Demystifying PACES - Neurological [Station 3] (02 Feb 2024)

SPEAKER_02 0:00

Hello, my name is Kat Ralston and I'm a member of the Training and Members Committee as well as a Medicine of the Elderly Registrar in Edinburgh. I'm delighted to introduce this new podcast series called Demystifying PACE. In this series we will discuss each station in detail with an experienced PACES examiner to share top tips for success, common challenges, insights and advice. We will also have episodes exploring the exam from the candidate perspective. This series focuses on candidates sitting in the UK, and while the principles will be the same for those sitting internationally, local variation will of course be present. We hope that this will be helpful in both your preparation for PACE and your experience on the exam day itself. So hello and welcome to this episode of Demystifying PACE, brought to you by the Royal College of Physicians of Edinburgh Trainee and Members Committee. My name's Kat Ralston, and I'm a member of the TNMC as well as a Medical Education Fellow and Geriatrics Registrar in Edinburgh. I'm delighted to be joined today by Dr. Kathy White, who's a consultant neurologist in Dundee and a PACES examiner since 2018. Kathy's interested in epilepsy and functional neurological disorders. Welcome, Kathy. Thank you very much for having me. Delighted that you could join us. So the episode today is designed to guide you through the neurology station of the MRCP PACES exam. And what we'd like is to get some top tips and common challenges faced using the insight of an experienced examiner. So first of all, it would be good just to give a bit of an outline on what the neurology station looks like in PACES. Can you tell us a bit about it?

SPEAKER_03 1:44

Well, it's combined with the cardiology. The neurology station is 10 minutes, for which you have six minutes to do your examination. After that, you'll be given a warning at five minutes that you have a minute to go. And then after the six minutes, you'll have some questions from the examiners. Don't panic.

SPEAKER_02 2:06

Don't panic, I think it's a good sign. I think the neurology station is often one that people tend to feel most worried about. Why do you think that is?

SPEAKER_03 2:14

I think there's been an air of mystery cultivated by neurologists. But actually, it's very logical. I always view neurology as being a bit like a detective. So you have a problem to solve, you're looking for your clues, and then you have to sum up your evidence and then sort of synthesize that with neurology. It's always where is the lesion? And then you can think, well, once I've decided that, what sort of things can cause that lesion or lesions? And in your head, you can have a sort of sieve of a few things that might cause those things that you recall.

SPEAKER_02 2:55

Yeah, I think that's a nice way of putting it. And I like the thought that neurology has an air of mystery, but hopefully this episode is going to, as the series is called, demystify what that neurology station looks like and try and give people the best chance as possible of passing it. So can we just quickly talk about what skills are being assessed in the neurology station?

SPEAKER_03 3:16

So you will be being assessed on your physical examination and your technique. And you need to look fluent and practiced. And you need to do it correctly. So that means you have to practice. And I would suggest that every time you examine a patient for fun, do a neurological examination. Or if you don't have time, just do part of it. Examine the motor system or examine the sensory system or examine coordination or the cranial nerves. Just so you're doing it regularly, because we can tell if you're doing it regularly. The next section is finding physical signs. Now that is examined separately from physical examination. So you can do an examination that's not technically correct, but pick up the signs. You might not get bull marks for the physical examination, but you'll get the marks for the signs. Then comes the discussion, and that's where we have clinical judgment, and you'll be asked for your thoughts as to what's going on, and you should always start with where is the lesion and then your differential diagnosis as to what that might be. You will then be asked for judgment as to how you're going to investigate and manage a patient. We're not expecting you to be neurologists, we're just expecting you to be able to do the examination, pick up the signs, and have an idea where it is and what common things might cause that, and what would be the common investigations that you would do, and what would you do as a general medical team managing that patient?

