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Category: Pulmonology

LUNG AUSCULTATION: HEARING CRACKLES

LUNG AUSCULTATION: HEARING CRACKLES

You are seeing a patient with suspected pneumonia. Your attending hears crackles but you do not hear them. Later the radiograph shows pneumonia right where the attending heard crackles. What can you do to improve your pulmonary examination?   Sit up and take a deep breath might be bad advice?   Increase signal Sensitivity for auscultation of crackles is increased in the supine position. Should you always listen supine? No. That is hard to do because anterior is less helpful…

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PNEUMONIA: CLINICAL VS RADIOGRAPHIC DIAGNOSIS

PNEUMONIA: CLINICAL VS RADIOGRAPHIC DIAGNOSIS

An elderly patient presents with cough and shortness of breath. The resident says the lung examination is normal and the chest x-ray is negative and wants to send the patient home. But you hear crackles posteriorly at the right base. And the oxygen saturation is 94%. And the patient looks ill. What do you do?   If your practice is to use chest radiograph as the gold standard for pneumonia (following IDSA guidelines – Mandell 2007) then you might be…

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COPD EXACERBATION AS A DIAGNOSIS OF EXCLUSION?

COPD EXACERBATION AS A DIAGNOSIS OF EXCLUSION?

A patient a history of COPD presents with shortness of breath. Physical examination shows pursed lip breathing, prolonged exhalation, recruitment of accessory muscles, etc. COPD exacerbation, right?   Hold on. Have a COPD patient jog around the parking lot and they will look just the same. Anything that causes shortness of breath in a COPD patient will accentuate the physical signs of COPD. All those signs mean is that they are either having to breath harder, or deal with secretions….

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RECOGNIZE APNEA RISK FOR BRONCHIOLITIS IN THE FIRST 2 MONTHS OF LIFE

RECOGNIZE APNEA RISK FOR BRONCHIOLITIS IN THE FIRST 2 MONTHS OF LIFE

A 5 week old presents with nasal congestion and difficulty breathing. RSV bronchiolitis is ultimately diagnosed. Can the patient go home? Not every infant with bronchiolitis can be admitted. But the ED provider must be aware that the dreaded complication of apnea tends to occur in patients who are under 2-3 months old. The studies on apnea from bronchiolitis are heterogeneous and the results are mixed. For example the incidence of apnea in newborns varies from <1% to 24% (Ralston…

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SUPINE POSITIONING CAUSES AUTO-PEEP

SUPINE POSITIONING CAUSES AUTO-PEEP

Why do some critically ill patients, when they are laid flat for intubation, either get worse or sometimes even go into cardiac arrest?  Patients with CHF, COPD, and morbid obesity are all known to have expiratory flow limitation when laid supine. They do not exhale all the way. This is air trapping, small airways are occluded.  The simplest way to think about it, and perhaps there is more to it, is that the diaphragm is compressed by abdominal contents. Supine,…

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LOOK, LISTEN, AND FEEL: PHYSICAL DIAGNOSIS OF PULMONARY HYPERTENSION

LOOK, LISTEN, AND FEEL: PHYSICAL DIAGNOSIS OF PULMONARY HYPERTENSION

Pulmonary hypertension is known for being difficult to diagnose, but there are some physical signs that may offer a clue: Giant A waves in the jugular venous pulse. Loud P2 a parasternal heave at the left lower sternal border 1) Giant A waves in the jugular venous pulse can be a sign of pulmonary hypertension.  The A stands for atrial systole, and is present just before the carotid impulse.  Paul Wood, a famous cardiologist and teacher from the 20th century,…

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