Re: Clinical Case Reports

NJ_VN — Wed, 06 Jul 2011 18:52:36 GMT

Brilliant thank you so much

Re: Clinical Case Reports

Nick Shackleton — Wed, 06 Jul 2011 17:48:17 GMT

Radiographic Report 1

Name: Jason Species: Canine

Breed: Maltese Terrier D.O.B: 23/01/01

Sex: Male (Neutered) Weight: 4.3kilograms

Clinical History:

Patient presented with a profound cough and pyrexia.

The patient had previously been referred for collapsing trachea and an intraluminal self expanding nitinol stent had been placed to expand the area of collapse. Under conscious fluoroscopic examination it was evident that the previous stent had migrated caudally into the thoracic trachea. The main area of collapse was around the thoracic inlet and because the stent had migrated from this area it was not being expanded and therefore causing the coughing. The patient was admitted for repeat radiographs for a second stent to be measured.

Restraint:

The patient was premedicated with a combination of 0.13mg acepromazine (ACP 2mg/ml, Novartis) and 0.43mg butorphanol (Torbugesic 10mg/ml Forte Dodge) via intramuscular injection 30 minutes prior to inducing anaesthesia. Anaesthesia was induced using 30mg propofol (ProFlo 10mg/ml, Abbott Laboratories Ltd). The patient was intubated with a size 5.0 cuffed end tracheal (ET) tube. Anaesthesia was maintained using oxygen and isoflurane (ISoFlo, Abbott Laboratories Ltd.).

Area to be radiographed:

The patient was placed in left lateral recumbency, the limbs were held in a neutral position by means of sandbags. A foam wedge was placed under the patient’s sternum to give a true lateral. Two left lateral thoracic radiographs were obtained, with the patient extubated and intubated respectively. On both images the thoracic inlet of the patient was included.

Film 1: An extubated radiograph was taken to see the extent of the patient’s tracheal collapse. A marker wire was placed down the patient’s oesophagus so that the length of tracheal collapse could be measured.

Film 2: The patient was re-intubated. The ET tube was relocated rostrally into the larynx and gently inflated to form a seal. The patient’s lungs were then inflated using the valve and reservoir bag on the anaesthetic circuit during exposure. This allowed measurement of the maximum diameter of the trachea. A person wearing a lead gown and thyroid shield performed this procedure.

Screen/film/grid combination:

24x30cm cassette (Ortho Regular) with rare earth screens and AGFA Ortho CP-G Plus Film were used. As the patient thorax was less than 10 cm deep, a grid was not required. The use of a grid is to reduce scatter when higher exposure factors are used.

View	Kv	mA	ms
Lateral Thorax	46	200	20
Lateral Thorax: Inflated	46	200	20

Radiographic Appraisal

Positioning:

Positioning was good. However, there is not complete superimposition of the fore limbs and cranial ribs. This could have been improved by putting more foam supports between the form limbs and under the sternum of the patient. The entire thorax and trachea could be seen on both films.

Centring:

The light beam was centred on the patient’s scapula producing good diagnostic films.

Collimation:

Four collimated edges can be seen on both films. However, the x-ray beam could have been slightly collimated inwards on the ventral and dorsal aspect of the films.

Exposure:

The exposure used is good and provides high quality diagnostic radiographs for examining soft tissue opacities.

Processing:

The radiograph is properly developed; this is shown by the gas opacity surrounding the patient is black. Processing is standardised using an automatic processor (see appendix). This helps safeguard against human error. No processor marks are evident on the films.

Labelling:

Labelling should ideally be performed at the time of taking radiographs by using x-rite tape or similar product.

In this practice labelling is standardised using a light marker box and electronic labelling machine. It’s labelled with patient and owner surname, date and practice initials.

Other Marks:

Left markers are clear on both films, although on film 1 it is slightly off the edge of the collimated area. There are a few fingerprints evident from handling the films.

Film 1:

In the cranioventral field there is soft tissue opacity consistent with an intravenous fluid therapy administration set.
In the central ventral area two metallic opacities consistent with two electrocardiograph crocodile clips.
In the central field a mesh structure of metallic opacity consistent with the migrated tracheal stent.
Dorsal to this a linear structure of varying opacities. It can be seen running cranial and caudal. This is consistent with the measurement probe, lying within the oesophagus.
In the middle of the film superimposed over the scapulae there is varying metallic opacity consistent with a microchip.

