[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]”This patient has attended outpatient follow up after a recent hospital admission. Please examine his respiratory system and present your findings to the examiners.”[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191688″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][/vc_column][/vc_row]
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This patient has a tracheostomy scar and breath sounds characteristic of bronchiectasis.
Bronchiectasis is often misdiagnosed as bronchial asthma, bronchitis or recurrent pneumonia. Diagnosis of bronchiectasis is often delayed by many months or sometimes for years. Chest x-ray reveals dilated bronchi and can also diagnose pneumonia if present, which is a common complication. The defining test for bronchiectasis is CT chest.
The major features of bronchiectasis on CT include:
- Airway dilatations: a luminal airway diameter more than 1.5 times the adjacent vessel is indicative of cylindrical bronchiectasis.
- Lack of tapering along with dilatation may be more specific than bronchial dilatation alone.
- Bronchial wall thickening observed in dilated airways may be the best correlate and predictor of functional decline.
- Airways affected by bronchiectasis may contain mucopurulent plugs or debris accompanied by post-obstructive air trapping.
- Cysts off the bronchial wall are a feature of more destructive bronchiectasis. Blebs, seen in emphysema, are thinner walled and not accompanied by proximal airway changes.
Some other features which may be seen on HRCT but are not characteristic or diagnostic of bronchiectasis:
- Consolidation of a segment or lobe (from pneumonia)
- Enlarged lymph nodes, likely a reaction to infection
- Areas of low attenuation and vascular disruption suggesting emphysema
The evaluation of a patient with bronchiectasis consists of laboratory testing, radiographic imaging, and pulmonary function testing. The purpose of evaluation is to identify potentially treatable cause and pathogen along with functional assessment.
The following laboratory investigations are typically part of the initial evaluation of a patient with bronchiectasis:
- Full blood count with differential counts
- Measurement of the levels of the immunoglobulins IgG, IgM, and IgA
- Testing for cystic fibrosis: Sweat chloride and/or mutation analysis of the cystic fibrosis transmembrane conductance regulator (CFTR) gene if young
- Sputum smear and culture for bacteria, mycobacteria, and fungi
Additional tests that are obtained in the appropriate setting may include:
- Specific aspergillus IgE and IgG antibodies, total serum IgE level
- IgG subclass levels
- Antibody titres to pneumococcal serotypes before and four weeks after vaccination with polysaccharide pneumococcal vaccine
- Alpha-1 antitrypsin level and/or genotype
- Rheumatoid factor
Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea. It is most often performed in patients who have had difficulty weaning off a ventilator, followed by those who have suffered trauma or a catastrophic neurologic insult.
Tracheostomy is a commonly performed elective procedure. Indications for tracheostomy are any condition that necessitates long term mechanical ventilation in an intensive care setting; failure to wean; upper airway obstruction and finally copious secretions. Tracheostomy can also be performed to provide a mechanical route for ventilation in respiratory failure in cases of inadequate cough or aspiration and inability to handle secretions.
Tracheostomy is contraindicated if there is any presence of a skin infection around the site and any prior surgery which causes the anatomy to be obscured.
Tracheostomy is usually performed under general anaesthesia and hence requires the patient to be evaluated for general anaesthetic fitness.
Tracheostomy is performed by two techniques: open and percutaneous. But the selection of the method depends upon the surgeon or anaesthetist’s personal expertise and the conditions, facilities and the reason for performing the tracheostomy.
A tracheostomy is generally a safe and effective procedure. However, as with all surgical procedures, there is a small risk of complications, including bleeding, infection, oesophageal perforation, surgical emphysema and breathing difficulties and in the long term tracheal stenosis and fistulae formations very rarely. The likelihood of complications depends upon the age and health of the patient and for the reason tracheostomy is being performed. Other preventable complications depend on the fact that the cricothyroid muscle, vocal muscles and vocal cords are vulnerable to injury during the procedure, so are the major vessels like carotid and internal jugular vessels.
Tracheostomy can also lead into a late complication of a collapsed lung and collapsed or narrowed windpipe.
- Review / Skip
Question 1 of 7
What scar can you see on the patient’s neck?CorrectIncorrect
Question 2 of 7
How would you describe the patient’s chest expansion?CorrectIncorrect
Question 3 of 7
Describe the percussion note throughout the precordium.CorrectIncorrect
Question 4 of 7
What clinical signs can be heard in the patient’s chest on auscultation?CorrectIncorrect
Question 5 of 7
The patient complains of a chronic productive cough despite not smoking. What is the diagnosis?CorrectIncorrect
Question 6 of 7
A 62-year old man presents to a chest physician with complaints of cough and sputum production, gradually worsening over last one and half years. He also has complaints of shortness of breath and fatigue. He has been treated with antibiotics for bronchitis 4 times by his primary care physician in last 1 year. He has no history of tuberculosis or other chest infections. There is no family history of chest diseases. A chest x-ray was done to evaluate this patient which shows dilated airways in many areas. HRCT of chest was ordered to confirm the diagnosis. Which of the following is true about the patient’s CT chest?CorrectIncorrect
Question 7 of 7
Which of the following investigations have no routine role in initial evaluation of a patient with bronchiectasis?CorrectIncorrect