2. physicalsignsof pulmonarysyndromes · pdf filepulmonaryinfiltration physicalexamination2....

2. 2. PhysicalPhysical signssigns of of

pulmonarypulmonary syndromessyndromes

Dr. Dr. NebenfNebenfüührerhrer ZsuzsaZsuzsa

�� InfiltrationInfiltration

�� PneumoniaPneumonia

�� PulmonaryPulmonary embolismembolism

�� AtelectasisAtelectasis

�� PleuralPleural effusioneffusion

�� PneumothoraxPneumothorax

�� MediastinalMediastinal massmass

PulmonaryPulmonary infiltrationinfiltration

causescauses

ExsudateExsudate, tumor, , tumor, bloodblood inin thethe alveolialveoli. .

�� PneumoniaPneumonia

�� lobarlobar

�� viralviral

�� bronchopneumoniabronchopneumonia

�� PulmonayPulmonay embolismembolism

�� TumorTumor

�� TbcTbc


historyhistory

�� ShakingShaking chillchill, , sputumsputum: : pneumoniapneumonia

�� OperationOperation, , immobilisationimmobilisation, , chestchest painpain, ,

bloodybloody sputumsputum: : infarctioninfarction afterafter PE PE

�� WeightWeight lossloss, , smokingsmoking, , bloodybloody sputumsputum: :

tumor tumor


physicalphysical examinationexamination 1.1.

�� InspectionInspection: : chestchest excursionexcursion decreaseddecreased

�� TactileTactile fremitusfremitus: : increasedincreased

�� PercussionPercussion: : dullnessdullness


physicalphysical examinationexamination 2.2.

�� AuscultationAuscultation: :

�� CracklesCrackles atat thethe beginningbeginning ((crepitatiocrepitatio

induxindux))

�� BronchialBronchial breathbreath soundssounds

�� CracklesCrackles atat thethe end (end (crepitatiocrepitatio reduxredux))

�� BronchophonyBronchophony increasedincreased

PneumoniaPneumonia

DefDef: : inflammationinflammation of of thethe parenchymaparenchyma, ,

alveolialveoli, , connectiveconnective tissuetissue, , bronchiolibronchioli ofof

thethe lunglung

CausesCauses: : bacteriabacteria, , virusvirus, , MycoplasmaMycoplasma, ,

fungifungi, , chemicalchemical of of physicalphysical effectseffects

PneumoniaPneumonia

clinicalclinical picturepicture

�� SymptomsSymptoms: : highhigh feverfever, , dyspnoedyspnoe, ,

cyanosiscyanosis , , chestchest painpain, ,

coughcough: : drydry →→ puspus / / bloodybloody

�� ExsudativeExsudative pleuritispleuritis ((possiblepossible) )

�� LabLab: : leukocytosisleukocytosis, , leftleft shift, ESR shift, ESR ↑↑, ,

CRP CRP ↑↑

�� XX--rayray: : infiltrationinfiltration

AtypicalAtypical infiltationinfiltation

�� MassiveMassive: : alsoalso thethe bronchibronchi filledfilled withwith

exsudationexsudation oror tumortumor

�� CentralCentral: : inin thethe hilarhilar regionregion

PulmonaryPulmonary embolismembolism


= = emboliaembolia pulmonumpulmonum

= = thrombusthrombus inin thethe arteriesarteries of of thethe lunglung

SourceSource: : veinsveins of of thethe lowerlower extremitiesextremities / /

pelvispelvis

AnamnesisAnamnesis !!!!!!!!


