MRCP PACES is a challenging examination requiring in-depth clinical knowledge, excellent clinical skills and the ability to present each case concisely and. Download Clinical Medicine for the MRCP PACES Volume 1. Volume 1 of a two volume MRCP text, this book includes cases which mimic the style and. Consultant led videos featuring the most common. & rare cases per station. Notes on how to pass your MRCP PACES Exam. & 5 E M B E D D E D V I D E O S.
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At this point, it is common for any given presentation, it offers the potential candidates to falter and not proceed to expand to demonstrate understanding and develop upon the diagnosis, and management thereof, context, gaining valuable marks.
The strength of this to demonstrate a holistic approach and include: While where smoking is a prominent modifiable you are not afforded the results of your chosen risk factor investigations, it is safe to assume that you While on first glance such a list seems can go on to discuss management of a single cumbersome, rest assured that with practice all condition, regardless of whether the actual can be covered swiftly and succinctly.
Demonstrate an understanding In discussing management, it is useful to consider the distinctions between conservative, of the value and role of appropriate medical and surgical intervention. While such further investigation categorisations complement the approach to As a general rule, an investigation should be management in surgical exams, they can be referred to using the full and unabbreviated somewhat cumbersome in the medical context.
That said, they are a useful starting point in Station 2: Conservative management Chapter 6 lays out commonly encountered should be considered as modifiable risk factors themes in station 2. The detail included is not that require lifestyle change such as dietary intended to serve as a reference text, rather to advice and smoking cessation. Thereafter, risk highlight the important principles of each case factors that require medical treatment such as and offer insight as to the type of discussion and blood pressure can be discussed leading the narrative required to communicate the salient discussion logically on to pharmacological points.
It is important to note that conservative management is also often seen as a watch and wait option, which has a certain Prior to entering the room implication of doing nothing when really close The candidate information provides details of monitoring better reflects the rationale.
Comparatively, station shunting TIPS in gastroenterology, coiling 2 offers the most detail in the candidate of subarachnoid haemorrhages in neurology. Thus, in each example we invasive procedures and are held in the offer various approaches to utilise the time realm of medical management.
Confusion afforded to prepare for commonly encountered as to whether to consider them medical or scenarios. Formulating a plan will prove surgical is unnecessary; the importance lies invaluable in steering a logical and organised in understanding their indications for use discussion from the outset and it can be useful and where applicable their role as either to attempt working through potential lines of first line treatment or as options only where enquiry in your mind to preempt potentially pharmacological therapy as failed.
Doubtless the patient will introduce the occasional theme or topic that will In summary not fit with the best-laid plans but this stresses the importance of avoiding assumptions and You should aim to present the salient positive remaining open to the patients narrative as the examination findings, avoiding a long list of station progresses. With sufficient preparation and your individual approach to station 2. Some practice it will become easier to establish a candidates choose to make use of paper and working diagnosis that will form the basis pen, which is provided, to jot down important of a differential list.
Thereafter, appropriate phrases from the scenario, possible differential investigation should reinforce the likely diagnoses, or pertinent questions to use as a diagnosis upon which to form a management prompt when faced with the patient. This can plan.
You should then proceed to give a be useful but if you do not normally write your brief and fact-laden prcis of the most likely history as you talk with patients then dont diagnosis, and suggest initial management. Be aware This framework encourages a logical of the risk of failing to establish a rapport with progression for discussion of any patient the patient at the cost of focusing on your within the examination setting.
The proposed penmanship. Indeed, where you intend to use structure, expanded upon in this book, notes ask the patient if it is acceptable to write as offers a framework that makes it possible to you talk and thereafter be sure not to use it as a talk for several minutes in an authoritative crutch.
Focus on maintaining eye contact, keep and insightful manner. It is likely that any notes short and try to avoid reading off them subsequent viva questioning will either be verbatim when dealing with the examiner. Regardless, this open questioning approach allows you to determine, in large part, The encounter with the patient is allotted the content of the discussion. Thereafter, you Explore ideas, concerns and may choose to take time to reflect upon the information gathered and organise their expectations thoughts before engaging in a discussion with Actively determining and appropriately the examiner to conclude the station.
The exploring ideas, concerns, and expectations is importance of stressing the timings of the station central to reaffirming the patients agenda and at this point is to highlight the considerable uncovering other themes requiring discussion. Understanding to the patient and reaffirm your role to them the ideas or beliefs upon which these as outlined in the scenario. Thereafter, begin preconceptions are based is vital to achieving with an open question and allow the patient to a shared understanding of the problems respond, uninterrupted, without directing the encountered.
Often, exploring ideas will involve patients response. Avoid interrogating with unpicking a web of information from previous closed questioning from the outset, instead consultations, family members, or research from focus on establishing a rapport and employ search engines and internet sites. Your aim is to make the Patient concerns or worries often relate to the patient feel at ease, and facilitate the passage of impact of symptoms or a particular diagnosis information with reassuring gestures, echoing on quality of life, ability to work, or relationships important statements, gentle steering and with loved ones or family members.
It is repeated open questioning, underpinned with important in this respect to attempt to gain an displays of empathy and sensitivity in response understanding of the impact of each problem to appropriate cues. The initial stages should from the patients perspective. The stigma be used to allow the patient to unburden him surrounding any given diagnosis is also a or herself of information and get a feel for the commonly encountered cause for concern.
