CM- Pulmonary History/Physical Flashcards
What are the 3 cardinal symptoms caused by lung disease?
- cough
- dyspnea/shortness of breath
- hemoptysis (coughing up blood)
What is the differential diagnosis for cough?
- ACEI
- Asthma (bronchial)
- Bronchitis
- Cancer (Lung)
- Drip (postnasal)
- Foreign bodies
- GERD
- pneumonia
- tuberculosis
(AABCDFGPT)
What is the differential diagnosis for hemoptysis?
- abscess (lung)
- bronchitis (most common)
- bronchiectasis (wide flappy airways)
- cancer (lung)
- cystic fibrosis
- CHF
- fungal disease
- Infarct (pulmonary)
- pneumonia
- TB
- Vasculitis
(ABBCCCFIPTV)
What is the differential diagnosis for dyspnea/SOB?
- Asthma
- anemia
- anxiety (most common)
- CHF
- COPD
- Embolism (pulmonary)
- ILD
- MI
- pneumonia
- TB
- valvular disorders
(AAACCEIMPTV)
What is the mechanism by which a cough occurs?
What are the afferent branches and efferent branches?
Stimulus to cause deep inspiration, glottis closure, and contraction against the glottis to increase intrathoracic and intra-airway pressure
Afferent - trigeminal, superior laryngeal, glossopharyngeal, and vagus
Efferent- recurrent laryngeal causes closing of the glottis and spinal nerves contract abdominal and throacic muscles against the closed glottis
What are questions you want to ask someone that has a cough?
- is it productive? How much sputum?
- is it worse at night? (GERD)
- recent travel?
- pets? birds? (pscitacossis- down feathers)
- what is the occupation? (pneumoconioses)
What is the most likely cause of:
- acute cough
- chronic cough
- fever and chills with cough
- seasonal cough
- new medication cough
- cough at night
- pneumococcal pneumonia
- TB or bronchitis
- TB or pneumonia
- postnasal drip
- ACEI
- GERD
What is the difference between hemoptysis and hematemesis?
origin, color and content, pH
Hemoptysis is blood-streaked sputum or gross blood that is coming from the respiratory tract It will be bright red, frothy with hemosiderin macrophages. It will be alkaline pH
Hematemesis is blood coming from the GI tract (throwing up blood vs. spitting up blood). It will be associated with nausea, vomiting, abdominal pain. The blood will be dark red and the pH will be acidic
What is the likely cause if the hemoptysis is associated with:
- fever, chills, weight loss
- pleuritic chest pain
- just blood streaked
- large amounts of gross blood (100-600ml/24hrs)
- TB or cancer
- infarct or vasculitis
- bronchitis or pneumonia
- pulmonary hemorrhage, bleeding disorder, excessive anticoagulant
What is a “massive” hemoptysis defined as?
What are the 3 most likely causes?
It is a loss of 100-600mL blood coughed up over a 24hr period. This amount is life threatening bc it can cause asphyxiation and aspiration
- Pulmonary hemorrhage
- bleeding disorder
- excessive anticoagulant drug administration
What is the mechanism by which dyspnea is believed to occur?
Respiratory centers in the brain are stimulated by the vagus nerve, afferent somatic nerves from the chest wall and respiratory muscles, chemoreceptors in the carotid, or afferent phrenic stimulation to increase the work of breathing .
What is the likely cause of dyspnea if it is :
- positional
- exertional
- associated with fever
- associated with wheezing
- with pleuritic chest pain
- PND
- you ruled everything else out
- CHF
- CHF, valvular disease, anemia
- infection
- asthma, COPD
- PE, vasculitis
- CHF
- anxiety
What is respiratory paradox?
What is it a sign of?
What treatment usually follows?
When the diaphragm is weak and overworked, it moves up during inspiration and the abdominal wall muscles move inward during inspiration.
It is a sign of respiratory failure and means the patient will probably require mechanical ventilation
What are the four steps of the pulmonary physical exam?
- inspection
- palpation
- percussion
- auscultation
In the pulmonary exam, what eight things do you look at during inspection?
- chest wall deformities
- accessory muscle use
- tracheal deviation
- splinting
- clubbing
- cyanosis
- inspiratory/expiratory ratio
- pulsus paradoxis
What are the 3 major chest wall deformities? Describe each one.
What are likely causes of each?
- barrel chest- appearance of increased thoracic AP diameter that is an illusion caused by decreased abdominal AP diameter (also thoracic might be slightly wider due to reduced elastic recoil)
- COPD - pectus carinatum (pigeon chest) - protrusion of the sternum with a narrowed thorax.
- Rickets, Marfan’s, diaphragm abnormalities - pectus excavatum (funnel chest)- retraction of sternum producing an oval pit near infrasternal notch
- Marfan’s, rickets, tracheomalacia, bronchomalacia, CHD
SCM are normally not used during respiration. If they are being used, it means what?
