6/6/2016 (1)beginningofstudyingpaces

ZeinMahgoub PACESSimplifiedZeinMahgoub
April24

ThisisDr.AbubakrwhopassedPACESatKhartoumcentre(Sobauniversityhospital)withascoreof170..

Myexamon2/4/2016day2cycle1insobauniversityhospital

Station2history
Scenarioof(35yearsoldladyhasfatiguefor6monthshergpdidabloodtestandconfirmedtobeirondeficiencyanaemia
)
Iintroducedmyself,explainedmyroleaskedaboutherjob(sheisateacher)andagreedtheagenda
AsshehasfatigueIstartedbyanalysingherfatigueandthengeneralsymptomsandshegavehxofwtlossof5kg..When
Iaskedaboutjointpainasapartofgeneralsymptomssheansweredthatshehadjointspainfor2yearsandshehadbeen
diagnosedtohaveosteoarthritisbyorthopaedicconsultant.
ThenIaskedifsheuseanymedicinesforthatshesaidsheuses2medicinesibuprofenandanotherNSAID.These
medicinesweregivenwithoutprophylacticPPI.Shehashxoflocalisedepigastricpainmadeworsebyeatingasswith
nauseabutnovomiting....sometimesheartburn
therewasnomelenaorhaematemesis.
Nomouthulcer
Nochangeinherbowelhabits
Nobleedingthroughherbackpassage.
Thereisnobloatingandnotummypainwithspecifictypeoffood(wheatproducts)
Normalmenstrualcycle
Shetakesbalanceddietandshegavemeexampleofherusualdiet.
Thenreviewofhersystemswasnegative.
Herpasthxandfamilyhxarenegative.
ItakethedrughxaspartofHPI
Insocialhxsheisaffectedgreatlybyherfatigueandalsoshecan'tdoherhobbiesassheusedpreviouslytorunandgoto
gym.
SheisconcernedaboutthecauseofherfatigueandhowcanIhelphertocontinueherhobbies.
Iexplainedtoherthelikelycauseofherfatigueisrelatedtothejointmedicinesandthatweneedtodoacammeratestand
weneedtostophermedicinesafterdiscussingthiswithherorthopedicsurgeonandifweneedtocontinueonitwewillgive
PPIandwearegoingtogiveherironreplacementandafterthatIwillreplybacktohergp.
ThenIcheckherunderstandingandthankedher.

Firstexaminerquestion
Didyouaskaboutsmoking Isaidnosorry.
Doyouthinkitisimportant?Isaidyesasptmostlikelyhasgastritisorpepticulcerdiseasesosmokingimpairsthehealing
oftheulcer.
Thendidyouaskaboutalcohol ?
AgainIforget
Sodoyouthinkitisimportant??
Yesasitmaycausegastritis.
Thenheaskwhyyouaskaboutnumbnessandunsteadiness???
BecauseifmalabsorptionisthecausethenB12maycausesubacutecombineddegenerationofthecord
ThenaskaboutDD
Iputgastritis
Gastricandduodenalulcer
Malignancybecauseofthewtloss
ThencoeliacdiseaseandIBD
HeaskedwhetherNSAIDcanCAUSEsmallbowelulcersapartfromduodenum???Isaiditisnotcommonbutifmultiple
thenweneedtothinkofZollingerElissonsyndrome
Howcanendscopyhelp???
Macroscopicwecanseeifthereistheulcerandwecantakebiopsy
Whattotestinbiopsy???
ThepresenceofmalignantcellandalsoH.Pylori
AnyrelationbetweenNSAIDandH.Pylori??? IsaidIdon'tknow
ThenhowNSAIDcausepepticulcer???AfterexplainthenagainheaskanyrelationbetweenNSAIDandH.Pylori???
IfeelthatheneedmetosayyessoItellyestheremaybearelation
ThenhowyouwilltreatH.Pylori???IsaidtriplebeforegivethenameoftriplehetellifyoustopNSAIDwhatothermedicine
youwillgivetotheptIsaidparacetamol

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****IthinktheywillmarkmenegativelyasIforgetimportantpartofsocialhxbutsurprisinglyIgot20

Thenstation3
CVS.....
Ayoungfemalewithsmallvolumepulseandsheispale
Shehaschestdeformity...activepericardiumwithvisiblepulsations.Theapexisnotdisplacedwithpalpable2ndheart
soundandpositiveltparasternalheaveandonthrill.
Thereisapansystolicmurmurinltparasternalborderwithmaximumintensityintheapexbutnoradiatingtoaxillawithloud
2ndheartsound
IpresentmycaseasMRwithpulmonaryhtnthentheexamineraskedwhetherthemurmurradiatetoaxillaornot???Isaid
noandthemurmurisinLtsternalbordersoitsdifferentialisTR,MR,VSDwithpulmonaryhtn.
Thenaskedaboutthecausesofpulmonaryhtnandinvestigations
(Igot20)

