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)

Differentiating Murmurs of Aortic Stenosis and Mitral Regurgitation

One of the questions I was asked at the recent IBC Dubai PACES course was how would one differentiate the systolic murmurs of aortic stenosis from mitral regurgitation.
This is a good question. Most often it is very easy to make out whether it is aortic stenosis or mitral regurgitation but sometimes the features are not clear and then the differentiation can become exceedingly difficult.
The answer is not to depend on the characteristics of the murmur but to take into account all the other information gleaned on clinical examination.
To start with mitral valve disease is more likely in a female and aortic stenosis if the patient is a male (these are genralisations and not to be regarded as rules).
On general examination one may note a very pale appearance in association with aortic stenosis (Dresden doll appearance ACES for PACES page 180)
Elfin facies is associated with aortic stenosis ACES for PACES page 182
A malar flush would be in keeping with mitral valve disease and pulmonary hypertension ACES for PACES page 186
High arched palate may occur in supravalvular aortic stenosis ACES for PACES page 187
Atrial fibrillation more likely mitral valve disease ACES for PACES page 193
Low volume, slow rising pulse in aortic stenosis ACES for PACES page 193,194
Brachio-radial delay aortic stenosis ACES for PACES page 196
Displaced apex beat mitral regurgitation ACES for PACES page 202
Thrusting apex mitral regurgitation ACES for PACES page 202
Heaving apex aortic stenosis ACES for PACES page 202
Apical thrill mitral regurgitation ACES for PACES page 203
Thrill 2nd right intercostal space aortic stenosis ACES for PACES page 203
Soft 1st heart sound mitral regurgitation ACES for PACES page 205
Soft 2nd heart sound aortic stenosis ACES for PACES page 206
Pan systolic murmur radiating to the axilla inferior angle of scapula mitral regurgitation ACES for PACES page 211,213 (remember mitral regurgitation can also cause ejection systolic murmurs ACES for PACES page 211)
Ejection systolic murmur radiating to the neck aortic stenosis ACES for PACES page 210,213

This exercise in differentiating murmurs is a good illustration of the importance of following each step of the clinical examination, focussing one’s mind on the findings and analysing the findings before moving on to the next step (i.e. following the elephant’s footstep ACES for PACES preface)

History Taking, Communication and Ethics for MRCP PACES

Many candidates and unfortunately many from outside the UK do not do well in these two stations.
One of the main reasons for this is failure to ask and take into account the patient’s, or in the case of a scenario in the communication skill station, the relation or carer’s perspective.
This may be due to the fact that this has not been standard teaching or standard practice when taking histories. Indeed many clinical skills books do not give a structure or framework for asking about the patient’s perspective.
It is essential to include the patient’s perspective in standard history taking. This is the only way in which one will do this naturally rather than in an artificial way in exams.
In order to do so it is vital to have a structure of framework for doing so.
In ACES for PACES I have provided such a structure (see chapters 4 and 18)
I have also provided an acronym as an aid to memorising this structure
It is I PASSED By Employing ACES, which stands for :
Identification and Introduction
Purposefully
Analyse
Symptoms
Systems
Elicit
Details
Beliefs
Expectations
Anxieties (regarding)
Causes
Effects
Survival

Cardiovascular Examination

We had another good case at the recently concluded MRCP PACES course conducted by IBC in Dubai.
The patient was a young child who looked small.
In a small child with a cardiovascular problem one should consider congenital heart disease or rheumatic heart disease (ACES for PACES page 178)
On examination of the pulse we noted sinus rhythm approximately 80 beats per minute, no abnormality in volume or character, all pulses equal and synchronous.
No abnormality in the head or neck.
On examination of the praecordium the apex appeared displaced and was thrusting in nature.
A thrusting apex suggests mitral regurgitation, aortic regurgitation or ventricular septal defect (ACES for PACES page 202)
The fact that the pulse was of normal volume and not collapsing would make aortic regurgitation unlikely.
The fact that the pulse was in sinus rhythm would make mitral valve disease unlikely.
As we were already suspecting congenital heart disease VSD would be very likely.
On further palpation of the praecordium, we felt a systolic thrill at the left sternal edge. This would fit in with our suspicion of VSD.
Auscultation confirmed a harsh pan systolic murmur at the left sternal edge with no radiation of the murmur confirming our diagnosis of VSD.
Lungs were clear
Diagnosis
Ventricular Septal Defect
Sinus rhythm
No heart failure
No reversal of shunt

Respiratory Examination

We saw another good case at the Dubai MRCP PACES course run by IBC.
The patient was a young Asian male man who seemed of normal height and weight.
On examination of his head there was no abnormality. On examination of his hands, initial examination seemed to reveal no abnormality, but on using the method of dividing the hands into systems (see ACES for PACES) it became evident that there was a difference in size and shape of the two hands. The left hand was smaller and narrower than the right. This was a consequence of an earlier injury during childhood. It had no bearing on the diagnosis but it did reveal the importance of correct method in revealing clinical findings.
On examination of the neck we noted that the trachea was deviated to the left. This indicated either a lesion pulling from the left or pushing it from the right.
On examination of the chest we noted that there was asymmetry of the chest with some flattening of the right apex and we also noted reduced movement of the right hemithorax. This showed that the lesion was on the right hand side. A lesion pushing the trachea from the right side. As a pneumothorax was unlikely in the setting of a course, the most likely diagnosis was right sided pleural effusion.
The remainder of the examination was now much easier as it was only confirmation of the findings of right sided pleural effusion.
The findings were an increased respiratory rate, apex beat was difficult to palpate, decreased vocal fremitus and reduced respiratory movements confirmed by palpation. Stony dull percussion note at the right base and decreased breath sounds and vocal resonance. Aegophony was heard at the upper border of the effusion.
Diagnosis
Right sided pleural effusion
Probably due to tuberculosis
Impaired respiratory function