EXAMINATION



EXAMINATION

INSPECTION

← General look of the patient

i. Cyanosed ii. Breathless iii. Air hunger

iv. Pursed lip breathing (COPD) v. Pink puffer (Emphysema)

vi. Blue Bloaters (chronic Bronchitis)

← Inspection of Chest

• Respiratory rate

• Shape of the chest (Elliptical- Normal, Barrel, Funnel, Ricketic, Pigeon shape)

• Movement of chest

• Symmetry of Chest (Symmetrical, Asymmetrical)

• Types of Respiration (Abdomino-thoracic or Thoraco-abdominal)

• Visible Apex Beat

• In drawing of Ribs

• Tracheal Tug

• Supraclavicular Fossae

• Prominent Veins, Scar, Pigmentation

PALPATION

← Trachea (Normally it is centrally placed) if not then

• Pull (Fibrosis, Collapse)

• Push (Pleural Effusion, Pneumothorax, Malignancy)

• Trail Sign is +ve in COPD

← Chest Expansion (Normal expansion is 3-5 cm)

• Decreased in (Fibrosis, Collapse, Pleural effusion, Pneumothorax, Consolidation)

← Vocal Fremitus (Tactile Fremitus)

• Increased in (Consolidation, Cavitation, Collapse with Patent Bronchus)

• Decreased in (Pleural Effusion, Pneumothorax, Fibrosis, Collapse with Obs: Bronchus)

← Apex Beat

• Displaced in (Collapse, Pleural Effusion, Pneumothorax, Fibrosis)

← Tenderness

• Hypertrophic Pulmonary Osteoarthropathy (Bronchogenic Carcinoma)

• Teitz Syndrome (Costo-chondritis)

• Fracture of Rib

PERCUSSION

← Normal percussion note is RESONANT

← Hyper-Resonant (Emphysema, Pneumothorax)

← Dull (Consolidation, Fibrosis, Collapse)

← Stony Dull (Pleural effusion)

← We do Tidal Percussion for the movement of Diaphragm

AUSCULTATION

← Normal Breathing is “Vesicular Breathing”

• Inspiration is longer than Expiration

• Inspiration is harsher than Expiration

• No gap b/w Inspiration & Expiration

← Bronchial Breathing (Consolidation, Fibrosis, Collapse)

• Expiration is longer than Inspiration

• Marked gap b/w Inspiration & Expiration

← Plural Rub (Pleuritis)

← Pericardial Rub (Pericarditis)

← Pleuro-Pericarditis

← Crepitations (Fine in Pulmonary edema, Coarse in TB & Pneumonia)

← Wheeze (Asthma, COPD)

← Vocal Resonance

• Increased in (Consolidation, Cavitation, Collapse with Patent Bronchus)

• Decreased in (Pleural Effusion, Pneumothorax, Fibrosis, Collapse with Obs: Bronchus)

PNEUMONIA

Def: Acute inflammatory consolidation of lung parenchyma.

CLASSIFICATION OF PNEUMONIA

ANATOMICAL

← Lobar Pneumonia

← Segmental / Lobular Pneumonia

← Broncho pneumonia

HISTOLOGICAL

← Typical Pneumonia

← Atypical Pneumonia

PATHOLOGICAL (Causative Organism)

← Bacterial Pneumonia

i. Streptococcal Pneumonia ii. H-influenza

iii. Staphylococcal Aureus iv. Klebsella

v. Moraxella Catarrhalis vi. Pseudomonas

vii. E-coli viii. Anaerobes

ix. Mycoplasma x. Coxiella Burnetti

xi. Rickettsia xii. Legionella

← Viral Pneumonia

i. Adeno virus ii. Coxsackie Virus

iii. Influenza virus A, B etc….

← Parasites (Loeffler’s Pneumonia)

i. Ascaris Lumbricoides ii. Toxicora

iii. Paragonimus Westermeni

← Fungal Pneumonia

i. Aspergilloma

← Lipid Pneumonia (Bronchogenic Carcinoma)

CLINICAL CLASSIFICATION

← Community Acquired Pneumonia (Pneumonia which occur in previously healthy or within 48 hours of hospitalization)

← Hospital Acquired Pneumonia (After 48 hours of hospitalization)

(E-Coli, Klebsella, Pseudomonas, Staphylococcus Aureus)

C/F

▪ Fever (high grade) with Chills

▪ Cough initially dry then productive (initially Mucoid then Purulent)

