Physical signs of pulmonary syndromes

2. Physical signs of
pulmonary syndromes
Dr. Nebenführer
Nebenf hrer Zsuzsa

Infiltration
Pneumonia
Pulmonary embolism
Atelectasis
Pleural effusion
Pneumothorax
Mediastinal mass

Pulmonary infiltration
causes
Exsudate, Exsudate,
tumor, blood in the alveoli. alveoli.
Pneumonia
lobar
viral
bronchopneumonia
Pneumonia
Pulmonay embolism
Tumor
Tbc

Pulmonary infiltration
history
Shaking chill, chill,
sputum: sputum:
pneumonia
Operation,
Operation,
immobilisation,
immobilisation,
chest pain, pain,
bloody sputum: sputum:
infarction after PE
Weight loss, loss,
smoking, smoking,
bloody sputum: sputum:
tumor

Pulmonary infiltration
physical examination 1.
Inspection:
Inspection:
chest excursion decreased
Tactile fremitus: fremitus:
increased
Percussion:
Percussion:
dullness

Pulmonary infiltration
physical examination 2.
Auscultation:
Auscultation:
Crackles at the beginning (crepitatio crepitatio
indux) indux
Bronchial breath sounds
Crackles at the end (crepitatio ( crepitatio redux) redux
Bronchophony increased

Pneumonia
Def: Def:
inflammation of the parenchyma,
parenchyma,
alveoli, alveoli,
connective tissue, tissue,
bronchioli of
the lung
Causes: Causes:
bacteria, bacteria,
virus, virus,
Mycoplasma,
Mycoplasma,
fungi, fungi,
chemical of physical effects

Pneumonia
clinical picture
Symptoms:
Symptoms:
high fever, fever,
dyspnoe, dyspnoe,
cyanosis , chest pain, pain,
cough: cough:
dry → pus / bloody
Exsudative pleuritis (possible possible) )
Lab: Lab:
leukocytosis,
leukocytosis,
left shift, ESR ↑, ,
CRP ↑
X-ray ray: : infiltration

Atypical infiltation
Massive: Massive:
also the bronchi filled with
exsudation or tumor
Central: Central:
in the hilar region

Pulmonary embolism

Pulmonary embolism
= embolia pulmonum
= thrombus in the arteries of the lung
Source: Source:
veins of the lower extremities /
pelvis
Anamnesis !!!!

Pulmonary embolism
symptoms
Short of breath = dyspnea
Pleural chest pain
Bloody sputum = haemoptysis
Collapse = syncope
Palpitation
Fatigue
Cough

Pulmonary embolism
Tachypnea
Cyanosis
Bronchospasm
Pleural friction rub
Hypotension
Tachycardia
Hypotension
Tachycardia
Fever
Fever
DVT
physical signs

Pulmonary embolism
other exams
ECG: right deviation, deviation,
P pulmonale,
pulmonale,
PSVT, AF
Lab: Lab:
D-dimer dimer, , LDH, sebi
Blood gases: gases:
hypoxia, hypoxia,
hypocapnia +
alcalosis
Scintigraphy
Angio-CT Angio CT

Atelectasis

Atelectasis
Airless alveoli, alveoli,
air absorbed
Causes: Causes
Insufficient breathing (weak weak patient, patient,
long
bed rest, after abdominal operation) operation
Bronchial obstruction or stenosis by
foreign body / tumor / mucus
Obstruction of the lung by pleural fluid
X-ray ray

Atelectasis
Bronchostenosis
tactile fremitus: fremitus:
decreased
percussion:
percussion:
dullness
auscultation:
auscultation:
diminished breath sounds
bronchophony:
bronchophony:
decreased
Insufficient breathing or compression: compression:
air in
the bronchi = similar than infiltration :
bronchial breath sounds, sounds,
crackles

Pleural effusion
Def: Def:
fluid accumulation between layers of the pleura
Transsudate
Increased intrathoracic pressure (heart heart failure) failure
Decreased oncotic pressure: pressure:
hypoproteinaemia (liver liver
cirrhosis, cirrhosis,
nephrosis sy) sy
Exsudate
Permeability of the pleura increased +
Lymphatic absorption decreased (occlusion occlusion or narrowing)
narrowing
Blood
Pus
Chyle

Transsudate
Heart failure
Liver cirrhosis
Pulmonary embolism
Nephrotic syndrome
Meigs-syndrome
Meigs syndrome, , ovarian
hyperstimulation
Peritoneal dialysis
Myxoedema
Pleural effusion
causes
Exsudate
Tumor
Infection
Pulmonary embolism
Lung infarction
Abdominal diseases
Autoimmun diseases
Eosinophilic pneumonia
Asbest
Irradiation
Eosophageal perforation
Haemothorax
Chylothorax
Empyema thoracis

Pleural effusion
Anamnesis:
Anamnesis:
pleuritis sicca (possible possible)
Symptoms:
Symptoms:
cough
dyspnea
chest pain

