it because t is protective he said
excellent answer i got 16/20
Actually it was nice experience and the examiners was
good
:Station 3
The cardio was an old patient with regular pulse and
on examination he has pansystolic murmur radiating to
the axilla
Examiner asked what is your finding
And he was so happy about my presentation
I said that the patient has regular pulse 70 per minute
and he has pansystolic murmur radiating to axilla and
my impression is that the patient has mitral
regurgitation and the differential is Tricuspid
regurgitation but the things that against are no
hepatomegaly and raised JVP and the other differential
.is VSD and the age of the patient against that
The examiner agreed
And then what are the causes of mitral regurgitation
What investigations
What are the treatment
I said replacement and then he asked about the
indication for it
Then he asked me about the medical treatment and i
said vasodilators and diuretics
I got 20/20
The neuro was old patient with mask face
The instruction was to examine this patient
I started doing the parkinson disease examination
I asked the patient a question how he came to the
hospital
And then i examined him for tremor
And then i did the tone in hands
And the examination for bradykinesia
In upper and lower limbs
Then i asked him to walk
And the finger nose test
Just i forget to test the supra nuclear palsy
But the examiners were so happy and he said you still
have time but i said i don not have anything to do else
and then he said what about the eyes then i
remembered and i told him how i will do it and he said
ok no need to do it
In discussion
What is your diagnosis
What is the differential
I said parkinson plus and the drugs induced
What investigation
I said it is a clinical diagnosis but if in doubt we can do
CT and MRI and SPECT scan
What treatment
I said all the medication with their side effects
He asked what this patient at risk of
I said fall
He said what you will do
I said multidisciplinary with physio and occupational to
adjust the house and also the social worker for benefits
i got 20/20
Station 4
The scenario was 54 old patient with congestive heart
failure and he is at maximum treatment and the
cardiologist said no more added treatment then he
complained of lump in his neck and biopsy was taken
and CT abdomen revealed that the patient has primary
kidney cancer which is spread all over his body
The task was to break that news and to tell the patient
that he is for palliative treatment and the role of
.specialist nurse
I started by asking him if he wants some one to attend
with him and he said no body
Then i asked him what he knows about his condition
and he said everything about his cardiac condition and
he knows what the cardiologist said
And he said that he has a lump and a biopsy was taken
and he wants to know the result
So i asked what do you think the cause and he said am

afraid of the worst so i told him am afraid you are right
and then i told him the result if the biopsy and the CT
Then i kept silent and i let him speak and he took his
time then i said can you tell me what is going in your
mind and then he said he is shocked so i show empathy
and i gave him time again then i asked him do you
want me to proceed
He said yes and then i told him about the palliative

treatment and i told him that we will provide support
to him and his family and he is wondering how to tell
his family so i offered to him to bring them in the
upcoming meeting and i will tell them
Then he asked about how long he will live and
empathetically i said i don not know then i proceed
and told him about the specialist nurse and i asked him
again for more questions he said he can not think now
so i told him to write every question come to his mind
and we will discuss in the upcoming meeting and then
he repeat the question again about how long tine he
has
And again i said i don not know and i explained that no
body can tell
Time finished and the surrogate while he is going out
he told me verygood
I got 14/16
The discussion was about why you did not specify time
the examiner wants me to tell the patient that he has
months to live so as to prepare his living will
And then she asked me about the ethical issues
I said breaking bad news
And beneficence vs malfecience
Both examiners were happy
And the. She asked what websites you want him to
search on and what you don not want to search
I told her that i don not want him to search for hope
while there is no and treatment will harm him more
and his functional level already impaired
By the cardiac problem
And during my discussion with the patient i advised

him to go to support group and that is why she asked
about the benefits if the support group so o told her
the benefits are for the patient and his carers
I finished the exam with score 148/172
Sorry i forgot also i told him about the role of the
specialist nurse and how she will help him and his
family
Oman 9/4/2017
Day 4 Cycle 2
My case a lady of 35 years old present complaining of
fatigue and weight gain 3 Kh in the last 6 months , she
gave history of typical hypothyroidism
I ask about other hypos no other symptoms apart from
. ) amenorrhea ( hypogonadism
She had family history of thyroid problem ( her mother
)and her any is using regular vitamin injection but she
. is not sure what is it
Her last delivery about
months ago and was eventful, she had been 18
transfused much amount of blood , but against
Sheehan's syndrome she is lactating for more than one
.year
.No PMH and not on any medications
: Examiner question what is your DD
Postpartum thyroditis ( he ask why you think about it )
I told him because her symptoms started after delivery
)
Autoimmune poly glandular syndrome (family history
)of endocrine disease
Sheehan's syndrome .( against it no symptoms
suggesting hypoadrenalism and she is lactating for one
. year
: Other questions
.Investigations and treatment
At the end he asked about Addison disease

? How do will treat patient with Addison disease
I stared if he came in emergency I will stared with IV
fluid normal saline
Before I answer hydrocortisone bell rang
Station 3
*Cardiology*
. Examine this patient and present your findings
First and second heart sound are metallic clic
MVR + AVR
:Questions
Investigations
Echo , What is single blood test you want to do (*He
)*want INR
Other question can you prescribe for him new oral
anticoagulant ? I told him up to date it's not license in
patient with metallic valve
)*Neurology*(
: Strange case
.Young patient with lower limbs weakness
On examination LMN weakness (proximal myopathy)+
loss of vibration sense with intact joint position in the
.) left side
Most probably the patient had Becker ( I could not
) match the things together
I told him proximal myopathy for DD but against that
the loss of vibration sense in the left side
He ask me forget about vibration sense , what could be
the cause of his weakness ? How are you going to
investigate him
Bell rang
*Station 4*
years old Omani male he is complianing of fatigue 29
and dizziness for the last 6 months , today he had been
call by his GP because he has abnormal renal function ,
.your role to explain to him his condition
BP : 160/105
K : 5.2
High creatinine
. High Urea
. High creatinine
During discussion he told me I have cut wound in my
? hand 5 years before could it be related
My BP was high since that time and the Dr.at that time
. did not bother him self
? What is final treatment
I explain to him what chronic renal failure , what is
complications and what are option of treatment
.)including renal replacement therapy ( dialysis
:*Examiners Questions*
You mention to this gentleman that you want to admit
him , why ? During the discussion the patient
mentioned that he has shortness of breathing ,
consequently I told him you might need dialysis after I
.) full examined you and doing CXR ( fluid overload
As he is lower what mode of dialysis you will over him
? I told him haemodialysis is better ( less chance of
.)complications
Then he asked me what is problem of high serum K ?
?Do you think 5.2 need dialysis
*Station 5*
*BCC 1*
years old male complaining of attacks of 35
. headache, sweating and palpitations
When I went inside I'm asking about course, onset and
.duration of symptoms
I asked also about aggravating and decreasing factors
)(none
Loss of weight , fever night sweating , analysis of
headache , analysis of palpitations
Mean while am asking I told the surrogate I will
examine the patient meanwhile I will ask some
questions
It was clear neurofibromatosis
After that I ask about PMH , family history ( he had
family history of similar condition). Medications history
.
I ask about the concerns. She ask me what the is cause

? for his problem
? How he can be treated
? How skin lesions be treated
I ask I want to examine BP , they told me no need
I examine the back of the patient looking for cafe auilt
spots
. Auscultation of heart sound
.Bell rang
:Examiner Questions
?What is your diagnosis
DD
.Management
. Time finished
*BCC2*
years old male with history of loss of weight and 38
. fatigue
Hyperthyroidism
.Graves' disease
)Alhamdulilah passed PACES in Malta ( 2/4/17
Neuro: lower limb umn monoperesis
Cardio: AR
Abdomen: ?CLD
Respiratory: ILD
BCC1: IHD with stent complaining of chest pain one
month, one episode faintaing ( bradycardia on
atenelol), stent thrombosis
BBC2: spine surgery 6 wks back complaining of fever,
lethargy n persistent back pain one week? epidural
abcess
Communication: 80 yrs old female admitted with CAP
.developed delirium 3 days after admisdion. Talk to son
Son concerned if his mother will have permanant
.psychiatric problem
History taking: young marathon ...chest pain
.palpitation and syncope
Concern,,,,if its an epilepsy
My experience of PACES 01.04.2017 MALTA
I started with station 2 : 24yrs old lady c/o fatigue and
headaches found to have high BP 160/98 on different
occasions. No family hx , no
complications.....examiners asked would you start
treatment...i said not now if secondary causes r/o
including white coat htn then yes. Discussion about
.secondary causes of htn and investigation
Got 20/20
.management
Got 16/20
Station 4: talk to the wife of 50years man known MND
recurrent admissions for pneumonia. This time
admitted with aspiration pneumonia not responding to
anti biotics and confused. Discuss with her his
told that i did not told about NIV when the wife asked.
Got 15/16
took hx all joints pain including hand joints. Surrogate
told she was told by GP that she has double joints. I
was more confused...asked what u mean double joint
she said i dont know gp told me that and he was not
sure.i examined no sign of inflammation. Raised skin
dorsum of hand elastic . Checked functions. Found
high arched palate. Joints hyperextensible.arm lenght
normal. Gave diff of marfans pseudoxanthoma
elasticum forgot to tell ehlers danlos syndrome.
Examiner asked were there marfanoid features i said
no. I wanted to examine chest they stopped me asked
what u want to see i said AR....they said normal. Asked
how you investigate joints in general...started with
inflam marker RA factor ACCP...time finished got 28/28
nd cast st.5: believe me i totally forgot....got 23/282

over mid line laprotomy scar below umbilicus. Shifting
dullness+ could not appreciate any organomegaly or
mass due to tenderness. Differential ...causes of ascites
asked about causes of transudative ascitic fluid....got
8/20

Got 20/20
Wish success for all you going for PACES......my advice
is to perform during exam in relaxed way, smile and
forget about any station where you did not perform
.well
My experience
I did my paces exam in malta
Mater dei hospital on 2 April 2017
At 9 am
St 4
ys woman admitted 2 days agowih chest infection 80
started antibiotic IV and today became aggressive
refuse treatment and she said doctor and nurse will kill
her diagnosed delirium
Note the pt at time of admission
OK conscious and oriented develop this at hospital
Please took to her son had many concern
And discuss future management
I entered the room
I started same as Dr Zein told us because this the first
time to do delirium
I great the son agreed agenda
?What you know about your mother condition
He tell me what written up
So I told him you are right
He all time disturbed me
Why she developed this
I said I answer your questions
But let me ask you about your mother before is she ok
He said she is completely ok
So I asked is she developed same condition like this
before
He said yes I remembered now 2 year2ago had same
like this but short period and less aggressive I know
from him
Not associated with admittion or treatment or
changing home and resolve spontaneous without
seeking medical advice
So I ask what do you think might be wrong with your
mother
Said I don't know
I asked about concern he what to know why she
developed this
And what treatment
And if she will be OK
What about future
I try to remember all this
Concern
So I said your mother had conditions called in medical
term delirium do your heard about it said no
I will give you leaflet and about it is acute confusion
state
Means disturbed in her brain fuction so change her
way of thinking not knowing time place and person
because of that think that doctor and nurse want to kill
her
And some time the cause can be infection itself
He stop me and said she is OK when came here
I said is she complain of any
Water problem he said no
I said infection of water can come without any illness
and can cause this and her infection of chest and some
people when changing Their place can have this and
also some sort of treatment can cause this I will call my
senior to revise her medication
Is your mother in general ward means with other pt

He said yes
I told first step in tr
Treatment to shift your mother in single room and one
nurse or medical aid who is available (because I don't
know who will sit with her)to be wih her to be sure not
hurt her self
And I will call my senior
And also I will call one doctor in our team we work
closely with him called psychiatric to give you mother
medicine through blood tube to be calm to start again
her medication is that OK
And about becoming ok I am afraid I wouldn't gruntee
about that I am sorry to say that but might become
completely ok or might not but I am sorry to that your
mother had previous problem like this and her age 80
So this also factors(show empathy all through the
station l understand your feeling l know you are
worried about your mother) and right now I am
thinking about dementia do you heard about it here
said yes and he started explain it
I said yes it is aging process
But cannot come suddenly
I will give you leaflet about future who is with your
mother at home he said alone
Where are you said living away for work coming only
weekend I said any possibility to shift with your
mother town or to shift your mother with you he said
no
I asked about financial problems no if your mother
become ok we will talk to social worker and
occupational therapist to do home modifications but if
not we should discuss future career nursing home
He said yes you mean nursing home care I said yes
He started to say oh oh
At this time I told him I know I gave you so many
information so I will give near appointment in this
afternoon with me myself and my consultant to discuss
nursing home care and all you queries and worried he
)said thanks it ok(really I said that to be in safe side
I summarize and check understand
Qs by examiner he ask everything that I told to son
And then he said you said psychiatric some time not at
hospital and pt fighting
I said I will discuss to my senior to give pt haloeridol
What about leave son to sit with his mother at single
room
I said according to hospital policy the examiner laugh
and said you are doctor who putting policy I said if
possible better to stay with his mother familiar face
can help her I got 15/16
My exam experience in kolkata

st 4 pt non compliant to take steroid, kc Addison.
Husband pt of MS
St 5 (1)RA
)LOC(2
St (1)hepatosplenomegaly wth jaundice

ILD wth systemic sclerosis
St 2)return traveller bloody diarrhoea grandfather ca
.colon dx at age 78, 2nd cousin having UC
St 3 1)mixed mvd with af with hf, 2)spastic paraplegia
.traumatic
I just finished the exam b4 1 hour. Please pray for me
I pass my exam in chennia India-- Thank good

It was tough one with very atypical clinical stations
Abd : middle age male with active fistula + LL odema
No signs of fluid over load
Not on anti rejection Med
Ploysystic kidney disease
With cystic liver
Q.1 what is ur diagnosis
Q.2 did u see the rash �� now clue if there was any
Q.3 what can cause liver cirrhosis in this pt 😅😅
)worst station got 14/20 (
I think the rash is lichen plans with HCV I do not know
:Resp
Middle age man again active fistula
With hyperinflated chest
Tar stain in fingers and teeth
With no wheezes only fine Basel crip
Not changing with coughs
Copd with lung fibrosis
Q.2 how would you like to investigate Q.3 any
relationship between his lung problems and dialysis
First thing 😔😔 may be Med then saved by the bell 🔔
one of the examiners was sitting on his chair at the (
foot of the pt
I asked him to move politely and even moved his chair
to sit far away 😅😅😅
Station 5
I was happy 😊
st case 1
Unilateral limb swelling
All vitals are stable
I put diff of cellulits + rupture beacker test
And I entered
To very young male
Again on dialysis 😗😗 with permicath
With chronic limb swelling over 5 years
Pain less with strange knee joint
?? No history of insect 🐜 bite
I examined the limb
Slightly pitting
Not hot or tender I examined inguinal
LN ��
I asked pt to walk then sensation
Examiners escip and normal respectively
There was parathyroid scar
Concern by relative
is it related to dialysis should we increase the the )1
dialysis frequency
I answered not related and best to talk to your kidney
specialist if you have any concerns regarding dialysis
What is the cause)2
It most likely due to lymphatic obstruction
We need to start to do some test to know exact cause
😌😌😌😌 and he do not need admission
Examiners
Q 1.what is cause of swelling
Lymphodema
Q 2. How would you like to investigate him
Stupid answer lymphogram
What might be the cause in this country
With more stupid smile
Chagass disease ( how stupid you may become in exam
Totally forget flaria) where Chagas come from
Saved by bell 🔔
Got 18/26
nd case2
Totally straight forward
Bilateral limb swelling in HTN
I put differential
Then went to role out serious complication of HTN
There is decrease frequency of urination
With drug history on
Nefedipine for one year
Complain also from � headache
Plan of management
Admit the pt
Switch nefedipine to other Med
Doing some test and scan to ur kidneys
Those were the answer of the concerns
Examiners
Q1. How to mange pt
Education, stop medications switch to other Med,
elevation of the foot
Q2. What Med you will give pt
I said ACI
Why not diuretic
I said not recommend as pt having dependent odema +
there no evidence of fluid over load
Station 3
Cardio
Middle age female again active fistula in right arm
Exam
Obvious Lowe limb edema
Raises JVP with v wave
Obvious apical pulsation
No thrill ,LPH
Irregular pulse
Loud s1
Could not ass the 2 heat sound coz of the fistula thrill (
)which irritates the examiner 😂🤣
Diastolic murmur in apex
And hypothetical tricusp reg
Q1.what is ur diagnosis
Q.2 what r the causes of MS
Any congenital MS syndrome you know
I answered lutinbaker 🙃🙃🙃
Got 13/20
CNS
Straight forward
Pt presented with dysphasia
Examine LL
Young male with CVA posture
Q.1 what is the lesion
)Q.2 where is the lesion (subcortical
Q.3 how to investigate and mage
Indian male not understanding English lot of time (
missed in translations, I couldn't not ass the pulse
heart or cranial nerve or ask pt to walk but I told
) examainr I want to do so
Luckily I got 20/20
Station 2
History
Middle age female newly diagnosed HTN
With persistent high reading
Approach with systemic manners
No symptoms suggestive of end organ damage
No symptoms of all secondary causes of HTN
Reached gynecology history
Pt was having irregular menses with prescribed OCP for
1 year
No other important history
after I reached concern I remembered to ask (
biological family if the pt was adopted (APkD) as in
) DR.zain scenario
Concerns
Do I need to take Med for life .1
Ans as your HTN probably due to Med there is a good
chance it might be temporary
will it affect me having babies.2
Ans. High Blood pressure may serious with pregnancy
multi desplinary team involving pregnancy specialist
and your physician would keep a good eye over it
Plan of management
Stop the OCP , seek alternative with the help of ur
pregnancy specialist
We will do some test and may be scan to ur kidneys to
see the extend of ur disease
Examiners questions
Q.1 what is ur diagnosis and differential
Q.2 what is common-cause in this country if it is renal
cause
I answered post streptococcus GN
I got 20/20
Common scenario=Station 4
Young male with ulcerative colitis un controlled with
mesalazine
Then pt afraid. From steroid as he read about side
effects
Involved the GP
Conserns
for how long you will use steroid )1
Ans
Until we control the disease the dec dose till we reach
remission with minimal dose
I want to use herbs 🌿 )2
Ans
Sorry but I can't be sure what will be the effect on 🌿
on the disease course or how it may interact with
steroid
DR.zain advice never say no to stupid thing pt want (
to do just smile and give all options to him and then till
)him ultimately you may hurt your self
Discussion
anemia)1
Which type
All type
)Norm normo (of chronic disease
)Megaloblastis ( fe + b12 malabsorption
)Iron deficiency ( due to blood loss
colorectal Ca )2
what kind of diet you will give him )3
I tried to be smart �� I will refers to dietitian
Then agin what diet
I told him high fiber diet 😆😆😆
He asked me ru sure 😅😅😅
Yes sure
I got 20/20
My exam experience in bradford royal infirmary on 27

.march 17
:BCC1
previous hx of some brain surgery (hypophysectomy
and she was on steroids, levothyroxine and GH) hx
looks like OSAS. It didn't clicked to my mind that she is
acromegaly and OSAS is due to acromegaly itself. I
gave differential of hypothyroidism and cushing being
cause of her OSAS. Exam findings were nil for anything
:-( she repeatedly gave me clue why she is sleepless
.and i kept on beating about the bush, same as viva
.BCC2: RA with sob and GP mentioned nodules in xray
auscultation:-( and gave d/d if rhenatoid lung and they
asked about any d/d of pulmonary nodules, i said
.neoplastic. Next qs about invx and mx
:4
Deal with annoyed son who is NIK and his mother was
admitted yesterday with acute confusional state due to
UTI and AKI (brought by ex husband who claims to be
taking care for her) son seems to be away and less
caring but he was annoyed why his father (who left his
mother when she needed) is around and he demanded
that his father shouldn't be around and why the son
was not called by the hospital. And he semanded that
when she will be discharged he doesn't want his father
to be around. (Being next of kin he demanded that he
has the right to decide about his mother) i inquired
about power of attorneyband advance directive which
.son said he has no idea and repeated that he is NIK
.Questions were about rights of next of kin
and if son claims that his father is using mother to get
financial benefits and he is responsible for her ill health
then what should be your stance. Will u ignore it,
)where to report it.(I had no idea
In case there is no legal report where you will get
guidance (i said hospital legal advisor, examiner asked
who else, i said ex husband. He asked who else..then
)he told my by himself that GP can be contacted
then he asked if she gets improved then how will u
manage the issue. I said if she is proven competent
.)upon recovery then she should decide (autonomy
:3
:Cvs
،،،lady with palpitations
Midline sternotomy, audible click with 1st heart sound.
Pacemaker scar. I gave MVR and functioning well.
Other candidates told there was ejection systolic
(-:murmur of aortic which i didn't find
.Questions were typical
.Neuro : examine lower limb of lady who has weakness
Examination showed power 3/5 both lower limbs.
.absent ankle jerks, downgoing plantars
Stocking sensory loss of all modalities. I gave d/d of
peripheral sensorimotor neuropathy but examiner was
.interested in spinal causes and spinal level
.Asked me to give specific investigations only
:2
Yrs lady with multiple visits with sob and wheeze, 40
smoker. GP found wheeze at exanination. And no DVT
Further hx
Cat at home. Hx of sob at cold exposure. CONCERN : is
.it cardiac
No suggestions of cardiac). I gave dd of asthma copd (
churg strauss etc. I am still confused whether there
.was any trick in case
:1
:Abd
.male with night sweats
lymphoproliferative and myeloprolifetive disorders
.viva about invx and management
Respiratory : subtle findings. I found wheeze, examiner
was interested in clubbing (though not apparent, he
wanted clear answer whether there is clubbing or not.
.Viva about invx and management
Khartoum exam today

History IBD
Communication counselling regarding warfarin
Speaking with son
Station five AF for dd
Station bcc 2scleroderma
Abdomen transplanted kidney
Chest double pathology???fibrosis and effusion
wheezey
CNS proximal weakness
CVS valve replacement
another cycle in sudan

Hx : palpitation
post partum thyroiditis
Station 5: RA no clear deformity pt clubbed chest
wheeses more prominent with possible crackles on
methotrexate the scenario from outside only dry
cough & short ness of breath
history panhypopiturism sheehan synd
communication counselling newly discovered renal
failure pt eith shrunken kideny
another cycle in sudan

RT.1
Left.lower lobectomy.1
.cystic fibrosis.2
MVR. FLASID PP.3
.Renal biopsy in SLE.4
.BCC1Peripheral neuropathy due to anti TB.5
BBC2.Familial hypercholestrolemia

..my exam experience Glasgow Feb 2017
I started by st 3
Cardio
Pt e SOB; O/E; mid sternotomy scar, metallic click , no
murmur , my D; MVR, viva inv & manag + valve types!!,
why no saphenous scar?! got 20/20
Neuro; pt with falls; examine his neurological system; I

started as regular greeted the pt and asked to walk;
Parkinsonian gait, I examined tone then tried
Parkinson approach as Ealing vedio but no tremor
evident, then I was stuck and don’t know what to do
more, I tried power, reflexes and bulbar ex and time
out, viva about Parkinson, I thought I performed bad,
20/20
st 4
syncope due to OHG overdose in depressed nurse, who
denies the act but confirmed inv and previously told
about insulinoma, task to communicate D and manage
;concerns
concern: confidentiality, financial troubles & support, I
missed in scenario from where she got the OHG,
thought she was D then corrected myself (looked not
)good
viva; what ethics here, from where she got the OHG
and if from hospital any implications, what kind of
support! And how about psychiatry assessment
I got 11/16
BBC1
Systemic sclerosis with swallowing problems, straight
forward, concern; is it curable?! I don’t know what I
missed, 26/28
BBC2
young man with Visible Haematuria with normal Ex
and history, concern is it cancer, I missed a good DD
and plan of management , EX were upset , got 22/28
st 1
Abdomen
Scar of liver transplant + drum stick clubbing, viva abt
possible D and Inv , transplant medications and SEs,
got 20/20
chest
COPD with bronchiectasis, viva causes and inv and
st 2
Dizzy spells , postural hypotention and tachy, in AF +
DM+IDH+HTN+DVT, gave DD uncontrolled AF / Drug /
Autonomic neuropathy, viva inv and management, got
20/20
I hope this helps

Paces is a very tough but amusing experience, I passed
from 3rd trial all in UK, done courses in Ealing,
Hammersmith in London and paces 4 u in Manch, got
110 in 1st trial and 117 in 2nd , now 159 praise and
favour to Allah
Try to study hard 50% and try to practice in your real
life 150% and in shaa Allah you will Pass
Hope the best for you all, much thanks to this group
and all colleagues, your experiences were so helpful
…Have a nice day
Malta centr 2 April 2017
.Pneumonectomy straightforward
S2
.concerned is it epilepsy
.PHx similar episodes but no loss of consciousness
. No DM NO epilepsy or other illness no trauma
Drug Hx
. think they wanted you to think about prolonged QT
FHx adopted
Social negative
. Concern is it epilepsy
.regurgitation
S4
.explain mangement and answer concern
.
S5
fever
. Discussion how to cover staph aureus
...........
Other case
years post CABG presented with chest symptoms 12
. and faint concern is it heart attack
I have passed PACES 168/172 on 7th March 2017, 1st

diet , my exam center is new YGH, Yangon, Myanmar
I started with St 2
St 2 wt gain fatigue , amenorrhea, 18 mths post partum
ho of PPH blood 4 units given
DDx Hypothyroid most probably due to post partum
thyroiditis
I got 18/20
St 3
MS with AF
Examiner asked what's your findings, Dx, DDx, how
would you manage, if the pt has vegetation in echo,
?can it affect the INR target
I got 20/20
Neuro station
A young lady presented with difficulty in walking, plz
examine her neurological system
Dx- Lt sided hemiplegia due to cardio embolic stroke
I got 20/20
Scenario given was the pt had history of high blood
pressure since 5 yrs ago which was found out when he
got accident. He didn't take any medication nor any
follow up since then. Now he suffered SOB and saw his
GP , done blood test showing eGFR < 15, Hb 6.5,
Potassium 5.3, USG showing bilateral contracted
.kidney. He is now seeing you what happens to him
Task - discuss his current condition and future
.management plan as appropriate
I got 16/16
St 5 BCC1 a young lady presented with SOB SpO2 88%
Examiner ask Dx, DDx for SOB in this pt, Management
I got 26/28
BCC 2
Dx Unstable angina(ACS) with hypothoidism
Hidden agenda here was to refer to hormone specialist
to reduce her thyroxine dose
I got 28/28
St 1
Hepatomegaly
Dx Thalassaemia
Examiner asked Dx, points for Dx, DDx, infectious
causes of HSM, treatment of Thalassemia
I got 20/20
Examiner asked Dx, points for Dx, DDx of dullness at
base of lung, Ix, Mx, what would you consider if this pt
?is working in shipyard
I got 20/20
Thanks a lot PEC group! I may not get this achievement
.without your help
،Great thanks
My experience
Mater dei hospital on 2 April
At 9 am
St 4
I entered the room
time to do delirium
before
from him
mother
Said I don't know
developed this
And what treatment
What about future
Concern
state
her

He said yes
hurt her self
no

room
My exam experience in chennai today 3/4/17
Station 2
months. She has fever on and off but no night sweating
weight loss of 6 kg within 6
.antibiotics without improvement
During childhood she has asthma which improved. Not
smoker or drinker. But unfortunately the diagnosis was
.extrinsic allergies alveolitis. I miss birds at home
Station 3
.Mitral stenosis with AF it was clear
Neuro
Is parkinson plus CVA. Rigidity only on distraction so I
put parkinsonism plus CVA reflexes was exaggerated
.on the right upper limb only no tremor
Stations 4
.Easy case explain renal biopsy for SLE patient
Station 5
.bowel four times
.I don't know the case
Second case history of bilateral knee pain with stiffness
less than 10 minutes. It was osteoarthritis no other
significant history of skin rashes or other joint problem
.except back pain occasionally
Stations one
Polycystic kidney and clear function fistula on dialysis.
Polycystic kidney is common in chennai take care it
..mimics hepatosplenomegaly
.Chest I don't know it
pray for all candidates in chennai please
i hv passed paces this diet..i hv already shared my
experience before..i just want to share my notes i hv
prepared by myself.. i prepared all that notes by help
of books, Dr. Ayesha audios and most importantly by
guidance of Dr. Rashmi kushal ( Owner of paces ahead
and examiner of paces exam ) during attending the
course... all of these regarding preasentation of st 1
and 3
*******************
hopefully these will help u
*******************
here all imp topics for abdomen station and their
presentation
its My own notes about presentation of imp topics ....
of abd..hopefully al these will help u taking
****** ...preparation...best wishes
ADPKD
After examining this gentleman my impression is he
has ADPKD as evidenced by
Bilateral flank masses which are ballotable

it is possible to to palpate above the masses and
.The overlying percussion note is resonant
However presence of plethoric face indicating
polycythemia and rt sided nephrectomy scar is also
strongly suggestive of my dx
There is no sign of fluid overload, uremia &
encephalopathy
There is no evidence of active renal replacement
.therapy
I’d like to complete my examination by checking
BP
Examining
Cardiovascular
neurological system &
Doing
& Fundoscopy
Bedside urine
..…take history about
Abd pain
recurrent urinary infection
High colored urine
Headache
Chest pain/palpitation
I ll request for
Urine microscopy
Renal function test creatinine, urea,electrolyte
USG of whole abdomen
ECG and Echo
MRA or DSA
:Liver transplant
has Cirrhosis of liver with liver transplant functionally
active as evidenced by
.A Mercedes benz scar on upper Abdomen

There is another scar on rt iliac fossa with underlying [
smooth mass represents concurrently transplanted
]renal allograft
There are scar marks associated with postoperative
intensive care,such as tracheotomy, central venous line
.for vascular access,and abdominal drains
Functional status) the transplant is functionally active (
at the moment Given there is no sign of fluid overload,
portal HTN, coagulopathy & no sign of hepatic
encephalopathy
There is no sign of transplant dysfunction, rejection or
.recurrence of ds
complication of immunosuppression) presence of skin (
thinning with purpura and cushingoid appearance
indicates steroid therapy/ presence of fine tremor &
dm (tacrolimus)/ presence of hirsutism,gum
hypertrophy, coarse tremor dm htn indicates
.cyclosporine therapy
However Presence of some residual stigmata of CLD
like finger clubbing, leukonychia, palmar erythema,
multiple spider naevi on trunk and back ,
gynecomastia, loss of body hair indicates previous
.chronic liver disease
Furthermore there are some pin prick marks on finger
tips,diabetic dermopathy, increased BMI is suggestive
.of NASH as underlying aetiology of cirrhosis
Presence of Dupuytren contracture and parotid
enlargement are suggestive of Alcohol intake as
.underlying aetiology of cirrhosis
Presence of tattoo and needle marks (i/v drug use)
photosensitive rash -porphyria cutanea tarda(hep c)
palpable purpura and livido
reticularis(Cryoglobulinemia) are suggestive of chronic
hep b and c infection as underlying aetiology of
.cirrhosis
Presence of excoriation mark, xanthelasma,tendon
xanthoma, and hyperpigmentation are suggestive of
.PBC as underlying aetiology of cirrhosis
Presence of bronze pigmentation,
arthropathy,fingertip skin prick suggestive of
.haemochromatosis as underlying aetiology of cirrhosis
Presence of KF ring, abnormal involuntary movements
suggestive of wilson's ds as underlying aetiology of
.cirrhosis

BP
doing
& Bedside urine
Fundoscopy
looking the observation chart
Alcohol intake
Hep infection ,jaundice, i/v drug use or blood
tranfusion
pruritus
Joint pain and pigmentation of skin
Involuntary movements
Drugs
I ll request for
Liver function test, including PT
USG of W/A
Ciclosporin and tacrolimus blood level
Renal Transplant
has ESRD with Renal Transplant which appears to be
functioning well as evidenced by
Current mode of RRT) A scar in the rt iliac fossa which (

overlies a smooth firm and nontender mass with dull
.percussion note over it
Previous mode of RRT)There are scar marks on the (
chest wall for previous sites of vascular access for
hemodialysis. And also there is a non active non
.functioning arteriovenous fistula In left forearm
Functional status) the transplant is functionally active (
at the moment Given there is no sign of fluid overload ,
no stigmata of uremia and absence of other signs of
.active renal replacement therapy
complication of immunosuppression) presence of skin (
thinning with purpura and cushingoid appearance
indicates steroid therapy/ presence of fine tremor &
dm (tacrolimus)/ presence of hirsutism,gum
hypertrophy, coarse tremor dm htn indicates
.cyclosporine therapy
However there are some pin prick marks on finger
tips,lipodystrophy,diabetic retinopathy is suggestive of
DM as underlying aetiology
Palpable kidney / nephrectomy scar indicating ADPKD
Hearing aid- Alports
Adenoma sebaceum-tuberous sclerosis
Skin rash joint prob-vasculitis
Lipoatrophy-membranoproliferative gn
BP
doing
& Bedside urine
Fundoscopy
Abd pain
recurrent urinary infection
Headache
Drugs
Hep infection,joint prob skin rashs
I ll request for
Renal function test, creatinine urea,electrolyte
Ciclosporin and tacrolimus blood level
:Ascites
has ascites as evidenced by
Presence of some stigmata of CLD that includes finger

clubbing, leukonychia, palmar erythema, multiple
spider naevi on trunk and back there is gynecomastia,
loss of body hair & multiple purpura & ecchymosis as
.consequence of coagulopathy
distended abdomen with fullness of flanks .it is soft
. and non tender
The abd is dull to percussion on both flanks with
.shifting dullness positive
.Fluid thrill couldn't be demonstrated
However I couldn't appreciate any organomegaly &
.lymphadenopathy
There is no sign of fluid overload , no sign of CLD or
.hepatic encephalopathy
BP
cvs
doing
Bedside urine
Alcohol
jaundice
Altered bowel habit
Weight loss
Abd pain
I ll request for
CBC
Liver function test, including PT
Diagnostic paracentesis
USG of W/A
:CLD
has cirrhosis of liver with portal HTN as evidenced by

On exam of abd the is distended with fullness of flanks
& some visible dilated veins around umbilicus i
the spleen is enlarged 6-8 cm from left ant axillary line
..towards rt iliac fossa.splenic notch is palpable
Percussion note is over the splenic area with shifting
dullness positive indicating indicating portal HTN
There is no sign of fluid overload , no sign of hepatic
.encephalopathy
However there are some pin prick marks on finger

tips,diabetic dermopathy, increased BMI is suggestive
.of NASH as underlying aetiology of cirrhosis
Presence of Dupuytren contracture and parotid
enlargement are suggestive of Alcohol intake as
.underlying aetiology of cirrhosis
Presence of tattoo and needle marks (i/v drug use)
photosensitive rash -porphyria cutanea tarda(hep c)
palpable purpura and livido
reticularis(Cryoglobulinemia) are suggestive of chronic
hep b and c infection as underlying aetiology of
.cirrhosis
Presence of excoriation mark, xanthelasma,tendon
xanthoma, and hyperpigmentation are suggestive of
.PBC as underlying aetiology of cirrhosis
Presence of bronze pigmentation,
arthropathy,fingertip skin prick suggestive of
.haemochromatosis as underlying aetiology of cirrhosis
Presence of KF ring, abnormal involuntery movements
suggestive of wilsons ds as underlying aetiology of
.cirrhosis
BP
doing
& Bedside urine
Fundoscopy
Alcohol intake
i/v drug or blood tranfusion
Sleep cycle
pruritus
Joint pain and pigmentation of skin
Involuntery movements
I ll request for
Liver function test, including alt ast alp PT,serum alb
Usg of W/A
Upeer GI endoscopy
:Hepatomegaly
BP
Ext genitalia
Hernial orifices
doing
& Bedside urine
...Examination of this gentleman revealed

He is cachexic and icteric.there is evidence of anemia
.as well
On exam of Abd there is hepatomegaly Which is 4 cm
from rt costal margin at midclavicular line,tender, firm
to hard in consistency, with sharp margin & nodular
surface,upper border of dullness at 6th ICS with
.hepatic bruit
.No other organomegaly or ascites is there
There is no sign of encephalopathy or coagulopathy to
.suggest hep failure
He is euvolemic
So my dx is he has hepatomegaly
However presence of cachexia,anemia and jaundice
.strongly suggests towards malignancy as most likely cz
:Splenomegaly
I’d like to complete my examination by checking.1
BP
Ext genitalia
Hernial orifices
doing
& Bedside urine
…Examination of this gentleman revealed

On exam of abd the spleen is enlarged 6-8 cm from left
ant axillary line towards rt iliac fossa.splenic notch is
..palpable
Percussion note is over the splenic area with shifting
dullness positive indicating indicating portal HTN
There is no sign of fluid overload , no sign of hepatic
.encephalopathy
He is cachexic and icteric.there is evidence of anemia
.as well
However presence of Hepatosplenomegaly with
cachexia ,anemia, and lymphadenopathy suggests
towards Lymphoproliferative disorder as most
possible dx
…Examination of this gentleman revealed .2

. He is anemic
There are widespread lymphadenopathy involving
.cervical and axillary groups
There are also some excoriation marks suggesting
.pruritus
On exm of abd there is hepatosplenomegaly with the
liver edge palpable 3 cm below the rt costal margin at
midclavicular line, non tender,soft to firm in
consistency, with sharp margin & smooth
surface,upper border of dullness at 6th ICS without any
hepatic bruit and the splenic edge 4 cm from left ant
axillary line towards rt iliac fossa.splenic notch is
palpable with dull Percussion note over the splenic
area
There is no Ascites or peripheral edema
However presence of Hepatosplenomegaly with
cachexia ,anemia, and lymphadenopathy suggests
towards Lymphoproliferative disorder as most
.possible dx

BP
Ext genitalia
Hernial orifices
And inguinal LN
doing
& Bedside urine
looking the observation chart including temp chart
Taking history about
Fluctuating fever
wet loss
night sweat
Pruritus
I’d like to request for
CBC with ESR
USG of W/A
LFTs
PBF
Lymph node biopsy
Immunophenotyping
…Examination of this gentleman revealed .3
. He is anemic
There are a symmetrical deforming arthropathy
affecting the small joints of both hands with ulnar
.deviation and nodules in forearms
On exam of abd there is splenomegaly with the splenic
edge 4 cm from left ant axillary line towards rt iliac
fossa.splenic notch is palpable with dull Percussion
note over the splenic area
There is no Ascites or peripheral edema or sign of
.hepatic encephalopathy
However presence of rheumatoid hand deformity with
rheumatoid nodules and splenomegaly makes Felty’s
.Syndrome most likely Dx

BP
Complete Rheumatological exam
doing
& Bedside urine
Taking history
Recurrent infection
Weakness
Joint problems
I’d like to request for
CBC with looking for neutropenia to confirm my dx
*****************
History: Intro
Hi there... My name is Dr. Imam. I m the a specialist
.… register working in this clinic today
Can i start by checking ur detail? U r Mr. Paul
Coling?and u r 62 yrs old..which one u would u prefer
.me to call u?mr. Coling or paul
So paul I m here to hv a brief discussion about the
helth problem u r experiencing recently .we’ll also
discus the management plan towards the end on of the
?session.is that alright
So i’ve come to know u hv had fever ... wd u like to tell
me a lot about what has been going on & why u r here
.today / what made u come here & see me today
Right...i do appreciate your concern.we'll discuss all urs
symptoms one by one..however there is no need to b
alarmed at this stage...we need to take detail history
and do further testing to eliminate certain dx like
meningitis.(should there be any concern regarding
meningitis diagnosis we have excellent treatment plans
that we will implement to get u completely cured). u r
assured that u’ll be receiving effective treatment for
any shorts of diagnosis.all our doctors here will make
.sure u feel comfortable.we'll be doing our best
however..i’d like to go through the history again
.clarifying some details
What i understand u hv had fever for some couple of
days. And u r so concern whether it is something
..serious like meningitis or not
Is there anything else that u wanna address today in ur
clinical appointment? Okay
Now i m coming to ur sympoms
History : H/O present illness
I just wanna go through the history again clarifying

.some detail
What do u mean by funny turn or
.And about the cough can u describe it for me
?How long the cough has been there for
?Has it started suddenly or gradually
?IS it with u all the time or comes on and off
?Is it getting better or worse than before
?Is it there any particular time of the day or night
How about on a scale 1 to 10 is that cough to u 10
?being worst possible
?Does it keep u off work
?Does it wake u up at night
?What makes it worse
?Does anything make it better
Hv u had a pain/ cough like this before?what it exactly
.like this one?what did u do then
Hv u seen ur doc or done any tests for that?taken any
?medication?did it helped
Hv u got any other symptoms like…...is that been there
?for same amount of time
:History
D/D: I’m going ask u some more specific questions
.now
:Systemic Inquiry
I just want to go through any keys changes of ur body
.system, just to find out about ur overall health
Can u tell me, hv u had any unexplained weight
?loss?unusual weight gain
?Is there any fever or any shivering
hv u noticed any lumps or bumps
anywhere?where?how did u notice it?any other lumps
?and bumps elsewhere in body
Can u tell me do u hv a headache?hv u seen ur doc for

?the headache
?Any problem with memory or concentration
Hv u ever hd weakness or unusual sensation of any
?part of your body?any walking difficulty
Ok so how about ur vision?Did u experience Watery
eyes? Do u think u had any redness of eyes?so do u
?wear glasses
What about ur nasal passage Do u hv nasal blockage?

Any sinus problems? nothing like that? Ok
.Any issues of the chest
any pain in ur chest-
do u hv a cough-
?difficulties in breathing-
?do u ever feel ur heart is racing or thumping-
?ok so can u remember if Hv u ever had blackouts-
?are ur feets swollen-
.…And about ur tummy
?is there any tummy pain at all -
?difficulty in swallowing food or water-
.What about ur taste?do u enjoy ur meal-
?do u feel sick? Do u throw up-
hv u ever noticed yellow discoloration of eyes or -
?urine
ok may sound awkward but have to ask u about ur -
?bowels, working alright? Is there any recent alteration
any unusual bleeding from any of ur orifices??great-
what about ur water works?are u passing more /less -
water than u used to? high colored urine or frothy
.urine?excellent
Now tell me about ur joints movements, do they move

freely?do u feel any joint pain
?or stiffness
?ever felt difficulties in combing hair/climbing hair-
hv u had mouth ulcers-
what about ur skin?any recent color changes or -
..rashes or nail changes?great
Do u hv preference of hot or cold? which one do u
?prefer
:Medical Hx
.I want to talk about your health issues
Hv u had any long term illness?like
?High BP
?so u hv high BP?ok...when was it dxed-
?is it well controlled-
when was it last checked?everything was -
.great?perfect
Any other long term illness?high blood sugar?u
?do?alright
?when was it dxed -
do u know what type u hv?(one with tabs or insulin) -
.ok so u hv ur tabs
so when hv u had ur last check up?were they -
.happy?ok
?Lipid prob or heart prob which one do u hv
?Hv u had any gland prob or hormonal prob
:Family Hx
Do any of ur family members ur mom, dad or siblings,
has any of them had any long term illness? Had anyone
had cancer?perfect
:Surgical Hx
Now I'd like to review your surgical hostory.hv u had
any operation in ur past?Alright.could ur recall?Any
?blood transfusion
:Hospitalization
?Ever been Hospitalized before
:Drug Hx
.Lets talk about your medication
Do u take any prescribed medications?i know u hv high
BP and high BS.what r the medications u r on right
.now
R u taking all of these medications regularly?excellent
?Any side effect of them
.Any recent changes in dose of medications
Any over the counter medications or herbal
medication hv been taken? Great
I hope u wont mind me asking, hv u ever taken any
?recreational drugs
?Hv u got any drug allergies
:Allergy Hx
Allergic to anything other things like dust, any food like
nuts or any other env agents at all?brilliant
:Travelling Hx
?Any recent travels abroad
?Where?for how long did u stay there
?What was the reason for your travel
?How frequently were u required to travel
?Was it a rural or urban area?where did u stay
?From where did u manage food and drinking water
?Did u swim in local pool
?Did u hv any insect bite at that area
Was there any endemic ds prevailed at that time?Did u
?taken ur anti malarial medications before travelling
hope u wouldn’t mind me asking u some personal
?ques?hv u had sex with local girls
:Sexual Hx
Would u mind me asking u some personal questions
?Are u in a relationship
?May i know is it a male or female
?How long have you been living together
?Do u use protection
?Have u or partner ever beee. tested for HIV
Any other relationship or casual sex apart from ur
?regular partner
:Social History
Soooo if u don't mind i just want to ask u few personal
ques.and a bit about ur social background is that
?alright
Do u smoke at all?can i ask u what do u smoke?how
many ciggs u go through a day.and for how long you
have been a smoker?alright.hv u ever thought about
giving up?u dont want to consider that at the
moment.when u are ready, we r always here for u. we
hv got support strategies to help you. so whenever u
feel u’d like to talk about quitting smoking we are here,
.just to let u know
Going to talk about alcohol intake....do u drink?what
do u normally drink.ok.and how much wine do u drink
?a day
Tell me about ur diet.wonderfull.do u exercise?If u find
some time it wd b really relaxing and it suppose to help
.u.its good for ur blood sugar as well
Can i ask u about ur mood.how are u feeling today?no
low mood?no sleep prob?everything good?excellent
What about ur occupation.what do u do for living?hv u
ever been exposed heavily to dust or any other
substances at ur work? Coping well?u happy with ur
.work?no stress?everything good?perfect
U said u hv GF.u live with her?/ who do u live with at
.home?right and u r living happily?no stress?excellent
Do u live in a house or flat?how many flights of stairs
?do u need to climb
.Any pets at home?alright
Let me sum up all this info if u dont mind and plz

.correct me if i got anything wrong
Hv i missed anything imp?wd u like to add anything
?else
History: discussion
D/D: From what you have told me today, there could

be a few possible reasons for the backache that u have
...been experiencing...including
However ,A thorough examination is required along
with some further tests to reach our dx and to make
sure that there is no serious issues/something else is
not going on.we’ll do it as outpatient. U do not need to
.be admitted to hospital
PLAN: today I will examine you and we’ll send off some
blood tests before u leave the clinic and also to do a
xray to hv a look at ur back bones.../u’ll get a call
letting u know the next date of appointment/ date for
the telescope test...and then we’ll arrange to see u
back in clinic with the results...depending on the test
results we’ll b able to advise on treatment at our clinic
or by referring u to a respective specialist..is that ok
?with u?is there anything u’d like to ask me
Check:Hv we covered everything that u r concerned

about? Are there any other problems that u’hv been
.having that we hvn’t covered today
Further plan:if u hv any problem in the meantime just
give a call to the clinic they'll b able to notify one of our
.doctors to discuss any issues with you
.Goodbye. See u soon with the results
UK ; Luton and Dunstable

St 4. 89 year old, k/c of A. Fib and past Hx of TIA
admitted with Stroke, missed his last appointment at
INR clinic. INR on admission was 1.2. Task is talk to the
daughter and explain act Scan findings, need for
patient to be admitted in hospital
St 5. BCC 1. Myasthenia with thymectomy scar. Typical

.case
BCC2. Diplopia for 3 days then resolved. I gave d/d of
M.S, tia or stroke
.St 2
Patent k/c of bipolar, hypothyroid and HTN. Presented
with nausea and gastritis, upper GI endoscopy shows
mild erosions, USG abdomen shows no abnormality.
But GP found out that she has got raised calcium levels.
Rest was typical history of hypercalcemia. I gave d/d of
parathyroid hormone secretion/adenoma, paget, CA
lung, vitamin D toxicity. He still wanted to know
something but I have no idea what. Further in history
patient said she does not have any hypothyroid
problems and wasn’t aware of this problem
.St 1
Abdomen - jaundice+splenectomy, no ascites d/d of
sickle cell, spherocytosis, malaria, leukaemia
Resp was right sided scar (smaller than lobectomy)
coarse crackles not changing character. I gave COPD
woth bronchiectasis but examiner convinced
.St 3
Neuro ; fascioscapulohumeral
Cardio ; was MR
Hi all 3rd carousel blue selayang 17.4 2017

Respi lung fibrosis sec to scleroderma
Abdo ballotable both kidney, mild splenomegaly, a bit
jaundice and pale
Neuro bilateral ptosis MG
Cardio DVR
Hx talking pt with t1dm presented with weight loss and
recurrent hypo. Also got dyspesis symptom
Blood test egfr 34,hb10,hba1c a bit high
Comm skill breaking bad news pt cxr have mass,
counsel for bronch, ct thorax etc
Bcc1 pt ihd dm got unilateral ptosis and double vision 3
days
Bcc2 dermatomyositis
My experience of PACES 01.04.2017 MALTA

I started with station 2 : 24yrs old lady c/o fatigue and
headaches found to have high BP 160/98 on different
occasions. No family hx , no
complications.....examiners asked would you start
treatment...i said not now if secondary causes r/o
including white coat htn then yes. Discussion about
.secondary causes of htn and investigation
Got 20/20
.management
Got 16/20
Station 4: talk to the wife of 50years man known MND
recurrent admissions for pneumonia. This time
admitted with aspiration pneumonia not responding to
anti biotics and confused. Discuss with her his
told that i did not told about NIV when the wife asked.
Got 15/16
took hx all joints pain including hand joints. Surrogate
told she was told by GP that she has double joints. I
was more confused...asked what u mean double joint
she said i dont know gp told me that and he was not
sure.i examined no sign of inflammation. Raised skin
dorsum of hand elastic . Checked functions. Found
high arched palate. Joints hyperextensible.arm lenght
normal. Gave diff of marfans pseudoxanthoma
elasticum forgot to tell ehlers danlos syndrome.
Examiner asked were there marfanoid features i said
no. I wanted to examine chest they stopped me asked
what u want to see i said AR....they said normal. Asked
how you investigate joints in general...started with
inflam marker RA factor ACCP...time finished got 28/28
nd cast st.5: believe me i totally forgot....got 23/282

over mid line laprotomy scar below umbilicus. Shifting
dullness+ could not appreciate any organomegaly or
mass due to tenderness. Differential ...causes of ascites
asked about causes of transudative ascitic fluid....got
8/20