▪ Dysponea, Chest pain

EXAMINATION

Inspection

▪ Increased Respiratory Rate

▪ Decreased Chest Movement on the affected side

Palpation

▪ Chest expansion reduced

▪ Increased Vocal Fremitus

▪ Trachea may be deviated to opposite side if pleural effusion

Percussion

▪ Note is DULL

Auscultation

▪ Bronchial Breathing

▪ Some times Crepitations

INVESTIGATION

1. Chest X-ray:

▪ Consolidation (Opacity) in Lobar / Segmental

▪ Patchy infiltration in Bilateral Bronchopneumonia

▪ Para pneumonic Effusion

2. Blood CP:

▪ Increased WBC

▪ Raised ESR

3. Sputum for Microscopy

4. Sputum for Culture

5. Serology

▪ Ab (against Mycoplasma, Rickettsia, Chlamydia, Legionella etc…)

▪ Immunoflouresence Ab

▪ Coombs Test

ATYPICAL PNEUMONIA

In this case extra pulmonary are more common.

i. Low grade fever ii. Head ache iii. Nausea iv. Vomiting

v. Diarrhea vi. Myalgia vii. Arthralgia viii. Dry Cough

TREATMENT OF PNEUMONIA

Empirical therapy (out patient treatment) for 14 days

▪ Amoxycillin + Clavilumic Acid (Augmentin 625mg 1+0+1) OR

▪ Cefaclor (Ceclor 500mg) OR

▪ Cefuraxime axetil (Zinacef 250mg 1 x OD) OR

▪ Clarithromycin (Klaricid) OR

▪ Ofloxacin (Oflobid) OR

▪ Levofloxacin (Xeflox, Novidate).

CRITERIA FOR HOSPITALIZATION

➢ Extreme of Age (>65 years or 140 beats/ min

o Tachypenia >30 breaths/ min

o PaO2 10pack year (20 cigarettes per day till 10 years)

Passive

➢ Pollution

➢ Free Radicals

➢ Alpha 1 Anti trypsin deficiency (Pi ZZ) genotype

Symptoms

➢ Persistent Cough, some times turbid, productive usually in morning time.

➢ Dysponea

Signs (on inspection)

➢ Barrel shaped chest

➢ Pink puffer / Blue bloaters

➢ Pursed Lip Breathing

➢ Accessory muscle use during respiration

➢ In drawing of ribs

➢ Prominent Supra Clavicular Fossa

➢ Tracheal tug may be seen

➢ RR may be increased

On Palpation

➢ Tracheal tug (trail sign)

➢ Apex beat may be displaced

On Percussion

➢ Hyper resonant

On Auscultation

➢ NVB with may be prolong expiration

➢ There may be Wheeze

➢ There may be Crepitations

INVESTIGATION

1. Chest x-ray

▪ Hyper translucent Lung folds

▪ Widening of intercostal spaces

▪ Flattening of diaphragm

▪ Tubular Heart

▪ Emphysematous Bullae

2. Pulmonary Function Test (Spirometry)

▪ FEV1 = 120/ min + pulsus Paradoxus + RR >30 /min +Use of Accessory Muscle +Cyanosed

INVESTIGATION

1. Pulmonary Function Test (gold standard)

▪ FEV1 = Coma -----> Death

Adrenal gland: - Addison’s disease

Liver: - Jaundice, Carcinomatous Cirrhosis, Liver Failure, Hepatic Encephalopathy, Coma, and Death

Bone: - Decreased density if bone, Bone Fracture etc…

INVESTIGATION

1. Biopsy (Trans bronchial)

2. Chest X-ray

▪ Consolidation

▪ Fibrosis

▪ Mediasternal widening

▪ Trachea shifted

▪ Collapse

▪ Rib Erosions

▪ Bronchogram Pattern

3. Sputum Cytology

4. CT Scan (Chest, Brain, Abdomen)

▪ To know the extent of tumor & Metastasis

5. Other Lab Investigations

▪ Blood CP (Polycythemia, Increased ESR >100)

▪ LFTS (may be deranged, PT & APTT may be prolonged)

TREATMENT

Small Cell Carcinoma Chemotherapy

Squamous Cell Carcinoma Radiotherapy followed by Chemotherapy

Large Cell Carcinoma Very Resistant to treatment

Adeno Carcinoma Chemotherapy

STAGING

Stage 0 Ca in situ

Stage I Only Tissue Involvement

Stage II Tissue Involved + 1 Lymph Node involve

A (more than 3 tissue involvement & 2 Lymph nodes)

Stage III

B (> 3 tissue involvement & 3 Lymph Nodes)

Stage IV Metastasis

RX According to Stage

If Stage I & Stage II ----------( Surgery followed by specific treatment of particular Ca.

Stage III A ----------( may be benefited from Surgery

Stage III B & Stage IV ----------( Chemotherapy & Radiotherapy & Palliative treatment.

PLEURAL EFFUSION

Def: Abnormal collection of fluid in the pleural cavity is called Pleural effusion.

Normally 15 ml is present in the pleural space.

