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UKRAINIAN MINISTRY OF PUBLIC HEALTH
Vinnytsya National Medical University n.a. M.I. Pyrogov
«APPROVED»
At the methodological meeting of the internal medicine propedeutics department
Chief of the department
____________ prof. Mostovoy Y.M.
«______»_______________ 200 ___ y.
Guidelines
for Third-year Students of the Medical Department
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Subgect |
Propedeutics of the internal medicine |
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Modul № |
1 |
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Enclosure module № |
1 |
|
Topic |
Instrumental and laboratory methods of examination of the respiratory system |
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Course |
3 |
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Faculty |
Medical № 1 |
Methodical recommendations are made in accordance with educationally-qualifying descriptions and educationally-professional programs of preparation of the specialists ratified by Order MES of Ukraine from 16.05 2003 years № 239 and experimentally - curriculum, that is developed on principles of the European credit-transfer system (ECTS) and Ukraine ratified by the order of MPH of Ukraine from 31.01.2005 year № 52.
Vinnytsya- 2007
Instrumental and laboratory diagnostic procedures are used for establishing suspected diagnosis or obtaining data that can help to reveal unclear or unexplained changes at the patient’s condition. Modern additional methods of examination are very various and informative. They are very important and indispensable for accurate and timely diagnostics of the respiratory diseases.
2. Concrete aims:
3. Basic training level
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Previous subject |
Obtained skill |
|
Biological physics |
Principles of radiology and optics |
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Normal anatomy |
Anatomy of the airways and lungs, their blood supply and innervation |
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Normal physiology |
Mechanics of breathing, gas exchange in the lung and tissues of system organs |
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Histology |
Ontogenesis of the respiratory tract, histological structure of the respiratory tract and alveoli |
4. Task for self-depending preparation to practical training
4.1. List of the main terms that should know student preparing practical training
|
Term |
Definition |
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Peak expiratory flow |
The highest speed of flow in the beginning of forced expiration |
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Pulse oximetry |
Non-invasive assessment of peripheral O2 saturation |
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Obstructive defect |
Reduced speed parameters more than volume ones |
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Restrictive defect |
Reduced volume parameters more than speed ones |
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Fibreoptic bronchoscopy |
Assessment of the large airways using fibreoptic tube inserted into their |
|
Pleural puncture |
Inserted special needle into pleural cavity for diagnostic or therapeutic aspiration pleural fluid at the patient with pleural effusion |
4.2. Theoretical questions:
4.3. Practical task that should be performed during practical training
Topic content
Lung function tests
Spirometry is a measure of airflow and lung volumes during a forced expiratory maneuver from full inspiration. It is the simplest of all respiratory functional tests. Indication for Lung function tests:
Correct interpretation of spirometry requires that it be performed correctly. To obtain an accurate recording the subject should be told to:
Two FEV1s and FVCs within 200 mL and within 5% of each other should be obtained.
Using spirometry tidal volume (VT), vital capacity (VC), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), forced vital capacity (FVC), forced expiratory volume in 1s (FEV1), forced expiratory flow between 25% and 75% of FVC (FEF25-75%), peak expiratory flow (PEF), maximum voluntary ventilation (MVV) can be measured.
All spirometry parameters depend on patient age, sex, height and weight. They are calculated by computer programs of spirometer and named predictor value. For patient normal values of lung function are 80% and more from predictor.
The FEV1/FVC ratio gives a good estimate of severity of airflow obstruction; normal ratio is 75-80%.
In case of obstructive defects (for example COPD or asthma) FEV1 is reduced more than the FVC and FEV1/FVC ratio is< 70%.
In case of restrictive defects (for example lung fibrosis, sarcoidosis, pneumoconiosis, interstitial pneumonias, connective tissue diseases, pleural effusion, obesity, kyphoscoliosis, neuromuscular problems) FVC is reduced and the FEV1/FVC ratio is normal or raised.
