Medical Semiology II

compressive vs obstructive atelectasis

compressive has increased tactile fremitus

tactile fremitus in pneumonia vs pleural effusion

pneumonia - increased
effusion - decreased

a solitary pul nodule w/ mediastinum widening and atelectasis is seen in which patho

lung cancer

why do we percuss supraclavicular area

Pancoast Tobias tumour (apical lung)

trousseau's syndrome occurs in which patho

lung cancer (vascular syndrome)

neurologic syndromes from lung cancer

eaton-lambert

endocrine syndromes from lung cancer

hypercalcemia, oliguria, Cushing

when is there hoarseness in lung cancer

laryngeal n paralysis from left side tumour

manifestations of lung cancer

- asymptomatic
- non specific (weight loss, anemia)
- pul lesion -> cough, hemoptysis, dsypnea, wheeze, atelectasis
- intrathoracic spread -> dysphagia, hiccups, horner's, pleural effusion
- extrathoracic spread -> bone, liver, adrenal, brain
- paraneoplastic syndrome

lung cancer is divided into

NSCLC (adeno, squamous + large cell carcinoma) and SCLC

risk factors for lung cancer

smoking, carcinogens, copd, women who smoke, black men, HIV, inheritance

ECG w/ increase S1 and T3 pattern is indicate of which patho

pul embolism

signs of pul embolism on xray

Westermark (dilation of pul vessel), Hampton hump (triangular infiltrate)

physical exam in pul embolism

unilateral leg swell, tachycardia, hypotension, consolidation signs of lungs, d-dimer

symptoms of pul embolism

pleuritis chest pain, hemoptysis, back + shoulder + upper abd pain

consequences of pul embolism are primarily

hemodynamic (emboli, resp insufficiency)

patient-related predisoping factors of pul embolism

age, history of prevout VTE, cancer, major surgery, MI, estrogen use

hereditaroy factors for v thromboemebolism are those related to

thrombophilia (AT3, protein C, S)

etiology of pul embolism

DVT -> thromboembolism

DD bw abscess and lobar pneumonia

coarse crackles in abscess

physical findings of lung asbcess

clubbing, consolidation sounds (coarse crackles, decreased sounds), pleural rub

manifestations of lung asbcess

chill, low fever, foul smell sputum, hemoptysis, dyspnea, night sweats

classifcation of lung abscess

primary by aspiration
secondary by bronchiectasis, immunocompromised or tumour

patients with mouth diseases, seizures and dysphagia + impaired consciousness are at higher risk of what

lung abscess

pleural effusion

collection of fluid in pleural linings

causes of pleural effusion

congestive hf, malignancy, infections and pul emboli

transudate vs exudate pleural effusion

transudate - ultrafiltrates of plasma in pleura from hydrostatic and oncotic forc imbalance, <protein
exudate - inflammation of pleura itself from lung disease or impaired lymph drainage, >protein

manifestations of pleural effusion

unilateral + sharp pain, worsens w/ inspiration and cough
dyspnea
dry cough

xray of pleural effusion

hemidiaphragm elevated

thoracentesis

removal fluid from pleural effusion, diagnostic or therapeutic

therapeutic thoracentesis (+limit)

removes larger amounts pleural effusion to alleviate dyspnea, max 1500ml

putrid odor pleural fluid in effusion suggests

anaerobic empyema

ammonia odor pleural fluid in effusion suggests

urinothorax

black pleural fluid in effusion suggests

aspergillosis

yellow/green pleural fluid in effusion suggests

rheumatoid pleural effusion

bloody pleural fluid in effusion suggests

trauma, malignancy, high amounts is hemothorax

when is pleural effusion considered an exudate

high protein and LDH

pleural fluid ldh levels >1000 IU/L suggests

empyema, malignant effusion or rheumatoid effusion

low pleural fluid glucose in effusion suggests

malignancy, TB or empyema

how to test for TB pleural effusion

acid-fast bacillus stain or ADA (adenosine deaminase)

high triglycerides, chol and milky pleural fluids suggests

chylothorax

in patients with pleural effusion, bronchoscopy is only done when

patient has parenchymal abnormalities or hemopytsis

causes of pleural transudate effusions

congestive heart failure, cirrhosis, nephrotic syndrome

congestive HF causing pleural transudate effusions

biventricular failure causing bilateral effusions, also called hydrothorax

forms of pleural exudative effusions caused by infections

parapneumonic effusion
- uncomplicated (pneumonia)
- complicated (bacteria, increased neutrophils)
- empyema (loculated pus)

causes of empyema

trauma, lung abscess rupture, septic infarction, infection, esophageal rupture

manifestations of parapneumonic effusions

symptoms of effusion (pain, dyspnea, dry cough) with fever

anaerobic bacterial parapneumonic effusion manifestation

weight loss

physical exam of pleural effusion

febrile, tachypnea, tachycardia (looks like SIRS), diaphragm in upper position, dullness, decreased breath sounds + fremitus, tracheal shift

