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  <head>
    <title>016-02 Pattern localisation, blood-gas compensation, and investigation quality</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Localisation, compensation and investigation quality">
      <outline text="Localising the respiratory problem">
        <outline text="Upper airway: stridor, voice, swallowing, position"/>
        <outline text="Conducting airways: wheeze, cough, mucus, variable flow"/>
        <outline text="Alveolar: hypoxaemia, crackles, opacities"/>
        <outline text="Interstitial: reduced compliance and diffusion"/>
        <outline text="Vascular: dead space and right-heart load"/>
        <outline text="Pleural: pain and mechanical restriction"/>
        <outline text="Pump failure despite normal parenchyma">
          <outline text="Central, spinal, nerve, junction, muscle, wall, obesity"/>
          <outline text="Weak cough and bulbar dysfunction raise aspiration risk"/>
          <outline text="Normal early saturation does not exclude failure"/>
        </outline>
        <outline text="Tempo refines localisation">
          <outline text="Abrupt: pneumothorax, embolism, pleural irritation"/>
          <outline text="Months to years: chronic airway, interstitial, vascular"/>
        </outline>
      </outline>
      <outline text="Examination as transmission tests">
        <outline text="Percussion asks how tissue transmits sound">
          <outline text="Air resonant, fluid dull, excess gas hyperresonant"/>
        </outline>
        <outline text="Fremitus and vocal resonance follow voice vibration">
          <outline text="Airless lung with an open airway transmits strongly"/>
          <outline text="Pleural fluid or gas separates lung from chest wall"/>
          <outline text="Bronchial breathing above a large effusion"/>
        </outline>
        <outline text="Crackles are brief discontinuous sounds">
          <outline text="Fine late: sudden opening of small stiff airways"/>
          <outline text="Coarse: larger-airway secretions, change after cough"/>
        </outline>
        <outline text="Wheeze needs airflow, so severe obstruction goes quiet"/>
        <outline text="Asymmetry has high localising value">
          <outline text="Dullness suggests fluid, hyperresonance pleural gas"/>
          <outline text="Confirm anatomy with ultrasound or radiography"/>
        </outline>
      </outline>
      <outline text="Blood-gas compensation step by step">
        <outline text="A normal pH can hide two opposing disorders"/>
        <outline text="Compensation never overshoots the opposite state"/>
        <outline text="Respiratory acidosis: buffers first, kidneys over days"/>
        <outline text="Metabolic acidosis should lower carbon dioxide"/>
        <outline text="Carbon dioxide above expectation: added respiratory acidosis"/>
        <outline text="Carbon dioxide below expectation: added respiratory alkalosis"/>
        <outline text="Metabolic alkalosis: hypoxaemia limits hypoventilation"/>
        <outline text="Anion gap estimates unmeasured anions"/>
        <outline text="Hypoalbuminaemia conceals an important gap"/>
      </outline>
      <outline text="Oxygenation and sampling reliability">
        <outline text="A sample after a device change is not at equilibrium"/>
        <outline text="Device and flow are part of the result"/>
        <outline text="Air bubbles raise low oxygen, lower high carbon dioxide"/>
        <outline text="Delayed analysis consumes oxygen, makes carbon dioxide"/>
        <outline text="Venous contamination lowers measured oxygen"/>
        <outline text="An inconsistent result needs a sample-quality review"/>
        <outline text="Oximetry gives trend, not pH or carbon dioxide"/>
      </outline>
      <outline text="Pulmonary-function quality">
        <outline text="Early termination lowers capacity and raises the ratio"/>
        <outline text="Cough, leak, glottic closure and pain leave signatures"/>
        <outline text="Lower limit of normal beats one fixed ratio"/>
        <outline text="A low value is not automatically important"/>
        <outline text="Total lung capacity establishes restriction"/>
        <outline text="Diffusing capacity needs haemoglobin interpretation"/>
        <outline text="Transfer coefficient is not a hidden normal lung"/>
      </outline>
      <outline text="Imaging patterns and pre-test probability">
        <outline text="Technical adequacy first: rotation, inspiration, supine"/>
        <outline text="Air-space opacity: infection, oedema, haemorrhage, tumour"/>
        <outline text="Interstitial pattern: oedema, fibrosis, lymphatic spread"/>
        <outline text="Distribution, air bronchograms and time course narrow it"/>
        <outline text="Nodules: size, morphology, risk and prior imaging"/>
        <outline text="Pleural sliding argues against pneumothorax at that point"/>
      </outline>
      <outline text="Microbiology and invasive sampling">
        <outline text="Squamous cells suggest oral contamination"/>
        <outline text="Lavage samples a defined region but adds risk"/>
        <outline text="Tissue is needed for architecture, invasion, malignancy"/>
        <outline text="Molecular assays stay positive after viability falls"/>
        <outline text="Culture is slower but gives susceptibility"/>
        <outline text="Pleural fluid: systemic pressure or local pleural disease"/>
      </outline>
      <outline text="Closing the diagnostic loop">
        <outline text="Reconcile every result with the physiological model"/>
        <outline text="Normal spirometry with episodic wheeze: look further"/>
        <outline text="Severe imaging, mild symptoms: assess reserve"/>
        <outline text="Treatment failure: adherence, technique, resistance, second pathology"/>
        <outline text="Document oxygen, rate, work, speech, gas trajectory"/>
        <outline text="Safety comes from convergence, not one image"/>
        <outline text="State the decision an invasive test will change"/>
        <outline text="Weigh procedural risk against what can be established"/>
        <outline text="Prepare reserve, urgency, alternatives, specimen handling"/>
        <outline text="Serial observation needs constant measurement conditions"/>
        <outline text="Record rest or walking, position, oxygen, inhaler, fever"/>
        <outline text="Same saturation on more oxygen is deterioration"/>
        <outline text="Falling rate with falling volume means exhaustion"/>
      </outline>
    </outline>
  </body>
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