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QuickScroll  Case 1

Case ID: 1
Created: 30 November 2006

Examine this gentleman's cardiovascular system .



    This is an interesting case and I think you know that it is an important case in your MRCP PACES examination. You notice this gentleman has very prominent pulsation in the neck ( carotid artery) which is described as dancing carotids. Yes, you are right, it is Corrigan's sign. Some candidates may think that it can be quite difficult sometime to differentiate Corrigan's sign from raised JVP with prominent 'V' waves in patients with severe Tricuspid Regurgitation. I think one technique to differentiate these two signs is by trying to occlude the JVP. You might remember as a medical student that Jugular Venous Pulsation can be obliterated and not palpable, therefore if you are in doubt, feel the pulsation, you can feel a strong carotid pulsation if you are dealing with Corrigan's sign.You are expected to find the following signs as well in this gentleman,

arrowCollapsing pulse. A lot of candidates do not know the proper technique to feel for collapsing pulse. My friend failed his MRCP because of this mistake!
arrowDisplaced apex beat- forceful and displaced.
arrowEarly diastolic murmur - at the left sternal edge especially when patient sits forward and when in expiration.

After you know the diagnosis of aortic regurgitation, you must pay attention to the following,

     arrowLook for any other concomitant valvular lesions,

 arrowAssess the severity of the heart lesion,
    arrowFind the possible underlying cause for the heart lesion,
    arrowAssess the complications of the heart lesion,

Therefore, in this case, since that the underlying cause of Aortic Regurgitation you see in developing countires is still Chronic Rheumatic Heart Disease, always look for other valvular heart lesions such as Mitral stenosis, Aortic stenosis etc.To assess the severity of Aortic Regurgitation, remember the following (T-ABCD),
    arrowThird heart sound,
    arrowAustin-Flint murmur,
    arrowBlood Pressure- wide pulse pressure,
    arrowCardiac failure-signs suggesting failure,  
    arrowDuration of the murmur, the longer, more severe is the lesion.

To find the possible underlying cause of the Aortic Regurgitation, as I said earlier, 80% of the time, you are dealing with Chronic Rheumatic Heart Disease in your examination, however, if you find you are dealing with ISOLATED Aortic Regurgitation, remember there are three popular causes in MRCP PACES namely Marfan's Syndrome Syphilis ( look for presence of Argyll Robertson Pupil) and Ankylosing Spondylitis.

Last but not least, always assess the possible complications of Aortic Regurgitation, look for any signs to suggest infective endocarditis and heart failure.

Common questions examiners would ask you,

1) How do you manage this gentleman and what are the indications for surgical intervention?
2) If you find a young patient with only isolated Aortic Regurgitation, what conditions you must always consider?


This gentleman has mixed aortic valve lesions due to CRHD .

Extra points:

1) Indications for surgical intervention in Aortic Regurgitation include symptomatic heart failure, poor ejection fraction, aortic root dilatation more than 50mm and end systolic dimension of left ventricle more than 55mm. ( remember 50-55!)

2) Other Aortic Regurgitation signs you can mention in exam to impress your examiners are Quincke's sign,de Musset's signand Muller's sign.Do not worry about these signs, just remember that and give your answers in case they ask you in your MRCP PACES!


1) 250 Cases in Clinical Medicine

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