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Pulmonology > History and Physical Exam of the Pulmonary System > Flashcards

History and Physical Exam of the Pulmonary System Flashcards

1
Q

Air conduction tract

A

Upper: nasopharynx, oropharynx, larynx

Lower: trachea, primary bronchial tree bifurcation

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2
Q

Respiratory Tract

A

Smallest bronchioles and alveoli–gaseous exchange, mucous secreting cells

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3
Q

Physiology of movement of air into lungs

A

Inhaled air is hydrated, putting it into solution

Air is heated by underlying blood vessels

Air cells surrounded by capillaries allow for rapid diffusion of gases

Mucous secreting goblet cells excrete mucous that traps particular matter; mucociliary escalator move it up toward glottis

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4
Q

Mechanics of Respiration

A

Inspiration is active, controlled largely by diaphragm

Expiration is passive

When under stress, intercostals and abdominal muscles are recruited to assist

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5
Q

Amount of air moved in quiet breathing

A

500mL

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6
Q

Dyspnea

A

Subjective description of difficult, labored, or uncomfortable breathing

“Shortness of breath”

“Breathlessness”

“Not getting enough air”

Dyspnea is not dianosis of itself, should be considered a significant sx of another dx

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7
Q

Orthopnea

A

Dyspnea in the recumbant position

Most often the result of volume overload, PE, COPD

Documented in terms of number of pillows

Progression is of particular importance

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8
Q

Paroxysmal Nocturnal Dyspnea (PND)

A

Orthopnea that wakes the patient from sleep

May be associated with left sided heart failure (early pulmonary edema that comes on quickly)

AKA “cardiac asthma”

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9
Q

Wheezing

A

Musical respiratory sound that may be audible to patient and others

Suggestive of partial airway obstruction from:
**secretions
tissue inflammation
foreign body **

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10
Q

Tachypnea

A

Rapid breathing

May or may not be associated with dysnpea

RR >20

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11
Q

Bradypnea

A

Slow breathing

RR<12

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12
Q

Platypnea

A

Dyspnea in the upright position

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13
Q

Hyperpnea

A

Hyperventilation (basically)

Minute ventilation in excess of metabolic demand

Rapid and deep respirations; can lead to respiratory alkalosis

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14
Q

Carpopedal spasm

A

Associated with:

Hyperventilation (psychologic)

Hypocalcemia (physiologic)

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15
Q

Tactile Fremitus

A

Palpable vibrations transmitted through the bronchopylmonary tree to the chest wall when pt speaks (99)

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16
Q

Bronchophony/Egophony

A

The phenomena of increased volume and clarity of sounds transmitted through a solid or liquid opposed to through air

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17
Q

Chest Wall Expansion

A

Normal, symmetricular upward and outward movement of the ribs and chest wall during inspiration

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18
Q

Diaphragmatic Excursion

A

Movement of the diaphragm from its high resting position to its lower, flattened position when it is flexed in inspiration

Normal: 5-6cm on either side

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19
Q

Hypoxia

A

Inadequate oxygenation of the blood

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20
Q

Cyanosis

A

Bluish discoloration of the skin secondary to hypoxia or to inadequate peripheral circulation

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21
Q

Carboxyhemoglobin

A

Stable complex of CO and hemoglobin in RBCs

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22
Q

Pulse Oximetry

A

SaO2

Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through.

Deoxygenated (or reduced) hemoglobin absorbs more light adn allows more infrared light to pass through

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23
Q

Vesicular

A

Soft and low pitch.