CNS....
Ayoungmalewithstickbesidethebed..Examinethelowerlimbs.
ThereispescavusandwastingofbothlegwithhypotoniaandweaknessesofLMNLbutproximallymorethandisatlly
Absentreflexsandequivocalplanter.
Coordinationdifficultaspowergrade0
Intactsensations.
Iwantedtoexaminethegaitbuthetellnoneed
ThenIexaminetheupperlimbswithsamefinding
Exwhatisyoupositivefinding???
Whatisyourdiagnosis???
IsaidLMNLweaknesseithermuscleproblemorpuremotorPNbutwithpatternofweaknessproximalIwillgowithmuscle
disorderthenaskedabouthowcangaithelpyouandDDofpuremotorneuropathytheninvestigationandmanagementof
proximalmyopthy.
(Igot20)

Station4communication
Scenarioofdelayeddiagnosisofpheochromoctomainayoungmalesufferingfor5years.Hewasseenbymanydoctors
includingapsychiatristforpanicattacksandhavebeenprescribeddiazepamandalsohashtnthatwasdifficulttocontrol
andonHISINSISTENCEthegpreferredhimtoyourclinic.Youarethedoctorinhypertensionclinic...thetestsdonefor
himshowamassof5cminhisRTadrenalandurinetestalsopositive.
Yourtaskistoexplainforhimthediagnosisandtoanswerhisconcerns...

IstardasDrzeintaughtus
Introducedmyself,explainedmyrole,askedabouthisjobandifthereisanyonehewouldliketoinvitetoattendthe
meetingandthenagreedtheagenda&askedhimtotellmemore.Hewasattackinginnature...feelsthatheissufferingfor
5yearsandseenbymanydoctorsandprescribedsleepingpillsbutwithoutanyimprovement.
Ishowedempathyregardinghissufferingfor5yearstheexplainedtohimthattheresultsarewithmenowandthat
unfortunatelyitisnotaswehopethentellingthatitshowpheochromoctomaandwhetherheheardaboutithesaynotheni
askedifhewouldlikemetoexplainmore....theIexplinpheochromoctomaandthatthegoodnewsarethatwefoundthe
causeofhissufferinganditiscurableconditioninthemajority...theniexplainedthatitisagrowth...heaskedwhetheritis
cancerornot.Iexplainedtohimthepossibilityofcanceris10%whenItoldhimitiscurableheaskedhow?Itoldhim
surgerythenheishabbyandsaidOKjustremoveditnow(verbalcue)..Itoldhimitisnoteasysurgery,weneedtocontrol
yourbloodpressurefirstasIamadoctorinhypertensionclinicthenIamgoingtoinvolveMDT.HeaskedwhatMDT?I
apologisedandthenexplaineditisateamofexpertpeopleincludingtheglanddoctor,thesurgeonandanaesthetistand
theywillmakeameetingtodecidethewaytomanagehim.
Heaskedwhentheywilldecide???
Irepliedassoonaspossible.
Thenhismainconcernwhetherthereisnegligenceornot
IansweredIneedtogobacktoyourrecordstoseewhatexactlydoneforyou.Thenhesaiddoctorthereisnegligenceand
Iwillcomplainagainstmygp....Itoldhimitisyourrighttomakeacomplaint...
ThehebroughtanotherconcernaboutanydamagehappentohimfromHTN???
Itoldhimlneedtoexaminehimandtodosometeststoseetheeffectsofhtn.
Iaskedanyotherconcern...
Herepliedno..
Thenimadeasummary,,,checkedtheunderstandingandtoldIwillreplybacktothegp,andofferedhelpandleafletsand
ifhecandrivealone.

TheBritishexaminer

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Whatdoyouthinkaboutthiscase???thenIgivesummaryofthecaseandmyplan.
Whyyoudidnottellhimaboutrisksofsurgery???
IansweredIjustbrokethebadnewsforhimandIdon'twanttogivehimallbadnewsatonetimesincehewillhavea
mettingwiththesurgicalteamwhoisgoingtodiscusstherisksofsurgery(thenhesmiled)
Howyouwilltreathishtn???
Alphablockerandthenbetablocker
Doyouthinkthereisnegligenceinthiscase??? Igivehimthesameanswerforthesurrogatethenheaskedis
thereanydamagefromhishtn???
Igavethesameanswergiventothepatient,thatIneedtoexaminehimandtodofundoscopyandinvestigationstoseeif
hehasdamage.
Thenheaskedagainifthereisanynegligence???
Inoticedthatboththesurrogateandexaminerareconcernedaboutdamagefromhtn,thenItoldhimtheptissufferingfor5
yearsandnotdiagnosedthisisnotusualandifthereisdamagehappenfromhishtnOFCOURSEthereisanegligence(I
Don'tknowwhyIsaidofcourse)
Thenheaskedmedoyouthinktheptishappyandhecandrivealone???
Ikeptsilentforawhilethensaidyesheishappy.
Thebellrang
TheBritishexaminersaidwelldone.
(Igot15)

Station5
BCC1
A55yearsoldfemalewithLthandweakness..

