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Tutorial for MRCP PACES Station 3 ( Last modified: 12 January 2007)
Cardiovascular station
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I was always asked by candidates the best way to present thier findings in MRCP PACES examination. Generally I would tell them that there are two ways to present your findings in MRCP PACES. The first way that I call as 'classical way'. What I mean the' classical way ' is that you have to present to your examiners all important positive physical signs and a few important negative signs and finally give the examiners your diagnosis. An example for this style of presentation is as follow,
1) Classical way
"Mr ………… is comfortable at rest, his pulse rate is 92 beat per min irregularly irregular with variable volume but not collapsing in nature. This is no stigmata of infective endocarditis nor he has peripheral or central cyanosis. His JVP is raised with positive hepatojugular reflux with presence of bilateral lower limbs pitting oedema. His apex beat is not displaced but tapping in nature. First and second heart sounds were heard with presence ( absence) of opening snap. The first heart sound is loud in nature as well as the pulmonary component of the second heart sound. There is presence of long mid diastolic rumbling murmur at the mitral area which is accentuated when the patient is on left lateral position and in expiration. There is another pan systolic murmur best heard over left sternal edge when patient is in inspiration. His lung is clear.
In summary, I suspect this gentleman has severe mitral stenosis currently complicated with pulmonary hypertension and tricuspid regurgitation. He is in atrial fibrillation but there is no stigmata of infective endocarditis. The underlying etiology for his MS is probably due to chronic rheumatic heart disease. I would say that his mitral stenosis is mild/moderate/severe because.............."
The second way of cardiovascular station presentation is what I call ' confident way' , candidate can start the presentation by saying the diagnosis and then proceed to tell the examiners all the positive signs and a few important negative signs. An example of this style is as follow,
2) Confident way
" I suspect Mr ........ has mitral regurgitation because I notice that his apex beat is located at sixth intercostals space ,2 cm lateral to the midclavicular line and it is thrusting in nature. First and second heart sounds were heard in which the first heart sound is soft and the second heart sound is loud. Third heart sound was heard as well . There is presence of pansystolic murmur over the mitral area radiating to the axilla and best heard when the patient is in expiration. However, there is no stigmata of infective endocarditis. I think his mitral regurgitation is probably due to underlying chronic rheumatic heart disease. The mitral regurgitation is severe/moderate/mild because......... ."
Now, the dilemma is which style to use in MRCP PACES examination, I always think the first style is better style because it is safer. You might still be able to get some points even though you have the wrong diagnosis because some physical signs may be correct. The dangerous part about the second way is you tend to fit in ( or even create your own physical signs) all your physical signs into one correct diagnosis, therefore, you tend to score either very well or badly in your examination by using this style.
So my advice to you, try to use the first style unless you are very confident about the diagnosis in your examination!
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