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Chest - Dr Abo-ElAsrar - By El Azhar Medical Students 2012
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( BETA EDITION)
With
Prof. Dr Mohammed Abo El-Asrar
Edited By
El-Azhar Medical students 2012
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Total pages = 55
Total time = about 6.5 hours
1- lecture 56 4 - 1
introduction to chest ( page 4 )
2- lecture 57 19 29
Bronchial asthma ( page 19 )
3- lecture 58 29 3
cont. BA (types of asthma) ( page 29 ) Pneumonia ( intro ) ( page 31 )
Pneumococci ( page 33 )
staph pneumonia ( page 34 )
streptococci + gram -ve ( page 35 )
viral ( page 36 )
4- lecture 59 38 - 5
mycoplasma ( page 38 )
Acute bronchiolitis ( page 38 )
Bronchiectasis ( page 43 )
Croup ( page 50 )
Dry pleurisy ( page 53 )
Pleural effusion ( page 54 )
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:
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..-Itemssub items
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18/4/2012 ./
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symptomschest
,,chest
,,,
..
1- cough
,,,dry coughproductive cough
2- expectoration
3- Dyspnea
,,,dyspnea,,Hypoxia
dyspneagradegrades of respiratory distress
:
4- Noisy respiration
,,naked ear(,,
),,,,
,,noisy respiration
,,,respiratory tract:
Nosenaso pharynxLarynx
- Medium sized airway
-small bronchus
-small bronchusterminal bronchiole
-terminal bronchiolealveoli
tracheamajor bronchus
tracheaMajor bronchusconnectorsUpperlower
connectors,,ringcartilageringcartilage
chest
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- during respiration
diameterlowerupper
Lower respiratory tractinspiration,,,
-Upper respiratory tract,,,
Uppper respiratory tractInspiration
,,,,,
lower respiratory tract
expiration
-upper respiratory tractlower respiratory tract..,,
alveolialveoli..alveoli,,elastic
Inspiration,,,recoilalveoli..
,,
bronchusconstrictiondiameter
upper respiratory tractexpirationdiameter
diameterUpper respiratory tractinspiration
diameterlower respiratory tractexpiration
,,partialcomplete
partial obstruction,,partial obstruction
..diameterdiameter
-,,,,Inspirationexpiration
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Noisy respiration
,,,timinginspirationexpiration
,,,upperlower
,,noisy respiration
a -nose due to partial obstruction
-nasal polyprhinitisnasal congestion
-,,,inspiration,,Inspiration
expiration
b -Naso pharynx
-adenoidpartial obstructionInspiration
:,,,
,,
,,parasympatheticairway
chest
c -Larynx stridor ( charactarstic )
Upper,,,Inspiratory...Stridor
:,,,,
,,Inspiratory sound
d -medium sized and small bronchus as in bronchospasm Wheeze
- during expiration ( as the disease in lower respiratory tract called wheeze ( )
e -alveoli grunting
- Expiratory sound = pneumonia
gruntingalveolar pathologyalveolar pathology
pneumonia
:gruntingpneumonialarynx
-alveolicells:
Type one alveolar cell & Type two alveolar cell
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1- type one alveolar cell ,,
Mucous secretionair way..
airway
-alveoliinspirationexpiration
-()expiration2 surfacesalveoli
fluid..(alveoli,,,)
two layers
)
,,..
2- type two alveolar cell
surfactant(which prevent alveolar collapse during full expiration)
,,InfectionalveoliMucous secretion(rhinitisNasal discharge)
surfactant
..
-pneumonia(collapse)full expiration
spasm of adductors of the vocal cordsVC..alveoli
two layersalveolicollapse
grunting
F - connectors Trachea & large bronchus
-secretionbronchitistacheitis
-secretions(Inspiratoryexpiratory)
-()rackling sound..
5- chest pain
..chest pain
a-dry pleurisy stitching pain .
,,:
b-Muscle strain Diffuse dull aching pain
,,,,
-Muscle strainabdominal wallchest wall
6- hemoptysis
-malignancy,,tuberculosis,,
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-bronchitisInfection
7- cyanosis
:..respiratory failure
chest
fever,,Infection,,
signsexamination..chest
4
,,
chestinspection
A Signs of respiratory distress :
-respiratory distress
-distressedWhich degree1- 1st degree of respiaratory distress :
respiratory distress
-respiratory problemretentionCarbon dioxideoxygen saturation
..,,
-brainchemo receptorsrespiratory center
blood gases,,respiratory
rate
sayadultrespiratory ratesay 1830
so, tachypnea
working ala nasai..,,
2- 2nd degree respiratory distress :
-respiratory systemwithin limits
respiratory rate
compensation
-accessory muscles of respiration
accessory muscle of respiration
-negative pressure inside the thorax
LunghypoxiaHyper capnia
hyper inflation of the lung-:
antero posterior diameter of the chestvertical diameter of the chest
a- either antero posterior diameter : HOW ?? contraction of intercostal & subcostal ms.
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Intercostal and subcostal retraction
ribsObliqueIntercostal muscleribs
Horizontalantero posterior diameter
Intercostal muscles
-indrawinginter costal spacesubcostal spaces
intercostal retractionsubcostal &..grade
b- or vertical diameter : HOW ?? contraction of sternomastoid ms. one of the major accessory muscle
suprasternal & supraclavicular retraction
-clavicle,,,sternomastoid
supraclavicular & suprasternal indrowing
1- if upper respiratory tract obstruction (as stridor)
sternamastoid acts as accessory ms. (not intercostal ms. ) suprasternal & supraclavicular retractio
-..tachypnea..working ala nasaisupra sternal and supra clavicular retraction
2- but if lower respiratory tract obstruction (as pnumonia or BA )
intercostal ms act as accessory ms. (not sternomastoid ms. ) intercostal & subcostal retraction
-..tachy pnea..working ala nasai
intercostalsubcostal retraction
anatomy
:embryologycommon dermatome
embryology,,
refered painembryology
common dermatome..,,,
-:upper respiratory systemsterno mastoiddermatome
upper respiratory tractaccessory muscledermatome
sterno mastoid
-,,,Lower respiratory tractInter costal
-NB,,,,,
chest
inter costasubcostalsupra sternalsupra clavicular,,,Mental retarded
..ENT,,,!!
