PULMONARY MEDICINE

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PULMONARY MEDICINE

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PULMONARY MEDICINE

  1. 1. <ul><li>PULMONARY MEDICINE </li></ul><ul><li>http://crisbertcualteros.page.tl </li></ul>
  2. 2. <ul><li>History </li></ul><ul><li>Physical examination </li></ul><ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Palpation </li></ul></ul><ul><ul><li>Percussion </li></ul></ul><ul><ul><li>Auscultation </li></ul></ul>
  3. 3. HISTORY <ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Exposure history </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><ul><li>Age started smoking </li></ul></ul></ul><ul><ul><ul><li>Current smoker? Ex-smoker? </li></ul></ul></ul><ul><ul><ul><li>Exposure burden (pack-years) </li></ul></ul></ul><ul><ul><ul><li>Active vs passive smoking </li></ul></ul></ul>
  4. 4. <ul><li>Exposure history… </li></ul><ul><ul><li>Work/exposure to industrial pollutants (e.g. coal, silica, asbestos, wool, etc) </li></ul></ul><ul><ul><li>Biomass fuel exposure </li></ul></ul><ul><ul><li>Residence </li></ul></ul><ul><ul><li>Recent trips </li></ul></ul><ul><ul><li>Infectious exposure (e.g.TB) </li></ul></ul>
  5. 5. <ul><li>Family history </li></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Bronchial asthma </li></ul></ul><ul><ul><li>Atopy </li></ul></ul><ul><ul><li>Cystic fibrosis </li></ul></ul><ul><ul><li>Pulmonary hypertension </li></ul></ul><ul><li>Personal </li></ul><ul><ul><li>Drug use/abuse </li></ul></ul><ul><ul><li>Sexual history </li></ul></ul><ul><ul><li>Sleeping habits </li></ul></ul><ul><li>Others </li></ul><ul><ul><li>Pharmacologic agents (e.g β -blockers, amiodarone, ASA, diet pills, contraceptives, etc.) </li></ul></ul>
  6. 6. Cardinal Symptoms of Respiratory Diseases <ul><li>Dyspnea </li></ul><ul><li>Cough </li></ul><ul><li>Hemoptysis </li></ul><ul><li>Cyanosis </li></ul><ul><li>Clubbing </li></ul><ul><li>Thoracic pain </li></ul>
  7. 7. DYSPNEA <ul><li>Breathlessness/ shortness of breath </li></ul><ul><li>Designate variety of sensations </li></ul><ul><ul><li>Shortness of breath </li></ul></ul><ul><ul><li>Chest tightness </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Abnormal breathing patterns </li></ul></ul><ul><ul><li>“ nervousness”, palpitations </li></ul></ul><ul><li>Variable quality </li></ul>
  8. 8. Causes of Acute & Chronic Dyspnea Tracheal stenosis Pulmonary hemorrhage Psychogenic Pleural effusion Anemia ARDS Pulmonary vascular disease Pneumonia Pulmonary thromboembolic disease Pulmonary embolism Pleural effusion Spontaneous pneumothorax Diffuse interstitial fibrosis Chest wall injury CHF Asthma (exacerbation) COPD/asthma Pulmonary edema Chronic Acute
  9. 9. ATS Dyspnea Scale Very severe 4 Too breathless to leave the house; breathless on dressing/undressing Severe 3 Stops for breath after walking about 100 y or after a few minutes on the level Moderate 2 Walks more slowly than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level Mild 1 Troubled by shortness of breath when hurrying on the level or walking up a slight hill None 0 Not troubled by shortness of breath when hurrying on the level or walking up a slight hill Degree Grade Descriptions
  10. 10. <ul><li>Precipitating factors </li></ul><ul><li>Relation to activity </li></ul><ul><li>Relieving factors </li></ul><ul><li>Temporal profile </li></ul><ul><li>Relation to position </li></ul><ul><li>Related symptoms </li></ul>
  11. 11. COUGH <ul><li>Explosive expiration </li></ul><ul><li>Reflex & protective </li></ul><ul><li>Varied in cause – mechanical, inflammatory, psychogenic </li></ul><ul><li>Non-specific </li></ul>
