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Respiratory for PACES

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  1. Respiratory for PACES Cases for finals Monday 8th October 2012 Dr James Milburn Dr Chris Kyriacou

  2. Outline • Signs to be seen in examination, both expected and miscellaneous • Common cases we had/are to be expected in the exam • Hx and Ex • Ix • Mx

  3. Respiratory Exam • End of bed inspection • General Exam • Chest • Inspection • Palpation • Percussion • Auscultation • Added extras

  4. Inspection (End of bed) • Observe patient – breathless/comfortable • Look at surroundings – inhaler/oxygen/nebulisers etc • Use of accessory muscles • Cachexic

  5. General Examination • Hands • Face • Neck • Legs

  6. Hands

  7. Hands

  8. Hands

  9. Hands • Clubbing • Bronchiectasis, CF, Carcinoma, Fibrosingalveolitis • 4 signs - FACE • Flucance of nail bed • Angle loss • Curvature of nail • Expansion of terminal phalynx • Tar staining • Small muscle wasting • Lung Ca  pressure on brachial plexus

  10. Hands • HPOA • Periosteal inflammation in distal ends of long bones • Primary lung Ca, Meso • Flap/Tremor • CO2 retention • Fine tremor from β2-agonists • Pulse • Rate and rhythm • Bounding • Cyanosis

  11. Face

  12. Face

  13. Face • Plethoric • Secondary polycythaemia, SVC obstruction • Horner’s (Ptosis, miosis, anhydrosis) • Pancoast’s, (Demyelination, Carotid aneurysm) • Anaemia • Central cyanosis • Mouth – Halitosis/Thrush

  14. Neck • Lymphadenopathy • JVP

  15. Legs

  16. Inspection - Chest

  17. Inspection - Chest

  18. Inspection - Chest

  19. Inspection - Chest

  20. Inspection - Chest

  21. Inspection - Chest

  22. Inspection Chest

  23. Inspection - Chest • Shape • Barrel-chested (AP>Lateral) • Excavatum/Carinatum • Scars • Dilated veins • Ask them to take deep breath • Reduced expansion • Symetrical

  24. Palpation • Trachea • Apex • Expansion • Vocal fremitus

  25. Percussion • Flat – Pleural effusion (thigh) • Dull – Lobar pneumonia (liver) • Resonant • Hyper-resonant – Emphysema/Pneumothorax • Tympany – Large pneumothorax (puffed out cheek)

  26. Auscultation • Crackles • Nature of crackles • Fine – Oedema/Fibrosis (velcro) • Coarse – Bronchiectasis • Timing • Early insp – COPD/Bronchitis • Mid-late – Fibrosis/Oedema • Clear on coughing? • Yes - ?bronchiectasis • No – Fibrosis/Oedema

  27. Auscultation • Wheeze • Inspiratory/Expiratory • Fixed monophonic - Bronchial Ca • Polyphonic - Asthma • Pleural rub • Vocal resonance

  28. Auscultation • Breath sounds • Vesicular – Insp longer than exp • Bronchial – Exp longer than insp • Causes of bronchial breath sounds • Consolidation • Collapse • Fibrosis

  29. Back of chest • Repeat

  30. Added Extras to offer • Sats • Temp chart • Sputum pot • PEFR • CVS exam

  31. Case 1 • Mrs Jones is 40 yr old women who presents with a chronic cough • Please take a history

  32. History • Cough for last 2 years although now worsening • No diurnal variation • No obvious exacerbating factors • Productive of around ½-1 cupful of foul-smelling green sputum daily • Occasional flecks of blood mixed in with sputum • Had 3 ‘chest infections’ in the last 6 months • No weight loss

  33. History • 2 years ago could walk several miles with no SOB • During exacerbation is <50yards • No fever/night sweats • No chest pain

  34. History PMH, • Laparoscopic cholecystectomy 2007 • Whooping cough ~1970 FH, • Nil of note Drugs and Allergies, • Nil • NKDA SH, • Legal secretary for last 15yrs no hx of asbestos exposure • Ex-smoker for 5 years in her 20’s • Minimal drinker • No pets • No recent travel

  35. Differentials

  36. Differentials • Bronchiectasis • Most likely from pertussis as child • CF unlikely though screen in <40 • Chronic infection • COPD – very unlikely without FH of α1-antitrypsin • TB – rule out, no foreign travel, no known exposure • Malignancy – rule out, no wt loss, non-smoker etc • Fibrosis – not dry cough, no occupational risk

  37. Examination • On examination the patient was clubbed and had coarse inspiratory crackles bilaterally R>L • Not dyspnoeic at rest and no use of accessory muscles. • A/E and expansion equal • No wheeze

  38. Investigations • Bedside • Bloods • Imaging • Special tests

  39. Bedside

  40. Bedside • Sputum • PEFR • Sats • Temperature

  41. Bloods

  42. Bloods • FBC • Hb – 10.8 • WCC – 14.2 • MCV – 92 • U+E’s • Na – 139 • K – 4.1 • Cr – 130 • Ur – 5.2 • CRP – 56.2

  43. Bloods • FBC • Anaemia (chronic disease/haemoptysis) • Polycythaemia (secondary to hypoxia in more advanced cases) • Raised WCC if infection • Eosinophilia if ABPA • Inflammatory markers – ESR/CRP • U&E’s • Renal dysfunction due to amyloid deposition • Serum immunoglobulins • Genotyping/Sweat test

  44. Imaging

  45. Imaging

  46. Imaging

  47. Imaging • CXR • Flattened diaphragms • Tramlines from thickened bronchial walls • Cystic shadows • CT/HRCT • Signet rings • Bronchial wall thickening

  48. Management

  49. Management • Conservative • Medical • Surgical

  50. Conservative • Postural drainage • Chest physiotherapy • Pulmonary rehab • Oscillating positive expiratory devices (Acapella)