pace your MRCP-PACES

*🟦 ECG Logic in One Line 2* (by pace your MRCP – Dr Tanzeel Bukhari) *📌 One-Line ECG Rule:* “Peaked T waves are the earliest ECG sign of hyperkalaemia.” --- *Why this matters:* Hyperkalaemia follows a predictable ECG progression: 1️⃣ Tall, narrow, peaked T waves → earliest change 2️⃣ PR prolongation 3️⃣ QRS widening 4️⃣ Sine-wave → ventricular standstill --- *⭐ ECG Take-Home:* If you see tall peaked T waves → treat hyperkalaemia immediately.

*⚠️ Exam Technique Mistake 2 – Ignoring Patient’s Position Before Starting the Examination* (by pace your MRCP – Dr Tanzeel Bukhari) One of the most COMMON and costly PACES mistakes is starting the examination without adjusting the patient’s position. *🔹 What candidates do wrong:* Begin respiratory exam while the patient is half-lying Start cardiovascular exam without raising the bed Perform abdominal exam with the patient sitting up Forget to expose correctly before starting This immediately signals poor technique and unsafe practice to the examiner. --- *🔹 What examiners want to see:* A simple, safe, structured line: > “Let me adjust the bed and make sure you’re comfortable before we begin.” Then: Respiratory exam → patient at 45° Cardiovascular exam → 45° Abdominal exam → lying flat with pillow Lower limb exam → lying flat Neurology → depends on the system, but ALWAYS ensure comfort + correct angle --- *🔹 Why this mistake loses marks:* Suggests lack of structure Appears rushed Considered unsafe Reduces accuracy of findings --- *💡 PACES Tip:* Before touching the patient, ALWAYS think: “Bed angle – exposure – comfort – consent.” Examiners give marks for this even before the real exam starts

