Midterm 2 Flashcards
Definition of Non-Productive Cough
A Non-productive (or minimally productive) cough does not generate regurgitation of lung mucus or fluid
What diseases are seen with a cough?
a) Pulmonary Emphysema
b) Viral or mycoplasma pneumonia
c) Occasionally asthma
What is a Productive Cough?
A productive cough is generates sputum
What is a productive cough seen with?
a) Chronic bronchitis
b) Bacterial or lobar pneumonia
c) Upper respiratory tract infections (URTI) ie: bronchitis
d) Sputum: Evaluate for viscosity, color, odor, pus
Types of Sputum
I.“Sticky and Clear” = bronchiole infection
II.“Sticky, white/grey” = chronic bronchitis
III.“Translucent green/yellow” = acute bronchitis
IIII.“Yellow, green, purulent” = bacterial infection
V.“Pink and Frothy” = pulmonary edema
VI.“Foul odor” = bronchiectasis, lung abscess
What is Hemoptysis
Expectoration of frank blood
~Over 100 causes of blood in sputum
Common causes of Hemoptysis
I.Chronic Bronchitis
II.Tuberculosis/bronchiectasis
III.Bronchogenic carcinoma
Sticky and Clear Sputum
Bronchiole Infection
Sticky, White/Grey Sputum
Chronic Bronchitis
Translucent Green/Yellow Sputum
Acute Bronchitis
Yellow/Green/Purulent Sputum
Bacterial Infection
Pink and Frothy Sputum
Pulmonary Edema
Foul Odour Sputum
Bronchiectasis, lung abscess
Whats sometimes the only sign of someone with lung cancer?
Having an episode of hemoptysis
What other conditions can cause hemoptysis?
Left Ventricular Failure
Mitral Valve Stenosis
Trauma
Lung Disease
What is Dyspnea?
An uncomfortable awareness with breathing either at rest or during physical exertion
What is Orthopnea?
The need to be upright in order to breath
Pulmonary Chest Pain of “SUPERFICIAL” Origin
~ Pain from thoracic cage such as the skin, ribs, cartilage, intercostal mm. and intercostal nerves
~ Pleuritic Pain either inflammatory or non inflammatory
~Mm pain is aggravated by deep palpitation
~Thoracic pain is increased by thoracic movements, stretching, deep inspiration and coughing
Where does the intercostal mm fibres travel when you have peripheral diaphragm pain?
Travel via the 5th and 6th intercostal nerves
Pleural pain that is sharp and localized is from what 2 things?
Atelectasis or Pneumothorax
Where does posterior diaphragm pain refer?
To the thoracolumbar spine akin to kidney or pancreatic pain
Pulmonary Chest pain of “DEEP” origin (Internal)
~ Deep pain not localized
~Deep pain is less easily exacerbated
~ Pain from the trachea and larger bronchi can be well localized
~ Manifests as raw, burning, sub-sternal pain this is exacerbated by coughing ie: Acute Bronchitis
In Deep pulmonary chest pain what areas are considered pain sensitive?
Lung parenchyma
Visceral pleura
Deep Pulmonary chest pain fibers travel along …?
The phrenic nerve C3 - C5 nerve roots
Where does Deep chest pain refer?
To the Ipsilateral Shoulder
What does a pulmonary emboli pain mimic?
Heart Attack
What does pulmonary HTN chest pain mimic?
Angina Pectoris during periods of exertion
Excessive Nasal Secretions
- Nasal Catarrh
2. Beware: Head Trauma
2 Normal Breathing sounds
Bronchial
Vesicular
Bronchial Breathing sounds
Also called Tracheal breath sounds
Their auscultated over the trachea and larger bronchials
Vesicular breath sounds
Are heard over the lung parenchyma and terminal bronchioles
When are normal breathing sounds more soft, low pitched and breezy?
During Inspiration
Where are Bronchovesicular sounds heard?
Parasternally and represent a combination of the bronchial and vesicular sounds
Types of Abnormal Breath sounds?
Rales/Crackles
Rhonchi
What are the types of Rales?
Discontinuous
Basilar
Coarse
What is a Discontinuous Rale?
Sounds or crackles arising from air passing through fluid that is accumulated in the airways
What is a Basilar Rales?
Classically associated with pulmonary edema resulting from CHF
Most significant if they fail to clear after coughing
What is Coarse Rales?
Loud crackles associated with the resolution of lobar pneumonia
Types of Rhonchi Breathing?
Continuous
Monophonic Wheeze
Pleural Friction Rub
What is a Continuous Rhonchi?
Sounds from partially included obstructed bronchi
What is a Monophonic Wheeze?
Is a ronchus sound produced by occlusion of an airway at a solitary site. Such occlusion can represent a foreign object or a tumour mass such as in bronchogenic carcinoma
What is a Pleural Friction Rub?
An auscultated crackle emanating from the site of pleural effusion
Inspection
Look at effort of respiration
Does the patient exhibit SOB
Is the patient using accessory muscles of respiration
Look at the thorax shape: The A to P diameter will increase with
age or COPD
What is the normal shape of a thorax?
Ovoid
*The Anterior to Posterior diameter is less than the transverse (Sides) diameter
What does a Barrel Chest indicate?
Lung pathology
Late Chronic Bronchitis
Late Pulmonary Emphysema
Late Chronic Bronchitis patients will exhibit what severity of a barrel chest?
Moderate Barrel Chest
What severity of a barrel chest does a Late Pulmonary Emphysema patient have?
Severe Barrel Chest
What is Pectus Excavatum
Funnel Chest
What is a Pectus Carinatum Chest?
Pigeon Chest
What diseases are a severe Kyphoscoliosis patient at risk for
Pulmonary HTN
Lung Disease
Heart Disease
How is Thoracic Excursion measured?
By placing thumbs at the 10th ribs costovertebral junction and asking the patient to inhale
What is the normal measurement for Thoracic Excursion?
3-5 cm
Normal respiration rate for Newborn/Infant?
30-40 breaths per min
Normal respiration rate for children age 2-5?
24-28 BPM
Normal respiration rates for adults?
12-20 BPM
What does segmental rib or vertebral tenderness reflect?
A dysfunction of the costovertebral joints
When is Rib head dysfunction pain exacerbated?
