[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left”][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 and present your findings to the examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191693″][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”][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 last on examination has a left prosthetic breast insert in her bra. On respiratory examination she has stony dull percussion at the left middle and lower zones with reduced chest expansion on the same side. On auscultation she has reduced breath sounds in the middle and lower left sided zones.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]This lady has an interesting clinical story, which is entirely determinable from the clinical examination. This case demonstrates the value in exposing (while maintaining dignity) and ensuring you look at the patient properly. You would miss the key feature if you do not.

She has a left prosthetic breast insert in her bra – this is used to maintain the shape of the breasts, that many women post mastectomy use either while waiting for breast implantation, or if they cannot/do not want a breast implant. On examination she has a clear left sided pleural effusion, which in this case indicates that the breast cancer has returned and spread to the chest.

The total number of patients with breast cancer in the West that will suffer some recurrence is around 40%, but this is dependent upon a number of factors and has a number of layers. The 5-year overall survival with isolated recurrence of the chest wall is 68% and 81% after intra-breast recurrence. Recurrence is highest in the initial 2-3 years after diagnosis and treatment. Lung and pleural recurrence can affect up to three-quarters of those that have recurrence.

The management in this lady will include the following:

  • breast examination (with chaperone)
  • baseline bloods
    • looking for anaemia, infection, hypercalcaemia with bone metastases and liver dysfunction from the same
    • clotting screen and platelet count prior to chest aspiration
  • plain chest radiograph
    • confirm clinical findings
  • diagnostic aspiration under ultrasound guidance
    • laboratory analysis for protein, blood, infection and cytology
    • confirm whether the effusion is an exudate or not – if not, then further investigations for other causes required (Light’s criteria)
  • therapeutic aspiration if symptomatic (breathless on exertion and/or oxygen de-saturation)
  • urgent breast mammogram and biopsy as required
  • staging CT of the chest, abdomen and pelvis to confirm if other metastases are present
  • referral to the Breast Multi-Disciplinary Meeting for discussion about treatment options

For more information about breast cancer recurrence, here is a thorough review.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient is a smoker and has clinical evidence of a previous left pneumonectomy and also has a Horner’s syndrome and a cervical lymph node.  I am concerned they have a Pancoast tumour, which may be a new lesion or a recurrence following a failed attempt at resection.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]