Finally, having spent time gathering the Choosing when to draw a line under open relevant history, establishing a patients questioning will depend upon the nature of the expectations can be useful in transitioning information and readiness to proceed along a to a management plan. Incorporating their particular line of enquiry, the willingness of the expectations from the consultation, goals in patient to continue to talk openly without the relation to treatment, or envisaged outcomes, need for continual encouragement, or where forms the basis of shared forward planning.
The transition to closed questioning is often What to tell the patient best achieved by interjecting with a summary Summarise the case as you understand it and of what the patient has said. Reiterating the formalise a plan considering the need for: In such a situation it is not Recognised complications unreasonable to admit to the fact and suggest Relevant past medical history and family a plan in which the information is obtained or history confirmed with a senior colleague and relayed Review of medication to the patient at a later date.
It should be stressed that this is not admissions. The brief clinical consultation advocated as an acceptable approach to disguise format challenges candidates to demonstrate failings in core medical knowledge! Indeed, it is the upon ensuring core understanding of the only station in which all seven areas of the most important take home messages, using marking scheme are assessed at one time.
This is a key skill in of itself, vital to a marks available in the exam are attributed patient-centred approach, which is increasingly to station 5. It is important, however, not to favoured in these scenarios. Indeed, negotiating over-prepare for this station simply because a management plan, with the patient at the of the allocation of marks. The foundation of centre of the decision making process, should a strong performance in station 5 stems from be prioritised over an in depth discussion of thorough preparation for all other stations the battery of available investigations and and relies upon successfully adapting the treatments.
What to tell the examiner In covering station 5, Chapter 5 focuses upon scenarios drawn from rheumatology and Impressing upon the examiner an appreciation musculoskeletal medicine, endocrinology, of the pertinent points from the encounter ophthalmology and dermatology reflecting the upon which the investigation and management areas of medicine previously examined prior plans have been built, will lay the foundations to the introduction of the new format of station for discussion of relevant themes.
Be prepared 5. However, the nature of the station is such to expand upon the details of specific issues that conceivably any area of medicine could touched upon in the history, including wider be incorporated.
Thus we encourage you to be aspects such as prognosis and relevant follow up mindful not only of the content presented but or specialist input. Developing a systematic framework upon Station 4: To successfully navigate this station requires a fundamental appreciation of the core principles Performing a focused history and involved for any given scenario.
Chapter 7 aims examination to provide you with a prcis of those principles The history and examination should not be for commonly encountered situations. The considered as separate entities and a stepwise exact nature of the station will depend upon the approach, taking the history followed by context of the encounter and the interaction an examination, should be avoided if at all with the patient.
Preparing for a range of patient possible. Instead, begin the dialogue with types by role-playing with peers, is a useful an open question that establishes the main exercise in the lead up to the exam. Practising area of concern allowing the early initiation applied communication skills through role-play of a relevant examination. Thereafter, the should aim to explore ways of explaining the consultation can continue with an integrative same information in different ways.
Attempting approach, taking the history and examining to predict the reaction of the angry versus the patient in parallel.
With the identification the withdrawn, depressed, patient or similar of physical signs, targeted questioning should dichotomies in personalities or behaviours. Alternatively, the history may suggest additional areas Station 5: It is through assessment appropriate questioning and choice of relevant Station 5 represents a global assessment examination s , with the potential need to of applied clinical skills, centred upon prioritise breadth of interrogation at the commonly encountered problems in daily expense of depth that forms the basis of an practice on the wards or acute medical assessment of clinical judgment.
Thereafter be sure to check answering questions, allaying fears or dealing the patients understanding and answer any with areas of concern questions that arise. The discussion with the patient should resemble the conclusion of Justifying the need for further investigation and appropriate use of follow up the history station and focus upon agreeing a arrangements management plan.
Exploring management strategies What to tell the examiner As such, succinctly presenting the The discussion with the examiner is likely to examination findings in the context of the revolve around: Chapter 1. Aortic stenosis. Instruction to the candidate Soft or absent S2 This year-old man has been complaining Narrow or reverse split S2 as A2 is increasingly delayed of worsening shortness of breath on exertion. Please examine his cardiovascular system and Timing of the ejection systolic murmur: Importantly, the a discussion of your proposed management.
The auscultatory features leading to a working Slow-rising pulse parvus et tardus: A narrow pulse Most prominent in the right second pressure is a sign of severe aortic stenosis intercostal space loudest in end-expiration Aortic thrill with the patient sitting forward Sustained, heaving undisplaced apex beat.
In Equal radiation to the carotids severe disease the left ventricle may become The murmur can radiate to the apex dilated and thus the apex beat will become termed the Gallavardin phenomenon: This Follow with a summary of demonstrates that while the character and timing of the murmur with respect to the relevant negative findings cardiac cycle are consistent, anatomical A common statement used in the cardiology characteristics, such as the radiation, can station is the patient did not display signs of vary and hence are not always reliable cardiac failure.
If a patient with consistent with severe aortic stenosis and should valvular pathology has signs of cardiac failure be commented upon where detected: Table 1.
The murmur valvular pathology. In this case remember to of coarctation is best heard on the back in comment on mitral regurgitation or, where there the interscapular area. Subaortic membrane the need to comment on any peripheral stigmata Supravalvular: Williams syndrome: Patients also have dentition and indwelling intravenous access. This patient has signs consistent with severe aortic Degenerative the commonest cause in stenosis, likely secondary to calcific degeneration.