Inhalation
What can myofascial pain effect?
The intercostal or spinal mm. eliciting pain on palpation
What to look at during palpation?
Rib Heads
Vertebral Tenderness
Myofascial pain
Costovertebral angle tenderness
Palpating for Costovertebral Angle Tenderness
Palpation near the 12th costovertebral articulation can illicit pain in cases of rib dysfuntion as well as renal pathologies
Where does Kidney disease refer to?
Referred Viscero-Somatic pain in the Thoracolumbar transition area
What is Viscero-Somatic pain accompanied by?
Reflexive hypertonicity of the surrounding para spinal musculature
SSX of Renal pathology or inflammation
Thoracolumbar pain/tenderness
Palpable mm spasm and lateral flexion toward the involved side
Systemic chills and fever
Supine patient may flex the hip on the involved side attempting to relieve the pain
What is Kernigs Sign?
Supine patient may flex the hip on the involved side attempting to relieve the pain
What is Murphy’s Punch?
Percussion over the kidney on the non affected side with firm force. Inflamed kidney will elicit significant pain
What is Heel Jar Test?
With the patient supine and his/her legs extended, strike the hell pads with an open palm to elicit the symptomatic pain
What is Tactile Fremitus
A perceptible vibration palpated over the lung fields. The airways must be open to conduct vibration
Have patient speak as you palpate over the lung apices, anterior, posterior and lateral thorax
Compare results bilaterally
Normal tactile fremitus varies greatly from person to person depending chiefly on voice pitch
What are the 2 types of Abnormal Tactile Fremitus
Increased
Decreased
What is Decreased Tactile Fremitus
seen in pulmonary emphysema or pleural pathologies
What is Increased Tactile Fremitus
Seen in consolidation such as lobar pneumonia
In a lung examination should percussion or auscultation be preformed first?
Percussion precedes auscultation such that percussion may loosen impacted secretions making their presence better known upon auscultation
What does percussion reflect?
the solid or hollow consistency of the tissue underlying the point of tapotement
Whats the Normal Lung Field Tone produced called?
Resonant
Reflects normal lung parenchyma
What does Hyper-Resonant mean?
Decreased lung tissue density in the pleura or parenchyma
What patient disease will Hyper Resonant appear?
Emphysema
Tubercular Cavitation
What kind of note will Increased Lung Tissue Density in the pleura or parenchyma produce?
A dull note on percussion
What diseases will have Increased Lung Tissue Density?
Bacterial Lobar Pneumonia
Pleural Effusion
How to preform Auscultation?
All the lung fields can be auscultated on the posterior thorax with the patient in the seated position with the exception of the RIGHT MIDDLE LOBE!
Instruct patient to complete one full inspiration with each placement of the stethoscope over the lung fields
Reduced or Absent Breath Sounds are heard with …?
Non patent airways due to either atelectasis, emphysema or any and all pleural pathologies such as pleurisy, pneumothorax
Increased breath sounds are heard over regions of…?
Consolidation such as with lobar pneumonia
Types of breath sounds?
Vesicular
Bronchial
Crackles/Rales
Rhonchi
Wheezing
Stridor
Friction Rub
What is Vesicular?
Normal breath sounds over lung fields
What is Bronchial breath sounds?
Auscultated over trachea. If heard over other lung fields = are of lung consolidation as in pneumonia
What is Crackles/Rales Breath sounds?
Discontinuous lungs sounds that mimic the crackling of plastic wrap
What is Rhonchi Breath sounds?
Low pitched sounds, similar to snoring
What is wheezing?
Whistling, musical breath sound worse during expiration
What is Stridor?
A high pitched sound worse on inspiration
What is Friction Rub?
Grating or creaking that sounds like skin dragged over wet leather
What is COPD?
A clinically significant dyspnea on exertion with objective evidence of reduced airflow that is not explained by infiltrative lung disease or by pre-existing heart disease
What is Chronic Bronchitis?
A persistent, mucous producing cough that is persistent on most days for at least 3 months or several consecutive years.
What is the most common debilitating respiratory disease in North America?
Chronic Bronchitis
What is Chronic Bronchitis most often associated with?
Active Cigarette smoking and the presence of “smokers cough”
Risk factors for Chronic Bronchitis?
Family history of Chronic Bronchitis or other lung disease
Personal history of early childhood lung disease or severe allergies
Chronic exposure to dusk and lung irritants
Deficient immune system
What does Chronic Diffuse Bronchial Inflammation lead to?
- Partial bronchial obstruction due to mucous hyper secretion
- A predisposition to bronchospasm (asthma)
- Secondary structural changes to the bronchi (loss of cilia)
- Eventually hypoxemia and pulmonary HTN with the potential for right heart failure
Is Chronic Bronchitis painful or painless?
Usually Painless
SSX of a patient with Chronic Bronchitis
Moderate Barrel Chest
Moderate DOE
Productive mucoid cough with large amounts of clear/white sputum =
“smokers hack”
Prolonged inhalation and expiration times due to bronchial obstruction
Generally overweight and experience supplemental weight gain
associated with systemic edema
Jugular Vein distention and hepatomegaly
Digital clubbing
Blue Bloater
Whats Digital Clubbing?
Hypertrophy of the soft tissues of the terminal phalanges due to chronic hypoxemia
What is a Blue Bloater?
Systemic Edema and systemic cyanosis
*Chronic Bronchitis
Percussion Exam Findings
Non specific with the exception of later stages of the condition of being associated with percussion of an enlarged liver
Auscultation Exam Findings
A combination of Rhonchi and rales over most/all lung fields and bronchiolar constriction may produce wheezes
~Consolidation of certain lobes may exaggerate all breath sounds
Complications associated with Chronic Bronchitis
- Decreased ventilation initiates hypoxia
- Blood gas abnormalities ensue
- Right sided heart failure
- High risk of recurrent lung infection in response to inflammation
- Associated risk of lung cancer
What is Right Sided Heart Failure?
