NOTES LABORATORY OF PNEUMOPATHY - DR.

JOEL BELTRE

CLINICAL HISTORY
The medical history (pneumopathology): is the confidential legal medical document that
It arises from the conversation between doctor and patient. The definition has been changing a bit over time.
the years since now with technology (SINCE JOEL has added) aside from legal-confidential
which can also sometimes be an electronic document that is no longer just the physical paper that
we found in the office and that does not cease to have legal character.
The medical history has two parts:
1. Anamnesis/conversational/interrogation/interview/passive part
2. Physical examination.

• Anamnesis or Conversatorio / is divided into 7 steps

To achieve an accurate anamnesis, these 7 steps must be taken:

1. General data/ personal data/ presentation data:
A) Datos de identificación: nombre (no influye en Dx), apellido, edad (clasificación
of pathologies that fall into the group), gender, ethnicity, nickname.
B) Geographic location data: nationality, origin, residence, (data of
location, its importance lies in the fact that respiratory pathologies are favored in
crowded environments, influence therapeutic measures,
C) Sociocultural data: education level (to be taken into account to know how it will be
direct the patient), marital status, occupation, religion (lifestyle habits, professional
2. Reasons for consultations/ signs and symptoms of presentation: it is the main cause for
that the patient goes to the doctor

- Rule: chronological order in medical terms and no more than 5. (Helps in the
clinical orientation
Technique: ask him what was the first thing that started to hurt

3. Current illness history: chronological account of how the reasons occurred

consultations. Intimate relationship with the reasons for consultations. (What, how, when)

4. Non-pathological personal background: sociodemographic background, where you live,

How many people, when they collect the garbage, if they burn it, how much do they earn?

5. Personal pathological background: it is divided by life stages: childhood,

adolescence, adulthood (it is said that the patient suffered in each stage) then it is put on the
toxic habits: coffee, tea, cigarette and he/she lists the surgical history: transfusions,
 medications, traumatic or dermatological history: e.g.: if you had chickenpox... if
The gynecological history goes as a woman.

6. Family medical history: what did the father/mother suffer from

7. Review by systems: besides signs and symptoms if you have anything else (always)
they collect signs
It doesn't matter the modification of the HC as long as its essence is not lost.
All the questions asked in the HC are to bring us closer to the diagnosis if it does not apply.

THORAX
The thorax is made up of the ribs, the sternum, the spine, the clavicle and the
Shoulder blades that are part of the rib cage

Function: protect the organs within the thorax from the cavity called the mediastinum.
The organs that occupy the largest volume are the lungs and the trachea.

The thorax, from a semiological point of view, is divided into 4:

1. Auscultation viewpoint:

A. an anterior thorax: heart

B. A posterior thorax; the lungs

C. A lateral thorax: heart and lungs

2. Inspection viewpoint: the place must be well lit because I will be looking for: stains,
nodules, masses, tumors, etc.

Within the endothoracic fascia are the mammary glands, which are the secondary characteristics.
feminine, but the man has it too. Some pathology may be found. The physical examination
moms is a whole section. During the inspection, the degree of symmetry is evaluated,

Alterations of symmetry (look it up).

3. Inside the inspection:

• Hair distribution: which can be stigmas of liver disease, if there is one.

universal alopecia, if there are tinea.

Lighting is important and the acclimatization will be inspected.

In the thorax, the 4 maneuvers are performed:

Inspection:
2. Auscultation:
3. Palpation:
4. Percussion:

There is no order in doing it, but the first is the inspection (view) by default.

Inspection and palpation are the two maneuvers that are always performed (they are everywhere
of the body)

The neck must be viewed from 5 different perspectives:

Osseous:
2. Vascular:
Muscular
4. Ganglionic:
Visceral

It is about seeking findings whether positive or negative.

Important: the thorax is divided by imaginary lines:

Anterior Thorax

A line passes through the middle of the thorax: mid-thoracic line or mid-sternal line
2. Parallel lines that run through the middle of the collarbone: midclavicular line
3. A line that passes through the middle of the armpit: anterior axillary
4. Two transversal lines: sixth costal line and third costal line

The lateral thorax: (search

Previous line:

In the posterior thorax, tumors called lipomas may appear: lipo: fat oma: body.
benign tumors of fat.

