pace your MRCP-PACES

👉 *IMPORTANT 62* 👈 *Important for station 2 N 5* Always rule out congenital cardiac anamolies in a case of syncope ( even it is a clear case of Vasovagal syncope ) in a young patient as it is a hot cake in PACES. Either the candidate is going to ask it in his concerns or the examiner is going to ask you while discussing DD. Good luck.

👉 *IMPORTANT 61* 👈 *Back pain criteria for diagnosing ankylosing spondylitis* ( very common in station 5 ) 1. Age of onset < 45 years 2. Insidious onset 3. Improvement of back pain with exercise 4.No improvement of back pain with rest 5.Pain at night ( with improvement on getting up ) The presence of four of the five criteria suggests ankylosing spondylitis with 80 % sensitivity. Good luck.

👉 *IMPORTANT 60* 👈 *Some info about Tracheal Tug* In simple words Tracheal tug is the inferior movement of trachea during inspiration which can be felt by resting the fingers on trachea and asking the patient to take deep breaths. Be careful not to pinch deep in the neck of patient. A tracheal tug  indicates the presence of significant lung fibrosis or severe airflow obstruction. Oliver's sign is an abnormal downward movement of the trachea during systole that can indicate a dilation or aneurysm of the aortic arch. Good luck.

👉 *IMPORTANT 59* 👈 *Some info about vasovagal syncope and driving* People having vasovagal syncope and *type 1 license can drive* until and unless they are able to recognize and avoid triggers. People having vasovagal syncope and *type 2 license must stop driving* and inform DVLA. Please note that this info is about vasovagal syncope occuring while standing, which is by far more common in PACES. Good luck.

*Some info about Stress echocardiography* 1.Performed before and immediately after exercise. 2.Exercise-induced ischemia is evidenced by wall motion abnormalities (e.g., akinesis or hypokinesis) not present at rest. This study is less reliable in patients with existing wall motion abnormalities or lowered EF. 3.Favored by many cardiologists over stress ECG. It is more sensitive in detecting ischemia, can assess LV size and function, can diagnose valvular disease, and can be used to identify CAD in the presence of pre-existing ECG abnormalities. Ideally patients with a positive test result should undergo cardiac catheterization. *Copied* Good luck.

👉 *IMPORTANT 58* 👈 Please remember While *inspecting the FACE in respiratory system* Never miss to look for these 1.signs of Horner’s syndrome 2.conjunctival pallor, 3.central cyanosis (please ask patient to stick out tongue), 4.pursed lip breathing Good luck..

👉 *IMPORTANT 57* 👈 Please remember While *examining for Trachea in respiratory system* Never forget these steps 1. Feel in sternal notch for deviation 2.Assess cricosternal distance in finger-breadths 3. feel for tracheal tug Good luck..

👉 *IMPORTANT 56* 👈 Please remember *NEPHROLOGIST* might be considered as a Jargon by some of the examiners so be careful while using it in exam and always say *KIDNEY SPECIALIST* to your patient  Good luck..

👉 *IMPORTANT 55* 👈 *In examination of respiratory system* *Inspect the hands for* Tobacco staining , peripheral cyanosis, clubbing,asterixis ( Ask the patient to hold their hands out and cock their wrists back ) signs of systemic disease (systemic sclerosis, rheumatoid arthritis) Good luck.

ANNOUNCEMENT Hello n salam everyone Regarding our *Oct 2022 online course for PACES MRCP (UK) ( duration 15 days ).* starting from *14 Oct* till *31 Oct* *All slots for active participation are completely occupied, however you can still join us as a listener* Interested candidates may send a personal message for details. WhatsApp No: 00923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

*Some points about diagnosis of Coronary artery disease* Note that physical examination in most patients with CAD is normal. 1. *Resting ECG* a. Usually normal in patients with stable angina b. Q waves are consistent with a prior MI c. If ST-segment or T-wave abnormalities are present during an episode of chest pain, then treat as unstable angina. 2. *Stress test* —useful for patients with an intermediate pretest probability of CAD based upon age, gender, and symptoms. *Copied* Good luck.

👉 *IMPORTANT 54* 👈 *Headache in Acromegaly* Can be due to 1. Pituitary adenoma per se 2. Obstructive sleep apnea. A detiled history specially aggrevating factors will help to demarcate both types of pain. Also vision involvement in history and examination will further clarify. Good luck.

