呼吸系統(tǒng)課件：clinical-clerkship

ClinicalclerkshipClinicalclerkship1BasicsciencetrainingDevelopclinicalscenarioProblemyouwillface:Medicalinformation

Patientdata

IncompatibilityoftwosetsofknowledgeBasicsciencetraining2Medicalknowledgecomprisesmillionsoffacts

---organized

bydiseasestate

---bypathophysiologyMedicalknowledgecomprisesmi3Willpatientspresentadiseasetoyou?LooselyconstructedchainofcomplaintsElaboratepsychologicalconstructtopreventdisclosureofpainfuleventsDealingwithhundreds,ifnotthousands,offactsWillpatientspresentadiseas4Clinician’sJobmanagetheinformationPatient’sdataneedtobetranslated

intoclinicalpresentationAtechnique:compatibilityofknowledge

Thoughtprocesses:

Comprisemuchoffabricofclinicalexperience

“secondnature“AccuratelyassessedClinician’sJobmanagetheinfo5Howcanwegettheinformationandpatient’sdata?MedicalvisitHowcanwegettheinformation6PurposeofMedicalvisitCarefulandcompletehistoryThoroughphysicalexaminationPurposeofMedicalvisitCarefu7MedicalhistorychiefcomplainPresentPastFamilySocialhistoriesSystemreviewMedicalhistorychiefcomplain8MajorPulmonarysymptomsDyspneaCoughMajorPulmonarysymptomsDyspne9DyspneaGreekprefixof“dys”---painful,difficult,breathItisasubjectiveexperienceofbreathingdiscomfortthatiscomprisedofqualitativelydistinctsensationsthatvaryinintensity.DyspneaGreekprefixof“dys”--10DiagnosisapproachDifferentialdiagnosisofdyspnea:

lung,heart,chestwallneuromuscular

renal

endocrine

rheumatologic

hematologic

psychiatricdiseaseDiagnosisapproachDifferentia11Understand---Thegoalofrespiratoryandcardiovascularsystem:takeO2fromtheair

transferittohemoglobin

deliverittometabolicallyactivetissue

transportCO2backtolung,toeliminate

Understand---Thegoalofresp12Theprocessofrespirationcanbedividedinto3components:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)

Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan13Theprocessofrespirationcanbedividedinto3components:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)

Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus

3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan14VENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

1)Stimulationofchemoreceptors--conditionsleadingtoacutehypoxemia

(Impairedgasexchanger,Environmental

hypoxia)VENTILATORYCONTROLLERANDGAS15---conditionsleadingtoincreasedeadspaceand/oracutehypercapniaImpairedgasexchanger：asthma

Impairedventilatorpump:muscleweakness,

airflowobstruction---conditionsleadingtoincre16--Metabolicacidosisa.Renaldisease(renalfailure,renaltubularacidosis)

b.Decreasedoxygencarryingcapacity(eg.Anemia)

c.Decreasedreleaseofoxygentotissues(hemoglobinopaty:thalassemia)

d.Decreasedcardiacoutput--Metabolicacidosis17VENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

2)Stimulationofpulmonaryreceptors(Irritant,Mechanical,Vascular)

ILD

Pleuraleffusion(compressiveatelectasis)

Pleuralvasculardisease

CongestiveheartfailureVENTILATORYCONTROLLERANDGAS183)Behavioralfactors

hyperventilationsyndrome

anxietydisorder

panicattacksVENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

3)BehavioralfactorsVENTILATO19Theprocessofrespirationcanbedividedinto3components:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus

3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan20VENTILATORYPUMP—INCREASEDEFFORTORWOROFBREATHING

MuscleweaknessDecreasedComplianceofthechestwallAirflowobstructionVENTILATORYPUMP—INCREASEDEFF21Thekeyareasofinquiry(MedicalHistory)

(1)qualityofthesymptom;

(2)persistenceorvariabilityofthesymptom

(3)aggravatingorprecipitatingsymptom.Thekeyareasofinquiry(Medi22IntermittentdyspneaPersistentorprogressivedyspneaNocturnaldyspneaDyspneaintherecumbentpositionPsychogenicdyspneaRaynaud’sphenomenonIntermittentdyspnea23CoughAseriesofrespiratorymaneuversthatleadtoacharacteristiccoughsound.Mostsensitivesitesforinitiatingcough:

larynx,tracheobronchialtree,carina

thepointsofbronchialbranchingCoughAseriesofrespiratorym24APPROCHTOCOUGHThe

causeofthecoughTreatthecauseAPPROCHTOCOUGHThecauseoft25CommoncausesofcoughCommoncausesofcough26Coughwithsputumproduction:bronchitis,bronchiectasis3weeks–acutoffpointforanacutecough(duetoanupperrespiratoryinfection)Cough:acute,chronicCoughwithsputumproduction:27Acutecough

