EXAMINATION - Weebly
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…)
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