Medical Interactive Cases are excellent resources with state of the art online presentation provided free by New England Journal of Medicine. By using them you can learn interactively, get immediate feedback, and compare your performance with that of others.
These can improve your clinical skills and help you in your preparation for the MRCP PACES examination.

Following are some of the links:

Breathlessness

A Bird’s-Eye View of Fever

A Problem in Gestation

A Sleeping Giant

A Sweet Source of Abdominal Pain

Lying Low

A Crazy Cause of Dyspnea

Bitter Pills

Hard to Conceive

A Rash Hypothesis

The Beat Goes On

Stalking the Diagnosis

Painful Purple Toes

A Crisis in Late Pregnancy

A Bloody Mystery

The Writing on the Wall

FALLS:
These may be of 2 types:
1- With loss of consciousness – Epilepsy, Syncope, metabolic

2- Without loss of consciousness - Neuromuscular instability or Disequilibrium

Falls without loss of consciousness

Differential Diagnosis and Questions to ask

1. Visual problems – cataract, glaucoma, macular degeneration: Do you have any visual problems?

2. Limb weakness – stroke, neuropathy: do you have any weakness in your legs?

3. Arthritis: do you suffer from arthritis in your knees? Do your knees ever give way?

4. Postural hypotension: Does the fall happen on suddenly getting up from sitting position? If yes, ask about:

a.Autonomic neuropathy – diabetes

b.Polypharmacy – Do the falls happen at any specific time of the day, like some time after you have taken your tablets? Drugs: benzodiazepines, tricyclic antidepressants, antihypertensives, diuretics, levodopa and alcohol

c.Addison’s disease: vomiting, nausea, weight loss, vitiligo, pigmentation

5. Vertigo: Just before you fall, does the room start spinning around you? Do you feel sick? If yes, ask about:

a.Benign positional: Do you feel dizzy when you turn your head in bed?

b.Meniere’s disease: Do you have dizziness with vomiting and hearing problem?

c.vertebra-basilar ischemia: Does the fall happen on bending your neck backwards?

d.SOL- acoustic neuroma: Do you have headache? Have you been diagnosed as having a

6. Sensory ataxia: What is balance like in between the falls? Is your balance all right in the dark?

7. Cerebellar ataxia: Do you feel your balance is disturbed? Do your hands feel clumsy?

8. Parkinson’s disease: Do you feel stiffness in your body? Have you noticed any tremor in your hands?

9. Dementia: What is your memory like? Has there been a problem in your memory recently?

More later…

TIREDNESS

Ask whether tired all the time or general fatigue after minim activity/weakness, specific muscle groups involved, present all day or episodic, or is it stiffness which improves on activity (rheumatoid arthritis)
All other characters etc, insidious/sudden, after some illness, duration, intensity, episodic, associated symptoms, etc

Past history: cranial/pituitary radiation

Differential Diagnosis

1. anemia pallor: hx, diet: veg/non-veg, meat/bleeding/ulcer
2. hypothyroidism: preference for wamth, weight gain, thyroid disease,
3. Addison’s: dizziness on getting up, vomiting, nausea, wt loss, vitiligo, pigmentation
4. diabetes mellitus: polyuria, polypgagia, polydipsia,
5. Obstructive Sleep Apnoea: snoring, obesity
6. Heart failure: dyspnoea, orthonoea, paroxysmal nocturnal dypnoea
7. chronic lung disease: dyspnoea
8. chronic kidney disease: nocturia/oliguria
9. inflammatory bowel disease
10. Chronic infection: fever etc
11. Malignancy:
1- Lung cancer: haemoptysis, weight loss, smoking history
2- Colorectal cancer: bowel habit altered, pr bleeding, wt loss,
3- Myelo/lymphoproliferative disease: wt loss, fatigue, +/-sweating
12. Depression: feel depressed, lost interest in activities, loss of concentration, change in appetite, disturbed sleep
13. periodic paralysis: sudden attacks of weakness
14. myasthenia: arms get tired if you have to raise them or lift something for some time
15. polymyositis/polymyalgia rheumatica: proximal muscle weakness/pain. difficulty walking up the stairs/getting put of chair
16. chronic fatigue syndrome: fatigue after minimal activity, preceeding viral illness
17. b-blockers: drug history

