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Acing the
Cardiovascular
Station in PACES
6 Aug 2019
Dr Koh Choong Hou
Scope
• Knowing the Enemy
• Nailing the Performance
• Gaming the System
• Pearls… or See Hum
Disclaimers
• I am not a PACES guru (only took it
once… long long time ago)
• This is not a PACES preparatory course
• Real life (and ward rounds) is very
different from PACES
Knowing the Enemy
Nailing the
Performance
Professional &
Elegant
• Smile
• Greet and seek permission
• Preserve the patient’s modesty (cover
up the ladies after initial exposure)
• Make an effort to observe from the foot
of the bed (this is a performance after
all!)
Slick and Smooth
1. Positioning
• 45 degrees
• Remove the top for men; unbutton top for ladies,
remove undergarments (usually already
removed), then cover back the top
• Roll up pants to below knees (start observing –
edema, clubbing, distal cyanosis, bruising)
Slick and Smooth
2. Hands
• Dorsum: clubbing, splinter hrr, cyanosis,
coolness to touch
• Palm: Osler’s (if seen, run your thumb over to
feel for raised lesions), Janeway
• Observe: PICC line, IVDA scars, bruising
(anticoagulation), audible clicks
Slick and Smooth
3. Pulse
• Radial: rate (10-15s, don’t waste time), rhythm,
volume; R-R delay (if no delay, volumes equal?);
R-F delay
• Collapsing pulse: ask about UL/shoulder pain
first, let pt know what you are about to do.
 Support elbow with left hand (fingers palpating brachial pulse)
 Radial pulse with right hand fingers
 Lift UL rapidly to vertical position – pulse collapses from radial
to brachial
Slick and Smooth
4. Head & Neck
• Eyes: depress right lower eyelid & ask pt to look
up and left – jaundice / pallor / conjunctival hrr;
xanthelesma, corneal arcus
• Face: malar flush (mitral facies)
• Tongue: central cyanosis
• Carotid: palpate pt’s right carotid with your left
thumb (fingers supporting the neck)
• JVP: elevation of JVP, cannon A, giant V
• Goitre / thyroidectomy scars (AF)
Slick and Smooth
5. Legs
• Depress bilateral medial malleoli (eyes on pt at
all times to check for discomfort) for pedal
edema
• Quick look at toes again if you forgot to check for
cyanosis / clubbing
Slick and Smooth
6. Chest
• Inspect: scars
• Apex: whole palm with
fingers towards axilla
 Position (beware dextrocardia)
 Tapping (MS)
 Thrusting (volume loaded) or
Heaving (pressure loaded) – use
heel of hand
• Thrills: apex, LLSE, RV
heave, palpable P2
Slick & Smooth
7. Auscultation (maintain left hand on
carotid for timing). In sequence:
• Mitral: bell for MS, turn to left lateral, re-palpate
apex beat, then use bell again
• Tricuspid: TR
• Pulmonic: loud P2, PR murmur of repaired ToF
(esp if BTS scar)
• Aortic: AS – if heard, move to carotids for
radiation
• LLSE: AR – sit pt forward and exhale + hold
• Lung bases: crepitations
Slick & Smooth
8. Concluding requests
• Vital signs charts for BP, temperature,
saturation
• Urine dipstick: haematuria
• Fundoscopy: Roth spots
• Abdominal exam: ascites, pulsatile
hepatomegaly of TR / constriction,
splenomegaly (IE)
 Do not ask for abdo / fundo exam if not relevant
to your case! You may well be asked to do it!
Aortic Regurgitation
• Isolated or Mixed (predom AR with collapsing pulse, displaced +
thrusting apex, wide pulse pressure)
• Severe AR: HF, S3 present
• Grades
o Mild: apex not displaced
o Mod: apex displaced
o Severe: HF, S3
• Complications: IE, HF
• Aetiology
o Root problem (functional): syphilis (screen for Argyll-Robertson pupils), CTD (RA, ank
spond, MFS), severe HYPT (request BP check, also for wide pulse pressure)
• Valve problem: bicuspid (young man), IE, RHD
• Lots of eponymous signs – do not get too caught up!
