Handbook on Clinical Approach to Respiratory Medicine

Handbook on Clinical Approach to Respiratory Medicine

K Surendra Menon MD

Professor and Head Department of Pulmonary Medicine Mahatma Gandhi Medical College and Research Institute Puducherry, India

R Pajanivel MD

Professor Department of Pulmonary Medicine Mahatma Gandhi Medical College and Research Institute Puducherry, India

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Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2017, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/ author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/ editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: [email protected] Handbook on Clinical Approach to Respiratory Medicine First Edition: 2017 ISBN: 978-93-86261-77-9 Printed at

Dedicated to Medical profession

PREFACE Handbook on Clinical Approach to Respiratory Medicine is published with the intention of reaching out to the undergraduates, interns and postgraduates to understand the importance of proper case taking. Medicine is all about knowledge and observation. The essential element is the decisional process by probing history, recognition of signs and clinical reasoning. Hands, ears and the brain play a major role in diagnosing in spite of the laboratory tools available. As scientists, we are on a mission to alleviate the patients' sufferings and have to go deeper into every aspect of the patient’s disease process. The art of history taking and proper examination of the patient has become almost extinct. This book confines basically to case taking in respiratory medicine and will give the reader a deeper insight into history taking and examination of the patient. This methodology will help the reader in examining the other systems like CVS, CNS, etc. Without a correct diagnosis, all our efforts will be futile to treat the patient. K Surendra Menon R Pajanivel

Acknowledgments We express our gratitude to our family members, all the faculty and postgraduate students in the Department of Pulmonary Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India.

Contents

1. Anatomical Principles ■■ Important Anatomical Landmarks  1

1-16

2. Symptomatology ■■ Cardinal Rule to History Taking  17 ■■ Symptoms of Respiratory Diseases  19 ■■ History Taking  31 ■■ Making Provisional Diagnosis from History Obtained  33

17-35



36-75

3. Examination of Respiratory System ■■ Vital Signs  36 ■■ General Physical Examination  37 ■■ Examination of Respiratory System  45

4. Common Investigations in Respiratory Evaluation ■■ Diagnostic Tests  76 ■■ Certain Important Tests (Not Commonly Done)  79 ■■ Case Study I  79 ■■ Case Study II  80 ■■ Case Study III  81

76-82

5. Management of Pulmonary Emergencies 83-98 ■■ Acute Exacerbation of Bronchial Asthma  83 ■■ Acute Exacerbation of Copd 90 ■■ Tension Pneumothorax  92 ■■ Hemoptysis 94 ■■ Respiratory Failure  95

Index

99

introduction The content of the book emphasizes on the correct way of history taking, examination of the patient, relevant investigations and arriving at a final diagnosis. History taking is the time when the doctor and the patient get to know each other and the patient’s fears and concerns can be understood. The skills in taking history develop with experience; so, students are encouraged to take history independently. Difficult diagnostic problems are more often solved by carefully taken history than by a battery of laboratory tests. At the end of history taking, the examiner may be able to arrive at a few differential diagnoses before even touching the patient. Our studies have shown that the correct history taking will make us zero in, onto a possible diagnosis in nearly 80% of the cases. From examination point of view, long case includes history taking and examination of the patient. All systems are required to be examined. So, a quick history taking without missing any relevant points is essential and the ‘last minute panic’ can be avoided. It is advisable to finish the history taking in 10–12 minutes. But remember this pattern has to be followed after graduation also to become a successful clinician. Symptoms narrated by the patient should be carefully listened to and as a ‘medical detective’ ask pertinent questions as some patients may go off the track. Patient’s complaints should be documented and analyzed. Like a perfect diplomat, we should show tactfulness and patience when the subject mentions the complaint.

CHAPTER

1

Anatomical Principles IMPORTANT ANATOMICAL LANDMARKS One should have a clear understanding of anatomy of the respiratory system to perform a proper physical examination. Some of the important anatomical landmarks are outlined below. The upper respiratory tract starts from the mouth or nose and includes all the structures in the mouth, nose and sinus up to the larynx (the details of which will be discussed later). Lower respiratory tract, starts from the lower border of cricoid cartilage which includes the trachea, airways and lung parenchyma containing alveoli.

Trachea 1. Starts from cricoid cartilage (lower border of larynx at the level of 6th cervical vertebra posteriorly) to sternal angle anteriorly (angle of Louis) and T5 spinous process posteriorly, where it divides into left and right main stem bronchi. The inner diameter is 25 mm and the length is about 10–16 cm. 2. Trachea is generally in the midline but slight deviation to right may occur in normal individuals (by right aortic arch

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