I Can't Feel Yer Pulse!

Recently, I had the privilege to be invited as an MRCP PACES mock examiner in one of my local hospitals. It reminded me much of my days when me and my few close comrades were striving to perfect our clinical skills and to embark on the MRCPian journey.

I must say that it was a very 'close to heart' experience, as I truely shared the bitterness and joy shown in the candidates.

Amongst the cases, the toughest (being most elusive) one is a young boy with the following station stem.

Station 3: Mr K is admitted with uncontrolled hypertension. Please examine the cardiovascular system.

I would complete my examination by measuring his blood pressure on both sides.
Examiner:"The blood pressure is 170/100mmHg on both sides."

The principal findings on this young man are radiofemoral delay with absent lower limbs distal pulses. I could not feel the posterior tibial and dorsalis pedis pulses on both sides, though the popliteal pulses were feeble. There were no puncture marks or haematoma on the groins to suggest a recent intraarterial procedure. Examination of the precordium revealed no abnormalities, in particular, there is no murmur to suggest an intracardiac shunt or aortic root abnormalities. There was no scar seen. There was no sign of heart failure.

With the aforementioned findings, I think this young man has coarctation of aorta complicated by uncontrolled hypertension. It would be most pertinent to look for signs of target organ damage urgently, ie preliminarily funduscopy, urinalysis and serum creatinine. In view of his age, I would also consider the differential diagnosis of Takayasu arteritis.

The verdict:
All candidates who were given this case failed to elicit the delay in pulses. Frankly, I don't think anyone would hardly miss the diagnosis if it's a normal daily clinic case. Young hypertensives... there are only a handful of conditions that can be presented in a PACES short case station!