Pulmonary HTN causes back pressure on heart
Right side of heart has to work hard to pump blood into the lungs
Can results in right side heart failure
Pulmonary Info:
- chronic inflammation of LU tissue
- genetic disposition
- diminished elasticity
- loss of septa in aveolus= over inhalation/distal air trapping
- associated with smoking
What is the genetic disposition for Pulmonary Emphysema?
reduced ability to produce alpha antitrypsin= overactive monocytes in LUs
is pulmonary emphysema painful?
no not usually
does pulmonary emphysema have difficulty inhaling or exhaling?
exhaling
Pulmonary Emphysema SX:
1) chronic, non-productive cough
2) severe DOE
3) laboured expiration
4) overdeveloped accessory muscle of respiration (scalenes, traps, pec. major, SCM, intercostals, abs)
5) barrel chest= loss of elastic recoil
6) underweight (use more energy to breathe)
7) *lacks digital clubbing/doesnt appear cyanotic
8) “pink puffers” (effort of respiration)
Pulmonary Emphysema physical exam findings:
1) observation: reduced thoracic excursion
2) percussion: hyper-resonant sounds
3) auscultation: sounds reduced
Pulmonary Emphysema complications:
1) respiratory insifficiency
2) R-sided HT failure (only in severe case)
3) hypoxia, hypercapnia (acidosis), pulmonary HTN
Respiratory DZ SX:
1) excessive nasal secretions
2) cough (non-productive, productive, hemoptysis)
3) chest pain (superficial, deep)
sticky clear sputum:
bronchiole infection
sticky white grey sputum:
chronic bronchitis
translucent green/yellow sputum
acute bronchitis
yellow, green, purulent sputum:
bacteria
pink, frothy sputum
pulmonary edema
foul odour sputum:
bronchiectasis
superficial chest pain:
- skin, ribs, cartilage, intercostal muscles/nerves
- posterior diaphragm
- NMS/muscular origin aggravated by palpation
- pleural pain
- peripheral diaphragm
deep chest pain:
- not well localized (except trachea, bronchi)
- less easily aggravated
- raw, burning, substernal
- aggravated by coughing
normal breath sounds:
1) bronchial/trachial
2) vesicular (heard over parenchyma/terminal branches), soft, low pitched, breezy, more pronounced during inpsiration
Abnormal breath sounds
1) rales/crackles
2) Rhonchi
what are the kinds of rales?
1) discontinuous= ‘crackles’, pass thru fluid
2) basilar= pulmonary edema
3) coarse= loud ‘crackles’= lobar pneumonia
what are the kinds of rhonchi?
1) continuous= partially obstructed bronchi
2) monophonic wheeze= occlusion of airway at solitary site (tumor/foreign object)
3) pleural friction rub= crackle from pleural effusion
inspection for respiratory Dz?
1) effort of respiration (SOB? using accessory muscles?)
2) thorax shape (normal= ovoid)
3) thoracic excersion
4) respiration rates (normal= infant:30-40/min, 2-5 yrs: 24-28, adults: 12-20/min)
What are abnormal thorax shapes?
1) barrel chest= moderate: late chronic bronchitis, severe: late pulmonary emphysema
2) funnel chest= pectus excavatum (inverted)
3) pigeon chest= pectus carinatum (extroverted)
4) severe scoliosis= increase risk of pumonlary HTN, lung Dz, HT Dz
what is thoracic excersion?
- ribcage naturally expands with inhale
- place thumbs at 10th ribs, measure movement
- normal= 3-5cm
Palpation for lung Dz?
1) rib/vertebrae tenderness= dys. of costovertebral joints
2) myofacial pain
3) costovertebral angle tenderness= pain at 12th intercostal= renal pathology, viscero-somatic pain= KID Dz
4) orthorthopedic tests
what is Kernigs sign?
indicator of renal pathology/inflammation
-patient in supine pos., flex hip to relieve pain
SX of renal pathology/inflammation:
1) thoracolumbar pain
2) palpable muscle spasm, lateral flexion to affected side
3) systemic cills/fever
2 types of orthopedic tests
1) murphys punch= percussion over KIDs on non-affected side with firm force, infected KID will elicit pain
2) Heel Jar test= supine, legs extended, strike heel with open palm to elicit pain
what is tactile fremitus?
vibration palpated over LU fields
Percussion for LU Dz
- during examination: start with percussion to loosen secretions followed by auscultation
- normal= resonant tone
- abnormal= hyper-resonant, dull note
2 Types of Abnormal Tactile Fremitus?
Decreased Tactile Fremitus
Increased Tactile Fremitus
What is Decreased Tactile Fremitus?
Is seen with pulmonary emphysema or pleural pathologies
What is Tactile Fremitus?
Is seen with consolidation such as lobar pneumonia
What does Resonant mean?
Normal lung field tone produced that reflects normal lung parenchyma
What does the tone of percussion reflect?
Reflects the solid or hollow consistency of the tissue underlying the point of tapotement
What does Hyper Resonant mean?
Decreased lung tissue density in the pleura or parenchyma during percussion
What 2 conditions is Hyper-Resonant seen in?
Emphysema
Tubercular Cavitation
What type of note will Increased Lung Tissue density produce?
A DULL note in the pleura and parenchyma
Seen in Bacterial Lobar pneumonia
Pleural Effusion
How to use Auscultation?
Done on posterior thorax with the patient in a seated position with the exception of the right middle lobe.
Instruct patient to complete one full inspiration with each placement of the stethoscope over the lung fields
Reduced or absent breath sounds are heard with..
Non patent airways due to either atelectasis, emphysema or any pleural pathologies
Increased breath sounds are heard over regions of…
Consolidation such as with lobar pneumonia
What is Pulmonary Emphysema?
Is the result of chronic inflammation of the lung tissue. It results in the destruction of the alveolar septal wall and leads to the enlargement of the air spaces distal to the terminal bronchioles
Is there a genetic predisposition for emphysema patients?
yes
What is the genetic predisposition for emphysema patients?
The reduced ability to produce Alpha -1 Anti-Trypsin results in over activity of alveolar monocytes circulating within the lungs. This diminishes the elastic properties of the lungs. The loss of septa within the alveolus results in alveolar “over inflation” and “distal air trapping”
SSX of Emphysema patients
Difficulty exhaling
Painless
Associated with active or passive cigarette smoking
Chronic, mostly non-productive cough
Severe DOE
Expiration is labored and requires extra effort
Results in overdeveloped accessory mm of respiration
Barrel Chest
Underweight
Lacks digital clubbing and does not appear cyanotic
Pink Puffers
Whats a Pink Puffer?
