9/8- Respiratory H&P Flashcards
What is dyspnea? What causes it (broadly)?
Def: subjective experience of breathing discomfort; the sensation is holistic
- Results from interaction (mismatch) of various efferent and afferent signals
- May be respiratory, cardiovascular, or non-cardiac non-respiratory
What are some specific causes of dyspnea?
(Recall: interaction/mismatch of various efferent and afferent signals)
- Mechanical interference with ventilation
- Weakness of respiratory pump
- Increased respiratory drive
- Wasted ventilation
- Physiologic
In what situations may dyspnea due to mechanical interference with ventilation arise?
- Airflow obstruction (COPD)
- Increased resistance of lung
- Resistance of chest wall
In what situations may dyspnea due to weakness of respiratory pump arise?
- Neuromuscular disorders
- Hyperinflation
- Pleural disorders
In what situations may dyspnea due to increased respiratory drive arise?
- Hypoxemia
- Metabolic acidosis
- Stimulation of receptors
In what situations may dyspnea due to wasted ventilation arise?
- Capillary destruction (COPD)
- Large vessel obstruction (PE)
In what situations may dyspnea due to physiologic arise?
- Anxiety
- Somatization
- Litigation
What is platypnea?
Shortness of breath worse when sitting up (as opposed to lying down)
What is orthopnea?
Shortness of breath when laying down
T/F: A pt can have RR = 30 without being dyspneic
True
Hyperventilation does NOT = dyspnea
How can dyspnea be quantified?
Modified Borg Scale:
0- Nothing at all
0.5- Very, very slight, just noticeable
1- Very slight ……
5- Severe
10- Maximal
Visual Analog Scale (0-10)
Important things to follow up with dyspnea?
- Onset (gradual, acute/sudden)
- Positional
- Associated qualitative descriptors
- Quantify
What is a “chronic” cough? Most common causes?
Lasts > 8 weeks
1. Postnasal drip syndrome (upper airway cough syndrome)- typ worse in morning
2. GERD- typ worse after lying down/eating
3. Asthma/other obstructive lung diseases- typ worse at night
Important things to follow up with cough?
- Dry vs. productive
- Timing/when is it worse (early morning vs. night)
- Precipitating/relieving factors
Important things to follow up with sputum production?
- Quantity
- Consistency
- Color
What is bronchorrhea?
In what condition is it commonly found?
Production of copious amounts of sputum
- Classic for broncho-alveolar carcinoma
- Bronchiectasis: obstructive disease; destruction of airways
“Tenacious” mucoid (hard to get out of cup) is found in what condition(s)?
Asthma
Purulent (watery) sputum is found in what conditions?
- Bronchitis
- Bronchiectasis
What should you think of with green sputum?
Pseudomonas
Important things to follow up with hemoptysis?
- Streaks or clots
- Quantity
- Which side it’s coming from
- Past history of TB, histoplasma
What qualifies as “massive” hemoptysis? What is the problem?
Massive = 500 mL in 24 hours (or 250 in 6 hrs)
- 1 foam cup = 125 mL
Problem is not the blood loss, but rather the volume in the lung
What is wheezing?
Musical respiratory sounds that may be audible to patient or others
Important things to follow up with wheezing?
- When it occurs (day, night, exercise, foods)
- Relieving factors
- Positional
How does substernal thyroid goiter present?
Wheezing that is worse when supine
T/F: lung tissue has extensive pain fibers
False; lung tissue has no pain fibers!
(Pleura, however, has many)
In what conditions is chest pain typically felt?
- Pneumothorax
- Pleuritic chest pain (worse with inspiration!)
- Cardiac chest pain
- Muscle strain
Important respiratory things to cover in the history?
- Family History
- Occupational History (Important!)
- Smoking history
- Exposures
What parts of the physical exam inspection should be noted in regard to the respiratory system?
- Color (pallor, cherry-red, cyanosis)
- Smell of breath
- Nails (clubbing)
- Neck
- Shape of chest (barrel, thoracic kyphoscoliosis, pectus excavatum)
- Signs of respiratory distress
What are some distinctive breath smells tied to medical conditions?
- Foul
- Ketone
- Bitter almond
- Foul smelling sputum: anaerobic infection
- Ketone/”rotten apple”: diabetic ketoacidosis
- Bitter almond: cyanide poisoning
What are signs up respiratory distress to be aware of upon inspection?
- Tachypnea
- Intercostal retractions
- Respiratory alternans (alternating pulse pressure with breathing)
- Pursed lip breathing
- Use of accessory muscles
How can tracheal position be abnormal?
