감별 진단학 7
TRANSCRIPT
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감별 진단학
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Dyspnea
uncomfortable awareness of breathing, and as the experience of breathlessness
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acute dyspnea cause
Cardiovascular disease :
acute myocardial ischemia,
congestive heart failure,
cardiac tamponade
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Respiratory disease :
bronchospasm,
pulmonary embolism,
pneumothorax,
pulmonary infection (bronchitis, pneumonia),
upper airway obstruction
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chronic dyspnea cause
Obstructive lung disease : asthma, COPD
Restrictive lung disease :
interstitial lung disease,
kyphoscoliosis
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Nonpumonary cause :
congestive heart failure,
ischemic heart disease,
anemia,
obesity
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substernal chest pain- cardiac ischemia,
fever , cough, sputum-respiratory infection, Urticaria- anaphylxasis,
Wheezing- bronchospasm,
Stridor- upper airway obstruction
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Trepopnea Dyspnea
in one lateral position but not in the other cause Unilateral lung diseases, Unilateral pleural effusion, Unilateral obstruction of the airway, Chronic obstructive pulmonary disease ,
Congestive heart failure
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Orthopnea Dyspnea in the recumbent position
Cause
Left ventricular failure ,Mitral stenosis ,Obstructive airway disease, Respiratory muscle weakness, Diaphragmatic paralysis,
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Platypnea Dyspnea in the upright position and relieved by recumbency
Cause
Atrial septal defects ,Liver cirrhosis, Pulmonary arterial-venous malformation,Hypovolemia, Neuromuscular diseases
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physical examination,Chest X-ray,EKG ,ABGA, Spirometry
Chest X-ray : pneumonia, pneumothorax, pleural effusion, congestive heart failure
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Chest X-ray – normal
pulmonary embolism
deep vein thrombosis 의 risk factors
plasma D-dimer,perfusion lung scan
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Arterial Blood Gas Analysis :
acid-base balance,
PaO2
Spirometry : asthma, COPD, DILD, chest wall abnormality, lung resection
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Hemoptysis
haemoptysis is the expectoration of blood or of blood-
stained sputum from the bronchi, larynx, trachea, or lungs
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massive hemoptysis : 24 hours 100~600 cc
Cause
Tuberculsosis, Bronchiectasis,
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cause
Neoplasm ,
Bronchiectasis ,
Infections,
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Vascular
Pulmonary infarct and embolism ,
Mitral stenosis,
Iatrogenic rupture of pulmonary artery,
Arteriobronchial fistula ,
Ruptured thoracic aneurysm
AV malformation,
Vasculitis
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etc.
Anticoagulation therapy ,
coagulopathy,
Trauma
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most common causes of hemoptysis :
bronchitis.
bronchogenic carcinoma
most comnon causes of massive hemoptysis :
tuberculosis.
bronchiectasis
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Tracheobronchial Disorders sputum test (TB, parasites, fungi, cytology)
bronchoscopy,
HRCT High Resolution - CT
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Localized Parenchymal Diseases
sputum test (TB, parasites, fungi, cytology)
Chest CT ,
Lung biosy with special stains
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Diffuse Parenchymal Diseases
sputum test (cytology)
laboratory test(BUN, ANA, RF, ANCA Anti neutrophil cytopasmic Ab
)
Lung or kidney biopsy with special stains ,
HRCT
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Cardiovascular Disorders
echocardiography,
ABGA ,
Pulmonary arteriogram
CT
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Hematologic Disorders
Coagulation studies ,
Bone marrow biopsy
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treatment
bed rest,
Transfusion,
oxygen therapy ,
endotracheal intubation ,
DrugBronchiectasis- β-adrenergic agonist, theophylline
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Chronic bronchitis- mucociliary escalator,
Nonsmoking,
artery angiography+bronchial artery embolization
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pulmonary edema
Pulmonary edema is a condition characterized by fluid
accumulation in the lungs caused by back pressure in the
Lung veins.
Lung/pulmonary congestion , Lung water
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cause
A) cardiogenic : rise of pulmonary hydrostatic
(1) LA outflow impairment ,
(2) LV systolic or diastolic dysfunction ,
(3) LV volume overload ,
(4) LV outflow obstruction
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B) noncardiogenic:
pulmonary capillary permeability ↑blood pulmonary capillary pressure is normal
acute respiratory distress syndrome
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pathophysiology
Cardiogenic
pulmonary edema,left ventricular dysfunction,pulmonary capillary permeability ↑
pulmonary capillary wedge pressure : PCWP
non cardiogenic acute respiratory distress syndromePCWP
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non cardiogenic rare type
(1) altitude pulmonary edema
(2)neurogenic pulmonary edema
(3) Surgery
(4) toxic gases : Nitrogen dioxide, CO, Smoke
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Symptoms
Extreme shortness of breath,
severe difficult breathing ,
Feeling of "air hunger" ,
Inability to lie down ,
Rales ,
Wheezing
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Anxiety ,
Cough , Excessive sweating ,
Pale skin ,
Coughing up blood ,
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diagnosis
1) Chest PA
2) EKG : T wave inversion, QT↑
3) Swan-Ganz catheterization
4) Plasma brain natriuretic peptide (BNP) 20pg/ml
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treatment
Hospitalization ,
Oxygen is given ,
Medications FurosemideMorphine vasodilators
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acute respiratory distress syndrome
Severe, acute lung injury involving diffuse alveolar damage, increased microvascular permeability and
non cardiogenic pulmonary edema acute refractoryhypoxemia
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diagnosis
Acute onset
Oxygenation Pao2/Flo2<200 mmHg
Chest RadiographBilateral infiltrates seen on frontal chest radiograph
Pulmonary Artery Wedge Pressure
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CAUSE
Direct Lung Injury: a) pneumonitis
b) pulmonary contusion, penetrating lung injury
c) fat emboli
d) drowning
e) inhalation injury
f) lung transplant
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Indirect lung injurya) sepsis
b) severe trauma
c) drug over dose
d) acute pancreatitis
e) transfusion of multp blood products
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phase
1. Exudative (acute) phase - 0- 4 days
2. Proliferative phase - 4- 8 days
3. Fibrotic phase - >8 days
4. Recovery
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pneumonia
Pneumonia is an infection of one or both lungs which is
usually caused by bacteria, viruses, or fungi.
