Each station in the PACES has cases that occur more commonly than others. This is due to a number of factors that include the number of patients with the conditions, being able to elicit decent clinical signs and create a ‘story’ out of very little history or background information.
Many candidates worry about the weird and wonderful of cardiac murmurs, and there is a discrepancy between what appears commonly in everyday practice versus the MRCP PACES exam. There are, however, some common conditions that do recur, and you will far more likely encounter a prosthetic valve or aortic stenosis as opposed to Tetralogy of Fallot with a Blalock shunt. In countries that still have rheumatic heart disease then the patient might be younger with complications from this.
Prosthetic valves, especially mechanical ones, appear commonly and often you can hear these at the end of the bed with a characteristic metallic click. This makes your job easy – all you then need to do is determine whether the prosthetic valve click coincides with S1 or S2 to figure out of the valve is likely to be an aortic or mitral replacement.
Mitral valve disease and aortic valve disease are as common in the exam as they are in everyday practice. Both stenosis and incompetence occur reasonably commonly in both valves so do not forget to listen in all areas and to conduct all manouvres necessary to elicit more subtle murmurs, such as aortic regurgitation.
Atrial fibrillation is also a common finding, and you should look for associated features, such as medication (the side effects of amiodarone) or heart failure.
Mixed valve disease is also common so do not assume simply because you’re confident that you’ve heard mitral regurgitation, for example, that there is nothing else to be found. It happens, unfortunately. In reality, everyone’s cardiac auscultation improves after the echocardiogram has been done(!) but in the PACES it’s just you, the patient and your stethoscope.