3- 3rd degree respiratory distress :
= Grunting in pneumonia only .
4- 4th degree cyanosis if respiratory failure .
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B chest movement :
Inspection,,,commentMovement of the chest)
-chest walllimitation of movement
(limitation of movementpathology)
pathologyBilaterallimitation,,,
Unilateral
-confirmpalpationfold of skin..
-where is the lesion nothing else
-Limitation of movement bilateralbilateral pathology
-,,,,,Normal,,
diseased
C - Bulge or retraction :
,,,bulgeretraction
||,movement
- if bulge at one side ( means massive pleural effusion,tension pneumothorax or unilatera
emphysema )
if bulged side is bulged ( diseased ) or normal & the other side is retracted ??- if retraction at one side ( means fibrosis or collapse )
if retracted side is retracted ( diseased ) or normal & the other side is bulged ??
bulgeretraction
movement
affectedaffected
unilateral retraction
fibrosiscollapse
,,,,,,,,
bulge
bulge
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massive pleural effusion
massivebulge
,,bulgetension pneumothorax
tension pneumothoraxPleura
LungUnilateral emphysema
Unilateral bulge
tension pneumothorax
unilateral emphysema
massive pleural effusion
clinical:Unilateral retraction
trasnverse diameter of the chestanteroposterior diameter
,,transverseanteroposterior()
Transverse : anteroposterior = 3 : 2
,,,antero posterior diametertransverse diameter
antero posterior diameter
-,,limitation of movement bilateralbilateral bulge
Barrel shaped chest
bilateral bulge
,,,..lung
bronchial asthmaattack
bronchiolitis,,
Lung,,emphysema
-bilateral pleural effusionMassivegeneralized edemaNephrotic,,
lung
3
A Trachea :
-Index fingersupra sternal notch
-,,,resistance
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tracheatracheaMiddle lineslightly to the right..
,,resistance
-sternomastoid muscleresistance
trachea
NBtrachea is shifted to the left..Shifted
tracheaexaminer!!!,,,trachea
-,,..
right side
1- trache is retracted( pulled ) to Lt side
-pushed
-Inspection..:
- limitation of mov. In lt side & retraction in lt side
tracheaLt....
trachea..
2- trache is pushed( from Rt. side ) to Lt side
-retracted
-Inspection..:
- limitation of mov. In Rt side & bulge in Rt. side
tracheaLt....
trachea..
NB,,,pathologybilateraltracheacentral
B palpable sounds :
-Intercostal space
supra mammary
mammary area
Infra mammary
,,,Mid clavicular line..,,anterior axillaryMid axillary
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-,,,
1- may wheeze :
-palpable wheezebroncho spasm
2- may pleural rub :-friction rub
,,actually
C Tacitile vocal fremitus :
-TVFco operative
,,,ninity nine,,
-,,palpable sounds
NBTVFcompartive,,TVF bilaterally diminishedTVF
bilaterally
TVF,,TVF
NB . Any pathology decrease TVF except : 3 Cs
- Pneumonia ( consolidation ) .
- lobe Collapse with patent bronchus .
- Cavity (superficial ) .
-Normal percussion of the chestLight percussion
-light percussionpercussionwrist
-Heavy percussionmental retardedelbow!!
more heavyshoulder!!!!!!!!!!!!
NBPercussionwrist
-Percussionmid clavicular linecompartive
-anterior axillarycompartivemid axillaryinter scapularinfra scapular
-percussionlungNormally resonant
,,,abnormal
1- dullness or impaired note :
Dullness,,,pathologydullness
,,stony dullnessstony dullnessdiagnosticpleural effusion
2- hyper resonant :
Percussion of the chest..Hyper resonant chest
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hyper resonance
bilateral
bilateral
-emphysemabronchial asthma during the attackbronchiolitis
,,,Unilateral hyper resonant chest..
Pleura,,,Unilateral pnumo thorax
lung,,Unilateral emphysema
auscultation of the chestcomment3
1- air entry :
respiratory distress(chestrespiratory distressbronchitis)
diminished air entry
- bilateral diminished air entry or unilateral diminished air entry
2- breath sound :
A Normal vesicular breath sound
-Normallayalveoli
-alveoli
Lung
,,,,,
,,....)
-,,,..
alvoli..inspiration()expiration()
Normal vesicular breathing
B Harsh vesicular breath sound or prolonged expiratory time
:
a- obstruction of air outlet
Outletalveoliobstructionairway
b- or not recoil alveoli ( inelastic alveoli )
alveoliIn elasticrecoilrecoil
NBharsh vesicular breathingnormal breathing
-air way
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-,,,,,normal breathing
-pathologylungharsh vesicular breathing
NB. No gap
C Bronchial breathing :
-Pneumonia..alveoliInflammatory secretionalveolus..alveoli(masscollapse)
-,,alveoli..