more to come later

This station is a new change in the PACES exam. Not much information or help is

available about it which make it one of the most dreaded and confusing Stations

for most candidates. Here is some detailed advice about this station which a

colleague wrote and very kindly allowed me to use it on this website for the

benefit of all candidates.

At Station 5, outside the examination room, there will be 2 written scenarios and a

paper to write notes on. Though it is said that you are allowed 5 minutes outside

the station, in fact, you get only four and a half minute to go through the

scenarios. Thirty seconds will be lost in moving around, settling down and

handing over mark sheets to examiner. This is a precious time. Make use of it.

Practice to finish reading each scenario in 2 minute.

Each scenario will have only 4 to 5 lines. Read them, make the diagnosis (station

5 usually targets a single diagnosis) and any possible differential diagnoses.

You have to think really fast and you can only do that if you have practiced

different scenarios with colleagues already.

Think about what questions to ask and what physical examination to do, 2 or 3

important investigations and important treatment.

Write it down on the paper. This should finish in 2 minutes.

Move to the second scenario. Do the same.

You should be ready at least 15 seconds before you go in. When the bell rings the

lead examiner for the first case will invite you, in shake hands with you and

introduce the second examiner and tell you that this is your 1st case. Make sure

you identify the case and the scenario. Introduce yourself to patient and then start

off.

Keeping the diagnosis/differential diagnoses in mind ask all the relevant

questions.

When you are done with questions, start examining in a way relevant to the

problem.

You should keep talking to patient while examining, i.e., you can continue with

some of the history while examining.

No need for detailed social, family, personal, drug or occupational history but you

should ask relevant things related to the problem.

You may tell the patient what you think his problem is and what you are planning

to do.

Ask him if he has any concerns/worries/questions, and answer those.

Do not worry, you will get enough time as there are 8 minutes.

By three and a half to 4 minutes most of the history should be over. Start

examining and continue the history. By six and a half minutes everything should

be over. Spend the last minute and half (2 minutes would be ideal) explaining

things to patient and answering his concerns. At 8 minutes the examiner will stop

you.

The lead examiner will ask the following questions only as the time left is 2

minutes:

1) what are your findings and what is your diagnosis, any D/D.

2) Important investigations and treatment.

If you have already discussed the investigations with patient, the examiner has

heard it and will only ask treatment.

Always look at the lead examiner and answer and just a glance in between to the

other examiner. Look straight into the eye of the examiner and answer. Don’t shift

your eye here and there and do not move around. You may look at the patient in

between to take your eyes off the examiner if that will help you. Sometimes you

may get a patient who speaks no English and then you will have a translator. This applies to the centres outside the UK. You

should interact for the history with the translator and then examine the patient

(not the translator!).

This was the general idea about Station 5. I hope this helps.

Any scenarios can come in the station 5. You should have one strategy to tackle

them. Read/think about all possible scenarios. PRACTICE, PRACTICE, PRACTICE

with colleagues or seniors.

Practice makes perfect when it come to the PACES exam.

Two latest books are out with Station 5 scenarios and advice, the OST book is highly praised:

OST: Clinical Medicine for the MRCP PACES
Volume 2: History-Taking, Communication and Ethics
Iqbal and Mehta

OST: Clinical Medicine for the MRCP PACE
Volume 1: Stations: 1,3 & 5 – Core Clinical Skills
Iqbal and Mehta

Revision Notes for MRCP 2 PACES
Shibley Rahman, Avinash Sharma

Read all scenarios for history taking from Ryder Mir volume 2. Other books to refer to are Success in PACES by Philip Kelly and PACES for the MRCP by Tim Hall.

