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
202
Bronchial breathing
There is a prolonged expiration phase with definite silence between
inspiration and expiration (the same as the sound heard with the stetho-
scope bell over the trachea).
Some differential diagnoses and typical outline evidence
Consolidation Suggested by: fever, reduced breath sounds, reduced
percussion, crackles, increased tactile vocal fremitus
Confirmed by: CXR (see Figs. 19.1a, 19.1b, 19.15)
Lung cavity Suggested by: localized bronchial breathing, otherwise
normal examination
Confirmed by: CXR, CT thorax
Pulmonary
fibrosis
Suggested by: reduced expansion, normal or reduced
percussion, late inspiratory fine crackles, clubbing
Confirmed by: HR-CT thorax (see Fig. 19.17)
FINE INSPIRATORY CRACKLES1
203
Fine inspiratory crackles
Fine crackles resemble the sound made when hair near the ear is rolled
between the finger and thumb or by unfastening a Velcro pad.
Some differential diagnoses and typical outline evidence
Incidental Suggested by: late in inspiration, disappears on coughing
Confirmed by: CXR
showing normal lung fields
Pulmonary
edema
Suggested by: crackles late in inspiration, dullness to
percussion at lung bases (with associated effusion),
third heart sound
Confirmed by: CXR showing fluffy shadows, large heart
and linear opacities (Kerley lines) in upper lobes.
Echocardiogram may show reduced LV contraction,
low ejection fraction (EF) (see Fig. 19.13)
Pulmonary
fibrosis
Suggested by: very fine crackles late in inspiration,
reduced chest expansion, finger clubbing.
Confirmed by: CXR and HR-CT thorax
(see Fig. 19.3, 19.17)
Consolidation Suggested by: early inspiratory crackles, fever, reduced
breath sounds, reduced percussion, increased tactile
vocal fremitus
Confirmed by: CXR (see Figs. 19.1a, 19.1b, 19.15)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 9 Respiratory signs
204
Coarse crackles
These are bubbly crackles.
Some differential diagnoses and typical outline evidence
Bronchiectasis Suggested by: copious amounts of mucopurulent
sputum, chest pain, wheezing. Previous chest infec-
tions, asthma, surgery, or cystic fibrosis. Crackles not
disappearing after coughing, clubbing
Confirmed by: CXR, HR-CT thorax (see Fig. 19.18)
Pleural rub
This sounds like two wet leather surfaces rubbing together (or crunching
through snow). It is caused by inflammation of the pleura.
Some differential diagnoses and typical outline evidence
Pleuritic
infection with
adjacent
pneumonia
Suggested by: fever, reduced breath sounds, reduced
percussion, crackles, increased tactile vocal fremitus
Confirmed 0062y: CXR, sputum, blood cultures
Pulmonary
embolus (PE)
Suggested by: signs of DVT, loud P2, tachycardia,
dyspnea, hypoxia, dPaCO
2
, d-dimer
Confirmed by: V/Q, helical CT, (rarely now) pulmonary
angiogram
Pleural
tumors, e.g.,
secondaries or
mesothelioma
Suggested by: history, e.g., asbestos exposure
Confirmed by: CT thorax, pleural biopsy
STRIDOR ± INSPIRATORY WHEEZE1
205
Stridor ± inspiratory wheeze
Suggests obstruction in or near larynx.
Some differential diagnoses and typical outline evidence
Epiglottitis Suggested by: fever, upper respiratory tract infection
(URTI) coryzal symptoms, drooling
Confirmed by: “thumb sign” on lateral neck X-ray,
indirect laryngoscopy under controlled (anesthetic)
conditions
Croup Suggested by: high-pitched cough in infants
Confirmed by: above presentation and findings
Inhaled foreign
body
Suggested by: history of inhaling peanut, bead, etc.
Confirmed by: CXR, CT thorax, bronchoscopy
Rapidly
progressive
laryngomalacia
Suggested by: change in voice over months to years.
Confirmed by: indirect laryngoscopy, CT thorax.