  12. 12. <ul><li>Attributes </li></ul><ul><ul><li>Chronic vs acute </li></ul></ul><ul><ul><li>Productive vs dry </li></ul></ul><ul><ul><li>General condition of patient </li></ul></ul><ul><ul><li>Other comorbidities </li></ul></ul>Interpretation of significance depends on the clinical company that it keeps
  13. 13. Top Five Causes of Chronic Cough <ul><li>Bronchial asthma </li></ul><ul><li>COPD </li></ul><ul><li>Upper airway cough syndrome </li></ul><ul><li>Pulmonary TB </li></ul><ul><li>GERD </li></ul>
  14. 14. HEMOPTYSIS <ul><li>Coughing up of blood </li></ul><ul><ul><li>Blood-tinged </li></ul></ul><ul><ul><li>Pure blood </li></ul></ul><ul><ul><li>Minimal vs massive </li></ul></ul><ul><li>Respiratory vs other sources </li></ul><ul><ul><li>Hematemesis </li></ul></ul><ul><ul><li>Aspirated blood </li></ul></ul><ul><li>Blood from airways </li></ul><ul><li>Bright red </li></ul><ul><li>Admixed with sputum </li></ul><ul><li>Frothy </li></ul><ul><li>Alkaline pH </li></ul><ul><li>Blood from GIT </li></ul><ul><li>Dark </li></ul><ul><li>Gastric complaints </li></ul><ul><li>Food particles </li></ul><ul><li>Acidic pH </li></ul>
  15. 15. Common Causes of Hemoptysis <ul><li>Infections </li></ul><ul><ul><li>Bronchitis </li></ul></ul><ul><ul><li>TB </li></ul></ul><ul><ul><li>Fungal infections </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Lung abscess </li></ul></ul><ul><ul><li>Bronchiectasis </li></ul></ul><ul><li>Neoplasms </li></ul><ul><li>Cardiovascular disorders </li></ul><ul><ul><li>Pulmonary infarction </li></ul></ul><ul><ul><li>Mitral stenosis </li></ul></ul><ul><li>Trauma </li></ul><ul><li>Foreign body </li></ul><ul><li>Systemic disorders </li></ul>
  16. 16. <ul><li>Circumstances surrounding the event </li></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>“ Gurgling”/”boiling” sensation </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Sputum production </li></ul></ul><ul><ul><li>Patient profile </li></ul></ul>
  17. 18. CYANOSIS <ul><li>Bluish discoloration of the skin </li></ul><ul><ul><li>Earlobes </li></ul></ul><ul><ul><li>Lips </li></ul></ul><ul><ul><li>Nail beds </li></ul></ul><ul><ul><li>Mucous membranes </li></ul></ul><ul><ul><li>Retina </li></ul></ul><ul><li>Increased amounts of reduced Hgb </li></ul><ul><ul><li>Degree of discoloration proportional to absolute concentration of reduced Hgb </li></ul></ul><ul><li>~Arterial hypoxemia </li></ul>(SaO 2 <85%)
  18. 19. CAUSES OF CYANOSIS <ul><li>Peripheral cyanosis </li></ul><ul><ul><li>Abnormally large extraction of O 2 in the peripheral circulation – CHF </li></ul></ul><ul><ul><li>Peripheral vasoconstriction – Raynaud’s phenomenon </li></ul></ul><ul><ul><li>Shock </li></ul></ul>Normal oxygenation Consider S/Sx of underlying disorder
  19. 20. Cyanosis Due to Pulmonary Disease <ul><li>Ventilation-perfusion mismatch </li></ul><ul><li>Low FiO 2 </li></ul><ul><li>Hypoventilation </li></ul><ul><li>Shunt </li></ul><ul><li>Diffusion disorders </li></ul>Arterial hypoxemia
  20. 21. CLUBBING
  21. 22. Denotes long-standing (>6 mos) hypoxemia
  22. 23. Clubbing vs Hypertrophic Osteoarthopathy
  23. 24. Thoracic Pain <ul><li>Pleuritic </li></ul><ul><ul><li>‘ Close to the chest wall” </li></ul></ul><ul><ul><li>Predominantly inspiratory </li></ul></ul><ul><ul><li>Aggravate by coughing, laughing </li></ul></ul><ul><ul><li>Patient clutches chest </li></ul></ul><ul><ul><li>Accompanied by respiratory symptoms </li></ul></ul>Must be differentiated from cardiac pain!!!
