Professional Documents
Culture Documents
MRCP (UK)
EXAM PREPARATION GUIDE
www.ealingpaces.com
paces@ealingpaces.com
0203 330 0031
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Spring/Summer 2014
Contents
Welcome to Ealing Paces ...................................................................................................................... 5
Exam Outline......................................................................................................................................... 6
Course Structure ................................................................................................................................... 8
Course Timetable .................................................................................................................................. 9
The individual groups will rotate through stations A-G as follows: ................................................... 9
Station 1: The Respiratory System ...................................................................................................... 10
1. Most Common Cases .................................................................................................................. 10
2. The basic examination: Inspections and Observation ................................................................ 10
3. Then proceed with the Respiratory Examination of the Chest .................................................. 12
4. Key Diagnostic Test ..................................................................................................................... 12
5. Management............................................................................................................................... 13
6. Presentation................................................................................................................................ 17
Station 1: Abdominal System .............................................................................................................. 18
1. Most Common Cases .................................................................................................................. 18
2. General inspection ...................................................................................................................... 18
4. Common differential diagnoses:................................................................................................. 19
5. Presentation................................................................................................................................ 20
Station 2: History Taking Skills ............................................................................................................ 21
1. Most Common Cases .................................................................................................................. 21
2. Introduction ................................................................................................................................ 21
Station 3: Neurology Station & Cardiovascular Station ...................................................................... 24
1. Most Common Cases .................................................................................................................. 24
2. Introduction ................................................................................................................................ 24
3. Cranial nerves ............................................................................................................................. 25
4. Speech examination.................................................................................................................... 29
Station 4: Cardiovascular .................................................................................................................... 34
Most Common Cases: ..................................................................................................................... 34
Station 4: Communication Skills & Ethics ........................................................................................... 42
1. Most Common Cases .................................................................................................................. 42
2. Format of station ........................................................................................................................ 43
3. How to conduct the interview .................................................................................................... 43
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4. Driving regulations ...................................................................................................................... 43
5. Consent ....................................................................................................................................... 45
6. Criteria for brainstem death (Conference of Medical Royal Colleges 1976-1981)..................... 46
7. How to pass the ethics station.................................................................................................... 46
Station 5: Integrated Clinical Assessment .......................................................................................... 47
1. Ophthalmology Station ............................................................................................................... 47
1.1 Most Common Cases ................................................................................................................ 47
2 Scenarios ...................................................................................................................................... 49
Diabetic retinopathy ....................................................................................................................... 49
3. Endocrinology ............................................................................................................................. 54
3.1 Most Common Cases ................................................................................................................ 54
4. Dermatology & Rheumatology ....................................................................................................... 57
4.1 Most Common Cases ................................................................................................................ 57
Contributing Authors .......................................................................................................................... 62
Appendices ......................................................................................................................................... 63
Appendix 1 – Mark Sheets .............................................................................................................. 63
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Welcome to Ealing Paces
The Ealing Paces MRCP course has been running since 1992 and is the leading course in the
country. You will have the opportunity to see over 80 system examinations (short cases), as
well as receive advice on examination technique and skills for the exam.
This guide has been written by our highly experienced teachers to help you prepare in
advance for the course and your exam. Please read thoroughly as part of your preparation.
Getting there:
For details on how to get there via public transport, please visit either the TFL website on:
http://journeyplanner.tfl.gov.uk/
http://www.ealinghospital.nhs.uk/how-to-find-us/
If travelling by car, please follow the ‘Ealing Paces MRCP Car Park’ signs which are clearly
displayed upon entering the hospital to find the free parking allocated for you , as shown by
the X on the map.
Walk through the main entrance and follow the signs marked ‘Ealing Paces MRCP Registration’
which will be in the lecture theatre on the third floor.
If you need to get in touch with one of the co-ordinators on the day, please call 020 3330
0031.
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Exam Outline
Before attending the Ealing Paces Course, it is essential that you have a detailed
understanding of the MRCP UK exam and marking scheme.
The MRCP (UK) PACES website has video demonstrations that are worth watching before you
attend http://www.mrcpuk.org/PACES/Pages/CandidateVideo.aspx.
Make sure that you have thoroughly revised your examination skills so that you can perform both
of these examinations in 6 minutes, giving yourself a further 4 minutes to present your findings and
discussing the differential diagnoses with the examiners.
The history-taking skills station aims to assess your ability to gather data from the patient,
construct a differential diagnosis, deal with concerns the patient may have, construct a
management plan that is explained to the patient clearly and treat the patient with dignity and
respect. Instructions for the case are given to the candidate during the 5-minute interval before the
station, usually in the form of a letter from the patient's GP. 14 minutes are allowed for the history-
taking, followed by a 1-minute period of reflection, followed by 5 minutes for discussion with the
examiners.
You should make sure that you can examine the entire cardiovascular system, each part of the
neurological system in 6 minutes, giving yourself 4 minutes for “discussion”. There are stations
dedicated to cardiovascular and neurological examinations, and to get the most out of these, you
need to arrive already knowing how to examine each of these systems.
The communication skills and ethics station aims to assess your ability to guide and organise the
interview with the subject (who may be a patient, relative, or surrogate, such as a healthcare
worker), explain clinical information, apply clinical knowledge, including knowledge of ethics, to the
management of the case or situation, provide emotional support and treat the patient with dignity
and respect.
Instructions for the case are given to the candidate during the five-minute interval before this
station with two examiners present throughout. 14 minutes are allowed for the patient interaction,
followed by 1 minute to reflect, followed by 5 minutes for discussion (after the patient has left the
station).
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Station 5: The Integrated Clinical Assessment 1 (10 minutes)
The Integrated Clinical Assessment 2 (10 minutes)
This station is the one that has worried candidates most, but for the well prepared, it is a gift. The
idea is to mimic a typical 8 minute outpatient consultation, including possible examination.
Although any examination can come up, it transpires that cases with Rheumatological,
Dermatological, Endocrine and ophthalmological diseases come up most often. A brief examination
is thus possible in patients with arthritis, and the case may go on to discuss the management of the
patient, including new drugs. It is thus worthwhile spending a short time making sure you are up to
date on the following conditions:
Psoriasis
Eczema
Thyroid lumps and Graves’ disease
Acromegaly
Cushing’s Syndrome
Osteoarthritis
Rheumatoid Arthritis
Diabetic retinopathy, including the step up of treatment of poorly controlled type 2
diabetes, where worsening eye disease suggests that control is poor.
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Course Structure
The Ealing Paces course has been carefully designed to prepare you for the MRCP (UK)
Examination. Over the weekend you will see a wide variety of typical exam cases and be taught and
assisted by a team of highly experienced teachers.
The course is structured into seven distinct stations, each lasting one hour.
Station D Exam Stations 3 Short cases in skin, locomotor, cardiovascular and neurology
and 5
Station E Exam Station 4 Communication skills
Station G Exam station 5 Eyes, endocrine, neurology and short cases, which in the current
exam has two 10 minute Stations.
Before attending, please read through the above details, and practice your examination skills. We
look forward to seeing you on the course.
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Course Timetable
Saturday
08:00 – Registration
09:15 – Helpers will direct you to your first station based on your coloured badge
There is no lecture on Sunday. Please arrive at 9.00am to start at the relevant station for 9.20am.
Timetable
Time Session
9.20 – 10.20 1
10.20-
10.20-11.20 2
11.20-
11.20-11.35 Coffee
11.35-
11.35-12.35 3
12.35-
12.35-1.35 4
1.35-
1.35-2.15 Lunch
2.15-
2.15-3.15 5
3.15-
3.15-4.15 6
4.15-
4.15-4.30 Coffee
4.30-
4.30-5.30 7
Session
1 2 3 4 5 6 7
Blue A B C D E F G
Pink B C D E F G A
Red C D E F G A B
Green D E F G A B C
Yellow E F G A B C D
White F G A B C D E
Orange G A B C D E F
Adhering to timescales will benefit both yourself and your fellow candidates. Staff will identify
when a session changeover is about to happen.
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Station 1: The Respiratory System
(10 minutes)
Before doing anything else take a moment to look around the bed side to look for helpful clues.
2.1 Environment
Look around the patient area, specifically note if any of the following are present:
Respiratory pattern and rate: Is the patient breathless at rest? Are they breathing through
pursed lips? A prolonged expiratory time is suggestive of obstructive lung disease.
Nutritional status
Chest expansion:
- Is there any obvious asymmetry? The side with reduced chest expansion is likely to be the
side with the pathology
- Is the thorax hyper inflated with decreased expansion – highly suggestive of an obstructive
pathology with significant air-trapping
- Is there any deformity of the chest wall
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2.3 Surgical Scars for the physician
While thoracic scars are largely the domain of the surgeon, they often provide a valuable clue to
the underlying medical pathology. For this reason YOU MUST FULLY EXPOSE THE PATIENT AND
INSPECT THE BACK AND UNDER THE ARMS. If you fail to fully expose the patient you will risk
missing important signs
Thoracotomy scars: Very important but easily missed. Can be anterolateral or posterolateral.
You will have to ensure that the patient is fully exposed and inspect the back to ensure that you
don’t miss these scars. Typical operations, wedge resections, lobectomy, pneumonectomy,
decortication, single lung transplant.
Bilateral anterolateral thoracotomy combined with transverse sternotomy – a.k.a The Clam
shell. This will look like bilateral thoracotomy scars that meet in the middle over the sternum.
This incision is often used for bilateral lung transplants, but also for other procedures that
require access to the thorax.
Chest drain scars: Easily missed, look in the triangle of safety (under the axilla between the
pectoralis and lat dorsi muscles. Implies previous pleural effusions or pneumothorax.
VATS (video-assisted thoracoscopic surgery) scars: Indistinguishable from a chest drain scar. If
you suspect that pulmonary fibrosis is on the differential diagnosis, then the patient may have
undergone a VATS lung biopsy to get a tissue diagnosis. Also used for pleural biopsies,
decortication, pleurodesis
Tracheostomy scars – imply previous invasive ventilation on the intensive care unit
Mediastinoscopy scars – a horizontal scar about 1 cm above the sternal notch, very easily
mistaken for a tracheostomy scar. Used for the investigation of mediastinal lymphadenopathy.
e.g. Sarcoid, TB, lymphoma, staging of primary lung cancer.
Thoracoplasty – will be obvious, with marked thoracic asymmetry, deformity and a thoracotomy
scar. Some ribs may be missing. A treatment for TB before current therapies were available.
Rarely performed for severe pleural infections.
Phrenic nerve crush scars. A small scar seen in the supraclavicular fossa, an old treatment for TB
– A few patients with these scars can still be found. The patient may have reduced air entry on
the base of the affected side.
Radiotherapy tattoos: can be easily missed, but will tell you that the patient has had
radiotherapy for a thoracic malignancy
The hands
The face
The JVP and peripheral oedema (cor pulmonale is an important finding suggestive of severe
respiratory disease)
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3. Then proceed with the Respiratory Examination of the Chest
If you hear bilateral creps, think of two diagnoses: Pulmonary Fibrosis or bronchiectasis.
If you see a VATS scar with fine creps, the favoured diagnosis is pulmonary fibrosis/Diffuse
Interstitial lung disease.
If you hear coarse creps, with a sputum pot at the bed side, the favoured diagnosis is
bronchiectasis.
Standard Spirometry for all. This usually includes an FEV1 and FVC and it is a pre-requisite to
differentiate between obstructive and restrictive pathologies. Bronchodilator reversibility
testing and PEFR diaries are simple tests that can help distinguish between Asthma and COPD
Transfer factors – Will tell you about a problem with gas exchange and will often be low in
Diffuse Interstitial Lung Disease.