SPEAKER_02 5:00

Yeah, I think that's a really useful way to think about it. So this is from your general medicine hat. We're not expecting you to be an expert in neurology. And also really good advice about just practice, practice, practice in terms of the fluency of that neurology exam. And you know, anyone that we're clerking in the front door should be having a neurology exam. So I think that's a good advice for just getting used to running through it. Obviously, it's going to be a bit more detailed, likely in your pieces, but just practicing at any opportunity seems like good advice. And I always think it's useful just to talk a little bit about how the examiners calibrate for signs in the neurology station, how you decide on what elements of the neurology exam are going to be essential in that exam. So, you know, we're not expecting you to do the whole neurology exam in a station, it's going to be part of it. And how you decide on kind of pass-fail signs that a candidate must detect. Can you tell us a bit about that?

SPEAKER_03 5:56

So the examiners are encouraged to take the cue that you have, follow the instructions, and actually see the patient blind. So we should do the exam and then we compare notes. And if we don't agree on things, then we have to come to a compromise. So if I think a sign is too subtle, then I wouldn't expect a candidate to pick it up. If I think it's an important sign, then we would say that's a pass fail. We normally will have three or four signs that are there, and we will decide how many you need to get to pass. We'll also decide what would be a borderline, because we can only decide past borderline and unsatisfactory.

SPEAKER_02 6:47

Yeah, I always think it's reassuring to know that the examiners, when they're calibrating, are entering it blind as a candidate would as well, and then comparing notes. Because I think that's reassuring when you're sitting the exam that they're going through the same thing you have, even though it's likely a bit less stressful than when you're midst exam.

SPEAKER_03 7:03

The patients who volunteer should have really clear signs. It should be a fairly barned or situation, which shouldn't be too mystifying.

SPEAKER_02 7:15

Yeah, absolutely. Okay, so I think next it'd be good just to talk about the general approach to the neurology station. So perhaps first of all we can think about the timing. So do you find that candidates struggle with the timing on this station? Is there bits where they might spend too long on or bits that they're not spending long enough on? What kind of sort of advice would you give for that?

SPEAKER_03 7:39

I suppose the first thing I would say is take a deep breath and read your instructions clearly and follow the instructions. If you don't understand, ask. You won't be doing the whole neurological exam because you don't have time. You only have six minutes. You are not to take a history. If you're doing cranial nerves, there are certain things that I find tend to be a bit rushed. Like visual fields. Make sure you get yourself into the ideal position and you will be provided with pins if you need them. But if you're doing a visual field to start off with confrontation, you can use your hands. And one of the things I notice is that people are just too quick at moving their targets in. So give yourself a little bit of time and make sure the patient tells you that they've seen it and check whether they haven't seen. If you're too quick, you might miss a hemionopia.

SPEAKER_02 8:41

And I want just to ask about the instructions. How obvious are they, do you find, in terms of directing the candidate to what part of the neurology exam they should be focusing on?

SPEAKER_03 8:51

They should usually say something. This patient has difficulty walking, examine the lower limbs, or this person has difficulty with their vision, examine the cranial nerves. In a neurology station, if you are asked to do fundoscopy, you should be able to darken the room and there should be a ophthalmoscope present and the patient's eyes should be dilated. I've actually not come across a neurology station where fundoscopy in the cranial nerves is the main purpose of the examination. And sometimes you'll be told if you ask to do it, you may well be told you don't need to, it's normal. It seems to come up more in the two cases. The other thing I find that people get a little bit panicky about is doing reflexes. When I'm teaching students, I say actually it's a bit like being a baton twirler. You have to hold your tendon hammer at the end and have a good wrist action so that the weight of the tendon hammer impacts on the tendon. One of the things that I tend to notice is when people are unpractised and a little bit anxious, they tend to jab at the reflexes. And that's particularly a problem with ankle reflexes, which I think people find problematic. And the trick there is really to positioning the patient properly. As is the positioning for motor examination for reflexes generally, you want the limbs in a symmetrical position so you compare the reflex with the other side.

SPEAKER_02 10:32

Yeah, and if you've got any other tips in the reflexes, people struggle to get, so we've talked about kind of holding the tendon hammer right at the end, so you've got the weight of the tendon hammer and a good sort of flip there. Any other tips about the positioning? People sometimes do different things with the ankle jerks, so you might, you know, rest the foot on the other leg, or sometimes people push up the foot. What would you say in terms of positioning for reflexes?