Film 2:

In the central ventral area two metallic opacities consistent with two electrocardiograph crocodile clips.
In the central field a mesh structure of metallic opacity consistent with the migrated tracheal stent.
Dorsal to this a linear artefact of varying opacities. It can be seen running cranial and caudal. This is consistent with the measurement probe, lying within the oesophagus.
In the craniodorsal region there is soft tissue opacity consistent with the endo tracheal tube lying within the trachea.
In the middle of the film superimposed over the scapulae there is varying metallic opacity consistent with a microchip.

Discussion:

Tracheal collapse is most often seen in toy dog breeds. This is due to a weakness in the structural rigidity of the tracheal rings. Dynamic narrowing of the tracheal lumen due to tracheal instability occurs during inspiration and in the thoracic trachea during expiration (Kneller 2002).

There are several treatments for tracheal collapse including placement of a wire mesh stent or plastic replacement tracheal rings. As a practice we use the placement of a tracheal stent to treat this condition as it is less invasive than replacing the tracheal rings.

An extubated view was taken to assess the degree of collapse that was present and the position of the previous stent. The inflated view is taken in order to measure the maximum diameter of the area of collapse.

One complication of the use of self-expanding nitinol stents is migration this maybe due to inaccurate measurement prior to order and fitting the stent. It was evident from the radiographs that the previous stent that had been placed had migrated caudally and was now positioned in the thoracic portion of the trachea. Sura and Krahwinkel (2208) suggested that when the inflated radiographs are performed that the cuff of the endo-tracheal tube is inflated to 20cmH₂O and that when inflating the lungs this should also be to 20cmH₂O. We were not able to measure exactly what pressure the cuff and the lungs were inflated. As a consequence of this it is possible that the area of collapse is not fully expanded on the images.

As a member of staff must remain within the room during exposure to inflate the patient’s lungs, adequate protection must be worn. A lead apron and thyroid shield must be worn. These are only effective at protecting against scatter radiation. Energy levels within the primary beam are high enough to allow for penetration through the lead with radiation. Lead protection usually has 0.5mm of lead. Lead protection should be hung and never folded, as this can causes cracks or splits.

Theses can allow for scatter radiation to pass through and expose personnel. Also all members of staff should wear dosimeters, which are sent away every two months to ensure members of staff aren’t receiving too higher exposure to radiation. When wearing lead protection, dosimeters should be worn underneath, to ensure adequate protection is provided (Easton 2002).

These radiographs were of good diagnostic quality as they allowed the veterinary surgeon to measure the trachea so that a second stent could to be ordered and placed at a later date. Although the measurements are as objective as possible there is still a risk of underestimating the maximum size and accurate diameter of the trachea. In this case, when the dog already had one migrated stent caudal to the area of collapse the new stent would not be able to migrate, as it would span the entire length of the trachea and be applied within the lumen of the original stent.

Reference:

Easton S. Chapter 14 Radiation Protection. Page 129-137. Practical Radiography For Veterinary Nurses. Butterworth Heinemann International Edition 2002
Kneller S. K. Chapter 26 Neck & Thorax – Companion Animals. Page 323-329. Textbook of Veterinary Diagnostic Radiology Thrall D E 4^th Edition. W. B. Saunders International Edition 2002
Sura P. A. & Krahwinkel D. J. Self-expanding nitinol stents for treatment of tracheal collapse in dogs: 12 cases (2001- 2004)JAVMA 2008; 232, 2: 228-236

Here is one of my radiography case reports for my Advanced Diploma Casebooks. My feedback from accessors was 'nicely written with clear layout. Great to read and easy to mark'

Re: Clinical Case Reports

NJ_VN — Wed, 06 Jul 2011 17:32:10 GMT

One has to be radiography and one has to be lab based (i can do blood tests or biopsys ect) If you could that would be brilliant, thank you

Re: Clinical Case Reports

Nick Shackleton — Wed, 06 Jul 2011 17:15:48 GMT

Medical? Surgical? Anaesthesia? Radiography?

I can post examples of anaesthesia, Radiography and surgical nursing from my Dip AVN casebooks

Clinical Case Reports

Re: Clinical Case Reports

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Re: Clinical Case Reports

Re: Clinical Case Reports