Got 20/20
Wish success for all you going for PACES......my advice
is to perform during exam in relaxed way, smile and
forget about any station where you did not perform
.well
My experience
PACES 1/2017 Yangon center
Delayed Dx of phaeochromocytoma
Examiner asked acceptable delay or not
She wanted the following reasons
1. Different presentations of the disease
2. Episodic in nature
3. Rare disease
I explained surrogate only no 1
14/16
Station 5 BCC 1
Common case Graves' disease presented with
palpitations and grittiness of the eyes
BCC 2
Pt at rheumato clinic for knee pain , UL hypertension
presented with reduced urine output
Higher diclo dose by herself
also taking ACEi
I couldnt organize the case very well
Gave dx of AKI due to NSAID
Forgot to tell abt Interstitial nephritis
25/28
Staion 1
Resp Collaspe with effusion Rt
Ddx TB vs Malignancy
Abd Polycystic kidneys with no evidence of RRT
Q. Ddx of abd pain in PCKD
Infection , cyst haemorrhage and also Traumatic
rupture
Station 2
Yg lady with IBS presented with worsening pain and
diarrhoea
not respond to antispasmodics
Stress factors (+)
Alarm features absent except Noctural diarrhoea
So gave DDX Coeliac . Crohn s . Other malabsorptive
disorder . Infection. Endocrine
Invx Examiner ask abt inflammatory vs
noninflammatory
how to exclude ddx infection
Station3
Neoro
Yg man with bilateral foot drop and minimal sensory
disturbance
Motor dominant PN
Ddx GB syndrome
Forgot to do LP
19/20
CVS
MR AR
No peripheral sign of AR except
Collalpsing pulse
Possible cause of AR in Middle age man
What do u want to look for in Echo
Examiner wanted LV size assessment
Passed with a total score of 166/172
I think practice and patient centered approach is very
important.
Hope my experience would be some helpful tips for u.
Thank u all who ve shared their experiences which
indeed helped me during preparartion for PACES.
Myanmar. PACES 1/2017
I started with St1.
St1 Resp: COPD with bronchiectasis
Examiner Q: DDx. Investigations. 18/20
Abd: Massive hepatosplenomegaly with
anaemia and tinge jaundice (Haemolytic
anaemia - Thalassaemia, Thalassaemic face+)
Examiner Q: Complications of Thalassaemia,
Findings in blood film, Managemant 20/20
St2 young hypertension - conn's $
Examiner Q: DDx, Investigations for Each
Differential 18/20
GP refer the Young female patient with
hypertension for furthur invetigations and
managemnt. Serum electrolytes, urea, creatine
all normal. Urine REME shows proteinuria and
hematuria.
The only symptom patient has is fatigue,
headache, h/o of fever (?viral illness) few weeks
ago.
No urinary symptoms like frothy urine,
hematuria, or color changes, difficulty in
urination, frequency etc. no leg oedema, no
puffy face. So I asked how about in the past, still
no.
As she has headache, I excluded
phaeochromocytoma. No palpitation and
sweating.
For APKD, no family history, not an adopted
child, No abd distension or pain, not notice any
mass, as she has fever asked about symptoms
of UTI which which is absent.
Symptoms of glomerulonephritis and causes -
Nil
No rash. No hepatitis h/o B,C infection. Slight
loss of weight (but Pt dun know exactly how
many kg) but no loss of appetite. No lumps or
bumps anywhere.
Exclde systemic sclerosis, Cushing,
acromegaly, thyroid problems etc.
No past medical history.
Nothing got from system review.
No family history of note.
Drug history -Not on any medication and no
allergy to medication.
So with no significant symptoms, I gave Renal
artery stenosis and Conn first.
Glomerulonephritis (Because of asymptomatic
proteinuria and hematuria, I gave it second
defferential). Vasculitis, Takayasu one of the
possibilities as she has headache.
Examiner discussed mainly about Conn like
how will u diagnose Conn. I answered I'll chek
renin which will be low and aldosterone will be
high. K can be normal in >20% (As the senario
gave normal potassium).
And then Differentials n Investigations related to
DDx.
St3 Cardiac: Combined AS and AR
Examiner Q: Which one is dominant? Finding in
Echo, Severity, Causes of AS and AR in this
patient, Surgical role in this patient 20/20
Neuro: Flaccid paraparesis with Motor and
sensory involvement
Examiner Q: DDx, Causes, Management 20/20
St4 80yrs old male with right sideded weakness.
CT - cerebral infarct. INR 1.2. Past h/o of
recurrent TIA and AF. Missed follow up for AF.
Task - Tell the CT result, management plan,
admission to stroke unit and answer the pt
concern. (You are doctor at emergency
depeartment) 13/16
St5 BCC1 Upper GI bleeding d/t NSAID (pt has
back pain and on examinatin signs of
Ankylosing spondylitis +). He is also alcoholic.
Abd exam: mild hepatomegaly. Also gave
alcoholic hepatitis as differential. 22/28
BCC2 peripheral sensory and moter neuropathy
with DM and its complications, Taking
metformin and currently on treatment for TB
(HRZE). Patient is vegetarian ( I missed to asked
about it 🙈) 20/28
Passed with total score of 151/172. Hope my
experience helps u all.
And also thankful for this group as it is so much
helpful while preparing my PACES
Thanku to every member of this Group

,AulhumduliAllah ,Allah has passed my Paces MRCP
(UK) exam in first attempt. I learnt alot from every
people here really.
I want to share my experience which I took in
Birmingham Sandwell General Hospital.
Abdomen; PCKD .
Respiratory; rt pneumonectomy
CVS; MVR with AF.
Neuro; Charcot marrie tooth Disease
Hx; young lady with peristent reg. palpitations ( DDX
clinically hyperthyroidism, sinus tachycardia, AF,
SVT, Functional ).
CCS; Ptn with PE ,counselling him regarding start of
warfarin. Addressing his concerns huge list.
BCC 1 Obese young male with acanthosis nigrican in
arm pits having uncontrolled BP .He was non
compliant to Rx.(DDX rule out pri and sec cause of
Htn most probably Cushing synd).
BCC 2 Young ptn with CD having colostomy bag in
RIF Having chest pain (DDX ACS, MSK pain,
PE,GERD).
.
My experience
Mater dei hospital on 2 April
At 9 am
St 4
I entered the room
time to do delirium
before
from him
mother
Said I don't know
developed this
And what treatment
What about future
Concern
state
her

He said yes
hurt her self
no

room
hurt her self
no

room
!!!Hi guys
I recently passed my MRCP PACES exam, thanks for
God, and I’d like to share my experience of this exam
.with you
My duration of the preparation was about 5 months,

on average of 2 to 6 hours of study per day. I took
about one to two days off every week. I read few
books, subscribed to online pastest videos and
.studying materials and attended three courses
Regarding books, my personal advice is as the

:following
Station 1&3, read it from Cases For Paces, with back •
up support from Manual of MRCP PACES (by pastest)
and from oxford speciality training, along with revising
.the videos on pastest website
Station 5, read it from Manual of MRCP PACES, with •
back up support from oxford speciality training. Do not
forget to revise station 5 videos on the pastest
.website. They are really useful
Station 2, mainly from Ryder plus revising differential •
diagnosis from oxford speciality training and videos on
pastest website. In addition, it is a good idea to have a
.look at station 2 samples on the MRCPUK website
Station 4, mainly from Cases For Paces. The ethics •
and the communication principles are written in a very
nice way in this book. The other thing to do to prepare
for this station is to practice station 4 scenarios
available on the MRCPUK website along with the
.videos on pastest website
In addition to reading books, attending courses and

practicing with a study partner is a must. I did practice
with a colleague in the last one month and a half
before the exam. Also, it is a very good idea to
dedicate about one hour a day in the last month before
the exam to practice the examination techniques
either on your friend or on your partner. By doing this,
in the exam you will look professional, confident,
.thorough and sleek in your examination skills
The other useful thing that you can do is to download

the PACES marking sheet from the MRCPUK website
and to try to fulfil all the criteria required during your
.revision and your practice
:The courses I did, which I found worthy and useful, are

Pastest course: 4-day course in London •
PACES4U course: the first day was station 4 and 5 •
.teaching, and the second day was a mock exam
Ealing course: 2-day intensive course in London •
As far as station 1 and 3 are concerned, there is an

important tip to follow. Sometimes in PACES exam
spotting the diagnosis is not enough to pass. In other
words, it is not sufficient at the level of MRCP
candidate as a fifth year medical student can spot the
diagnosis as well. I am going to give you an example
just to make it a bit clearer. If in the respiratory station
you find a case of pulmonary fibrosis, it is not enough
to say to the examiner this is a case of pulmonary
fibrosis. You have to show to the examiner that you
look for the underlying cause, for instance, any signs of
connective tissue disease in the hands. Also you need
to look for any possible complication that you can pick
up by the clinical examination, such as signs of
pulmonary hypertension (loud P2 and right parasternal
heave) and signs of cor pulmonale (raised JVP and
pedal oedema). Thus, when you present your findings
to the examiner, you mention the positive findings
which lead you to the diagnosis of pulmonary fibrosis
and to mention the important negatives. So, you can
say this is a case of idiopathic pulmonary fibrosis.
There are no signs of pulmonary hypertension or cor
.pulmonale
I hope that this information is useful and good luck for

.you all
I had my exam there cases were very straightforward

station 5 diabetic retinopathy he had all the
complication of diabetes like peripheral neuropathy
ischemic heart disease etc so I ran out of time a
bit,bcc2 was thyrotoxicosis with a solitary nodule it
was very easy. Abdomen was kidney and pancreas
transplant with lots of scars he was blind of one eye
with vitiligo so diabetes was a reason for the tx.
Respiration was bronchiectasis. History was PUO. Cx I
couldn't understand it was bbn with lung mass but she
didn't know that so I messed it up.CNS was cerebellar
syndrome. I cannot recall CVS good luck
My UK exam exerience, Hull (18 March, 2017)...I

started with station 5, my first case was an old lady
with a skin rash. As soon as I set my eyes on her, I
quickly figured out that she had extensive scaly
maculopapular rash affecting her head, face and trunk.
Hx>>>Long standing for almost 20 years, Worse on
exposure to sunlight, no itching or pain, now getting
worse, drinks alcohol. I examined her elbows and back
of the years as well as examined for arthropathy. Viva
questions were about diagnosis, differential diagnosis
and management. I got 15/28 😳
Next ST5 second case was a lady in her fifties who had
elevated ALT on routine examination and had some
painful periods. Nothing else of note. No findings on
examination. Questions were about diagnosis,
differential and management. I told them that it's
most likely Non-alcoholic fatty liver disease, other
differentials were alcoholic liver disease but I told the
examiner that in that case, I expect AST to be higher
than ALT as well as high GGT. Other differential I said
could be autoimmune hepatitis. She asked what
investigations....? ASMA....I got 14/28😳😳😳
Next I went for respiratory st. An old man, actually
there were no significant findings on auscultation. But
thanks to Dr. Magdy, I was thorough in clinical
examination, therefore I missed the diagnosis but still
got 9/20. It was COPD but don't know how, (perhaps
in exam pressure) I said Interstitial lung disease. My
viva was about causes and managment of ILD.
Next I went to Abdomen. Patient had gum
hypertrophy, Tremors, PD catheter mark and as scar in
Rt. iliac fossa with a nontender underlying mass. My
diagnosis was a kidney transplant. Viva questions
were about what modality of dialysis was he on, I said
PD. Then what meds he could be taking, I said
Cyclosporin because he has tremors and gum
hypertrophy. He asked are these side effects only
because of cyclosporin. I said they are a common side
effects of any calcineurin inhibitors. Then, he asked
me if this pt came with fever and abdominal pain, what
could be the possibilities? I said Infections., UTI etc etc.
He asked me could he be rejecting? I said yes, but in
that case the graft will be tender. How will you
investigate rejection? again, thanks to Dr. Magdy, I said
blood works, including routine CBC, renal profile etc,
special such as cyclosporine levels and imaging Renal
US and possibly a kidney Bx...I got 19/20
Next was History, a man in his 40s, on multiple meds,
had A.Fib on warfarin and a number of other meds
including simvastatin, IHD, c/o difficulty walking.
Initially I thought, it was ?Stroke, but he had difficulty
climbing up stairs as well as coming down, generalized
body pains, shoulders, legs etc. I thought of
Polymyalgia rheumatica but his age was against it. I
thought of proximal myopathy, Cushings,
hypothyroidism but no features to suggest them. I
could not tell a unifying diagnosis, and forgot to stop
his statin. But I told the examiner that he needs
physio, stop statin and investigate for the above
causes. I got 10/20☺️
Next I had neuro: Again messed up. A freightening
case, a lady sitting in a wheelchair with short hands
and lax skin, having right sided weakness of all muscle
groups and depressed reflexes but no sensory
affection. I said MND😔 But when he asked me what's
against MND, I said unilateral signs. He said where is
the lesion, by that time I had realized what mistake I
had made. I said cervical spine...Examiner was looking
at me, then he asked me if I had seen the back of the
......neck, I said no. He asked me to do so. AND
There was a scar at the back of the neck.....😔😔Got
10/20 Next cardio,
Here I would advise candidates who think in UK, an old
white man >>>thnink of aortic valve, young female
>>>mitral ....THIS CONCEPT IS WRONG and
Decieving....It was an old white male, but his first heart
sound was metallic with central sternotomy scan. No
murmurs. Thanks to Dr. Magdy for giving us an
excellent opportunity of cardiology practice. Exam
questions were: Diagnosis, MVR. Valve functioning
well? Yes, management, anticoagulation. Indications?
Got 19/20 Last, I
had ST4. Task was to talk to the son of a patient who
was started on Amiodarone for V. Tach and now
admitted with pulmonary fibosis. He was insisting why
it was started if it could harm him. I showed empathy,
told him that I can completely understand his feelings,
and he is feeling so because of his love and care for his
father. Let me tell you that when the drug was started,
it was given to him in his best interest as the other
alternates are not as effective as this drug is. He said
my GP never informed us of the S/E. I said I was not
part of the team when it was started, so don't know
exactly what happened. Will look at the charts and get
back to you. Let's look forward now and see how we
can help your father. I asked his whether his father's
bedroom is on ground floor or he has to climb up the
stairs, who lives with him, how he used to manage his
activities of daily living prior to admission, and offered
him all the social support. I got 16/16
My overall score was 112. Didn't pass this time and I
.think my actual problem was station 5
calcutta , India -
sta1 . res - rt. pl effusion
abd - hepatomegaly with splenectomy
(heamolytic anemia)
sta2 . HB- 9.8 , c/o fatigue ?nsaid induced
sta3 . cvs - MS
cns - spastic paraplegia
sta4 . open TB , wants to go DAMA
sta5 . a) TIA
b) goiter with hyperthyroidism
Calcutta , India -
st1 liver transplant.
Chesy old with ILD in RA
Sts changle bowel habbit
St3 hemonymous hemianopia examine cranial n
Cardio biological valve with mr ,phtn
St5 bbn SAH with INR 4
St 5 takayasu
sta 2 - Hemtatemsis nsaids vs crohns
3rd carousel blue selayang 17.4 2017
Respi lung fibrosis sec to scleroderma
Abdo ballotable both kidney, mild splenomegaly, a bit
jaundice and pale
Neuro bilateral ptosis MG
Cardio DVR
Hx talking pt with t1dm presented with weight loss
and recurrent hypo. Also got dyspesis symptom
Blood test egfr 34,hb10,hba1c a bit high
Comm skill breaking bad news pt cxr have mass,
counsel for bronch, ct thorax etc
Bcc1 pt ihd dm got unilateral ptosis and double vision
3 days
Bcc2 dermatomyositis
Station 2 very tough. I just put pt hypos possibly
1.MEN-insulinoma and gastrinoma
2.advance CKD
3.overdose
Bcc1
Complaint of diplopia 3 and double vision
No sign stroke
DM well controlled.
HPt controlled
Meds antiplt, OHA, antihpt
Possible dx
1.cva
2.mononeurtis multiplex
3.MG
4.TIA
Oman center on 10/4/2017...
Chest case Bronchectesis
Abdomen case Renal transplant
History
Cystic fibrosis
Cardiology MVR
Neurology HSM PN
Communication
Renal biopsy from SLE
Station 5
BCC1 Diarrhea in Rhumatoid and psoriasis
BCC2 Goiter
Sudan- Khartoum-- 9-4-2017-
Station five AF for dd
Station bcc 2scleroderma
Abdomen transplanted kidney
Chest double pathology???fibrosis and effusion
wheezey
CNS proximal weakness
CVS valve replacement
History IBD
Communication counselling regarding warfarin
Edinburgh - centre Glan Clwyd Hospital in Rhyl-

Wales
1.a) Abdo- multiple abdominal scars which
looked like renal transplant scars but no kidney
underneath palpable. AV fistula which was
buzzing and looked like had been recently
needled. Could feel a retro peritoneal mass- said
it might be a polycystic kidney. Also had
parathyroidectomy scar. Was asked for Mx. Said
U&E , Doppler US of abdomen. Then bell rang. I
thought this station was a disaster and would
fail. 16/20
1 b) Resp- 65 yr old man reading newspaper.
Only finding was some crackles R>L and
perhaps a dull left lung base. My DD's were ILD,
Bronchiectasis and pleural effusion. Said would
start with CXR then HRCT. Examiner directed
discussion towards dull lung base. Reasons,
lights criteria and cut of of pH for empyema.
Thought I had failed this as well as was not sure
about the dull lung base and this obviously was
the diagnosis. 18/20
3 a) Neuro. Elderly lady in wheelchair. Examine
LL. Asked if I could see her walk. Examiner said
not needed. B/L increased tone L>R, B/L
Proximal weakness in pyramidal distribution.
Knee jerk increased. Ankles N. plantars
equivocal, coordination N. Sensation N. asked
to check coordination in upper limb as pt was
having problems lifting legs. Examiner said its
LL examination. Anyway when i was presenting
my findings he started asking me questions
about reasons for cerebelar dysfunction. Did
not give me chance to give my diagnosis which
most likely was spastic paraparesis. Was not
sure how i had done. Got 13/20
3.b) metallic MVR with AF. Pt tachycardic. Was
expecting atleast 18/20. Questions- if this pt
came With SOB- what would your dd's be. Got
14/20
2. Hx. 30 yr old female with palpitations.
Recently had a baby. Fx hx of some auto
immune condition. Dx- post partum thyroiditis.
Was expecting 20/20. Got 16/20
4) communication skills: elderly lady with end
stage heart failure and new renal failure who
has just died. While going through notes you
notice that she was earlier on digoxin which
was stopped due to renal failure and new
bradycardia. However this was inadvertently
started by the on call team. Tell this to pts
daughter. I told her what had happened.
Apologised for mistake. Told her would do
incident report and RCA. Try to ensure this
doesn't happen again. She asked if the digoxin
could have killed her mother. I told her that this
might have been the immediate cause although
her heart was already in a bad way. Told her
would inform coroner about this. Key point -
apologise, be honest about drug error possibly
being the cause of death. Got 14/16
5 a) 60 yr man with weakness and pain in L hand
. Worried if it could be TIA. I did not have a clue
till I started examining. By fluke, I felt pulse in
both hands and noted absent radial pulse in L
hand. Went up and absent brachial as well. Told
DD as Takayasu's and examiner frowned and
asked what else. Said subclavian steal
syndrome and he gave me the thumbs up. 28/28
5 b) Gp referral for pt with dizziness. BP 130/80.
Hx of diet controlled diabetes. On asking pt
gives hx of postural hypotension. And if you ask
about standing BP , examiner tells you its 90/60.
If you check medications, then on 4 anti
hypertensives. Acei, bisoprolol, alpha blocker
and calcium channel blocker as well. So told pt
will stop both alpha and calcium channel
blocker as pt also had ankle swelling. 28/28
Bangalore. Manipal ..7/4/17

st2...Anaemia (MHA.) H/o ibs 6 yrs on
peppermint oil,occasion leg swelling,ho rta and
nsaids ,father died of cancer colon,mother
taking inj.3 monthly for anaemia,so many
issues, ,DD was so many
issues..coeliac..nsaids, ,ulcer
barrier was prob. I didn't understand what he
told about sensation, ,planter was very
confusing, ,Indian examiner didn't tell anything!
!
sided chest pain.. o/e Dec breath sound.rt
mid.dd was ptx,pul embolism, ,pneumonia. It
was good
St5 female was increase weight,,increase
bp,,,and proximal myopathy, ,o e no thyroid
oedema, ,dd,was cushing, ,hypothyroidism,
metabolic syndrome, ,discuss was on cushing. .
Malta center 2April2017

S2
Drug Hx
FHx adopted
Social negative
Concern is it epilepsy .
regurgitation.
S4
.
S5
fever
...........
Other case

Bcc.Abdominal pain for 2 days, fever and oligiuria
known DM. ddx
CNS: Lt hemiplegia
CVS: systolic murmur with AVF machinery mur mur
Resp: LL BBS+crep ddx think lower zone fibrosis or
consolidation
overload.
NEUROPATHY.
Chennai Day 1 -11.45 am cases
Pheochromocytoma telling the diagnosis to patient
station 4.
Bcc 1 diabetes and UTI, bcc2 diabetes and loss of
vision - funds examination.
abdominal pain. Cardioloy AS / HOCM ? Associated
MR also. Neuro b/l cerebellar signs with absent
reflexes .. best of luck to all of you
history. Cough for 6 mts SOB. Bird fancier lungs.
BCC1 seizures.
3/4/17
Station 2
months. She has fever on and off but no night
sweating weight loss of 6 kg within 6
antibiotics without improvement.
During childhood she has asthma which improved.
Not smoker or drinker. But unfortunately the
diagnosis was extrinsic allergies alveolitis. I miss birds
at home.
Station 3
Neuro
Is parkinson plus CVA. Rigidity only on distraction
so I put parkinsonism plus CVA reflexes was
exaggerated on the right upper limb only no tremor.
Stations 4
Station 5
bowel four times.
stiffness less than 10 minutes. It was osteoarthritis no
other significant history of skin rashes or other joint
problem except back pain occasionally.
Stations one
dialysis. Polycystic kidney is common in chennai take
care it mimics hepatosplenomegaly..
Mohamed Fadel
Thank good
I pass my exam in chennia India
It was tough one with very atypical clinical stations
Abd : middle age male with active fistula + LL odema
No signs of fluid over load
Not on anti rejection Med
Ploysystic kidney disease
With cystic liver
Q.2 did u see the rash ️ ️ now clue if there was
any
Q.3 what can cause liver cirrhosis in this pt 😅 😅
( worst station got 14/20)
I think the rash is lichen plans with HCV I do not
know
Resp:
Middle age man again active fistula
With hyperinflated chest
Tar stain in fingers and teeth
With no wheezes only fine Basel crip
Not changing with coughs
Copd with lung fibrosis
Q.2 how would you like to investigate Q.3 any
relationship between his lung problems and dialysis
First thing 😔 😔 may be Med then saved by the
bell 🔔
( one of the examiners was sitting on his chair at the
foot of the pt
I asked him to move politely and even moved his
chair to sit far away 😅 😅 😅 got 17/20
Mohamed Fadel
Station 3
Cardio
Middle age female again active fistula in right arm
Exam
Obvious Lowe limb edema
Raises JVP with v wave
Obvious apical pulsation
No thrill ,LPH
Irregular pulse
Loud s1
Could not ass the 2 heat sound coz of the fistula thrill
( which irritates the examiner 😂 ️)
Diastolic murmur in apex
And hypothetical tricusp reg
Q1.what is ur diagnosis
Q.2 what r the causes of MS
Any congenital MS syndrome you know
I answered lutinbaker 🙃 🙃 🙃
Got 13/20
CNS
Straight forward
Pt presented with dysphasia
Examine LL
Young male with CVA posture
Q.1 what is the lesion
Q.2 where is the lesion (subcortical)
Q.3 how to investigate and mage
( Indian male not understanding English lot of time
missed in translations, I couldn't not ass the pulse
heart or cranial nerve or ask pt to walk but I told
examainr I want to do so )
Luckily I got 20/20
Mohamed Fadel
Station 4
Common scenario
Young male with ulcerative colitis un controlled with
mesalazine
Then pt afraid. From steroid as he read about side
effects
Involved the GP
Conserns
1) for how long you will use steroid
Ans
Until we control the disease the dec dose till we reach
remission with minimal dose
2) I want to use herbs 🌿
Ans
Sorry but I can't be sure what will be the effect on
🌿 on the disease course or how it may interact with
steroid
( DR.zain advice never say no to stupid thing pt want
to do just smile and give all options to him and then
till him ultimately you may hurt your self)
Discussion
1)anemia
Which type
All type
Norm normo (of chronic disease)
Megaloblastis ( fe + b12 malabsorption)
Iron deficiency ( due to blood loss)
2) colorectal Ca
3) what kind of diet you will give him
I tried to be smart ️ ️ ️ I will refers to dietitian
Then agin what diet
I told him high fiber diet 😆 😆 😆
He asked me ru sure 😅 😅 😅
Yes sure
I got 20/20
Mohamed Fadel
Station 5
I was 😁 😁then 😵 😵 😵
1 st case
Unilateral limb swelling
All vitals are stable
I put diff of cellulits + rupture beacker test
And I entered
To very young male
Again on dialysis 😗 😗 with permicath
With chronic limb swelling over 5 years
Pain less with strange knee joint
No history of insect 🐜 bite ??
I examined the limb
Slightly pitting
Not hot or tender I examined inguinal
LN ️ ️ ️
I asked pt to walk then sensation
Examiners escip and normal respectively
There was parathyroid scar
Concern by relative
1) is it related to dialysis should we increase the the
dialysis frequency
I answered not related and best to talk to your kidney
specialist if you have any concerns regarding dialysis
2)What is the cause
It most likely due to lymphatic obstruction
We need to start to do some test to know exact
cause 😌 😌 😌 😌 and he do not need admission
Examiners
Q 1.what is cause of swelling
Lymphodema
Q 2. How would you like to investigate him
Stupid answer lymphogram
What might be the cause in this country
With more stupid smile
Chagass disease ( how stupid you may become in
exam
Totally forget flaria) where Chagas come from
Saved by bell 🔔
Got 18/26
2nd case
Totally straight forward
Bilateral limb swelling in HTN
I put differential
Then went to role out serious complication of HTN
There is decrease frequency of urination
With drug history on
Nefedipine for one year
Complain also from ️ headache
Plan of management
Admit the pt
Switch nefedipine to other Med
Doing some test and scan to ur kidneys
Those were the answer of the concerns
Examiners
Q1. How to mange pt
Education, stop medications switch to other Med,
elevation of the foot
Q2. What Med you will give pt
I said ACI
Why not diuretic
I said not recommend as pt having dependent odema
+ there no evidence of fluid over load
I got 24/26
Mohamed Fadel
Station 2
History
Middle age female newly diagnosed HTN
With persistent high reading
Approach with systemic manners
No symptoms suggestive of end organ damage
No symptoms of all secondary causes of HTN
Reached gynecology history
Pt was having irregular menses with prescribed OCP
for 1 year
No other important history
( after I reached concern I remembered to ask
biological family if the pt was adopted (APkD) as in
DR.zain scenario )
Concerns
1. Do I need to take Med for life
Ans as your HTN probably due to Med there is a
good chance it might be temporary
2.will it affect me having babies
Ans. High Blood pressure may serious with
pregnancy multi desplinary team involving
pregnancy specialist and your physician would keep a
good eye over it
Plan of management
Stop the OCP , seek alternative with the help of ur
pregnancy specialist
We will do some test and may be scan to ur kidneys to
see the extend of ur disease
Examiners questions
Q.1 what is ur diagnosis and differential
Q.2 what is common-cause in this country if it is renal
cause
I answered post streptococcus GN
I got 20/20
PACES result
1st attempt
Royal Hospital Muscat
Bronchiectasis 14/20
Transplanted kidney 15/20
History ....young lady fatigue ,chronic diarrhea 9
years ...Coeliac disease 11/20...don't know why
CVS ..AVR ,20/20
CNS . MS 18/20
Communication ....delayed Diagnosis of
Pheochromocytoma .... 01/16 can't believe ..but ..
BCC1 ...Frozen shoulder 25/28
BCC2 ...young male weight loss 27/28
Total 131
Failed in clinical communication .
Sorry couldn't write in detail
Good luck to you all
‫أعجبني‬
‫أحببته‬
My experience in MALTA Center 1/2017
Communication ; to discuss with the wife whose
husband is 45 years old gentleman who suffered from
headache and rapid deterioration of the general
condition within few hours (while being at work)
bought to the hospital and final diagnosis is
meningococcal meningitis ,GCS ONLY 7 and the plan
to shift him to ICU .
After the usual introduction almost she knew nothing
about his condition, I explained everything about
meningococcal meningitis with the help of a paper to
draw something about the brain and surrounding
meninges,
I explained about the expected outcomes considering
the GCS ONLY 7 and the plan to shift him to ICU
and the prognosis is guarded,
She was to much concerned about her heath and her
son are there any risk they might got the infection. I
explained about infection control department in
contact tracing and MDT, offered all forms of
support.
Finally I asked if there is anybody to drop her home
-She was understanding appreciatiating everything. I
got 16/16
-
- BCC1: Elderly PT with Ankylosing spondylitis. Has
low back pain. With history of treated breast Ca.
Chrons dis. Multiple abd scars. DD. 1_Active AS for
optimisation of treatment 2_recurrence of breast Ca
with metastases 3- osteoporotic frature, what are the
months. Examining her she has expiratory wheeze
otherwise normal concern again about the cause DD
Exacerbation of bronchial asthma. When I mentioned
people as she is using oops the examiners didnot agree
(no tachycardia or leg swelling) I think I missed
asthma mimics as I went deeply in thinking
Unnecessarily I got 19/28
-
-Station 1 Chest
:bilateral basal pulmonary fibrosis. Discussion about
the causes and investigations and management. I
answered all only forget to mention drug induced
among the causes. Scored 19/20.
NEUROLOGY ;SPASTIC PARAPLEGIA
WITHOUT SENSORY LEVEL, discussion as usual
around DD, investigations (20/20)
Cardiology; an adult pt, with PSM over the apex
mostly MR ,discussion around DD,
investigations,echo FINIDING (15/20)
Abdomen ; left hypochondrial mass for DD mostly
spleen , DD, plan, no features of CLD ,no
lymphadenopathy , no facial plethora, 12/20,
WAITING FOR THE FEEDBACK TO SEE WHY
THIS MARK
HISTORY; adult pt. with migraine developed sever
headache (7/10) at the occipital area with gait
unsteadiness since three days , unsteadiness
improving partially ,no wakness , no sensory
abnormality, no visual problem, no fits, I did not ask
about vertigo , NO FEVER , NO NECK STIFFNESS
DD I mentioned storke , SAH (THAT THE
EXAMINERS DID NOT LIKE) WORSENING OF
MIRAINE
.DISCUSSION ABOUT workup , why not meningitis
, I got 14/20
FINALLY PASS 143/172
Wishing all the best for all of you, the exam needs
reasonable preparation, good practi
Alhamdulillah i have passed paces

First attempt in Royal Hospital Oman held on 8th
April 2017
Scored 146 😁
Well before i share my experience I would like to
thank dr Ali Hameed
Dr Ali Raza
And all Mypaces team for their generous support and
a very special thank to Dr Abdul Fateh
I learnt alot from his course and it really helped me
all through preparation 😄 especially Neurology
which was the big elephant 🐘 for me since final
year MBBS
I got my result a little later then my other colleagues
which made me think 😒 Mera Faisala bhi Mehfooz
ho gaya hai (my Pakistani colleagues can relate to this
joke 😤)
Down below is my experience (i was very sure i failed
because I didn't follow my scheme during exam that i
had made while preparing for the Exam but they say
miracles do happen 😇)
Started with station 4 delayed diagnosis of
pheochromocytoma
Surrogate was not aware of the diagnosis which i had
to break and give him reasons for delay in diagnosis
Dont know what i did wrong got 3/16 😲
Station 5 BCC1 frozen left shoulder in Diabetic pt
In the d/d I didn't mention Frozen joint at all and
kept beating around the bush ️ got 25/28
BCC2 was Toxic Goiter staright forward got 26/28
Station 1 😩 😩 unsure of the actual diagnosis of
Resp case but i diagnosed as COPD with Bi Basal
Fibrosis/bronchiectesis (i know doesn't make sense )
pt didn't have tht wet type of cough but crepts were
course and didn't change with cough
Viva was usual on management of the pt and
investgations got 18/20
Abdomen was Renal Transplant due to Apkd ,well
here also the examiner pulled diagnosis out of
stomach 🙄 as i was again not telling the actual
diagnosis in my presentation ,and i also failed to
identify the transplanted kidney(i said may be he had
some abdominal surgery for some infection 😧 ,what
was I thinking 😳still got 17/20
Station 2 coelic disease (lady with fatigue ankle
swelling and Microcytic Anemia) Viva was about the
investigations specifically asked me the Antibodies
and management of coelic got 18/20
Station 3 (my most feared but the best station ️)
Cardio was young male around 25 yrs with AVR no
murmur at all,though he had Afib,viva on
management of replaced valve pts ,I mentioned all the
usual with diet and medicine care, he asked me which
is the most common medicine interfering with INR ,i
said Antibiotics 😎 got 20/20
Neurology was young 25 to 30 yrs probably with
involvement of post columns and PYrmidal type
weakness in L/L left then right
Reflexes exaggerated in right diminished in
left(appeared with reinforcement) i gave D/D of MS
,syringomelia,Friedrch with MS on top due to patchy
involvement ( remembered a line by my hubby when
nothing makes sense its MS ️)
Viva was usual on investigation and management of
MS got 19/20
So now my advice to all preparing
Have a study partner
Think simple in exam
Do loads of prayers (as i did 😎)
Allah make things easier for all of you
Ameen
Thanks again to all my teachers who taught me my
parents my in laws they were huge support to all my
whining and self speculations of failure
❤ ❤
KOLKATA.
St 1 liver transplant.
Chesy old with ILD in RA
Sts changle bowel habbit
St3 hemonymous hemianopia examine cranial n
Cardio biological valve with mr ,phtn
St5 bbn SAH with INR 4
St 5 takayasu
Hemtatemsis nsaids vs crohns
I am from Myanmar. I have passed PACES

168/172 on 7th March 2017, 1st diet , my exam
center is new YGH, Yangon, Myanmar
I started with St 2
St 2 wt gain fatigue , amenorrhea, 18 mths post
partum ho of PPH blood 4 units given
DDx Hypothyroid most probably due to post partum
thyroiditis
I got 18/20
St 3
MS with AF
Examiner asked what's your findings, Dx, DDx, how
would you manage, if the pt has vegetation in echo,
can it affect the INR target?
I got 20/20
Neuro station
A young lady presented with difficulty in walking, plz
examine her neurological system
Dx- Lt sided hemiplegia due to cardio embolic stroke
I got 20/20
Scenario given was the pt had history of high blood
pressure since 5 yrs ago which was found out when he
got accident. He didn't take any medication nor any
follow up since then. Now he suffered SOB and saw
his GP , done blood test showing eGFR < 15, Hb 6.5,
Potassium 5.3, USG showing bilateral contracted
kidney. He is now seeing you what happens to him.
Task - discuss his current condition and further
management plan as appropriate.
I got 16/16
St 5 BCC1 a young lady presented with SOB SpO2
88%
Examiner ask Dx, DDx for SOB in this pt,
Management
I got 26/28
BCC 2
Dx Unstable angina(ACS) with hypothyroidism
Hidden agenda here was to refer to hormone
specialist to reduce her thyroxine dose
I got 28/28
St 1
Hepatomegaly
Dx Thalassaemia
Examiner asked Dx, points for Dx, DDx, infectious
causes of HSM, treatment of Thalassemia
I got 20/20
Examiner asked Dx, points for Dx, DDx of dullness at
base of lung, Ix, Mx, what would you consider if this
pt is working in shipyard?
I got 20/20
Thanks a lot PEC group! I may not get this
achievement without your help.
Malta center 2April2017
Left hypochondrial mass said spleen score 8
score 20/20
S2
Drug Hx
FHx adopted
Social negative
Concern is it epilepsy . Score 13/20
regurgitation I mentioned to them the diastolic
murmer 12/20
20/20
S4
.16/16
S5
lady after back surgery came with pain and fever
...........
Other case
28/28 &26/28 not sure which is which
Malaysia paces - Kuala Lumpur hospital first

carousel @ 16/4/17
Blue team
Station one : left thoracotomy scar with previous
chest tube scar -
Abd : adpkd
Station two : post partum thyroiditis
Station three : neuro pure motor neuropathy
Cvs mr n ar
Station four : explain meningococcal septicemia
Station five : bcc 1 left surgical 3rd nerve palsy
Bcc 2 hypercalcemia due to possible
hyperparathyroidism...
Red team
Station one : respi scleroderma with pulm fibrosis
Abd cld
Station two same
Ststion 3 cvs vsd, neuro cmt
Station 4 same
Station 5 bcc 1 optic atrophy
Bcc 2 ugib secondary to nsaids...
Thank you... n hv a nice day...
Glasgow royal infirmary

St1
Resp:: Pulmonary fibrosis (ILD)
Git:: massive splenomegaly plus laparotomy scar
midline
St3
Aortic stenosis
Idiopathic parkinson disease
St5
BCC ::miss nora 54 year with fatigue and dizzy spell
while standing ,bp 98/60 .((Addison disease)
BCC2::Mr patrick mcalney 62 year old man with
past history of liver transplant 2011, presented with
painful knee swelling,already talking allopurinol and
multiple other drugs including CCB
Acute attack of gout
St2
Mr mark brown type 1 dm since 15 year complicated
with dm nephropathy,retinopathy presented with
recurrent hypoglycaemia,fatigue and anemia,4 kg wt
loss,nausea and abd pain.
Again
Addison disease
St 4::
BBN of renal cell Ca with on ct
And cervical lymphadenopathy
UK
Station 4 : Lost FNAC report
Station 2 : Hx of IBS but strong family hx of ca colon
(father, uncle, grand father)
Cardio : MR +CABG
Neuro : Peripheral Motor Sensory Neuropathy
Respiratory : Pleural effusion
Abdomen : HHT
BCC 1 : Psoriatic Arthritis
BCC 2 : Diabetic retinopathy
Glasgow royal infirmary

St1
Resp:: Pulmonary fibrosis (ILD)
Git:: massive splenomegaly plus laparotomy scar
midline
St3
Aortic stenosis
Idiopathic parkinson disease
St5
BCC ::miss nora 54 year with fatigue and dizzy spell
while standing ,bp 98/60 .((Addison disease)
BCC2::Mr patrick mcalney 62 year old man with
past history of liver transplant 2011, presented with
painful knee swelling,already talking allopurinol and
multiple other drugs including CCB
Acute attack of gout
St2
Mr mark brown type 1 dm since 15 year complicated
with dm nephropathy,retinopathy presented with
recurrent hypoglycaemia,fatigue and anemia,4 kg wt
loss,nausea and abd pain.
Again
Addison disease
St 4::
BBN of renal cell Ca with on ct
And cervical lymphadenopathy
Cochin, diet 1
St2 fatigue in young lady. D/d depression
Celiac. Hypothyroidism. Gi malignancy?
St 3 stroke and Avr.
St 4 steroid psychosis.
St 5 addisons and ankylosing
St 1 ild due to ss . Cld with no organomegaly.
Glasgow
History:
1st time Blackout, no presyncopal symptoms, 30sec,
PMH CABG, DHx bisoprolol, atorva, aspirin. HR 50,
asked about driving and flying on holiday already
booked.
Communication
Delirium, failed discharge, heel black ulcer, angry
son, discharge planning.
Station 5
BCC 1 : Parkinsonism
BCC 2 : asymptomatic palpitations, on/off for few
months, normal patient examination.
CVS Midsternotomy scar, no harvesting scars LL

Corrigen sign
Large volume pulse
Unequal pulse, very weak R radial
ESM
?AVR + flow murmur
NEURO
Cerebellar syndrome
Abd:
Spleenomegally, jaundice, cholecystectomy scar. DD,
discussion about hereditary spherocytosis.
Resp:
Midsternotomy scar, plethoric face, cushingnoid
appearance, bilateral LL odema, tremor,
consolidation over right lower zone.
Discussion lung transplant
Royal infirmary glasgow
St2.
57yr old lady with past hx of lymphoma treated with
radiation
She was doing fine till aweek ago when she collalsed
at the supermarket and had left sided jerky
movement witnessed by her friend.
+ve hx of headache (SOL character)
+ve hx of recurrent chest infection last 2 weeks not
responding well to abx
St5:
BBC1: Hand & shoulder pain with excersional
dyspnea
Inside RA deformity with bilateral basal creps.
Pt is using NSAID as well for the pain but no signs or
symltoms of aneamia or GI bleed.
BBC2:
Patient referred from dentist because of high BP
GP examined him, have upper and lower limb
swelling and gp askimg ypur opinion to do echo
Inside: acromegally pt with no visual field defect.
St. 1
Chest: Left lobectomy with mid sternotomy scar
Abdomen: peg tube and coloctomy bag
St3.
Cardio: Aortic valve replacement with pacemaker
scar, +ve clubbing
Neurology: 3rd and 6th cranial nerve palsy, bilateral
hearing aids (discussion was about cavernous sinus
lesion)
St4: a 78 year old male known case of COPD

admitted with infective exacerbation of COPD, he
was started on non ivasive ventilator but he asked to
stop using it and it was explained for him that he
might die if didnt use it, he agree with as he has no
quality of life . The team has agreed to stop it and to
continue with other medication apart from mask.
Talk to his daughter.
station 4 in UK today
St4: a 78 year old male known case of COPD
admitted with infective exacerbation of COPD, he
was started on non invasive ventilation but he asked
to stop using it and it was explained for him that he
might die if didnt use it, Pt agreed with that as he has
no quality of life . The team has agreed to stop it and
to continue with other medication apart from mask.In
scenario no specific details about mangement plan..
They just wrote that they will continue with other
treatment apart from non invasive ventilation. Talk
to his daughter.
- Daughter said pt was troubled a lot recently with his
COPD and was having reurrent infection
- Why pt didn't want non invasive mask - because his
quality of life is not good enough
- One of concern was about prognosis of pt
- touched palliative care but not in detail
- Candidate didn't ask about smoking as it seemed to
be a terminal case
-When candidate started asking about social aspect
and home situation the examiner pointed to the
sentence of DONT TAKE HISTORY written on the
task paper
- Viva ; discussion about four aspect of ethical
principle, option of palliative care
UK Experience diet 1
Station 4,
GBS case , talk to wife , patient is off ventilation,
Neurologist initially said good prognosis but now he
said lower limb won't recover ,
Wife questions
1) is it been misdiagnosed
2) Husband is depressed now what are you going to
do for his depression
3) who will look after him at home
4) can I take him home
5) any chances of recovery (asked this many times)
6) will physiotherapy benefit him
Examiner
Discuss the scanerio
Ethical principles
History
20 years female collapse , brother has epilepsy
was waiting in bank que where she collapse ,
Positive - sweating, dizziness, 5-6 LOC, urinary
incontinence
Using mafenamic acid for menstruations problems
Concerns
Is it epilepsy
Applying for driving licence should I apply
what I need to do to prevent it
Diagnosis _ Vasovagal
Examiner
D/D
Investigation
BCC1-
79 male , collapse while talking to wife ,
Post ictal 30 minutes
Tongue bite ,
Jerking of limbs
Background
Benign brain growth
Concern -Driving
Examiner
Are you going to start anti epileptic
BCC2
70 male , breathlessness -5 months
MI 1 year ago,
Can walk 100 yards now , 6months back can walk
normally
Cough -dry since 6 months
No leg swelling ,no chest pain , no palpitations,
Forget to ask Orthopnea and PND
On usual drugs of post MI
O/E
Pulmonary Fibrosis
Occupation -clerk ,
Respiratory-
Lobectomy
Examiner questions
Difference between Lobectomy and pneumonectomy
Why patient is dyspnoeic
Abdomen
Renal transplant
Neuro
Diplopia
6th Nerve palsy
Examiner questions
D/D
If it because of DM what are you going to do for him
Cardio
Loud P2
?systolic murmur
Examiner
What are the causes of secondary pulmonary
hypertension
my exam experience Glasgow Feb 2017..
I started by st 3
Cardio
Pt e SOB; O/E; mid sternotomy scar, metallic click ,
no murmur , my D; MVR, viva inv & manag + valve
types!!, why no saphenous scar?! got 20/20
Neuro; pt with falls; examine his neurological system;
I started as regular greeted the pt and asked to walk;
20/20
st 4
syncope due to OHG overdose in depressed nurse,
who denies the act but confirmed inv and previously
told about insulinoma, task to communicate D and
manage concerns;
concern: confidentiality, financial troubles & support,
I missed in scenario from where she got the OHG,
good)
I got 11/16
BBC1
missed, 26/28
BBC2
st 1
Abdomen
Scar of liver transplant + drum stick clubbing, viva
abt possible D and Inv , transplant medications and
SEs, got 20/20
chest
st 2
DM+IDH+HTN+DVT, gave DD uncontrolled AF /
Drug / Autonomic neuropathy, viva inv and
I hope this helps
Paces is a very tough but amusing experience, I
passed from 3rd trial all in UK, done courses in
Ealing, Hammersmith in London and paces 4 u in
Manch, got 110 in 1st trial and 117 in 2nd , now 159
praise and favour to Allah
Try to study hard 50% and try to practice in your
real life 150% and in shaa Allah you will Pass
Have a nice day…
My Cases in bangalore. Manipal ..7/4/17

Started with st2...Anaemia (MHA.) H/o ibs 6 yrs
on peppermint oil,occasion leg swelling,ho rta
and nsaids ,father died of cancer colon,mother
taking inj.3 monthly for anaemia,so many
issues, ,DD was so many
issues..coeliac..nsaids, ,ulcer
barrier was prob. I didn't understand what he
told about sensation, ,planter was very
confusing, ,Indian examiner didn't tell anything!
!
sided chest pain.. o/e Dec breath sound.rt
mid.dd was ptx,pul embolism, ,pneumonia. It
was good
St5 female was increase weight,,increase
bp,,,and proximal myopathy, ,o e no thyroid
oedema, ,dd,was cushing, ,hypothyroidism,
metabolic syndrome, ,discuss was on cushing. .
Thnx and pray for me...
Oman center today

Chest case Bronchectesis
Abdomen case Renal transplant
History
Cystic fibrosis
Cardiology MVR
Neurology HSM PN
Communication
Renal biopsy from SLE
Station 5
BCC1 Diarrhea in Rhumatoid and psoriasis
BCC2 Goiter

Bcc.Abdominal pain for 2 days, fever and oligiuria
known DM. ddx
CNS: Lt hemiplegia
CVS: systolic murmur with AVF machinery mur mur
Resp: LL BBS+crep ddx think lower zone fibrosis or
consolidation
overload.
NEUROPATHY.
Chennai Day 1 11.45 am cases
Pheochromocytoma telling the diagnosis to patient
station 4.
Bcc 1 diabetes and UTI, bcc2 diabetes and loss of
vision - funds examination.
abdominal pain. Cardioloy AS / HOCM ? Associated
MR also. Neuro b/l cerebellar signs with absent
reflexes .. best of luck to all of you
history. Cough for 6 mts SOB. Bird fancier lungs.
BCC1 seizures.
3/4/17
Station 2
months. She has fever on and off but no night
sweating weight loss of 6 kg within 6
antibiotics without improvement.
During childhood she has asthma which improved.
Not smoker or drinker. But unfortunately the
diagnosis was extrinsic allergies alveolitis. I miss birds
at home.
Station 3
Neuro
Is parkinson plus CVA. Rigidity only on distraction
so I put parkinsonism plus CVA reflexes was
exaggerated on the right upper limb only no tremor.
Stations 4
Station 5
bowel four times.
stiffness less than 10 minutes. It was osteoarthritis no
other significant history of skin rashes or other joint
problem except back pain occasionally.
Stations one
dialysis. Polycystic kidney is common in chennai take
care it mimics hepatosplenomegaly..
Chest I don't know it.
Barnet hospital March 2017