Western countries He is clinically euvolaemic, displaying no features Calcific, accelerated by: He does not have any Chronic kidney disease features of infective endocarditis. Rheumatic fever often with associated mitral involvement Differential of an ejection systolic murmur: Homozygous familial hypercholesterolaemia.
Aortic stenosis Pulmonary stenosis Demonstrate the importance Aortic sclerosis calcified valve, with no of clinical context suggest stenosis or impediment to flow hence no radiation to the carotids nor impact upon relevant questions that would be pulse pressure taken in a patient history Subvalvular hypertrophic cardiomyopathy Seek to elicit the cardinal symptoms that relate with left ventricular outflow tract obstruction, to survival and suggest severe disease: It can be 65 years of age the leading cause.
Congenital useful to make reference to the vignette, which valvulopathy bicuspid or extremely rarely may describe symptoms as in this case with unicuspid which presents in younger individuals shortness of breath on exertion. Beware of is the second most common aetiology. Thus, asymptomatic patients who may be limiting the age of the patient may provide a clue to the their activities to avoid symptoms.
Alternatively, consider the aetiology as congenital or acquired: Demonstrate an understanding of Congenital: This precludes stenosis who are either declined conventional cannulation or clamping of the surgical aortic valve replacement during patient ascending aorta during cardiothoracic selection or are considered high risk. It has been surgery. Patient selection is key, and a multidisciplinary approach Transvalvular gradients and aortic valve area amongst non-invasive and invasive cardiologists Table 1.
It should Degree of calcification, and tricuspid versus also be remembered that TAVI is still an invasive bicuspid valves procedure requiring a general anaesthetic, large Left ventricular wall thickness, systolic and bore vascular access and temporary cardiac diastolic function pacing.
Stroke is a major complication. Other Aortic root dimensions and associated complications include vascular injury, coronary aortic pathology especially important in the embolisation, device embolisation, paravalvular context of bicuspid valves leak and death.
Stress testing: Asymptomatic severe aortic stenosis can be further evaluated Always offer a management plan with a medically supervised exercise test, Symptomatic, severe AS requires aortic valve watching closely for symptoms, and abnormal replacement.
Aortic valve replacement is also haemodynamic response to exercise or indicated in moderate AS in the context of arrhythmia. Discrepancies between transvalvular surgical coronary revascularisation or other gradients and aortic valve area do occur concomitant cardiovascular surgery. Asymptomatic mild to moderate aortic For example, low dose dobutamine stress stenosis should receive outpatient follow-up to echocardiography is used in cases of severely monitor the natural history of the condition.
Dobutamine increases myocardial inhibitors or nitrates , thereby reducing venous contractility, revealing either a falsely low return and exacerbating transvalvular gradients. Truly asymptomatic patients should be Cardiac catheterisation: A Asymptomatic patients with an abnormal non-invasive assessment of coronary anatomy supervised exercise test e. Guidelines Aortic valve replacement is also indicated on the management of valvular heart disease: Eur Heart J ; Instruction to the candidate A mid-systolic ejection click followed by a This year-old man presents with dyspnoea.
The click results from sudden tensing of the mitral valve apparatus bowing back into the left atrium Begin with a summary of Certain manoeuvres can alter the auscultatory positive findings characteristics of mitral valve prolapse: Peripheral signs in mitral regurgitation includes: The murmur is prolonged by reducing venous return e. The presence or absence of the following findings should be mentioned to the examiner: Left ventricular dilatation indicated by a displaced apex beat An irregular pulse suggestive of atrial Signs of left ventricular failure fibrillation.
Comment on the rate, embolic A wide split S2 an early A2 indicating complications and any peripheral stigmata of premature aortic valve closure due to a large anticoagulation that may be present regurgitant volume across the mitral valve Peripheral stigmata of infective endocarditis. Ask the examiner for the temperature and a urine dip looking for microscopic Mitral valve prolapse haematuria , and comment on dental hygiene and the presence or absence of Mitral valve prolapse is most commonly due to indwelling intravenous access myxomatous degeneration, but also occurs with inherited connective tissue diseases including Signs of cardiac failure, including pulmonary oedema, peripheral oedema, raised JVP and Marfan syndrome, EhlersDanlos syndrome, S3 gallop, which if present would indicate pseudoxanthoma elasticum and osteogenesis cardiac decompensation imperfecta.
The auscultatory features of mitral valve prolapse include: State the most likely diagnosis include breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, and pedal oedema.
Any on the basis of these findings history of palpitations should also be elicited, The most likely diagnosis in this patient, who specifically considering the increased likelihood has a pan-systolic murmur and is in atrial of AF. Demonstrate an understanding Offer relevant differential of the value of further diagnoses investigation The differential diagnoses of a pansystolic The most important investigations and their murmur include: Mitral regurgitation A lead electrocardiogram ECG: Ventricular septal defect P mitrale broad, bifid P waves of left Tricuspid regurgitation atrial dilatation Aortic stenosis can be mistaken for mitral Atrial fibrillation regurgitation, especially when it radiates to the Look for ischaemic changes as a possible apex termed the Gallavardin phenomenon.
Evidence of left atrial dilatation The differential diagnosis of the underlying Pulmonary oedema cause of mitral regurgitation can therefore be Echocardiography: Clues suggesting important. They will demonstrate: These left ventricular cavity size and systolic. Case 2 Mitral regurgitation 7.
