Med_ Px with Diseases of Respi System

8/4/2019 Med_ Px with Diseases of Respi System

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1

Reasons for Consultation:

Symptoms

Abnormal chest X-ray

Both

Approach:

1.

History2. P.E.

With good clinical diagnosis, you may be able to

manage your patient and give proper diagnosis

and therapy.

CLINICAL HISTORY

A good clinical history should have the ff info:

Most prominent symptom

- chief complaint

Temporal Profile

- is it acute, chronic, progressive etc.

Inventory of substances that can harm the

lungs

- inorganic substances (asbestos, silicone)

- occup/envi exposure should be at least

more than a year.

Personal habits

-Smoking

- Sticks/packs per day, how long is the

patient smoking

Pharmacologic agents

- Taking of anti-hypertensive drugs (ACE

inhibitor)

Family history

- Carcinoma

- Asthma

Common Respiratory Complaints

-common but not specific

A. Shortness of breath / dyspnea

B. Cough

C. Hemoptysis

D. Chest pain ( pleuritic )

A. DYSPNEA

Time course

- be able to eliminate diseases according to

its time course

- if your patient has an acute symptom, then

your line of questioning and diagnosis

should target acute respi diseases.

Acute (<3 weeks)

Sub-acute (3-8 weeks) Chronic (>8 weeks)

Pattern of presentation

Exacerbation and remission -asthma

Progressive - COPD

Triggers -Allergies (weather, allergen,

dust, smoke etc)

Causes of Acute Dyspnea

Laryngeal edema or acute asthma- Usually caused by an allergy

- Sudden onset

Acute cardiogenic or non-cardiogenic

pulmonary edema

Bacterial pneumonia

Pneumothorax pulmonary embolus

- Sudden onset

Example: Male patient, thin, tall, plays

basketball, no risk factors. Suddenly

experiences dyspnea. Suspectpneumothorax.

Causes of Sub-acute Dyspnea

Asthma

Mycobacterial or fungal pneumonia

Noninfectious inflammatory process

- Autoimmune Disease

- SLE

Neuromuscular diseases

-Myasthenia Gravis

Pleural diseases

- Pleural Effusion

- Pneumothorax due to COPD or

Chronic PTB

Causes of Chronic Dyspnea

Asthma

COPD

Pleural effusion

-long-term due to malignancy

Subject: MedicineTopic: Approach To Patient WithDiseases Of Respiratory SystemLecturer: Dr. Jacob P. Singh

Date of Lecture: 14 Sept 2011

Transcriptionist: Teriyaki and SushiPages: 6

S Y

2 0 1 1 - 2 0 1 2



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Diffuse interstitial fibrosis

Pulmonary vascular disease

Pulmonary thromboembolic disease

Left ventricular failure

Severe anemia

Postintubation tracheal stenosis

- Patients on a long-term mechanical

ventilator

B. COUGH

Causes:

Pulmonary

- Acute / chronic infections of the lungs

- Inflammatory disorders

Tumors

- Airway obstruction

Foreign bodies

Cardiovascular

- Pulmonary congestion will affect the

pulmonary parenchyma= cough

Gastro-intestinal

- GERD (common cause of chronic cough)

EENT disorders

- Chronic sinusitis

Common causes of chronic cough:

1. Asthma

2. GERD

3. Sinusitis

PULMONARY:

risk factor

- occupational hazard/ exposure

- smoking history

- family history

- previous TB infection

- previous pneumonia

- age of the patient

dyspnea usually noted after paroxysms

cough

- simply put, cough dyspnea

- hallmark of a pulmonary problem

usually more chronic

CARDIAC:

risk factors

usually more acute in onset aggravated by supine position together with

the dyspnea

dyspneacough

Example: LV dysfunction pulmo congestion

DYSPNEA irritation of lung parenchyma

COUGH

C. HEMOPTYSIS

Upper respiratory tract

-nasopharynx

- oropharynx

Lower respiratory tract

- tracheobronchial tree

- parenchyma

Infectious Causes:

Chronic Bronchitis

Bronchiectasis

Tuberculosis

Non-tuberculous Mycobacteria

Lung Abscess

Necrotizing Pneumonia

Mycetoma

Cystic Fibrosis

From respi tract:

- bright red; frothy

- alkaline pH

From GIT:

-Dark red

- Acidic pH

- Contains food particles

Massive Hemoptysis- >100ml/ 24 hrs

Non- Massive Hemoptysis - <100ml/24 hrs

ALGORITHM FOR NON-MASSIVE HEMOPTYSIS



3

PHYSICAL EXAMINATION

General aspects

- Look for abnormalities, asymmetry,

lesions etc.