TYPES OF THORAX ON INSPECTION:

• pyramidal thorax
• In puppet (Shrek) patients with acromegaly
• In barrel: thorax with increased anteroposterior diameter, typical in patients with diseases.
respiratory, patients with bronchopulmonary diseases, obstructive or chronic diseases or COPD.
SIGN OF HYPERINFLATION. This occurs due to a decrease in volumes of
lung capacities are forced to constantly work the muscles
 breathing accessories and as a compensatory mechanism they widen the box
thoracic in search of a greater volume of air intake (it never happens) and that's why it
widen from front to back
• Diaphragm contributes 85% of breathing.
• If the muscle expands the thoracic cavity: inspiratory muscles
• If the muscle decreases the diameter of the thoracic cavity: expiratory muscles.
• Accessory muscles of respiration: inspiratory and expiratory: the rectus muscles of the abdomen,
the trapezius, he is sternocleidomastoid, etc. They are accesses because they participate in a way
passive in breathing: when the diagram has a problem, and the volumes and the
capabilities are diminished
• COPD: emphysema, chronic bronchitis, and small airway diseases

• Tension: contraction of the neck muscle. Active participation of the neck muscles.
breathing
• Retraction: intercostal muscles
• COPD Phenotypes: SEARCH

• Pink abogotado: the costal arches are marked because there is costal participation
• Blue abogotado: barrel-shaped thorax

From the bone point of view:

Bone pathologies that can affect the thoracic cage may include: tumors, fractures,
deformations

From the vascular point of view: aneurysms must be taken into account, although they are not
They can visibly cause compressive syndrome inclusion.

From a muscular point of view: a very common reason for consultation in internal medicine:
myalgias, neuralgias (herpes zoster (shingles)), they will never join the head because they continue
the course of a nerve and these do not form anastomosis

From the ganglionic point, tumors are taken into account, the thorax is divided into 7.
ganglionic levels.

Difference between a neoplastic lymph node and an inflammatory lymph node

- Neoplastic: they are painless, immobile, and are adhered to deep planes (the reason for which
they have less mobility), irregular shapes and surfaces
- Inflammatory: they are painful (main characteristic), very mobile, they are flatly adhered.
superficial, regular shapes and surfaces

A lymph node above the clavicle is an indicator of pathologies that are below it.
diaphragm. E.g.: lymph node metastasis of a gastric carcinoma. Or any other process
neoinflammatory that is below the diaphragm drains into the supraclavicular lymph node
left
And those that are above the diaphragm drain into the right supraclavicular lymph node.

Tumors can cause compressive syndromes: superior vena cava syndrome,

From a visceral point of view:

Inspection

Lungs: it needs to be inspected, to see how much the thorax expands, how much it relaxes. It has
two parts: one dynamic and the other passive

In the dynamics, the respiratory movements are seen.

In the passive, I see the static: the form, the hair.

Auscultation

The findings of both the right and left lung fields should be compared.

The normal sound of the lung is the vesicular murmur.

One does not auscultate over bone but over the intercostal spaces.

Vesicular murmur: it is the breathing heard through a stethoscope

Lung auscultation is performed during forced ventilation to clearly hear the alterations.

Liquid pleural pathologies (effusions), tumors or pneumonias decrease the fremitus.

The murmur is the passage of air through the respiratory tract.

If I have air in the lung, pleura: self-obstruction of the lung parenchyma and there is a
increase of the murmuring

Auscultation - pathological sounds

Crepitant stridor
2. Hissing Estridorr
3. Raucous stridor

Stridor: pathological noise or added to the lung.

Rumbles are noises that sound like snoring and occur when the air is obstructed or the flow
the air becomes rough through the large airways.
Sibilant is the passage of air through the airways.

• inspiration: foreign bodies

• On expiration: patient with asthma,

An endobronchial tumor is wheezing. Typical in wheezing on inspiration as the tumor

behaves like a foreign body and is localized.

Patient with asthma is heard throughout the lung as the inflammation is at a general level.
pulmonary parenchyma.

Creaking:

• Wet: typical of pulmonary edema

• Dry: pneumonias.

Palpation: thoracic expansiveness, place open hands under the lung at the scapula and
tried to join my two thumbs.

If it is pathological, the expansion will be slower or lesser.

