EMQs in Clinical Medicine.pdf - Peshawar Medical College

46 Respiratory medicine
The mediastinum is therefore shifted to the contralateral side. This
prejudices both ventilation of the other lung and filling of the heart. In this
scenario there is reduced expansion on the right side and mediastinal shift
to the left, so decompression on the right side is indicated. A cannula must
be inserted into the second intercostal space in the mid-clavicular line of
the affected side until a functioning intercostal tube can be positioned.
C
A young man presents with an acute onset shortness of breath.
Examination reveals decreased expansion on the right: SaO 2 95
per cent.
A chest radiograph is indicated here to confirm the diagnosis of pneumothorax
and to assess the degree of collapse.
In healthy patients a small pneumothorax will often heal without further
intervention. The patient should be observed for 6 hours and, if there is
no increase in the size of the pneumothorax, may be discharged with
early follow-up and repeated chest radiograph. Spontaneous pneumothoraces
are relatively common in young adults (especially tall thin men)
and older patients with emphysema. In patients with thoracic
disease/large pneumothoraces, simple aspiration is recommended as firstline
treatment. If this is unsuccessful, a chest drain will be required.
18 Management of COPD
Answers: A F L D H
A
F
L
D
A previously healthy 65-year-old smoker with early COPD complains
of shortness of breath on exertion.
Stopping smoking, encouraging exercise and reducing obesity should
all be encouraged. The use of inhaled bronchodilators is first-line
pharmacological therapy for early COPD.
A 65-year-old woman with longstanding COPD presents with shortness
of breath and cough productive of coloured sputum.
This is the presentation for an infective exacerbation of COPD.
A 70-year-old man admitted with acute severe exacerbation of COPD
does not respond to oxygen and nebulized bronchodilators.
If such a patient deteriorates on medical therapy, early use of NIPPV may
improve outcome and avoid intubation.
A 65-year-old patient with advanced COPD treated with bronchodilators
and steroids still feels breathless. His baseline PaO 2 is around
6.5 kPa.
Long-term oxygen therapy should be considered in clinically stable nonsmokers
with PaO 2 7.3 kPa. There is evidence to suggest that keeping
the PaO 2 8.0 kPa for more than 15 h every day increases survival.