Table Of ContentPACES for the MRCP
Senior Content Strategist: Pauline Graham
Senior Content Development Specialist: Ailsa Laing
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PACES for the MRCP
With 250 clinical cases
Third edition
Tim HallMBChB FRCP MRCGP DipClinEd FHEA
Consultant in Geriatric Medicine and Acute and General (Internal) Medicine, Plymouth Hospitals NHS
Trust/South West Peninsula Deanery, Plymouth, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2013
An imprint of Elsevier Ltd.
© 2013, Timothy Hall. All rights reserved.
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First edition 2003
Second edition 2008
Reprinted 2009
Third edition 2013
ISBN 978-0-7020-5141-8
E-book ISBN 978-0-7020-5466-2
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others, including parties for whom they have a
professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,
to verify the recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate
safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material
herein.
The
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policy is to use
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from sustainable forests
Printed in China
Contents
Acknowledgements..............................................xi 1.11 Kartagener’s syndrome...........................38
Preface................................................................xiii 1.12 Tuberculosis ..........................................39
1.13 Idiopathic pulmonary fibrosis and
interstitial lung disease .........................43
Introduction
1.14 Rheumatoid lung ..................................50
1.15 Hypersensitivity pneumonitis
The Practical Assessment of Clinical
(extrinsic allergic alveolitis) .................50
Examination Skills (PACES) ...........................1
1.16 Asbestos-related lung disease and
PACES for the MRCP .......................................5 pneumoconiosis .....................................52
Further reading ...............................................8 1.17 Pulmonary sarcoidosis ...........................55
1.18 Pulmonary hypertension ........................58
1.19 Cor pulmonale .....................................60
Station 1 Respiratory and 1.20 Pulmonary embolism .............................61
abdominal system 1.21 Pleural effusion ....................................66
1.22 Pleural rub ..........................................71
1.23 Pneumothorax ......................................71
RESPIRATORY SYSTEM
1.24 Obstructive sleep apnoea–hypopnoea
Examination of the respiratory system ........10
syndrome .............................................74
Cases 1.25 Lung transplant ....................................76
1.1 Chronic obstructive pulmonary disease ....14 ABDOMINAL SYSTEM
1.2 Consolidation .......................................21
Examination of the abdominal system ........77
1.3 Dullness at the lung base ......................22
Cases
1.4 Pneumonia ...........................................23
1.5 Lung cancer .........................................26 1.26 Chronic liver disease .............................81
1.6 Pancoast’s syndrome ..............................31 1.27 Jaundice ..............................................90
1.7 Superior vena cava obstruction ..............32 1.28 Ascites .................................................92
1.8 Collapse / pneumonectomy / lobectomy ......33 1.29 Alcoholic liver disease ...........................94
1.9 Bronchiectasis .......................................34 1.30 Viral hepatitis ......................................96
1.10 Cystic fibrosis .......................................36 1.31 Autoimmune hepatitis .........................100
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Contents Contents
1.32 Primary biliary cirrhosis .......................101 Abdominal problems ..................................158
1.33 Genetic haemochromatosis ...................103 2.3 Dyspepsia and upper gastrointestinal
1.34 Wilson’s disease ..................................105 bleeding .............................................158
1.35 Hepatomegaly.....................................106 2.4 Dysphagia ..........................................166
1.36 Splenomegaly .....................................108 2.5 Abdominal pain ..................................168
1.37 Hepatosplenomegaly ............................109 2.6 Altered bowel habit and lower
1.38 Felty’s syndrome ..................................109 gastrointestinal bleeding ......................171
1.39 Abdominal mass ..................................110
Cardiovascular problems ............................177
1.40 Crohn’s disease ....................................111
2.7 Weight gain, obesity, and prevention
1.41 Ulcerative colitis ..................................114
of cardiovascular disease .....................177
1.42 Enteric and urinary stomas...................117
2.8 Chest pain and stable angina ..............183
1.43 Carcinoid syndrome .............................118
2.9 Acute coronary syndrome .....................189
1.44 Chronic myeloid leukaemia .................120
2.10 Heart failure ......................................199
1.45 Polycythaemia vera,
2.11 Palpitations ........................................207
myeloproliferative disorders
2.12 Atrial fibrillation .................................211
and myelodysplasia .............................124
2.13 Dyslipidaemia ....................................218
1.46 Chronic lymphocytic leukaemia ............128
2.14 Hypertension ......................................227
1.47 Lymphadenopathy and lymphoma .........129
1.48 Polycystic kidney disease ......................133 Neurological problems ...............................234
1.49 Nephrotic syndrome ............................134 2.15 Headache ...........................................234
1.50 Renal transplant .................................135 2.16 Transient ischaemic attack ...................241
Further reading ...........................................138 2.17 Weakness and wasting ........................246
2.18 Multiple sclerosis ................................248
2.19 Tremor ...............................................252
Station 2 History-taking skills
Rheumatological problems ........................254
INTRODUCTION TO HISTORY-TAKING SKILLS 2.20 Back pain and osteoporosis ..................254
2.21 Joint pain ..........................................261