6 minute walk tests: a good way of establishing functional status and holds prognostic value.
Inspiratory muscle testing and cough PEFR. Can be important in patients with neuromuscular
weakness who are at risk of developing chronic respiratory failure.
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4.2 Imaging
Standard CT Thorax: Will demonstrate mass lesions and lymph nodes, will not reliably detect
interstitial lung disease or bronchiectasis
HRCT: will demonstrate interstitial lung diseases and bronchiectasis. It will not reliably
evaluate lymphadenopathy or a mass lesion.
Sputum samples. NEVER FORGET to send the sputum for microscopy, culture and sensitivity.
Ziehl-Neelsen stains to look for acid fast bacilli are required when you suspect active
pulmonary TB infection
Tuberculin skin tests. The Mantoux test is useful for identifying those who have been in
contact with tuberculosis. It is most useful for contact tracing and diagnosing latent TB.
Interferon-Gamma release assays (IGRAs – like ELISPOT or QuantiFERON-TB Glod tests) have a
similar role to tuberculin skin tests, and are often used in combination with the Mantoux to
screen for TB contacts or latent TB.
Bronchoscopy – One of the most common tests in the evaluation of a possible lung cancer.
Frequently performed in cases of atypical infections, TB, etc. Sometimes performed in the
work up of ILD. Also starting to develop an interventional role.
Bronchoscopic transbronchial lung biopsies are occasionally helpful in the investigation of some
interstitial diseases, particularly if Sarcoid is suspected.
Lung biopsy. If ILD is suspected, the patient will often require an open lung biopsy, this can
often be achieved via a VATS procedure. CT Guided biopsies are only useful for peripheral
pulmonary lesions to exclude neoplasm
Allergy Testing – commonly with simple skin-prick testing. Consider in the atopic individual
5. Management
It is not possible to cover the management of every respiratory diagnosis that you may see in your
PACES exam. However, it is usual to consider the following basic principles when you try to
construct your presentation.
Smoking will worsen any pulmonary pathology, and cessation should obviously be encouraged at
every opportunity. You should be able to comment on dedicated cessation services and helplines
combined with specific pharmacological therapy such as Nicotine replacement and Champix
(varenicline)
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5.2 Bronchodilators and Steroids
SABAs: Short acting Beta Agonists (e.g. salbutamol) - The first line bronchodilator in any
obstructive airways disease
LABAs: Long acting beta Agonists (e.g. salmeterol or formeterol) - Usually introduced at step 3
in the treatment of asthma. Often used in a combined inhaler with a corticosteroid
SAMA: short acting muscarinic antagonists (e.g Atrovent / Ipratropium) - Rarely used as an
inhaler since the development of LAMAs, now only really used as a nebuliser during acute
exacerbations.
LAMA: Long acting muscarinic antagonists (e.g. Tiotropium / Spiriva) - Primarily used in the
chronic management of COPD. Not routinely used in asthma. Rarely/occasionally used for
Asthma in refractory cases.
Theophyllines - Usually introduced in cases that are refractory to inhaled therapy
Leukotriene receptor antagonists - E.g. Singulair / Montelukast. Particularly helpful in
asthmatics with nasal symptoms / allergic rhinitis. Not used in COPD
Inhaled steroids are frequently used in the management of Asthma and COPD.
Systemic steroids are generally reserved for acute exacerbations of airways disease, or sometimes
in the long-term management of refractory disease.
Systemic steroids +/- steroid sparing agents have a role in the chronic management of selected
interstitial diseases (e.g. selected cases of sarcoidosis). Always consider PPI / bisphosphonate
prophylaxis.
It would be unwise to spend too much time talking about the different inhalers and
bronchodilators that are available. You should be able to explain that in the context of obstructive
airways disease, bronchodilators are introduced in a step-wise fashion (as per the British Thoracic
Society Guidelines)
Asthma Guidelines
http://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/qrg101%202011.pdf
COPD Guidelines
http://guidance.nice.org.uk/CG101
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5.3 Physiotherapy
Physio is very useful for teaching the patient sputum clearance techniques and postural drainage in
cases of bronchiectasis or cystic fibrosis. It also has a role in helping patients achieve better control
over their breathing. There is good evidence that Pulmonary Rehab can improve both symptoms
and functional status in COPD, and it is probably helpful in many respiratory conditions. Beyond
the exercise training, most pulmonary rehab programmes will also aim to provide both educational
and psychosocial support to their patients.
Long term / prophylactic antibiotics do have a role in bronchiectasis where patients are suffering
from very frequent exacerbations. A typical regimen might include azithromycin 250-500mg three
times / week. The role for long-term antibiotics in other conditions is less clear. COPD patients are
more likely to be provided with a “rescue pack” of antibiotics and steroids for the next
exacerbation, in the hope that prompt treatment may prevent further hospital admissions
Long-term nebulised antibiotics have a role in the management of CF, particularly when colonised
with pseudomonas. Some centres will adopt a similar approach for non-CF bronchiectasis, but the
evidence is limited.
TB therapy: Old TB is a common case for PACES, and the candidate would be expected to comment
on a typical regimen for simple pulmonary TB. The candidate should be able to counsel a patient
on therapy, including side-effects. You should also be able to discuss the usual diagnostic tests, the
need for contact tracing, HIV testing, and when to isolate a patient.
The majority of patients with TB can be safely isolated in the community. They do not need
admission to hospital. After admission, patients who are smear positive should be isolated for 2
weeks. For further information, see the guidelines.
A typical regimen for fully sensitive pulmonary tuberculosis is below. The most common side
effects are also listed below, and the patient should be counselled on these possible side effects
before the initiation of therapy.
Rifampicin: 6 months
Hepatotoxicity, P450 Enzyme induction (often has a major impact on drug interactions),
orange-red discoloration of all bodily fluids
Isoniazid: 6 months
Hepatotoxicity, peripheral neuropathy, Vit B6 depletion.
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Ethambutol: 2 months
Optic Neuritis / colour blindness
Pyrazinamide: 2 months
Hepatotoxicity, arthralgia.
Pyridoxine
No anti-TB activity, Co-administered with Isoniazid to counteract risk of peripheral neuropathy
/ B6 deficiency.
Gastro-intestinal symptoms are also common when on all of the above drugs.
It is routine practice to regularly monitor blood tests while on anti-TB therapy, with particular
attention to the LFTs. More information can be found at the following resource:
http://www.nice.org.uk/nicemedia/pdf/CG33quickreffguide.pdf
Advanced planning and Symptom control is an important part of treatment in advanced respiratory
disease, and it is often neglected in non-cancer diagnoses. Many cases of suspected cancer, and all
cases of proven cancer should be discussed in an MDT meeting. The respiratory MDT will often
guide the treatment of many other conditions (e.g. Diffuse Interstitial lung disease)
LTOT is often prescribed for individuals with chronic respiratory failure, typically with a PaO2
<7.3kPa, or a PaO2 between 7.3kPa – 8kPa with coexisting polycythaemia or pulmonary artery
hypertension. Once prescribed, it is usually worn for at least 15 hours/day. Guidelines on the use
of LTOT are found on the following link:
http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Oxygen-Use-in-the-Home.aspx
The emergency use of CPAP and BiPAP will not be discussed here.
Strictly speaking, non-invasive CPAP (Continuous Positive Airway Pressure) does not offer support
for ventilation. In Obstructive sleep apnoea, CPAP acts as a “splint” that will prevent the upper
airways from collapsing during the night. Beyond keeping the airways open, it does not offer any
further assistance to the process of ventilation (i.e. moving air in and out of the thorax).
The most common mode of providing long-term ventilation is through non-invasive BiPAP (Bilevel
Positive Airway Pressure) via a tight-fitting mask.
Spring/Summer 2014
controversial. BiPAP for COPD is used in some centres as there is some evidence to say that it is of
benefit, but this has not been universally adopted at this time. Another common indication of long-
term ventilation is chronic neuromuscular weakness, but this will always be under the supervision
of a specialist centre.
There are many different methods of supporting a patient’s ventilation, and this topic is beyond the
scope of this text. It will be sufficient to have a basic awareness of the most common indications
for long-term ventilation.
Patients with lung cancer may often suffer with recurrent pleural effusions. These are often
managed with a VATS procedure with a pleurodesis, but if the patient is too frail for theatre it is
possible to perform a medical pleurodesis on the ward. Alternatively patients with recurrent
symptomatic pleural effusions can be managed with a long-term tunnelled pleural drain.
6. Presentation
Dullness to percussion + decreased vocal resonance + reduced air entry = pleural effusion or
pleural thickening
Having spent about 6 minutes examining the patient, you then have 4 minutes to summarise your
findings and discuss a management plan with your examiner.
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Station 1: Abdominal System
(10 minutes)
Polycystic kidneys
Transplanted kidney
Chronic liver disease
Hepatosplenamegaly
Splenomegaly
Hepatomegaly
Ascites
Abdominal Mass
Hepatomegaly
Polycythemia rubra vera
Hepatomegaly
2. General inspection
The patient in the abdominal station will often either have chronic liver disease or end-stage renal
disease. Occasionally patients with hepatosplenomegaly due to haematological conditions also
appear in this station.
Don’t forget to inspect the forearm for AV fistulae (evidence of current or previous renal
replacement therapy)
Examine the Eyes: for evidence of anaemia; look under the upper eyelid for subtle conjunctival
icterus (jaundice)
Oral examination: Is there evidence of pigmentation? Don’t forget to inspect the gums (Gum
hypertrophy may be seen in patients who have been on ciclosporine after renal transplant.)
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It is best to leave examination of the neck (& axillae) for lymphadenopathy to the end. This will give
you some time to collect your thoughts about your findings before you present to the examiner!
4.1 Ascites
Transudate
Cirrhosis
Cardiac failure, constrictive pericarditis
Nephrotic syndrome, renal failure
Exudate
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4.2 Hepatomegaly
4.3. Splenomegaly
Cystic kidney
Carcinoma
Hydronephrosis
Pyonephrosis
Hypertrophy (following contralateral nephrectomy)
Perirenal haematoma
Congenital anomaly
5. Presentation
Hepatomegaly
Having spent about 6 minutes examining the patient, you then have 4 minutes to summarise your
findings and discuss a management plan with your examiner.
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Station 2: History Taking Skills
(20 minutes)
Abdominal swelling
Ankle swelling
Asymptomatic hypertension
Back pain
Breathlessness
Burning of the feet
Chest pain
Cold and painful fingers
Collapse? Cause
Confusion
2. Introduction
The history taking station is an important station. It lasts twice as long as most of the other
stations. It is easy to become complacent about this station as history taking is something that we
do every day but it is easy to underperform on this station if you are not adequately prepared.
There is a 5 minute rest break before this station. During this rest break, you will be able to read
the scenario that you are about to encounter. You will usually be asked not to write on the
instruction sheet outside the room and there is a separate copy of the instruction sheet inside the
room. When you enter the room, you will have 20 minutes: 14 minutes to talk to the patient (with
a “two minutes left” warning after 12 minutes), 1 minute in silence to gather your thoughts, and
then 5 minutes of questioning from the examiners.
We will have a one hour teaching session on history taking per day on the course. This teaching
session is carried out in small groups with 3 candidates per instructor. The instructor will aim to get
you to take a full history, ask you some questions in the style of the examiner, and then give you
some feedback within the space of 20 minutes. In the interests of time, we are not going to give
you 5 minutes for preparation beforehand and we will skip your minute of silence. You will hear
some knocking on the door of the room you are in. This is deliberate – it is the course co-ordinators
signalling to the instructors that 12 minutes and then 20 minutes have elapsed.
