Anatomy of the chest

By Brent Hawkins,2014-06-26 19:33
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Anatomy of the chest ...

    Importance of history

    o Good history -- dx disease in pt 80-90% of the time

    Problems with chest and lungs

    o Few symptoms

     ?Most common pt complaint - cough

     ?Dyspnea - difficult of breathing

     ?Hemoptosis, chest pain, hoarseness, snoring

    o May present in the ER due to alterations of mental status

    Different parts of history taking

    o General Data

     ?Name, address, age, sex, religion, work, place of origin, how

     many times pt consulted

     ?Work history important - may have bearing with the symptoms,

     cause of symptoms

    ? Some industrial dust affecting pt causing respi problems

     ?Causing cough, dyspnea

     ?Industrial dusts

    ? Asbestos - found in substances used in making boilers

     (big tank where water is boiled to heat it)

     ?Found in hotels, restaurant kitchens

     ?Insulators for refrigerators

     ?May cause fibrosis in the lungs; after long time

    exposure to it (25 yrs), pt may develop cancer

     (mesotheloma) - cancer of the pleura

     ?Pt comes in with mesothelioma

     complaint, ask about the work history

    ? Coal - winter months to heat homes

     ?Coal miners

     ?This year - accident reports

     ?Coal dust causes fibrosis of the

    lungs 2ndry to exposure to coal -

    pneumoconosis (can be


     ?Can file for work


    ? Silica

     ?Fibrosis of the lungs

     ?Cause pt to develop chronic cough and dyspnea

     ?Also associated with development of lung cancer

     ?Or irritations of the airway

    ? Cotton dusts

     ?Big industry for cotton

     ?Pt exposed develop occupational asthma

     ?Pt goes to work in morning, asymptomatic

     ?But at end of the work day,

    starting to have signs and

    symptoms of dyspnea, coughing,

    conditions worsen at dinner,

    relieved at 10 pm, next morning

     dyspnea again

     ?Weekend, not working --no

     symptoms; during holidays

    ? Grain dust

     ?Wheat, rice

     ?Pt exposed, may also precipitate pt to have

     symptoms like asthma

     ?Aka occupational asthma

    ? Animals


     ?9/11 - envelope full of anthrax

     ?Seen among pts near cattle

     ?Diseases of the bird

     ?Bird flu still dreaded during the summer

     due to bird migration

     ?Transmitted to humans


     ?Parrot transmits to you causing


     ?Pt is veterinary maybe

    ? Moldy hay

     ?True in temperate zones, where you're raising


     ?Store hay, molds in hay can be enhaled causing

     flu-like symptoms

    ? Chronic exposure

     ?Similar to pneumonitis

     ?Exposure to air conditioner/humidifier

     ?Centralized a/c of big buildings; cooling

    tower; use water to cool the air (water

     maybe contaminated by microorganism)

     ?Infection may develop - legion?? In

     the lungs

     ?Residency of pt also important/place of origin

    ? Certain areas endemic for infections

    ? Fungal infection

     ?Endemic in N America

     ?Especially in south and midwestern -


     ?Cocci diquidomysosi - sout

     ?Hydatid cyts - mediterranean


     ?Dogs may eat the dead sheep and

    get infection and transmit the

     disease in the human

     ?Paragonninasis, central china

     ?Schistosomiasis causing pulmonary



     ?Lifestyle of pt

    ? Cigarette smoking --risk factor for lung ca and other


     ?Inc risk dev of COPD; high morbidity

     ?Also increases risk for dev of

     ?spontaneous pneumothorax

     ?collection of air in the pleural space

     ?Lung will just rupture - pneumothorax


     ?Smokers at higher risk of dev pneumonia

     ?Smoking affects defense mechanism of


     ?Number of cigarettes has bearing on type of


     ?How many packs years pt smokes

     ?If you smoke 1 pack of cig a day per

     year = 1 pack year

     ?If 1/2 pack for 10 years = 5 pack


     ?If 1/4 pack 10 = 2.5 pack years

     ?If you smoke 2 pack every day for

     5 years = 10 pack years

     ?If 20 pack years, risk of dev

    different lung problems inc


     ?Exposure to pets

    ? Pets maybe allergenic to pt causing bronchospasm

     ?Symptoms similar to asthma

    ? Pneumonia

     ?Qfever, tularemia - exposure to cattle

     ?Alcoholics - Pneumococcus, ….

