pace your MRCP-PACES

*ANNOUNCEMENT* Hello n salam everyone We are pleased to announce admissions for our *Aug 2023 online course ( 15 days ) for PACES MRCP (UK) new pattern PACES23 and CLINICAL EXAM MRCPI .* We will start from *7th of Aug and finish on 25 Aug* *Active slots available on first come--first served basis.* Listener slot available too. *Atleast 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions.* After the performance a detailed feedback will be given to elaborate the weak skills. It is equally beneficial for those who are beginners or have exam in coming diet. Interested candidates may send a personal message for details. WhatsApp No: 00923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

Hello dear colleagues I am travelling for a couple of days so please excuse me for some time. I am sorry for any inconvenience

*ANNOUNCEMENT* Hello n salam everyone We are pleased to announce admissions for our *Aug 2023 online course ( 15 days ) for PACES MRCP (UK) new pattern PACES23 and CLINICAL EXAM MRCPI .* We will start from *7th of Aug and finish on 25 Aug* *Active slots available on first come--first served basis.* Listener slot available too. *Atleast 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions.* After the performance a detailed feedback will be given to elaborate the weak skills. It is equally beneficial for those who are beginners or have exam in coming diet. Interested candidates may send a personal message for details. WhatsApp No: 00923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

*IMPORTANT 48* *For clinicalconsultations* Please remember For confirmation of diagnosis of seronegative spondylarthropathies presence of HLA B27 is mandatory ( alongwith negative automimune profile) so always mention it in investigation of these conditions as we may have patients having conditions mimicking them without HLA but we don't classify them as seronegative spondyarthropathy. PaceUrMRCP.

*IMPORTANT 47* *HAS-BLED Score* Hypertension (systolic blood pressure >160 mmHg) 1 Abnormal renal and liver function* (1 point each) 1 or 2 Stroke 1 Bleeding tendency/predisposition* 1 Labile INRs (if on warfarin)* 1 Elderly (eg, age >65 y) 1 Drugs or alcohol (1 point each)* 1 or 2 A HAS-BLED score of ≥3 indicates that caution is warranted when prescribing oral anticoagulation and regular review is recommended. *Abnormal renal function is classified as the presence of chronic dialysis, renal transplantation, or serum creatinine ≥200 mmolL. Abnormal liver function is defined as chronic hepatic disease (eg, cirrhosis) or biochemical evidence of significant hepatic derangement (bilirubin 2 to 3 times the upper limit of normal, in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase 3 times the upper limit normal, etc), history of bleeding or predisposition (anemia), labile INR (ie, time in therapeutic range <60%), concomitant antiplatelets or nonsteroidal anti-inflammatory drugs, or excess alcohol. PaceUrMRCP.

*IMPORTANT 46* *Some info about heart sounds* *The 1st heart sound (S1)* Represents closure of mitral and tricuspid valves. Splitting in inspiration may be heard and is normal. • *Loud S1* In mitral stenosis, because the narrowed valve orifice limits ventricular filling, there is no gradual decrease in flow towards the end of diastole. The valves are, therefore, at their maximum excursion at the end of diastole, and so shut rapidly leading to a loud S1 (the ‘tapping’ apex). S1 is also loud if diastolic filling time is shortened, eg if the PR interval is short, and in tachycardia. • *Soft S1* occurs if the diastolic filling time is prolonged, eg prolonged PR interval, or if the mitral valve leaflets fail to close properly (ie mitral incompetence). *The intensity of S1 is variable* in AV block, AF, and nodal or ventricular tachycardia. PaceUrMRCP.