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2.3 Suggested Interview Structure
2.4 Tips
Most centres will give you a clipboard with some paper – you could use this blank paper to jot
down some ideas of what to ask before you go into the room
You should think about a list of differential diagnoses before you walk into the room – this list
will help to guide your history taking
Do not address the patient by their first name (unless the patient specifically invites you to do
so)
Avoid using jargon with the patient
Listen carefully and follow up any important cues
Do not forget to ask about drug allergies and family history (candidates often forget to do this)
You must evaluate the effects of the illness and side effects of any treatment on the patient’s
functional status and general well-being (you should ask relevant questions in the history of
presenting complaint and / or in the social history)
A good question to ask is, “How does this illness affect your day-to-day life?”
The social history should be detailed – besides the usual smoking and drinking questions, ask
about work, relationships, and accommodation
Get a full history before you start addressing the patient’s concerns – some candidates only
take half a history, then start discussing the issues that are highlighted on the instruction
sheet, and then never finish getting the history
If you finish taking your history before the 14 minutes is up, you cannot move on to
questioning early – the examiners are under instructions to let you know how much time is left
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and not otherwise talk to you; if you finish really early then summarise your history and, in
doing so, you will hopefully discover the areas that you forgot to ask about
In the minute of silence for quiet reflection, think about your differential diagnoses and now
try to order them with the most likely answers first (based on the history you have now
obtained) and create a problem list
Do not present your history after the minute of silence – the examiners have just spent 14
minutes listening to you take the whole history – wait and let them ask you a question
Listen carefully to the examiners’ questions and answer them concisely (like in a job interview:
pause for a second to decide how you want to answer, deliver the answer, and then be quiet)
– do not “dig a hole for yourself” by talking too much and straying into dangerous territory!
Try not to argue with the examiners (even if you are sure that you are right and they are
wrong)
Do not try and whisper answers to another candidate – you will not be in the exam to help
them and the instructors have better hearing than you think!
After the course, consider practising history taking in front of colleagues at your own hospital
and getting some feedback – just like the physical examination stations, you need other
people to point out what you might be doing wrong and you need to get in the habit of taking
a history with the pressure of other people watching you
We would strongly advise you to look at the example scenarios on the MRCP website:
www.mrcpuk.org/PACES/Pages/PacesFormat.aspx
Remember, this station is about you asking a complete and relevant history, answering the
patient’s concerns, and constructing a sensible differential diagnosis and management plan.
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Station 3: Neurology Station & Cardiovascular Station
(10 minutes)
Peripheral neuropathy
Myotonic dystrophy (dystrophia myotonica)
Parkinson’s disease
Charcot-Marie-Tooth disease (hereditary motor and sensory neuropathy)
Abnormal gait
Spastic paraparesis
Cerebellar syndrome
Hemiplegia
Muscular dystrophy
Multiple sclerosis
2. Introduction
The neurology station is often the most feared examination station for PACES. However, it
shouldn’t be, and this guide is to help you become confident with it. There are two main
differences from the other stations:
If you fail to elicit a reflex due to bad technique, the examiner will notice. Honing your
technique, especially for reflexes, it is essential in neurology to know your routine. Most of the
signs are elicited from inspection or observation, (and not from palpation or auscultation).
Unfortunately we still see many candidates pausing or forgetting steps during the
examination. Time spent pondering over this is time taken away from the focus and analysis of
signs leading to a diagnosis and presentation.
Neurology actually combines three main examinations – cranial nerves, upper limbs, and
lower limbs – and some special approaches. Correspondingly, there are more possible cases in
neurology than in other stations. This does not mean you need to know all possible differential
diagnoses. It is more important to think systematically about your findings, even if you don’t
reach the diagnosis.
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3. Cranial nerves
Because of time, often you’ll be asked to examine the eyes (CN II, III, IV and VI) or the lower cranial
nerves (V, VII – XII). Remember certain patterns of lesions:
3.1 General
3.2 Inspection
Ptosis, glasses, wasting of temporalis, jaw deviation, face asymmetry, scars, etc.
CN I
‘Have you noticed any difficulty with your sense of smell or taste?’
CN II
CN III, IV & VI
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CN V
CN VII
Upper face: ‘Raise your eyebrows’, ‘Squeeze your eyes shut tight’
Lower face: ‘Keep your lips together’, ‘Puff out your cheeks’, ‘Show me your teeth’
CN VIII
Cover one ear, ‘Repeat the number that I whisper into your ear’
If abnormal: Rinné’s & Weber’s tests
CN IX & X
Uvula elevation
CN XI
CN XII
3.4 General
The upper limb and lower limb examinations are similar in sequence. There is some flexibility in the
order that they can be performed in. We would suggest leaving sensation until the end as it is time-
consuming and often may be normal. It is critical that you have your own practiced method so that
you don’t forget any part of the examination. All teachers have their own order, which you may or
may not follow. By contrast, it can be useful to perform gait at the start of the examination so that
there is some idea of the diagnosis already. A typical routine would be:
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3.6 Inspection
Walking aids (especially for lower limb exam), fasciculations, scars, wasting, etc.
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3.7 Special examinations
Cerebellar examination
Head
Nystagmus or broken smooth pursuit or ocular dysmetria horizontally (towards the lesion)
Speech for slurring or ‘staccato’/scanning quality (each syllable pronounced separately)
Upper limbs
Finger-nose testing for intention tremor and past-pointing (dysmetria)
Alternating hand movements for Dysdiadochokinesis
Lower limbs
Heel-shin test
Gait
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Truncal ataxia (unable to sit unsupported) is a sign of midline cerebellar disease affecting the
vermis.
Start with demonstration of the core features, then proceed to other signs and signs of ‘plus’
syndromes.
Core features
Resting tremor, worse on distraction
Rigidity on testing tone
Bradykinesia of movements (decrease in speed and amplitude of repeated hand movements)
Gait
Difficulty initiating and stopping
Shuffling with small steps (reduced stride length and foot lifting)
Festinant (appears hurried after initiation)
Turning en-bloc (turn whole body like a statue)
Loss of arm swing
Other features
Quiet speech
Expressionless facies
Micrographia
4. Speech examination
Usually this means the patient will have a cerebellar lesion, or a bulbar/pseudobulbar palsy, but
there are other causes too.
Ask a simple question (e.g. ‘what is your full name?’ ‘What did you have for breakfast today?’)
Ask patient to repeat phrases (e.g. ‘British constitution’ ‘West Register Street’)
This should give some idea of where the lesion is, and you can proceed to test from the relevant
step:
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Hearing (if no answer)
Test cranial nerves starting with CN VIII
Multiple Sclerosis
This should be suspected if you find upper motor neuron signs or cellebellar signs together with
sensory signs. The disease classically relapses and remits and examination of eye movement can
yield the following.
CN III lesion
If the pupil is equally reactive, then this could be a ‘medical’ cause sparing parasympathetic fibres.
If the pupil is only ‘out’ instead of ‘down and out’, then there may be a CN IV lesion too. If other
eye muscles or the other eye is affected, then it is a ‘complex ophthalmoplegia’.
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CN VII lesion
See if the weakness is forehead-sparing (UMN) or not (LMN). If LMN facial weakness, then check if
CN V and CN VIII are intact (for cerebellopontine angle lesions), and then look for causes of facial
nerve palsy: parotid scar or swelling, and vesicles around the ear
CN VIII lesion
See if the hearing loss is sensorineural or conductive. A 512Hz (or if not available, 256Hz) tuning
fork is used for the tests. Avoid the 128Hz tuning fork which is really meant for vibration sense. For
Rinné’s test, place the base of the fork on the mastoid then the fork tip next to the ear canal. Air
conduction should be louder than bone conduction in sensorineural deafness or healthy people.
For Weber’s test, place the base of the fork on the centre of the forehead. It localises towards
conductive deafness and away from sensorineural deafness.
Limb weakness
There are many possibilities and it is first important to identify if it is upper or lower motor neuron
in type, or a muscle disorder.
Remember that the presence of mixed upper and lower motor neuron signs with normal sensation
suggests motor neuron disease.
Look for relatively preserved muscle bulk, increased tone, brisk reflexes, upgoing plantar response.
Flaccid paraparesis
Cauda equina syndrome
Would be a neurosurgical emergency, and must ask about bowel and bladder symptoms
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Radiculopathy
Unilateral weakness of specific muscles (eg. foot drop for L5 lesion)
Associated with sensory loss over the corresponding dermatome (eg. dorsum of foot)
Peripheral neuropathy
Bilateral, symmetrical weakness often with ‘glove and stocking’ sensory loss
Neuromuscular junction
Proximal bilateral weakness, which can be asymmetrical
Fatiguable weakness
Can affect face and extraocular muscles
Normal sensation
Myopathy
Proximal bilateral weakness
Usually normal tone and reflexes until late in the disease
Normal sensation
Sensory loss
Sensory level
Loss of sensation below a certain dermatome usually on the trunk or in the arms.
Suggests spinal cord compression at that dermatome level.
Mononeuropathy
Specific patterns of sensory loss may occur due to injury of a particular nerve.
Median nerve compression at the carpal tunnel is the commonest with loss of or altered
sensation over the lateral 3 and ½ fingers and weakness of the ‘LOAF’ muscles. Do Tinel’s test
and Phalen’s test to check for compression.
Ulnar nerve injury (usually at the elbow) leads to sensory loss over medial 1 and ½ fingers with
weakness of other intrinsic hand muscles.
Radial nerve injury (usually along humerus) leads to sensory loss of dorsum of hand with wrist
drop.
Present your finding: almost all patients can be subdivided into upper or lower motor neurone
diseases, or cerebellar signs, or peripheral neuropathy. We would recommend that you present
this, and then give a differential diagnosis.
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For example:
This patient has upper motor neurone signs as evidenced by the increased tone and brisk reflexes
in the left arm. There is also some weakness and some cerebral signs. My differential diagnosis
includes a stroke or a brain tumour and I would like to obtain a history of the speed of onset to
distinguish them and do a brain scan.
Remember that the mark scheme mainly rewards good examination rather than spotting the
diagnosis.
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Station 4: Cardiovascular
(10 Minutes)
In all stations it is important to have a structured approach not just to your examination but also
your presentation and thought process. Nowhere is this more essential than the cardiology station
where it is possible to begin your diagnostic thought process from the moment you enter the
room. Many students consider themselves (often inaccurately!) to have below-average
auscultatory skills – whilst this is rarely the case, it is both possible and important to have a good
idea of what you might hear you even put your stethoscope to the patient’s chest.
Move in an ordered direction from ‘finger tips to feet’. This will ensure on the day you will look
smooth and practiced:
Introduction
General inspection
Hand inspection
Radial pulses
Collapsing pulse
Blood pressure
Eyes inspection
Mouth inspection
JVP inspection
Carotid pulse examination
Praecordial palpation
Auscultation
Lung oscillation
Ankle examination
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4.3 Introduction
As always, introduce yourself to the patient, ask permission to examine them then take a step back
and inspect.
The diagnostic process should begin as you walk in the room, the key thing to look for in cardiology
is the presence of chest wall scars. Obviously, this tells you whether they have had an operation or
not but you should also start thinking logically about what the likely procedure they could have had
and what other signs you may therefore expect:
CABG – With a central sternotomy scar, the next thing to look for is leg scars (for vein harvest)
or site of scars in the arms (for radial harvest scars). It is possible to have had CABG without leg
or arm scars if the patient has had an internal mammary (LIMA) graft.