History taking: when you read the scenario:

1. make a list of differential diagnosis, most are given in that scenario discussion
2. for each differential diagnosis find out which questions to ask to rule it out
3. learn what are the alarm symptoms for each system of the body
4. make a problem list as you go on taking history, note on the paper

Now how to tackle the history taking:

When you practice history taking with a colleague:

Read the scenario carefully and on a piece of paper make notes where you write down important points from the scenario and make a structure for taking history like:

1. Introduce yourself and confirm identity of patient: “Mr Wilkin’s?” The patient will say yes or will nod. Say, “Nice to meet you.” I am Dr Candidate, I am a Senior House Officer in ER/ Admissions unit/ Cadiology/ Gastroenterology unit.

2. Verify the information with the patient by saying that your GP has written this letter saying that you are 54 years old and you have chest pain for the last 2 months plus any other information – the examiner marksheet has marks for this especially. Just remember that what the GP has written may not be true, so it is important to verify. And GP’s suspicions about the patients diagnosis may not be true either.

3. Hx of presenting complaints: Always start with an open question like, “Your GP has written so and so, tell me more about it”. Take detailed history about the presenting complaint like, breathlessness, pain, fatigue, etc. E.g., full history of pain: site, nature, character, intermittent or continuous, severity, radiation, whether is the same, improving or deteriorating, associated symptoms and its effect on the patient’s life. Alarm symptoms like wt loss, bleeding, etc.
4. Previous investigations: it is good idea to ask the patient about this because it reveals further information which the patient has not yet revealed.

5. Systemic review and alarm symptoms plus menstrual history for women. One by one rule out all diseases from your list of differential diagnosis, like joint pains and hand deformity in rheumatoid arthritis, any silvery/scaly rashes for psoriasis.

Alarm symptoms: Pt with cancer: symptoms of cord compression, hypercalcemia (polyuria/polydipsia), superior vena cava obstruction (swelling of face) and neutropenia (frequent infections).

Liver diasease: symptoms of ascites, melaena, confusion and jaundice.

Heart disease: symptoms of chest pain at rest, syncope and family h/o sudden death.

Abdominal pain: symptoms of wt loss, jaundice and family h/o intra-abdominal malignancy.

Back pain: h/o loss of bladder or bowel control, leg weakness.

6. Past Hx of relevant or any other diseases including ongoing complaints: diabetes, asthma, angina, heart attack, high blood pressure. Any surgeries. Any relevant travel history.

7. Drug Hx and allergies: Any drugs, whether effective or not. Any side effects. Keep in mind any drugs which maybe causing the patients symptoms, like, diuretics causing falls (postural hypotension), amiodarone causing thyrotoxicosis or hypothyroid symptoms, etc.

8. Family Hx: of similar or any other disease. Diabetes, asthma, angina, heart attack, high blood pressure. Parents, early death in family due to heart disease in relevant cases. Family h/o sudden death, etc

9. Social Hx: marital status, occupation – relate occupation to the patient’s symptoms, social circumstances. Stairs, etc., in the house in case of mobility problem. Any assistance at home, any dependents.

Smoking: do you smoke, if “no”, then if you have ever smoked, how many cigarettes, for how long, when did you stop. If “yes”, then have you ever tried or thought about quitting.

Drinking: if denies heavy drinking but you suspect symptoms to be drinking related, then ask the CAGE questions: C – have you ever tried to cut down on your drinking? A – have you ever felt annoyed if others criticize your excessive drinking? G – Have you ever felt guilty about drinking too much? E – do you feel like having a glass of alcohol early in the morning ( eye opener)?

Illicit Drug History: marijuana, injecting drugs, sharing needles.

