MRCP PACES · SHORT-CASE PRACTICE

Six minutes.
One clinical argument.

These are focused practice structures—not scripts to perform blindly. Use the candidate instruction and the first discriminating finding to decide where your time goes, then present a defensible synthesis.

01

SYSTEM ROUTINE

Cardiovascular examination

Example instruction

Examine this patient’s cardiovascular system. You have six minutes before discussion.

Opening standard

Clean your hands, introduce yourself, confirm identity and consent, ask about pain or breathlessness, position at roughly 45° and expose the chest while preserving dignity. Look once from the end of the bed before touching the patient.

Six-minute map

  1. General survey and hands

    Work of breathing, colour, body habitus, oxygen or devices; clubbing, peripheral cyanosis, splinter haemorrhages, tar staining, temperature and capillary refill.

  2. Pulse, face and neck

    Rate, rhythm, character and radio-radial delay when relevant; conjunctivae and mouth; jugular venous pressure and waveform. Assess each carotid separately and avoid simultaneous compression.

  3. Praecordium

    Inspect scars and visible pulsation. Locate the apex, assess character and displacement, then heaves and thrills. Auscultate systematically with diaphragm and bell; use left lateral or forward positioning only when it tests a hypothesis.

  4. Extend deliberately

    Check lungs for congestion, sacrum or ankles for oedema, and peripheral perfusion. Add blood pressure or peripheral pulses when the instruction and findings make them discriminating.

  5. Close and synthesise

    Thank and cover the patient. State the dominant lesion, severity clues, ventricular response, rhythm, heart-failure evidence and the most important uncertainty.

Discriminating findings

  • Pulse character plus murmur timing and radiation
  • Apex character and displacement
  • JVP height and waveform
  • Pulmonary congestion or peripheral oedema
  • Sternotomy, device or valve-surgery clues

Presentation frame

“This patient has clinical evidence of [dominant lesion], supported by [two discriminating positive findings]. There is [evidence/no evidence] of haemodynamic consequence or heart failure. The rhythm is [state it]. I would clarify [key uncertainty] with ECG and echocardiography, while first addressing [any immediate safety issue].”

Four-minute examiner discussion

What is the most likely lesion?

Commit to one lesion, then link the pulse, apex and murmur rather than describing them separately.

How severe is it clinically?

Use consequence: symptoms supplied by the examiner, pulse or blood-pressure response, ventricular enlargement and heart-failure signs. Do not claim an echo grade from examination alone.

What would you do next?

Prioritise immediate instability first, then ECG and transthoracic echocardiography; state what finding would accelerate specialist review or intervention.

Unsafe or weak performance

Omitting consent or welfare checks; compressing both carotids; calling a murmur severe without consequence; missing decompensation; or reciting every possible valve lesion without committing to a synthesis.

02

SYSTEM ROUTINE

Respiratory examination

Example instruction

Examine this patient’s respiratory system. You have six minutes before discussion.

Opening standard

Clean your hands, introduce yourself, confirm consent and ask about pain or breathlessness. Sit the patient as upright as tolerated, expose the chest appropriately and begin by counting respiratory rate while observing the whole patient.

Six-minute map

  1. End of bed and hands

    Respiratory distress, oxygen delivery, cough, sputum, cachexia or asymmetry; clubbing, nicotine staining, peripheral cyanosis, tremor and asterixis where relevant.

  2. Pulse, face and neck

    Pulse, conjunctivae, central cyanosis, Horner-pattern clues, cervical or supraclavicular nodes and tracheal position. Do not force neck examination if uncomfortable.

  3. Chest examination

    Inspect shape, scars and movement. Compare expansion, percussion and breath sounds side-to-side in a repeatable ladder. Add vocal resonance only when it helps distinguish consolidation, collapse or pleural disease.

  4. Complete the system

    Look for cor pulmonale, ankle oedema, calf asymmetry when clinically relevant, inhalers, sputum pot or mobility limitation. Check posterior fields if not already examined.

  5. Close and synthesise

    Thank and cover the patient. Name the anatomical pattern, likely process, severity evidence and whether there is respiratory failure or urgent deterioration.

Discriminating findings

  • Tracheal position and hemithorax volume
  • Expansion, percussion and breath sounds interpreted together
  • Focal versus diffuse crackles
  • Clubbing, nodes or Horner-pattern findings
  • Oxygen requirement and work of breathing

Presentation frame

“This patient has a [focal/diffuse] respiratory pattern localised to [site], with [key linked findings]. The leading process is [diagnosis or physiological pattern]. Severity is suggested by [work of breathing, oxygen or systemic findings]. I would urgently clarify [safety issue], then use imaging and physiological testing to distinguish [main alternative].”

Four-minute examiner discussion

Where is the abnormality?

Localise before naming a disease: side, zone and whether the pattern suggests air-space, airway, interstitial or pleural pathology.

What is your strongest alternative?

Choose the alternative that explains the same signs and give the one finding or investigation most likely to separate it.

Is this patient safe to remain here?

Use respiratory rate, work of breathing, oxygen requirement, mental state and haemodynamic context; do not wait for a perfect diagnosis before escalating instability.

Unsafe or weak performance

Failing to recognise distress; examining a breathless patient flat; interpreting a single sign in isolation; missing a unilateral volume or tracheal shift; or proposing routine outpatient tests for an unstable patient.