- Also bear in mind that they may have had a CABG in conjunction with another
structural heart operation (especially valve replacement). Surgeons will look for an
excuse to replace valves at the same time as a CABG (even if they are only moderately
diseased) to avoid a potential repeat operation.
Valve replacement – listen for a click. If you cannot hear one this does not mean the patient
doesn’t have a metallic valve – they can be quiet, particularly in patients with a thick chest wall.
The patient may also have a biological valve. Look for bruising over the patient’s limbs and
body (warfarin).
A SIMPLE structural heart operation – such as a VSD or ASD repair. A mitral valve repair is also a
possibility. You are likely to find NO murmurs with these operations.
A COMPLEX structural heart operation – such as repair of tetralogy of fallots. You are likely to
FIND murmurs with this as although the physiology is acceptable the resultant anatomy
remains imperfect.
Coarctation repair – it is very unlikely that you will meet a patient with an unrepaired
coarctation because they will be left with irreversible hypertension. Instead, you may meet
someone with a thoracotomy scar: focus then on comparing the radial pulses (the left may be
reduced) and examining for radio-femoral delay
Blalock-Taussig shunt – performed palliatively as part of the tetralogy repair; however, unlike a
coarctation repair it must have a central sternotomy scar accompanying it to signify they have
gone on to have a complete repair. Again, compare radial pulses (the left may be reduced).
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4.7 Sub-mammary scar (right or left side):
Mitral valve surgery – a mini-mitral valve repair (no murmurs) or mitral valvotomy for mitral
stenosis (MR murmur likely as well as residual mild MS) can be done through this route. Also,
the new TAVI procedure (percutaneous aortic valve replacement) can be performed through a
transapical approach giving a left-sided submammary scar.
Either just below the clavicle or in the cephalic groove – can you feel the device?
Age:
- Elderly patients - considering valvular and/or coronary disease – either treated (central
sternotomy scar) or untreated (no scars evident)
- Younger patients – consider structural problems, again treated (scars as above) or
untreated
Skin changes:
- If on sun-exposed regions think of amiodarone therapy (focus on pulse rhythm)
- Cheeks – malar flush (diastolic murmur)
- Bruising – valve replacement (look for a click and note any scars) or AF (rhythm)
4.10 Other:
Finally, use this opportunity to ensure the patient is positioned appropriately at 45 degrees.
4.11 Hands
Ask the patient to stretch both hands out in front of them. Inspect the dorsum then ask them to
turn them over and inspect the palmar surface. Look for:
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4.12 Radial Pulse
Whilst both hands are outstretched, feel both radial pulses at the same time. Then ask the patient
to rest their left hand on their lap and focus on their right radial pulse:
Rate
Rhythm – is the patient in AF
Radial-radial comparison – particularly if the patient has a thoracotomy scar (see above).
Other causes of a reduced radial pulse: large vessel arteritis, cervical rib, subclavian stenosis,
iatrogenic (radial harvest or damage during a radial angiogram).
Avoid performing:
- Radio-femoral delay – this can be too intimate for a lot of patients so do not do as
standard; instead, tell the examiners you would like to examine for it only if you
anticipate it being abnormal (i.e. with a thoracotomy scar)
- Character – other than the collapsing nature, this should be assessed at the carotid
pulse
This is taught in a huge variety of ways (not all of them correct) and therefore can be easily
misunderstood. Think about it pathophysiologically: it is essentially a peripheral manifestation
of a wide pulse pressure, caused by a high stroke volume ejected at the start of systole and
then a rapid fall in blood volume (and therefore pressure) back into the ventricle in diastole
through an incompetent aortic valve.
Place the flats of your fingers of both your hands on the patient’s forearm and raise the arm
quickly and smoothly upwards after obtaining permission from the patient, beware of
shoulder pain, due to tendinitis arthritis. What you should feel is described as a ‘tapping’
feeling: this means the pulse volume feels larger than normal and falls away rapidly. You are
also likely to appreciate it over a large number of your fingers due to the high stroke volume.
Practice this on your colleagues – it is important to ‘look good’ whilst doing this and it is
surprisingly easy to look awkward if you position your hands incorrectly to start.
While you are performing it look at the neck – you can therefore assess for Corrigan’s sign at
the same time
Ask for a blood pressure at this point. If you wait to the end to do so you may forget in the heat of
the moment.
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4.15 Face:
Eyes:
- Conjunctiva - look for anaemia by pulling the eyelids down (you do not need to look at
the upper lid as well, this can be uncomfortable for the patient)
- Xanthalasmata and corneal arcus – (look for a CABG scar)
- Jaundice – valve replacement or aortic stenosis
Mouth:
- Make a note of dentition: in valve replacement cases this is important to comment on,
even if good
- High arched palate: if the patient is tall think Marfan’s (AR), if they are short think
Noonan’s (PS) or Turner’s (coarctation).
- Cyanosis
4.16 Neck
4.17 JVP
If raised, the most likely cause in the exam is right sided heart failure. You should already have
an idea if their ankles are swollen from your general inspection.
If you cannot see it, press gently but firmly over the right upper quadrant to elecit the hepato-
jugular reflex. Always check with the patient that they don’t mind you doing this beforehand.
If you can see the JVP, try and characterise the wave pattern. If you struggle with this,
remember two straight forward things that you can comment on in your presentation:
- You should know their cardiac rhythm by now: if they are in AF, comment on the
absence of a waves
- Giant v waves occur with tricuspid regurgitation so when you come to auscultate listen
for a systolic murmur that gets louder on inspiration
Character:
- Slow rising – aortic stenosis
- Collapsing – aortic regurgitation
- Bisferiens – both slow rising and collapsing – AS and AR
- Jerky – hypertrophic cardiomyopathy
If a patient has had their valve operated on the pulse character should return to normal as the
pathology that caused it has been corrected
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4.19 Praecordial Palpation
Apex beat
- With your hand flat to the chest wall, locate the furthest point you can feel the
heartbeat. Make a point to count down the number of rib spaces with your other hand
marking this spot. If you cannot feel the apex at all, remember dextrocardia and swiftly
check it is not palpable on the right side using your free hand.
- Character:
tapping - mitral stenosis
thrusting - mitral regurgitation
heaving - LVH, often from aortic stenosis
- Thrills – this is a palpable murmur so if you are going to comment on it they must have
the appropriate finding on auscultation. Feel across the praecordium with three hand
positions: one as for apical examination feeling the mitral and tricuspid regions, one
across the left of the sternum feeling tricuspid and pulmonary regions and one
covering both aortic and pulmonary regions at the top of the sternum.
Devices – if there is a device scar GENTLY palpate to feel the device. You are confirming its
presence and assessing its size. Pacemakers are very small but you may be able to recognise
them from ICDs as defibrillators are much larger.
4.20 Auscultation
General points:
- Valve replacements:
Metal valves will sound distinctly metallic whereas bioprosthetic valves will
sound like a normal heart sound although they are usually louder.
In some patients with a metallic valve you will only hear the metallic nature of
the valve in certain regions and not across the whole praecordium.
Generally speaking all aortic valve replacement patients will have a systolic
flow murmur; mitral valve replacement patients rarely have the equivalent
diastolic flow murmur.
It is very unusual to replace right sided heart valves as the physiology does not
need to be as perfect as it is a ‘low pressured’ system. Therefore if the first
heart sound is metallic mitral is most likely and the second, aortic.
- Timing – time the cardiac cycle with the carotid pulse. If you are REALLY struggling to
feel it, use the brachial. Never use the radial, it will not help and looks unprofessional.
- WHERE things are loudest across the praecordium (i.e. in the respective valve regions)
can only guide your diagnosis as this can be variable even in single valve lesions. WHEN
things are loudest within the cardiac cycle (i.e. in relation to the first or second heart
sound) on the other hand cannot be questioned and are much more objective. So if
you heard a metallic first heart sound loudest in the aortic region it is almost certainly a
prothetic mitral valve.
- Right sided lesions get louder with inspiration, left sided with expiration.
39 | P a g e MRCP – REVISION COURSE GUIDE
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4.21 Now listen in the four areas:
Lung bases – keep the patient sitting forwards after listening for AR. Auscultate for crackles
signifying left sided heart failure.
Ankle swelling – press gently, AFTER CHECKING WITH THE PATIENT THEY ARE NOT SORE
Inform the examiner you would like to see the temperature, dip the urine and examine for
Roth spot’s.
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4.23 Presentation
This is often thought to be the hardest part of the station. However, if you are considering your
diagnosis from the outset you will find this much easier.
General rules:
Present the signs you elicited in the order you examined for them: i.e. finger tips to feet
Avoid spending too long listing negative points, particularly when found peripherally. As a
general rule, if the following are negative it is worth mentioning them (but keep it brief):
- The patient is comfortable at rest
- The patient is in sinus rhythm
- The patient has no peripheral stigmata of endocarditis
- There are no features of heart failure
- No thrills, heaves and an undisplaced apex
- Any negative relevant to the diagnosis you have made
It is important to show the examiners that you found the positive signs relatively early in your
presentation.
Finish with a summary of your findings to show the examiners you haven’t missed anything and
to conclude strongly
If you have found a sign that doesn’t agree with your diagnosis, either don’t mention it (if you
doubt your finding) or mention it but point out how it disagrees with your diagnosis. For
example: “although the pulse was collapsing in nature I couldn’t hear a diastolic murmur
therefore I suspect this was just a physiological phenomenon/bounding pulse; I would obviously
like an echocardiogram to confirm my diagnosis”
If you don’t think you have found a ‘single’ diagnosis, do not be afraid of presenting your
differential but find a reason to order it in terms of likelihood. For example, if the murmur is
louder in a particular region or a relevant sign of severity is present use this to guide you.
So, for a patient with mild aortic stenosis for example the presentation might be:
I examined Mr Smith’s cardiovascular system. I note he is comfortable at rest and he has no scars
on his chest. He is in sinus rhythm and his pulse character was normal and not slow rising; you have
told me his BP is 130/85 and therefore not narrow. He had no peripheral stigmata of endocarditis.
He had no thrills or heaves and his apex was undisplaced. On auscultation the most obvious finding
was an ejection systolic murmur which radiates to his carotids but not to his axilla. His second heart
sound was normal in volume. His lung bases were clear and his ankles were not swollen.
In summary, this man appears to have aortic stenosis which is not severe and he has no evidence of
endocarditis or heart failure.
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Station 4: Communication Skills & Ethics
(20 minutes)
The course has two mock ethics station, and you will have the opportunity to practice your own
ethics cases. You will be in groups of 3, and will thus have a full mock ethics station of your own on
Saturday, and again on Sunday. As with the history taking stations, you will thus go through three
history taking stations, for one of which, you will be in the “hot seat”. In general we find that
candidates improve vastly between the first and the second day.
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2. Format of station
Before commencing the case, you will be given a piece of paper with 2-3 lines explaining the
scenario.
You will spend 13-14min interviewing the actor.
There will be a knock on the door at 14min, after which the actor will leave
The examiners will ask you to summarise the case to them
The examiners will viva you on the case
The case finishes after 20min in total
In the course, you will have a mock ethics station on both days.
It is important to do some things to make your ‘performance’ appear more authentic, and get the
right info from the patient.
4. Driving regulations
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4.1 Heart attacks:
Group 1. You need to stop driving for 4 weeks, but do not need to tell the DVLA.
