Briefs for MRCP PACES (by Dr.

Tanzeel Bokhari) , An initiative by paceUrMRCP

Contents
PREFACE .................................................................................................................. 2
ADDENDUM .............................................................................................................. 3
HISTORY TAKING ..................................................................................................... 4
GENERAL ASPECTS ................................................................................................. 4
NEUROLOGY: ........................................................................................................... 4
UROLOGY: ................................................................................................................ 5
PULMONOLGY: ......................................................................................................... 6
GASTROENTEROLOGY: .......................................................................................... 7
MEDICINE HISTORY: ................................................................................................ 8
JARGON LIST: ........................................................................................................... 9
COMMUNICATION SKILLS: .................................................................................... 11
CLINICAL STATIONS: .............................................................................................. 12
GENERAL PRINCIPLES FOR CLINICAL EXAMNATIONS: ..................................... 12
PULMONOLOGY: .................................................................................................... 13
HAEMATOLOGY: ..................................................................................................... 14
OPTHALMOLOGY: .................................................................................................. 15
CARDIOLOGY: ........................................................................................................ 16
RHEUMATOLOGY: .................................................................................................. 18
SCORES .................................................................................................................. 19

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 Briefs for MRCP PACES (by Dr.Tanzeel Bokhari) , An initiative by paceUrMRCP

PREFACE
Briefs for MRCP PACES (by Dr. Tanzeel Bokhari)
Over the past couple of years, I have been sharing important bullet points on my
social media groups. These points were random, unorganized, and lacked a specific
pattern. Initially, I would note down key points from my readings and share them in
my groups. As a result, a substantial amount of data has accumulated, making it an
opportune time to organize it systematically.
This initiative, Briefs for MRCP PACES (by Dr. Tanzeel Bokhari), aims to provide a
structured approach. I plan to release four editions annually, continually updating
with new important points. The file consists of two parts:
Part 1: Addendum - New important points will be added randomly in every new
edition.
Part 2: Organized content - Newly added important points from the addendum will be
arranged under specific headings.
To maximize the benefits of this document, I recommend reading Part 2 regularly as
part of your core exam preparation, while briefly reviewing the addendum in each
new edition.
I take full responsibility for the information presented in this file. Although I have
verified the content through multiple sources, medical knowledge is constantly
evolving. If you find any errors or discrepancies, please contact me via WhatsApp
(00923346036496) or email ([email protected]). Both contacts are listed
on every page of this document.

I wish you the best of luck in your future endeavors.

Dr. Tanzeel Bokhari.
WhatsApp: +923346036496
Email: [email protected]

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ADDENDUM
This part will be updated with new important points in the next edition of this
document.

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 Briefs for MRCP PACES (by Dr.Tanzeel Bokhari) , An initiative by paceUrMRCP

HISTORY TAKING

GENERAL ASPECTS

NEUROLOGY:
1. HEADACHE & VISION are TWINS. Which means they must be asked together.
So, never miss to ask any vision problem in a patient of headache and any
headache in a patient of vision problem, this can give you important clues in the
very beginning.

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HISTORY TAKING

UROLOGY:
1. To inquire about the DRIBBLING IN URINARY SYMPTOMS, always ask your
patient: DO YOU HAVE ANY PROBLEMS IN STOPPING YOUR WATER
WORKS WHEN YOU ARE DONE.
2. To inquire about the HESITANCY in urinary symptoms, ask the patient DO YOU
HAVE ANY PROBLEMS IN STARTING YOUR WATER WORKS. Hesitancy
might be considered as Jargon by some examiners.
3. To ask about the PENILE DISCHARGE, ask your patient: DO YOU HAVE ANY
DISCHARGE FROM YOUR PRIVATE PARTS. Always take permission before
these questions (like if you don't mind may I ask you some personal questions)
4. To inquire about the URGENCY in urinary symptoms, always ask your patient:
DO YOU EVER RUSH (OR HAVE YOU EVER RUSHED) TO THE
WASHROOM TO PASS WATER.
5.