Systolic function should be The indications for surgery preferably repair, hyperdynamic if considered normal in otherwise replacement in mitral regurgitation severe MR, as the left ventricle offloads vary depending on whether the patient is into both the aorta and the left atrium. Left atrial dimensions and pulmonary artery systolic pressure are also evaluated Symptomatic severe MR: Otherwise, in asymptomatic MR, surgery is indicated in Antibiotic prophylaxis: ACE inhibitors, beta- Patients with resultant pulmonary blockers and potassium-sparing diuretics in hypertension accordance with conventional cardiac failure Patients undergoing other concomitant management cardiovascular surgery, such as coronary Patients with AF should receive anticoagulation artery bypass grafting CABG or other and rate control.
Pursuit of sinus rhythm valve surgery following AF in severe MR is unlikely to be In selected cases depending upon anatomical successful in the long-term without correction suitability and patient profile, there are of the underlying valvular lesion percutaneous options for the treatment of severe MR. These would be considered following specialist referral, and include the Mitral regurgitation and its various Mitraclip and Cardioband devices.
Guidelines but remember to mention during your present on the management of valvular heart disease: Case 3: Ventricular septal defect. Instruction to the candidate Follow with a summary of This year-old woman feels well and is under relevant negative findings cardiology follow-up. Please examine her The following represent clinical complications of cardiovascular system.
Clinical context of ventricular septal Infective endocarditis: Concomitant AR due to prolapse of the right coronary cusp can occur particularly in Peripheral signs perimembranous VSDs The morphologic features of known disease It is also important to comment on associations: The finding of a thoracic scar can be indicative of a childhood surgical closure A systolic precordial thrill may be felt on State the most likely diagnosis palpation on the basis of these findings The following is an example presentation Auscultatory features to the examiner, relating to a patient with A pansystolic murmur loudest at the left sternal a haemodynamically insignificant and edge between the 3rd and 4th intercostal spaces.
Note that the loudness of the murmur is not indicative of shunt size but rather of the pressure This patient has signs consistent with a gradient. She has no evidence with a chronic VSD: I would like to Surgically repaired without residual shunt take a full history to establish her symptomatic With residual shunt, which can then lead to status, and my investigation of choice would the following groups: Quantification and direction of the shunt The causes of a VSD include: Also remark on prophylaxis see Infective endocarditis, p.
Surgical closure is the method of Demonstrate an understanding choice, but the procedure can also be carried out in a percutaneous fashion if the patient of the value of further is considered too high-risk or unsuitable for investigation surgical, or in the case of an anatomically suitable muscular VSD. The following list should be mentioned to Patients with symptoms, left ventricular the examiner as relevant investigations in the volume overload, mild pulmonary hypertension, evaluation of patients with a VSD: If the of the symptomatology spectrum, such as VSD is small, a normal ECG can be expected patients who have developed Eisenmengers A CXR may demonstrate the following syndrome, or asymptomatic patients with small, radiographic findings: An enlarged main pulmonary artery, with reduced peripheral vascular markings in patients with pulmonary Further reading hypertension Deanfield J, Thaulow E, Warnes C, et al.
Management Echocardiography, the gold-standard of grown up congenital heart disease. Eur Heart diagnostic investigation, will demonstrate: J ; Case 4: Hypertrophic obstructive cardiomyopathy. Instruction to the candidate Valsalva can be performed in the context of This year-old man complains of palpitations diagnostic studies for these purposes, but and exertional dyspnoea. Please examine his should not be performed as part of the clinical cardiovascular system.
Begin with a summary of positive findings Follow with a summary of The peripheral signs of hypertrophic relevant negative findings cardiomyopathy include: The absence of the following clinical signs should be mentioned in cases of hypertrophic A bifid double carotid pulse. This physical cardiomyopathy: Cardiac systole failure may be due to diastolic dysfunction, The jugular venous pressure will be raised or in the later stages of the natural history of if the patient is in cardiac failure, with the disease, due to systolic dysfunction prominent a waves, which indicate right The finding of an irregular pulse, suggestive atrial systole against a reduced compliance of atrial fibrillation, is a marker of poorer right ventricle due to the impact of the prognosis hypertrophied interventricular septum Infective endocarditis: The following quotation relates to a standard An ejection systolic murmur at the left sternal case of hypertrophic cardiomyopathy: A pansystolic murmur of mitral regurgitation The ejection systolic murmur suggests a left due to systolic anterior movement of the ventricular outflow tract gradient, and the anterior mitral valve leaflet apical pansystolic murmur indicates mitral A fourth heart sound S4 regurgitation secondary to systolic anterior motion of the anterior mitral valve leaflet.
Auscultation in a HOCM case I would like to take a full history to establish his symptomatic status, a family history to The left ventricular outflow tract LVOT gradient establish pedigree of the disease, and my and thus the loudness of the ejection systolic initial investigation of choice would be an murmur vary directly with preload and afterload: Increasing preload by squatting or afterload by the handgrip manoeuvre reduces the Offer relevant differential gradient, with a consequently softer murmur Reducing preload by the Valsalva manoeuvre, diagnoses standing from sitting, or use of diuretic or A suitable differential diagnosis that can be nitrate medications, or reducing afterload by given to the examiner is that of an ejection administration of vasodilators will exacerbate systolic murmur as given in Aortic stenosis p.