FEV1 has decreased to below 30% of normal.
With chronic used SCM hypertrophy
What is the normal movement of intercostal muscles during inspiration?
They move inward during inspiration and outward in expiration.
Diaphragm contracts to make negative intrapleural pressure to pull them inward during inspiration.
What causes an exaggerated inward retraction of intercostal muscles?
Exaggerated inward retraction is due to airway obstruction that doesn’t allow the lung to fill keeping the intrapleural pressure negative and yanking intercostals further inward.
- flail chest
- COPD
- constrictive pericarditis
- restrictive lung disease
What causes decreased inward retraction of the intercostal muscles?
Decreased inward retraction during inspiration is indicative of increased expansion of the lungs with fluid or inflammation. This causes a LESS negative intrathoracic pressure when the diaphragm contracts.
- consolidation
- tension pneumothorax
- pleural effusion
What causes an exaggerated outward bulging of the intercostals during expiration?
It means there is increased intrathoracic pressure or that the lungs are unable to fully empty.
- emphysema
- acute asthma exacerbation
- tension pneumothorax
- flail chest
What causes a constant bulging of the intercostal muscles?
Massive pleural effusions which create a large positive pleural pressure and prevent lungs from filling
What are the two main situations that shift the trachea to the unaffected side?
What are two situations that shift the trachea toward the pathologic side?
To unaffected side:
- pneumothorax
- pleural effusion
Toward the affected side:
- Atelectasis
- consolidation with obstruction (closed bronchi)
What is splinting?
What are 4 potential causes?
Asymmetric expansion of one side of the chest.
- unilateral diaphragm paralysis
- pneumothorax
- bronchial obstruction
- massive pleural effusion
What is clubbing?
What diseases is it seen in?
What is it likely due to?
It is rounded fingers that when you put pointer fingers together, there is no gap (Shamroth’s sign) that is due to chronic hypoxia
- lung disease
- congenital heart disease
- endocarditis
It is thought to be the deposition of megakaryocyte fragments due to increased PDGF. The excess is usually filtered in the lung, but congenital shunts, bypass the lung and allow deposition in small capillaries of fingers/toes
What are the 3 substances built up in generalized cyanosis?
What causes the buildup for each?
- methemoglobinemia- toxin/congenital
- sulfhemoglobinemia-toxin/congenital
- deoxyhemoglobinemia- most common cause and is due to oxyhemoglobinemia passing through capillary beds and losing oxygen to tissue
What does the Hb level need to be in order to cause deoxyhemoglobinemia–> cyanosis?
5g/dL because it is the concentration of oxygen that is important.
The more Hb someone has, the more easily they will get cyanosis.
7.5 –> 67% unsaturation to be the same blue that someone with
15g/dl –>33% unsaturated to be blue
How does peripheral cyanosis differ from generalized cyanosis?
It is when the Hb concentration is normal but there is decreased cutaneous blood flow leading to increased tissue extraction of O2.
-anxiety, cold, hypoperfusion
What is the normal inspiratory/expiratory ratio?
How would it change with obstructive lung disease?
How would it change with restrictive lung disease?
Normal:
Inspiration is half as long as expiration. I/E ratio is 1:2
Obstructive lung disease:
Air trapping causes hyperinflation of the lung so there is an increased I/E ratio. 1:3 because they need to spend more time in expiration to “get the air out”
Restrictive Lung disease:
generally does NOT cause increased ratio
What is pulsus paradoxus?
Decreased systolic BP by more than 15mmHg with inspiration.
Usually caused by pericardial tamponade or severe pulmonary disease
When you palpate the chest wall, what 4 major things are you looking for?
- nodules
- tender ribs (trauma)
- tenderness of chest (costochondritis)
- crepitus (subcutaneous emphysema from trauma– needs a chest tube bc they likely have air in pleural space)
What is fremitus?
When you feel for it, what 4 locations should you feel?
What are you looking for?
What should the patient say?
It is vibration felt when placing one’s hand on the chest wall while the patient speaks.
- posterior apices
- intrascapular
- paravertebral
- supradiaphragmatic
You are looking for symmetry
Say “O”
What would decrease fremitus?
Anything that blocks sound travel from the bronchi/alveoli to the pleural (displaced lung or blockage)
- atelectasis due to mucus plugging
- consolidation with closed bronchi
- pneumothorax
What would increase fremitus?
If there was fluid in the alveoli with an open bronchus the sound would travel better and vibration would be stronger.
- pneumonia
- heart failure
What causes dullness on percussion?
Normal lungs are resonant bc sound impulse travels through air.
If there is fluid in the pleural space or lung (consolidation) the sound will be dull
1. pleural effusion
2. consolidation (open or closed bronchi)
What causes hyperresonance on percussion?
