Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
.pdf
CHAPTER 9 Respiratory signs
192
Bilateral poor chest expansion
Some differential diagnoses and typical outline evidence
Obesity Suggested by: insidious onset of breathlessness.
Confirmed by: examination, BMI >30 kg/m
2
Emphysema
(also can come
under the term
COPD)
Suggested by: hyperinflation, poor air entry,
hyperresonance, pursed-lip breathing. Hyperinflation
and paucity of lung markings on CXR
Confirmed by: CT thorax, obstructive deficit with
reduced carbon monoxide diffusing capacity (DL
CO
)
and no reversibility on pulmonary function testing
(PFT) (see Figs. 19.19a, 19.19b, 19.21)
Pulmonary
fibrosis
Suggested by: clubbed (60%–70%), fine, late inspira
t
ory
bibasilar crackles. Loss of lung volume on CXR (not
corresponding to a single lobe)
Confirmed by: High-resolution (HR)-CT thorax.
Restrictive deficit with reduced DL
CO
on pulmonary
function testing (see Fig. 19.17)
Muscular
dystrophy
(other rarer
myopathies)
Suggested by: early age onset, FH, pseudohypertrophy
of calf muscles, lower motor neuron (LMN) signs,
restrictive deficit on pulmonary function testing
(especially when lying flat) with preservation of
corrected DL
CO
Confirmed by: muscle biopsy
Amyotrophic
lateral sclerosis
(ALS)
Suggested by: late-onset mixed upper motor neuron
(UMN)/LMN signs, tongue fasciculation, bulbar palsy.
Restrictive deficit on pulmonary function testing
(especially when lying flat) with preservation of
corrected DL
CO
Confirmed by: electromyography (EMG)
Guillain–Barré
syndrome
Suggested by: ascending weakness, autonomic
disturbances, recent infection. Restrictive deficit on
pulmonary function testing (especially when lying flat)
with preservation of corrected DL
CO
. Rapid deterio-
ration of forced vital capacity (FVC) or forced
expiratory volume in 1 second (FEV
1
)
Confirmed by: history, characteristic nerve conduction
velocity testing and CSF findings (increased protein),
response to steroids and plasmapheresis or
immunoglobulin (Ig) infusions
UNILATERAL POOR CHEST EXPANSION1
193
Unilateral poor chest expansion
Some differential diagnoses and typical outline evidence
Pleural effusion
Suggested by: reduced breath sounds, reduced tactile
vocal fremitus, stony dull percussion note
Confirmed by: CXR, CT, or ultrasound of chest showing
effusion (see Fig. 19.4)
Pneumothorax
Suggested by: reduced breath sounds, reduced tactile
vocal fremitus, resonant percussion note, tracheal
deviation
Confirmed by: CXR showing no lung markings next to
chest wall, and line of demarcation with lung tissue.
Best seen at lung apex (see Fig. 19.20)
Extensive
consolidation
Suggested by: reduced breath sounds, bronchial breath-
ing, increased tactile vocal fremitus, reduced
percussion note
Confirmed by: CXR (see Figs. 19.1a, 19.1b, 19.15)
Fractured ribs
Suggested by: antecedent trauma, focal tenderness
Confirmed by: CXR
Flail segment
following
trauma
Suggested by: paradoxical movement of part of
chest wall
Confirmed by: CXR, spinal X-ray
Musculoskeletal,
e.g., previous
thoracoplasty
Suggested by: history, scar
Confirmed by: CXR
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 9 Respiratory signs
194
Trachea displaced
Palpate with the middle finger, with the index and ring fingers on either
side of the trachea. Localize apex beat to see if the lower mediastinum is
also displaced.
