Neurology

The neurology section of the PACES examination is often the major cause of (unnecessary!) anxiety for MRCP candidates. The key is to approach the patient in a logical fashion. Some neurology cases are simply an exercise in pattern recognition – noticing the frontal balding and ptosis of myotonic dystrophy, the distal wasting and pes cavus of Charcot–Marie–Tooth disease, for example. However, in those cases without obvious clues to the underlying diagnosis, a clear systematic approach will usually pay dividends. When faced with a neurological problem, the first question that should be posed is the site of the lesion. During the course of the examination, identify signs that might help in localization: • Cortex: signs of dysfunction of higher cognitive function. • Subcortical: upper motor neuron (UMN) signs (hypertonia, pyramidal pattern of weakness, hyper-reflexia, extensor plantars), slowness of thought. • Basal ganglia: cogwheel rigidity, resting tremor, bradykinesia, postural instability, dyskinesias, dystonias. • Brainstem: cranial nerve abnormalities with contralateral UMN signs. • Cerebellum: gait ataxia, nystagmus, finger-nose ataxia, past-pointing. • Spinal cord: bilateral UMN signs, presence of a sensory level. • Nerve root: lower motor neuron (LMN) signs (wasting, weakness, hyporeflexia, sensory loss) in a myotomal or dermatomal distribution. • Single or multiple nerve/plexus: LMN signs that are focal, and are not consistent with a nerve root lesion. • Polyneuropathy: LMN signs, more pronounced distally, affecting the legs more than the hands, diminished reflexes, sensory signs. • Neuromuscular junction: weakness without sensory involvement or significant wasting, usually but not invariably proximal, which fluctuates (either with time of day or during the course of the examination). • Muscle: wasting and weakness with normal reflexes and sensation. Once the lesion has been localized, consider the disease processes that commonly affect that site. Clues may be obtained from the history, if you are permitted to ask questions. The most helpful aspect of the history is usually the speed of onset: • Seconds: electrical disturbance (i.e. epilepsy), trauma. • <5 minutes: infarction. • > 5 minutes: migraine, haemorrhage. • Minutes–hours: infection, inflammation, drugs. • Hours–days: infection, inflammation, nutritional, drugs.

MRCPI

The MRCPI part 2 clinical examination is the final hurdle in the membership trilogy, and can be viewed as a practical interview before entering higher specialist training. It is equivalent to the UK PACES; however, there are some important variations in its format, and this chapter will guide a candidate through the appropriate preparation required to succeed in the examination. Unlike the written examination, it affords examiners a relatively short period of time to judge a candidate’s history taking and examination skills. They must also evaluate a candidate’s ability to formulate differential diagnosis, investigations and management plans. The examiners will also ‘get a feel’ for the candidate’s confidence, and their empathy in dealing with patients. The examination is generally fair in that the examiners try to find out what the candidate knows, rather than try to catch them out. It is important to realize, however, that each examiner will vary in their personality, patience and style of examining. While some may forgive or overlook an outlandish candidate response during questioning, others may choose to further expose a potential weakness. The aim of this chapter is to provide a comprehensive approach to the MRCPI ‘long case’. The format and approach to MRCPI short cases will also be addressed in brief. Whilst the basic principles of history taking do not differ between the 2 examinations, it is important to note that candidates are given a fixed 15 minutes for the history-taking station on the PACES examination, whereas MRCPI candidates have 45 minutes for history and examination. In light of this, we have adapted the timing of the history-taking pro forma, permitting a more in-depth exploration of certain aspects of the history. As a coherent presentation of the history and examination is crucial to the success of the candidate, particular importance has been given to not just what to say, but also how to say it. The first case, therefore, is a fully detailed dialogue between candidate and patient, and provides a foundation for the general manner of successful history taking.