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(1)community-acquired pneumonia :
Streptococcus pneumoniae,Haemophilus influenzae,Moraxella catarrhalis,Mycoplasma pneumoniae,Chlamydia pneumoniae, Legionella pneumoniae
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(2)hospital-acquired pneumonia :
Klebsiella pneumoniae,Escheichia coli,Pseudomonas aeruginosa,Staphylococcus aureus
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symptoms:
fever, chills ,(cough, sputum, shortness of breath, Hemoptysis, chest
pain)
acute and purulent sputum- Bacterial pneumonia
subacute and not sputum - atypical pneumonia
hospital-acquired pneumonia
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diagnosis
Laboratory
leukocytosis ,
Chest Radiographradiological infiltration: infiltration
Gram stain and microbiological culture
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treatment
drugs
beta-lactam, macrolide,quinolone,tetracy-cline
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lung abscess
A localized area of destruction of lung parenchyma in
which infection by pyogenic organisms results in tissue
necrosis & suppuration
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Primary = abscess in previously healthy patient or in a
patient at risk for aspiration
Secondary = associated bronchogenic neoplasm or immunocompromised patient.
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cause
Peptostreptococcus, F. nucleatum,P. melaninogenica,Klebsiella pneumoniae,Staphylococcus aureus,Haemophilus influenzae
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diagnosis
cough,purulent sputum,hemoptysis,chest pain , increase of white blood cell count
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Treatmentpostural drainage
DrugPenicillin
Surgery
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tuberculosis
TB, is an infectious bacterial disease caused by Mycobacterium tuberculosis, which most commonly affects the lungs. It is transmitted from person to
person via droplets from the throat and lungs of people
with the active respiratory disease
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Mycobacterium
Nontuberculous mycobacteriosis(Mycobacterium avium, Mycobacterium kansasii)
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Symptoms (usually) lungs
lymph nodes ,bones, joints,
other organs fever , leukocytosis ,anemia, cough,hemoptysis ,dyspnoea
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diagnosis
Chest Radiograph
primary - middle lobe , lower lobe, ipsilateral en-larged
lymph
second - both lesions( upper) , Fibrosis, calcification
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tuberculosis’mass,
bronchiectasis,
airway obstruction,
pulmonary embolism,
pleural effusion,
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Sputum examination
There are direct smear and culture
Direct smear examination is only positive when large numbers of bacilli begin to be excreted
A negative smear by no means excludes tuberculosis
A negative smear in the presence of extensive disease and cavitation makes the diagnosis less likely.
Particularly if the negatives are frequently repeated
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Tuberculin testing
A positive tuberculin test although it is of great use in children, but it has limited diagnostic significance in older age groups
less than 5 mm (-) 5-9 mm is considered positive (+)10-19 mm is considered positive (++) more than 20 mm is considered positive (+++)
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treatment
drugs isoniazid,rifampicin,ethambutol,pyrazina-mide,streptomycin
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bronchiectasis
Bronchiectasis is a term that describes damage to the walls of the large airways, or bronchial tubes, of the
lung. Inflammation due to infection or other causes destroys the smooth muscles that allow the bronchial tubes to be elastic and prevents secretions that are normally made by lung tissue to be cleared
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cause Infectious causes
A) Virus Infection: Adenovirus, Influenza virus
B) Bacterial infection: Staphylococcus aureus, Klebsiella,
C) Tuberculosis
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decrease of the host defense mechanism
Localized impairment
Generalized impairment:(1) panhypogammaglobulinemia,(2) primary ciliary dyskinesia,(3) cystic fibrosis
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other cause ammonia ,
allergic bronchopulmonary aspergillosis(ABPA)
ulcerative colitis ,
rheumatoid arthritis ,
Sjögren's syndrome,
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symptoms
Continuous or recurrent cough,
purulent sputum ,
hemoptysis,
dyspnoea ,
wheezing
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Diagnosis
The radiological findings Chest radiograph
plate-like atelectasis,dilated and thickened airways,tram-track or parallel lines,
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impaction of mucopurulent plugs,
signet ring sign ,
cluster of cysts,
string of cysts,
air-fluid level within cysts
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bronchoscopy:
foreign bodies,
tumors,
structural deformity,
extrinsic compression by lymph nodes
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pulmonary function tests:
spirometry obstructive dysfunction (obstructive impairment)
FVC normal or decreased,
FEV1 and FEV1/FVC↓
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treatment
remove secretions(vibration),(percussion) ,(postural drainage)
drugs antibiotics drugs ( Ampicillin, Amoxicillin ,Trimethoprim -sulfamethoxazole)
Respiratory Relaxants
Surgerybronchial artery embolization