Egan's Ch. 16: Bedside Assessment of the Patient

Question 1

Diagnosis

Differential diagnosis

Signs

Symptoms

Answer 1

Diagnosis:

• process of identifying nature and cause of illness
• systematic based on:
  
  • History
  • Physical exam
  • Labs

Differential diagnosis:

• when signs and symptoms are shared by many diseases

Signs:

• objective manifestation of illness

Symptoms:

• subjective experienc of some aspect of an illness

Question 2

Purpose of interviews and taking a medical history:

Answer 2

1. To establish a rapport between the clinician and patient.
2. To obtain information essential for making a diagnosis.
3. To help monitor changes in the patient’s symptoms and response to therapy.

Question 3

Types of Questions Used in Patient Interviews

Answer 3

• Open-ended questions
  
  • encourage patients to describe events and priorities as they see them, helping to bring out concerns and attitudes and to promote understanding.
    
    • “What brought you to the hospital?”
    • “What happened next?” encourage conversational flow and rapport, while giving patients enough direction to know where to start.
• Closed questions
  
  • “When did your cough start?”
  • “How long did the pain last?” focus on specific information and provide clarification.
• Direct questions
  • ​can be open-ended or closed and always end in a question mark.
    
    • Although they are used to obtain specific information, a series of direct questions or frequent use of the question “Why?” can be intimidating and cause the patient to minimize his or her responses to questions.
• Indirect questions
  
  • less threatening than direct questions because they sound like statements (e.g., “I gather your doctor told you to take the treatments every 4 hours”).
  • Inquiries of this type also work well to confront discrepancies in the patient’s statements (e.g., “If I understood you correctly, it is harder for you to breathe now than it was before your treatment”).
• Neutral questions and statements
  
  • preferred for all interactions with the patient.
  • “What happened next?” and
  • “Can you tell me more about … ?” are neutral, open-ended questions.
  • A neutral, closed question may give the patient a choice of responses, while focusing on the type of information desired (e.g., “Would you say there was a teaspoon, a tablespoon, or a half cup?”).
  • Leading questions, such as “You didn’t cough up blood, did you?” should be avoided because they imply an answer.

Question 4

Dyspnea

Answer 4

Breathing discomfort

• subjective
• percieved as life-threatening
• different than pain as is describes the difficulty in the mechanical act of breathing.

Factors affecting this sensation:

1. The neural drive to breathe emanating from the respiratory centers in the brainstem
   * Neuromechanical dissociation
2. The tension developed in the respiratory muscles
3. The corresponding displacement of the lungs and chest wall

Question 5

Breathlessness

Answer 5

Triggered by acute hypercapnia, acidosis, or hypoxemia.

Question 6

Hypercapnia

Answer 6

excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration.

Question 7

Postional Dyspnea (4 types)

Answer 7

Orthopnea:

• triggered in reclining position
• common in patients with CHF, mitral valve disease, superior vena cava syndrom

Platypnea

• triggered in upright position
• occurs after pneumonectomy, in patients w/chronic liver disease (hepatoplmonary syndrome), hypovolemia, and some neurological diseases.
• may be accompanied by orthodeoxia

Orthodeoxia

• oxygen desaturation on assuming an upright position

Trepopnea

• lying on one side to relieve dyspnea
• associated with CHF or pleural effusion

Question 8

hypovolemia

Answer 8

a decreased volume of circulating blood in the body.

Signs & Symptoms:

• Rapid heartbeat.
• Quick, shallow breathing.
• Feeling weak.
• Being tired.
• Confusion or wooziness.
• Little or no pee.
• Low blood pressure.
• Cool, clammy skin.

Diagnosis. Hypovolemia can be recognized by a fast heart rate, low blood pressure, and the absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary refill on forehead, lips and nail beds

Cause: Significant and sudden blood or fluid losses within your body. Blood loss of this magnitude can occur because of: bleeding from serious cuts or wounds. bleeding from blunt traumatic injuries due to accidents

Question 9

Assessing Dyspnea

Answer 9

• can the patient speak in full sentences?
  
  • if not,
    
    • interview should be curtailed and treatment initiated as soon as possible
    • questions structred for yes or no response
    • brief
• for chronic cardioplmonary disease:
  
  • ask what activities of daily living tend to trigger episodes of dyspnea.
    • is dyspnea triggered by walking on flat surfaces, by climbing stairs, by bathing, by dressing?
  • ask how much exertion makes the patient to stop to catch his or her breath with different activities.
    • Does the patient need to stop after walking up one flight of stairs or one step?
    • Dyspnea provoked by less strenuous activities indicates more advanced disease.
• ask whether the quality or the sensation of breathing discomfort varies with different activities.
• Patient’s history
  
  • ask the patient to recall when dyspnea first began and how it has evolved over time.
  • Has dyspnea progressed slowly or rapidly?
  • How long has this progression taken place: over a period of months or years?
  • Has there been a dramatic change in the intensity of dyspnea over the recent past?

Question 10

Cough

Answer 10

Note characteristics:

• dry or loose
• productive or unproductive
• acute or chronic
• frequency/times (day or night)

Examples:

• Dry, unprodctive cough is typical for CHF or pulmonary fibrosis
• Loose, productiv cough is associated with inflammatory obstructive diseases like bronchitis and asthma.
• Chronic coughs last 8 weeks or longs

Question 11

Psychogenic Dyspnea: Panic Disorders and Hyperventilation.