Mild erythema of the face associated with the effort of respiration
Physical exam findings of Emphysema
Observation: Reduced thoracic excursion
Percussion: Hyper-Resonant sounds over lung fields
Auscultation: All breath sounds are reduced
Complications associated with emphysema
~Respiratory insufficiency creating secondary infections, pneumothorax or pulmonary emboli
~Right side heart failure end stages of disease
~Decreased gas exchange results in hypoxia, pulmonary HTN
What is Asthma?
Exaggerated bronchoconstrictor response to lung irritation due to either immunologic sensitivities or exercise
Asthma Stimuli Induce….
Paroxysms of bronchial smooth muscle contraction
Bronchial inflammation and mucus hyper secretion
Vasodilation and subsequent Edema of the bronchial mucosa
An accumulation of Eosinophils (WBC) if allergy induced
SSX of an Asthma patient
Airflow limitation primarily on expiration creating a sense of tightness in the chest
Marked Dyspnea
Wheezing and/or coughing
The asthma attack is usually self limiting. At the end of the attack the patient my report mucoid, productive cough
Objective Symptoms of an Asthma Attack
Anxiety associated with diaphoresis
Excessive use of accessory respiratory mm
Tachypnea and Tachycardia
An expiratory “Grunt” due to the increased effort of exhalation
Auscultation of wheezing Rhonchi
Rate of Tachypnea
> 30 min
Rate of Tachycardia
> 100 BPM
When is Bacterial Lobar Pneumonia present
Present as an acute inflammation of the lung with consolidation
SSX of Bacterial Lobar Pneumonia
Rapid onset of:
- Dyspnea & Tachypnea (25-45 breaths per min)
- Fever (40c)
- Decreased thoracic wall motion over the site of involvement
- Sharp, pleuritic chest pain secondary to pleural inflammation
- Paroxysmal productive cough with a muco-purulent sputum
- Percussion is a flat/dull note over affected area
- Increased breath sounds provided the airways are patent
- Increased tactile Fremitus over site of infection
- Chest wall breath sounds will sound “Bronchial” accompanied by
coarse rales
What happens if Bacterial Lobar Pneumonia is left untreated?
Fatal up to 40% of the cases
~Primarily in elderly and immune compromised
What is Obstructive Atelectasis?
The collapse of lung tissue caused by the complete obstruction of a bronchus
In Obstructive Atelectasis what can the bronchus be blocked by?
Aspiration of a foreign body
Conditions causing excessive bronchial secretions (mucus plug)
Tumour growing on a bronchial wall
What happens once occlusion happens in Obstructive Atelectasis?
The rate collapse depends on how quickly the gases are reabsorbed form the affected acinar unit. This process may or may not cause pain. As the lung pulls away from the chest wall it may produce pleuritic chest pain
SSX of Obstructive Atelectasis
Cough
Sputum production depends on causative agent
Decreased chest motion over site of involvement
Tracheal deviation toward the side of involvement (If pleura is intact)
Reduced or absent tactile Fremitus over site of involvement
Auscultation is reduced or absent vesicular sounds over the site of
involvement
What is Pneumothorax
Air within the intrapleural space allows the pleural membrane to pull away from the chest wall. The normal elastic recoil of the lung parenchyma causes the affected area to collapse
AKA: “Relaxation Atelectasis”
Pneumothorax initiates parietal plural chest pain
In the case of spontaneous pneumothorax air enters the intrapleural space through a tear in the visceral pleura in a distended alveolus
SSX of Pneumothorax
Rapid onset of pleuritic chest pain
They may complain of a “rib being out”
Dyspnea with Tachypnea
Percussion: Hyper-resonant over painful area
Palpation: Reduced tactile fremitus over affected area
Tracheal deviation away from the side of lesion
Auscultation: Decreased vesicular breath sounds
Does size matter in Pneumothorax?
yes the larger the affected area the more severe the SSx will be
*Most cases of pneumothorax resolve without significant intervention
What is Pleural Effusion?
Is the accumulation of fluid within the intrapleural space forcing the pleural membrane away from the chest wall. The fluid accumulation combined with the elastic recoil of the lung causes the affected lung lobe to collapse
Whats another name for Pleural Effusion?
Compressive Atelectasis
4 Sources of Fluid causes Pleuritic Chest Pain
Hydrothorax
Chylothorax
Hemothorax
Pyothorax
Pyothorax
Pus from existing infection
Hemothorax
Blood form ruptured blood vessels
Hydrothorax
Serous fluid from pulmonary edema
Chylothorax
Lymph fluid from cancerous lymph nodes
SSX of Pleural Effusion
Tachypnea and decreased chest movement on the involved side
Possible tracheal deviation away from the site of involvement
Decreased tactile fremitus over the affected side
Decreased breath sounds over the site
Pleural Effusion Fact
If there is pathological involvement of the pleura there will always be reduced breath sounds and reduced tactile fremitus over the affected region
What is Bronchogenic Carcinoma
Cancerous tumors affecting the lungs
SSX of Bronchial Carcinoma
Manifest initially depending on the site of origin. Vast majority of tumours first manifest near the bronchioles
An initial cough with or without hemoptysis
The cough is often ascribed to the onset of chronic bronchitis
Will mediastinal shift toward the side of lesion
Percussion: A Flat/Dull tone over area of involvement
Auscultation: Bronchial narrowing will result in a monophonic wheeze
*90% of the lung cancers are associated with smoking cigarettes
Things to remember with Bronchogenic Carcinoma
A single episode of hemoptysis may represent the only sign of a bronchogenic Tumor
Most cancers place excessive stress on the immune system and patients frequently report weight loss
When do Peripheral Nodular tumors become symptomatic?
When they infiltrate the chest wall and cause pleuritic chest pain
Otherwise their often asymptomatic
Whats a Pancoast tumor?
Carcinomas within the apices of the lungs
The tumor infiltrates the brachial plexus and the cervical sympathetic ganglia causing pain, numbness and weakness of affected limb
Lung Cancers often Metastasize where?
Bone
Breast
Kidneys
Where do expansive tumors irritate or compress?