Laryngeal
papillomas
Suggested by: change in voice over weeks to months
Confirmed by: indirect laryngoscopy
Laryngeal
edema
due to
anaphylaxis
Suggested by: flushing of face and trunk, urticarial rash,
lip and facial swelling, tachycardia, BPd
Confirmed by: improvement with adrenaline IM and
removal of precipitating allergen
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 9 Respiratory signs
206
Inspiratory rhonchus or wheeze
This suggests large airway obstruction. A lesion above the carina can be
immediately life threatening, as neither lung can be ventilated.
Some differential diagnoses and typical outline evidence
Acute bilateral
vocal cord
paralysis
Suggested by: change in voice, which becomes weaker
over minutes to hours
Confirmed by: laryngoscopy
Inhalation of
foreign body
Suggested by: history of inhaling peanut, bead, or other
foreign body
Confirmed by: CXR, CT thorax and neck, bronchoscopy
Tracheal
tumors or
stenosis after
ventilation
Suggested by: Stridor, over weeks to months, bilateral
reduced breath sounds
Confirmed by: bronchoscopy
Extrinsic
compression
by mediastinal
masses
Suggested by: neck and chest discomfort ± swelling
over weeks to months
Confirmed by: CT thorax and neck
Extrinsic
compression
by esophageal
tumors
Suggested by: dysphagia, weight loss over weeks to
months
Confirmed by: CT thorax and neck
Tracheal blunt
trauma
Suggested by: history, pain and swelling, change in voice
over minutes or hours after trauma
Confirmed by: laryngoscopy, bronchoscopy
Laryngeal
edema
due to
anaphylaxis
Suggested by: flushing of face and trunk, urticarial rash,
lip and facial swelling, tachycardia, BPd
Confirmed by: improvement with adrenaline IM and
removal of precipitating allergen
EXPIRATORY RHONCHUS1
207
Expiratory rhonchus
This is large airway obstruction.
Some differential diagnoses and typical outline evidence
Endobronchial
carcinoma
(benign lesions
very rare)
Suggested by: smoker, weight loss, cough, chest pain,
hemoptysis, clubbing. Unilateral wheeze and reduced
breath sounds. Signs of consolidation
Confirmed by: bronchoscopy and biopsy
Acute bilateral
vocal cord
paralysis
Suggested by: change in voice, bilateral reduced breath
sounds and wheeze
Confirmed by: laryngoscopy
Inhalation of
foreign body
Suggested by: history of sudden cough and stridor
when eating
Confirmed by: CXR, CT thorax and neck, bronchoscopy
Tracheal
tumors
Suggested by: cough, hemoptysis
Confirmed by: bronchoscopy
Extrinsic
compression
by mediastinal
masses
Suggested by: neck or chest discomfort ± swelling
Confirmed by: CT thorax and neck
Extrinsic
compression
by esophageal
tumors
Suggested by: dysphagia, weight loss over weeks to
months
Confirmed by: CT thorax and neck
Tracheal blunt
trauma
Suggested by: history, pain and swelling, change in voice
over minutes or hours after trauma
Confirmed by: laryngoscopy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 9 Respiratory signs
208
Expiratory polyphonic, high-pitched
wheeze
This suggests small airways obstruction.
