Week One - Case One

Question 1

what is musculoskeletal pain caused by

Answer 1

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

Question 2

when would musculoskeletal pain occur

Answer 2

after some exertion or injury - exacerbated by movement

Question 3

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

Answer 3

no

Question 4

what is the most common form of chest pain

Answer 4

musculoskeletal pain

Question 5

what are some question to ask when querying musculoskeletal pain

Answer 5

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?

Question 6

what is pleurisy

Answer 6

is an inflammation of the pleura - the two layers

Question 7

what kind of pain does pleurisy cause

Answer 7

sharp pain due to the innervation of the parietal pleural innervation

Question 8

what are the most common causes of pleurisy

Answer 8

viral or bacterial infections

Question 9

what are the symptoms of pleurisy

Answer 9

cough, runny nose and fever

Question 10

what is absent in pleurisy

Answer 10

Haemoptysis

Question 11

what are questions to ask when querying pleurisy

Answer 11

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?

Question 12

what is a pneumothorax

Answer 12

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

Question 13

how does this air leak cause lung collapse

Answer 13

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

Question 14

what are the symptoms of a pneumothorax

Answer 14

sharp chest pain and breathlessness

Question 15

what are risk factors for pneumothorax

Answer 15

underlying lung disease, being male, smoking

Question 16

what are questions to ask if querying a pneumothorax

Answer 16

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?

Question 17

what is a pulmonary embolism

Answer 17

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

Question 18

what are the symptoms of PE

Answer 18

breathlessness
pleuritic chest pain
sometimes Haemoptysis

Question 19

can there be calf swelling with PE

Answer 19

yes

Question 20

what are the questions to ask about when querying a PE

Answer 20

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?

Question 21

what is a primary spontaneous pneumothorax

Answer 21

no underlying disease

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

Question 22

who is a primary spontaneous pneumothorax most common in

Answer 22

most common in tall young men

Question 23

what is homocystinurea

Answer 23

body can’t process the amino avid methionine

Question 23

what is the recurrence rate

Answer 23

25-50%

Question 23

what are risk factors for primary pneumothorax

Answer 23

smoking including cannabis

family history

Marfan syndrome

Homocytinurea

Familial Birt-Hogg-Dube syndrome

Question 23

what is a secondary pneumothorax

Answer 23

secondary to underlying disease

Question 24

what is Marfan syndrome

Answer 24

autosomal dominant connective tissue disorder

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

Question 24

what may these underlying diseases be

Answer 24

COPD
Cystic fibrosis
Lung malignancy
Pneumonia
TB

Question 24

what is familial Birt-Hogg-Dube syndrome

Answer 24

autosomal dominant mutation in the folliculin gene

Question 25

what is a standard or simple pneumothorax

Answer 25

air in the pleural space but the volume is not increasing

Question 25

what is the presentation of a primary pneumothorax

Answer 25

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

Question 25

what is the presentation of a secondary pneumothorax

Answer 25

similar to primary

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

Question 25

what does a simple pneumothorax look like on a CXR

Answer 25

trachea is not deviated, lung collapse may be visible

Question 25

what is a tension pneumothorax

Answer 25

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

Question 26

what is a tension pneumothorax due to

Answer 26

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

Question 26

what is visible on a CXR in a tension pneumothorax

Answer 26

a tracheal deviation away from the side of the pneumothorax

Question 27

what does a tension pneumothorax cause

Answer 27

rapidly increased intra-thoracic pressure

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

Question 27

what is a Iatrogenic Pneumothorax

Answer 27

procedure related / barotrauma in ICU

Question 28

what is a non-iatrogenic pneumothorax

Answer 28

RTC, trauma, fall

Question 29

what are the clinical features of a tension pneumothorax

Answer 29

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

Question 30

how do you differentiate between a simple and tension pneumothorax

Answer 30

A tension pneumothorax will have;

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

Question 31

what is the investigations in pneumothorax

Answer 31

usually a clinical diagnosis - it is a tension pneumothorax

Question 32

what kind of CXR is taken

Answer 32

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

Question 33

what is the presentation of a small pneumothorax on a CXR

Answer 33

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.

Question 34

what is the presentation of a large pneumothorax on a CXR

Answer 34

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

Question 35

what is seen on a supine CXR

Answer 35

deep sulcus sign

Question 36

what are the measurements used to classify small/large

Answer 36

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

Question 37

what are the indications for a CT

Answer 37

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

Question 38

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

Answer 38

Ultrasound

Question 39

what shows on a ABG

Answer 39

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

Question 39

when can respiratory alkalosis occur

Answer 39

if there is sufficient hyperventilation to cause low carbon dioxide

Question 39

what is the treatment for a standard pneumothorax <2cm

Answer 39

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

Question 40

what is the treatment for a primary pneumothorax

Answer 40

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

Question 41

what is the treatment for secondary pneumothorax

Answer 41

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

Question 42

what’s the treatment for a tension pneumothorax

Answer 42

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.

Question 43

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

Answer 43

consider pleurodesis (VATS procedure)

Question 44

what is the pathophysiology of a pneumothorax

Answer 44

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.

Question 45

at FRC what are the pressures present?

Answer 45

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

Question 46

what are changes in alveolar pressure a result of

Answer 46

changes in pleural pressure

Question 47

what is the most common ECG abnormality

Answer 47

sinus tachycardia