Group 2. You need to stop driving, and can only get your licence back if you pass stage 3 of an ETT
off anti-anginal treatment! i.e. you will be off work for a while.
4.2 Seizures:
Group 2: This is end of your career. You need to stop driving for 10 years, and only regain it if fit
free for 10 years, and are off anticonvulsants when reassessed.
4.3 Diabetes
Group 1: this is generally fine, as long as you do not have poor vision, frequent hypos, severe hypos
(enough to bring you to hospital) or hypoglycaemic unawareness.
Group 2: Until recently, you could not have this type of licence and be on insulin treatment. This
rule has recently been relaxed. You can drive a group 2 vehicle on insulin if:
Remember, these regulations mean that if you want to start insulin, you must take 3 months off
driving your lorry.
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5. Consent
Competent patient:
This is simple. You must gain their consent to perform a procedure / treatment.
Incompetent patient:
The patient cannot consent, so no one can consent for them. The medical team must make a
decision in the best interests of the patient. This does not mean you make a decision on your own!
You must consider:
This is a legal document which informs medical staff what medical treatment a patient would not
want in the future if they ‘lacked capacity’. For instance, you could say that you would or would not
agree to CPR, if required. The advanced directive needs to be followed if it is relevant to the
management decision.
5.3. The patient has made a lasting power of attorney (formally known as enduring power of
attorney)
This is a legal document, which allows a patient to appoint a person (an ‘attorney’) to make
decisions about medical care, when the patient is no longer able to make these decisions (i.e they
are incompetent). So doctors need to speak to and gain consent from the lasting power of
attorney.
NB: this has nothing to do with “Power of Attorney”, which just gives someone else the power to
sell or manage your financial asset e.g. close your bank account.
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6. Criteria for brainstem death (Conference of Medical Royal Colleges 1976-
1981)
This is a common viva topic, so please make sure you know them.
Unfortunately, most candidates do very little or no practice of common ethics cases. There is a
limited number of ethical issues that are likely to be examined. It is therefore difficult to pass if you
are unfamiliar with the issues surrounding these common cases.
Practice, practice, practice. You need to be comfortable doing the common scenarios – you
have a real head-start if you have done your case before (with a friend / partner)
Get enough info from the actor. Ask some direct questions. Think about if you need to discuss
things like employment (will it be affected?), social security benefits, patient support groups,
genetic counselling.
Know the regulations
Always check they understand you
Summarise
Make a follow-up plan
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Station 5: Integrated Clinical Assessment
(10 minutes x2)
In previous years, station 5 patients were four stations each of five minutes approximately included
the following:
Ophthalmology station.
Endocrinology station
Rheumatology station
Dermatology station.
Station 5 now consists of two 10-minute “integrated” stations to include history, possible brief
examination (7 minutes), explanation to the patient (1 minute) and then discussion with the
examiners (2 minutes). Patients with the above four conditions are commonly used for this station,
and it is thus worth knowing a bit about each of these.
1. Ophthalmology Station
Diabetic Retinopathy
Retinitis Pigmentosa
Optic Atrophy
Ocular Palsy
Visual Field Defect
Retinal Vein Occlusion
Old Choroiditis
Papilloedema
Cataracts
Myasthenia Gravis
1.2 Introduction
Fundoscopy is not difficult! Finding the time and inclination to practice it so it becomes easy is the
difficult part. The old ‘short case’ style of examining a fundus and providing a diagnosis or
differential diagnosis is no longer required. You have 8 minutes with each patient to conduct a
history focusing on a particular clinical issue, carry out appropriate examinations and respond to
any concerns from the patient. You may not even have to examine the fundus; taking a history,
examining ocular motility in a patient with diplopia and discussing your findings will easily take up 8
minutes.
Before we move onto typical scenarios, a reminder on how to carry out fundoscopy:
1. Introduce and explain what you are going to do – make sure the patient is at ease that you will
be coming very close to them and that they should continue to breathe normally. Most
‘professional’ patients will know the drill.
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2. Try and ensure adequate positioning of the patient on the chair/bedside, especially if you are
particularly short or tall – being comfortable during the examination is important.
3. Don’t forget the general inspection! It is unlikely that the examiners will allow the very obvious
clue of a guide dog to be in the examination room, but dark glasses and a white stick may mean
the patient has severe sight impairment, so comment on them.
4. Ask the patient to remove their spectacles if they wear any and dim the room lights – it helps
with contrast sensitivity and with patients whose pupils don’t dilate very well. As regards what
to do about your own spectacles, it depends on how comfortable you are examining with them
on. We will talk about refractive errors and any adjustments that might need to be made
during the practical session.
5. Before moving onto fundoscopy, check the red reflex – if there is no red reflex, fundoscopy will
be very difficult, if not impossible. It would be unfair for you to be asked to examine an artificial
eye (this would definitely not have a red reflex!)
6. Ask the patient to fixate on a distant target, slightly above head height (helps to move the
upper lid). You may rest your second hand on the patient’s forehead, but do not hold the
upper lid forcibly open. If the patient cannot blink, they will complain that the eye is
uncomfortable and the cornea drying out will impact adversely on your examination.
7. Looking through the ophthalmoscope, approach the patient’s eye ensuring that the light source
is steady on the pupil as you approach. You need to get close enough, so that your entire view
through the eyepiece is through the pupil. If you can see any of the iris visible, you are either
not close enough or you have veered off target.
8. Unless you have a good reason not to (e.g. blind in one eye), you should examine the patient’s
right eye using your right hand and your right eye and vice versa for the patient’s left eye. It is
difficult to get close enough otherwise.
9. Focus on the retinal features and have a logical method of examination: disc, vessels, macula. If
you get ‘lost’ within the eye, follow the bifurcation of retinal vessels back to the disc. Get the
disc into focus and carry on with your routine.
10. Examine the left eye and present your findings in a consistent fashion (be guided by the history
that you have elicited.
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2 Scenarios
Diabetic retinopathy
By far the commonest eye condition to be encountered in an examination setting, as there are lots
of diabetic patients that can be called upon. Ensure you know what laser photocoagulation looks
like and don’t confuse it with retinitis pigmentosa (RP) or choroiditis. The scenario may require you
to think about other areas that may need to be examined as well as the eyes, impact on lifestyle
and treatment modalities for the underlying condition.
This patient with long standing type 2 diabetes has come for an annual review in the diabetic clinic.
You need to perform a brief annual review, including history and ophthalmological examination.
You are NOT required to assess for peripheral neuropathy on this occasion.
Commonly patients with poorly controlled type 2 diabetes will give a history compatible with high
levels of glucose including glycosuria and recurrent urinary tract infections.
Ensure you are aware of NICE guidelines for treatment of type 2 diabetes, and remember to always
mention lifestyle changes in addition to drug treatments. Most patients should be on Metformin,
but you should consider the incremental treatments including sulphonylureas which are second
line to metformin, and then recognise the thiozolidinediones, the GLP-1 (injectable) analogues, the
DPP4 inhibitors (“gliptins”) and the new SGLT2 inhibitors (dapagliflozin) which increase glycosuria
and are rarely used. Remember that insulin is also a very effective treatment. Talk to the patient
about their concerns of poor control of diabetes.
Fundoscopy may reveal changes of background diabetic retinopathy, or laser burns commonly.
Make sure you know the features of commonly occurring abnormalities:
If you see background retinopathy, then you should inform the patient that you can see changes
that suggest that control can be improved, and then explain to the patient how you can do this
using diet exercise and the drugs above.
In the final 2 minutes, you will need to tell the examiners what you have found, and be prepared
for questions about the different treatments available.
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2.1 Loss of vision
History: acute or slowly progressive? Acute onset suggests a vascular aetiology (e.g. vein
occlusion, ischaemic optic neuropathy). Slower onset may be something as simple as a cataract
(can be picked up checking the red reflex) or something sinister such as a compressive lesion.
Unilateral or bilateral? Bilateral disease may mean an underlying systemic/genetic cause (e.g.
diabetes or RP)
Painful or painless? Painful causes (e.g. retrobulbar neuritis, giant cell arteritis)
Is vision loss generalised or specific? Central vision loss implies macular disease (e.g. diabetic
maculopathy, age-related macular degeneration). Peripheral vision loss (e.g. RP, glaucoma).
Hemianopia/quadrantanopia secondary to previous CVA.
2.2 Diplopia
Monocular (with only one eye open)? Usually due to cataract or corneal pathology.
Binocular (only with both eyes open)? Usually due to extraocular muscle imbalance:
- Nerve palsies
- Thyroid eye disease (TED)
- Myasthenia
- Ocular myopathies
Variability? Diplopia in nerve palsies and TED generally doesn’t vary whereas myasthaenia and
ocular myopathies can give rise to variable and intermittent diplopia
Direction? Constant horizontal diplopia suggests CN VI palsy, whereas constant vertical diplopia
may be due to CN IV palsy
Ptosis? Constant ptosis and diplopia may mean a CN III palsy and a variable, fatigable ptosis with
variable diplopia suggests myasthaenia
CN III palsy and pupil: if the pupil is involved (i.e. dilated) with a CN III palsy, this is potentially a
neurosurgical emergency, therefore mandatory to check pupil size with suspected CN III palsy.
There are two uses of the COVER test. If a patient has an obvious squint, you can prove this by
asking them to look at you, and covering the “good” eye.
http://eyeontechs.com/new/?p=230
If a patient develops double vision while you are checking their eye movements, then you can
check which eye is weaker by covering each eye in turn. The weak eye ALWAYS sees the outer
image.
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51 | P a g e MRCP – REVISION COURSE GUIDE
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2.3 Pupil reactions
Equal or not equal? Need to check in dim light as well as bright light. Larger pupil in bright
light or smaller pupil in dim light points to the affected side.
Ptosis? If associated with smaller pupil may mean Horner’s syndrome (congenital or
acquired). If acquired, need to think about potential causes.
Ptosis? Associated with larger pupil and abnormal eye movement (pupil involving CN III palsy
– see above)
Adies pupil is a tonically dilated pupil, probably due to a viral infection. More common in
women. May have loss of deep tendon reflexes (Holmes-Adie syndrome).
Pharmacological: either iatrogenic or recreational
RAPD (Relative Afferent Pupillary Defect): a positive RAPD test is a sign of optic nerve
disease. May be an acute finding (e.g. retrobulbar neuritis) or longstanding (previous
ischaemic optic neuropathy).
‘Optic atrophy’ is not a diagnosis. Pale optic nerves may be due to many causes and you
must put this finding into the context of the patient you have in front of you (e.g. if it is a
young woman, then more likely to be 2º to demyelination, whereas if it is an elderly man
with hypertension and diabetes, Non Arteritic Ischaemic Optic Neuropathy (NAION) is more
likely.
HINT:
What would you do if (following inspection as you walk into the room) you suspect a Horner’s
syndrome?
Answer: Darken the room enough to be able to see a difference in the pupil size. It is the failure
of dilatation that is the problem. Shining a light into the eye will show normal constriction, and is
a common cause of the diagnosis being missed.
There are many causes of retinitis pigmentosa. It can occur by itself, and be autosomal dominant,
autosomal recessive or X-linked. At this point you would refer them for a specialist opinion. You
need to know nothing else about the condition. There is some small print about one of the causes
(Refsum’s disease) that you might read for interest.
2.5 Small print that you don’t need to know about Refsum’s disease. There are only a few cases
in the UK.
Refsums disease occurs in patients who cannot metabolise phytanic acid, which is a fatty acid
which is a metabolite of chlorophyll. It is concentrated in the fat of animals that eat grass (lamb,
beef). It causes retinitis pigmentosa. Phytanoyl CoA hydroxylase is absent, so that phytanic acid
levels climb. Patients are managed with a diet low in phytanic acid, so they can’t eat beef or lamb.