SPEAKER_03 10:55

Ideally, you want to rest the ankle jerk on the other leg and have the foot just slightly dorsiflexed, but only slightly. You just want to be able to see the Achilles tendon is a little bit tensed, but not too tensed. If you tense it too much, you won't get a jerk. Obviously, there are different ways of doing ankle jerks, and some people will slightly dorsiflex the foot with their hand and just tap on their fingers on the bottom of the foot. That is a reasonable screening test, but I do think you need to show that you can position the ankle jerk. The ankle jerks should either be exaggerated or absent or normal and it should be clear cut.

SPEAKER_02 11:44

Yeah. And I think the other one people find difficult is sort of the triceps reflex.

SPEAKER_03 11:50

The triceps jerks, you want to have the arms in a nice rested position with the elbow flexed and the forearms crossed over each other, so that the patient should be symmetrical. Then when you're doing the triceps jerk, if you just very lightly flex the arm at the biceps, and it's a sort of overhand way of doing the jerk, and you do need a good swing on a triceps jerk. But if you're doing arms, again, there should be some clear signs to detect.

SPEAKER_02 12:24

Yeah, yeah. And do you expect people to do sort of reinforcements if they're not getting the reflexes? Yes, I would expect them to show that they know the different techniques. Yeah, grand. So we've talked a little bit about examination technique and the things that people find tricky. So we've talked about visual fields, we've talked about reflexes. Is there anything else when people are doing the examination that they seem to find a bit tricky or are a bit more unsure of?

SPEAKER_03 12:52

I think eye movement is always something that people are worried about. I think the instructions from the college about doing a nice clear H and not rushing. Not rushing so you can actually see and look at the eyes, look at what they're doing. And remembering to ask the patient if they're seeing double. Obviously, that could be in the instruction. This patient has double vision. Please examine the cranial nerves.

SPEAKER_02 13:20

Yeah, I think sometimes that's where that fluency of examination and being very used to it is important because you're not thinking about what you're doing, you're looking for the signs. When you're not as practiced, you're thinking about what next, or thinking about what to do, and you're forgetting to actually look at what's happening. And one of the other skills in all of those stations is the maintaining patient welfare one, which should, I hope, feel fairly straightforward. But have you seen any situations in the neurology exam where people have sort of fallen down on this?

SPEAKER_03 13:50

Basically, there shouldn't be any problem with this. But obviously, you mustn't hurt the patient, so you mustn't be rough. And ideally, if you're testing sensation, you want to use a neurotip, no blunted needles. Neurotips should be provided, and ideally you shouldn't draw blood. Now, sometimes in elderly ladies with thin skin, that can be a bit difficult. But ideally, you shouldn't be drawing blood with your neurotip. I suppose that's something else that sometimes people are a bit quick with their sensory examination. I would say six minutes is plenty of time to do what you have to do.

SPEAKER_02 14:33

Yeah. And in terms of the approach to the sensory examination, I guess to do what you need to do, what would you be expecting in terms of different modalities? So light touch, pin prick, you're obviously testing two different things there, sort of a dermatomal approach. How should people be approaching that sensation?

SPEAKER_03 14:48

Because I think people can find that tricky to make sure you've got your patient reasonably exposed. Make sure that you have the limbs symmetrical and make sure the patient understands the instructions. Then a first screen in a dermatological pattern is perfectly reasonable. And then if it seems likely that it may be a peripheral neuropathy, then you want to look distantly to proximally or to go from the area of altered sensation to an area of normal sensation to define the loss of sensation. You will be expected to do pinprick, light touch, joint position. If you're asked to do vibration, there should be a thick vibration, and you should be showing that you know how to use a thick tuning fork.

SPEAKER_02 15:42

Okay, so when you're checking sensation, say in the lower limbs, you would be expecting fine touch, pinprick, and joint position as a basic. And then you might do more depending on what you're finding if they do look like they've got a sensory deficit.

SPEAKER_03 15:56

I think that for the exam, if you cover those, you will pick up the deficit. And providing you outline the deficit, that's the important thing. Yeah, absolutely. Okay.

