Clinical Assessment Module 3 Pulm Flashcards

Question 1

Q

Health History

what 7 things would you want to ask a patient about if they are presenting with pulm complaint

Answer

A

Chest pain-Wheezing in chest pain ….. No pain fibers in lungs themselves… what hurts is the chest space (parietal space) want to rule out chest pain…. Could be a pleurtis (between ribs and lungs)

Dyspnea- SOB, how does it affect your ADL’s (activity of daily living)

Wheezing

Cough-Cough, productive (wet), sputum (color), how often is the cough

Hemoptysis- coughing up blood (maybe TB or cancer)

Smoking history

Immunization history- flu pneumonia vaccinations

Question 2

Q

Techniques for exam

Answer

A

Inspection- Rate Rhythm Depth and Effort

Palpation

Percussion

Auscultation- And listen to lungs (normal or adventitious breath sounds)

Question 3

Q

What is Stridor

Answer

A

Audible high-pitched wheeze
Sign of upper airway obstruction in the larynx or trachea
Something you notice when you walk in the room. Don’t need a stethoscope.
Common with croup
More on inspiration than expiration…. Obstruction in upper airways

Question 4

Q

What does Nasal Flaring represent?

Answer

A

Represents an increased effort of breathing
Trying to increase a way that air can get in from having low O2

Question 5

Q

what does intercostal retractions represent?

Answer

A

Represents an increased effort of breathing
Increased lung volume
When fluid in lungs and body experiences hypoxemia
Inspect patient without clothes and gown to really see the chest

Question 6

Q

Tripoding

what three conditions do you commonly see it with?

Answer

A

Helps to open airway….
Common in emphysema
Epiglottitis common
Haemophilus influenzae

Question 7

Q

Normal Breathing sound words to use (3)

Answer

A

Vesicular- Usually they are quiet and vesicular (heard more on inspiration)

Bronchial- louder and higher pitches (bronchial) more tracheal mostly on expiration

Bronchovesicular

Question 8

Q

Adventitious Sounds

Answer

A

Adventitious souds: abnormal sounds

Crackles
Wheezes
Rhonchi

Question 9

Q

So, do you just listen to the back of the chest for lung sounds?

what are you missing?

Answer

A

NO NO NO NO! If you don’t listen to the front you ARE NOT even listening to the right middle lung….

Question 10

Q

where do you listen?

Question 11

Q

Crackles

Answer

A

Intermittent, Brief
Nonmusical
Suggestive of pneumonia or heart failure
Mostly inspiration
stepping on dry leaves (crackling tissue paper)
Loud crackles everywhere — inspect chest (may be hairy or clothes)

Question 12

Q

Wheezing

Answer

A

Relatively high-pitched sound with hissing or shrill quality
Suggestive of narrowed airways, as in asthma, COPD asthma or bronchitis
Constricted airway- airway smaller as air goes through=wheezing
You sometimes can here it without auscultation
Inspiration and expiration

Question 13

Q

Rhonchi

Answer

A

Relatively low-pitched sound with snoring quality
Suggestive of secretions in large airways
Can ask them to cough and it can maybe clear it
Usually heard more on expiration

Question 14

Q

Speical tests: list them (4)

Answer

A

TACTILE FREMITUS

BRONCHOPHONY

EGOPHONY

WHISPERED PECTORILOQUY

Quick info Hoffman listed off :

See Bates Table 8-5 (p 328)
Fremitus- transmission of vibration through chest
If weird stuff going on then you have increased fremitus
If you hear more profound on one side then that can be where the consolidation is
Listen anterior and posterior!
Bronchophony/ egophony/ whispered pectoriloquy = do only one to better help understand consolidattion in lungs of the pt
Fluid transmits vibration more then air

Question 15

Q

Tactile Fremitus

when is it increased? when is it decreased?

Answer

A

presence of fluid transmits better through liquid than air

Technique: Use the ulnar surface of the hand and ask the patient to repeat the words “ninety-nine” as the entire posterior thorax is covered

Findings:

Normal lung transmits a palpable vibratory sensation to the chest wall; this is called fremitus

Fremitus becomes more pronounced over areas of consolidation, as in pneumonia (when the normally air-filled parenchyma becomes fluid-filled)

Fremitus is decreased or absent when the transmission of vibrations is impeded by a thick chest wall, an obstructed bronchus, COPD or pleural changes (eg, effusion or air)

Question 16

Q

Bronchophony

Answer

A

Techniques: Ask the patient to repeat the word “ninety-nine” each time the lung fields are auscultated

Findings:

Normally the lung sounds transmitted through the chest wall are muffled and indistinct

Bronchophony is when the spoken words are louder or more clear as would be the case over consolidation, as in pneumonia

Question 17

Q

Egophony

Answer

A

Techniques: Ask the patient to repeat the vowel “E” each time the lung fields are auscultated

Findings: Normally the spoken “E” is heard as “E”
If “E” sounds like “A,” egophony is present, seen in lobar consolidation from pneumonia

Question 18

Q

Whispered Pectoriloquy

Answer

A

Techniques: Ask the patient to whisper “one-two-three” while the lung fields are auscultated

Findings: Normally the whispered words are heard faintly and indistinctly, if at all

Louder, clearer whispered words are called whispered pectoriloquy and represent consolidation, as in pneumonia

Question 19

Q

CASE 1:

14 Y.O. Female w/ no medical Hx presents c/o SOB.
HPI: Onset 2 weeks prior with SOB and cough when going outside in the cold. Lasts 1-2 hours. Seems to be getting worse. Can’t play outside. Now doesn’t want to go to school.
Meds – None
Exam – WD/WN/WF. Sitting on exam table. Anxious.

–V.S. – P-94, RR-32, BP-117/72, T-37, SaO2-97% RA

what do we think?

Answer

A

•Further exam:

Heart - reg, no murmur
Lungs – diffuse expiratory wheezes, prolonged expiratory time
- Percussion, egophany, fremitus normal, no whispered pectoriloquy
Peak flow = 100 L/min (want to see at least 200, so this is bad)
Abdomen – benign
Extremities – pulses 2+, No edema
DDX – COPD, Bronchitis, Asthma, Anxiety/Panic
Other diagnostics:
CXR
PFTs (reversibility)

What we discussed:

(Wheezes start in expiratory and if bad enough go to inspiration

No consolidation because of no whispered pertorlioquy

Bad peak flow—cant breathe out

Such thing as a cardiac wheeze

If someone is faking a wheeze then you hear it more up top vs. where it should come from lower.)

WHAT IS IT: Asthma

Question 20

Q

Asthma

what are the four categorizations?

what do you treat with?

what airway size does this effect?

why is it harder to exhale and not inhale (as much)?

Answer

A

Categorization (tells us the treatment)
- Intermittent- comes at certain time with certain stressor
- Mild persistent
- Moderate persistent
- Severe persistent
Tx:
- Beta agonists- use 10-20 min before going outside
  - Short vs. long acting
- Steroids (reduce inflammation—make lumen wider)- then move onto steroids once under control
  - Inhaled vs. systemic
  - Leukotriene receptor antagonists

NOTES:

Airway becomes inflamed but smaller in the middle (becomes thicker) so muscles are are squishing in on airway —- resistance of flow goes up exponentially while inflamed (constricted) airway

Harder to exhale–

Radial traction=

Inhale-diaphragm drops chest wall out and enlarge chest= when that happens the lumen get a tiny bit bigger this is radial traction (pulling from center out)

Exhale-diaphragm rises chest wall closes and diameter closes in pushed towards center (when we exhale you have more constriction) that’s why you hear wheezes on exhale and when its really bad it is on inhale because they can barely exhale

Question 21

Q

62 Y.O. male w/ Hx heart Dz, Diabetes, HTN, presents c/o malaise.
HPI: Onset 2 days prior with fatigue and non-productive cough. Yesterday developed increasing malaise and fever of 100.4. Admits to chills.
Meds – metformin, metoprolol, lisinopril, aspirin, atorvastatin
Exam – WD/WN/WM. Sitting on exam table. Appears ill.

–V.S. – P-94, RR-28, BP-133/85, T-38.2, SaO2-93% RA

– What do you think? –

Answer

A

Pulse- high- metoprolol
RR-high– increase o2 with infection
Temp- fever
O2- low- low o2 stat suggest pulmonary
Maybe infection

Further exam:

Heart - reg, no murmur
Lungs – Diminshed over LLL
- Percussion dull at L base, no egophany or whispered pectoriloquy, fremitus decreased over LLL
Abdomen – benign
Extremities – pulses 2+, No edema

DDX – COPD, Bronchitis, pneumonia, pleural effusion, heart failure

Other diagnostics:

CXR- yes with this case you should get it … required for pleural effusion diagnosis
CBC (white count elevated with neutrophils will tell us infection) , sputum Cx, EKG, Troponin-I

COPD- basically asthma on steroids

Bronchitis- no because this is viral so don’t expect fever and malaise

Pneumonia- no because he doesn’t have signs of consolidation

Pleural effusion- possibly

Heart failure- fluid can back up into the lungs but then you would expect crackles and no fever

What is it?

Pleural Effusion - ? empyema

Question 22

Q

Pleural Effusion vs empyema

what test shoul you do?

what are the two treatment plans depending on the fluid type?

Answer

A

•Tx:

Thoracentesis with analysis
- Cell count, cytology, culture, chemistries
? Antibiotics – yes due to infection
? Diuretics– if infection NO – if from heart failure (yes!)

