PACES MRCP UK - Where MRCPians Meet Since 2006

MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.

Wednesday, August 23, 2006

Midline Sternotomy Scar

Case record by Wuchereria

Examine the Cardiovascular system

This pt has a pulse rate of 80/min which is irregularly irregular. There is no radio-radial delay or collapsing pulse. There is no clubbing or peripheral stigmata of infective endocarditis. She is pale. There is no jaundice, cyanosis. JVP is not elevated and there is no pedal oedema of the legs.

On examination of the precordium, there is a midline sternotomy scar.

Apex beat is displaced, 5th intercostals space 2 cm lateral to MCL. No parasternal heave or thrills.

Metallic click of the 1st HS, normal 2nd HS

Lungs clear

I would like to complete my examination by checking the fundus for Roth spot or fundal haemorrhage, look for signs of overwarfarinization, examine the CNS for evidence of CVA, look for splenomegaly, urine dipstick for haematuria, check BP, all peripheral pulses

My diagnosis is that this pt has Mitral valve replacement and is in atrial fibrillation and is anaemic. There are no signs to suggest infective endocarditis, pulmonary hypertension, overwarfarinization or heart failure. There is also no evidence of valve leakage.

1. What are the causes of anaemia ?
*Bleeding due to anticoagulation
*Secondary to IE
2. Advantages of Porcine heart valve
*No need anticoagulation
3. Disadvantage of Porcine heart valve
*Degeneration with time – may need reoperation (after about 7 years)



At 8/24/2006 12:09:00 AM, Blogger saramin said...

Two things are important regarding weather we choose a mechanical or a bioprosthetic valve:
1- If the life expectancy of the valve is shorter than the life expectancy of the patient.
2- If anticoagulation cannot be used (difficult to achieve, bleeding tendency, questionable follow up...etc).

Another thing. Given the above findings (by Wech.), I think that there was mitral regurgitation plus minus mitral stenosis, and the regurgitation was the hemodynamically predominant lesion at that time. The presence of displaced apex and atrial fibrillation point to a moderate to severe degree of valvular pathology from the outset, so I think that absence of signs of pulmonary hypertension, or bibasilar crackles would be unusual.
Thank you
Dr. O Amin

At 8/24/2006 10:12:00 PM, Blogger Axonopathic said...

Hey wuchereria, how come don't post urself :P

At 8/25/2006 08:34:00 AM, Blogger eMRCPian said...

Probably the surgery was done before significant pul HPT develop. I am not surpise that there is no bibasal creps as there are no other signs to suggest HF or valve leaking.

At 8/27/2006 03:46:00 AM, Blogger said...

Edward J.

More info about classes and pharmacotherapeutical treatment of hypertension and related medical conditions of high blood pressure:
Hypertension Diseases - - ICD-10


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