SPEAKER_02 16:08

So we've talked about sort of common pitfalls. And earlier you were talking in general about the neurology exam and the focus really being on where's the site of the lesion is really what you're hanging your hat on in terms of making that diagnosis and you know using those four minutes at the end to get those marks. Do you have any advice or tips on, I guess, the approach to that, and partly maybe about pattern recognition as well? Because I think a lot of neurology is also about pattern recognition in terms of targeting that examination.

SPEAKER_03 16:39

Well, if you think where the lesion is, you can go through. Well, is it central or is it peripheral to start off with? If it's central, so if we're talking about the motor system, is it pyramidal or extra pyramidal or lower motor neuro? So you've only got three choices. If it's peripheral, is it sensory or motor? If it's peripheral, is it one nerve or many nerves? Or could it be a root lesion? So if you think of it logically, then you should be able to work out which one it is. You may be given somebody who has a hemiparesis, and then basically what you want to look for is a pattern of the arm being held in flexion and the legs being in extension. So that differential between flexor strength and extensor strength that you get with pyramidal weakness.

SPEAKER_02 17:36

And we were talking a little bit about the prompts at the start, and if the prompt might be someone who's having difficulty walking or something, you know, we talked about cranial nerves upper and lower, but it might be that someone actually has a cerebellar pathology or Parkinsonism, and the examinations for those involve some extra bits. Do you have any tips around, I guess, deciding on when to put those extra bits in and what's sort of useful in those examinations?

SPEAKER_03 18:01

Well, if you have somebody with Parkinsonism, it should be obvious from the end of the bed that they have a masked face and they have a resting trauma. I would expect it to be fairly clear, and that will give you the clue. When you're testing tone, you have to make it clear that you're looking for both extra pyramidal tone with the slow movements as well as the pyramidal tone with a clasp knife movement. In a motor examination, you should always examine coordination. So that would be rapid alternating movements and finger-nose coordination or heel-shin coordination. And if somebody has difficulty walking and they're on a bed, you should ask if you can walk them. If they say they can't walk, which may well be the case, then just concentrate on finding the signs in the legs.

SPEAKER_02 18:57

Yeah, absolutely. And I'm just gonna mention tone because I wonder whether that might be something for people to get your insight on too. So what are you looking for when someone's assessing tone in a patient?

SPEAKER_03 19:10

I'm looking that they're getting the patient relaxed, that they're getting the patient into a good position with their arms or legs, that they're doing a nice smooth movement to look for extra pramidal tone, such as lead pipe rigidity, and that they're doing sudden movements to look for velocity dependent increase in tone, which is what spasticity is. And it should be clear cut. And if it's not clear cut, it's likely the tone is normal. Tone might be reduced in somebody with peripheral lesions, but more often than not it's likely to be normal, unless they're very floppy, and that would be very obvious. So the movements in the arms are important. In the leg, I would expect a candidate to briefly lift up the thigh and let it drop to see what happens to the foot and how the leg falls. And then I would expect them to move the ankle in and out very slowly and then to catch, to see if there's a spastic catch.

SPEAKER_02 20:16

I think that's helpful. And I'm just thinking about Parkinsonism. If you were detecting someone who had Parkinsonism, would you be expecting them to then look for sort of bady kinesia things as well? Yeah.

SPEAKER_03 20:26

I think if somebody looks obviously Parkinsonian, the next thing to do is to look at fine finger movements with finger tapping and spinning of the hands.

SPEAKER_02 20:37

Yeah, absolutely. So I guess part of it is around thinking about what you're seeing and what you're finding, and then, you know, looking for other evidence to back up what you're finding. So if it finds some cerebellar signs, then think about what else you might need to do for that. Similar with sort of Parkinsonism. And would you expect our candidate to ask about right or left-handedness in paces?

SPEAKER_03 21:01

I don't think you'll lose any points for asking. Okay, but not essential. I don't think it's essential because the science should be clear to you. Yeah. It's obviously much more important when you're assessing speech. I haven't come across an aphasia as part of the science because I think that would be very difficult for the patient to sustain. It'd be too tiring.