Aortic Stenosis
• Isolated or Mixed (predom AS with pulsus tardus/parvus,
narrow pulse pressure, systolic thrill, heaving apex)
• Severe AS: late peaking ESM, radiation to carotids, small
volume pulse, silent S2 (very stiff cusps and very small
orifice)
• Austin Flint murmur of functional MS (AR jet impinging
anterior mitral valve during diastole)
• Grades
o Mild: normal pulse
o Mod: heaving apex, small and slow pulse
o Severe: S4, HF
• Complications: IE, HF
• Aetiology: bicuspid (young male), RHD, degenerative (old
pt, ESRF)
Mitral Stenosis
• Isolated or Mixed (predom MS with loud S1 + pulsus
parvus)
• If apex displaced, listen for MR
• Severe MS: early OS, longer murmur, loud P2
• Grades
o Mild: no PH
o Mod: PH
o Severe: HF
• Complications: AF (look for pronator drift, NGT of CVA),
anticoagulation, IE, PH / HF
• Aetiology: rheumatic vs degenerative
o Know Duckett Jones criteria for rheumatic fever
Mitral Regurgitation
• Isolated or Mixed (predom MR with S3, apex displaced and
thrusting)
• Severe MR: S3, short MDM (increased flow across MV due
to regurgitant volume – not to be confused with MS)
• Grades
o Mild: no PH
o Mod: PH
o Severe: S3, HF
• Complications: IE, PH (listen for functional TR –
consequent of dilated RV), HF
• Aetiology
o Annulus problem: dilated CMP, IHD
o Valve problem: MVP, ruptured chordae, CTD (RA, SLE, ank spond), IE
(perforation)
Tricuspid
Regurgitation
• PSM differentials: TR, MR, VSD
o TR: giant CV waves in JVP, pulsatile liver
o MR: displaced and thrusting apex, S3
o VSD: harsh PSM, palpable thrill often present
• Aetiology
o Functional = commonest (PH, lung disease, MS/MR)
o Rarely: IE, RHD, TVP, Carcinoid (facial flushing, hx of chronic diarrhea in stem)
Ventricular Septal Defect
• Isolated or Syndromic (Down’s, ToF)
• Severe: displaced apex (LV enlargement), PH
• Complications: IE, HF, Eisenmenger
• Aetiology: congenital (young), acquired (AMI related
VSR)
• If thrill over pulmonic area, +/- RV heave, consider
concomitant PS = Tetralogy of Fallot (VSD, RVH,
PS, overriding aorta)
Atrial Septal Defect
• ESM at pulmonic area:
o ASD – fixed splitting S2
o PS – soft P2
o PH – loud P2
• Complications: AF, PH, Eisenmenger’s
• Associations
o Primum ASD: Down’s, MR (cleft MV)
o Holt-Oram syndrome (thumb defect + ASD)
o Lutembacher Syndrome (MS + ASD)
Patent Ductus Arteriosus
• Stem may contain: premature birth, maternal rubella
• Key clinical features
o Heaving apex beat, collapsing pulse (diastolic run-off), continuous
“machinery” murmur (PSM + early diastole) best heard LUSE +
subclavicular
o Differentials for continuous murmurs: VSD + AR (prolapsed RCC),
AR + MR (dilated LV with functional MR), pulmonary AVF
• Complications: IE (endarteritis), Eisenmenger’s
(look for differential cyanosis between UL abd LL)
Mechanical Valves
• Which valve?