Some differential diagnoses and typical outline evidence
Scoliosis
Suggested by: chest wall deformity and curved spine
Confirmed by: spinal X-ray, CXR
Pulled by
ipsilateral
pneumothorax
Suggested by: reduced breath sounds, reduced tactile
vocal fremitus, resonant percussion note
Confirmed by: CXR showing space with absent lung
markings “pulling” on mediastinum
Pulled by
ipsilateral upper
lobe fibrosis,
atelectasis, or
resection
Suggested by: tuberculosis (TB) (chronic), radiation
fibrosis (skin changes, tattoo marks), surgery (scar),
ankylosing spondylitis, sarcoidosis. Reduced upper
chest wall expansion
Confirmed by: chest X-ray or CT findings
Pushed by
contralateral
tension
pneumothorax
Suggested by: in extremis with high pulse rate and
hypotension, reduced breath sounds, reduced tactile
vocal fremitus, resonant percussion note
Confirmed by: insertion of needle into second
intercostal space
Pushed by
contralateral
pleural effusion
Suggested by: reduced breath sounds, reduced tactile
vocal fremitus, stony dull percussion note
Confirmed by: CXR showing large homogenous white
opacification “pushing” on mediastinum
REDUCED VOCAL FREMITUS1
195
Reduced vocal fremitus
Some differential diagnoses and typical outline evidence
Pleural effusion Suggested by: reduced breath sounds, reduced
expansion, stony dull percussion noted
Confirmed by: CXR, CT
, or ultrasound of chest.
(see Figs. 19.4, 19.22)
Pneumothorax Suggested by: reduced breath sounds, reduced
expansion, resonant percussion note. Trachea and
apex displaced
Confirmed by: CXR showing no lung markings next to
chest wall, and line of demarcation with lung tissue.
Best seen at lung apex (see Fig. 19.20)
Collapsed lobe
with no
consolidation
Suggested by: reduced breath sounds, reduced
expansion, normal percussion note
Confirmed by: CXR (see Fig. 19.2; collapse of different
lobes will have different patterns radiologically, e.g.,
showing fan-shaped shadow arising from mediastinum,
mediastinal shift, raised hemidiaphragm, displaced
horizontal fissure or “sail sign”). CT thorax confirms
lobar collapse.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 9 Respiratory signs
196
Stony dull percussion
This implies pleural effusion (see Fig. 19.4).
Some differential diagnoses and typical outline evidence
Transudates Suggested by: bilateral effusions, underlying clinical
cause
Confirmed by: dprotein in effusion or fluid–serum
protein ratio <0.5 (except in treated heart failure)
Left heart
failure, SVC
obstruction,
pericarditis,
peritoneal
dialysis
Suggested by: peripheral edema, raised JVP, basal
crackles, third heart sound
Confirmed by: CXR, echocardiogram, CT thorax
Low albumin
states, e.g., liver
cirrhosis,
nephrotic
syndrome
Suggested by: malnutrition, generalized edema
Confirmed by: low serum albumin
Miscellaneous
causes:
myxedema,
atelectasis
STONY DULL PERCUSSION1
197
Exudates Suggested by: unilateral effusion (but may be bilateral)
Confirmed by: iprotein in effusion or fluid–serum
protein ratio >0.5
Infective:
bacterial/
empyema, TB,
viral, etc.
Suggested by: history, fever, pHd, glucose in pleural
fluid d. Many lymphocytes in exudates often seen in
TB, caseating granuloma on pleural biopsy
Confirmed by: Gram stain or ZN stain and cultures
of pleural fluid and blood or cultures from pleural
biopsy
Neoplastic: lung
primary or
secondaries,
breast, ovarian,
lymphomas,
Kaposi’s, local
chest wall
tumors,
mesothelioma
Suggested by: history, especially weight loss. Signs of
local or distal spread
Confirmed by: pleural aspiration, biopsy, or other tissue
histology (see Fig. 19.22)
Rheumatoid,
SLE, etc.
Suggested by: history, other organ-specific involvement,
positive rheumatoid factor in fluid, very low fluid glucose
Confirmed by: autoantibodies, response to
immunosuppression
Pulmonary
infarction
Suggested by: history. Sudden onset of pleuritic chest
pain, and breathlessness. Associated risk factors. Usually
hypoxic. CXR may show other evidence, e.g., Fleischner
lines, Hampton’s hump, wedge-shaped shadowing
Confirmed by: helical
CT (spiral CT, CT pulmonary
angiogram [CTPA]
)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 9 Respiratory signs
198
Dull to percussion but not stony dull
Some differential diagnoses and typical outline evidence
Consolidation Suggested by: reduced breath sounds, bronchial
breathing, increased tactile vocal fremitus. Fever,
cough (may be productive)
Confirmed by: air bronchogram on CXR and CT
(see Figs. 19.1a, 19.1b, 19.15)
Pulmonary
edema usually
due to left
ventricular
failure
Suggested by: displaced apex beat, S3, basal crackles
Confirmed by: CXR, echocardiogram (see Fig. 19.13)
Elevated
hemidiaphragm
Suggested by: absent breath sounds (asymptomatic).