INSPECTION OF THE CHEST

rate and pattern of breathing

symmetry of lung expansion

visible abnormalities of the

thoracic cage

- AP diameter

- Pectus carinatum/ excavatum

Inspect extrapulmonary sites like nails

(clubbing), cyanosis which may be

suggestive of pulmo problems.

PALPATION OF THE CHEST

presence or absence of symmetry of tactile

fremitus (remember tres tres???)

- decreased or absent in pleural effusion or

endobronchial obstruction

- increased in consolidation

may also reveal focal tenderness

PERCUSSION OF THE CHEST

resonance or dullness of the tissueunderlying the chest

- normal is resonant

- consolidated lung or pleural effusion sounds

dull

- emphysema is hyperresonant

AUSCULTATION OF THE CHEST

listen for quality and intensity of breath

sounds

1.

Bronchial breath sound

- Expiratory phase is louder and longer

- Large or central airways

2. Vesicular breath sound

- Inspiratory phase is more prominent

- Usually heard at the periphery

Listen for the presence of extra, or

adventitious sounds

breath sound diminished or absent in

endobronchial obstruction, COPD or by air

or liquid in the pleural space

listen for Bronchophony and whispered

pectoriloquy

listen for Egophony (ee becomes ay)

Adventitious lung sounds

• Crackles

- open/close of alveoli

- pneumonia

- congestion

- lung parenchyma abnormalities

- heard best during expiratory phase

• Wheezes

- Due to constriction of airways

- Airways spasm

- Turbulence of airway due to transudate

or exudate

- Heard best during expiratory

• Rhonchi

- Patients with a lot of secretion in

airways

- Transient sound

- Relieved by expectoration

- Halak in Filipino

• Pleural friction rub

- Dses of lung pleura

•

Stridor

- Upper airway obstruction

- Heard even without the use of steth

- Patients with laryngeal/ tracheal

stenosis

*differentiation of common pulmonary

conditions can be found on the last page

DIAGNOSIS

Chest xray, pulmonary function tests, CT scans

are used just to confirm your assessment. If

you're a good doctor, then your assessment will

jive with your diagnostic tests.

Assess the age of the patient and what their risk

factors are. If cardiac or pulmonary, can be

cardiac-hypertensive, previous stroke, medicine

for Coronary Artery Diseases, Pulmonary-

smoker, inhaler, asthma treatment, TB

treatment. Get the chief complaint and to

determine whether it ’ s an acute or chronic

disease to arrive at a differential diagnosis.



4

LABORATORY TESTS

1. Chest X-Ray

2. Pulmonary Function Test

3. Bronchoscopy

4.

Computerized Tomography Scan (CTScan)

5. Magnetic Resonance Imaging (MRI)

Chest X-ray

Most common and easiest

Types of chest x-ray finding:

a. Diseases that increase lung density -

opacifications, infiltrates, fluid

b. Diseases that decrease lung

density- emphysema, peumothorax

c. Plueral disease – pneumothorax,

plueral effusion

Types of x-ray findings associated with

clinical conditions:

1. Some patients may come to you

with a respiratory complaint with

an abnormal chest x-ray

a. Solitary circumscribed density

b.

Localized opacification

(pneumonia, neoplasm,

radiation pneumonities,

bronchiolitis obliterans with

organizing pneumonia (BOOP),

bornchocentric granulomatosis,

pulmonary infarction)

c. Diffuse interstitial diseases

(idiopathic pulmonary fibrosis,

pulmonary fibrosis, sarciodosis,

drug-induced lung disease,

pneumoconiosis,

hypersensitivity pneumonitis,

infection which can be

pneumocystis or viral,

eosinophilic granuloma)

d. Diffuse alveolar disease

(cardiogenic pulmonary

edema, ARDS, diffuse alveolar

hemorrhage, infection which

can be peumocystis, viral, or

bacterial, sarcoidosis)

e. Diffuse nodular disease

(pulmonary metastasis,

hematogenous spread of

infection, pneumoconiosis,

eosinophilic granuloma)

2. But sometimes a patient will come

to you with an abnormal chest x-ray

with no respiratory complaint

a. Localized disease affecting the

airways or the pulmonary

parenchyma

b. Masses or nodules

c. Current or previous infectious

processes

3.

