[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 presented to the acute medical unit on account of shortness of breath.  Please examine their respiratory system to identify why then tell the examiners what signs you find and discuss your proposed management”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191689″][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_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient most likely has COPD.

The clinical signs exhibited in this video include:

  1. Nicotine staining of the fingers;
  2. Quiet anterior breath sounds;
  3. Diffuse wheeze posteriorly.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Cigarette smoking is the most important risk factor for development of COPD. The causal relationship of smoking and COPD is fully established. Studies have established “dose-response relationship” for smoking and lung function but considerable variability is present among individuals.

In early stages of COPD, physical examination may be normal. Patients having more severe disease may have a prolonged expiratory phase. Signs of hyperinflation such as barrel shaped chest, increased resonance on percussion may be present. On auscultation, expiratory wheezing, decreased breath sounds, crackles at the base of lungs may be present. Chest x-ray is not required for making a diagnosis of COPD. It is typically performed to look for complication such as pneumonia, pneumothorax, and heart failure during acute exacerbations. Increased hyperlucency, flat diaphragm and long narrow cardiac shadow is visible on postero-anterior view of chest x-ray.

The major components of in-hospital management of exacerbations of COPD include reversing airflow limitation with inhaled short-acting bronchodilators and systemic glucocorticoids, treating infection, ensuring adequate oxygenation. Respiratory status, heart rate and rhythm, and fluid status should be monitored regularly. Arterial blood gas measurement should be performed to check for respiratory acidosis, confirm the oxygen saturation, and to monitor hypercapnia.

Supplemental oxygen therapy is of critical importance in management of acute condition. The target of oxygen therapy should be pulse oxygen saturation (SpO2) of 88 to 92 percent or arterial oxygen tension (PaO2) of approximately 60 to 70 mmHg.

Inhaled short-acting beta adrenergic agonists (e.g., salbutamol (aka albuterol) and levalbuterol) are the mainstay of therapy for an exacerbation of COPD. Onset of action is rapid and effectively produces bronchodilation. Beta adrenergic agonists may be combined with a short acting anticholinergic agent like ipratropium.

Systemic glucocorticoids are added to the bronchodilator therapies to improve symptoms and lung function, and decrease the length of hospital stay. Oral administration of glucocorticoids appears equally efficacious to intravenous glucocorticoids for treating most exacerbations of COPD. Intravenous glucocorticoids should be considered for patients with a severe exacerbation, who respond poorly to oral glucocorticoids, who are unable to take orally or who may have impaired absorption of oral medication.

There is good clinical evidence to suggest use of glucocorticoids in patients of COPD both in setting of acute exacerbation and stable COPD. Both systemic and inhaled glucocorticoids are widely prescribed for patients with chronic obstructive pulmonary disease (COPD).

Systemic (oral or intravenous) glucocorticoids improve symptoms, hasten recovery, reduced treatment failure and increased the rate of improvement in lung function. Hospitalized patients with COPD exacerbation also benefit from systemic glucocorticoid therapy. The benefits of glucocorticoids appear to be greatest in the first 72 hours after administration. Oral therapy appears to be equally effective if patients are able to take orally. Intravenous glucocorticoids should be considered in cases of failure to respond with oral regimen, very severe, exacerbation or in patient having poor oral absorption.

The mainstays of drug therapy of stable symptomatic COPD are inhaled bronchodilators (beta agonists and anticholinergics) with or without inhaled glucocorticoids depending upon the severity, risk of exacerbations, and response to therapy.

Inhaled glucocorticoids are part of the stepwise approach to management of stable COPD, which is intended to control symptoms, decrease exacerbations, and improve patient function and quality of life. Inhaled corticosteroids are not recommended as monotherapy for stable COPD patients because inhaled bronchodilators have greater benefits with fewer adverse effects.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has a diffuse wheeze throughout his posterior chest wall and markedly nicotine-stained fingers.  I think he most likely has COPD although I would like to confirm this with spirometry.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]