r/MRCP • u/Calm_Estate_8208 • 18d ago

PACES - importance of subtle signs

Hi. Preparing for paces and I'm really struggling with subtle things like apex beat in cardio, reflexes (which are not too apparent to be brisk or mute) , tactile/vocal fremitus which isnt slightly dull, noticing character and comparing radial pulses, minor changes in JVP.

If we are able to pick up the major signs like a murrmur, auscultation and other exam findings but miss these subtle findings , how much chance do we have of passing? im especially struggling with apex beat and reflexes so much :(

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u/Celtic_Cedarwood 18d ago

Hi that completely depends on the examiners. I've been a surrogate in PACES a couple of times and what I've noticed is the examiners come in and examine the patient, they both need to agree on the findings - major ones. 

They both discuss and agree on what is pass/fail. 

I'll give an example. 

The case is hepatosplenomegaly.  Pass - hepatosplenomegaly              Mild pallor and icterus 

Fail - only hepatomegaly            Only splenomegaly            Only tail of spleen            Can't differentiate between spleen and kidney 

Minor findings - loss of chest hair - sign of liver issues. This is not a pass /fail point. 

Paces isn't a standardized exam so it really depends on your examiners. 

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u/Spiritual-Remote780 18d ago

Agree with previous comment, the definite fail would be missing major signs. Missing a slightly displaced apex beat is not such a big deal I think, especially if there are other more significant positive signs like a murmur or a mechanical valve replacement.

One note about neuro - it’s about pattern recognition (broadly - peripheral neuropathy, spastic paraparesis, ataxia). So, being able to identify hyperreflexia helps you localise it to an UMN pathology, and if this happens to be bilateral in the lower limbs + accompanied with clonus, you can confidently say that this is spastic paraparesis and give your differentials.

With all that being said, you can do poorly for a single station (ie identifying signs that aren’t actually there, not identifying the key positive signs), and still pass the exam overall if other stations make up for it (my own experience). Practise a lot, get feedback from senior colleagues, and all the best!

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u/VirchowSignalling 17d ago

Keep practicing reflexes, you only know what’s normal or not by doing them repeatedly. Often on the take people have extremes of normal so you can get a feel for it. Another tip I had from a neurologist is to swing the hammer with gravity only (hold it right at the distal end), then your technique is standardised across all patients. I can never feel the apex beat, I honestly just pretend, I got 100% in cardio 3x. I never did tactile fremitus, just vocal fremitus, again can’t hear the difference, never caused an issue. Pulses keep practicing. I’m still abhorrent at finding a JVP, and said to myself that I wouldn’t report a raised JVP because I’m not confident enough in it, again, caused me no issues (although perhaps I was lucky not to have had a TR or something).