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1

chest pain - where from?

- lungs = asensate
- heart = autonomic , referred
- parietal pleura = intercostal
- bones, muscles, skin
- GI tract

2

what to ask about

site
onset
character
radiation
associations
timing
exacerbating and alleviating factors
severity

3

chest pain - cardiac pain

- all referred pain
- central, crushing, heavy, tight band
- usually left sided
- can be epigastric
- often radiates = left arm, neck, jaw/teeth
- autonomic symptoms
- usually exertion

4

chest pain - respiratory

- pleuritic = sharp, worse on inspiration, usually located easily, non-specific
- lungs = contain no pain receptors, do contain J receptors, cough, pleurisy if the pathology reaches the pleura
- GI = oesophageal spasm, trapped wind, rflux oesophagus
- muscloskeletal = usually worse on movement, recent trauma, reproducible

5

brethlessness

- symptom, not sign
- people get breathless because of
- exercise and weight
- fitness, cardiac function, respiratory function

6

breathlessness questions

- what do you mean by breathlessness?
- cant breath in or out?
- when?
- doing what?
- orthopnoea?
- paroxysmal noctunal dyspnoea?
- associated symptoms eg wheeze, stridor, cough
- time frame?

7

time frame for breathless ness

acute
- PE, pneumothorax, pulmonary oedema
subacute
- pneumonia, pulmonary oedema, pleural effusion, asthma
chronic
- COPD, pulmonary fibrosis, PE

8

dry cough

- acute
- < 8 weeks
- almost always viral aetilogy
- very common
- sometimes just airway disease

9

sinister cough

- lung cancer
- mesothelioma
- pulmonary metastases

- pulmonary fibrosis
- sarcoidosis
- pneumonitisis
- EAA

10

chronic dry cough

- GORD
- ACE-1
- upper airway disease

increase in stimulus
- smoking, GORD, allergens, ACE-1

11

productive cough

- productive of SPUTUM mainly
- suptum = neutrophils, eosinophils, bacteria/fungus, /virus
- airway secretion

12

haemoptysis

coughing up blood
massive > 500ml in 24 hours
non massive < 500 ml in 24 hours

13

causes of haemoptysis

- infection
- carcinoma
- pulmonary embolism
- bronchiectasis

- cardiac
- AVM
- anticoagulation

14

general resp examinaation

- look at whole patient
- respiratory distress
- stridor = high pitched wheezing sound on inspiration
- cyanosis = bluish colour
- state of nutrition

15

peripheral signs in resp exam

- mouth
- hands
- skin perfusion
- CO2 flap
- lymph nodes
- JVP
- chest - finally

16

cyanosis

- central = tongue, peripheries warm, vasodilated
- there may be secondary polycythaemia
- peripheral = hands, feet, nose
- cardiovascular collapse
- peripheral vascular disease

17

CO2 flap

- due to hypercapnic encephalopathy
- irregular flapping of hand when wrist hyperextended
- associated confusion
- peripheral vasodilation

18

skin

yellow fingernail due to nicotime, tar, fungus
- eczema with atopic disease

19

causes of clubbing

- bronchial carcinoma
- fibrosis alveolitis
- lung suppuration
- cyanotic congenital heart disease
- infective enocarditis
- malabsorption states
- congenital, idiopathic

20

eyes

horners syndrome = small pupil, ptosis, enophthalmos, unilateral loss of sweating

21

the neck

- super clavicular
- cervical chain
- submental, submandibular
- partotid
- post articular
- occipital

22

examination of chest

- inspection
- palpation
- percussion
- auscultation

23

inspection of chest

- chest wall deformity
- operation scars
- expansion

24

pectus excavatum

- pulmonary artery flow murmur
- big dent near nipple

25

palpation of chest

- tracheal deviation = towards collapse lung , towards consolidatoin, away from effusion
- crepitation (crackles) = surgical emphysema

26

percussion of chest

- hyper-resonance - emphysema, pneumothroax
- impaired resonance = consolidatoin, pleural thickening
- stony dull percussoins - pleural effusion

27

auscultation of chest

low pitched = bell of stethoscope
high pitched = diaphragm of stethoscope

28

auscultation - added sounds

- wheeze - air breathed out
- localised - eg large airwau tumour
- generalised - polyphinc, small airway obstructoin
- squeak - bronchiolitis
- crackles