  24. 25. <ul><li>Pulmonary pain </li></ul><ul><ul><li>Accompanies tracheitis or tracheobronchitis </li></ul></ul><ul><ul><li>Searing </li></ul></ul><ul><ul><li>Pronounced after cough </li></ul></ul><ul><li>Pain in pulmonary HPN </li></ul>
  25. 26. <ul><li>Chest wall pain </li></ul><ul><ul><li>from within the thorax </li></ul></ul><ul><ul><li>referred pain </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Costochondritis </li></ul></ul><ul><ul><li>Abdominal pathology </li></ul></ul><ul><ul><li>Neuralgia </li></ul></ul>
  26. 27. PHYSICAL EXAMINATION <ul><li>Inspection </li></ul><ul><li>Palpation </li></ul><ul><li>Percussion </li></ul><ul><li>Auscultation </li></ul>
  27. 28. INSPECTION/OBSERVATION http://crisbertcualteros.page.tl
  28. 33. <ul><li>Pay particular attention to </li></ul><ul><ul><li>General comfort and breathing pattern </li></ul></ul><ul><ul><ul><li>`distressed, diaphoretic, labored? </li></ul></ul></ul><ul><ul><li>Are the breaths regular and deep? </li></ul></ul><ul><li>Use of accessory muscles of breathing </li></ul><ul><li>Color of the patient </li></ul><ul><li>Lips & nail beds </li></ul>
  29. 34. <ul><li>The position of the patient </li></ul><ul><ul><li>Those with extreme pulmonary dysfunction will often sit up-right </li></ul></ul>
  30. 35. <ul><li>Pursed lip breathing – emphysema/COPD </li></ul><ul><li>Ability to speak </li></ul><ul><li>Audible noises associated with breathing </li></ul><ul><ul><li>wheezing </li></ul></ul><ul><ul><li>gurgling caused by secretions in large airways are audible to the &quot;naked&quot; ear. </li></ul></ul><ul><li>The direction of abdominal wall movement during inspiration </li></ul><ul><ul><li>paradoxical breathing </li></ul></ul><ul><ul><li>placing your hand on the patient's abdomen may accentuate this movement </li></ul></ul>
  31. 36. <ul><li>Use of accessory muscles </li></ul><ul><ul><li>Sternocleidomastoid (SCM), scalenes & serratus </li></ul></ul><ul><ul><ul><li>Use of these muscles at rest is a sign of respiratory distress </li></ul></ul></ul><ul><ul><li>Intercostal retractions </li></ul></ul><ul><li>Chest lag </li></ul>
  32. 37. <ul><li>Chest or spine deformities </li></ul><ul><ul><li>Pectus excavatum: Congenital posterior displacement of lower aspect of sternum. This gives the chest a somewhat &quot;hollowed-out&quot; appearance. </li></ul></ul><ul><li>Barrel chest: Associated with emphysema and lung hyperinflation. Accompanying xray also demonstrates increased anterior-posterior diameter as well as diaphragmatic flattening. </li></ul><ul><li>Kyphosis: Causes the patient to be bent forward. Accompanying X-Ray of same patient clearly demonstrates extreme curvature of the spine. </li></ul>
  33. 38. CHEST DEFORMITIES http://crisbertcualteros.page.tl
  34. 39. <ul><li>Pectus excavatum - indented sternum </li></ul><ul><li>Pectus carinatum (pigeon chest)- sternum protrudes </li></ul><ul><li>Increased anteroposterior (AP) diameter or &quot;barrel chest&quot; </li></ul><ul><ul><li>chronic lung disease </li></ul></ul><ul><ul><li>hyperexpanded lungs </li></ul></ul><ul><ul><li>normal adults – transverse diameter > AP </li></ul></ul>
  35. 45. http://crisbertcualteros.page.tl
  36. 46. PALPATION <ul><li>Relatively minor role </li></ul><ul><li>Accentuating normal chest excursion </li></ul><ul><li>Unequal excursion </li></ul><ul><ul><li>Pneumothorax </li></ul></ul><ul><ul><li>Effusion </li></ul></ul><ul><ul><li>Atelectasis </li></ul></ul><ul><ul><li>Fibrothorax </li></ul></ul><ul><ul><li>Poat-pneumonectomy </li></ul></ul><ul><ul><li>Acute chest wall injury </li></ul></ul><ul><ul><li>There has considerable plerual disease before asymmetry can be identified on exam. </li></ul></ul>