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HISTORY TAKING

PULMONOLGY:
1. To inquire about the POSTNASAL DRIP, always ask your patient: DO YOU
FEEL SOMETHING FALLING IN BACK OF YOUR THROAT.

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HISTORY TAKING

GASTROENTEROLOGY:
1. To inquire about the ACID REFLEX OR GERD IN GIT SYSTEM, always ask
your patient: DO YOU HAVE ANY BURNING SENSATIONS IN YOUR CHEST.
2. To inquire about the REGURGITATION IN GIT SYSTEM, always ask your
patient: DO YOU HAVE ANY BAD TASTE OR FOUL SMELLING TASTE IN
YOUR MOUTH.
3.

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HISTORY TAKING

MEDICINE HISTORY:
1. Medicine history is very important in all cases, but it becomes more important
when you have calcium disorders, so always keep in mind that LOOP
DIURETICS can cause HYPOCALCEMIA. Please remember that THIAZIDE
DIURETICS can cause HYPERCALCEMIA. If you find your patient is having
high calcium levels and he is taking thiazide diuretics then you must address it,
otherwise you lose marks in clinical judgement.
2.

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HISTORY TAKING

JARGON LIST:
1. ANAESTHESIA/ANAESTHETICS/LOCAL ANAESTHESIA/ LOCAL
ANAESTHETICS might be considered as a Jargon by some examiners so
please avoid using it. Always tell the patient that: We will give you some
NUMBING AGENTS for your health condition.
2. ANALGESICS and/or ANALGESIA are PAIN KILLERS in layman terminology,
please avoid using ANALGESICS and/or ANALGESIA in exam, as it is
considered a Jargon by most of the examiners.
3. ANTIBIOTIC/ANTIBIOTICS might be considered as a Jargon by some
examiners so please avoid using it.Always ask the patient:We will give you
some BUG KILLING/KILLER MEDICINE/MEDICINES for your health condition.
4. CONTRACEPTIVE PILLS (ANY TYPE) might be considered as a Jargon by
some of the examiners so be careful while using it in exam and always say
BIRTH CONTROL PILLS to your patient.
5. DEHYDRATED/ DEHYDRATION can be considered as Jargon by some of the
examiners so always say REDUCED AMOUNT OF WATER/FLUIDS/LIQUIDS
IN YOUR BODY to your patient.
6. DIURETICS (ANY CLASS) might be considered as a Jargon by some of the
examiners so be careful while using it in exam and always say WE WILL GIVE
YOU WATER PILLS OR ARE YOU USING ANY WATER PILLS to your patient.
7. EASY BRUISING is considered as a Jargon by many examiners so please
avoid using it. Always ask the patient: Do you notice (or have you noticed) any
BLUISH SPOTS ON YOUR SKIN EVEN AFTER SMALL INJURY (OR
TRAUMA).
8. ECHOCARDIOGRAPHY OF HEART is a Jargon, always explain it to your
patient as SCAN OF THE HEART (some people use JELLY SCAN the heart for
echocardiography too) during the discussion
9. ENDOCRINOLOGY and ENDOCRINOLOGIST are considered as Jargons by
most of the examiners so always say PROBLEM IN YOUR GLAND/ GLANDS
and GLAND SPECIALIST to your patient Please remember GLAND is not a
Jargon and you can easily use it.
10. ENZYME/ENZYMES is considered as Jargon by most of the examiners so
always say PROBLEM IN LEVEL OF SALT/SALTS IN YOUR BODY to your
patient.
11. FATIGUE is considered as a Jargon by some examiners, so avoid it and say do
you feel TIRED or TIREDNESS.
12. FEVER is considered as a Jargon by most of the examiners, so avoid it and say
HIGH BODY TEMPERATURE.
13. GENETELIA are called as PRIVATE PARTS ( at least in exam)
14. HBA1C might be considered as a Jargon by some of the examiners so be
careful while using it in exam and always say (LAST ) 3 MONTHS BLOOD
SUGAR RECORD/LEVEL to your patient.

