[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has presented to the acute medical unit on account of shortness of breath.  Please examine their respiratory system to identify why then tell the examiners what signs you find and discuss your proposed management”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191691″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has a psoriatic rash on his elbows and also bibasal crepitations in keeping with pulmonary fibrosis.

 

The clinical signs exhibited in this video include:

 

  1. Psoriasis;
  2. Fine bibasal crepitations in both bases.

 

The character of the crepitations is in keeping with pulmonary fibrosis of uncertain aetiology.  Psoriasis is generally not considered causal of pulmonary fibrosis, but patients treated with medication such as methotrexate may develop pulmonary fibrosis due to this.  A candidate seeking a good score could speculate that the pulmonary fibrosis might in this case be secondary to treatment of the patient’s psoriasis.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]There are a great number of potential causes of interstitial lung disease ranging from inflammatory conditions to occupational causes to medication.  It is important in the MRCP PACES to not presume that every patient with evidence of basal pulmonary fibrosis necessarily has idiopathic pulmonary fibrosis.  In many cases there may be an identifiable underlying cause and you have the opportunity to impress the examiners if you’re able to pick up clues as to what this might be.

 

Causes include:

  1. Drugs: nitrofurantoin, bleomycin, methotrexate are common culprits, but a huge number of other agents are also associated with pulmonary fibrosis;
  2. Environmental exposure: dusts, such as asbestos, coal, silica and beryllium;
  3. Connective tissue disease: scleroderma, SLE, rheumatoid arthritis;
  4. Granulomatous: sarcoidosis;
  5. Other: idiopathic pulmonary fibrosis.

 

Always be alert to potential clinical clues as to the underlying cause of your patient’s interstitial lung disease, and never assume just because IPF is common in the exam that this will necessarily prove to be the explanation![/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has fine basal crackles in keeping with possible interstitial lung disease.  I also noticed a scaly rash on the extensor surface of the elbows in keeping with psoriasis.  It is possible that the patient has been treated with a drug such as methotrexate which may have caused lung damage, although I’d like to confirm this with a complete history.  To investigate this patient further in the first instance I would like to conduct a chest x-ray and spirometry.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]