[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 A&E with non-specific chest pain.  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/138191690″][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]These breath sounds were in fact reproduced from a patient with a left diaphragmatic palsy leading to dullness in the left base.  However, it is not feasible clinically to differentiate this from a pleural effusion and a candidate would likely be given credit for assuming this is the diagnosis.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Clinical features:

The presentation of a patient with diaphragmatic paralysis depends whether the condition is unilateral or bilateral, acute in onset or chronic and which underlying pathology it is associated with. In unilateral diaphragmatic paralysis, the patient is usually asymptomatic while at rest but have dyspnea on exercise which impairs their ability to carry on the task. If there is an underlying pathology of the lung, then dyspea may be present at rest too. In these a patient, if orthopnea is present, it is usually more severe than that present in bilateral condition. A patient with bilateral diaphragmatic paralysis presents with symptoms similar to heart failure and can hence be misdiagnosed. There is respiratory failure which gets aggravated in supine position. In a recumbent position, patient has tachycardia, shallow and rapid respiration.

Patient may also complain of insomnia, anxiety, headache, fatigue, daytime somnolence and nonspecific GIT symptoms.

Initial investigation:

In patients with bilateral diaphragmatic paralysis, ABGs analysis shows hypoxia. Chest radiography is done that shows elevated hemidiaphragms. Fluoroscopy, CT, MRI and ultrasonography of the chest help in the diagnosis. Pulmonary function tests are also done. In cases of unilateral diaphragmatic paralysis, it is diagnosed accidently on radiography.

Underlying pathology:

Diaphragm is most significant in the mechanism of breathing which helps develop negative intrathoracic pressure that aids in ventilation. On inspiration, the diaphragmatic muscles contract giving space to the lungs to expand. The nerve supply of the diaphragm is from C3-5 motor neurons. The accessory muscles of respiration help the diaphragm in its function. In case of diaphragmatic paralysis due to any etiology, accessory muscle workload is increased and they get fatigued. This results in ventilatory failure.

Common treatments:

Unilateral diaphragmatic paralysis doesn’t require treatment but if the cause is known, it should be treated. Diaphragmatic plication is opted in some cases. Treatment of bilateral diaphragmatic paralysis depends on etiology and severity. In severe cases that have arisen acutely invasive ventilation may be a lifesaving temporary management approach while the precipitant is dealt with.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has absent breath sounds at the left base in keeping with a pleural effusion or a diaphragmatic palsy.  I would like to investigate next with a chest radiograph.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]