Subject: Medicine Topic: Approach To Patient With Diseases Of Respiratory System Lecturer: Dr. Jacob P.

Singh Date of Lecture: 14 Sept 2011 Transcriptionist: Teriyaki and Sushi Pages: 6

Reasons for Consultation: Symptoms Abnormal chest X-ray Both Approach: 1. History 2. 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. B. C. D. Shortness of breath / dyspnea Cough Hemoptysis Chest pain ( pleuritic )

- 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. Suspect pneumothorax. 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

A. DYSPNEA Time course

SY 2011-2012

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

- hallmark of a pulmonary problem usually more chronic

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

CARDIAC: risk factors usually more acute in onset aggravated by supine position together with the 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 - parenchyma Infectious Causes: Chronic Bronchitis Bronchiectasis Tuberculosis Non-tuberculous Mycobacteria Lung Abscess Necrotizing Pneumonia Mycetoma Cystic Fibrosis

From respi tract: PULMONARY: - bright red; frothy risk factor - alkaline pH - occupational hazard/ exposure From GIT: - smoking history - Dark red - family history - Acidic pH - previous TB infection - Contains food particles - previous pneumonia - age of the patient Massive Hemoptysis- >100ml/ 24 hrs dyspnea usually noted after paroxysms Non- Massive Hemoptysis - <100ml/24 hrs cough - simply put, cough dyspnea ALGORITHM FOR NON-MASSIVE HEMOPTYSIS

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 tissue underlying 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, Pulmonarysmoker, inhaler, asthma treatment, TB treatment. Get the chief complaint and to determine whether its an acute or chronic disease to arrive at a differential diagnosis. 3

LABORATORY TESTS 1. 2. 3. 4. Chest X-Ray Pulmonary Function Test Bronchoscopy Computerized Tomography Scan (CT Scan) 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 and obstructive 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

*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) 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

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

Thanks Armin for semi-transcribing Thanks Sheila for the voice recording Hello to all Saringhimig members!!! Hi Marv and Kith!!!

GREETINGS Hello IDK!!! Hello UST-Sampaloc Chapter Media 2015! Yeyat, Carl, Bruks, Charlon, Sam, Tracy, Ike

Differentiation of Common Pulmonary Conditions

Bold and underlined words were given emphasis during the lecture

Condition Asthma

Vital Signs Tachypnea tachycardia

Emphysema

Stable

Inspection Dyspnea; use of accessory muscles; possible cyanosis; hyperinflation Increased AP diameter; use of accessory muscles; thin individual Possible cyanosis; short stocky individual Possible cyanosis; possible splinting on affected side Often normal

Palpation Often normal; decreased femitus (which is due to air trapping) Decreased tactile fremitus (air involvement)

Percussion Often normal; hyperresonant; low diaphragms

Auscultation Prolonged expiration; wheezes; decreased lung sounds Decreased lung sounds; decreased vocal fremitus

Increased resonance; decreased excursion of diaphragm Often normal

Chronic bronchitis

Tachycardia

Often normal

Early crackles

Pneumonia

Tachycardia; fever; tachypnea

Increased tactile fremitus

Dull

Late crackles; bronchial breath sounds

Pulmonary embolism Pulmonary edema

Tachycardia; tachypnea Tachycardia; tachypnea

Usually normal

Usually normal

Usually normal

Pneumothorax

Tachycardia; tachypnea

Possible signs of elevated right heart pressures Often normal lag on affected side

Often normal

Often normal

Early crackles

Pleural effusion

Tachycardia; tachypnea

Often normal lag on affected side Often normal lag on affected side Use of accessory muscles; cyanosis

Atelectasis

Tachycardia; tachypnea

ARDS

Tachycardia; tachypnea

Absent fremitus; trachea may be shifted to other side Decreased fremitus; trachea shifted to other side Decreased fremitus; trachea shifted to other side Usually normal

Hyperresonant

Absent breath sounds

Dullness

Absent breath sounds

dullness

Absent breath sounds

Often normal

Normal initially; crackles and decreased lung sounds late