RESPIRATORY

Take a focused history from the patient with a pneumothorax, to include past medical history, drug history, family history and social history. If the patient is well enough, perform a focused respiratory examination.

If the patient has a chest drain in situ, assess it fully, making sure to note:

• Assess the drain site: at what length is the drain sutured in? is the site clean and dressed? Is there any evidence of subcutaneous emphysema?

• Assess the tubing: is the drain clamped? is there debris in the drain tubing itself?

• Assess the bottle: is the chest drain bubbling and/or swinging?

Look at the chest drain monitoring chart at the end of the bed to assess any drain output.

If you're not sure what these terms mean, or more information, have a look at this summary sheet from OSCEStop.

Consider three or four differential diagnoses for the patient's symptoms. For each one, suggest two features from the history that make them more or less likely.

What initial investigations would be useful and what are you expecting them to show?

Construct a mind-map covering the following points:

• How can pneumothorax be classified?

• What are the causes of a pneumothorax?

• How would you clinically assess the severity of a pneumothorax and, accordingly, what would be your initial management?

Compare your notes with the BTS Guidelines summary available here.

Find some relevant guidelines on the management of pneumothorax (e.g. BTS Pneumothorax 2010) and consider how best the patient you have seen should be managed.

Some prompts for consideration:

• Does this patient need a pleural procedure? If so, what kind?

• Could this patient be discharged? If so, how should they be followed up?

• What advice should be given to this patient?

If the patient goes on to have a pleural procedure e.g. pleural aspiration or chest drain insertion, complete the following tasks:

1. Find the local LocSSIPs for pleural procedures. Work through the questions with reference to the patient you have seen.

2. Find and complete the relevant sections of a mock consent form with the indication and risks for the procedure. Practice taking consent from a colleague if possible.

NB. You should not take consent from the patient - this should be done by the qualified professional performing the procedure. Make it clear on the consent form you have used that it is for teaching purposes only.

Highlight three key things you have learned today. Summarise them on a post-it note and keep it somewhere you will find in a week or two.

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1. http://www.radiopaedia.org

2. http://www.oxfordmedicaleducation.com/wp-content/uploads/2015/04/BTS-guidelines-for-pneumothorax-1024x720.jpg

3. https://thorax.bmj.com/content/65/Suppl_2/ii1.full