Introduction

The format of the Practical Assessment of Clinical Examination Skills (PACES) was overhauled in 2023, particularly the clinical consultation station. The station is now a 20-minute station, integrating all seven skills and improving both the fidelity and reliability of these tests inreal-life scenarios. As always, the PACES exam is employed to determine whether candidates have the required skills of a medical registrar.

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The purpose of the two 20-minute consultation stations areto:

“to assess the way in which the candidate approaches a clinical problem in an integrated manner, using history-taking, examination,and communication with a patient or a surrogate.”

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Format station

 The 20-minute stations will have:

• Written instructions for the case, usually in the form of a short note or referral letter, given to the candidate during the 5-minute interval before this station
• There will be 15 minutes for the case, including history, examination, explanation to the patient, and answering any questions or concerns that they might have.

Suggested breakdown of the 15 minutes

This will depend on the brief and the presentation, but in general, the aim is to move on to examination as early as possible to give yourself enough time to identify all the signs.

You do not need to do the whole cardiovascular examination; instead, choose the relevant bits, which will be different for each case.

For example, for a patient with suspected Marfan’s or ankylosing spondylitis, I would do a collapsing pulse and then auscultate, an aortic regurgitation is more likely, whereas in general, a collapsing pulse is something you may consider skipping over!

NB: You can always ask questions whilst you examine!

• I would spend around 4 minutes on history
• Start examining at 5 minutes
• At 10 minutes – Time to re-discuss with the patient and explain the next steps and to think about
• Admission vs ambulatory care
• What investigations?
• Further specialist input?

Reading the referral letter

Make sure you remember where you are in the hospital – Medical assessment unit vs Emergency Department vs Resus vs Ambulatory Care.  

• Formulate a differential diagnosis – some have a small list, and some have a huge list to explore and go through during your consultation.
• Think carefully about what system(s) you need to examine for the station.
• Leave time to explain the management plan to the patient and answer any concerns.
• Always cover safety points  e.g. blackout and the implications for driving.

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Example Station

Please read the referral letter below. You make notes and bring these into the consultation, making further notes during the consultation if you wish. When the bell sounds, enter the room.

Your task is to:

• Assess the problem by means of a focused clinical history and a relevant physical examination.
• You do not need to complete the history before commencing the physical examination.
• Advise the patient of your probable diagnosis (or differential diagnoses), and discuss your plan for investigation and treatment, where appropriate.
• Respond directly to any specific questions/concerns which the patient may have.

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You have 15 minutes with the patient. The examiners will alert you when 13 minutes have elapsed leaving you 2 minutes to finalise the consultation. In the remaining 5 minutes, the examiner will ask you to report on any abnormal physical signs elicited, your diagnosis or differential diagnoses, and your plan for management.

Example of preparation

The presenting complaint here is syncope in a young gentleman. While we are not given any other history or past medical history, we still have enough information to direct and plan our consultation. Essentially, we will take a “syncope history".

Differential Diagnosis of Syncope

Having a list of the potential causes of syncope would be useful. Below is an (inexhaustive) list of potential causes of syncope:

Cardiac causes

• Arrhythmia
• Vasovagal
• Vasovagal
• Outflow obstruction e.g. aortic stenosis (In a young man it is more likely to be a congenital cause such as a bicuspid aortic valve)
• Pulmonary embolism
• Postural Hypotension

Neurological

• Seizures
• Rarely TIA/Stroke mimics
• Encephalitis

Metabolic – Hypoglycemia, hypoadrenalism

• Hypoglycemia
• Hypoadrenalism

Others – Anaemia, Drugs (Opiates, Benzodiazepines,cocaine, amphetamines)  

• Anaemia
• Drugs (Opiates, Benzodiazepines , cocaine, amphetamines)   

Systems to examine

Depending on the history – it already seems apparent that the cardiovascular and neurology system are the key systems to examine.

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Case Summary

Adam is normally fit and healthy.

Adam has had two recurrent episodes of syncope – where he lost consciousness. The first episode was a month ago after going for a run in the morning. He came home and lost consciousness in the kitchen. His sister heard a loud “thud”, but it was unwitnessed. His sister did not report any seizure-like movements, urinary incontinence or anything else – just that Adam had passed out and looked pale. Adam thought he just pushed himself running too much in preparation for a half-marathon.

The second time was two days ago at the gym. Adam had just finished with the treadmill and collapsed. Again no seizure activity, but felt palpitations (as he was exercising). He was surrounded by other gym members,who offered him a drink and he felt better soon enough. He has not exercised since and feels fine but is worried about what this might be.

Social History: Works as a clerical officer. Non-smoker,drinks occasionally and no recreational drugs

Family history:  significant for grandfather having a myocardial infarction at the age of 67 and his uncle passing away when he was quite young in his 30’s. No family history of epilepsy.

Examination

Essentially unremarkable, except an ejection systolic murmur loudest over the lower left sternal edge.

Adam’s questions

1.       What could be causing this?

2.       What happens now?

3.       Is this related to my heart?

4.       Can this be cured?

5.       How does this affect me in the future?

6.       Can this be passed on?

Potential Viva Questions

1.       What is your diagnosis?

2.       How do you manage Adam?

3.       Are there any interventions that will help Adam in the future?

4.       Are there any other specialists that need to be involved in Adam’s care?

5.       What is HOCM?

Mock Mark scheme

Physical Examination (A)

• Assesses pulse for atrial fibrillation.
• Performs a focussed cardiovascular examination assessing for theapex, auscultation for heart and lungs sounds.
• Assessing the JVP.
• Evaluating for oedema.

Identifying Physical Signs (B)

• Ejection systolic murmur.
• Thrill at lower left sternal edge.

Clinical Communication Skills (C)

• The candidate must take a history which adequately explores all areas relevant to the differential diagnoses – it is not sufficient to take a history which confirms a suspected diagnosis without adequately exploring other possibilities or relevant personal history.
• The candidate should agree a management plan with the patient.
• Important to note family history and past cardiac history.  

Differential Diagnosis (D)

• HCM
• Aortic Stenosis
• Aortic sclerosis

Clinical Judgement (E)

• Blood tests
• Electrocardiogram
• Chest radiograph
• Echocardiogram
• Cardiac MRI
• Holter

Managing Patient's Concerns (F)

• Addresses the patient’s questions and concerns in an appropriate manner

Maintaining Patient Welfare (G)

• Treats the patient respectfully, sensitively and ensures comfort, safety and dignity
• Does not cause physical or emotional discomfort or jeopardise safety