Sexual History: If relevant. Partners, contact with prostitutes, homo-hetero sexual. Unsafe sex, especially during travels to sub-Saharan Africa

10. Patient’s Concerns/beliefs/insight: What do you think your symptoms are caused by? Do you have any concerns? Do you have any questions? It is very important to address any concerns of the patient. Does the patient really understand the severity of the disease? They may ask “do I have cancer, doctor?” You need to talk to them appropriately. You must not rush this part.

11. Summarize, explain plan, and any follow up arrangements

12. Create a problem list including management plan

Click here to read History Taking notes: TIREDNESS

Click here to read History Taking notes: FALLS

A SPANISH Teacher was explaining to her class that in Spanish, unlike
English, nouns are designated as either masculine or feminine.

‘House’ for instance, is feminine: ‘la casa.’
‘Pencil,’ however, is masculine: ‘el lapiz.’

A student asked, ‘What gender is ‘computer’?’

Instead of giving the answer, the teacher split the class into two
groups, male and female, and asked them to decide for themselves
whether computer’ should be a masculine or a feminine noun. Each group
was asked to give four reasons for its recommendation.

The men’s group decided that ‘computer’ should definitely be of the
feminine gender (‘la computadora’), because:

1. No one but their creator understands their internal logic;

2. The native language they use to communicate with other computers is
incomprehensible to everyone else;

3. Even the smallest mistakes are stored in long term memory for
possible later retrieval; and

4. As soon as you make a commitment to one, you find yourself
spending half your paycheck on accessories for it.

(THIS GETS BETTER!)

The women’s group, however, concluded that computers should be
Masculine (‘el computador’), because:

1. In order to do anything with them, you have to turn them on;

2. They have a lot of data but still can’t think for themselves;

3. They are supposed to help you solve problems, but half the time
they ARE the problem; and

4. As soon as you commit to one, you realize that if you had waited a
little longer, you could have gotten a better model.

The women won.

Linguist Sardar Muhammad Khan

Late linguist Sardar Muhammad Khan has compiled the dictionary while Sachal Studios and Pakistan Punjabi Adbi Board Lahore has jointly published it.

Sardar Muhammad Khan (1915 – 1998), known as SMK, was a renowned Indian researcher of Linguistics. He was born in a Pathan family at Basti Danishmandan (Jalandhar). After doing his secondary and higher secondary education, he did his B.A from the University of Punjab in 1934. He joined united Indian Army as a civilian employee and retired as a civilian gazetted officer from the G.H.Q, Rawalpindi in 1969. Being a government servant, under the rules, he could not publish any book until his retirement.
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Mazar-e-Quaid is the tomb of the founder of Pakistan, Muhammad Ali Jinnah. It is an iconic symbol of Karachi throughout the world. The mausoleum is situated at the heart of the city and was completed in the 1960s. The Mazar-e-Quaid has been officially recognized as the National Mausoleum of the country.

Tomb of the Qauid

The mausoleum is made of white Marble with curved Moorish arches and copper grills rest on an elevated 54 meters square platform. The crystal chandelier inside the tomb was gifted by the people of China.
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An Urdu article by Imran Khan presenting his point of view in the so called war against terror as well as about Pakistani politics in world perspective.
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Thursday, April 23, 2009
By Imran Khan

The reason why there is so much despondency in Pakistan is because there is no road map to get out of the so-called War on Terror – a nomenclature that even the Obama Administration has discarded as being a negative misnomer. To cure the patient the diagnosis has to be accurate, otherwise the wrong medicine can sometimes kill the patient. In order to find the cure, first six myths that have been spun around the US-led “Global War on Terror” (GWOT) have to be debunked.
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Falling in love may have evolved because people who focus their attention on a single ideal partner save time and energy, therefore improve their chances of survival and reproduction. Unfortunately, this also means people are pre-disposed to terrible suffering when jilted by their beloved.

Painful emotions develop when the reward centres of the brain, associated with the dopamine high of falling in love, fail to get their hit. Paradoxically when we get dumped we tend to love back even harder, as the brain networks and chemicals associated with love increase. First we protest and attempt to win the beloved back. Panic also kicks in as we feel something akin to the separation anxiety experiences by young mammals abandoned by their mothers.
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I received an email containing this message below. I thought I would share it with you all.