BeforeshakingthepthanditseemsheisinpainsoIapologisedfornotshakinghandsbcsofthepain.
Thensurrogategaveahxofbothhandspainindisruptionofmediannervewithoutanythinginthesystemicreviewgiving
cluetothecause...
HoweverinthePMHshewasdiagnosedtohavehypothyroidismandnotonfollowupfortwoyearsbutusingherthyroxin
100mcg.
Noothersignificanthx
O/E
Clearsignsofcarpaltunnelsyndromebilaterallyandmoreinthelt.
ThenIcheckedforthyroidstatus.
Concernedaboutthecauseofherproblem
Otherconcernwhetherherlthandwillbecomeparalysed
Irespondedtothe2concernsandexplainedtheneedtocheckherthyroidstatusandregularfollowupandwemayneedto
dosurgery.
TheBritishexaminersaidstillyouhave1minute
ThenagainIexplainedtheimportanceofregularfollowup.
Theexaminersmiled&saidstillyouhave30secondbutnoproblemyoucanreviewyourthouhts....
ThenaskthediagnosisandtheDD
Theinvestigationandmanagement
(Igot28)

BCC2
A50yearsoldmalewithblackoutandnormalvitalsigns.
FromhxblackoutmainlyinthemorningandduringsleepalsoIgotconfusedhowduringsleep!!
Heisaverynicesurrogatehetoldmehebitshistongueandwetshimself.
Iaskedanyshakesherepliedno.
IreviewedtheCNSanditisnegative.thenaskedabouttraumawhichisnegative,thenaboutgeneralsymptomsincluding
skinrash...
Hesaidyeshehaveskinrashinhisfacefor20yearswhichdifficulttofadeaway...Ilookedtothefaceandthenfeltrelaxed
asIcatchthedignosis...
Pasthxofhtnandonamlodipine5mgwithnochangeinthedose.
Familyhxofabdominalsurgeryin2ofhissisterandskinrashinhisbrother.
Heisateacher!!!!andIaskedabouthisschoolperformancehesaiditisgoodandhedriveaprivatecaranddonotdrink
alcohol.
Iexaminedthefacefortherashandthethepronaterdriftforanyweakness.
Checkedthetrunkforashleafspotandexaminethebackforshagreenbatch.
Offerabdominalexaminationbutexaminersaidnormal.Offeredchestexamagainhesaidnormal.OfferedtocheckBPand
hesaid130/70.OfferedfundusforphakomashesmiledandsaidDoit

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IcheckquicklyasthepupilisnotdilatedIknowthatnothingwillbethere.
Thepatientisconcernedaboutwhatisgoingon...
Iexplainedtuberoussclerosis
Anotherconcernabouthiskids...
Explainthateachhas50%chancetogetthedisease.
Nootherconcern
Theexaminer:stillyouhave1minute.
ThenIexplainedtheepilepsyanddrivingbutstillthereistimethenIexplainedthescreeningoffamilyandgentic
counselling.

Examinerquestion
Whatisyourdiagnosis???
Investigationsandmanagement
(Igot28)

Station1
Abdomen
YoungfemalelooksillandverypalewithcannulainherRTarmwithtingofjaundice,hepatosplenomaglyandabsent
stigmataofCLD.
IexaminedonlyforonegroupofaxillaryLNbecausetimedidn'tallowmorethanthat.
ThenaskedaboutDD.
Thediscussionaboutmyeloproliferativedisorders
(Igot19)

Chest
Amiddleagedmalewithobviouslydepressedltsideofthechestwhichwasmovingless,andaverystrangescaronthelt
sideonlythetipofscarisseenanteriorlysoItriedtogofasttoexaminethebackfromanterior.Thetracheadeviatedtolt
withimpairedpercussiononltanddecreasedairenteryonltandvocalresonance.Howeverthereisincreasedvocal
resonanceinltupperpartandbronchialbreathinginsameltupperzone.
Posteriorlysamefindingandthatscar(stillconfusingmeitlooklikelongthoracotmyscarbutsurprisinglythereareaabout2
cmofnormalskin)
SoIpresentedmycaseasLtpneumenoctomy.
ThentheexamineraskeddidhearanythingabnormalinltsideIrepliedincreasevocalresonance.Iwasafraidofinventing
signs,soIdidnotmentionedbronchialbreathingbutheisveryhelpfulexaminerandaskedmewhattypeofbreathinginlt
upperzonethenconfidentlyItellbronchialbreathing.ThenheaskedwhatcouldbethecauseagainIsaidthiscouldbe
fromstump....hesmiled&saidstumpcannotcausethis?heaskedwhatcouldcauseincreasevocalresonanceand
bronchialbreathingIsaidcavity.....hesaidyesnowwhatcouldbethecause?Imentionedfibrocavitatorylesion...he
lookedsatisfiedandaskedaboutthecommonestcauseandhowtoinvestigate..TB
(IGOT20)

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