How to ace PACES

Paces is the clinical skill exam of MRCP. It has 5 stations, each lasting 20 minutes

Station 1:
• Respiratory : commonest cases are – COPD, pulmonary fibrosis, bronchiectasis, scar cases – lung transplant / lobectomy
Study material: OST / pocketbook of paces ( I absolutely loved this book for paces! )

• Abdomen:
Ascites, hepato/ splenomegaly, CLD( usually with stigmata), Plycystic Kidney Disease, renal transplant, liver transplant, nephrectomy scars

Abdomen is probably the easiest one to score. Generally quite straightforward unless there is very subtle hepatomegaly or scars that not followed the usual pattern, generated by the surgeons imagination!!

Study material: OST / pocketbook of paces ( specially for those who are planning to sit for UK centres- abdomen is very well written in this book)

Station 2: History station.
I will elaborate about station 2 and 4 in my next post. Just to mention few bullet points
• Taking a proper history is the key, we need to have a very compact structure to elicit all the hidden information.
• This is not all about diagnosis, you may put very reasonable DD still may fail because of lack of structure.
• Ask everything that seems relevant. Specially drug history, family history and sexual history, these are pits they want you to fall into.
• Which ever DD you put, you must have points for and against. They are not asking for a professor level diagnosis, they are looking for a registrar who can put reasonable differentials and act upon it by ordering investigation and involving other specialties.

Station 3:Cardiology
In UK centres – 80-90% chance you will get valve replacement , younger patient tissue valve, older patient may be tissue/ metallic valve( this is a rough idea)
For metallic valve, please spend a good few seconds to listen from outside.
For tissue valve: we should try to find flow murmur corresponding to the valve replaced.

Red herring: In my hospital, while volunteering for arranging the exam, I have seen 2 cases: they got an absolute healthy medical student, there was no sign and 3 out of 5 candidates found mitral regurge and in another case, an elderly man who just had AF with no precordial finding, we all thought he had Aortic stenosis!

Moral of the story: lets not make up signs.

Study material: OST (best for Cardio) / Cases for paces / for treatment.

Neurology: hardest of them all!

What to expect: 1st thing is ability to perform a very sleek, neat neurological examination in 6 minutes, thats the toughest part.

Cases: unlike other systems, here we should think of reasonable differentials than the diagnosis. The best way to put differentials:

1st find out – what type of lesion – Upper motor/ lower motor or mixed,
2nd: where is the lesion – cerebral, cerebellar ,cord, brainstem or peripheral nervous system
3rd: distribution of the lesion ( Upper limb, lower limb)

4th: any other clue – scar/ wheel chair/ corrective glasses/ asymmetric arm or leg movement/ characteristic face and speech etc.

I used to calculate in my mind with above 4 criterias while doing the examination and then put up the differentials. It takes a lot of practice specially eliciting the signs and putting it into the table of diagnosis. But very doable with reasonable amount of practice, so dont worry.

Station 4 – communication: 
Its a saga of success or failure stories specially for overseas candidates. I will discuss separately as it needs more highlight.
Study material: Ryder paces book/ Tim and hall

Station 5:
This is the heart of the exam. You perform well, get 56 out of 56 and you seal the victory. Again needs extreme practice, sleek exam , structured core history taking pattern and most importantly easy 3 line feedback pattern.
Will discuss about it in a different post.

Study material: Ryder paces book/ pocket book of paces/ cases for paces.
Best place to get cases – PG hospital D block 16th floor.


Paces is a pandoras box. You can get good cases ( may not be easy ones but reasonable cases) , you may get absolute disaster cases. So expect for the best, prepare for the worst.

Remember, everyone passes, so never lose hope with number of attempts.Even here in this country, many trainees take 3-4 attempts to pass. So no matter how many times you attempt, its the pass score you are looking for and you will definitely succeed.

All the best

ST3 Trainee( East Midlands Deanery) 


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