During inspiration
-alveolitracheanearby bronchus
Gap
-inspiration..Nearby bronchusalveoli,,,
alveoli..,,,,gap
Expiration
,,alveoli
expiration
-bronchial breathing
bronchial breathing,,,,Inspirationexpirationgap
-NBalveoli..tubetubular sound
tubehollow breathing
NBbronchial breathingTVF
TVFbronchus
3- advential sound :
rhonchi..creptitation
A Rhonchi : 2 types
a- sibilant rhonchi = wheeze :
,,,,siblent rhonchibroncho spasmbroncho stenosis
-siblent rhonchi
bronchial asthma..bronchiolitis..viral pneumonia
-unilateral obstruction
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1-
,,foreign body inhalationunilateral obstruction
2-(bronchus)
3-wall of the bronchus,,
-bronchusbronchus
,,,
b- sonorous rhonchi :
-sonorous rhonchicoarse crepititation
-..secretionbronchussonorous rhonchicoarse
crepitus
sonorous rhonchi
snoring
coarse crepititation
B Crepitations :
a- Coarse :
b- Fine crepitations :
wall of the alveoliIn elastic
-alveoli..
-,,fine crepititation
-pneumonia
-congestive heart failure
-bronchiectasis
complicationschest
complications of respiratory diseases,,,:
1- Respiratory failure
respiratory failurecentral cyanosis
,,,central cyanosisrespiratory failure(respiratory
failureblood gases),,respiratory diseaserespiratory
failure
2- Heart failure :
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a- toxic myocarditis
bacterial infection,,toxinsbacteriatoxic myocarditis
b- viral infection
viral myocarditisHeart failure
c- may be due to cor pulmonale right sided failure
cor pulmonaleLung pathologyfibrosisPulmonary arterypulmonary
artery vessel..Pulmonary artery pressure..
-Pulmonary artery pressureback pressureright ventricle
d- also, severe hypoxia may cause cardiomyopathy .
,,
1- chest X ray :
chestchest X - ray..chest X - raydiagnostic2- CBC :
-CBC
-chesttotal leucocytic countinfection
differential countInfection
Lympho cytosis..viraltuberculus
Neutrophilsbacterial
esinophilsvisceral larva migrans..parastic infection..allergicasthma
3- Blood gases for dignosis of respiratory failure.
a- PH < 7.1 b- PCO2 > 60 mmHg c- PO2 < 50 mmHg
PH7.17.2
CO260 mm Hg50
PO2
4- specific investigations according to the pathologyspecific investigations
skeleton
treatmentrespiratory distress
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1- Hospitalization
-respiratory distress
complete bed rest,,,,
,,,,Intra venous fluids
maintenance fluids
maintenance fluids900
-600
,,9006002/3
hypoxiahypoxiaADH
full maintenancepulmonary edema3Oxygenoxygen therapyoxygen therapy
2- ttt of underlying etiology .
distress
PneumoniaPneumoina
3- ttt of complications .
-Heart failure,,diuretics,,digoxinrespiratory
distress
-respiratory failure,,,mechanical ventilator
4- symptomatic ttt never give cough sedatives in pediatrics .
-feverish,,anti pyretics
-broncho spasm,,broncho dilator
-,,mucolyticexpectorant,,,,cough
therapy
(cough therapy)
-,,respiratory distresshospitalization
-distressedrespiratory failureHeart failure
complications
Underlying etiologysymptomatic treatment
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pathogenesisC / P
-bronchial asthmaso common,,,,,,,,,,,,
asthma
-stressmost common type of asthmaallergic asthma
allergic induced asthmaextrinsic asthma
......
....:
Item:
,,, ,,,allergenallergens
-most common allergen,,,viral infection
-allergendustfumes..pollens
-,,
,,,,,,,,,,
allergenssurfaceMucosaskin
..branched cellsdendritic cells
dendritic cellsallergens..dendritic cellsInterlukin one
activationT helper cell
-
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stimulationB lymphocytes
T helper cells..OnceactivatedactivationB lymphocyte
Direct activationInterlukin onedendritic cellsallergen
activationactivated T helper cells
-B lymphocytesOnce activatedPlasma cells
-Plasma cellsimmune globulinsallergen()Ig E
Ig G4
-allergensimmune globulin EImmune globulin G4
-,,atopic..atopic,,,,
""feedback inhibitionImmune globulins Eimmune globulin G4
-activationT suppressor cells
T suppressor cells,,OnceactivatedsuppressionT helpersuppression
B lymphocytes
Immune globulin Eimmune globulin G4 production
,,,viral infection..allergens
dustdustdust mites
dust mites,,
123
-autosomal dominant gene..
geneautosomal
malefemale
,,,,,,Incidencepre adolescence
Malefemale..adolescent period..gene factor
exposuremalefemales
out of control
dominant genepathological gene
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positive family history..is diseased
bronchial asthmaatopic diseases
genechromosome11
-asthmagenechromosome11
colonyT suppressorT helper cells
allergenimmune globulin EImmune globulin G4
-blockT suppressor
-activationcycleT helper
allergensImmune globulins Eimmune globulins G4allergic
-allergic
-allergic
-allergicpollens
-virus Infectionvirus induced asthma
""defectcolonyallergen
management,,,,..asthma
Immune globulin EYspecific receptorspecific cells
cellsMast cells
,,esinophils,,,basiophils""
:esinophilsmast cells
-Immune globulins E
surfacemast cellsesinophils
-,,sensitized cells,,,
antibodycell membrane
Is an inert antibody
-
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allergen
-allergen,,antibodymast cells
esinophils
-antibody..direct antigen antibody reaction
-antibodytwo ends
cell membrane
back endantibody bindingallergen
-Y,,allergens..allergens
two armsallergens
,,allergen
-two limbs..
antibody()
-antibodyallergenstwo limbs(Y shaped end)
(
antibodyY
mast cellsesinophils
Yallergen
two ends
allergen
cell membrane
Calcium channels
Calcium channelCalcium channel)
two armscalcium channelsCalcium channels
calciumInfluxmast cellsesinophils
-..esinophilsMast cellsesinophilsMast cellsvesicles
,,,light microscopevesicle
,,,,,,vesicleLight microscope
,,granulesvesiclesvesiclesInflammatory mediators
allergic inflammatory mediatorsvesicles
""
histamine
Prostaglandin E2
-
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thromboxane E2
prostacyclin
Platelets activating factorsPAF
bradykinine
slow releasing substance of anaphylaxisLeukotrines
vesicle,,,electron microscopevesiclecell
membranemyo epithelial fibersMuscle fibersactin and myosine
calciumcytoplasm
-actinmyosintroponine C and troponine Ssliding of actin over
myosin
vesiclecell membraneContraction
-vesiclecell membranecell membrane
cell membrane
-membranes..adhesion,,vesicle..allergic Mediators
....vesicle
-vesiclemembranevesiclemembrane
-vesicleallergic mediators
vesicle..