Palpation, the vocal fremitus is also sought: sound words should be felt in the fingers.
vibrations and those vibrations are normal.

If there is no feeling, there is a decrease in fremitus. Translate: lung collapse.

CHEST X-RAY -
Chest X-ray
Everything is 4:

• 4 techniques
• 4 patterns
• 4 densities
Within the 4 techniques, we have centralization, inspiration, penetration, and rotation.
Among the 4 densities, we have air, water, fat, bone.
Among the 4 patterns are interstitial, alveolar, restrictive, mass.
These imaging methods have a nomenclature:
• Ultrasound: Anechoic or hypoechoic depending on the echo uptake

In radiography, two terms are used to refer to the image that will be projected onto the film.
X-rays.
• Radiolucent: it is an image that appears dark and is because it absorbs few X-rays
• Radiopaque: it is that image that appears white since it absorbs X-rays the most.
 In an X-ray (everything is reversed): The transparent is opaque and the opaque is transparent.

• Everything that is to the right of the doctor is really the left side of the patient.
• Everything on the left of the Doctor is the right side of the patient.

For example: 'look for a radiolucent image on the left side' you have to look for it on the right side.
There is a radiopaque image on the left side.
• Interface pattern theory: explains that for two anatomical structures to be observed
In a chest X-ray, there must be totally opposite densities.
When evaluating an x-ray, the first thing one assesses is the technique. Because if the technique is poorly done,
the elaborate is not worth evaluating the clinic
• There are 4 densities: we have air, water, fat, bone. THE HIGH DENSITIES ARE
CALCIUM AND AIR.
• The air and the calcium are radiopaque: white and then dark gray fat and light gray water are one.
gray scale
So for them to be clearly observed, they must have opposing densities. For example, the lung...
I see a whole blackness because it is filled with air and does not allow differentiation, but the heart can be visualized.
because it is a completely opposite density.
The x-ray device is called a chassis and must be attached to the anatomical area where it will be performed.
X-ray. The equipment that is facing is the X-ray beam and the tube that projects these.
When we talk about projections: posteroanterior, anteroposterior, lateral, lateral decubitus,
Bipedestation REFERS TO THE POSITION OF THE PATIENT IN RELATION TO THE CHASSIS OR RAYS
WHERE IT ENTERS AND WHERE IT EXITS.
• If the X-ray is anteroposterior: it enters through the front part of the patient and exits through the back part.
• If the x-ray is posteroanterior: I entered through the back and came out through the front.
• If rx is lateral: it is sideways.
• If it is lateral decubitus: it is lying down and on the side

The most commonly used projection in pulmonology and internal medicine is the posteroanterior projection.
The anteroposterior is used to determine if there is a fracture of the rib cage.
Generally, the posteroanterior X-ray is accompanied by another lateral X-ray in pulmonology.
the most used is the right lateral and cardiology on the left lateral.
The right lateral is frequently used since lung pathologies are more common in the
right side than the left. The cardiologist uses the left lateral more because the heart is
left-oriented.
A left-sided pathology is of poor prognosis.
The only reasons why the gastric camera is not seen:
• Because it was not done while standing.
• Because he/she ingested a large amount of food recently.

The visualization of the gastric chamber is indicative that the X-ray was taken in an upright position.

2D: height and width

3D: height, width, and depth (PA-LD)
• TECHNIQUES
There is no order for searching the techniques.

Criteria: centralized, inspired, rotated, and penetrated.

Criteria to know if it is inspired or not: it is to count the rib arches, which should be counted from 6-7 arches.
anterior costal cartilages and 8 to 9 posterior costal cartilages touching the corresponding hemidiaphragm
(depending on the side being counted).
The arch that is seen posterior turns out to be the anterior because the patient is facing backwards PA. The first
the arch marked on the x-ray is the posterior arch

The intercostal spaces can be counted as 7-8.

 When a posteroanterior X-ray is taken, the patient is asked to hug the chassis so that the...
scapulae because if they do not remove the visualization of the pulmonary field

Penetration Criterion: amount of lightning entering the structure. It depends on the location of the
chassis, distance beam-chassis (1.5 meters at minimum). If it is too close, it comes out very penetrated and
vice versa
3-5 spinous processes are counted
2. that the spine is observed through the cardiac silhouette.
For practice purposes, the vascular plot is not used.
Rotation Criteria: it is verified that the X-ray is not rotated, that one shoulder is not more inward or more outward.
outside of what it should be.
1. Both clavicles must be equidistant from the sternal joint. The spinous process is the
which is used as a reference to know that both sides are at the same distance. WHERE
IF THE EQUIDISTANCE IS LOST, IT IS BECAUSE THERE IS ROTATION.