     ?Drug abuse

    ? IV - high risk of dev lung abscess due to dirty needle

    ? Pt has hiv infection --pneumonia develops -- caused by

     pneumocystic carinii ---AIDS

    Chief Complaints

    o Cough - most common symptom

     ?Forceful projection of air under pressure from tracheobronchial

     tree and alveoli


    ? Acute

     ?If lasted < 3 weeks

    ? Chronic

     ?If lasted > 3 weeks

     ?Character of cough

    ? Productive

     ?Character of the sputum

     ?Color, consistency, whether blood

    streaking exists, foul smelling (tells you pt

    has infection; infecting micro is

     anaerobic microorg)

     ?Described as being mucoid, mucopurulent,



     ?more like the saliva we


     ?Mucopurulent sputum -

     ?Mixture of saliva and


     ?Condensed milk compared to


     ?Fluid like water


     ?Purulent sputum

     ?looks like condensed milk

     ?Whether sputum white,

     green or yellow

     ?Depends on viscosity

    ? Non-productive

    o Cause of the cough

     ?Acute onset

    ? Infectious cause


     ?pneumonia (lobar), by viruses,

     ?pt has exacerbation of chronic bronchitis -

     acute on top of chronic bronchitis

     ?If pt has infection of airway causing cough

     ?Mechanism of cough - inflammation of

     airway causing irritations in airway

     ?In case of pneumonia

     ?Mechanism - decrease in compliance of

     lung causing pt to cough


     ?Sore throat, runny nose, eye

     ?Lobar pneumonia

     ?Symp of upper respit tract infection

     ?Dry cough --then productive

     ?Certain microorganism cause

     characteristic sputum

     ?Grape-red sputum, blood sputum;

    char of infection caused by strep


     ?Jelly-like sputum - sticky, reddish


     ?Char of infection caused by

     klebsiela pneum


     ?Dry cough


     ?Viral pneumonia

     ?Productive of mucoid, bloodlike sputum,

     ?flu-like syndrome (fever, body malaise,

     generalized body ache)? Irritant not 2ndry to infection

? Caused by aspiration of foreign body

     ?Aspirate body, cough out

     ?Causing airway obs, irritation

     ?If can't cough out body, sig airway

    obstruction and asphyxiation - pt dies of

     foreign body

    o Chronic

     ?Infectious cause

    ? Chronic bronchitis - pt has cough productive of

     sputum for > 3 consecutive months/ > 2 years

    ? Mucoid sputum - may become purulent mucopurulents

? Bronchiectasis

     ?Copious sputum

     ?Copious, foul, pururlent cough

     ?Collect sputum - glass full a day

     ?It would layer into 3 layers? TB

     ?Persistant coughs with blood sputum

? Fungal infection

? Non inflammatory

     ?Interstitial fibrosis

     ?Non productive cough

     ?Causes - dusts, silica, asbestos

     ?Exposure to drugs - bleomycin,

     cyclophosphamide, etc.

     ?Some pts develop it without the cause

     ?Non-infectious cause

    ? Smoking

     ?Injected pharynx - coughing persistant marked

     in morning

     ?Slightly productive unless associated with

     chronic bronchitis? Tumor

     ?Bronchogenic cancer - cough non-productive

     to productive for weeks to months

     ?Small hemoptosis

     ?Alveolar cell carcinoma

     ?Productive cough, sputum mucoid/watery

     ?Non-purulent - lots of sputum

     ?Benign tumor of the lungs

     ?Esp if in the airway

     ?Mechanism - irritations of the airway

     ?Mech - irritations of airway by

     foreign body/inflamm

     ?Irritations of airway by


     ?Decrease in lung compliance

     seen in pts with pneumonia

     ?Tension on the airway

     ?Mediastinal tumor

     ?Not in airway, not in lung parenchyma

     ?Why cough?

     ?Mediastinum - area of the heart; If tumor there, pt complains of cough,

    dyspnea (tumor presses on the airway);

    coughing due to tumor pressing on the

    airway; tension on the airway -- would

     also cause pt to cough

     ?Primary complex in TB - affects kid

     ?Enlarged lymph nodes in

     mediastinal area

     ?Causing inc pressure on

     airway; pt coughs

     ?Press airway above sternum

     - you'll cough

     ?Lung infiltrates in lower lung

     ?Aortic aneurism

     ?Cough char - brassy

    ? Foreign body

     ?When they lodge in smaller airway

     ?Aspirate small things - go to airway - -obstruction


     ?Obstructive pneumonitis

    ? Cardiovascular disease

     ?Due to dec in lung compliance

     ?Heart failure - development congestion of the

     lungs -- pt presents with cough

     ?Cough intensified when they lie down

     ?With aggravation of dyspnea

     ?Underlying mech

     ?Due to dec in lung compliance

    ? Pulmonary infarction

     ?Cough and pt develops hemoptosis - coughing up


In Bates

Cough with hemoptosis transparency shown (table in textbook)