• Position of apex: displaced + MVR = MR; undisplaced +
MVR = MS, displaced + AVR = AR
• AF + valve replacement = MS usually
• Dual valves AVR + MVR is not rare
• Complications of
o Prosthetic Valves: valve thrombosis (clicks blunted),
regurgitation, haemolysis (jaundice + pallor), IE
o Management: anticogulation (bruising)
Gaming the System
Types of CV
Cases
• Good CV cases are getting harder to
recruit
• Many cases may be recycled – attend the
preparatory courses!! **NHCS PACES
course**
• Most, if not all, CV station cases, will be
clinically stable on the day of the exam –
highly unlikely to be freshly post op, or in
decompensated state
Types of CV
Cases
• Valvular Cases: AS, AR, MS, MR, TR, prosthetic
valves (bioprosthetic vs mechanical - for mech,
usually MV or AV; mechanical TV is possible but
rare)
• Congenital Cases: ASD, VSD, PDA, repaired
TOF
• Cardiomyopathy: hypertrophic CMP, dilated
CMP
• Miscellaneous: dextrocardia
Sherlock the
Clues
• Scars: median sternotomy, lateral thoracotomy
(valvotomy), lower limbs saphenous vein
harvesting
• Devices: pacemaker / ICD
• Spot diagnosis: Marfan’s / Ehler’s Danlos,
Rheumatoid Arthritis – think floppy valves,
dissection
Sherlock the
Clues
• Almost spot diagnosis:
 Age: young – think congenital diseases, old – think
degenerative diseases / prosthetic valves
 Gender: female – connective tissues diseases, male
– bicuspid AV
Sherlock the
Clues
• Always be on the lookout for:
 Associations: habitus, joints, needle marks,
pacemaker
 Complications (of disease or Rx): IE stigmata,
bleeding (bruises / CVA), haemolysis (pallor /
jaundice)
 Surroundings: ABx drip, PICC line, walking aids
Pearls or See Hum
• Form a study group (tough if you’ve been nasty
and you have no friends)
• Sing your own song, make your own notes
• Plan your postings (where possible)
• Block your leave (where possible and when
manpower allows – don’t be a prick)
• Arrange tutorials
• Useful resources: textbooks, senior’s notes,
prep courses (**NHCS PACES course**),
websites, YouTube
6-9 Months
3-4 Weeks
• Drill each other in common cases
• Mock exams
• Be one with your songs – make it second
nature
• Practice presentation skills in front of a
mirror / each other
• Schedule night calls / floats at least 2 weeks
before the exam
1 Week
• Consolidate
• “Spot Questions”
• Relax
 if you hardly studied until this point, it’s too late to
panic anyway
 It is IMPOSSIBLE to know everything
• Stay healthy (not gonna help taking an exam
with a raging fever or a whooping cough)
D minus 1
• Get enough rest / sleep
• Unwind
• Pack the necessary documents
• Ready your combat outfit
 look professional… this is not a fashion show, most
examiners are fuddy-duddies, even if they don’t
admit it
 Easy on the make up / perfume / cologne
D-Day
• Easy on the caffeine, clear your
bowels, eat your breakfast
• Plan your transport, set off early to
avoid peak hour traffic
D-Day
• WYSIWYG – “what you see is what you get”; don’t make up
signs if you don’t detect one
• You are allowed to return to the patient to re-examine signs
that you think you missed or to re-confirm findings (within
the 6 minutes)
• Posture and mannerisms during presentation – eye contact,
stand straight, mind the hands, present confidently
• DO NOT cause pain / discomfort / distress to the patient –
this is usually heavily penalized
• If the examiners persist on “are you sure….?”, usually YOU
are wrong. This is the chance for about-turn. Most
examiners are kind and not out to fail you in their line of
questioning
All the Best.
Remember, what
doesn’t kill you will
make you…
Half-dead

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Tips and tricks to pass the cardiovascular station for PACES exam

  • 1. Acing the Cardiovascular Station in PACES 6 Aug 2019 Dr Koh Choong Hou
  • 2. Scope • Knowing the Enemy • Nailing the Performance • Gaming the System • Pearls… or See Hum
  • 3. Disclaimers • I am not a PACES guru (only took it once… long long time ago) • This is not a PACES preparatory course • Real life (and ward rounds) is very different from PACES
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  • 10. Professional & Elegant • Smile • Greet and seek permission • Preserve the patient’s modesty (cover up the ladies after initial exposure) • Make an effort to observe from the foot of the bed (this is a performance after all!)