Peak expiratory flow (PEF) is measured by a maximal forced expiration through a peak flow meter. It correlates well with the forced expiratory volume in 1 second (FEV1) and is used as an estimate of airway caliber. Peak flow rates should be measured regularly in asthmatics to monitor response to therapy and disease control.
Pulse oximetry allows non-invasive assessment of peripheral O2 saturation. It provides a useful tool for monitoring those who are acutely ill or at risk of deterioration. On most pulse oximeters, the alarm is set at 90%. An oxygen saturation of <80% is clearly abnormal and action is required (unless this is normal for the patient, e.g. in COPD. Here, check arterial blood gases (ABG) as PaCO2 may be rising despite a normal PaO2). Erroneous readings may be caused by: poor perfusion, motion, excess light, skin pigmentation, nail varnish, dyshaemoglobinaemias, and carbon monoxide poisoning.
Fibreoptic bronchoscopy is an essential tool in the investigation of many forms of respiratory diseases. Under local anesthesia, the flexible bronchoscope is passed through the nose, pharynx and larynx, down the trachea, and the bronchial tree is then inspected.
Diagnostic indications:
Bronchial lavage fluid may be sent to the lab for microscopy, culture, and cytology. Mucosal abnormalities may be brushed (cytology) and biopsied (histopathology). Flexible biopsy forceps are passed down a channel inside the bronchoscope, and are used to obtain tissue samples for histological examination. In diffuse interstitial lung disease; such as sarcoidosis or pulmonary fibrosis, the technique of transbronchial biopsy can be used to obtain small specimens of lung parenchyma for histological examination and confirmation of the diagnosis.
Therapeutic indications:
Complications: respiratory depression, bleeding, and pneumothorax
Roentgenography or X-ray examination is commonly and widely used for diagnostics of the different respiratory diseases. It is obviously for confirming pneumonia, tuberculosis, pleural effusion, pneumothorax and revealing some form of lung cancer and other. For diagnostics of the respiratory diseases it should be performed in two positions: posterioranterior and lateral. If patient is bedridden anteriorposterior position is used but films of this position are inferior to posterioranterior view. Assessing X-ray film of the chest includes position, shadow of soft tissue (breast at women or subcutaneous layer at obesity patients, muscle and other), bones, diaphragm position, clear, opacity, different types of nodular shadows, mediastinum, heart and roots (hilum).
Computed tomography is cross-sectional scanning of the chest. This technique is more sensitive than plain radiography in detecting respiratory abnormalities. Computed tomography makes possible to distinguish more accurate tumors, small indurations, cavities and caverns in the lungs. This method is far better than radiographic studies at characterizing tissue density, distinguishing subtle differences in density between adjacent structures, and providing accurate size assessment of lesions. Indications for computed tomography:
Magnetic resonance imaging provides a less detailed view of the pulmonary parenchyma as well as poor spatial resolution. However, magnetic resonance imaging offers several advantages over computed tomography in certain clinical settings: for imaging abnormalities near the lung apex, the spine, and the thoracoabdominal junction. Vascular structures can be distinguished from nonvascular without the need of contrast.
Bronchography is an integral part of the diagnosis evaluation of diseases of bronchi. The standard technique requires the injection of contrast medium, usually iodolipol, into the bronchi lumen. This may be done through a catheter passed via the nose or mouth through the anaesthetized larynx. Then radiographs are taken, that give a distinct patterns of the bronchial tree. This procedure is of particular importance to the evaluation of bronchiectasis, abscesses, caverns in the lungs, and compression of the bronchi by tumor.
Sputum examination Collect a good sample; if necessary ask a physiotherapist to help. Note the appearance: clear and colorless (chronic bronchitis), yellow/green (pulmonary infection), red (hemoptysis), black (smoke, coal), or frothy white/pink (pulmonary edema). Send the sample to the laboratory for microscopy (Gram stain and auramine/ZN stain, if indicated), culture, and cytology.
Thoracentesis is performed to aspirate pleural fluid for diagnostic purposes and in case of a large effusion to remove fluid from pleural cavity.
