2. Physical signs of
pulmonary syndromes
Dr. Nebenfü
Nebenführer Zsuzsa
Infiltration
Pneumonia
Pulmonary embolism
Atelectasis
Pleural effusion
Pneumothorax
Mediastinal mass
Pulmonary infiltration
causes
Exsudate, tumor, blood in the alveoli.
Pneumonia
lobar
viral
bronchopneumonia
Pulmonay embolism
Tumor
Tbc
Pulmonary infiltration
history
Shaking chill, sputum: pneumonia
Operation, immobilisation, chest pain,
bloody sputum: infarction after PE
Weight loss, smoking, bloody sputum:
tumor
Pulmonary infiltration
physical examination 1.
Inspection: chest excursion decreased
Tactile fremitus: increased
Percussion: dullness
Pulmonary infiltration
physical examination 2.
Auscultation:
Crackles at the beginning (crepitatio
indux)
Bronchial breath sounds
Crackles at the end (crepitatio redux)
Bronchophony increased
Pneumonia
Def: inflammation of the parenchyma,
alveoli, connective tissue, bronchioli of
the lung
Causes: bacteria, virus, Mycoplasma,
fungi, chemical of physical effects
Pneumonia
clinical picture
Symptoms: high fever, dyspnoe,
cyanosis , chest pain,
cough: dry → pus / bloody
Exsudative pleuritis (possible)
Lab: leukocytosis, left shift, ESR ↑,
CRP ↑
X-ray: infiltration
Atypical infiltation
Massive: also the bronchi filled with
exsudation or tumor
Central: in the hilar region
Pulmonary embolism
Pulmonary embolism
= embolia pulmonum
= thrombus in the arteries of the lung
Source: veins of the lower extremities /
pelvis
Anamnesis !!!!
Pulmonary embolism
symptoms
Short of breath = dyspnea
Pleural chest pain
Bloody sputum = haemoptysis
Collapse = syncope
Palpitation
Fatigue
Cough
Pulmonary embolism
physical signs
Tachypnea
Cyanosis
Bronchospasm
Pleural friction rub
Hypotension
Tachycardia
Fever
DVT
Pulmonary embolism
other exams
ECG: right deviation, P pulmonale,
PSVT, AF
Lab: D-dimer, LDH, sebi
Blood gases: hypoxia, hypocapnia +
alcalosis
Scintigraphy
Angio-CT
Atelectasis
Atelectasis
Airless alveoli, air absorbed
Causes:
Insufficient breathing (weak patient, long
bed rest, after abdominal operation)
Bronchial obstruction or stenosis by
foreign body / tumor / mucus
Obstruction of the lung by pleural fluid
X-ray
Atelectasis
Bronchostenosis
tactile fremitus: decreased
percussion: dullness
auscultation: diminished breath sounds
bronchophony: decreased
Insufficient breathing or compression: air in
the bronchi = similar than infiltration :
bronchial breath sounds, crackles
Pleural effusion
Def: fluid accumulation between layers of the pleura
Transsudate
Exsudate
Increased intrathoracic pressure (heart failure)
Decreased oncotic pressure: hypoproteinaemia (liver
cirrhosis, nephrosis sy)
Permeability of the pleura increased +
Lymphatic absorption decreased (occlusion or narrowing)
Blood
Pus
Chyle
Pleural effusion
causes
Transsudate
Heart failure
Liver cirrhosis
Pulmonary embolism
Nephrotic syndrome
Meigs-syndrome, ovarian
hyperstimulation
Peritoneal dialysis
Myxoedema
Exsudate
Tumor
Infection
Pulmonary embolism
Lung infarction
Abdominal diseases
Autoimmun diseases
Eosinophilic pneumonia
Asbest
Irradiation
Eosophageal perforation
Haemothorax
Chylothorax
Empyema thoracis
Pleural effusion
Anamnesis: pleuritis sicca (possible)
Symptoms:
cough
dyspnea
chest pain
Pleural effusion
physical signs
Inspection: bulging of the affected
side, excursion decreased
Tactile fremitus: decreased
Percussion: dullness
Auscultation: breath sounds
decreased or absent
