Abdomen System

1. Jaundice is a marker of severity of liver disease, as well as a consequence of decompensation. Yellow discolouration is not usually seen until the serum bilirubin is >40μmol/L (twice the upper limit of normal), although the earliest signs of jaundice can be detected in the periphery of the conjunctivae, or in the buccal mucosa. Remember, there are other causes of jaundice in liver disease, such as Zieve’s syndrome (haemolysis and hyperlipidaemia in alcohol misuse), or biliary obstruction. 2. Cachexia can be established by demonstrating muscle and fat loss. Wasting of the temporalis muscle is an early sign of generalized muscle atrophy. A reduced triceps skin-fold thickness is a marker of loss of fat stores. This can be demonstrated by palpating for redundant skin over the triceps area between your thumb and forefingers. 3. Anaemia is most reliably demonstrated by looking for conjunctival pallor. This is thought to be more sensitive than looking for pallor of skin creases, nails, or other mucosal membranes. If there is no evidence of anaemia, it is an important negative to mention to the examiner. The principal causes of anaemia in chronic liver disease are blood loss from portal hypertensive gastropathy, alcohol excess causing bone marrow suppression and poor nutrition. 4. Other gastrointestinal (GI) causes of clubbing include inflammatory bowel disease (IBD), coeliac disease, GI lymphoma and rare causes of malabsorption such as tropical sprue and Whipple’s disease. 5. Leuconychia is a non-specific finding which is associated with hypoalbuminaemia as well as other conditions such as heart failure, renal disease, Hodgkin’s lymphoma (HL) and diabetes mellitus (see Case 8—Nephrotic Syndrome). 6. Palmar erythema reflects the vasodilated state of cirrhosis. Other causes of palmar erythema include hypercapnoea, rheumatoid arthritis, thyrotoxicosis, pregnancy, fever, and exercise. 7. Spider naevi are vascular lesions, with a central arteriole that supplies smaller surrounding vessels. Generally, the number and size correlate with the severity of liver disease, although they may occur in normal individuals and pregnancy. Spider naevi, palmar erythema, gynaecomastia, and loss of body hair are thought to be the consequence of altered sex hormone metabolism, and an increase in the oestradiol:free testosterone ratio.

Cardiovascular System

1. Always mention presence/absence of signs of endocarditis in any patient with physical signs of valvular heart disease. More than often, they are absent—but this is an important negative finding. 2. Both a low volume and a slow-rising pulse are signs of severe aortic stenosis. If the patient is in atrial fibrillation (AF), then the pulse usually has a variable volume, and some examiners believe that one cannot fully conclusively comment on pulse volume in AF. In patients with aortic stenosis and AF, the pulse exhbits a variable but diminished volume. It would be more appropriate in this setting to say, ‘the pulse is of variable but diminished volume’. 3. A narrow pulse pressure signifies a low cardiac output state, thus a sign of severe aortic stenosis. Other causes of a narrow pulse pressure include severe mitral stenosis or a hypovolaemic state. 4. If venous pressure is elevated, then look for signs of pulmonary hypertension (usually with giant systolic ‘v’ waves of tricuspid regurgitation, parasternal heave and thrill, and a loud pulmonary component to the second heart sound) or pulmonary congestion/cardiac failure (bibasal crepitations). The presence of pulmonary hypertension and pulmonary congestion are markers of severe aortic stenosis. 5. The left ventricle (LV) is hypertrophied, and is minimally displaced with a heaving character. A displaced apex beat indicates a dilated left ventricle, i.e. left ventricular failure. In the late stages of severe aortic stenosis, the left ventricle dilates and heart failure develops. However, the character of the apex beat remains the same. If the apex is displaced, in the absence of signs of severe aortic stenosis, then consider other causes of heart failure. 6. The presystolic impulse is transmission of atrial contraction just before closure of the mitral valve, as a result of forceful atrial contraction against a highly non-compliant and hypertrophied left ventricle. This is often accompanied by a fourth heart sound, and would be a marker of severe aortic stenosis. These signs would not be present in AF. A presystolic impulse is seen in other conditions with marked left ventricular hypertrophy, i.e. hypertensive heart disease or hypertrophic cardiomyopathy (giving a double apical impulse).