SPEAKER_02 21:25

So I guess that brings us nicely on to just thinking about what common conditions appear in the neurology station. And is there any that people tend to find particularly challenging? Because we've talked about the fact that it's got to be people with stable signs that are consistent and that are going to be fairly obvious to people on the day. What kind of things do we see?

SPEAKER_03 21:48

In the cranial nerves, it may well be some form of visual field defect. It could be a nerve palsy. Could be something simple like a bell's palsy. And also the other things I have heard but not seen, but people with bilateral facial weakness. I think sometimes people find that difficult because it can look symmetrical. But I think you need to sort of take a step back and look clearly at the face. So visual fields, facial weakness, upper motor neuron versus lower motor neuron. A biopathic face can be difficult, but it should be a fairly obvious one. In the limbs, you may have somebody who's had a stroke, so hemiparesis. Very commonly you'll get lower limbs to examine. And the common things there will be a spastic parapresis, which there's various causes, but the common things that we tend to see are patients with MS and also hereditary spastic paraparesis, which I know it's not the commonest, but it's one of the commonest inherited conditions, and they have very stable and good signs. I know candidates that I've spoken to after unhappy experiences have been taken aback by things like myotonic dystrophy. Again, there should be a clue in the face with that. And then of course you need to look for myotonia. In the lower limbs, apart from spastic parapresis, the other common thing that comes up is a peripheral neuropathy. So it could simply be a length-dependent diabetic peripheral neuropathy with absent reflexes, or it could be, I see the common one that you see patients coming in for regularly would be chronic demyelinating inflammatory body neuropathy or CIDP. The differential would be an acute demyelinating neuropathy, such as Gion Baret. So you could see somebody who's in rehab for Gion Baret.

SPEAKER_02 23:59

Yeah. So basically it's really mostly going to be people with stable chronic signs that are fairly obvious and clear to see.

SPEAKER_01 24:06

Yeah.

SPEAKER_03 24:07

And remember the patients have to do this multiple times. So it has to be something that's not going to be too onerous for them and too tiring. That's a good point as well.

SPEAKER_02 24:18

And I guess the thing to say is you might have something that's quite rare, like hereditary spastic paraporesis to the general medic, that would feel quite rare, but actually the focus isn't on getting that exact diagnosis. It's getting the signs, knowing where the lesion is, and then thinking about what that could be. Would that be good?

SPEAKER_03 24:35

So I would say that we're wanting you to say, oh, this is a central problem, probably in the spinal cord. It's evidenced by this particular pattern of weakness, brisk reflexes, and they should have extensor plant responses that are obvious. They should have good going, increased tone. They may or may not have clonus, and that can sometimes be sometimes people with long-standing spinal cord problems don't always have very easily elicitable ankle jerks. Okay. So maybe don't be put off by that. If the knee jerks are very brisk and the tone is increased, don't be pushed off. I suppose another possibility that you might come across is that you might want to think about in your differential is something like a subacute combined degeneration where you would get upper motor neurone signs and absent reflexes.

SPEAKER_02 25:29

Yeah. So just having a sensible differential list as opposed to knowing exactly what's going on for that patient.

SPEAKER_03 25:35

I always think of things like being, is it structural? Could it be inflammatory? Could it be vascular? Could it be genetic?

SPEAKER_02 25:44

Yeah. So that sounds like your Civ you were talking about. So what categories, where is the lesion, what categories of things could cause that lesion in that place? And we talked a couple of times about sort of myopathic face, that myotonic dystrophy is something that's been a challenge. Have you got any sort of top tips for that?

SPEAKER_03 26:02

Basically look hard at the face. And if the patient is sort of looking out at you under their eyelids, it suggests that they've got bilateral facial weakness. And test their eye closure and test their mouth closure. And look for things like wrinkling of the forehead and things like that.

SPEAKER_02 26:22

So that's one thing we've not talked about a lot is that inspection part of it, which is clearly quite important at the end of the med. Any other sort of top tips for the inspection phase of the exam?