Exam experience :
S2: 40 yrs old lady with a headache...past
history of CVA CT was done small infarct ..from
the history she has symptoms of increase
intracranial pressure..she afraid she may have
the same condition again discussion was about
dd :SOL ,IIH its possible causes and risk factors
investigations basic and CT brain ..if itis SOL
what its types..he want solitary lesion or mets
..if mets from where ? : from breast ca? ..if CT
normal? :for LP what you will see in LP ..the
pressure cells etc 18/20
S3: CVS: pt in 50s with collapsing pulse and
clear systolic murmur in aortic area radiate to
the neck i said Mixed aortic valve what you will
do for him ..in failure or not ..i think i missed the
AF as they asked me to check the pulse again if
regular or not ..not sure of this case 12/20
Neuro: cranial nerve examination in a lady of
50s ..when i asked her if she has any problem
with the sense of smelling she said yes..but i
forgot it in in the discussion ..other affected
cranial nerves ; Rt 5 , lower 7,
8 and 12 ..the discussion about DD why the 12th
is involved. it's pathway?
What you will do. .MRI why MRI and not CT ..to
see the post fossa. .18/20
S4: explain SLE and the need for biopsy for
young lady: i explained the
disease for her, the biopsy and its importance
for treatment , its complications,
She concerned about the effect of the disease
on her life ..i told her itis not curable but
controllable by good follow up also asked about
pregnancy: planned pregnancy then follow up
with woman doctor and the joint
doctor..multidisciplinary team..she was student
i told her also we will give her sick report in the
day of her biopsy and during her current
admission..i offer also a meeting with my
consultant when she wasnt convinced with the
biopsy..but finally she accept it.. I asked her
about her concerns and any thoughts in her
mind many times, she mentioned the point of
pregnancy at the last..i summarized and
checked her understanding ..when i finished
still i have time..so again i asked about her
social history more and summarize again...they
asked if i convince her or not ..what if she
refuse : i will give her a chance to think about it
again and arrange a meeting with my
consultant..what if she still refuse ..i will respect
her autonomy..asked again about
prgnancy...16/16
S5 : 50 yrs old man post MI a few weeks ago..
came with lethargy and tiredness : i didnt know
the diagnosis ..i thought about anemia and
hypothyroidism both was negative from the
history and examination ..so i just tried to be
diplomatic took good history rapid examination
offer investigations to know the cause..the
examiner asked me what you want to do ..as
from the history he has dizzi spell i told him
sitting and standing BP basic investigations
including the ECG ..i dont remember if he was
diabetic or not...i thought i will fail this station
because i didnt know what is the diagnosis
25/28
The 2nd one was easier but i did badly..young
lady came with headach and convulsions.. I
took rapid history about the convulsions and
first time or not ? She was epileptic and stopped
her ttt due to pregancy ..i asked about her social
history..i did rapid examination for the pt power
ask about her concerns advice her to follow
with the neurologist and not to stop the
medication by her self ..yes most of the
antiepileptics has bad effects on the baby but
the neurologist will choose the safest one and
will outweigh between the risks and benefits..in
the history i asked about the symptoms of
increase intracranial pressure but when i knew
that she had epilepsy and stopped the treatment
bcoz of pregnancy i didnt think about it in the
examination ..they asked me what you missed
and when i see the ophthalmoscope beside the
pt i said fundoscopy..they asked what i will look
for? i forgot also..but after a while i remembered
the papilledema! They also asked me why i
didnt ask specifically about the drug name
..which was valporate they said she was
intelligent enough to stop it.(i didnt agree but
but i didnt argue with him (this is the
rule ^^) ...anyhow he was generous enough to
give me the 15/28
S1: COPD ..the discussion was straight forward
investigations,management including ttt for
respiratory failure ..difference between
emphysema and bronchitis 20/20
Abd: i forgot many things in this station ..was
also direct: Renal transplant..i forget to cheque
for the fistulae if functioning or not and when he
asked me if the transplanted kidney functioning
or not i told him i should cheq for the fistula he
asked me to go back and see the pt..it was
fibrosed ..the pt had skin rash in his Rt forearm
also i didnt know it just said may be cellulitis
..he asked about the causes i said DM,HTN
,polycystic and mentioned some other causes
he asked me for a one cause ..i said DM
..why?most common ...how can you know it ?
by finger pricks (which i forgot to look for!)..the
first question after i finishe examination was
what ttt is he taking : Tacrolimus ..Why? Due to
the tremor..mention other drugs:
Azathioprine...what its side effects ...what test
we do before starting it : we measure enzyme
but i dont remeber its name! ...at the end he
smile and said you didnt check and find the
polycystic kidney!(at this poit i thought i missed
the diagnosis and failed) i told him i checked for
the kidney but didnt find it...20/20
Thats all...of course i want to thank both dr Zain
and Dr Ramadan for their v hepfull courses and
advices ..
My exam was in wythenshawe Manchester

: In station 5 my first case was on ANGINA.
instruction was like that::: middle aged lady
present with chest pain. All finding are normal
on observations. On taking history, chest
tightness for couples of months on exertion.
HTN, HYPERLIPIDEMIA, ON TREATMENT.
2nd case . Young lady present with collapse
while listening music
It was a 2nd episode, first 3month back without
warning, no chest pain or palpitation. I took history
from cardiac as well neurology point of view. Social
history was significant as she was a bus driver. I
follow the history, exam, and ask for concern. And
advise not to drive.
Thursday 16/3/2017
Dear friends, I am going to share my painful and
tragic experience with you. I have passed the
paces (overall score) on two occasions
achieved 147/172 and 138/172 , but failed in one
SKILL, first time by one mark and second time
by 2 marks only. ONE CAN SAY IT A HARD
LUCK, but my struggle will continue and
INSHAALLAH with the never given up approach,
success will be on the way some day.
Please pray for me. Good luck for everyone.
My PACES experience,
28th February 2017 at Aberdeen Royal Infirmary.
RCP Edinburgh.
While I was in the elevator to 1st floor where the
exam was to be held, I was accompanied by an old
gentleman who asked me why I was here...I told him I
have exam here...he said 'I might be one of ur guinea
pigs'....I felt an urge to ask him what was wrong with
him (bcz we 2 were alone in the elevator anyway) but
didn't do so for fear of getting disqualified from the
exam!!
Station 1:
Respiratory : left thoracotomy scar.
Chest expansion was equal on both sides, nd
percussion was resonant bilaterally so I excluded
pneumonectomy. No abnormal findings in
contralateral lung. So dx i made was lobectomy.
Examiner asked about causes of lobectomy. When I
mentioned TB as one of the causes, he didn't like that
but then I carried on to mention others with which he
was happy. He then asked me how I would
investigate,,,I mentioned baselines and pulse oximetry
and pulmonary function tests and then THE BELL
RANG.
Score 11/20
ABDOMINAL:
White patient who had extensive spider naevi over
upper torso and upper limbs. It took me time to
differentiate naevi from telangiectasia and I kept on
pressing on them to check how they refilled. Patient
had clubbing and slight tremor. He also had
hepatomegaly, no splenomegaly. He had marked
flank fullness and when I asked him to lean forward a
little, the fullness became even more prominent. I
thought these are polycystic kidneys. I ran out of time
and couldn't check for ascites, pedal edema and the
back of the patient!!! And I made a dx of polycystic
kidney disease. It could very well have been CLD with
ascites!!!! Examiner didn't ask many questions bcz it
took more time for me to justify the dx I had made.
Score 9/20
Station 2:
50 yr old Patient who had a witnessed collapse. Seen
to be jerking his left upper and lower limbs. GP
concerned if it is epilepsy.
I took a detailed and thorough hx and addressed the
patients concerns and gave a good list of d.dx.
Patient had a hx of lymphoma nd hx of radiations to
the chest. He also had a hx of non resolving chest
infection.
Score : 14/20 which was quite unnvelievable bcz I
didn't miss anything in this one - or at least I thought
so
Station 3:
CVS:
patient had AS murmur, collapsing pulse but pulse
was good volume. So I told him that patient has AS
murmur and pulse is good volume which does not fit
well so he may be having mixed aortic valve disease.
He didn't seem to understand my point (this was
taught to us in Ealing and paces ahead courses). He
then asked me how to investigate the case and then
the bell rang.
I had forgotten to check for radiation to the carotid
and examiner asked me about that too.
Score: 7/20
CNS:
Here I met the old patient who I had net b4 in the
elevator. Command was to examine his left hand.
This was a technically very difficult case bcz
examining a big gentleman with left hand weakness
from the right side is very difficult. And his hand
couldn't move or bend at all so it took me a while to
position him for the different parts of motor
examination. In this chaos I forgot to ask him to
clench his teeth so I could reinforce the absent
reflexes which I got. And I was left with sensory
examination when examiner said it have 2 min left. So
in hurry I just ran the sharp pin over a straight line
on the patient's hand instead of checking in
dermatomal fashion. I asked to walk the patient but
examiner said not to check that. When in was asked
to explain my findings, I started off asked nd
examiner told me in between that I didn't reinforce
the reflexes and I didn't check for pain in
dermatomal fashion. I gave dx of MND whereas it
was monoplegic stroke :( I knew I had flunk the
station!!!!!
Score 5/20
Station 4:
60 yr old lady with iron Def anemia. Gets blood
transfusions nd feels better. Task was to counsel
against risks of blood transfusions nd guide about
investigations. Scenario also mentioned that cause of
anemia has been localised to bleeding from the gut.
The patient told me sge had taken iron supplements
for anemia but they made her sick so she is not on any
more now. I told her about rare infections
transmitted through transfusions, transfusion
reactions, risk of fluid overload etc. I told her she wl
need an endoscopy at which she said aloud that she is
never going to have it bcz she had it in the past nd
had a terrible experience and so they had to cancel it
and wl never have it again. I told her she wl be given
a numbing agent sprayed at her throat so she doesn't
feel irritated when the scope is passed through her
mouth,,,at which she cried out aloud: 'u never told me
it's going to be through the mouth' and I felt shocked
bcz she had just told me she had it in the past!!! So I
presumed she would be knowing it's through the
mouth.
Anyhow I counselled her....
But examiner told me i should have told her that she
has a suspicion of cancer which needs to be ruled out
and investigations are necessary for that.
He also told me i should have offered to reduce the
dose of iron supplements to avoid nausea.
Score: 12/16
Station 5:
BCC1 :
Patient with hemoptysis and family hx of malignancy.
I forgot to ask about occupation. And I didn't percuss
on the back bcz I had done complete examination
from the front which was unremarkable and time was
limited and so ended up missing on pleural effusion.
Rest went okey.
Score: 23/28
BCC2:
Patient with dryness of skin and constipation. BP
158/90. Having severe headache.
While taking hx I got to know patient has
hypothyroidism. For headache, I offered to do
fundoscopy but was told that it is normal. Then i did
visual fields...they were also normal. That confused
me bcz this ruled out pituitary adenoma as a cause of
the hypothyroidism and HTN. But I should have said
that it looks like a small non compressing pituitary
adenoma. And patient kept on talking about
headache and what it could have been but I was
clueless....and so missed even offering her some opioid
analgesics for the headache that was not responding
to paracetamol, nsaids etc.
Score: 15/28
So i couldn't clear the exam. I had studied cases for
paces, hx and communication skills from ryder mir,
stations 1 and 3 from gautam mehta and had watched
all the pastest videos. Still I guess i messed it up in the
exam. I tried to be over gentle with patients and so I
ran short of time :(
I also complicated simple things like CLD or
monoplegic stroke.
And last but not the least, I must say the exam is
stricter than i had expected bcz i lost marks even in
the stations that I had done perfect.
Hope this helps
i have passed alhamdulillah

Sharing my experience at London hospital
Station 1...obese patient with tattoo marks and
multiple scars on abdomen...signs of CLD and gum
hypertrophy with livervtransplant...i didnt get the scar
as it wasnt the typical mercedes benz..examiner asked
if he has CLD what would u expect..i said LT then
questions about othet causes of end stage liver and
immunosuppression
Respiratory was broncheictasis with COPD..questions
about D...
Egypt 6 of February, New Kasr Alainy Hospital ..first
carousel
Station 4》
A lady admitted to hospital with UTI found to have
... PCKD complicated by ESRD
Task: to peak to her daughter.. I started by greeting her
daughter
Asked her about the previous health of the mother
that led to her being admitted.. BROKE the bad news
with empathy,asked about her knowledge...explained
the disease..it's manifestation..complication..talked to
her specifically about ESRD at that her mother is in
need for dialysis..she was depressed because of her
mother condition explained that this disease runs in
family that's why we need to do certain tests to see
if.she is having the disease as she is at the proper
age....she had many questions which I respond to if she
will end like her mom..explained that there is a
possibility at 60but we will follow her closely..so that
we can control the complications..I asked if she had a
partner she said no.. Siblings she had 2 their ages they
were over 20
Which she did not have asked about any more concern
she had told her that it's the proper age for counselling
about the disease... Summarized what we talked
about.. Checked her understanding Checked if there is
any one looking after the mother with whom she was
... living offered help
The examiner asked what is the issues in this
...scenario
I told him BBN and counselling the daughter
He was smiling all through from the start so that gave
me some relief thank god 😅
First didn't get his point 😒why will she not be ok 😳
Second question was do you think if even she had done
the investigation and turned not to have the disease
she will be ok
Then he explained imean for not having the disease
and carrying the gene..Yes of course she needs to be
counselled about the disease before having the tests
done
Thank god I got 16/16
Station 5》
It seemed like a nightmare😅
Even before entering the room..I was shaking so bad
anyway I managed to get to the room😅😅
BCC1 was a man 30 yrs weight gain ☆
I took the history it was going with hypothyroidism
which caused him fatigue.. prox.weakness😊then I
proceeded to examine him..finished the past history
d.h...f.h..social..offered some help group as his
prob.was affecting him socially and his work..his
concern was what is my problem..is it
treatable..examiner asked what's his problem..what
did you find when you examined him..you found him
to have prox.myopthy 😅why not examine lower
limbs😯I answered examined for prox.myopthy..in his
upper limbs..how.are you going to investigate him..he
was smiling all through😊I was still shaking😅
I got 24
BCC2 ☆
A lady about 30 diagnosed one year with skin lesion
and has DM
I asked about the lesion 1 year ago started as vesicles
itchy affecting her mouth..she was put on steroid
devoped cm 6months...I went to examine her started
with the lesion ..asked for torch they won't offer it
unless you ask😬asked about other side effects of
steroid she was not any prophylaxis..offered help
groups in social history..her concern was was the
diabetes related to my treatment any other options I
told her it's an essential ttt for your condition on
weighing the risk and benefits can go back to the skin
doctor to revise the dose and give you some
prophylactic ttt..regarding other options yes there are
other options but also with side effects so let's refer
you to skin doctor the gland doctor etc
Examiner asked what's your diagnosis I said pemphigus
vulgaris...what is the cause of her d.m..I told him her
.steroid..other options I said yes azatiopurine
I got 28 😊
Station one》
Chest😢worst ☆
Positive findings bilateral dullness.trachea deviated to
rt..deceased air entrance bilat..increased tactile vocal
fremitus...examiner what's yr diagnosis I said bilateral
fibrosis more on rt side..then he asked about the
causes of fibrosis
I got 8😢
..Abdomen ☆
I tried to forget about the last case..patient was
jaundiced..pale..Abdomen left subcondrial scar..liver
palpable tender 6cm below coastal margins 14cm
span..No signs of ascites...examiner asked what's your
positive findings?!like I said above..what's yr diagnosis
appendectomy..plus hepatomegally possible cause
)haemolytic anemia(thalassemia
How can you explain the hepatomegally I said
secondary to repeated blood transfusion developed
hepatitis or coincided with the anaemia😊
What will you find in blood film of this patient I said hj
bodies😀
I got 18😊
Station 2》
years old male with history of rt side chest pain 48
occurred when he is at work mainly of short duration
no aggravating or reliefing factors associated with
sweating. palpitaion.dizziness ..known Hypertensive
last reading was was 150/90 on ttt.not known
diabetic..No history of high cholestrol..clots.positive FH
of sudden death his brother..otherwise not known to
smoke drink alcohol
CONCERN what is my problem as it is recurrent..can
you give me some painkiller.. at that point I had put on
my mind differential to be honest😅😅😅 no difinit
cause...so I said to him for right now to be able
to.answer your concern.I have to do some tests and
examine you...as there are many possible causes like
..unstable angina..HOCM..arrhythmia
Examiners so what's your diagnosis I said My
differential diagnosis is unstable
angina..HOCM...Arrhythmia
Why don't.you.give him just pain killer...me he is HTN
plus history of sudden death his brother I would have
to role.out serious.causes then I can give him the pain
killer..so you will admit him...yes to investigate..so
what investigation general..then.ECG..cxr..cardiac
enzymes..echo..😬
I got 17😄
Station 3》
Cardio...old man lying in cardiac bed dyspnic..pulse ☆
small volume irregular..AF...apex difficult to
detect...1st heart sound loud..2nd heart sound
accentuated at pulmonary area
MDM at the mitral area..so my diagnosis was
M.S..AF..PHTN
...EXAMINER what's your diagnosis
I got 20😊
..Neurology ☆
.Instructions are to examine lower limbs
Female unable to walk for long time
On examining her she had increased tone.clasp knife
rigiditiy..power of umn pattern..increased
reflex..normal sensation in lower limbs..I asked to
proceed and examine upper limbs which was
normal...Examiner what's your diagnosis I said spastic
paraplegia e normal sensation
What are the possible causes I said hereditary spastic
para...CP..then he said what else would help you to
confirm your diagnosis I told him FH...then he said time
.up
I got 20
،،، UK Experience
Glasgow ,, Febriwary 2017
Aberdeen hospital
St_1
Abdomen = HSM
cirrhosis
Respir= rt. lower lobe LOBECTOMY secondery to
telangectasia
St_2
elderly male e type 2 DM
presented e lethergy for 6 months
having HBA1C 5.5 & Chr.kid.dis stage 3
St_3
Cardio = Aortic valve rep
metallic=marfan
Neuro = examin upper limb
pt. has stroke
St_4
BBN to the daughter regard her father who has
advanced bladder cancer .. diag. 3ys back & now
presened to hospital w drowsiness
St_5
BBC1:: ELDER LADY
known RA presened w lt. wrist & forearm pain
take focused history &proceed
::BBC2
young male w sudden loss of vision
in rt. eye
diagnosed to have central branch obstruction
my experience in paces UK , station 1.....copd

+bronchiectasis20/20 .renal transplant in diabetic
، pt15/20
St2 .attacks of diarrhoea&vomiting in diabetic pt dd
(autonomic neuropathy, Addison, bacterial
overgrowth) 20/20
St 3...cardiovascular MR+Af 18/20......neuro pt 50 yr
complain, diplopia and difficult walk he has cerebellar
signs on the lt side, I missed it coz of confusion 4/20
St 5.....psoriatic arthropathy 28/28........acute Back pain
in female 35yrs old she has history of cushing disease
removal from brain taking hydrocortisone dd vertebral
fracture, mets, disc 23/28
Score 133/172, but I fail in physical examination minus
one mark , so I fail but alhamdlillah
..my exam experience Glasgow Feb 2017
I started by st 3
Cardio
Pt e SOB; O/E; mid sternotomy scar, metallic click , no
murmur , my D; MVR, viva inv & manag + valve types!!,
why no saphenous scar?! got 20/20
Neuro; pt with falls; examine his neurological system; I
started as regular greeted the pt and asked to walk;
20/20
st 4
syncope due to OHG overdose in depressed nurse, who
denies the act but confirmed inv and previously told
about insulinoma, task to communicate D and manage
;concerns
concern: confidentiality, financial troubles & support, I
missed in scenario from where she got the OHG,
)good
I got 11/16
BBC1
missed, 26/28
BBC2
st 1
Abdomen
Scar of liver transplant + drum stick clubbing, viva abt
possible D and Inv , transplant medications and SEs,
got 20/20
chest
st 2
DM+IDH+HTN+DVT, gave DD uncontrolled AF / Drug /
Autonomic neuropathy, viva inv and management, got
20/20
I hope this helps
Paces is a very tough but amusing experience, I passed
from 3rd trial all in UK, done courses in Ealing,
Hammersmith in London and paces 4 u in Manch, got
110 in 1st trial and 117 in 2nd , now 159 praise and
favour to Allah
Try to study hard 50% and try to practice in your real
life 150% and in shaa Allah you will Pass
…Have a nice day
:UK PACES experience

I would like to share with the group my exam stations,
.in the UK Luton and Dunstable Hospital - #London
:Station one ○
:Abdomen °
.Pre-emptive renal transplant secondary to DM
:Resp °
Bilateral lungs transplan (clampshell scar )with
.evidence of fine end crepts
:Station 2 ○
history suggestive for Core Pulmonale secondary to
advance COPD, lots of social issue to address, advice on
.smoking cessation and LTOT
Concern: Had recent history of IE COPD led to
intubation, worried to happen again, I suggested
.vaccinations and rescue bag of medication
:Station 3 ○
CNS: pastic paraparesis secondary to probable MS °
)(Young lady
CVS: Mixed Aortic valve disease with predominant °
.)AR (Collapsing pulse
:Station 4 ○
Medical error, wrong dose insulin charted over the
.weekend caused hypoglycemia to the patient
Concern: how could I ensure that doesn't happen to
?other patients? Is the service bad over the weekend
Examiner asked me how would you report a medical
error in the NHS
For this scenario particularly there is a sample in the (
neck website which show how exactly to report and
)address error, I felt quite confident with it
Station 5 ○
BCC1: Right homonomus hemiaopia , secondary to °
.Stroke
.Make sure to start Aspirin after CT BRAIN
The patient is a Taxi driver, should be reported to the
.DVLA to stop driving
Examiner asked about investigations and site of the
.lesion
BCC2: Carpo pedial spasm secondary to iatrogenic °
hypocalcemia after a thyroid operation. (She want tell
.)you about it till you notice the scar in the neck
?Concern : would I be cured
I mentioned the endocrinology input and the
.treatment of hypocalcemia
Examiner asked about how could I clinical demonstrate
.hypocalcemia (the two signs), management plan
My exam first cycle dubai 20/2

I start with history Yong patient complain of chest pain
with family history father died at 45 years IHD and they
gave that his cholesterol is high upper normal started
by grating the patient introduce my self as Dr told us
then I asked about the pain dull aching not radiated no
any other symptoms
He is smoker
his work as something inthe bulding carrying object
that what I understand and he was seen by other
doctor and stress done for him 9 month back
Then his concerns what is the cause of the pain I said
we need to rule out ischemic cause first as he had
strong family history and smocker and his cholesterol is
high but he is not happy then I said we need to do echo
and possible coranery angio then
I closed by checking understanding
Discussion with examiner's what could be the cause
I said ischaemia. And mention many differential but he
is not happy at the end I said muscular
Then he told me what will be your first diagnosis then
I said ischemic then muscular time finshed i am not
happy they gave me 12
Station 3 first
Cardilogy aortic stenosis with classic murmur but large
volume pulse collapsing and neck vein pulsation
Pulse regular
Discussion what is your finding
Diagnosis
AS and possibly AR but I could not heard the murmur
who you confirm ur diagnosis
echo looking for 1234
Management
Education and counselling avoid exercise
Valve replacement then at end what other i said TAVI
I got 20
Neur examin hands of the patient
No obvious deformity I start with inspection then I
examin ulnar median and redial she had lt hand
median palsy
Discussion what could be the cause investigation
I got 20
suspected
mam wants to know we will inform her we will not
enforce information to her and this will help her to talk
in medical team. and accepted. Another concern want
to take her mama I said now we need to do some test
and I need to consult my senior and oncologist then if
she remain stable after she can be discharged then
discussion was about ethical issues, why you will
inform the pt I answered as said to daughter and the
autonomy of pt as she is competent. as about elment
of competence he asked about involving the senior
I got 16
Yangon (10.3.2017) last round

Station 3 MS AF Pulmonary HT� Spastic paraplegia on
�anti TB
�STATION 2 postpartum thyroiditis
Station 1 pleural effusion
�ADPKD neckline scar and AVF
Station 4 steroid UC ( main concern want to take
alternative medicine (herbal medicine) instead of
�steroid
Station 5 Bcc 1 TIA Hypertension Grade 2 and 3
�hypertensive retinopathy on both sides
Bcc 2 chest pain ( pleurisy) and burnt out RA hand
Malta 🇲🇹
Station 1
Hepatosplenomegaly
Chest scar
Station 2
Diarrhea IBS
Station 3
MR AS
Spastic paraparesis with intact sensation
Communication
Cancer pancreas
Station 5
Asthma with pregnancy
Tremors
Hi everyone would like to share my exam experience
😊
Egypt 6 of February New Kasr Aainy Hospital ..first
carousel
I Started with st4
A lady admitted to hospital with UTI found to have
PCKD complicated by ESRD ...task..speak to her
daughter.. I started by greeting her daughter
Asked her about the previous health of the mother
that led to her being admitted.. BROKE the bad news
with empathy,asked about her knowledge...explained
the disease..it's manifestation..complication..talked to
her specifically about ESRD at that her mother is in
need for dialysis..she was depressed because of her
mother condition explained that this disease runs in
family that's why we need to do certain tests to see
if.she is having the disease as she is at the proper
age....she had many questions which I respond to if she
will end like her mom..explained that there is a
possibility at 60but we will follow her closely..so that
we can control the complications..I asked if she had a
partner she said no.. Siblings she had 2 their ages they
were over 20
Which she did not have asked about any more concern
she had told her that it's the proper age for counselling
about the disease... Summarized what we talked
about.. Checked her understanding Checked if there is
any one looking after the mother with whom she was
... living offered help
The examiner asked what is the issues in this
...scenario
I told him BBN and counselling the daughter
He was smiling all through from the start so that gave
me some relief thank god 😅
First didn't get his point 😒why will she not be ok 😳
Second question was do you think if even she had done
the investigation and turned not to have the disease
she will be ok
Then he explained imean for not having the disease
and carrying the gene..Yes of course she needs to be
counselled about the disease before having the tests
done
Thank god I got 16😁
Station 5 seemed like a nightmare😅
Even before entering the room..I was shaking so bad
anyway I managed to get to the room😅😅
BCC1 was a man 30 yrs weight gain
I took the history it was going with hypothyroidism
which caused him fatigue.. prox.weakness😊then I
proceeded to examine him..finished the past history
d.h...f.h..social..offered some help group as his
prob.was affecting him socially and his work..his
concern was what is my problem..is it
treatable..examiner asked what's his problem..what
did you find when you examined him..you found him
to have prox.myopthy 😅why not examine lower
limbs😯I answered examined for prox.myopthy..in his
upper limbs..how.are you going to investigate him..he
was smiling all through😊I was still shaking😅I got 24
BCC2 a lady about 30 diagnosed one year with skin
lesion and has DM
I asked about the lesion 1 year ago started as vesicles
itchy affecting her mouth..she was put on steroid
devoped cm 6months...I went to examine her started
with the lesion ..asked for torch they won't offer it
unless you ask😬asked about other side effects of
steroid she was not any prophylaxis..offered help
groups in social history..her concern was was the
diabetes related to my treatment any other options I
told her it's an essential ttt for your condition on
weighing the risk and benefits can go back to the skin
doctor to revise the dose and give you some
prophylactic ttt..regarding other options yes there are
other options but also with side effects so let's refer
you to skin doctor the gland doctor ect...the e
Examiner asked what's your diagnosis I said pemphigus
vulgaris...what is the cause of her d.m..I told him her
steroid..other options I said yes azatiopurine. Igot 28
😊
Station one chest😢worst
Positive findings bilateral dullness.trachea deviated to
rt..deceased air entrance bilat..increased tactile vocal
fremitus...examiner what's yr diagnosis I said bilateral
fibrosis more on rt side..then he asked about the
causes of fibrosis I got 8😢😢😢
Abdomen..tried to forget about the last case..patient
was jaundiced..pale..Abdomen left subcondrial
scar..liver palpable tender 6cm below coastal margins
14cm span..No signs of ascites...examiner asked what's
your positive findings?!like I said above..what's yr
diagnosis appendectomy..plus hepatomegally possible
)cause haemolytic anemia(thalassemia
How can you explain the hepatomegally I said
secondary to repeated blood transfusion developed
hepatitis or coincided with the anaemia😊
What will you find in blood film of this patient I said hj
bodies😀Igot18😊
Station 2
years old male with history of rt side chest pain 40
occurred when he is at work mainly of short duration
no aggravating or reliefing factors associated with
sweating. palpitaion.dizziness ..known Hypertensive
last reading was was 150/90 on ttt.not known
diabetic..No history of high cholestrol..clots.positive FH
of sudden death his brother..otherwise not known to
smoke drink alcohol
CONCERN what is my problem as it is recurrent..can
you give me some painkiller.. at that point I had put on
my mind differential to be honest😅😅😅 no difinit
cause...so I said to him for right now to be able
to.answer your concern.I have to do some tests and
examine you...as there are many possible causes like
..unstable angina..HOCM..arrhythmia
Examiners so what's your diagnosis I said My
differential diagnosis is unstable
angina..HOCM...Arrhythmia
Why don't.you.give him just pain killer...me he is HTN
plus history of sudden death his brother I would have
to role.out serious.causes then I can give him the pain
killer..so you will admit him...yes to investigate..so
what investigation general..then.ECG..cxr..cardiac
enzymes..echo..😬Igot 17😄
Station 3
Cardio...old man lying in cardiac bed dyspnic..pulse
small volume irregular..AF...apex difficult to
detect...1st heart sound loud..2nd heart sound
accentuated at pulmonary area
MDM at the mitral area..so my diagnosis was
M.S..AF..PHTN
EXAMINER what's your diagnosis...I got 20😊
Neurology..instruction examine lower limbs
Female unable to walk for long time
On examining her she had increased tone.clasp knife
rigiditiy..power of umn pattern..increased
reflex..normal sensation in lower limbs..I asked to
proceed and examine upper limbs which was
normal...Examiner what's your diagnosis I said spastic
paraplegia e normal sensation
What are the possible causes I said hereditary spastic
para...CP..then he said what else would help you to
confirm your diagnosis I told him FH...then he said time
up.I got 20
:My experience in PACES exam 1/2017

I had the exam in Cairo,Kasr Eleiny 3rd carousel
، 6/2/2017
، I got 150 / 172
First I would like to thank our brother and teacher dr
Ahmed Maher Eliwa and all people who supported us
and I appreciate your efforts
.with us for learning and success
My advice to all doctors who will enter the exam in the
future as dr
Shaimaa Mohamed Abdou said is not to put any
previous failure in your mind and try to sleep well
before the exam ,and also try not to read or revise any
.thing the day before the exam ,to relax your brain
;I started with station 4 communication
.Outside the exam room, the scenario was
years old female patient admitted by community 80
acquired pneumonia and received antibiotics then
developed delerium,she became confused, agitated
and refusing to receive any treatment and has idea
that she had been poisoned,and she has past history of
.hypertension
The task was to explain the condition and management
.plan to her son
I started by the usual introduction and asked the son
about what he knows about her condition and after
that started gradually to explain the condition to him
and what delerium means and i asked about her
previous history of any memory problems . and the
surrogate said that she has some memory problems
،but deteriorated after the pneumonia
the concerns were, is this reversible ,when my mother
will improve and go home, does she will need imaging
for her brain,how can she will receive medications and
.she is agitated and can hurt herself
I tried to reassure him and that we will form MDT from
chest doctor,ICU doctor and neurologist to assess her,
and that the neurologist may decide to give her
medications to relax her and the medical team and
nursing will be with her and so she will not hurt herself
and we can not expect the time of recovery now but
we will do the best effort for her ,I told him that
delerium is common in old people after infection and
that it is reversible, and that the neurologist is the
person who can decide if she will need imaging for
brain or not, and i provide help for her after discharge
.,summery,checked understanding
During discussion the examiner asked me to
summarize the scenario,asked me, is delerium
reversible,i said yes after treatment of the cause.he
asked about causes of delerium ,I said infections as
pneumonia and urinary tract infection ,he asked about
drugs that cause delerium ,i said dieuretics can cause
dehydration and delerium and also antibiotics can
cause this, then he asked about ethical issues in
.scenario and the bell ring
.I did well but I got 12 / 14 ,I do not know why
;Station 5
First scenario outside exam room was, skin rash in 40
.years female patient
Outside exam room i expected that the case will be
psoriasis or pemphigus but when I entered the room it
appears as vasculitic rash on both upper and lower
limbs but i was not sure and afraid to loose the case,
but in the history with the surrogate the patient is on
.treatment for hepatitis c
The concern was is this rash related to her condition, i
said that yes it may be related to hepatitis c by
،affection of blood condeu and, the seconed
possibility is a condition called lichen planus which also
may be related to hepatitis c so we will refer her to
skin doctor and her liver doctor to diagnose and give
.treatment
During discussion the examiner asked what is ur
diagnosis ,I said the first possibility is vasculitic rash,he
said which type of vasculitis ,I said cryoglobulinemia,
he said what other DD of this rash , I said lichen planus
.and porphyria cutenea tarda
He asked how to treat cryoglobulinemia ,I said steroids
.,immunosuppressive drugs and treatment of the cause
He asked how to differentiate between this
differentials, I kept silent then the bell ring then I said
skin biopsy ( the two examiners were very helpful and
)with nice smile
.I got 28 / 28
Seconed scenario outside exam room was, weight gain
.in 40 years female patient
when I entered and took history it was a direct case of
cushing syndrome with all evident manifestations of
the syndrome (do not forget to ask about steroids in
this case) and complications of cushing syndrome and
.weight gain as obstructive sleep apnea
The discussion was about DD and how to diagnose and
differentiate between different causes of cortisone
excess, and the last question was which drug is used to
treat diabetes in patient with cushing syndrome, but i
.do not know what the examiner need
.I also got 28 / 28
:Station 1
; Chest
It was a case of right lower lobectomy with fibrosis on
the same side and bronchiactesis on other side with
.also obstructive lung disease
Discussion was about indications of lobectomy,
.diagnosis and managment plan
.I got 18 / 20
Abdomen; it was not good for me and it was also the
most case I do not like during preparation for the exam
.especially detection of presence or abscense of ascites
There was hepatosplenomegaly and during
presentation I said that I can detect ascites by
examination but I want to confirm by ultrasound but
.the examiner was not happy when I said ascites
I told the examiner that I would like to examine lymph
.nodes but there was no time
During discussion the examiner asked about DD of
hepatosplenomegaly, I said chronic liver disease with
all its causes and myeloproliferative disorders, he
asked about how to diagnose HCC if the patient
develped this ,I said basic investigations,alpha feto
.protein and ultrasound
He asked if this patient has lymph nodes what will be
.the cause,I said metastesis from HCC
I was not happy in this case and has some sort of
.mental block
.I got 13 / 18
:Station 2 History
Outside exam room ,the scenario was 25 years old
female patient who had developed skin rash on the
face and forearm which disappeared after receiving
steroids then recurr again after travelling to Luxor and
also she has fatigue during the last 3 months and
.neutropenia
Inside the exam room it is very important to confirm
that it is the same type of rash in the two attacks
during analysis of the rash and during history she has
. ankle and hand joint pain and has one abortion
The diagnosis was SLE with antiphospholipid
.syndrome
The concerns were, Is this blood cancer causing
fatigue?can I get pregnant now?,I said that it is unlikely
to be blood cancer and I explained the diagnosis to her
and I said that she will be referred to MDT including
rheumatologist and obstetrician to give her the best
treatment and to decide about pregnancy because it
.can be affected by her condition
،During discussion the examiner asked
What types of skin rash in SLE?, I said photosensitive
.rash, malar rash and discoid rash
What is the distribution of the rash on the face in SLE?,I
.said rash on the face sparing the nasolabial folds
How can u diagnose SLE and what are the most specific
antibodies in SLE?, I said anti dsDNA and anti smith and
.other investigations
Which inflammatory marker is raised in SLE?, I said
.ESR
What is the treatment of SLE?I said the types and drugs
.used in the treatment
.I got 19 / 20
:Station 3
.Neurology; examine the lower limbs
It was also not good case and I did not detect physical
.findings well
There was peripheral neuropathy and I think that there
were also pyramidal manifestations but were not
.clearly evident as usual
During discussion I said peripheral neuropathy and did
not say other thing because I was afraid to say things
not present, but the examiner said what else , I said
.mostly the patient has combinations of lesions
The examiner asked so what ur other diagnosis, I said
MS and also said to him that MS do not cause
.peripheral neuropathy
.He asked about investigations
.I got 12 / 20
Cardiology; It was a direct case of mitral valve
.replacement
Discussion was about indications of mitral valve
replacement, complications of anti coagulants and
management of cases of metallic valves, the last
question was which antibiotic is used for prophylaxis
against infective endocarditis but I said I can not
.remember then the bell rang
.I got 20 / 20
:Finally I got
.Patient welfare 32 /32
.Physical examination 23 / 24
.concern 14 / 16
.clinical communication 13 / 16
.Physical signs 18 / 24
.Differential diagnosis 22 / 28
.Clinical judjement 28 / 32
.Total score 150 / 172
.I hope success for all. — with Ahmed Maher Eliwa
Hi all,I would like to share my station

Day 5 round 2 Yangon
Station 1
Resp - Rt.sided pleural effusion with Lt crepts and
rhonchi
)Abd- Hepatosplenomegaly (Thalassaemia
Station 2
yrs old lady with hypertension20
GP did urine dipstick show proteinuria and haematuria.
.Pt also c/o fatigue for 6mths and fever for 3weeks ago
Station 3
CNS- MND
CVS- MVR with vulvotomy scar
Station 4
Talk with granddaughter about 89yrs old rt. sided
weakness. PMH - TIA and AF with wafarin ,fail to follow
، up at wafarin clinic
INR 1.2,CT - infarct stroke and no bleed
Task - explain about CT result and refer to stroke unit
Station 5
BCC1 - H&M due to NSAID and prednisolone overdose
with low back pain and ankylosing spondylitis
BCC2 - Peripheral neuropathy with DM and also taking
anti -TB and diet -vegetatrian
UK Experience
Primary experience in Eastbourne District General
Hospital
St_1
Chest: bronchiectasis + old
Abd: severe hsm without stigmata of cld
St_2
History: presyncope... family with valve replacement &
rupture aneurysm
Tall? Marfan? Discussed aortic stenosis hocm
St_3
Cvs: mvr good function with malar rash, ll edema not
cardiac
Neuro: spastic paraparesis but patern of weakness not
clear lt weaker
With loss touch at level umbilicus on rt side
St_4
Comm bbn colectomy for uc 25 years precancerous
colon
St_5
St 5 ... blurring vision rt eye
laser surgeries in eyes, dm 2
Fundus not seen well
Asked if I did light reflex
St 5 fever.... only +ve is diarrhea
Exam experience
On 8th of February 2017
) In Military Medical Academy ( Almaadi - Cairo
Station 3
Cardio
)Two local examiner( Egyptions
After greating examiners, I washed my hands, quickly
having a look at complaint on the wall, Then I greated
the pt, asked for permission, and asked about pain
(crucial for welfare also for identifying physical signs
for example if he
Pt points to the right upper abdomen look for CV
waves on
JVP and other signs of pulmonary HTN including
.pansystolic murmur of tricuspid reg )my had none that
His pulse was regular with average volume,no special
character (again asked about right upper limb before
raising it for examing for collapsing pulse) .Other
general exam was unremarkable. He had
midsterntomy scar,apex was difficult to localised (don't
panic and waste your time on it if you confronted with
)such patients
First heart sound was soft while the second one was .
metalic. There was pansystolic murmur in the apex
with harsh ejection systolic murmur in aortic area that
radiated to the clavicle . Not in heart failure, No signs
of perpheral infective endocarditis or signs of over
.anticoagulation
Then covered and thanked him
Examiner questions .
?What's your findings
As above. In summary this has aortic valve
replacement with mitral regurgitation I would like to
do echocardiography to confirm my diagnosis to assess
valve function because the murmur in aortic area
.radiates up to clavicle
?How will investigate him
Basic investigation including INR, ECG, CXR and
.echocardiography
?How you treat him
.Social, fiancial and psychological support
Counselling about prophylaxis again endocarditis and
.anticoagulation
.Regular follow up with echocardiography
?When endocarditis prophylaxis indicated
Dental work with blood and work on septic area but
not for endoscopy or other procedures
?Target of INR
3-2
? Role of NOAC
.No role of NOAC in metalic valves
?What do you think the cause of his valve problems
Rheumatic heart disease most likely, also could be
bicuspid aortic valve or degeneration I would like to
.know his age
Time finished
I got 20/ 20
Exam experience
Station 2
History
Young man with long standing
Backache .After greating examiners. I greated the
pt/actor, introduced myself, confirmed pt identity and
ageed agenda . I asked him if there is any thing else
(apart from Backache) bothering him he wants us to
?discuss.what you do for living
.I started by open questions
PC lower back pain which is more in the morning with
stiffness last about 15 minutes for three years (he
)didn't seek medical advice only using analgesics
.No H/O trauma
I asked about symptoms of cord compression(to show
.them that I am a safe doctor)there was none
I asked symptoms suggestive of malignancy and
infections
to show them that I am a safe doctor) there was (
.none
Then I asked about other symptoms of Ankylosing
spondylitis (the A'S ) he had H/O red painful eyes , but
didn't know
.What's the diagnosis was. Also he had heel pain
Then I asked about symptoms of other seronegative
.spondyloarthropathy,there was none
PH there was upper GIT bleeding (asked him
)specifically since he was using analgesics
For which he was admitted to hospital. Apart from that
.No PMH of note
FH I asked specifically about FH of Backache or joints
problems .His father has long standing Backache. Also
FH psoriasis .Then I double checked that the pt doesn't
have skin rash(I asked before when asked about
)symptoms of seronegative spondyloarthropathy
)DH only analgesics (paracetamol and codeine
SH
Impact( how his symptoms affecting his life) and
function
.He is not driving
I summaried and asked him if he wants to add anything
.or if we missed something
I asked him what is the cause of his symptoms from his
.point of view
Upon hearing 2 minutes remaining I asked him about
.his concerns
? What I have
. He asked about exercise
I addressed his concerns told him the plan and thanked
him
.Examiner questions.
?What is your diagnosis
This gentleman gave histry of inflammatory Backache
together with heel pain and H/O red painful eye
.)moreover has FH of long standing Backache(his father
?What's your differential diagnosis
Psoriatic spondyloarthropathy but no history of skin
.rash
Entropathic spondyloarthropathy but no history of
.bowel problems
. Reactive arthritis but no symptoms suggestive of that
?How you investigate him
Basic investigation including CBC, LFT, RFT,
inflammatory markers, CXR specially if I am
Considering biological agents, and Xray of the spine
and sacroiliac joints (I told them about possible
)abnormalities specially of the last two
I told them if X ray is normal MRI is more sensitive in
.showing sacroilitis changes
?How you will treat him
.Social, fiancial and psychological support
Physiotherapy, occupational therapy, Exercise incuding
.swimming
.NSAID with PPI after counselling
If he developed perpheral arthritis sulphasalazine will
be helpful but it has no role in spine like other
DMARDS
If pt fails to respond to 2 NSAID then he will be
.candidate for biological agents
?What are they
Anti TNF alpha like adalimumab
.and etanercept
?What are the precautions for them
Excluding
Active bacterial infection and
.Tuberculosis
Bell rang
.I Thanked examiners while leaving the room
I got 18/20
They are not happy about the way I addressed the pt
concern
The examiner said to me you didn't explain the
diagnosis well
.To him. So they gave 2/4 for concerns I believe
UK Barnet Hospital
St2: lady in 40s headache with symptoms of increase
intracranial pressure
S 3: mixed aortic valve +AF ..not sure
Neuro ..cranial nerve examination 5,7,8,12 plasy for
deffrential
Communication: explain SLE and the need for biopsy
for a young lady
S5;1- epileptic pt came with convulsions and headache.
.pregnant off treatment due to pregnancy
Post MI a few weeks ago came with lethargy and -2
.tiredness. .also has dizzy spells
Respiratory; COPD and discussion about the
management
Abd: Renal transplant causes, side effects of
.treatments
.Yangon (9.3.2017) D4R1

Abd. Bilateral polycystic kidney disease �Resp. Rt .
collapse consolidation �CNS. Spastic paraparesis
�CVS ARMR�BCC 1.. gritty eyes with weight loss &
tachycardia Grave ophthalmopathy �2.. reduced urine
output in elderly lady taking treatment for knee pain at
rheumatology clinic �History.. altered bowel habit..
got t/m at GP for IBS but still not relieved �Comm..
delayed disgnosis of pheochromocytoma
Yangon (9.3.2017) D4R2�CVS= AS+ or -AR�CNS
=sensory T10.spastic paraplegia�Resp
=Bronchiectasis�Abd=Thalassaemia �(only
splenomegaly)�BCC2 old lady has Fever and
.underlying hypertension
Yangon (9.3.2017) D4R3-�St 4- mother admitted with
UTI found out ADPCKD and CKD stage4 talk to
daughter. �St5 a, 56 yr old female - blurring of vision.
Diabetic rertinopathy.�5.b 56 yr female feeling dizzy
and faint. Hypopit due to snake bite.�St1 abd - COL
with HSM and ascities. I didn't get liver. �Resp: COPD
with Brochiectasis.�St 2- 25 yr female with bloody
diahorrea and fever 3 days. Returned from Thailand.
Uncle has chron disease. -Ddx infective and IBD�St3-
CNS - multiple CN palsy with ptosis - I couldn't finish all
CN exam and Dx�CVS- MSMR with AF, heart failure
🍭Asalam 3laikom guys 🍭

: I am going to share wz u my paces exam experience in
..ALMAADI MILITARY ACADEMY/EYGPT
.nd carousel2 .. 8.2.17
I started with 🔖 station 5 🔖
📌BCC 1📌
..Instruction this pt is complaining of inability to walk
I was stressed and confused stood on z lt side of z pt
🙄started asking z surrogate he said it started 1 yr ago
after few questions I turned out that he has backache
and stiffness for more than 2 hrs and he can walk 😡😡
so I asked about any restriction of movement of spine
and neck he said am not sure so I started z standard
examination of ankylosing spondylitis asked about z
complications but I didn't explore the other
differentials & didn't hear z examiner saying 2 mins
remaining and so missed z concerns😭😭
Z first Q by z examiner was did u answer the concern of
this patient I told him am sorry I ran out of time �..
Then what is ur diagnosis and why, DD, investigations
..and ttt
..I thought I totally messed up but got 20/28
📌BCC2📌
..Instruction see this 32 yr old man with poor vision
Hx revealed gradual loss of vision for 2 yrs and he has
behcet disease on ttt including warfarin, I did acquity
he can't see on Rt side & can only appreciate hand
movements on z left.. funduscopy pale discs with bony
specules.. Asked about FH said his brother is blind,
tried to screen for syndromes associated with Retinitis
..pigmentosa
concern was: can he regain his vision,, is it related to
..his behcet's, chances of his kids to be affected
Examiner Qs: what is ur diagnosis and could be related
..to behcet and why?? Mode of inheritance, ttt
Got 28/28
🔖station 1 🔖
📌chest📌
Young average built gentleman with no peripheral
signs
has left thoractomy scar which I saw in the last minute
while examining the back(it wasn't extending to z
side)🙄 for me nothing conclusive in the exam apart
from fine basal crackles more on the Rt base with a
scar of an intercostal tube I guess , I had no idea what
to tell the examiner who kept arguing about z site of z
trachea and said how would u explain that z scar is on z
left while trachea was to the Rt🙄
..Q: cause of lobectomy,, inv,, ttt
..It was my worst station
😢20/13
📌abdomen📌
Young boy pale with supraumbilical midline scar
hepatomegaly and resontant splenic bed, no palpable
..lymph nodes
It was thalassemia, discussion went deep on
thalassemia complications and treatment of each,
what u will see in blood film before and after
..splenectomy
20/19
🔖Station 2🔖
Scenario : 29 yr old lady with one week history of fever
..and bloody diarrhoea after she came from Kenya
Inside she stayed there for 3/52 with her husband and
son ate from local food, took full vaccination&
prophylaxis before travel and continued after she came
back, diarrhoea started on the second day of arrival
home bloody frequent with fever, denied any
diarrhoea from before has weight loss no risk factors
..for HIV, has an uncle with crohn's disease
..So I put infective diarrhoea and IBD
Examiner said which is first I answered infective
diarrhoea coz of z short Hx of diarrhoea and travel
..history but could be as well first presentation of IBD
..All discussion was about work up and ttt of IBD
20/20
🔖Station 3🔖
📌CVS📌
double valve replacement discussion about the usual
questions, what u will do for him, target INR,
indications of IE prophylaxis and how frequent u want
..to see him in the clinic
📌Neuro📌
..Peripheral sensori motor neuropathy
The loss of sensation and weakness were
asymmetrical, knee reflex was persevered on Rt lost on
z lt
I was not happy as z pt was an old man and has
..difficulty obeying my commands
Examiner Q: possible causes I mentioned DM he said
it's not common in this country 😱so I mentioned other
..courses,, inv ,, ttt of diabetic neuropathy
20/17
🔖Station 4 🔖
BBN
Long scenario about a 49 yr old gentleman heavy
smoker diagnosed with dialted cardiomyopathy on
maximum medical ttt, his cardiologist said nothing to
be added.. Came now with cervical lymph nodes and
CT abdomen and chest showed renal cellcarcinoma
invadingelse cell invading z capsule with lung and
.. vertebral metasteses
Task was speak to him about diagnosis , prognosis and
..role of specialist nurse on his palliative ttt
So I started by asking him about his health and how is
coping with his heart condition then asked about did
any one told him why these investigations were done
..for him he said no
Then I told him I have the results with me and
unfortunately it is not as we hope... It showed he has a
growth in his kidney... A nasty growth what we call
cancer.. I gave him time to express his feelings .. then
he told me to be honest with him and tell him every
thing and asked me is it curable I told him am afraid it
is not, it has already gone to ur spine and lungs.. So the
ttt now is to keep u comfortable and free of pain but
no cure😞
Then he asked how much time left for me I told this
..will definitely shorten your life
Then he told his wife will be very depressed if she
knows this & he doesnt know how to tell her I offered
him to bring her with him next visit if he WISHES& will
.. help him telling her
Then he said he wants to travel and enjoy before he
dies I told u will be assessed by heart doctor and
tumour doctor and they r z one to decide, he told me u
r doctor as well tell me 😭 I told him am afraid that ur
heart problem might limit ur options and suggest he
can still enjoy around and spend time wz his family 😇
Then he told me I love gardening but I cant take care of
my garden coz of my dyspnea please give me to help
me 😔 ( it was mentioned he is on maximum ttt
nothing to be added) I didn't want to hurt him by
saying this he already had enough I guess so instead I
told him u can make gardening a family time to pass ur
experience to ur kids and wife who will cherish this
time forever after you leave ☺️
I concluded by referring him to MDT including
oncologist, psychotherapist, social worker and
Macmillan nurse team who will help him and his family
passing this difficult time😔
..I showed great empathy all through our conversation
I forgot to summarize and check understanding😁
:Examiner Q's
What z oncologist will do for him: I told pain control
and may be local radiotherapy for vertebral metastes
..then asked any thing else?? Is he for palliative chemo
..If he insisted to travel how u will help him
Do u think u have convinced him and accepted his
..diagnosis
..What is z role of Macmillan nurse team
16/16
Alhamdullah I passed,, I am grateful to every one who
.. took a moment and shared something in this group
..It was of great help for me and others
..Stay blessed
UK Experience
،Station 4
GBS case , talk to wife , patient is off ventilation,
Neurologist initially said good prognosis but now he
، said lower limb won't recover
Wife questions
is it been misdiagnosed )1
Husband is depressed now what are you going to )2
do for his depression
who will look after him at home )3
can I take him home )4
)any chances of recovery (asked this many times )5
will physiotherapy benefit him )6
Examiner
Discuss the scanerio
Ethical principles
History
years female collapse , brother has epilepsy 20
، was waiting in bank que where she collapse
Positive - sweating, dizziness, 5-6 LOC, urinary
incontinence
Using mafenamic acid for menstruations problems
Concerns
Is it epilepsy
Applying for driving licence should I apply
what I need to do to prevent it
Diagnosis _ Vasovagal
Examiner
D/D
Investigation
-BCC1
، male , collapse while talking to wife 79
Post ictal 30 minutes
، Tongue bite
Jerking of limbs
Background
Benign brain growth
Concern -Driving
Examiner
Are you going to start anti epileptic
BCC2
male , breathlessness -5 months 70
،MI 1 year ago
Can walk 100 yards now , 6months back can walk
normally
Cough -dry since 6 months
،No leg swelling ,no chest pain , no palpitations
Forget to ask Orthopnea and PND
On usual drugs of post MI
O/E
Pulmonary Fibrosis
، Occupation -clerk
-Respiratory
Lobectomy
Examiner questions
Difference between Lobectomy and pneumonectomy
Why patient is dyspnoeic
Abdomen
Renal transplant
Neuro
Diplopia
th Nerve palsy6
Examiner questions
D/D
If it because of DM what are you going to do for him
Cardio
Loud P2
systolic murmur?
Examiner
What are the causes of secondary pulmonary
hypertension
My experience
Yangon, Myanmar
7.3.17
Day 2, Round 1
Station 1
Abdomen - Anaemia with hepatosplenomegaly
Respiratory system - Rt sided pl effusion
Station 2
yr old woman with tiredness, wt gain, amenorrhoea 28
Station 3
CVS - AR
)CNS - Rt sided 3rd N palsy, (pupil sparing
Station 4
CRF - to explain dx and Rx
Station - 5
BCC 1 - systemic sclerosis with breathlessness
BCC 2- Hypothyroidism with chest pain
BEST OF LUCK for all
Myanmar (Yangon) center (8.2.2017) 2nd round

station 3 CVS..1. AS but firstly i wrongly gave dx of MR,
forgot to tell carotid radiation. But examiner lead to
Aortic stenosis. So i told again AS with gallerverdin
.phenomenom and continue management about AS
MS with AF�Neuro..1. Spastic para with sensory .2
about T5. Examiner asked about mx but i answered
general things but she still want other differential may
.be MS or Fredrich, i dun know
Flaccid paraplegia�Station 4.. BBN to wife of SAH .2
pt in ICU with taking warfarin for DVT and thiazide for
HT not regularly taking medications. INR- 4. Neuro
team decided that not fit for surgery. Examiner asked
about ventilator.not including task about removal of
ventilator. Concern... is it due to warfarin? Is it
recover? �BCC..1. Rheumato clinic for 5 yrs for
bilateral hand jt pain, now complaint of dizziness and
breathlessness..drugs taking methotrexate, ibuprofen,
aspirin, prednisolone, statin, losartan.Come with
malena and collapse.�May be postural hypotension
due to malena.or losartan. �BCC 2.endocrine clinic for
5 yrs come with vomiting.�Taking sterois for 2
yrs.abruptly stop for 1 wk. Hypoadrenalism��Station
..1 Abd..1.renal transplant with scar having AVF
Hepatosplenomegaly�Respi..1.bilateral .2
bronchiectasis with clubbing
Rt UL collapse consolidation with pleural effusion .2
History..recurrent chest infection and cough in pt �
with DM and asthma not responding to
antibiotics..cystic fibrosis
�Myanmar (Yangon) (8.2.2017) last round
Station 1 resp copd� Abd. Thalassemia �Station 2
IDA diclofenac induced GI loss� Family Hx of Ca colon ,
Coeliac �Station 3 CVS MVR or AVR?� CNS peripheral
neuropathy�Station 4 SLE with renal biopsy�Station
5 DM HT with headache ....Acromegaly�Optic atrophy
:My exam experience