Brief clinical consultation

The brief clinical consultation station, which was introduced in the 3rd diet of the PACES examination in 2009, aims to assess the way in which the candidate approaches a clinical problem in an integrated manner, using history taking, examination and communication with a patient or a surrogate patient. The objective of this station is to reflect the way in which clinical problems are considered in the ward, emergency medical admissions unit, or medical outpatient clinic in normal clinical practice. During this station the candidate will be assessed on their ability to focus on the most important parts of history and examination when posed with a clinical problem. In addition, the candidate will be expected to explain their management plan succinctly to the patient and answer any questions they might have. Careful preparation for this station is vital, particularly as it carries a third of the overall marks of the PACES examination. There are 2 cases in this 20-minute station – each lasting 10 minutes. Candidates will be given written instructions for each of the 2 cases, usually in the form of short notes or referral letters, during the 5-minute interval before this station. During this time candidates ought to draw up a list of differential diagnoses based on the presenting complaint. They should plan the questions that they will need to ask and the most important aspects of the clinical examination that they will be required to perform in order to enable them to differentiate between these diagnoses. The timekeeper will sound a bell to signal the start of the station and 1 examiner will take the candidate into the first of the 2 cases. Candidates will have 8 minutes to take a focused history, carry out a relevant examination, and respond to the patient’s concerns. After 6 minutes have elapsed, candidates will be alerted that they have 2 minutes left with the patient. During the remaining 2 minutes, an examiner will ask the candidate to describe the positive physical findings and discuss the preferred diagnosis and any differential diagnosis as well as the management plan.

History taking

Welcome to station 2, history taking. We would like to start by saying that having worked very hard to pass the written papers you deserve to be sitting this prestigious exam and PACES is an opportunity to perform as a clinician and formally demonstrate your unique clinical skills that make you an excellent physician. History taking is traditionally an area of the PACES exam that candidates find very difficult. Taking a good history from a patient is the most fundamental skill of a training physician and PACES candidates often feel that their general daily work practice is adequate preparation for this station. This is not the case, despite most candidates being well skilled in clerking a patient from A&E or clinic where few limitations apply. Unfortunately, faced with strict time constraints, exam anxiety and often deliberately unusual scenarios, poorly prepared PACES candidates may demonstrate a fundamental weakness in what should be a basic part of physician training. Do not devalue your chance of success in the PACES examination by poor preparation or anxiety. The practice needed in order to succeed in the history taking station should not be underestimated. As well as running out of time, a candidate’s main concern is the broad range of scenarios that can be chosen as an examination topic and this can easily unsettle and panic even the best prepared. This chapter offers a structured approach that will help to alleviate this fear. The stopwatch begins once a candidate has been handed the scenario (usually in the form of a letter addressed to the candidate from another healthcare practitioner). • 5 minutes private preparation – candidate then called into the exam room. • 14 minutes with the patient being observed by examiners. • 1 minute of personal reflection time. • 5 minutes for questions from the examiners. The initial preparation period is of huge importance and when sitting PACES, we would suggest using the structured template in Fig. 4.1 which can be adapted to any scenario given to a PACES candidate in the exam. We would encourage you to memorize this template for reproducibility during this preparation time.

Respiratory

The MRCP PACES respiratory station offers an opportunity to demonstrate a slick examination technique that is performed on practically all patients. Respiratory diseases, after cardiovascular and musculoskeletal complaints, are the third most common cause for presentation to either the Emergency Department or the general practitioner (GP) and remains proof of the concept that ‘common things are common’. Respiratory disease can be generally divided into 3 major categories: airways, parenchymal and pleural disease. We have aimed to structure the following chapter to reflect this. Certain ‘high-yield’ or ‘favourites’ that recur in the PACES examination are covered in this section. During PACES, examiners assess your ability to both elicit and then correctly interpret physical signs. A general sense exists that a decision to pass or fail a candidate rests on an aura of competence (or incompetence!) during the clinical performance. In essence, the examiners are looking for you to demonstrate correct techniques whilst eliciting the signs and logical thinking when interpreting them. Therefore, eliciting the physical signs is only the first step; the interpretation and presentation are equally, if not more, important. With this in mind, the following useful general points should be considered: • The respiratory examination does not need to be a lengthy one. Start at the peripheries with the hands and then move to the back (unless specifically advised otherwise by your examiners). Traditionally the physical examination starts with the anterior chest but it is perfectly acceptable to do the back first then return to the front (most signs and clues to the diagnosis e.g. scars, will be detected by examining the posterior chest). • A 6-minute period is allowed for the examination portion of the station and it is our advice to spend the first 2 minutes examining the patient from a general perspective (including full inspection, hands and face) then the second 2 minutes on the posterior chest and the final 2 minutes on the anterior chest. As time is limited, palpate for features of pulmonary hypertension or right-sided heart failure at the anterior chest, before moving to the respiratory signs.

