MRCP PACES Station 1: High-Yield Respiratory Examination Guide

Why Station 1 Respiratory Cases Trip Up Good Candidates

Station 1 of MRCP PACES is the first clinical encounter candidates face, and respiratory cases dominate the majority of slots. Despite being a "physical sign" station, candidates lose marks not because they cannot identify a wheeze or crackle, but because their examination lacks a consultant-level flow, their sign interpretation is shallow, or they fail to integrate findings into a coherent differential under time pressure. This guide covers the structure of Station 1, the high-yield respiratory cases examiners choose, and the technique that separates a pass from a borderline performance.

Station 1 Format: What You Are Actually Marked On

Station 1 is a 10-minute station comprising two patient encounters, each lasting 5 minutes. The examiner allocates approximately 4 minutes for examination and 1 minute for questions per patient. The two systems tested are Respiratory and Abdomen, though you may sometimes face alternative pairings depending on the cycle.

The marking is split across three domains, all of which must be evidenced in your respiratory encounter:

• Physical Examination (P) – systematic, fluent, thorough technique

• Identifying Physical Signs (I) – accurate detection of signs present in the patient

• Clinical Reasoning (C) – interpreting findings, formulating a differential, suggesting investigations

The PACES23 mark sheet is unforgiving: you must demonstrate all three, not just one. A beautiful examination of a patient with a missed sign, or a clever differential without a structured examination, will both fail.

The Consultant-Level Respiratory Examination Sequence

Candidates who score highly do not run through a generic "inspect, palpate, percuss, auscultate" list. They perform a reasoned sequence that builds the diagnosis in the examiner's mind. Use the following structure:

1. End-of-Bed Inspection (Don't Skip This)

• Oxygen delivery – type, flow rate, saturation

• Breathing pattern – rate, depth, pursed-lip breathing, use of accessory muscles, paradoxical breathing

• Cyanosis – central or peripheral

• Body habitus – cachexia (lung cancer, COPD), obesity (OSA, obesity hypoventilation)

• Distress – ability to complete sentences

• Sputum pots, inhalers, nebulisers at bedside

• Walking aids, home oxygen

2. Hands

• Clubbing – look at the thumb/index, Schamroth's window

• Cyanosis – peripheral

• Tar staining – smoking history clue

• CO2 flap (asterixis) – type 2 respiratory failure

• Fine tremor – salbutamol use

• Wasting of intrinsic muscles – Pancoast tumour, severe COPD

• Radial pulse – pulsus paradoxus (severe asthma)

3. Face and Neck

• Central cyanosis (tongue, lips)

• Horner's syndrome – Pancoast tumour

• SVC obstruction features – facial plethora, periorbital oedema, distended neck veins

• Mouth breathing, pursed-lip breathing

• Tracheal position – central, deviated, or pulled

• JVP – elevated in cor pulmonale, pulmonary hypertension

• Cervical lymphadenopathy – lung cancer, sarcoidosis, TB

4. Chest Inspection (Front Then Back)

• Deformity – barrel chest, pectus excavatum, pectus carinatum, kyphoscoliosis

• Scars – thoracotomy, lobectomy, VATS, chest drain sites

• Radiotherapy marks – skin changes, tattoo dots

• Asymmetry – volume loss, collapse, fibrosis

• Chest wall movement – symmetry, expansion

5. Palpation

• Trachea – confirm position

• Apex beat – displaced (consolidation, effusion), tethered (fibrosis, TB)

• Chest expansion – reduced on the affected side in most pathologies

6. Percussion

• Compare side to side, apex to base

• Dull – effusion, consolidation, collapse, fibrosis, raised hemidiaphragm

• Resonant/normal – healthy lung

• Hyper-resonant – pneumothorax, hyperinflation (COPD), large bullae

7. Auscultation

• Breath sounds: vesicular, bronchial, reduced, absent

• Added sounds:

  • Fine end-inspiratory crackles – interstitial lung disease, pulmonary oedema

  • Coarse crackles – bronchiectasis, pneumonia, pulmonary oedema

  • Wheeze (monophonic/polyphonic) – asthma, COPD, focal obstruction

  • Stridor – upper airway obstruction

  • Pleural rub – pleurisy, pulmonary infarction

8. Vocal Resonance

• Increased – consolidation

• Decreased – effusion, pneumothorax, collapse

• Always compare symmetrically

9. Completion

• Sacral oedema

• Ankle oedema – cor pulmonale

• Thank the patient, offer to help them redress

A clean, well-practised sequence takes 3.5 minutes. You will then have 1 minute for questions.

