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Tutorial for MRCP PACES Station 1 ( Last modified: 12 January 2007)

1)Abdominal Examination

Abdominal station is always a favourite station for candidates in MRCP PACES as well as for examiners. This reason is simple because it is an easy station and usually takes less than 5 minutes for candidates to complete the physical examination ( therefore examiners are happy too since they do not need to stand so long waiting for you to open your mouth!) Unlike respiratory station,candidates usually do not have problems in completing their physical examination in abdominal station. Since the examiners have lots of time after your physical examination, they are very likely to ask you a lot of questions, therefore prepare your theory well in abdominal station! Below is the algorithm how a abdomianl case should be examined,

MRCP Abdominal station

During your examination, always remember a few fatal mistakes candidates tend to make during their MRCP PACES examination,

Being not sensitive, some candidates insist on exposing the patient until below the groin.Besides embrassing your patient, you certainly have one thousand and one reasons to fail!Always cover your patient's private part,

Go straight to the abdomen, always spend time in inspection ( I tend to stand at the end of patient's bed to do inspection and then come to patient's bedsde to start examining his/her hand), always inform your patient what you want to do.I always start with patient's hand ( clubbing, palmar erythema, leukonychia, hepatic flap), upper limbs ( fistula, scratch mark, spider naevi), eye ( anaemia, jaundice), upper chest ( spider naevi, gynaecomastia and loss of axillary hair),

Being rude and not sensitive- always ask the patient whether the abdomen is painful or not before doing superficial and deep palpation.You will get a clear fail if you cause any pain to patient,

Forget to show shifting dullness or fluid thrill when you suspect there is presence of ascites.Look for any recent peritoneal tapping scar as well,

Forget to ballot for kidneys while examining the patient. Always look for ballotable kidney,

Forget to auscultate for renal bruit. Remember to look for this especially in a transplanted kidney and hypertensive patient!

Remember that after your physical examination, suggest to examiners what other physical signs you want to look for, for an example, if you suspect patient has chronic liver disease, you certainly want to do a per-rectum examination to look for upper gastro-intestinal bleeding especially if the patient appears to be pale as well. Try to suggest something relevant rather than routine examination!

After you examination, summarize you physical signs,

" Mr...... is comfortable in bed, he is pale and jaundiced. I also notice there is presence of palmar erythema and multiple spider naevi over his upper chest. His abdomen is grossly distended with ascites. The shifting dullness is positive. Palpitation reveals that Mr....... has hepatosplenomegaly. His liver is enlarged and 4-finger breadth below the costal margin. His spleen is enlarged 3-finger breadth below the costal margin. In summary, I suspect Mr....... has chronic liver disease and the underlying etiology is most probably chronic viral hepatitis in view of the prevalence of this disease in this part of the world. I will be interested to know about his alcohol intake history."

Always tell your examiners your provisional diagnosis and explain to them your plan of action. When I was a medical student, my lecturer told me, the best thing in an oral examination is you have all the chance to talk and the examiners keep quiet. Usually, if this happens, you are saying some interesting points and the examiners think you are eligible to pass the exam. If the examiners keep on interrupting you , stay calm and present your findings systematically. Always show them you know a lot about a topic, tell them something you know and avoid saying something you are unsure of!

2)Respiratory Examination

Respiratory station is the nightmare for all MRCP PACES candidates. This station is difficult in two ways, you have problems to complete your physical examination and the second problem is the physical signs may be difficult to pick up!However, remember the following steps while examining your patients,

MRCP Abdominal station

Remember a few fatal mistakes candidates tend to make during their MRCP PACES respiratory station,

Fail to feel the tracheal position, I always tell my junior doctors, tracheal position is the single most important physical sign in respiratory station,

Fail to observe bedside clues while examining the patient, these clues include sputum cup, peak expiratory flow meter, oxygen supplement,

Unable to complete your physical examination,practice with your friends before your MRCP PACES, try to complete your full examination ( front and back of the chest) within 7 mins,

Fail to differentiate dullness from stony dullness. Remember that you may be given a case of minimal pleural effusion in your exam, therefore, it is important to pay attention to your percussion note to differentiate either it is dull or stony dull!