Answer 11

The RT always must approach any situation involving hyperventilation or dyspnea as if it had a pathogenic basis.

1. Measure the vital signs, including SaO 2 ,
2. start a 12-lead electrocardiogram
3. Obtain arterial blood gases.

A psychogenic source is considered only after a pathogenic source for hyperventilation or dyspnea has been ruled out.

Question 12

Chronic Cough in Adults

(>8 weeks Duration)

Answer 12

Common Sources

• Upper airway cough syndrome (formerly known as “postnasal drip”)
• Asthma
• Gastroesophageal reflux
• Chronic bronchitis associated with cigarette smoking
• Angiotensin-converting enzyme–1 cough (caused by the antihypertensive drug angiotensin-converting enzyme inhibitor)
• Nonasthmatic eosinophilic bronchitis

Less Common Sources

• Postinfection (e.g., pertussis, mycoplasma)
• Interstitial lung disease
• Bronchiectasis
• Obstructive sleep apnea
• Primary lung cancer
• Heart failure
• Pulmonary tuberculosis
• Environmental exposures

Uncommon Sources

• Sarcoidosis
• Recurrent aspiration
• Chronic tonsillar enlargement
• Chronic auditory canal irritation
• Foreign body aspiration
• Endemic fungi
• Peritoneal dialysis
• Cystic fibrosis
• Tracheomalacia
• Habit or “tic cough”

Kacmarek, Robert M.,Stoller, James K.,Heuer, Al. Egan’s Fundamentals of Respiratory Care (Kindle Locations 16819-16845). Elsevier Health Sciences. Kindle Edition.

Question 13

Sputum

Answer 13

• phlegm:
  
  • Mucus from the tracheobronchial tree, uncontaminated by oral secretions .
• sputum
  
  • Mucus from the lungs that passes through the mouth as it is expectorated .
    
    • Sputum that contains pus cells is said to be purulent , suggesting a bacterial infection. Purulent sputum appears thick, colored, and sticky.
    • Sputum that is foul-smelling is said to be fetid.
    • Sputum that is clear and thick is mucoid and commonly is seen in patients with asthma.

Question 14

Hemoptysis

Answer 14

Coughing up blood or blood-streaked sputum from the lungs is common in patients with pulmonary disease

Massive hemoptysis:

• more than 300 ml of blood is expectorated over 24 hours and represents a medical emergency.
• Common causes include bronchiectasis, lung abscess, and acute or chronic tuberculosis.

Nonmassive hemoptysis

• observed in many conditions such as airway infections, pneumonia, lung cancer, tuberculosis, blunt or penetrating chest trauma, and pulmonary embolism.

Infection-associated hemoptysis

• blood-streaked, purulent sputum.
• Hemoptysis from bronchogenic carcinoma often is chronic and may be associated with a monophonic wheeze and cough.

Question 15

Chest Pain: Pleuritic or Nonpleuritic

Answer 15

Pleuritic chest pain (lungs)

• located laterally
• worsens when taking a deep breath.
• sharp, stabbing pain
• diseases that cause the pleural lining of the lung to become inflamed (such as pneumonia, empyema, pleural effusion)
• a common symptom in pulmonary embolism.

Nonpleuritic chest pain (heart)

• centrally located (may radiate to the shoulder, neck, or back.)
• not affected by breathing
• dull ache or pressure type of pain.
• common cause is angina
• Causes: gastroesophageal reflux, esophageal spasm, chest wall pain (e.g., costochondritis), and gallbladder disease

Question 16

JVD (Jugular vein distention)

Answer 16

Jugular vein distention occurs when the pressure inside the vena cava increases and appears as a bulge running down the right side of a person’s neck.

Causes

Right-sided heart failure. The right ventricle of the heart is responsible for pumping blood to the lungs to collect oxygen. The left ventricle is responsible for pumping the blood out to the rest of the body. People with right-sided heart failure have usually already experienced left-sided heart failure. The blood accumulation in the lungs caused by left ventricle failure means the right ventricle has to work harder and becomes weakened until it cannot pump effectively anymore. This failure causes the veins to bulge as blood accumulates.

Pulmonary hypertension. This condition occurs when the pressure in blood vessels becomes dangerously high, causing their walls to thicken and stiffen, meaning less blood can pass through. This can damage the right side of the heart and increase pressure in the superior vena cava.

Tricuspid valve stenosis. This is caused by a stiffening of the valve that separates the right atrium and the right ventricle of the heart. This results in blood backing up in the veins.

Superior vena cava obstruction. Superior vena cava obstruction can occur if a tumorgrowing in the chest or a clot in the superior vena cava restricts blood flow in the vein.

Constrictive pericarditis. If the pericardium or the fluid-filled sac around the heart becomes stiff, it can prevent the chambers of the hearts from filling up with blood properly. This situation can cause the blood to back up in the veins.

Cardiac tamponade. This is a condition that occurs when the sac around the heart fills up with fluid and no longer allows the heart to fill with blood properly. This can happen for a variety of reasons, including infection and bleeding. It causes heart failure as well as JVD.