Centralization:
Both cost angles must be viewed below and above what is above the
clavicles.

RADIOGRAPHIC PATTERNS
DX is not done with images.
4 radiographic patterns:
It is evaluated from top to bottom and from the inside out: subcutaneous tissue (fat), bone tissue, lungs
and trachea.
5th Density: Metal is pathological (it can be a bullet). It is more opaque than bone, it is above.
of the calcium.
Calcium density.
It is correct to perform a PA and lateral X-ray because it provides a better location of foreign bodies or pathology.

In Rx, everything straight is left.

• Radiopaque: white.
• Radiolucent: black.

If there is a radiopacity in the lung, it could be a bullet and therefore hemothorax. Or vascular congestion.
(collapsed lung, tries to compensate and there is condensation).

There may be pulmonary abscess, pneumonia, pulmonary congestion (radiopacity)

Trachea deviated to the right side, typical of pleural effusions, obliteration of the costophrenic angle.
left.
Destructive pattern: destruction of pulmonary parenchyma. Typical of neoplasms, COPD.
Hyperradiolucency (filled with air and black).
2. Alveolar pattern: diseases that affect the alveoli. It can be localized (in a single lobe)
and diffuse (it occupies the whole lung). Alveolar because it is fluffy. Typical of pneumonia.
 3. Nodular or interstitial reticular pattern: affects the lung interstitium. Typical of fibrotorax.
Pneumoconiosis and adult respiratory diseases.
4. Dough pattern: pierced dough.
Pleural effusions do not fit into any pattern, but if they were to, it would be in the mass category. Because of their
radiographic features that resemble each other. Pleural effusion is not a lung pathology but rather
pleural pathology. The trachea is deviated.
Pleural effusions are divided depending on the fluid: hemothorax if it is blood, chylothorax if it is lymph,
pyothorax if it is pus, hydrothorax if it is any liquid.
According to their origin, they are classified as traumatic and spontaneous.

Grade 2 pneumothorax: midclavicular line, the edge of the lung coincides with the midclavicular line.
Hyperradiolucency. There may be vascular congestion.
Destructive pattern: it can occur in TB or COPD.
Sign of the silhouette: when a density erases the cardiac density. Density that borders on the
heart rate.
To read Rx. Example: there is radiopacity or lucency at the right perihilar level that extends to the
base, which adjoins the cardiac silhouette cannot delimit it therefore it is subjective in sign of the
cardiac silhouette. Relate to clinic. (What is there, at what level and subjective of what), it is verified with the
clinic.

SPIROMETRY
Forced spirometry is an exploratory test used as an objective method.
for the assessment of lung function and for the monitoring of diseases
respiratory conditions that have a component specifically from the pulmonary part
Test that evaluates and assesses lung function
It is the most useful in clinical practice.
Forced spirometry measures lung volumes and flows and the speed at which
they move
The difference between a simple spirometry and a forced one is the time.
Forced spirometry takes time into account, but simple spirometry does not.
Amount of time considered for forced spirometry: 1 sec.
This test basically measures volumes and capacities.
• Spirometry is the basic test in pulmonology.
• In theory, it is easy to do, but in practice, it is not so simple.
Forced spirometry measures:
• FVC: Forced Vital Capacity: the volume that the patient is capable of expelling completely
expiration.
The maneuver consists of 3 steps:
Fill the patient's lungs with air.
2. Then the nose is covered with a ring and then they let the air out through the device.
3. Breathe in again

• FEV1: forced expiratory volume in the first second: the volume that it is capable of
expel the patient during the first second of expiration
• FEV1/FVC: it is the ratio expressed as a percentage (Tiffeneau index)

This is plotted volume-time,

The flow-volume curve always has to have the shape (look for the document)
The y-axis represents volume and the x-axis represents time.
3.5 liters of air: it's within normal range.
Parameters: (it doesn't matter to him that we learn them because the capabilities are enough)

In the flow-volume curve, flow is represented by liters x seconds.