Confirmed by: CXR
Severe
fibrosis or
atelectasis
Suggested by: reduced breath sounds, crackles, poor
expansion, tracheal deviation
Confirmed by: CXR, CT thorax (see Figs 19.2, 19.17)
Mesothelioma
or severe
pleural
thickening
Suggested by: chest pain, weight loss, asbestos
exposure, clubbing, reduced breath sounds
Confirmed by: CT thorax and pleural biopsy
HYPERRESONANT PERCUSSION1
199
Hyperresonant percussion
Some differential diagnoses and typical outline evidence
Emphysema
(also can come
under the term
COPD)
Suggested by: >10 pack-year smoking history, chronic,
progressive breathlessness, cough with sputum,
reduced breath sounds, hyperresonance, pursed-lip
breathing, tracheal tug. Hyperinflation and paucity of
lung markings on CXR
Confirmed by: CT thorax, obstructive deficit with
reduced transfer factor and no reversibility on lung
function (see Figs. 19.19a, 19.19b)
Large bullae Suggested by: other signs of emphysema
Confirmed by: CT thorax (see Fig. 19.21)
Pneumothorax Suggested by: acute breathlessness, chest pain,
unilateral signs such as reduced breath sounds,
reduced tactile vocal fremitus, poor expansion
Confirmed by: CXR
showing no lung markings next to
chest wall and line of demarcation with lung tissue
(see Fig. 19.20)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 9 Respiratory signs
200
Diminished breath sounds
Ensure that the patient breathes with the mouth open, regularly and
deeply, and does not vocalize (e.g., groaning).
Some differential diagnoses and typical outline evidence
Poor respiratory
effort
Suggested by: reduced consciousness or coopera-
tion, any cause of poor chest wall expansion
(see p. 192).
Confirmed by: history, physical exam, arterial
blood gas (ABG)
Pleural effusion Suggested by: reduced expansion, stony dull
percussion, reduced tactile vocal fremitus
Confirmed by: CXR, CT, or ultrasound of chest.
(see Fig. 19.4)
Endobronchial
obstruction, e.g.,
tumor, retained
secretions, inhaled
foreign body
Suggested by: cough, stridor, unilateral dullness to
percussion, crackles, and reduced breath sounds
Confirmed by: CT thorax, bronchoscopy
Severe asthma
(bronchoconstriction)
Suggested by: history, sudden onset, often
precipitating factor; wheezing (though may be
absent in worst cases). Patient in extremis,
reduced consciousness.
Confirmed by: peak flow rate undetectable. ABG
,
very i airway pressure after intubation and
mechanical ventilation begun
Emphysema (or
COPD)
Suggested by: history of COPD, smoking; chronic,
progressive breathlessness; cough with sputum;
hyperinflation, hyperresonance, pursed-lip
breathing. Hyperinflation and paucity of lung
markings on CXR
Confirmed by: CT thorax, obstructive deficit with
decreased DL
CO
and no reversibility on pulmonary
function testing (see Figs. 19.19a, 19.19b)
Mesothelioma or
severe pleural
thickening
Suggested by: chest pain, weight loss, asbestos
exposure, clubbing, reduced breath sounds
Confirmed by: CT thorax and pleural biopsy
Bullae Suggested by: history or physical findings or pul-
monary function test findings of COPD, localized
bronchial breathing (if large)
Confirmed by: CXR, CT thorax (see Fig. 19.21)
DIMINISHED BREATH SOUNDS1
201
Consolidation Suggested by: reduced percussion, increased tactile
vocal fremitus, bronchial breathing
Confirmed by: CXR (see Figs. 19.1a, 19.1b, 19.15)
Pneumothorax Suggested by: acute breathlessness, chest pain, reduced
expansion, hyperresonance
Confirmed by: CXR (see Fig. 19.20)
Elevated
hemidiaphragm,
phrenic nerve
paralysis
Suggested by: being asymptomatic. Scar from phrenic
nerve surgery or injury
Confirmed by: CXR
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Соседние файлы в папке Библиотека им академика М.И. Перельмана