Overview of Station 1: Respiratory
Station 1 of PACES gives you 10 minutes to examine a patient's respiratory system and present your findings. You will be assessed on your examination technique, ability to identify physical signs, and clinical reasoning.
The respiratory station is one of the most predictable in PACES — the same conditions appear repeatedly because they produce reliable, reproducible signs.
The Systematic Approach
Your examination should follow this sequence every single time, regardless of what you find:
General Inspection (30 seconds)
Before touching the patient, observe from the end of the bed:
- Respiratory rate and pattern — is the patient tachypnoeic, using accessory muscles?
- Body habitus — cachexia (malignancy), obesity (OSA)
- Oxygen — nasal cannulae, Venturi mask, home oxygen
- Bedside clues — inhalers, sputum pots, peak flow meters, chest drains
Hands and Arms (60 seconds)
- Clubbing (fibrosis, bronchiectasis, lung cancer, empyema)
- Tar staining
- Fine tremor (salbutamol)
- Peripheral cyanosis
- CO2 retention flap (asterixis)
- Wasting of small muscles (Pancoast tumour)
Face and Neck (60 seconds)
- Central cyanosis (tongue)
- Horner's syndrome (Pancoast)
- JVP — raised in cor pulmonale, SVC obstruction
- Tracheal position — always check (deviation = key sign)
- Lymphadenopathy
Chest Examination (6 minutes)
Examine the front and back systematically using:
- Inspection — scars (thoracotomy, chest drain), deformity, asymmetry of expansion
- Palpation — apex beat displacement, expansion (hands around lower chest), tactile vocal fremitus
- Percussion — compare side to side, include axillae. Note: stony dull = effusion, dull = consolidation, hyper-resonant = pneumothorax
- Auscultation — breath sounds (vesicular/bronchial), added sounds (crackles, wheeze, rub), vocal resonance
The Top 5 Respiratory Cases in PACES
Based on data from recent exam diets, these are the most frequently encountered conditions:
| Condition | Key Signs | Presentation Clue |
|---|---|---|
| Pulmonary fibrosis | Fine end-inspiratory crackles (bibasal), clubbing | "Velcro" crackles, reduced expansion |
| COPD | Hyperexpanded chest, reduced breath sounds, wheeze | Barrel chest, pursed lip breathing |
| Pleural effusion | Stony dull percussion, reduced breath sounds, reduced VR | Trachea pushed away (if large) |
| Bronchiectasis | Coarse crackles, clubbing, sputum pot | Coarse creps that shift with coughing |
| Lung collapse/Lobectomy | Reduced breath sounds, dull percussion, trachea pulled towards | Thoracotomy scar, mediastinal shift |
How to Present Your Findings
Use this framework for a confident, structured presentation:
"This patient is comfortable at rest with no supplemental oxygen. On examination, I found [key positive findings]. The important negatives are [relevant negatives]. My differential diagnosis is [most likely first], and I would like to confirm this with [investigation]."
Example:
"This gentleman is comfortable at rest. On inspection, I noted bilateral clubbing and fine inspiratory crackles at both bases posteriorly, extending to the mid-zones. There is reduced expansion bilaterally. Percussion is resonant throughout. There is no wheeze, no lymphadenopathy, and the trachea is central. My primary diagnosis is idiopathic pulmonary fibrosis, and I would like to confirm this with high-resolution CT of the chest and pulmonary function tests showing a restrictive pattern."
Common Mistakes to Avoid
- Forgetting to check the trachea — this is a key discriminating sign and examiners will notice if you skip it
- Not examining the back — you will miss posterior basal crackles and effusions
- Rushing percussion — take your time, compare side to side methodically
- Presenting without a differential — always commit to a diagnosis, even if you're uncertain
- Ignoring bedside clues — the oxygen, inhalers, and sputum pot are there for a reason
Practice Strategy
The best way to prepare for the respiratory station:
- Examine at least 10-15 patients with genuine respiratory signs before your exam
- Time yourself — you should complete your examination in 7 minutes, leaving 3 minutes for presentation and questions
- Record yourself presenting and listen back for filler words and hesitations
- Practise with a partner who can challenge your differential
At our PACES courses at Guy's Hospital [blocked], you'll examine multiple respiratory patients with confirmed signs and receive immediate consultant feedback on your technique and presentation.
Continue your preparation: The Complete Guide to MRCP PACES 2026 [blocked] | How to Pass PACES First Time [blocked]