168.Dr Tan Wei Loon 167.Dr Muhammad Afkham ( MRCPI ) 166.Dr Ismail Fawaz ( MRCPI ) 165.Dr Javeria 164.Dr Adan 163.Dr Aisha 162.Dr Mehwish Touseef 161.Dr Mahabalraj 160.Dr Gouri. 159.Dr Nicholas 158.Dr Sashank Chavali 157.Dr Charles Chun 156.Dr Johnny Khor 155. Dr G Karthikeyan 154.Dr Irshad Khan 153.Dr Umamah 152.Dr Ammara Ansar 151.Dr Tasnuva Aman Khan 150.Dr Mohammed Akif Bin Haleem 149.Dr Adil Tahseen 148.Dr Meera Patil 147.Dr Ashini ( MRCPI ) 146.Dr Ali Moùsa ( MRCPI ) 145.Dr Naomi ( MRCPI ) 144.Dr Samreen Mazhar 143.Dr Sairam 142.Dr Priya 141.Dr Yousuf 140.Dr Moe Pwint Phyu 139.Dr Fahad Ul Fazal 138.Dr Ravi Bangeja 137.Dr Vamshidhar Vanam 136.Dr Hanadi ( MRCPI ) 135.Dr Azher ( MRCPI ) 134.Dr Noman Hossain 133.Dr Abhinav Meelu 132.Dr Nurul Islam 131.Dr kadhaum ibrahem 130.Dr Inayut 129.Dr Susovan Mitra 128.Dr Bhavesh Kaswala 127.Dr Rashid Ali Khan 126.Dr Bisma 125.Dr Samiah 124.Dr Madiha Mahmood 123.Dr Ratan Kumar 122.Dr Dilfuza Usmanova 121.Dr Mohd Hafiz 120.Dr Colin Cheah 119.Dr Kuan Yau Yeh 118.Dr Satesh Ramasundram 117.Dr Calvin 116.Dr Wan Mohamad 115.Dr Aravinthan Balakrishnan 114.Dr Athirah Azizol 113.Dr Massum 112.Dr Rafa Faaria Alam 111.Dr Benojeer Akter 110.Dr Sonal Karpe 109.Dr Shahla 108.Dr Muhammad Faizal 107.Dr Aisha Sohail 106.Dr Sheetal 105.Dr Anand Kumar 104.Dr Paul 103.Dr Ehsan Ul Haq 102.Dr Amna Gardezi 101.Dr Muhammad Rahib 100.Dr Shilpa 99.Dr Nagaraj Patil 98.Dr Vincent Jose ( MRCPI ) 97.Dr Hana Abdalla Adam Mohamed ( MRCPI ) 96.Dr Thanuja Alahakoon 95.Dr Farehah ( MRCPI ) 94.Dr Sankar Nath Jha ( MRCPI ) 93.Dr Saadia Khan 92.Dr Montasir Elmobark 91.Dr Kiran 90.Dr Ai Yun Loh 89.Dr Eow 88.Dr Lim 87.Dr Lalitha 86.Dr Ashwin Mathew 85.Dr Kasthuri 84.Dr Rohit 83.Dr Sangshaptak Saha 82.Dr Hira Jamil 81.Dr Santa Subhra Chatterjee 80.Dr Shishir 79.Dr Rubeya Ahmad 78.Dr Javaria Imran 77.Dr Rishi Gopalakrishnan 76.Dr Ramandeep Kaur 75.Dr Shakeel 74.Dr Shamla 73.Dr Murtaza 72.Dr Urvashi 71.Dr Urmimala Bhattacharjee 70.Dr Jayalakshmi 69.Dr Steffin Methai Kattor 68.Dr Yew 67.Dr Cyrin 66.Dr Farhat Nazneen 65.Dr Meenal 64.Dr Adil 63.Dr Umar Iftikhar 62.Dr Sohail ( MRCPI ) 61.Dr Amarnath duraikannan 60.Dr Maha 59.Dr Samar 58.Dr Sidra German 57.Dr Mahmood Akhtar 56.Dr Muhammad Hashim 55.Dr Manmohan 54.Dr Pooja 53.Dr Haithem Alghebra ( MRCPI ) 52.Dr Amna 51.Dr Nandhakumar 50.Dr Ew Ju Vern 49.Dr Mohamed Muslim 48.Dr Jerry John 47.Dr Majid Iqbal 46.Dr Phoebe 45.Dr Aimi N Zainudin 44.Dr Tahseen Azim 43.Dr Samina 42.Dr Suzi 41.Dr Samia 40.Dr Tan 39.Dr Kalpesh Kondalkar 38.Dr Sunil Abhishek 37.Dr Faiz Mashood ( MRCPI ) 36.Dr Sharalaa Engatramana 35.Dr Prasad ( MRCPI ) 34.Dr Kalyan Nath ( MRCPI ) 33.Dr Reshma Thalikan 32.Dr Aneesa Shahul 31.Dr Arooj 30.Dr Esraa Soliman 29.Dr Amitave Chatterjee 28.Dr Malik Dilaver 27.Dr Ravi 26.Dr Priya 25.Dr Mujtaba Waris 24.Dr Shaheen Noman 23.Dr Apoorv Tiwari 22.Dr Niaz 21.Dr Janaki 20.Dr Lavanya Devi Palaniswamy 19.Dr Waqas 18.Dr Sadaf Hammad 17.Dr Osama Abdelaziz 16.Dr Rajeev Sharma 15.Dr Nehal Kunjomoidu 14.Dr Steffy 13.Dr Mustafizur Rahman (MRCPI) 12.Dr Vareeja Kasibian 11.Dr Niya Jamaludheen 10.Dr Farook Abdelgioum 9.Dr Kamran Ali 8.Dr Anik Rahman 7.Dr Manoj Dodiyah 6.Dr Madhusha 5.Dr Komal Zahid 4.Dr Hina Shaikh 3.Dr Sameer Abdus Samad 2.Dr Saurabh Gaba 1.Dr Rithik Mohan