SPEAKER_03 26:34

Well, look for resting tremor, look for posture, look to see if there's any asymmetry in the face, look for the posture of the limbs. Somebody who has had an old stroke may have a flexion deformity at the elbow and an extended leg. So those sorts of things. Also look for muscle wasting. I suppose one of the things that comes up as well is your inspection. You then come to your palpation where you're looking for fasciculations. And you want to do that clearly that you do that before you move the limb, that you flick the muscles to see if there is any fasciculation.

SPEAKER_02 27:14

Yeah, that's a useful tip. So make it obvious as to what you're doing. Yeah. And I was going to say just take the time to have a proper look before you rush into everything. So I think we're probably then moving on to after the exam, so that four minutes of presenting in questions. What advice would you give candidates in terms of presenting their findings?

SPEAKER_03 27:34

Listen to what the examiner asks you to start with. Commonly they will say, please can you tell me your positive physical findings? So don't go on about a lot of negatives unless they're important to what you've found. So they want you to present the signs. You could then go on to present the pattern and say, This makes me think that there is a problem in this part of the nervous system. Examiners are quite happy for you to break it down. They want to see that you can think logically.

SPEAKER_02 28:10

I think that's useful advice because I think people get worried about the presenting, what should they include in that? So it's useful to know that it's really positive findings and really important negatives to whatever you find. And people often sometimes want to kind of then rush into giving a list of differential diagnoses, investigations, and don't let the examiner come in at that point. What would you say to that?

SPEAKER_03 28:32

I would say that the examiner should be directing you. I think people do worry about getting the differential diagnosis and the diagnosis and the investigations and management in because you want to get all the points for it. But those examiners should also be managing their time. If you feel that you haven't answered all the questions, then you may want to volunteer them. But they should ask you clearly questions that are going to help them fill in your marksheet.

SPEAKER_02 29:00

So the examiners are really asking questions to try and help you get points.

SPEAKER_03 29:04

Yes. We're there to try and help you. What you're doing should be a common thing that you're doing in your daily work. That's a useful way to think about it.

SPEAKER_02 29:14

How do you decide what questions you're going to ask out of interest?

SPEAKER_03 29:18

We calibrate those when we calibrate the findings. And we basically say, well, we expect them to find these things. We expect them to say this is where the problem is. We expect them to come up with probably two or three differentials. And then we would ask them what we think the top of their list is. And then we would ask, well, how are you going to investigate and manage that?

SPEAKER_02 29:46

So it sounds like in terms of presenting, really what you're looking for is positive signs, important negatives. You can go on to then have a think about where you think the lesion is and what this is consistent with, like a pyramidal weakness, extra pyramidal, like we've said. And then probably best to let the examiner guide you in the questions beyond that so that you're getting the most points as possible. And if an examiner interrupts a candidate, I think it's useful to think about what that means because that can be a bit off-pitting if you're a candidate.

SPEAKER_03 30:14

It may be that they think you're running out of time and they want to get you to the next thing. I would try not to think too much about it and just answer the question. We do try to guide people back to the right so that people can get the mask. And it may simply be that. But basically, I would listen to what the examiner's saying. A sign that somebody sort of verbally spouting differentials and investigations and management, sometimes it doesn't sound as though it's right because you're meant to be thinking about that particular patient.

SPEAKER_02 30:48

Yeah.

SPEAKER_03 30:49

Okay.

SPEAKER_02 30:49

And what happens when a candidate doesn't know the answer to the question? What do you think is a good strategy for the candidate to have when that happens?

SPEAKER_03 30:56

If they don't know, say they don't know, and the examiner should move them on to something else.

SPEAKER_02 31:03

Yeah, because you can sometimes be tempted just to go into sort of a rambly answer, which might lose you time.

SPEAKER_03 31:08

Yeah.

SPEAKER_02 31:09

All right. Great. And one thing I often think about is that you are marking both of these stations as the examiner. So this is combined with the cardiology station, and you're kind of moving on from one to the next. How do you as an examiner separate those two in your mind? So it certainly in my paces I had a terrible abdominal station and then went on to another station which I did absolutely fine in. But I wondered whether they're kind of judging you from your last performance to this one.