-Microscopevesicle
degranulationreduction of the number of the vesicle inside the cell
-,,first 6 hoursjust broncho spasm
broncho spasmcontractionsmooth muscle of the bronchus
broncho dilatordramatic response
,,,:
broncho spasm,,,broncho spasmLumenbronchus
edemaMucosabronchusbronchus
-,,,Mucous secretion,,secretionLumen
,,,broncho dilatortwo factors
air wayedemasecretion
-
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..
bronchospasm , secretions & odema
wall of the bronchusmucous membranemusclemediators
6bronchospasmlumen..Dry cough
prolonged expirationHarshlower
Expirati
Wheeze....palpable
6mucosal odemaecretions
Dyspnea..coughproductive..:
sonorus rhonchi & coarse crepitations due to secretions
bronchusalveolihyperinflated
bilateral bulgebarrel shaped chesthyperresonant percussion (
bilatera
alveoliwalldegenerationalveoli
emphysematous bullae
lungpleura..bullae....
pneumothorax
-pleurapneumomediastinal()
surgical emphysema..lunglung
collapse
1. Cough dry (6 hours) then productive2. Expectoration3. respiratory distress --Dyspnea4. Wheeze5. () chest pain mostly dull aching pain due to ms strain6. respiratory failure central cyanosis
History of repeated attacks of6
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1- Signs of respiratory distress
Tachypnea Working ala nasai Suprasternal and supra clavicular retractionintercostal and subcostal retraction & central cyanosis2- Bilateral limitation of movement of the chest
air entry
3- bilateral bulge Barrel shaped chest
Disease here is bilateral
tracheacentral
Palpable ronchiPalpable wheeze
TVF
bilateral hyper resonant chest
1- Air entry bilateral diminished air entry
2- breath sounds harsh vesicular breathing
3- advential sound - siblent rhonchi
then may sonorous rhonchi & coarse crepitaions
1) May HF 3
1- Hypoxia (if severe asthma)
2- Cor pulmonale
If marked emphysema >> alveoli >> wall of alveoli >>
compress the capillaries of the pulm a. >> pulm. HTN >> RSHF (cor pulmonale )
3- If precepitating factor is viral infection >> may viral myocarditis and HF
2) Respiratory Failure.
3) Specific complications
1- Emphysema2- Pneumothorax , pneumomediastinum ( ) may lead to massive lung collapse
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(d.t. severe pneumothorax.)
3- Surgical emphysema.
1) Chest X-ray Hyperinflated lung
-Not diagnostic in BA (only to exclude other causes of wheezy chest)
>> Leucocytosis
- In all allergic asthma >>>>> Eosinophilia
3) Blood gases : for Resp. Failure (cyanosis )
4) Specific investigations :
1- Sputum analysis
- in Allergic asthma >>>> Eosinophils
If PPFs is infection >>>> Lymphocytes or others
2- IgE & IgG4 >>> in Extrensic asthma
3- In Extrensic asthma >> so, skin brick test
3
a- But not goodve >>> antihistaminic
b- means
+ve
c- (skin brick test)
Invitro test ( )
4- Pulmonary functions:
(asthma grade of asthma )
asthma>> (dehydration )
-
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((oral intake
3- Oxygen therapy.B - ttt of underlying aetiology ( )
1- ()
2-3-4- Psychological factors :5- > odema & secretions ()
2- selective B2 agonist as salbutamol
-B2((selective B2 agonist as Salbutamol
inhalationnebulizer(saline)
mucosal decongestionVCmucolytic effectsecretion
nebulizer.
3
3- Parasympatholytic
-parasympatholyticnebulizeripratropium
ampulenebulizerbronchodil,secretion & odema
B2atrovent
-
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4- Aminophyllin
-cAMPphosphodiesterase enztheophillineenz
-cAMPgive initial dose then maintainance > 1st 24 Hrs6Give 1 mg/kg/dose
ICUcomplications
- for fever, expectoration,infection give symptomatic
D In between attacks
3In between attacks
1- Avoid :
triggering factors ( .- )
also avoid psychological factors >>>psychological support
2- Pharmacotherapy >>> (attacks )
a- give single bronchodilator (B2)
b- theophylline
c- inhaler corticosteroids Or leukotrien receptor antagonist :
-..
inhaler corticosteroids Or leukotrien receptor antagonist
-
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d- short course corticosteroids or mast cell stabilizer if frequent attcks.
- attack may give short course corticosteroids
maymast cell stabilizer prevent Ca influx to inside ofmast cell .
1- Extrensic autosomal dominant gene ...
2- Intrinsic
A in adult ( )
due chronic irritaion with smoking
B in childern :post viral repeated viral infection" >>> irritate parasymp. Ns >>> vagus >>> Asthma
So, it as a neurogenic not an allergic asthma
- ( triggering factor viral infection ) + -ve family history + -ve skin test + normal IgE & IgG4
Grades according to :
1- Frequency of the attacks :
:
1-attack()
2-nebulizer
3-..