Clinical reasoning .......................................142
Endocrine problems ...................................263
The traditional medical history model ......143
2.22 Type 1 diabetes mellitus ......................263
Incorporating the patient’s perspective –
2.23 Type 2 diabetes mellitus ......................271
ideas, concerns and expectations ...............143
Eye problems ..............................................278
History-taking skills – the communication
2.24 Visual loss .........................................278
skills that make history taking effective ....144
Renal and metabolic problems ..................279
The traditional model and communication
skills – putting these together ....................147 2.25 Acute kidney injury .............................279
2.26 Chronic kidney disease ........................287
Cases
2.27 Glomerulonephritis .............................296
Respiratory problems ..................................149
2.28 Systemic vasculitis ...............................301
2.1 Breathlessness and other respiratory 2.29 Hypercalcaemia ..................................308
symptoms ...........................................149 2.30 Hyponatraemia ...................................315
2.2 Asthma ..............................................153 2.31 Poisoning and metabolic disturbance ....322
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Contents
Haematological problems ..........................327 3.6 Other right-sided heart murmurs .........472
3.7 Mixed valve disease .............................473
2.32 Anaemia ............................................327
3.8 Mitral valve prolapse ..........................474
2.33 Sickle cell disease and thalassaemia .....333
3.9 Prosthetic valves .................................475
2.34 Purpura .............................................338
3.10 Permanent pacemaker and cardiac
2.35 Haemophilia ......................................342
device therapies ..................................476
2.36 Deep vein thrombosis ..........................344
3.11 Infective endocarditis ..........................477
2.37 Thrombophilic tendency .......................347
3.12 Congenital acyanotic heart disease .......481
2.38 Myeloma ............................................351
3.13 Cyanotic heart disease .........................483
Other problems in acute and general
3.14 Hypertrophic (obstructive)
medicine and elderly care ..........................357
cardiomyopathy ..................................484
2.39 Human immunodeficiency virus 3.15 Pericardial rub and pericardial
infection ............................................357 disease ...............................................487
2.40 Falls ..................................................368
NERVOUS SYSTEM
2.41 Syncope ..............................................372
Examination of the nervous system ...........488
2.42 Seizures .............................................383
2.43 Delirium and acute confusion ..............391 Examination of the nervous system –
2.44 Mild cognitive impairment and overview ......................................................488
dementia ............................................396
Examination of the cranial nerves .............489
2.45 Incontinence .......................................408
Examination of higher cortical function
2.46 Raised inflammatory markers ................411
and specific lobes .......................................496
2.47 Polymyalgia and giant cell arteritis ......421
2.48 Pyrexia and sepsis ...............................425 Examination of speech and language ........498
2.49 Weight loss and malignancy ................435
Examination of coordination .....................501
2.50 Tiredness ............................................440
Examination of power and sensation –
Further reading ...........................................442
overview ......................................................503
Examination of the upper limbs ................508
Station 3 Cardiovascular and Examination of the lower limbs .................512
nervous system
Examination of gait ....................................514
Cases
CARDIOVASCULAR SYSTEM
3.16 Visual field defects ..............................516
Examination of the cardiovascular
3.17 Ocular nerve lesions ...........................518
system ..........................................................452
3.18 Internuclear ophthalmoplegia ..............520
Cases
3.19 Nystagmus .........................................521
3.1 Mitral stenosis ....................................462 3.20 Ptosis .................................................523
3.2 Mitral regurgitation ............................465 3.21 Large pupil ........................................524
3.3 Aortic stenosis ....................................467 3.22 Small pupil ........................................525
3.4 Aortic regurgitation ............................469 3.23 Horner’s syndrome ..............................526
3.5 Tricuspid regurgitation and 3.24 Cerebellopontine angle syndrome..........527
Ebstein’s anomaly ...............................471 3.25 Facial nerve palsy ...............................529
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Contents Contents
3.26 Bulbar palsy .......................................531 Cases
3.27 Anterior circulation stroke Discussing clinical management ................618
syndromes ..........................................532
4.1 Explaining a diagnosis ........................618
3.28 Dysphasia and dysarthria ....................548
4.2 Explaining an investigation .................619
3.29 Pseudobulbar palsy .............................549
4.3 Discussing treatment ...........................622
3.30 Agnosias and apraxias .........................550
4.4 Discussing management, prognosis
3.31 Posterior circulation stroke syndromes ...553
and possible complications in a
3.32 Parkinson’s disease ..............................556
patient with multiple problems.............625
3.33 Cerebellar disease ...............................565
4.5 Discussing diagnostic uncertainty .........626
3.34 Spastic paraparesis and
4.6 Discussing risk and treatment effect .....628
Brown–Séquard syndrome ....................566
4.7 Negotiating a management plan
3.35 Syringomyelia .....................................569
for a chronic disease / long-term