Communication skills and ethics

The communication skills and ethics station aims to assess your ability to guide and organize an interview with a patient, relative or surrogate (such as a healthcare worker). The skills specifically tested in this station include: • Clinical communication skills • Managing patients’ concerns • Clinical judgement (including knowledge of ethics and law) • Managing patient welfare. Written instructions are provided for the scenario during the 5-minute interval before the station starts. 14 minutes are allowed for the patient interaction, followed by 1 minute for the candidate to reflect their thoughts. A 5-minute discussion with the 2 examiners will then take place after the patient has left the station. Each examiner has a structured marksheet for the case. • Approach the station as a 2-way discussion rather than a rigid ‘tick-box task’. • Set aside time each week to practise scenarios with colleagues under timed conditions. • Familiarize yourself with recent NICE guidance (especially with new or controversial or rationed treatments) and DVLA advice. • Remember that skills needed in this station are also particularly applicable to those required in station 2 (history taking) and station 5 (brief clinical consultations), and it is therefore essential that you spend adequate time practising these skills to maximize your performance in the examination. • Identify key issues that need to be addressed during the consultation (e.g. breaking bad news) as well as ‘hidden clues’ (e.g. a single parent may have concerns regarding childcare if she herself is admitted to hospital). • Make notes during this time, but avoid the temptation to make notes during the consultation itself, as it distracts from the flow of the discussion. • Start with open-ended questions and establish the patient’s understanding, knowledge and concerns at an early stage – these are all specifically mentioned in the clinical marksheet. • Use ‘2-way acting’ where appropriate – you can improvise within reason to aid the flow and realism of the consultation (e.g. ‘Are you feeling better since I saw you on the ward last week?’).

Cardiology

A useful mnemonic for any examination routine is HELP. Every case should begin with: • Hello: introduce yourself to the patient and explain what you are going to do. • Expose: expose the patient adequately for the proposed examination but with utmost care to preserve the patient’s modesty and dignity. For the cardiovascular examination, you need to expose from the waist up as well as the arms, and the lower limbs. Once you have finished inspecting, cover the patient up to avoid exposing for an unnecessary length of time. • Lighting: a spotlight should be shone upwards at the neck at 45 ° (90 ° away from your viewing angle) to enable you to maximize the chances of seeing any pulsations. • Pain and Position: always ensure that the patient is comfortable and is appropriately positioned at 45 ° to enable accurate assessment of the venous pressure. 1. Look at the patient from the end of the bed and don’t forget to look around the bed for additional clues. Vital clues such as a raised JVP can be identified at an early stage with appropriate inspection. 2. Check hands, nails, lips, mouth and conjunctivae for peripheral signs of possible cardiac disease. 3. Feel the radial pulse noting the 5 features (rate, rhythm, character, volume and nature of the vessel wall, then feel both radial pulses simultaneously, eliciting for radial–radial delay or a difference in volume between the 2 sides. Then assess for radial–femoral delay. While you are doing this, look for the JVP at the same time. 4. Check for a collapsing pulse. (This is frequently forgotten by candidates.) 5. Palpate the apex, noting position and character – if you can’t feel it, be honest, but remember to check on the right! 6. Listen at the apex remembering to time against the carotid pulse and while you are doing this note for any abnormality (slow-rising, bisferiens, jerky). If you hear a systolic murmur, check for radiation to axilla. If you don’t hear a diastolic murmur, listen with the bell and if necessary perform the reinforcement manoeuvres described later.