Medical Military Hospital- Cairo- Feb. 7th
:I started with Station 5
Around 50 yo lady c/o confusion over the past 1 -1
;week. She just received chemo 1 week before
After introduction – analysis of complaint OCD – any
fluctuations? No – Memory problems and to recent or
old events ? coping and home and self care? Getting
lost sometimes and forgetting names of familiar ppl
?like you? Any previous episodes
Then asked about DD of delirium like infections ( UTI
and Pneumonia ) – pumps and lumps and wt loss?
Abnormal hand movemts ( Parkinson’s plus ) and
neurological system specially headaches with increased
.ICP which was negative
Then moved into the chronological hx of cancer and
.chemotherapy
Examination : general survey by checking the pulse, the
eyes for pallor then quick neurological ex like pronator
drift, quick tone and power and plantar reflexes. All
.were negative and I also offered fundoscopy
.Management: admit for IV fluids and brain imaging
Examiners : D.D: Hypercalcemia due to malignancy,
Brain mets. – IVF and Bisphosphonates, brain CT to r/o
Mets. Did u reassure the son? Is it reversible ? A:
Hypercalcemia can be corrected but if there are any
.mets the prognosis should be worst
28/28
;Wt loss in 50 yo female -2
Analysis of complaint, OCD , how many KG over how
long? Appetite was good with no diff swallowing, not
.intentional
I asked about my D.D which I found all negative!
..Malignancy – TB – Endocrinal – Chronic infections
I jumped into PMHX: any long standing problems? So:
like what! Any gland problems particularly the gland in
front of her neck ? yes she had HYPOthyroid 2 years
ago and on levothyroxine. Any change in the dose? Is
.… she compliant
I then started to ask about autoimmune associations –
joint ? rash ? ….. then the only thing I picked was
polyuria and polydipsia when asked about DM .. then I
continued any recurrent infections like in the water
work ? no . Any skin infections particularly fungal? No ,
any discharge from the private part ? YES colour smelly
? No answer – is it white cheesy like – examiner said
!yes! Is it itchy? Examiner said yes
.I maily examined the thyroid – no findings
D.D : DM – Levothyroxine overdose – Polyglandular
.syndrome
28/28
:Station 1
Respiratory : Young patient with lt lateral -1
thoracotomy scar with reduced chest movement and
expansion on the left side. Trachea was mildly shifted
to the rt!! Percussion was heterogeneous on the left
side dull on the left base. Heterogeneous on the rt side
also. VR was reduced on the lt base. There was bibasel
.end insp crackles not changing by cough
On presentation I was confused .. I didn’t mention the
say upper or lower ) with bilateral fibrosis ( did not

mention any areas) I basically wanted the examiner to
direct me as the case was quite difficult – didn’t want
.to invent signs or come up with a wrong diagnosis
Q: Causes for lobectomy ? what are other reasons for
the the scar – said oesophageal and cardiac surgeries!
Management and possible cause in this particular
case> said in this young man with lobectomy and
.fibrosis TB is my first differential
20/20
Abdomen : Middle aged woman – do u have any -2
pains ? yes – where ? here ( right hypochondrium ) I
was like Huh
Started me palpation trying to avoid causing pains, the
abdomen was distended ( ascites ) while trying to
palpate the liver the patient was uncomfortable – I
stopped my examination and said : Sir, the patient is in
pain should I proceed ? Procced gently :D
Couldn’t get the border of the rt lobe cause of the pain
and ascites, lt lobe was 6-8 cm below xiphsternum.
Spleen was palpable but couldn’t get the border/span
.for the same reasons
Presentation : HSM with Ascites , could get the rt lobe
span and same for the spleen :D
D.D : No signs of chronic liver disease – could be
Chronic viral hepatitis with Bilhariziasis causing portal
.hypertension and ascites
Discussion about Investigation and went deep into
diagnosing Bilharisiasis – said urine/ stool – how about
serum ? wanted to hear ELISA . Also asked about the
HBV markers – what if the HBSag –ve and AB positive :
Pt is immunised.. what if Core +ve : previous infection
!– he was smiling and I was too
20/20
Station 2: Hx- difficulty moving over the past one week.
.He had hx of radiotherapy for lung cancer
I think I got the full mark in this one cause of deep
analysis of complaint ( back pain ) which I got the
incontinence problems – then I went deep into how
this is affecting his life and the embarrassment he
suffers with. I stopped at this point showing a lot of
empathy and sympathy as if it’s a communication
station – also asked about occupational hx and
.asbestos exposure
Dx: cord metastasis with compression symptoms –
urgent admission - IV dexamethasone and urgent
.neurosurgical review
20/20
:Station 3
Neurology: Rt sided hemiparesis with Rt -1
.hemihpothesia
Discussion was about the possible causes ( thrombo-
embolic ) and site of lesion ( r tint. Capsule ) and
) management ( in acute and chronic presentation
20/20
Cardiology : was a difficult case, Middle aged -2
female, raised JVP and when I asked about abdominal
pains she said yes. I asked the examiner to do the
hepato-jagular reflex he said no need. By then I knew
the patient had TR! I could hear the systolic murmur of
TR which increased on inspiration, I also Heard systolic
murmur over the apex ( not radiating to the axilla ) and
on aortic area ( not reading to carotids and no palpable
) thrill
I then decided to only mention the surest finding ( TR )
and give differentials for the others, trying to avoid
wrong diagnosis or invented signes. ( wanted to get
) some marks better than loosing it all
The examiner asked about diagnoses ( TR ) what causes
( Rheumatic ) he was not satisfied and asked whether
RF affects the tricuspid valve? I said rarely as it
commonly affects the mitral then the most common
etiology for isolated TR should be pulmonary HTN, he
was then a bit satisfied and the discussion went over
the pulmonary htn 1ry and 2ry causes , inv and
.managements
Seems like I missed the loud P2 or a parasternal heave (
the P2 was loud but I didn’t want to mention it as I was
) not quite sure
Got 13/20
Station 4 : 50 yo lady collapsed at home the previous
night. Admitted to hospital; with HB of 7.4 g/dl ,
received BT and now feeling better. She is on Ibuprofen
for a long time. Her husband is at home with a recent
.MI and is diabetic who needs someone to take care of
Task: convince the patient to stay at hospital and to
.offer any investigations you may see appropriate
So I realised I needed to convince the patient to stay
for upper GI endoscopy for possible bleeding d.t
.ibuprofen
Introduction , confirm identity , breaking the ice ( hope
u’ve not been waiting for me for long – examiner was
happy nodding his head! )then confirming agenda –
exploration and expectations and possible initial
.concerns
She said she’s fine now and wants to go home to take
care of her husband, she new she had BT and her HB
was quite low, She had no idea about any possible
.cause
I started to explain possible bleeding and the need for
further inv. When I mentioned the ( camera test ) she
was annoyed and strongly refused it – I then realized I
!was on the track
Started to explore the reasons why she refuses – she
had a previous bad experience with an endoscopy 7
years ago. She stopped. I asked again ( with a smiley
face ) would u plz tell me more what happened and
what kind of pressures u had ? she said there was no
privacy, uncomfortable as I could feel it all and
!eventually they found nothing
I reassured her regarding every point ( the privacy –
skilled doctors – more anaesthesia … ) and will ask the
.social worked to take care of ur husband
She finally agrees – can explain the procedure for you –
..I demonstrated with drawing
asks whether I could have discharged her then she
comes back later – why? My husband! I reinforced
again about the social services we have………… and
explained we won’t guarantee what happens if she
goes home and we need to know what’s going on
.before discharge
She was concerned about any other possible cause, ( I
felt she was asking about cancer ) I asked are u
concerned about any particular condition – she said
cancer – I said that can’t be ruled out I am afraid, but
we need to investigate the most probable cause first
which is the possible bleeding from your stomach due
.to the painkillers
She now agrees and has no further concerns ,
Summarized then said ( I will have another meeting
with u with my consultant after the procedure and may
be we need to do further investigations according to
the endoscopy results ) then told her about the
.consent which she agreed to sign
Examiner: what is the case … then asked whether she
may have cancer – I said probably – asked did u ask
about the alarm signs? Said NO for two reasons; I
didn’t want to go into hx taking in a communication
station and I wanted to fulfil my task to convince her to
stay for the upper GI endoscopy. Do you feel any inv.
Should has been furtherly discussed, said yes
Colonoscopy and that’s why I told her I am going to
have another discussion with u after the endoscopy :D
Examiner was happy then asked; what if she refused? I
said in that case there’s an ethicl issue which is
patients autonomy and I have to respect her wish, on
the other hand Beneficiance should be fulfilled by
trying to convince her to go for it for her best interest.
!He was then smiling
16/16
Got 165/ 172
.Wish you all the best of success
Hi good evening My experience in kilmarnock

crosshouse hospital
Station 1 resp: right sided thoracormy scar with left
sided fine end inspiraory basal crepts diagnosis right
lobectomy due to fibrosis
Abdomen Patient with black pigmentation on hands
dorsal surface with two dialysis fostula on both arms.
no marks of recent use. want to see gum hypertrophy
but he was wearing dentures. was pale. having
laparotmy scar cvp line scar in neck. i cant palpate
masses gave diagnosis of ESRD with renal trnplant.
exmainer was not happy. this patient came in previous
.attempts i think its there chornic patient
St2 55 Y old male smoker DM on metformin and
sitagliptin poor control had MI and atrial fibrialltion
with DVT few years back taking betablocker also. latest
BP sitting 146.78 standing 120.81 INR 1.5 came with
recent onset of dizzy spells for 3 week woth chest
tightness and palpitipns Gave DD of postural hypo
autonomic neuropathy drug induced hypoglymic
attacks cardiac arthmias P.E
Station 3 CVS MVR patient with metallic S1 best heard
in mitral area. Viva was usual. examiner asked me
types of metallic valves😳
CNS parkinson disease command was patient with falls
examine do appropraite exam. there was tremors
more marked in right side blefroclonus
shufling gait stoped posture cog wheel lead pipe ridigt
masked face with slow speech. viva usual. examiner
asked indocation of MRI or CT in parkinso diseaze
station 4
Y old female nurse came with loss of consousness 33
found to have hypoglecemia she is not DM. high C
peptide junior staff told her it is insulinoma later urine
came positive for sulphonylurea overdose
your task to tell her diagnosis and try to convince her
for phychiatric assessment
i totally messed it up. exmainer told me she had fight
with husband whonis diabetic and she took gliclazide
tabs for suicide😔
station 5 patient with pain in hands and dysphagia had
typicsl features of Systemic sclerosis viva typical
next patient was 28 y old male with 6 month
intermiettnt hematuria urine positive for RBCs protein
negative i gave DD
Myanmar, Yangon Center (7.3.2017) last round

Resp: collapse consolidation with finger clubbing
Abd: jaundice with hepatosplenomegaly
CNS: spastic paraplegia
History: chest pain.... musculoskeleton pain history of
trauma present
Family history of MI, obesity, hyperlipemia present
Communication: uncertain diagnosis of CA pancreas
BCC1: know RA patient with proximal myopathy and
Cushingnoid face, taking steriod
BCC2: polyuria and polydipsia
Pt has blood disorder and taking blood transfusion for
thalessemia
Hi good evening.... I would like to share my
experiences in London feb 2017
Started with a station 2 young professionals with
history of losses motion for 6 month ..his concern is it
cancer
Station 3 CVS MVR
CNS pt was in wheel chair
Next station 4 was talk to the husband of a pt which
was admitted due to non STMI recived aspirin and she
had allergies to aspirin previous she had GIT upset due
to aspirin and told is allergy to her she advice for
station aspirin plavix lansoprazol pt refused to take
medicines
Station 5 hemochromatosis with DM presented with
....hand pain
Epistaxsis_2
Station 1 chest was not good to me pt was with oxygen
calender and had sternotomy scar next to him was
anticoagulant yellow card...present with SOB I hear
only fine crakels at base .... they ask what you do what
diagnosis
Abd was young African pt with hepatospleenmegaly
)almaadi military hospital second carousel. (8.2.2017
st 4 ; an old man k/c of advance heart failure did
lymphnode biopsy showed Rcc with vertebral mets on
bone scan for palliative care consultation went bbn to
palliative care to consern he has 3 consern 1-he has
acaring wife &he didnt want to tell her bec as she may
become deppressd I said we can help you in this by
telling her e great empathy &our psychologist can help
her if he agree because you need her support 2- how
long he will live as he want to travel abroad, he didn't
enjoy his life I told him yr ca is so advance &is likely to
shorten yr life he ask for estimation isaid monthes
rather than year then he said can you give meds to
prolong my survival to travel I said travel is not good
4you bec of Hf &yr ca (this taken against me ) 3-he has
agarden &he want to continue gardening Isaid I.ll refer
you to OT then isummarize &check understanding ,
offer help. In discussion summarize yr case .why you
insist to tell his wife & not respecting his autonomy ;
bec he is need of her support &I ask him if he agree .
Why you didnt allow him to travel isaid bec he may
deteriorate &of hf he said if he insist how you will
solve problem I said he need to tell his health
insurance &for his hf ikept silent he said assessment
for fitness to fly then he ask can we give meds to
prolong survival of Rcc I said am aware of new meds
used in advance Rcc but couldn't remember he said
why you didnt offer it for him isaid may be he will ask
for it &i have no information about it he laugh then
bell rang alhamdellah iwent out thinking v.bad about
my self as didn't answer his
Consern well but igot 14
St5: first case is young male e difficulty in walking no
other information I was completely disorganized ithink
about neuro inside problem for 2yr no neuro
symptoms I ask 4examination he said ok iask pt to raise
his leg he raised them well again v.bad feelig second
case is lost the it come to my mind to see his gait he
said ok at that time I recognized question mark posture
I ask is he has pain yes in lower back alhamdellah AS
isaid i want to do occiput walltest he said do it then I
ask about other symptom &assoc then iexamine cvs ,
resp .I ask 4 schoper test he said do it again ilet pt to
stand idid it improperly iforget to check for tenderness
& to ask for chest exp bec of time concern what is the
course &need tretment I answer we will do blood test
&image & refer to dpecilized dr iremeber the job in the
last second &he is adriver alhamdellah questions about
diagnosis inv&management really am thinking about
20 but i got 28 . Second case is young male blaring of
vision again no other information inside it is chronic it
started at night & progressd colour vision affected so it
come to my mind RP iask for exam he said do then V/A
he can.t see even moving fingers going to fundus with
typical RP then iask about assoc nothing is there he has
positive fh of blindness his brother iask about med list
serugate said steriod &immunosuppressant isaid 4
what she said for behecit dis I ask e what he presented
she didn't understand me the other examiner answer
me e DVT is he ok now regarding his behecit &no
problem e meds she said yes .consern is it related to
behecit & about his kids .questions is about behecit the
examiner is v.tough he ask why eye signs is not related
to behecit .what behecit can cause in the eye I said
pale disc due to sagittal thrmbosis he is not happy he
want other thing but my mind is stocked why is asking
about behecit &forget RP he gave bad impression
about this &I think he will give me 16 or some thing but
alhamdellah he gave me 26 . Iwill write other statoin in
separate post because ihave problem in my mobile
.rgarding long post
St 1 resp young male with pruductive couph he look
healthy when i ask him to couph it simulate the couph
of copd his chest exam is completly normal only
hyperexpanded chest couldn't appreciate any thing
else ipresent the casevas copd he said where is the
trachea isaid slightly deviated to the right he said what
is the cause of couph isaid infective exacerbation then
he ask about how to diagnose .common organisms.NIV
&LTOT when iwent out one of my colleque he
diagnosed him with pleural effusion ifeel v.bad about
my self how I diagnose copd only with character of
couph &hyperinflation so again this xase is lost
completely ithink he will give me 8but surprisingly igot
. 19
Abdomen :cld male pt pale & jaundiced e parotid
swelling enlarged lt liver lobe .splenomegaly &ascites
&ll odema discussion about causes , diagnosis .acute
.presentation &treatment of varceal bleeding &SBP
St2 young lady e bloody diarrhea e h/o travel to kenya
inside it is for 3week since she came about 12time/day
.fever.shivering .wt loss no other symptoms positive fh
of CDher cousin her family travel e her &are ok & she is
on lopermide from her Gp consern is what is the cause
I said mostly cd but am going to admit you doing blood
test &images to exclude others& to stop lopermide
time is finished before discussing mangement the
examiner again very tough asking about diff igave cd ,
infective diarrhea he said what else isaid ca but far as
she is young &no fh he said what else ikept silent he
said what about malaria as could be but far for bloody
diarrhea like this he ask why you want to admitt isaid
bec of severe colitis according to true love criteria je
said you didnt assess the volume &he is right I forget to
ask again ithink he will give me 14 or15 but he is
generous he gave me 19 alhamdellah
St3 which is my disaster since my previous attempt
neuro aman e difficult y in walking examine LLon
screening he is unable to raise his ul.&ll so hemiplegia
e hemesensory loss I finished early he ask what you
want to examine I said CN he said ok idid 7 , 12both are
affected he said what else isaid heart he said no need
then what isaid carotid he said no need what else isaid
gait as if he is waiting for this question is present yr
finding .diagnosis .dd.inv if he came in acute attack
meds given acutely .if AF what you will give isaid
warfarin he said can you give noac isaid yes he said if
Af isaid no give me samples of noac i gave 3 I got 20
.cvs alady e sob she has small volume pulse reg , raised
jvp , midline sternotomy scar mvr , TR loud p2 ll
oedema , ESM In AA not radiated ididnt mentioned it in
presentation but he ask for it questions about couses
.complication of valve replacement .INR &SBE
alhamdellah igot 20
UK Exam
was in the western general hospital in 3/3/2017
St_1
Chest case with fine crepitations and cushinoid
features I said ILD
Abd with bilateral right and left IF scars with renal
transplant twice
St_3
Cardio mid sternotomy scar old age with metalic click
with second sound
Neuro has partial third with internuc ophthalmoplegia
my first possibility was ms
St_5
BCC1 goitre with no peripheral stigmata he asked me
what have you found clinical signs and how to
investigat
BCC2 case with LMNL 7 th and they asked me why you
didnt examine the 4.5.6 and unfortu I examined only
7.8.3
St_2
Hist
is anemia with family hist of cancer colon
St_4
communication
BBN=Pt with mass in x ray and the task is to tell him
further investigations and possibility of cancer and
patient was insisting to get false hope
My experience in PACES exam 1/2017:

I had the exam in Cairo,Kasr Eleiny 3rd carousel
6/2/2017 ,
I got 150 / 172 ,
First I would like to thank our brother and teacher dr
Ahmed Maher Eliwa and all people who supported us
and I appreciate your efforts
with us for learning and success.
My advice to all doctors who will enter the exam in
the future as dr
Shaimaa Mohamed Abdou said is not to put any
previous failure in your mind and try to sleep well
before the exam ,and also try not to read or revise any
thing the day before the exam ,to relax your brain.
I started with station 4 communication;
Outside the exam room, the scenario was.
80 years old female patient admitted by community
acquired pneumonia and received antibiotics then
developed delerium,she became confused, agitated
and refusing to receive any treatment and has idea
that she had been poisoned,and she has past history of
hypertension.
The task was to explain the condition and
management plan to her son.
I started by the usual introduction and asked the son
about what he knows about her condition and after
that started gradually to explain the condition to him
and what delerium means and i asked about her
previous history of any memory problems . and the
surrogate said that she has some memory problems
but deteriorated after the pneumonia,
the concerns were, is this reversible ,when my mother
will improve and go home, does she will need imaging
for her brain,how can she will receive medications
and she is agitated and can hurt herself.
I tried to reassure him and that we will form MDT
from chest doctor,ICU doctor and neurologist to
assess her, and that the neurologist may decide to give
her medications to relax her and the medical team
and nursing will be with her and so she will not hurt
herself and we can not expect the time of recovery
now but we will do the best effort for her ,I told him
that delerium is common in old people after infection
and that it is reversible, and that the neurologist is the
person who can decide if she will need imaging for
brain or not, and i provide help for her after
discharge ,summery,checked understanding.
During discussion the examiner asked me to
summarize the scenario,asked me, is delerium
reversible,i said yes after treatment of the cause.he
asked about causes of delerium ,I said infections as
pneumonia and urinary tract infection ,he asked
about drugs that cause delerium ,i said dieuretics can
cause dehydration and delerium and also antibiotics
can cause this, then he asked about ethical issues in
scenario and the bell ring.
I did well but I got 12 / 14 ,I do not know why.
Station 5;
First scenario outside exam room was, skin rash in 40
years female patient.
Outside exam room i expected that the case will be
psoriasis or pemphigus but when I entered the room
it appears as vasculitic rash on both upper and lower
limbs but i was not sure and afraid to loose the case,
but in the history with the surrogate the patient is on
treatment for hepatitis c.
The concern was is this rash related to her condition,
i said that yes it may be related to hepatitis c by
affection of blood condeu and, the seconed,
possibility is a condition called lichen planus which
also may be related to hepatitis c so we will refer her
to skin doctor and her liver doctor to diagnose and
give treatment.
During discussion the examiner asked what is ur
diagnosis ,I said the first possibility is vasculitic
rash,he said which type of vasculitis ,I said
cryoglobulinemia, he said what other DD of this rash ,
I said lichen planus and porphyria cutenea tarda.
He asked how to treat cryoglobulinemia ,I said
steroids ,immunosuppressive drugs and treatment of
the cause.
He asked how to differentiate between this
differentials, I kept silent then the bell ring then I said
skin biopsy ( the two examiners were very helpful and
with nice smile)
I got 28 / 28.
Seconed scenario outside exam room was, weight gain
in 40 years female patient.
when I entered and took history it was a direct case of
cushing syndrome with all evident manifestations of
the syndrome (do not forget to ask about steroids in
this case) and complications of cushing syndrome and
weight gain as obstructive sleep apnea.
The discussion was about DD and how to diagnose
and differentiate between different causes of cortisone
excess, and the last question was which drug is used
to treat diabetes in patient with cushing syndrome,
but i do not know what the examiner need.
I also got 28 / 28.
Station 1:
Chest ;
It was a case of right lower lobectomy with fibrosis on
the same side and bronchiactesis on other side with
also obstructive lung disease.
Discussion was about indications of lobectomy,
diagnosis and managment plan.
I got 18 / 20.
Abdomen; it was not good for me and it was also the
most case I do not like during preparation for the
exam especially detection of presence or abscense of
ascites.
There was hepatosplenomegaly and during
presentation I said that I can detect ascites by
examination but I want to confirm by ultrasound but
the examiner was not happy when I said ascites.
I told the examiner that I would like to examine
lymph nodes but there was no time.
During discussion the examiner asked about DD of
hepatosplenomegaly, I said chronic liver disease with
all its causes and myeloproliferative disorders, he
asked about how to diagnose HCC if the patient
develped this ,I said basic investigations,alpha feto
protein and ultrasound.
He asked if this patient has lymph nodes what will be
the cause,I said metastesis from HCC.
I was not happy in this case and has some sort of
mental block.
I got 13 / 18.
Station 2 History:
Outside exam room ,the scenario was 25 years old
female patient who had developed skin rash on the
face and forearm which disappeared after receiving
steroids then recurr again after travelling to Luxor
and also she has fatigue during the last 3 months and
neutropenia.
Inside the exam room it is very important to confirm
that it is the same type of rash in the two attacks
during analysis of the rash and during history she has
ankle and hand joint pain and has one abortion .
The diagnosis was SLE with antiphospholipid
syndrome.
The concerns were, Is this blood cancer causing
fatigue?can I get pregnant now?,I said that it is
unlikely to be blood cancer and I explained the
diagnosis to her and I said that she will be referred to
MDT including rheumatologist and obstetrician to
give her the best treatment and to decide about
pregnancy because it can be affected by her
condition.
During discussion the examiner asked,
What types of skin rash in SLE?, I said photosensitive
rash, malar rash and discoid rash.
What is the distribution of the rash on the face in
SLE?,I said rash on the face sparing the nasolabial
folds.
How can u diagnose SLE and what are the most
specific antibodies in SLE?, I said anti dsDNA and
anti smith and other investigations.
Which inflammatory marker is raised in SLE?, I said
ESR.
What is the treatment of SLE?I said the types and
drugs used in the treatment.
I got 19 / 20.
Station 3:
Neurology; examine the lower limbs.
It was also not good case and I did not detect physical
findings well.
There was peripheral neuropathy and I think that
there were also pyramidal manifestations but were
not clearly evident as usual.
During discussion I said peripheral neuropathy and
did not say other thing because I was afraid to say
things not present, but the examiner said what else , I
said mostly the patient has combinations of lesions.
The examiner asked so what ur other diagnosis, I said
MS and also said to him that MS do not cause
peripheral neuropathy.
He asked about investigations.
I got 12 / 20.
Cardiology; It was a direct case of mitral valve
replacement.
Discussion was about indications of mitral valve
replacement, complications of anti coagulants and
management of cases of metallic valves, the last
question was which antibiotic is used for prophylaxis
against infective endocarditis but I said I can not
remember then the bell rang.
I got 20 / 20.
Finally I got:
Patient welfare 32 /32.
Physical examination 23 / 24.
concern 14 / 16.
clinical communication 13 / 16.
Physical signs 18 / 24.
Differential diagnosis 22 / 28.
Clinical judjement 28 / 32.
Total score 150 / 172.
I hope success for all.
Ygn - 1st day , (6.3.2017) 1st round ��St 5: nf , c/o
headache , Htn �Phaecomocytoma & migrane ( z z line
b4 unilateral headache )�Tia : vision loss��St 1:
hepatomegaly e v Long scar on right
side�Consolidation with brochitesis ��St 2: bloody
d - IBD , INFECTIVE ��ST 3: indian boy - myotonic
dydrophy �Cvs : AS ? , ASD ? ��St 4: ILD with
amiodarone induced
� Myanmar, Yangon (6.3.2017) 1st day 3rd round
st4 menigococcal septicaemia explain condition of
husband Q: can b cure �any disablity�what should I
do for my childern�should I inform to his
office��st2 back pain �straight forward
h/o�ankylosing spondylitis� family history of
psoriasis�examinar Q : dx ddx mm��CVS MS MR
with ht failure MS dorminant�examinar Q : which is
dorminant �m/m diff b/t MS MR��CNS rt LMN
facial palsy 8 th palsy Q: finding ddx invx��resp:
difficult not enough time dullness in rt lower zone
reduced VBS/VF dullness in rt up zone but I heard
nothing give ddx of dullness in rt lower zone other
candidate also didn't notice up zone �examinar ask
what do u think about up zone? bad feeling for this
station��abd: deep jaundice up ward enlargement of
liver no sign of chronic �Q: ddx invx hep B tm��BCC
1 chronic RA with H/ T 5 yr breathlessness for 1mth Bp
160/120 PR 120 spo2 92 sugar 192 RR 18�on exam:
fine basal creps not change with cough I think give R
nodule both up limb with limitation of movement�dx
p.fibrosis ask another dx hypertensive ht failure
another candidate said OA with ht failure��BCC 2
Dizziness with DM on metformin hypoglycemic attack
postural hypo�dx addison��another candidate not
same case for CNS foot drop Abd huge splenomegaly
)Ygn - 1st day , 1st round ( my experience

St 5: nf , c/o headache , Htn
Tia : vision loss
St 1: hepatomegaly e v Long scar on right side
Consolidation with brochitesis
St 2: bloody d - IBD , INFECTIVE
ST 3: indian boy - myotonic dydrophy
? Cvs : AS ? , ASD
St 4: ILD with amiodarone induced
This Exam Experience was published before by My

colleague Dr.Lai Yee ,,,but this copy is Well-Organized
EGYPT ,,, Febr. 2017
Hellow Drs am going to write my exam experience.
..actually at that day I had flu and I feel may I couldn't
concentrate bez of that and bez this is first trial for me
igave my self big power try to pass
I started with st3 neuro
it was hemplegia I asked to examined lower limb from
his posture I see it was hemplegia ifiished lower then I
asked the examiner to iwant to examin gait upper and
cardio and iwant to examined cranial he told me just
look at his face of course there's mouth devation then
he start of gave me guestion where the lesion and
investigation and managment really the most
important is to keep good impression from examiner
about how yu comunicate with the pts during yu
examin contine tell every thing yu will do and yur eye
on pt face while examining him it's difficult but try yur
best don't forget covering and thanks him behaviour is
important not only infomation iget20/20
Shifting to cardio
my case metallic aortic replacement with ejection
systolic murmur for echo and mitral regur then he ask
about how yu will investigate how yu will manage and
about INR and about finding in echo get20/20
I go comunication
it was acceptable mother want yu talk to her daughter
she has possibility of cholangiocrcinomer or cancer
head of pancreas but still not found in ct oe ercp and
the mother she has feature of obstructive joundice and
on pain I started to to talk to daughter about her
mother she cry a lot that she felt guilty bez she delay
briging her mother to hospital and her concern that if
cancer not tell her mother about that bes she felt
delaying not bringing her mother early is the cause and
she was really upset but I proceed as I was learn to give
empathy and polity talk about mother right if she ask
bez mother competence she want also discharge her
mothers bez share is busy ienterfer with social worker
and we cannot discharge her bez she need admition
mangining her pain and so on then I made closing
summary and understanding get16/16😄
Then I started history
young man with back pain I did well but only giving
me13/20 really I don't knowwhy🙄😳 I think it was
straightforward history and iput nice dd going with his
family history father has psoriasis grand mother had
back pain in his history he has chronic eye
inflammation iput inflammatory ankylosing type back
pain then iput
Then I go st5
really case not difficult but time very very short start
with reumatoid hands complicated with rt knee
osteoarthritis I take history then I felt time go soonly I
try difficulty to examind hand and rt knee very badly in
interupted way am afraid then I start to manage her
concern not finish it the bell rang😰I felt badly and I
answered all his guestions but really I felt down but I
told my self forget get25/28
The next st5
headache really I started it trying to manage my fault I
take history and as same tme I start to examind then
really I put hard work to take high score in this bez I
think I did badly in first one😄I did good complete i
take 28/28😀😀😀😀
All history is negative only i found the clue when asked
family history of haemorrhage in head peace and
history of kidney disease is that her mother on dialysis
so I put in mind subarachnoid haemorrhage
so also I advice to make emage for her head and
kidneys to exclude
The Examiner ask me before surgery how can yu help
???her
The Examiner want to hear Nimodopine then ask me
about group of it and the dose and also he ask me
what and when yu do CSF and what yu will find he
want Xanthochromia after 12 hours
Then i go st1
chest 😀copd with corpulmona
Abdomen= 20/20 abd hepatomeglly with splenectomy
examiner kind asking dd
and managment 18/20😊
at end thanks God I pass score160/172
:My exam experience

Medical Military Hospital- Cairo- Feb. 7th
:I started with Station 5
Around 50 yo lady c/o confusion over the past 1 -1
;week. She just received chemo 1 week before
After introduction – analysis of complaint OCD – any
fluctuations? No – Memory problems and to recent or
old events ? coping and home and self care? Getting
lost sometimes and forgetting names of familiar ppl
?like you? Any previous episodes
Then asked about DD of delirium like infections ( UTI
and Pneumonia ) – pumps and lumps and wt loss?
Abnormal hand movemts ( Parkinson’s plus ) and
neurological system specially headaches with increased
.ICP which was negative
Then moved into the chronological hx of cancer and
.chemotherapy
Examination : general survey by checking the pulse, the
eyes for pallor then quick neurological ex like pronator
drift, quick tone and power and plantar reflexes. All
.were negative and I also offered fundoscopy
.Management: admit for IV fluids and brain imaging
Examiners : D.D: Hypercalcemia due to malignancy,
Brain mets. – IVF and Bisphosphonates, brain CT to r/o
Mets. Did u reassure the son? Is it reversible ? A:
Hypercalcemia can be corrected but if there are any
.mets the prognosis should be worst
28/28
;Wt loss in 50 yo female -2
Analysis of complaint, OCD , how many KG over how
long? Appetite was good with no diff swallowing, not
.intentional
I asked about my D.D which I found all negative!
..Malignancy – TB – Endocrinal – Chronic infections
I jumped into PMHX: any long standing problems? So:
like what! Any gland problems particularly the gland in
front of her neck ? yes she had HYPOthyroid 2 years
ago and on levothyroxine. Any change in the dose? Is
.… she compliant
I then started to ask about autoimmune associations –
joint ? rash ? ….. then the only thing I picked was
polyuria and polydipsia when asked about DM .. then I
continued any recurrent infections like in the water
work ? no . Any skin infections particularly fungal? No ,
any discharge from the private part ? YES colour smelly
? No answer – is it white cheesy like – examiner said
!yes! Is it itchy? Examiner said yes
.I maily examined the thyroid – no findings
D.D : DM – Levothyroxine overdose – Polyglandular
.syndrome
28/28
:Station 1
Respiratory : Young patient with lt lateral -1
thoracotomy scar with reduced chest movement and
expansion on the left side. Trachea was mildly shifted
to the rt!! Percussion was heterogeneous on the left
side dull on the left base. Heterogeneous on the rt side
also. VR was reduced on the lt base. There was bibasel
.end insp crackles not changing by cough
On presentation I was confused .. I didn’t mention the
say upper or lower ) with bilateral fibrosis ( did not

mention any areas) I basically wanted the examiner to
direct me as the case was quite difficult – didn’t want
.to invent signs or come up with a wrong diagnosis
Q: Causes for lobectomy ? what are other reasons for
the the scar – said oesophageal and cardiac surgeries!
Management and possible cause in this particular
case> said in this young man with lobectomy and
.fibrosis TB is my first differential
20/20
Abdomen : Middle aged woman – do u have any -2
pains ? yes – where ? here ( right hypochondrium ) I
was like Huh
Started me palpation trying to avoid causing pains, the
abdomen was distended ( ascites ) while trying to
palpate the liver the patient was uncomfortable – I
stopped my examination and said : Sir, the patient is in
pain should I proceed ? Procced gently :D
Couldn’t get the border of the rt lobe cause of the pain
and ascites, lt lobe was 6-8 cm below xiphsternum.
Spleen was palpable but couldn’t get the border/span
.for the same reasons
Presentation : HSM with Ascites , could get the rt lobe
span and same for the spleen :D
D.D : No signs of chronic liver disease – could be
Chronic viral hepatitis with Bilhariziasis causing portal
.hypertension and ascites
Discussion about Investigation and went deep into
diagnosing Bilharisiasis – said urine/ stool – how about
serum ? wanted to hear ELISA . Also asked about the
HBV markers – what if the HBSag –ve and AB positive :
Pt is immunised.. what if Core +ve : previous infection
!– he was smiling and I was too
20/20
Station 2: Hx- difficulty moving over the past one week.
.He had hx of radiotherapy for lung cancer
I think I got the full mark in this one cause of deep
analysis of complaint ( back pain ) which I got the
incontinence problems – then I went deep into how
this is affecting his life and the embarrassment he
suffers with. I stopped at this point showing a lot of
empathy and sympathy as if it’s a communication
station – also asked about occupational hx and
.asbestos exposure
Dx: cord metastasis with compression symptoms –
urgent admission - IV dexamethasone and urgent
.neurosurgical review
20/20
:Station 3
Neurology: Rt sided hemiparesis with Rt -1
.hemihpothesia
Discussion was about the possible causes ( thrombo-
embolic ) and site of lesion ( r tint. Capsule ) and
) management ( in acute and chronic presentation
20/20
Cardiology : was a difficult case, Middle aged -2
female, raised JVP and when I asked about abdominal
pains she said yes. I asked the examiner to do the
hepato-jagular reflex he said no need. By then I knew
the patient had TR! I could hear the systolic murmur of
TR which increased on inspiration, I also Heard systolic
murmur over the apex ( not radiating to the axilla ) and
on aortic area ( not reading to carotids and no palpable
) thrill
I then decided to only mention the surest finding ( TR )
and give differentials for the others, trying to avoid
wrong diagnosis or invented signes. ( wanted to get
) some marks better than loosing it all
The examiner asked about diagnoses ( TR ) what causes
( Rheumatic ) he was not satisfied and asked whether
RF affects the tricuspid valve? I said rarely as it
commonly affects the mitral then the most common
etiology for isolated TR should be pulmonary HTN, he
was then a bit satisfied and the discussion went over
the pulmonary htn 1ry and 2ry causes , inv and
.managements
Seems like I missed the loud P2 or a parasternal heave (
the P2 was loud but I didn’t want to mention it as I was
) not quite sure
Got 13/20
Station 4 : 50 yo lady collapsed at home the previous
night. Admitted to hospital; with HB of 7.4 g/dl ,
received BT and now feeling better. She is on Ibuprofen
for a long time. Her husband is at home with a recent
.MI and is diabetic who needs someone to take care of
Task: convince the patient to stay at hospital and to
.offer any investigations you may see appropriate
So I realised I needed to convince the patient to stay
for upper GI endoscopy for possible bleeding d.t
.ibuprofen
Introduction , confirm identity , breaking the ice ( hope
u’ve not been waiting for me for long – examiner was
happy nodding his head! )then confirming agenda –
exploration and expectations and possible initial
.concerns
She said she’s fine now and wants to go home to take
care of her husband, she new she had BT and her HB
was quite low, She had no idea about any possible
.cause
I started to explain possible bleeding and the need for
further inv. When I mentioned the ( camera test ) she
was annoyed and strongly refused it – I then realized I
!was on the track
Started to explore the reasons why she refuses – she
had a previous bad experience with an endoscopy 7
years ago. She stopped. I asked again ( with a smiley
face ) would u plz tell me more what happened and
what kind of pressures u had ? she said there was no
privacy, uncomfortable as I could feel it all and
!eventually they found nothing
I reassured her regarding every point ( the privacy –
skilled doctors – more anaesthesia … ) and will ask the
.social worked to take care of ur husband
She finally agrees – can explain the procedure for you –
..I demonstrated with drawing
asks whether I could have discharged her then she
comes back later – why? My husband! I reinforced
again about the social services we have………… and
explained we won’t guarantee what happens if she
goes home and we need to know what’s going on
.before discharge
She was concerned about any other possible cause, ( I
felt she was asking about cancer ) I asked are u
concerned about any particular condition – she said
cancer – I said that can’t be ruled out I am afraid, but
we need to investigate the most probable cause first
which is the possible bleeding from your stomach due
.to the painkillers
She now agrees and has no further concerns ,
Summarized then said ( I will have another meeting
with u with my consultant after the procedure and may
be we need to do further investigations according to
the endoscopy results ) then told her about the
.consent which she agreed to sign
Examiner: what is the case … then asked whether she
may have cancer – I said probably – asked did u ask
about the alarm signs? Said NO for two reasons; I
didn’t want to go into hx taking in a communication
station and I wanted to fulfil my task to convince her to
stay for the upper GI endoscopy. Do you feel any inv.
Should has been furtherly discussed, said yes
Colonoscopy and that’s why I told her I am going to
have another discussion with u after the endoscopy :D
Examiner was happy then asked; what if she refused? I
said in that case there’s an ethicl issue which is
patients autonomy and I have to respect her wish, on
the other hand Beneficiance should be fulfilled by
trying to convince her to go for it for her best interest.
!He was then smiling
16/16
‫الحمد هلل رب العالمين‬
Got 165/ 172
.Wish you all the best of success
Am going to write my exp in paces my exam was on

.almaadi military hospital second carousel
First of all I want to thanx dr.Ahmed Maher Eliwa for
his great & generous support
Istart e st 4 ; an old man k/c of advance heart failure
did lymphnode biopsy showed Rcc with vertebral mets
on bone scan for palliative care consultation went bbn
to palliative care to consern he has 3 consern 1-he has
acaring wife &he didnt want to tell her bec as she may
become deppressd I said we can help you in this by
telling her e great empathy &our psychologist can help
her if he agree because you need her support 2- how
long he will live as he want to travel abroad, he didn't
enjoy his life I told him yr ca is so advance &is likely to
shorten yr life he ask for estimation isaid monthes
rather than year then he said can you give meds to
prolong my survival to travel I said travel is not good
4you bec of Hf &yr ca (this taken against me ) 3-he has
agarden &he want to continue gardening Isaid I.ll refer
you to OT then isummarize &check understanding ,
offer help. In discussion summarize yr case .why you
insist to tell his wife & not respecting his autonomy ;
bec he is need of her support &I ask him if he agree .
Why you didnt allow him to travel isaid bec he may
deteriorate &of hf he said if he insist how you will
solve problem I said he need to tell his health
insurance &for his hf ikept silent he said assessment
for fitness to fly then he ask can we give meds to
prolong survival of Rcc I said am aware of new meds
used in advance Rcc but couldn't remember he said
why you didnt offer it for him isaid may be he will ask
for it &i have no information about it he laugh then
bell rang alhamdellah iwent out thinking v.bad about
my self as didn't answer his
Consern well but igot 14
St5: first case is young male e difficulty in walking no
other information I was completely disorganized ithink
about neuro inside problem for 2yr no neuro
symptoms I ask 4examination he said ok iask pt to raise
his leg he raised them well again v.bad feelig second
case is lost the it come to my mind to see his gait he
said ok at that time I recognized question mark posture
I ask is he has pain yes in lower back alhamdellah AS
isaid i want to do occiput walltest he said do it then I
ask about other symptom &assoc then iexamine cvs ,
resp .I ask 4 schoper test he said do it again ilet pt to
stand idid it improperly iforget to check for tenderness
& to ask for chest exp bec of time concern what is the
course &need tretment I answer we will do blood test
&image & refer to dpecilized dr iremeber the job in the
last second &he is adriver alhamdellah questions about
diagnosis inv&management really am thinking about
20 but i got 28 . Second case is young male blaring of
vision again no other information inside it is chronic it
started at night & progressd colour vision affected so it
come to my mind RP iask for exam he said do then V/A
he can.t see even moving fingers going to fundus with
typical RP then iask about assoc nothing is there he has
positive fh of blindness his brother iask about med list
serugate said steriod &immunosuppressant isaid 4
what she said for behecit dis I ask e what he presented
she didn't understand me the other examiner answer
me e DVT is he ok now regarding his behecit &no
problem e meds she said yes .consern is it related to
behecit & about his kids .questions is about behecit the
examiner is v.tough he ask why eye signs is not related
to behecit .what behecit can cause in the eye I said
pale disc due to sagittal thrmbosis he is not happy he
want other thing but my mind is stocked why is asking
about behecit &forget RP he gave bad impression
about this &I think he will give me 16 or some thing but
alhamdellah he gave me 26 . Iwill write other statoin in
separate post because ihave problem in my mobile
.rgarding long post
Cont : my exam is on 8/4/2017
St 1 resp young male with pruductive couph he look
healthy when i ask him to couph it simulate the couph
of copd his chest exam is completly normal only
hyperexpanded chest couldn't appreciate any thing
else ipresent the casevas copd he said where is the
trachea isaid slightly deviated to the right he said what
is the cause of couph isaid infective exacerbation then
he ask about how to diagnose .common organisms.NIV
&LTOT when iwent out one of my colleque he
diagnosed him with pleural effusion ifeel v.bad about
my self how I diagnose copd only with character of
couph &hyperinflation so again this xase is lost
completely ithink he will give me 8but surprisingly igot
. 19
Abdomen :cld male pt pale & jaundiced e parotid
swelling enlarged lt liver lobe .splenomegaly &ascites
&ll odema discussion about causes , diagnosis .acute
.presentation &treatment of varceal bleeding &SBP
St2 young lady e bloody diarrhea e h/o travel to kenya
inside it is for 3week since she came about 12time/day
.fever.shivering .wt loss no other symptoms positive fh
of CDher cousin her family travel e her &are ok & she is
on lopermide from her Gp consern is what is the cause
I said mostly cd but am going to admit you doing blood
test &images to exclude others& to stop lopermide
time is finished before discussing mangement the
examiner again very tough asking about diff igave cd ,
infective diarrhea he said what else isaid ca but far as
she is young &no fh he said what else ikept silent he
said what about malaria as could be but far for bloody
diarrhea like this he ask why you want to admitt isaid
bec of severe colitis according to true love criteria je
said you didnt assess the volume &he is right I forget to
ask again ithink he will give me 14 or15 but he is
generous he gave me 19 alhamdellah
St3 which is my disaster since my previous attempt
neuro aman e difficult y in walking examine LLon
screening he is unable to raise his ul.&ll so hemiplegia
e hemesensory loss I finished early he ask what you
want to examine I said CN he said ok idid 7 , 12both are
affected he said what else isaid heart he said no need
then what isaid carotid he said no need what else isaid
gait as if he is waiting for this question is present yr
finding .diagnosis .dd.inv if he came in acute attack
meds given acutely .if AF what you will give isaid
warfarin he said can you give noac isaid yes he said if
Af isaid no give me samples of noac i gave 3 I got 20
.cvs alady e sob she has small volume pulse reg , raised
jvp , midline sternotomy scar mvr , TR loud p2 ll
oedema , ESM In AA not radiated ididnt mentioned it in
presentation but he ask for it questions about couses
.complication of valve replacement .INR &SBE
alhamdellah igot 20
So my score is 166 this is my second attempt . My
advise is to be confident exam is easy but we
‫ والحمدهلل الذي بفضله تتم الصالحات‬. complicate it
my experience in kasr elaini 6/2/2017

