PACES MRCP UK - Where MRCPians Meet Since 2006

MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.

Wednesday, May 10, 2006

Abdomem = Easy Station ?!

My seniors used to tell me that PACES candidates must score for abdomen cases. One of the reasons is the signs are obvious and easily detected. Hence, the expectation from the fellows is higher for this station compared to others e.g. neurology station. Every steps must be perfect for this station including examination skills, formulation of diagnosis and discussion.

Common pitfalls:
1. Wrong exam skills:
* Forget to position patient correctly i.e. examine with >1 pillow
* Inadequate exposure
* Forget to inspect from the end of the bed
* Check ankle edema without looking at patient face
* Examine lymph node in supine position
* Percuss Traube's space in lateral position
* Assume no splenomegaly without checking spleen in right lateral position
* Forget to ballot kidneys
* Fail to detect ascites
* Forget to ascultate
* Fail to end examination by mentioning relevant tests

2.Wrong formulation of diagnosis:
* Fail to formulate correct diagnosis at the end of examination
* Do not correlate the signs with the scenario given

In PACES, you will be asked the differential diagnosis for your patient. Some of the common combination of the signs would be:

1. Liver + Spleen
* Myelofibrosis
* Lymphoproliferative
* Cirrhosis + portal hypertension (CLD signs)
* Hereditary hemolytic anemia (Jaundice, pallor, hyperpigmented, short stature, young age)

2. Liver + Spleen + LNs
* Lymphoma
* CML in blastic crisis

3. Spleen + LNs
* CLL/ lymphoma
* Infections eg Infectious mononucleosis
* Felty syndrome ( RA hands!)

4. Isolated Spleen
* CML/ Myelofibrosis
* Lymphoma
* Polycythemia rubra vera (plethora)

* Chronic malaria (fever, jaundice)
* IE, typhoid

* Cirrhosis with portal hypertension (CLD signs)

5. Isolated Liver
* Cirrhosis (CLD)
* Mitotic lesion (primary or secondary)
* CCF ( tender liver, edematous)
* Acute hepatitis (tender, fever, jaundice, no CLD)
* Liver abscess (tender, fever, jaundice, no CLD)

So, is it an easy station compare to others? What do you think?



At 5/11/2006 09:29:00 PM, Blogger spinosum said...

Regarding the Traube space:
1. There is controversy about whether to percuss the Traube space in exam; many of my professors told me NOT to do that in post-grad exams. Any comment?

2. What do you mean by: wrong to percuss Traube space in lateral position?

At 5/12/2006 01:18:00 AM, Blogger eMRCPian said...

This comment has been removed by a blog administrator.

At 5/12/2006 01:19:00 AM, Blogger eMRCPian said...

1. You should check the Traube space because it is one of the features that differentiate spleen from kidney

2.You should percuss it in supine position

At 5/12/2006 06:34:00 PM, Blogger BloodDoc said...

I found this interesting info:

- "Ludwig Traube. The man and his space." ; Archives of Internal Medicine, 1992 Apr;152(4):701-3.

- Here is the abstract:

** The detection of dullness to percussion in the left hemithorax raises the possibility of pleural effusion, consolidation, or atelectasis. Percussion of Traube's space, a semilunar tympanitic area overlying the gas bubble in the stomach, is a valuable maneuver in this regard: obliteration of Traube's space favors a pleural effusion. Knowledge of the remarkable life of Traube, and the ability to demonstrate the utility of his sign on rounds, provides an opportunity in a technologic age to remind the medical student of the romance of bedside medicine.**

unfortunately only abstarct is available online. Anyone has access to this journal in the library might want to enlighten us on what was the original clinical indication of Traube space dullness.

Maybe someone senior out there can give input?


At 5/12/2006 06:38:00 PM, Blogger eMRCPian said...

I got the same info from google search. It's confusing.

At 5/12/2006 10:36:00 PM, Blogger Axonopathic said...

Hi guys,

Have written a blog on this issue. Yep I agree it's rather confusing. Hope it'll help;)

At 5/12/2006 11:36:00 PM, Blogger BloodDoc said...

Hi Axonopathic
read your entry, intersting and informative.

another piece of info from pub med

Percussion of Traube's space--a useful index of splenic enlargement; J Assoc Physicians India. 2000 Mar;48(3):326-8.

**OBJECTIVE: To evaluate the sensitivity and specificity of palpation and percussion for splenic enlargement, as the accuracy of many of the clinical maneuvers we perform remains largely unstudied. METHODS: One hundred cases were selected at random from medical wards, and splenic enlargement was assessed by palpation and percussion of the Traube's space (Barkuns method), which was confirmed by the ultrasonography of the abdomen. The results of the various tests were tabulated and assessed statistically. RESULTS: 1) Performance of Traube's space percussion shows 24 true positive and 48 true negative cases, the test thus had an overall sensitivity of 67% and specificity of 75%. It was also found that the BMI of the false negative cases was significantly higher (29.43 Kg/m2). 2) Palpation as a diagnostic maneuver had a high specificity of 96.87% along with high false negative rate with overall low sensitivity of 44.44%. 3) Interpolation of findings of Traube's space percussion and palpation showed that maximum clinical utility could be achieved when both percussion and palpation were positive.**

their conclusion
**CONCLUSION: Percussion of the Traube's space is a useful clinical screening test for splenomegaly, with a sensitivity of 67% and specificity of 75%, as compared to palpation (sensitivity of 44.44% and specificity of 96.87%). And maximum clinical utility is achieved when both percussion and palpation are combined.**

I think it will be interesting to find out how the this sign has changed from indicating a lung disease to splenic enlargement.



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