Abdomen

The abdominal station in MRCP PACES should be a ‘set piece’ that can be approached with confidence. You are likely to encounter patients with chronic stable disease such as chronic liver disease, haematological malignancy with associated hepatosplenomegaly and chronic kidney disease, particularly those undergoing some form of renal replacement therapy, for instance dialysis or transplantation. Signs in the abdomen are generally straightforward to elicit and the commonest obstacles to passing are poor presentation or a failure to put the features together in a logical fashion. Many diagnostic findings in the abdominal station can be identified by inspection alone, so particular attention should be paid to adequate exposure and the identification of extra-abdominal signs (e.g. multiple spider naevi of chronic liver disease, telangiectasia of hereditary haemorrhagic telangiectasia and xanthelasmata in primary biliary cirrhosis). Do not forget to have a good look at the back as important signs may be restricted there (e.g. spider naevi or posterior nephrectomy scars). During the observation phase, attention should be paid to the nutritional status of the patient and to any other available clues (for instance, one of the authors, BA, diagnosed bilateral adrenalectomies from a medic alert bracelet at the bedside in his MRCP exam). The presence of abdominal scars is very useful as they usually overlie the organs that have been surgically handled. Whist surgery is frequently concerned with resecting parts or the whole of organs, remember that organs, including kidneys, pancreas and liver, may also be transplanted. As a result of a detailed end-of-the bed examination, sufficient information may be garnered to allow a diagnosis to be formulated, with subsequent palpation, percussion and auscultation, simply confirming the suspected diagnosis. Keep to a well-practised order to produce a fluid display which you should be able to complete in around 5 minutes. 1. Introduce yourself to the patient and lie them down if this has not already been done. Ask if there is pain or tenderness anywhere. 2. Inspect the patient from the end of the bed. Ensure that you look for any additional clues, such as those around the bedside.

Introduction

The Royal College of Physicians was founded by royal charter of King Henry VIII in 1518. For nearly 500 years it has engaged in a wide range of activities dedicated to its overall aim of upholding and improving standards of medical practice. The examination for the Membership of the Royal College of Physicians (MRCP) (London) was first set in 1859. The Royal College of Physicians (Edinburgh) and the Faculty of Physicians and Surgeons of Glasgow introduced their own professional examinations in 1881 and 1886 respectively. A need to have a unified membership examination throughout the United Kingdom (UK) was identified in the late 1960s, following which the first joint examination took place in October 1968. The MRCP(UK) subsequently developed into the current internationally recognized three-part examination. From 2001, the five-station PACES (Practical Assessment of Clinical Examination Skills) examination was introduced, replacing the traditional long case, short cases and viva format. The rationale for this change was to standardize the candidate experience, to permit direct observation of candidate–patient interaction throughout the examination, and to place added emphasis on the assessment of communication skills. The MRCP(UK) format evolved further in 2009. In response to the development of competency-based training and assessment, the key components of the examination were redefined as seven ‘core clinical skills’: A) Physical examination B) Identifying physical signs C) Clinical communication skills D) Differential diagnosis E) Clinical judgement F) Managing patients’ concerns G) Maintaining patient welfare. Each ‘core clinical skill’ is assessed at several different stations of the PACES examination and the marks for each ‘skill’ are integrated. A minimum pass mark for each ‘core clinical skill’ was introduced to ensure that candidates who scored poorly in one ‘core clinical skill’ area could not pass the examination by scoring highly in another skill (a compensatory marking system had existed prior to 2009). Furthermore, the requirement to obtain a minimum overall test score has been maintained. At the time of writing this book, a score of 130/172 was required to pass.