Reference:
Forced respiratory flow:
• 25%:
• 50%
• 75%

To identify the so-called small airways disease, precursor of COPD (it really is
an COPD) or emphysema or bronchitis are changes in airflow in the airways and are noticeable in the flow
forced respiratory of 25-75%
The flow volume curve will have two loops: one upwards and one downwards. The loop that goes upwards
above is the expiration and the loop that goes down is the inspiration
Contraindication of spirometry:
• retinal detachment
• Recent or active pneumothorax
• Hemoptysis
• Recent cataract surgery
• Cardiac instability
• Severe or active respiratory crises
In children, because they will not understand the maneuver.
To the elderly
Patient with mental problems
It is necessary to explain why the study will be conducted.
Avoid the use of stimulating or depressant drugs, whether muscular or of the CNS, as
the study is sensitive to these, there is even a special spirometry that is done post
bronchodilation.
Both COPD and asthma present obstructive patterns, to differentiate in a spirometry a
obstructive pattern due to asthma or COPD is treated with a bronchodilator, as the reversibility of
the COPD is at 15% but in asthma it is higher since it responds very well to the
bronchodilators.
• cannot smoke hours before
• Do not exercise 30 minutes before

If the patient used beta2 with salbutamol, they must wait 6 hours to undergo the study.
If I use delayed-action Theophylline, I have to wait 36-48 hours.
There are sociodemographic variables:

• sex: because the woman's rib cage is smaller than the man's therefore
it has a smaller amount of volume
• age
• Height: because the taller the patient, the longer and larger their thoracic cavity will be.
volume will have
• Weight: overweight patients will have a decrease in volumes and capacities.
pulmonary as it will have a restriction of the elasticity of the compiganse at the level
pulmonary
• Ethnicity

An FEV1 of 70 in an obese patient is not the same as a 70 in a healthy patient.

The correct way is to do it with the patient sitting, with the chest uncovered, positioning of the
nozzle.
Acceptability criteria:
1. Start of the maneuver: rapid ascent
2. Duration of the maneuver: route near the reference points
3. Morphology of the curve: convex outward
4. Progressive completion near the FVC reference point.
Reproducibility criteria:
It is obtained from the difference between two of the 3 acceptable curves created. This is because
When one does the spirometry, the maneuver is done 3 times (inhale, exhale) maximum.
8.
2. The curve is reproducible if the difference in FVC is less than 5% or 100,000, which is
same. Example: 93-95-94
Spirometric patterns:
1. Obstructive pattern:
FVC: Normal
FEV1: Low
FEV1/FVC: Low

FEV1/FVC Normal: Greater than or equal to 70%

FEV1 and FVC Normal: Greater than or equal to 80%

Patologías: EPOC, ASMA, BRONQUIECTASIAS, FIBROSIS QUISTICA

Interpretation of the obstructive pattern

FEV1/FVC: Low
Normal
Low

Phase effort-dep equal

Decreased PEF
Phase in effort – superior concavity
Very gentle final slope

2. Restrictive pattern:
Low
FEV1: Low
FEV1/FVC: Normal

FEV1/FVC Normal: Greater than or equal to 70%

FEV1 and FVC Normal: Greater than or equal to 80%

Patologías: FIBROSIS PULMONAR, ATELECTASIAS, NEUMONECTOMIA,

PULMONARY EDEMA, CIFOISCOLIOSIS, NEUROMUSCULAR DISEASE

Interpretation:
FEV1/FVC: Normal
FVC: Low
Low

Similar, but sharper

Rapid ascent to the PEF and straight descent until cutting the axis
Mixed Pattern
FEV1/FVC: Low
Low
FEV1: Doubly low

FEV1/FVC Normal: Greater than or equal to 70%

FEV1 and FVC Normal: Greater than or equal to 80%

Pathologies: Combination of obstruction + restriction: Pneumoconiosis + COPD or COPD

very serious

Interpretation
FEV1/FVC: Low
FVC: Low
FEV1: Doubly low

Reduced size and obstructive morphology

SUMMARY OF SPIROMETRIC PATTERNS

DIAGNOSTIC ALGORITHM
Mayor

Merry Christmas

ATT: AP