But sometimes a patient will come

to you with a respiratory complaint

with normal chest x-ray

a. Disease affecting the airways

which may be neuromuscular

b. Disease affecting the

respiratory pump

Pulmonary Function Test

We test for lung function via

spirometry for restrictive andobstructive lung diseases

to limit differential diagnosis

SPIROMETRY – measures lung

volumes and airflow parameters.

The patient is instructed to inhale

maximally to TLC and exhale

forcefully to RV for 6 seconds



5

BASICS OF PULMONARY FUNCTION TEST

Physiologic basis

Spirometry

Lung volume studies Diffusing capacities

Maximal respiratory pressures

SPECIAL EXTRAPULMONARY CONDITIONS

Chronic heart failure

Obesity

Decreased compliance

Increase airways resistance

Rapid,shallow breathing pattern

Decrease respiratory muscle

function

Pregnancy

Neuromuscular disorders

Diabetes mellitus

Preoperative evaluation

DYNAMIC LUNG FUNCTION

1. Forced expiratory maneuver

2. Cardio-pulmonary exercise test

*these tests are now available to predict and

measure lung function performance during

exercise

CT SCAN

-this test demonstrate the size of the tumor,

especially peripheral lesions.

OTHER DIAGNOSTIC TEST

Bronchoscopy (can be bronchogenic

carcinoma, bronchial adenoma, or

metastatic disease)

Blood chemistries

Blood gases

SUMMARY

Common signs and symptoms of

patients with respiratory disease

Common physical exam findings in

patient with respiratory disease

How to use data from history and

physical exam in arriving at a logical

clinical impression

Common diagnostic test used to work

up patients with respiratory distress

“Fear not for I am with you: be not dismayed, for I am your God: I will strengthen you, I will help you, I will uphold

you with My righteous right hand.” Isaiah 41:10

G R E E T I N G S

Thanks Armin for semi-transcribing Hello IDK!!!

Thanks Sheila for the voice recording Hello UST-Sampaloc Chapter

Hello to all Saringhimig members!!! Media 2015! Yeyat, Carl, Bruks, Charlon, Sam, Tracy, Ike

Hi Marv and Kith!!!



6

Differentiation of Common Pulmonary Conditions

Bold and underlined words were given emphasis during the lecture

Condition Vital Signs Inspection Palpation Percussion Auscultation

Asthma Tachypneatachycardia

Dyspnea; useof accessory

muscles;

possible

cyanosis;

hyperinflation

Often normal;decreased

femitus (which

is due to air

trapping)

Often normal;hyperresonant;

low

diaphragms

Prolongedexpiration;

wheezes;

decreased lung

sounds

Emphysema Stable Increased AP

diameter; use

of accessory

muscles; thin

individual

Decreased

tactile

fremitus (air

involvement)

Increased

resonance;

decreased

excursion of

diaphragm

Decreased

lung sounds;

decreased

vocal fremitus

Chronic

bronchitis

Tachycardia Possible

cyanosis; short

stocky

individual

Often normal Often normal Early crackles

Pneumonia Tachycardia;

fever;

tachypnea

Possible

cyanosis;

possible

splinting on

affected side

Increased

tactile fremitus

Dull Late crackles;

bronchial

breath sounds

Pulmonary

embolism

Tachycardia;

tachypnea

Often normal Usually normal Usually normal Usually normal

Pulmonary

edema

Tachycardia;

tachypnea

Possible signs

of elevated

right heart

pressures

Often normal Often normal Early crackles

Pneumothorax Tachycardia;

tachypnea

Often normal

lag on affected

side

Absent

fremitus;

trachea may

be shifted to

other side

Hyperresonant Absent breath

sounds

Pleural

effusion

Tachycardia;

tachypnea

Often normal

lag on affectedside

Decreased

fremitus;trachea shifted

to other side

Dullness Absent breath

sounds

Atelectasis Tachycardia;

tachypnea

Often normal

lag on affected

side

Decreased

fremitus;

trachea shifted

to other side

dullness Absent breath

sounds

ARDS Tachycardia;

tachypnea

Use of

accessory

muscles;

cyanosis

Usually normal Often normal Normal

initially;

crackles and

decreased lung

sounds late

Med_ Px with Diseases of Respi System

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