The muscles and nerves that supply the throat
Phrenic
Glossopharyngeal
What are the 2 throat nerves?
Phrenic Nerve
Glossopharyngeal Nerve
Constitutional Signs of Cancer
Malaise
Anorexia
Fever
Fatigue
Cancerous growths will often cause pain at what time of day?
Night
~ during the initial onset of the disease
Signs of normal Lymph
Normal Lymph nodes are not visible upon inspection
Not palpable
Whats Shotty Lymph Nodes
Nodes that were previously involved in an inflammatory condition and have fibrosed following the infection
SSX of Shotty Lymph Nodes
Firm Moveable Non-Tender Discrete = have palpable borders Usually less than 1cm in diameter
SSX of Acute Pyogenic Infections
Nodes are larger, tender and discrete
Nodes are initially soft and become firm
Nodes may fluctuate in size during course of infection
SSX of Metastatic Cancer Lymph Nodes
Firm to hard, discrete, unilateral
Not tender
Become more immobile if the metastasis invades the surrounding
tissues
Patient will experience constitutional SSX
SSX of Lymphomas
Very large, non tender, discrete, firm and rubbery
May experience fever, night sweats and weight loss
SSX of Supraclavicular Nodes
Found in Supraclavivular Fossa at base of the neck
Near the terminus of the lymphatic trunks
Enlargement of either Right SC node or Left SC node represent
systemic disease
Where does the Right SC node drain?
Drains the right arm and side of head and neck
Where does the Left SC node drain
Drains entire body
Whats another name for Left SC node?
Virchow’s Node
Abdominal Pain Causes
- Abdominal distention of hollow viscera (common)
- Intense contraction of the hollow viscera (common)
- Rapid stretching of the capsules of the parenchymatous organs
- Other sources include anoxemia (decreased oxygen in the blood) of visceral musculature, inflammatory states, chemical stimuli, traction or compression of ligaments or vessels
Parietal Pain Thresholds
Pain Thresholds
•Parietal serous membranes (peritoneum or organ capsule)
a) Pain is normally sharp and well localized
b) Patient is usually antalgic as movement of the membrane stimulates pain
c) Parietal pain tends to radiate into adjacent structures
d) Parietal pain tends to fully involve one of four quadrants
e) Parietal pain can mimic nerve of body wall pain
f) Patient is often antalgic in a forward flexed position
4 Abdominal Quadrants
~Umbilical = left upper and right upper quadrant
~Hypogastric = left lower and right lower quadrant
Walls of Hollow Viscera
a) Smooth muscle is sensitive to stretch that produces a dull, poorly localized pain
b) Visceral pain is hard to describe because it is vague, dull, gnawing, burning
c) Changes in position do not relieve visceral pain, therefore, the patient is moving around seeking antalgia
d) Visceral pain is often noted at the midline of the abdomen (umbilicus)
e) Visceral pain tends to refer to a distant part of the body
Do Parenchymatous (solid) Organs have the same or different characteristics as hollow viscera?
Same or Similar as hollow viscera
Types of Hollow Organs
- Stomach
- Small Intestine
- Large Intestine
- Rectum
- Gall Bladder
Types of Solid Organs
- Heart* (not in abdomen and “hollow”)
- Lungs*
- Liver
- Spleen
- Pancreas
- Kidneys
- Ovaries
Abdominal Inspection
- A sweaty face and dilated pupils reflects severe pain
- Skin texture and color
Striae = stretch marks
Location of scars
Evidence of jaundice - Superficial venous pattens are normally not evident (NB: veins above umbilicus drain upward and those below drain downward)
- Portal HTN = venous distention due to liver cirrhosis or space occupying lesions
Caput medusa = periumbilical dilated veins - The normal abdominal cavity is symmetrical and is relatively or smoothly rounded
- The 5 F’s of abdominal distention are : Fat, Fluid, Feces, Flatus, Fetus
What is Striae?
Stretch Marks
What is Portal HTN
venous distention due to liver cirrhosis or space occupying lesions
What is Caput medusa?
Peri Umbilical Dilated Veins
What are the 5 F’s of Abdominal Distention
Fat Fluid Feces Flatus Fetus
What is Diastis Recti
Separation of the rectus muscles due to tearing of the linea alba consequential to pregnancy
Where is a frequent site of herniation?
The peri-umbilical region is a frequent site of herniation
Trauma abdominal signs
~Bluish flank ecchymosis (Turner’s sn)
~ periumbilical ecchymosis (Cullen’s sn) is often a sn of retroperitoneal hemorrhage
Abdominal Auscultation
Auscultation is a form of light palpation and the discomfort elicited by pressure may reflect cutaneous hypresthesia associated with abdominal disorders
Bowel sounds increase in frequency and intensity after a meal 9post-prandially)
Ingesting food initiates peristalsis within the small intestine and subsequent motility within the bowel. This results in the need to defecate as a result of the gastro-colonic reflex.
Where do most bowel signs originate?
Most bowel sounds originate in the small intestine and occur every 5-15 seconds
When you ingest food what happens…
Ingesting food initiates peristalsis within the small intestine and subsequent motility within the bowel. This results in the need to defecate as a result of the gastro-colonic reflex.
The disruption of bowel sounds is known as…
Is known as ileus
I.Ileus is normally a lack of bowel sounds
II.Most often the result of organic obstruction such as a fecalith or a tumor
III.It may also result form disease states (diabetes) or peritonitis
IIII.Abdominal distention, gas retention, and fluid retention are often associated with ileus
Hyperactive bowel sounds are in certain diseases such as…
Diarrhea
~ Early mechanical obstruction can result in hyperactive bowel sounds
Often this coincides with cramping and pain
~Late mechanical obstruction results in high-pitched sounds or ileus
In abdominal auscultation you shouldn’t be able to hear what..
The pulsation of the aorta, renal arteries or iliac arteries
Abdominal Auscultation facts…
a) As the bowel becomes ischemic, the frequency and intensity of the bowel sounds decreases
b) On examination, each quadrant should be auscultated for 1 minute before concluding that the bowel sounds are absent
Abdominal Percussion
- The normal abdominal percussion note is tympanic (hollow)
Example: Gastric air bubble (magenblasse) - The percussion note over fluid filled structures is dull
- An inflamed peritoneal membrane will always be tender to palpation and percussion. Therefore, always begin these activities at a site most distant to the pain
- As a result of abdominal ileus, the occluded bowel segment will percuss as tympanic, but usually elicit pain
Whats the type of note over a fluid filled structure on abdominal percussion?
