pace your MRCP-PACES

👉 IMPORTANT 805👈 Serial assessment of CRP has a prognostic value in a case of acute pancreatitis. pace your MRCP-PACES

👉 IMPORTANT 804👈 Serum lipase levels have more diagnostic accuracy for acute pancreatitis as compared to serum Amylase. pace your MRCP-PACES

Dear colleagues i regret to inform you that due to poor health, our today's session is postponed, I am sorry for any inconvenience.

Photo from Dr Tanzeel Bukhari

✅ Match the Pairs – Answers & Reasoning A️⃣ → 2️⃣ Subarachnoid haemorrhage Thunderclap headache, vomiting, neck stiffness are classic for SAH. B️⃣ → 5️⃣ Congestive cardiac failure Progressive exertional dyspnoea with raised JVP and ankle oedema suggests CCF. C️⃣ → 3️⃣ Supraventricular tachycardia (SVT) Sudden onset and offset palpitations with narrow QRS are typical of SVT. D️⃣ → 1️⃣ Pulmonary embolism Acute breathlessness, pleuritic pain, hypoxia, and clear chest point to PE. E️⃣ → 4️⃣ Hypertrophic obstructive cardiomyopathy (HOCM) Exertional syncope in a young patient with systolic murmur is classic.

✅ Mini Quiz – Answers & Explanations Question 1 Correct answer: A️⃣ Acute pulmonary embolism Why? Hypoxia + respiratory alkalosis (high pH, low PaCO₂) Clear chest on examination Classic for PE Why not others? Asthma → wheeze, prolonged expiration LVF → crackles, raised JVP Anxiety → usually normal oxygenation Question 2 Correct answer: B️⃣ Normal PaCO₂ Why? In acute severe asthma, expected PaCO₂ is low A normal PaCO₂ indicates respiratory muscle fatigue → impending respiratory failure This is a life-threatening red flag Question 3 Correct answer: C️⃣ Blood cultures Why? Blood cultures must be taken BEFORE antibiotics At least 3 sets from different sites Echo follows after cultures Why not echo first? Echo helps confirm diagnosis but does not replace microbiological diagnosis

*🧩 Match the Pairs – Acute Presentations* (by pace your MRCP – Dr Tanzeel Bukhari) Match Column A (Clinical Scenario) with Column B (Most Likely Diagnosis) 🅰️ Column A A️⃣ Sudden severe headache, vomiting, neck stiffness B️⃣ Progressive exertional dyspnoea, raised JVP, ankle oedema C️⃣ Episodic palpitations, sudden onset and offset, narrow QRS D️⃣ Acute breathlessness, pleuritic chest pain, clear chest E️⃣ Syncope during exertion in a young patient, systolic murmur 🅱️ Column B 1️⃣ Pulmonary embolism 2️⃣ Subarachnoid haemorrhage 3️⃣ Supraventricular tachycardia (SVT) 4️⃣ Hypertrophic obstructive cardiomyopathy (HOCM) 5️⃣ Congestive cardiac failure

*🧠 Mini Quiz – Cardiorespiratory Focus* (by pace your MRCP – Dr Tanzeel Bukhari) *Question 1* A 65-year-old man presents with acute shortness of breath. On ABG: pH 7.48, PaCO₂ 3.8 kPa, PaO₂ 7.5 kPa (on air). Chest examination is clear. What is the MOST likely diagnosis? A️⃣ Acute pulmonary embolism B️⃣ Acute asthma exacerbation C️⃣ Left ventricular failure D️⃣ Anxiety-related hyperventilation *Question 2* Which ONE of the following is a red-flag sign in acute severe asthma? A️⃣ Loud widespread wheeze B️⃣ Normal PaCO₂ C️⃣ Tachycardia D️⃣ Use of accessory muscles *Question 3* In a patient with suspected infective endocarditis, which investigation should be done FIRST? A️⃣ Transthoracic echocardiography B️⃣ Transoesophageal echocardiography C️⃣ Blood cultures D️⃣ CRP and ESR

Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari

*🩺 Case Discussion – Acute Confusion in an Elderly Patient* (by pace your MRCP – Dr Tanzeel Bukhari) *🧠 Scenario:* A 78-year-old man is brought in with sudden confusion over 24 hours. Family reports fluctuating alertness and poor sleep. He has a background of hypertension and osteoarthritis. *O/E:* Afebrile, BP 138/84 mmHg HR 96/min, SpO₂ 95% on air Chest: mild basal crackles Neurology: no focal deficit GCS fluctuates between 13–15 *❓ Questions:* 1️⃣ What is the most likely diagnosis? 2️⃣ What are the key causes to look for? 3️⃣ What are the immediate management priorities? *✅ Discussion:* *🔹 Most likely diagnosis:* Delirium (acute confusional state) 🔹 *Common precipitants (think “PINCH ME”):* Pain Infection (UTI, pneumonia) Nutrition (dehydration, hypoglycaemia) Constipation Hypoxia Medications (opioids, anticholinergics) Electrolyte imbalance *🔹 Immediate management priorities:* Treat the cause (e.g., antibiotics for infection) ABCDE assessment Ensure hydration, oxygenation, analgesia Avoid restraints and sedatives if possible Provide reorientation (clock, family presence, quiet environment) *💡 Exam Tip:* Always distinguish delirium (acute, fluctuating) from dementia (chronic, progressive) and state reversible causes first.