*ANNOUNCEMENT* Hello n salam everyone We are pleased to announce admissions for our *Aug 2023 online course ( 15 days ) for PACES MRCP (UK) new pattern PACES23 and CLINICAL EXAM MRCPI .* We will start from *7th of Aug and finish on 25 Aug* *Active slots available on first come--first served basis.* Listener slot available too. *Atleast 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions.* After the performance a detailed feedback will be given to elaborate the weak skills. It is equally beneficial for those who are beginners or have exam in coming diet. Interested candidates may send a personal message for details. WhatsApp No: 00923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

*IMPORTANT 45* *Please remember for clinical consultations* *Massive pulmonary embolism can cause fainting* and has appeared quite often as a cause of fainting. So plz be alert and always try to get hints from the history. PaceUrMRCP

*IMPORTANT 44* *Some abnormalities of the JVP* • *Raised JVP with normal waveform* : Fluid overload, right heart failure. • *Fixed raised JVP with absent pulsation* : SVC obstruction. • *Large a wave* : Pulmonary hypertension, pulmonary stenosis. • *Cannon a wave* : When the right atrium contracts against a closed tricuspid valve, large ‘cannon’ a waves result. Causes—complete heart block, single chamber ventricular pacing, ventricular arrhythmias/ectopics. • *Absent a wave* : Atrial fibrillation. • *Large v waves* : Tricuspid regurgitation—look for earlobe movement. • *Constrictive pericarditis* : High plateau of JVP (which rises on inspiration—Kussmaul’s sign) with deep x and y descents. • *Absent JVP* : When lying flat, the jugular vein should be filled. If there is reduced circulatory volume (eg dehydration, haemorrhage) the JVP may be absent. PaceUrMRCP.

*IMPORTANT 43* Regarding JVP the pulsation is venous if it is • Usually impalpable, and obliterated by finger pressure on the vessel. • Rises transiently with pressure on abdomen (abdominojugular reflux) or on liver(hepatojugular reflux), and alters with posture and respiration (disappears when patient sits from lying flat). • Usually has a double pulse for every arterial pulse. ( Concomitantly palpate the arterial pulse ) paceUrMRCP .

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*ANNOUNCEMENT* Hello n salam everyone We are pleased to announce admissions for our *Aug 2023 online course ( 15 days ) for PACES MRCP (UK) new pattern PACES23 and CLINICAL EXAM MRCPI .* We will start from *7th of Aug and finish on 25 Aug* *Active slots available on first come--first served basis.* Listener slot available too. *Atleast 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions.* After the performance a detailed feedback will be given to elaborate the weak skills. It is equally beneficial for those who are beginners or have exam in coming diet. Interested candidates may send a personal message for details. WhatsApp No: 00923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

*Announcement for Online Session No 95* *30 July 2023* *WE WILL NOT RECORD THIS SESSION* DEAR DOCTORS : MAY I HAVE YOUR ATTENTION PLEASE : *Today we will have an online session on Zoom discussing 1 Clinical Consultation* regarding our preparation for MRCP PACES ( UK ) and MRCPI ( Ireland ) TIMINGS : Saudia Arabia: 4 00 pm Pakistan : 6 00 pm Bangladesh : 7 00 pm India : 6 30 pm Singapore : 9 00 pm Hong Kong : 9 00 pm Malaysia : 9 00 pm Egypt : 4 00 pm Libya : 3 00 pm Bahrain : 4 00 pm Burma ( Myanmar ) :7 30 pm Sudan : 3 00 pm UAE : 5 00 pm UK : 2 00 pm Ireland ( Dublin ) : 2 00 pm Afghanistan : 5 30 pm Kenya : 4 00 pm Germany ( Berlin ) : 3 00 pm Nigeria : 2 00 pm Japan ( Tokyo ) : 10 00 pm Denmark : 3 00 pm Qatar : 4 00 pm Oman : 5 00 pm Italy : 3 00 pm Indonesia : 8 00 pm Mauritius : 5 00 pm Iraq : 4 00 pm Texas Usa : 8 00 am Kuwait : 4 00 pm Sri Lanka : 6 30 pm Somalia : 4 00 pm ( please Google for your local time zones to avoid any inconvenience ) Zoom meeting link will be shared 5 minutes before start time. The candidate for today's session has been selected. GOOD LUCK.