Cause:

1.upperrespiratorytractinfection

2.pneumonia

3.congestivecardiacfailure

4.AECOPD

5.aspiration

6.pulmonaryembolism

Acutecough28Chroniccough

Cause:

Asthma

GER

postnasaldrip

chronicbronchitis

bronchiectasisChroniccough29PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection30PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection31AppearancesuggestivebloodgasdisturbanceLookfordyspnea,tachypnea,slowRRPatient’sfingersforperipheralcyanosisSkinforwarmthTongueandlipsforcentralcyanosisAppearancesuggestivebloodg32ObservingtheshapeandsymmetryofthechestBarrelchestpectuscarinatumsurgicalscars

Observingtheshapeandsymmet33RhythmofbreathKussmaul’sbreathingCheyne-StokesrespirationsRhythmofbreath34RRlow(<10/min)

--carbondioxidenarcosis

--Drugs(alcohol,benzodiazepine)

--RaisedintracranialpressureRRlow(<10/min)35PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection36Chestwallabnormalities

chestshape

chestchangeonmovementforasymmetryBilateralpoorchestexpansion

obesity

EmphysemaUnilateralpoorchestexpansion

Pleuraleffusion

PneumothoraxChestwallabnormalities37Tracheadisplaced

Scoliosis

Pneumothorax

PleuraleffusionReducedvocalfremitus

Pleuraleffusion

PneumothoraxTracheadisplaced38PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection39Stonydullpercussion

ThisimpliespleuraleffusionDulltopercussionbutnotstonydull

Consolidation

PulmonaryedemausuallyduetoleftventricularfailureStonydullpercussion40Hyperresonantpercussion

Emphysema

Largebullae

PneumothoraxHyperresonantpercussion41PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection42Diminishedbreathsounds

poorrespiratoryeffort

Pleuraleffusion

Endobronchialobstruction

Severeasthma

EmphysemaDiminishedbreathsounds43Bronchialbreathing

Consolidation

PulmonaryfibrosisFineinspiratorycrackles

Pulmonaryedema

Pulmonaryfibrosis

ConsolidationBronchialbreathing44Pleuralrub

Pleuralinfectionwithadjacentpneumonia

PulmonaryembolusPleuralrub45Inspiratoryrhonchusorwheeze

Acutebilateralvocalcordparalysis

Inhalationofforeignbody

TrachealtumorsorstenosisInspiratoryrhonchusorwheeze46Expiratoryrhonchus(largeairwayobstruction)

Endobronchialcarcinoma

Acutebilateralvocalcordparalysis

Expiratoryrhonchus(largeair47Expiratorypolyphonic,high-pitchedwheeze

(smallairwayobstruction)

Bronchialasthma

cardiacasthma=leftventricularfailureandpulmonaryedemaExpiratorypolyphonic,high-pi48VideoforPEhttp:///v_show/id_XNzA0OTgzODE2.htmlVideoforPE49ReferenceOxfordtextbookofMedicineCecilmedicineTextbookofphysicaldiagnosisReferenceOxfordtextbookofMe50ThanksforattentionThanksforattention51ClinicalclerkshipClinicalclerkship52BasicsciencetrainingDevelopclinicalscenarioProblemyouwillface:Medicalinformation

Patientdata

IncompatibilityoftwosetsofknowledgeBasicsciencetraining53Medicalknowledgecomprisesmillionsoffacts

---organized

bydiseasestate

---bypathophysiologyMedicalknowledgecomprisesmi54Willpatientspresentadiseasetoyou?LooselyconstructedchainofcomplaintsElaboratepsychologicalconstructtopreventdisclosureofpainfuleventsDealingwithhundreds,ifnotthousands,offactsWillpatientspresentadiseas55Clinician’sJobmanagetheinformationPatient’sdataneedtobetranslated

intoclinicalpresentationAtechnique:compatibilityofknowledge

Thoughtprocesses:

Comprisemuchoffabricofclinicalexperience

“secondnature“AccuratelyassessedClinician’sJobmanagetheinfo56Howcanwegettheinformationandpatient’sdata?MedicalvisitHowcanwegettheinformation57PurposeofMedicalvisitCarefulandcompletehistoryThoroughphysicalexaminationPurposeofMedicalvisitCarefu58MedicalhistorychiefcomplainPresentPastFamilySocialhistoriesSystemreviewMedicalhistorychiefcomplain59MajorPulmonarysymptomsDyspneaCoughMajorPulmonarysymptomsDyspne60DyspneaGreekprefixof“dys”---painful,difficult,breathItisasubjectiveexperienceofbreathingdiscomfortthatiscomprisedofqualitativelydistinctsensationsthatvaryinintensity.DyspneaGreekprefixof“dys”--61DiagnosisapproachDifferentialdiagnosisofdyspnea:

lung,heart,chestwallneuromuscular

renal

endocrine

rheumatologic

hematologic

psychiatricdiseaseDiagnosisapproachDifferentia62Understand---Thegoalofrespiratoryandcardiovascularsystem:takeO2fromtheair

transferittohemoglobin

deliverittometabolicallyactivetissue

transportCO2backtolung,toeliminate

Understand---Thegoalofresp63Theprocessofrespirationcanbedividedinto3components:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)

Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan64Theprocessofrespirationcanbedividedinto3components:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)

Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus

3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan65VENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

1)Stimulationofchemoreceptors--conditionsleadingtoacutehypoxemia

(Impairedgasexchanger,Environmental

hypoxia)VENTILATORYCONTROLLERANDGAS66---conditionsleadingtoincreasedeadspaceand/oracutehypercapniaImpairedgasexchanger：asthma

Impairedventilatorpump:muscleweakness,

airflowobstruction---conditionsleadingtoincre67--Metabolicacidosisa.Renaldisease(renalfailure,renaltubularacidosis)

b.Decreasedoxygencarryingcapacity(eg.Anemia)

c.Decreasedreleaseofoxygentotissues(hemoglobinopaty:thalassemia)

d.Decreasedcardiacoutput--Metabolicacidosis68VENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

2)Stimulationofpulmonaryreceptors(Irritant,Mechanical,Vascular)

ILD

Pleuraleffusion(compressiveatelectasis)

Pleuralvasculardisease

CongestiveheartfailureVENTILATORYCONTROLLERANDGAS693)Behavioralfactors

hyperventilationsyndrome

anxietydisorder

panicattacksVENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

3)BehavioralfactorsVENTILATO70Theprocessofrespirationcanbedividedinto3components:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus

3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan71VENTILATORYPUMP—INCREASEDEFFORTORWOROFBREATHING

MuscleweaknessDecreasedComplianceofthechestwallAirflowobstructionVENTILATORYPUMP—INCREASEDEFF72Thekeyareasofinquiry(MedicalHistory)

(1)qualityofthesymptom;

(2)persistenceorvariabilityofthesymptom

(3)aggravatingorprecipitatingsymptom.Thekeyareasofinquiry(Medi73IntermittentdyspneaPersistentorprogressivedyspneaNocturnaldyspneaDyspneaintherecumbentpositionPsychogenicdyspneaRaynaud’sphenomenonIntermittentdyspnea74CoughAseriesofrespiratorymaneuversthatleadtoacharacteristiccoughsound.Mostsensitivesitesforinitiatingcough:

larynx,tracheobronchialtree,carina

thepointsofbronchialbranchingCoughAseriesofrespiratorym75APPROCHTOCOUGHThe

causeofthecoughTreatthecauseAPPROCHTOCOUGHThecauseoft76CommoncausesofcoughCommoncausesofcough77Coughwithsputumproduction:bronchitis,bronchiectasis3weeks–acutoffpointforanacutecough(duetoanupperrespiratoryinfection)Cough:acute,chronicCoughwithsputumproduction:78Acutecough

Cause:

1.upperrespiratorytractinfection

2.pneumonia

3.congestivecardiacfailure

4.AECOPD

5.aspiration

6.pulmonaryembolism

Acutecough79Chroniccough

Cause:

Asthma

GER

postnasaldrip

chronicbronchitis

bronchiectasisChroniccough80PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection81PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection82AppearancesuggestivebloodgasdisturbanceLookfordyspnea,tachypnea,slowRRPatient’sfingersforperipheralcyanosisSkinforwarmthTongueandlipsforcentralcyanosisAppearancesuggestivebloodg83ObservingtheshapeandsymmetryofthechestBarrelchestpectuscarinatumsurgicalscars

Observingtheshapeandsymmet84RhythmofbreathKussmaul’sbreathingCheyne-StokesrespirationsRhythmofbreath85RRlow(<10/min)

--carbondioxidenarcosis

--Drugs(alcohol,benzodiazepine)

--RaisedintracranialpressureRRlow(<10/min)86PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection87Chestwallabnormalities

chestshape

chestchangeonmovementforasymmetryBilateralpoorchestexpansion

obesity

EmphysemaUnilateralpoorchestexpansion

Pleuraleffusion

PneumothoraxChestwallabnormalities88Tracheadisplaced

Scoliosis

Pneumothorax

PleuraleffusionReducedvocalfremi