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
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