My Marianas Trench

I think I've probably reached my lowest point today. And really, it can only get better from here. And step 1 to making it better: sleep early.

Nineveh

From the Encyclopaedia Britannica
'Nineveh, the oldest and most populous city of the ancient Assyrian Empire...'

First mentioned in the Bible in Genesis 10:11, where a chap called Cush 'built' it.

Not seen until Jonah, where the focus was on Jonah running away from a summons to preach against it.


'That man deserves to die for what he did.'
'Why do I do stuff like this to myself?'

Like Jonah, it's easy to pass judgement on everything, even on ourselves (probably why anyone could judge X-Factor!).

'But the Lord replied, "Have you any right to be angry?"

The right to be angry is a given, what isn't is how we proclaim judgement and refuse to take God's considerations into account. Self-pity, jealousy, anger, bitterness, unforgiveness; all are part of the emotional spectrum implanted into us but if I let these take over my actions without allowing God any say, its not going to produce the best results.

But what stood out for me in this reading of Jonah 3 was how the king of Nineveh responded to Jonah's message.

The king of the city 'rose from his throne, took off his royal robes, covered himself with sackcloth and sat down in the dust.'

No one responds to a wayward prophet like that, certainly not the king of an important city unless he recognises the God behind the man.

More PACES stuff

CVS:
1. Before doing anything, check for scars - a midline sternotomy scar without a corresponding vein graft scar on the legs suggests a valve replacement (AVR has a flow murmur with a loud 2HS)
2. In Blalock-Taussig shunts - there is usually a midline scar + L/R posterior thoracotomy scar
3. Whereas in complete repair of VSD the only sign may be pulm regurg/stenosis

CNS:
1. In 3rd CN palsy, check with cover test to exclude lazy eye.

Respi:
4 causes with scars (pneumonectomy, thoracoplasty, lobectomy, lung transplant)
4 causes without scars (effusion, fibrosis, bronchiectasis, COPD)

How I prepared for PACES

I had thought about writing this post for a while, if only to serve as a reminder to myself because I'll likely be needing to repeat the exam next year. But also I guess I'm hoping to give other first-timers to the PACES bit of the MRCP some idea of what to expect. Most of the following can actually be found on the PACES bit of the MRCP UK website as well.

First up, the format:

PACES is 5 stations of 20 mins with 5 mins break in between each station.

Station 1 is Abdo Exam (10 mins) and Respi Exam (10 mins)
Station 2 is History taking (20 mins)
Station 3 is CVS Exam (10 mins) and Neuro Exam (10 mins)
Station 4 is Comm Skills (20 mins)
Station 5 is 2 cases of either skin, eyes, locomotor or endocrine (10 mins each)

For the examination stations (1 and 3) you'll get 6 mins to examine and 4 mins to present your findings and be questioned by the invigilators (there'll be 2 in each station with one doing the talking).
For the history/comm skills station you'll get 14 mins to either take a history or resolve a comm skills situation (eg breaking bad news or calming a patient after a prescribing error), 1 min to put everything together and 5 mins to present to the examiners.
For station 5, you'll have 8 mins to take a history/examine each patient and 2 mins to present and be questioned by the examiner.

At the start of the exam you'll be ushered into a room with your other 4 candidates (5 to a stream) and have to fill out your name and examination/center number on 16 marksheets. These, togetherwith your steth, and a pencil are all you have to bring around as you go (though people have also brought their own opthalmoscope/pen torch etc - all these are provided).

You'll then be brought to your stations and have to wait for the bell to ring, signifying the start of the first 5 min break. When the bell rings again, the door opens, a friendly examiner's head pokes out and the exam begins!

In terms of preparation, the key books that I've been told about are Ryder's Aid to the MRCP PACES, Cases for Paces and Baliga's 250 Cases in Clinical Medicine. Certainly most people I've spoken tohave read through the first 2 of these. The other key is to form up a practice group with other PACES candidates and start compiling a list of patients with signs to practice on 2-3 months before the exam and testing each other(trying to get consultants/regs to supervise whenever possible).

A PACES course is a good idea just because of the sheer amount of patients with signs to see - there is always some practical advice worth gleaning from these courses as well (some of which I will try to reproduce here) and to get an idea of how you stand with other candidates in terms of preparation.

Practicing comm skills and history taking with your PACES buddies is also a good idea to get an idea of time (so you have a sense of how long 14 mins is in an exam situation) and the comm skills in particular are worth working through as there are some points to be gained from practice (eg remembering to ask how a patient is going home after breaking bad news - ideally someone at home with her and not driving alone)

Paces Tips I Should Remember:
1. When presenting after each case, its a good idea to take the steth off and put my hands behind my back and to NOT look back at the patient while presenting to the examiners.
2. When presenting a CVS patient, always a good idea to mention the presence/absence of 'peripheral stigmata of infective endocarditis and/or heart failure'
3. When presenting a Respi patient, always good to mention the presence/absence of 'pulmonary hypertension'
4. When presenting a renal transplant patient (in the Abdo station) always good to mention the presence/abscence of 'modes of renal replacement therapy eg AV fistulas and whether they are working or not, signs of immunosuppression'
5. Always good to give an idea of the diagnosis of why the patient has had a renal transplant, or an enlarged liver, or pulmonary fibrosis etc
6. Always mention the key phrases 'I would like to complete my examination by...' (differs according to each system eg CVS - doing an ECG, checking the urine for haematuria and checking the BP / Respi  - checking the bedside obs incl O2 sats, looking at the sputum pot, doing peak flows and checking for signs of heart failure / Abdo - checking the hernial orifices, checking for inguinal lymphadenopathy and doing a PR / Neuro - doing a full upper/lower limb neuro exam and checking for cerebellar signs)
7. So a complete presentation might sound like 'I've examined Mr X who looks tachypnoeic at rest with a RR of 22 breaths per min. He has evidence of clubbing and central cyanosis and has a productive cough. His positive findings on his chest were coarse crepitations on both lung bases which changed in nature with coughing. He had no evidence of pulmonary hypertension or pitting oedema to suggest heartfailure. My diagnosis for this patient would be that of bronchiectasis. I would like to finish my exam by checking the sputum pot, checking his bedside obs incl O2 sats and confirm my findings by doing bld tests to exclude infection as well as a CXR to look for evidence of basal consolidation. I would also send the sputum off for culture/sensitivity.'
8.Cases for Paces should really be the baseline reading book I think - its a good springboard to more xomplex stuff however Ryder is also well worth a read, if only for the pictures and the comm skills/history taking scenarios in Book 2.
9. I also used the Pastest Online website which is not, as you might imagine, an ideal way to practice for this exam - but it does give some idea of what to expect as well as some good pictures/spot diagnoses to look at.
10. Do a mock exam - useful to get an idea of what to expect and to gauge where you stand with other candidates - its useful after you'vedone some work, but even if you're not fully prepped, its good for that figurative kick in the butt! Also those who've done one don't seem to have that fear of the unknown on the day of their actual PACES.

All the best if you're prepping forit and if you're prepping from Australia, specifically Melbourne Australia, let me know and we can buddy up!

So it's the 1st of Nov is it?

Happy birthday Pa!

The second photo is from Linda Tan who took both of you recently - a pretty good one I thought!