Station 1 - Respiratory System

• step-by-step approach to respiratory system is easily available in any clinical medicine book ie. Clinical Examination by Talley O'Connor
• for those who has just begun to prepare for PACES, it is good to go through such books - to remind us back the physiology/pathophysiology of clinical signs
• go through the steps until you master it and able to perform it naturally. Need not to be on real patients.. teddy bear, friends, or even in your mind...
• time issue? make an effort to perform full clinical examination during ward rounds or clinic encounter. It should only take 6 minutes of your time for 1 system.
• preparing a good and impressive presentation need a lot of hard work and practice. Unless you have exceptionally good command of english.
• Maybe at the initial period as you are just starting to get yourself used to PACES, conservative way (from periphery to the the organ of concern) is a good idea. In a way it helps you not to forget examination steps. Once you are more matured in terms of exam preparation, you can choose to present "hit-hard" or maintain the conservative way
• Most importantly, choose a method that you are comfortable with so that you look smart on the exam day
• In general.. examiners like "hit-hard". I say this because, unless you are the first candidate, by the end of the 6th minute, their question: "Tell me your positive findings"
• Important in the presentation to make sure the presentation is short and sweet. Ryder and Freeman has good examples of presentations
• end the examination by requesting to see sputum pot, temperature chart, oxygen saturation, PEFR (if necessary)
• at the end of presentation, tell the examiner the diagnosis, likely cause and current functional status.
• example a case of pleural effusion:

Mr X is in respiratory distress as he is tachypnoeic, tachycardic and using his accessory muscles of respiration to breathe. He requires oxygen therapy via 2L/min nasal prong. He has bilateral finger clubbing and nicotine staining. He is not cyanosed and does not have signs of carbon dioxide retention. His trachea is deviated and apex beat displaced/not felt (if necessary, comment on pulmonary component of the second heart sound). On examination of the chest the findings are localized to: _____ whereby there is reduced chest expansion, reduced vocal resonance and fremitus, stony dull to percussion and diminished breath sound.

In conclusion, Mr X has massive pleural effusion, most likely secondary to ___, currently in respiratory distress.

Getting started for PACES

To get started.. good references will be extremely important. Here are the "must-have":

• these two great books are still relevant though they have changed the station 5 to "brief clinical consultation

• Next will be the "Look & Proceed - A guide for the clinical medicine examination" by Derrick Aw - this great book gives a step-by-step approach for each systems and important disease in PACES.

Will be great if you have this too:

Destination: MRCP

For a lot of house officers in Malaysia, by the end of their postings, they already started to think what they should do next. Taking up external examination papers? Or Masters programmes in whatever field they are interested in. Some will be lucky enough to be attached to the department that will be relevant to their future career path. Paediatric was my third posting.. I wasn't sure whether I should do paediatric or adult medicine. Later, I got posted to Department of Medicine and I was told that I would have to stay there until forever.. usual reason... shortage of doctors there. Not to say experience in the department was awesome, but I could well see myself as a physician more than a paediatrician. So, the chance to stay back in Medical Department was just great!

Again I was at the crossroad.. deciding to take MRCP (Membership for the Royal College of Physicians) or Masters in Internal Medicine. My environment at that time was encouraging for MRCP.. had few other friends who wanted to pursue MRCP and few other seniors who were still in the process to complete their membership. Plus, I had to wait for another 3 years before I could send my application for Masters. Knowing how I am.. waiting too long will definitely kill off my interest and momentum to study.

I decided to take up Part 1 MRCP in 2007. It wasn't really a road trip to Part 1.. it was an air trip down to Singapore. So after adequate break, I proceeded with the second part in 2008. This time in UM.

Here comes 2009.. PACES time! Again decisions.. decisions... when, where? At that time I did not know how to start studying. Plus short cases really not my strength when I was a medical student. Again, my friends and I were lucky. We had a great tutor. He was the first person who exposed us to the examination style. Until now I haven't forgotten how I performed and presented my first case. I did terribly bad! Just like medical students and even worse than them! Knowing what was lacking, my friends and I continued practising and correct each other.. including with "heart-slicing" comments. Just to see each other successful.

Again.. opening date... everybody was busy checking the websites, printing forms and getting money ready.. that's a lot of money! Finally decided to take in Singapore (June) though I knew chances of getting a place was slim.. and true enough.. our money was returned back to us. I guess I was fated not to take it at that time.. not so ready anyway.

It was different this time. We had to queue in front of the MRCP Secretariat in UM, just to secure our place for the exams. We waited for almost an hour before the door of the office opened. When it finally accepted our applications... big relief! However... on a bigger picture..... get your bottom up! Time to go full force for the preparation... and we did!

Some of us was queuing up to hand in our application to MRCP Secretariat in UMMC.

It was really a road trip for me and for a lot more I think, as now Seremban is a new examination centre! I spent 1 day before the exam driving from my house to UMMC. I tried parking at the faculty.. not a good choice! It was raining but that was good in the sense that I could test how I would end up looking if I were to park there the next day on the real exam day... WET! So, I tried parking at the UMMC itself... horrendous! Very stressful! So, I decided to follow Dato Dr Kiew's advice.. get someone to send you. So I did.. I got a taxi-driver to send me there. Good choice! I arrived in good time, enough to calm myself down.

Kringggg!! Exams started and so I gave my best on that day and what a big relief after all of it over! To go through it again?? Given a choice.. nobody would! Too tiring but at the same time... enjoyable. Especially if (quoting from a friend) you are fated to have a good bunch!

4 weeks we all waited... since 20th Nov.. we were not at rest.. looking at the MRCP website so frequently! And finally 24th November 2009.. the results were out... PASS! I am so happy and grateful to Allah, my family, teachers, and friends! (You all know who you are!).

So, MRCP is not about the destination alone.. the road trip that is more important. It teaches friendship, responsibility, maturity.. I hope this blog will be a beneficial adjunct to help you prepare yourselves along the road trip, also for others to share their road trip too! I hope it will serve a map, compass and backpack for the journey. Have a safe and successful journey!