Unilateral?
Bilateral?
Hyperresonance indicates air between the chest wall and the lung tissue.
unilateral hyperresonance
-pneumothorax
bilateral
- COPD
- asthma
You are doing percussions on a patient and they are dull.
Fremitus is increased. What is the likely causes?
What if fremitus was decreased?
Increased fremitus:
- consolidation with open bronchi
Decreased fremitus:
- consolidation with closed bronchus
- pleural effusion
What is diaphragmatic excursion?
Percuss the inferior lung fields starting at resonant level until area of dullness. Do this on both sides while the patient takes a deep breath.
Right diaphragm should be higher than left, so elevation of the left is abnormal
- paralysis
- LUQ mass
- pleural effusion
- left lower lobe lesion
Describe the fremitus and percussion findings of lung consolidation with closed bronchus.
decreased fremitus, dullness to percussion
Describe fremitus and percussion findings of lung consolidation with open bronchus.
increased fremitus, dullness
Describe the percussion and palpation findings for a pneumothorax.
decreased fremitus, hyperresonance
Describe the percussion and palpation findings for a pleural effusion.
decreased fremitus, dullness
During ausculation, what 5 things do you check for?
- intensity
- type of breath sounds
- I/E ratio
- pitch and timbre
- adventitious breath sounds
If breath sounds do not go to one area of the lung, this indicates disease in bronchi or alveoli of that region.
What are 3 causes of bronchial disease?
4 causes of alveolar disease?
Bronchial-
- foreign bodies
- obstruction (COPD)
- asthma
Alveolar-
- consolidation
- pneumothorax
- pleural effusion
- pleural fibrosis
If you hear diffuse decreased breath sounds (and the person is not obese) what are the 3 likely causes?
How do you know the breath sounds are decreased and this is not just the person’s normal breathing pattern?
- restrictive lung disease
- expanded lungs with obstruction (COPD)
- obstructive lung disease
Compare patients breath sounds with past normal patients
What is bronchophony?
normal lung sounds, but in the wrong location.
For example:
Trachea sounds in the periphery of the lung indicates a solid connection between the lung and trachea:
1. consolidation with open bronchus
2. extrinsic compression from pleural effusion or lymph nodes
What are the 4 types of breath sounds?
Where are they heard?
When are they heard, inspiration or expiration?
- Vesicular
- most of the lung (in normal, absent in diseased)
- “alveolar” below 200Hz
- longer during inspiration - Bronchial
- manubrium near the main bronchi
- louder, higher frequency
- longer in expiration - Bronchovesicular
- 1st and 2nd intercostal spaces
- equal in inspiration/expiration - Tracheal
- trachea/neck
- equal inspiration/expiration
- loudest
What is pitch, volume and timbre?
Pitch- frequency in Hz
Volume- intensity or amplitude of sound
Timbre- color or pronunciation
What are the 5 adventitious sounds?
- stridor
- rhonchi
- wheezes
- crackles (rales)
- pleural rub
What is stridor?
Is it heard in inspiration or expiration?
What does it indicate?
Hissing in inspiration indicating an upper airway obstruction (trachea, larynx, epiglottis)
“hot potato voice” = EMERGENCY
What are rhonchi?
Is it heard in inspiration or expiration?
What does it indicate?
It is a continuous sound in the larger airways caused by fluid rupture or airway wall vibrations.
It is heard in inspiration and expiration
Indicative of secretions in large airways or collapsible large airways
What are wheezes?
Are they heard in inspiration or expiration?
What does it indicate?
Continuous sound indicative of airway obstruction that is in a smaller airway than stridor.
It is usually decreased flow through bronchi or bronchioles
Heard in both inspiration and expiration
Indicates:
- COPD
- Asthma
- foreign body
What are crackles (rales)?
What are the 2 types?
When are they heard (insp or exp)?
What do they indicate?
discontinuous sound caused by explosive opening of the alveoli and small airways.
- Coarse (wet) - mid to late inspiration
- bronchiectasis
- pneumonia
- CHF - Fine (dry) - late inspiration
- ILD
What is the differential diagnosis of fine crackles?
Sarcoid Heart failure, hemorrhage Infection, idiopathic pulm. fibrosis Trauma, toxins Fungal, familial Aspiration, allergic, alveolar proteinosis Cancer, collagen vascular disease Eosinophilic Drugs, dust
What is egophony?
Change in timbre without changing pitch or volume.
“E” to “A” (bee to goat)
This indicates consolidation in the lungs
What is pectoriloquy?
Normally you cannot hear a patients words when they speak during auscultation, just jumbled sound.
In consolidated lung, the trachea, lung and chest wall are all connected and you can make out words.
have patient whisper 66
