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.

Monday, April 30, 2007

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!



At 5/07/2007 09:18:00 PM, Blogger Dr. David Teoh (eMRCPian) said...

Wow, I would probably miss it as I do not check femoral-radial delay routinely!

At 5/09/2007 03:06:00 AM, Blogger Hospital Slave said...

If the patient is a female, don't forget to look for signs of Turner's syndrome.

At 5/09/2007 09:55:00 AM, Blogger Axonopathic said...

Thanks hospital slave, it's a good point

At 11/11/2007 11:42:00 PM, Anonymous Anonymous said...

I got a 50 yr old gentle man who had cyanosis, a weak pulse in the left radial artery, midline sternotomy scar and a systolic murmur.
Retrograde thought --> ? tetralogy of fallot + blalock taussig shunt


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