*Hall of fame PACES* *pace your MRCP-PACES* We are thankful to our respected colleagues who have made us proud by their success in PACES MRCP ( UK ) and PART 2 CLINICAL EXAM MRCPI. We believe that this number will keep on increasing. 352.Dr Faisal Khan 351.Dr Safwa 350.Dr Anil Kumar 349.Dr Hamza 348.Dr Amber Usama 347.Dr Mst. Tajlina Khatun 346.Dr Mumtaz Ahmed 345.Dr Saraswathi Kalki 344.Dr Bilal Azam 343.Dr Sofi Hafizi 342.Dr Asifa 341.Dr Amr Akef 340. Dr Ahmed Syed Hamadi 339.Dr Hotchand 338. Dr Sawson Abdeklaziz 337.Dr Ramsha Kashif 336.Dr Riaz 335.Dr Azima Sultana 334.Dr Mosab Yosef 333.Dr Abdul Rahman 332.Dr Syeda Fatima 331.Dr Alaa Hussein 330.Dr Usman 329.Dr Ahmad Khan 328.Dr Ayesha Zubair 327.Dr Choney Wangmo 326.Dr Awais Shafi 325.Dr Atefah 324.Dr Lacumi 323.Dr Mon Ei Ei Moe. 322.Dr Muhammad Hamza Sazeed 321.Dr Chan 320.Dr Anusri 319.Muhammad Nadeem Qureshi 318.Dr Sumeet 317. Dr Mohamed Peer 316.Dr Kholoud Algoshiti 315.Dr Tricia Lopez 314.Dr Aqtab 313.Dr Raghav Bansal 312.Dr Alston 311.Dr Shuvashis Saha Shuvo 310.Dr Muhammad Silarsab 309.Dr Jayasree 308.Dr Prabal 307.Dr Ananto Kumar 306.Dr Aparna 305.Dr Deepa Vanjari 304.Dr Priyanka Hinduja 303. Dr Jissa Mariam 302. Dr Anna Nalumansi. 301.Dr Jeevan Kumar 300.Dr Najee 299.Dr Mahmood 298.Dr Aathiyaa 297.Dr Asma Hussin 296.Dr Wajeeha 295.Dr Nahush chafekar 294.Dr Ong 293.Dr Rakesh 292.Dr Prabal Chakraborty 291.Dr Rahul Abir 290.Dr Suhanya 289.Dr Sowndhariya VA 288.Dr Bilal Hameed 287.Dr Swati Chouhan 286.Dr Mohammed Elfadil 285.Dr Ayondyuti Bora 284.Dr Mohammed Ali 283.Dr Abhishek Ghosh 282.Dr Mamun 281.Dr Noor Ul Nisa 280.Dr Taleea 279.Dr Marsin ( MRCPI ) 278.Dr Wania Rafaey 277.Dr Mohammed Omar Yousofzai 276.Dr Ayesha Javed 275.Dr Samia 274.Dr Durga Rao 273.Dr Vinayraj 272.Dr Kartiben Nagarajan ( MRCPI ) 271.Dr Alaa Hussein ( MRCPI ) 270.Dr Haleem Baksh 269.Dr Upasana 268.Dr T Nivethitha 267.Dr R Kavitha 266.Dr Olufemi Pirisola 265.Dr Afia Tani 264.Dr Fatema Tuj Johara 263.Dr Saneeya Shafaat 262.Dr Kumar Santosh Sekhani 261.Dr Mohammed Imran Undre 260.Dr Shahina Saleem 259.Dr Zahid Ahmed Khan 258.Dr Muhd Ilham Azib 257.Dr Puteri 256.Dr Versha 255.Dr Usman Rasheed 254.Dr Lee Ling Wei 253.Dr Warda 252.Dr Shaista Qamar 251.Dr Nusayba Mustafa 250.Dr Shakilone Tharmaseelan 249.Dr Fatema 248.Dr Yousry Yousif ( MRCPI ) 247.Dr Shilpi Shukla 246.Dr Dibbs 245.Dr Shaon Sikder Tutu 244.Dr Lakshmi J 243.Dr Tamrina Parvin 242.Dr Aiman Nasir 241.Dr Asad Saleem 240.Dr Ali Tanvir Rahat Haque 239.Dr Shoaib 238.Dr Zainab Mahmood 237.Dr Khaing Pyae Pyae Win 236.Dr Mansoor 235.Dr Harini 234.Dr Ben Cheah 233.Dr Parichatra 232.Dr Sabreen Mohammed 231. Dr Soe Min Maung 230.Dr Aniruddha Jog 229. Dr Praveen Kumar 228.Dr Samson Charan 227.Dr Riyaz 226.Dr Geethika 225.Dr Adeyemo Abiodun Waliyullah 224.Dr Dipika 223.Dr Raihan 222.Dr Rafeea Shah 221.Dr Jason 220.Dr Ashiru Sikirat Yetunde 219.Dr Ghulam 218.Dr Mehwish Usman 217.Dr Lau Wen Jie 216.Dr H.Kumara 215.Dr Darshini 214.Dr Geetha 213.Dr seema 212.Dr Akheri Parvin 211.Dr Syed Najam Al Hassan Shah 210.Dr Umair 209.Dr Rakhwin Sandhu 208. Dr Raymond Madzivanyika 207.Dr Nabeel 206.Dr Sidra Aslam 205.Dr Narendra 204.Dr Rashmy Arun 203.Dr Sandhya 202.Dr Narayanee Rajasekaran 201.Dr Ismail Fawaz 200.Dr Daphnie 199.Dr Stephen Ponnampalam 198.Dr Mohammed Ahmed 197.Dr Yasmin Yusuf 196.Dr Praveetha 195.Dr Sarthak Rastogi 194.Dr Ahammed Ashar 193.Dr Mohamed Abdullahi 192.Dr Sankar Nath Jha 191.Dr Asim 190.Dr Chia 189.Dr Md Kabir Udin 188.Dr Khai Leng 187.Dr Shaima Bashir 186.Dr Joel Quadros 185.Dr Suroop Chand 184.Dr Mayesha 183.Dr Poornima Nair 182.Dr Munira 181.Dr Maryam Abdalla 180.Dr Kokila 179.Dr Thushani 178.Dr Irfan Ahmad Mir 174.Dr Mohammed Abubaker 173.Dr Asrul 172.Dr Toqeer Bhatti 171.Dr Elanchezian 170.Dr Muthumani 169.Dr Muhammad Idrees