*Few etiologies of dyspnoea by timing of onset* *Acute* Foreign body Pneumothorax Pulmonary embolus Acute pulmonary oedema *Subacute* Asthma Parenchymal disease,eg alveolitis pneumonia, Effusion *Chronic* COPD and chronic parenchymal diseases Non-respiratory causes, eg cardiac failure, anaemia *Copied* Good luck..

*MRC Dyspnoea Scale* 1.Not troubled by breathlessness except on strenuous exercise. 2.Short of breath when hurrying or walking up a slight hill 3.Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace 4.Stops for breath after walking about 100m or after a few minutes on level ground 5.Too breathless to leave house or breathless when dressing *Copied* Good luck.

*Few DVT Risk Factors:* *Hematological* • Thrombophilia: e.g. Activated protein C resistance, protein C and S deficiency • Polycythemia • Paroxysmal nocturnal hemoglobinuria • Hyperviscosity syndrome *Autoimmune* • Antiphospholipid syndrome • Behcet's *Drugs* • Combined oral contraceptive pill • Antipsychotics (especially olanzapine) have recently been shown to be a risk factor Other conditions • Homocystinuria *Copied* Good luck.

*Some risk factors for Ischemic heart disease* *a. Diabetes mellitus* (DM)—worst risk factor *b. Hyperlipidemia* —elevated low-density lipoprotein (LDL) *c. Hypertension* (HTN)—most common risk factor *d. Cigarette smoking* *e. Age* (men >45 years; women >55 years) *f. Family history* of premature coronary artery disease (CAD) or myocardial infarction (MI) in first-degree relative: Men <55 years; women <65 years *g. Low levels of high-density lipoprotein*(HDL) *h.end-stage renal disease* (ESRD) on hemodialysis, *i.human immunodeficiency virus* (HIV) infection, *j.history of mediastinal radiation*. *And never miss to ask about obesity,sedentary lifestyle (lack of physical activity), stress, excess alcohol use.* *Copied* Good luck.

ANNOUNCEMENT Hello n salam everyone Regarding our *Oct 2022 online course for PACES MRCP (UK) ( duration 15 days ).* starting from *14 Oct* till *31 Oct* Only *3 Active slots are available* Listener slot available too. Interested candidates may send a personal message for details. WhatsApp No: 00923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

*Some info about Dyspnoea* Subjective sensation of shortness of breath, often exacerbated by exertion. • Lung—airway and interstitial disease. May be hard to separate from cardiac causes; asthma may wake patient, and cause early morning dyspnoea & wheeze. • Cardiac—eg ischaemic heart disease or left ventricular failure (LVF), mitral stenosis, of any cause. LVF is associated with orthopnoea (dyspnoea worse on lying; ‘How many pillows do you use while sleeping?’) and paroxysmal nocturnal dyspnoea (PND;dyspnoea waking one up). Other features include ankle oedema, lung crepitations, and raised JVP. • Anatomical—eg diseases of the chest wall, muscles, pleura. Ascites can cause breathlessness by splinting the diaphragm, restricting its movement. • Others Any shocked patient may also be dyspnoeic—dyspnoea may be shock’s presenting feature. Also anaemia or metabolic acidosis causing respiratory compensation, eg ketoacidosis, aspirin poisoning. Look for other clues—dyspnoea at rest unassociated with exertion, may be psychogenic: prolonged hyperventilation causes respiratory alkalosis. This causes a fall in ionized calcium leading to apparent hypocalcaemia. Features include peripheral and perioral paraesthesiae ± carpopedal spasm. Speed of onset helps diagnosis. *Copied* Good luck.

👉 *IMPORTANT 53* 👈 How to explain *OPACITY IN THE LUNG* in station 4 Always say that you have *abnormal shadow or abnormal finding* in your x ray to your patient  Good luck.

*Some info about NOACS by the courtesy of Dr Shaheen* The table below summaries the three direct oral anticoagulants (DOACs): dabigatran, rivaroxaban and apixaban. Dabigatran(Pradaxa) Rivaroxaban(Xarelto) Apixaban(Eliquis) DABIGATRIN: ExcretionMajority renal RIVAROXABAN: Majority liver. APIXABAN Majority faecal. NICE indications. Prevention of VTE following hip/knee surgery Treatment of DVT and PE Prevention of stroke in non-valvular AF . Dabigatrin reversal:Idarucizumab RIVORAXABAN and APIXABAN Reversal:Andexanet. NICE stipulate that certain other risk factors should be present. These are complicated and differ between the DOACs but generally require one of the following to be present: prior stroke or transient ischaemic attack age 75 years or older hypertension diabetes mellitus heart failure