: started with station 1
abdomen: young male pale with huge splenomegaly
"crossing midline" and mild hepatomegaly with
multiple small cervical l.n
i presented the case as huge splenomegaly and
hepatomegaly my diag. CML the other d.d i only
mentioned bilharziasis and i didnt mention anything
else , even lymph nodes i didnt mention
discussion : whether this pat. has cld i said no
whether he has ascites i said no then he asked me how
i know this is spleen i told him i cant insinuate hand
above it and continous with splenic dullness he asked
what else i told him the notch but i didnt appreciate
the notch he asked this is spleen or a mass i answered
this is spleen . cause of anemia and inv. blood film >>
blast cells i was not satisfied with my performance
although i m sure of my findings he asked me at the
end whether the pat. has jaundice i said he has tinge of
jaundice "not sure" i have got 11/20
chest : old male with cachexia , clubbing , tar staining ,
hyperinflated chest but only findibgs bilateral basal
crepitations i said in this patient we should exclude
cancer first then my diagnosis i said he has obstructive
airway disease and interstitial lung fibrosis the
examiner told me ok so you think the patient has
clubbing and interstitial lung fibrosis? i said yes ! then
the discussion was about IPF inv., findings in blood
. gases , pulmonary function and HRCT
i got 19/20
station 2 : history .. young male with recurrent attacks
of typical chest pain with positive family history of
sudden death at young age my diagnosis was familial
hyperlipidemia
the examiner was very irritating that he didnt give any
chance to think he asked what if his inv. is normal i said
i will refer him for cardiac cath. the examiner was
shocked cath. immediately! i told him that the patient
should be considered unstable angina as newly
diagnosed angina but he has no chest pain for the last
48 hours he stares unstable ! 🙄
asked about treatment i told him that i will give this
patient ASA and b blocker until his inv. declared the
!examiner looks not satisfied at all
he asked what if all his inv. came normal i forgat
!!! everthing about psychic and anxiety
i was very upset by the end of this station
‫" تابعونا في الحلقة القادمة‬i got 18/20 !! "to be continued
:my exam experience final word
my little advice if applicable
never give up as the exam. is easy to pass and very -
easy to fail and you will not know when either will
.happen
spend extra time examining patients and searching -
for physical findings in your practice and little time
with books while you are preparing for the exam.
except for history and station 5
don't search for rare diagnoses as they are also rare in -
exam. but don't miss the common ones and don't miss
.the clear signs which are clear to examiners too
examiners are rarely cardiologist or neurologist so -
.don't try to search for what they already missed
!are very helpful ‫ دعاء‬a lot of prayer and doaa -
finally not every one smile to you love you and not -
every one give you -sorry- a shit hate you ... and so
examiners 😂😂
thanks for all our colleagues who helped us and
continue to help others in the hard journey of MRCP
specially dr Ahmed Maher Eliwa Hope Hope.... i like
you 😍
: started with station 1

: Chest
. Rt lower lobectomy
: Abdomen
. Hepatosplenomegaly fo differential
: CVS
Marfan with MR
midline sternotomy scar
. Loud metallis second heart sound
:CNS
Examine LL
Sensory motor peripheral neuropathy
The pt had swollen deformed knees and medial scars
over the both knees and varicose veins
: Station 2
History of travellers bloody diarrhea , fever , abdominal
. pain , just returned from a travel in Kenya
Her concern was her auncle had chron's disease and
. she was afraid from having the same disease
:Station 4
A man who had terminal heart failure and the
cardiologist told him there is nothing more to do for
. him
He discovered a lump in hos neck of which a biopsy
was taken and discovered to be a metastasis from a
. kidney cancer
Break the bad news and discuss the prognosis and the
. ttt options
: Station 5
. A 25 yr old lady presented with joint pains
On taking history and examining her she had Ehlor
Danlos , her brother also had the same disease . She
had a past history of pneumothorax and quit smoking
. ever since then
Concern : joint pains in all her joints , mainly her
shoulder (dislocating and returning it back intentionally
by her self ) and the other concern was her child , she
has a boy and she was asking how to take care of him
The examiner asked how can she screen her child for
Ehlors Danlos
: Station 5
A man presented with daytime somnolence , he was
diabetic type 2
On taking history and examining him he had ankylosing
. spondylitis and obstructive sleep apnea
) He was not obese(
my experience in mrcp diet 1/2017

Cairo almaady military hospital
last day 8/2/2017 3rd carousel
i started with station 1 then 2, 3, 4, lastly 5
station 1 chest & abdomen
i started with chest case male about 20-30 years this pt
has no any sign of chest problem no cynosis, no
clubing, trachea central,other examination normal
except only dullness in the lt base in the mid axillary
line,i noticed also skin changes in this area due to
pevious dressing and plaster marks, and peripheral
venous line in rt arm, i became confused , because i
was expect chest case to have many sign that we see in
the course,and i have not reach any diagnosis after
finishing the examination, i present the case as lt
peural effusion mild to moderate, after that discussion
was very tough with British examiner of African origin
he is not giving time to think discussion about causes i
said postpneumonic, TB, tumour
. investigation i said basic and cxr ct chest
treatment i said pleural taping he ask what else for
taping i said therapeutic and diagnostic , how I said for
analysis protein, cells, LDH, PH , how differentiate
between transaudate and exudate I said light criteria
he asked about light criteria but he not give time to
think, then ask if recurrent effusion I said pleurodesis
asked what indication I said I recurrent pneumothorax
and try to remember another causes but he didn’t give
time to collect your thought , asked about type of
pleurodesis I said talc power he what else I didn’t
answer at the end he asked he has any thing else,I said
no and I felt I loss the station because I didn’t know the
diagnosis and vey tough discussion, but the result came
.19/20
Addomen case : middle age pt average body built , no
sign of chronic liver disease, no jaundice, no anemia, I
felt the rt lobe of liver 6 cm, lt lobe 6cm, but I felt the
total span about 12 cm , spleen felt 6 cm, no ascites,
there is lt axillary lymphadenopathy, I was confused to
said hepatosplenomegaly with lymphadenopathy or
splenomegaly with lymphadenopathy, first I said
hepatosplenomegaly hepatosplenomegaly with
lymphadenopathy, then said no splenomegaly with
lymphadenopathy for DD lymphoproliferative,
myeloproliferative, infection asked like what I said TB,
then asked about investigation I said basic the u/s
abdomen, ct abdomen , LN biopsy asked if LN was
negative I said do bone marrow examination, then he
asked why not chronic liver disease I said in this case
no peripheral stigmata of chronic liver disease, I
remember he this question twice and I answer the
same . at the end I felt I also lost the case but I scored
.14/20
At the end of this station I felt I lost the whole station
and get depressed I said one station not the and try to
.do better in the next
: Station 2 history
Middle age male c/o back pain for 18 month, some lab
،investigation I didn’t remember that was normal
I start by identify my self, my role, check pt identity,
and agenda of meeting,make analysis pain, gradual
onset for 18 month, localized to whole spine, not
reffered, morning stiffness, improved with exercise and
initially with paracetamol but now not helping, not
increased by cough, straining, cannot bend forward to
pick anything from ground, no trauma, no neurological
manifestation, no sob, no cough, no chest pain, no
palpitation, no GIT symptom, no rash, no mouth ulcer,
no oral ulcer, no fatigue, no muscle pain, no wt gain or
loss no lump or pump , no eye symptom but he had eye
problem many years ago treated with eye drops by eye
doctor but he doesn’t know the diagnosis, no joint pain
but he had pain at back of his knee many years ago
treated with analgesia, then I ask him he had anything
he want to add I forget to ask about, then the
surrogate become confused and asked what do want
to known, I said anything with your health he said only
pain affect me so much.the I summarize to him the
.problem
.PH; NO previous similar condition, no chronic illness
FH; his father has skin rash looks like psoriasis, his
.grandfather has similar pain
،Social H ; NO alcohol, no smoker
Job ; desk job work
No travel abroad
Hoppies like to play football but now affect by pain,
and this pain affect his daily activity badly
Concerns; I said to him from you have back pain with
previous eye problem and tendon Achilles affection,
and your father has skin rash and grandfather has
similar pain, so you most likely has a condition called
ankylosing spondylitis inflammation of joint of your
spine, then he said it curable, I said I’m sorry it’s not
curable but controllable we give some medication to
control pain and prevent progression of disease . He
.has no other concern
I told him we do some blood tests and imaging of the
.spine and give appointment to tell the result
Discussion : what is diagnosis, I told +ve finding of
history then I said ankylosing spondylitis he said why
not osteoporosis you are not asking about the I said no
( till now I didn’t know relation between fever and
osteoporosis ) ask about investigation I said basic cbc,
esr, rf, then HLA B 27 then imagining xr spine MRI,
THEN ask about treatment I said multidisciplinary
team, physiotherapy , occupational therapy , he said
what type of physiotherapy I said swimming ,then ask
about medication I said NSAIDs he said if he has git
pain I said we give PPIs, he said but you don’t ask
about manifestation of git bleeding I said I didn’t ask
specifically but he has not any git symptom, then he
said you ask about it indirectly when you ask him do
you have anything you want to add I forget ask about
it. Then he ask if pain not control I said to give
biological treatment he asked about precautions I said
.TB screening
I thought I did this scenario vey well and I will get near
full marker but I get 12/20 ididnt know why
station 3 cvs & neuro
Neuro examine lower limb
Old pt about 60 years I strat by screening found that he
has Lt hemiplegia hypertonia, hyperrflexia, extensor
plantar, +ve pathological reflexes, I forget to do clonus,
loss of all modality of sensation except vibration sense,
I present my findings, and I said lt hemiplegia with
hemisensory loss he asked about causes l said
thromboembolic, hemorrhage, and he asked what else
I said AF he asked what else what else I didn't answer
and ask about management I said if acute stage we do
CT brain to rule out hge then give antiplatalate, Statin,
risk factor control he if he came within one hours I said
،to thrombolysis
In chronic stage physiotherapy, bowel care bladder
.care. I got 17/20
CVS. Pt has sternotomy scar, pulse regular no special
character, apex can't be located with inspection and
palpation 1st accentued with pansystolic murmur
propagated to axilla, 2nd heart sound metallic with
ejection systolic murmur l AVR with mitral
regurgitation ask about management I said education
and councilling, cbc, coagulation profile, ECHO, ask
about frequency of inr monitoring I said daily till reach
target then every 3 month,ask about new
anticoagulant I said not indicated in valve replacement,
ask about endocarditis prophylaxis I said if pt need
.invasive procedure in septic area, I got 20/20
suspected
wants to know we will inform her we will not enforce
information to her and this will help her to talk
in medical team. She asked not to inform mama for
thee times and every time I answer her the same,
finally she accepted. Another concern want to take her
mama I said no she can't, then discussion was about
ethical issues, why you will inform the pt I answered as
said to daughter and the autonomy of pt as she is
competent. He asked what could be the lesion I said
small intestine tumour compressing from out side he
asked about the I didn't know he said retroperitonneal
.sarcoma. I got 12/16
station 5
BCC1 middle age female c/o hand pain and b/l knee
pain
some investigation normal
When I saw the pt I found ulnar deviation of both
hands history go with Rheumatoid arthritis no PM NO
FH NO SMOKING NO ALCOHOL HOUSE WIFE pain
affecting daily living activities
Concern what I have
O/E swelling tense fingers,palmar erythema, hotness,
،at joint wrist, pip,mcp
Ulnar deviation, no sign of carpal tunel syndrome,
function persevered, no nodules, i examine the knee.
And asked to examine the chest he said examine.i ask
to elevet the clothes he said examine while dressed I
auscultate no finding
I answered concerned Rheumatoid arthritis not curable
but controllable we some blood test and images to
confirm the diagnosis Discussion about management
Multidisciplinary team physiotherapy, DMARDs, if
failed biological, then he ask me why you examine the
chest I said due to Rheumatoid lung disease then he
show me the hand and ask what this I said palmar
erythema show me whitish lesion at dip joint of Lt
thumb I didn't answer I didn't know what is it. At this
.time I realized that I have lost the case but i get 27/28
DCC2
Young female presented with sudden onset of severe
headache in back of heade 8/10 no sign of increased
icp, no eye symptoms. no scalp tenderness, no rash, no
joint pain, no muscle pain, PH of migraine this
headache is different to migraine no aura no
neurological symptom, no nasal stiffness, No history of
chronic illness, FH cerebral bleeding, SOCIAL HISTORY
،no alcohol, no smoking, house wife
concern what I have
Examination BP normal, no diplopia, no visual field
defect, I ask for fundus examination said no need
I answer concern sah we need to do brain image to rule
out and we'll give medication for pain control, other
concern could be anything else I said yes could be
atypical migraine but our priority to rule out brain hge
Discuss e examiner about diagnoses I said SAH, DD
atypical migraine, investigation CT brain if normal I said
LP when you do i said 12 hour what do you find I said
xanthochromia, then asked about posterior fossa
anyneuresm manifestations I said unstidness but he
want which cranial nerve affected by posterior
communicating anyneuresm l said the sixth abducent
but it's the third oclumotor that affected
Treatment I said abc then BP control he said what will
give I said nimodipine,then asked about neurosurgery I
said yes if has anyneuresm will do clipping or
endcoiling. I got 23/28
After the examination I was depressed because l felt I
did bad in first and five station but I get good score in
this two station chest 19/20,abdomen 17/20, station 5
I get 23/28, 27/28. And station that I expect I do very
good Station 2 I get 12/20, and station 4 I get 12/16
Finally l passed with total score 144/172
Allahamdoollah in clinical communication skill l get I
exact pass mark 11/16
Experience of our dear colleague Dr.Shaimaa

Mohamed Abdou
She PASSED PACES in EGYPT Febr. 2017
dear colleagues here you are my experience in paces
exam 1/2017
concerning pre-exam period I advice to sleep well and
not read from many sources...don't put previous
failure in your mind and keep telling yourself you will
pass...really that seems simple but it is very important
before the previous attempt I read many sources I took
...many courses but I failed
concentrate on cases for paces 2015 and the course of
dr. Ahmed Maher Eliwa really it was very beneficial
...and different from other courses and I'll tell you how
don't put false ideas in advance like maadi centre is
difficult than kasr elaini or try to remember the
!!patients...all this is nonsense
all patients in exams are acute like you see in life they
will obey your orders if you was clear but they may
...waste some time...ok!this what will happen in life
my exam was in maadi military hospital 7/2/2017
I knew I will start from station 3 which was my
nightmare in previous exam...anyway I tried to put out
this idea from my head and tell myself I am ready and
it will be inshallah different
the bell rang I entered the room first case was neuro 55
yr old man(by the way age is not real or scenerio but
you should proceed on information they gave to
you!!the man looked older!!)anyway I examined
without interruption it was examine lower limb it was
clear that it is hemiplegia but when I was comparing
sensation to face he kept saying please stick to lower
limb only!!!ok I am just comparing then he said what
else I told him I'd like to check coordination in upper
limb he said no need...so I wanted to examine gait he
was very happy as if he was waiting for this!!it was
clear then he started to ask where is lesion I actually
had no time to check cranial nerves 7,12 but I told him
it is above pons then asked me about causes in "this
young man"I told him thrombosis or embolism so how
you will manage..I told aspirin and control blood
pressure ...I was upset as I didn't examine for cranial
nerves...he wanted this.anyway I scored 19/20
then cardiology female patient 40 years old with
shortness of breath by examination I found raised JVP
,pulmonary hypertension,mitral regurge ,tricuspid
regurge..no scars..he asked about positive findings and
what investigations I told him ecg..echo..he said how
to manage...here mental block occur so I was silent..I
think I should have told diuretic test first...and he was
waiting what criteria in echo to diagnose it actually I
didn't know what he ment I scored 17/20
continue my experience in paces 1/2017 military maadi
:hospital 7/2/2017
second station for me was communication I was still
thinking in last station so I was feeling bad and not in
desired mood anyway also the surrogate was the same
in.previous exam.again I put this of my mind she was a
patient with anemia and wanted to discharge herself
against medical advice ..she received blood transfusion
improved but you want to convince her to stay for
more investigation mainly endoscopy but she wants to
go as her husband had MI and needed help...ofcourse
outside the room I divided my talk to
introduction,body and summary as I heard in dr.
Ahmed Maher Eliwa video..they discuss with me if she
still insist to go I told them I will tell her that I'll arrange
meeting with consultant but if she still insist she can go
with near appointment for endoscopy..he said you will
let her go??I told him I have to respect her
autonomy...I scored 13/16 for mistake that when she
said too early that she wanted to go for her husband I
should've told her immediately that I'll refer you to
social worker not delay it...and also they wanted me to
take very brief history of her condition to justify my
investigation to her(all this came in my mind again
)!!before I leave
then station 5 with very big marks so I tried to
concentrate as scenerios I find first difficult 55 year old
female with increase forgetfulness and abnormal
behaviour!!!I put alzheimer...renal or liver
failure...that's all I entered the room (again most
patients are normal and they are inventing
scenerio)the only positive from history with suurogate
when I asked about her health before she said she had
chemotherapy for kidney tumour 10 yrs back....oh!!so I
thought of hypercalcemia asked about its symptoms
examined abdomen...then in discussion he asked me
can it be brain mets ??I told yes but no localizing sign
but it is possibility...he said but you didn't examine for
it!!I scored 20/28
the second case 50 yrs old female with history of
weight loss...all negative except he told there is
polyuria and hypothyroidism on treatment..I thought
for autoimmune causes mainly but first I told him over
replacement of thyroxine ...ok he said but seems to
wait for something else ...I told diabetes...and he
wanted this and started asking about
investigations...anyway I scored 21/28
then station 1 chest 30 yrs old male actually I was
exhausted !!I didn't check for clubbing and thin skin for
steroid and time was running I detected creps of
fibrosis but dullness over the left base but I wasn't sure
about dullness so I didn't tell when he asked what
else..but I told him.patient is plethoric(in myself I think
this from steroids)he asked about fibrosis when to give
steroids what investigation and treatment I scored
14/20
abdomen female 55 years with ascites
hepatomegaly..?splenomegaly(this time I was not sure
but I told there is splenomegaly)he asked about liver
span,positive findings,differential diagnosis I told early
liver cell failure he said early can cause ascites I told no
it should be cirrhotic not enlarged then I told him
autoimmune he was happy to hear it ;non alcoholic
liver disease asked me about complications of ascites I
scored 18/20
third and last part of my exam in maadi military
hospital 7/2/2017
last station was history young male 40 years old with
poor mobility??I divided my talk to introduction then
system affected here either neuro or musculoskeletal
cause and end of discussion with summary and telling
patient most probable diagnosis and plan of
management from history he said only feeling can't
walk properly with history of lung cancer before for
which he received radiotherapy and they told him he is
ok..he told he is having problem with control of his
sphincters so the talk was about it is most probably
compression of cord and need urgent hospital
admission and MRI and to deliver that message to
patient discussion was about management and what
differential I COULDN'T find anything except lambert
eaton syndrome..I scored 17/20
total score 139/172
....but alhamdolilah I passed after all
again believe in yourself...practice very much...read
cases for paces for clinical and ryder for history and
communication...attend preparatory course then
advanced with dr. Ahmed Maher Eliwa as he is
different in the way of arranging your thoughts
systematically and in approach of station 5 which
represents big bulk of your total marks
finally thanks to ALLAH then dr. Ahmed maher
good luck for all and sorry for talking too much and
..dividing the post as I was afraid the mobile will be off
good luck and ready for any questions if something not
clear
kochi experience : st1) respi : rt sided thoracotomy

scars(2 scars) all examinations were normal except
widespread wheeze abdo: av fistula in left hand with
no other finding st2) possibly sheehan syndrome, I
guess st3) cardio: bradycardia with water hammer
pulse no findings in precordium possibly slow af in
heart failure neuro: peripheral neuropathy st4)
breaking bad news about young pt in icu due to
hemorrhagic stroke st5) pt with seizure with htn no
findings on examination possibly due to uncontrolled
htn, visual disturbance due to dm with others
complications of dm
Dubai paces today 20/2/2017

third circle
Satation5
Young pt with headache&uncontroled Bp
)Pheochromocytoma(
Pt post Ml
Present with chest pain&fever
Dressler's syndrom
History
Loose motion without loss of weight
)IBS(
Station 1
Abdomen
Transplanted kidney
Chest
Lobectomy scar
Station 3
Cardio
Sternotomy scar
With murmur in aortic
area
Pt have xanthlasma in his face
????
Neuro
Spastic parapariesis withaout sensory loss
For DD
Communication
Case of ca prostate
Bilateral hydronephrosis
With high k
Management plan
Nephrestomy
DNR
Good luck for all
No click sound or
metalic sound in cardiology case and the diagnosis is
Aortic stenosis
Cochin
St.1 Abd: ckd with av fistula peritoneal dialysis catheter
.and cv line bandage, Had some rash all over body
Respiratory- syst. Sclerosis with ILD
History: 35 yr old female, 2 episodes of rash, both
subsided, now with fatigue and neutropenia. prev
history of loss of conception
.Wants to get pregnant
St.3 CVS: mr with pulm htn and probable TR
CNS: Peripheral sensorimotor neuropathy
St.4- UC, given mesal and local steroid, not responding,
now advised to take oral steroid
Doesn't want to take it, looking for alternative
treatment
Discuss treatment & management plan
BCC1. 35, F, had fever& rash 10 days bk, now subsided,
h/o allergy, nothing on exam
BCC2. 80,F, hypertensive, now stooping and difficulty
in walking, knee pain, anaemic & kyphotic
Kochin )22.2.2017(
BCC: 1. Young lady with right upper limb pain
Examination absent pulse and carotid, subclavian bruit,
)Aortoarteritis (Takarasu
Partial seizure , pt with past history of breast ca .2
Resp: Systemic sclerosis with ILD
Abd: CLD
CNS: myasthenia gravis
CVS: ASD
.History... altered bowel habit for 3 months
Cochin )23.2.2017(
CVS: Avr mrtallic for AR moderate in cardiac failure bcs
..of thyrotoxicosis
Abd: postrenal transplant for probably lupus nephritis
..with cyclosporin tox
Resp: left pneumonectomy with compensatory
hyperinflation and upper lobe fib on opposite side
..probbly tb
CNS: young stroke with oral ulcer alopecia pallor
.probbly apla lupus
History postpartum thyrotox .. examiner wanted
.something more in diagnosis
station 4 newly diag tb. Hemoptysis... break the bad
.news counsel everything wants to go out of uk
.Bcc: 1. CAD, t2dm, ischemic dcm, mr
..fever with hsm.2
Kochin evening round )23.2.2017(
St 1. Abd: CLD with massive ascites spider nevi n
dilated veins-portal hypertension
Resp: ILD
History: Syncope with jerky movements - palpitation n
on exertion
St3: CNS: Peripheral neuropathy
CVS: Prosthetic valve
Station4. Meningococcal meningitis informing wife
BCC... 1. Psoriasis
LOw back pain with pain radiating down early .2
morning ? Inflammatory - sacroilitis
UK Experience ,,, Febriuary 2017
st 3
Neuro
parkinsonism with no tremor evident
Cardio
mitral valve replacement
st 4
syncope due to OHG overdose in depressed lady
concern :::confidentiality &support
st 5
BBC1
Systemic sclerosis with swallwing problems
BBC2
Visible Haematuria with no signs
st 1
Abdomen
liver transplant + clubbing
chest
COPD with bronchiectasis
st 2
Dizzy spells ,, post hypotention in AF +
DM+IDH+HTN+DVT
Sharjah today 23/2/2017

St1 Abd splenomegaly with liver cirrhosis
Chest COPD
St2 history Dizzy spells in Dm .. history of Mi DVT .. AF
... family history of DVT .on Ramipril
St.3 CVS MR + TR
CNS spastic paraparesis without sensory involvement
St4 pt with arrhythmia on amiodarone developed lung
fibrosis .. speak to the daughter
St.5 a.. HYPOKALEMIC PERIODIC PARALYSIS
B .. Dizzy spells (again ) IN pt with DM.and on ramipril
It is my pleasure to share my experience in

up
sign
management.
consent
examiner q :
I Saied yes
answer above
is :
about the drugs
azathio.
Saied yes
during pregnancy
ok thank u
Station 5:
for ur kind care :
pain
of myathenai qravis
his back no rash
my scalp
lot.
management for him
kind care.
solid
nor alarm signs
which was negative
significant.
extension
is it treatable
examiner q:
how u will mange:
symptoms
endoscopy
patient.
Station 1:
1. Abdomen:
he looks so
my findings
what I found
some drainage scars
the costal margin
of lymphadenopathy
Examiner q :
top of my DD
hemochromatosis.
LFT
lobectomy
Station 2:
No other symptoms
sensitive way.
work.
antibiotic usage
So examiner q:
what is ur dd
chemistry…….
xray
immunoglobulin
Na sweat test
Station 3:
CNS:
Neuro case :
wasting
sensiation.
syndrome
Whats ur DD?
syndrome?
hypothyroidism.
completely)
I said Iam not sure
CSF analysis, VEP
Vit b12 level, THT
،،، UK Experience
Nottingham city hosp 25/2/17
Start with station 5
Bcc 1
Man with lethargy
Got DM, joints pain, loss of sex drive, rashes on face
Dx:Hemochromatosis
Bcc 2
.y.o frequent falls 84
.Instability
.When ask to walk, examiner said normal
When I want check eye, they said normal. Want check
.power they said normal
.So I listen to heart that normal
And he has postural hypotension on citalopram and
.clopidogrel
Ddx : postural hypotension with instability
.I mention post circulation cva
)Now I think it may be NPH(
I ask others candidate, they said mechanical fall as
.patient trip over
St 1
Abdomen
.Rif scar with renal transplant, acf fistula
Got pedal edema
Respi
.Normal lungs!!!! Patient snores. I said OSA
St 2
Clear cut cystic fibrosis from history
Recurrent chest infections
St 3
Cardio AS
Neuro distal mixed sensory and motor neuropathy _
cmt/dm
St 4
Many said difficult
Patient keen active, sister wants paliative... Pt
disseminate bowel ca
Cochin )25.2.2017(
St 1. copd with bronchiectasis
abdo- ascitis with jaundice
.st 2. History of Ankylosing spnd
st3 cardio- I said- AS with MR,not sure
neuro- Lmn Rt facial palsy
st 4. convince pts sister about palliative care of a
metstatic cancer. sister wants sedation. parent wants
agressive Mx. pt had bleeding ulcer. nnow nneed
embolisation sister doesnt want.a bit complicated
st 5. a pt with neck swelling- multinodular goitre
another pt male with fatigue- I found OSAS Due to
obesity, wanted to rule out endocrine and metabolic
syndrome
)Dubai (21.2.2017
Station 1 : resp: pleural effusion
Abd: bilateral palpable kidneys with dialysis catheter
and right iliac fossa mass
Station 3: neuro is peripheral neuropathy
CVS: diastolic murmur de is mitral stenosis vs aortic
regurg
Station 2: lady with palpitations delivered 1 month
ago. Postpartum thyroiditis
Had heat intolerance and loss of weight
Family history : her father died with hemorrhagic
stroke. Brother had a heart attack at age 48
Occasionally uses inhalation for asthma
Her palpitations were on exertion
Station 4: lady with sle and proteinuria. task to explain
the diagnosis and the need for renal biopsy
St 5: sudden loss of vision in a htn patient in one eye
lasted for about 30 minutes with complete recovery
St5: lady with me has numbness of the hands
UK- Experience ((Glasgow ))%% Alexander parade

%%hospital
St1
collapse with consolidation
Ascites for DD
St2
diarrhoea, vomiting in pt with DM ( poor
control)&dialysis for last 3 yrs
St3
AR in downs syndrome
Parkinson's disease
St4
pt with achalasia did esophageal dilatation &ended by
perforation discuss with son who concern about
negligence
St5
headache for 2 months with scalp tender ness (giant
) cell arteritis
)Loss of vision for 10 mins (TIA
Exam 16/2/2017, uk centre

،Station 5 : sudden onset visual disturbance
Elderly male , vision disturbance since 1 day , came on
while watching tv, problem with central vision RT
SIded, history of diabetes, Examination , bruit in right
carotid, pulse regular , power normal , fundoscopy new
vessels at disc, D/d diabetic retinopathy /
maculaopathy /Amurosis fugax
BCC 2 : 84 yr old headache past 2 months , central
headache no aggravating, relieving factors taking
analgesics, No history to suggest pituitary tumour, SOL,
GCA,stroke. I gave D/d could be tension haeadche or
analgesic overuse
Abdomen : hepato spleenomegaly , 50 y old male with
abdominal distension, Plamar erythema , jaundice ,
liver enlarged 4 fb, spleen 2 fb, no acites , no
lymphnodes,Gave d/d myeloproliferative disorders,
CLD. There were some other cases in abdomen 1
person just got hepatomegaly ,with no spleenomegaly
Resp 2 patients : Young gentleman with clubbing,
Bronchietasis. d/d cystic fibrosis , ciliary dyskinesias
and immune related problems
Old gentleman clubbing and fine crackles , pul fibrosis
History : bloody diarrhoea d/d infectious , IBD
Station 4 : counselling lady with Ulcerative colitis ,
counsel regarding steroids , she is not willing to take
steroids due to side effects
Neuro : spastic paraparesis with no sensory
.involvement
D/d Hereditary spastic , MND
Diet_1#
7.2.2017: Cairo
Dubai exam today
(St 5 (carpal tunnel syndrome &TIA
ST 2 palpitation for evaluation
Comm SLE for renal biopsy
#######################
unfortunately:::
Candidate was shock &didn't give more details other
than these
Experience of my dear Brother ,, please PRAY 4 him
Ayr university hospital (Edinburgh)
1st carousel 19/2/2017
Station 1
Chest:
Elderly man has left pneumonectomy (scar in the
back NOT apparent anteriorly at all). Cushingoid
face, purpura, thin skin and proximal myopathy.
Right basal fibrosis.
Questions:
- Findings
- Causes of surgery
- Investigations
- Treatment of PF
Abdomen:
Left iliac fossa scar with underlying mass. Evidence
of gum hypertrophy and neck scar. Two anticubital
fossa scars.
- Findings
- Cause of ESRD in the patient
- How will you investigate?
- If the patient comes at night with tender abdomen
and fever what will you do as you are on-call?
Station 2
Full scenario is:
49 year old male has 6 weeks history of chest pain
which he couldn't give clear description. Sometimes
it's related to eating but didn't improve with
omeprazole. Cardiac and chest examination are
normal. ECG is normal. Please see and advice.
- ONLY Positive info from hx = Smoker + HTN +
brother died from heart attack at age of 40 y.
Questions:
- DD
- What are general causes of chest pain
- What are hereditary cardiac causes of chest pain
- Examiner wants HOCM although NOTHING fits at
all.
- How will you treat the chest pain?
- How will you treat his uncontrolled HTN?
- What's investigations and treatment?
Station 3
Neuro:
Lady with difficult walking. Examine LIMBS.
Although survey is NORMAL.
Clear left resting tremors and evident extrapyramidal
signs (Parkinson's disease)
I asked to let the lady walk + talk + write
GAIT looks ok but slight difficult only when turns to
side.
I asked to measure sitting and standing BP, to check
nystagmus or upper gaze palsy. Examiners said No
need.
Questions:
- Findings
- How to diagnose Parkinson's
- When do you need imaging
- Treatment medical and surgical
Cardio:
Elderly patient with dyspnea.
COMPLETELY NORMAL EXAMINATION
Questions
- Positive findings (I told NORMAL
EXAMINATION)
- Causes of dyspnea when normal examination
- How to investigate him
- What will do for him if comes to you in the clinic
Station 4
40 years male was feeling cold while on his office. He
had high fever and suddenly collapsed.
Meningococcal septicemia is diagnosed. He was
started on IVF and antibiotics. Awaiting for ICU
admission.
Talk to the wife.
Station 5
These questions are asked in the the 2 cases:
Diagnosis
DD
Investigation
Rx
BCC1:
58 y male with type II DM on insulin. He has bilateral
charcoat joints. Four weeks ago he has right foot
ulcer on his sole. For your assessment.
BCC2:
28 y male complains of red itchy eyes. His thyroid
function was abnormal and started on treatment. His
eyes are still concern. For your assessment.
Good luck.
Copied from WhatsApp group

(14.2.2017) England Exam
Resp: Fibrosis secondary to RA and lobectomy scar
Abdo: young girl with liver transplant scar with
lobectomy scar with tracheostomy and multiple striae
Cardio: AVR
Neuro: mixed UMN and LMN signs with peripheral
neuropathy ??cause
Station 4: BBN
Station 2: Recurrent hypoglycemia episodes in T1DM
Station 5s: 1. PF in scleroderma patient,
2. RP
(Copied) Egypt 1/2017 Almaadi Hospital

8th February last cycle
Station 1:
*chest COPD + corpulmonale
*Abdomen hepatomegaly with spleenectomy scar
Station 3 :
*CVS Double valve replacment
*Neuro Hemiplegia
Station 2:
*Back pain in young male ,?with family history and
grandther had psoriasis
Station 4:
Speak to daughter whose mother did ERCP and
diagnosed as gallstone cancer, daughter is feeling bad
and doesn't want her mother to be informed about
diagnosis coz she delayed bringing her to doctor
👆2nd concern in station 4 ,she wants to take her
home
Station 5:
BCC1,female known RA presented with new knee
pain ?osteoarthritis
BCC2, female with blowing headache ,past history of
migrane different from this pain ,family history of
dialysis , father died early with brains hrge , PKD
Cairo 3rd carousel (8.2.2017)

St 1:Hepatosplenomgally with lymph node
Pleural effusion
St2: Ankylosing
St3:Avr with mitral regurge
Hemiplagia
St4: Explain uncertainty diagnosis cancer pancreas
St5:1.Subarachnoid
2.Rheumatoid
(8.2.2017) Egypt
Station 1
HSM
History
Diarrhea with family history of crohn's
Communication
Palliative care in advanced renal cell carcinoma
Neuro
PN
Cardio
AVR MVR
Station 5
1.Ankylosing
2.Retinitis pigmentosa
carousel 1:maadi 7/2/2017

station 3: rt side hemiplegia
cardio:MR,TR,pulm.HTN
station 4:convincing lady with anemia to stay in
hospital for further investigation(endoscopy)she is on
painkillers
station 5-1)female with increased forgetfulness and
abnormal behaviour...history of renal
cancer...hypercalcemia vs brain mets
2)loss of weight with hypothyroid...from history
..polyuria...he wanted DM
station 1:pulmonary fibrosis
abd.hepato ?splenomegaly with ascites
station 2:poor mobility with poor history of lung
cancer and radiotherapy....cord compression
carousel 1:maadi 7/2

station 3: rt side hemiplegia
cardio:MR,TR,pulm.HTN
station 4:convincing lady with anemia to stay in
hospital for further investigation(endoscopy)she is on
painkillers
station 5-1)female with increased forgetfulness and
abnormal behaviour...history of renal
cancer...hypercalcemia vs brain mets
2)loss of weight with hypothyroid...from history
..polyuria...he wanted DM
station 1:pulmonary fibrosis
abd.hepato ?splenomegaly with ascites
station 2:poor mobility with poor history of lung
cancer and radiotherapy....cord compression
good luck
pray 4 me please
I needed anti-mental block at that time!!!!
Carousel 3 (5.2.2017) Egypt

St 5: 1. psoriasis with HCV
2. HTN , DM with fundus
Station 3 : TR MR with PH
Spastic paraplegia
Station 1 : Splenectomy with Hemolytic anemia
COPD with left effusion
Communication : MI
Exam UK Experience
Dundy hospital...Febr.2017
St1
Abdomen: Renal Transplant
Chest :COPD
St 3
Cardio : AVR
Neuro: charcot marie tooth synd
St 5:
Retinitis pigmentosa+Night vision
the second on ?????
That is ALL
St George hospital, London

Carousel 3 Cairo 6/2/2017:
Station1:
Abdomen:hepatosplenomegaly (chronic liver disease).
Chest: right lower lobectomy with bronchiactesis on
left side.
Station2:history:female patient with photosensitive
rash and fatigue and neutropenia. ( SLE with
antiphospholipid).
Station 3:
Cardiology:mitral valve replacement.
Neuro:paraplegia and peripheral neuropathy.
Station4:communication:female patient80years
admitted by pneumonia and then developed delirium
the task was to explain the condition and
Statio5:
-weight gain in female patient :Cushing.
-skin rash in female patient who has hepatitis
c:cryogloglobulinemia versus lichen planus
EGYPT ,, CAIRO ..FEBR. 2016

Carousel 3
kasr Eleiny 6/2/2017:
Station1:
Abdomen:hepatosplenomegaly (chronic liver disease).
Chest: right lower lobectomy with bronchiactesis on
left side.
Station2:history:female patient with photosensitive
rash and fatigue and neutropenia. ( SLE with
antiphospholipid).
Station 3:
Cardiology:mitral valve replacement.
Neuro:paraplegia and peripheral neuropathy.
Station4:communication:female patient80years
admitted by pneumonia and then developed delirium
the task was to explain the condition and
Statio5:
-weight gain in female patient :Cushing.
-skin rash in female patient who has hepatitis
c:cryogloglobulinemia versus lichen planus
EGYPT ,, CAIRO ..FEBR. 2016

Carousel 1
Communication
APCKD
History
HOCM
Station 3
MR ?
Spastic paraplegia
Station 5
Pemphegus
Hypothyroidism
Station 1
Hemolytic anemia
Chest : ILD
Experience of my friend=EGYPT ,, Kasr

Alaieni,,5/4/2017
St5
My 1st case.. Behcet.. scenario diminution of vision.
Second case scenario diarrhea and weight loss. I
consider the case lymphoma..
HSP+lyphadenopathy+diarhea + night sweats.
I put tb on my dd as there's history of contact with tb
but i said lymphoma more likely.
CVS... Systolic murmer in thalathemic pt for dd.....
MR or TR. And the examiner asked me could me
hematinis murmer i said yes but i don't know what's
hematinic murmer!
Neuro case is different.. Young woman with lt sided
weakness.
Abd case was very huge splen with hepatomegaly also
and axillary lymph node i sade lymphoproliferative
vss myeloproliferative.
Chest... Copd but examiner was hard also straight
forward case.
History... Proximal myopathy for dd... Statin induced
vss polymositis.
Communication.. BBN meningitis.
Carousel 1
Communication
APCKD
History
HOCM
Station 3
MR ?
Spastic paraplegia
Station 5
Pemphegus
Hypothyroidism
Station 1
Hemolytic anemia
Cairo today
St 1 copd .huge spleen
St2 proximalmyopathy for d.d
St 3 monoparesis .mr +pht ?
St4 bbn mengiosepsi
St5 bhcet .abdomial tb
4.2.2017 Egypt Carousel 3

Abd... Thalassemia
Resp...Basal fibrosis and COPD
History ...Anemia and fatigue
CNS ...paraplegia with PN
CVS ...AR
Communication ....Suspected bronchogenic
carcinoma in pt working in shipyard
Station 5
1.Thyrotoxicosis
2.Optic atrophy in MS pt
Today first carousel in Egypt

1) lt lobectomy for DD
Splenomegaly for DD
2)diarrhea &vomiting in DM with RRT
3) mitral valvotomy scar in patient with SOB
Rt lower limb monoparesis with intact sensation
4) functional disorder, the surrogate denies all
stresses!! ️
5) fatigue in pallor transfusion jaundice splenectomy
2nd carousel Egypt 🇪🇬

COPD
Splenomegaly for DD
History
Same as first carousel
Diarrhea with DM and hemodialysis
CVS
PH TR
CNS
Monoplegia with cerebellar signs
Communication
Functional disorder, headache same as first carousel.
Station 5
Anemia with splenectomy and blood transfusion in
febrile pt
Systemic sclerosis with PH and basal fibrosis
Egypt exam today

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

10 December 2016
ST 5
1= back pain=ankylos. spond
2=abdom. pain+wt loss
Alcoholic liver dis +HCV
Station 1
Respiratory = lobectomy
Abd == bilat enlarged kidneys
ST 2
History = ABDOMINAL PAIN== PARACETAMOL
OVERDOSE
ST 3
Cardio=Mitral sten+AF
CNS = PARAPARESIS
ST 4
communication ==hypoglycemia unawareness,,DM
Khartoum 5th December

2016
Day 3, Cycle 3
○ Station 1
° Chest: Bronchiectasis
Examiner Q:
+ve finding
I mentioned :
Wheezes
Crakles (then he asked which part of the chest ,I told
basal ,then coarse or fine )
Dull percussion note on the lung Base.
Then he asked what about trachea (I told central )and
breathing sounds (l told reduced over the Base of the
lung )
I mentioned clubbing (but I am not sure so I thought
I was invented that because the examiner is
wondering about that)
Then I mentioned reduce chest expansion .
Then he asked about DD (I MENTIONED FIBROSIS
&COPD)
Then he which is more likely fibrosis or
bronchiectasis (I told bronchiectasis )
He told me the patient is not smoker (so I said COPD
is unlikely but can occur )
Then he asked what questions you would ask the
patient (l mentioned sputum production
&occupational history )
Lastly he asked about causes of bronchiectasis and
investigation
I got 18
° Abdomen:
Cirrhosis with splenomegaly
The patient is male jaundiced & pale with shrunken
liver and splenomegaly and lower limb edema
Q:
Diagnosis
I mentioned Liver cirrhosis with portal hypertension
Then she asked about causesof cirrhosis (I mentioned
alcohol, viral,autoimmune. Vascular )
Investigation and management of of varices (l
mentioned endoscopic band ligation and beta
blocker,then she asked if beta blocker is CI, I told
nitrate but it is controversial and lastly she asked
How to control bleeding l told mennisota tube (l
forgot the name of sengestaken tube )
I got 20
○ ST2
Facial and tongue swelling and history of recurrent
abdominal pain. The patient is 28years old adopted
lady.
I started with greating the patient and who am I and
asked her to tell me more about her symptoms then
system reviews is normal apart from recurrent
abdominal pain &no symptoms of connective tissue
diseases
PMH :appendectomy
Drug & allergy is nil
FH (she doesn't know about her family because she's
adopted )
Social history :
University student
Non smoker or alcohol consumer
Concern about disease transmission to her kids and is
it serious and do I need dietary restriction
I told her the possible diagnosis is hereditary
angioedema and I explained it to her and (l told there
is the chance that the kids can be affected and the
disease can be serious if not treated and I will refer
her to dietitian for dietary advice and lmmune
specialist and I told her they are more expert than me
in discussing things further )and I also adviced her to
come to hospital if symptoms develop again and I told
epipen is ineffective for hereditary angioedema)
When 2min left l checked her understanding &any
further questions and I summerize to her and I will
write to the GP
Examiner Q :
1-who is support this lady (l told sorry I forgot to ask
)
2-DD
Anaphylaxis
Idiopathic angioedema
3-what is difference between anaphylaxis &
hereditary angioedema (l told absence of skin rash in
the later)
4- What is the pathophysiology (C1 estrase inhibitor
defeciency)
5- Drugs causing anaphylaxis (l mentioned ACEI &
NSAID )
6- mode of inheritance (l don't know )
7- Is appendectomy related to her condition (lam not
sure because l told the patient it's not related )
I got 18 (I am not expecting to get high mark)
○ ST3
° CVS
Young man with AR&MR WITH LUNG congestion
(I am not organized I forgot the JVP and I examined
collapsing pulse at the end & didn't present some of
the positive sign )
Q:
About investigation & and management and what is
suitable metallic or tissue
And Q about age limit (I told I don't know but the
tissue valve for elderly and the durability of them 10-
20 years
I got 13
° CNS
Upper limb examination
Motor neuropathy (wasting. Hypotonia.
Hyporeflexia. Intact sensation. Inability to do
coordination )
Q: DD
Myopthy
Motor neuropathy
Then investigation and management
I got 20
○ ST4
(from Dr. Zein course)
Hodgkin lymphoma stage IIA
For Hickman line and chemotherapy (I introduced
my self we agreed agenda withthe patient then I
asked him about his understanding he knows every
thing so I explained the need for chemo and Hickman
line insertion and I explained this to him and the side
effects of chemo .his main concern is fertility and his
job so I told about sperm bank and sickleave, then he
asked me shall I tell my wife? (I told I am happy to
arrange meeting for you and your wife if you agreed.
Then he asked what if decided not to take chemo, I
told I am sorry to tell you might die from the cancer .
At the end no more Q or concerns then I asked what
message you will take home and summerize and close
the consultation
Q:
1-summerize the main issue in the case
2-you told the patient you will offer him sperm bank
do you have it in Sudan (l told I don't know but he is
UK patient )
3-you told him to wear mask against infections what
other measures you will offer? I told vaccine. Q
:against what? I told pneumococal & infleunza.Q :do
you have this in Sudan (idont know I am not working
in Sudan )
4-What is ethical principles here
I mentioned autonomy and beneficence
5. Is the wife has the right to know about her husband
infertility?
I told no unless her husband agreed ,the examiner
tried to shake me but I didn't change my answer.
I got 15 (although I used some medical jargon but
only 2)
○ ST5
° BCC1
JOINT pain with hoarseness of voice and muscle
cramp for 3 month. With history of thyroidectomy
The patient has obvious stridor
Discussion about causes and investigation
I got 22
° BCC2
Young lady with dysphagia for solid for 3 month in
patients with scleroderma
Discussion about differential and mangement
I got 26
Again thank you dr.Ahmed for all help you provide.