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15. HORMONE/HORMONES is considered as Jargons by most of the examiners so

always say PROBLEM IN SOME PROTEINS to your patient.
16. Infective agents (bacteria viruses, parasites and Fungus) are BUGS. The word
INFECTION is tolerable (not considered as a Jargon by most of the examiners)
so u will say to your patient that you have bug infection (in your lungs, tummy
whatever etc).
17. INFLAMMATION is a controversial word and may be considered as Jargon by
some of the examiners so be careful and always say IRRITATION OR
SORENESS to your patient.
18. INR (International normalized ratio) is a Jargon, so be careful while using it in
exam especially when asking for the follow up of anticoagulants, always tell
your patient that *WE WILL / WE NEED TO CHECK YOUR BLOOD THINNING
LEVEL ( OR LEVEL OF BLOOD THINNING ) during this therapy.
19. NAUSEA is a common ENGLISH word, but it may be considered as Jargon by
some of the examiners so be careful while using it in exam and always say DO
YOU FEEL SICK / OR ANY FEELING OF SICKNESS to your patient.
20. NEUROPHYSICIANS/NEUROSURGEONS might be considered as a Jargon by
some of the examiners so be careful while using it in exam and always say
BRAIN DOCTOR/SURGEON to your patient.
21. PROGNOSIS might be considered as a Jargon by some of the examiners so be
careful while using it in exam and always say OUTLOOK/ OUTCOME/ FINAL
RESULT OF THE DISEASE to your patient.
22. RHEUMATOLOGIST might be considered as a Jargon by some of the
examiners so be careful while using it in exam and always say JOINT DOCTOR
/ SPECIALIST to your patient.
23. VOMITING is a common ENGLISH word, but it may be considered as a Jargon
by some of the examiners so be careful while using it in exam and always say
HAVE YOH EVER THROWN UP/ DO YOU EVER THROW UP to your patient.
24.

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COMMUNICATION SKILLS:
1. For Breaking Bad News in Communication Station:
Always give a warning shot before telling the bad news to the patient.Always
say :
I am sorry I have something concerning to tell you.
Or the results have not come as we were expecting.
Or I am afraid we have something serious to discuss.
2. Never hesitate in breaking the bad news and never delay/linger on to do
it.Always break the bad news as early as possible after giving the warning
shot, ideally within the first couple of minutes of conversation.
3.

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CLINICAL STATIONS:

GENERAL PRINCIPLES FOR CLINICAL EXAMNATIONS:

1. Xanthomata are localized deposits of fat under the skin, occurring over joints,
tendons, hands, and feet.

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CLINICAL STATIONS

PULMONOLOGY:
1. When you suspect pulmonary embolism then you have to calculate Modified
Two level PE Wells Score ( or at least mention it to the examiner that you will
like to calculate it ).If score is more than 4 go for immediate CTPA ( Or treat
empirically with anticoagulants If there is delay in CTPA ).If score is less than 4,
do D Dimers , if D Dimers come out to be positive go for immediate CTPA or
empirical treatment with anticoagulants. If D Dimers are negative, then consider
alternative diagnosis.
2. Modified two level PE Wells score is not used for suspicion of Pulmonary
embolism in pregnant women. Women presenting with symptoms and signs
suggestive of an acute PE should have an electrocardiogram and a chest X-ray
performed. In women with suspected PE who also have symptoms and signs of
DVT, lower limb duplex ultrasound and Doppler ultrasound of illiac veins should
be performed. If this confirms the presence of DVT, no further investigation is
necessary and treatment for VTE should continue. In women with suspected PE
and/or abnormal chest X ray (even without symptoms and signs of DVT) either
CTPA or a V/Q Scan should be performed. However, when the chest X-ray is
abnormal CTPA is preferred over V/Q scan. There is risk of radiation exposure
with both of them but the risk associated with missing the diagnosis of PE are
far more than it. Ideally, informed consent should be obtained before these tests
are undertaken. Decision to start prophylactic anticoagulants in pregnancy
depends upon the clinical presentation and should be discussed with senior
consultants.D-dimer testing is not usually suggested in the investigations of
acute VTE/PE in pregnancy as they are often raised.
3. Duration of treatment for pulmonary embolism may vary according to clinical
presentation of the patient and consultant opinion but the general rules are as
follows:
For Provoked PE: 3 months and then reassess risk to benefit profile (depends
on whether risk factor persists)
For Unprovoked PE: treatment is usually continued for > 3 months (people with
no identifiable risk factor)
For PE in Malignancy: continue treatment for 6 months or until cure of cancer
For PE in Pregnancy: LMWH is continued until delivery/end of pregnancy
4. Pulmonary embolism ( Massive ) can cause fainting and has appeared quite
often as a cause of fainting.So please be alert and always try to get hints from
history.
5.

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CLINICAL STATIONS

HAEMATOLOGY:
1. In a case of Antiphospholipid antibody syndrome conventional anticoagulants
(heparin and warfarin) are still preferred for anticoagulation otherwise now a
days NOACS are preferred for anticoagulation whenever required.

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CLINICAL STATIONS

OPTHALMOLOGY:
1. Xanthelasma refers to xanthoma on the eyelid.
2. Corneal arcus is a crescentic-shaped opacity at the periphery of the cornea.
Common in those over 60yrs, can be normal, but may represent
hyperlipidaemia, especially in those under this age.

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CLINICAL STATIONS

CARDIOLOGY:
1. Some Characters and volumes of pulse
Bounding pulses are caused by CO2 retention, liver failure, and sepsis.
Small volume pulses occur in aortic stenosis, shock, and pericardial effusion.
Collapsing (‘water hammer’) pulses are caused by aortic incompetence, AV
malformations, and a patent ductus arteriosus.
Anacrotic (slow rising) pulses occur in aortic stenosis.
Bisferiens pulses occur in combined aortic stenosis and regurgitation.
Pulsus alternans (alternating strong and weak beats) suggests LVF,
cardiomyopathy, or aortic stenosis.
Jerky pulses occur in HOCM.
Pulsus paradoxus (systolic pressure weakens in inspiration by >10mmHg)
occurs in severe asthma, pericardial constriction, or cardiac tamponade.
2. Regarding JVP the pulsation is venous if it is: Usually impalpable and
obliterated by finger pressure on the vessel. Rises transiently with pressure on
abdomen (abdominojugular reflux) or on liver (hepatojugular reflux) and alters
with posture and respiration (disappears when patient sits from lying flat).
Usually has a double pulse for every arterial pulse. (Concomitantly palpate the
arterial pulse)
3. Some abnormalities of the JVP:
Raised JVP with normal waveform: Fluid overload, right heart failure.
Fixed raised JVP with absent pulsation: SVC obstruction.
Large a wave: Pulmonary hypertension, pulmonary stenosis.
Cannon a wave: When the right atrium contracts against a closed tricuspid
valve.
Large ‘cannon’ a waves result. Causes—complete heart block, single chamber
ventricular pacing, ventricular arrhythmias/ectopics.
Absent a wave: Atrial fibrillation.
Large v waves: Tricuspid regurgitation—look for earlobe movement.
Constrictive pericarditis: High plateau of JVP (which rises on inspiration—
Kussmaul’s sign) with deep x and y descents.
Absent JVP: When lying flat, the jugular vein should be filled. If there is
reduced circulatory volume (eg dehydration, haemorrhage) the JVP may be
absent.
4. Some info about heart sounds:
The 1st heart sound (S1): Represents closure of mitral and tricuspid valves.
Splitting in inspiration may be heard and is normal.
Loud S1: In mitral stenosis, because the narrowed valve orifice limits
ventricular filling, there is no gradual decrease in flow towards the end of
diastole. The valves are, therefore, at their maximum excursion at the end of
diastole, and so shut rapidly leading to a loud S1 (the ‘tapping’ apex). S1 is
also loud if diastolic filling time is shortened, eg if the PR interval is short, and
in tachycardia.