The percussion note over fluid filled structures is dull
Abdominal Palpation
All four quadrants should be palpated and assessed for the presence of abdominal mass
The patient’s reaction to palpation is an important indicator of the nature of the pathology
Palpate the diameter of the patient’s aorta above the umbilicus
What does extremely painful abdominal palpation indicate?
Peritonitis
What does pain due to deep palpation on abdominal palpation indicate?
Obstructive bowel
What does slightly painful to light abdominal palpation indicate?
Early bowel inflammation
Whats a normal Aorta size?
Normal = 2.5-4cm
A normal pulsation should be palpated
What’s an abnormal Aorta size and what does it reflect?
An enlarged diameter (7cm) may reflect impending rupture
Abdominal &/or low back pain may indicate impending rupture
What’s Murphy’s Sign
Marked “inspiratory arrest” due to painful palpation of the liver or gallbladder
How do you do a Rebound Tenderness test?
Gently depress the abdomen away from the sight of the pain and then quickly release the contact and assess for increased pain.
Whats a non-specific test for an inflamed peritoneum?
Rebound Tenderness Test
What are the two tests to use for Abdominal Tenderness?
Murphy’s Sign
Rebound Tenderness
What’s Acute Abdomen?
- Distended superficial abdominal veins
- Abdominal distention associated with reflex ileus following functional obstruction, physical obstruction or ascites (free fluid in the abdomen)
General Findings in Acute Abdomen with percussion?
I.Percussion elicits sharp pain with peritonitis
II.Percussion elicits generalized pain with liver or spleen inflammation
III.RUQ percussion will elicit pain with gallbladder inflammation
IIII.Epigastric percussion will often elicit pain with peptic ulcers
Findings on palpation in Acute Abdomen
- On palpation, most abdominal conditions will exhibit muscular rigidity associated with peritoneal inflammation
- Cutaneous Hyperesthesia is commonly observed when palpating the area overlying the inflamed visceral structure
- Point tenderness is more commonly associated with parietal inflammation
A patient with Acute Abdomen complains of things that are usually of ..
- Abrupt onset
- Brief Duration
- Unknown cause
•The condition is usually associated with severe abdominal pain that is due to inflammation, perforation, obstruction, infarction (necrotic tissue d/t inadequate blood supply), or rupture of the intra-abdominal muscles
Key Elements of Acute Abdomen?
- Pain characteristics
- Evidence of shock
- Evidence of abdominal distention
- Characteristics of bowel sounds
- Evidence of peritonitis
Pain Characteristics in Acute Abdomen?
- Where was the pain initially?
- Where is the pain now?
- Where has the pain referred or did it radiate to other sites?
- Remember; Visceral pain is most often central or peri-umbilical
- Intermittent, wavelike colic is the most common form of visceral pain. It is often a manifestation of increased peristalsis
- Colic is associated with irritation or infection
- A continuous or steady visceral pain is seen with inflammation or ischemia
- Remember: Parietal pain is sharper and more well localized
- Parietal pain is usually continuous or steady
Evidence of Shock
1.Assess the patients vital signs : BP, Temp, Pulse, Respiration
2.Pulses should be checked in all four extremities to rule out abdominal aneurysm
3.If you suspect trauma, assess patient in the standing position
4.Orthostatic HTN in a patient with acute abdominal pain implies intra-vascular volume depletion
5. Patient will exhibit tachycardia
6. Cold, clammy extremities may aslo be noted
7. The patient may be asked questions to assess patient’s awareness of person, place, and time. The assesses normal mentation.
I.What’s your name?
II.Where are you?
III.What day is it?
The 5 F’s of increased Abdominal Girth
I.Fat
II.Feces: Constipation or intestinal obstruction
III.Flatus: Constipation or intestinal obstruction
IIII.Fetus: Pregnancy or other abdominal masses
V.Fluid: Ascites
Evidence of Abdominal Distention
- Ascites is the presence of free floating fluid within the abdominal cavity
- A shifting dullness or fluid wave is palpable with movement of the abdomen as the fluid moves to shift to another gravity dependent position
•Characteristics of bowel sounds (see independent conditions)
Evidence of Peritonitis
- Involuntary guarding is the most reliable indicator of parietal peritonitis
- Despite the physician’s care, the abdomen still tenses in response to palpation
- Rigidity of the abdomen refers to a constant, unyielding, board-like hardness of the abdomen. It implies advanced peritonitis
Factors that increase the likelihood of acute abdomen
a) Increased pain with deep inspiration
b) Persistent vomiting that provides relief of sx suggests intestinal obstruction
c) Feculent vomitus suggests intestinal obstruction
d) Frank blood or melena in the vomitus suggests gastro-intestinal obstruction
E) Undigested food in the vomitus suggests gastro-intestinal obstruction
F) Constipation that precedes onset of pain by 2-3 days
G) High fever (>39.4oC/102oF)
H) Use of corticosteroids (edema/stomach ulcers)
Factors that decrease likelihood of acute abdomen
a) Vomiting that precedes onset of pain by an hour or more
b) Vomiting without pain
c) Presence of bile in vomit
Exam findings that may suggest acute abdomen
a) Localized, unchanging, severe, direct pain under the examiner’s hand
b) Rebound tenderness
Contralateral Tenderness in Acute Abdomen
I.Pressure to the opposite side of the abdomen reproduces the symptomatic pain
II.Example: Rovsing’s sign in appendicitis - pressure in the LLQ over the position corresponding to McBurney’s point elicits pain
Where is Mcburneys Point?
2/3rd the distance from umbilicus to ASIS
What test do you use for pain in the neck or shoulder that is accompanied by abdominal pain?
Kehrs Sign
- Diaphragmatic friction rub from an inflamed liver or spleen (Kehr’s sign)
- Kehr’s sign is a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone.
What do you do if you suspect someone has acute abdominal pain?
Call 911
Disorders that sometimes mimic acute abdomen?