Laboratory assessment of pleural fluid:
1. Common – visual assessment, comparative density, Rivalt test.
2. Biochemistry for measurement of protein, LDH, glucose, cholesterol, triglycerides, amylase, depending on the clinical circumstances.
3. Cytology for examination for malignant cells and differential cell count.
4. Microbiology for Gram stain and microscopy, culture, MBT examination.
Is the pleural effusion a transudates or exudates?
|
Sign |
Transudates |
Exudates |
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Comparative density |
< 1,015-1,018 |
>1,018 |
|
Rivalt test |
Negative |
Positive |
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Protein |
<30 g/l |
>30 g/l |
|
Pleural fluid protein/serum protein ratio |
<0,5 |
>0,5 |
|
LDH |
<1,6 mMol/l |
>1,6 mMol/l |
|
Pleural fluid LDG/serum LDG ratio |
<0,6 |
>0,6 |
|
Erythrocytes |
<10*109/l |
>100*109/l |
|
Leucocytes |
<1*109/l |
>1*109/l |
|
PH |
>7,3 |
<7,3 |
|
Glucose |
3,3-5,5 mMol/l |
<3,3 mMol/l |
Materials for self-control (added)
7. Reference source
Professor assistant Demchuk A.V.
Test for self-control
1. What is a spirometry?
a. Measuring airflow and lung volumes during a forced expiratory maneuver from full inspiration
b. Measuring inspiratory volume
c. Measuring tidal volume
d. Measuring airflow
e. All mentioned above
2. Which parameters can be measured with open spirometry?
a. FEV1, FVC
b. TLC, RAV
c. O2 saturation
d. O2 consumption
e. all mentioned above
3. Which types of the ventilation disorders do you know?
a. obstruction
b. restriction
c. mixed
d. all mentioned above
e. northing mentioned above
4. If patient’s FEV1 is low and FVC is normal, he has…
5. If patient’s FVC is low and FEV1 is normal, he has…
6. What is the lower limit of the normal parameters of lung function?
7. Ratio FEV1/FVC is used for diagnostics of
8. What is a peak flowmetry?
9. What is pulse oximetry?
10. What is normal level of the O2 saturation?
11. What is diagnostic indication for bronchoscopy?
12. What is therapeutic indication for bronchoscopy?
13. Which radiologic method of lung examination is routinely used?
14. Which radiologic method of lung examination has the highest level of resolution for distinguishing the smallest lung structures?
15 Which method of sputum examination is used for establishing the pathogen of pneumonia?
16. Which method of sputum examination is used for establishing revealing tuberculosis mycobacterium?
17. Which method of sputum examination may help to establish lung cancer?
18. How long should be sputum transported to laboratory for bacteriological investigation?
19. Which property could not transudes have?
20. Which property could not exudates have?
Control questions
4.3. Practical task that should be performed during practical training
Situation tasks
Task 1
20-year-old male patient, height 170 sm, never smoked, complaints of episodic wheeze and chest tightness, particularly in the early morning and during exercise. At auscultation you hear rough vesicular breathe.
Task 2
39-year-old female patient complains of dyspnea, cough with purulent sputum and left side chest pain. The symptoms appeared after hard work and overcooling 3 days before. At the visual inspection skin is pale and cyanotic, respiratory rate is 32 and left part of the chest is left behind from right. At auscultation you hear weakened vesicular breath sound and a fine soft crack in a pitch of the inspiration.
Task 3
74-year-old male was admitted to pulmonology department with hemoptysis. During examination patient’s general condition is moderate severe, at auscultation – weakened vesicular breath sound over lower right lobe. You suppose a lung cancer.
Task 4
47-year-old female patient notes dry cough and left side chest pain increasing at the deep breathing and cough. Patient condition is moderate severe, diffuse cyanosis; left part of the chest is left behind from right. At auscultation – absent of vesicular breathing over lower left lobe. You suppose a pleural effusion.