pace your MRCP-PACES

*IMPORTANT 94* Please remember The symptoms of hypermagnesiumia can mimic Botulism. paceUrMRCP.

*IMPORTANT 93* *Be careful while eliciting Clonus in lower limbs* Plantar flex the foot then quickly dorsiflex and hold. More than 3 beats of plantar flexion is sustained clonus and is abnormal. Clonus can also be elicited at the patella with rapid downward movement of patella but please don,t do it in PACES. Hypertonia and clonus suggest an upper motor neuron lesion. paceUrMRCP.

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*Announcement for Online Session No 98* *27 Aug 2023* *WE WILL NOT RECORD THIS SESSION* DEAR DOCTORS : MAY I HAVE YOUR ATTENTION PLEASE : *Today we will have an online session on Zoom for GENERAL DISCUSSION about Clinical Consultation and Communication* regarding our preparation for MRCP PACES ( UK ) and MRCPI ( Ireland ) TIMINGS : Saudia Arabia: 3 00 pm Pakistan : 5 00 pm Bangladesh : 6 00 pm India : 5 30 pm Singapore : 8 00 pm Hong Kong : 8 00 pm Malaysia : 8 00 pm Egypt : 2 00 pm Libya : 2 00 pm Bahrain : 3 00 pm Burma ( Myanmar ) :6 30 pm Sudan : 2 00 pm UAE : 4 00 pm UK : 1 00 pm Ireland ( Dublin ) : 1 00 pm Afghanistan : 4 30 pm Kenya : 3 00 pm Germany ( Berlin ) : 2 00 pm Nigeria : 1 00 pm Japan ( Tokyo ) : 09 00 pm Denmark : 2 00 pm Qatar : 3 00 pm Oman : 4 00 pm Italy : 2 00 pm Indonesia : 7 00 pm Mauritius : 4 00 pm Iraq : 3 00 pm Texas Usa : 7 00 am Kuwait : 3 00 pm Sri Lanka : 5 30 pm Somalia : 3 00 pm ( please Google for your local time zones to avoid any inconvenience ) Zoom meeting link will be shared 5 minutes before start time. GOOD LUCK.

*Announcement for Online Session No 98* *27 Aug 2023* *WE WILL NOT RECORD THIS SESSION* DEAR DOCTORS : MAY I HAVE YOUR ATTENTION PLEASE : *Tomorrow we will have an online session on Zoom for GENERAL DISCUSSION about Clinical Consultation and Communication* regarding our preparation for MRCP PACES ( UK ) and MRCPI ( Ireland ) TIMINGS : Saudia Arabia: 3 00 pm Pakistan : 5 00 pm Bangladesh : 6 00 pm India : 5 30 pm Singapore : 8 00 pm Hong Kong : 8 00 pm Malaysia : 8 00 pm Egypt : 2 00 pm Libya : 2 00 pm Bahrain : 3 00 pm Burma ( Myanmar ) :6 30 pm Sudan : 2 00 pm UAE : 4 00 pm UK : 1 00 pm Ireland ( Dublin ) : 1 00 pm Afghanistan : 4 30 pm Kenya : 3 00 pm Germany ( Berlin ) : 2 00 pm Nigeria : 1 00 pm Japan ( Tokyo ) : 09 00 pm Denmark : 2 00 pm Qatar : 3 00 pm Oman : 4 00 pm Italy : 2 00 pm Indonesia : 7 00 pm Mauritius : 4 00 pm Iraq : 3 00 pm Texas Usa : 7 00 am Kuwait : 3 00 pm Sri Lanka : 5 30 pm Somalia : 3 00 pm ( please Google for your local time zones to avoid any inconvenience ) Zoom meeting link will be shared 5 minutes before start time. GOOD LUCK.

*IMPORTANT 92* Please remember: While inspecting lower limbs in a case of lower limb examination, always check either any of the limb is smaller as compared to the other one. This may happen in POLIO which is not uncommon in PACES specially in some asian centers. paceUrMRCP.