symptomssymptoms

�� ShortShort of of breathbreath = = dyspneadyspnea

�� PleuralPleural chestchest painpain

�� BloodyBloody sputumsputum = = haemoptysishaemoptysis

�� CollapseCollapse = = syncopesyncope

�� PalpitationPalpitation

�� FatigueFatigue

�� CoughCough


physicalphysical signssigns

�� TachypneaTachypnea

�� CyanosisCyanosis

�� BronchospasmBronchospasm

�� PleuralPleural frictionfriction rubrub

�� HypotensionHypotension

�� TachycardiaTachycardia

�� FeverFever

�� DVTDVT


otherother examsexams

�� ECG: right ECG: right deviationdeviation, P , P pulmonalepulmonale, ,

PSVT, AFPSVT, AF

�� LabLab: : DD--dimerdimer, LDH, sebi , LDH, sebi

�� BloodBlood gasesgases: : hypoxiahypoxia, , hypocapniahypocapnia + +

alcalosisalcalosis

�� ScintigraphyScintigraphy

�� AngioAngio--CTCT

AtelectasisAtelectasis


AirlessAirless alveolialveoli, air , air absorbedabsorbed

�� CausesCauses::

�� InsufficientInsufficient breathingbreathing ((weakweak patientpatient, , longlongbedbed rest, rest, afterafter abdominalabdominal operationoperation))

�� BronchialBronchial obstructionobstruction oror stenosisstenosis bybyforeignforeign body / tumor / mucus body / tumor / mucus

�� ObstructionObstruction of of thethe lunglung byby pleuralpleural fluid fluid

�� XX--rayray


BronchostenosisBronchostenosis

�� tactiletactile fremitusfremitus: : decreaseddecreased

�� percussionpercussion: : dullnessdullness

�� auscultationauscultation: : diminisheddiminished breathbreath soundssounds

�� bronchophonybronchophony: : decreaseddecreased

InsufficientInsufficient breathingbreathing oror compressioncompression: air : air ininthethe bronchibronchi = = similarsimilar thanthan infiltrationinfiltration : : bronchialbronchial breathbreath soundssounds, , cracklescrackles

PleuralPleural effusioneffusion

DefDef: fluid : fluid accumulationaccumulation betweenbetween layerslayers of of thethe pleurapleura

�� TranssudateTranssudate�� IncreasedIncreased intrathoracicintrathoracic pressurepressure ((heartheart failurefailure))

�� DecreasedDecreased oncoticoncotic pressurepressure: : hypoproteinaemiahypoproteinaemia ((liverlivercirrhosiscirrhosis, , nephrosisnephrosis sysy))

�� ExsudateExsudate�� PermeabilityPermeability of of thethe pleurapleura increasedincreased ++

�� LymphaticLymphatic absorptionabsorption decreaseddecreased ((occlusionocclusion oror narrowingnarrowing))

�� BloodBlood

�� PusPus

�� ChyleChyle


causescausesTranssudateTranssudate�� HeartHeart failurefailure

�� LiverLiver cirrhosiscirrhosis


�� NephroticNephrotic syndromesyndrome

�� MeigsMeigs--syndromesyndrome, , ovarianovarianhyperstimulationhyperstimulation

�� PeritonealPeritoneal dialysisdialysis

�� MyxoedemaMyxoedema

ExsudateExsudate�� TumorTumor

�� InfectionInfection


�� LungLung infarctioninfarction

�� AbdominalAbdominal diseasesdiseases

�� Autoimmun Autoimmun diseasesdiseases

�� EosinophilicEosinophilic pneumoniapneumonia

�� AsbestAsbest

�� IrradiationIrradiation

�� EosophagealEosophageal perforationperforation

�� HaemothoraxHaemothorax

�� ChylothoraxChylothorax

�� EmpyemaEmpyema thoracisthoracis


�� AnamnesisAnamnesis: : pleuritispleuritis siccasicca ((possiblepossible))

�� SymptomsSymptoms: :

�� coughcough

�� dyspneadyspnea

�� chestchest painpain


physicalphysical signssigns

�� InspectionInspection: : bulgingbulging of of thethe affectedaffectedsideside, , excursionexcursion decreaseddecreased