Demonstrate the importance The presence and quantitation of LVOT obstruction of clinical context suggest The presence and quantitation of mitral relevant questions that would regurgitation due to systolic anterior motion of the anterior mitral valve leaflet be taken in a patient history The absence of other conditions that Relevant history questions to mention to the might give rise to left ventricular examiner include direct questioning to elicit the hypertrophy, such as aortic stenosis or following important symptoms: A clear assessment of hypertrophic cardiomyopathy, family pedigree is important with respect to especially when echocardiography has establishing the diagnosis and the investigation been inconclusive particularly in cases and treatment of relatives.
It is also useful in The patients job and driving status need to the differentiation of alternative causes of be sought in order to establish adherence to myocardial hypertrophy. MRI can also be vehicle licensing regulations.
Negative results in adult relatives should be of the value of further reevaluated at 5 yearly intervals. Adolescent investigation relatives require annual screening. Genotyping has been used in the research The following investigations yield important setting and also to establish family pedigrees diagnostic and prognostic information in hypertrophic cardiomyopathy: An ECG will show various combinations of Risk stratification in hypertrophic the following electrocardiographic features: Left atrial or biatrial enlargement A personal history of syncope or previous Atrial tachyarrhythmia: A family history of unexplained premature On CXR, abnormal findings are variable, sudden death and may include cardiomegaly due to left Abnormal haemodynamic response to ventricular dilatation or evidence of left atrial exercise on supervised treadmill testing dilatation Non-sustained VT on 24 hours Holter Echocardiography is the gold-standard monitoring, or an episode of spontaneous diagnostic modality demonstrating: This will include family The management of AF may require screening, which is discussed in the specialist input from cardiomyopathy and investigation section of this case.
With regard electrophysiology subspecialties to driving, heavy goods vehicle or passenger- Interventional options for patients with carrying vehicle driving licence holders will not symptomatic LVOT obstruction include surgical be allowed to continue to hold this licence and septal myectomy, which remains the gold need to inform the DVLA. Patients with an ICD standard for this problem.
Percutaneous alcohol need to inform the DVLA and adhere to this set septal ablation is an alternative approach. Risk stratification should be performed include telling them what they must avoid. Medical therapy in hypertrophic Further reading cardiomyopathy includes: Amiodarone should be considered for atrial A report of the American College of Cardiology or ventricular arrhythmia suppression Foundation Task Force on clinical expert A low threshold for anticoagulation exists consensus documents and the European Society for AF in hypertrophic cardiomyopathy of Cardiology Committee for practice guidelines.
Instruction to the candidate The auscultatory feature of tricuspid regurgitation is a pansystolic murmur heard This year-old woman presents with loudest at the lower left sternal edge in flushing and dyspnoea. Please examine her inspiration Carvallos sign. Begin with a summary of Follow with a summary of positive findings relevant negative findings The absence of signs of right heart failure S3, The positive findings in tricuspid regurgitation peripheral oedema and ascites and signs of include a combination of peripheral findings pulmonary hypertension a left parasternal and auscultatory features.
The key peripheral signs to elicit and mention As with other valvulopathies, comment to the examiner are: Importantly in right-sided lesion, acute, chronic and compensated, or chronic and comment on any signs of intravenous drug use. In PACES you will see the latter two presentations, but remember to mention during your presentation that cases of acute TR State the most likely diagnosis can present, for example, in the setting of either on the basis of these findings RV infarction, or sepsis in the case of infective This patient has signs consistent with severe endocarditis.
The Instruction to the candidate mentions flushing and dyspnoea, Demonstrate the importance which could be suggestive of carcinoid heart disease resulting from carcinoid syndrome.
Offer to the examiner the differential diagnosis Additionally, the clinical history can elicit features of a systolic murmur, as discussed in previous suggesting the aetiology of the valve lesion: Infective endocarditis: Disorders of any childhood rheumatic fever. Leaflets Endocarditis review for signs of Rheumatic fever check for concomitant intravenous drug abuse, intravenous mitral stenosis access especially in patients receiving Carcinoid syndrome check for renal replacement therapy , peripheral concomitant pulmonary valve and less stigmata commonly left-sided valve lesions, and flushed appearance Leaflet malcoaptation or trauma due to RV pacing lead Anorectic drugs e.
Demonstrate an understanding atrial tachyarrhythmias via the accessory pathway. The following cardiac investigations offer a The definitive management of tricuspid complete assessment of tricuspid regurgitation: Indications for surgery which include plication, annuloplasty, or 12 lead electrocardiogram: If the ECG replacement are: There may be delta waves treatment suggesting pre-excitation in Ebsteins At least moderate TR in patients undergoing anomaly left-sided valve surgery Echocardiography: Evaluation of patient co-morbid status, right The severity of TR is assessed by colour ventricular dysfunction, presence of pulmonary Doppler and by jet width vena contracta hypertension and previous cardiothoracic The mechanism and underlying cause surgery are all considerations prior to deciding of TR is elucidated by looking at all upon surgical intervention.
Furthermore, redo atrial dimensions must be assessed surgery for persistent TR following correction Cardiac MRI is currently the gold standard of left-sided valvular lesions carries a higher tool for determination of right ventricular risk. Therefore severe TR secondary to mitral size and systolic function valve disease should be fully evaluated and Cardiac catheterisation is performed in concomitantly intervened upon in patients cases of suspected pulmonary arterial undergoing left-sided valve surgery.