A)Cardiac disorders: MI, Pericarditis, CHF leading to liver failure
b) Pulmonary disorders: pneumonia, pulmonary embolus, pneumothorax
c) GI tract disorders: gastroenteritis, food poisoning, pancreatitis
d) Urologic Disorders: ureterolithiasis, pyelonephritis
E) Gynecological disorders: PID, Ovarian cyst, ectopic pregnancy
f) Neurologic disorders: Nerve root compression, Herpetic zoster
G) Metabolic disorders: diabetic ketoacidosis, lead poisoning, narcotic use
h) Hematologic disorders: acute leukemias
Anatomy of Esophagus
- The upper esophageal sphincter (UES) represents a 2-4cm region of increased intra-lumenal pressure
- UES is found at the level of the cricoid cartilage and the body of the C6 vertebra
- Relaxation of the UES relies on neurological control of the CNS to allow the food bolus to pass through
Upper Esophageal Sphincter Dysphagia occurs from lesions to what?
Cranial nerve IX, X, or XI, posterior pharyngeal diverticuli, SOL’s (space occupying lesions), trauma or edema
What controls normal swallowing?
oro-pharyngeal swallowing center within the medulla
How many times does an adult swallow? Hee hee ;)
Normal adults swallow about 600x a day, but only 200 of these occur while eating
Where is the lower esophageal sphincter found?
The lower esophageal sphincter (LES) is found below the level of the diaphragm
Lower Esophageal Sphincter facts
- The LES tends to move axially with respiration and is tonically constricted as is the UES
- Relaxation of the LES is mediated locally approximately 1-2 seconds after the act of swallowing
- There exists a thickened mucosal layer at the level of the LES
What does the “anti reflux barrier rely” on?
Relies on a competent LES
Normally, the resting LES pressure is >12mm Hg than intragastric pressure. Any increase to intragastric pressure can normally be met by a reflexive increase in LES pressure
Factors affecting Lower Esophageal Sphincter Competency?
a) Increase LES resting pressure helps prevent gastric reflux
b) LES basal pressure is increased by: Gastric alkalization, protein meals, increased intra-abdominal pressure, and gastrin
c) LES basal pressure is decreased by: Gastric acidification, nicotine, alcohol, fat, caffiene, nitrates and mints (spearmint, peppermint)
What is Globus Hystericus?
The sensation of a lump in the throat. It is caused chiefly by emotional disorders
What is Odynophagia?
Pain upon swallowing. Implies mucosal inflammation and/or spasm of the esophageal musculature
What is Esophagitis?
Causes linear, substernal burning from the stomach to the oropharynx and it may arise from dysphagia
What is Dysphagia?
Difficulty in swallowing. It is the sensation that food is impeded from passing from the mouth to the stomach
What is Anatomic Dysphagia (obstructive disorders)?
Most often due to mucosal inflammation (sore throat)
Also seen with SOL’s
First noted as difficulty swallowing solid foods
It is more often of insidious onset
What is Neuromuscular Dysphagia (motility disorders)?
Seen with lesions of skeletal and/or smooth muscle
It can arise from altered neuromuscular coordination from TIA of CVA
It is first noticed with both liquids and solids
It tends to be more rapid and progressive
What is Pre-esophageal dysphagia?
Apart from a sore throat, there are conditions that can obstruct the oropharynx
Zenker’s Diverticulum
Extrinsic obstructions of the oropharynx can also result in dysphagia. The most common of these is post-traumatic cervical whiplash syndrome
What is Zenker’s Diverticulum?
Zenker’s Diverticulum:
I.Herniation of the esophagus forms a pouch in which food collects at the level of the cricoid cartilage
II.These patients are most often males over 60 complaining of intermittent dysphagia accompanied by halitosis and regurgitation of undigested food
Esophageal Edema is most often caused by what?
The edema is most often due to retro-pharyngeal hematoma
What is GERD?
•Gastroesophageal Reflux Disease
Primarily the result of acid refluxing into the esophagus and produces an epigastric pain or substernal pain that most people commonly describe as heart burn
Factors involved in GERD?
- An incompetent LES
~ Patients who suffer from GERD have inadequate LES baseline pressures that result in free reflux with bending, straining or lifting - Reduced esophageal clearance
~ Swallowing induced peristalsis is less frequent when we are sleeping and therefore patients who eat before going to bed increase the likelihood of esophageal exposure to acid - Delayed gastric emptying: primarily due to meal with high fat content
- Late pregnancy:
~ The sub-diaphragmatic portion of the esophagus is pushed above the diaphragm inhibiting normal reflux barriers
Are Hiatus Hernias involved with GERD?
Hiatal hernias are generally not a factor associated with GERD although they may impede esophageal clearance in some patients
GERD Symptoms
- Symptoms triggered by dietary indiscretion and/or bedtime snacking
- Heartburn normally occurs 30-60 minutes after a meal
- Symptoms are aggravated or triggered by bending forward
- Symptoms relieved by taking antacids or baking soda
GERD Patients complain of what?
a) Sour reflux and bitter taste in the mouth
b) Pyrosis: retro-sternal pain and burning
c) 40% of patients report referred pain to the intra-scapular spin
d) 5% of patients report referred pain to the left arm
e) NB: Must be differentiated from cardiogenic chest pain
What is Pyrosis?
retro-sternal pain and burning
Complications of GERD?
- Barret’s Esophagus
2. Aspiration pneumonitis
What is Barret’s Esophagus?
epithelial cells of the LES are chronically damaged and undergo metaplasia to form columnar epithelium. If a Barret’s esophagus progresses, it most usually results in an adenocarcinoma of the lower esophagus
What is Aspiration pneumonitis?
The aspiration of acid into the lungs with resultant chronic lung inflammation
Conservative Tx of GERD?
- Enhance esophageal clearance by eating smaller meals and not lying down after eating
- Improve the physiologic barrier by avoiding nicotine, alcohol, caffeine, chocolate, peppermint, spearmint and fat
- Minimize chemicals that stimulate acid production such as caffeine, decaffeinated coffee, alcohol, colas, tobacco, red peppers, niacin and calcium supplements
- Minimize use of gastric irritants: aspirin, anti-inflammatory medications, NSAIDs, chili peppers, cloves, etc.