Some differential diagnoses and typical outline evidence
Bronchial
asthma
Suggested by: nonproductive cough or white sputum,
worse in the morning. Some episodes not related to
infection
Confirmed by: FEV
1
response to bronchodilators
Wheezy
bronchitis
Suggested by: association with infective episodes of
bronchitis alone
Confirmed by: FEV
1
response to bronchodilators and
antibiotics
Anaphylaxis Suggested by: history of allergen exposure, feeling of
dread, hypotension, facial or generalized edema,
flushed, urticaria
Confirmed by: above history, response to adrenaline
and removal of precipitating cause
Left ventricular
failure and
pulmonary
edema
Suggested by: “cardiac asthma”: pink frothy sputum,
third heart sound, displaced apex beat
Confirmed by: echocardiogram, CXR (see Fig. 19.13)
Chapter 10
209
GI symptoms
Severe weight loss over weeks or months 210
Vomiting 211
Vomiting with weight loss 212
Vomiting without weight loss 213
Vomiting shortly after food 214
Vomiting with abdominal pain and fever 215
Vomiting with abdominal pain alone (unrelated to
food and no fever)—nonmetabolic causes 216
Vomiting with abdominal pain alone (unrelated to
food and no fever)—metabolic causes 217
Vomiting with headache alone (unrelated to
food and no abdominal pain) 218
Vomiting alone (unrelated to food and without
abdominal pain or headaches) 219
Jaundice 220
Prehepatic jaundice due to hemolysis 221
Hepatic jaundice due to congenital enzyme defect 222
Hepatocellular jaundice (due to hepatitis
or very severe liver failure) 223
Obstructive jaundice 224
Dysphagia 226
Dysphagia for solids that stick 226
Dysphagia for solids (that do not stick) > for fluids 227
Sore throat 228
Dysphagia for fluids > solids 229
Acute abdominal pain 230
Acute pain in the upper abdomen 230
Acute central abdominal pain 232
Acute lateral abdominal pain 233
Acute lower central (hypogastric) abdominal pain 234
Diarrhea 235
Sudden diarrhea, fever, and vomiting 235
Recurrent diarrhea with blood ± mucus—bloody flux 236
Acute bloody diarrhea ± mucus—“dysentery” 237
Watery diarrhea 238
Recurrent diarrhea with no blood in the stools, no fever 239
Change in bowel habit 240
Hematemesis ± melena 242
Passage of blood per rectum 244
Tenesmus 246
Anorectal pain 247
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 10 GI symptoms
210
Severe weight loss over weeks
or months
The degree and speed of weight loss is relevant; the more severe, and
the more likely is it to be due to a demonstrable cause.
Some differential diagnoses and typical outline evidence
Any advanced
malignancy
Suggested by: progressive onset over weeks or months
of specific symptoms, e.g., neurological deficit, hemop-
tysis, rectal bleeding, change in bowel habits
Confirmed by: metastases on CXR, metastases on
ultrasound scan of liver, or leukemic changes on CBC
or tumor on bronchoscopy or GI endoscopy
Depression Suggested by: sleep disorders, poor concentration,
social withdrawal, lack of interest in usual activities
Confirmed by: response to antidepressants.
Psychotherapy
Thyrotoxicosis Suggested by: heat intolerance, tremor, nervousness,
palpitation, frequency of bowel movements, goiter,
fine tremor, warm and moist palms
Confirmed by: TSHd, iFT4, iFT3
Uncontrolled
diabetes
mellitus
Suggested by: thirst, polydipsia, polyuria
Confirmed by: fasting blood glucose >125 mg/dL
(on two occasions) OR random or GTT blood glucose
>200 mgl/dL
Infection,
e.g., tuberculosis
Suggested by: night sweats, fever, malaise, cough
Confirmed by: CXR showing opacification of pneumonia
and presence of AFB
in sputum on microscopy and
culture
Addison’s
disease
Suggested by: lethargy, weakness, dizziness,
hyperpigmentation (buccal, scar), hypotension
Confirmed by: 9
A.M. plasma cortisol d and impaired
response to short ACTH stimulation test (cosyntropin
stimulation test)
VOMITING1
211
Vomiting
Vomiting is not only a feature of GI disorders but is also associated with
a wide variety of local and systemic disorders. Therefore, more leads are
needed. Ask about the amount, frequency, and nature of vomitus—red
blood (hematemesis), “coffee-ground” appearance, and timing in relation
to meals. Also ask about weight loss, fever, headache, and abdominal
pain.
Try subdividing vomiting into
- Vomiting with weight loss
- Vomiting without weight loss
- Vomiting (within hours) of food
- Vomiting unrelated to food but with abdominal pain AND fever
- Vomiting unrelated to food, with abdominal pain but NO fever
(nonmetabolic)
- Vomiting unrelated to food, with abdominal pain but NO fever
(metabolic)
- Vomiting unrelated to food without abdominal pain but with
headaches
- Vomiting unrelated to food and without abdominal pain or headaches
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Соседние файлы в папке Библиотека им академика М.И. Перельмана