investigations of pleural effusion

increased ESR, leukocytosis

what used to be the most common cause of pleural effusion

tb

hemothorax

collection of blood within pleural cavity

etiology of hemothorax

trauma, hematologic disorders, pleural malignancies, aorta rupture, TB

manifestations of hemothorax

low BP, fainting, anemia

classification of pneumothorax

simple spontaneous pneumothorax (tall thin smokers)
secondary pneumothorax (from lung disease, AIDS)
iatrogenic pneumothorax (ventilation, biopsy)
traumatic pneumothorax (rib fracture)

which part of lungs are involved in simple spontaneous pneumothorax

right lung

mannifestations of pneumothorax

sudden dyspnea, tachycardia, hypotension, cyanosis, JVD

chest radiography in pneumothorax

confirms it, linear shadow, small ones only evident in expiration

acute bronchitis

acute inflammation of mucous membrane lining upper airways lasting 10 d

etiology of acute bronchitis

respiratory tract viruses

what should be asked in taking history of patient with bronchitis

recent cold, exposure to allergens, smoking, family history of lung disease

manifestations of acute bronchitis

cough, sputum production, upper respo tract symptoms, general chills or fever, angina

cough in acute bronchitis

starts dry, then becomes productive (yellow/green sputum)

examination of acute bronchitis

unremarkable

what lung sound may be present in acute bronchitis

stridor, ronchi or wheezes

why is a chest x-ray done in patients with acute bronchitis

to rule out pneumonia

chronic bronchitis

cough with sputum expectoration for >3m during a period of 2 consecutive yrs

how does chronic bronchitis progress

progressive airflow limitation w/ emphysema -> COPD

etiology of chronic bronchitis

smoking, pollution, infections

classification of chronic bronchitis

simple (mucoid sputum production)
chronic mucopurulent (persistent purulent sputum)
chronic bronchitis w/ obstruction

chronic bronchitis with obstruction must be distinguished from

chronic infective asthma

manifestations of chronic bronchitis

chronic cough (worse in mornings), sputum hyperproduction, frequent resp infections, dyspnea, wheezing, fatigue

physical exam of chronic bronchitis

blue boater or pink puffer

signs of blue boater

overweight, increased resp + heart rate, use of accessory m, cyanosis, clubbing, cor pulmonale

signs of cor pulmonale causing chronic bronchitis

peripheral edema (in blue boater)

thorax exam in blue boater chronic bronchitis

barrel chest, decreased fremitus, hyper resonant percussion, decreased breath sounds w/ crackles + wheezes

spirometry has obstructive pattern in which pathos

chronic bronchitis (COPD), asthma

emphysema

abnormal permanent air spaces enlargement, marked by decreased respiratory function; associated with smoking or chronic bronchitis or old age

etiology of emphysema

smoking, alpha-antitrypsin deficiency, infections

classification of emphysema

panlobular
centrilobular

manifestations of emphysema

pink puffer, progressive dyspnea, wet cough

exam of emphysema

tachypnea + tachycardia, accessory m, warm cyanosis, exophthalmos, injected conjunctivas, clubbing

chest of emphysema

barrel chest, decreased wall movements + fremitus, hyperresonant auscultation

xray in emphysema

diaphragm flattened (translucent)

COPD

chronic bronchitis + emphysema, preventable + reversible

risk factors for COPD

genetics, smoke, pollution

symptoms of COPD

progressive dyspnea, productive cough, recurrent pul infections, cardiac/respo failure w/ edema, hepatomegaly, exopthalmus, jvd

types of copd

blue bloaters -> chronic bronchitis
pink puffers -> emphysema

what investigations makes diagnosis for COPD

spirometry

copd vs asthma

asthma is reversible, copd is not
asthma onset in childhood while copd in midlife
copd is progressive

asthma bronchiale

chronic inflammatory disorder of airways causing recurring episodes of wheezing, breathlessness, chest tightness and coughing (at night)

family history of what is in patients w/ asthma

allergy, sinusitis, rhinitis, asthma

evidence of resp distress

tachypnea, tachycardia, diaphoresis, accessory m use, orthopnea, cyanosis, pulsus paradoxus

pulsus paradoxus

fall in systolic bp in inspiration, during acute asthma attack

chest exam in asthma

hyperinflated chest, decreased fremitus + breath sounds, expiratory wheezing, hyperresonance

types of asthma

allergenic, exercise induced, nocturnal, drug induced, cough-variant

non-allergic asthma is related to what

viral infections or chronic bronchitis

severity levels of asthma

mild/intermittent, mild/persistent, mod/severe

resp failure

syndrome where lung unable to meet metabolic demands of body, from failure of tissue oxygenation + failure of CO2 homeostasis.

resp failure is defined as PaO2 + PaCO2 value

PaO2 <60mmHg while breathing air
PaCO2 >50mmHg