NOTES:

Have to always sample it

Empyema is an exudate

Transudate- fluid has been transmitted through a barrier

Exudates- dumped by something (dead cells dump blood, cancer cells dump, bacterial infections dump puss)

Question 23

Q

62 Y.O. male w/ Hx heart Dz, Diabetes, HTN, presents c/o malaise.
HPI: Onset 2 days prior with fatigue and cough productive of green sputum. Yesterday developed increasing malaise and fever of 100.4. Admits to chills.
Meds – metformin, metoprolol, lisinopril, aspirin, atorvastatin
Exam – WD/WN/WM. Sitting on exam table. Appears ill.

–V.S. – P-94, RR-28, BP-133/85, T-38.2, SaO2-93% RA

– What do you think? –

Answer

A

Green sputum- has productive cough compared to last guy

Pulse- HIGH

RR- high

BP-ok

Temp-high

O2- low

Productive cough usually tells you RESPIRATORY

Further exam:
- Heart - reg, no murmur
- Lungs – Inspiratory crackles over LLL
  - Percussion normal, has some egophany and whispered pectoriloquy, fremitus increased over LLL
- Abdomen – benign
- Extremities – pulses 2+, No edema
DDX – COPD, Bronchitis, pneumonia, heart failure
Other diagnostics:
- CXR- YES!!!! NECESSARY TO CONFIRM THE DIAGNOSIS
- CBC (elevated white count), sputum Cx (if you can YES), EKG, Troponin-I

NOTES: HE HAS CONSOLIDATION= CRACKLES

WHAT IS IT: Pneumonia – Likely acute bacterial

Question 24

Q

Pneumonia – Likely acute bacterial

Answer

A

Tx:

Antibiotics – Consider appropriate choice- CAP vs. HCAP
Fluids
Bronchodilators (if wheezing) /mucolytics (if something needs to be broken up)
Chest physiotherapy (tap on the chest)
Flutter valve (helpful to also break things up)
Oxygen (no O2 with stats in 90’s)

NOTES: COMMUNITY AQUIRED PNEUMONIA (CAP) VS. HEALTH CARE ACQUIRED PNEUMONIA (HCAP)

Has acute infection should have fluids

Question 25

Q

41 Y.O. female smoker presents c/o SOB.
HPI: Onset this morning at 0830 with sudden onset SOB. Pain in R chest, sharp. Worse with inspiration. No cough.
Meds – OCPs.
Exam – WD/WN/WF. Sitting on exam table. Anxious.

–V.S. – P-108, RR-28, BP-101/68, T-38.0, SaO2-90% RA

– What do you think? –

Answer

A

Notes: THEY new EXACTLY What TIME! THIS IS TELLING

Chest pain- heart, aorta, pulmonary embolism

Left sided chest pain is more concerning then right side pain

Sharp pain- less concerned about heart because usually dull pain

inspiration worse- less concerned with heart issues… doesn’t usually change with inspiration with heart issues

HR- high

RR- high

BP- low (soft)

T- elevated

O2- low

Smoker, birth control, certain spot of chest, sharp, no cough, tachy, high RR, BP soft from no blood to left side of heart), saturation drops, and fever a bit can occur

Further exam:

Heart - reg, no murmur
Lungs – vesicular (normal)
- Percussion normal, no egophany or whispered pectoriloquy, fremitus normal.
Abdomen – benign
Extremities – pulses 2+, No edema

DDX – ACS, Anxiety, Pneumonia, Heart failure, Pulmonary embolism, pneumothorax (maybe, sharp pain, specific area but tympani with percussion)

Other diagnostics:

CXR (to see if there is a pneumothorax)
ABG (arterial blood gas) how well lungs are exchanging oxygen
EKG (inexpensive and easy… not sensitive but it is SPECIFIC)
CBC (INFECTION- THEN WBC-no role in this case), D-Dimer (fibrin degradation process– people form clots they break down and release this D-Dimer) (but it can be elevated for a lot of reasons) (makes it sensitive but not specific) , sputum Cx (fever so she could get this?) , Troponin-I
Chest CTA (CT angiogram) gold Standard.. Have to put dye but puts strain on kidneys… cant use this on people with renal disease
VQ scan (people with chronic lung disease already have VQ abnormalities)
Lower extremity venous Doppler (look at deep veins) if positive the suspicion for PE goes WAY UP!

Normal lung exam except for pain with inspiration- hallmark of pulmonary embolism

WHAT IS IT? Pulmonary Embolism

Question 26

Q

Pulmonary Embolism

TX

Answer

A

Tx:

Anticoagulation (use 1 of these 4 things)
- Heparin (IV at hospital)
- Low molecular weight heparin (sub Q injection… can go home)
- Warfarin (provoked DVT- 6 months)
- Factor X-A inhibitor (Riv. Doesn’t need to be monitored like warfarin and effectively immediately) BUT doesn’t have an antidote
Oxygen (maybe dependent)
Pain control (pain with inspiration)
Vena cava filter (uncommon)— clot gets trapped from filter

Question 27

Q

Wells Criteria

Answer

A

criteria of whether they have PE or not

Pretest probability

Can give some ideas of what to do it you cant use a diagnostic test listed previously

Question 28

Q

19 Y.O. female smoker presents c/o SOB.
HPI: Onset this morning at 0830 with sudden onset SOB. Pain in R chest, sharp. Worse with inspiration. No cough.
Meds – OCPs.
Exam – WD/WN/WF. Sitting on exam table. Anxious.

–V.S. – P-108, RR-28, BP-101/68, T-37.0, SaO2-90% RA

– What do you think? –

Answer

A

Hr- high
Rr- high
Bp- soft
Temp- no fever
O2- stat
Saturation really made him feel not anxiety but before thought maybe that

Further exam:

Heart - reg, no murmur
Lungs – vesicular
- Percussion tympanic RUL, no egophany or whispered pectoriloquy, fremitus normal.
Abdomen – benign
Extremities – pulses 2+, No edema

DDX – ACS, Anxiety (yes, until o2 and exam), Pneumonia (no consolidation), Heart failure, Pulmonary embolism (less likely with tympani) , pneumothorax

Other diagnostics:

CXR– tool of choice for diagnosising this… but rarely obvious on a chest x-ray
Ask for end exhalation views (want it to be as dense as possible – more squished)
ABG
EKG
CBC, D-Dimer, sputum Cx, Troponin-I (no Acute coronary syndrome don’t need this)
Chest CTA– maybe … chest x-ray may give answer
VQ scan
Lower extremity venous Doppler

NOTES:

Exam= tympani leans towards maybe spontaneous pneumothorax

Right upper lobe… think about gravity… air escaping lung and going into space.. The air will go up in the water like a bubble… so you will here tympani upwards because of this

If you have fluid trapped it will go down!

WhaT is it? Pneumothorax

Question 29

Q

Pneumothorax

TX

Answer

A

Tx:

Observation vs. chest decompression (needle aspiration)
- <2-3 cm
- >3 cm
Needle aspiration
Chest tube
Oxygen
Pain control
pleurodesis

Question 30

Q

41 Y.O. female smoker presents c/o cough.
HPI: Onset this morning at 0830 upon awakening with hacking non-productive cough. Pain throughout chest with cough. Admits to URI Sx up until yesterday.
Meds – OCPs.
Exam – WD/WN/WF. Sitting on exam table, NAD (no apparent distressed).

–V.S. – P-90, RR-18, BP-101/68, T-37.0, SaO2-96% RA

– What do you think? –

Answer

A

Hr- little high
Rr- good
Bp- fine
T-fine
SaO2-fine
What are we worried about in these vital signs- not worried about vital signs

Further exam:

Heart - reg, no murmur
Lungs – vesicular except she wheezes when she coughs
Percussion normal, no egophany or whispered pectoriloquy, fremitus normal.
Abdomen – benign
Extremities – pulses 2+, No edema

DDX – ACS, Pneumonia (not likely but not uncommon for someone with obstructive disease to then get a bacterial infection), Heart failure, Pulmonary embolism (no pain), bronchitis, pneumothorax

Other diagnostics:

CXR– get the chest x-ray if available …but this can be a clinical diagnosis
EKG– +/-
CBC, D-Dimer, sputum Cx, Troponin-I (for ruling out ACS don’t need that here)
Chest CTA
VQ scan
Lower extremity venous Doppler

WHAT IS IT? Acute Bronchitis

Question 31

Q

Acute Bronchitis

treatment?

what is it aimed at?

Answer

A

•Tx:

–Possibly bronchodilators, cough suppressants

–Tincture of time (reassurance)

–Consider antibiotics (not necessarily needed)

Frequently follows colds
And cough can last for weeks
Want to treat the symptoms

Question 32

Q

41 Y.O. female smoker presents c/o SOB.
HPI: Not sure when it began. Maybe months to years ago. Hates medical providers and avoided coming in. Admits hacking cough, worse in a.m. Swallows sputum. No fever or chills. No hemoptysis.
Meds – OCPs.
Exam – WD/WN/WF. Sitting on exam table. Irritable. Thin. Barrel chested. + digital clubbing. + pursed lip breathing when she moves about.

–V.S. – P-100, RR-20, BP-144/95, T-37.3, SaO2-90% RA

– What do you think? –

Answer

A

P- high
RR-normal
BP- high
T- normal
O2- low
Lung cancer would have more hemoptysis
CANCER- UNEXPLAINED WEIGHT LOSS!

