Cardiovascular Examination in MRCP PACES (Station 3)

What this station tests and how the time runs

Station 3 pairs a cardiovascular case with a nervous-system case; each is a separate short-case encounter with its own pair of examiners. You get 6 minutes to examine and present, followed by 4 minutes of discussion. In that first six minutes you are expected to complete a focused cardiovascular examination, spot the abnormal signs, and offer a diagnosis with a short summary — not to narrate every manoeuvre.

The discussion probes whether you understood what you found: the likely lesion, its severity, differentials, relevant investigations and a sensible management plan. Examiners are looking for a candidate who examines fluently, reads the signs correctly and thinks like a safe registrar. The commonest failures are missing a sign or misreading a murmur, so accuracy under time pressure is everything.

The marking skills that apply

This encounter is scored on five of the seven PACES clinical skills — A, B, D, E and G — each graded Satisfactory, Borderline or Unsatisfactory.

Skill A (Physical Examination): a satisfactory pass means a thorough, systematic technique that covers everything relevant — peripheries, pulse, praecordium, auscultation with dynamic manoeuvres and the back and legs — without missing parts. Sequence matters less than completeness.

Skill B (Identifying Physical Signs): the pivotal skill. You must correctly identify the signs that are present (the character of a murmur, a displaced apex, a raised JVP) and, just as importantly, not invent signs that are not there.

Skill D (Differential Diagnosis): offer a sensible differential that contains the correct diagnosis — for example distinguishing aortic stenosis from sclerosis, or naming the likely cause of a valve lesion.

Skill E (Clinical Judgement): apply accurate knowledge to propose relevant investigations (ECG, echocardiogram, bloods) and a management plan with a realistic timescale.

Skill G (Maintaining Patient Welfare): for practice this means the clinical-safety substance — safe examination, sensible safety-netting and disposition — rather than courtesies.

A systematic routine you can drill

Build one fixed framework so nothing is forgotten under pressure. Start at the end of the bed: comfort, breathlessness, scars, a midline sternotomy, or an audible click from a metal valve. Move to the hands for clubbing, splinter haemorrhages and peripheral cyanosis, then the pulse for rate, rhythm and character (a slow-rising pulse suggests aortic stenosis; a collapsing pulse suggests aortic regurgitation). Check blood pressure if offered.

Assess the JVP for height and waveform, inspect the face and mouth (malar flush, high-arched palate, central cyanosis, dental hygiene relevant to endocarditis). At the praecordium, look for scars and pacemaker boxes, palpate the apex beat for position and character, and feel for heaves and thrills.

Auscultate all four areas with the diaphragm and bell, timing each sound against the carotid pulse. Use dynamic manoeuvres — sit forward in expiration for aortic regurgitation, roll to the left in expiration for mitral stenosis — and listen at the axilla and carotids for radiation. Finish with the lung bases, sacral and ankle oedema, and offer to check the peripheral pulses, temperature chart and urine. Then present a crisp summary and your leading diagnosis.

Common conditions and how to prepare

The bread-and-butter cases are the valve lesions — mitral stenosis and regurgitation, aortic stenosis and regurgitation — plus mixed valve disease, and their signs of severity and complications. Rehearse how each lesion changes the pulse, apex and murmur, and how you would grade severity clinically.

Two high-yield presentations have their own dedicated pages: atrial fibrillation, where an irregularly irregular pulse points you toward the underlying cause and thromboembolic risk, and the prosthetic heart valve, where a sternotomy scar, a metallic sound and anticoagulation are the story. Work through both alongside the valve lesions, since they recur constantly and reward a confident, structured answer.