3.36 Absent ankle jerks and extensor
condition ...........................................631
plantars .............................................569
4.8 Encouraging concordance with
3.37 Motor neurone disease ........................573
treatment and prevention ....................633
3.38 Cervical myeloradiculopathy ................577
Communication in special
3.39 Cauda equina syndrome ......................578
circumstances ..............................................635
3.40 Carpal tunnel syndrome (median
nerve lesion) .....................................581 4.9 Cross-cultural communication ..............635
3.41 Ulnar nerve lesion ..............................583 4.10 Communicating with angry patients
3.42 Radial nerve lesion .............................585 or relatives .........................................636
3.43 Wasting of the small (intrinsic) 4.11 Communicating with upset or
muscles of the hand ............................586 distressed relatives ..............................638
3.44 Common peroneal nerve lesion.............588 4.12 Discharge against medical advice .........639
3.45 Peripheral neuropathy .........................589 4.13 Delayed discharge ...............................641
3.46 Charcot–Marie–Tooth disease and
Breaking bad news ......................................643
hereditary neuropathies .......................597
4.14 Cancer – potentially curable ................643
3.47 Guillain–Barré syndrome.....................598
4.15 Cancer – probably incurable ................646
3.48 Myasthenia gravis ...............................602
4.16 Cancer – patient not fit for active
3.49 Myopathy and myositis ........................604
treatment ...........................................648
3.50 Myotonic dystrophy ..............................610
4.17 Chronic disease ..................................650
Further reading ...........................................612
4.18 Discussing an acutely terminal
situation with relatives ........................651
Confidentiality, consent and capacity ........653
Station 4 Communication skills
and ethics 4.19 Legal points in confidentiality ..............653
4.20 Breaching confidentiality when a
third party may be at risk ...................654
INTRODUCTION TO COMMUNICATION
4.21 Breaching confidentiality in the
SKILLS AND ETHICS
public interest ....................................656
Communication skills ................................616
4.22 Confidentiality when talking with
Ethics ...........................................................617 relatives and other third parties ...........658
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Contents
4.23 Consent for investigation or 4.46 HIV testing ........................................729
treatment ...........................................660 4.47 Needlestick injury ...............................730
4.24 Consent and capacity ..........................663 4.48 Medical opinion on fitness for
4.25 Refusal of consent ...............................668 anaesthesia ........................................732
4.26 Deliberate self-harm ...........................670 4.49 Fitness to drive ...................................734
End-of-life issues .........................................673 4.50 Industrial injury benefits .....................735
Further reading ...........................................737
4.27 End of life and palliative care ..............673
4.28 Advance decision making .....................681
4.29 Resuscitation status decision-making –
Station 5 Integrated clinical
discussion with patient ........................683
assessment
4.30 Resuscitation status decision-making –
discussion with relative .......................688
SKIN PROBLEMS
4.31 Appropriateness of intensive therapy
unit transfer .......................................690 Examination of the skin .............................740
4.32 Withholding and withdrawing
Cases
life-prolonging treatments – antibiotics
5.1 Psoriasis ............................................742
and drugs ..........................................692
5.2 Dermatitis .........................................746
4.33 Withholding and withdrawing
5.3 Lichen planus .....................................749
life-prolonging treatments – clinically
5.4 Blistering skin disorders ......................751
assisted nutrition and hydration ...........693
5.5 Facial rash .........................................756
4.34 Percutaneous endoscopic gastrostomy
5.6 Scleroderma, vitiligo and
feeding ..............................................697
autoimmune skin disease .....................759
4.35 Vegetative state ...................................701
5.7 Oral lesions and nail lesions ................761
4.36 Brainstem death .................................705
5.8 Shin lesions ........................................764
4.37 Discussing live organ donation.............707
5.9 Neurofibromatosis and tuberose
4.38 Requesting an autopsy (post mortem) ..709
sclerosis .............................................767
Clinical governance .....................................711
5.10 Neoplastic skin lesions .........................771
4.39 Critical incident ..................................711
RHEUMATOLOGICAL PROBLEMS
4.40 Managing a complaint and the
Examination of the joints ...........................774
question of negligence .........................714
4.41 Fitness to practise – poor performance Examination of the joints – overview ........774
in a colleague .....................................717
Examination of the hands and arms ..........777
4.42 Fitness to practise – misconduct in
Examination of the legs ..............................782
a colleague .........................................720
4.43 Fitness to practise – health problems Examination of the spine ...........................784
in a colleague .....................................722 Cases
4.44 Recruitment to a randomised
5.11 Rheumatoid hands and rheumatoid
controlled trial ...................................723
arthritis .............................................786
Other communication, ethical and
5.12 Ankylosing spondylitis and
legal scenarios .............................................727
spondyloarthropathies ..........................793
4.45 Genetic testing ...................................727 5.13 Systemic lupus erythematosus ...............797
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