How to present a case in PACES (with model presentations)

The structure that works

1. Headline. "This [age] [man/woman] has [diagnosis or syndrome], evidenced by [two or three key findings]."
2. Supporting findings. The remaining positive findings that matter, grouped logically.
3. Severity and complications. For example, signs of severe aortic stenosis, portal hypertension or respiratory failure.
4. Cause and context. Clues to aetiology and treatment: a sternotomy scar, rheumatoid hands, an AV fistula, inhalers or oxygen by the bed.
5. Relevant negatives. Only the ones that change your thinking (for example, "there are no signs of heart failure").
6. Differential diagnosis. The most likely first, then one or two sensible alternatives.
7. To complete. One line on what you would add: "To complete my examination I would check the blood pressure and look at the observation chart."

Model presentations

Cardiovascular: aortic stenosis

"This 78-year-old man has signs of severe aortic stenosis. He has a slow-rising pulse with a narrow pulse pressure, a heaving, undisplaced apex beat, and an ejection systolic murmur loudest in the aortic area radiating to the carotids, with a soft second heart sound. There are no signs of heart failure and no sternotomy scar. The main differential would be aortic sclerosis, but the slow-rising pulse and soft second heart sound point to significant stenosis. To complete my examination I would measure his blood pressure and review an ECG and echocardiogram."

Respiratory: pulmonary fibrosis

"This 70-year-old woman has signs of pulmonary fibrosis. She has finger clubbing, reduced chest expansion bilaterally and fine end-inspiratory crackles at both bases that do not change with coughing. She has changes of rheumatoid arthritis in her hands, which may be the cause. She is not breathless at rest and I saw no signs of right heart failure. The differential includes bronchiectasis, although the crackles were fine rather than coarse. To complete my examination I would check her oxygen saturations, and I would want a high-resolution CT and full lung function tests including transfer factor."

Abdominal: chronic liver disease

"This 55-year-old man has signs of chronic liver disease with portal hypertension. He has palmar erythema, Dupuytren's contracture, multiple spider naevi and gynaecomastia. There is splenomegaly extending about 4 cm below the left costal margin, and shifting dullness consistent with ascites. He is not jaundiced and there is no asterixis to suggest encephalopathy. The most likely cause is alcohol-related liver disease; other causes to consider include viral hepatitis, metabolic dysfunction-associated steatotic liver disease, haemochromatosis and autoimmune liver disease."

For liver cases, a four-part structure keeps you organised: chronic liver disease; compensated or decompensated; the likely cause; and any signs of treatment, such as ascitic tap marks or a transplant scar.

Neurology: cerebellar syndrome

"This 35-year-old woman has a right-sided cerebellar syndrome. There is intention tremor and past-pointing on the right, dysdiadochokinesia and right heel–shin ataxia, and her gait is broad-based. She also has a mild spastic weakness of the left leg with brisk reflexes. The combination of cerebellar and pyramidal signs in a young woman makes multiple sclerosis the most likely cause; alternatives include a posterior fossa lesion or stroke. To complete my examination I would look for nystagmus and an internuclear ophthalmoplegia, and examine her fundi for optic atrophy."

Handling the questions

• Answer the question asked. The Federation's advice to candidates stresses listening carefully and answering precisely. Examiners interrupt for time, not because you're wrong.
• Investigations: bedside to specialist. Start with the simple (observations, bloods, ECG, urine) and work up to the specific test that confirms the diagnosis.
• Management: safe, then specific. Immediate safety, then treatment of the condition, then complications and follow-up, involving the right specialists.
• It's fine not to know. "I'm not sure; I would discuss that with a senior colleague" is safe. A confident wrong answer is not.

Common mistakes

• Starting with two minutes of "on general inspection…" before getting to the point.
• Listing every normal finding.
• Reporting a sign you didn't actually elicit.
• Hedging so much that the examiners can't tell what you think.
• Contradicting your own findings in the differential.

Sources

• Preparatory advice and information to candidates, PACES (May 2026)
• Examiners’ Guide to PACES (version 3, February 2025)
• Federation: PACES format