Tips and tricks to pass the cardiovascular station for PACES exam

Tips and tricks to pass the cardiovascular station for PACES exam

1. Passing 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

4. Knowing the Enemy

5. Nailing the Performance

6. 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!)

7. Slick and Smooth 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)

8. Slick and Smooth 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

9. Slick and Smooth 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

10. Slick and Smooth 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)

11. Slick and Smooth 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

12. Slick and Smooth 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

13. Slick & Smooth Auscultation (maintain left hand on carotid for timing). In sequence: Mitr al: 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

14. Slick & Smooth 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! Y ou may well be asked to do it!

15. Aortic Regurgitation Isolated or Mixed ( predom AR with collapsing pulse, displaced + thrusting apex, wide pulse pressure) Severe AR: HF, S3 present Grades Mild: apex not displaced Mod: apex displaced Severe: HF, S3 Complications: IE, HF Aetiology 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!

16. 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 Mild: normal pulse Mod: heaving apex, small and slow pulse Severe: S4, HF Complications: IE, HF Aetiology : bicuspid (young male), RHD, degenerative (old pt, ESRF)

17. 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 Mild: no PH Mod: PH Severe: HF Complications: AF (look for pronator drift, NGT of CVA), anticoagulation, IE, PH / HF Aetiology : rheumatic vs degenerative Know Duckett Jones criteria for rheumatic fever

18. 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 Mild: no PH Mod: PH Severe: S3, HF Complications: IE, PH (listen for functional TR – consequent of dilated RV), HF Aetiology Annulus problem: dilated CMP, IHD Valve problem: MVP, ruptured chordae , CTD (RA, SLE, ank spond ), IE (perforation)

19. Tricuspid Regurgitation PSM differentials: TR, MR, VSD TR: giant CV waves in JVP, pulsatile liver MR: displaced and thrusting apex, S3 VSD: harsh PSM, palpable thrill often present Aetiology Functional = commonest (PH, lung disease, MS/MR) Rarely: IE, RHD, TVP, Carcinoid (facial flushing, hx of chronic diarrhea in stem)

20. 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)

21. Atrial Septal Defect ESM at pulmonic area: ASD – fixed splitting S2 PS – soft P2 PH – loud P2 Complications: AF, PH, Eisenmenger’s Associations Primum ASD: Down’s, MR (cleft MV) Holt- Oram syndrome (thumb defect + ASD) Lutembacher Syndrome (MS + ASD)

22. Patent Ductus Arteriosus Stem may contain: premature birth, maternal rubella Key clinical features Heaving apex beat, collapsing pulse (diastolic run-off), continuous “machinery” murmur (PSM + early diastole) best heard LUSE + subclavicular 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)

23. Mechanical Valves Which valve? Positio n 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 Prosthetic Valves: valve thrombosis (clicks blunted), regurgitation, haemolysis (jaundice + pallor), IE Management: anticogulation (bruising)

24. Gaming the System

25. 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

26. 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

27. 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

28. 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

29. 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

30. Pearls or See Hum

31. 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

32. 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

33. 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)

34. 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

35. D-Day Easy on the caffeine, clear your bowels, eat your breakfast Plan your transport, set off early to avoid peak hour traffic

36. 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

37. All the Best. Remember, what doesn’t kill you will make you…

38. Half-dead