clinicalclerkship呼吸系統(tǒng)課件

ClinicalclerkshipRespiratorysystemRenJiHospitalZouJingClinicalclerkshipRespiratory1BasicsciencetrainingDevelopclinicalscenarioProblemyouwillface:MedicalinformationPatientdata

InpatibilityoftwosetsofknowledgeBasicsciencetraining2Medicalknowledgeprisesmillionsoffacts

---organizedbydiseasestate---bypathophysiologyMedicalknowledgeprisesmilli3Willpatientspresentadiseasetoyou?LooselyconstructedchainofplaintsElaboratepsychologicalconstructtopreventdisclosureofpainfuleventsDealingwithhundreds,ifnotthousands,offactsWillpatientspresentadiseas4Clinician’sJobmanagetheinformationPatient’sdataneedtobetranslatedintoclinicalpresentationAtechnique:patibilityofknowledge

Thoughtprocesses:prisemuchoffabricofclinicalexperience

“secondnature“AccuratelyassessedClinician’sJobmanagetheinfo5Howcanwegettheinformationandpatient’sdata?MedicalvisitHowcanwegettheinformation6PurposeofMedicalvisitCarefulandpletehistoryThoroughphysicalexaminationPurposeofMedicalvisitCarefu7MedicalhistorychiefplainPresentPastFamilySocialhistoriesSystemreviewMedicalhistorychiefplain8MajorPulmonarysymptomsDyspneaCoughMajorPulmonarysymptomsDyspne9DyspneaGreekprefixof“dys”---painful,difficult,breathItisasubjectiveexperienceofbreathingdisfortthatisprisedofqualitativelydistinctsensationsthatvaryinintensity.DyspneaGreekprefixof“dys”--10DiagnosisapproachDifferentialdiagnosisofdyspnea:

lung,heart,chestwallneuromuscularrenalendocrinerheumatologichematologicpsychiatricdiseaseDiagnosisapproachDifferentia11Understand---Thegoalofrespiratoryandcardiovascularsystem:takeO2fromtheairtransferittohemoglobindeliverittometabolicallyactivetissuetransportCO2backtolung,toeliminate

Understand---Thegoalofresp12Theprocessofrespirationcanbedividedinto3ponents:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan13Theprocessofrespirationcanbedividedinto3ponents:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus

3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan14VENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

1)Stimulationofchemoreceptors--conditionsleadingtoacutehypoxemia(Impairedgasexchanger,Environmentalhypoxia)VENTILATORYCONTROLLERANDGAS15---conditionsleadingtoincreasedeadspaceand/oracutehypercapniaImpairedgasexchanger：asthmaImpairedventilatorpump:muscleweakness,airflowobstruction---conditionsleadingtoincre16--Metabolicacidosisa.Renaldisease(renalfailure,renaltubularacidosis)b.Decreasedogencarryingcapacity(eg.Anemia)c.Decreasedreleaseofogentotissues(hemoglobinopaty:thalassemia)d.Decreasedcardiacoutput--Metabolicacidosis17VENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

2)Stimulationofpulmonaryreceptors(Irritant,Mechanical,Vascular)ILDPleuraleffusion(pressiveatelectasis)PleuralvasculardiseaseCongestiveheartfailureVENTILATORYCONTROLLERANDGAS183)BehavioralfactorshyperventilationsyndromeanxietydisorderpanicattacksVENTILATORYCONTROLLERANDGASEXCHANGER—INCREASERESPIRATORYDIRVE

3)BehavioralfactorsVENTILATO19Theprocessofrespirationcanbedividedinto3ponents:

1)Acontroller,whichdeterminestherateanddepthofbreathing2)Agasexchanger,whichconsistsofthepulmonaryvasculatureandthealveolus3)Aventilatorpump,whichfacilitatesthemovementofgasintoandoutofthealveolusTheprocessofrespirationcan20VENTILATORYPUMP—INCREASEDEFFORTORWOROFBREATHING

MuscleweaknessDecreasedplianceofthechestwallAirflowobstructionVENTILATORYPUMP—INCREASEDEFF21Thekeyareasofinquiry(MedicalHistory)(1)qualityofthesymptom;(2)persistenceorvariabilityofthesymptom(3)aggravatingorprecipitatingsymptom.Thekeyareasofinquiry(Medi22IntermittentdyspneaPersistentorprogressivedyspneaNocturnaldyspneaDyspneaintherecumbentpositionPsychogenicdyspneaRaynaud’sphenomenonIntermittentdyspnea23CoughAseriesofrespiratorymaneuversthatleadtoacharacteristiccoughsound.Mostsensitivesitesforinitiatingcough:larynx,tracheobronchialtree,carinathepointsofbronchialbranchingCoughAseriesofrespiratorym24APPROCHTOCOUGHThe

causeofthecoughTreatthecauseAPPROCHTOCOUGHThecauseoft25moncausesofcoughmoncausesofcough26Coughwithsputumproduction:bronchitis,bronchiectasis3weeks–acutoffpointforanacutecough(duetoanupperrespiratoryinfection)Cough:acute,chronicCoughwithsputumproduction:27AcutecoughCause:

1.upperrespiratorytractinfection2.pneumonia3.congestivecardiacfailure4.AECOPD5.aspiration6.pulmonaryembolism

Acutecough28ChroniccoughCause:

AsthmaGERpostnasaldripchronicbronchitisbronchiectasisChroniccough29PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection30PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection31AppearancesuggestivebloodgasdisturbanceLookfordyspnea,tachypnea,slowRRPatient’sfingersforperipheralosisSkinforwarmthTongueandlipsforcentralosisAppearancesuggestivebloodg32ObservingtheshapeandsymmetryofthechestBarrelchestpectuscarinatumsurgicalscars

Observingtheshapeandsymmet33RhythmofbreathKussmaul’sbreathingCheyne-StokesrespirationsRhythmofbreath34RRlow(<10/min)--carbondioxidenarcosis--Drugs(alcohol,benzodiazepine)--RaisedintracranialpressureRRlow(<10/min)35PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection36ChestwallabnormalitieschestshapechestchangeonmovementforasymmetryBilateralpoorchestexpansionobesityEmphysemaUnilateralpoorchestexpansionPleuraleffusionPneumothoraxChestwallabnormalities37TracheadisplacedScoliosisPneumothoraxPleuraleffusionReducedvocalfremitusPleuraleffusionPneumothoraxTracheadisplaced38PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection39StonydullpercussionThisimpliespleuraleffusionDulltopercussionbutnotstonydullConsolidationPulmonaryedemausuallyduetoleftventricularfailureStonydullpercussion40HyperresonantpercussionEmphysemaLargebullaePneumothoraxHyperresonantpercussion41PhysicalexaminationInspectionPalpationPercussionAuscultationPhysicalexaminationInspection42DiminishedbreathsoundspoorrespiratoryeffortPleuraleffusionEndobronchialobstructionSevereasthmaEmphysemaDiminishedbreathsounds43BronchialbreathingConsolidationPulmonaryfibrosisFineinspiratorycracklesPulmonaryedemaPulmonaryfibrosisConsolidationBronchialbreathing44PleuralrubPl