Acute inflammation

    o Acute cough

    o Hoarseness esp if viral

    Other diseases included

    o Post nasal drip ---now called chronic upper respiratory syndrome

     ?Causing pt to have chronic cough -- due to continous

     irritations of throat

    ? From posterior seg of nose to oropharyngealPedia age group

    o Post nasal drip - most common cause

    o 3rd most common cough


    o Cigarette smoking

    o Among non smoker

     ?Post nasal drip


    o Pt complains of dyspnea

    o Variant asthma

     ?Seen among pediatrics - pt only presents with chronic


     ?Auscultate pt - pt has wheezes

    o Not just dyspnea

     ?Cough, difficulty of breathing, wheezes

Gastroesophageal reflux

    o Cough at night, early in morning

    o Cough may worsen after a meal

    o Gastro reflux --may lead to asthma

     ?Due to constant irritation of airway due to aspiration

Cancers and Cardiovascular disorders



    o Difficulty of breathing

    o Subjective symptom

    o Experienced by pt --act of breathing becomes

     ?Uncomfortable, distressing, difficult and labored - subjective

    o Psychological dyspnea

     ?Rule out organic cause first

    o Organic cause

     ?Take mode of onset

     ?Frequency of occurrence

     ?Severity of symptoms

     ?Duration of dyspnea

     ?Exacerbating factors

     ?Recovery time

    ? How long pt has to rest before dyspnea disappears

     ?Walking to 4th floor - short of breath; rest for 5

     minutes --okay

     ?Lung problem -rest for 15-30 minutes before

     catching their breath

? Due to asthmatic attack

     ?Give meds --how soon did pt get better

    o Onset

     ?Acute - go to sleep at night, no problem, good rest

    ? Wake up in the morning - dyspnea

    ? Another example

     ?Went to work; in office after lunch break --move

     furniture - afterwards develop dyspnea? You're quite well; suddenly develop coughing --after 2

     days --dyspnea


    ? More gradual onset of dyspnea

    ? Pt presents with acute type

    ? progressive

     ?Initially, pt only has dyspnea when they climb 2

     flights of stairs

     ?After few months, dyspnea when they

     climb only 1 flight of stairs

     ?After another few months -- dyspnea ---

    when walk fast on level ground ---can't

     catch up with companion --

     ?Dyspnea when you groom yourself - take a bath,

     comb your hair, change your clothes

    o Acute onset of dyspnea

     ?Pulmonary, asthma, injury to chest wall, spont pneyumo,

     pulmonary embolism, pneumonia

     ?Pulmonary emboli

    o Chronic progressive

    ? COPD

     ?Pt with heart failure

    ? Diffuse interstiaial fibrosis


    ? Mild intermittent

     ?Asthmatic attack only once/twice a year? Mild persistant

     ?Symptoms twice a month

? Moderate persistant

    ? Severe persistant

     ?Every day - chronic

     ?Pleural effusion

    ? Collection of fluid in pleural cavity

    ? If develops very fast ---acute onset

     ?Collect 1.5 L in 2 days time ---acute

     ?If 1.5 fluid collect gradually over period of 1-2

     month - chronic

     ?Pulmonary thromboembolic disease

    ? Emboli may not be large

    ? Depends on the size of emboi

     ?You cut off 50% of pulmonary circulation

     ?If 50% of emboli built of gradually over a

     month's time ---chronic difficulty of breathing

     ?Every day you add 1%, 2% ---gradual ---


     ?Pulmonary vascular disease

    ? Pts among pulmonary hypertension

     ?Psychogenic cause

    ? Depending on circumstances --- if you have problem in

    lung --dyspnea --associated with activities --when you

     walk, run, lift heavy objects

     ?When you rest --no dyspnea? Pt will complain of dyspnea when they're resting

     ?Reading books, watching tv, conscious of their

? History

     ?Quarrel with family members

     ?Right after being scolded ? Pt has psychological problem - symptoms last for years

     ?Won't believe diagnostic workups that show

     negative tests

     ?Not satisfied with CT scan ---even

     requests for MRI

     ?Severe anemia

    ? Overlooked a lot

    ? Develops gradually

     ?If acutely, you have hypotension on top of it? Gradual loss of blood among pt with hookworm in the


    ? Pt with problem of rbc synthesis esp with renal failure

     ?Post intubation tracheal stenosis

    ? Injure airway ---narrowing of airway develops

     ?Hypersensitivity disorder

    o Table showed again in Bates

     ?Spontaneous pneumothorax

    ? Acute

    ? Associated symptoms of cough and chest pain

     ?Pulmonary emboli

    ? From deep vein of lower extremities? Sudden in onset

    ? Retrosternal chest pain

    ? If occlusion small


    ? Pt with chronic heart/lung problem

     ?Or wit clotting disorder

     ?Someone with fracture -- prolonged


    o Diffuse interstitial fibrosis

     ?Abnormal and widespread infiltration of cells…..

     ?Many causes

     ?Dyspnea - progressive --variable range of development


    ? Exertion

     ?Relieved by rest --even during rest have dyspnea

     ?Pt complains of weakness, fatigue and cough


    ? Depending on exposure

    ? No history of exposure

    o Pneumonia

     ?Inflamm of lung parenchyma


     ?Sub acute

     ?Fever, cough, sputum production

     ?Setting varied

    o COPD

     ?Due to overdistention/chronic inflamm of airway

    ? Overdistention of alveoli --dev of emphysema


    ? Aggravated by activity; relieved by rest --persistant

     sometimes during rest


     ?Significant/non-sig sputum production

     ?Smoking --#1 risk factor

     ?Genetic disorder

    ? Alcohol antitripsin???

     ?Viral infection of upper respi tract

    o Heart failure

     ?Aggravated by lying down/exertion

     ?Pt with history of heart disease

    o Anxiety/hyperventilation



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