03

SYSTEM ROUTINE

Abdominal examination

Example instruction

Examine this patient’s abdomen. You have six minutes before discussion.

Opening standard

Clean your hands, introduce yourself, confirm consent, ask about pain and position the patient comfortably. Expose from xiphisternum to the relevant lower-abdominal boundary while protecting dignity; inspect before palpation.

Six-minute map

  1. General survey, hands and face

    Nutritional state, jaundice, pallor, devices or drains; clubbing, leukonychia, palmar erythema, Dupuytren’s change and asterixis only when present. Examine eyes and mouth with purpose.

  2. Abdomen

    Inspect contour, movement, scars, veins, stomas and masses. Lightly palpate away from pain, then assess liver, spleen, kidneys and aorta as relevant. Percuss organ borders and test for ascites when the examination supports it.

  3. Focused extension

    Auscultate when bowel sounds or a bruit matter to the task. Check hernial orifices, nodes, legs, sacrum or transplant site when indicated—explain what you would add rather than performing intimate examination without specific consent and setting.

  4. Look for consequence

    Assess oedema, chronic liver-disease complications, portal-hypertension clues, encephalopathy, volume status or graft function clues according to the dominant pattern.

  5. Close and synthesise

    Thank and cover the patient. Present the organ or syndrome, likely cause, decompensation or complication, and the finding that requires urgent action.

Discriminating findings

  • Tenderness versus peritonism
  • True organ enlargement versus another mass
  • Ascites plus evidence of portal hypertension
  • Chronic liver disease with or without decompensation
  • Native-organ versus transplant anatomy and scars

Presentation frame

“This patient has [syndrome or organ finding], demonstrated by [two linked findings]. There is [evidence/no evidence] of decompensation, portal hypertension, obstruction or peritonism. The likely cause is [leading diagnosis], but I would distinguish it from [strong alternative] using [specific next investigation].”

Four-minute examiner discussion

What complication matters most now?

Prioritise peritonism, sepsis, bleeding, encephalopathy, obstruction, acute kidney injury or graft dysfunction when supported by the case.

What would you investigate first?

Choose tests that answer the immediate question: focused bloods, urinalysis, ultrasound or cross-sectional imaging—not an unranked catalogue.

What did you not examine?

State relevant omitted components and the consent, chaperone or positioning needed. Do not claim a rectal, genital or hernial examination that you did not perform.

Unsafe or weak performance

Palpating aggressively over pain; exposing the patient unnecessarily; missing peritonism or encephalopathy; examining a stoma or intimate area without explanation and consent; or presenting a list of stigmata without a clinical syndrome.

04

SYSTEM ROUTINE

Neurological examination

Example instruction

Perform the neurological examination requested in the candidate instruction. You have six minutes before discussion.

Opening standard

Read the task literally: a focused limb, cranial-nerve, gait or coordination examination is not a full neurological survey. Clean your hands, introduce yourself, confirm consent, ask about pain or mobility risk and position safely before testing.

Six-minute map

  1. Define the problem

    Observe speech, posture, spontaneous movement, aids and asymmetry. Translate the instruction into the anatomical question you need to answer.

  2. Run a reproducible core

    For a limb: inspect, tone, power and reflexes, then coordination and sensation selected to answer the task. Compare sides and test proximal and distal groups. For cranial nerves, preserve a consistent sequence but concentrate on the instructed deficit.

  3. Localise with discriminators

    Use pattern—upper versus lower motor neuron, nerve versus root versus plexus, cortical versus brainstem versus cerebellar. Add plantar responses, sensory level, neglect, fundoscopy or speech assessment only when they change localisation.

  4. Function and safety

    Assess gait only when safe, with an aid or assistant if needed. Include transfers, stance or coordination as the task requires. Use only examination-centre equipment for sensory testing.

  5. Close and synthesise

    Thank the patient. State syndrome, side, anatomical level, likely cause, important alternative and whether onset or associated features demand emergency assessment.

Discriminating findings

  • Distribution of weakness
  • Tone, reflexes and plantar response considered together
  • Sensory modality and anatomical boundary
  • Coordination interpreted after allowing for weakness
  • Gait pattern and functional consequence

Presentation frame

“This patient has a [motor/sensory/coordination] syndrome affecting [distribution and side]. The findings localise to [anatomical level], principally because of [two discriminating signs]. The leading cause is [diagnosis], with [alternative] important because [reason]. I would first establish [time course or urgent red flag] before targeted imaging or neurophysiology.”

Four-minute examiner discussion

Where is the lesion?

Give one anatomical level and prove it with the pattern. Avoid jumping straight from one weak movement to a disease label.

What finding would change urgency?

Sudden onset, bulbar or respiratory involvement, cord compression features, altered consciousness or rapidly progressive weakness should trigger immediate escalation.

How would you complete the examination?

Name only components that test your localisation or immediate safety, and explain why each matters.

Unsafe or weak performance

Attempting unsupported gait; causing pain; using personal sharp sensory equipment; reporting coordination abnormality caused by weakness as cerebellar disease; or missing a time-critical onset or bulbar/respiratory threat.

HOW TO REHEARSE

Do not reward speed alone

  1. Give the candidate the instruction only.
  2. Stop the examination at six minutes.
  3. Ask one localisation, one severity and one next-step question.
  4. Mark observable behaviour across the relevant PACES skills.
  5. Repeat the weakest 60 seconds immediately.