  • 11. Slick and Smooth 1. Positioning • 45 degrees • Remove the top for men; unbutton top for ladies, remove undergarments (usually already removed), then cover back the top • Roll up pants to below knees (start observing – edema, clubbing, distal cyanosis, bruising)
  • 12. Slick and Smooth 2. Hands • Dorsum: clubbing, splinter hrr, cyanosis, coolness to touch • Palm: Osler’s (if seen, run your thumb over to feel for raised lesions), Janeway • Observe: PICC line, IVDA scars, bruising (anticoagulation), audible clicks
  • 13. Slick and Smooth 3. Pulse • Radial: rate (10-15s, don’t waste time), rhythm, volume; R-R delay (if no delay, volumes equal?); R-F delay • Collapsing pulse: ask about UL/shoulder pain first, let pt know what you are about to do.  Support elbow with left hand (fingers palpating brachial pulse)  Radial pulse with right hand fingers  Lift UL rapidly to vertical position – pulse collapses from radial to brachial
  • 14. Slick and Smooth 4. Head & Neck • Eyes: depress right lower eyelid & ask pt to look up and left – jaundice / pallor / conjunctival hrr; xanthelesma, corneal arcus • Face: malar flush (mitral facies) • Tongue: central cyanosis • Carotid: palpate pt’s right carotid with your left thumb (fingers supporting the neck) • JVP: elevation of JVP, cannon A, giant V • Goitre / thyroidectomy scars (AF)
  • 15. Slick and Smooth 5. Legs • Depress bilateral medial malleoli (eyes on pt at all times to check for discomfort) for pedal edema • Quick look at toes again if you forgot to check for cyanosis / clubbing
  • 16. Slick and Smooth 6. Chest • Inspect: scars • Apex: whole palm with fingers towards axilla  Position (beware dextrocardia)  Tapping (MS)  Thrusting (volume loaded) or Heaving (pressure loaded) – use heel of hand • Thrills: apex, LLSE, RV heave, palpable P2
  • 17. Slick & Smooth 7. Auscultation (maintain left hand on carotid for timing). In sequence: • Mitral: bell for MS, turn to left lateral, re-palpate apex beat, then use bell again • Tricuspid: TR • Pulmonic: loud P2, PR murmur of repaired ToF (esp if BTS scar) • Aortic: AS – if heard, move to carotids for radiation • LLSE: AR – sit pt forward and exhale + hold • Lung bases: crepitations
  • 18. Slick & Smooth 8. Concluding requests • Vital signs charts for BP, temperature, saturation • Urine dipstick: haematuria • Fundoscopy: Roth spots • Abdominal exam: ascites, pulsatile hepatomegaly of TR / constriction, splenomegaly (IE)  Do not ask for abdo / fundo exam if not relevant to your case! You may well be asked to do it!
  • 19. Aortic Regurgitation • Isolated or Mixed (predom AR with collapsing pulse, displaced + thrusting apex, wide pulse pressure) • Severe AR: HF, S3 present • Grades o Mild: apex not displaced o Mod: apex displaced o Severe: HF, S3 • Complications: IE, HF • Aetiology o Root problem (functional): syphilis (screen for Argyll-Robertson pupils), CTD (RA, ank spond, MFS), severe HYPT (request BP check, also for wide pulse pressure) • Valve problem: bicuspid (young man), IE, RHD • Lots of eponymous signs – do not get too caught up!
  • 20.
  • 21.
