Hello listeners, it's Sam here again with the usual shout out for our brilliant sponsors before this week's show. You can get access to Quasmed's amazing Paces revision platform which is linked in any of the show notes and you can use the discount code prepaces15 that's all in capital's prepaces15 to get 15% off at the checkout. I think most Paces citizens would agree this is more or less essential to complement your award best preparation for your Paces exam. And to add to that, Paces ahead have courses towards the end of 2025 and the start of 2026. The course from the 6th to the 9th of October is almost fully booked but there are a few last minute places available if you wanted to be there in October. But for those of you thinking ahead to 2026, the course dates for your diary are the 19th to the 22nd of January and the 26th to the 29th of January, 2026. I strongly advise you to book in advance to avoid disappointment for the best course there is to support your Paces preparation. With Quasmed and Paces ahead, they are all you need to smash your Paces exam and succeed in getting your MRCP sorted. But enough on that for now, let's get into this week's episode of the prepaces podcast. Welcome listeners to this episode of the prepaces podcast with me, Dr Sam Williams. And back by popular demand is our perfect presentations format. This episode in particular is dedicated to one of the IMTs currently on the ward I'm working on, Anna, who was currently revising for her exam in about 6 weeks time. And she requested that I do a perfect presentations episode on a very popular topic that went out last year and surely one of the most common stations in Paces. And that is interstitial lung disease or pulmonary fibrosis. For those of you who haven't listened before, in this episode format, we focus on how to present a case back to the examiner at the end of a Paces station, making sure you do it clearly, confidently and within the limited time you're given. And in this case, it will be within the four minutes of discussion with the examiner at the end of your respiratory examination station. As always, this is not intended to be the only way to do it, nor is it exhaustive. Instead, this is simply a structured framework you can adapt to your own style to execute in your own way, in your own exam. So if you haven't listened to my dedicated episode on this topic, you can go back and listen to my discussion with Dr. Hosea Faradam Ali of South Meal Hospital in Bristol in episode number 115. So go back and listen to that if you haven't already. But before we get into this week's episode, you can thank the legendary Bimeo Coffee Heroes that mean that this podcast remains free at the point of use. To this week, our thanks go to Orthy and Owen, both of whom who donated to Moad, Zahan and Anna who all passed, thank you to Kit who said they would still tune in yearly for the Christmas bloopers episode. Thank you to Cameron who said the pod improved his medical knowledge and practiced as an IMT. And thank you to Peter Arnold Smith who found out he passed whilst on holiday with his mum. That's as wholesome as it gets. But without further ado, let's get into this week's episode on Perfect Presentations of Pormony Fibrosis. So as usual, we start this episode by picturing the scene. You have just completed a full respiratory examination. You thank the patient and you turn to the examiner. For your context, the written vignette before the station started red. This is Mrs Thompson, a 64 year old woman with progressive exertional breathlessness. Please examine her respiratory system. Don't forget you'll hear a ding at the end of each minute and a double ding at the end of your penultimate minute denoting one minute left. So you finished your examination and the examiner turns to you and says, "Would you like to present your findings?" Yes, absolutely. So this is Mrs Thompson, a 64 year old woman whose respiratory system I have examined today. The most significant finding on examination is bilateral fine respiratory crepitations at the lung bases consistent with institial lung disease. On general inspection, she's mildly breathless at rest but there's no respiratory distress. She has digital clubbing, bilaterally. There are no signs of heart failure, core pulmonarly and she is not clinically in actual fibrillation. On examination of the chest, chest expansion is reduced by, actually, particularly at the bases. The percussion note is normal throughout. On oscillation, there are fine crackles present at both bases which persist after coughing. There's no wheeze and I did not find any features to suggest obstructive airways disease, such as a prolonged expiratory phase when quietly breathing at rest. There are no obvious extra pulmonary features of autoimmune disease on inspection, particularly no small joint polyarthropathy of the hands, no skin thickening, rashes, joint deformities or muscle wasting. In summary, this patient has clinical features consistent with interstitial lung disease. Given her age and presentation, possible causes include idiopathic pulmonary fibrosis, well controlled autoimmune related interstitial lung disease without evidence of joint disease, and given the crackles were had predominantly at the bases, other causes of basal predominant pulmonary fibrosis include asbestos related lung disease and drug induced pulmonary fibrosis. These would be important features to ask about within the history. To further assess this patient, I would want to take a full history, asking specifically about those elements mentioned. I would request a full set of observations paying particular attention to the respiratory rate and the oxygen situations. I would request formal