Previous valvular intervention typically mitral valve repair or replacement with Atrial arrhythmias, particularly atrial flutter, unresolved TR are common and require management of both the rhythm itself especially if poorly tolerated due to underlying congenital heart disease Further reading or pulmonary hypertension, for example Vahanian A, Baumgartner H, Bax J, et al. Guidelines and anticoagulation where appropriate. Accessory pathways are also recognised in The Task Force on the Management of Valvular Ebsteins anomaly for which the contemporary Heart Disease of the European Society of treatment is a Cone repair , and hence ablation Cardiology.
Pulmonary stenosis. Instruction to the candidate State the most likely diagnosis This year-old woman presents with on the basis of these findings dyspnoea. Please examine her cardiovascular This patient has signs consistent with system. She has clinical features of right Begin with a summary of heart failure, but does not have any features of infective endocarditis. I would like to take a positive findings full history to establish her symptomatic status, Peripheral signs of pulmonary stenosis include: See include: This can Congenital pulmonary stenosis may feature radiate to the left shoulder and the left lung as part of an eponymous syndrome: Aortic and pulmonary stenosis is located at the infundibulum stenoses are associated with this syndrome Findings suggestive of right heart failure Presence of right ventricular S4 Demonstrate the importance Follow with a summary of of clinical context suggest relevant negative findings relevant questions that would be In addition to commenting on the absence of taken in a patient history stigmata of infective endocarditis and on the Relevant questions in any history of pulmonary absence of signs of right heart failure including stenosis would include: Features suggesting aetiology, e.
To exclude other coexisting congenital cardiac lesions Pulse oximetry: Instruction to the candidate sound. A tapping apex beat and an opening snap are both clinical indicators of a pliable This year-old woman presents with exertional mitral valve, which would be more suitable dyspnoea.
Please examine her cardiovascular to percutaneous balloon mitral valvuloplasty system. Auscultatory features of mitral stenosis include: Begin with a summary of positive findings A loud first heart sound and opening snap after S2: The patient is female A low pitch, rumbling mid-diastolic murmur, rheumatic mitral stenosis has a 2: If the patient is in sinus rhythm, a presystolic Mitral facies: The malar flush of pink and murmur termed presystolic accentuation purple patches on the cheeks will be heard as left atrial contraction forces Pulse: The interval between S2 and the opening Connective tissue disease most commonly snap and thus the duration of the diastolic systemic lupus erythematosus or rheumatoid murmur is the auscultatory feature of arthritis severity in mitral stenosis.
This is reflective Carcinoid heart disease of the degree of left atrial pressure. Higher Drugs: Anatomic lesions that mimic mitral stenosis Thus, the time between S2 and the opening arise above the left ventricle and therefore also snap is reduced with higher left atrial reflect raised pressures back to the pulmonary pressures, indicating more severe MS. In venous system.
All of these conditions can such cases the diastolic murmur is therefore manifest as pulmonary oedema and pulmonary longer hypertension, but the auscultatory features will The presence of pulmonary hypertension is differ from those described in mitral stenosis.
Mitral stenosis tends to present in the 3rd to 4th Raised JVP decade of life with a stepwise decline in exercise Left parasternal heave pressure-loaded tolerance. The chronology of symptoms tends right ventricle to be revealing of the natural history of the Loud P2 condition. Pregnancy may unmask less severe Graham Steell murmur rare mitral stenosis due to the increase in circulating volume during the second trimester.
Symptoms State the most likely diagnosis to directly ascertain include: Childhood history of rheumatic fever, She is clinically euvolaemic, but is in atrial country of birth and childhood fibrillation with signs of pulmonary hypertension.
History of cerebral embolic events I would like to take a full history to establish More rarely, haemoptysis has been described. Less common An investigative work-up in a case of mitral causes include: Antibiotic prophylaxis see Infective P mitral broad, bifid P waves of left atrial endocarditis, p. All patients with AF Atrial fibrillation paroxysmal or permanent should receive Plain chest radiograph: This demonstrates: The mean transvalvular Beta-blockers to reduce heart rate and gradient is measured by Doppler flow.
See thus lengthen the duration of diastolic left Table 1. The Wilkins score is a system that grades Symptomatic, severe mitral stenosis mitral valve mobility, calcification, leaflet Asymptomatic patients but with high risk of thickening and subvalvular thickening to embolism e.
Estimated pulmonary arterial and right The decision regarding the percutaneous atrial pressures versus surgical most commonly valve Right ventricular size and systolic replacement approaches to treating severe function.
MS rests upon factors including the patients Cardiac catheterisation is only required when functional status and comorbid burden, discrepancy exists after clinical assessment anatomical suitability for balloon valvuloplasty, and echocardiography, or to rule out and local expertise in both approaches.
Guidelines on the management of valvular heart disease: Always offer a management plan the task force on the management of valvular Medical management of mitral stenosis heart disease of the European Society of includes: Case 8: Aortic regurgitation. Instruction to the candidate De Mussets sign head nodding in time with systole This year-old man presents with exertional dyspnoea. Please examine his cardiovascular Of the clinical signs mentioned above, those system.