High-Yield Respiratory Cases in Station 1

Examiners choose patients with stable, demonstrable signs. The most commonly selected conditions, in approximate order of frequency, are:

1. COPD (with or without Cor Pulmonale)

Key signs:

• Barrel chest, hyperinflation, reduced cricosternal distance

• Reduced expansion bilaterally

• Hyper-resonant percussion

• Quiet breath sounds, wheeze (often expiratory)

• Tar-stained fingers

• Pursed-lip breathing, accessory muscle use

• Peripheral oedema if cor pulmonale present

• JVP elevated, often with right heart heave

Differential to mention:

• Asthma (if reversibility and atopy)

• Bronchiectasis (coarse crackles, copious sputum)

• Alpha-1 antitrypsin deficiency (younger, basal emphysema)

Key investigations to offer:

• Spirometry (FEV1/FVC < 0.7, FEV1 % predicted for severity grading)

• ABG (assess for type 2 respiratory failure)

• ECG (right heart strain, P pulmonale)

• CXR (hyperinflation, flattened diaphragm, bullae)

• Echocardiogram (cor pulmonale)

• Alpha-1 antitrypsin level (if young or basal disease)

2. Interstitial Lung Disease / Pulmonary Fibrosis

Key signs:

• Bilateral fine end-inspiratory crackles (often described as "Velcro")

• Reduced expansion (often bibasally in IPF)

• Tethered trachea (towards the more affected side, often lower zone)

• Clubbing (50–80% of IPF)

• Cyanosis if advanced

Differential to mention:

• Idiopathic pulmonary fibrosis (most common)

• Connective tissue disease (RA, scleroderma, polymyositis)

• Hypersensitivity pneumonitis (bird fancier, farmer)

• Drug-induced (amiodarone, methotrexate, bleomycin, nitrofurantoin)

• Asbestosis (occupational history)

• Sarcoidosis (look for lupus pernio, lymphadenopathy)

Key investigations:

• Spirometry (restrictive pattern, FVC reduced)

• CXR and HRCT (honeycombing, traction bronchiectasis)

• Autoimmune screen (ANA, ENA, RF, anti-CCP, myositis antibodies)

• Echocardiogram (RV function, pulmonary hypertension)

• 6-minute walk test

• Lung biopsy if diagnostic uncertainty

3. Bronchiectasis

Key signs:

• Coarse inspiratory crackles, often bilateral, with a "crunch" quality

• Clubbing (in advanced cases)

• Copious sputum production (always ask about volume and character)

• Halitosis

• Tracheal deviation if upper lobe predominant (post-TB, cystic fibrosis)

Differential to mention:

• Post-infective (childhood TB, whooping cough, severe pneumonia)

• Cystic fibrosis (young patient, nasal polyps, recurrent infections)

• ABPA (asthma history, eosinophilia, central bronchiectasis)

• Primary ciliary dyskinesia (situs inversus, infertility, chronic sinusitis)

• Immunodeficiency (HIV, hypogammaglobulinaemia)

• Connective tissue disease (RA, SLE)

Investigations:

• HRCT (signet ring sign, tram tracking, bronchial wall thickening)

• Sputum culture (chronic Pseudomonas, Staph aureus, H. influenzae)

• Immunoglobulins

• CF genotyping, sweat test (younger patients)

• Aspergillus precipitins, IgE (ABPA)

4. Pleural Effusion

Key signs:

• Trachea deviated away (if large, under tension)

• Reduced expansion on affected side

• Stony dull percussion

• Reduced or absent breath sounds

• Reduced vocal resonance

Differential and cause to consider:

• Transudate (heart failure, cirrhosis, nephrotic syndrome) vs exudate (Light's criteria)

• Malignancy (mesothelioma, metastatic)

• Infection (parapneumonic, empyema, TB)

• PE (with infarction)

• Connective tissue disease (RA, SLE)

• Pancreatitis, post-CABG (Dressler's)

Investigations:

• CXR (meniscus sign), CT thorax with contrast

• Bedside ultrasound (loculation, size for safe aspiration)

• Diagnostic pleural aspiration (Light's criteria, pH, glucose, LDH, protein, cytology, microbiology, adenosine deaminase for TB)