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*🗣️ Patient Explanation Skill – Explaining High Blood Pressure* (by pace your MRCP – Dr Tanzeel Bukhari) *🧠 Scenario:* A patient’s repeated readings show high blood pressure. They look anxious and ask: > “Doctor, is this serious? Will I need medicines forever?” --- *✅ How to Explain High Blood Pressure in PACES* *1️⃣ Start with reassurance* “I want to reassure you — your blood pressure is high, but it’s manageable, and you’re not in immediate danger.” *2️⃣ Explain what it means* “High blood pressure means your heart is having to work a bit harder to push blood around your body. Over many years, this can increase the risk of stroke, heart disease, and kidney strain — but we can prevent these complications by controlling it early.” *3️⃣ Give a clear plan — structured and practical* “We’ll manage it in two ways: a) Lifestyle changes Reduce salt Regular walking Weight control Avoid smoking Manage stress These alone can bring the BP down significantly. b) Medication “Because your readings are consistently high, starting a tablet will help protect your heart and prevent long-term problems. Most BP medicines are safe and well-tolerated.” *4️⃣ Address the biggest fear: “lifelong medication”* “You may not need it forever. If your readings improve with lifestyle changes, we can reduce or even stop the medication. We will review it regularly together.” *5️⃣ Check understanding and offer partnership* “I want to work with you on this. Do you have any worries about taking medication or changing your lifestyle?” --- *💡 PACES Tip:* Examiners look for: Reassurance Avoiding panic Mentioning long-term risk without scaring A structured plan (lifestyle + medication) Checking understanding

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*✔️ True or False 2 – Statements.* (by pace your MRCP – Dr Tanzeel Bukhari) 1️⃣ A normal chest X-ray excludes a pulmonary embolism. 2️⃣ In COPD exacerbation, oxygen should be targeted to 88–92%. 3️⃣ Wheeze is always due to asthma. 4️⃣ Silent chest in asthma is a life-threatening sign.

*🧠 Match the Pairs 2 – Cardiology.* (by pace your MRCP – Dr Tanzeel Bukhari) Match the clinical presentation (A–E) with the most likely diagnosis (1–5). *A* . Sudden palpitations + narrow-complex tachycardia *B* . Exertional chest pain relieved by rest *C* . Sudden tearing chest pain radiating to the back *D* . Pedal oedema + raised JVP + basal crackles *E* . Syncope during exercise in a young adult *1* . Aortic dissection *2* . Hypertrophic cardiomyopathy (HOCM) *3* . SVT (Supraventricular Tachycardia) *4* . Stable Angina *5* . Congestive Cardiac Failure

Photo from Dr Tanzeel Bukhari

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*🗣️ Communication Scenario 2 – Explaining a New Diagnosis of Type 2 Diabetes* (by pace your MRCP – Dr Tanzeel Bukhari) *🧠 Scenario:* You are seeing a 52-year-old patient whose blood tests confirm Type 2 Diabetes. The patient looks worried and asks: > “Does this mean my life is going to change completely?” --- *✅ How to explain it (safe, empathetic, structured — without making it a bad news)* *1️⃣ Start with reassurance — soften the emotional impact* “Firstly, I want to reassure you — this is not bad news, and it does not mean something serious or dangerous has happened today.” *2️⃣ Acknowledge feelings* “It’s natural to feel worried when you hear the word diabetes, and I completely understand.” *3️⃣ Give simple, positive, balanced information* “Your blood test shows Type 2 Diabetes, which means your body is not using insulin as effectively as it should. But the important point is: It is very manageable, Many people lead completely normal lives, And we will work together to control it step by step.” *4️⃣ Outline a clear plan (gives control and reduces fear)* Improving diet and activity Starting metformin if needed Monitoring HbA1c every 3–6 months Annual eye, kidney, and foot checks *5️⃣ Address the patient’s fear directly* “This diagnosis does not mean your life will drastically change. You won’t lose your routine or freedom — we just need some gradual adjustments.” *6️⃣ Check understanding & explore concerns* “Can you share what worries you the most so I can help clarify it?” --- *💡 PACES Tip:* When giving a diagnosis like Type 2 Diabetes, always combine: Reassurance + Normalisation + Clear plan, so the patient never feels it is a “bad news conversation.”