SPEAKER_03 31:33

No, they're entirely separate. You can certainly do not so well in one and then be fine in another. So I would take a deep breath. If you don't feel that you've done well, take a deep breath, start afresh. But we have separate papers for each case, and we'll have separate calibrations for each of them. And I don't often examine on the neurology station because I think it's unfair to have a specialist. Occasionally I do, but I tend to take a back seat and put my general medical hat on. And what I expect a core medical trainee or IMT now to be finding.

SPEAKER_02 32:16

Yeah, I think that's also reassuring that most of the time they avoid having a specialist in the exam. Even if the specialist had their general medical hat on, I think it's important to think about it from a generalist perspective, not from a specialist.

SPEAKER_03 32:27

Yes, I I'm fine with the cardiology. My view is if I can't hear something, it's not there. If I can hear something, since I don't listen to very many murmurs these days, then in those situations I would expect that to be audible. I do very much expect the neurology cases to be very standard. I don't think we should be using esoteric cases unless there's good signs and you can talk about one of the more common conditions.

SPEAKER_02 33:00

Yeah, absolutely. Something people say, oh, I had this really, really rare thing, but actually, yeah, you might get some rare cases and pieces, but actually it's about finding the signs and coming to a sensible differential and not about identifying what's wrong with that exact patient at that time.

SPEAKER_03 33:13

I think one thing I might mention, we were talking about fundoscopy. I haven't tended to see fundoscopy in the main neurology station. It can come up in the longer cases, station two and five. And in those cases, as I said, the pupils should be dilated for you and you should be able to turn the lights down. And what you're looking at should be very clear to you. The sorts of things that come up on a thundoscopy, you're unlikely to get somebody with papilledema because they'll be poorly. But it may well be that you've got somebody with diabetic eye disease. That's quite commonly comes up. Very rarely you'll have somebody with retinitis pigmentosa. And the thing there is you must look at the periphery of the retina. And that means asking the patient to look down left and right. So you do need to have been practicing fundoscopy. And in somebody who has something like retinitis pigmentosa, there may be other coincidental changes like some changes of hypertension. So if you see those, don't forget to mention them.

SPEAKER_02 34:24

Yeah. But again, you know, the findings are from fundoscopy are going to need to be fairly obvious that a non-specialist will be able to pick them up in the calibration, which I think always people get really scared about pendoscopy coming up in paces. But I think having an approach of how to do it and knowing that hopefully the signs should be fairly obvious is a bit of reassuring.

SPEAKER_03 34:43

Yeah. And if they're asking you to do fundoscopy, then it should be fairly obvious what's there. So don't panic and take your time.

SPEAKER_02 34:51

Yeah, take your time seems to be a key message. So I think we're probably wrapping up. I wondered whether you had any sort of final top tips, take home messages for those listening in terms of having the best chance of success in the neurology station.

SPEAKER_03 35:07

I think take a deep breath and don't panic. It's not going to be as bad as you think it's going to be. I think sometimes people can affect their own performance because of nerves. Lots of practice will help you do things more automatically. So then you can control your nerves better. And yes, look for the patterns, but do things logically. We're not trying to catch you out. We really aren't.

SPEAKER_02 35:36

Thank you so much. So I hope that's been helpful to the listeners and that you have success in your PACES examination when it comes. This is part of a wider series looking through all the examination stations. So hope to see you next time listening. And thank you so much again, Kathy, for joining us today.

SPEAKER_03 35:54

It's been a pleasure, thank you. And I wish you all great success in your exams.

SPEAKER_00 36:18

When I was chatting to successful candidates recently when they were receiving their diploma, I was pleased to hear about how they valued Edinburgh and the education that it provides from evening medical updates through to the PACES podcasts. And that was one of the reasons that they chose Edinburgh as their college of entry. Add to this the experts team in the examinations department who will try and help smooth your way through your PACES application, along with the fact that we provide PACES centers throughout the UK. I would encourage you to think of Edinburgh as your college of entry when doing PACES.