pace your MRCP-PACES

☝️ *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) Good luck.

☝️ *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  Good luck.

☝️ *IMPORTANT 38* ☝️ Please remember *HBA1C* might be considered as a Jargon by some of the examiners so be careful while using it in exam and always say *( LAST ) 3 MONTHS BLOOD SUGAR RECORD/LEVEL* to your patient  Good luck.

☝️ *IMPORTANT 37* ☝️ Please remember *For Breaking Bad News in Station 4* Never hesitate in breaking the bad news and never delay/linger on to do it. Always break the bad news as early as possible after giving the warning shot, ideally within the first couple of minutes. Good luck.

☝️ *IMPORTANT 36* ☝️ Please remember *For Breaking Bad News in Station 4* Always give a warning shot before telling the bad news to the patient Always say I am sorry I have something concernig to tell you , Or the results have not come as we were expecting, Or I am afraid we have something serious to discuss. Good luck.

👉 *IMPORTANT 566* 👈 *Examination in CKD.* Look for • *Periphery*: Peripheral oedema. Signs of peripheral vascular disease or neuropathy. A vasculitic rash. Gouty tophi. Joint disease. Arteriovenous fistula (thrill, bruit, recently needling?). Signs of immunosuppression: bruising from steroids, skin malignancy. Uraemic flap/encephalopathy if GFR<15. • *Face:* Anaemia, xanthelasma, yellow tinge (uraemia), jaundice (hepatorenal),gum hypertrophy (ciclosporin), Cushingoid (steroids), periorbital oedema (nephrotic syndrome), taut skin/telangiectasia (scleroderma), facial lipodystrophy (glomerulonephritis). *•Neck:* JVP for fluid state, tunnelled line (if removed, look for small scar over in ternal jugular, and a larger scar in 'breast pocket' area), scar from parathyroid ectomy, lymphadenopathy. • *Cardiovascular:* BP, sternotomy, cardiomegaly, stigmata of endocarditis. If right-sided heart failure/tricuspid regurgitation, JVP does not reflect fluid state. • *Respiratory:* Pulmonary oedema or effusion. • *Abdomen:* PD catheter or scars from previous catheter (small scars just below umbilicus and to side of midline), signs of previous transplant (scar, palpable graft), ballotable polycystic kidneys± palpable liver. Good Luck

👉 *IMPORTANT 565* 👈 *Common symptoms of CKD* Symptoms of fluid overload (SOB, peripheral oedema) anorexia nausea vomiting rest less legs fatigue weakness pruritus bone pain amenorrhoea impotence. Good Luck

👉 *IMPORTANT 564* 👈 *The most common causes of CKD in the UK are* diabetes (24%), Glomerulonephritis (13%) Increased BP/renovascular disease (11%). Good Luck

👉 *IMPORTANT 563* 👈 *Certain systemic diseases which may cause CKD* Diabetes amyloidosis sarcoidosis Heart failure TTP Alport syndrome Fabry disease Good Luck

👉 *IMPORTANT 562* 👈 *Possible complications of Renal Replacement Therapy:* Risks of dialysis catheter insertion and maintenance Procedural hypotension Bleeding due to the requirement for anticoagulation Altered nutrition and drug clearance. Good Luck

👉 *IMPORTANT 561* 👈 *Possible indications for renal replacement therapy:* Fluid overload unresponsive to medical treatment. Severe/prolonged acidosis. Recurrent/persistent hyperkalaemia despite medical treatment. Uraemia eg pericarditis, encephalopathy (more common in CKD). Good Luck

👉 *IMPORTANT 560* 👈 *Few important points about treatment of hyperkalemia* Treat K>6.5mmol/L or any with ECG changes 1.10mL of 10% calcium chloride (or 30mL of 10% calcium gluconate) IV via a big vein over 5-10min, repeated if necessary and if ECG changes persist. This is cardioprotective (for 30-60min) but does not treat K level. 2. Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125mL of 20% glucose). Insulin stimulates intracellular uptake of K, lowering serum K by 0.65-10mmol/L over 30-60min. Monitor hourly for hypoglycaemia which may be delayed in renal impairment (up to 6 hours after infusion). 3. Salbutamol also causes an intracellular K shift but high doses are required (10-20mg via nebulizer) and tachycardia can limit use (10mg dose in IHD, avoid in tachyarrhythmias). 4. Definitive treatment requires K' removal. If the underlying pathology cannot be corrected renal replacement may be indicated. Good Luck

👉 *IMPORTANT 559* 👈 *ECG changes on hyperkalemia* In order: tall 'tented' T waves increased PR interval small or absent P wave widened QRS complex sine wave' pattern asystole. There is considerable inter-individual susceptibility. Good Luck

👉 *IMPORTANT 558* 👈 *Commonly used criteria for Acidosis* Mild = pH 7.30-7.36 (~bicarbonate >20mmol/L). Moderate pH 7.20-7.29 (~bicarbonate 10-19mmol/L). Severe = pH <7.2 (~bicarbonate <10mmol/L) Good Luck

Here is the recording of yesterday's session. Please try to listen the recording in 1 day as Zoom provides limited space and it automatically deletes the old recordings to keep space for new ones ..so the recording will not be available after 1 day☝️☝️☝️

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