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Physical signs of pulmonary syndromes

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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

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