Bronchophony: decreased
Pleural effusion
percussion
Upper border: Ellis-Damoiseau-line:
highest point in the posterior axillary scapular line, going down on both
sides
Korányi-triangle: fluid dislocates the
mediastinum = triangle of dullness on
the other side, bordered by the
diaphragm and the midline
Pleural effusion
punction
Transsudate
Exsudate
protein g/l
1-2
3
specific weight
< 1015
1018
albumin gradient
> 1,1
< 1,1
LDH gradient
< 0,6
> 0,6
sediment
mesothelial cells
lymphocyte
leukocyte (pneumonia)
malignant cells (tumor)
blood
tbc, PE
tumor
Thickening of the pleura
Causes: callus or tumor
Inspection: retraction of the affected
side, chest excursion decreased
Percussion: dullness
Auscultation: decreased or absent
X-ray: shadow, calcification
Pleuritis sicca
Severe, sharp pain, friction rub at in- and
exspiration
Patient lies on the affected side
Shallow breath
If only the diaphragmal pleura affected:
pain only at breathing
can cause defense in the abdominal muscles at
deep inspiration
can radiate to the apex, neck
Pneumothorax
Air in the pleural cavity
Causes:
from the lung (bulla, bleb) through
visceral pleura
injury of the chest wall
Collapse of the lung = atelectasis +
mediastinal shift toward the healthy
side
Pneumothorax
clinics
Symptoms: sharp pain at the moment
Signs:
collaps
dyspnea
tachycadia
Pneumothorax
physical exam
Inspection: the affected side is bulging, chest
excursion decreased
Tactile fremitus: decreased or absent
Percussion :
small: almost no difference
large: tympanic
dullness of the heart shifted towards the healthy side
Auscultation: decreased or absent
Bronchophony: decreased or absent
Seropneumothorax
Fluid at the bottom of the chest
X-ray: the border always horizontal
Hyppocrat: shake !
Acut tracheo-bronchitis
Fever, sore throat
Cough (dry → sputum mucouspurulent)
Louder breath sounds, prolonged
exspiration, adventitious sounds
(wheezes, crackles)
COPD = chronic aspecific
pulmonary disease
Chronic bronchitis
Emphysema
Chronic bronchitis
Cough
Sputum
Dyspnea
No change on X-ray !
Symptoms for at least 2 years, for 3
mo /year
No other underlying disease
Bronchial asthma
Sudden onset dyspnea caused by
reversible airway obstruction
Prolonged exspiration, wheezesrhonchi, use of accessory muscles,
tachypnea
Emphysema
Def: abnormal, permanent enlargement of air
spaces distal to bronchioli accompanied by the
destruction of its walls
Horizontal ribs, lower aperture of the thorax
wide, lung borders lower
Chest expansion decreased, absolute dullness of
the heart decreased or missing
Exspiration obstructed, air trapping
Percussion: hyperresonance
Auscultation: decreased vesicular sound
Syndrome of mediastinal
tumor
Mediastinal lymph nodes: lymphoma,
metastasis, Boeck sarcoidosis
Aortic aneurysm
Substernal goiter
Extreme dilatation of left atrium
Pericardial fluid
Signs of compression caused
by mediastinal masses
Veins
Superior vena cava
syndrome
Thrombosis
Portal hypertension
Trachea
Cough
Asphyxia
Tracheomalatia
Esophagus
Dysphagia
Bleeding from
dilated veins
Cerebrovascular
Ischaemia
Nerves
Recurrent laryngeal
nerve palsy →
hoarsness
Phrenical nerve
palsy
Horner-triad
Chyle
Chylothorax
Superior vena cava
syndrome
Venous congestion in the head, neck
and upper extremities = Stokes-collar
Causes:
stenosis, occlusion, thrombosis of
mediastinal veins
manipulation on veins or PM
implantation
substernal goiter