1、Clinical clerkship Basic science training Develop clinical scenario Problem you will face:Medical information Patient data Incompatibility of two sets of knowledge Medical knowledge comprises millions of facts -organized by disease state -by pathophysiologyWill patients present a disease to you?Loos
2、ely constructed chain of complaintsElaborate psychological construct to prevent disclosure of painful eventsDealing with hundreds,if not thousands,of factsClinicians Job manage the information Patients data need to be translated into clinical presentation A technique:compatibility of knowledge Thoug
3、ht processes:Comprise much of fabric of clinical experience “second nature“Accurately assessed How can we get the information and patients data?Medical visitPurpose of Medical visit Careful and complete history Thorough physical examinationMedical history1)chief complain2)Present3)Past4)Family5)Soci
4、al histories6)System reviewMajor Pulmonary symptoms Dyspnea CoughDyspnea Greek prefix of“dys”-painful,difficult,breath It is a subjective experience of breathing discomfort that is comprised 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 disease Understand-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 proc
6、ess of respiration can be divided into 3 components: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 respir
7、ation can be divided into 3 components: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 EX
8、CHANGERINCREASE RESPIRATORY DIRVE 1)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 ob
9、struction-Metabolic acidosis a.Renal disease(renal failure,renal tubular acidosis)b.Decreased oxygen carrying capacity(eg.Anemia)c.Decreased release of oxygen to tissues(hemoglobinopaty:thalassemia)d.Decreased cardiac outputVENTILATORY CONTROLLER AND GAS EXCHANGERINCREASE RESPIRATORY DIRVE2)Stimulat
10、ion of pulmonary receptors(Irritant,Mechanical,Vascular)ILD Pleural effusion(compressive atelectasis)Pleural vascular disease Congestive heart failure3)Behavioral factors hyperventilation syndrome anxiety disorder panic attacksVENTILATORY CONTROLLER AND GAS EXCHANGERINCREASE RESPIRATORY DIRVEThe pro
11、cess of respiration can be divided into 3 components: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 alveolus VENTILATORY PUMPIN
12、CREASED EFFORT OR WOR OF BREATHING Muscle weakness Decreased Compliance of the chest wall Airflow obstruction The key areas of inquiry(Medical History)(1)quality of the symptom;(2)persistence or variability of the symptom(3)aggravating or precipitating symptom.Intermittent dyspnea Persistent or prog
13、ressive dyspnea Nocturnal dyspnea Dyspnea in the recumbent position Psychogenic dyspnea Raynauds phenomenonCough A 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 branching
14、APPROCH TO COUGH The cause of the cough Treat the causeCommon causes of cough Cough with sputum production:bronchitis,bronchiectasis 3 weeks a cutoff point for an acute cough (due to an upper respiratory infection)Cough:acute,chronic Acute cough Cause:1.upper respiratory tract infection 2.pneumonia
15、3.congestive cardiac failure 4.AECOPD 5.aspiration 6.pulmonary embolism Chronic cough Cause:Asthma GER postnasal drip chronic bronchitis bronchiectasisPhysical examination Inspection Palpation Percussion AuscultationPhysical examination Inspection Palpation Percussion Auscultation Appearance suggest
16、ive blood gas disturbance Look for dyspnea,tachypnea,slow RR Patients fingers for peripheral cyanosis Skin for warmth Tongue and lips for central cyanosisObserving the shape and symmetry of the chest Barrel chest pectus carinatum surgical scars Rhythm of breath Kussmauls breathing Cheyne-Stokes resp
17、irations RR low(10/min)-carbon dioxide narcosis -Drugs(alcohol,benzodiazepine)-Raised intracranial pressurePhysical examination Inspection Palpation Percussion Auscultation Chest wall abnormalities chest shape chest change on movement for asymmetry Bilateral poor chest expansion obesity Emphysema Un
18、ilateral poor chest expansion Pleural effusion Pneumothorax Trachea displaced Scoliosis Pneumothorax Pleural effusion Reduced vocal fremitus Pleural effusion PneumothoraxPhysical examination Inspection Palpation Percussion Auscultation Stony dull percussion This implies pleural effusion Dull to perc
19、ussion but not stony dull Consolidation Pulmonary edema usually due to left ventricular failure Hyperresonant percussion Emphysema Large bullae PneumothoraxPhysical examination Inspection Palpation Percussion Auscultation Diminished breath sounds poor respiratory effort Pleural effusion Endobronchia
20、l obstruction Severe asthma Emphysema Bronchial breathing Consolidation Pulmonary fibrosis Fine inspiratory crackles Pulmonary edema Pulmonary fibrosis Consolidation Pleural rub Pleural infection with adjacent pneumonia Pulmonary embolus Inspiratory rhonchus or wheeze Acute bilateral vocal cord para
21、lysis Inhalation of foreign body Tracheal tumors or stenosis Expiratory rhonchus(large 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:/ Oxford textbook of Medicine Cecil medicine Textbook of physical diagnosisThanks for attention
