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1、Clinical clerkshipRespiratory systemRen Ji HospitalZou JingBasic science trainingDevelop clinical scenarioProblem you will face:Medical information Patient data Inpatibility of two sets of knowledgeMedical knowledge prises millions of facts -organized by disease state -by pathophysiologyWill patient
2、s present a disease to you?Loosely constructed chain of plaintsElaborate psychological construct to prevent disclosure of painful eventsDealing with hundreds,if not thousands,of factsClinicians Jobmanage the informationPatients data need to be translated into clinical presentationA technique:patibil
3、ity of knowledge Thought processes:prise much of fabric of clinical experience “second nature“Accurately assessedHow can we get the information and patients data?Medical visitPurpose of Medical visitCareful and plete historyThorough physical examinationMedical history1)chief plain2)Present3)Past4)Fa
4、mily5)Social histories6)System reviewMajor Pulmonary symptomsDyspneaCoughDyspneaGreek prefix of“dys”-painful,difficult,breathIt is a subjective experience of breathing disfort that is prised of qualitatively distinct sensations that vary in intensity.Diagnosis approach Differential diagnosis of dysp
5、nea:lung,heart,chest wall neuromuscular renal endocrine rheumatologic hematologic psychiatric diseaseUnderstand-The goal of respiratory and cardiovascular system:take O2 from the air transfer it to hemoglobin deliver it to metabolically active tissue transport CO2 back to lung,to eliminate The proce
6、ss of respiration can be divided into 3 ponents:1)A controller,which determines the rate and depth of breathing2)A gas exchanger,which consists of the pulmonary vasculature and the alveolus3)A ventilator pump,which facilitates the movement of gas into and out of the alveolusThe process of respiratio
7、n can be divided into 3 ponents:1)A controller,which determines the rate and depth of breathing2)A gas exchanger,which consists of the pulmonary vasculature and the alveolus 3)A ventilator pump,which facilitates the movement of gas into and out of the alveolusVENTILATORY CONTROLLER AND GAS EXCHANGER
8、INCREASE RESPIRATORY DIRVE1)Stimulation of chemoreceptors -conditions leading to acute hypoxemia (Impaired gas exchanger,Environmental hypoxia)-conditions leading to increase dead space and/or acute hypercapnia Impaired gas exchanger：asthma Impaired ventilator pump:muscle weakness,airflow obstructio
9、n-Metabolic acidosis a.Renal disease(renal failure,renal tubular acidosis)b.Decreased ogen carrying capacity(eg.Anemia)c.Decreased release of ogen to tissues(hemoglobinopaty:thalassemia)d.Decreased cardiac outputVENTILATORY CONTROLLER AND GAS EXCHANGERINCREASE RESPIRATORY DIRVE2)Stimulation of pulmo
10、nary receptors(Irritant,Mechanical,Vascular)ILD Pleural effusion(pressive atelectasis)Pleural vascular disease Congestive heart failure3)Behavioral factors hyperventilation syndrome anxiety disorder panic attacksVENTILATORY CONTROLLER AND GAS EXCHANGERINCREASE RESPIRATORY DIRVEThe process of respira
11、tion can be divided into 3 ponents:1)A controller,which determines the rate and depth of breathing2)A gas exchanger,which consists of the pulmonary vasculature and the alveolus 3)A ventilator pump,which facilitates the movement of gas into and out of the alveolusVENTILATORY PUMPINCREASED EFFORT OR W
12、OR OF BREATHING Muscle weakness Decreased pliance of the chest wall Airflow obstructionThe key areas of inquiry(Medical History)(1)quality of the symptom;(2)persistence or variability of the symptom(3)aggravating or precipitating symptom.Intermittent dyspneaPersistent or progressive dyspneaNocturnal
13、 dyspneaDyspnea in the recumbent positionPsychogenic dyspneaRaynauds phenomenonCoughA series of respiratory maneuvers that lead to a characteristic cough sound.Most sensitive sites for initiating cough:larynx,tracheobronchial tree,carina the points of bronchial branchingAPPROCH TO COUGHThe cause of
14、the coughTreat the causemon causes of coughCough with sputum production:bronchitis,bronchiectasis3 weeks a cutoff point for an acute cough (due to an upper respiratory infection)Cough:acute,chronicAcute cough Cause:1.upper respiratory tract infection 2.pneumonia 3.congestive cardiac failure 4.AECOPD
15、 5.aspiration 6.pulmonary embolism Chronic cough Cause:Asthma GER postnasal drip chronic bronchitis bronchiectasisPhysical examinationInspectionPalpationPercussionAuscultationPhysical examinationInspectionPalpationPercussionAuscultationAppearance suggestive blood gas disturbance Look for dyspnea,tac
16、hypnea,slow RR Patients fingers for peripheral osis Skin for warmth Tongue and lips for central osisObserving the shape and symmetry of the chestBarrel chestpectus carinatumsurgical scars Rhythm of breathKussmauls breathingCheyne-Stokes respirationsRR low(10/min)-carbon dioxide narcosis -Drugs(alcoh
17、ol,benzodiazepine)-Raised intracranial pressurePhysical examinationInspectionPalpationPercussionAuscultationChest wall abnormalities chest shape chest change on movement for asymmetryBilateral poor chest expansion obesity EmphysemaUnilateral poor chest expansion Pleural effusion PneumothoraxTrachea
18、displaced Scoliosis Pneumothorax Pleural effusionReduced vocal fremitus Pleural effusion PneumothoraxPhysical examinationInspectionPalpationPercussionAuscultationStony dull percussion This implies pleural effusionDull to percussion but not stony dull Consolidation Pulmonary edema usually due to left
19、 ventricular failureHyperresonant percussion Emphysema Large bullae PneumothoraxPhysical examinationInspectionPalpationPercussionAuscultationDiminished breath sounds poor respiratory effort Pleural effusion Endobronchial obstruction Severe asthma EmphysemaBronchial breathing Consolidation Pulmonary
20、fibrosisFine inspiratory crackles Pulmonary edema Pulmonary fibrosis ConsolidationPleural rub Pleural infection with adjacent pneumonia Pulmonary embolusInspiratory rhonchus or wheeze Acute bilateral vocal cord paralysis Inhalation of foreign body Tracheal tumors or stenosisExpiratory rhonchus(large
21、 airway obstruction)Endobronchial carcinoma Acute bilateral vocal cord paralysis Expiratory polyphonic,high-pitched wheeze (small airway obstruction)Bronchial asthma cardiac asthma=left ventricular failure and pulmonary edemaVideo for PEhttp:/v.youku./v_show/id_XNzA0OTgzODE2.htmlReferenceOxford textbook of MedicineCecil medicineTextbook of physical diagnosisThanks for attention