A wide pulse pressure noteably low diastolic Begin with a summary of blood pressure positive findings A collapsing pulse Long duration of the early diastolic murmur Peripheral signs in aortic regurgitation include: The presence of signs of cardiac failure Collapsing water-hammer pulse at the The presence of an Austin Flint murmur brachial artery with the patients arm raised vertically Follow with a summary of Wide pulse pressure Thrusting volume-loaded , laterally relevant negative findings displaced apex beat The absence of stigmata of infective endocarditis Aortic thrill and signs of cardiac failure are important to Look for associated aetiological features see mention to the examiner.
State that you would Table 1. The auscultatory features of aortic regurgitation include: State the most likely diagnosis Early diastolic murmur: He Associated murmurs: I would Ejection systolic murmur mixed aortic like to take a full history to establish his valve disease symptomatic status and my investigation of Austin Flint murmur: The important ones to know and seek to whether the lesion is congenital or acquired.
The commonest cause of congenital aortic regurgitation is a bicuspid aortic valve. Acquired Corrigans sign a visible carotid pulsation causes of aortic regurgitation are considered in Quinckes sign capillary pulsation in the Table 1. Valve leaflet Endocarditis review dentition, Rheumatic fever check for concomitant mitral stenosis intravenous access, peripheral Connective tissue diseases e. Hyperthyroidism Valve morphology: To visualise the thoracic aorta for taken in a patient history associated abnormalities Relevant history questions include those aimed Cardiac MRI can be used to assess left ventricular volumes and aortic valve at identifying underlying cause and those regurgitant fractions when echocardiography regarding symptoms of cardiac failure.
This can also be used to visualise the thoracic aorta for associated Demonstrate an understanding abnormalities of the value of further Cardiac catheterisation: Aortic dimensions and The key investigations include a lead visualisation of AR on aortogram can also be electrocardiogram, a plain chest radiograph, assessed and a transthoracic echocardiogram.
The findings of such relevant investigations include: Divide the reading up into sections to be covered each week. Remember, when required, you can always supplement the books chosen with further information from Internet-based resources.
Many of the cases included in this book have suggested references and weblinks for further reading. It is recommended that you read through this pocketbook systematically, but also carry it with you when you examine patients, both during your routine clinical work and when you review patients in preparation for PACES.
This pocketbook highlights the key points of each case and suggests ways in which you may extend your examination for a particular patient. If you have omitted any part of the examination, you will be able to return to your patient immediately to see if these clinical signs can be elicited.
Reading relevant exam-oriented information shortly after reviewing patients will reinforce the key facts for each scenario and help you to recall them during the PACES examination. This process will also help to make the essential techniques of clinical examination second nature.
Look through your rotas and timetable slots during which you can review patients together — aim to review patients two or three times each week, more frequently as the examination approaches.
If you are already aware of the diagnosis, be the examiner for one of your colleagues — it is good to practice being on the other side of the fence too! It is also important to draw on the experience of senior colleagues during your teaching sessions wherever possible.
Examination of the peripheries did not show any stigmata of infective endocarditis. A neurological examination would be useful to screen for any signs of stroke. There are no complications of heart failure, AF or IE. This is a genetic condition. Dextrocardia Examination After the routine examination Request to examine the abdomen for a liver on the left side of the abdomen for situs inversus Presentation Sir this patient has dextrocardia as evidenced by: o Right apex beat o Heart sounds that are better heard on the right than on the left The heart sounds are normal and there are no murmurs detected.
She is in SR with a rate of 84bpm On examination of his lungs posteriorly, there was no evidence of coarse late inspiratory crepitations to suggest bronchiectasis and patient does not have a nasal voice to suggest sinusitis. I would like to complete my examination examining the abdomen for a left sided liver for situs inversus.
In summary this patient has got dextrocardia and is well clinically and is of congenital etiology. Questions What is the significance of situs inversus in patients with dextrocardia? Bronchiectasis Presentation Sir, this patient has got bronchiectasis affecting both lower lobes as evidenced by late, coarse inspiratory crepitations heard best posteriorly in the lower one third bilaterally.
Patient has a productive cough with large volume of purulent sputum with hemoptysis associated with clubbing. Chest excursion was reduced bilaterally with a normal percussion note and vocal resonance. Trachea is central and the apex beat is not displaced. There are no signs to suggest presence of COPD. There is concomitant COPD with a reduced chest excursion bilaterally, hyperinflation of the chest associated with hyperresonance on percussion with loss of liver and cardiac dullness.
There is presence of ronchi and a prolonged expiratory phase. Vocal resonance is normal. Trachea is central and apex beat is not displaced.
There is complication of pulmonary hypertension with a loud and palpable component of the second heart sound associated with a left parasternal heave.
There is also cor pulmonale with a raised JVP of 3 cm with prominent a wave associated with bilateral pedal oedema. Clinically there are no signs of polycythemia such as plethoric facies or conjunctival suffusion.
He is not in respiratory distress with a RR of 14 bpm without use of accessory muscles of respiration. There are no signs of respiratory failure he does not require any supplemental oxygen and there is no central cyanosis; there is also no flapping trem or of the hands and no bounding pulse. There is also no nicotine staining of the fingers, patient is not cachexic looking and no enlarged Cx LNs. In addition, there is no symmetrical deforming polyarthropathy to suggest RA or any cutaneous signs of SLE.
There is no kyphoscoliosis. With regards to treatment, patient has a steroid metered-dose inhaler, salbutamol and ipratropium metered-dose inhalers by the bed side.