lung function tests, including spiroometry, observing specifically for a restrictive breathing pattern. An arterial blood gas may be helpful to guide the need for long-term oxygen therapy if the diagnosis is confirmed. Routine blood tests will be helpful, but specifically an autoimmune screen will be helpful to examine for an underlying cause. Chest imaging by X-ray would be helpful, but the diagnosis would be confirmed on a high resolution CT scan of the chest, which would characterise the pattern of interstitial lung disease. In terms of further management, I would refer her to a respiratory specialist for further investigations of management. Yes, alright. So, could you tell me some other causes of clubbing within the respiratory system aside from interstitial lung disease? Yes, other respiratory causes of clubbing include subprative lung diseases such as bronchitis or cystic fibrosis. These are less likely here as the patient had predominantly fine crepitations, and the crackles typically associated with bronchitis would be coarse. Other causes of clubbing include lung cancer, lung abscesses or tuberculosis. One minute left. Okay, and can you state some causes of upper zone pulmonary fibrosis? Yes, so typically causes of upper zone pulmonary fibrosis might include radiotherapy-related fibrosis, particularly for patients who have received radiotherapy for lung cancer or breast cancer, and while most autoimmune conditions will cause lower zone fibrosis and collosing spondylitis typically causes upper zone fibrosis. New maconiosis or silicoces can cause upper zone fibrosis as well as tuberculosis and pulmonary sarcoid can also cause fibrosis of the upper zones. You mentioned that you would perform pulmonary function tests. What would you expect to see in this particular case? So if the diagnosis is confirmed that this is interditional lung disease, pulmonary function tests would typically show a restrictive pattern with reduced lung volumes and reduced force vital capacity with a slight reduction or a normal FEV1, so the FEV1 to FBC ratio is usually preserved. Okay, and. I've started so I'll finish. What are the cornerstones of management of interstitial lung disease? The management should involve an MDT approach led by a respiratory physician with an interest in interstitial lung disease. Many members of the MDT are important, such as specialist nurses as well as chest physiotherapists. In terms of lifestyle changes, the patient can make. The patient should abstain from smoking and avoid any exacerbating agents which may either be the underlying cause or contribute to their symptoms. One-time oxygen therapy can be considered as an important element of management and a role in the patient in programs such as pulmonary rehabilitation are also very important. Patients should also be routinely vaccinated on an annual basis. In terms of medical management, steroids can be utilized in acute flares if their condition is steroid responsive and anti-fibrotic agents such as nintedinib or perphenidone may be helpful but I would leave their prescription to the discretion of the respiratory team. Thank you. So there we go listeners, that's the end of our perfect presentation on interstitial lung disease and just a few important exam techniques points to highlight here. Notice how the candidate stuck the preferred diagnosis.
front and centre of their presentation with it stated within the first couple of sentences. This is really crucial to demonstrate the examiners you're confident in your diagnosis. Secondly, the crepitations were described as fine, in-spiritsry and basal in nature. These descriptors really matter and saying just crepitations or just crackles alone is rarely enough to get you the mark. Lastly, negative findings are used quite sparingly. You don't need to list everything that's normal, but only what helps narrow the differential or might point towards a specific differential diagnosis. Finally, investigations are justified when mentioned, not simply listed. A high resolution CT is mentioned because it defines the pattern of disease and, although not mentioned in the presentation, it's important to leave some low-hanging fruit for the examiner questions such as what pattern would you expect to see on the lung function tests? An important point to remember as well is that even if the examiner interrupts you early, at this point you've already demonstrated safe diagnosis, pattern recognition and prioritisation of the important steps of management. Some examiners will interrupt very early in these types of stations, particularly once you've said the diagnosis and identified the relevant clinical signs. That's not a bad thing, and it usually means they're satisfied you've reached the diagnosis and they want to try and maximise your marks in other areas of the marking scheme. So I hope that gives you some important points to take into your presentation of interstitial lung disease. But that's just about all the time we've got for this week's show. I hope you've enjoyed this perfect presentation episode as much as I love bringing them to you. If you'd like a specific perfect presentation topic, please do get in touch. You can do that via the website prepacespodcast.com or via the email
[email protected]. Don't forget to like, follow, subscribe or leave a five star review to the show wherever you get your podcasts. And as ever, if you want to go above and beyond and support the show, you can do that at bimicoffee.com/prepacespodcast. But for now, we're just about out of time. I'd be Dr. Sound Williams. Thank you so much for listening and we'll see you next time on the prepacespodcast. [Music]
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