1 – First Important Lesson – Cleaning Lady.

During my second month of college, our professor gave us a pop quiz.

I was a conscientious student and had breezed through the questions until I read the last one:

“What is the first name of the woman who cleans the school?”

Surely this was some kind of joke. I had seen the cleaning woman several times. She was tall, dark-haired and in her 50′s, but how would I know her name?

I handed in my paper, leaving the last question blank. Just before class ended, one student asked if the last question would count toward our quiz grade.

“Absolutely, ” said the professor. “In your careers, you will meet many people. All are significant. They deserve your attention and care, even if all you do is smile and say “hello.”

I’ve never forgotten that lesson. I also learned her name was Dorothy.

A thing of beauty, a joy forever

FACE CARE:

Baking soda can also do wonders for your face.

Exfoliating: Make a paste of 3 parts baking soda to 1 part water, and use as a gentle, exfoliating facial scrub after washing with soap and water. Rinse your face clean.

Facial Scrub: Mix baking soda with oatmeal in your blender; it makes a great facial scrub.

Shaving: Men with sensitive skin may find that a solution of 1 tablespoon baking soda in 1 cup water makes a great preshave treatment or a soothing aftershave rinse.
Read more…

There are so many makeup products out there for women that it is hard to know which ones to choose. Here are some basic products awarded for being the best by the votes of the general public in the US.

This list will make it easy for you to choose your next product:

LIP GLOSS

Maybelline New York Shiny-licious Lip Gloss ($6)
Shiny-licious is a three-time award winner. It looks “rich,” voters say, but it’s never gloppy.

Victoria’s Secret Beauty Rush Lip Gloss ($7)
It comes in 30 “delicious” flavors and has a nice sheen.

FOUNDATION

CoverGirl Clean Liquid Makeup ($4.50)
voters rave about the “great range of shades” that “don’t clog pores.” Happily, the stuff’s also “absolutely weightless.”
Read more…

Joomla Admin. Click to view larger image.

Step 1 – Install Joomla

Upload and Install Joomla to your website.

Log in to your Administrator.

Step 2 – Create Section for Articles
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Ingredients:
4 good-quality hamburger buns or rolls, I am a fan of brioche buns
500g (1 lb 2 oz) lean beef mince
1 red onion grated
Sea salt
Freshly ground black pepper
3 tablespoons olive oil
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PACES (Practical Assessment of Clinical Examination Skills) is the clinical part of the MRCP exam.

The exam demands:

*Good history taking skills

*Good clinical examination

*Ability to detect the presence or absence of physical signs

*Interpretation of these physical signs

*Good case presentation.

*Making appropriate diagnosis

*Discussion of emergency short term and long management plans

*Ability to communicate clinical information to colleagues, patients or their relatives

*Ability to appreciate the ethical issues that relate to day-to-day clinical practice.

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We visited the Riyadh zoo recently. It was a great opportunity in Riyadh for us to enjoy a lazy Thurday afternoon.

Zebra is my favourite and in my opinion, is one of the most beautiful and graceful four legged animals.

Zebra

the stripes, are they black on white or white on black? You decide:) 
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Shangri La Resort

Skardu is absolutely a heaven on earth. The natural beauty is breath-taking. The harsh, high mountains, golden wheat fields, cold streams and green lakes. The fruit laden trees: apricot, apple, walnut, cherries and more. Simple, beautiful, honest people; most not yet tarnished by the selfishness of the modern world. Read more…

Papaya Enzyme Peel

For Normal, Dry, Mature, Oily, Blemish-Prone & Sensitive Skin

Rub the inside of a papaya peel on a clean face and neck. You may also apply under eyes, on and around lips and the tops of your hands. Let dry for approximately 20 minutes and rinse off with tepid water.
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