Gastric Secretions
- A heavy layer of mucus produced by the mucosal cells, protect the mucosa from stomach acid
- Pepsinogen is a peptidase secreted by chief cells within the gastric pits of the mucosa
- Hydrochloric acid is produced near the top of the gastric pits by parietal cells
- All three of these substances are produced in response to stimulation by the parasympathetic nervous system
The gastric mucosal barrier is protected by…
is protected by releasing the acid and inactive pepsinogen with gel-forming mucus within the neck of the gastric pits. Surrounding epithelial cells release bicarbonate and anti-inflammatory prostaglandins into the gel-like mucus to protect the pit
Agents that break the stomach mucosal barrier?
1.Aspirin
~Aspirin in an acidic environment is not ionized, is readily absorbed and can destroy surface epithelial cells
~ Aspirin can also inhibit prostaglandin formation at the neck of the gastric pits
2.NSAIDs
~NSAIDs and aspirin inhibit prostaglandin synthesis which also leads to reduced bicarbonate production
- Alcohol
~ Alcohol is readily absorbed across the stomach mucosa and can lead to gastric inflammation and/or erosion - Ischemia may accelerate a breakdown caused by other factors and may also be a factor in stress induced ulcers
Consequences of a break in the mucosal layer?
- With little or no acid in the lumen of the stomach, any break in the mucosal barrier can be regenerated with little to no bleeding
- These tears can repair themselves within 24-48 hours
- With acid in the stomach, once the barrier is broken, cells desquamate and interstitial fluid leaks into the lumen
- Acid stimulates gastric motility and pepsinogen secretion and the acid activates the pepsinogen to pepsin that further destroys the mucosa
- Acid also stimulates histamine release there by causing further acid production and greater vascular permeability that increases the severity of the bleed
- The acid/inflammation may cause rupture of the blood vessels and cause overt bleeding
- This process may continue until the noxious stimulus is removed and/or the acid is neutralized
NSAID facts on gastro toxicity
Gastrointestinal toxicity resulting from the use of NSAIDs is the primary adverse reaction reported to the FDA. The FDA estimates that up to 4% of chronic NSAID users will develop upper GI bleeding, a symptomatic ulcer, or an intestinal perforation each year. Up to as many as 2000 deaths occur annually as a result of NSAID induced GI injury
What is Acute Gastritis?
- Gastritis is a non-specific term used to refer to an inflammatory condition of the stomach
- It can only be verified by endoscopy (with biopsy)
- Acute gastritis is most often due to exogenous causes
- The inflammation in acute gastritis is usually superficial in nature
- The inflammation usually results in petechiae and focal erosions in the mucosa
Most common causes of acute gastritis?
a) Chronic alcohol use/abuse
b) Chronic aspirin or NSAID use
c) Heavy smoking is regularly implicated as having a synergistic effect on the actions of alcohol, ASA, and NSAIDs
Other causes of acute gastritis
a) Chemotherapy or radiation therapy
b) Stress ulceration
c) Enterotoxins associated with food poisoning
d) Infectious diseases
What is Dyspepsia?
Epigastric pain or discomfort accompanied by fullness, burning, belching, bloating, nausea, vomiting, fatty food intolerance or difficulty finishing a meal. Bowels remain essentially normal
SSX of Acute Gastritis?
Dyspepsia: Epigastric pain or discomfort accompanied by fullness, burning, belching, bloating, nausea, vomiting, fatty food intolerance or difficulty finishing a meal. Bowels remain essentially normal
If the patient reports vomiting, it will occur post-parandially
Minimal or occult GI bleeding is very common
TX of acute gastritis
symptomatic, palliative, avoid gastric irritation
Acute gastritis is a common cause of GI bleeding (30%), what are the 3 kinds?
1) hematemesis
2) melena
3) hematochezia
what is hematemesis
vomit frank blood (fresh red)
what is melena
black tarry stools (bleeding must exceed 50mg/day to show)
what is hematochezia
pass frank blood thru the rectum
What are the two kinds of Peptic Ulcers Diseases (PUD)
1) gastric
2) duodenum
what is an ulcer
lesion that penetrates muscularis mucosa
What are the two main causes of peptic ulcers
1) heliobacter pylori (primary cause of duodenum- 90%)
2) NSAIDs (aspirin)= most ulcerogenic (primary cause of gastric)
NSAIDs complications:
higher doses, advanced age, first three months, corticosteroid use, prior PUD history, other medical illness
PUD is more common in ….
smokers
PUD SX
1) dyspepsia (not specific enough to use as diagnostic)
2) exaggerated sensation of hunger
3) rhythmic pain (day/night)
4) food (better= duodenum, worse= gastric)
5) ulcer perforation= eating sx, change in rhythmic sx to constant, radiating pain
6) anemia= GI bleeding
which ulcer type is more common
duodenum
ages for duodenum ulcer
30-55
ages for gastric ulcer
55-70
which ulcer type is increasing in incedents
gastric, duodenum is decreasing
ulcer pain:
duodenum: well localized, gnawing, aching
gastric: variant epigastric pain
weight change with ulcers
duodenum: gain
gastric: lose
sleep and ulcers
duodenum: may wake patient at night
gastric: uncertain
ulcer complications
duodenum: smoking
gastric: alcohol, NSAIDs
risks of duodenum ulcers
1) genetic (first degree relative= 3x more likely)
2) hyperacid secretion (increase parietal activity)
3) rapid gastric emptying
4) stress
ulcer TX
1) avoid irritants/LES inhibitors/ gastric acid sectretogues (caffeine, alcohol)
2) avoid nicotine and supplements (patch/gum)
3) rule out food sensitivities
4) include zinc (100mg/day), glutamine (400mg before bed)
5) 1L cabbage juice/day
Gastric Carcinoma risk factors
1) chronic gastritis
2) 85% over age 50, rare under 40
3) more common in men
is gastric carcinoma increasing or decreasing is occurance?
increasing
gastric carcinoma SX
- rarely occur unless advanced
1) dyspepsia with weightloss
2) antacids offer early relief, not for advanced
complications of gastric carcinoma
hematemesis, low esophageal/pyloric obstruction, melena, progressive dysphagia, metastasis
diagnosis of gastric carcinoma
examination= unremarkable
enlarged virchows node
anemia
1) endoscopy
2) biopsy