Types of Fluid:

▪ Transudates

▪ Exudates s

▪ Chylous

▪ Hemorrhagic

TRANSUDATIVE CAUSE

▪ Liver Cirrhosis

▪ Protein losing Enteropathy HypoAlbuminemia

▪ Nephrotic Syndrome

▪ Malnutrition

▪ CCF

▪ Constrictive Pericarditis Cardiac Causes

▪ Cardiac Temponade

▪ Peritoneal Dialysis

▪ Myxedema

EXUDATIVE CAUSES (Inflammation)

▪ Para pneumonic Effusion (Empyema)

▪ T.B

▪ Malignancy

▪ Connective tissue disorder

▪ Pulmonary Embolism

▪ Rickettsia, Chlamydia Infection

▪ Meig’s Syndrome (Ovarian Fibroma + Rt Sided Pleural Effusion)

▪ Viral Infections

▪ Fungal infections

▪ Parasitic infections

▪ Dressler’s syndrome (shoulder pain, fever, pleuropericardial effusion)

CHYLOUS EFFUSION: (Milky white lymph accumulation)

▪ Lymph Node enlargement & compression over lymphatic draining the pleural cavity

▪ T.B

▪ Malignancy

▪ Sarcoidosis

▪ Milroy’s disease

HEMORRHAGIC EFFUSION

▪ Trauma

▪ Tumor

▪ Esophageal rupture

▪ Acute Pancreatitis

C/F

▪ Exertional Dysponea

▪ Cough

▪ Restlessness

▪ Chest pain

▪ Wt: loss

▪ Wasting

▪ May be fever etc…

INVESTIGATIONS

1. Clinical Examination

▪ Chest movement reduced

▪ Trachea may be shifted

▪ Vocal Fremitus decreased

▪ Percussion note is Stony Dull

▪ Breath Sounds Diminished

2. Chest X-ray

▪ Loss of Costopherinic angle (initially)

▪ Loss of Lung Field (Massive Effusion)

3. Chest U /s (for loculated effusion)

4. Diagnostic Thoracentesis

▪ Aspirate pleural fluid for the diagnosis of cause of effusion.

LIGHT’S CRITERIA (modified) for Exudates

▪ Pleural fluid LDH > 200 units

▪ Pleural fluid proteins / serum proteins ratio > 0.5

▪ Pleural fluid LDH / serum LDH ratio >0.6

▪ Serum effusion Albumin gradient 1000 units

▪ If Pleural Glucose 10 sec at least 10- 15 times/ hrs during sleep

Types

Obstructive Central

Usually in very obese ON DINE Curse

Pickwickian Syndrome in this central ventriculatory

Even with proper ventilatory drive drive is inadequate

DIAGNOSIS

▪ Sleep Study (Polysomnography)

TREATMENT

▪ Continuous +ve Airway Pressure

▪ Uvulopalatopharyngoplasty (UPPP)

▪ Nasal septoplasty

ATELACTESIS

Collapse of lung

TYPES

1. COMPRESSION ATELACTESIS

▪ Pneumothorax

▪ Pleural effusion

▪ Malignancy

2. RESORPTION ATELACTESIS

▪ Foreign body

▪ Operational hematoma

▪ Tumor

▪ Mucous Plug

3. MICRO ATELACTESIS (Absent Surfactant)

▪ ARDS

▪ Acute Pancreatitis

▪ Heavy Smoke

4. BASAL ATELACTESIS

▪ Diaphragm move inadequately

C/F

▪ Dysponea

▪ Fever

▪ Tachycardia / palpitation

SIGNS

▪ Trachea deviated

▪ Collapse with patent bronchus then vocal Fremitus increased

▪ Breath sounds decreased

DIAGNOSIS

▪ Chest X-ray

TREATMENT

Treat the cause

If mucous plug / hematoma then do BRONCHOSCOPY

If compression Atelactesis then treat the pleural effusion & Pneumothorax

If Micro Atelactesis then give SURFACTANT

PULMONARY HTN

Def: Pulmonary Arterial pressure is more than 30 mmHg

TYPES

▪ Primary pulmonary HTN

▪ Secondary pulmonary HTN

C/F

▪ Dysponea

▪ Orthopnea

▪ Chest pain

SIGNS

▪ P2 Loud

▪ Systolic ejection click

▪ Raised JVP

▪ Peripheral Cyanosis

▪ Bat Wing X-ray Appearance

INVESTIGATIONS

▪ Chest X-ray

▪ Echo

▪ ECG

▪ Pulmonary Function Test

TREATMENT

Once pulmonary HTN develops then HEART LUNG TRANSPLANTATION

Or we can give vasodilator (Ca++ blocker, Nitroglycerine, Hydralizine etc…)

We try our level best to cover all important topic & provide all possible knowledge about the topic and we done proof reading too but if there is any mistake please inform us and check the textbook for correction.

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