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*🩺 Case of the Week 2 – Neurology* (by pace your MRCP – Dr Tanzeel Bukhari) *🧠 Scenario:* A 45-year-old man presents with progressive unilateral facial weakness over 24 hours. He cannot close his right eye fully, struggles to smile, and reports altered taste. No limb weakness, no fever, and no ear pain. *O/E:* Right LMN facial palsy Forehead involved No other cranial nerve deficits Limb exam normal --- *❓ Question:* What is the most likely diagnosis, and what key steps are needed in immediate management? --- *✅ Answer:* 🔹 Most likely diagnosis: Bell’s palsy (LMN facial nerve palsy) *🔹 Key management steps:* 1️⃣ Prednisolone within 72 hours 2️⃣ Eye care: lubricating drops + eye patch at night 3️⃣ Check for red flags (rash, vesicles → consider Ramsay Hunt) 4️⃣ Safety-net: return if worse or no improvement in 3 weeks --- *💡 PACES Tip:* Always differentiate between UMN vs LMN facial palsy: Forehead spared → UMN Forehead involved → LMN (Bell’s palsy)

🩺 Case Discussion 2 – Sudden Shortness of Breath (by pace your MRCP – Dr Tanzeel Bukhari) 🧠 Scenario: A 62-year-old woman presents with sudden onset shortness of breath while walking to the bathroom. She describes pleuritic chest pain, mild cough, and feels anxious. O/E: RR 28/min, HR 112/min, BP 128/82, SpO₂ 90% on air; chest is clear, calves slightly tender. ❓ Question: What are the top differentials, and what is the best next investigation? --- ✅ Answer: 🔹 Most likely diagnosis: Pulmonary embolism (PE) — sudden dyspnoea + pleuritic pain + tachycardia + calf tenderness 🔹 Other differentials: Pneumothorax (less likely: chest clear, stable BP) Pneumonia (no fever, cough mild) Anxiety/hyperventilation (SpO₂ too low for this) 🔹 Best next investigation: CT Pulmonary Angiography (CTPA) If unstable → bedside Echocardiography for RV strain 💡 PACES Tip: For sudden breathlessness + clear chest, always think PE first.

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*🩺 Management Essential 2 – Acute Severe Asthma (Adult)* (by pace your MRCP – Dr Tanzeel Bukhari) Acute severe asthma is a medical emergency. Early structured management saves lives. *🔹 Immediate Management* (ABCDE-based) 1️⃣ High-flow oxygen to maintain SpO₂ 94–98% 2️⃣ Continuous nebulised salbutamol (or back-to-back nebs) 3️⃣ Add ipratropium nebuliser every 20–30 min 4️⃣ Give IV hydrocortisone (or oral prednisolone if able) 5️⃣ Consider IV magnesium sulphate if poor response 6️⃣ Start frequent PEFR monitoring 7️⃣ Assess for exhaustion (silent chest, rising CO₂ → life-threatening) *🔹 Investigations* Peak flow ABG if no improvement Chest X-ray (if complications suspected) *🔹 When to admit to HDU/ICU* Persistent hypoxia Rising PaCO₂ Silent chest Altered consciousness Failure to respond to initial therapy *💡 PACES Tip:* Always mention oxygen, bronchodilators, steroids, magnesium, and admission criteria. This shows structured emergency management.

*🧠 Mnemonic 2 – Causes of Hypercalcaemia (CHIMPANZEES)* (by pace your MRCP – Dr Tanzeel Bukhari) Use the classic mnemonic CHIMPANZEES to recall the major causes of hypercalcaemia: C – Calcium supplements H – Hyperparathyroidism (primary/tertiary) I – Iatrogenic (thiazides, lithium) M – Milk-alkali syndrome P – Paget’s disease A – Acromegaly / Addison’s disease N – Neoplasms (myeloma, bone mets) Z – Zollinger–Ellison syndrome E – Excess vitamin D E – Excess vitamin A S – Sarcoidosis / granulomatous diseases --- *💡 PACES Tip:* When a patient presents with bones, stones, groans, or psychiatric overtones, always think hypercalcaemia and quote CHIMPANZEES.

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