Brief Clinical Consultations: General Approach to Brief Clinical Consultations

The new Station 5, Integrative Clinical Assessment involves two 10-minute encounters, each known as a ‘Brief Clinical Consultation’. Following an introductory referral, the candidate has 8 minutes to undertake a focused history and examination to solve a clinical problem, answer any questions the patient may have and explain their investigation and/or treatment plan to the patient. The remaining 2 minutes are spent with the examiners, to relate the relevant physical findings and differential diagnosis. Remember, you are not expected to take a complete history or conduct a complete and thorough examination, as you would in the other stations. Candidates should be prepared to encounter scenarios relating to: 1. Old Station 5 cases, i.e. skin, eye, locomotor, and endocrine systems. 2. Other stations of the examination (stations 1 and 3). 3. Medical problems encountered in everyday practice, i.e. chest pain, hypotension, jaundice, and deterioration in renal function. In principle, this station can include any possible inpatient and outpatient medical scenario, and therefore providing a comprehensive selection of cases will never be feasible. Some patients may not display a wealth of clinical signs, and this often occurs in everyday practice. The candidate should understand the key principles, and develop the art of integrative clinical assessment. This will ensure success in any clinical scenario provided. This integrated approach is a test of higher clinical reasoning and professionalism, rather than a simple test of clinical skills— this should be kept in mind when preparing for this station. The compilation of 20 cases in this section is designed to achieve this, and encourages the candidate to adopt a uniform style, and a thoughtful approach and strategy in tackling this station. • Explanatory referrals are provided in the 5 minute interval before the station. • Read these carefully, and identify the clinical problem(s). • Develop a differential diagnosis based on the limited information available, even before seeing the patient. • A preliminary differential diagnosis will initially help guide the focused history. • The history and examination should not be seen as separate components, where the history is followed by the examination. • Instead, both history and examination should be integrated.

Respiratory System

Interstitial lung disease is a common case for the respiratory section of the MRCP PACES examination. Quite often they are cases of idiopathic pulmonary fibrosis (cryptogenic fibrosing alveolitis) or in the context of systemic (commonly rheumatological) disease. The above cases reflect these common scenarios. To make the diagnosis of interstitial lung disease is relatively straightforward, but presenting other physical signs of underlying aetiologies, mentioning important negatives, and appreciating and recognizing complications of therapy and the disease will impress examiners, not to mention gain considerable extra marks. 1. In approaching a respiratory patient, it is often useful in starting to present the case with a comment on functional status. They may be breathless at rest. They may be on oxygen therapy. Ask the patient to cough. The presence of a non-productive or a productive cough should give clues to underlying diagnosis. Patients with interstitial lung disease often have a non-productive cough, unless this has been complicated by infection. 2. Patients often have peripheral cyanosis. Central cyanosis may be present in advanced disease. 3. Clubbing may not always be present in cases of interstitial lung disease. If present, don’t miss it! 4. Spend a little extra time when examining hands and making general observations. There are many systemic disorders that are associated with pulmonary fibrosis. The presence of peripheral stigmata of systemic disease, usually connective tissue or rheumatological disease, will provide an important clue to the respiratory diagnosis. Look for • rheumatoid arthritis (symmetrical deforming arthropathy of the hands, rheumatoid nodules) • systemic sclerosis (tight and shiny skin, telangiectasia, sclerodactyly, calcinosis, atrophic nails, and Raynaud’s phenomenon) • SLE (petechial rash, livedo reticularis, purpura, arthropathy, butterfly skin rash) • dermatomyositis (Gottron’s papules, heliotrope rash of eyelids/periorbital areas, proximal myopathy) • ankylosing spondylitis (loss of lumber lordosis, fixed kyphosis, stooped posture) • neurofibromatoisis (neurofibromata, café au lait patches) • sarcoidosis (erythema nodosum, maculopapular skin lesions, lupus pernio, lympahdenopathy) • drugs, i.e. amiodarone (grey slate skin pigmentation—the irregular pulse of atrial fibrillation (AF) may be a clue) • radiation therapy (erythema and/or field markings on chest wall)

Central Nervous System

As with all neurological patients, you will be more likely to pick up the diagnosis if you take a step back and look at the whole patient. Take some time to assess their facial expressions, speech, tremor, and posture. A common instruction at this station, with the patient seated on a chair is ‘Look at this patient, and examine as appropriate’. Candidates are often baffled, when given this instruction. Often the patients with Parkinson’s disease are given specific instructions to interlock the fingers of both hands, or place hands flat on their lap to mask the tremor. Picking up an expressionless face and low volume monotonous speech from the outset will provide useful clues to the diagnosis. If you are not sure at this stage, proceed to examining the gait. Once you are certain, that this is Parkinson’s disease, you may proceed to demonstrate the other features. 1. Patients with Parkinson’s disease have characteristic expressionless facies (hypomimia), often described as ‘mask-like’. This is a manifestation of bradykinesia. There is a reduced blink rate. The glabellar tap (Myerson’s sign) is an unreliable sign and is not recommended in the examination. This involves tapping the patient’s forehead repeatedly. Normal subjects will stop blinking, but in Parkinson’s disease, the patient will continue to blink. The patient may be drooling saliva (resulting from dysphagia and sialorrhoea-due to autonomic dysfunction) 2. Patients may have soft speech (hypophonia). This is also a manifestation of bradykinesia, and characteristically, the speech is low-volume, monotonous and tremulous (appears slurred). 3. Blepharoclonus is tremor of the eyelids. This will only be demonstrated if the eyes are gently closed, as opposed to tightly closing the eyes. 4. The classic tremor is present at rest and asymmetrical (more marked on one side). It is classically described as being 4–6Hz and is the initial symptom in 60% of cases, although 20% of patients never have a tremor. The tremor may appear as a ‘pill-rolling’ motion of the hand or a simple oscillation of the hand or arm. It is easier to spot a tremor if you ask the patient to rest their arms in their lap in the semi-prone position.