INSTRUCTION

Examine this patient's chest.

SALIENT FEATURES

History

· Sudden onset of breathlessness.

· History of cough.

· History of asthma, TB, lung cancer.

Examination

· Trachea deviated to the affected side.

· Movements decreased on the affected side.

· Percussion note dull on the affected side.

· Breath sounds diminished on the affected side.

Proceed as follows:

Tell the examiner that you would like to look for tar staining (tobacco smoking), clubbing and cachexia (bronchogenic carcinoma, see

pp 274-6).

DIAGNOSIS

This patient has a collapsed lung (lesion); you would like to exclude malignancy (aetiology). He is breathless at rest (functional

status).

QUESTIONS

What are the causes of lung collapse?

These include:

· Bronchogenic carcinoma.

· Mucus plugs (asthma, allergic bronchopulmonary aspergillosis; BMJ1982; 285: 552).

· Extrinsic compression from hilar adenopathy (e.g. primary TB).

· Tuberculosis (Brock's syndrome).

· Other intrabronchial tumours including bronchial adenoma.

What are the chest radiograph findings of collapse of the right middle lobe?

The loss of definition of the right heart border reflects collapse (or consolidation) affecting the right middle lc}he

What is Brock's syndrome?

It is collapse due to compression of the right middle lobe bronchus by an enlarged lymph node.

Sir Russell C. Brock (1903-1980) graduated from Guy's Hospital and was surgeon at Guy's and Brompton Hospitals. His interests included both

thoracic and cardiac surgery. He was the President of the Royal College of Surgeons, 1963-1966.

INSTRUCTION

Look at this patient.

SALIENT FEATURES

History

· Daytime somnolence.

· Unrefreshing sleep.

· Daytime fatigue.

· Snoring.

· Shortness of breath.

· Headache, particularly in the morning.

· Swelling of feet.

· Poor concentration.

· Systemic hypertension.

· Family history of obesity.

· Gastro-oesophageal reflux.

· Poor quality of life.

Examination

· Obese patient who is plethoric and cyanosed.

· Maxillary or mandibular hypoplasia.

· Shortness of breath at rest.

· May be nodding off to sleep.

· Systemic hypertension.

· Nocturnal angina.

· Look for signs of pulmonary hypertension and right heart failure.

Remember. Nearly 50% of patients with sleep apnoea syndrome are not obese.

DIAGNOSIS

This patient has marked obesity and hypersomnolence with signs of pulmonary hypertension (lesion) which indicate that she has

pickwickian syndrome. The patient is in cardiac failure (functional status).

Read reviews: J R Coil Phys (Lond) 1993; 27: 3634; J R Coil Phys (Lond) 1993; 27: 375.

ADVANCED-LEVEL QUESTIONS

What is the cause of cyanosis in such a patient?

A mixture of obstructive apnoea and sleep-induced hypoventilation. The blood gas picture is hypoxia and carbon dioxide retention.

Where is the obstruction?

It is caused by the apposition of the tongue and the palate on the posterior pharyngeal wall.

How would you treat such a patient?

· Weight reduction.

· Avoidance of smoking and alcohol.

· Progesterone (enhances respiratory drive).

· Continuous nasal positive airway pressure delivered by a nasal mask (lancet 1999; 353: 2100-5).

· Home oxygen.

· Surgery: tracheostomy, uvulopalatopharyngoplasty, linguoplasty, mandibular advancement, plastic remodelling of the uvula

(laser-assisted or radiofrequency ablation).

· Drugs: serotonin receptor blockade, acetazolamide, methylxanthines, weight loss medications.

INSTRUCTION

Examine this patient's chest.

SALIENT FEATURES

History

· Fever and night sweats.

· Malaise, fatigue, anorexia.

· Weight loss.

· Cough with sputum.

Examination

These'patients tend to have signs of common chest diseases which are not cut and dried. There are several masons for this, such

as pleural thickening, thoracotomy and pneumonectomy, associated COAD, associated chest infection, plombage or phrenic nerve

crush.

The following provide some examples:

Patient 1

The candidate was asked to examine the chest from the front, as a result of which the old thoracotomy scar was not seen. The

patient was wheezy. The trachea was deviated to the right. Percussion note was stony dull from the right second inter-costal space

downwards. Wheeze was present on the left side. This patient had a right pneumonectomy with COAD in the left lung. The

candidate's diagnosis of right-sided pleural effusion with underlying collapse and left-sided COAD was accepted.

Patient 2

The trachea was central. A phrenic nerve crush scar was seen. Percussion note was dull in the left infra-axillary region and there

were associated crackles. The diag-nosis of pleural thickening with associated chest infection was accepted; that of pleural effusion

was not.

QUESTIONS

How would you manage a patient with old tuberculosis?

Old tuberculosis requires no antituberculosis treatment. However, the patient may require symptomatic treatment for wheeze and

shortness of breath.

In which groups of people is the risk of tuberculosis high?

· Asian and Irish immigrants.

· The elderly.

· Immunocompromised individuals, particularly AIDS patients.

· Alcoholics.

* Occupations at risk: doctors, nurses, chest physiotherapists.

ADVANCED-LEVEL QUESTIONS

Would you isolate a patient with newly diagnosed, sputum-positive, pulmonary TB?

Yes. Segregation in a single room for 2 weeks is recommended for patients with smear-positive tuberculosis. Barrier nursing,

however, is unnecessary. Adults with smear-negative or non-pulmonary disease may be in a general ward. A child with TB should

be segregated until the source case is identified as this person may be visiting the child.

How are contacts investigated?

Contacts are investigated by inquiry into bacille Calmette-Gudrin (BCG) vac-cination site, Heaf testing and CXR examination.

To whom would you offer BCG vaccination?

BCG vaccination is offered to previously unvaccinated, persistently Heat' test-negative or grade 1 contacts aged under 35 years

unless there is a special occu-pational, travel or ethnic risk. Patients with known or suspected HIV infection should not be offered the

vaccination.

What are the indications for chemoprophylaxis?

· Chemoprophylaxis may be given to those with strongly positive Heat' test reactions but no clinical or radiological evidence of

TB (Thorax 1994; 49:1193-200).

· Chemoprophylaxis should be given to children under 5 years who are close contacts of a smear-positive adult irrespective of

their tuberculin test result.

· If chemoprophylaxis is not undertaken, follow-up with periodic CXR examin-ations for 2 years is recommended in all these

groups.

Which rapid test allows early diagnosis of tuberculosis?

Polymerase chain reaction (PCR).

Robert Koch (1843-1910), Institute for Infectious Diseases, Berlin, was awarded the 1905 Nobel Prize for Medicine for his

investigations and discoveries in relation to tuberculosis.

Kary Mullis of the USA was awarded the Nobel Prize for developing the technique of polymerase chain reaction.