Further exam:

Heart - reg, no murmur
Lungs – Almost inaudible. (ALMOST CAN’T HEAR THEM)
Abdomen – benign
Extremities – pulses 2+, No edema

DDX – ACS, Pneumonia (no signs of consolidation), Heart failure, Pulmonary embolism, pneumothorax (only inaudible over a certain side, and would have hypotension and pulse), COPD

Other diagnostics:

CXR– yes!
EKG
CBC, ABG, D-Dimer, sputum Cx, Troponin-I
Chest CTA (for PE)
VQ scan (for PE)
Lower extremity venous Doppler
Bronchoscopy (if chest x-ray does not help… these do)

WHAT IS IT?? COPD

Question 33

Q

COPD

what is the difference in acute and maitenance treatment?

Answer

A

Acute Tx:
Short acting Beta adrenergic, anticholinergic, or combination
Steroids (in combination only)
Maintenance Tx
Possibly LABA
Long acting Anticholinergics
Theophylline
PDE-4 inhibitors
Other approaches
- Oxygen
- Smoking cessation
- Vaccinations
- Rehab
- Education
- Nutrition
- Lung volume reduction surgery

Emphysema vs. chronic bronchitis

NOTES: Regulate breathing on pH of blood– medullary= breathing control.– CO2 level regulates all of our breathing…. Breathe out to remove carbon dioxide from blood

In COPD cant remove carbon dioxide effectively and receptors get messed up in midbrain … so o2 sensors stimulate COPD people to breathe… by giving COPD patients oxygen it removes their want to breathe … but don’t try to get it to 98% spO2 get it to 80-90%

On ambulance ride- not going to kill them if you give too much O2– but if you admit them in the hospital and put them on 4% O2 and then now it’s at 98% they slowly decrease their respiration and carbon dioxide levels slowly increase they have hypoxic drive so they can become comatose and die. :(

Question 34

Q

Blue Bloater Vs. Pink Puffer

Question 35

Q

COPD lung Vs. Healthy lung

Answer

A

Barrel chest and air trapping so when they try to take a deep breathe very little air comes in or out.
So COPD usually hardly any breath
COPD= blue bloaters

Question 36

Q

71 Y.O. female smoker with Hx DM-2 presents c/o SOB.
HPI: Onset last week with nausea followed by Dyspenia On Exertion (DOE progressing to SOB. Sleeping in a recliner. No chest pain. No cough.
Meds – Metformin, glargine insulin
Exam – WD/WN/WF. Sitting on exam table. Anxious. Can’t lay flat for exam.

–V.S. – P-108, RR-28, BP-101/68, T-37.0, SaO2-90% RA

– What do you think? –

Answer

A

P-high
Rr-high
Bp-soft
T-ok
O2-low

Further exam:

Heart - reg, no murmur
Lungs – crackles from bases to 2/3 up to the apex bilateral
Percussion dull in bases, no egophany or whispered pectoriloquy, fremitus normal.
Abdomen – benign
Extremities – pulses 2+, 3+ bilateral LE edema

DDX – ACS (no chest pain), Anxiety, Pneumonia (crackles), Heart failure (fluid drains out in the lungs– crackles), Pulmonary embolism, pleural effusion

Other diagnostics:

CXR- YES
EKG- YES
CBC (hemoglobin!), BNP (marker for heart failure… increases with atrial stretch), D-Dimer (don’t get D-dimer if no worry about PE), sputum Cx, Troponin-I (YES!)
Chest CTA
2D Echo– (YES!… Picture of heart)
VQ scan
Lower extremity venous Doppler
Pulmonary Ultra sound (US)– chest filled with air and US doesn’t do well with air but there is a new technique to use US for heart failure it is sensitive and specific

NOTES: EDEMA!

Diabetes ACS- nausea! (suspicion of MI— Do work up for MI)

REASON FOR EVERY TEST! KNOW WHAT TO DO IF IT’S positive OR negative

WHAT IS IT? CHF

Question 37

Q

CHF

what is the treatment?

Answer

A

Tx:
Diuresis (gets them out of acute heart failure)
Oxygen
Possibly
ACE-I
Beta blocker (cardio protective for people who have had an MI)
Aldosterone antagonist (reduce fluid retention and people in heart failure)

NOTES:

CHF because they now have wall motion abnormality because they had an MI last week (remmeber from the case)

Cant lay flat because of fluid and gravity

Had the big one (MI) (last week) not having it now

Question 38

Q

CXR Challenges

(7)

Answer

A

2 dimensional image
Focus without a lens
Magnification
Alignment (must be straight on)
Crowding
Fluid and tissue density
Anatomical variation or abnormality (breasts)

Question 39

Q

Standard Views

Answer

A

The standard chest examination
- PA (Posterior-Anterior) and lateral chest x-ray
- Films are read together
- AP (Anterior- Posterior) portable or supine
- AP/Lateral

Question 40

Q

Why does the x-ray have a lot of distance from the patient?

Answer

A

Need distance to focus rays because there is no lens

Only the straight rays make it

Question 41

Q

What side is lateral view always on?

Answer

A

Always LEFT SIDE of patient against receptor

Because of heart

So put heart as close to receptor as we can get so that it is in focus as best as can

Question 42

Q

Positioning for xrays?

why are PA preferred to AP?

and why is lateral always have the plate against the pts left side?

Answer

A

Why PA and not AP?
Why left side against the film on the lateral view?

o It diminishes the effect of blurring and magnification on the heart.

•On the AP film, the heart shadow is magnified and blurred because it is an anterior structure.

You want the heart to be as close to the receptor (plate) as possible, so must be facing backwards

Question 43

Q

What About Supine vs. Upright?

Answer

A

On the AP supine film there is more equalization (cephalization) of the pulmonary vasculature when the size of the lower lobe vessels are compared to the upper.
X Ray tube is closer to the receptor

NOTES:

AP- heart will be bigger

Supine- equalize vasculature (cephalization)

See vasculature more prominent in bases of lungs when standing (gravity)…. If we cephalization when standing— heart failure

when patient laying supine it minics the cephalization and can look like pathology, but in fact its how the patient was positioned so need to know this when interpreting the xray

Question 44

Q

Answer

A

AP is a tougher xray to read and harder to interpret since farther away from the receptor

Question 45

Q

First, HOW to evaluate the Image

Answer

A

Turn off stray lights, optimize room lighting
Patient Data (name, date, old films)
Routine Technique:

oAP/PA

oSupine, erect, portable

•Quality issues

o Inspiration

o Exposure/penetration

o Rotation

Question 46

Q

How should the patient be examined

(inspiration or expiration? )

what levels should the diaphram be at compared with anterior and posterior ribs?

Answer

A

•The patient should be examined in full inspiration.

o Diaphragm at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib.

Question 47

Q

what is a good tactic to measure the penetration on a xray?

what do you want to see to tell that it is appropriate penetration?

Answer

A

•A good PA film

oThe thoracic spine disc spaces should be barely visible through the heart but bony details of the spine are not usually seen

Look at spine disc spaces… want to make sure they are a little visible through heart

Question 48

Q

Answer

A

left- over penetration (removes details, makes it so you miss something)

right- under penetrated (everything looks brighter, can’t interpret this)

Question 49

Q

Lateral View Penetration

what are two landmarks or patterns you want to recognize from the lateral view to confirm there is appropriate penetration?

Answer

A

•Observe that the spine appears to darken as you look caudally.

o This is due to more air in lung in the lower lobes and less chest wall.

•The sternum should be seen edge on.

Want to see spinal canal and more seen as you go down caudally

Question 50

Q

Assessing Rotation

Answer

A

The patient must be imaged flat against the cassette
If there is rotation of the patient, the structures may look very unusual
Observe the clavicular head alignment with spinous process

NOTES on Picture:

Clavicle front
Spinous process back
So to see if they are turned can see that it wont be middle

Question 51

Q

check it out

Question 52

Q

know your anatomy

Answer

A

OMG KNOW YOUR ANATOMY

In front LUL goes all the way to bottom!!!! no way! that’s crayzeee

Question 53

Q

Reading the Image

what shouldn’t you do for technique?

what should you do for technique?

Answer

A

•Conduct a directed search

o Avoid simply gazing at the film

o Have a planned search in mind

Question 54

Q

What to Examine on a CXR

6 categories

Answer

A

Lungs: Trachea, L & R mainstem bronchi, abnormal shadowing, or lucency
Pleura: effusion, thickening, calcification
Heart: thorax: heart width > 2:1 ? Heart Borders. Cardiac configuration?
Mediastinum: contour, width, mass?
Hila: masses, lymphadenopathy
Pulmonary vessels: artery or vein enlargement
Soft tissues: subcutaneous emphysema, mastectomy
Bones: lesions or fractures

Question 55

Q

What is it?

Answer

A

Emphysema

Chronic obstructive pulmonary disease

Barrel chest

Lower hemi diagrams (flattened)

Looks over exposed

Question 56

Q

What is it

Answer

A

Pleural Effusions

Air goes up fluid goes down

Cant see the costaphrenic angle and meniscus from fluid

(this would be seen in the corner between the diaphram and the ribs, in Pleural effusion this is obliterated)

Question 57

Q

What’s this?

Answer

A

Large Pleural Effusion

Now a bucket of fluid and an air fluid line on the left side

the line at the top is the key to differentiate between conslidation like pneumonia, it has pushed everything to the right side

Question 58

Q

what is this?

Answer

A

Pneumothorax

Lines markings inside and no markings outside, look for visceral line

**make sure expiratory view!**

Question 59

Q

what is this?

Answer

A

Right Sided Pneumo-thorax

Right side… all open space

Question 60

Q

what’s this?

Answer

A

Resolved Pneumo-thorax with Sub Q air

A lot of sub Q emphysema

Don’t want air under left diaphragm….