  • 22. Aortic Stenosis • Isolated or Mixed (predom AS with pulsus tardus/parvus, narrow pulse pressure, systolic thrill, heaving apex) • Severe AS: late peaking ESM, radiation to carotids, small volume pulse, silent S2 (very stiff cusps and very small orifice) • Austin Flint murmur of functional MS (AR jet impinging anterior mitral valve during diastole) • Grades o Mild: normal pulse o Mod: heaving apex, small and slow pulse o Severe: S4, HF • Complications: IE, HF • Aetiology: bicuspid (young male), RHD, degenerative (old pt, ESRF)
  • 23.
  • 24. Mitral Stenosis • Isolated or Mixed (predom MS with loud S1 + pulsus parvus) • If apex displaced, listen for MR • Severe MS: early OS, longer murmur, loud P2 • Grades o Mild: no PH o Mod: PH o Severe: HF • Complications: AF (look for pronator drift, NGT of CVA), anticoagulation, IE, PH / HF • Aetiology: rheumatic vs degenerative o Know Duckett Jones criteria for rheumatic fever
  • 25.
  • 26. Mitral Regurgitation • Isolated or Mixed (predom MR with S3, apex displaced and thrusting) • Severe MR: S3, short MDM (increased flow across MV due to regurgitant volume – not to be confused with MS) • Grades o Mild: no PH o Mod: PH o Severe: S3, HF • Complications: IE, PH (listen for functional TR – consequent of dilated RV), HF • Aetiology o Annulus problem: dilated CMP, IHD o Valve problem: MVP, ruptured chordae, CTD (RA, SLE, ank spond), IE (perforation)
  • 27.
  • 28. Tricuspid Regurgitation • PSM differentials: TR, MR, VSD o TR: giant CV waves in JVP, pulsatile liver o MR: displaced and thrusting apex, S3 o VSD: harsh PSM, palpable thrill often present • Aetiology o Functional = commonest (PH, lung disease, MS/MR) o Rarely: IE, RHD, TVP, Carcinoid (facial flushing, hx of chronic diarrhea in stem)
  • 29. Ventricular Septal Defect • Isolated or Syndromic (Down’s, ToF) • Severe: displaced apex (LV enlargement), PH • Complications: IE, HF, Eisenmenger • Aetiology: congenital (young), acquired (AMI related VSR) • If thrill over pulmonic area, +/- RV heave, consider concomitant PS = Tetralogy of Fallot (VSD, RVH, PS, overriding aorta)
  • 30.
  • 31. Atrial Septal Defect • ESM at pulmonic area: o ASD – fixed splitting S2 o PS – soft P2 o PH – loud P2 • Complications: AF, PH, Eisenmenger’s • Associations o Primum ASD: Down’s, MR (cleft MV) o Holt-Oram syndrome (thumb defect + ASD) o Lutembacher Syndrome (MS + ASD)
  • 32.
  • 33. Patent Ductus Arteriosus • Stem may contain: premature birth, maternal rubella • Key clinical features o Heaving apex beat, collapsing pulse (diastolic run-off), continuous “machinery” murmur (PSM + early diastole) best heard LUSE + subclavicular o Differentials for continuous murmurs: VSD + AR (prolapsed RCC), AR + MR (dilated LV with functional MR), pulmonary AVF • Complications: IE (endarteritis), Eisenmenger’s (look for differential cyanosis between UL abd LL)
  • 34.
  • 35. Mechanical Valves • Which valve? • Position of apex: displaced + MVR = MR; undisplaced + MVR = MS, displaced + AVR = AR • AF + valve replacement = MS usually • Dual valves AVR + MVR is not rare • Complications of o Prosthetic Valves: valve thrombosis (clicks blunted), regurgitation, haemolysis (jaundice + pallor), IE o Management: anticogulation (bruising)
  • 36.