*IMPORTANT 91* *Few things never to be missed while examining GAIT* 1.Ask patient to walk a few metres, turn, and walk back to you. 2.Note use of walking aids, symmetry, size of paces, arm swing. 3.Ask patient to ‘walk heel-to-toe as if on a tightrope’ to exaggerate any instability. 3.Ask patient to walk on tiptoes, then on heels. ( Inability to walk on tiptoes indicates S1 or gastrocnemius lesion. Inability to walk on heels indicates L4,5 lesion or foot drop ) And always be ready to support the patient if he fumbles. paceUrMRCP.

*IMPORTANT 90* *A few causes of absent apical impulse* • Obesity/emphysema • Right pneumonectomy with displacement • Pericardial effusion or constriction • Dextrocardia ( never forget to palpate on right side of chest if you can,t find it ) paceUrMRCP.

*ANNOUNCEMENT* Hello n salam everyone We are pleased to announce admissions for our *Aug-Sep 2023 online course ( 15 days ) for PACES MRCP (UK) new pattern PACES23 and CLINICAL EXAM MRCPI .* We will start from *28th of Aug and finish on 15 Sep* *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 89* Please consider admission in a case of palpitations associated with : syncope or near syncope, particularly when the patient is aged 75 years or older and has an abnormal ECG, hemaotocrit less than 30%, shortness of breath, respiratory rate higher than 24/min,,or a history of HF. paceUrMRCP.

*IMPORTANT 88* Please remeber that A stress test is generally considered positive if the patient develops any of the following during exercise: ST-segment depression, chest pain, hypotension, or significant arrhythmias. paceUrMRCP.

*IMPORTANT 87* *Upper limb reflexes with their root values* •Biceps (C5,6) •Triceps (C7) •Supinator (C6) paceUrMRCP.

*IMPORTANT 86* *While doing general inspection of upper limbs in CNS station never miss to look for* *Abnormal posturing* *asymmetry* *abnormal movements* (fasciculation/tremor/dystonia/athetosis) *muscle wasting* (especially small muscles of the hand)—symmetrical/asymmetrical? Local/general? paceUrMRCP.

*IMPORTANT 85* *Please try to rule out LOCAL CAUSES of pain in any case of headache along with red flags.* These may include : • Neck—cervical disc pathology. • Bone/sinuses—sinusitis, neoplasia. • Eye—glaucoma, iritis, orbital cellulitis,eye strain, AVM. • Temporomandibular joint—arthritis or idiopathic dysfunction (common). • Teeth/gums—caries, broken teeth, abscess, malocclusion. • Ear—otitis media,otitis externa. • Vascular/vasculitis—arteriovenous fistula, aneurysm,or AVM at the cerebellopontine angle, giant cell arteritis, SLE. paceUrMRCP.

*IMPORTANT 84* *Poor prognostic factors for HOCM* : 1.Syncope. 2.Young age at presentation. 3.Family history of HOCM and sudden death. 4.Non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring. 5.Abnormal blood pressure changes on exercise (drop of BP during peak exercise on stress testing). 6.An increased septal wall thickness ˃ 3 cm. paceUrMRCP.

*ANNOUNCEMENT* Hello n salam everyone We are pleased to announce admissions for our *Aug-Sep 2023 online course ( 15 days ) for PACES MRCP (UK) new pattern PACES23 and CLINICAL EXAM MRCPI .* We will start from *28th of Aug and finish on 15 Sep* *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 84* *Poor prognostic factors for HOCM* : 1.Syncope. 2.Young age at presentation. 3.Family history of HOCM and sudden death. 4.Non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring. 5.Abnormal blood pressure changes on exercise (drop of BP during peak exercise on stress testing). 6.An increased septal wall thickness ˃ 3 cm. paceUrMRCP.

*IMPORTANT 83* *Drugs to avoid in HOCM* : 1. Nitrates 2. ACE-inhibitors 3. Inotropes paceUrMRCP.