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12.11.29 Respiratory exam

Observation
  • Jaundice (metastatic Ca)
  • Steroid use
    • Oral thrush
    • Facies
  • Symmetry of chest movement - from end of bed
  • Chest shape
  • Sputum pots
    • Bronchiectasis => LOADS of sputum
  • Chest drain
    • Check water level is swinging (right site)
    • If it's bubbling, pneumothorax is not fixed yet

Signs of cancer
  • Key differential!
  • Check:
    • Nutritional status
    • SVC obstruction
      • Raised JVP
      • Swollen face
    • Horner's
    • Wasting of dorsal interossei

Tracheal deviation
  • Slight deviation to the right is normal
  • If you suspect deviation, check to see if the mediastinum is shifted, by checking the apex beat

Tracheal tug
  • KEY SIGN
  • Indicates hyperexpansion
    • COPD
    • Acute asthma
  • Can operate to remove a bit of lung => Reduced hyperexpansion

Palpation
  • Check chest expansion in three areas
  • Don't forget lymph nodes - do them now, rather than forgetting them at the end
  • Do tactile resonance for exam purposes

Percussion
  • Compare sides
  • Tap from the wrist and bounce straight back
  • Don't mute sound by resting other fingers on chest
  • Reduced percussion note
    • Pleural thickening
    • Consolidation

Auscultation
  • 1 - Breath sounds
    • Vesicular or bronchial
  • 2 - Crackles
    • Fluid (heart failure)
    • Pneumonia
    • Fibrosis
    • Bronchiectasis
  • 3 - Wheeze
    • Asthma
    • COPD
    • Cardiac wheeze (fluid in small airways)
  • 4 - Air entry
    • Collapse
    • Effusion
    • Pneumothorax
    • Musculoskeletal


Other systems to examine
  • Spine (mets)
  • Abdo (liver mets)
  • CVS (mets)

Cor pulmonale
  • Think laterally!
    • Raised JVP?
    • Peripheral oedema?
    • RV overload - heave?

Ventilation
  • CPAP treats HYPOXIA
  • BiPAP is used for COPD
  • Key question - "Can they get out of the house"
    • If not, they won't ever get off ventilation, so don't bother


Atypical pneumonias
  • Big three
    • Chlamydia psittaci
      • Causes psittacosis
    • Legionella pneumophila
      • Causes a Legionnaires' disease - very severe
    • Mycoplasma pneumoniae
      • Usually occurs in younger age groups and may be associated with neurological and systemic symptoms
  • Others
    • Chlamydophila pneumoniae
      • Mild form of pneumonia with relatively mild symptoms
    • Coxiella burnetii
      • Causes Q fever
    • Francisella tularensis
      • Causes tularemia


Causes of COPD exacerbations
  • Definition
    • Sustained worsening of the patient's symptoms from his or her usual stable state, which is beyond normal day-to-day variations and is acute in onset
  • Bacterial infection
    • Streptococcus pneumoniae
    • Haemophilus influenzae
    • Moraxella catarrhalis
  • Viral infection
    • Rhinoviruses
    • Influenza
    • Parainfluenza
    • Coronavirus
    • Adenovirus 
    • RSV
  • MI
  • Pollutants
  • Cold ??

COPD subtypes
  • Blue bloater
    • Primarily bronchitis
    • Capillary bed is unchanged => Big VQ mismatch
      • Causes hypoxaemia, hypercapnia, polycythaemia
    • Hypoxia causes pulmonary vasoconstriction
    • Leads to 
      • Cor pulmonale
      • Peripheral oedema
    • These patients end up dependent on hypoxic drive
  • Pink puffer
    • Primarily emphysema
    • Destruction of gas exchange surface but also capillary bed => Less VQ mismatch
    • Can compensate by puffing
    • => Maintain relatively normal blood gases


Sequential nephron blockade
  • Use more than one diuretic, which different MOA
  • Breaks resistance to diuretics in edematous states
  • e.g. Furosemide + acetazolamide 
  • e.g. Loop diuretic + metolazone (thiazide)


Eisenmenger's syndrome
  • Combination of systemic-to-pulmonary communication, pulmonary vascular disease, and cyanosis
    • e.g. Reversal of flow down PDA, following pulmonary hypertension
  • Causes differential clubbing (feet first) due to where the PDA comes off


CXR findings
  • Check for a fluid level in the costophrenic angles, to distinguish pleural effusion from breast shadowing
  • Fibrosis vs bronchiectasis
    • Both reticulonodular
    • Fibrosis
      • Pulls diaphragm up
      • Obscures R heart border
    • Bronchiectasis
      • Ring sign (dilated, inflamed, end-on airways)
      • Tram lines (dilated, inflamed, side-on airways)

Notes
  • Need >5 g/dl of deoxygenated Hb to cause cyanosis
    • => Harder to pick up if anaemic
  • CO2 flap = Asteristix
  • Senile tremor
    • Essential tremor tends to become worse with age
  • IPF is the most common cause of fibrosis
  • Fine vs Coarse crackles is so subjective it is meaningless
  • Pancoast tumor
    • Tumour of the pulmonary apex
    • Characteristically causes Horner's syndrome
  • Flecainide 
    • Very proarrhythmic in patients with: 
      • CAD
      • CHF 
      • Ventricular dysrhythmias 
    • Used primarily in atrial fibrillation when concerns for proarrhythmias are not present
  • TIMI score
    • Used to categorize the risk of death and ischemic events in unstable angina or NSTEMI

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