So, my experience was posted on this group before my
result been release.Here you find it e marks.
I started my exam with station 3
▶Neurology: examine Young lady upper limbs:
General inspection global wasting but predominantly
small muscles of both hands
Hypotonia, hyperreflexia and weakness almost
equally distributed 2/5.I needed to examine sensory
system and proceed to see the fasciculation over the
thigh but examiner told me skip it and I proceeded
for CN examination where I found obvious tongue
fasciculation.She was not able to speak and she had
drooling of saliva.All of what I commented on during
my presentation.She was a case of MND.
The discussion started with if the pt been admitted
several times to the hospital because of pneumonia.
My response was:asp. Pneumonia due to bulbar palsy
as a part of her condition. Then deep details about
MND, types(I offered),where is the lesion?
investigations(clinically),management(MDT in details
from swallowing therapist up to psychological
support)
Treatment and benefit from it and cost effectiveness(I
offered and I said its not).
20/20
▶Cardio:
Female of 40s
Pulse irreg irreg+Raised JVP midsternotomy
scar,diffused apex, palpable P2,PSM rad. to axilla, no
click.
MR after MVR e tissue valve AF,Pulm.HTN.
Discussion was about investigation, ttt medical and
surgical, wich valve you are going to use and to
monitor her.
▶Station 4: BBN
physical trainer presented with eye sight problem and
cerebellar dysfunction first time(inside when you
ask).Your consultant think of MS and he is away,
MRI Brain highly suggestive,I started as dr.Zain
taught us and get through all the important points
but I forget the driving issue and they didn't asked
me.
Examiner questions:
Ethical issues:
BBN. So,you BBN but with uncertainty
Me, yes,because this is the first attack and the MRI
became highly suggestive so I need to revise and
discuss with my consultant again.
autonomy.
examiner:where in the scenario?pt didn't want to tell
his partner.
Ex:Do u think its important to tell his partner
Me:yes,she will help him emotionally and physically.
Ex:asked about fertility,inheritance, chance of the
babies to get the disease?
I responded exactly like in dr.Zain sheet and I havr
already discussed the same q e the surrogate.
Ex:what about his job?same advice I gave to the
surrogate I gave to the Ex:
Its early to anticipate but you need to be in regular
F/UP in order maximise the free of symptoms period
and reduce the attacks.
How the disaese behaves?same answer?behaves
differently in different people later on we may be
more familiar with the type you might,again the F/up
is crucial for you(him to Ex).
I mentioned the need for giving him steroids.And new
medication but they didn't ask the name.
13/16
▶BCC1:
Young male e recurrent mouth ulcers
i covered all GIT AND MSS and no skin rash all of
were negative.
I asked about DVT which he had 3 years ago. I asked
about PE and its symptoms
(-ve).
I examine the mouth I found about 3 small ulcers
similar to the aphthus ulcers.then immediately I
jumped to the legs and I fully examine the legs for
DVT (Lt leg below knee)good peripheral pulsation.
I examined the precordium and there was loud P2.
Concern:what is the cause of the ulcers
And what you will do for him?
I replied like Behcets disease causing DVT and
PE.both to the relative(not PE) § Examiner
He asked me how can you justify that there were no
symptoms?recurrent micro throbi passing unnoticed.
What about the skin rash over the Limb e DVT?
Me:😰😰😰.I don't know.
investigations, ttt
28/28
▶BCC2:
Pt around 50yrs old
Known RA has back P.
I analysed the BackP:sudden mechanical e no
neurological manifestations, sphincters intact.
RA is controlled.
DH:on prednisone 15mg for 3yrs.
All others not significant
Examination:back is tender on percussion.
LL.exam:upgoin planter with pyramidal weakness
but examiner did not allow me to complete for
sensation.
I diverted to examine the hands for RA (activity
§disability)😱😱😱 there was drumstick clubbing then
I jumped to the chest thinking of HPOA due to Ca
lung causing mets to the spine as a cause of his Back P
Chest:coarse crackles § Wheezing
Concern:what's wrong e my dad.is there any thin
wrong?I replied same as to Examiner.
Examiner :what is the problem e this pt?steroids
induced osteoporosis, causing vertebral #.although I
have DD like Ca lung e mets to the back.
What is the cause of the clubbing?Ca lung
In the context of RA😨😰
I don't know.He needed an answer and I hadn't
it.Lung fibrosis unlikely to cause clubbing in the
context of RA and he agreed.Again what is the
cause!!!
So how are you going to manage him?
Urgent MRI spine,neurosurgery consultation bill
rang alhamdulillah.
22/28
▶Satation 1:
↪Chest: under built Young lady e sputum pot filled e
yellow to greenish sputum.
Clear case of bronchiectasis but the examiner wasn't
happy about that
He asked what is your DD?
Me:DD for bronchiectasis or the causes of it?
Ex:For Bronchiectasis
Me:Lung fibrosis
Then the discussion diverted to Lung fibrosis,causes,
upper and lower zone fibrosis, unilateral and
bilateral.We ended e TB, investigations.
19/20
▶ Abdomen :
Young male e huge hepatomegaly almost approaching
the Lt hypochondium.e no features of CLD.
I knew that I trapped my self.
I felt duputryn contracture on one hand, and I think I
started to imagine temporal wasting, which were not.
Q:DD :I sayed there causes for hepatomegaly alone
again I trapped my self because I started with what I
was thinking about:Alcoholic liver disease
Ex:is it common in your country…l realised my
mistake, no way to fix it.
investigations, ttt.
13/20
▶ Station 2
75 yrs Male found collapsed.
High s.cr BU § S.Na.
After doing my introduction
I started e open ended question, daughter had been
called that her father found collapsed.So the analysis
of collapse was not informative.So I changed the plan
and I went searching for losses by system.GI(GE 5d
ago treated at home but he was doing fine) including
upper or lower GI Bleed, was -ve)
GUS :polurea for more than 3 months
Surrogate was very kind but she spent about almost
5min unstoppable speech it was hard to interrupt her.
I used to go systemically but I couldn't because the
time left were v.limited I was afraid, to lose
marks,however I thought I cover all.
Pt has depression since his wife death,he takes
medicine for it,which well controls his symptoms, I
rapidly assess his mood,sleep,appetite,all were ok I
didn't ask about suicidal ideas but she told he was ok.
Nothing else was significant.
I answered her concerns, Explaining DI, sequences of
Lithium toxicity,the contribution of the DHD(caused
by GE)to the problem.
I replied to the examiner almost in the same manner.
Discussion was about type of DI and which one this pt
has.How to investigate and what you expect to
find.How to treat.She agreed all.
At the end Ex asked:for how long pt has polyuria
Me:6 months.
How did he compensated for this?
Me:I didn't ask.But I should.
17/20
Alhamdulillah
I hope the best for all
☆ Station 5:
1. A 59 yrs old lady presented with a 10 days history
of diarrhea.
VS: pulse 90 bpm 100/60
Inside: a relatively middle aged lady sleepy ,dry
mucus membranes ,history of diabetes 20 yrs ago.
The diarrhea is not containing blood or mucus ,no
alarming symptoms or signs, no autonomic features,
no constitutional symptoms ,there was history of
recurrent antibiotic use for UTI; last course was 2wks
ago.
Concern is it cancer?
My differential: antibiotic induced
pseudomembraneous colitis ,infective diarrhea,
autonomic neuropathy as she mentioned the diarrhea
wakes her at night.
Examiner was interested in something else they try to
push me to say something ,I didn't get them, but when
I finished they told me IBS️
2.
A 54 yrs old lady with long standing joint pain for
knee replacement, all vitals were normal, pulse60,
Inside: joint pain is not specific multiple joints.
Surrogate did not know anything about her
everything. When asked why u r here? She replied i
was sent by the surgical unit but I don't know why.
Examination noooooormal ,fit lady , then 2mins left,
and the examinar was very annoyed then he told me
she has fatiguability does it give u any hints,
I digged and found she is hypothyroid. I had to check
the neck and the thyroid status, she had a scar in the
neck the examiners were surprised about it then they
told me it was from trauma to the neck😳😳
less than one min, concerned about can we do the
surgery answered the concern and then simple
questions how to investigate, she had diabetes then
what could be the etiology for her hypothyroid, I
scanned her for autoimmune illnesses in the history
earlier.
28/28
☆ Station 1:
¤ CVS :
DVR very clear & straightforward
20/20
¤ Neurology :
veeeeeery difficult case young girl 15 yrs of age.
Instructions: examine this patient neurologically
😐 OK from where to start!!
Face nothing impressive ,she was very shy and i guess
low IQ, very uncooperative, laughing, globally wasted
upper and lower limbs, with pes cavus, power strong,
tone normal, reflexes normal, gait normal,
One min left ,cerebellum one side a bit impaired, time
over..
Qs:
Summarize your findings, very confused thoughts but
tried to organize it. Then I noticed that she is moving
the shoulders ️️strange enough?? What could be
the cause.
I said young girl with possible cerebellar so
hereditary Stacia's, abnormal movement no localizing
sign so chorea is possible ,
What could be the cause I replied Wilson's or
rheumatic fever
How to investigate ,️time over..
Surprisingly I got 16/20 I thought only 8
Al7amdolellah
☆ Station 2:
¤ A40 yrs old deliveryman with lower limb swelling
,blood pressure normal urine ++ of protein.. see and
advise.
Inside very clear nephrotic syndrome with all the
water retention symptoms, start to look for the cause,
diabetic but very controlled ,then asked about
vasculitis, there was history of joint pain for six
months did not seek medical advise, taking over the
counter ibuprofen 400 my tds,
Now clear picture of either vasculitis causing
nephrotic, Rheumatoid arthritis causing nephrotic, or
drug induced nephrotic syndrome
The discussion was on the management.
Got 16/20
☆ Station 3:
¤ Abdomen: A young cachexic lady, very pale, with
maaaaasive ascites , not jaundice and no signs of
chronic liver disease & no lymph nodes, Differential:
decompensated CLD but no signs of liver disease,
heart failure but no peripheral oedema I did even
examine the lung bases after permission of the
examiners as I finished early no lower limb oedema.
Abd : young lady cachexic , very pale, with

maaaaasive ascites , no jaundice or signs of chronic
liver disease no lymph nodes, differential :
decompensated CLD but no signs of liver
disease,heart failure but no peripheral oedema I did
even examine the lung bases after permission of the
examiners as I finished early no lower limb oedema &
infections like TB.
Renal disease also remote possibility.
☆ Station 4:
The nurse with conversion disorder ,stroke ,imaging

normal ,she heard the nurses sayi
Khartoum PACES, December 2016

Day 2 - last cycle 3
□ Station 4,
Communication Skills :-
Dealing with an angry son, his mother underwent hip
replacement , on rehabilitation centre she developed
headache , the doctor suspect gaint cell artritis he
gave her 40 mg predonsolone. She developed steroid
induced psychosis , they reffered her to the general
hospital where she was seen by the rheumatologist
who ruled out gaint cell artertis , and started to
tapper the steroid.
Her son at home and they didn't call him at night &
he is ungrey for that..
his concern , is it reversable
and could my mother returned back to the
rehabilitation program ?
I got 16/16
□ Station 5
♢ BCC1
A 70 yrs male with joint problem since 15 yrs
developed SOB and cough for 6 months , inside the pt
had obvious RA with deformities , on Hx he is on
methoteraxate ,
O/E had creps all over the chest Concern is it heart
attack?
I got 26/28
♢ BCC2:
35 yrs female developed pain on both hands with
change in appearnce , in side when i went to greet her
i saw fingers deformities and skin rash , it is psoriasis
wih psoriatic arthropathy
I got 27/28
□ Station 1:-
♢ Abdomen , obese female pt treated for anaemia ,
had nonfunctioning fistula, she had ascites with
peritoneal dialysis cath ,
😬😬 Iam short stature , the female is obese , the
couch is high, i couldn't palpate the Lt kidney but the
right is palpable , APKD
I got 18/20
♢ Chest:-
Obvious features of scleroderma with bibasal fibrosis
I got 20/20
□ Station 2:-
35 yrs male with type 1 DM had collapse & black out
, he had all macro & microvascular & autonomic
complications, it's a long Hx 😰
the concern , what could be the cause ,
I finshed the Hx without managing his concern , time
over ,
I got 17/20
□ Station 3:-
♢ Neuro,
sensory motor peripheral neuropathy , I got 20/20
♢Cardio:-
midsterniotomy scar , the pt had ESM at aortic area ,
itis prosthetic aortic valve ,
I got 20/20
YANGON CENTRE
Day 1 (7.11.16)
Station1
Resp: male pt, cough & SOB for 3 months
O/E: clubbing,dullness percussion, reduced VBS, no
ronchi,no crepts
I gave first consolidation.
Examiner ask DDx
I gave pleural effusion,pulmonaryfibrosis, Ca lung
Pleural thickening
Invx.
Khartoum paces exam

December 2016
St:3
NEURO:MND e bulbar(dysarthria.tongue
Fasciculations)
Cardio:Mid sternotomy scar+PSM rad to
axilla+pulm htn
AF
St4:Physical trainer.with cerebellar
features.MRI:highly suggestive MS
BCC1:Behcet +DVT+PHTN
BCC2: RA came e Back P sudden onset due steroid
use
OE :CLUBBED hands
Chest full of wheeze and crackled
Examiner wanted bronchiolitis obliterans
St1:chest:chest full ofcoarse crackles +wheeze sputom
pot sputum yellowish colour
Examiner wanted lung fibrosis 😷
Abdomen :huge liver
Polycyctic liver
St2 Hx:lithium toxicity
08/10/2016
Muscat
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
Station 1
Middle aged man with
progressive SOB.
On examination patient was dyslexic with
Rheumatoid hand and fine end inspiratory
crepts
Questions What's are the finding ,how will
you investigate and manage.
20/20
Abdomen was a young male with icterus
and Spenomegaly
Again same questions
Finding how will you investigate
I gave a diagnosis of Thalassemia but I seem to have
missed
Some physical findings
How will you manage
What are the complications of blood
transfusion
Score 16/20
Station 2
35 year old male working as a financial
consultant with frequent travel to Africa
Had history of drenching night sweats
and weight loss
On taking history had past history of
travel with poor compliance of taking
prophylaxis for malaria
No risk factors for HIV
Travel to urban areas of Africa
Gave d/d of TB,Lymphomas,chronic malaria
Discussion on TB investigation
Concerns can it be cancer
Score 20/20
CVS: was a tough one not sure of
diagnosis
Discussion indications of valve replacement
9/20
Neuro: Young female with complaints
of having problems with vision.Examine
cranial nerves
On examination patient had right sided
homonymous Hemianopia
Discussion on where could be the lesion
Causes in young female
Investigation you would ask for
20/20
Station 4
Was a long scenario
Mr A is a known case of COPD admitted with acute
exacerbation in HDU. Was started on iv antibiotics.
Culture were negative.
He is not doing well and has developed generalised
body swelling and started on diuretics
Patient is mildly confused. The treating Consultant is
of the view that Mr A does not have a good prognosis
though he has not yet spoken to ICU and no decision
for or against.Also Mr A continued to smoke even
after previous admissions. Intubation has been taken.
Job is to Speak to daughter for which Mr A had given
consent, discuss the management plan and prognosis .
Daughter wanted MR A to attend a wedding which
was after 3 months and Mr A had expressed that
everything be done to help him live longer.
Discussion was on whether to intubate and is always
intubation difficult to waen from MV
Who will take the final decision to intubate or not
If patient is not confused does he have a say
Station 5 case 1
Middle aged man known case Of DM since 3 years
complaining of alteration of sensation on left lateral
thigh.
On OHA
Duration 2 weeks
On examination absent sensation on lateral side of left
thigh( distribution of lateral cutaneous nerve of thigh
No other abnormalities
Diagnosis: Meralgia Parasthetica
Concern : Is it due to diabetes or Metformin
Discussion investigation and management
28/28
Case 2
50 year old female c/o SOB and difficulty in
swallowing
On examination
Systemic sclerosis
Concern will it worsen
Discussion on investigation and management
24/28
##########################################
Detailes of the communication case
As mentioned before the written scenario was long
(full A4 page)
Job was to explain to daughter the management
done,prognosis and future plan of management.
After confirming the identity and being next of kin, I
asked her how much she knew
Of her father's disease
She said that he had been suffering from breathing
difficulties and had several previous admissions after
which he would improve and would be discharged
home
However he would continue to smoke(which was also
mentioned in the scenario
Taking the discussion further I asked whether her
father had any advance directives .she replied that
her father had expressed his view that everything
possible be done to help him live longer
Then I explained to her the present clinical status of
her father and during the present admission he is not
doing well and tried to show some empathy
Also her father had developed complications in
simple terms with generalised swelling and confusion
Daughter then asked me Why we are not shifting him
to ICU
I then explained that the treating Consultant views
that he did not have a good prognosis at the same
time repeatedly showing empathy
Though the consultant has not yet taken a decision
I tried to tell her that once on the breathing
machine,such patient are difficult to wean off
At warning of 12 minutes I asked her for her concern,
she said she wanted her father to attend marriage
ceremony which was due after 3 months
At this I summarised the discussion and told her I
would be informing my consultant of the discussion
and also inform him about your consent as well as
patient desire that everything that can be done to be
done for himm
And the end I said I would be leaving my contact
details and she was free to contact me
For any new concern she may have
Discussion with Examiner was centred mainly on
intubation
Of such patients
Who will take the decision for shifting the patient to
ICU
Do the family members have a say in Taking a
decision on Intubation and ICU tranfer
Suppose If the patient was not confused
Will he have a say in a decision of his transfer to ICU
and intubation
Is it always that COPD patient are not to be intubated
and are difficult to wean off
As usual the examiners were expressionless
To be truthful I was not sure how I have done but
Alhamdullilah got 16/16
My experience at leicester royal infirmary,uk on

20/11/2016
Cardio..severe mr 2ndry to rheumatological
disease...19/20
Neuro..upper limbs..proximal myopathy...20/20
Respiration..left upper lobectomy..13/20..i totally
missed lobectomy scar.
Abdomen...myelofibrosis..20/20
Bcc1.....psoriatic arthropathy with both hands n feet
involvement..23/28
Bcc2...microscopic hematuria...23/28
History..angioedma...02/20...?
Communication...psychogenic hemiparysis...05...?
Total...125
I failed...
Malta 1st day 1st carousel

december 2016
Chest
pneumonectomy e lung cancer
Abd
HSM CLD
Hitory
uncontrolledHTN
Cardio
AS MR
Neuro
Heam. Heamanopia
Comm
COPD terminal for discharge
BCC1
migrain e headache analgesic misuse vs tension
headache
2 infective diarrhoea in pt. E crohns received ABX
pseudomem.cholitis
Manipal hospital- Bangalore,INDIA, day 2

Station 4
26yrs old lady physiotherapy as st. Working in stroke
unit .admitted with flaccid limb weakness , CT and
MRI normal explain about functional weakness . Pt
was reluctant to accept the diagnosis and wish to see
neurologist urgently don't want to see psychiatrist
.social issue about job , and grandmother died 3
months back with stroke.discussed about psychiatric
referral and physiotherapy
Station 5
1 st case 30 yrs old lady with high prolactin levels and
normal TSH c/o scanty and irregular menstruation.
presented with right sided pleuritic chest pain ,with
fever. Discussion about DD of chest pain.
Station 1
- Respiratory -- lung fibrosis
jaundice, parotid swelling,flapping tremor, spider
nevi , examiner asked about if there is fever what can
be the cause and how to treat
Station 2
30 yrs old lady with facial and neck swelling sudden
onset ,adopted child , no other positive history ,
concern about allergy .DD- hereditary angioedema .
Investigation and treatment .
Station 3
Neuro - right sided weakness , with proximal wasting
,sensory normal .
Cardio -- young lady with MS - tapping apex sinus
rhythm ,loud S1 diastolic murmur , phtn and raised
jvp .
Copied from telgram channel of

Dr. Mahmoud Abo-Khadija
** Paces uk study group** On Telegram
1. Station 1
A. Respiratory : ILD due to SLE in a male patient.
Fine end inspiratory Crackles were heard on
auscultation in both lung fields, more prominent on
left upper to mid zone.
Patient had no other stigmata, only had hairloss of
scalp and eyebrow.
Asked about causes , investigations and management.
I scored 19/20.
B. Abdomen: a middle aged lady with AV fistula ,
active, old scars in her neck for venous access, huge
ascites with everted umbilicus. There was a mass
palpable and ballotable even though there was huge
ascites.
I carefully percussed and tried to figure out the get
above the swelling and was quite confident about
palpable kidney.
So it was actually an ESRF on MHD patient with
ADPKD with huge ascites .
I got 19/20 lost one mark probably for not checking
fluid thrill , i thought only shifting dullness would be
enough. But examiners asked about fluid thrill and
probably cut 1 mark in clinical examination.
2. History station
A 24-year-old lady presented with fatigue and
tiredness , lab reports suggestive of IDA, has history
of menorrhagia , no thyroid problem. This lady has
been receiving treatment for IBS
A nice surrogate , i elicited all the informations acc to
the format which helped me find out the actual
reason of anaemia was malabsorption, it was celiac
disease but the were no precipitant food item. I
excluded all the causes of Malabsorption.
Crossings were centred around DDs , reasons to
establish celiac as a cause , investigations and mx of
celiac in 3 words.
Got 20/20
Station 3:
A. Cardio :
Middle aged man with mid line sternotomy scars ,
audible metallic click from outside, 2nd heart sound
replaced by metallic click and a flow murmur more
prominent in aortic region.
Completed examining him in 5 minutes and i was
asked hundreds of questions regarding aoric and
mitral valve diseases , indications, signs of severity,
Investigations, management , INR.
20/20
B. Neuro :
Young lady with stroke - clonus/ spasticity/ hyper
reflexia / weakness / extensor plantar- of left side /
intact sensory, didnt let me check the gait. I asked to
see the upper limb and allowed to inspect only and
found her to have left sided hemiplegic posture .
Asked permission to check pulse , carotids and
precordium along with thorough history onset and
progression. Times up then.
Questions were around DD , causes of young stroke,
cardiac causes of stroke, whether it was an embolic or
thrombotic one. Asked y would i wanted to check
pulse carotids and precordium. I was asked to imitate
a hemiplegic gait. Investigation and management.
Examiners seemed to be really pleased
Got 20/20
Station 4:
Task was to talk to the daughter of a 70-year-old
gentleman who was diagnosed with parkinsons for 7
years. He got admitted with fall 2 days back . Nurse
observed today that the patient is increasingly stiff
and having difficulty with standing up from chair. He
also had some cough and abnormal breathing. Nurse
on duty today checked and found out that patient was
not given stelavo since admission as the medication
was not available in the pharmacy.
My task was to explain the mishap and discuss
further management.
It was difficult, had to cover a lot of thing, managed
time well completed it in 14 minutes
Apologised 1st , calm the angry surrogate, discussed
about the occupational health team , SALT team ,
neurologist , adressed chest infection , managed her
concern about hospital acquired infection, advanced
directive related issues , social care , asked the lady
for any help.
Examiners were discussing regarding the issues and
answered everything confidently.
I was happy about the station as i thought this was a
completely new and unusual scenario, it would be
tough. But it went well.
16/16.
Station 5
A. 34 year old lady presented with fever and weight
loss. I asked for all possible details including exposure
history and travel. Sign i could elicit was only an
anterior cervical chain lymphadenopathy. Asked for
temperature chart.
DD given TB lymphoma leukaemia HIV
Crossing was all about investigation, histological
finding of tb lymphadenitis. Out line of management.
28/28
B. A 58-year-old lady presented with bluish
discoloration of fingers and shortness of breath. It
was a case of systemic sclerosis with ILD.
Asked about investigation and management.
So its quite possible to obtain full marks in all the
stations. Just you need to be well rehearsed and little
bit of good luck to get good cases and cordial
examiners.
EXAM Malta today
11DECEMBER 2016
St1
(respiratory OLD with pulmonary fibrosis
Abd transplant kidney
St2
haematemesis in heavy alcoholic drinking
St3
AS cardio
Neuro cerebellar SYND
ST4
discuss delayed of cancer discover in a lady came with
vomiting of blood &many investigation done do her
(endoscopy, x-ray &Abd US )then CT chest
&abdomen show cancer in carina with mets
Discuss with her daughter even if cancer discover
early it's for palliative treatment
ST 5
(back pain with fever in old lady with Hx of back
surgery 6 wks ago
2nd one us caeliac disease (loose motion with
anaemia)
PACES EXAM MALTA

11 DECEMBER 2016
St 3
Cardio = MIXED (AS & MR)
Neuro PARKINSON dis
St2
SOB (COPD)
St 1
Abd ,,, ABDOMINAL MASS
Chest pneumonectomy
St5
(night sweat )
Asthma uncontrolled with charge straous
St 4
ca pancreas (delayed diagnosis &for palliative
treatment )came with multiple visit with Abd pain
lastly CT done &show ca
Pt angry &want complain
Thanks for this group for much support. My exam

second day first round in Mandalay centre (
15.11.16).
Station 2
Analgesic induced headache with underlying
migraine
CVS- ESM at apex with radiation to mid axilla &
ESM at aortic area with no radiation no AF No
HEart failure no IE- I give MR . Other candidate give
MR too. DX- MR
CNS- prompt- examine cranial nerve- right 12 CN
palsy with hard voice with salivation & right hand
small muscle wasting with claw hand
Only have time for finger adduction& fromen sign.
No time for motor& sensory& jerk
Examiner ask me what do you want to do if I have
time ? Said sensory& cerebellar & motor.
Common cause in her middle age - MS,
syringomyelia, pseudo bulbar DX- Syringobulbia :)
St4- Steven Johnson due to penicillins during birth
Abd- ascites with no organomegaly- COL with portal
hypertension
Respi- Rt lower lobe consolidation
St 5- 1)Acromegaly
2) fatigue all the time with RA deformed hand in
middle age female with bilateral ptosis with I think
pallor
I rule out MG with evening worse fatigue ,
hypothyroid , Addison,
Drug history- NSAID according to doc three times
per day with increasing pain in her hand
Can't find anything- give DX as analgesic induce
blood loss
Anaemia due to chronic diseases
I passed
MALTA paces exam

December 2016
ST 5
1= fresh bloody diarrhea==crohn dis
2=HEADACH==may be migrain or medication
overuse
Station 1
Respiratory = Interstitial lung dis
Abd =hepatosplenomegally
ST 2
History = poor control ABP
important to say in ttt AMPULATORY &HOME BP
monitoring
ST 3
Cardio=Mitral reg
CNS = Examin the EYE????!!!
ST 4
communication ==Angry son refusing Discharge of
his mum from hospital
MALTA
DECEMBER 2016
St5
(night sweat )
St2
sob (copd)
St 3
Ms with Af
Neuro Essential tremer
St 1
Abd hernia
Chest pneumonectomy
St 4
EXAM Malta today

2nd carousel
11DECEMBER 2016
St1
respiratory Pnumonectomy
Abd Abd mass
St2
St3
cardio VSD
Neuro spastic paraparesis with no sensory level
ST4
ST 5
surgery 6 wks ago
anaemia)
2016/3
17/11/2016 Chennai (Sundaram Medical Foundation
Hospital)
Station 3
CVS MVR
20/20
CNS Examine cranial nerve: Bell palsy
18/20
(I cannot answer when examiner asks me why there is
loss of nasolabial fold on the contralateral side and
role of nerve conduction study for 7th nerve palsy)
Station 4, End stage COPD lady, Admitted for Type 2
respiratory Failure, not responsive to non-invasive
ventilation and getting deteriorating. pt has her own
nebulizer and oxygen cylinder at home. Patient is
keen for self discharge (mentally competent) Task is
to speak to the son and explain about self discharge.
It is like breaking bad news. I did badly and I thought
I will fail this station as I have left nearly 5 minutes
by the time I finished all the tasks and solved his
concerns : (
13/16
Station 5
BCC 1 65 yr old lady with knee pain > 6 months
Dx: likely OA
28/28
BCC2 30 yr old man, present with fever ,cough X 1
month (pt give history of night sweats, poor appetite,
weight loss, hemotypsis, but no exposure to TB, no
risks of contracting HIV ) Examination findings
seems to be normal.
DDx TB, Ca Lungs, Lymphoma
26/28
Resp
I did badly in this station because of limited time,
Unfortunately, I started examination at the front
which I found nothing abnormal, except reduced
cricosternal distance and barrel shaped chest wall
which is not quite obvious..There was no clubbing/no
cyanosis on general inspection.
When I started to check the patient's back, only 1
minute left, so, I listened only his back which I heard
crep on the right lung base.
But examiner asked me whether crep is unilateral or
bilateral.So seem like bilateral.
17/20
Abdomen
This is my worst station.
Young Lady with functioning AVF (but not recently
used) , no features of chronic liver disease.
I found only very small splenomegaly which I am not
quite confident to tell the examiners.
Examiners lead me questions about Chronic Liver
Disease.
13/20
Station 2
30 year old lady, mild anaemia (normochronic
normocytic anaemia), BP 140/80, present with
Fatigue
Dx: SLE with Antiphospholipid antibody syndrome.
main concerns: pregnancy
20/20
Total 155/172 and I passed PACES finally!
Thanks to my parents, my teachers, friends and
colleagues, especially my husband who helped me
intensively before my exam. Without his support and
encouragement, I won't be able to pass this exam.
Thank you everyone!
Malta 1st day 1st carousel

december 2016
Chest
pneumonectomy e lung cancer
Abd
HSM CLD
Hitory
uncontrolledHTN
Cardio
AS MR
Neuro
Heam. Heamanopia
Comm
COPD terminal for discharge
BCC1
migrain e headache analgesic misuse vs tension
headache
2 infective diarrhoea in pt. E crohns received ABX
pseudomem.cholitis
Manipal hospital- Bangalore,INDIA, day 2

Station 4
26yrs old lady physiotherapy as st. Working in stroke
unit .admitted with flaccid limb weakness , CT and
MRI normal explain about functional weakness . Pt
was reluctant to accept the diagnosis and wish to see
neurologist urgently don't want to see psychiatrist
.social issue about job , and grandmother died 3
months back with stroke.discussed about psychiatric
referral and physiotherapy
Station 5
1 st case 30 yrs old lady with high prolactin levels and
normal TSH c/o scanty and irregular menstruation.
presented with right sided pleuritic chest pain ,with
fever. Discussion about DD of chest pain.
Station 1
- Respiratory -- lung fibrosis
jaundice, parotid swelling,flapping tremor, spider
nevi , examiner asked about if there is fever what can
be the cause and how to treat
Station 2
30 yrs old lady with facial and neck swelling sudden
onset ,adopted child , no other positive history ,
concern about allergy .DD- hereditary angioedema .
Investigation and treatment .
Station 3
Neuro - right sided weakness , with proximal wasting
,sensory normal .
Cardio -- young lady with MS - tapping apex sinus
rhythm ,loud S1 diastolic murmur , phtn and raised
jvp .
Copied from telgram channel of

Dr. Mahmoud Abo-Khadija
** Paces uk study group** On Telegram
1. Station 1
A. Respiratory : ILD due to SLE in a male patient.
Fine end inspiratory Crackles were heard on
auscultation in both lung fields, more prominent on
left upper to mid zone.
Patient had no other stigmata, only had hairloss of
scalp and eyebrow.
Asked about causes , investigations and management.
I scored 19/20.
B. Abdomen: a middle aged lady with AV fistula ,
active, old scars in her neck for venous access, huge
ascites with everted umbilicus. There was a mass
palpable and ballotable even though there was huge
ascites.
I carefully percussed and tried to figure out the get
above the swelling and was quite confident about
palpable kidney.
So it was actually an ESRF on MHD patient with
ADPKD with huge ascites .
I got 19/20 lost one mark probably for not checking
fluid thrill , i thought only shifting dullness would be
enough. But examiners asked about fluid thrill and
probably cut 1 mark in clinical examination.
2. History station
A 24-year-old lady presented with fatigue and
tiredness , lab reports suggestive of IDA, has history
of menorrhagia , no thyroid problem. This lady has
been receiving treatment for IBS
A nice surrogate , i elicited all the informations acc to
the format which helped me find out the actual
reason of anaemia was malabsorption, it was celiac
disease but the were no precipitant food item. I
excluded all the causes of Malabsorption.
Crossings were centred around DDs , reasons to
establish celiac as a cause , investigations and mx of
celiac in 3 words.
Got 20/20
Station 3:
A. Cardio :
Middle aged man with mid line sternotomy scars ,
audible metallic click from outside, 2nd heart sound
replaced by metallic click and a flow murmur more
prominent in aortic region.
Completed examining him in 5 minutes and i was
asked hundreds of questions regarding aoric and
mitral valve diseases , indications, signs of severity,
Investigations, management , INR.
20/20
B. Neuro :
Young lady with stroke - clonus/ spasticity/ hyper
reflexia / weakness / extensor plantar- of left side /
intact sensory, didnt let me check the gait. I asked to
see the upper limb and allowed to inspect only and
found her to have left sided hemiplegic posture .
Asked permission to check pulse , carotids and
precordium along with thorough history onset and
progression. Times up then.
Questions were around DD , causes of young stroke,
cardiac causes of stroke, whether it was an embolic or
thrombotic one. Asked y would i wanted to check
pulse carotids and precordium. I was asked to imitate
a hemiplegic gait. Investigation and management.
Examiners seemed to be really pleased
Got 20/20
Station 4:
Task was to talk to the daughter of a 70-year-old
gentleman who was diagnosed with parkinsons for 7
years. He got admitted with fall 2 days back . Nurse
observed today that the patient is increasingly stiff
and having difficulty with standing up from chair. He
also had some cough and abnormal breathing. Nurse
on duty today checked and found out that patient was
not given stelavo since admission as the medication
was not available in the pharmacy.
My task was to explain the mishap and discuss
further management.
It was difficult, had to cover a lot of thing, managed
time well completed it in 14 minutes
Apologised 1st , calm the angry surrogate, discussed
about the occupational health team , SALT team ,
neurologist , adressed chest infection , managed her
concern about hospital acquired infection, advanced
directive related issues , social care , asked the lady
for any help.
Examiners were discussing regarding the issues and
answered everything confidently.
I was happy about the station as i thought this was a
completely new and unusual scenario, it would be
tough. But it went well.
16/16.
Station 5
A. 34 year old lady presented with fever and weight
loss. I asked for all possible details including exposure
history and travel. Sign i could elicit was only an
anterior cervical chain lymphadenopathy. Asked for
temperature chart.
DD given TB lymphoma leukaemia HIV
Crossing was all about investigation, histological
finding of tb lymphadenitis. Out line of management.
28/28
B. A 58-year-old lady presented with bluish
discoloration of fingers and shortness of breath. It
was a case of systemic sclerosis with ILD.
Asked about investigation and management.
So its quite possible to obtain full marks in all the
stations. Just you need to be well rehearsed and little
bit of good luck to get good cases and cordial
examiners.
EXAM Malta today

11DECEMBER 2016
St1
(respiratory OLD with pulmonary fibrosis
Abd transplant kidney
St2
St3
AS cardio
Neuro cerebellar SYND
ST4
ST 5
surgery 6 wks ago
anaemia)
Oman 10/4 cycle 1

Station 3 :
Cardio MVR
CNS CMT
Station 4 :
New diagnosis of SLE
proteinuria 4 g/ L haematouria
Discuss the diagnosis and renal biopsy
Station5 1:
Diarrhea nail lesion skin rash joint pain in hands
? Psoriatic arthropathy
2: dysphagia thyroid nodule
euthyroid, no retrosternal extension
At the end the examiner asked would you expect a
small goitre to cause dysphgia😰
Station 1: chest lt side bronchiactasis
Abd: ill pt 2 paramedian scars multple other scars😱
Rt iliac fossa mass i gave differential diagnosis
transplanted kidney? Appendicular mass? Chrons?
Caecal mass? Discussion was about transplanted
kidney
Station 2: pt 29 male hx of asthma and type2 DM CO:
recurrent chest infection
In hx: cough productive of large amount sputum..
bulky difficult to flush motions.. DM on insuline.. hx
of infertility.. I gave diagnosis of CF what other
possible causes
PACES EXAM MALTA

11 DECEMBER 2016
St 3
Cardio = MIXED (AS & MR)
Neuro PARKINSON dis
St2
SOB (COPD)
St 1
Abd ,,, ABDOMINAL MASS
Chest pneumonectomy
St5
(night sweat )
St 4
Thanks for this group for much support. My exam

second day first round in Mandalay centre (
15.11.16).
Station 2
Analgesic induced headache with underlying
migraine
CVS- ESM at apex with radiation to mid axilla &
ESM at aortic area with no radiation no AF No
HEart failure no IE- I give MR . Other candidate give
MR too. DX- MR
CNS- prompt- examine cranial nerve- right 12 CN
palsy with hard voice with salivation & right hand
small muscle wasting with claw hand
Only have time for finger adduction& fromen sign.
No time for motor& sensory& jerk
Examiner ask me what do you want to do if I have
time ? Said sensory& cerebellar & motor.
Common cause in her middle age - MS,
syringomyelia, pseudo bulbar DX- Syringobulbia :)
St4- Steven Johnson due to penicillins during birth
Abd- ascites with no organomegaly- COL with portal
hypertension
Respi- Rt lower lobe consolidation
St 5- 1)Acromegaly
2) fatigue all the time with RA deformed hand in
middle age female with bilateral ptosis with I think
pallor
I rule out MG with evening worse fatigue ,
hypothyroid , Addison,
Drug history- NSAID according to doc three times
per day with increasing pain in her hand
Can't find anything- give DX as analgesic induce
blood loss
Anaemia due to chronic diseases
I passed
MALTA paces exam

December 2016
ST 5
1= fresh bloody diarrhea==crohn dis
2=HEADACH==may be migrain or medication
overuse
Station 1
Respiratory = Interstitial lung dis
ST 2
History = poor control ABP
important to say in ttt AMPULATORY &HOME BP
monitoring
ST 3
Cardio=Mitral reg
CNS = Examin the EYE????!!!
ST 4
communication ==Angry son refusing Discharge of
his mum from hospital
MALTA
DECEMBER 2016
St5
(night sweat )
St2
sob (copd)
St 3
Ms with Af
Neuro Essential tremer
St 1
Abd hernia
Chest pneumonectomy
St 4
EXAM Malta today
2nd carousel
11DECEMBER 2016
St1
respiratory Pnumonectomy
Abd Abd mass
St2
St3
cardio VSD
Neuro spastic paraparesis with no sensory level
ST4
ST 5
surgery 6 wks ago
anaemia)
2016/3
17/11/2016 Chennai (Sundaram Medical Foundation
Hospital)
Station 3
CVS MVR
20/20
CNS Examine cranial nerve: Bell palsy
18/20
(I cannot answer when examiner asks me why there is
loss of nasolabial fold on the contralateral side and
role of nerve conduction study for 7th nerve palsy)
Station 4, End stage COPD lady, Admitted for Type 2
respiratory Failure, not responsive to non-invasive
ventilation and getting deteriorating. pt has her own
nebulizer and oxygen cylinder at home. Patient is
keen for self discharge (mentally competent) Task is
to speak to the son and explain about self discharge.
It is like breaking bad news. I did badly and I thought
I will fail this station as I have left nearly 5 minutes
by the time I finished all the tasks and solved his
concerns : (
13/16
Station 5
BCC 1 65 yr old lady with knee pain > 6 months
Dx: likely OA
28/28
BCC2 30 yr old man, present with fever ,cough X 1
month (pt give history of night sweats, poor appetite,
weight loss, hemotypsis, but no exposure to TB, no
risks of contracting HIV ) Examination findings
seems to be normal.
DDx TB, Ca Lungs, Lymphoma
26/28
Resp
I did badly in this station because of limited time,
Unfortunately, I started examination at the front
which I found nothing abnormal, except reduced
cricosternal distance and barrel shaped chest wall
which is not quite obvious..There was no clubbing/no
cyanosis on general inspection.
When I started to check the patient's back, only 1
minute left, so, I listened only his back which I heard
crep on the right lung base.
But examiner asked me whether crep is unilateral or
bilateral.So seem like bilateral.
17/20
Abdomen
This is my worst station.
Young Lady with functioning AVF (but not recently
used) , no features of chronic liver disease.
I found only very small splenomegaly which I am not
quite confident to tell the examiners.
Examiners lead me questions about Chronic Liver
Disease.
13/20
Station 2
30 year old lady, mild anaemia (normochronic
normocytic anaemia), BP 140/80, present with
Fatigue
Dx: SLE with Antiphospholipid antibody syndrome.
main concerns: pregnancy
20/20
Total 155/172 and I passed PACES finally!
Thanks to my parents, my teachers, friends and
colleagues, especially my husband who helped me
intensively before my exam. Without his support and
encouragement, I won't be able to pass this exam.
Thank you everyone!
My exam was at chennai Sundaram medical
foundation on 18.12. 2016
Thanks all in this group. I got much help from you
all.
Started with st 2: young unmarried lady complaining
Transient Left arm weakness.....taking OCP....dx was
Hemiplegic migraine....dd was TIA. got 18/20
Then st 3: cvs case was AVR with CABG....discussion
was about causes of
AVR....inv.....treatment....warfarin.....INR...IE
prophylaxis....got 20/20
Neuro case was Stroke....findings were not so typical.
But old stroke may give such findings. So pls examine
stroke pt as many as possible. got 20/20.
st 4: ADPKD, concern was about perinatal
testing....family screening...surrogate was happy but
indian examiner was so tough.....asked so many
questions. got 10/16
St 5: 1. Neck lump....euthyroid....concern was about
surgery....discussion was about dd....indication of
surgery....got 28/28
St 5: 2. Chronic diarrhoea....strong family history of
CRC....RIF tenderness on examination....dd were
Chron's disease.....CRC.....discussion was about
investigations....got 27/28
St 1: Abdomen case was PKD. Discussion was about
associations.....mx. got 20/20
Resp case was COPD, bronchiectasis....discussion was
about treatment of COPD and complications of
bronchiectasis....got 20/20
Total score 163. Passed. Thank you all again. May
Allah bless us all.
Exam experience in Chennai

Nov 16--2016
St 1.
- Resp. Middle aged lady with COPD and
fibrocavitatory lesion.
Qs: causes of COPD, what are the possible cause of
the lesion (old TB, ABPS), what investigations to do
and how would you manage. When I was presenting
my findings I got confused and forgot to mention the
bronchial breathing and VR over the cavitatory
lesion. 15/20
- Abdomen. Young male with functioning AV fistula
and HSP, no signs of CLD. I wasn't sure exactly how
to link all findings together when asked. I suggested
2ry amyloidosis or CTD leading to ESRD. Also asked
what investigations would u do for him. 19/20
St 2.
Young male known to have asthma with worsening
symptoms over 4 months. The key point in history
was a new pet cat he purchased 3 months ago. His
concern was losing his job because of recurrent
absence.
Examiner asked me about differential diagnosis, tests
to be done. I said skin allergen test then he asked
about the latest test -> RAST. he asked about the
method of RAST test which I didn't know then he
went on to ask about the difference between atopy
and anaphylaxis but thankfully time was up. 19/20
St 3.
Neuro. Young lady with cerebellar syndrome and pes
cavus.
Qs: what is pes cavus associated with? Differential
diagnosis for this case (FA, MS, vascular, tumor)
What sensory findings to expect if she had friedrich's
ataxia -> peripheral neuropathy. What
Investigations? 20/20
Cardio. Confusing case. Lady with midsternotomy
scar, palpable S2, LPH. I couldn't hear any prosthetic
valve clicks or murmurs. S2 was split. I gave
differentail diagnosis of ASD with previous corrective
surgery or pulmonic valve disease and pulmonary
HTN. Examiner asked about investigations only. And
surprisingly I got 20/20
St 4.
25 yr old lady with diabetes was admitted to the
hospital with pneumonia and while she was admitted
ahe received the wrong type of insulin when
compared to her GP notes and developed only 1
episode of mild hypoglycemia. Task was to explain
the error to a "somewhat" angry patient.
Concern was having another hypoglycemic attacks at
home. Examiner asked who was responsible for the
error I said it was a medical team responsibility as
there are multiple factors leading to it. While the
doctor was overwhelmed in the emergency room his
senior or the nurse could have contacted the GP for
the medication list. Examiner seemed happy with that
response and asked what could have been done to
avoid it. I suggested a double signature system for
medications and a pharmacy policy to review GP
records of long term medications before prescribing.
16/16
St 5.
Case 1. Middle aged female with worsening exertional
dyspnea and ankle swelling. From history she said she
was hypertensive for 2 years but didn't take any
medications for it. On examination she had an
inframammary scar, raised jvp and bibasal crackles
as well as lower limb edema up to the knees. I
couldn't hear any murmur probably because she was
a little obese and I was rushing to address the
concerns. I said the pt was in heart failure, the scar
suggests mitral valve disease that was repaired and
probably recured. The other possibility is untreated
HTN. Examiner asked about management of heart
failure and hypertension. 23/28
Case 2. 30 yr old male with uncontrolled high BP
170/100.
History was only positive for similar problem in his
father who had high BP and developed an
intracranial hemorrhage. Examination was negative
but I forgot to check for radiofemoral delay so of
course the examiner asked about coarctation of the
aorta, what were the other diffentials (APKD,
phaeochromocytoma) and if I would admit him. 24/28
Overall it was a tough exam but I passed with the
praise of Allah
UK
Station 2
54 male with back pain for 5 months . X-ray collapse
of t6 to t10 due to osteoporosis.
Granny had concern was osteoporosis at 60 yrs of age
and became wheelchair bound.
History of diarrhea on taking systemic review.
D/d
MalAbsorption syndrome ,celiac,
Viva
What other dd. How would you manage osteoporosis.
what tests ?
How you will manage Pt concern.?
Investigations, work up. Management.
Dexa scan . Bisphosphonates.
Side effects of bisphos
What would you do before start of bisphosphonates?
Dental fitness.
Station4.
90 female present to ed with sob. Hb 6 . Was
transfused. But denied any further work Up for Ida.
Had capacity at that time. Now 3 days later present
with and wall mi. Decided for ward level
Bbn
Explain further palliative approach
Concern : pts daughter wanted to speed up the
process. I said that there is no way that we could
speedup the natural process,but what we can do is to
make it as comfortable and painless as we could
# daughter was concerned that how would you know
that she is comfortable: bp and pulse would tell us
that.
Viva :
#summarize your encounter
# what could be the causes of unconscious Ness in this
Pt?
Cns event/anoxic brain injury or drugs morphine for
pain relief in this case.
# do you agree with the team's decision.if yes explain
why
She is 90 and had IDA but didn't want further work
up done . Pts had capacity at that time. Thus
respecting pts autonomy .
Other point is more risk of complications during
angioplasty the not beneficial for Pt.
Examiners:A little bit about euthanasia. But illegal in
UK.
#pts wished to die at home. How would you facilitate
that?
BCC 1 :
68 male with diplopia.
Inside was graves opthalmopathy.was on carbimazole
with levothyroxine
Viva :
Your dd
What else you want to look for.
Pts was on stop and replace treatment, why this
choice.
Pts was on rivaroxaban .? Why
BCC 2 :
25 male with weight loss and inc sweating.
Thyroid normal.
Bp 158/90
On lisinopril
No positive s/s
No positive history.
Except for off headaches
Dd.
Lymphoma
Pheochromocytoma
Men
Viva :
Positive findings
Dd: investigation
Manage htn
I made dd of lymphoma too thus most of the viva
regarding investigation and findings in lymphoma (no
physical findings like lymphedenopathy or
splenomegaly present)
Abdomen: renal transplant due to apckd

Resp:pul fibrosis sec to scleroderma
Cardio: mitral valve replace
Neuro : Spastic paresis
Some had Charcot marie tooth
👆Further advice by candidate who passed 👆bcc 1 :
Block & replace treatment prevents worsening of
graves opthalmopathy. While radio iodine worsens it
👆St :4 - Ida =iron deficiency anaemia. Pt was already
for ward level management. So we would ask
palliative care to see her. There are facilities provided
by palliative team like end of life care at home.
UK
Station1:
Abdomen : renal transplant
Resp : Pulm Fibrosis
Station 2: extrinsic allergic alveolitis
Neuro : spinocerebeller ataxia
Cardio : Mitral regurg
Station 4
Breaking bad news pancreatic ca
Station 5
Fascuscapulohumeral dystrophy
Mixed ctd
Dubai
Abdomen : Renal transplant
Respiratory : Lobectomy
Neuro : Spastic paraparesis for DD
Cardio : Double valve replacement
St 2 : Irritable bowel syndrome with father having
history of bowel cancer ; concern of possibility of
bowel cancer
St 4 : Severe prognosis of guillain barre syndrome.
Speak to the wife
BCC 1 : Anterior neck swelling with weight loss
BCC 2 : Hematuria with hypertension
Sharjah today.
Neuro : fasciso scapulo humeral dystrophh
Cardio : old sick patient who was breathless and not
following commands. infective endocarditis signs witl
lvf .. could not find the murmer
RESP : copd
Abd ( hepatomegally ) .
Station 2 : young male with dm -1 and weigh loss ..
reason was poor compliance with insulin due to
breakup with fiance Communication : BBN of cancer
BCC 1 : toxic nodular goiter
BCC2 :axial plus pain in all large n small joints..
symmetrical ... with no rash from past 5 years ..
morning stiffness with difficulty in writing ( concern
of the patient ) . i gave differential of RA vs
ankylosing sp
Dubai , Diet 1
Station 2 :
A young lady with history of transient loss of
consciousness. Brother has history of epilepsy . It was
Vasovagal syncope . Concern was epilepsy and
driving.
Station 4 :
The daughter whose father was admitted with curb 5,
in that case apology was required as he was the
candidate for hdu from the beginning , that's what
the examiner told me.
The point for coummunication station should be
noted
All candidates including me did it wrong
Though In the communication scenario it was not
given
But on the bases of curb score, examiner mentioned
should be admitted to hdu
So apology was required at beginning
In scenario they wrote no bed was available in
medical ward so pt was admitted in surgical ward.
Examiner said forget abt scenario, tell me with curb 5
he deserved a bed in hdu or not ? The examiner
mentioned that the dr who admitted her did wrong. Y
she was not admitted in hdu at first place
Respiratory :
Lobectomy
Abdomen :
Hepatosplenomegaly
Neurology :
Cerebellar syndrome
Cardiology :
Mitral valve replacement
BCC 1 :
Female with fatigue. Inside proximal muscle
weakness and tenderness. History of overian cancer
BCC 2 :
History of pituitary surgery, now again with
headache
One point I must mention here

Don't go on station 5 scenarios from outside and
make d/ds
Just need to read. Otherwise one become preoccupied
Just go inside and decide there
Cairo
St 1 chest,,
Finding hyperresonant percussion bilterally ,,wheezes
all over trachea is central
Examiner qu
DD
Mangement
St 2
Male pt about 35 yrs of age has bloating losse motion
refered by Gp who thinks about Ibs
Inside:
All symptoms for last 4yrs going with IBS.,exaggerted
recently when his father daignosed byca colon
No wt loss.,,no symptoms of malabsorption...
No hx of recent travelling abroad...
Examiner qu:
DD?
Plan of mangement
St3
Cardio.,.
Young femal
S1 metalic.,
Pr regular
Examiner:
Invs
Mangement
Neurology:
Idid the screening test she can raise her upper limbs
but never move her legs
Iamnot sure about power distrubution because she
was in pain when Iwant to do planter reflex the
examiner ask me donot do beacuse has sole pain 😳
Examiner :
Clincal diagnosis?
planter reflex is very important for me to reach the
diagnosis? He told me is down going‫الحمدهلل‬
What are Dd?
Invs
Mangement
St 4:
Mr x brought from his work with high temp skin rash
Temp 39 GCS 7
Menengiococsemia was confirmed,prepared to be
shifted to ITU
Wife conserns?
Will improve?
Examiner :
husbund death?
recover?
He asked me as if he never hear the conversation
between us
St 5
All vital signs are normal apart of high bp160/100
Inside:
Trunkal obesity
Abd strae thin legs
Other signs with every step the examiner ask me not
to do no need,what you want to see!
BBC2:
Normal vital signs
Inside: fit man with scaly skin rah with mild redness
at his dorsum of both foot..no other area involved
No joint pain no hx of eye redness all hx not sure or
NO
At last minute iasked about the job he is working at
detergent factory snd all these symotoms came after
working at factory and consern about his job because
he has no other job
Examiner :
Pray for me ,,reasonable cases but when will be under
stress even your name diffuclt to memorize it😇
Finding.,
Dignosis
Mangement
Drug hx.,,never used steroid
Exam experience in wishaw general hospital wishaw.

