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, July 04, 2007

History - Quiz Chest Pain

The most failed station according to a PACES book is Station 2 - History because it is the least practiced for the exam station. We were discussing about this a moment ago.

Scenario : Mdm Ma is a 40 years old Malay lady who has been diagnosed hypertension and is currently on T. Metoprolol 25 mg bd. The GP has referred this case as this lady has been complaining of chest pain for the past 6 weeks.

Kindly take a history from this patient.

Based on the history,

This lady had the following characteristics of chest pain - crushing, radiating to the back, lasting for 5 minutes, at rest, almost everyday, not related to meals or respiration. No DM, Stroke. Strong family history of IHD - Father IHD at 60 y.o, Brother IHD - passed away at 45y.o and grandmother IHD at 71 years old. Non-smoker, no alcohol consumption. Works as a clerk, married with 4 children.

This is the very brief history.

  1. What are the provisional diagnosis in this case ?
  2. What is the differential diagnosis in this case and so with the differential diagnosis, and what are the further questions you would like to ask ?
  3. What investigations and plan ?

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At 7/05/2007 03:25:00 PM, Blogger Xiao_zhai said...

My provisional diagnosis is unstable angina.

My differential diagnosis would be prinzmetal angina, AMI, aortic dissection.

The questions I would like to ask,is when did it first start, how's the progression since?Has it been progressively worse? Number of episodes a day? Any DM symptoms i.e. polydipsia, polyuria and nocturia? Uncontrolled and undiagnosed DM could mask an AMI. Besides, the episodes lasting less than 30 minutes, make AMI less likely but not unlikly. Any upper limb weakness looking for limb ischemia due to dissecting aorta?

Investigations would be ECG looking for ST depression. Blood for Cardiac enzymes, FBC and fasting blood sugar.

For unstable angina, I would admit the patient for an urgent angioplasty on top of ongoing medical therapy.Give the patient morphonine, Oxygen, Nitrate and Aspirin. Start the patient then on low molecular weight heparin.

At 7/06/2007 07:17:00 PM, Anonymous Anonymous said...

what's an AMI!

At 7/07/2007 04:24:00 PM, Anonymous Anonymous said...

AMI=Acute myocardiac infart

At 7/17/2007 12:59:00 AM, Anonymous Anonymous said...

Should I go into the DD of Hypertension
Thank you

At 2/24/2008 01:42:00 AM, Anonymous Anonymous said...


At 5/02/2008 03:47:00 AM, Anonymous drrizvanahmed said...

aortic dissection, mitral valve prolapse.esophageal spasm.

At 10/21/2008 11:16:00 AM, Anonymous drrizvanahmed said...

She has chest pain radiating to back so aortic dissection should be considered butI wonder if aortic dissection would stay for 6 weeks.In such a case urgent transesophageal echo should be one of the first investigations and thrombolysis is contraindicated

At 5/23/2010 10:48:00 PM, Anonymous Anonymous said...

40 yr old lady with HT strong FHx IHD, suggest acute coronary syndrome.
DD cardiac or non cardiac chest pain. Further Hx- Is HT under controle? Is she got bronchospasms?
Need resting ECG-STEMI/NonSTEMI/UA?
Troponin T levels, lipid profile .....


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