Chart Review - Pulmonary Flashcards
parts of the chart review
“first part”
history of present illness
pulmonary fxn tests
other tests
“first part” includes
past medical history
family history of pulmonary pathology
personal and social history
what does past medical history include
thoracic trauma or surgery
use of oxygen or ventilatory
use of O2 of ventilatory –> PMH
assisting devices
chronic pulmonary dzs
dx testing
family history of pulmonary pathology
TB
cystic fibrosis
emphysema
allergies
malignancies
personal and social history includes
employment
home environment
tobacco use
exposure to respiratory infections
nutritional status
hobbies
use of alc
use of illegal drugs
exercise tolerance
how is history of the present illness maintained
medical chart
from the pt directly through interview
history of present illness includes
cough
SHOB
chest pain
lab, radiographic and surgical tests
cough includes
onset
nature
sputum production
pattern
severity
associated sxs
efoorts to tx
onset of cough
when did it start
progression
progression of cough
sudden
gradual
sudden onset of cough
one day they didn’t have a cough and the next they did
gradual onset of cough
mild cough that has become more severe
nature of the cough
dry
moist
wet
hacking
hoarse
productive or non productive
productive/non-productive cough
of sputum or mucus
sputum production
duration
frequency
w/ activity
at certain times of day?
sputum characteristics
amount
color
consistency
odor
pattern of cough
occasional
regular
related to time of day
weather
activity
severity of cough
causes fatigue
disrupts sleep
causes chest pain
associated sxs
SOB
chest pain
tightness w/ breathing
fever
stuffy nose
noisy respirations
efforts to tx
prescription or non-prescription drugs
vaporizers
effectiveness
SOB
onset
pattern
severity
onset of SOB
sudden or gradual
how long have they had it for
was there something that started this SOB
pattern of SOB
most comfortable position
of pillows used to relieve
related to extent of exercise
harder to inhale or exhale
severity of SOB
extent of activity limitation
fatigue w/ breathing
anxiety about getting air?
restrictive lung dz
hard to get air into the body
obstructive lung dz
hard to get air out of the body
chest pain
onset and duration
associated sxs
efforts to tx
other meds
onset and duration of chest pain
associated w/ trauma
coughing or lower respiratory infection
associated sxs of chest pain
shallow breathing
fever
uneven chest expansion
coughing or radiation of pain to neck or arms?
efforts to tx chest pain
heat
splinting
pain meds
other meds for chest pain
for unrelated problem
lab, radiograph and surgical tests
chest x-ray
arterial blood gases
what does a chest x-ray provide
clinician w/ statis assessment or anatomic abnormalities
arterial blood gasses are
sensitive indicators of a pt’s changing physiologic state
2 major reasons to determine and monitor ABGs
is the pt adequately oxygenated?
the acid base balance of the pt
what will the ABGs provide
invaluable info for planning appropriate and safe txs
pulmonary fxn tests are
essential part of the assessment
range from very complex to very simple
what are pulmonary fxn tests primarily used for
as PTs
objective way to document effectiveness or response to tx
other tests (less common tests)
tomography
gallium scanning
pleural fluid analysis
surgical tests
surgical tests
direct laryngoscopy
bronchoscopy
biopsy