2- Frequency of nocturnal symptoms
3- according to Pulmonary function test ( FEV 1 Sec. )
Mild, Moderate, Sever
-prognosis..:
a mild & moderate asthma50 % releaved ) complete improve ( at 10 years max. at 20 yrs
-recurrence
b - sever asthma >> only 5%
& 95 % develop adult asthma ( )
-
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1- Aspirin induced asthma
allergic asthma
: 2 pathways Arachidonic acid -
A - by PG, Thromboxane, Prostacycline
B - or by Leukotriens (slow releasing substance of anaphylaxis)
Mast cells & Esinophils Arachidonic acid -
Allergic mediators
slow releasing substance (Leukotreins) arachidonic acid Cyclooxygenase Aspirin
Mast cells & Esinophils Vesicles Aspirin Fever
Leukotriens as allergic mediator + long acting >> So, cause sever attack
of asthma & may Status Asthmaticus >> anti leukotriens >>
asthma2- Exercise induced asthma
-attacks
exercisedryness of secretions..
hyperosmoler statedegranulationmast cell
3- Nocturnal asthma
..
1- parasymp. Bronchospasm2- cortisone level (circadian rhythm)3- Weak cardiac sphincter asthma >> asthma GER aspiration asthma
Asthma
1 - Over crowding & Poverty ""
Chronic irritation asthma
Intrinsic asthma
-
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3 - Maternal Smoking chronic irritation
- Also if father is smoker
NBguide lineasthma
..asthma.
4 - Maternal age if20 years oldincidence of having asthmatic child
... asthma 2.5
5 - Psychological factors
Asthma
Inflamation in lung parynchma = alveoli
A - Anatomically x-ray
1- Alveoli in one lobe is affected
2- or in X ray inflammation around the alveoli around the bronchus called bronchopneumonia
Inflamation Bronchus Alveoli
broncho pneumonia>> Patchy
3- Hilar or Interstitial pneumonia
-main bronchushilum of the lung.
Bilateral & around hiluBilateral & patchyUnilateral (one lobe
only)
ViralViral OR bacterialBacterial only ( )
virus
B - Etiological classification :
1- bacterial
as pneumococci, staph, H. infl., psuedomonas, klebs, TB
2- Viral :
Rsv
3- Fungal : as aspergellus , candida only in immunocompromized
-
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4- Paraseticas pneumocystic carnii
5- Physical Pnuemonia due to sudden change of body temp.
signs of distress
6- Orthostatic or hypostatic pnuemonia
Stagnation of lung secretions >> infection
7- Chemical pneumonia:
Very irritant to alvehydrocarbons
8- May due to Radiotherapy >>
: Pneumonia ..
....
pneumonia..
..
A - Complaint:
1) Fever >> high grade in bact. & low in viral() Infection
2) Cough >> dry then productive3) Expectoration4) Dyspnea5) Grunting6) Chest pain >> d.t. pluerisyPluera Surface of the lung Pneumonic patches
Pleurisy
7) If RF >> CyanosisB - Examination
1- Inspection
I. Respiratory diseress syndrome (Tachypnea_Working ala nasi_intercostal & subcostal retraction &grunting or cyanosis)
II. Movement >> Limitation- lobar >> uni - Broncho & Interstitial >> Bi
-
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2- Palpation
I. Tarachea >> centerII. Palpaple sound >> rub if pleurisyIII. TVF >>
- lobar >> on affected lobe
- broncho >> patchy
- interstitial >> parasternal
3- percussion >> dulness
as TVF ()
-sometimes tender >> if pleurisy ()
4- Auscultation
I. Air entry >> diminished on affected areasII. Breath sound >> bronchial breathingIII. Adventitial >> fine and medium sized crepitations C - Complications
1- RF
2- HF if bact. > HF due to Toxic myocarditis & if viral > HF due to viral myocarditis
3- Plural effusion >>
4- May paralytic illeus (Toxic or Hypoxic)
D - Investigations
1) Chest x-ray: -type -complicated or not2) CBC >> total leukocytic count infection
Lemphocytes for diagnosis of RF " 4) Isolation of the organism >>culture >>
-sputum or blood sample or pleural tab if pleural effusion
E - TTT
1) Hospitalization : -Rest O2 therapy -IV fluid maintainance2)
TTT of eitiology: -antibiotics acc. to culture
-G +ve >> penecilline (if resistant >> give cephalosporine)
-Gve >> 3rd generation cephalosporine
3) symptomatic ttt :
i. Fever >> not aspirin if viableii. If productive couph >> expectorant4) ttt of complication
-
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-
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Prevention :
pneumococcal vaccine
Staph infection ...
Fruncle or breast abscess in mother >> lequifaction & localization of infection
(lobar (
C/P
1) Complaint : high grade fever2) ExaminationI. Inspection>> unilat limitation of movement >> mostly on right sideII. Palpation >> rub + TVF ( unilat & patchy )III. Percussion : as TVFIV. Auscultation : as TVF
Investigations
X-ray
Complications :
- Pl. eff : >> pus=emphysema- Lung abscess
) Abscess ) Encysted plneumatocele Cloxacilline
Brocho or lobar
Complication :
-post streptococcal GN or Rh. Fever - may septic focus in bone or joint
Investigations : ASO
gram positive,,,penicillin,,,
,,,third generation cephalosporin
-
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A H. influenza pneumonia
Pneumo coccal pneumonia,,,
Complications
complicationsmeningismMeningitis
The same
,,,Lumbar puncturemeningismmeningitis
third generation cephalosporingram negative
prevention
preventionH. Influenza vaccine
pneumo coccal pneumonia
Influenza vaccine
B - klebsiel la pneumoina
Klebsiellagram negative bacteria..
- cause broncho or lobar .