5. Lung Cancer / Lung Mass

Key signs:

• Finger clubbing (especially with hypertrophic pulmonary osteoarthropathy)

• Cachexia

• Lymphadenopathy (cervical, supraclavicular – especially left-sided Virchow's node)

• Horner's syndrome (Pancoast tumour)

• SVC obstruction (facial plethora, distended neck veins)

• Monophonic wheeze (focal obstruction)

• Dullness and reduced breath sounds if effusion or collapse

• Hepatomegaly if metastases

Differential / type to mention:

• NSCLC vs SCLC

• Pancoast (superior sulcus)

• Mesothelioma (asbestos exposure history)

• Single metastasis (renal, colon, sarcoma)

Investigations:

• CXR, CT thorax/abdomen/pelvis, PET-CT

• Biopsy (CT-guided, bronchoscopy, EBUS, pleural if effusion)

• Staging investigations (MRI brain, bone scan, EBUS)

• Lung function tests (for surgical fitness)

6. Pneumothorax

Key signs:

• Hyper-resonance, reduced/absent breath sounds

• Reduced expansion

• Trachea central in simple pneumothorax, deviated away in tension

• Tachycardia, hypoxia

• Surgical emphysema (if traumatic or post-procedural)

Differential:

• Primary (tall, thin, young male, smoker)

• Secondary (underlying lung disease – COPD, CF, LAM, lymphangioleiomyomatosis, Marfan)

• Tension (medical emergency)

• Traumatic / iatrogenic

Investigations:

• CXR (look for visible visceral pleural line)

• Bedside ultrasound (absent lung sliding)

• ABG

7. Lobar Collapse

Key signs vary by lobe:

• RUL collapse – trachea and apex pulled up and right

• LUL collapse – trachea pulled left, decreased expansion, dullness anteriorly

• LLL collapse – dullness at left base, preserved heart border, "sail sign"

• RLL collapse – dullness at right base

• Reduced breath sounds and vocal resonance

Most common cause:

• Bronchial carcinoma (especially in smokers and the over-50s)

• Mucus plug (post-operative, severe asthma)

• Foreign body (aspiration in children, elderly, neurological impairment)

• TB (in endemic areas)

Investigations:

• CXR (look for volume loss, mediastinal shift, elevated hemidiaphragm)

• CT thorax

• Bronchoscopy (diagnostic and therapeutic for mucus plug)

8. Other Frequently Tested Cases

• Asthma (well-controlled) – quiet chest between exacerbations; may be subtly hyperinflated

• Pulmonary hypertension – loud P2, right ventricular heave, elevated JVP, tricuspid regurgitation murmur

• Kyphoscoliosis – restrictive pattern, asymmetric chest

• Previous lobectomy / pneumonectomy – scars, absent breath sounds, dullness on affected side, compensatory hyperinflation

• Tuberculosis (old) – destroyed lung – fibrosis, traction, often unilateral

• Sarcoidosis – bilateral hilar lymphadenopathy, lupus pernio, may have skin or eye signs

Examiner Question Bank: What They Will Ask

In the final minute, expect two or three questions. Common variants include:

• "What is the most likely diagnosis?" – state your top diagnosis, justify with three to four sign-based points, then offer a credible alternative.

• "What is your differential?" – group by cause (airway, parenchymal, pleural, vascular, chest wall) or by pathophysiology (obstructive vs restrictive).

• "What investigations would you request?" – start with a bedside test (peak flow, sputum, ABG), move to first-line imaging (CXR), then second-line (CT, spirometry, echo).

• "How would you manage this acutely?" – ABCDE, oxygen titration (use venturi mask in COPD if CO2 retainer), bronchodilators, steroids, antibiotics, escalation plan.

• "What is the underlying cause?" – smoking, occupational exposure, drug history, connective tissue disease, family history.

• "What is the prognosis?" – base on severity grading, FEV1 (GOLD), mMRC dyspnoea scale, frequency of exacerbations, hospital admissions, comorbidity.

A common failure mode is to give a one-line answer. The examiner wants to hear structured, prioritised, sign-anchored reasoning, in roughly 30–45 seconds per question.

Common Pitfalls in Station 1 Respiratory Cases

1. Forgetting the end of bed. Walking straight to the patient and missing 50% of the diagnosis (sputum pots, oxygen, distress) is the most common error.