_______________

Great explanation from Ruth: :)

“I’m pretty sure the air under the left diaphragm is gastric air - the sub Q air is the grainy texture throughout the right and mid torso, very diffuse. He described it as “rice crispies” under the skin that popped and crackled.”

Question 61

Q

what is this?

Answer

A

Right sided tension pneumothorax

o Right sided lucency

o Leftward mediastinal shift

o This is a medical emergency

Question 62

Q

Silhouette Sign

Answer

A

One of the most useful signs in chest radiology
- Elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled lung
- Most commonly associated with infiltrates
- If an intrathoracic opacity is in anatomic contact with, for example, the heart border, then the opacity will obscure that border
Commonly applied to:
- Heart
- Aorta
- Chest wall
- Diaphragm

NOTE on X-RAY

Border of something is obscured in chest

Question 63

Q

what is this?

Answer

A

Silhouette Sign

The right heart border is silhouetted out
Which lobe does the infiltrate affect?

infiltrative process, but you can’t tell which lobe since all the lobes (think about bates picture) overlap here, you can’t tell

Question 64

Q

not sure about this guys? sorry

Right middle lobe touches that portion of the hear

Silhouette of left lower lobe means left hemi diagram is obscured?

Answer 61

A

you can tell where the consolidation is here because you think about the structure of the lung. the fluid/pus or whatever is stays here because its is contained within one lobe, thats why its not all the way at the bottom near the diaphram

Answer 62

A

Burring of right hemi diaphragm so right lower lobe ….

Silhouette

Answer 63

A

what was said in class:R oblique fissure

BUT confusing card

but pneumonia looks like RUL

Answer 64

A

again said this in class R oblique fissure

but looks like RUL

Answer 65

A

R oblique fissure

Because of aorta being obscured

Answer 66

A

•60 year-old male with shortness of breath and orthopnea

o Cardiomegaly

o Marked prominence of the pulmonary vascularity

o Increased density in the small vasculature and alveolar spaces

o Kerley B lines

HEART FAILURE– heart dilates and gets bigger (hypertrophy or dilation–floppy bag)

Bronchial cupping–can see thickness of it because full of fluid

Answer 67

A

Post Operative Acute Pulmonary Edema

Answer 68

A

Severe HF: Before and after treatment

Heart failure from heart

Cardiomegaly

Answer 69

A

Imaging/procedural testing
PFTs (peak flows)
VQ scan
Chest CTA (CT scan with pulmonary angiography)
Thoracic US
MRI (rarely for chest unless looking for masses)
Bronchoscopy
Thoracoscopy
Thoracentesis (pulling fluid out)
Echocardiagram

Answer 70

A

Pulmonary function test

Used for obstructive disease

**pay attention to the first image on the left, the exhale loop above the x axis, thats normal, but when see the second line, it is characteristic of obstructive lung disease**

Answer 71

A

VQ Scan Showing PE

Nuclear imaging …. Vs…. Perfusion

Whole lung is ventilated but not perfused

So embolism blocking that

Answer 72

A

Chest CTA showing PE

Dark area where not perfusing LOT

Answer 73

A

bullus emphasema CT

BIG BALLS OF EMPHYSEMISIS CHAnGES… WHERE SURFACE AREA IS GONE

Answer 74

A

CBC, CMP
D-Dimer
ABG
Fluid studies

o Cytology

o Culture

o Other

Answer 75

A

pnuemonia

She said this like 93840928 times during class so think you might want to know it….

Answer 76

A

the lumen gets narrower
the muscles around the tube contract

Answer 77

A

you want them to exhale completely because it hightlights where there is more air

usually for lung xray, you have the patient inhale all the way, but that will hide the pneumothorax, so you need t ohave the patient exhale compeltely and then it wil highlight it

Answer 78

A

2-3 observe

>3 decompress

can do this by needle aspiration or chest tube

Answer 79

A

coronary syndrome….Heart failure!!! which leads to pulmonary edema!!!

Answer 80

A

it will be more opaque because of breast tissue

this is important to keep in mind because you don’t want to confuse this opacity with pathologic disease

Answer 81

A

BEHIND THE HEART

this is important

Answer 82

A

1) Spirometry : Measure Volume of Air Movement
2) Body Plethysmography: Total Lung Capacity + Residual Volume
3) Inhalation Challenge Tests: Nebulized Meds Followed by Spirometry
4) Exercise Stress Tests: Followed by Spirometry

Answer 83

A

1) Arterial Blood Gas
2) Carbon Monoxide Diffusion Capacity (DLCO)

Answer 84

A

Measures Amount of O2 + CO2 in Blood
Measure Acidity + Alkalinity
Avoid Unless Necessary (Invasive)

Answer 85

A

Measures How Well Lungs Transfer CO into Blood

Answer 86

A

Degradation Product of Fibrin – Indicates Ongoing Activation of Hemostatic System

Reference [Concen] < 0.5 ug/mL FEU

Causes of Elevated D-Dimer:

Pregnancy
Rheumatoid Arthritis
Trauma
Elevated Triglycerides
Heart + Liver Disease

Clinical Setting Where There is a Need to R/o Thrombotic Cause of Symptom
Never Rely SOLELY on a D-Dimer to R/i or R/o a Pulmonary Embolus (Helps to Exclude Dx – Not Make One)
A D-Dimer(-) is Most Valid and Useful When Test is Completed on People Who are Low Risk for Thrombosis

Answer 87

A

Can Detect Pulmonary Embolism

Answer 88

A

Can Detect Abnormalities Well

picture: pulmonary embolism

Answer 89

A

Small Amount of Radioactive Material to Study Ventilation + Perfusion
Radioactive Material is Inhaled – Allowing the Capture of Images of Air Movement within Lungs

Answer 90

A

Gold Standard dx PE

Provides Very Clear Image of Blood Flow within the Lungs
Usually Performed AFTER Other Tests FAIL to Provide Answers
Potentially Serious Risks – Heart Arrhythmia, Renal Damage from Dye

Answer 91

A

Right Saddle Embolus

Bridges Across the Pulmonary Artery From Heart as it Divides into Right + Left Pulmonary Arteries – Causes Sudden Death

Answer 92

A

CT angiogram

Answer 93

A

R/o Pulmonary Embolism in Pregnancy/Allergy

Traditionally Reserved for Pregnant Women or Patients with Renal Disease (Pulmonary Angiogram Too Risky)
Use of Helium-3 + Other Gases Have Greatly Increased the Value of MRI

Answer 94

A

Direct Visual Exam of Larynx + Upper Airway

Investigate Suspected Bleeding
Sample Tissue if Cancer Suspected
Sample Fluid to ID Pathogens
Assess Burns + Smoke Inhalation

Answer 95

A

Collect Specimens from Smaller Airways + Alveoli that Cannot be Visualized (Fluid Exam)

Saline Infused, Suctioned, Examined
May Reveal Neoplastic Cells
Fluid Cultured to Determine Pathogen

Answer 96

A

Visual Examination of Lung + Pleural Spaces

Video Assisted Thoracoscopic Surgery VATS
Obtain Tumor Samples

Answer 97

A

Removal of Fluid in Pleural Space (Effusion)

Main 2 Reasons Done – Relieve SOB + Obtain a Sample for Diagnostic Testing

Complications (Low Risk) –

May Puncture Lung
Cause Pneumothorax
Puncture Spleen or Liver

Answer 98

A

Ask yourself what you will gain
Never go “searching” without a reason – use your clinical skills to determine differential diagnosis
Select the test based on your differential diagnosis

Answer 99

A

Rales/crackles
Symmetric Findings
Occurs first in most dependent portion of lower lobes
As disease progresses, sounds heard throughout

Answer 100

A

Rales/crackles
Heard over distinct area, restricted to a specific lung region
The consolidation associated w/ pna causes central lung sounds to be heard in periphery (use “eee” and “aaah” tests to determine if this is occurring)
Tactile Fremitus Increased

Answer 101

A

Distinct, harsh, diffuse crackles (think of Velcro)—Looks like cob webs

Answer 102

A

Rhonchi
Cough >5 days
Airway passages are inflamed
Tip: Don’t always need abx (viral)

Answer 103

A

Severe:

Breathing will produce very little sound
Wheezing in severe emphysema indicates a superimposed acute inflammatory process

Answer 104

A

Decreased tactile fremitus
Dullness to percussion
Absence of breath sounds

Answer 105

A

Chronic Bronchitis + Emphysema

Chronic Bronchitis: Cough & Sputum most days of 3mo of two successive years

Emphysema: Loss of elastic recoil of lung & histologic changes of small airways & destruction of walls of alveoli

Nat’l Inst for Hlthcre Excell Dx Crit:

Age >35
Hx of Smoking
Long standing production of sputum, cough, SOB w/o clear variations throughout the day

Answer 106

A

Pink Puffers:

have good ventilation of alveoli
Near normal O2
Low/normal CO2 in blood
No cyanosis

Blue Bloaters:

Poor ventilation of alveoli
Low oxygen
Heart failure common

Answer 107

A

Inflammation of airways

Constriction of flow

Often present w/ increased RR & HR (working hard to breath)

Intercostal Retractions (Pediatrics)

Wheeze

Critical Hx in Acute Asthma Pts:

“Have you ever been intubated?”
Prior need for intubation should increase your suspicion of severe dz
Any hx of IC admission for asthma?
3 or more ED visits, 2 or more admissions in the last year
The hx should put you on alert that this pt could decompensate rapidly

Tips:

Carefully assess tactile fremitus, breath sounds, & perussion
It is the combination of these findings which will help you differentiate between diagnosis
You may have to do the exam components more than once to work out what is going on

Red Flags:

Cyanosis
Decreased level of activity awareness
Rapid Pulse
Severe anxiety
Sweating
Increased time for expiration (doubles that on inspiration)

Further Testing:

PulseOX-measures oxygen sat (at rest&ambulation)
Measurement of distanced walked in certain time
Have the pt attempt stair climbing (watch for SOB)
This indicates the pt’s functional status

Chest XRAY “Gold Standard”

CT Scan- used to evaluate finding on CXR or in trauma setting w/ obv injury or if pt obviously very ill, but no findings on CXR

MRI-used less frequently-typically to take a closer look at a tumor, adjunct structures

Answer 108

A

Pulmonary Edema

**there is fluid on the inside of the lungs, so you on’t see the fluid where the lungs are, not in the costoverteral angles like pleural effusion…starts at the bottom of the lungs because the fluid falls to gravity :)**

Answer 109

A

Pneumonia

Answer 110

A

Pulmonary Fibrosis

Answer 111

A

bronchitis

Answer 112

A

emphysema

Answer 113

A

pleural effusion

Answer 114

A

Pink puffer

Answer 115

A

blue bloater

Answer 116

A

Inspection/ Observation:

Breathing Pattern (fast, slow, shallow, struggling, etc)
Use of Accessary Muscles
Color of nail beds, skin
Cyanosis of Nail Beds
Perioral Cyanosis
Deformity? (Pectus excavatum)
Tripod position

Anatomy:

Anterior View: RUL, LUL, RML, RLL, LLL
Right Lateral View: RUL, RLL, RML
Left Later View: LUL LLL

Palpation:

Assess for tenderness
Equal Expansion
Tactile Fremitus
- Consolidation: When normally air filled lung becomes engorged w/ fluid or tissue (i.e pna). Fremitus becomes more PRONOUNCED.
- Pleural Effusion: Fluid collection in the potential space that exists between the lung and chest wall. Displaces lung upwards. Fremitus over effusion is DECREASED.

Percussion:

Generally:
- Resonant over air
- Dull over fluid or tissue
Pleural effusions/ pneumonia:
- Deadened tone
Chronic (emphysema) or acute (pneumothorax
- Hyper-resonant (drum-like)
Tip: Try doing percussion quickly-it will sometimes assist you in hearing the different tones

Ausculatation:

Right lower lobe: Heard best in right axilla

Lower lobes: Bottom ¾ of the posterior fields

Upper lobes: Anterior chest and top ¼ of posterior fields

Vesicular(Normal): Soft sound of rushing air on inspiration, no, or minimal sound, on expiration.

Wheezing (lower airway): Whistling sound secondary to air being forced through narrowed airways

Strider: Wheezing heard only on inspiration and typically caused by mechanical obstruction at level of trachea/upper airway (epiglottis)

Rales/Crackles: Scratchy sounds-occur in assoc w/ processes that lead to fluid accumulation in alveolar & interstitial spaces (Pulm edema)

Rhonchi: Gurgling type sounds (slurping thru a straw)

Egophony:

Increased resonance of voice sounds transmitted through consolidation or other abnormal areas
High nasal quality
Patient says “eee”; you hear “eee” over healthy lungs
over consolidation it sounds like “aaay”

Answer 117

A

RR is about 14-20 per min in normal adults and upto 44 per min in infants

Answer 118

A

slow breathing

slow breathing may be secnodary to diabetic coma, durg induced repiratory depression, and increased intracranial pressure

Answer 119

A

breathing punctured by frequent sighs should alert you to the possibility of hyperventilation syndrome- a common cause of dyspnea and dizziness. ocassional sighs are normal

Answer 120

A

rapid shallow breathing

Rapid shallowing breathing has a number of causes:

restircitve lung disease
pleuritic chest pain
elevated diaphragm

Answer 121

A

Periods of deep breathing alternate with periods of apnea (no breathing).
children and aging people normally may show this pattern in sleep
Other causes
- heart failure
- uremia
- drug induces repiratory depression
- brain damage (typically on both sides of the cerebral hemispheres or diencephalon)

Answer 122

A

In obstructive lung disease, expiration is prolonged because narrowed airways increase the resistance to air flow.
Casues:
- asthma
- chronic bronchitis
- COPD

Answer 123

A

Rapid Deep Breathing

Casues
- exercise
- anxiety
- meatbolic acidosis
in comatose patient consider
- infarction
- hypoxia
- hypoglycemia affecting midbrain or pons

Answer 124

A

deep breathing due to metabolic acidosis

may be fast, normal in rate or slow

Answer 125

A

Biot’s breathing

unpredictable irregularity
breaths may be shallow or deep, and stop for short periods
casues
- repiratory depression
- brain damage medullary level

Answer 126

A

from partial airway obstruction from secretions and tissue inflammation in asthma, or from a foreign body

Answer 127

A

Mucoid: white or gray

Purulent: yellow or green

Answer 128

A

anaerobic lung abscess

tenacious sputum in cystic fibrosis

Answer 129

A

bronchiectasis

or

lung abscess

Answer 130

A

Rare: infants, children, adolescents

common: cystic fibrosis

Answer 131

A

Stomach blood is draker and mixed with food particles compared to that or Resp. tract

Answer 132

A

coronary artery disease: 2-4 X higher
Stroke: 2-4 X higher
Peripheral vascular disease: 10 time higher
COPD Mortality: 12-13 time higher
Lung Cancer mortality: 23 times higher in men, 13 times higher in women

Answer 133

A

Ask about tobacco use

Adivse to quit

Assess willingness to make a quit attempt

Assist in quit attempt

Arrange follow up

Answer 134

A

Precontemplation- I dont want to quit

Contemplation- i am concerned but not ready to quit now

Preparation- I am ready to qut

Action- I just quit

Maintenance- i quit 6 months ago

Answer 135

A

bronchiectasis
congenital heart disese
pulmonary fibrosis
cystic fibrosis
lung abscess
malignancy

Answer 136

A

high pitched wheeze

ominoous sign of upper airway obstruction in larynx or trachea

Answer 137

A

pneumothorax

pleural effusion

atelectasis

Answer 138

A

chronic fibrosis of the underlying lung or pleura

Answer 139

A

unilateral pleural effusion
pneumothorax
neoplasm

due to decreased transmission of low frequency sounds

Answer 140

A

unilateral pneumonia

increased transmission through conolidated tissue

Answer 141

A

dullness replaces resonance when fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your percussing fingers

lobar pneumonia (the alveloi are filled with fluid and bloof cells
pleural accumulations of serous fluid (pleural effusion)
blood (hemothorax)
Pus (empyema)
fibrous tusse
tumor

Answer 142

A

heard over the hyperinflated lungs of COPD and asthma

unilateral hyperressonace siggests a large pneumothorax or a large air filled bulla in the lunh

Answer 143

A

abnormally high level suggests pleural effusion or a high diaphragm as in atelectasis or phernic nerve paralysis

Answer 144

A

alight it is probably due to the excessive amount of chest hair…..get out the wax… you have to wax this patient

just kidding! either press harder or wet the hair!

never listen over clothes!

Answer 145

A

you may hear muscle contraction sounds- muffled low pitched rumbling or roraring noises

change the patients position

Answer 146

A

inspriatory and expiratory sounds are about equal

often heard in 1st and 2nd interspaces anteriorly and between the scap

Answer 147

A

expir. sounds last longer than inspiratory ones

insitiry of expir sound: loud

Pitch of expir sound: relativ. high

heard over manubrium

Answer 148

A

inspir and expiratory sounds are about equal

intensity of expir: very loud

pitch or expir: relativ. high

heard over the trachea in the neck

Answer 149

A

bronchitis

atelectasis

Answer 150

A

abnormal. in lungs: pneumonia, fibrosis, early HF

Abnorm. in airways: bronchitis, bronchiectasis

Answer 151

A

narrowed airways

asthma

COPD

bronchitis

Answer 152

A

secretions in large airways

Answer 153

A

wheezing

hx of smoking, age and decreased breath sounds

diagnosis: spirometry and other pulm testing

Answer 154

A

louder voice sounds

Answer 155

A

sit leaning forward

lips pursed during exhalation

arms supported o their knees or a table

Answer 156

A

pleural fluid usuall sinks to the lowest part of pleural space (posteriorly in a supine patient)

Answer 157

A

behind right breast!

Answer 158

A

process: inflammation of trachea and large bronchi
Location: upper sternal or on either sife of the sternum
quality: burning
severity: mild to mod
timing: variable
aggrevating factors: coughing
relieving factors: lying on the involved side
associated symptoms: cough

Answer 159

A

process: inflamm. of the pariteal pleura like in pleurisy, pneumonia, pulm infarction, neoplasm
Location: chest wall overlying the process
quality: sharp, knife like
severity: severe
timing: presistent
aggrevating factors: deep inspiration, coughing, movements of the trunk
relieving factors: n/a
associated symptoms: underlying illness

Answer 160

A

process: excessie mucus prodiction in bronchi, followed by chronic obstuction of airways
timing: chornic productive cough followed by slowly progressive dyspnea
aggrevating factors: exertion, inhaled irritants, repir. infections
relieving factors: expectoration; rest, though dyspnea may become persistent
associated symptoms: chronic productive cough, recurrent resp. infeciton, wheezing
setting: Hx smoking, air polluntants, recurrent resp infections

Answer 161

A

Process:
- overdistention of air spaces distal to terminal bronchioles,
- destuction of alceolar septa,
- alveloar enlargement and
- limitaiton of expiratory air flow
timing:
- slowly progressive dyspnea
- mild cough later
aggrevating factors: exertion
relieving factors: rest
associated symptoms: cough, scant mucoid sputum
setting: smoking, air pullutants, familial deficency in alpha1-antitrypsin

Answer 162

A

Process:
- reversible bronchial hyperresponsiveness involving release of inflamm. mediators
- increased airway secretions
- bronchoconstrition
Timing:
- acute episodes seperated by symp free periods
- nocturanl episodes common
Aggrevating Factors:
- variable, allergens, irritants, resp infec, exercise, emotion
Relieve: seperation form aggravating factors
Assoicated symp: wheezing, cough, tightness
setting: envir and emotion conditions

Answer 163

A

Process: inflamm of lung parenchyma from the respiratory bronchioled to the alveoli
Timing: acute illness
associated symptoms:
- pleurtic chest pain
- cough
- sputum
- fever
setting: varied

Answer 164

A

Process: leakage of air into pleural space through blebs on visceral pleura, resulting partial or complete collapse of lung
timing: suden onset of dyspnea
associated symptoms: pleurtic pain, cough
setting: often previously healthy young adult

Answer 165

A

Process: sudden occlusion of all or part of pulmonary arterial tree by a blood clot that usually orginates in deep veins of legs or pelvis
timing: sudden onset of dyspnea
associated symptoms: often none.
- pleurtic pain
- cough
- hemoptysis may follow embolism is pulmonary infarction ensues
- symptom of anxiety
setting:
- postpartum or postopertive
- bed rest
- HF
- chronic lung disease
- fractures of hip/leg
- DVT

Answer 166

A

Process: overbreathing, resultant respiratory alkalosis
- fall in arterial partial pressure of Carbon Dioxide
timing: episodic, recurrent
Aggrevating: at rest, upsetting event may not be evident
Relieving: breathing in and out of a paper of plastic bag may help
associated symptoms:
- sighing
- lightheadedness
- numbness/tingeling of hands and feet
- palpitations
- chest pain
setting: often manifestations of anxiety may be present, such as chest pain daiphoresis, palpations

Answer 167

A

Laryngitis:
- Dry cough (no sputum)
- may become productive
- acute
- minor illness with hoarseness
- associated with viral nasopharyngitis
Tracheobronchitis:
- dry cough
- may become productive
- acut
- viral illness
- burning retrosternal discomfort
Mycoplasma and Viral Pnemonias
- dry hacking cough
- productive with mucoid sputum
- acute febrile illness
- malaise
- headache
- possibe dyspnea
Bacterial Pnemonia
- Pneumococcal: sputum mucoid or purulent
- blood streaked
- diffusely pinkish
- rusty
- KLEBSIELLA: stick red and jelly-like (typically occurs in older alcoholic men)
- acut illness with chills
- high fever
- dyspnea
- chest pain
- ususally proceded by acute upper resp. infection

Answer 168

A

Postnasal Drip:
- chronic cough, mucoid or mucopurulent
- repeated attempts to clear throat
- seen in post. pharynx
- associated with allergic rhinitis
CHronic Bronchitis
- chronic cough, mucoid or purulent
- blood streaked or even bloody
- hisroty of smoking
- recurrent superimposed infections
- wheezing/dyspnea may develop
Bronchiectasis:
- chronic chough
- purulent
- copious
- foul smelling
- blood streaked or bloody
- recurrent bronchopulmonary infection
- sinusitis may coexist
Pulmonary Tuberculosis
- cough dry
- mucoid or purulent
- blood dtreaked or bloody
- early no symp.
- later: anorexia, weight loss, ftigue, fever, night sweats
LUng abscess:
- purulent
- foul smelling
- bloody
- febrile
- poor dental hygiene
- prior episoe of impaired consciousness
Asthma
- cough
- thick mucoid (near end of an attack)
- wheezing
- dyspnea
- cough may occur alone
- hx of allergy
gatroesophageal refux
- chronic cough
- nigh or early monring
- wheezing (night)
- early morning horseness
- repested attempts to clear throat
- history of heart burn and regurgitation

Answer 169

A

cough dry to productive
blood streaked or bloody
hx of smoking
dyspnea
weight loss

Answer 170

A

often dry cough (specially on exertion of at night)

PINK FROTHY SPUTUM

Answer 171

A

dry to productive
may be dark
bright red
mixed with blood
dyspnea
anxiety
chest pain
fever
factors that predispose to DVT

Answer 172

A

thorax should be wider than deep
lateral is larger than it AP diameter

Answer 173

A

depression in lower portion of the sternum
compression of the heart and great vessels may cause murmurs

Answer 174

A

increased AP diam.
shape is normal during infancy
accompanies aging and COPD

Answer 175

A

sternum siplaced anteriorly
increased AP diameter
costal cartilages adjacent to protruding sternum are drepressed

Answer 176

A

multiple rib fractures= results in paradoxical movements of the thorax
on inspiration injured area curved inward
expiration area moved outward

Answer 177

A

abnormal spinal curvature and vertebral rotation defrom chest
sitortion of underlying lungs -interpretations of lung findings may be difficult

Answer 178

A

result of series of tiny explosions when small airways, deflated during expiration, pop open during inspiration
- explains the late inspirartoy crackels of intersitial lung disease and early HF
crackles result from air bubles flowing through secresions or lightly closed airways during respiration
- explains at least some coarse crackles

Late Inspiratory crackles: appear first at base of lungs spread upwar as the condition worsens

ie. intersitual lung diease (pulm fibrosis) and HF

Early inspirartory crackles: coarse

ie. chronic bronchitis, asthma

Midinspiratory and expiratory crackles: heard in bronchiectasis (not specific for this diagnosis however)

Answer 179

A

when air flows rapidly thorugh bronchi that are narrowed nearly to the point of closure
sometimes can hear at the mouth as well as chest wall
asthma : heard only in expiration or in both phases of the respiratory cycle
COPD
HF
Rhonchi: suggest secretion in larger airways
chronic bronchitis: you can clear wheezes and rhonchi with coughing

Answer 180

A

sometime in severe obstructive pulmonary disease patietn is unable to force enough air through the narrowed bronchi to produce wheezing.

resulting in silent chest

this is ominous and warratns immediate attention

Answer 181

A

patrial obstuction of a bronchus

seen with tumor or foreign body

may be inspir. or expir. or both

Answer 182

A

wheeze that is entirely or predominantly inspiratory
louder in the neck than over the chest wall
indicated partial obstruction of the larynx or trachea
immediate attention

Answer 183

A

inflamed or roughened pleural surface grate against each other as they are momentarily and repeatedly delayed by increase friction
creaking sounds
usually during expiration
resemble crackles but produced by diff athologic processes.
dicrete… sometimes can merge into continuous sound
confined to small area of chest wall
heard on both phases of respiration
when inflammed pleural surfaces are seperated by fluid and sound disappears

Answer 184

A

series of precordial crackles synchronous with heart beat not with respiration
best heard on left lateral position (due to mediastinal emphysema)

Answer 185

A

bronchi chronically inflammed and productive cough is present. airway obstruction may develop

Percussion: resonant
Breath Souds: vesicular
Advenitious sounds: none (or scattered coarse crackles in early inspriation and perhaps expiration, or wheezes or rhonic)
Tactile frem/voice sounds: normal

Answer 186

A

increased pressure in the pulm viens casues congestion and intersitial edema

percussion sound: reson.
breath sounds: vesicular
adventitious sounds: late inspir. crackles in deendent portions of lung, possible wheeze
tactile fremitus/voice sounds: normal

Answer 187

A

Alveoli dill with fluid aor blood cells, as in pneumonia, pulmonart edema, or pulmoary hemorrhage

percussion sound: dull over the airless area
breath sounds: bronchial over involved area
adventitious sounds: Late inspiratory crackles over involv. area
tactile fremitus/voice sounds: increased over involv. area with bronchophony, egophony, and whipered pectoriloquy

Answer 188

A

when a plug in a mainstem bronchus obstructs air flow, affected lung tissue collapses into an airless state

trachea may be shifted toward involved side

percussion sound: dull over airless area
breath sounds: usually absent when bornchial plug persists. expetion is upper right lobe atelectasis where adjacent tracheal sounds may be transmitted
adventitious sounds: none
tactile fremitus/voice sounds: usually absent when the bronchial plug persists. exception (R. upper love atelectasis) may be increased

Answer 189

A

fluid accumlates in the peural space, speerated air filled lung from the chest wall, blocking the transmission of sound

trachea may be shifted away from large effusion

percussion sound: dull to flat over fluid
breath sounds: decreased to absent, bornchial breath sounds may be heard near top of large effusion
adventitious sounds: none
tactile fremitus/voice sounds: decreased to absent, may be increased toward top of a large effusion

Answer 190

A

when air leaks into the pleural space, usually unilaterally, lung recoils from the chest wall. pleural air blcks transmission of sound

trachea shifted toward opposite side if much air

percussion sound: hyperresonant or tympanic over the pleural air
breath sounds: decreased to absent over pleural air
adventitious sounds:none
tactile fremitus/voice sounds: decreased to absent over pleural air

Answer 191

A

slowly pogressive disrder in which the distal air spaces enlarge and lungs become hyperinflated. chronci bronchitis is often assoiated

percussion sound: hyperresonant
breath sounds: decreased to absent
adventitious sounds: none, or the crackles, wheezes, and rohonchi or assoiated chronic bronchitis
tactile fremitus/voice sounds: decreased

