Observation - Jaundice (metastatic Ca)
- Steroid use
- 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
- Horner's
- Wasting of dorsal interossei
- 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
- 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
- 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
- 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
- Francisella tularensis
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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