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5. Soft S1: occurs if the diastolic filling time is prolonged, eg prolonged PR

interval, or if the mitral valve leaflets fail to close properly (i.e. mitral
incompetence).
The intensity of S1 is variable: in AV block, AF, and nodal or ventricular
tachycardia.

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CLINICAL STATIONS

RHEUMATOLOGY:
1. For confirmation of diagnosis of seronegative spondyloarthropathies presence
of HLA B27 is mandatory (along with negative autoimmune profile) so always
mention it in investigation of these conditions as we may have patients having
conditions mimicking them without HLA but we don't classify them as
seronegative spondyloarthropathy.
2. Some info about GOUT, CKD N DIURETICS:
If diuretics are being used to treat hypertension an alternative hypertensive
should be considered, but they should not be stopped in the presence of CHF.
They are not absolutely contraindicated in hyperurecemia in CKD but if
possible other options should be used. Steroids can be used in case other
medicines used for management of acute gout are not safe.But steroids have
their own side effect profile.
3.

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SCORES
1. CHA2DS2 VASc stroke risk scoring system for non-valvular atrial fibrillation:
Parameter= Score
C- Congestive heart failure= 1 point
H- Hypertension history =1 point
A2- Age > 75 years= 2 points
D- Diabetes mellitus= 1 point
S2- Previous stroke or Transient ischemic attack= 2 points
V- vascular disease =1 point
A -Age 65-74 years =1 point
Sc- Sex catagory female= 1 point
Maximum total score 9 points
Annual stroke risk
0 point = 0 %no prophylaxis required
1 point= 1.3 % (oral anticoagulation recomended in males only )
2 points = > 2.2% (oral anticoagulation recomended)
2. Modified two level PE Wells score:
Feature
Clinical signs and symptoms of DVT (leg pain and pain on deep palpation of
veins) = 3
Heart rate > 100 beats per minute= 1.5
Recently bed-ridden (> 3 days) or major surgery (< 4 weeks)= 1.5
Previous DVT or PE =1.5
Hemoptysis =1
Cancer receiving active treatment, treated in last 6/12, palliative= 1
An alternative diagnosis is less likely than PE =3
(Score more than 4 PE likely, score less than 4 PE unlikely)
3. HAS-BLED Score:
Hypertension (systolic blood pressure >160 mmHg) = 1
Abnormal renal and liver function (1 point each) =1 or 2
Stroke= 1
Bleeding tendency/predisposition= 1
Labile INRs (if on warfarin) = 1
Elderly (eg, age >65 y) = 1
Drugs or alcohol (1 point each) = 1 or 2
A HAS-BLED score of ≥3 indicates that caution is warranted when prescribing
oral anticoagulation and regular review is recommended.
(Abnormal renal function is classified as the presence of chronic dialysis, renal
transplantation, or serum creatinine ≥200 mmolL)
(Abnormal liver function is defined as chronic hepatic disease (eg, cirrhosis) or
biochemical evidence of significant hepatic derangement (bilirubin 2 to 3 times
the upper limit of normal, in association with aspartate
aminotransferase/alanine aminotransferase/alkaline phosphatase 3 times the
upper limit normal, etc), history of bleeding or predisposition (anemia), labile

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INR (ie, time in therapeutic range <60%), concomitant antiplatelets or

nonsteroidal anti-inflammatory drugs, or excess alcohol)
4.

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