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medpulmo

medpulmo

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Published by: Iñaki Delos Santos Ramos on Sep 19, 2011
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01/17/2013

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 1 Reasons for Consultation:
 
Symptoms
 
Abnormal chest X-ray
 
BothApproach:1.
 
History2.
 
P.E.With good clinical diagnosis, you may be able tomanage your patient and give proper diagnosisand 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 thelungs
-
inorganic substances (asbestos, silicone)
-
occup/envi exposure should be at leastmore than a year.
 
Personal habits
-
Smoking
-
Sticks/packs per day, how long is thepatient smoking
 
Pharmacologic agents
-
Taking of anti-hypertensive drugs (ACEinhibitor)
 
Family history
-
Carcinoma
-
AsthmaCommon Respiratory Complaints-common but not specificA.
 
Shortness of breath / dyspneaB.
 
CoughC.
 
HemoptysisD.
 
Chest pain ( pleuritic )
A.
 
DYSPNEA
Time course
-
be able to eliminate diseases according toits time course
-
if your patient has an acute symptom, thenyour line of questioning and diagnosisshould 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-cardiogenicpulmonary edema
 
Bacterial pneumonia
 
Pneumothorax pulmonary embolus
-
Sudden onsetExample: Male patient, thin, tall, playsbasketball, no risk factors. Suddenlyexperiences 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 orChronic PTBCauses of Chronic Dyspnea
 
Asthma
 
COPD
 
Pleural effusion
-
long-term due to malignancy
 
Subject: MedicineTopic: Approach To Patient WithDiseases Of Respiratory SystemLecturer: Dr. Jacob P. SinghDate of Lecture: 14 Sept 2011Transcriptionist: Teriyaki and SushiPages: 6
   S   Y   2   0   1   1  -   2   0   1   2
 
 2 
 
Diffuse interstitial fibrosis
 
Pulmonary vascular disease
 
Pulmonary thromboembolic disease
 
Left ventricular failure
 
Severe anemia
 
Postintubation tracheal stenosis
-
Patients on a long-term mechanicalventilator
B.
 
COUGH
Causes:
 
Pulmonary
-
Acute / chronic infections of the lungs
-
Inflammatory disorders
 
Tumors
-
Airway obstruction
 
Foreign bodies
 
Cardiovascular
-
Pulmonary congestion will affect thepulmonary parenchyma= cough
 
Gastro-intestinal
-
GERD (common cause of chronic cough)
 
EENT disorders
-
Chronic sinusitisCommon causes of chronic cough:1.
 
Asthma2.
 
GERD3.
 
SinusitisPULMONARY:
 
risk factor- occupational hazard/ exposure- smoking history- family history- previous TB infection- previous pneumonia- age of the patient
 
dyspnea usually noted after paroxysmscough
-
simply put,
cough
dyspnea
 
-
hallmark of a pulmonary problem
 
usually more chronicCARDIAC:
 
risk factors
 
usually more acute in onset
 
aggravated by supine position together withthe dyspnea
 
dyspnea
cough
Example: LV dysfunction
pulmo congestion
 DYSPNEA
irritation of lung parenchyma
 COUGH
C.
 
HEMOPTYSIS
 
Upper respiratory tract
-
nasopharynx
-
oropharynx
 
Lower respiratory tract
-
tracheobronchial tree
-
parenchymaInfectious Causes:
 
Chronic Bronchitis
 
Bronchiectasis
 
Tuberculosis
 
Non-tuberculous Mycobacteria
 
Lung Abscess
 
Necrotizing Pneumonia
 
Mycetoma
 
Cystic FibrosisFrom respi tract:- bright red; frothy- alkaline pHFrom GIT:
-
Dark red
-
Acidic pH
-
Contains food particlesMassive Hemoptysis- >100ml/ 24 hrsNon- Massive Hemoptysis - <100ml/24 hrsALGORITHM 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 thethoracic cage
-
AP diameter
-
Pectus carinatum/ excavatum
 
Inspect extrapulmonary sites like nails(clubbing), cyanosis which may besuggestive of pulmo problems.PALPATION OF THE CHEST
 
presence or absence of symmetry of tactilefremitus (remember
tres tres
???)
-
decreased or absent in pleural effusion orendobronchial obstruction
-
increased in consolidation
 
may also reveal focal tendernessPERCUSSION OF THE CHEST
 
resonance or dullness of the tissueunderlying the chest- normal is resonant- consolidated lung or pleural effusion soundsdull- emphysema is hyperresonantAUSCULTATION OF THE CHEST
 
listen for quality and intensity of 
breathsounds
 1.
 
Bronchial breath sound
-
 
Expiratory phase is louder and longer
-
 
Large or central airways2.
 
Vesicular breath sound
-
 
Inspiratory phase is more prominent
-
 
Usually heard at the periphery
 
Listen for the presence of extra, oradventitious sounds
 
breath sound diminished or absent inendobronchial obstruction, COPD or by airor liquid in the pleural space
 
listen for Bronchophony and whisperedpectoriloquy
 
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 transudateor exudate
-
 
Heard best during expiratory
 
Rhonchi
-
 
Patients with a lot of secretion inairways
-
 
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/ trachealstenosis
*differentiation of common pulmonary conditions can be found on the last page
 
DIAGNOSIS
 
Chest xray, pulmonary function tests, CT scansare 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 becardiac-hypertensive, previous stroke, medicine for Coronary Artery Diseases, Pulmonary-smoker, inhaler, asthma treatment, TBtreatment. Get the chief complaint and todetermine whether it 
’ 
s an acute or chronicdisease to arrive at a differential diagnosis.

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