*💊 Drug of the Day – Metformin* (by pace your MRCP – Dr Tanzeel Bukhari) *🔹 Indication* First-line treatment for Type 2 Diabetes Mellitus, especially in overweight patients. 🔹 Mechanism (one line) ↓ Hepatic gluconeogenesis + ↑ peripheral insulin sensitivity. *🔹 Key Benefits* Weight-neutral / modest weight loss Low risk of hypoglycaemia Cardiovascular benefit *🔹 Important Side Effects* GI upset (nausea, diarrhoea) — start low, titrate up Vitamin B12 deficiency (check if long-term use) Lactic acidosis (rare; risk ↑ in renal failure, sepsis) *🔹 When to Stop / Avoid* eGFR <30 mL/min/1.73 m² Acute illness, dehydration, sepsis Before iodinated contrast (withhold and restart after renal check) *🩺 Exam Tip:* Always mention renal function and B12 monitoring when discussing metformin.

*🧠 Mnemonic – Causes of Secondary Hypertension (ABCDE)* (by pace your MRCP – Dr Tanzeel Bukhari) Use ABCDE to recall the important causes of secondary hypertension: *A – Aldosteronism* • Conn’s syndrome (primary hyperaldosteronism) *B – Bruits (Renal artery stenosis)* • Atherosclerotic or fibromuscular dysplasia *C – Catecholamines* • Phaeochromocytoma *D – Drugs* • NSAIDs, steroids, OCPs, decongestants, cocaine *E – Endocrine & Others* • Cushing’s syndrome • Thyroid disease • Coarctation of aorta • Obstructive sleep apnoea *💡 PACES Tip:* Suspect secondary hypertension in: Young patients Resistant hypertension Hypokalaemia Sudden worsening of previously controlled BP

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*🔬 Investigation Pearl 4 – Urine Sodium & Osmolality in Hyponatraemia* (by pace your MRCP – Dr Tanzeel Bukhari) *💡 Key Principle:* In hyponatraemia, urine sodium and urine osmolality help identify the mechanism, not just the diagnosis. *🔹 Step 1: Check Urine Osmolality* <100 mOsm/kg → Appropriate suppression of ADH 👉 Think primary polydipsia or low solute intake >100 mOsm/kg → Inappropriate ADH effect 👉 Go to urine sodium 🔹 *Step 2: Check Urine Sodium* <30 mmol/L 👉 Volume depletion (vomiting, diarrhoea, diuretics) 👉 Body trying to conserve sodium >30 mmol/L 👉 SIADH, adrenal insufficiency, renal salt wasting *🧠 PACES Line* “In hyponatraemia, a concentrated urine with high urine sodium suggests SIADH, while a low urine sodium suggests hypovolaemia.” *⚠️ Common Pitfall:* Never interpret urine sodium without considering: Volume status Diuretic use Renal function

*🩺 Symptom Snapshot 3 – Shortness of Breath* (by pace your MRCP – Dr Tanzeel Bukhari) *1️⃣ Heart Failure* 💡 Exertional dyspnoea, orthopnoea, PND; associated ankle swelling and raised JVP. *2️⃣ Pulmonary Embolism* 💡 Sudden onset dyspnoea with pleuritic chest pain, tachycardia, hypoxia; often a clear chest on auscultation. *3️⃣ COPD/Asthma Exacerbation* 💡 Wheeze, prolonged expiration, chest tightness; history of smoking or atopy.

*🩺 Symptom Snapshot 3 – Shortness of Breath* (by pace your MRCP – Dr Tanzeel Bukhari) *1️⃣ Heart Failure* 💡 Exertional dyspnoea, orthopnoea, PND; associated ankle swelling and raised JVP. *2️⃣ Pulmonary Embolism* 💡 Sudden onset dyspnoea with pleuritic chest pain, tachycardia, hypoxia; often a clear chest on auscultation. *3️⃣ COPD/Asthma Exacerbation* 💡 Wheeze, prolonged expiration, chest tightness; history of smoking or atopy.

Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari