Chart Review - Pulmonary Flashcards by Victoria Caridi | Brainscape

Q

parts of the chart review

A

“first part”

history of present illness

pulmonary fxn tests

other tests

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Q

“first part” includes

A

past medical history

family history of pulmonary pathology

personal and social history

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Q

what does past medical history include

A

thoracic trauma or surgery

use of oxygen or ventilatory

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Q

use of O2 of ventilatory –> PMH

A

assisting devices

chronic pulmonary dzs

dx testing

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Q

family history of pulmonary pathology

A

TB

cystic fibrosis

emphysema

allergies

malignancies

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Q

personal and social history includes

A

employment

home environment

tobacco use

exposure to respiratory infections

nutritional status

hobbies

use of alc

use of illegal drugs

exercise tolerance

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Q

how is history of the present illness maintained

A

medical chart

from the pt directly through interview

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Q

history of present illness includes

A

cough

SHOB

chest pain

lab, radiographic and surgical tests

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Q

cough includes

A

onset

nature

sputum production

pattern

severity

associated sxs

efoorts to tx

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Q

onset of cough

A

when did it start

progression

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Q

progression of cough

A

sudden

gradual

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Q

sudden onset of cough

A

one day they didn’t have a cough and the next they did

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Q

gradual onset of cough

A

mild cough that has become more severe

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Q

nature of the cough

A

dry

moist

wet

hacking

hoarse

productive or non productive

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Q

productive/non-productive cough

A

of sputum or mucus

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Q

sputum production

A

duration

frequency

w/ activity

at certain times of day?

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Q

sputum characteristics

A

amount

color

consistency

odor

Q

pattern of cough

A

occasional

regular

related to time of day

weather

activity

Q

severity of cough

A

causes fatigue

disrupts sleep

causes chest pain

Q

associated sxs

A

SOB

chest pain

tightness w/ breathing

fever

stuffy nose

noisy respirations

Q

efforts to tx

A

prescription or non-prescription drugs

vaporizers

effectiveness

Q

SOB

A

onset

pattern

severity

Q

onset of SOB

A

sudden or gradual

how long have they had it for

was there something that started this SOB

Q

pattern of SOB

A

most comfortable position

of pillows used to relieve

related to extent of exercise

harder to inhale or exhale

Q

severity of SOB

A

extent of activity limitation

fatigue w/ breathing

anxiety about getting air?

Q

restrictive lung dz

A

hard to get air into the body

Q

obstructive lung dz

A

hard to get air out of the body

Q

chest pain

A

onset and duration

associated sxs

efforts to tx

other meds

Q

onset and duration of chest pain

A

associated w/ trauma

coughing or lower respiratory infection

Q

associated sxs of chest pain

A

shallow breathing

fever

uneven chest expansion

coughing or radiation of pain to neck or arms?

Q

efforts to tx chest pain

A

heat

splinting

pain meds

Q

other meds for chest pain

A

for unrelated problem

Q

lab, radiograph and surgical tests

A

chest x-ray

arterial blood gases

Q

what does a chest x-ray provide

A

clinician w/ statis assessment or anatomic abnormalities

Q

arterial blood gasses are

A

sensitive indicators of a pt’s changing physiologic state

Q

2 major reasons to determine and monitor ABGs

A

is the pt adequately oxygenated?

the acid base balance of the pt

Q

what will the ABGs provide

A

invaluable info for planning appropriate and safe txs

Q

pulmonary fxn tests are

A

essential part of the assessment

range from very complex to very simple

Q

what are pulmonary fxn tests primarily used for

A

as PTs

objective way to document effectiveness or response to tx

Q

other tests (less common tests)

A

tomography

gallium scanning

pleural fluid analysis

surgical tests

Q

surgical tests

A

direct laryngoscopy

bronchoscopy

biopsy