�� TactileTactile fremitusfremitus: : decreaseddecreased


�� AuscultationAuscultation: : breathbreath soundssoundsdecreaseddecreased oror absentabsent

�� BronchophonyBronchophony: : decreaseddecreased


percussionpercussion

�� UpperUpper borderborder: : EllisEllis--DamoiseauDamoiseau--lineline: :

highesthighest pointpoint inin thethe posteriorposterior axillaryaxillary --

scapularscapular line, line, goinggoing down down onon bothboth

sidessides

�� KorKoráányinyi--triangletriangle: fluid : fluid dislocatesdislocates thethe

mediastinummediastinum = = triangletriangle of of dullnessdullness onon

thethe otherother sideside, bordered , bordered byby thethe

diaphragmdiaphragm and and thethe midlinemidline


punctionpunction

tumor

tbc, PEblood

malignant cells (tumor)

leukocyte (pneumonia)

lymphocytemesothelial cellssediment

> 0,6< 0,6LDH gradient

< 1,1> 1,1albumin gradient

� 1018< 1015specific weight

� 31-2protein g/l

ExsudateTranssudate

ThickeningThickening of of thethe pleurapleura

�� CausesCauses: : calluscallus oror tumortumor

�� InspectionInspection: : retractionretraction of of thethe affectedaffectedsideside, , chestchest excursionexcursion decreaseddecreased


�� AuscultationAuscultation: : decreaseddecreased oror absentabsent

�� XX--rayray: : shadowshadow, , calcificationcalcification

PleuritisPleuritis siccasicca

�� SevereSevere, , sharpsharp painpain, , frictionfriction rubrub atat inin-- and and exspirationexspiration

�� PatientPatient lieslies onon thethe affectedaffected sideside

�� ShallowShallow breathbreath

�� IfIf onlyonly thethe diaphragmaldiaphragmal pleurapleura affectedaffected: : painpain onlyonly atat breathingbreathing

�� cancan causecause defensedefense inin thethe abdominalabdominal musclesmuscles atatdeepdeep inspirationinspiration

�� cancan radiateradiate toto thethe apexapex, , neckneck

PneumothoraxPneumothorax

�� Air Air inin thethe pleuralpleural cavitycavity

�� CausesCauses: :

�� fromfrom thethe lunglung (bulla, (bulla, blebbleb) ) throughthroughvisceralvisceral pleurapleura

�� injuryinjury of of thethe chestchest wallwall

�� CollapseCollapse of of thethe lunglung = = atelectasisatelectasis + + mediastinalmediastinal shift shift towardtoward thethe healthyhealthysideside


clinicsclinics

�� SymptomsSymptoms: : sharpsharp painpain atat thethe momentmoment

�� SignsSigns: :

�� collapscollaps

�� dyspneadyspnea

�� tachycadiatachycadia


physicalphysical examexam

�� InspectionInspection: : thethe affectedaffected sideside is is bulgingbulging, , chestchestexcursionexcursion decreaseddecreased

�� TactileTactile fremitusfremitus: : decreaseddecreased oror absentabsent

�� PercussionPercussion ::�� smallsmall: almost no : almost no differencedifference

�� largelarge: : tympanictympanic

�� dullnessdullness of of thethe heartheart shifted shifted towardstowards thethe healthyhealthy sideside

�� AuscultationAuscultation: : decreaseddecreased oror absentabsent

�� BronchophonyBronchophony: : decreaseddecreased oror absentabsent

SeropneumothoraxSeropneumothorax

Fluid Fluid atat thethe bottombottom of of thethe chestchest

XX--rayray: : thethe borderborder alwaysalways horizontalhorizontal

HyppocratHyppocrat: : shakeshake !!

