[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/138191693″][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 left pleural effusion.  This is one of the commonest clinical scenarios encountered in the respiratory station during PACES.

The clinical signs exhibited in this video include:

  1. Reduced expansion on the left hemithorax;
  2. Reduced tactile vocal fremitus at the left base;
  3. Reduced percussion note in the left lower zone;
  4. Reduced breath sounds in the left lower zone.

Most texts also cite tracheal deviation away from the side of the pleural effusion as another clinical sign that may be observed.  However, it is very unlikely that a patient well enough to attend the MRCP PACES would have a pleural effusion large enough to cause this sign to be discernable.  Some patients have a rim of bronchial breathing in the lung just above the pleural effusion.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]For the MRCP PACES examination to have any chance of passing candidates would need to confidently identify the presence of a pleural effusion.  They would also be expected to propose an appropriate management plan and provide some differentials regarding the underlying cause.

In the video shown here it is not possible to determine why the patient has a pleural effusion.  In general when this is the case it is satisfactory to state that there are no clinical signs that point towards an underlying cause.

Signs that may be present and point to an underlying cause include:

  1. Peripheral stigmata of chronic liver disease – leuconychia, spider naevi, gynaecomastia;
  2. Evidence of chronic renal failure – AV fistulae;
  3. Congestive cardiac failure – raised JVP, pedal oedema;
  4. Malignancy – clubbing, lymphadenopathy, surgical scars from resections.
  5. Evidence of inflammatory conditions – rheumatoid hands, malar rash.

Further investigation of patients with a pleural effusion would usually proceed with basic venous bloods, a chest x-ray and an ultrasound guided pleural aspiration to determine whether the fluid is exudative or transudative.  In many cases patients will also require CT imaging of their thorax.

Causes of transudates include heart failure, chronic renal failure and chronic liver failure.  Exudate causes include malignancy, infection, infarction and inflammation.

Criteria for determining whether a pleural effusion is exudative or transudative include the following:

  1. Protein > 30g/L = exudate;
  2. Effusion albumin / plasma albumin >0.5 = exudate;
  3. Effusion LDH / plasma LDH > 0.6 = exudate;

In addition a pH less than 7.2 should prompt consideration of an empyema as the underlying cause, while effusion cytology may prove useful in determining the cause of a malignant pleural effusion.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has a left pleural effusion. His chest is dull to percussion at the left base where he also has reduced breath sounds. There is also reduced expansion on the left. I was not able to elicit any peripheral signs that pointed to an underlying cause. To investigate this patient further I would like to organise some basic venous bloods, arrange a chest x-ray and conduct a pleural aspiration.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]