2. Inadequate chest expansion testing. Anterior AND posterior, with the hands properly positioned on the chest wall, not just resting on the flanks.

3. Skipping vocal resonance. It is part of the standard sequence, and you will lose the "thoroughness" mark without it.

4. Not looking for associated signs. A patient with COPD needs JVP, peripheral oedema, and heart auscultation. A patient with apical fibrosis needs the face (lupus pernio), hands (sclerodactyly, telangiectasia), and joints.

5. Failing to complete the examination. Always check ankles, sacrum, and offer to help the patient back into their clothes. It signals consultant-level professionalism.

6. Giving a list rather than a synthesis. "He has clubbing, crackles, and a rash" is weaker than "The combination of bilateral fine end-inspiratory crackles, finger clubbing, and sclerodactyly makes me think of scleroderma-associated interstitial lung disease, and I would want to examine the face for telangiectasiae and the hands for calcinosis."

7. Not stating negatives. "Trachea is central, expansion is equal, percussion is resonant throughout" is part of a thorough assessment.

8. Poor hand hygiene – always offer alcohol gel at the start and end of the examination.

How to Practise Station 1 Effectively

A focused, deliberate practice plan outperforms a high-volume, unfocused one. The following structure works for the average candidate over 4–6 weeks:

• Week 1 – Build the sequence. Practise the full examination on a willing colleague, family member, or AI patient simulator, focusing on fluidity and timing. Aim for 3.5 minutes of examination plus 1 minute of questioning.

• Week 2 – Sign library. Watch at least one high-quality video of each of the major signs (use trusted YouTube channels or your local PACES teaching). Build a personal "sign atlas" with short notes on cause and significance.

• Week 3 – Real patients. Volunteer in respiratory outpatients, COPD rehab, ILD clinics, or TB services. Sign recognition is dramatically better on a real patient than a textbook.

• Week 4 – Mock PACES. Book at least two mock PACES cycles, ideally with consultant examiners. Use the mark sheet honestly and identify recurring weaknesses (e.g., examination sequence, differential, communication).

• Week 5 – Targeted remediation. Drill the two or three weak areas. Common choices are percussion technique, vocal resonance, and the question segment.

• Week 6 – Confidence and timing. Run full mock stations under timed conditions, including the abdominal and the other station. Recovery between cases matters as much as each case itself.

The Communication Element in Station 1

Although Station 1 is sign-led, candidates regularly lose marks for poor patient communication. The patient is, after all, a real person being examined by a stranger in a stressful exam.

• Introduce yourself with your full name and role.

• Ask permission to examine ("Is it alright if I examine your chest today?").

• Explain what you are going to do before you do it.

• Be gentle on cold stethoscopes, percussion, and posterior chest expansion.

• If the patient is in pain, breathless, or distressed, slow down and acknowledge it.

• Thank the patient at the end and offer to help them re-dress.

• Wash or gel your hands before and after.

Examiners notice this. The mark sheet allows for "patient-centred" behaviour, and it is a discriminator at the borderline pass/fail mark.

High-Yield One-Liner Sign Recognition

For rapid revision in the final week, the following one-liners cover the majority of examiner questions:

• Bilateral fine end-inspiratory crackles + clubbing + tethered trachea → interstitial lung disease (consider CTD, IPF, drug-induced)

• Coarse crackles + copious sputum + halitosis → bronchiectasis (consider CF if young, ABPA if asthmatic)

• Hyperinflation + quiet breath sounds + pursed-lip breathing + tar staining → COPD

• Stony dull + reduced breath sounds + trachea away → pleural effusion
  n- Hyper-resonance + absent breath sounds + reduced expansion + central trachea → pneumothorax

• Trachea deviated to affected side + dullness + reduced breath sounds → collapse or fibrosis (consider malignancy if collapse, TB if upper lobe)

• Horner's + wasted intrinsic hand muscles → Pancoast tumour

• Loud P2 + RV heave + elevated JVP → pulmonary hypertension / cor pulmonale

Final Thought

Station 1 rewards preparation, not luck. Examiners choose stable, demonstrable cases because they want to see whether you can detect and interpret a sign, then reason through it like a registrar presenting to a consultant. Practise the sequence until it is automatic, learn the sign interpretation, drill the differential, and rehearse the question segment. The candidates who pass Station 1 are the ones who walk in knowing exactly what they are going to do in the first 30 seconds, regardless of which patient they find.