PACES MRCP UK - Where MRCPians Meet Since 2006

MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.


Wednesday, June 13, 2007

Respiratory Quiz




During yesterday’s MRCP mock exam, Wuchereria had a tough time with one of the local examiner.

This patient has clubbing with cyanosis and bilateral fine crepitations over the bases with a scar as seen in the picture. He also has an area of consolidation over the R lower zone

Examiner : How do you correlate the scar and the findings ?

Any takers?

This case is contributed by Wuchereria.

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23 Comments:

At 6/13/2007 08:29:00 PM, Blogger Xiao_zhai said...

Clubbing in CVS means mainly two things :
1. bacterial endocarditis
2. cyanotic congenital heart disease.

The midline sternotomy scar indicates a previous cardiac surgery.

He's currently cyanosed, which I would not really expect of a patient who had a surgery done to correct his congenital cyanotic heart disease.

I couldn't tie in the lung finding. Could just be a pneumonia, the reason for the worsening of his cyanosis and his admission this time.

 
At 6/13/2007 09:36:00 PM, Blogger Dr. David Teoh (eMRCPian) said...

Good try:)
Need to remind you that this is Respiratory station
NOT CVS!

Try again?!

 
At 6/13/2007 10:06:00 PM, Blogger Xiao_zhai said...

xgcqi

Hahaha....I didn't notice the most obvious.....

Common Diff for clubbing for respi then:
1. Lung Ca
2. Idiopathic pulmonary fibrosis
3. Chronic suppurative lung disease.

Could this be idiopathic pulmonary fibrosis?

 
At 6/13/2007 10:11:00 PM, Anonymous Anonymous said...

i think this person has got cystic fibrosis and the scar is from previous lung surgery.

 
At 6/14/2007 04:36:00 AM, Anonymous Anonymous said...

this young lady has got cyanosis,clubbing and midline sternotomy scar,she has got bilateral lung transplant dut to cystic fibrosis and would be tachypnoeic due to left lower lobe consolidation

 
At 6/14/2007 07:43:00 AM, Blogger Dr. David Teoh (eMRCPian) said...

Good thoughts.

HINT: this patient had CABG before

Any takers?

 
At 6/14/2007 11:54:00 AM, Anonymous Wuchereria said...

Quick, quick....all answer so far wrong

 
At 6/14/2007 02:26:00 PM, Anonymous hipspaica said...

CABG means pt previousy had coronary artery disease.

he might have an infarct which leeds to ruptured septum causing VSD after few years he dev eisenmenger syndrome due to right to left shunt causing cyanosis and finger cubbing. he is currently in failure as evidence by bibasal creps with superimposed pneumonia at right lower lobe.

heee just trying

 
At 6/14/2007 08:19:00 PM, Anonymous Anonymous said...

amiodarone induce lung fibrosis------suprisingly quite common actually

 
At 6/14/2007 11:19:00 PM, Blogger Dr. David Teoh (eMRCPian) said...

Bingo!

 
At 6/14/2007 11:26:00 PM, Blogger Axonopathic said...

Yes, the incidence of AF after any cardiac surgery is between 10%-50%.

Although a AV nodal blocking agent is generally preferred (class I) as the 1st line for AF after cardiac surgery, some patients might not be able to tolerate one. Hence amiodarone (class IIa) is used in these patients.

Good correlation. Keep up the good work!

 
At 8/14/2007 04:23:00 PM, Anonymous jafar saeed said...

ithink this pt has congenital hear disease then developed esinemenger syndrome this will explain both the finger clubing and the cyanosis for which undergone for cardiac surgey

 
At 9/11/2007 09:55:00 PM, Anonymous Anonymous said...

why not broncogenic carcinoma in the rt lower zone which presents as consolidation and finger clubbing on top of bilateral lung fibrosis due to amiodarone

 
At 11/18/2007 10:51:00 PM, Blogger saeed1582004 said...

in respiratory station for patient with mid-thoracic sterniotomy, we have to look at leg for saphenoud or,sub-mammary scars,so as not to miss amiodarone induced lung fibrosis

 
At 6/07/2008 10:58:00 AM, Anonymous Anonymous said...

amiodarone induced lung fibrosis

 
At 6/27/2008 08:46:00 AM, Anonymous Anonymous said...

In resp station:
I think it may be lung transplant with bronchiolitis obliterans syndrome...
Need to look for signs of chronic steroid/cyclosporin usage...

 
At 8/24/2008 05:20:00 PM, Blogger Dr. A Chakraborty said...

Firstly, we have to know the age of the patient. In Respi station- young patient with clubbing, cyanosis and lung operation means CF unless proven otherwise.
CABG with amiodarone induced lung injury wont have clubbing and cyanosis.
Clubbing, cyanosis, sternotomy scar will be congenital heart disease with amiodarone induced fibrosis causing crackles.

 
At 9/02/2008 02:57:00 PM, Blogger Thiruppathy said...

amiodarone will not cause clubbing and moreover it will cause pigmentataion

 
At 10/25/2008 12:11:00 AM, Anonymous Anonymous said...

clubbing,cyanosis in a respiratory station is either fibrosing alveolitis, suppurative lung disease or ca lung the pt has ca lung leading to consilidation and the ischaemic heart disease is coincidence.

 
At 10/03/2009 09:47:00 AM, Anonymous Anonymous said...

young heavy smoker with premature coronary artey disease needing CABG had developed a lung CA possibly due to common aeitiolgy of smoking.

 
At 1/14/2010 03:43:00 AM, Anonymous Anonymous said...

Since when is rythm control better than rate control for AFib? Amiodarone may be used for post-cardiac surgery for rythm control but not for long periods. It is usually taken off, specially in young patients because of its s/e profile & if AFib persists it is managed with beta-blockers & anticoagulation.

Why would a young patient have CABG surgery??? Even if he is a heavy smoker & diabetic, CAD takes time to develop. More likely, he has underlying congenital heart disease.

Otherwise this is a dumb question, reason with me & tell me why it cant be-lung transplantation/advanced lung cancer with median lobectomy/Post-CABG with severe CHF etc. What rubbish!!!

 
At 5/23/2010 10:29:00 PM, Anonymous Anonymous said...

Post CABG multiple lung abcesses?
Amioderone induced cirrhosis?

 
At 10/13/2010 11:53:00 AM, Anonymous Anonymous said...

people what is the big fuss!!

this is a resp station, so simply amidarone induced lung fibrosis due to cyanotic heart disease or CABG or remotley heartlung transplantation with bronchioltiis obliterans..(lower zone consolidation)
that's it!

 

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