  37. 47. <ul><li>Investigating painful areas </li></ul><ul><ul><li>Carefully palpate around that area </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><ul><li>look for evidence of rib fracture </li></ul></ul></ul><ul><ul><ul><li>subcutaneous air </li></ul></ul></ul><ul><li>Palpate neck, axillary & supraclavicular areas </li></ul>
  38. 48. <ul><li>Palpate tracheal position </li></ul><ul><ul><li>Midline </li></ul></ul><ul><ul><li>Lateral/deviated - tension pneumothorax, mass, traction </li></ul></ul><ul><li>Tactile fremitus </li></ul><ul><ul><li>“ feeling” for palpable vibrations through the chest wall </li></ul></ul>
  39. 49. <ul><li>Decreased fremitus </li></ul><ul><ul><li>Something between the lung & chest wall </li></ul></ul><ul><ul><li>Pneumothorax </li></ul></ul><ul><ul><li>Pleural effusion </li></ul></ul><ul><ul><li>Scarred, thickened pleura </li></ul></ul><ul><li>Increased fremitus </li></ul><ul><ul><li>Pneumonia </li></ul></ul>
  40. 50. PERCUSSION <ul><li>Technique </li></ul><ul><ul><li>Use your index and long finger </li></ul></ul><ul><ul><li>“ Wrist job” </li></ul></ul><ul><ul><li>Strike the DIP joint of the long finger of your other hand, which is on the patient's chest wall </li></ul></ul><ul><ul><li>Move from side to side, comparing sides </li></ul></ul>
  41. 53. <ul><li>Low pitched & drumlike on the air-filled normal lung </li></ul><ul><li>Higher pitched on the abdomen </li></ul><ul><li>Flat over water & solids </li></ul>Percussion Sounds
  42. 54. <ul><li>Hyperresonance: louder & hollower than usual with: </li></ul><ul><ul><ul><li>Pneumothorax </li></ul></ul></ul><ul><ul><ul><li>COPD/asthma with hyperinflation </li></ul></ul></ul><ul><li>Dullness to percussion (more liquid or solid) </li></ul><ul><ul><ul><li>Pleural effusion </li></ul></ul></ul><ul><ul><ul><li>Consolidation </li></ul></ul></ul><ul><ul><ul><li>Also percuss for diaphragmatic excursion, which should be 3 to 5 cm from inspiration to expiration. </li></ul></ul></ul>
  43. 55. inspiration
  44. 56. AUSCULTATION
  45. 57. AUSCULTATION <ul><li>Technique </li></ul><ul><ul><li>Diaphragm of your stethoscope </li></ul></ul><ul><ul><li>Move from side to side </li></ul></ul>
  46. 58. <ul><li>Don't get in the habit of performing auscultation through clothing! </li></ul><ul><li>Ask the patient to take slow, deep breaths through their mouths </li></ul><ul><ul><li>Forces the patient to move greater volumes of air with each breath </li></ul></ul><ul><ul><ul><li> duration, intensity </li></ul></ul></ul><ul><ul><ul><li>Accentuates abnormal breath sounds </li></ul></ul></ul>
  47. 59. <ul><li>Have the patient cough a few times prior to beginning auscultation </li></ul><ul><ul><li>Clears airway secretions & opens small atelectatic areas at the lung bases. </li></ul></ul><ul><li>Let patient exhale forcibly </li></ul><ul><ul><li>accentuate abnormal breath sounds (in particular, wheezing) that might not be heard when they are breathing at normal flow rates. </li></ul></ul>
  48. 60. Listen for… <ul><li>Breath sounds </li></ul><ul><li>Vocal resonance </li></ul><ul><ul><li>Transmission of patient's voice </li></ul></ul><ul><ul><li>Auditory equivalent of tactile fremitus </li></ul></ul>
