Week One - Case One Flashcards

1
Q

what is musculoskeletal pain caused by

A

injury to the muscles or bones that is detected via the pain receptors that carry impulses to the brain

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2
Q

when would musculoskeletal pain occur

A

after some exertion or injury - exacerbated by movement

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3
Q

would there be any additional features such as coughing blood or fever in musculoskeletal pain

A

no

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4
Q

what is the most common form of chest pain

A

musculoskeletal pain

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5
Q

what are some question to ask when querying musculoskeletal pain

A

Has the patient done any strenuous exertion or exercise recently that may have caused the pain?
Does the pain get worse if the patient twists their upper chest or touch their chest wall?
Has this ever happened before?

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6
Q

what is pleurisy

A

is an inflammation of the pleura - the two layers

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7
Q

what kind of pain does pleurisy cause

A

sharp pain due to the innervation of the parietal pleural innervation

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8
Q

what are the most common causes of pleurisy

A

viral or bacterial infections

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9
Q

what are the symptoms of pleurisy

A

cough, runny nose and fever

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10
Q

what is absent in pleurisy

A

Haemoptysis

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11
Q

what are questions to ask when querying pleurisy

A

Has the patient had a recent cough, cold or viral infection?
Has the patient had a recent fever?
Is there a cough? Is it productive?
Has this ever happened before?

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12
Q

what is a pneumothorax

A

the presence of abnormal air between the two pleural linings called the pleural space

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13
Q

how does this air leak cause lung collapse

A

this air leak builds up, thus stretching the pleural lining and presses on the lung to cause it to collapse

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14
Q

what are the symptoms of a pneumothorax

A

sharp chest pain and breathlessness

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15
Q

what are risk factors for pneumothorax

A

underlying lung disease, being male, smoking

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16
Q

what are questions to ask if querying a pneumothorax

A

Does the patient’s gender and age fit with those in the population most at risk?
Does the patient smoke?
Has this ever happened before?

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17
Q

what is a pulmonary embolism

A

is an abnormal clot formation in the pulmonary circulation to the lung that results in reduced blood flow to the region of the lung that the pulmonary artery supplies

this causes infection of the lung

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18
Q

what are the symptoms of PE

A

breathlessness
pleuritic chest pain
sometimes Haemoptysis

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19
Q

can there be calf swelling with PE

A

yes

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20
Q

what are the questions to ask about when querying a PE

A

Does the patient have any risk factors for PE?
Is there any coughing of blood?
Has the patient noticed any calf swelling?
Has this ever happened before?

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21
Q

what is a primary spontaneous pneumothorax

A

no underlying disease

usually the result of rupture of a pleural ‘bleb’ - congenital defect in the tissue of the alveolar wall

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22
Q

who is a primary spontaneous pneumothorax most common in

A

most common in tall young men

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23
Q

what is homocystinurea

A

body can’t process the amino avid methionine

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23
Q

what is the recurrence rate

A

25-50%

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23
Q

what are risk factors for primary pneumothorax

A

smoking including cannabis

family history

Marfan syndrome

Homocytinurea

Familial Birt-Hogg-Dube syndrome

23
Q

what is a secondary pneumothorax

A

secondary to underlying disease

24
Q

what is Marfan syndrome

A

autosomal dominant connective tissue disorder

mutation of FBN-1 gene, decreased production of extracellular microfibril (maintenance of elastic fibres)

24
Q

what may these underlying diseases be

A

COPD
Cystic fibrosis
Lung malignancy
Pneumonia
TB

24
Q

what is familial Birt-Hogg-Dube syndrome

A

autosomal dominant mutation in the folliculin gene

25
Q

what is a standard or simple pneumothorax

A

air in the pleural space but the volume is not increasing

25
Q

what is the presentation of a primary pneumothorax

A

symptoms develop at rest
Sudden onset SOB and pleuritic chest pain
Reduced breath sounds on affected side
Hyperressonance to percussion on the affected side
Hypoxia

25
Q

what is the presentation of a secondary pneumothorax

A

similar to primary

However, symptoms are usually more severe in secondary pneumothorax - presumably due to the reduced reparatory reserve seen in underlying ling disease

25
Q

what does a simple pneumothorax look like on a CXR

A

trachea is not deviated, lung collapse may be visible

25
Q

what is a tension pneumothorax

A

LIFE THREATENING
air in the pleural space, and the volume continuing to increased

26
Q

what is a tension pneumothorax due to

A

the formation of a one way valve allowing air into the pleural space on inspiration but not out again on expiration

26
Q

what is visible on a CXR in a tension pneumothorax

A

a tracheal deviation away from the side of the pneumothorax

27
Q

what does a tension pneumothorax cause

A

rapidly increased intra-thoracic pressure

this reduces venous return to the heart and causes cardiac arrest if not treated quickly

27
Q

what is a Iatrogenic Pneumothorax

A

procedure related / barotrauma in ICU

28
Q

what is a non-iatrogenic pneumothorax

A

RTC, trauma, fall

29
Q

what are the clinical features of a tension pneumothorax

A

pleuritic chest pain
Breathlessness
Tracheal deviation
Reduced breath sounds in the affected area and hyper-resonant on percussion

30
Q

how do you differentiate between a simple and tension pneumothorax

A

A tension pneumothorax will have;

worsening clinical signs and symptoms (simple will be stable)
Tracheal deviation
Haemodynamically unstable
Hypotensive
Tachycardic
Elevated respiratory rate

31
Q

what is the investigations in pneumothorax

A

usually a clinical diagnosis - it is a tension pneumothorax

32
Q

what kind of CXR is taken

A

equally visible on inspiratory and expiratory chest X-rays. Standard inspiratory film is all that is usually required.

