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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
PulmonaryPulmonary infiltrationinfiltration
historyhistory
�� ShakingShaking chillchill, , sputumsputum: : pneumoniapneumonia
�� OperationOperation, , immobilisationimmobilisation, , chestchest painpain, ,
bloodybloody sputumsputum: : infarctioninfarction afterafter PE PE
�� WeightWeight lossloss, , smokingsmoking, , bloodybloody sputumsputum: :
tumor tumor
PulmonaryPulmonary infiltrationinfiltration
physicalphysical examinationexamination 1.1.
�� InspectionInspection: : chestchest excursionexcursion decreaseddecreased
�� TactileTactile fremitusfremitus: : increasedincreased
�� PercussionPercussion: : dullnessdullness
PulmonaryPulmonary infiltrationinfiltration
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
PulmonaryPulmonary embolismembolism
= = emboliaembolia pulmonumpulmonum
= = thrombusthrombus inin thethe arteriesarteries of of thethe lunglung
SourceSource: : veinsveins of of thethe lowerlower extremitiesextremities / /
pelvispelvis
AnamnesisAnamnesis !!!!!!!!
PulmonaryPulmonary embolismembolism
symptomssymptoms
�� ShortShort of of breathbreath = = dyspneadyspnea
�� PleuralPleural chestchest painpain
�� BloodyBloody sputumsputum = = haemoptysishaemoptysis
�� CollapseCollapse = = syncopesyncope
�� PalpitationPalpitation
�� FatigueFatigue
�� CoughCough
PulmonaryPulmonary embolismembolism
physicalphysical signssigns
�� TachypneaTachypnea
�� CyanosisCyanosis
�� BronchospasmBronchospasm
�� PleuralPleural frictionfriction rubrub
�� HypotensionHypotension
�� TachycardiaTachycardia
�� FeverFever
�� DVTDVT
PulmonaryPulmonary embolismembolism
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
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
AtelectasisAtelectasis
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
PleuralPleural effusioneffusion
causescausesTranssudateTranssudate�� HeartHeart failurefailure
�� LiverLiver cirrhosiscirrhosis
�� PulmonaryPulmonary embolismembolism
�� NephroticNephrotic syndromesyndrome
�� MeigsMeigs--syndromesyndrome, , ovarianovarianhyperstimulationhyperstimulation
�� PeritonealPeritoneal dialysisdialysis
�� MyxoedemaMyxoedema
ExsudateExsudate�� TumorTumor
�� InfectionInfection
�� PulmonaryPulmonary embolismembolism
�� LungLung infarctioninfarction
�� AbdominalAbdominal diseasesdiseases
�� Autoimmun Autoimmun diseasesdiseases
�� EosinophilicEosinophilic pneumoniapneumonia
�� AsbestAsbest
�� IrradiationIrradiation
�� EosophagealEosophageal perforationperforation
�� HaemothoraxHaemothorax
�� ChylothoraxChylothorax
�� EmpyemaEmpyema thoracisthoracis
PleuralPleural effusioneffusion
�� AnamnesisAnamnesis: : pleuritispleuritis siccasicca ((possiblepossible))
�� SymptomsSymptoms: :
�� coughcough
�� dyspneadyspnea
�� chestchest painpain
PleuralPleural effusioneffusion
physicalphysical signssigns
�� InspectionInspection: : bulgingbulging of of thethe affectedaffectedsideside, , excursionexcursion decreaseddecreased
�� TactileTactile fremitusfremitus: : decreaseddecreased
�� PercussionPercussion: : dullnessdullness
�� AuscultationAuscultation: : breathbreath soundssoundsdecreaseddecreased oror absentabsent
�� BronchophonyBronchophony: : decreaseddecreased
PleuralPleural effusioneffusion
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
PleuralPleural effusioneffusion
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
�� PercussionPercussion: : dullnessdullness
�� 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
PneumothoraxPneumothorax
clinicsclinics
�� SymptomsSymptoms: : sharpsharp painpain atat thethe momentmoment
�� SignsSigns: :
�� collapscollaps
�� dyspneadyspnea
�� tachycadiatachycadia
PneumothoraxPneumothorax
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
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