52 | P a g e MRCP – REVISION COURSE GUIDE
Spring/Summer 2014
As long as they are putting on weight, the fatty acids are safely out of the bloodstream and in
triglyceride, but if they lose weight, then the fatty acids are released into the circulation, and toxic
levels result in worsening retinitis pigmentosa, deafness and neurological signs.
Spring/Summer 2014
3. Endocrinology
Exophthalmos
Acromegaly
Graves’ disease
Goitre
Hypothyroidism
Cushing syndrome
Addison’s disease
Hypopituitarism
Pretibial myxoedema
Gynaecomastia
Features that suggest that the condition is currently active are important, and as there is time for
discussion, there are a few facts that you need to know. Thus having taken a history and examined
the patient, you need to also consider:
Acromegaly is probably one of the most over-represented stations in PACES. Patients are stable
with signs, and so get recruited. You can obtain a brief history from the patient, to include
particular questions about ring size (the patient has stopped wearing a wedding ring because it
became tight), shoe size and even hat size. To demonstrate the changes, the patient may even
have with them some old photographs. Ask about headache, an important feature of active
acromegaly, and proceed to examine the hands, feeling for the doughy palm and the spade like
shape of the hands. Inspect the tongue and teeth, looking for increased intradental separation, and
you can then proceed to explain what further investigations the patient needs. Sometimes you
need to make the diagnosis, but more often the rubric on the sheet tells you that the patient is
known to have acromegaly and that they have attended for an annual review.
Spring/Summer 2014
3.2 Complications of acromegaly
The tumour of acromegaly can be large enough to cause a bitemporal hemianiopia. Be sure to
check each eye individually, as with both eyes open, the fields will be normal.
You need to find out what medication the patient is on, and what treatment the patient has
already had. You may then be asked detailed information about the diagnosis and treatment of
acromegaly, especially if you are doing well, and there are relatively few things that you need to
know to look really good. The facts given here might be useful for your discussion. The usual first
line treatment is transphenoidal surgery followed if the patient is not cured, by radiotherapy, and
sometimes medical treatment. Drugs that help to control growth hormone levels include dopamine
agonists such as bromocriptine or cabergoline, or somatostatin analogues such as lanreotide or
octreotide. GH receptor antagonists can also be used (Pegvisomant), but at present this is
extremely expensive.
Also remember to discuss pituitary replacement if the patient has been rendered hypopituitary by
the treatment, so that they might need hydrocortisone, thyroxine or sex steroid replacement (HRT
in females or testosterone in males). Some patients may have diabetes insipidus as a consequence
of surgery, and will then be on DDAVP replacement.
Investigations that are undertaken include assessing GH burden with a glucose tolerance test, and
investigation of pituitary reserve with some form of stress test, usually with insulin
(hypoglycaemia). Imaging of the pituitary may reveal a pituitary adenoma.
Patients with Graves disease or a nodular goitre are common. There may be a history of features of
hyperthyroidism or hypothyroidism, and the patient may now be well controlled. For
hyperthyroidism, the diagnosis will either be autoimmune Graves disease, or a toxic nodular goitre.
The patient will now have been treated. Proceed as follows:
Spring/Summer 2014
or carbimazole), or radioiodine, or surgery. The medical treatments have well known side
effects including a rash and occasionally serious neutropaenia.
Surgery may cause damage to the recurrent laryngeal nerve, resulting in a possible change in
voice, and there is the risk of hypo-parathyroidism, which is difficult to live with in view of the
resulting hypocalcaemia. Radioiodine is safe, but one needs to know about radiation protection
rules (see http://radioiodine.info for details). After radioiodine, there is a good chance that the
patient will need lifelong thyroxine replacement.
A very common choice in the UK is for patients to have an 18 month course of thionamides,
and then a review. Half the patients are in remission at that point and will need no further
therapy. Those that relapse are then offered “definitive” therapy (radioiodine or surgery).
When males are affected, Graves disease is generally more aggressive, and males are thus
more likely to require definitive therapy.
To summarise, with the endocrine cases, you should keep your cool and present with confidence.
The discussion can become a detailed management plan. For example if you know all about Graves
disease, and have really revised the subject, having stated that the patient obviously has Graves
disease (“as evidenced by a smooth goitre and exophthalmos”) you can proceed to talk about
investigations and treatment. “I would like to check the patients thyroid function tests and
determine whether TSH receptor antibodies are present, to confirm the diagnosis. There are three
treatment options to be considered, medical treatment, radioiodine or surgery, and all three have
advantages and disadvantages. I will explain these to the patient and allow them to make the
choice.
Spring/Summer 2014
4. Dermatology & Rheumatology
4.1 Most Common Cases
Examination of the hands and deciding whether a patient has rheumatoid arthritis (RA) or
osteoarthritis (OA) is basic and important. RA commonly affects the proximal interphalangeal (PIP)
joints as well as the metacarpophalangeal (MCP) joints. OA affects the distal interphalangeal (DIP)
joints is important. Other seronegative arthritides are also important to consider. The treatment
hierarchy for rheumatoid disease is also key information. Patients may attend with longstanding
rheumatoid arthritis for a routine follow up, but they may have a new problem or worsening
symptoms that needs review. Thus a patient with stable rheumatoid arthritis might complain of
breathlessness and one should consider infection, pulmonary fibrosis or pneumonitis relating to
their medications.
- Always ask for a list of medications, the effects of the condition on the patient's life, functional
limitation, whether they have any questions or worries or concerns.
Spring/Summer 2014
4.2 Rheumatoid Arthritis:
History
- Duration, which joints, pain worse in the morning
- Is there morning stiffness (duration), functional limitation
- Any rashes (e.g psoriasis)
- What treatment, any side-effects
- Determine whether their RA is active
- Risks and benefits of DMARDs and biologics
Examination
- Symmetrical, deforming polyarthritis
- Nodules indicate seropositivity (RhF)
- Exclude psoriatic arthropathy (nails, skin)
- Assess activity (red, hot, swollen, painful joints)
- Assess function (e.g power, precision or key grip)
Investigations
- ESR, CRP
- Xrays hands and feet and chest (as baseline pre-methotrexate)
- RhF and anti-CCP Antibodies
History - as for RA
Examination
- Usually extensor surfaces - classical plaques (knees, elbows, behind ears, scalp, naval and
natal cleft), guttate, flexural, palmar-plantar pustulosis
- Nails (pitting, onycholysis, hyperkeratosis, discolouration, ridges)
- Koebner phenomen (psoriasis in a scar)
Spring/Summer 2014
Treatment
History
- Rashes, malar rash, photosensitivity, alopecia (?scarring), oral ulceration, dry eyes
(?secondary sjogrens), dry mouth, raynauds, PE/DVT/miscarriage (?secondary
antiphospholipid syndrome)
- Previous kidney or neurological involvement
Examination:
Investigations
Classified by the distribution of skin affected. The face may be involved in both.
Spring/Summer 2014
- Diarrhoea/constipation (?bacterial overgrowth)
- Interstitial lung disease (bibasal, fine-end inspiratory crepitations)
- Pulmonary hypertension (loud P2, RV heave, TR, raised JVP)
Investigations
Management
- Skin - camouflage
- Raynauds - gloves, calcium channel blockers, angiotensin II receptor antagonists,
fluoxetine, iloprost (prostacyclin)
- GI - omeprazole, ranitidine, prokinetics (metoclopramide)
4.6 Gout:
The patient may have a history of acute gout with no signs whatsoever, or may have chronic
tophaceous gout.
History:
- Attacks of gout - which joints, how often duration, how many attacks, ?trigger and risk
factors e.g. diet, alcohol, lympho or myeloproliferative disease
- ?renal impairment (may dictate management), ?urate stones
Examination:
Investigations:
Management:
Spring/Summer 2014
4.7 Ankylosing spondylitis
History
- Inflammatory back pain (worse in the morning, better with exercise, NSAID-responsive,
morning stiffness)
- ?Inflammatory bowel disease, ?psoriasis, uveitis
- ?family history
Examination
- Shoeber's test - 2 points in midline marked 10cm above dimples of venus and 5cm below.
Expand less than 5cm on maximum forward flexion
- kyphosis, loss of normal lumbar lordosis, extension at cervical spine
- Measure occiput-wall distance with patient stood against wall
- Look for signs of psoriasis, aortic regurgitation and apical pulmonary fibrosis
Investigations
Management
- Physiotherapy
- NSAIDs, TNF inhibitors
Paget’s disease of the bone affects older people, and may cause a warm bowed tibia. The patient
may also have a Pagetic skull. Carefully examine both legs and compare them. If one leg is warm
and bowed, then this is a possible diagnosis.
Investigations:
- ALP very high (normal calcium, phosphate, liver function tests)
- Bone scan
Management
- Analgesia, bisphosphonates
61 | P a g e MRCP – REVISION COURSE GUIDE
Spring/Summer 2014
Contributing Authors
Spring/Summer 2014
Appendices
Spring/Summer 2014
ROYAL COLLEGES OF PHYSICIANS OF THE UNITED KINGDOM
MRCP (UK) Part 2 Clinical Examination (PACES)
Examiners’ Calibration Record
STATION ONE: Abdominal Examination
Each examiner should record agreed physical signs and case specific marking criteria for each clinical skill assessed and
use the record as a personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Patient Name
ABDO
ROYAL COLLEGES OF PHYSICIANS OF THE UNITED KINGDOM
MRCP(UK) PACES EXAMINATION - CLINICAL MARKSHEET
STATION ONE - Abdominal System Examination
CANDIDATE NAME (PLEASE PRINT) Brief description of the case:
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 G
M
7 7 7 7 7 7 7 7 7 7 7 7 H
8 8 8 8 8 8 8 8 8 8 8 8 J
Did you lead at this case? Yes No
A
9 9 9 9 9 9 9 9 9 9 9 9 K
X
Please record your judgement for this candidate's performance on each of the clinical skills noted Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
H E
T
Thorough Omits significant or important tests
Fluent Unsystematic
IN
Systematic Hesitant and lacking in confidence
Professional technique of palpation and Unprofessional
E
percussion for masses, organomegaly and
ascites
Identifying
Physical
Signs
Identifies correct physical signs
U S Misses important physical signs
R
(B) Does not find signs that are not present Finds signs that are not present
Differential
Diagnosis
F O
Constructs a sensible differential Poor differential diagnosis
T
(D) diagnosis, including the correct diagnosis
Fails to consider the correct diagnosis
Clinical
Judgement
(E)
N O
Selects a sensible and appropriate
management plan
Unfamiliar with correct management plan
Selects inappropriate management
Maintaining
Patient
Treats patient respectfully and sensitively Causes patient physical or emotional
Welfare and ensures comfort, safety and dignity discomfort
(G)
Jeopardises patient safety
Patient Name
RESP
ROYAL COLLEGES OF PHYSICIANS OF THE UNITED KINGDOM
MRCP(UK) PACES EXAMINATION - CLINICAL MARKSHEET
STATION ONE - Respiratory System Examination
CANDIDATE NAME (PLEASE PRINT) Brief description of the case:
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
E
Clinical skill Satisfactory Borderline Unsatisfactory COMMENTS
H
Physical
Examination
T
Correct Incorrect techniques
(A)
Thorough Omits significant or important tests
IN
Fluent Unsystematic
Systematic Hesitant and lacking in confidence
D
Professional technique of palpation, Unprofessional
E
percussion and auscultation of the chest
Identifying
Physical
Signs
Identifies correct physical signs
US Misses important physical signs
E
(B) Does not find signs that are not present Finds signs that are not present
B
O
Differential
Diagnosis
T
Constructs a sensible differential diagnosis, Poor differential diagnosis
(D) including the correct diagnosis
Fails to consider the correct diagnosis
Clinical
Judgement
O T
N
Selects a sensible and appropriate Unfamiliar with correct management plan
(E) management plan
Selects inappropriate management
Maintaining
Patient Causes patient physical or emotional
Treats patient respectfully and sensitively discomfort
Welfare (G) and ensures comfort, safety and dignity
Jeopardises patient safety
Examiners must record agreed scenario specific marking criteria for each clinical skill
assessed.