33
Q

what is the presentation of a small pneumothorax on a CXR

A

Typically small and often appear as a rim of air around the lung. It is often possible to see a white line which represented the edge of the normal lung tissue.
Externally to this, there will be NO vascular lung markings.

34
Q

what is the presentation of a large pneumothorax on a CXR

A

larger pneumothoraxes are more obvious, with a clearly collapsed lung and a large proportion of the hemithorax with no vascular margins
Check for mediastinal shift - tension pneumothorax

35
Q

what is seen on a supine CXR

A

deep sulcus sign

36
Q

what are the measurements used to classify small/large

A

Measure the width of the rim of air to classify to
small < or equal to 2cm
Large > 2cm

37
Q

what are the indications for a CT

A

evidence of underlying lung disease on CXR
Uncertain diagnosis
Not routinely indicated.

38
Q

what is not routine for a pneumothorax but becoming more common in the acute setting

A

Ultrasound

39
Q

what shows on a ABG

A

hypoxia
Usually normal CO2 - the lung function is still good and often the remaining lung can proceed sufficient alveolar ventilation

39
Q

when can respiratory alkalosis occur

A

if there is sufficient hyperventilation to cause low carbon dioxide

39
Q

what is the treatment for a standard pneumothorax <2cm

A

should do CXR first before attempting to treat!

Rim of air <2cm – consider alternate diagnosis, OR small pneumothorax that will resolve with conservative management.

Consider observation for 4-6 hours and repeat CXR toensure it is not progressing

Then; discharge on advice – dont do strenuous exercise – and return if breathless.

Evaluate and re-x-ray at 2 weekly intervals until air is re-absorped

The rate of reabsorption is approximately 1-2% of the volume of the hemithroax per 24 hours. This can be increased to 6-8th with the use of humidifiedoxygen

It isrecommended that patient avoid air travel for at least 2 weeks after resolution. The exact risks are not known

40
Q

what is the treatment for a primary pneumothorax

A

SOB + rim of air >2cm on CXR:

Give supplemental oxygen
If acutely unwell (i.e. haemdynamically unstable), or tension pneumothorax:

Attempt aspiration – 2ND INTERCOSTAL SPACE, MIDCLAVICULAR LINE!

If unsuccessful, repeat

If unsuccessful, consider chest drain

Once successfully decompressed, will need a chest drain to allow continuing decompression

If not haemodynamically unstable:
Chest Drain (can be traditional thoracotomy or ‘pig-tail’ catheter (becoming more common – same equipment used as in supra-pubic catheter – therefore involves seldinger technique, is a less invasive procedure)
Remember to connect the chest tube to a water seal device – and check that the water ‘swings’ (rises and falls) with each breath – this confirms correct placement of the tubs within the pleural space

Refer to ICU if appropriate and admit to hospital

41
Q

what is the treatment for secondary pneumothorax

A

SOB + rim of air >2cm on CXR:

As above
Treat any underlying cause as appropriate
More likely to be hospitalised – because more likely to be unwell, and also because they may need treatment of the underlying condition and / more likely to require a pleurodesis

42
Q

what’s the treatment for a tension pneumothorax

A

If suspected, attempt to aspirate before CXR. Use a large bore cannula and, if possiblewith syringe, filled with saline, to act as a water seal, when entering the pleural space.

You should attempt decompression at the 2nd intercostal space at the mid-clavicular line. Feeling for this is sometimes a bit tricky – it is roughly 2 finger widths below the clavicle

Use along needle –preferable a cannula about 8cm or longer. Needle decompression fails in up to 50% of patients – often because too short of a needle is used. The typical distance from skin to pleura in an adult male is about 5cm

You should go injust abovethe third rib, so as to avoid the neurovasuclar bundle below the second rib.
Needle decompression is only a temporary measure –a chest tube should be placed as soon as possible. In a non-tension pneumothorax a chest drain is often the first line treatment of choice.

Needle decompression is suprisingly ineffective – one study suggested it was only about 67% effective at decompression, compared to over 90% for the placement of a chest tube. As such, a chest tube is preferred if circumstances allow, however it takes longer (mainly getting set up with all equipment . scrubbing up etc). If you are in doubt, do a needle aspiration first (you might save the patient’s life) and follow-up with a chest drain.

43
Q

what happens if a pneumothorax remains at 48 hours or recurrent episodes

A

consider pleurodesis (VATS procedure)

44
Q

what is the pathophysiology of a pneumothorax

A

In a healthy lung:

lungs tend to collapse due to elastic recoil
Connective tissue fibres (elastin)
Surface tension forces at the air/liquid interface in the alveolus

the chest wall tends to expand
The tendency for elastic recoil to collapse lungs and chest wall to expand means pleural pressure with be negative compared to alveolar pressure

when no muscles act on the chest wall, ‘equilibrium’ will be achieved, when the force generated by the pressure gradient across the alveolar wall (trans-pleural pressure: Pleural pressure (Ppl) - alveolar pressure(Palv) ) is equal and opposite to elastic recoil

Equilibrium is known as the Functional Residual Capacity. Lungs will sit at FRC at the end of every normal expiration, when respiratory muscles are relaxed.

45
Q

at FRC what are the pressures present?

A

Alveolar pressure equals atmospheric pressure therefore there is no airflow
for inspiration;

Alveolar pressure must be less than atmospheric pressure
for expiration;

Alveolar pressure must be greater than atmospheric pressure

46
Q

what are changes in alveolar pressure a result of

A

changes in pleural pressure

47
Q

what is the most common ECG abnormality

A

sinus tachycardia

48
Q
A