,,,
1- if cause lobar in immunocompromised not take triangular shape
LobarImmune compromisedLobar pnuemoniatringular
shap
loberoundedrounded shadow(tringular shadow)
X raytumor mass
2- extensive inflam. Reaction friable lung may Hge Hgic effusion
extensive inflammatory reactionsurface of the lungfriable
,,effusion..effusion,,,hemorrhagic effusion..Malignanc
Klebsiellalung malignancy
-gram negativethird generation cephalosporin
-,,,respiratory syncytial virus..influenzaPara influenzavirus
-
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-:broncho pneumoniainterstitial pneumonia
A Symptoms :
- Symptoms of upper respiratory tract ( catarrhal symptoms 2or 3 days befor pneumonia )
- low grade fever
- Wheeze
-wheeze..virus,,irritationvagus
para sympathetic over tonebroncho spasm
viral pneumonia,,,wheezy chest
-chest painviral myositisMuscle strain
-cyanosis,,,viral pneumonia
1-signs of respiratory disterss2-Limitation of movement bilaterally
bronchointerstitial
3-Trachea central
4-palpable sounds Palpable rhonchi
5-TVF increased
6- percussion dullness
7-auscultation,,,
*air entry diminished
*bronchial breathing
*fine Medium sized consenanting crepitation
*siblent ronchi due to broncho spasm
1-Respiratory failure
2-Heart failure)viral myocarditis)
3- post viral immune disease,,,complications..,,post viral auto immune disease
auto immune diseaseviral infection
1-hospitlization
2- ttt of cause
,,,Ribavirinpara influenza virusrespiratory syncytial virus
-
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3-symptomatic treatment
broncho dilator
4- ttt of complications
MycoplasmaOrganism..shcool childrenclosed contacts,
Over crowding
Mycoplasma pneumoniaPenumonia
1-cold antibodies
cold antibody,,,anti bodyactivated37
,,,Hypothermia
-cold antibody,,auto immune hemolytic anemia
Pneumoniaauto immune hemolytic anemiaPneumonia
mycoplasma
,,,viral pneumonia
viral pneumoniaauto immune disorderauto immune hemolytic
anemia
2-specific drug therapy
3rd generation cephalosporinanti viral
specific drug therapygeneration
,,,,,
acute bronchiolitis
Is the mose distressing disease
severe respiratory distress
small bronchus
serosaMucosaIn between,,,Musclosa
small bronchusembryologybudding..
-
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budding:
a- alveoli
-,,alveoli
b- terminal bronchiole
small bronchusterminal bronchiole
alveoligas exchange mechanism(5 %
)
,,,terminal bronchiole90 %gas exchange mechanism
at birth terminal bronchioles
:terminal bronchioles,,,
,,,,,
-95 %gas exchange mechanismalveoli
-5 %terminal bronchiole
- So, bronchiolitis Means inflammation in terminal bronchiles-inflammationmucosaedematous,,
,,,
1- at birth ( < 2 years )
-90 %gas exchange,
-..terminal bronchiolesedematous
alveoli,,gas exchangealveoli
gas exchange
2- after 2 years
,,,Pathology..Inflammationterminal bronchioles
5 %gas exchange
Lumen..edemaalveoli
alveoli(95% of gas exchange at this age)
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bronchiolitis,,,
asthmatic bronchitis
,,,,respiratory distress
respiratory distressMore severe
,,bronchiolitis
....
1st 2 years of life
-inflammation..
-...even so early
virus..RSVvirusdroplet infection
()
virusairwayirritation of parasympathaticbronchospasm
small & medium sized bronchus..
-
-..hyperinflation
-tracheainspection
-percussion
virusrapid spreading...alveoliinflammation in adjacent
alveoli
alveolar reaction that leading to pneumonitis & inelastic alveolar wall so, may .
Etiology
Inflammation in terminal broncheoles caused mainle by viral infection
( mostly RSV .. & may influnza , parainf. Viruses ,measles & mycoplasma )
1- History of upper respiratory tract catarrhal symptoms
-
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-,,rhinitissneezing,,,low grade fever
,,maximum39
-
2- Severe cough
expectoration
3- dyspnea
4- wheeze
5- & may central cyanosis
And very rapidlycentral cyanosis
*signs of respiratory distress
Tachypne Working ala nasai Intercostal and subcostal retratction If alveolar pathology grunting cyanosis*limitation of movement of the chest bilateral
*bulge bilateral ( Hyper inflated chest )or (barrel chest)
*trachea central
*palpable wheeze or palpable rhonchi dueto broncospasm
TVF ,,, bilaterally diminished
comperative signs
*bilateral hyper resonant chest
air entry diminished,,bilateral
-
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breath sounds ,,, harsh vesicular addventious sounds broncho spasm siblent ronchi pneumonic reaction fine crepititation
:bronchiolitisviral pneumonia
,,,viral pneumoniaacute bronchiolitis
-viral pneumoniadullness
-,,,Hyper resonant
1-respiratory failure
2-heart failure dueto
viral myocarditis severe hypoxia
,,,cor pulmonale..
severe acute,,,,,,,
Cor pulmonale
3-emphysematous bullae )due to hyperinflated chest ) may rupture
pneumo thoraxPneumo mediastinumsurgical emphysema
1- Chest X - ray hyper inflated lung
2-CBC
total leucocytic count + Lymphocytosis
3-Blood gases
respiratory failure
PH7.2-PO250-CO2respiratoryfailure
4-viral marker virus,,,
5-sputum cultures
secondary bacterial infection
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1- Hospitalization :
-
bronchiolitis,,
-oxygen therapy
-IV fluids2/3
2- ttt of virus :
-,,Ribavirinanti viralMost common
3- Symptomatic treatment
feverishanti pyretics
mucolytics and expectorant,,,
broncho spasmbroncho dilators
,,,:edemacortico steroid
cortico steroids:viral infection..,,controversal
,,,..cortico steroids
Some of the authors recommendcortico steroids
severe distressedematerminal bronchioles
4- ttt of complications :
-,,,Heart failure,,heart failure
-respiratory failure,,mechanicalventilators
Persistent cystic dilatation of the bronchi (small or medium sized bronchus )
medium sized bronchusdilatationsecretionsstagnant.