  • 38. Types of CV Cases • Good CV cases are getting harder to recruit • Many cases may be recycled – attend the preparatory courses!! **NHCS PACES course** • Most, if not all, CV station cases, will be clinically stable on the day of the exam – highly unlikely to be freshly post op, or in decompensated state
  • 39. Types of CV Cases • Valvular Cases: AS, AR, MS, MR, TR, prosthetic valves (bioprosthetic vs mechanical - for mech, usually MV or AV; mechanical TV is possible but rare) • Congenital Cases: ASD, VSD, PDA, repaired TOF • Cardiomyopathy: hypertrophic CMP, dilated CMP • Miscellaneous: dextrocardia
  • 40. Sherlock the Clues • Scars: median sternotomy, lateral thoracotomy (valvotomy), lower limbs saphenous vein harvesting • Devices: pacemaker / ICD • Spot diagnosis: Marfan’s / Ehler’s Danlos, Rheumatoid Arthritis – think floppy valves, dissection
  • 41. Sherlock the Clues • Almost spot diagnosis:  Age: young – think congenital diseases, old – think degenerative diseases / prosthetic valves  Gender: female – connective tissues diseases, male – bicuspid AV
  • 42. Sherlock the Clues • Always be on the lookout for:  Associations: habitus, joints, needle marks, pacemaker  Complications (of disease or Rx): IE stigmata, bleeding (bruises / CVA), haemolysis (pallor / jaundice)  Surroundings: ABx drip, PICC line, walking aids
  • 44. • Form a study group (tough if you’ve been nasty and you have no friends) • Sing your own song, make your own notes • Plan your postings (where possible) • Block your leave (where possible and when manpower allows – don’t be a prick) • Arrange tutorials • Useful resources: textbooks, senior’s notes, prep courses (**NHCS PACES course**), websites, YouTube 6-9 Months
  • 45.
  • 46. 3-4 Weeks • Drill each other in common cases • Mock exams • Be one with your songs – make it second nature • Practice presentation skills in front of a mirror / each other • Schedule night calls / floats at least 2 weeks before the exam
  • 47. 1 Week • Consolidate • “Spot Questions” • Relax  if you hardly studied until this point, it’s too late to panic anyway  It is IMPOSSIBLE to know everything • Stay healthy (not gonna help taking an exam with a raging fever or a whooping cough)
  • 48. D minus 1 • Get enough rest / sleep • Unwind • Pack the necessary documents • Ready your combat outfit  look professional… this is not a fashion show, most examiners are fuddy-duddies, even if they don’t admit it  Easy on the make up / perfume / cologne
  • 49. D-Day • Easy on the caffeine, clear your bowels, eat your breakfast • Plan your transport, set off early to avoid peak hour traffic
  • 50. D-Day • WYSIWYG – “what you see is what you get”; don’t make up signs if you don’t detect one • You are allowed to return to the patient to re-examine signs that you think you missed or to re-confirm findings (within the 6 minutes) • Posture and mannerisms during presentation – eye contact, stand straight, mind the hands, present confidently • DO NOT cause pain / discomfort / distress to the patient – this is usually heavily penalized • If the examiners persist on “are you sure….?”, usually YOU are wrong. This is the chance for about-turn. Most examiners are kind and not out to fail you in their line of questioning
  • 51. All the Best. Remember, what doesn’t kill you will make you…

Editor's Notes

  1. 百战不殆
  2. Malar flush: plum red discoloration of high cheeks due to CO2 retention and vasodilatory effects
  3. Malar flush: plum red discoloration of high cheeks due to CO2 retention and vasodilatory effects
  4. Malar flush: plum red discoloration of high cheeks due to CO2 retention and vasodilatory effects
  5. Usual apex beat: 5th ICS, mid axillary line (medial by 1 inch)
  6. AR
  7. S3
  8. AS
  9. >/= 2 major: Carditis, Arthritis, Subcut nodules, Erythema marginatum, Sydenham’s chorea (“CASES”) 1 major + 2 minor: Past hx rheum fever/RHD, Prolonged PR, Fever, Arthralgia, CRP, ESR (“PuPPet FACE”)
  10. MVP
  11. Holosytolic murmur
  12. ASD