By John D Firth; Claire Nicholl; Dee C Traue; Royal College of Physicians of London. Education Department
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Extra resources for Clinical skills
For instance, the appearance of a cannon A wave in the neck during a pause in the radial pulse indicates that the pause is due to a ventricular extrasystole, when the right atrium beats against a tricuspid valve that has been closed by the premature ventricular contraction. But DO NOT spend time looking for such things in the PACES exam because (1) you don’t have time to do so, (2) >90% of examiners will not know what you are talking about and think you are showing off, and (3) in real life you’d check an ECG, as would the examiner.
You are not quite confident enough just to say ‘it’s a liver’ . . so you are giving sensible data that explains why, later on, you will say you think it’s a liver) • ‘The mass on the left side also extends about 15 cm below the costal margin . . it feels smooth, firm and non-tender . . it is dull to percussion, I cannot get above it, I cannot palpate it bimanually, and I cannot feel a notch . ’ (again you aren’t confident enough just to say ‘spleen’, but you are giving the examiner information that says ‘I know how to try to do this’) • ‘There is no ascites .
The differential diagnosis of a diastolic murmur is generally straightforward, as shown 32 in Table 22. If the patient is young (or even middle aged), particularly with features such as clubbing, cyanosis or scars of cardiac surgery, then consider the possibility of congenital heart disease. g. Corrigan’s pulse Pulmonary regurgitation Early diastolic murmur – loudest in pulmonary area Features of mitral stenosis/mixed mitral valve disease Raised JVP Palpable right ventricular heave No features of aortic incompetence Mitral stenosis Mid-diastolic murmur at apex S1 loud Opening snap Early diastolic murmur (Graham Steell) – pulmonary area; caused by pulmonary hypertension secondary to mitral disease Mitral facies Atrial fibrillation very common Apex tapping but not displaced Features of pulmonary hypertension and/or tricuspid incompetence asked to say what the diagnosis was before reading their briefing notes.