  49. 61. <ul><li>Breath sounds are softer if </li></ul><ul><ul><li>• Patient has air around the lung (pneumothorax) </li></ul></ul><ul><ul><li>• Patient has fluid around the lung (pleural effusion) </li></ul></ul><ul><ul><li>• Patient is obese   or has pleural thickening or scarring </li></ul></ul><ul><ul><li>• Patient is moving less air (severe chronic obstructive lung disease or asthma) </li></ul></ul>
  50. 62. <ul><li>Vesicular sounds </li></ul><ul><ul><li>Over most of the lung </li></ul></ul><ul><ul><li>Breathy sound of air moving in small airways & alveoli </li></ul></ul><ul><ul><li>Inspiration = Expiration </li></ul></ul>NORMAL BREATH SOUNDS
  51. 63. <ul><li>Bronchovesicular sounds </li></ul><ul><ul><li>Medium pitched </li></ul></ul><ul><ul><li>Normally heard in central chest </li></ul></ul><ul><ul><li>If heard elsewhere, a sign of consolidation </li></ul></ul>
  52. 64. <ul><li>Bronchial sounds </li></ul><ul><ul><li>Higher pitched </li></ul></ul><ul><ul><li>Heard over the trachea </li></ul></ul><ul><ul><li>Abnormal elsewhere in the lungs </li></ul></ul>
  53. 65. <ul><li>Bronchophony </li></ul><ul><ul><li>Increased clarity of words, e.g. in area of pneumonia </li></ul></ul><ul><ul><li>Whispered pectoriloquy - an extreme form of bronchophony </li></ul></ul>
  54. 66. <ul><li>Egophony </li></ul><ul><ul><li>“ ee” heard as “ay” </li></ul></ul><ul><ul><li>Consolidation + fluid </li></ul></ul><ul><ul><li>May be the only physical examination abnormality in early pneumonia </li></ul></ul>
  55. 67. <ul><li>Crackles (rales) - fluid in the alveoli </li></ul><ul><ul><li>Heart failure </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Pulmonary fibrosis </li></ul></ul><ul><ul><li>Typically inspiratory </li></ul></ul><ul><ul><li>Sound of opening velcro </li></ul></ul>
  56. 68. <ul><li>Wheezes </li></ul><ul><ul><li>High pitched, continuous whistles </li></ul></ul><ul><ul><li>Usually in expiration </li></ul></ul><ul><ul><li>Airways narrowing </li></ul></ul><ul><ul><li>Forced airflow through abnormally collapsed airways with residual trapping of air </li></ul></ul><ul><ul><ul><li>Asthma </li></ul></ul></ul><ul><ul><ul><li>Airway swelling </li></ul></ul></ul><ul><ul><ul><li>Tumor </li></ul></ul></ul><ul><ul><ul><li>Obstructing foreign bodies </li></ul></ul></ul>
  57. 69. <ul><li>Rhonchi </li></ul><ul><ul><li>Low pitched, snore-like </li></ul></ul><ul><ul><li>Inspiration & expiration </li></ul></ul><ul><ul><li>Originate in larger airways </li></ul></ul><ul><ul><li>Sign of bronchitis. </li></ul></ul>
  58. 70. <ul><li>Friction rub </li></ul><ul><ul><li>Dry, leathery sound </li></ul></ul><ul><ul><li>Inspiration & expiration </li></ul></ul><ul><ul><li>Sign of inflammation of the pleura </li></ul></ul>
  59. 71. <ul><li>Stridor </li></ul><ul><ul><li>Inspiratory </li></ul></ul><ul><ul><li>Best heard over neck </li></ul></ul><ul><ul><li>Upper airway obstruction </li></ul></ul>
  60. 72. <ul><li>http://crisbertcualteros.page.tl </li></ul>
  61. 73. Classification of Common Lung Sounds Sonorous ronchus Ronchus Continuous sounds longer than 250 msec, low-pitched; dominant ferquency of < 200 Hz, snoring sound Sibilant ronchus Wheeze Continuous sounds longer than 250 msec, high-pitched; dominant ferquency of 400 Hz, hissing sound Fine rales, crepitation Fine crackles Discontinuous, interrupted, explosive sounds; less loud than above & of shorter duration; higher in pitch than coarse crackles Coarse rales Coarse crackles Discontinuous, interrupted, explosive sounds; loud, low pitch Common Synonyms ATS Nomenclature Acoustic Characteristics

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