Pleural effusion
physical signs
Inspection:
Inspection:
bulging of the affected
side, side,
excursion decreased
Tactile fremitus: fremitus:
decreased
Percussion:
Percussion:
dullness
Auscultation:
Auscultation:
breath sounds
decreased or absent
Bronchophony:
Bronchophony:
decreased

Pleural effusion
percussion
Upper border: border:
Ellis-Damoiseau
Ellis Damoiseau-line line: :
highest point in the posterior axillary -
scapular line, going down on both
sides
Korányi Kor nyi-triangle triangle: : fluid dislocates the
mediastinum = triangle of dullness on
the other side, side,
bordered by the
diaphragm and the midline

protein g/l
specific weight
albumin gradient
LDH gradient
sediment
blood
Pleural effusion
punction
Transsudate
1-2
< 1015
> 1,1
< 0,6
mesothelial cells
Exsudate
3
1018
< 1,1
> 0,6
lymphocyte
leukocyte (pneumonia)
malignant cells (tumor)
tbc, PE
tumor

Thickening of the pleura
Causes: Causes:
callus or tumor
Inspection:
Inspection:
retraction of the affected
side, side,
chest excursion decreased
Percussion:
Percussion:
dullness
Auscultation:
Auscultation:
decreased or absent
X-ray ray: : shadow, shadow,
calcification

Pleuritis sicca
Severe, Severe,
sharp pain, pain,
friction rub at in- in and
exspiration
Patient lies on the affected side
Shallow breath
If only the diaphragmal pleura affected: affected:
pain only at breathing
can cause defense in the abdominal muscles at
deep inspiration
can radiate to the apex, apex,
neck

Pneumothorax
Air in the pleural cavity
Causes: Causes:
from the lung (bulla, bleb) bleb)
through
visceral pleura
injury of the chest wall
Collapse of the lung = atelectasis +
mediastinal shift toward the healthy
side

Pneumothorax
clinics
Symptoms:
Symptoms:
sharp pain at the moment
Signs: Signs:
collaps
dyspnea
tachycadia

Pneumothorax
physical exam
Inspection:
Inspection:
the affected side is bulging, bulging,
chest
excursion decreased
Tactile fremitus: fremitus:
decreased or absent
Percussion :
small: small:
almost no difference
large: large:
tympanic
dullness of the heart shifted towards the healthy side
Auscultation:
Auscultation:
decreased or absent
Bronchophony:
Bronchophony:
decreased or absent

Seropneumothorax
Fluid at the bottom of the chest
X-ray ray: : the border always horizontal
Hyppocrat:
Hyppocrat:
shake !

Acut tracheo-bronchitis
tracheo bronchitis
Fever, Fever,
sore throat
Cough (dry dry → sputum mucous-
purulent) purulent
Louder breath sounds, sounds,
prolonged
exspiration,
exspiration,
adventitious sounds
(wheezes wheezes, , crackles)
crackles

COPD = chronic aspecific
pulmonary disease
Chronic bronchitis
Emphysema

Chronic bronchitis
Cough
Sputum
Dyspnea
No change on X-ray ray !
Symptoms for at least 2 years, years,
for 3
mo /year year
No other underlying disease

Bronchial asthma
Sudden onset dyspnea caused by
reversible airway obstruction
Prolonged exspiration,
exspiration,
wheezes-
rhonchi, rhonchi,
use of accessory muscles, muscles,
tachypnea

Emphysema
Def: Def:
abnormal, abnormal,
permanent enlargement of air
spaces distal to bronchioli accompanied by the
destruction of its walls
Horizontal ribs, ribs,
lower aperture of the thorax
wide, wide,
lung borders lower
Chest expansion decreased,
decreased,
absolute dullness of
the heart decreased or missing
Exspiration obstructed, obstructed,
air trapping
Percussion:
Percussion:
hyperresonance
Auscultation:
Auscultation:
decreased vesicular sound

Syndrome of mediastinal
tumor
Mediastinal lymph nodes: nodes:
lymphoma,
lymphoma,
metastasis,
metastasis,
Boeck sarcoidosis
Aortic aneurysm
Substernal goiter
Extreme dilatation of left atrium
Pericardial fluid

Signs of compression caused
by mediastinal masses
Veins
Superior vena cava
syndrome
Thrombosis
Portal hypertension
Trachea
Cough
Asphyxia
Tracheomalatia
Esophagus
Dysphagia
Bleeding from
dilated veins
Cerebrovascular
Ischaemia
Cerebrovascular
Ischaemia
Nerves
Nerves
Recurrent
Recurrent laryngeal
nerve palsy →
hoarsness
Phrenical nerve
palsy
Horner-triad
Horner triad
Chyle
Chylothorax

Superior vena cava
syndrome
Venous congestion in the head, head,
neck
and upper extremities = Stokes-collar
Stokes collar
Causes: Causes:
stenosis, stenosis,
occlusion, occlusion,
thrombosis of
mediastinal veins
manipulation on veins or PM
implantation
substernal goiter