Each examiner should record agreed physical findings and any specific agreed marking criteria and use the record as a
personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Scenario Number
Did the candidate display satisfactory history taking skills (see below)?
Managing Patients How should a satisfactory candidate respond to the concerns of the
Concerns (F) patient/surrogate?
Examiner information:
HISTORY
ROYAL COLLEGES OF PHYSICIANS OF THE UNITED KINGDOM
MRCP(UK) PACES EXAMINATION - CLINICAL MARKSHEET
STATION TWO - History Taking Skills
CANDIDATE NAME (PLEASE PRINT) Brief description of the case:
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
E
Clinical skill Satisfactory Borderline Unsatisfactory COMMENTS
H
Clinical
Communication Elicits presenting complaint, systems review, Omits important areas of the history
T
past, family and medication history, in a
Skills thorough, systematic, fluent and
Unsystematic
(C) professional manner Appears unpractised
IN
Unprofessional
Assesses impact of symptoms on patient’s
D
occupation, lifestyle and activities of daily
living
S E
Omits important information
Gives inaccurate information
U
Clear Uses jargon
Structured Poorly structured
E
Comprehensive Appears unpractised
B
Fluent and Unprofessional
Professional manner
Managing
Patients’
T O
Seeks, detects, acknowledges and
attempts to address patient's concerns
Overlooks patients concerns
Does not check knowledge and understanding
T
Concerns Confirms patient’s knowledge and Poor listening
understanding
(F)
O
Not empathic
Listens
N
Empathic
Differential
Diagnosis Constructs a sensible differential diagnosis, Poor differential diagnosis
including the correct diagnosis
(D) Fails to consider the correct diagnosis
Clinical
Judgement Selects a comprehensive, sensible and Unfamiliar with correct management plan
appropriate management plan
(E) Selects inappropriate management
Maintaining
Patient Treats patient respectfully and sensitively Causes patient physical or emotional
and ensures comfort, safety and dignity discomfort
Welfare (G)
Jeopardises patient safety
Patient Name
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
COMMENTS
E
Clinical skill Satisfactory Borderline Unsatisfactory
H
Physical
Examination
T
Correct Incorrect techniques
(A)
Thorough Omits significant or important tests
IN
Fluent Unsystematic
Systematic and professional technique of Hesitant and lacking in confidence
D
assessment of arterial and venous pulses
Unprofessional
and palpation and auscultation of the
E
precordium
Identifying
Physical
Signs (B)
Identifies correct physical signs
U S Misses important physical signs
E
Does not find signs that are not present Finds signs that are not present
Differential B
Diagnosis
(D)
T O
Constructs a sensible differential diagnosis,
including the correct diagnosis
Poor differential diagnosis
Fails to consider the correct diagnosis
Clinical
O T
N
Judgement
Selects a sensible and appropriate Unfamiliar with correct management plan
(E) management plan
Selects inappropriate management
Maintaining
Patient
Treats patient respectfully and sensitively Causes patient physical or emotional
Welfare and ensures comfort, safety and dignity discomfort
(G)
Jeopardises patient safety
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
E
Clinical skill Satisfactory Borderline Unsatisfactory COMMENTS
H
Physical
Examination
T
Correct Incorrect techniques
(A)
Thorough Omits significant or important tests
IN
Fluent Unsystematic
Systematic and professional technique of Hesitant and lacking in confidence
D
assessment of tone, power, reflexes,
Unprofessional
sensation, coordination and cranial nerve
E
function as appropriate
Identifying
Physical
Signs
Identifies correct physical signs
U S Misses important physical signs
Differential
Diagnosis
T O
Constructs a sensible differential diagnosis, Poor differential diagnosis
T
including the correct diagnosis
(D) Fails to consider the correct diagnosis
Clinical
Judgement
(E) N O
Selects a sensible and appropriate Unfamiliar with correct management plan
management plan
Selects inappropriate management
Maintaining
Patient
Treats patient respectfully and sensitively Causes patient physical or emotional
Welfare and ensures comfort, safety and dignity discomfort
(G)
Jeopardises patient safety
Patient Name
Examiners must record agreed scenario specific marking criteria for each clinical skill
assessed.
Each examiner should record agreed physical findings and any specific agreed marking criteria and use the record as a
personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Scenario number:
Examiner information:
Communication Skills Ethical Principles (E)
Defines purpose of interview (C) Respects the patient as a person
Avoids jargon (C) - their medical best interests
Uses open questions (C) - their wishes
Listens attentively (F) Uses professional judgment
Reacts to cues (F) - in face to uncertainty
Negotiates (E) - to communicate accurately and
Empathises (F) honestly
Explains clearly Tries to do more good than harm
Summarises-confirms understanding (C) Shows awareness of the principles of
justice and equity
QSXP 20/7/09 15:51 Page 1
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
COMMENTS
E
Clinical skill Satisfactory Borderline Unsatisfactory
H
Clinical
Communication
T
Explains relevant clinical information in an Omits important information
Skills
(C) Accurate Gives inaccurate or unclear information
IN
Clear Poorly structured
Structured Uses jargon
D
Comprehensive Appears unpractised
Fluent and Unprofessional
Professional manner
S E
U
Managing
Patients’
E
Seeks, detects, acknowledges and attempts Overlooks patient’s or relative’s concerns
Concerns to address patient’s or relative’s concerns Poor listening
B
(F)
Listens Not empathic
Confirms patient’s or relative’s knowledge
O
Does not check knowledge and understanding
and understanding
T
Empathic
T
Clinical
Judgement
O
Selects or negotiates a sensible and Selects or negotiates an inappropriate,
(E) appropriate management plan for this incomplete or incorrect management plan
N
patient, relative or clinical situation
Can apply clinical knowledge, including Cannot apply clinical knowledge, including
knowledge of law and ethics, to this case knowledge of law and ethics, to this case
Maintaining
Patient
Treats patient respectfully and sensitively Causes patient physical or emotional
Welfare and ensures comfort, safety and dignity discomfort
(G)
Jeopardises patient safety
Examiners must record agreed physical signs and case specific marking criteria for each
clinical skill assessed.
Each examiner should record agreed physical findings and any specific agreed marking criteria and use the record as a
personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Patient Name
Managing Patients How should a satisfactory candidate respond to the patient’s concerns?
Concerns (F)
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7
M
7 7 7 7 7 7 7 7 H
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
E
Clinical skill Satisfactory Borderline Unsatisfactory COMMENTS
H
Clinical
Communication Elicits history relevant to the complaint and Omits important areas of the history
T
explains information to the patient in a
Skills Unpractised
(C) Focused Unprofessional
IN
Fluent Poor explanation to the patient
Professional manner
D
Physical
E
Examination Correct Incorrect techniques
(A) Appropriate Omits significant or important tests
S
Practised Inappropriate focus to examination
U
Professional Hesitant and lacking in confidence
Unprofessional
Clinical
Judgement
(E)
Selects sensible and appropriate
investigations and treatment
B E Selects inappropriate investigations or
treatment
Managing
Patients’
TO
Detects, acknowledges and attempts to Overlooks patients concerns
T
address patient's concerns
Concerns Poor listening
(F) Listens Not empathic
O
Empathic
Identifying
Physical
Signs (B)
N Identifies correct physical signs
Does not find signs that are not present
Misses important physical signs
Finds signs that are not present
Differential
Diagnosis Constructs a sensible differential diagnosis, Poor differential diagnosis
including the correct diagnosis
(D) Fails to consider the correct diagnosis
Maintaining
Patient Treats patient respectfully and sensitively Causes patient physical or emotional
and ensures comfort, safety and dignity discomfort
Welfare
(G) Jeopardises patient safety
Examiners must record agreed physical signs and case specific marking criteria for each
clinical skill assessed.
Each examiner should record agreed physical findings and any specific agreed marking criteria and use the record as a
personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Patient Name
Managing Patients How should a satisfactory candidate respond to the patient’s concerns?
Concerns (F)
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AIGA 21/7/09 11:05 Page 1
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
COMMENTS
E
Clinical skill Satisfactory Borderline Unsatisfactory
H
Clinical
Communication Elicits history relevant to the complaint and Omits important areas of the history.
T
explains information to the patient in a Unpractised
Skills
Focused
(C) Unprofessional
IN
Fluent Poor explanation to the patient
Professional manner
D
Physical
E
Examination Correct Incorrect techniques
(A) Appropriate Omits significant or important tests
S
Practised Inappropriate focus to examination
U
Professional Hesitant and lacking in confidence
Unprofessional
Clinical
Judgement
(E)
Selects sensible and appropriate
investigations and treatment
B E Selects inappropriate investigations or
treatment
Managing
Patients’
TO
Detects, acknowledges and attempts to
address patient's concerns
Overlooks patients concerns
T
Concerns Poor listening
Listens
(F) Not empathic
O
Empathic
Identifying
Physical
Signs (B) N Identifies correct physical signs
Does not find signs that are not present
Misses important physical signs
Finds signs that are not present
Differential
Diagnosis Constructs a sensible differential diagnosis, Poor differential diagnosis
including the correct diagnosis Fails to consider the correct diagnosis
(D)
Maintaining
Patient Treats patient respectfully and sensitively Causes patient physical or emotional
and ensures comfort, safety and dignity discomfort
Welfare
Jeopardises patient safety
(G)
Patient Name
ABDO
ROYAL COLLEGES OF PHYSICIANS OF THE UNITED KINGDOM
MRCP(UK) PACES EXAMINATION - CLINICAL MARKSHEET
STATION ONE - Abdominal System Examination
CANDIDATE NAME (PLEASE PRINT) Brief description of the case:
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 G
M
7 7 7 7 7 7 7 7 7 7 7 7 H
8 8 8 8 8 8 8 8 8 8 8 8 J
Did you lead at this case? Yes No
A
9 9 9 9 9 9 9 9 9 9 9 9 K
X
Please record your judgement for this candidate's performance on each of the clinical skills noted Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
H E
T
Thorough Omits significant or important tests
Fluent Unsystematic
IN
Systematic Hesitant and lacking in confidence
Professional technique of palpation and Unprofessional
E
percussion for masses, organomegaly and
ascites
Identifying
Physical
Signs
Identifies correct physical signs
U S Misses important physical signs
R
(B) Does not find signs that are not present Finds signs that are not present
Differential
Diagnosis
F O
Constructs a sensible differential Poor differential diagnosis
T
(D) diagnosis, including the correct diagnosis
Fails to consider the correct diagnosis
Clinical
Judgement
(E)
N O
Selects a sensible and appropriate
management plan
Unfamiliar with correct management plan
Selects inappropriate management
Maintaining
Patient
Treats patient respectfully and sensitively Causes patient physical or emotional
Welfare and ensures comfort, safety and dignity discomfort
(G)
Jeopardises patient safety
Patient Name
RESP
ROYAL COLLEGES OF PHYSICIANS OF THE UNITED KINGDOM
MRCP(UK) PACES EXAMINATION - CLINICAL MARKSHEET
STATION ONE - Respiratory System Examination
CANDIDATE NAME (PLEASE PRINT) Brief description of the case:
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
E
Clinical skill Satisfactory Borderline Unsatisfactory COMMENTS
H
Physical
Examination
T
Correct Incorrect techniques
(A)
Thorough Omits significant or important tests
IN
Fluent Unsystematic
Systematic Hesitant and lacking in confidence
D
Professional technique of palpation, Unprofessional
E
percussion and auscultation of the chest
Identifying
Physical
Signs
Identifies correct physical signs
US Misses important physical signs
E
(B) Does not find signs that are not present Finds signs that are not present
B
O
Differential
Diagnosis
T
Constructs a sensible differential diagnosis, Poor differential diagnosis
(D) including the correct diagnosis
Fails to consider the correct diagnosis
Clinical
Judgement
O T
N
Selects a sensible and appropriate Unfamiliar with correct management plan
(E) management plan
Selects inappropriate management
Maintaining
Patient Causes patient physical or emotional
Treats patient respectfully and sensitively discomfort
Welfare (G) and ensures comfort, safety and dignity
Jeopardises patient safety
Examiners must record agreed scenario specific marking criteria for each clinical skill
assessed.