I would like to complete the examination by looking at the temperature chart for fever as well as an abdominal examination to look for splenomegaly from amyloidosis which can result from bronchiectasis. A neurological examination is useful to screen for deficit as patients are prone to brain abscesses.
In summary, this patient has bronchiectasis affecting both lower lobes with complications of pulmonary hypertension and cor pulmonale. There is no concomitant COPD and no polycythemia. He is clinically not in respiratory failure. Interstitial Lung Disease Presentation Sir, this patient has interstitial lung disease affecting both lower lobes upper lobes as evidenced by fine velcro-like late inspiratory crepitations heard best posteriorly anteriorly in the lower one third bilaterally.
There are no signs of pulmonary hypertension or cor pulmonale. There are also no features of polycythemia. Patient respiratory rate is 14 breaths per minute and there are no signs of respiratory distress. There are also no signs of respiratory failure. There is also no nicotine staining of the fingers and I note that the patient is cachexic looking with wasting of the temporalis muscles.
In terms of aetiology, there is no symmetrical deforming polyarthropathy of the hands to suggest RA, or cutaneous signs to suggest presence of SLE, dermatomyositis or scleroderma as these conditions may be complicated by pulmonary fibrosis.
With regards to treatment, patient is not Cushingoid and does not have papery thin skin or steroid purpura to suggest chronic steroid usage.
On inspection there are no surgical scars to suggest open lung biopsy. I would like to complete the examination by asking for a detailed drug history as well as an occupational history. In summary, this patient has got pulmonary fibrosis affecting bilateral lower lobes. There are no complications of pulmonary hypertension, cor pulmonale and polycythemia. He is clinically not in respiratory failure and has no features of chronic steroid usage.
The differential diagnoses include collagen vascular disease, drugs, occupational causes and idiopathic pulmonary fibrosis. Questions What are the differential diagnoses for clubbing and crepitations?
Pulmonary fibrosis Bronchiectasis Lung abscess Mitotic lung conditions What are the characteristic auscultatory findings? Late, fine inspiratory crepitations Velcro-like Disappears or quietens with the patient leaning forwards What are the causes of fibrosis? Gradual onset Progressive Median survival from time of dx about 3 years What are the causes of death? Rapidly progressive and fatal variant of interstitial lung disease 32 He is tachypneic at rest and requires use of intranasal oxygen supplementation.
Patient has got hyperinflated chest with reduced chest expansion bilaterally at 2cm. The percussion note is resonant with loss of liver and cardiac dullness.
There is prolonged expiratory phase with expiratory ronchi. There is complication of pulmonary hypertension as evidenced by loud and palpable P2 associated with a left parasternal heave. There is also cor pulmonale with raised JVP of 4cm with giant V waves associated with bilateral pedal oedema. There are also features of polycythemia with plethoric facies and conjunctival suffusion.
The patient is in respiratory distress. He is tachypneic at rest with a RR of 20 bpm and uses his accessory muscles of respiration at rest. He is also in respiratory failure with presence of central cyanosis and is oxygen dependent. However, he does not have a flapping tremor or a bounding pulse to suggest CO2 retention clinically. In terms of aetiology, the presence of nicotine staining of his fingers implies significant history of smoking. He is not clubbed.
The Cx LNs are not enlarged and he is not cachexic looking. There is presence of steroid MDI as well as bronchodilators by his side. There is no evidence of a hoarse voice or oral thrush or other features of chronic systemic steroid usage. In summary, this patient has got severe COPD with complications of pulmonary hypertension, cor pulmonale and polycythemia.
He is in respiratory failure and respiratory distress. The most likely aetiology is smoking. Depending on the underlying cause For mitotic lesion o Multidisciplinary approach o Education and counselling, support groups and stop smoking o Symptomatic treatment o For non-small cell Assessment for surgical resectability Staging up to stage IIIA ; ie once T4, N3 or M1 not a candidate Physiological staging Chemotherapy Neoadjuvant Adjuvant Radiotherapy Adjuvant Palliative Palliative Radiotherapy o Pain, bone mets o Dyspnea from bronchial obstruction, dysphagia o SVCO, pancoast syndrome Chemotherapy o For small cell: Chemotherapy How does patient with bronchogenic carcinoma present?
Tumour with obstruction of the SVC Plethoric facies Facial and UL oedema Conjunctival suffusion Undersurface of the tongue with multiple venous angiomata Fixed engorgement of the neck veins Stridor Upper chest telangiectasia Radiation marks NB think of polycythemia which also have plethoric facies Causes o Lung carcinoma, especially small cell o Lymphoma o Others — mediastinal goiter 39 Consolidation Presentation Sir, this patient has a right upper lobe consolidation as evidenced by reduced chest excursion of the right hemithorax associated with a dull percussion note, bronchial breath sounds and crepitations and increased vocal resonance.
These signs were best heard in the upper one third anteriorly in the right hemithorax. The trachea is central and apex beat is not displaced. There are no signs to suggest that the patient is in respiratory distress or in failure. There was also no associated pleural effusion or a raised right hemidiaphragm. He is also clubbed with HPOA and has nicotine staining of his fingers. He is cachexic looking with enlarged palpable cervical LNs.
In summary, patient has a right upper lobe consolidation complicated by SVCO. He is not in respiratory distress. The underlying cause is most likely a mitotic lesion of the lung. Questions What are the causes of a consolidation?