Answer 192

A

widespread narrowing of the trachobronchial tree diminshs air flow to a fluctuating degree. during attacks air flow decreases further and lungs hyperinflate.

percussion sound: resonant to diffusely hyperresonant
breath sounds: often obscured by wheezes
adventitious sounds: wheezes, possibly crackles
tactile fremitus/voice sounds: decreased

Answer 193

A

Age: 5 or older
advantages:
- newer inhaler have a dose counter
- delivery of medication in less than 2 min
- portable durable
- lower medication dose needed vs neb
diadvantages
- older inhalers do not have dose counter
- techinique and coordination may be difficult
- propellant may taste bad or irritate airways

Answer 194

A

Age
- if less then 4 use VHC with mask
- 4 or older use VHC
advantages:
- VHC enhances MDI tech
- VHC decreased topical side effects of inhaled corticosteriods (ICS)
- albuterol MDI with VHC is as effective as neb for asthma exacerbation
diadvantages:
- bulky
- lack of coverage by some insurance
- limited testing
- potential for increased systemic side effecxts with inhaled corticosteriod (ICS)

Answer 195

A

Age: any age, usually infants or elderly
advantages:
- no coordination
- O2 may be dellivered simutaneously with medications
diadvantages
- requires 5-15 min to deliver med
- limited number of medications available for neb
- not portable

Answer 196

A

Age: any age, usually infant or elderly
advantages:
- more portable than jet neb
- faster delivery of meds than jet neb
diadvantages
- heat generated from neb breaks down suspension for nebulization
- do not use with budesonide suspension for nebulization

Answer 197

A

Age:
- Aeroizer: 5 and older
- diskus: 4 years of age and older
- flexhaler: 6 years and older
- twisthaler: 12 years and older
advantages:
- easy to use
- has dose counter
- sweet taste
- quick delivery of med
diadvantages
- limited porfict stability 30-45 days after opening
- optimal delivery of medication in children less than 4 years old is not feasible because high inspiratory volume needed
- amount of lactose filler is insuficent to cause concern in lactose intolerance

Answer 198

A

remove cap and shake
exhale all air away from the inhaler
place mouthpiece in mouth with lips tightly around inhaler
to deliver: push down on the canister one time while inhaling a slow steady breath. a puff or mist of medication id sprayed out of the inhaler into the mouth
hold breath for 10 seconds
exhale
wait 1 min. if the dose is to be repeated
recap the inhaler when done
rinse your mouth with water if the medication is an inhaled corticosteroid.

Remember:

prime the MDI the first time it is used or its beeen more then 10 days. Prime the inhaler by spraying 4 sprays into the air
for patients who cannoy hold their breath for 10 seconds, instruct them to hold their breath as long as possible
do not immerse the canister of medication in water at any time
if a counter is not availble on the inhaler, the patient should tally the numbers of puffs used to determine when the inhaler is empty

Answer 199

A

Peak flow meters measure your peak expiratory flow rate (PEFR), a number that correlates with how open the lung’s airways are
as asthma worsens and the airways narrow, the PEFR decreases.
Monitoring can help you (the patient) and your healthcare provider determine the most appropriate asthma treatment plan.

The patient needs to be aware of this to help with management: The management of asthma relies on a patient’s ability to monitor their asthma regularly. Self-monitoring includes assessing the frequency and severity of symptoms (such as wheezing and shortness of breath) and measurement of lung function with a peak flow meter.

Answer 200

A

Experts recommend that people with moderate to severe persistent asthma have a peak flow meter at home and know how to use it
A peak flow meter is small, inexpensive, and easy for most patients to use.
patients should use a peak flow meter to:
- Regularly monitor lung function and response to treatment over the short- and long-term
- Determine the severity of an asthma attack
- Assess response to treatment during an attack
asthma diary to record (This can help to show a cause-and-effect relationship between exposure to triggers and decreases in peak flow)
- your daily peak flow meter readings
- exposure to potential asthma triggers
- asthma medication use
- asthma symptoms

Answer 201

A

Peak flow monitoring should be performed on a regular basis (even when asthma symptoms are not present)
Peak flow should also be checked if symptoms of coughing, wheezing, or shortness of breath develop.

Answer 202

A

The peak flow meter should read zero or its lowest reading when not in use.
Use the peak flow meter while standing up straight.
Take in as deep a breath as possible.
Place the peak flow meter in the mouth, with the tongue under the mouthpiece.
Close the lips tightly around the mouthpiece.
Blow out as hard and fast as possible; do not throw the head forward while blowing out.
Breathe a few normal breaths and then repeat the process two more times.
Write down the highest number obtained.
Do not average the numbers.
IMPORTANT: Repeat the test if your tongue partially blocks the mouthpiece or if you cough or spit during the test.

Answer 203

A

no “normal” peak flow measurement for everyone.
determine what peak flow value is normal for you.
Ideally, the baseline values should be obtained when the patient is feeling well after a period of maximal asthma therapy
To determine your normal peak flow measurement:
- measure peak flow when you have no asthma symptoms.
- Perform three measurements with the same peak flow meter two to four times daily for two to three weeks.
- note the highest peak flow measurement achieved; this is the “personal best.”
- This number is used to determine if future peak flow measurements are normal or low, and is also used to create a normal range (between 80 and 100 percent of the personal best peak flow measurement).
Readings below the normal range are a sign of airway narrowing in the lungs.
- A low peak flow measurement can occur before asthma symptoms such as wheezing or shortness of breath develop.
Remeasure your personal best peak flow value once per year to account for growth or changes in the disease .
verify home peak flow measurements with readings taken with equipment in a healthcare provider’s office since this equipment is more sensitive.
- PEFR measurements should be periodically correlated with office spirometry, since the PEFR in some cases has been less accurate than measurement of FEV1 in detecting airflow obstruction.
long term management= peak flow testing once per day, usually in the morning.

Answer 204

A

the PEFR percent predicted correlates reasonably well with the percent predicted value for the forced expiratory volume in one second (FEV ).
Monitoring the PEFR is useful for detecting changes or trends in a patient’s asthma control
significant testing variability makes it important to confirm or exclude airflow limitation with a more reliable test, such as spirometry
Self-monitoring can be performed by subjectively evaluating the frequency and severity of symptoms
Patients can gain further information by monitoring peak expiratory flow rates (PEFRs), which provide an objective measurement of airflow obstruction
can be performed accurately by most adults and children older than five years of age.
PEFR monitoring can provide the patient and clinician with objective data upon which to base therapeutic decisions

Answer 205

A

conflicting information and results

A number of studies failed to demonstrate an advantage of using PEFR monitoring over symptom monitoring to guide self management actions

Answer 206

A

The most conservative approach is to have patients monitor their condition using both objective and subjective measures
use a patient diary to record daily PFM readings and the presence of any asthma symptoms.
This dual approach may help patients observe a cause-and-effect relationship between exposure to triggers and decrements in peak flow and/or exacerbations of asthma.
The patient should understand that such monitoring is undertaken to check on the effectiveness of therapy and to give early warning of potential deterioration.

Answer 207

A

PEFR values can be compared to age-, gender- and height -matched normal subjects
When determining predicted PEFR values, the reference values should be derived from a peak flow meter, rather than spirometric values
Spirometric values tend to be lower than peak flow meter predicted values

Answer 208

A

Asthma action plan

Answer 209

A

It is suggested that a zone scheme similar to a traffic light system be used to illustrate a plan upon which patients can base self-management decisions:
- GREEN (80 to 100 percent of personal best) signals “all clear”. When readings are within this range and symptoms are not present, the patient is advised to adhere to his or her regular maintenance regimen.
- YELLOW (50 to 80 percent of personal best) signals “caution”, since the airways are somewhat obstructed.
  - The patient should implement the treatment plan decided upon with the clinician to reverse airway narrowing and regain control.
  - The wide range represented by the yellow zone can be subdivided above and below the 65 percent level if desired.
- RED (below 50 percent of personal best) signals “medical alert”. Bronchodilator therapy should be started immediately
  - clinician should be contacted if PEFR measures do not return immediately to the yellow or green zones.

Answer 210

A

(If the picture is too small I wrote it all out….the pictures never upload big enough)

Top of form:

long term meds and dose and instructions
quick relief meds and instructions

Bottom of form: Traffic light system

Green:

i feel good! Personal best peak flow
PREVENT asthma symp. everyday
take long term control meds
before exercise that ___ puffs of ____
avoid things that make asthma worse

Yellow:

symptoms may be: wheeze, tight chest, cough, SOB, waking up at night, decreased ability to do usual activities
take _____
still dont feel well and peak flow is not back up to green zone after one hour i should:
- increase____
- add_____
- call_______

RED:

i feel AWFUL
warning signs: its getting harder to breathe
unable to sleep or do usual acitivities because of breathing problem
MEDICAL ALERT… get help
take _____ until i get help immed.
take____
call_____
DANGER! GET HELP IMMED. call 911 if you have trouble walking or talking due to SOB or lips and fingernails are gray or blue

Answer 211

A

The peak expiratory flow rate (PEFR, also known as peak flow) is the maximal rate that a person can exhale during a short maximal expiratory effort after a full inspiration.
Monitoring the PEFR is useful for detecting changes or trends in a patient’s asthma control.
significant testing variability makes it important to use a more reliable test, such as spirometry, to confirm or exclude airflow limitation suggested by the PEFR.
When determining predicted PEFR values, the reference values should be derived from a peak flow meter, rather than spirometry.
The prolonged expiratory effort of spirometry tends to give a lower peak flow value than that obtained from the brief and rapid exhalation used with a peak flow meter.
PEFR values can be compared to age-, gender- and height-matched normal subjects
The predicted values for black and Hispanic minorities are approximately 10 percent lower than those shown in the tables on UP TO DATE
When instructing a patient on use of a peak flow meter at home, the first step is for the patient to demonstrate adequate peak flow technique.
patient is then asked to monitor and record their PEFR two to four times daily for two weeks, ideally during a time that their asthma is well-controlled.
At the next visit, the two-week baseline results are reviewed to determine that patient’s “personal best” PEFR value.
The personal best is generally the highest PEFR measurement achieved during this post-treatment monitoring period.
An individual patient’s normal PEFR range is defined as 80 and 100 percent of their personal best.
This value is used to develop an “asthma action plan”
The frequency of peak flow monitoring depends on the needs of the individual patient.