*Announcement for Online Session No 95* *30 July 2023* *WE WILL NOT RECORD THIS SESSION* DEAR DOCTORS : MAY I HAVE YOUR ATTENTION PLEASE : *Tomorrow we will have an online session on Zoom discussing 1 Clinical Consultation* regarding our preparation for MRCP PACES ( UK ) and MRCPI ( Ireland ) TIMINGS : Saudia Arabia: 4 00 pm Pakistan : 6 00 pm Bangladesh : 7 00 pm India : 6 30 pm Singapore : 9 00 pm Hong Kong : 9 00 pm Malaysia : 9 00 pm Egypt : 4 00 pm Libya : 3 00 pm Bahrain : 4 00 pm Burma ( Myanmar ) :7 30 pm Sudan : 3 00 pm UAE : 5 00 pm UK : 2 00 pm Ireland ( Dublin ) : 2 00 pm Afghanistan : 5 30 pm Kenya : 4 00 pm Germany ( Berlin ) : 3 00 pm Nigeria : 2 00 pm Japan ( Tokyo ) : 10 00 pm Denmark : 3 00 pm Qatar : 4 00 pm Oman : 5 00 pm Italy : 3 00 pm Indonesia : 8 00 pm Mauritius : 5 00 pm Iraq : 4 00 pm Texas Usa : 8 00 am Kuwait : 4 00 pm Sri Lanka : 6 30 pm Somalia : 4 00 pm ( please Google for your local time zones to avoid any inconvenience ) Zoom meeting link will be shared 5 minutes before start time. Interested candidate may send a personal message to take the case. GOOD LUCK.

*IMPORTANT 42* Some Characters and volumes of pulse • *Bounding pulses* are caused by CO2 retention, liver failure, and sepsis. • *Small volume pulses* occur in aortic stenosis, shock, and pericardial effusion. • *Collapsing (‘waterhammer’) pulses* are caused by aortic incompetence, AV malformations, and a patent ductus arteriosus. • *Anacrotic (slow-rising) pulses* occur in aortic stenosis. • *Bisferiens pulses* occur in combined aortic stenosis and regurgitation. • *Pulsus alternans* (alternating strong and weak beats) suggests LVF, cardiomyopathy, or aortic stenosis. • *Jerky pulses* occur in HOCM. • *Pulsus paradoxus* (systolic pressure weakens in inspiration by >10mmHg) occurs in severe asthma, pericardial constriction, or cardiac tamponade paceUrMRCP.

*IMPORTANT 41* *Xanthomata* are localized deposits of fat under the skin, occurring over joints, tendons, hands, and feet. *Xanthelasma* refers to xanthoma on the eyelid *Corneal arcus* is a crescentic-shaped opacity at the periphery of the cornea. Common in those over 60yrs, can be normal, but may represent hyperlipidaemia, especially in those under this age. paceUrMRCP.

*IMPORTANT 40* *CHA2DS2 VASc stroke risk scoring system for non-valvular atrial fibrillation* Parameter Score C Congestive heart failure 1 point H Hypertension history 1 point A2 Age > 75 years 2 points D Diabetes mellitus 1 point S2 Previous stroke or Transint ischemic attack 2 points V Vascular disease 1 point A Age 65-74 years 1 point Sc Sex catagory female 1 point Maximum total score 9 points Annual stroke risk 0 point = 0 %no prophylaxis required 1 point= 1.3 % ( oral anticoagulation recomended in males only ) 2 points = > 2.2% ( oral anticoagulation recomended) paceUrMRCP.

*IMPORTANT 39* Please remember *NEUROPHYSICIANS/NEUROSURGEONS* might be considered as a Jargon by some of the examiners so be careful while using it in exam and always say *BRAIN DOCTOR/SURGEON* to your patient paceUrMRCP.