The Respiratory Station in MRCP PACES (Station 1)

What this station tests and how the timing runs

Station 1 pairs a respiratory examination with a separate communication encounter, each with its own clock. For the respiratory case the timing is tight: you get 6 minutes to complete a focused chest examination, then 4 minutes of directed questioning in which the examiners ask for your findings, your differential, and how you would investigate and manage.

The task is deliberately non-verbal in its first half — you are being judged on your hands and eyes, not your patter. Assume the courtesy preliminaries (hand hygiene, introduction, consent, positioning at 45 degrees) are expected but not what earns marks. What earns marks is a clean, reproducible routine that surfaces the discriminating signs, followed by a crisp summary that commits to a diagnosis rather than listing everything you saw.

The marking skills that apply

Five of the seven PACES skills are marked here: A, B, D, E and G. Each is graded Satisfactory, Borderline or Unsatisfactory, and the encounter score is the sum of those five marks. Aim for Satisfactory across the board and know what that looks like for each.

• A — Physical Examination: a thorough, systematic technique that looks for every sign relevant to a chest case. It is completeness that counts, not the exact order — do not miss the parts that matter (chest wall, expansion, percussion, breath sounds, plus the peripheral clues).
• B — Identifying Physical Signs: correctly reading what is there and not inventing what is not. In practice this is where cases are won or lost — hearing fine end-inspiratory crackles versus coarse crackles, or calling reduced expansion on the correct side.
• D — Differential Diagnosis: offering a sensible differential that contains the correct diagnosis. A patient with bibasal fine crackles and clubbing should prompt a fibrosis-led differential, not a vague 'chest infection'.
• E — Clinical Judgement: a management plan with appropriate investigations and a timescale — for interstitial disease that means high-resolution CT, lung function with transfer factor, and an autoimmune screen, then a sensible onward plan.
• G — Maintaining Patient Welfare: examining safely and sensibly, and offering realistic safety-netting and disposition when asked. Do not hurt the patient or jeopardise their safety.

A systematic examination routine

Have one framework you can run on autopilot so your attention is free for the signs. Start at the hands: look for clubbing, tar staining, a fine tremor or CO2 flap, and peripheral cyanosis. Move to the pulse and respiratory rate, then the face for central cyanosis and pursed-lip breathing. Check the neck for a raised JVP (cor pulmonale) and lymphadenopathy, and glance for a tracheostomy scar or accessory muscle use.

At the chest, inspect for scars, chest wall deformity and asymmetry before you touch. Assess the trachea and apex beat for mediastinal shift, then chest expansion upper and lower. Percuss for dullness (effusion, consolidation, collapse) or hyper-resonance. Auscultate for breath sound quality, crackles (fine versus coarse, and their zone), wheeze, and bronchial breathing, and check vocal resonance. Do not forget to sit the patient forward for the posterior chest, feel for sacral or ankle oedema, and — mentally — offer to check sputum, oxygen saturations and a peak flow.

When you present, lead with the diagnosis you believe, support it with the two or three signs that clinch it, then give your differential. A confident, signposted summary reassures the examiners that your A and B were sound.

Common conditions and how to prepare

Respiratory short cases cluster around a handful of recurring pictures, so drill the pattern recognition. Interstitial lung disease and pulmonary fibrosis are perennial — bibasal fine end-inspiratory crackles with clubbing, where you should reach for idiopathic pulmonary fibrosis as the lead diagnosis while actively hunting for a secondary cause such as a connective tissue disorder like systemic sclerosis (tight, shiny skin, telangiectasia, sclerodactyly). Both are covered in depth on their own pages linked below.

Beyond fibrosis, prepare for pleural effusion (stony dull base, reduced expansion and breath sounds), bronchiectasis (coarse crackles that change with coughing, copious sputum), COPD (hyperinflation, wheeze, prolonged expiration), old tuberculosis or a lobectomy/pneumonectomy (thoracotomy scar, tracheal deviation, absent sounds over the resection), and the lung transplant patient. For each, rehearse the three signs that name it, the differential you would offer, and a first-line investigation plan — that is precisely what the 4-minute discussion asks for.