Dr Ahmed Ayuna passed PACES this summer and scored full marks in the Integrated Clinical Assessment (Station 5). Here's how he prepared, along with his top tips for succeeding in each station. 

Hi, I’m Ahmed, I passed my PACES exam from the first try in June 2015 in the UK and it was the toughest exam in my life, so let me tell you about my experience. 

Preparation

To start with, I spent about 3.5-4 months preparing for my exam by practising a proper clinical examination with timing; attending PACES teaching groups held in hospital where I work; reading some PACES books; attending a PACES preparation course and subscribing to Pastest PACES Online as it contain a wide range of videos and teaching material.

On exam day

I started with Station 1, Abdomen. It was a middle-aged lady with distended abdomen, a tinge of jaundice and huge ascites. I couldn’t feel any organomegaly, so I gave the differential diagnosis of ascites, then was asked about management. I didn’t score very highly in this station as I forgot to lay the patient flat!

Top tip – always position the patient correctly!

Next was the Respiratory Station with an elderly gentleman with mild kyphosis. It was a normal chest exam apart from slight reduction of chest expansion. In the question it said he had got intermittent dyspnea. On finishing my exam, I asked the patient for permission to examine his lower back to check for sacral oedema. He told me to be careful as it was sore; looking carefully there was a very small scar over the sacrum from recent surgery. The examiner asked about findings and diagnosis; I gave differential of PE following the operation to the lower back, asthma, resolving chest infection. Both examiners were happy and I got 16/20.

Top tip – always look very carefully so you don’t miss any clues!

Station 2 involved a young lady with recurrent chest infection; she presented with fever, cough, SOB and sweating. The examiner was concerned about the possibility of HIV.

Top tip – listen carefully for any clue that may be given by the patient while taking the history. Usually 3-4 clues are provided. You need to ask about them in detail, as you will be penalized severely if you neglect them.

In Station 3 Cardiology I saw an elderly lady with diastolic murmur in the apex and thoracotomy scar. Pulses were present on both radials and no radio femoral delay. I thought it was mitral valvotomy due to mitral stenosis, and I got 15/20. 

For Neurology I was asked to examine upper limb and I noticed signs of upper motor neuron. During examination I noticed he had cerebellar signs, so once I had finished full upper limb exam I did cerebellar exam as well. I thought this gentleman had MS. The examiner asked me about differential and management plan, and I scored full marks.

Top tip – remember that doing an extra examination related to your diagnosis will give you extra marks.

For Station 4 I saw a young gentleman with asymptomatic high blood pressure unresponsive to life style modification. He had a very healthy life and my consultant asked me to talk to him to do further investigation and start oral anti-hypertensive medications. The patient was very silent. He didn’t give any information and was not keen on doing any further tests nor taking medication. I explained to him the meaning of high blood pressure, complications and the medications along with their possible side effects. At the end the patient was happy to do the investigations and take the medications. The examiners were very impressed and gave me 16/16.

In Station 5, the first case was a middle-aged lady with sudden loss of vision 3 months ago. Her observations were fine apart from blood pressure of 170/110. In the history I asked for more details of what happened; she said she was driving and suddenly lost vision in the left eye. There was no eye pain, no headache and no vomiting. She wasn’t diabetic, and she is a housewife living with her husband and 2 children. On examination I found a newspaper on the bed side, so I asked her to read one line. Using the ophthalmoscope there was haziness of the disc and signs of grade 4 hypertensive retinopathy. The examiner asked me about the differential diagnosis, causes of painless loss of vision and anatomy of cerebral blood circulation. 

Case 2 was an elderly gentleman who collapsed while in church. The collateral history gave feature of cardiac cause and irregular palpitation; nonetheless I excluded other possibilities like neuro, postural hypotension, medications etc. On examination, I found pan-systolic murmur and sinus rhythm. The diagnosis was mitral regurgitation and atrial fibrillation. I scored 28/28 in each of these cases.

Top tip – you will be given 5 minutes before this station to read the scenarios. Analyse the scenarios very, very carefully as they always put clues in it!

In this station you should always concentrate of the social aspect of the history. This is what examiners want, because they want to see a safe, competent doctor who puts the patient at the centre and does his best to help and protect him. Make sure you ask who looks after the patient and about their health.