Each examiner should record agreed physical findings and any specific agreed marking criteria and use the record as a
personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Scenario Number
Did the candidate display satisfactory history taking skills (see below)?
Managing Patients How should a satisfactory candidate respond to the concerns of the
Concerns (F) patient/surrogate?
Examiner information:
HISTORY
ROYAL COLLEGES OF PHYSICIANS OF THE UNITED KINGDOM
MRCP(UK) PACES EXAMINATION - CLINICAL MARKSHEET
STATION TWO - History Taking Skills
CANDIDATE NAME (PLEASE PRINT) Brief description of the case:
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
E
Clinical skill Satisfactory Borderline Unsatisfactory COMMENTS
H
Clinical
Communication Elicits presenting complaint, systems review, Omits important areas of the history
T
past, family and medication history, in a
Skills thorough, systematic, fluent and
Unsystematic
(C) professional manner Appears unpractised
IN
Unprofessional
Assesses impact of symptoms on patient’s
D
occupation, lifestyle and activities of daily
living
S E
Omits important information
Gives inaccurate information
U
Clear Uses jargon
Structured Poorly structured
E
Comprehensive Appears unpractised
B
Fluent and Unprofessional
Professional manner
Managing
Patients’
T O
Seeks, detects, acknowledges and
attempts to address patient's concerns
Overlooks patients concerns
Does not check knowledge and understanding
T
Concerns Confirms patient’s knowledge and Poor listening
understanding
(F)
O
Not empathic
Listens
N
Empathic
Differential
Diagnosis Constructs a sensible differential diagnosis, Poor differential diagnosis
including the correct diagnosis
(D) Fails to consider the correct diagnosis
Clinical
Judgement Selects a comprehensive, sensible and Unfamiliar with correct management plan
appropriate management plan
(E) Selects inappropriate management
Maintaining
Patient Treats patient respectfully and sensitively Causes patient physical or emotional
and ensures comfort, safety and dignity discomfort
Welfare (G)
Jeopardises patient safety
Patient Name
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
COMMENTS
E
Clinical skill Satisfactory Borderline Unsatisfactory
H
Physical
Examination
T
Correct Incorrect techniques
(A)
Thorough Omits significant or important tests
IN
Fluent Unsystematic
Systematic and professional technique of Hesitant and lacking in confidence
D
assessment of arterial and venous pulses
Unprofessional
and palpation and auscultation of the
E
precordium
Identifying
Physical
Signs (B)
Identifies correct physical signs
U S Misses important physical signs
E
Does not find signs that are not present Finds signs that are not present
Differential B
Diagnosis
(D)
T O
Constructs a sensible differential diagnosis,
including the correct diagnosis
Poor differential diagnosis
Fails to consider the correct diagnosis
Clinical
O T
N
Judgement
Selects a sensible and appropriate Unfamiliar with correct management plan
(E) management plan
Selects inappropriate management
Maintaining
Patient
Treats patient respectfully and sensitively Causes patient physical or emotional
Welfare and ensures comfort, safety and dignity discomfort
(G)
Jeopardises patient safety
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
E
Clinical skill Satisfactory Borderline Unsatisfactory COMMENTS
H
Physical
Examination
T
Correct Incorrect techniques
(A)
Thorough Omits significant or important tests
IN
Fluent Unsystematic
Systematic and professional technique of Hesitant and lacking in confidence
D
assessment of tone, power, reflexes,
Unprofessional
sensation, coordination and cranial nerve
E
function as appropriate
Identifying
Physical
Signs
Identifies correct physical signs
U S Misses important physical signs
Differential
Diagnosis
T O
Constructs a sensible differential diagnosis, Poor differential diagnosis
T
including the correct diagnosis
(D) Fails to consider the correct diagnosis
Clinical
Judgement
(E) N O
Selects a sensible and appropriate Unfamiliar with correct management plan
management plan
Selects inappropriate management
Maintaining
Patient
Treats patient respectfully and sensitively Causes patient physical or emotional
Welfare and ensures comfort, safety and dignity discomfort
(G)
Jeopardises patient safety
Patient Name
Examiners must record agreed scenario specific marking criteria for each clinical skill
assessed.
Each examiner should record agreed physical findings and any specific agreed marking criteria and use the record as a
personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Scenario number:
Examiner information:
Communication Skills Ethical Principles (E)
Defines purpose of interview (C) Respects the patient as a person
Avoids jargon (C) - their medical best interests
Uses open questions (C) - their wishes
Listens attentively (F) Uses professional judgment
Reacts to cues (F) - in face to uncertainty
Negotiates (E) - to communicate accurately and
Empathises (F) honestly
Explains clearly Tries to do more good than harm
Summarises-confirms understanding (C) Shows awareness of the principles of
justice and equity
QSXP 20/7/09 15:51 Page 1
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
COMMENTS
E
Clinical skill Satisfactory Borderline Unsatisfactory
H
Clinical
Communication
T
Explains relevant clinical information in an Omits important information
Skills
(C) Accurate Gives inaccurate or unclear information
IN
Clear Poorly structured
Structured Uses jargon
D
Comprehensive Appears unpractised
Fluent and Unprofessional
Professional manner
S E
U
Managing
Patients’
E
Seeks, detects, acknowledges and attempts Overlooks patient’s or relative’s concerns
Concerns to address patient’s or relative’s concerns Poor listening
B
(F)
Listens Not empathic
Confirms patient’s or relative’s knowledge
O
Does not check knowledge and understanding
and understanding
T
Empathic
T
Clinical
Judgement
O
Selects or negotiates a sensible and Selects or negotiates an inappropriate,
(E) appropriate management plan for this incomplete or incorrect management plan
N
patient, relative or clinical situation
Can apply clinical knowledge, including Cannot apply clinical knowledge, including
knowledge of law and ethics, to this case knowledge of law and ethics, to this case
Maintaining
Patient
Treats patient respectfully and sensitively Causes patient physical or emotional
Welfare and ensures comfort, safety and dignity discomfort
(G)
Jeopardises patient safety
Examiners must record agreed physical signs and case specific marking criteria for each
clinical skill assessed.
Each examiner should record agreed physical findings and any specific agreed marking criteria and use the record as a
personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Patient Name
Managing Patients How should a satisfactory candidate respond to the patient’s concerns?
Concerns (F)
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7
M
7 7 7 7 7 7 7 7 H
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
E
Clinical skill Satisfactory Borderline Unsatisfactory COMMENTS
H
Clinical
Communication Elicits history relevant to the complaint and Omits important areas of the history
T
explains information to the patient in a
Skills Unpractised
(C) Focused Unprofessional
IN
Fluent Poor explanation to the patient
Professional manner
D
Physical
E
Examination Correct Incorrect techniques
(A) Appropriate Omits significant or important tests
S
Practised Inappropriate focus to examination
U
Professional Hesitant and lacking in confidence
Unprofessional
Clinical
Judgement
(E)
Selects sensible and appropriate
investigations and treatment
B E Selects inappropriate investigations or
treatment
Managing
Patients’
TO
Detects, acknowledges and attempts to Overlooks patients concerns
T
address patient's concerns
Concerns Poor listening
(F) Listens Not empathic
O
Empathic
Identifying
Physical
Signs (B)
N Identifies correct physical signs
Does not find signs that are not present
Misses important physical signs
Finds signs that are not present
Differential
Diagnosis Constructs a sensible differential diagnosis, Poor differential diagnosis
including the correct diagnosis
(D) Fails to consider the correct diagnosis
Maintaining
Patient Treats patient respectfully and sensitively Causes patient physical or emotional
and ensures comfort, safety and dignity discomfort
Welfare
(G) Jeopardises patient safety
Examiners must record agreed physical signs and case specific marking criteria for each
clinical skill assessed.
Each examiner should record agreed physical findings and any specific agreed marking criteria and use the record as a
personal aide-memoire during the subsequent cycle.
Examiner Number Examination Centre Number
Patient Name
Managing Patients How should a satisfactory candidate respond to the patient’s concerns?
Concerns (F)
Page 1 of 1
AIGA 21/7/09 11:05 Page 1
Examiner name:
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 C
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 D
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E Examiner signature:
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 F
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 G
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 H
M
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 J
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 K Did you lead at this case? Yes No
Please record your judgement for this candidate's performance on each of the clinical skills noted
X A
Counselling
E
below. Any award of an unsatisfactory or borderline mark MUST be accompanied by comments. recommended
COMMENTS
E
Clinical skill Satisfactory Borderline Unsatisfactory
H
Clinical
Communication Elicits history relevant to the complaint and Omits important areas of the history.
T
explains information to the patient in a Unpractised
Skills
Focused
(C) Unprofessional
IN
Fluent Poor explanation to the patient
Professional manner
D
Physical
E
Examination Correct Incorrect techniques
(A) Appropriate Omits significant or important tests
S
Practised Inappropriate focus to examination
U
Professional Hesitant and lacking in confidence
Unprofessional
Clinical
Judgement
(E)
Selects sensible and appropriate
investigations and treatment
B E Selects inappropriate investigations or
treatment
Managing
Patients’
TO
Detects, acknowledges and attempts to
address patient's concerns
Overlooks patients concerns
T
Concerns Poor listening
Listens
(F) Not empathic
O
Empathic
Identifying
Physical
Signs (B) N Identifies correct physical signs
Does not find signs that are not present
Misses important physical signs
Finds signs that are not present
Differential
Diagnosis Constructs a sensible differential diagnosis, Poor differential diagnosis
including the correct diagnosis Fails to consider the correct diagnosis
(D)
Maintaining
Patient Treats patient respectfully and sensitively Causes patient physical or emotional
and ensures comfort, safety and dignity discomfort
Welfare
Jeopardises patient safety
(G)
M R C P – R E V IS I O N C O U R S E G U I D E
Spring/Summer 2014
NOTES
M R C P – R E V IS I O N C O U R S E G U I D E
Spring/Summer 2014
NOTES
M R C P – R E V IS I O N C O U R S E G U I D E
Spring/Summer 2014
NOTES
M R C P – R E V IS I O N C O U R S E G U I D E
Spring/Summer 2014
NOTES
M R C P – R E V IS I O N C O U R S E G U I D E
Spring/Summer 2014