Respiratory System

BRONCHIECTASIS

destruction of small sized and medium sized bronchi
destruction of elastic and muscular elements

SIGNS AND SYMPTOMS

Chronic cough
Heamoptysis
Foul smelling sputum
Recurrent pulmonary infectoins( Psuedomonas)
sinusitis
immune deficiencies

wheezes /crackles
Secondary Polycythemia

Radiograph

Early:-Normal

Late stage:- 1-2 cm cysts, crowding of bronchi, tram tracking of bronchi

Best non-invasive way to diagnose :-HRCT

Treatment:-

• Control of Broncial secretions:-

* Bronchodilators
*Chest physical therapy
*Postural Drainage

• When sputum secretion increases or they have mild symptoms then(as Rotating Antibiotics ie diferent antibiotic each time to diminish resistance)

*Antibiotics
Amoxicillin, trimethoprim+sulphamethoxazole
Augmentin(Mox+clavulanic acid)

• In severe sypmtoms or Pneumonia

Give gram negative coverage
Ceftazidime, Quinolones, Aminoglycosides

Surgical Therapy
:considered with localized bronchiectasis with adequate pulmonary functions
:with massive hemoptysis

Vaccination
influenza annualy
Pneumococcus every 5 years

Complications
Massive heamoptysis
amyloidosis
cor pulmonale
visceral abscesses

Respiratory System

COPD

Emphysema
irreversible dilatation and destruction of cartilage beyond terminal bronchioles

P/E
distant breath sounds even audible in periphery

X ray
Hypreinflated periphery
small heart
increased retro sternal area
flattening of diaphragm

Chronic Bronchitis

P/E
wheezes and rhonchi

X Ray

Enhanced pumonary markings

Diagnostic of COPD
Pulmonary function tests are diagnostic and differentiate it from asthma where in being the reversible obstruction improves FEV1/FEC ratio with Bronchodilators in conrtast to COPD

Respiratory System

Pleural Effusion:-

Causes:-
Transudative:-(Bilateral and Equal)
CHF
Nephrotic
Cirrhosis
PE ( An unexplained transudative effusion cud be PE)

Exudative:-(Unilateral)
Infections(Pneumonia, TB)
Carcinoma
PE

Investigation of choice:-
Thoracocentesis

In transudative
LDH<200>200
LDHE/S>0.6
Protein E/s>o.5

Parapneumonic effusion
are caused by bacterial pneumonias
mandatory to perform thoracocenetsis
to rule out empyema(complicated parapneumonic effusion)
Needs chest-tube drainage.

Respiratory System

Radiographs

COPD
Asthma
Emphysema
Cor Pulmonale
Lung Cancer
Punemonia
Diffuse Infiltrate
ARDS
Pleural effusion
Atelectasis

Pleural effusion

Pulmonary Function Test



Pulmonary Nodule
Solitary Nodule
<35>
while in canada in first yr it is 3-6 month in first yr and every 6 month n 2nd year.
>50yrs, smoker is high risk for carcinoma.
Open Lung biopsy is best choice for diagnosis in USA as bronchoscopy wud not yield anything other than inflammatory cells in peripheral lesions.
While in canada CT , transthoracic aspiration cyto /Bronchoscopy precedes open lung biposy as per protocol.
Difference between Benign and Malignant Nodule Check kaplans for that.

Atelectasis

Acute atelectasis

most common reason
Post-op 1st day owing to poor inspiration and inadequate coughing
Other causes:
Tumour
Mucus plug
Foreign body

Signs and Symptoms:-

Acute atelectasis:-
Tacypnea, mild fever , cough , dypspnea ,hypoxemia.

Chronic :asymptomatic clinically , seen on x ray only.

X RAYS:

Upper lobe atelectasis:
Trachea deviation on same side

Lower Lobe atelectasis:
Elevation of diaphragm on same side.

Massive atelectasis:
Mediastinal shift

Treatment

Post op:
induce deep breathing
stimulate coughing
Incebtive spirmetery and pulmonary toilet are effective.

Treatment of choice in spontaneous atelectasis
Bronchospy with removal of mucus plug

Canada Examination portion:-

Chest wall abnormalities

Anterior chest wall

pectus carinatum , excavatun , sternal fissures

surgery for

Cosmetic purposes

resp./ cardiovascular insufficiency

Psychosocial factors

Thoracic outlet synd.

impingement of subclvian vessels and brachial plexus

etio: Congenital rib, Trauma, degenrative( osteoporosis , arthritis)

Sx/syx:

Neurogenic: distribution areas of ulnar and motor+sensory fn of median nerve

Arterial: Cold, fatigue,weakness, ischemic pain, paresthesia.

Venous:edema , collateral formation, cyanosis , venous distension

Treatment:

Conservative50-90%

Physiotherapy

Surgery if conservative fails , removal of cervical or first rib indicated.

Preventive Medicine

Preventive Medicine

Review points

Hepatitis A vaccine
needed in

*Travelers in endemic areas
*Homosexuals
*Chronic liver Disease (HBV,HBC)
*Day care Centre employees

Varicella
Live attenuated
Not to be given in immunocompromised/AIDS/pregnant patient

MMR
Live attenuated
Indications:
Healthy adults born after 1956 shud be vaccinated with one dose.
C/I
pregnant patient
immunocompromised(BUT Asymptomatic HIV may receive the vaccine)

Smoking Cessation

Ask about smoking
Advice quitting
Attempt to identify willing to quit
Assist: set a quit-date (usually 2 weeks)
Nicotine Patch or Gum OR oral antidepressant Bupropion ; both are equally effective.
Arrange Follow up

Cholesterol Screening Age

Men 35and plus
Women 45and plus

managemenet shudnt be based on single reading as cholestero may nomally vary upto 14% within two consecutive readings.

Diabetes Mellitus

Routine screening :- Only when patients is at high risk eg

*Obesity
*High Risk ethnicity
*Impaired fasting glucose
*Positive family History

Diagnosis
>126 fasting on two separate occassions
>200 Random on any occassion

Blood Pressure

screening recommended at every visit ; and atleast every two years

Alcohol Abuse

CAGE questionnaire
one 'yes' to cage= possibility of alcohol abuse

Prevention of Violence and Injury

Advice them about saftey practices.
In cases of violence simply asking them if they were hit or physically abused can increase identification by 10%

27 July 2008

Om namah Bhnagwate Vasudevaya!Om shri Gurve namah!