stagnant secretionsuper added infectioninfected secretion
small bronchusMedium sized bronchusmicro abscessesInfected sputum
bilateralbasalLower lobes
unilateral
Upper lobe,,,upper lobeLocalized
Upper lobelocal cause
:
-
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A - congenital
congenital:
1- isolated :
isolated,,,,,small bronchusMedium sized bronchus
dilate..stagnant secretion2ry infection
Unilateralbilateral..Lobe
2- as a part of immotile cilia syndrome
-syndrome:
a- Bronchiectasis :
-immotile cilia syndromeKartagnar syndrome
-Cilia,,,Immotile cilia,,,stagnant secretion
dominant lobes(lower lobes)+super added infection
Bronchiectatic changes
b- chronic sinusitis :-Bronchiectasis,,,,chronic sinusitis
-chronic sinusitisfrontalfrontal sinus
ciliagooddrainage
-cilia,,,good drainagesinus
stagnant secretionsinus
infection
-sinusitissinusesair
inflammatory secretions
Skull X - rayabsent frontal air sinus
c- Dextrocardia :
Heartcardiology
-heartapex of the heart
-apex..cardic tubecilia
cilia,,cardic tube..apex
-cilia,,,heart
isolated DextrocardiaB - acquired causes
1- any chronic infection in respiratory tract :
chronic infectionrespiratory tractbronchiectatic changes
-chronic infectionbronchus,,healing by fibrosis
-
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bronchusfibrous tissuewall,,,stagnantionsecretion
wall..wall,,,bronchus,,secretion
2-Obstruction
obstruction,,
a- in lumen as FB or dried secretions :
Lumenchest,,,Lumenbronchus
,,,
foreign bodyinspissated secretion
-prolonged coughanti histaminicdrynesssecretion
airwayforeign body,,,
b- outside lumen tumors or LNs
,,,Lymph nodestumors
bronchus,,,lymph nodestumor
c- from the wall granuloma of TB-wall,,,Obstruction
-T.B.granulomaT.B.wallbronchus
obstruction
-obstructionbroncheactasispartialcomplete
bronchectasis
C/P..C/P
pathology,,,lower lobes..bronchibronchusdilatedinspissated
pusinfected sputum
..fever,,,
-Hectic fever
,,,,,:..
-Inflammationair waycoughProductive cough
-,,,Huge amount of sputumexpectoration
:..yellowishgreenish
organismsecondary infection
Infected sputum,,,
-,,,
,,:,,
-
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,,,Lower lobe of the lung,,,sputum
Pus..,,,,,
- symptoms in winter
:,,,Infectionrespiratorysystem
sputum.. ,,,secretionNormal air way
..
-broncho spasmUpper lobe(Upper lobe)
:dyspneaMild dyspnea))
-Wheeze..,,,
-broncho spasm..alveoliUpper lobehyper inflated
Upper lobelimitation of movement
,,,bulgepercussionhyper resonantUpper lobe
Lower lobe,,,
-chronic infection,,,Inflammationalveoli
pneumoniaPneumonia,,,healing by
fibrosis..lower partretractiondullness
-Pneumonic reactionbronchial breathing..fine creptitation
-rhonchi,,,Lower lobessecretion
secretionsnorous rhonchicoarse creptitation,,,secretion
-broncho spasmrhonchisiblent rhonchi
-,,,Chronic infection
very toxicchronic toxemia..chronic toxemia,,,proliferation
nail bed..clubbing
-
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-chronic toxemiaamyloidosiskidney..Nephrotic Syndrome
,,generalized edema..,,,
puffinessamyloidosisKidney
-,,amyloidosis,,
Hypo proteinemia
:chronic toxemia
,,,..,,hypo proteinemia..edema
-,,Infectionwall of the bronchus..,,ulcer
ulcer,,,
,,,,,,hemoptysis
hemoptysis,,first signLocalized bronchiectasisupper
lobe
upper lobe,,,bronchectatic changesgood drainage
,,,,..hemoptysisfirst sign
Localized bronchiectasisUpper lobe
..
1-fever
2-cough
3-expectoration
expectoration,,,
-huge amountcolored
Related to certain postureon leaning forward
-winter timeearly morning
4-hemoptysis
Ulcerationair way
5-wheeze
broncho spasmUpper lobe
6-chest pain
pleurisy(dry pleurisy)Muscle strainchronic cough
-
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1-fever 2-very toxic 3-may pallor 4-may clubbing
5-Puffiness of the eyelids
puffiness of eyelids
chronic cough
,,,Hypo proteinemiaproductive cough
,,,renal amyloidosis
fibrosischronic infection
fibrosisPulmonary artery
Hyper inflated alveolicapillaries of the pulmonary artery
Pulmonary artery pressurePulmonary hypertension))
6-Lower limb edema
chronic cough
1-Inspection
*Mild respiratory distress
tachypnea
working ala nasai
Inter costal and subcostal retraction
,,,Pneumonic reactiongrunting
*limitation of movement (bilateral)
*bulge in the upper part retraction in the lower part
2-Palpation
*trachea central
*palpable sounds
-Upper lobepalpable wheeze
-pleural rubPleurisy
-
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*TVF
diminished..,,
3-percussion
,,,hyper resonance..Impaireddullness
4-auscultation
*air entry
bilaterally diminished
*breath sounds
-,,,Harsh vesicular
-,,,bronchialPneumonia
*adventious sounds
-,,,siblent rhonchi
-,,sonorous rhonchicoarse crepititationsecretionfine crepititation
pleural rubsurroundingPneumonia
1-renal amyloidosis
2-Lung
*Lung abscess , empyema ,Pleural effusion , cor pulmonale & Pyopneumothorax
1-Chest X - ray
-bilateral basal honey comb appearance
-upper lobehyper inflated
2-CBC
-total leucocytic count( ,,,infection)
Neutrophilsbacterial infection
3-blood gases NO NEED
-respiratory failurecomplications
blood gases4-sputum analysis and culture
Organism
5-broncho scopic examination
broncho graphy,,broncho scope
Obstructioninfection
-
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aspirationsecretion
Local antibiotic therapy
broncho scope
-cilia,,,bronchial tree
Immotile ciliaelectron microscope
1-Postural drainage
2-mucolytic and expectorant
3-broncho dilators
4-antibiotics
5-resistant cases
-,,Hemoptysis..surgical treatment
-lobe,,,Croupstridor
-croupy cough..larynx
LarynxIrritative cough
croupy cough
-vocal cord,,hoarseness of voice
-larynxstridor
respiratory distress
clinical condition, characterized by croupy cough, hoarseness of voice, stridor with or without respirator
distress .