Glasgow centre 2nd November.2016
Unfortunately i failed. Marks obtained 124. I started
from station 5. 1st scenario was of a lady with RA
complaining of recent SOB and family physician did
chest xray which doesnt show any malignancy but
some scarring. She was on methotrexate and she had
pernicious anemia too. I found right sided fine creps
(i guess left sided too) i gave diagnosis of pulm fibrosis
secondary to either RA itself or methotrexate. Q:
D/D. i missed taking h/ o smoking and examiner
asked : did she smoke. I sa.id sorry i didn't ask, then
he asked, in case.of smoking what will be differential.
How will u manage. Marks 23/28.
BCC2: a lady with multiple swellings in neck and
some problem in mouth, dryness.(i couldn't
undesstand well about mouth features, i guess
decaying teeth. No characteristic lesions). She had
almost all neck glands palpable. (Submandibular,
parotid, cervical lymph nodes, some drs noticed
surgical scar below jaw which i didn't notice ). She
didn't have any weight loss etc (i gave d/ d of miculicz
syndrome as she had pernicious anemia also, thinking
autoimmune process and examiner asked.what else, i
said lymphoma, he asked which is most probable, i
said she doesn't have B symptoms :-) he said u didn't
ask about it in history =-O). Which made me nervous
and i couldn't give good management plan :'( marks
18/28.
Station 1: abdominal examination was
hepatospelnomegaly and i guess was simple.he had
tattoos. I didn't find any signs of CLD but now i
doubt that maybe there were spider nevi. :-P what is
dd.how will u investigate.13/20. respiratory was
classic COPD case, went fine. Q: d/ d of wheezy chest.
How will u differentiate asthma.and copd.
Investigation, management plan.20/20.
History: lady with lethargy and fatigue for 3 months.
Gp started citalopram and now referred for
hyponatremia 124, history exploration revealed
weight loss and cough (gp started managing as
asthma.). She also had diverticulosis previously and
family hx of ca colon. Was concerned about that. I
gave d/d of SIADH due to paraneoplastic syndrome,
citalopram induced hyponatremia. How will u
investigate. i did not managee concerns well. I didnt
tell her that it can be ca lung.marks 13/20.
Neuro : lady with.clumsiness, examine upper limb. I
found pill rolling tremor (in happiness i missed exam
routine for which they categorically asked.. what
about reflexes...proprioception, which i missed
examining. Key is to do full scheme of examination ).
Viva: d/d. How will u differentiate PD from
parkinson plus (and asked whether u looked for any
signs, which i missed checking ). 16/20.
CVS: man with midline sternotomy scar, has sob ( i
didn't concentrate on command so missed important
d/d), i gave diagnosis of tissue valve replacement as no
metallic click or vein harvesting scar. They asked why
he has sob. and i became confused that only then i
noticed that scenario was for sob. Anyhow i managed
to answer a bit but as sob was not in my mind so
cpuldnt notice valve functioning etc. People say he
had aortic stensoaia murmur which i didn't
appreciate. 9/20.
Station 4: counsel.angry son of patient. Patient had
femur fracture and she shifted to rehab where she
was started on steroids as doctor on duty suspected
giant cell arrteritis when lady complained of
headaches. After steroids she developed psychosis and
MDT thought that she should be shifted to hospital.
Son was next of.kin and was angry why she was
shifted without informing him and why dr gave
steroids and wanted to complain. Asked about further
management and issues. I guess i did well in it. Viva :
how did this meeting went, (plz notice that for station
4 usually examiner ask this question that how did this
neeting went). Asked about ethical issues and what
ethical issues u know. Asked me in real life if u
encounter an issue like this how u will manage. also
asked whether i missed some issues or not. 16/16. Key
points : dont miss exam.routine. plz follow full
scheme of examination. read scenarios and
instructions well. 5 Minutes be
MALTA paces exam

December 2016
ST 5
1=ASTHMA with pregnant afraid from steroids
2=TREMORS
Station 1
Respiratory = pneumonectomy
chest scar
ST 2
History = Diarrhea=IBS
But his father &grand father develop CANCER
COLON at age more than 60 y & uncle at age 39
discussion about COLONOSCOPY
ST 3
Cardio=Mitral reg+AORTIC STENOSIS
butgood volume pulse
CNS = spastic paraparesis +normal sensation
ST 4
communication =cancer pancrease = BBN
Khartoum paces exam

December 2016
Station4
lady with femur fracture operated and refered to
rehabilitation program and developed headache the
doctor gave her steroid as he is suspecting gaint cell
arteritis then she developed steroid induced psycosis ,
her son is angery talk to him and address his
concerns.
Station 2
young man with DM 1 for 18 years all diabetic
complication presented with recurrent attacks of
collapse
: Station 3 cvs
mid sternotomy scar in old lady with anaemia and
s.o.b ??
: Neurolog
young lady with inability to walk flaccid paraperesis
with distal wasting and peripheral neuorapathy
: Station 1 abdomen
ascites with peritoneal dialysis catheter D/D for
ascites
: Respiratory
lower lobe fibrosis in patient with scleroderma
: Station 5
old man with RA on methotrexate and NSAIDS
presented with S.O.B chest exam crackles all over the
chest
: The other one is lady who is having swelling and
pain of the hand and change in the apearance
PACES Exam in Khartoum 5th December

2016
Day 3
Cycle 3
ST1
Chest
Bronchiectasis
Abdomen
Cirrhosis with splenomegaly
ST2
Facial and tongue swelling and history of recurrent
abdominal pain. The patient is 28years old adopted
lady
ST3
Cvs
Young man with AR&MR WITH LUNG congestion
CNS
upper limb examination
Motor neuropathy (wasting. Hypotonia.
Hyporeflexia. Intact sensation. Inability to do
coordination )
ST4
Hodgkin lymphoma stage IIA
For Hickman line and chemotherapy
ST5
BCC1
JOINT pain with hoarseness of voice and muscle
cramp for 3 month. With history of thyroidectomy
The patient has obvious stridor
Discussion about causes and investigation
BCC2
Young lady with dysphagia for solid for 3 month in
patients with scleroderma
Discussion about differential and mangement
Khartoum paces exam

December 2016
ST 5
Foot drop On anti TB
Peripheral neuropthy
dizziness e blurr of vision
Inside she has has vomiting for 3wks
Time went she has missed cycle
Something to do with BIH exacerbated with the
pregnancy
Station 1
Respiratory Copd
Abd splenectomy&Pallor
Discussion was on the splenectomy
ST 2
History son of a father recently had been diagnosed e
can colon
Son is stressed had abd pain and erratic bowel habits
ST 3
Cardiovascular aortic valve replacement
CNS HSMn
ST 4
communication Steven johnson syndrome in a lad
Who delivered recently
This is the ( Amulet luck) of this Diet ::
St 4
Breaking Bad News to husband Whose wife received
inj penicillin for strep,,then allergy + organ failure
Bruni December 2016

my experience 3rd cycle brunei:
history : collapse , mostly cardiac.
communication : breaking bad news polycystic
kidnay for renal dialysis.
cardiac : double vavle replacement.
respiratory: ILD but the examiner ask what the
cause? patient has ammutputed leg and 3 digit in
both side , no idea
abdomin: poly cystic kidney, flank mass with
fuctional AV fitula.
neuro: really bad , no idea , one leg there some
weakness , almost not detectable with exaggerated
knee reflex but absent ankle jerk , sensation intact...
station 5
bbc 1: hx of short period of vertiogo , nothing else ,
now he is free, asked for d(we meet the guy outside
and he said i have nothing...😡)
bbc 2 : skin rash , SLE but i thinks there levido
Reticularis ?
dont know
(even collage said its diffcult 2 station
PLEASE DOAA FOR us
My examination today cycle one

Khartoum paces exam
December 2016
: Started with
station 3 young man with ejection systolic murmur
over left 2nd intercostal space? ? Pulmonary stenosis
I think it was correct..
: Neuro young lady with cerebellar poserior colum
pyramidal wasting small hand muscles for
differential. .time was critical. .my advice don't waste
time seconds is important
: Communication...the girl with functional
disorder...normal ct mri brain
: Station 5 diarrhea end up with ibs concern is it
cancer
: Bcc2 came for knee surgery..the rest u need to get it
from history constipation weight gain...thyroid
surgery..hypothyroidism
: Abdominal distension pallor ascites. .abdominal tb
according to discussion
: Chest..lung fibrosis. ..obvious is packed nose...skin
tightness...systemic sclerosis
: History ankle swelling sob history oh
mi...proteinuria 3 cross..end up with ibuprofen
induced nepropathy so mi ia distraction..
PACES exam experience

Exam Alain center=Emirates
05/12/2016
St 1
Resp: CFA
Abd- splenomeg with lethargy for differentials
St 2 -HISTORY- pt has hyponatremia --- hx
St 3- cardio- metallic
Neuro- rt hemiparesis... Assess motor
St 5- skin lesion? Pemphigus vulgaris?
Rt leg swelling, on anticoag- oral...regular/ what can
the swelling be
St 4
Breaking news to husband that wife who received inj
penicillin for strep inf.
Upon labour, has gone into anaphylaxis/ multi organ
failure...
May die
My experience in MRCPI DUHBAI SEPT.

2 long cases
crohns with colostomy.
steroid induced proximal myopathy.
received infliximab. Tuberculin was positive. received
anti T.B. for sometimes. very complicated case.
discussion almost every thing about crohns and S.E.
of alot of drugs as azathiopurine. infliximab. ....
anklyosing spondyl. complicated with uveitis.
discussion about complications and new drugs
short cases.
1. it was the 1st station for me europian pt. with renal
transplant and hearing aids. horrible examiner bad
presenation and discussion
2 young lady with unilateral exophthalmus. and led
lag. couldnot appreciate goitre . I told graves with
other DD discussion management of graves and DD
3 young lady with clubbing has early rheumatoid
hands with boutonniere in 3 fingers. rt interscapular
fine crackes with bronchial breathing.
I told fibrosis with cavity. some told bronchiecatasis?
4 Examine cranial nerves RT LMN facial. discussion
causes of bells treatment. causes of bil facial palsy.
5 communication. angry lady her father on warfarin .
admitted with UTI I prescribed ciprofloxacin. inr
became 8 bleeding.
she was crying all the time.
Alhamdullelah pass
I was waiting for feedback for more benifit, but
unfortunately it seems they are not sending to any
body.
I would like to thank my dear teacher Dr.Maher who
taught me a lot. his amazing way of teaching. always
encouraging me . before,
during and after the course. we cannot reward you sir
whatever we said. Allah only may rewards you.
I will never forget both Khalids, always beside us.
watching us during practice. if any mistake done by
any candidate, will not pass easily, they catch it and
correct it in a fantastaic way.
I will not forget Dr. Abdulfattah . it was a very nice
preparation with him.
Gazakom Allah Khair to evey body help me and
others by any mean of help.
May Allah bless all of them
Khartoum paces exam

History
Facial and tongue swelling
(Hereditary angioedema)
ST4
Hodgkin lymphoma llA
For Hickman line
And chemotherapy
this is ONLY
as came from the source
Khartoum paces exam

December 2016
St5
1.pt persented e headach and plurring of vision
.htn..pitiutary adenoma
2.young male e jundice and fatigue..gilbert and
differntial
: St1
heptomegally ..liver cyst ..discusion of causes
hepatomegaly
chest..lung fibrosis e lopectomy
St3
AVR
Pseudopulpar palsy,, examin cranial nerve
: St2
b blocker induce asthma
Pt had hay fever
: St 4
COPD discussion management plan
passed the exam in yangon ,myanmar

station 1) resp ---- (?effusion )
but i mentioned collapse with effusion
discussion on ddx ,inx ,mx
I ONLY GOT 12 /20
abd ..thalassaemia ..19/20
station 2----lithium toxicity
i forget to explore frequency ,character of motion
i forget his definite past history
discussion ..dx ,ddx ,interpretation of biodata
i got 17/20
station 3= cvs .AS+AR...20/20
Cns...flaccid paralysis
i forget to test about joint position sense ..16/20
station 4...Lymphpma with hickman line
14/16
bcc1 --gout --25/28
bcc 2 --cushing disease --18/28
really thanks to PEC groups for sharing experiences
passed the PACES in 3/2016 diet New Yangon

General Hospital, 2nd day, 3rd Round.
This is my 2nd attempt!
I like to share my exam experience.
I start with Station 3
Neuro.. simply Parkison d/s I got 20/20
CVS.. i didn't do well.. I heard PSM n midline
thoracotomy scar but i can't hear metallic click n
forgot to check venous graft scar at legs. I give the
differential for PSM n i only got 14/20.
station 4 is yg lady with SAH n CT normal, came
from Australia planned to go back. I hv to tell the Dx
n need of LP. Examiner ask about Autonomy. I got
16/16.
Station5>>> BCC 1 Psoariasis.. examiner asks for
differential n i was thought-block. so i got only 23/28
BCC 2 >>> DM retinopathy with other DM
complication and Hypertension. Fundoscopy is my
weakest skill n i was shaking :P Examiner asked me is
there any hypertensive retinopathy and the bell rang
when i was answering. I got only 21/28 😭
Station1
Abdomen is moderate splenomegaly with jaundice.no
chronic liver insuff: signs. I m not sure about
hepatomegaly so i told the examiners honestly and i
want to confirm with USG. I give the Dx as
Thalessemia n other hemolytic anaemias. I got 20/20.
Respi is RUL lobectomy wih Rt thoracotomy scar n
Rt pleural effusion. I got 20/20.
station 2 is h/o collapse .. middle age lady with Poorly
controlled DM with autonomic neuropathy n
Hypertension taking OHA and diuretics and ACEi.
she is not aware of hypoglycemia. I give the Dx as
autonomic neuropathy with hypoglycemia and 2nd
differential is Postural hypotension due to drugs. I got
19/20.
Total 153 and i passed although i was not doing well
during exam. Only bcoz of hard praying n strong
belief in GOD!! 😁😁
Sri lanka =26 November 2016
St5
TIA
HAEMOPTYSIS
St1
Abdom hepatosplenomegally=haemolytic
anaemia
Reapir pleural effusion
St3
SPASTIC PARAPARISIS without sensory level
Mitral regurg
St 4
DM WITH HYPOGLYCEMIC ATTACK
St2
SLE
i passed the exam in yangon ,myanmar
station 1) resp ---- (?effusion )
but i mentioned collapse with effusion
discussion on ddx ,inx ,mx
I ONLY GOT 12 /20
abd ..thalassaemia ..19/20
station 2----lithium toxicity
i forget to explore frequency ,character of
motion
i forget his definite past history
discussion ..dx ,ddx ,interpretation of biodata
i got 17/20
station 3= cvs .AS+AR...20/20
Cns...flaccid paralysis
i forget to test about joint position sense ..16/20
station 4...Lymphpma with hickman line
14/16
bcc1 --gout --25/28
bcc 2 --cushing disease --18/28
really thanks to PEC groups for sharing
experiences
Alhamdulillah, I passed my exam in Golden

Jubilee National Hospital, Glasgow on 18th
November 2016.
Station 2: Painful right knee in a patient with
ESRF on regular HD, AF on warfarin.
Cardio: MR in AF with CABG scar.
Neuro: UMN signs in bilateral lower limb- MS
Station 4: Breaking bad news- multiple
sclerosis.
BCC1: multiple joint pain- osteoarthritis
BCC2: light headedness and sob in a 52 year
old man with history of UGIB. On examination
he has MR (likely MVP) in AF.
Respi: left Lung transplant, right lung fibrosis,
underlying psoriasis.
Abdomen: Tinge of jaundice in middle age man.
otherwise no other signs. Diagnosis: likely
autoimmune chronic liver disease
My exam experience at the Golden Jubilee

Hospital, Glasgow on 17/11/16
Abdominal - renal transplant functioning well
with old capd scars. No fistula,no neck catheter
scars. Questions on management,
immunosuppression 20/20
Respi - right lower lobe lobectomy, as trachea
central and apex not displaced. Questions on
causes, and then went on to sx ix and mx of PE
20/20
History - stem: collapse. Patient had focal
seizure with generalization, hx of breast ca on
anastrozole, no other sx. Questions on ddx,
immediate ix and mx. dx: seizure sec possible
brain mets
20/20
CVs: irregularly irregular pulse, otherwise all
normal. Mistakenly said loud S1 thinking it's MS
but examiners not happy. In the end questions
all about AF only, who needs warfarin, what new
drugs for anticoagulation, mx in emergency.
11/20
Neuro : complain of double vision, eyes all
normal (no overt ophthalmoplegia)except
worsening diplopia on sustained uPgaze and
also involving UL. has midline sternotomy scar.
Dx is MG. Questions about pathophysiology,
other ddx (lems, other myopathies) ix of choice
and mx. Was also asked about congenial MG
but said I don't know. 20/20 :p
Comms: break bad news: skin mole turned out
to be stage 1 malignant melanoma. Surrogate
was concerned her fruqent tanning caused it.
15/16
Bcc1: c/o bl LL skin itchiness and rash. On
examination looks like diabetic dermopathy, ddx
is venous insufficiency. Examiners asked about
dm, ddx, mx 27/28
Bcc 2: this one weird: stem was headache and
bp 140/90. On hx headache wakes him at night,
morning, had some accident. On examination of
eyes no visual field defect. Funduscope shows
‫‪grade 2 htn retinopahty, didn't see‬‬
‫‪papilloedema. Presented findings but not sure,‬‬
‫‪ddx was intracranial lesion. Ix CT scan no time‬‬
‫‪to discuss other. Examiners not too happy 16/28‬‬
‫‪Praise God is passed‬‬
‫الحمد هلل حمدا كثيرا طيبا مباركا فيه كما ينبغي‬

‫لجالل وجهه وعظيم سلطانه‪.‬‬
‫بفضل هللا وكرمه ونعمته حصلت على عضوية‬
‫الكلية الملكية البريطانية ألطباء الباطنية بعد‬
‫مجهود وتعب وإصرار ومساعدة أناس أوفياء‬
‫مخلصين من أصدقاء وأساتذة رائعين مميزين‪..‬‬
‫وواجب علي أن أقدم جزيل الشكر والعرفان لكل‬
‫من أسرتي وكل من أصدقائي (د‪.‬إسالم عشري‬
‫ود‪.‬سامح ود‪.‬وائل وحوش الجهاز الهضمي‬
‫😊ود‪.‬لميس الرائعة‪ ،‬وأساتذتي د‪.‬مجدي‬
‫وعبدالفتاح ود‪.‬ياسر ود‪.‬محمود منتصر الذين بدأت‬
‫مشواري معهم‪.‬‬
‫وأجد أنه البد هنا أن اقف احتراما وإجالال وتحية‬
‫للمعلم الرائع واألخ الفاضل واإلنسان الخلوق‬
‫المميز‬
‫(د‪.‬أحمد ماهر عليوة )‪Ahmed Maher Eliwaa‬الذي‬
‫لواله لما تمكنت من الوصول لهذا اإلنجاز والذي‬
‫أدين له بالفضل لكل توجيهاته وتعليماته التي‬
‫قادتني بفضل هللا لهذا النجاح‪ ،‬وإني ألجد نفسي‬
‫من المحظوظين ألكون أحد تالميذه الذين وجههم‬
‫بأسلوبه المبسط والسلس والمميز واألهم من ذلك‬
‫إخالصه في توصيل المعلومة المطلوبة لإلمتحان‪،‬‬
‫وإنها لشهادة نجاح أخرى أعتز بها في حياتي أني‬
‫تعرفت عليه وتعاملت معه وكان هو من مفاتيح‬
.‫نجاحي في هذه الخطوة المهمة والحمد هلل‬
..‫فشكرا لك يامعلمي وشكرا لكل من ساعدني ولو‬
. 👍 😊 🌷‫بكلمه‬
My exam experience ,perth Royal infirmary,

UK,9/11/2016
I didn't take any courses in UK bcs my Visa
valid only after 31 /10 and no courses available
in UK after October.i depended on Dr Ahmed
Maher course only (I attended 3 courses with
him ) .this is my 1st attempt
I would like to thank my dear prof dr Ahmed
Maher Eliwa for his great efforts with me
‫الخطيب‬,dr Hady Gad,Dr Marwah Yehia,dr
,Dr Khaled Magdy,special thanks to my study
partner dr Mohamed El Aghory ☺
Station 3
C.V.S
68 yrs old male with SOB by examination
Pulse irregular ,ejection systolic murmur at
aortic area
Disscussion ,what is your positive finding ,why
not aortic sclerosis, indication of replacement
I GOT 15
C.N.S ,,,examine his eyes
50 yrs old male wheelchair with nystagmus on lt
eye and faliure of adduction in rt eye ,INO it was
surprise ,I STOPPED 😂
Examiner asked me to examine cranial nerves
,there was 7th cranial UMNL
Disscussion, what is ur positive findings ,what
is your DD ,Treatment of MS
I GOT 17
Station 4
25 yrs old female 😂 😂US showed multiple
cysts in kidney and his father on dialysis due to
ADPKD
many concerns ,will be on dialysis like my
father ?I love my boyfriend and we prepare for
marriage can I tell him ?what about my kids ?
I GOT 8
Station 5
BCC1
82 yrs old female with fullness in her neck ,I
forgot to wash my hands and patient asked me
plz Dr wash your hand 😧
it was thyroid case since 10 yrs but recently the
swelling enlarged
No sign of thyrotoxicosis or malignancy but
there was slight change in her voice
Here concern ,what is the cause and what will
you do for me?
Examiner asked me the same Qs
I GOT 21
BCC 2
80 yrs old female with blurring of vision there
was Bitemporal hemianopia since 3 weeks ,I
asked for fundus examination he dimmed the
lights then he told me no need 😂
Concern ,what is the cause ,does my vision will
be normal ?
Examiners Qs ,what is ur dx ,what is the causes
?
I GOT 23
Station 1
Respiratory
45 yrs old female with lateral thoracotomy scar
,PNEUMONECTOMY
examiner Qs what is cause of pneumonectomy
in this patient ,deff bet lobectomy and
pneumonectomy
I GOT 19
ABDOMEN
renal transplant (functioning)with rt iliac fossa
scar ,rt subclavian scar and hepatomegaly
Examiners Qs what is your positive finding
,what is the cause of renal transplant in this
patient ,why liver enlarged
I GOT 20
STATION 2
30 yrs old female 😂with abnormal liver
function (elevated ALP ,GGT) and fatigue
My dx was primery biliary cirrhosis
Concern .what is the cause ,what is my
treatment, the cause of tiredness is my thyroid
illness or my liver problem?
Examiner was young British lady with blue eyes
and blond hair like the serrogate 😁 😂 😁so
how can I concentrate !!!!!
I GOT 11
Total score 134
‫الحمد والمنه هلل وحده‬
UK exam experience
November 2016
Hx : Abd pain and vomiting
Paracetamol overdose
Concerns :is it going to damage my liver ?
Has exams coming
Problem with boy friend :impulsive not suicidal
now ,regretting it.
Q: diagnosis /differential
Why did u ask about urinary symptoms?
Gyne questions very important to exclude
ectopic .
How are u going to manage ?
If she wants to leave what r u going to do ?
Psych review for capacity.
Important to ask about suicidal risk /support at
home or at university.
Time off and letter to university(she has exams)
Communication: Lady in her 50s with ESRF
High urea /creatinine more than 400 .uss
:bilateral small kidneys .
Had check up with insurance company 8 years
ago and BP was 140s/90 (high any way)
+blood + protein
Task :BBN and need for medical treatment and
dialysis in the future .
I think also to mention about link between
previous urine dip and this result (can not
remember wording exactly -but 2 tasks )
Concerns :job -accountant ,single and has one
daughter .
What is going to happen .
Angry as insurance company should have
warned her and told her to go to see GP before
is too late .
Questions:
Examiners said do you think I addressed her
concerns ?
What is best option for her ?PD/transplant as
young and active .
FH is it relevant here and why
1/47 y o lady with chest pain ,you are doctor in
emergency department .
classical angina Hx
Central ,worse with excercise ,lasts few minutes
and then stops .Husband brought her as
becoming more often .no obvious risk factors
,does not smoke ,no BP ,DM ,high cholesterol
.FH of IHD ,gi bleed
Concerns:is it heart attack ?what is it?
Normal cvs ,BP 135/80(not sure but was ok
),pulse :normal
When examining her back ,I saw the thick skin
(pseudoxanthoma elasticum ).
I asked of what is this ?(don't be afraid of
asking they will tell u or give you hints if
relevant or not ).
She said Oh I don't know ,someone mentioned it
recently but I don't know what was it .so I knew
it is relevant .
(If not relevant then she would tell u don't worry
about it or old injury or what ever.They don't
hide things from u )
I tried to exclude Elgar danlos by asking her to
try to pinch her skin and lift it up ,but it was
negative .
I explained to lady stable angina needs further
testing ,bloods,ecg,echo .
To be honest I was not sure if Pseudoxanthoma
or not .
So presented as angina possibly
Due to CT disorder as she has FH of GI bleed
and they can have GI perforation and aortic
dissection .
Examiner : what are the risk factors for IHD .
What are the names of CT disease you know
that can cause chest pain ?
Other differential for chest pain ?
Other case was :Neck lump and tiredness .
Hx of tiredness for 3 months ,lump 2/52,no
thyroid symptoms
No B sym /wt loss / night sweats
/no cough no other symptoms,
Pmh had tonsillectomy ,no medication
Concerns :back from Egypt 3 weeks ago ,is it
related ?is it thyroid
Had multiple LN :submandibular ,cervical
,Axillary
Did not do organomegally
Thyroid not palpable .not mobile when drinking .
Explained unlikely from his travel to Egypt
because sym started after his tiredness .
Needs to be seen by blood specialist to do
some bloods and sample from the glands.
Is it cancer ?possible blood cancer but needs
further tests .
We also need to exclude infections .we will do
tests and discuss with specialist .
I think I said admission
Examiners :what do U think ?
Differential
Investigation
Management
Other types of leukaemia you know
What infection can cause lymph node in 2
weeks ?
I said tiredness was for months so not Acute
,but infections like HIV/TB
(Long list but these what I remembered )
hydroxychloroquine
psychosis
St2 epilepsy
Maadi hospital exam in 12 Oct 2016 laste

carousel
1- abdomen :HSM +Pallor+left sub mandibular
LN +left axilla scare
Mostly lympho proliferative disease
Q about diagnosis ,DD,causes of generalised LN
viral EBV,.HIV,TB,SARCOIDOSIS plus
myeloproliferative
2_chest:
Left upper lobectomy +trachea shifted to left
+course crackles on bases mostly
bronchiectasis
Q about causes of lobectomy
Investigation when I mention CXR asked what
you will see I replay after hesitation tram lines
,then in CT signet ring appearance
Then asked about treatment
Station 2-asthmatic worsening symptoms in
young guy I explored pet animal at home
+taking propranolol from wife medicine
.concern about causes of deterioration. I ask
him to stop taking propranolol and forget to tell
keep away from the pet animal.examiner asked
why not tell him to keep away from that pet
animal I reply I was planning to ask him but
forget .
Then Q about Causes ,investigation
steps of BA ttt
3- cvs left infra mammary scare +AF+MS so
mitral restenosis post valvotomy with pul HTN
Q investigation and ttt
-Cns examin motor system in patient with
walking aid co difficult walking
He had left hemiparesis+left UMN facial palsy
(should examin LL +UL+motor CN )
Q investigation and ttt
Station 4-young visitor lady from USA with
cruciating occipital headache with
vomiting 1st CT normal ,planned for lumbar
punture but she want to go DAMA to fly back to
USA
I start as usual ,exploring her idea about her
illness then explain to her suspension of SAH
so need LP .any idea about it reply no so
explain about procedure advantages
She ask about altrnative investigation I reply
serial imaging of head peace (right answer MRI)
but LP is the best.
She agree for LP .concern she want to go DAMA
for fly back to USA I reply if you have SAH it is
dangerous to fly .then I concluded .checked
understanding then time finished
Q ethical issues .consenting, autonomy vs
beneficence
He asked if she refuse LP you told serial
imaging within how much time I replied 48 hrs .
Then he asked after LP if negative for SAH when
she can fly .I told needs bed rest for 6 hrs then
can be DC he asked when to fly I replied I will
take 2nd opinion from my consultant. He aggree
then time finished. I got 13
Station 5-BCC1- patient co
joint pain I notice psoriatic plaque so I do it as
usual asked about systemic complication
.examined for rash distribution sites ,heart,
chest I ask for examining back they replied no
need
Then I conclude Diagnosis psoriatic arthropathy
and replied concern
Q about D,DD .investigation and ttt
Bcc2-generalized strange rash never I saw
before started 2 weeks back with alopecia
totalis in HCV patient on interferon 5 months
ago +ribaverin
The rash wasn't bolus
I don't know the case so I ask about concern it
was what's the Diagnosis. I replied my be
related to interferon but don't stop your
medication till taking opinion of hepatologist.
I offer admission.
Examiner ask why admission I replied to make
comittee and take opinion of hepatologist and
dermatologist he told can be by telephone I told
yes.
This was the worst case in my exam no
candidate know the case
Examiner told one of our collegue may be lichen
plans?
Alhamd lillah I passed so every body should do
his best and when your time came in shaa Allah
you will pass.
Deal with exam as you deal in ER .practice as
much you can .in my work I took history and
examin as we trained for mrcp in courses
Best of wishes for all to pass soon in shaa allah
kuwait==November 2016
copied from Dr.Zain group
I started by station 2
Hx: instructions,: 45 years old male with
generalized body weakness for 4 month,, he
consulted his GP a month ago and given
ESCITALOPRAM for presumed depression, he
noticed no improvement, at f.u with GP labs
taken and found to have Na of 124 other labs are
normal.
Inside I started analyzing weakness and it is
fatique only, no symptoms of depression,
otherwise he has wt loss, dry cough for 6
months. All other systemic review is
unremarkable.
Pmh: Dm on metformin last HBA1C is 7.8,
Asthma diagnosed 5 months ago without proper
investigations and no previous respiratory
symptoms.
Dh: no diuretics, uses blue and brown inhalers
F.H: unremarkable.
SH: Smoked 20 / day for 20 yrs stoped 5 years
ago when diagnosed with asthma.
Works as instructions engineer in building
blocks factory.
Concern was
1-The cause
2-can I take salts to correct Na
Exammier: DD I answered SIADH due to 1-Lung
ca 2-ESCITALOPRAM.
Asked also about employment hazard
I GOT 20
Examminer asked is it likely due to
ESCITALOPRAM or less likely, I answered less
likely
CVS: I didn't do well but actually it was mixed
aortic but got abit confused, got 10
CNs: examine upper limb, bilateral cerebellar
syndrome without sensory impairment
Qs DD main discussion on Friedeick
Got 20
Communication: clear BBN 45 F ESRD HTN
Many qstions, wanted transplant now asking
very detailed questions regarding HD and PD
inspite of my early advise for nephrology
referral
I explained everything about ESRD, and related
issues, social issues and options, the surrogate
kept asking.
Got 12
BCC1: DM HTN with blurring of vision: it was
bilateral, gradual , can't read well, can't see
trafic lights well, no other symptoms.
Pmh: poorly controlled DM &htn, has peripheral
neuropathy.
Acuity + field were normal, fundus bilateral soft
and hard retinal exudates. Concern was driving.
My plan was referal to eye doc diabetes
management podiatrist and to stop driving.
Examminer was surprisingly unhappy with my
findings and asked why to stop driving if normal
acuity, I answered he has difficulty reading and
seeing traffic lights, wasn't satisfied
Got 18 only.
BCC2: 54 years old f with palpitations and
sweating
Normal BP
no thyroid symptoms
No CVS
Palpitations are self terminating no associated
symptoms
I thought I got lost and just a minute before
finishing I considered post menopause and it
came to be the right one with hot flushes dry
vagina and mood changes
I examined thyroid, CVS asked for BP
But un fortunately no time to answer all her
many questions.
DD Postmenopausal
Pheo
Arrhythmia
Thyroid
Examiner was a tough female was angry about
why I didn't discuss the issue of menopause in
depth I answered I should do if I got time
Got 21
Chest wad left upper fibrosis in a young thin
They asked about the single most likely
diagnosis I answered post TB, then general
management
Got 20
Abdomen thalassemia
Got 18
Finally passed and I would like to say ; don't
depend on any station, my marks in station 5
seems to be of a failing candidate but
fortunately I compensated by other stations
My exam dubai 11/10/2016

Station 4: old female patient in rehabilitation for
physiotherapy because fracture femur she
develop headache, the doctor on rehab
suggested temporal arteritis, steroid started
then she develop psychosis, they reffere her to
hospital she assessed there by rheumatologist
he said temporal arteritis less likely and adviced
tappering of steroid, ur role to speak with her
angry son.
His concern why they gave her thos steroid?
Why they refere her without informing him?
What is out come and prognosis of her
condition?
They will send her back to rehab after that?
Station 5:
2 patient presented by dysphagia 34 years old
and 35 years old( case one systemic sclerosis,
case 2 multinodular goitre euthyroid with
pressure symptoms), both concern is it
acancer?
Station 1: Abdomen splenomegally without
peripheral feature of CLD), egyption, most
probably shistsomiasis.
Chest: young male left lower lobectomy
because of aspergiloma.
Station 2: history.
54 years old collapse (epilepsy feature)
Station 3:
Neurology: young female flacid paraparesis
without sensory level.
Cardio: AF+raise JVP + double valve
replacement (aortic and mitral), functioning well.
wanna share my exam experience
Kuwait , Al Amiri center November 2016:
Station 1:
Chest:
Middle aged male cyanosed clubbed with raised
jvp and mild pedal edema
He had bilateral symmetrical fine to medium
sized inspiratory rales and midline sternotomy
scar
Tattoo on left arm
Impression ILD
Viva: what are ur findings?
What could be the cause and how would u
manage him
I got 20/20
Abdomen:
Middle aged patient average built
Pale with palmar erythema and purpuric
eruption on both shins ( he was happy when I
said cryo)
No ascites
Hepatosplenomegaly
Viva was on etiology and management
I got 20/20
Station 2:
40 year old lady
Diabetic
History of parathyroid surgery for high calcium
levels
Came with bouts of palpitations and irritability
with high bp
Impression was pheo as part of MEN 2a
Concern was what do I have and how will it
affect my job as a businessman
Viva
On differential diagnosis
Men syndrome
Management of high bp in pheo
Medullary thyroid carcinoma
I got 20/20
Station 3:
Neuro:
Middle aged male
Sensory motor neuropathy till knees
Deep sensory loss also
Stamping gait
Cerebellar signs could not be properly assessed
due to weakness but roughly absent
DDx sensory motor PN mostly hereditary
Viva
On causes
What would do for him
If u did a CXR as u say what may u find? I told
malignancy or sarcoidosis
I got 20/20
Cardio:
Middle aged male with hyper dynamic apex
Muffled S1
MR murmur
I appreciated a collapsing pulse and AR but they
were not happy with it !
Viva was on causes of MR in this age group
Management and indications of surgery
I got 13/20
Station 4:
Breaking bad news:
A medical student diagnosed with MS by MRI
and CSF after she got an episode of ON
The neurologist did not have time to explain to
her and now it's ur job
It's a common scenario but the surrogate was
very bad
Concern was complex:
What do I have?
Will I end up in a wheel chair?
Will I end up with a urine catheter?
Will it affect me as a medical student and will be
able to be a doctor !
How about my fertility! Will it affect my ability to
get married and have kids
I got 11/16
Station 5:
Case 1
25 yo Male previously healthy came with LL
edema
Systemic review excludes any cardiac, hepatic,
nutritional problem or anaphylaxis
He denied any face puffiness
Only positive for frothy urine (bubbles)
No evidence of autoimmune disease, viral inf or
malignancy
Concern: what do I have
I did not take a consent for renal biopsy!
Impression: nephrotic syndrome
Viva
How to diagnose
What types do u know
What to exclude in this case ( solid malignancy)
Anticoagulants in membranous nephropathy
Many question on membranous Nephropathy:
Why didn't u take consent for renal biopsy? I
told after I confirm my diagnosis with urine
albumin creatinine ratio first
I got 28/28
Case 2:
45 yo male with a troublesome skin lesions and
uncontrolled BP
Impression
Neurofibromatosis
Concern: high bp and ll edema caused by
norvasc
Viva
What are causes of htn in neurofibromatosis (
renal arteries stenosis, pheo and CPA lesion)
What is management of renal a stenosis
Is there any benefit from surgery in renal artery
stenosis ( no, multiple drug therapy with CCB,
central agents and direct vasodilators is equally
effective)
How can u elicit the presence of renal artery
stenosis
I got 23/28
Finally I passed thank god 155/172
I wish u all the best
paces exam cochin india 21/11/2016
st 1 ILD , ascites plus bilateral pitting oedema
st 2 DM type 1 with attack of hypo and
hyperglycemia plus hypothyroidism.
st 3 AS plus pansystolic murmur at apex,PNP
uncoperated pt
st 4 cs discuss w relative poor px of father with
advance copd and resp failure
st 5 Rh A , TIA with family hx of stroke

country) :
involvement
as MR and some as Mixed mitral valve disease
Methotrexate
paralysis
in hospital
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
Allhumduliah I have passed my exam held on
1st November 2016 .
My exam experience of wishaw general hospital
as below :
I started with station 2 .
Case outside was this lady was admired with
facial n tongue swelling now came for follow up
.
Young female student living in abroad had this
episode first time ever in morning with no
precipitating factor . Adopted child . No part
time job . No asthma and other allergies . No
atopic symptoms .
Explained her about medic alert bracelet ,
epipen,
Nurse specialist , further support , help , dial
999 in case of emergency let your friends know
about it .
Specialist input , exclude pregnancy ,
Psychosocial support .
Stress was upcoming exam and financial issues
.
I gave d/d C1 esterase inhibitor deficient .
Examiner discussion :
Asked about definite diagnosis , d/d
What are types of skin reaction type 1-4 skin
reaction which one should be found in patch
test .
Definitive diagnostic test ,
Management
Precautions
Allhumdulliah got 18/20
Station 5 :
BCC1 : this man presented with rt sided chest
pain .
Pt said its ache and sometimes feel palpitation
rather than pain , asked about Socrates ,
previous episode , smoking , job , had previous
asbestos exposure , constitutional symptoms ,
sun exposure , vit D , forgot about trauma but
mentioned him don't lift heavy things , any fever
, rash for herpes zoster , pt had ANKYLOSING
APONDYLITIS , allergic to multiple medication ,
had perforation of gut due to ulcer now taking
analgesic by patch ,
Excluded all cardiovascular risk factors ,
Examination findings : features of AS .
Pacemaker , median sternotomy scar ,
Laporotomy scar
On rt side chest no tenderness no rash .
D/d : musculoskeletal , trauma , part of AS ,
bone metastasis , vit D deficiency .
Examiner more interested about palpitation
explained that given hx of significant cvs histry
would definitely do ECG,echo as well along wth
other tests .
Got full marks 28/28 Allhumdulliah
Station 5
BCC 2:
This lady presented with difficulty swallowing ,
Tried to exclude malignancy , mechanical
causes , HIV risk factors ,
Smoking , job , Alcohol ,
Social hx ,
Impact on life .
Examined for thyroid , retrosternal goiter , Oral
cavity examination , cervical lymphnodes ,
axillary lymphnodes,
Examiner discussion :
Diagnosis , D/d .
Tests barium studies barium swallow . Thyroid
profile ,
Management , d/d
Got Full 28/28 Allhumdulliah
Cvs : prosthetic tissue valve REPLACEMNT with
no harvest scar in leg valve dysfunction
diastolic murmur on left stern border valve
REPLACEMNT secndry to b calcification of
aortic valve
Got 19/20
Abdominal
Elderly Caucasian cachetic , Icteric
No peripheral stigmata of CLD with a mass in rt
hypochondrm and epigastrium no cervical
lymphadenopathy
Pancreatic mass causing obstructive jaundice
Got 15
Respiratry
Pulmonary fibrosis secndry to sarcoidosis
Got full 20/20
Neuro
Double vision .
Don't know what was that
Pt had fatiguiblity with left partial ptosis no
Horner signs
Totally mess this 😆
Station 4
My case was dealing with daughter whose
father copd admired with pneumosepsis curb
Score high n bed not availbl in medical icu so in
surgery ward
Got good marks 14/16
Allhumdullilah for everything
Good luck everone
May Allah Pak grant success to all
Aammeen
👍
Today last round 15/11/2016 chennai MMM

hospital
Cvs:::: MSMR PTH (also got systolic murmur in
aorta area) 😔 😔 😔 😔
Cns :::::small muscle wasting in both upper
limbs with aflexia (sensory n cerebellar intact)
History ::::;IBS (strong family history of ca
bowel)
Resp ::::::left fibrocavitory lesion
Abdomen :::avf with liver enlargement
Comm ::::talk with pt' dg about pt refuse for
BKA . Pt admit to ward for 1/12 for infective left
DM foot
Last night got sudden critical ischemic change
Vascular consultant n medical consultant offer
for BKA ,,,pt refuse pt mental capacity
competent
Bcc1:::: 50yr old man Melanae
Pt taken naproxen n aspirin
Bcc2::: 30yr woman k/c sle .... right sided chest
pain for 2/52wk
Recent fever joint pain +
UK Experience on 18th of November2016

St:1
Resp....effusion and lobectomy
ABD....dnt know what it was....scenario was
ABD.distension
I tell them that may be asceties but not clinical
clue
Neuro....multiple sclerosis...spastic parapareses
Cardio
Only afib
Hist....melena due to cardiac medication
Comm.skill
DM,WANT BARIATRIC SURGERY
St 5
BBC1: DVT....done well
BBC2::Amiodaron induced hyperthyroidism
intermittent palpitation &wt loss
.....I cudnt pick
Mandalay center, 16.11.2016 last round

Station 1- Abd- polycystic kidney disease
Resp- pulmonary fibrosis ( bilateral basal)
Station2 - 30 yr old lady presented with 6
months history of tiredness. Hb 102 mg/do, MCV
75, menorrhagia(+) , Normal thyroid function
tests. PMH - IBS, history of wt loss(+). Concern-
causes of tiredness.
Station 3- CVS- 4 candidates answered MS with
AF, the one -dextrocardia
CNS- left ulner nerve palsy
Station 4- 75 yrs old lady with known CKD with
HT on Ramipril od presented with urinary
sepsis.Give amoxicillin and gentamicin. No
blood tests were done for 2 days. On Monday,
patient got oliguric and acute kidney injury.
Stop genta & Ramipril. IV fluid were given .
Nephrologist see and concluded that no renal
replacement therapy is required. Doctor 's task
is to explain her son( Angry patient).
Station 5
BCC1- 30 yrs man presented with Rt leg
swelling. ( Dx DVT)
BCC2- 55 yrs old lady with known HT with DM
presented with blurred vision. On fundoscopic
examination of Lt eye shows blackish pigments.
I can't answer well in this station.
first day first and second round

(14.11.2016) Myanmar, Mandalay Center
History recurrent hypoglycemia only sweating
RBS wide range hypo to 20 : irregular diet: dose
of insulin adjust herself.postural drop. fullness
of stomach.on levothyroxine . concern why she
has the attack. plan for getting married .can
have baby in the future?
CVS coarctation of aorta operated with aortic
valve replacement
CNS rt complete ptosis.3'4'6 th CN no pyramidal
symptom no cerebellar symptoms
BCC collapse causes ? GI bleed.Drug due to
propranolol 40mg BD
BCC Chest pain with unilateral leg swelling
diagnosis PE
Resp rt lung collapse with bronchiectasis
Abd haemochromatosis
communication in first and second round
parkinson disease for 7 years now two day
history of hospital admission .fall history with
carpet edge. stiffness more severe.swallowing
problem. no medication recently .because the
drug is not available. daughter want to know
why her father became deterioated. miss
medication. angry for that
UM red team Malaysia..26/10/16

Last carousel
St 1: hepatosplenomegaly with pallor- CML..got
20/20
RA with cushingoid features with interstitial
lung disease..got 20/20
St2- syncope with collapse-sounded
cardiogenic syncope.got 19/20
St3- MVR in failure..got 14/20
Bilateral claw hand with small muscle wasting
of hands probably bilateral ulnar nerve palsy
disucss along differentials..got 19/20
St 4: breaking a news of multiple sclerosis...did
badly got only 6/16
St5: BCC1- headache, young man has h.o acne
taking isotretinoin and pcm, gave differentials
BIH, migraine, tension headache..got 26/28
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....got 21/28
With gods grace passed 145/172...
16.11.2016 first round last day
Myanmar, Mdy Center
CNS proximal myopathy
CVS double valve replacement
Resp right upper lobe collapse with
bronchiectasis feature
Abd marked pallor with splenomegaly
BCC 1 joint pain 2days
DM.Beer drinking
On examination first metatarsal joint swelling
and tophi
Diagnosis gout
BCC2 c/o 43yr reduced vision one year
gradual not painful
initially right eye noticed during face washing
later left eye involved
hypertension history present
on examination bilateral optic atrophy and
hemianopia
History 28 yr c/o first time collapse during quee
.light headache and black out.urinary
incontinence present .not answer post ictal
confusion
family history of epilepsy present
no social problem
single . phone operator
no night duty
apply for driving licence
concern epilepsy?
what investigations needed
tell me do and do not
can get driving licence or not
Diagnosis first time unprovoked seizure
Communicatio 60 yrs male patient with COPD
six month ago lung function test FEV1 24%
history of NIV
now have AECOPD
treatment given at ICU
now out to general ward today is 8th day
but patient frequently get confusion with
increase CO2 with spO2 95%
explain poor prognosis to son ,not rule out
ventilator support.not rule out ICU care.not rule
out invasive ventilation
his son wants to be present of his father in his
grand daughter wedding
angry for not doing the above possible
treatment plan
request second opinion
15.11.2016.Mandalay last round second day

Resp consolidation
CVS MR pulmonary hypertension
Neuro spastic paraplegia
Abd splenomegaly
BCC hand tremor
on sodium valporate for epilepsy
last attack yesterday
alcohol drinking previously
postural tremor more marked then resting
tremor on examination
BCC chest pain
increased onexertion
relieved by antacid
hypertensione
smoking since 15year of age
ddx GORD IHD
History episidic headache and palpitation for 6
months in menopause lady
CCB for hypertension but side effect rash
omit it and now on losartan and thiazide but
uncontrol BP 160/100mmHg
sweating present
no panic attack. wt loss 3months
no LOA
Commumication UC flight attendent
concern married plan,need to tell boyfriend or
not
family planing
loose motion and problem with long hall flight
can continue her job or not
ask
medical report to show her boss
can write it for me
does not want to tell her boss, do not answer
her boss if ask
Myanmar, Mandalay Center
second day second round 15.11.2016
History35yr unilateral headache
took co-codamol 4tabs per day for one month
now headache became the whole headache
no stress
no family problem
concern why headache? migraine? SOL?
request for CT?
Communication
vaginal swab group B streptococci isolated
give IV benzyle penicillin to prevent child
getting infection during delivery
child condition well but mother developed
SJSyndrome
now unconsicious, renal impairment, liver
function impair,
plan for ICU care
concern can infection transmitted to baby
can recover after stopping medication
can predict outcome
what treatment will be given at ICU
can get recovery in ICU
complain procedure
CVS psm at lower sternum edge
CNS Motor neurone disease
Resp left massive pl effusion
Abd liver transplant
BCC c/o headache and hypertension
acromegaly
BCC fatigue and tiredness2months
known RA on methotrexate CQ NSAID
on examination partial ptosis with fatiguibility
test positive
dx RA and MG
Myanmar, Mandalay Center

Day2 round 2
Station 1 - left sided pleural effusion
Liver transplant
Station 2 - Headache
May b analgesic induced
Station 3 - PSM DDx
Bulbar + 12 CN palsy ( MND )
Station 4 - Explain to husband about Steven
Johnson's syndrome due to penicillin during
delivery
Station 5 - Acromegaly
- RA + Myasthenia Gravis
Good luck to all !!
St 2 Type 1 DM erratic sugar control with

frequent hypo attacks
DDx APS
Autonomic neuropathy
St 3
CVS AVR
CNS complete 3 rd N palsy
St 4
Dealing with angry pt's daughter-Parkinson
admitted with fall , missed medication since
admission
St 5
BCC. 1 collapse ( further exploring he said he
has heavy drink with previous ho of H&M)taking
propranolol
Postural BP drop +
Dx orthostatic hypotension due to DDx GI blood
loss, propranolol, autonomic failure due to
alcohol ( i said that apart from orthostatic
hypotension, hypoglycemia need to be excluded
due to underlying liver problem)
BCC 2. 37 male hemoptysis with chest pain _
Pul embolism
( on exploring ho- gave long haul flight)
St 1
COL
COPD , bronchiectasis
(14.11.2016) Myanmar, Mandalay Center

first day last round
History bronchial asthma with beta blocker
Communication Interstitial lung disease with
palliative care
BCC proximal muscle weakness with Graves
underlying Myasthenia gravis
BCC tall young man with chest pain underlying
Marfan syndrome
Resp pleural effusion
Abd J and hepatosplenomagaly
CNS flacid paraplegia
CVS pure mitral stenosis
Myanmar 14.11.16
Day 1
Round 2
1. Splenomegaly with anaemia
Bronchiectasis
2. Hypoglycaemia with Type 1 DM
Also have thyroid problem and autonomic
neuropathy
DDx APS
3. Proximal myopathy due to steroid
ASD???
4. Angry patient daughter about her father's
Parkinson disease miss to pay medication at
ward
Patient have aspiration pneumonia at currently
5. Collapse with COL
pulmonary embolism with DVT
Other people got 3rd CN palsy for Neuro
COL for abdomen
Aortic valve replacement for CVS
Good luck to all
(9.11.2016) 3rd day last round, Myanmar,Yangon
center
BCC 1. Joint pain in thalassemia
�BCC 2. Diabetic scar
�S2- SLE with antiphosholipid Symdrome
�S4, breaking the bad news MS
1st day 1st round, Myanmar center, Ygn

(7.11.16)
History - hemiplegic migraine
Comm - wrong insulin type injection / medical
error insulin injection
BCC1- OSA
BCC2-myotonic dystrophy
Resp... UL collapse with effusion
Abd... COL with gynecomastia surgery
CVS... MS+AF
CNS...Parkinsonism
(11.11.2016) last round last day Myanmar
Center, Yangon
CVS - AS ,
Resp - ?effusion with consolidation ,
Abd - PKD ,
CNS- peripheral neuropathy motor sensory ,
History- lithium toxicity ,
comms- hickman line ,
bcc - cushing ( pitutary) , gout
(11.11.2016) last day first round Myanmar

Center, Yangon
CNS... 5th+7th CN palsy
CVS.... AS???
Resp... ILD
Abd... Thalessemia
History.. confusion for 2-3 hrs dx.. transient
global amnesia
Comm... metastasis malignant melanoma
BCC... Acromegaly, Vitiligo+ goiter
(10.11.2016) 4th day 2nd round Myanmar,

Yangon Center
CVS... AS
CNS... 12th CN palsy+cerebellum
Resp.... UL collapse+ LL pleural effusion
Abd... renal transplant
History... Fatigue+ SOB, valve replacement done
taking warfarin, hypothyroid present.
Communication... Clostridium difficle
BCC... 1. Neurofibromatosis
2. Hypopitutarism
06/11/2016...3 pm...10 examinee...

