Respiratory Examination MRCP PACES

We were teaching for MRCP PACES yesterday and had a patient with a common problem but the examination showed up common mistakes made by candidates in their approach to the examination of the respiratory system

The candidate was asked to examine the respiratory system and proceeded with what appeared to be a reasonable method. However, she did commence examination of the chest from the posterior aspect and after finishing the examination of the back of the chest she said she had concluded the examination and gave the findings.

She said that the patient was breathless at rest, was using oxygen via nasal prongs, there were no peripheral signs and the chest was normal apart from bilateral basal crepitations.

When asked the diagnosis she said that the patient probably had fibrosing alveolitis.

We then asked about other causes of bilateral basal crepitations and why it was not heart failure or brocnhiectasis or atypical pneumonia and these questions were difficult to answer as she had not looked at the JVP nor looked around for sputum pots or inhalers

We then re-examined the patient using ACES

The patient was propped up in bed suggesting dyspnoea and we mentioned some of the causes of dyspnoea (ACES for PACES page 245)

The height and weight were satisfactory and the skin was tanned all suggesting that the patient had been reasonably well till admission and was able to get about and possibly have a holiday

On examination of the head we that his face was flushed. We questioned the candidate about the cause of this and she came out with the possibility of the patient being a pink puffer(ACES for PACES page 249). At this point the possibility of COPD was raised. We also noticed flaring of the alae nasi further reinforcing our idea that the patient had respiratory distress(ACES for PACES page 250).

On examination of the hands we did not notice any clubbing but the peripheries were warm and there was a high volume pulse that was not collapsing

On examination of the neck we noted a raised JVP almost to the ear lobe with no predominant waveform. This raised the possibility of cor pulmonale or heart failure but as we were already going on the lines of COPD cor pulmonale was more likely (ACES for PACES page 256-257).

There was inspiratory descent of the trachea, more features showing us the extent of the dyspnoea.

The trachea was in the midline but the cricosternal distance was decreased. This further reinforced the idea the patient had COPD (ACES for PACES page 257).

On examination of the chest it was barrel shaped and there was little movement of the chest wall with respiration being predominantly abdominal (ACES for PACES page 258).

The respiratory rate was 26 per minute, more evidence of respiratory distress

The apex beat was difficult to palpate (ACES for PACES page 202).

Respiratory movements were equal on the two sided vocal fremitus unremarkable

Percussion not showed increased resonance with diminished cardiac and liver dullness. This added further weight to our diagnosis of COPD (ACES for PACES page 262).

Breath sounds were vesicular

There were a few crepitations at both bases but they were mostly mid-inspiratory and cleared with coughing (ACES for PACES page 264-265).

Heart sounds were soft

Diagnosis

COPD

Respiratory failure

Cor pulmonale

This case demonstrated very clearly how a methodical examination with evaluation of the findings at each step (ACES) makes diagnosis much easier than collecting all the signs and trying to recognise a pattern at the end

SOCRATES versus ACES mnemonic

I was teaching a medical student this afternoon.
I discussed history taking with him. I asked him how he would analyse a patient’s symptoms and discussed analysis of pain.
He said he used the acronym SOCRATES and he proceeded to tell me the features he would ask for. The acronym was quite reasonable and he was able to name most features he would ask for in the analysis of symptoms.
I then discussed the mnemonic from ACES for PACES –Please Carefully Question This Method For Reliability and Resilience”- ACES for PACES page 22-24
He pondered this and said he would think about the two carefully as the ACES mnemonic seemed to be more comprehensive than the acronym he was using.
I then showed him how he could use the ACES mnemonic to analyse the pulse, murmurs, respiration and other functions of the body analysed on physical examination. ACES for PACES page 30-31
It is important to think about clinical skills and realise that a simple, common sense approach is all that is needed

Neurology for MRCP PACES

We saw a very interesting case when teaching for PACES
After the initial examination and presentation of findings we went through the case again one step at a time with analysis to demonstrate how examination and interpretation should be done.
We initially looked at the dimensions of the lower limb and then looked at the skin (ACES for PACES page 417)
At this point we noted that the patient had trophic changes in the skin (loss of hair, callosities)
Immediately we thought that this could indicate a peripheral neuropathy.
Next we looked at the muscle mass and noted wasting of the muscles of both lower limbs. This made us think of a lower motor neurone lesion and reinforced our initial suspicion of a peripheral neuropathy. ACES for PACES page 443
Tone was difficult to examine in this patient as he kept tightening up his limbs.
Muscle power was decreased especially in the distal muscles again in keeping with a lower motor neurone lesion and peripheral neuropathy (ACES for PACES page 452)
Reflexes were diminished even with reinforcement again in keeping with our initial suspicion (ACES for PACES page 453)
Coordination was difficult to assess as the patient had weakness of his lower limbs
Sensation was diminished especially in the lower part of his limbs (stocking distribution) again in keeping with our initial suspicion (ACES for PACES page 455)
The diagnosis of a peripheral neuropathy had been made clinically the next step was to think about the causes of peripheral neuropathy
This was a distal symmetrical polyneuropathy which could be due to a number of causes (ACES for PACES page 434-435)