AcutAcut tracheotracheo--bronchitisbronchitis

�� FeverFever, , soresore throatthroat

�� CoughCough ((drydry →→ sputumsputum mucousmucous--

purulentpurulent))

�� LouderLouder breathbreath soundssounds, , prolongedprolonged

exspirationexspiration, , adventitiousadventitious soundssounds

((wheezeswheezes, , cracklescrackles))

COPD = COPD = chronicchronic aspecificaspecific

pulmonarypulmonary diseasedisease

�� ChronicChronic bronchitis bronchitis

�� EmphysemaEmphysema

ChronicChronic bronchitisbronchitis

�� CoughCough

�� SputumSputum

�� DyspneaDyspnea

�� No No changechange onon XX--rayray ! !

�� SymptomsSymptoms forfor atat leastleast 2 2 yearsyears, , forfor 3 3 momo //yearyear

�� No No otherother underlyingunderlying diseasedisease

BronchialBronchial asthmaasthma

�� SuddenSudden onsetonset dyspneadyspnea causedcaused byby

reversiblereversible airwayairway obstructionobstruction

�� ProlongedProlonged exspirationexspiration, , wheezeswheezes--

rhonchirhonchi, , useuse of of accessoryaccessory musclesmuscles, ,

tachypneatachypnea

EmphysemaEmphysemaDefDef: : abnormalabnormal, , permanentpermanent enlargementenlargement of air of air spacesspaces distaldistal toto bronchiolibronchioli accompaniedaccompanied byby thethedestructiondestruction of of itsits wallswalls

�� HorizontalHorizontal ribsribs, , lowerlower apertureaperture of of thethe thoraxthoraxwidewide, , lunglung bordersborders lowerlower

�� ChestChest expansionexpansion decreaseddecreased, , absoluteabsolute dullnessdullness of of thethe heartheart decreaseddecreased oror missingmissing

�� ExspirationExspiration obstructedobstructed, air trapping , air trapping

�� PercussionPercussion: : hyperresonancehyperresonance

�� AuscultationAuscultation: : decreaseddecreased vesicularvesicular soundsound

SyndromeSyndrome of of mediastinalmediastinal

tumortumor

�� MediastinalMediastinal lymphlymph nodesnodes: : lymphomalymphoma, ,

metastasismetastasis, , BoeckBoeck sarcoidosissarcoidosis

�� AorticAortic aneurysmaneurysm

�� SubsternalSubsternal goitergoiter

�� ExtremeExtreme dilatationdilatation of of leftleft atriumatrium

�� PericardialPericardial fluidfluid

SignsSigns of of compressioncompression causedcaused

byby mediastinalmediastinal massesmasses�� VeinsVeins

�� SuperiorSuperior venavena cavacavasyndromesyndrome

�� ThrombosisThrombosis

�� PortalPortal hypertensionhypertension

�� TracheaTrachea

�� CoughCough

�� AsphyxiaAsphyxia

�� TracheomalatiaTracheomalatia

�� EsophagusEsophagus

�� DysphagiaDysphagia

�� BleedingBleeding fromfromdilateddilated veinsveins

�� CerebrovascularCerebrovascular

�� IschaemiaIschaemia

�� NervesNerves

�� RecurrentRecurrent laryngeallaryngealnervenerve palsypalsy →→hoarsnesshoarsness

�� PhrenicalPhrenical nervenervepalsypalsy

�� HornerHorner--triadtriad

�� ChyleChyle

�� ChylothoraxChylothorax

SuperiorSuperior venavena cavacava

syndromesyndrome

VenousVenous congestioncongestion inin thethe headhead, , neckneck

and and upperupper extremitiesextremities = = StokesStokes--collarcollar

CausesCauses: :

�� stenosisstenosis, , occlusionocclusion, , thrombosisthrombosis of of

mediastinalmediastinal veinsveins

�� manipulationmanipulation onon veinsveins oror PM PM

implantationimplantation

�� substernalsubsternal goitergoiter

2. physicalsignsof pulmonarysyndromes · pdf filepulmonaryinfiltration physicalexamination2....

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