Frimley park hospital...
Fracture clinic...
1. Respiratory- left lower lobectomy and COPD...
Abdomen - spleenomegaly and ascites, no
stigmata of CLD...I said CLD...the examiners
wanted something else...I think non cirrhotic
portal htn...
2. History - IBS reassurance...
3. Cardiology- sternotomy scar, pacemaker
scar, without graft scar or metallic sound, ESM
in Aortic area- I think tissue valve with re
stenosis...got completely busted in this
station...
Neurology - retinitis pigmentosa...examine the
vision...
4. Communication - missed medication
5. BCC 1- rheumatoid arthritis with malena...
Gastric erosion due to NSAID
BCC 2- a 40 yr old lady with progressive
weakness of rt hand...MND or, motor
neuropathy (no sensory loss)
(10.11.2016) 4th day last round Myanmar,

Yangon Center
History... sudden onset facial swelling and
tongue swelling Dx idiopathic angiodema ddx
hereditary angiodema
Comm.. BBN for ADPKD
CNS... Rt 3,6,7 CN palsy
CVS... MVR
Abd.... CLD with ascities
Resp... Lt lower lobe effusion
BCC...1. TIA with AF
2. SLE with wt gain with goiter and moon face
dx- Cushing, hypothyroid
YANGON CENTRE
Day 1(7.11.16)
Station 4
Tough station of all for me.
24,female,c/o abdominal pain
USG shows polycystic kidney disease
Father also had ADPKD & on PD & peritonitis
Task: explain dx
Concern: worried that she had to take RRT like
her father
Planning to marry & have a baby
Ethic: she ask if she told her fiancee about ds &
to screen her brother
Examiner asked me if she told her fiancee about
her disease, he might not marry her? I don't
know.
She is afraid of invasive Inc& don't come to
renal OPD, how would u do
To many difficult questions.
UK Experience
1-11-2016
JAMES COOK HOSPITAL 3RD CYCLE, 1ST DAY
Chest: rheumatoid hand with lobulated rt pleural
effusion
Abd : transplanted kidney ,
Cardio: valve replacement (tissue), with mital
regurge
Neuro: ?? , very difficult, last second I know
Parkinsonism
History: acute gastroenteritis, Acute kidney
injury and lithium toxcicty
Communication: BBN Cancer esophagus with
metastisis, inoperable, depreesed pt.
BCC1:BACK PAIN AND HEADACHE , POST
PITUITARY RESECTION, TANNED SKIN ON
REPLACEMENT THERAPY ( NELSON
SYNDROME)
BCC2: ACTOR WITH COLLAPSE AT WORK ON
CITALOPRAM WITH HISTORY OF SUDDEN
DEATH OF HER FATHER ??FAMILIAL
PROLONGED QT
(8.11.2016) 2nd day last round

Myanmar (Yangon Center)
Abd....anemia with splenomegaly ,
?hepatamegaly , prominent malar face Resp -
lobectomy CVS - midline sternectomy scar with
?PSM , no click and no CABG scar, History-
frequent collapse , comm - SAH and LP, BCC1
diabetic and hypertensive retinopathy with
uncontrolled hypertension and diabetes , visual
acuity reduced for two months, BCC2 psoriasis
with beta blockers�Neuro – parkinsonism
(9.11.2016) 3rd day 1st round Myanmar Yangon
centre
S1 Collapse conso+ effusion�HSmegaly with
ascites�S2 collapse�S3 MS+AF, Flaccid
para�S4 GCA on steroid become
psychosis�S5 vitiligo+thyroid, Anky Spond
Myanmar Center, YANGON

1st day Last Round (7.11.2016)
Station 2_History taking
34,male,accountant
Known case of irritable bowel syndrome
On antispasmodics
Father had colon cancer & took colectomy &
radiotherapy
Complaint: worsening crampy abd pain&
Erratic bowel function
Concern: worried that he have colon cancer
Q: PDx,DDx,Inx.
IBS
IBD
Celiac disease
Tropical sprue
Chronic bacterial overgrowth
Chronic pancreatitis
Whipple disease
HNPCC
Familial CRC
Inn: F BC,USG,colonoscopy,faecal
elastase,Anti_endomysial Ab,anti _TTG
His uncle also had colon cancer
CVS
1.AS,PS
2.MS+AF+ pulm HTN
Neuro
1.Difficulty in walking
Ex of LL
On Rt LL,Tone increased,power 3/5
Knee exaggerated,ankle reduced,EPR on both
side, sensory level +
Spinal cord compression
Transverse myelitis
Inx
2.Common Peroneal nerve palsy
BCC 1
Asthma with blurred vision
Worse in dim light & at night
Retinitis pigmentosa
Q: syndromes associated with RP
BCC 2
Long standing blood disease with wt loss
despite GOOD appetite
HO of more than 100 bags of blood
transfusion,hyperglycemia symptoms
How operation for blood ds
O/E Thalassemia, Hepatomegaly, splenectomy
scar
PDX,reason for splenectomy
Station 4
24,female,c/o abdominal pain
USG shows polycystic kidney disease
Father also had ADPKD & on PD & peritonitis
Task: explain dx
Concern: worried that she had to take RRT like
her father
Planning to marry & have a baby
Ethic: she ask if she told her fiancee about ds &
to screen her brother
Examiner asked me if she told her fiancee about
her disease, he might not marry her? I don't
know.
She is afraid of invasive Inc& don't come to
renal OPD, how would u do
To many difficult questions.
Station1
1.Resp: male pt, cough & SOB for 3 months
O/E: clubbing,dullness percussion, reduced
VBS, no ronchi,no crepts
Examiner ask DDx
I gave pleural effusion,pulmonaryfibrosis, Ca
lung
Pleural thickening
Invx.
2.Rt sided pleural effusion
Abdomen
1.A man with abdominal discomfort
O/E Hepatosplenomegaly,smooth
surface,dilated abdominal veins,no spider naevi,
jaundice,palmar erythema
Q: causes of HS , invx
2.Pallor+Jaundice+hepatosplenomegaly
Day 2 (8.11.2016) Myanmar center, Yangon 1st
round�Station 1 Rt upper lobe collapse &
effusion�PCKD with AV fistula�Station 2
palpitation�Pheochromocytoma�MEN2�Stati
on 3�Rt 7th cranial nerve palsy�Bilateral 6th
cranial nv palsy�MS AF�Station 4�CURB 65
pneumonia�Talk to daughter about patient's
death�Station 5�1)Rt homonymous
hemianopia�AF�2)systemic
sclerosis,malabsorption
UK west middlesex university hospital...

29/10/16
St1... bronchiectasis...kidney+pancreas
transplant...
st2...young female with an episode of loss of
conciousness and incontinence.. her brother
has epilepsy
St3... AVR... diabetic neuropathy sensory only
upto mid sheen
St4... old man with pul fibrosis.. talk to son
about palliative care
St5... OSA + gouty arthritis is hands...
YANGON CENTRE
Day 1(7.11.16)
Station 2_History taking
34,male,accountant
Known case of irritable bowel syndrome
On antispasmodics
Father had colon cancer & took colectomy &
radiotherapy
Complaint: worsening crampy abd pain&
Erratic bowel function
Concern: worried that he have colon cancer
Q: PDx,DDx,Inx.
IBS
IBD
Celiac disease
Tropical sprue
Chronic bacterial overgrowth
Chronic pancreatitis
Whipple disease
HNPCC
Familial CRC
Inn: F BC,USG,colonoscopy,faecal
elastase,Anti_endomysial Ab,anti _TTG
His uncle also had colon cancer
YANGON CENTRE
Day 1(7.11.16)
CVS_ I'm not sure
AS,PS
Neuro
Difficulty in walking
Ex of LL
On Rt LL,Tone increased,power 3/5
Knee exaggerated,ankle reduced,EPR on both
side, sensory level +
Spinal cord compression
Transverse myelitis
Inx
YANGON CENTRE
DAY 1 (7.11.16)
BCC 1
Asthma with blurred vision
Worse in dim light & at night
Q: syndromes associated with RP
BCC 2
Long standing blood disease with wt loss
despite GOOD appetite
HO of more than 100 bags of blood
transfusion,hyperglycemia symptoms
How operation for blood ds
O/E Thalassemia, Hepatomegaly, splenectomy
scar
PDX,reason for splenectomy
Dear colleague
I would like to share my exam experience in
Maddi armed hospital
St3: Examine motor system
By inspection patient has hemiplegic posture in
the left side and on screening there is weakness
in elevation on limbs on left side--- I said don’t
forget crainal nerve or heart examination
On exam left side hemiparesis Then I examined
the cranial nerves (7th,12th) , Both carotid ( as
per dr Ahmed recommendation ) ,Pluse. Finally I
asked to examine heart he has
midlinestrenotomy scar and Prothetic valve
(MVR on auscultation)
Examinaer Qs: what is your finding?
How would you manage the patient?if in acute
stage urgent Ct scan to rule out hemorrhagic
stroke if the patient in window phase to benefit
from anti thromotic therapy Vs chronic non
pharmacological Physiotherapy and
phamrcological ttt addressing the risk factor
Examiner went to discuss the cardiology in the
case by asking about the prophlyaxsis of
Infective endocarditis.
Cardio: patient is complining of shortness of
breath
Patient was young pale with congested neck
vein, midline sternotomy scar and
hyperdynamic apex left parasternal heave with
Af and 1st and 2nd heart sound is metallic
Examiner Q what is your finding ?
How would you mange the patient ? mentioning
the target INR 2.5-4 examiner said are you sure I
said yes ( I should have to say from 2.5-3.5 and
in his case additional risk factor as Af it should
be till 4 (dr AME)
St:4 Title : Iatrogenic renal impairment
She was a female patient 60 years old admitted
in the hospital. she has been having urinary
tract infection and she was given gentamycin
antibiotic and unfortuntly dose has not been
checked at the weekend and reached the toxic
dose and has been stopped afterwards.
Nephroplogy team came to assess the patient
and in their opninion she is not in need of
replacement. The patient was on ACEI and renal
function test was done previously to the
medication was normal
It was a case of Negligance and I proceed as
Appologise, Admit the mistake, Write incident
report, solving the current problem and
explaining the future plan for the patient
Surrogent question: who is responsible for this
mistake? Give me his name? I want to fire a
complaint? Will my mother get better?
I answer this is the mistake of whole team not
one member of it and all my apology on behalf
of the team and as you like if you want to fire a
complaint it is your right and from my side I ll
guide to proper place and person.
Examiner question:
• What kind of medical problem you are facing
in this case
I said it is a case of Negi lance
• How would you avoid such problem from
happening again?
By doing meeting with risk managerial team and
do through investigation analyze the root cause
analysis ( as per dr Ahmed words) the root
cause analysis of such problem to about why
and how such problems happened and doing
ordination to the staff to avoid it in the future
St5:
BCC1: 18 years old patient complaining of short
stature? ( Same case I Took at dr Ahmed
course)
At first glance I saw the patient she was having
thalassemic features and genelised pigmention
I first asked about the height previously? Height
of parents? Then chronic medical condition
(patient was on iron chelating agent and has
frequent blood transfusion in the past)? The I
asked about symptoms of panhypopitutrism ,
social and mood History of surgical operation
(splenectomy).
Examination I asked to let the patient sit so as
to mesurse the height and span (examiner told
me assume it is proproniate)
Then I asked to look at the (breast and axillae)
examiner told me absent
Then I do general survy (she was having
thalassemic features and genelised pigmention)
palor, then in the abdomen there was scar in the
left hypochrondrim then I palpate the liver and
percuss splenic bed to confirm splenectomy
Concern was
will I gain height again or not ?
I said frist we have to do imaging to look for
your bone age if it already closed or not and
accordling the management will be wather to
give you growth hormone or not
Will I ll be able to see my menses ?
We ll refer you to MDT including the women
doctor and gland doctor they may give you
recplacment hormnes in the form of Estrogen
and progesterone for your period
Examiner Q what is your finding? What will you
for this patient to get secondery sexual
character ?E+P ? will she be able to get
pregnant? She can be given Gnrh
BCC2: patient is having shortness of breath
On entering patient has hand deformity
characterstic of RA She has been complaining
of shortness of breath for 6 months and is
getting worse
Patient has been diagnosed as Rhumatoid
arthritis and she was on methotrexate for 2
years in addition she took NASID, No lower limb
odema, No dyspepsia or melana and no
associated other rhematological disease
On exam. She has RA deformity I assess for
Activity and function of the hand then I look for
pallor,PM, Lower limb odema, palapte the back
of the chest of the patient and then auscultate (
fine inspiratory crepitation in the base ) then
auscultate the pulmonary area (+P2)
Concern: what is the cause? Either the RA itself
or the medication she took I ll do for her
imagaing on the chest and refer to MDT
including the chest and joint doctor.
Examiner what is your finding? And what is the
cause
St:1 Abdomen
Patient complains of bleeding per gum
Pt was young with pallor, splenomegly and cx
and axillary LN
Examiner what is your finding? What is your
differnatial diagnosis? What is the cause of
bleeding per gum?
inflerative disease ex lymphoproliferative (LN),
chronic Infection, connective tissue disease.
How would you investigate? Basic investigation
including blood film
CBC, LDH, B2 microglobin, immunophentyping,
LN bipsy or bone marrow bipsy.
Chest
Patient complains of dyspnea
Patient had clubbing, dullness on the lung base
and breath sound was vesicular with prolonged
expiration with fine inspiratory crepitation on
base of the lung Dx bilateral basel lung fibrosis (
he has compensatory emphyema in the upper
lung zone)
Examiner ask about the cause? Management?
St 2 patient was 60 years old diabetic on and
hypertensive was sitting in the restaurant with
her friend and then got confused without losing
the consciousness for one hour she doesn’t
remember anything about what happened.
Through history all is NO.she concerned about
driving and if it will recour again? Examiner ask
about the cause? And management?
It was confusion for DD? TIA, subdural
hematoma, stroke
I would like to express my gratitude to Prof.
Dr Ahmed Maher Eliwa
i can't find a word to describe a single thing you
have done to me for longtime. You gave me
confidence in my self so as to beat all my
weakness and not only to take but also to give
the best to others. DR AHMED MAHER ELIWA
YOU ARE THE KEY MAKER OF SUCESS WITH
HELP OF ALLAH .
YANGON CENTRE
Day 1 (7.11.16)
Station1
Resp: male pt, cough & SOB for 3 months
O/E: clubbing,dullness percussion, reduced
VBS, no ronchi,no crepts
Examiner ask DDx
I gave pleural effusion,pulmonaryfibrosis, Ca
lung
Pleural thickening
Invx
YANGON CENTRE
Day 1(7.11.16)
Abdomen
A man with abdominal discomfort
O/E Hepatosplenomegaly,smooth
surface,dilated abdominal veins,no spider naevi,
jaundice,palmar erythema
Q: causes of HS , invx
(Courtesy of Dr Kefah Bashir who passed in this

diet)
My exam Dubai 11.10.2016
Start with communication :
Old lady was admitted on rehabilitation for
physiotherapy because she have fracture femur
,she develop headache there the doctor on
rehab centre suspected temporal arteritis
,received steroid then she develop psychosis
,referral to the hospital was done re assessed
by rheumatologist ,said temporal arteritis
unlikely , and advice tapering of steroid , ur rule
to speak of her sun , explain to him and answer
his question ?
His concern why they gave her this steroid ? He
is upset from doctor ?
What is the out come of her condition ,?
Why they refers her to hospital without inform
him ?
Station 5: 2 cases dysphagia ( 35 years old and
34 years old)
Case one systemic sclerosis case 2:
multinodular goitre ( euthyroid)
Chest: Lt owed lobe lobectomy because of
aspergilloma.( young male)
Abdomen: splenomegally ( no signs of CLD)
CNS: flacid paraparesis without sensory level(
young female)
CVS: AF+ raised JVP + double valve
replacement (AVR+MVR)functioning well.
History : 54 years old female presented by
collapse
Kuwait adan hospital

November 2016
Resp
ILD with rheumatoid hand
Abdomen
Polycystic kidney
Neuro
Peripheral sensory motor neuropathy
Charcot marie tooth
Cadio
Mixed aortic
History
Lithium toxicity
Communication
Breaking bad new pancreatic ca
Station 5
Diabetic maculopathy ? Not sure
IBD
Hope u all the best
Western General Hospital Edinburgh..

November 2016
Station 1
Abdomen CLD with hepatomegaly
Resp Left Sided Consolidation
Station 40y old female KC ulcerative colitis with
ileostomy bad having lightheadedness with
weakness.. creatinine 265 urea30 no proteinuria
no hematuria
i messed it up.. it was high output stoma.. i gave
dd of flare up of disease. saw examiner puttinf
unsatisfactry 😢
Station 3
CVS ESM not radiating anywhere
i gave DD examiner seems satiffied
CNS sensrimotor neuropathy for DD
Station 4
man admitted with hemetmesis confused
alcoholic explain to wife and expalin need for
urgent endoscopy
Concerns He is not drinking much
any other alternatvie
Station
Pulmonary embolism in 20 week pregnant lady
with previous misscariage she came in e.r
collapsed on inquiry she said chest pain and leg
swelling
2nd scenario weight loss palpitations on exam
there is thyroid swelling.. i gave dd pf thyroid
cancer but shud say toxic multonodular 😢
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
Sharjah 2016/3
Station 3
-Cardiology: CABG with bilateral Harvesting
scars and AV fistula functioning. Have AS,MR.
-Neurology : Spastic paraparesis with out
sensory level.
Station 4
The common scenario, speak to daughter of
Mr:X who is known case of COPD had been
admitted overnight with pneumonia to surgical
ward because no bed in medical ward, Pt
missed antibiotics dose because there was no
cannula, Pt was deteriorated shifted to ICU and
arrested there, CPR was not successful.
Station 5
-Neurofibromatosis.
-Multiple Myeloma.
Station 1
-Abdomen: Thalassemia with hepatomegaly and
splenectomy.
-Respiratory: Pleural effusion.
Station 2
acute renal failure to find out the cause
I hope this might help, if any one needs more
detailed feedback kindly contact me.
All the best.
Alhamdullilah I have passed

Score 166/172
PACES DIET 3, Royal Hospital
MUSCAT, OMAN
Day 2
Station 1
Abdomen; Renal transplant with failure pt on
Score 18/20
Chest; young male with rt lateral thoracotomy
He was clubbed.
Management
Organisms
20/20
Station 3
Cardio; young male with AS+/-AR .....dominant
AS.
ECHO findings
20/20
Neurology; a case of Charcot Marie tooth.
20/20
Station 5: BCC
27/28
26/28
Station 2: History taking
habits.
Diagnosed with IBS.
No ALARM
operated.
@39 yrs.
testing.
19/20
Station 4: Communication
Young female admitted with vertigo and
diplopia. Diagnosed as Multiple sclerosis.
Diagnosis was explained by Neurologist but pt
wasn't satisfied and wants to seek 2nd opinion
from candidate.
Explain her diagnosis.
Future implications and address her concerns
She is a school teacher and studying medicine.
Sole carer of her mother.
So raised questions about her careers future
and regarding care of her Mother.
Questions were asked related with ethical
issues like autonomy.
Examiners was rude.
Score 16/16
MANY MANY THANKS TO DR. ABDUL FATTAH
WHO TAUGHT ME AND IT WAS REALLY VERY
HELPFUL.
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
Egypt =Cairo
Maadi hospital
I have started with station 4: 38 yrs old male
with type 1 DM,
Had macro &micro complications, had Un
awareness of hypoglycaemia, & he lost his
driving lisence bz of this....
In side young age male.i asked about DM :
onset, duration, FU, cotrol ... Rx: insulin lantus
and apidra . He increased insulin dose e out Dr
opinion. ... decreased his meals after insulin...I
asked y? He told bz he wants to avoid further
complications. .. I showed empathy and
appreciate his effort but I told him unfortunately
this is not the right way as it resulted in frequent
hypo attacks. ..
I asked about all autonomic dysfunction
symptoms and r negative. .He has no FU e GP,
diabetes Dr, neuro, ophtha or chiropodist. ...I
advised for all and suggest referral...
He is covering his finances well and good family
support... I was afraid to ask further Qs not to
simulate history station...
Exam.Qs:
He was totally upset and asked:
Did u ask about other CV risk factors " HTN,
dyslexia, smoking?"
Drug list? He is on atenolol ... what's u r
opinion?
Do u think u Rx his concerns well?"how r u
going to help me? This is the concern"
I apologise, show that it a big mistake that I
did.... I act e facial expressions. ...
I realized that I lost this station....
They gave me 11....
Went out I reassure my self: always 1st station
is the worst...I will do my best for other
stations.... I remembered advise of Dr zain...
The 5 mins before S5 i was only reassuring my
self... only read the scinarios e no mental
preparation. ...
BCC1:
From out side middle age male e diarrhoea and
abd colic....
diarrhoea was bloody, in &off no wt loss...
I jumped to eam. Pt e psoriasis. ...rash
present....abd: nothing specific. ..drug list: I
forget but include MTX and NSAID, and one
other ttt. ..
Ph : only psoriasis. ..
Asked about precipitants in brief. ...All this & I
am not sure what is the relation. ..
And that was the concern 😑and exam. Q also:
My brain is empty that time, then I decided to
tell the truth' that I don't know the relation" to
psoriasis right now, but I need to do some tests
that my include camera test, and involve tummy
and skin Dr & at that time we will tell u whether
related or no...
Exam.Qs:
Is it related? Then the same answer 😂
DD: IBM
infections
Ca need to be ruled out
If IBD: which one? confidently I told crohns " I
don't know why I told this? 😳 I am sure no
one else can do such mistake...at this point I
feel I will get a big zero in this station and this
mean I lost the exam... so I decided to complete
my exam v cool bz I lost this already and it will
never differ again. . .. 😢
Strangely they gave me 24 😳
BCC2:pt e sore throat from out side . .and I have
differential in my mind other than flu, urti..
Inside : young male, analyse sore throat. ..no
feature of flu... then I asked did he took any ttt "
I mean for current condition".then she was v
generous and told he is taking Carbis azole, ok
god gave me this... 😍...so he is hyper thyroid?
Yes.. then I jumped to exam....throat and full
thyroid exam.... only positive? Diffuse goitre
and fine tremor?
Concern; is it related to his ttt?
I answered may be related, that's why I need to
admit do some tests then will tell whether
related. .. involve gland Dr bz he may need to
stop u r ttt for awhile and then resume it?
Exam.Qs; u r D. ...
Invest
Ttt
Admission or no?
I got 28
S1: I think modest station but was the worst....
Chest: elder man , lying at 90 digree almost, I
asked can I put him at 45 ? Answer he is
comfortable now... so I proceed... looks ill... I
search around for O2 or nebuliser machine.
..nothing...trachea central. .. crichosternal notch
distance reduced. ...
Has v quite and distant breathing... 😁 ..
Back v. Scattered rhonchi and basal creps. ..so I
present the Pt as lung fibrosis e obstructive
elements. .. discussion went thru this...at last 30
sec. Egyptian exam asked what about his ant.
Post. Diameter. ... 😁 it was increased. ..I told D
is copd complicated by fibrosis. .. He was
showing me how much I was wrong.... 😂
Onnnnnnly 7/20
Abd:HSM in
apt e valve replacement. ... I am not sure about
ascites so I told negative. ... exam.Qs:.
DD..invest....ttt. ....
Possibly I missed ascites so they gave me 11
St2:
37 yr lady ... has exhaustion...BP 145/95.... hb:
11 normo. ...
Inside; joints pain, malar rash, h/of abortion.
..h/of DVT. ..
not on pills. ..no features of other MCTD or
overlap syndrome
So SLE e antiphosphlipid syndrome. ...
Concern : can she have a child? I answered
after D and Pl good control she can get kids ...
but it should be planned. ..and need to involve
women & joint Dr. ..
19
St3; CNS: hemiplegia e facial palsy lower in Pt e
prosthetic valve....
Qs :findings
Diagosis
Cause
Invest
Ttt
20
CVS: lady with A., AS, P.HTN e TR
Qs:
D
Invest
Cause
20
AR*
In s4 dyslipidemia* sorry for mistake
Carbimazole*
kuwait amiri Hospital

November 2016
:abd cld hepatomegaly ,chest copd
,bronchiectasis ,cardio mR ,neuro mixed upper
moto and peripheral neuropathy LL,
St5 gravis d,ankylosing spondyliits
Communication medical error pt received wrong
dose of insulin
History 1ry biliry cirrosis
Kuwait exam ,,October 2016
mubarak hospital
Station 1:
HSM fot diff.
Localized bronchiactasis asking
cause,management.
Station 2:
Malabsorption synd. For 2years changed in ccc.
In last 6months with steatorrehea+abd pain
came from carribian 6 months ago she can't
remember the relation of the timing.
So malabsorption for DD.
Station 3:
flassid paraparesis with intact sensation for DD
MVR.
Station 4:
Pt with suspected SAHge want to LAMA. after ct
is normal but advice to do LP.
Station 5:
-MCTD with joint pain in boh hands.
-Goiter and hyperthyroid came with difcult
swallowing
Kuwait Amiri hospital
october 2016
Station 1 pulmonary fibrosis
Abdomen hepatimegaly
Station 2 pheochromocytoma MEN2
Station 3 MR
Motor sensory p.n
Station 4 explain diagnosis of MS and impact on
life
Station 5
NF Neurofibromatosis :skin problem and high
bp
Management
I didn't do well)
Nephrotic syndrome
Nephrotic:young man with lower limb swelling
Causes
Station 1:
HSM fot diff.
cause,management.
Station 2:
Station 3:
MVR.
Station 4:
Station 5:
swallowing.
Kuwait exam today

Station 1:
HSM fot diff.
cause,management.
Station 2:
Station 3:
MVR.
Station 4:
Station 5:
swallowing.
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 ofpsoriasis
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

Score 166/172
MUSCAT, OMAN
Day 2 cycle 2
Station 1
Score 18/20
He was clubbed.
Management
Organisms
19/20
Station 3
AS.
Dx
20/20
20/20
Station 5
27/28
26/28
Station 2
concerns.
16/16
4. History
habits.
Diagnosed with IBS.
No ALARM
operated.
@39 yrs.
testing.
19/20
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
9/10/2016
*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
** This is my exam yesterday in Mascut
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
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)
Score 166/172
MUSCAT, OMAN
Day 2 cycle 2
Station 1
Score 18/20
He was clubbed.
Management
Organisms
19/20
Station 3
AS.
Dx
20/20
20/20
Station 5
27/28
26/28
Station 2
concerns.
16/16
4. History
habits.
Diagnosed with IBS.
No ALARM
operated.
@39 yrs.
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

22nd Oct 2016.
BCC
months.
Station 1
Resp
Bronchiectasis
Abdo
Station 2
Hx of headache
Station 3
CVS AVR
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 💪🏻
22nd Oct 2016.
BCC
months.
Station 1
Resp
Bronchiectasis
Abdo
Station 2
Hx of headache
Station 3
CVS AVR
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
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
Communication
Steven Jonson
Neuro
spastic parapresis
Egypt exam today

10 - 10 - 2016
Station 5
Pemphegus
gout
History
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
EGYPT
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.
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
20/20
.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
20/20
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

.History.2
unilateral Headache.in female 30 yr.not relieved by
.simple analgesics,pizotifen and sumatryptan
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


. 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
.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

.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
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
.bacteria.Time was up
28/24
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
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
)20/12( .component
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
)20/18( .alcoholic liver 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
fever has affected her daily life and offer
)20/19(.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
)20/20( .standard
CVS: An elderly man with central sternotomy scar, vein

harvest scar, and MR. Got panicked and gave the
)20/10( .wrong diagnosis of AS. Did badly overall
:Station 4
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
)16/16(.ways to lodge a 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
)28/28(

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
)28/25(
: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 50
did 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 -2
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 .1
could not 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 .2
striae; 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 .3
and 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 .4
her 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 .5
scar. Dual 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 .6
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 .7
case. I lost 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 .8
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
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
20/20
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
So when i entered i shaked hands i was blank,i greet
r u z daughter of ms.maha, she said no i am ms ،her
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
20/20
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 there is substance called k ,it is going to be
we need to monitor her closely. to give her the ،high
.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
16/16
: 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
28/26
:Bcc2
yrs male with facial weakness,vitals r normal 54
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
28/28
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 . 4
on the 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 .5
. The only thing i found it useful in OST books .6
. 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 4
to 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 1
assess pt 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
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 29
،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
20/19
‫هللا ولي التوفيق‬
My advise is practice more than studying books
COPIED
Exam experience Kasr AlIny hospital
6016/6
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
20/18
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
20 /8
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
28
middle age pt with lower limb weakness with oral -2
ulcer
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
28
]12:14 25.06.16[ ،Muna Moon
]Forwarded from Muna Moon[
My exam experience gasr al3eni hospital first day 3rd
cycle
CVS -1
INR
Score 19/20
Abdomen
20/18
Chest
20 /8
Neuro
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
20/16
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
16/8
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 80
stroke 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
2
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
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 50
obstructive 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 50
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 2
not sure 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 2
150/95
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
)16/12( .and address patients concern
:Station 5
)28/20( Thyroid eye disease with cataract
)28/21( 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 the examiner. I was
)20/20( surprised by the marks
:Station 2
Pulmonary fibrosis secondary to methotrexate /
bronchial asthma / bronchiolitis obliterans. Questions
)20/15( .about bronchial 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
16/16
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-2
Station 2》
years old .DM.asthma presented 25
With recurrent chest infections for 6 months 6 times
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
.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
bronchiactesis
..😳 He said serum antibodies for pathogenes
😣 I was about to say immunoglins but bell rang
.CNS: Upper limb exam .3》
He has hemiparesis
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
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 :4》
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
:5》
years with skin lesion over her forhead and scalp 60
Looks like morphea
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
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
..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
) 20/8 ( AS and MR !!! I scored
CNS; lower limb exam.. patient was not cooperative )3
and misleading
he kept moving his lower limb during tone assessment
and giving contradicting information during sensory
..exam.. I could not formulate DD
) 20/7 ( I scored
Communication: 40 year old lady has IDDM her )4 ☆
،HbA1c 9 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
)20/4( I scored
BCC1: psoriatic arthritis has joint pain.. has skin )5 ☆
)rash over elbows and hair line.. I scored ( 28/28
BCC2: 70 year old lady history of loss of )5
consciousness and 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
)28/24 ( 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
) 20/20 ( discussion about complication of transplant
Chest: Rt upper lobe lobectomy with deviated )1
trachea discussion about indication of lobectomy and
) types of lung cancer ( 20/20
History: 55 year old male with symptomatic )2 ☆
.. anemia and melena on ibuprofen for knees pain
??His concern: Is it colon cancer
..I told him I ll request upper and lower GI scope
) 20/19( I scored
)172/130( 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-4
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 69
.and 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 24
.except 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 -5
: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 -2
refused 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
2016/6/9
St 5 ist case
osteogenesis imperfecta command was pt has
recurrent
fractures, viva about genetics types etc
nd case2
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, 45
blurred 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 42
LFT. 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 pair2
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 .5.2
nd day 3rd round2
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, 84
hyponatraemia, 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 .2
interval DDx hypopituitarism; autonomic neuropathy
Metalic click I told DVR (but friend said that it is .3
MVR)
--- .4
same as Hsu May Oo post --- .5
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 round4
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 .2
..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 1
complain is 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 2
..diagnosis
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
: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
2016-5-31
:Neuro
Left sided hemiparesis with normal reflexes
:Cardio
AVR
:Chest
: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:2
double valve replacement:3
Rt side hemiparesis
Examine the upper limb
provoked seizure (hyponatraemia) concern can it :4
? come again ? And can I drive
psoriatic arthropathy:5
Vetiligo....present with tirednes; pernicious anaemia
Adrenal insufficiency
2016/5/30
nd carousel2
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 ... 20 .1
Normal 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 35 .2
the soles 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 أجمعين‬
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 .2
insuficiency incl gynecomasia, bilateral parotid
yr old girl HMA, low iron 35 .2
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 3
base gait, bilateral cerebellee, increase knee jerk, no
sensory, CN - intact
Patient wafrin for AF, stroke again, INR -1.2, missed .4
last INR clinic appoinment. Talk to grandson
a.young lady, hypertension, blood sugar high - 5
Cushing
b. Known DM, impair vision - CRVO5
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 ... 20 .1
Normal 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 35 .2
the soles 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 -1
.history 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) -2
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 27
exopthalmous 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 40
hands family 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 round4( 16/.3/.10
)
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
20/20
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
20/20
Station3
Middle age gentleman with difficulty in holding objects
O/E resting tremor
Bradykinesia
Rigidity ?
Dx Parkinson d/s
ddx ET
20/14
Middle age female
MS AF Pulmonary HT
20/15
Station4
yr achalasia doing oesophageal dilatation resulting 75
perforation
Previous 2 times ok
risk signed in document%5
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
16 /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
28/27
BCC1
Skin lesion with painful in gentleman
Neurofibromatosis
Is it cancer
Can his son get this
How treatment
28/16
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

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 30
holidays 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
20/18
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
16/11
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 2
from hx 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 69
.and 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 24
.except 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
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 ..4
pt used 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 ??..5
cancer
..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
2016/4/2
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 40
with 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 )2
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 -1
candisartan 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
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
DD of etiology was bronchiactssis, fibrosis,Abcess and
،malignancy
(germ cell, and Sarcoma )and workup also asked if he
infection and thrombosis
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
I got 16
Hx: 50 years female , married , work as hospice nurse,
radiating to back
Gp letter mentioned high bilirbin 70 and high all Liver
enzymes
and dengue,autoimmune hep, and malignancy
assessment and rehydration if dehydrated,pain control
I got 20
CVS : old male has peripheral features of AR
apex displaced
I got 20
CNS : middle aged patient
Instruction was : this patient has problem lefting
objects
involvement
that I can't recall
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
usual aspirin and stop her oral feeding until the see her
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
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
gastritis
?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
stopped them both after got pregnant as She thought
،they're harmful
and FU with GP
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 50
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 55
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
،،CVS- MVR- midline scar , metallic sound, MD Murmur
examiner discussed about infective endo- how present,
wht investigation
20/17
Neuro- diffic. to walk- examine neurologically-- Rt
hemiplegia with facial palsy- where lesion? invest?
.acute presenta-- Alteplase
20/20
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 32
bloody diarr 4 wks, visited Cyprus. low back pain with
years stiffness-no fever , no wt loss- grandfather 57
colon cancer-- D/D- Inflammatory(IBD) or Infective- but
i do colonoscopy, examiner asked to exclude cancer
Invest of Infection, 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
‫ و أكثروا من الدعاء‬.who 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 -1
last less 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 *
History bloody diarrhea and arthritis .history of #
travel to Morocco
. colon
.Concern is it cancer like my grandfather
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
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
16/16
Station 2
yrs female with Episodic weakness in Rt upper limb 35
..and 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
.20/20
Abd: CLD pt with jaundice, ascites , splenomegally,
.palmar erythema
.Examiner : investigations and management
.20/20
Neuro : paraplegic with sensory level. 16/20
Chest : bronchectesis
20/13
CVS : AR and MS pt also has AF
20/17
Station 5 Acromegally
yrs with headache and HTN 30
..He has typical features
.28/27
nd is ankylosis2
..yrs with back pain 25
.He has morning stiffness and uvitis in the hx neck pain
..O/E.. only mild restriction of spine flexion
28/26
Malaysia
--) 2016-4-17 (
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 50
started 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
2016/4/12
COPDand CLD -1
yrs old female has h/o Diarrhoea wt:loss smoker 40-2
,no family history malignancy
young male AS & Transverse Mylitis -3
COPDpt admitted with pneumonia and he got one fit -4
and 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 -5
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 )2
sensory 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 2
from hx 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
St 3 cvs double valve replacement quite difficult the
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 1 -
hemianopia
nd pt with headache and blurring of vision 2 -
diagnosis from 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
St 3
CVS double valve replacement quite difficult the -
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 2☆
،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 weakness50》1
Neurofibromatosis compresses the ulner nerve. The pt.
underwent surgury for removal of fibroma recentely
A 53yrs male with long standing arthritis present 》1
..with dysphagia
have gritten eyes (sjogren) and have bibasal lung
fibrosis & is on methotrexate
Experience of my Friend,,get his Exam in Malta

2016/4/2
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 )2
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
‫بالتوفيق للجميع‬
Experience in Malta Centre

second day , carousel 1 16/4/2
: 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 ♧
radiating to back
Gp letter mentioned high bilirubin 70 and elevation of
..all Liver enzymes
DD : I mentioned Alcoholic hepatitis, viral hepatitis(A) ,
.autoimmune hep, and malignancy
Discussion was about working her up , and how to
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
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
gastritis
BCC 2 ♧
occurs at late night and early morning, no any other
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
reassure about safety in pregnancy, adviced Peak flow
diary and FU with GP
Examiner asked what is against infection, also asked if
? PE need to be ruled out & what to do
Castle Hill Hospital

Station 2》
the examiner
TB
bronchiactesis
He has hemiparesis
Not examin e nech
:CVS .3》
was soft
I told ACS
answer
..have mention it
:5》
Looks like morphea
scl
?Is it cancer
morphea
😥 nodules
I told dd
Mysthenia graves
:Station 1》
? abdomian pain
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 qs2
?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
16/3
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 ♤
But
further management
Is it serious
Is it cancer
Is there a cure
History station ♧
Young female 28
Mixed with stool
Now last 10 days
Painless
No backache
No oral ulcers
No skin changes
No jaundice
Cousin IBD UC
Father CA colon
No blood thinners
No steroid
No warfarin
No weight loss
Concern : cause
? Is it cancer
? What next tests
? What Med
:DD
IBD ( UC)
Infective Diarrhoea
Antibiotic associated Diarrhoea
And
Asked
In
Fever
Vomiting
But
He told
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 day2
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 /4
SLE c/o pluritic chest pain /5
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 16/4/2
: 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

2016 /4/ 3
COMMUNICATION
Explain Diagnosis PHEOCHROMOCYTOMA
Dr Ahmed Maher Eliwa discuss thi scenario with me 4
dayes before the exam
‫جزاه هللا خيرا‬
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 night2
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 الحسين‬
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-2
Right lung=Boncheal breath+dullness+high vocal -3
resonance
Under built-4
ask about the right one
DD
INVESTIG
TTT
STATION 5
Loose motions for eight mounth&anaemia -1
10.5=serrogate
Coeliac
Irritable bowel syndrome
Intractable dry cough for 3 mounth=serrogate-2
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 ●
.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 10
.... .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

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
.2
.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
.20/18
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
20/18
Neuro
.Left sided Hemiplegia
.Couldn't complete examination
.Discussion messed up
.20/12
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
16/8
sta-2 - tremor , was simple got 20/20
result -- pass
last round Chennai 18.3.2016
Bilateral knee pain
Abdomen. APKD
Station 3 CVS MVR
CNS Facial palsy
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
Bilateral knee pain
Abdomen. APKD
Station 3 CVS MVR
CNS Facial palsy
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

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 61
AND 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 30
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 day2
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 /4
SLE c/o pluritic chest pain /5
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 started my exam by station 3
.. not time it
and misleading
) 20/7 ( I scored
Communication: 40 year old lady has IDDM her )4
)20/4( I scored
BCC1: psoriatic arthritis has joint pain.. has skin )5
..up
..DVLA
!!No
)28/24 ( I scored
Abd: kidney and pancreas transplant , has gum )1
History: 55 year old male with symptomatic anemia )2
.. and melena on ibuprofen for knees pain
) 20/19( I scored
..passed
..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
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

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 round2
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

amyloidosis
.address her fears
Station 5
disease
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 . .2
igive hypopit n auto neuropathy
metalic click igive dvr but friend said that it is mvr .3
--- .4
same as Hsu May Oo post --- .5
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 -2
refused HAART
My fren sat the exam 1st of march 2016
Myanmar centre, Day 1, Round 3

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, 84
h/o 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, 45
blurred 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 42
LFT. 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

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 -1
last less 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 *
History bloody diarrhea and arthritis .history of #
travel to Morocco
. colon
.Concern is it cancer like my grandfather
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
who shared their experiences before
Exam in Glasgow 2016
: New scanerio
:Station 4
But
further management
Is it serious
Is it cancer
Is there a cure
History station
Young female 28
Mixed with stool
Now last 10 days
Painless
No backache
No oral ulcers
No skin changes
No jaundice
Cousin IBD UC
Father CA colon
No blood thinners
No steroid
No warfarin
No weight loss
Concern : cause
? Is it cancer
? What next tests
? What Med
:DD
IBD ( UC)
Infective Diarrhoea
Antibiotic associated Diarrhoea
And
Asked
In
Fever
Vomit
But
He told
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 5
was 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 /2
Station 5 ●
Pt has SOB: Then found to have Wt loss, diarrhoea, /1
.thyroid nodule & neck scar
ALSO SOB: progressive then found to have RA on /2
.MTX
Station 5 ●
hypertension newly diagnosed with fatigue and /1
dizziness on telmesartan,o/e had postural hypotension
Young female with depression one day Hx of /2
epigastric pain and vomiting?? she took 16 Tabs
panadol intermittently
Sharjah
Station 5 ●
year old young man presented with excessive 27 /1
thirst
year old abdominal pain ..flatulence ...lethargic 22 /2
..family history of thyroid ..coeliac disease
Station 5 ●
A young lady with 4 attacks of hypoglycaemia not /1
diabetic her 2 siblings have DM on insulin
yrs old lady with gradual loss of vision with 60 /2
symptoms of increased intracranial pressure
Cairo
Station 5 ●
A 30 yrs old male with tiredness & feeling hot vital /1
.signs all 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 /2
.IFN & 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 /2
Station 5 ●
Pt e visual distunance /1
Had optic atrophy and spastic paraparesis ... MS
old lady e features of hypothyroidism and tender /2
thyroid ... Thyroiditis
Station 5 ●
.yr male c/o headache, blurring of vision 35 /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 45 /2
،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 28.. /2
with SO2: 88 and BP: 110/60….PE
Station 5 ●
osteoarthritis /1
Small joints of the hand and knee with heberden's
nodes
fundus /2
DM and Hypertension
Blurring of vision
Station 5 ●
Chest pain ( ischemia ) /1
Unstable angina or mi
Pain in both hands RA /2
Oman
Station 5 ●
Man with history of lithotripsy for renal stones /1
comes with excessive hunger and hypoglycemia
Normal blood pressure no findings in the neck
?MEN
Typical history of breast discharge and mentrrual /2
problems 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 & /1
abnormal vision -----> Prolactinoma
male with h/o renal stone ..presented with /2
hypoglycaemic 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 /2
.Acromegally but unless you look to pt many times
Station 5 ●
male 60 years old did routine blood check up , all /1
normal , high alkaline phosphate. . C/o decrease
hearing over years ... Clinically has sensory impairment
...? Paget disease
male of 50 years presented with weaknesses for Rt /2
side for 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 /2
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 /2
Station 5 ●
paget disease /1
Patient with high alkaline phosphate and hearing
difficulty
TIA with high BP RIGHT SIDED WEAKNESS AND /2
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 32
...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 smile
discussion was about AS causes in young pt, ‫رمز تعبيري‬
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 32
...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 ,
‫ رمز تعبيري‬offered her 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 -1
.history 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) -2
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

amyloidosis
.address her fears
Station 5
disease
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 ..16/2/25

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 60
over 3 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 23
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 2-1
:Duration needed for clinical experience
years or more will be perfect (seen people passed 2
without 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

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, 40
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 :1
diarrhea. pt 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 :2
and 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 -1
candisartan 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
2016/2/10
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 )2
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
2014 10 20
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 , 50 -
.diarrhea , lumps
O/E cachexic , pale , Generalized lymphadenopathy :::::
.DD
.yrs M with recurrent oral ulcer55 -
Hx of knee pain , sore eyes, painful skin rash over the
shin. ::: b
.Behčet D + DD

th april 2015 oman paces9
Station 5a 55yrs old lady with mechanical type back
ache post menupausal
b. 30yrs old lady with skin lesions neurofibromatosis 5
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 75
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
)Eliwa
St5
Skin disease with s o b
It was scleroderma with lung fibrosis and
pulm.hypertension
)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==
)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 80
stroke 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 1
stiffness... Dd. Polymyalgia rheumatica.. Polymylitis
nd... Neck swelling with dysphagia.. Solitary thyroid 2
nodule. 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 ♤

But



further management

Is it serious
Is it cancer
Is there a cure

16/16
History station at same centre ♧
Opening : 11 points
Discussion : as under
Young female 28

Mixed with stool
Now last 10 days
Painless
No backache
No oral ulcers
No skin changes
No jaundice
Cousin IBD UC
Father CA colon
No blood thinners
No steroid
No warfarin
No weight loss
Concern : cause
? Is it cancer
? What next tests
? What Med
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
And
Asked
In
Fever
Vomiting
But
He told
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 started my exam by station 3 ☆

.. not time it
and misleading
) 20/7 ( I scored
Communication: 40 year old lady has IDDM her )4 ☆

)20/4( I scored
BCC1: psoriatic arthritis has joint pain.. has skin )5 ☆


..up
..DVLA
!!No
)28/24 ( I scored
Abd: kidney and pancreas transplant , has gum )1 ☆


History: 55 year old male with symptomatic )2 ☆

.. anemia and melena on ibuprofen for knees pain
) 20/19( I scored

..passed

:UK experience of one colleague

🏽👇🏽👇
Castle Hill Hospital ‫اليوم امتحنت في‬

.. ‫ واللغة ما كانت ساهلة‬tough ‫االمتحان كان‬
...
‫حاكتب تجربتي ودعواتكم‬
Station 2》
the examiner
TB
bronchiactesis

He has hemiparesis
Not examin e nech
:CVS .3》

was soft
I told ACS
answer


..have mention it
:5》
Looks like morphea
scl
?Is it cancer
morphea
😥 nodules
I told dd
Mysthenia graves
:Station 1》
? abdomian pain

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.2
i told him i want to take travel H to exclude tropical .3
spastic paraparsis
MS (he asked me what against MS i told the age and .4
the 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 :D2
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 .1
stabbing with history of leg swelling last weak
score 26/28
neck swelling.2
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 .2
was my 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.2
coiliac.3
inflammtory bowel UC.4
autonmic diarrhea.4
panhypopitiurism.5
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 .1
could not 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 .2
striae; 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 .3
and 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 .4
her 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 .5

scar. Dual 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 .6
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 .7
case. I lost 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 .8
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 60
over 3 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
use. On examination also nothing was ‫ى‬steroid
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 23
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
2016/2
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 2
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 24
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
.History.2
unilateral Headache.in female 30 yr.not relieved by
.simple analgesics,pizotifen and sumatryptan
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
. 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
.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
.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
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
.bacteria.Time was up
28/24
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
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
DD of etiology was bronchiactssis, fibrosis, Abcess and
،malignancy
(germ cell, and Satcoma ) and workup also asked if he
infection and thrombosis PE
)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
)I got 16(
:History □
radiating to back
Gp letter mentioned high T bilirubin 70 and high all
Liver enzymes
and dengue, autoimmune hep, and malignancy
)I got 20(
:Station 3 □
CVS: old male has peripheral features of AR ☆
apex displaced
)I got 20(
: CNS ☆
A middle aged patient
Instruction was : this patient has problem lifting
objects
involvement

that I can't recall
)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
.usual aspirin and stop her oral feeding until he see her
.when outweighing benefits and risk of LMWH

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
)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
gastritis

?How do you know if the pacemaker is non functioning
)I got 28(
BCC 2 ☆
occurs at late night and early morning,no any other
stopped them both after got pregnant as she thought
،they're harmful
and FU with GP

😃 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
INR
Score 19/20
Abdomen
20/18
Chest
20 /8
Neuro
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
20/16
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
16/8
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
28
middle age pt with lower limb weakness with oral -2
ulcer
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
28
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
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
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
20/20
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
So when i entered i shaked hands i was blank,i greet
r u z daughter of ms.maha, she said no i am ms ،her
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
20/20
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 there is substance called k ,it is going to be
we need to monitor her closely. to give her the ،high
....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
16/16
: 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
28/26
:Bcc2
yrs male with facial weakness,vitals r normal 54
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
28/28
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
20/20
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
28/24
:Second st5
years old presented with polyurea 29
،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
28/25
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
20/18
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
20/17
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
20/19
‫هللا ولي التوفيق‬

:Station 1
)20/12( .component

:Station 2
)20/19(.solutions
:Station 3
)20/20( .standard
:Station 4
:Station 5
)28/28(

)28/25(
:Personal opinion

.uncommon
PACES everywhere

:Station 1
)20/12( .component
:Station 2
)20/19(.solutions
:Station 3
)20/20( .standard

:Station 4
:Station 5
)28/28(

)28/25(
:Personal opinion

.uncommon

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. 25
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
y.o male with headache, high blood pressure 30
(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)
UK EXPERIENCE

young female recurrent abdominal pain. Refered .1
.from 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 . 2
seizures . grossly no neurological deficit . I explained
،about diagnosis, ask about driving
.My experience at whipps cross hospital 31/8/2016

young female referred from surgical department due .1
.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
what is the cause.1
.why ultrasound normal.2
.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 2.25
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
.what you will do (scan +eeg).2
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
Best of luck and good wishes to all my friends in this
group

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Great Golden Guide12Th

**‫ وقد رشدا‬،‫مروا على جدثي يا أرشد هللا من غاز‬

@4@ !!!،،،ً ‫@ أيهــــا الغربـــــاء مهـــــال‬4@

OUR GROUPS ON FACEBOOK

Valuable & Precious MRCP PACES MATERIALS

Podcast and DoctorCast 38 audios

Pastest Paces Videos - By Ibrahim Elbialy

outside eating banana singing to amr diab walla

neuro station unbelievable

a 75yrs old man with cough and heamopytsis

BCC 1: from outside patient with eosinophilia

a26 yr lady with mild nausea

station 1 last station

My exam centre was in Kochi-Aster Medcity

My examination started from station 2 (History

Total score: 143/172

Pray for your Brother to Pass this exam.

Station 1: Respiratory was pulmonary fibrosis

Station 2: chest pain and nocturnal reflux

Station 3: Cardio: possibly MR or AS

Station 4: speak to wife of a patient who had a

2nd case: patient with chest pain with recent

BCC2 79 year old male with blurring of vision

Positive findings :as I mentioned above 👆🏻.

☆Stem:47 years female present with headache

ith physiotherapy and

MRCP PACES exam

I started with station 5

Malta cases today 7dec 2018

viva; work up and if its broncheictasis , what

chest: bibasal crackles with left shift of trachea,

GI: hepatosleenomegaly( huge spleen) ddx:

: History: 50 y/o female with h/o valvular

concerned about GI malignancy, she gave h/o

: St 4: dealing with son of an old guy who had

Diet 32018 Egypt

MY EXAM IN CHENNIA MADRAS MEDICAL

CHEST patient with sob exam left side back

SOBA TEACHING HOSPITAL -SUDAN

BCC 1: recurrent hemoptysis since 2 weeks, he

viva; work up and if its broncheictasis , what

chest: bibasal crackles with left shift of trachea,

GI: hepatosleenomegaly( huge spleen) ddx:

: History: 50 y/o female with h/o valvular

concerned about GI malignancy, she gave h/o

: St 4: dealing with son of an old guy who had

UK EXPERIENCE 11 / 11/ 2018

Firstly, I would like to express my warmest

¤ Neuro was Backer with asymetical limb

2nd canse 28 man with HTN ,DM, kidney ds

159 Total score

Abdomen: Renal Transplant

Station 2: Bloody diarrhoea after return from

Neuro: Spastic Paraparesis for DD

Station 4: Counsel for Post AF start of NOAC

Breathing Difficulty because of ILD secondary

Diet 32018 Egypt

#CV patient with chest pain on exam

BCC2 patient with diarrhea eating from outside

#Abdomen patient wiith av shunt with

#Thank you for sharing & good luck

Experience in MRCP PACES examination diet

ST 1 chest was a middle age lady. I noticed

ST 2 middle age lady has difficulties in