Answer 212

A

Spirometry:
- most common of the lung function tests used for asthma.
- It’s a simple, quick, and painless way to check your lungs and airways.
- You just take a deep breath and exhale into a hose attached to a device called a spirometer.
- records how much air you blow out (FVC, or forced vital capacity) and how quickly you do it (FEV, or forced expiratory volume).
- Your score is lower if your airways are swollen or constricted because of asthma or other lung diseases.
- Your doctor may want you to have several spirometry lung function tests to monitor your asthma over time.
- You might have spirometry before and after you take medication to see if the medication helps.
- Your doctor may also want readings taken during exercise to see how your airways react to exercise.
Peak Flow meter
- measure how well your lungs push out air.
- less accurate than spirometry
- good way to regularly test your lung function at home – even before you feel any symptoms.
- A peak flow meter can help you know what makes your asthma worse, whether treatment is working, and when you need to seek emergency care.
- A peak flow meter is a handheld plastic tube with a mouthpiece on one end, which you breathe into.

Answer 213

A

An obstructive defect is indicated by a low forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio,
- If obstructive defect is present, the physician should determine if the disease is reversible based on the increase in FEV1 or FVC after bronchodilator treatment
- asthma is reversible after bronchidilator treatment whereas COPD is not
A restrictive pattern is indicated by a low FVC {below the fifth percentile (adults) or less than 80% (in patients five to 18 years of age). }
- If a restrictive pattern is present, full pulmonary function tests with diffusing capacity of the lung for carbon monoxide testing should be ordered to confirm restrictive lung disease and form a differential diagnosis.
If both the FEV1/FVC ratio and the FVC are low, the patient has a mixed defect.
- The severity of the abnormality is determined by the FEV1.
- If pulmonary function test results are normal, but the physician still suspects exercise- or allergen-induced asthma, bronchoprovocation (e.g., methacholine challenge, mannitol inhalation challenge, exercise testing) should be considered.

Answer 214

A

SPIROMETRY!

Answer 215

A

THIS MAKES IT ALL COME TOGETHER! SUCH A GOOD PICTURE! ITS IN THE ARTICLE FOR CA “A STEP-WISE APPROACH TO INTERPRETATION OFPULMONDARY FUNCTION TEST” IF YOU WANT TO GO FIND IT

Answer 216

A

(1) the volume-time curve reaches a plateau, and expiration lasts at least six seconds
(2) results of the two best efforts on the PFT are within 0.2 L of each other
(3) the flow-volume loops are free of artifacts and abnormalities.

******IF the patient’s efforts yield flattened flow-volume loops, submaximal effort is most likely; however, central or upper airway obstruction should be considered.*********

Answer 217

A

Step 1: Determine If the FEV1/FVC Ratio Is Low

GOLD STANDARD: cutoff is less than 70%
but some people say w/ symptoms if people between 5-18 can be ratio less than 85%
ATS Criteria: can also us LLN (lower limit of normal) in adults - less than fifth percentile
if low= indicative of obstructive

Step 2: Determine If the FVC Is Low

indicating a restrictive pattern, a mixed pattern (ratio and FVC low)

Step 3: Confirm the Restrictive Pattern

If the patient’s initial PFT results indicate a restrictive pattern or a mixed pattern that is not corrected with bronchodilators, the patient should be referred for full PFTs with DLCO testing.
DLCO is a quantitative measurement of gas transfer in the lungs. Diseases that decrease blood flow to the lungs or damage alveoli will cause less efficient gas exchange, resulting in a lower DLCO measurement.

Step 4: Grade the Severity of the Abnormality

should grade the severity of the abnormality based on the FEV1 percentage of predicted.

Severity FEV1 percentage of predicted

Mild > 70

Moderate 60 to 69

Moderately severe 50 to 59

Severe 35 to 49

Very severe < 35

Step 5: Determine Reversibility of the Obstructive Defect

determine if it is reversible based on the increase in FEV1 or FVC after bronchodilator treatment
asthma=reversible
COPD= not
if pt has mixed pattern and after bronchodilator treatment the FVC corrects itself (leaving you with only a low FEV1/FVC) then it is likely a pure obstructive lung disease with air trapping

Step 6: Bronchoprovocation

If PFT results are normal but the physician still suspects exercise- or allergen-induced asthma, the next step is bronchoprovocation (methacholine challenge, a mannitol inhalation challenge, exercise testing, or sometimes eucapnic voluntary hyperpnea testing.)
When the FEV1 is 70% or more of predicted on standard spirometry, bronchoprovocation should be used to make the diagnosis.
If the FEV1 is less than 70% of predicted, a therapeutic trial of a bronchodilator may be considered

Step 7: Establish the Differential Diagnosis

Step 8: Compare Current and Prior PFT Results

Answer 218

A

During the DLCO test, patients inhale a mixture of helium (10%), carbon monoxide (0.3%), oxygen (21%), and nitrogen (68.7%) then hold their breath for 10 seconds before exhaling.
The amounts of exhaled helium and carbon monoxide are used to calculate the DLCO.
Carbon monoxide is used to estimate gas transfer instead of oxygen due to its much higher affinity for hemoglobin.
A baseline hemoglobin level should be obtained before DLCO testing because results are adjusted for the hemoglobin level.
HIGH DLCO: asthma
NORMAL DLCO WITH RESTRICTIVE PATTERN: kyphoscolliosis, pleural effusion
NORMAL DLCO WITH OBSTRUCTIVE PATTERN: asthma, bronchiectasis, chronic bronchitis
LOW DLCO WITH RESTRICTION: asbestosis, isiopathic pulm. fibrosis, lymphangitic spread of tumor, tuberculosis, sarcoidosis
LOW DLCO WITH OBSTRUCTION: cystic fibrosis, emphysema
LOW DLCO WITH NORMAL PULMONARY FUNCTION TEST RESULTS: chronic pulm emboli, CHD, intersitial lung disease (early), pimary pulmonary hypertension

Answer 219

A

The methacholine challenge is highly sensitive for diagnosing asthma; however, its low specificity results in false-positive results.

high sensitivity

low specificity

Answer 220

A

The mannitol inhalation challenge has a lower sensitivity for the diagnosis of asthma or exercise-induced bronchoconstriction than the methacholine challenge, but has a higher specificity for the diagnosis of asthma.

low sensitivity

high specificty

Answer 221

A

A treadmill exercise test has excellent sensitivity and specificity for the diagnosis of exercise-induced bronchoconstriction, but has only modest sensitivity and specificity for the diagnosis of asthma.

In this test, baseline spirometry is measured, followed by exercise on a treadmill. The goal is to achieve 80% to 90% of the maximum heart rate within two minutes, and maintain that heart rate for eight minutes. Inhaled medical-grade dry air or an air conditioned room. The patient must wear a nose clip.

Answer 222

A

FEV1: forced expiratory volume in one second; total volume of air a patient is able to exhale in the first second during maximal effort
FVC: forced vital capacity; total volume of air a patient is able to exhale for the total duration of the test during maximal effort
FEV1/FVC ratio: the percentage of the FVC expired in one second
DLCO: diffusing capacity of the lung for carbon monoxide
EIB: exercise-induced bronchoconstriction
LLN: lower limit of normal, defined as below the fifth percentile of spirometry data obtained
TLC: total lung capacity; the volume of air in the lungs at maximal inflation
VC: vital capacity; the largest volume measured on complete exhalation after full inspiration

Answer 223

A

OBSTRUCTIVE

α1-antitrypsin deficiency (seen in COPD)
Asthma
Bronchiectasis
Bronchiolitis obliterans
Chronic obstructive pulmonary disease
Cystic fibrosis
Silicosis (early)

RESTRICTIVE

Chest wall
- Ankylosing spondylitis
- Kyphosis
- Morbid obesity
- Scoliosis
Drugs (adverse reaction)
- Amiodarone
- Methotrexate
- Nitrofurantoin (Furadantin)
Interstitial lung disease
- Asbestosis
- Eosinophilic pneumonia
- Idiopathic pulmonary fibrosis
- Sarcoidosis
- Silicosis (late)
Neuromuscular disorders
- Amyotrophic lateral sclerosis
- Guillain-Barré syndrome
- Muscular dystrophy
- Myasthenia gravis

***** I know we dont have to know all these… it was one of the charts in the reading… just read it over once and you should be good! just nice to know some differential diagnoses!*****

Answer 224

A

Pulse oximetry is a procedure used to measure the oxygen level (or oxygen saturation) [HYPOXEMIA] in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen delivery to the peripheral tissues (such as the finger, earlobe, or nose).

do this in people with possible Pnemonia

and obstructive lung diseases

well can do with anyone but these are some emphasized ones

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Clinical Assessment Module 3 Pulm Flashcards

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