How does it respond to certain medical conditions (pneumothorax, effusion, collapse, mass)?
Deviates:
- Away from pneumothorax and effusion
- Towards collapse
May also be deviated by a mass (e.g. enlarged lymph nodes)
How can vocal fremitus clue you in to a certain disorder?
- Increased over areas of consolidation
- Decreased/absent over areas of effusion or collapse
What may cause symmetrical reduction in chest expansion?
- Overinflated lungs (e.g. emphysema)
- Stiff lungs (e.g. pulmonary fibrosis)
- Ankylosing spondylitis
What may cause asymmetrical reduction in chest wall expansion?
Reduced expansion:
- Pulmonary consolidation
- Collapse
Absent expansion:
- Empyema
- Pleural effusion
Results of chest percussion (picture)?
Flatness: what is the relative intensity? pitch? duration? example location? pathologic example?
- Intensity: soft
- Pitch: high
- Duration: short
- Ex: thigh
- Pathologic: Large pleural effusion
Dullness: what is the relative intensity? pitch? duration? example location? pathologic example?
- Intensity: medium
- Pitch: medium
- Duration: medium
- Ex: liver
- Pathologic: Lobar pneumonia
Resonance: what is the relative intensity? pitch? duration? example location? pathologic example?
- Intensity: loud
- Pitch: low
- Duration: long
- Ex: normal lung
- Pathologic: –
Hyper-resonance: what is the relative intensity? pitch? duration? example location? pathologic example?
- Intensity: very loud
- Pitch: lower
- Duration: longer
- Ex: normal none (normally)
- Pathologic: Emphysema, pneumothorax
Tympany: what is the relative intensity? pitch? duration? example location? pathologic example?
- Intensity: loud
- Pitch: high* (musical timbre)
- Duration: *
- Ex: gastric air bubble or puffed out cheeks
- Pathologic: large pneumothorax
What percussion sounds are heard with the following conditions?
- Large pleural effusion
- Lobar pneumonia
- Emphysema
- Pneumothorax
- Large pneumothorax
- Large pleural effusion: flatness
- Lobar pneumonia: dullness
- Emphysema: hyper-resonance
- Pneumothorax: hyper-resonance
- Large pneumothorax: tympany
Vesicular breath sounds:
- Duration
- Intensity of Expiration
- Pitch of Expiration
- Normal location
- Sounds like
Vesicular breath sounds:
- Duration: insp > exp
- Intensity of Expiration: soft
- Pitch of Expiration: low
- Normal location: majority of both lungs
- Sounds like: wind blowing through trees
Broncho-vesicular breath sounds:
- Duration
- Intensity of Expiration
- Pitch of Expiration
- Normal location
- Sounds like
Broncho-vesicular breath sounds:
- Duration: insp = exp
- Intensity of Expiration: intermediate
- Pitch of Expiration: intermediate
- Normal location: ant 1-2 interspaces, between the scapula
- Sounds like: —
Bronchial breath sounds:
- Duration
- Intensity of Expiration
- Pitch of Expiration
- Normal location
- Sounds like
Bronchial breath sounds:
- Duration: exp > insp
- Intensity of Expiration: loud
- Pitch of Expiration: high
- Normal location: possibly over manubrium
- Sounds like: air blowing through cardboard tube
Characteristics of crackles?
When are fine/coarse crackles heard?
Aka rales
- Discontinuous
- Non-musical/brief
Fine crackles: soft, high pitched, very brief (fibrosis)
Coarse crackles: louder, lower in pitch, brief (pneumonia, CHF)
Characteristics of wheezes and ronchi? When is each heard?
- Continuous
- Musical prolonged
Wheezes: higher pitch with hissing, shrill quality (narrowed airways like asthma, COPD, bronchitis)
Rhonchi: lower pitch with snoring quality (secretions in large airways)
Characteristics of stridor?
Predominantly inspiratory; suggests partial obstruction of larynx or trachea
Characteristics of pleural rub?
Sound like crackles but more continuous in both phases and in small area
Characteristics of mediastinal crunch?
Precordial crackles synchronous with heart beat; best heard in left lateral
What does bronchophony indicate?
Consolidation
What is egophany?
- Patient says “ee”
- Normal: muffled “ee” sound
- Abnl: “ee” heard as “ay” with nasal quality
- Atelectasis from effusion; consolidation
What is whispered pectoriloquoy?
- Patient whispers “ninety-nine”
- Normal: heard faintly/indistinctly
- Abnl: louder, clearer whisper (Early pneumonia, atelectasis)
Summary of findings:
- Normal lung
- Pleural effusion
- Atelectasis
- Consolidation
- Pneumothorax
