Respiratory system 1 In The name of God Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Respiratory system 1In The name of God
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Physical Examination of the Chest
معاینھ فیزیکی سیستم تنفس
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Diagram of Thoracic Area
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Chest Topography: Anterior Chest
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Chest Topography:Lateral Chest
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Chest Topography:Posterior Chest
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8
Respiratory tract anatomy
fig 13-1
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Lung Anatomy• Right Lung
– Superior lobe– Middle lobe– Inferior lobe
• Left Lung– Superior lobe– Inferior lobe
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Fissures:
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Location of Lobes
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Lung Anterior
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Lung Posterior
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Lung Left Side
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Lung Right Side
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Physical Exam Techniques
• Observation• Palpation• Percussion• Auscultation
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Observation:Breathing Patterns
• Apnea• Tachypnea/Bradypnea• Biot’s• Cheynes-Stokes• Kussmaul
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Observation:Thoracic Contour
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Observation: Thoracic Contour(cont.)
• Pectus Excavatum• Pectus Carinatum• Kyphosis• Scoliosis• Kyphoscoliosis• Symmetry of chest movement
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Barrel Chest
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Scoliosis
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Kyphosis
Slide 18-22
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Observation: Clubbing
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Palpation: Tracheal Alignment
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Tracheal Alignment Abnormalities
• Pneumothorax – shifts to unaffected side• Pleural Effusion – shifts to unaffected side• Fibrosis or Atelectasis – shifts towards
affected side• Pulmonary consolidation – no shift
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Palpation : Chest Excursion
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Palpation: Vocal Fremitus
• BILATERAL comparison of vocal vibrations
• Increased with alveolar consolidation
• Decreased with increased distance between lung and chest wall– Pneumothorax, Pleural
effusion
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Percussion
• Assess density of underlying tissue
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Percussion Notes
• Resonance – normal• Dullness – increased density
– Atelectasis, alveolar filling/consolidation, pleural effusion, fibrosis
• Hyperresonance – decreased density– Hyperinflation (COPD), Pneumothorax
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Lets all listen in
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Auscultation: Listening to breath sounds with a stethoscope
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Normal Breath Sounds and Their Locations
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Abnormal Breath Sounds: Diminished or Absent
• Increased distance between aerated lung and chest wall:– Pneumothorax, Pleural effusion, Atelectasis,
Obesity around thorax• Decreased or absent airflow
– Airflow obstruction (eg asthma), Hyperinflation (COPD), Malpositioned ET Tube
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Abnormal Breath Sounds: Bronchial or Bronchovesicular
in abnormal part of the lung
• Lung has become more solid and less aerated in these areas
• Consolidation, eg, pneumonia, or Atelectasis
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Abnormal Breath Sounds: Adventitious Sounds
• Wheeze – continuous musical sounds heard mostly during expiration – May be also heard on inspiration
• Caused by a sudden change in airway caliber– Edema, spasm, secretions, foreign body
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Abnormal Breath Sounds: Adventitious Sounds
• Crackles – discontinuous sound heard mostly on inspiration
• Caused by small airways and alveoli popping open or from secretions in very large airways
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Condition Chest Excursion
Fremitus Percussion BreathSounds
Atelectasis
Pneumothorax
Pleural Effusion
COPD
Pulmonary Consolidation
Fibrosis
Pulmonary Edema
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Techniques - Projection
•P-A (relation of x-ray beam to patient)
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Techniques - Projection (continued)•Lateral
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Techniques - Projection (continued)
•Lateral Decubitus
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Techniques - Projection (continued)
•Oblique
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The Normal Chest X-ray• PA View:
1. Aortic arch2. Pulmonary trunk3. Left atrial appendage4. Left ventricle5. Right ventricle6. Superior vena cava7. Right hemidiaphragm8. Left hemidiaphragm9. Horizontal fissure
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Lung Anatomy• Trachea• Carina• Right and Left Pulmonary
Bronchi• Secondary Bronchi• Tertiary Bronchi• Bronchioles• Alveolar Duct• Alveoli
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Anatomy
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Rotation
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Rotation (continued)
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Penetration
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Inspiration/Expiration
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Technical Details
•Type•Rotation •Inspiration/expiration•Penetration
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Summary of Density • Air• Water• Bone• Tissue
Tissue
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DensitiesThe big two densities are:
(1) WHITE - Bone(2) BLACK - Air
The others are:
(3) DARK GREY- Fat (4) GREY- Soft tissue/water
And if anything Man-made is on the film, it is:
(5) BRIGHT WHITE - Man-made
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Pitfalls to Chest X-ray Interpretation
• Poor inspiration• Over or under penetration• Rotation• Forgetting the path of the x-ray beam
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Systematic Approach• Soft Tissues
– Breast shadows– Supraclavicular areas– Axillae– Tissues along side of
breasts
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Systematic Approach• Diaphragm and
Pleural Surfaces– Diaphragm
• Dome-shaped• Costophrenic angles
– Normal pleural is not visible
– Interlobar fissures
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Mediastinum
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Hilum
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Hilum
Made of:
1. Pulmonary Art.+Veins2. The Bronchi
Left Hilus higher (max 1-2,5 cm)
Identical: size, shape, density
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Ribs
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Lung Anatomy on Chest X-ray• The right upper lobe
(RUL) occupies the upper 1/3 of the right lung.
• Posteriorly, the RUL is adjacent to the first three to five ribs.
• Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib
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Lung Anatomy on Chest X-ray• The right middle lobe
is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum
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Lung Anatomy on Chest X-ray• The right lower lobe is the
largest of all three lobes, separated from the others by the major fissure.
• Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm.
• Review of the lateral plain film surprisingly shows the superior extent of the RLL.
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Lung Anatomy on Chest X-ray• These lobes can be separated
from one another by two fissures.
• The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes.
• Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body.
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Lung Anatomy on Chest X-ray• The lobar architecture
of the left lung is slightly different than the right.
• Because there is no defined left minor fissure, there are only two lobes on the left; the left upper
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Lung Anatomy on Chest X-ray• These two lobes are
separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location.
• The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.
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The Silhouette Sign• An intra-thoracic radio-
opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra-thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.
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Pathology
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RUL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
RML pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
RLL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
LUL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
LLL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Consolidation on CTCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Hilar m lCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
The Enlarged Hila
Causes:
1. Adenopathies (neoplasia, infection)
2. Primary Tumor
3. Vascular
4. Sarcoidosis
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Multiple MassesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Hilar Lymphadenopathy - BLCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
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Pleural EffusionCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Pulmonary FibrosisCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Heart failureCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
PneumothoraxCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
RUL collapseCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
EmphysemaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Cervical RibCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Cavitating lesionCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Hiatus herniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
Chest Tube, NG Tube, Pulm. artery cathCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)