with or without respiratory distressdegree ofOf obstruction of the airway
A - mechanical obstruction :
.. very common
1- foreign body
coins
2- congenital anomaly in Larynx as :
a-laryngeal web
-
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:,,,,,
b-larngeo malacia
:,,
,,collapselarynx
c-Mechanical compression as
goiter
retro pharyngeal abscesspara pharyngeal abscess
angioneurotic edemalarynxlarynx
B - Inflammatory conditions :
a- viral infection
Respiratory Syncytial Virus..para influenzaInfluenzaMeaslesvirusviral larngitis
laryngeo trachitis
acute laryngeo tracheo bronchitis
b- H influenza acute epiglotitis
-epiglotisacute epiglotitis..larynx,,,stridor
severe respiratory distress
40
,,drolling of saliva
Prone position,,,,,
-throat examination(Is absolutely contraindicated)
,,throat examinationcardic arrest..epiglotis
Highly innervated by vagus
c- Diphtheria
laryngeal diphtheria,,,Larynx.. ,,stridor
C - tetany :
spasm of the adductors of the vocal cords
laryngismus stridulus
D - papilloma :
,,,hemorrhagic polypvocal cordpapillomavocal cord
-
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1-croupy cough
2-hoarsness of voice
3-stridor
4-respiratory distress
Here on examination surasternal & supraclvicular retraction ( as the problem in upper not lowe
)
-upper,,Lower is free
Inspection,,palpation,,Percussion,,,auscultationnormal
-,,medical emergency..
1-plain X - ray
-
-anteroPosteriorlateral
-radio opaque foreign bodycoin
- radio opaque foreign body
- epi glotis ,, edematous- Narrowing below epiglotis
acute laryngeo tracheo bronchitis
1-hospitlization
a- bed rest
b- oxygen
-Oxygen,,cold modified
,,laryngeal edema
-vaso constriction of the capillaries..laryngeal edema
c- IV fluids
-
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2- TTT of the cause
foreign body..viral infectionribavirin
3- If no improvement give supportive ttt
a- give Epinephrin-larygeal edemaRacemic epinephrineInhaler epinephrine
nebulizerinhalation..epinephrinevaso constriction
capillaries
laryngeal edema
b- if not present give cortisone IV
c- If no improvement do tracheostomy
,,,,
irritative cough..allergic in nature
Diseases of the pleura
dry pleurisy..
dry fibrinous inflammation of the pleura
Primary pathologypleura
a- viral infection
viral infection,,virusviremiaPleura
dry pleurisy
b- renal failure
ureadepositpleuradry pleurisy
c- rheumatic fever
dry pericardititisdry pleurisydry peritonitisdry pleurisy
d- T.B.
Primarypleura..dry pleurisy
-
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a- lung as
Pneumonia ,, bronchiectasis,, abscess,, infarction
b- Mediastinum as
mediastinitis
c- chest wall
Osteomyelitis fracture rib
d- Infra diaphragmatic as
Liver abscess
-mainlyprimary cause
- chest pain stiching in character
coughrespirationholding of breathing
1- inespection
- limitation of movement
- tachypnea
2- palpation
pleural rub
3- PercussionPleurisy..tender percussion
4- auscultation
pleural rub
-Chest X ray to know the underlying cause
other pathology
chest X -rayrib
Chest X - raylung abscess
Lobar pneumonia
bronchiectasis
,,
analgesicspain
-
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pleural effusionX - ray()
fluid collectedpleural sac
fluid:
1- transudate :
,,transudate),, )generalized edematransudatebilateral effusion
2- Exudate :
-exudate,,surrounding pathologyLung,,Mediastinum,,pleura,,
diaphragmatic,,,infra diaphragmatic
3- Pus :
-Pus,,,staph pneumonia,,Lung abscess
4- Hemorrhagic effusion :klebsiellaT.B.,,traumachest wall..cancer
5- chylus : ( Lymph )
lymphatic system obstructiontraumathoracic duct
6- idiopathic exuadate :
Primary pleurisy..primary pleurisyexudates
1-Symptoms of the cause
2-Respiratory distress
signs of respiratory distress
Limitation of movement of the chestaffected side
bulge
*trachea ,,, pushed to the opposite side
*TVF diminished
stony dullnessdiagnostic
*air entry diminished in the affected side
breath sounds *adventious soundsunderlying pathology
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7/31/2019 Chest - Dr Abo-ElAsrar - By El Azhar Medical Students 2012
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Chest - Dr. Abo El-Asrar
A - Chest X - ray
B - CBC
empyemamarked neutrophiliatuberculusmarked lymphocytosis
C - blood gases
respiratory failure
D - Pleural tap
,,transudate
exudate
hemorrhagichemorrhagic
chylus
LDH
Chloridechemistry
mesenchymal cellstransudate
pus cellsempyema
caseous materialLymphocytesTuberculosis
malignant cellsmalignant effusion
1-TTT OF CAUSE
2-Inter costal tube IF :
massive effusion*respiratory distress
Pus*,,
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