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Section C
Short Case Records
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In this section and in Section I in Volume 3, we present aides-mémoire (clinical descriptions for presentation to the examiner) for over 226 short cases. We have called these aides-mémoire records. They are divided into the eight station subsections of the three clinical stations of PACES. The order in each subsection has been determined by the frequency with which, according to our surveys, these short cases have appeared in the PACES examination for that station. Thus, short case no. 1 in a particular station subsection occurred most commonly, followed by short case no. 2 and so on. The percentages given represent our best estimate of your chance of meeting a particular short case in that station subsection in any one attempt at the MRCP PACES examination.
It cannot be overstressed that the first short cases we have dealt with in each station subsection occurred very commonly and the last very rarely, with all grades in between. The implications for your priorities are obvious. There are those who are tempted to ignore the less common cases and, indeed a good case can be made for this approach, but it is a risky business (see Footnote, Station 3, CNS, Case 44).
In this section, the style of each record imagines you to be in the examination situation with the patient displaying the typical features of a particular condition; you are âchurning outâ these to the examiner along with the answers to various anticipated questions. Thus, you play the record of the condition to the examiner. Of course, the cases in the actual examination will only have some of the features (the record tends to describe the âfull houseâ case) and it is hoped that by becoming familiar with the whole record, you will be well equipped:
1 to pick up all the features present in the cases you meet on the day by scanning through the records in your mind; and
2 to adapt the record for the purpose of presenting those features which are present.
To facilitate quick revision, the main points of each short case are highlighted in italics. The small print is a mixed bag of additional features and facts, lists of differential diagnoses and answers to some of the questions that might be asked. With the lists of differential diagnoses, we have tended to put the most important ones (which you should consider first) in large print with longer lists in the smaller print. The lists are not necessarily meant to be comprehensive. Next to the diagnoses on these lists we have used brackets to give some of the features of the conditions concerned, or perhaps one or two features you could look for (indicated by ?). The question mark is put there as a cue for you to look for important diagnostic features. We make no apology for repeating some of the features often, in the hope that by constant reinforcement they will become more firmly embedded in your memory. When unilateral signs could affect either side, we have not usually specified the side in the record but have indicated this by R/L. In these cases, however, each R/L in the record refers to the same side. Also, ⊠is occasionally used for a sign in the lung fields or retina which could occur in any zone or to indicate the size of an organ or sign where the size is unspecified.
Presentation to the Examiner
Becoming familiar with the short case records will arm you for the examination, though obviously it will not always be necessary, or desirable, for you to use them. Sometimes it may be appropriate just to give the diagnosis; even so, it may still be possible to enrich it with some of the well-known features from the record. If the examinerâs question is: âWhat is the diagnosis?â you could answer âMitral stenosisâ and await his reaction. On the other hand, if you are certain of your diagnosis, it would be better to say: âThe diagnosis is mitral stenosis because there is a rough, rumbling mid-diastolic murmur localized to the apex of the heart, there is a sharp opening snap and a loud first heart sound, a tapping impulse, an impalpable left ventricular apex, a left parasternal heave and a small volume pulse. Furthermore, the chaotic rhythm suggests atrial fibrillation and the patient has a malar flushâ.
If you enlarge your response to âWhat is the diagnosis?â by giving the features in this way, it is best to give the evidence in order of its importance to the diagnosis (as shown in the example). However, if the question is: âWhat are your findings?â it is best to give them in the order they are elicited: âThe patient has a malar flush and is slightly breathless at rest. The pulse is irregular in rate and volume. The jugular venous pressure is not elevated and the cardiac apex is not palpable but there is a tapping impulse parasternally on the left side and there is a left parasternal heave. The first heart sound is loud and there is an opening snap followed closely by a mid-diastolic rumble which is localized to the apex. These signs suggest that the patient has mitral stenosisâ. Either way you score all the points under the heading âIdentifying physical signsâ. If there is a differential diagnosis (and there usually is) then you should obviously give it to score the points under that heading. However, if there is no differential diagnosis donât make one up just because of this heading! â simply state you do not believe there is a differential diagnosis in the case concerned. There is also a need to score points under the heading âClinical judgementâ. Depending...