Heard throughout inspiration, continue without pause throughout expiration, and then fade away about one third of the way through expiration

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24
Q

Bronchovesicular

A

Inspiratory and expiratory sounds are about equal length, sometimes with silent interval in between

Detecting differences in intensity and pitch is often easier during expiration

Louder because no compliance of these airways

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25
Q

Bronchial

A

Louder and higher in pitch, with short silence between inspiratory adn expiratory sounds

Expiratory sounds last longer than inspiratory sounds

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26
Q

Normal breath sounds

A

Vesicular

Bronchovesicular

Bronchial

*Tracheal

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27
Q

Adventitious Breath Sounds

A

Wheezing

Rales/Crackles

Rhonchi

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28
Q

Crackles/Rales

A

Intermittent, non-musical, brief sounds

Usually higher pitched and brief

Usually occur first in inspiration adn later in both inspiration and expiration

Described as fine or coarse

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29
Q

Rhonchi

A

Relatively low pitched nad may be described as snoring

Suggestive of secretions in larger airways

May be inspiratory or expiratory (or both)

30
Q

Wheezing

A

Relatively high pitched with a musical quality

Usually begin as an expiratory but with increasing severity can span entire respiratory cycle

31
Q

Questions related to Pulmonary Hx

A

Identify alarming symptoms such as associated chest pain.

Acute or chronic?

ROS: Pay particular attention to upper and lower respiratory tract, CV, and GI

Ask about smoking, environmental, and occupational exposures

Review current and prior medications and medication and environmental allergies.

PMSoHx including previous history of similar complaints, asthma, sinusitis, recent respiratory infections, TB exposure, CAD, and esophageal disease.

Family history of pulmonary disease like asthma, COPD and any exposure to second hand smoke.

32
Q

Pulmonary Risk Factors

A

SMOKING!

Aspiration –
stroke, NG tube, trouble protecting airway (i.e. alcoholic), dysphagia.

Debilitation –
alcohol misuse, extremes of age, immunosupression.

Chronic disease –
DM, renal failure, CHF, neuromuscular disorders like Guillian Barre’ or Myasthenia Gravis.

Pulmonary diseases –
Emphysema, Chronic Bronchitis, Asthma, Cystic Fibrosis, Hereditary A1 Antitrypsin deficiency.

33
Q

Inspection

A

Observe the shape of the chest and the movement of the chest wall

Asymmetry or obvious deformities

Retractions in ICS

Inspect skin for cyanosis

Nails for cyanosis or clubbing

34
Q

Variations in Chest Wall Shape

A

Barrell Chest

Traumatic Flail Chest

Funnel Chest (Pectus Excavatum)–depression in lower portion of sternum

Pigeon Chest (Pectus Carinatum)–anteriorly displaced sternum

Thoracic Kyphoscoliosis

35
Q

Palpation

A

Assess for tenderness, instability, or crepitus in trauma

Assess for chest expansion

Assess vocal fremitus

  • Increased fremitus–consolidated fluid magnifies vibration
  • Decreased fremitus–space b/w lung and chest wall magnified vibration
36
Q

Auscultation

A

Pt breathing with mouth open, somewhat more deeply than normal

Note intensity of breath sounds and any variations from normal vesicular breathing

  • Breath sounds are usually louder in the upper, anterior chest
  • Bronchovesicular breath sounds may be heard over the large airways, especially on the right

Identify any adventitious sounds, noting:

  • Timing in respiratory cycle
  • Location on chest wall
  • Do they clear with coughing?
37
Q

Percussion

A

Percuss in the same areas as auscultation

The heart produces areas of dull left of the sternum from the 3rd to 5th ICS

Percuss diaphragmatic excursion

38
Q

History: Evaluation of common or concerning respiratory complaints

A

Cough

Dyspnea

Hemoptysis

Wheezing

Chest Pain

39
Q

Cough

A

A mechanical reflex that involves a deep inspiration, which increases lung volume; followed by muscle contraction against a closed glottis; and then sudden opening of the glottis

Protective and helps clear mucus, secretions, and foreign objects from airway

40
Q

Acute Cough

A

Lasts less than 3 weeks

Usually self-limiting

Most common causes:

  • URI
  • Lower respiratory tract infections
  • Acute exacerbation of chronic COPD
  • Allergic rhinitis
  • Rhinitis due to irritants
  • Irritants to the respiratory tree
41
Q

Chronic Cough

A

Persistent cough lasting longer than 3 weeks

Most common causes:

  • COPD
  • Chronic sinus drainage
  • Asthma
  • GERD
  • Meds
  • Psychiatric
42
Q

Triggers of irritant receptors

A

Irritant–dust

Allergens–ragweed, pollen

Toxic substances–gastric acid

Inflammation–asthma

Cold air

Smoke

Rapid change in humidity or temperature

Infection–viral vs. bacterial

43
Q

Acute causes of cough

A

URI, sinusitis

LRI, bronchitis, pneumonia

Allergic rxn

Asthma

Environmental

Foreign body

44
Q

Chronic/Common Causes of Cough

A

Smoking

Postnasal discharge

Asthma

GE Reflux

ACE Inhibitors/ARBs

45
Q

Chronic/Uncommon Causes of Cough

A

CHF

bronchiectasis

Lung CA

Emphysema

Occupational

Recurrent aspiration

CF, interstitial

46
Q

Characteristics of a smoking induced cough

A

Usually worse in the AM, productive

47
Q

Characteristics of chronic bronchitic cough

A

usually productive

48
Q

Characteristics of rhinitis associated cough

A

associated with PND, nasal mucous drainage, often a hx of seasonal allergies

49
Q

Characteristics of an asthma related cough

A

Worse at night or after exercise

Associated with episodic wheezing

50
Q

Characteristics of a cough associated with meds

A

beta blocker–makes asthma worse

ACEI

51
Q

Characteristics of GE Reflux Associated Cough

A

H/o heartburn

Worse in supine position

Improves with antacids

52
Q

Alarming Symptoms

A

Cough with hemoptysis

Cough, fever, and purulent sputum production

Cough with excessive sputum production

Cough with wheezing and dyspnea

Cough with CP

Cough with unintentional weight loss

Cough, dyspnea, and lower extremity edema

53
Q

Dyspnea

Rule out the bad stuff

A

MI

PE

significant infections

CHF

54
Q

Dyspnea Hx Questions

A

Was the onset acute?

  • airway obstruction
  • PE
  • angioedema
  • allergic reaction

Was the onset gradual?

  • CHF
  • AECB
  • Anemia

Any current or previous diseases that may be an exacerbation of?

Any recent periods of immobility (surgery)?

55
Q

Differential Diagnosis of Acute Dyspnea

A

Pulmonary

  • CHF, pulmonary edema
  • Exacerbation of COPD
  • PE
  • Aspiration/foreign body
  • Acute infections
  • Spontaneous pneumothorax

Cardiac

  • Cardiac tamponade
  • Myocardial ischemia
  • Pericarditis/endocarditis
  • Mitral valve prolapse

Miscellanceous

  • Anaphylaxis
  • Metabolic acidosis
  • Guillain Barre
  • Myasthenia Gravis

Psych

  • Panic attack
  • Hyperventilation
56
Q

DDX of Chronic Dyspnea

A

Pulmonary

  • Asthma
  • COPD
  • Interstitial lung disease
  • Chronic pneumonia
  • Chronic pulmonary emboli
  • Pulmonary neoplasia
  • Pleural effusions

Cardiac

  • Cardiomyopathies
  • CHF
  • Myocardial ischemia
  • Primary pulmonary HTN
  • Pericardial dz

Miscellaneous

  • Deconditioning
  • Anemia
  • Neuromuscular dz

Psychiatric

57
Q

Most immediately life threatening causes of dyspnea

A

Upper airway obstruction, foreign body, angioedema, hemorrhage

Tension pneumothorax

Pulmonary embolism

Neuromuscular (MG, GB)

Anaphylaxis

58
Q

Alarming Symptoms

A

Chest pain

Pink, frothy sputum

Swelling, hives, or wheezing

Fever and sputum production

Weakness/fatigue

59
Q

Signs to promptly identify imminent respiratory failure

How to respond to these signs

A

Tachypnea, stridor, accessory muscle use.

Inability to speak because of breathlessness (3-word dysnpnea)

Agitation or lethargy as consequence of hypoxia

Paradoxical abdominal wall movement due to diaphragmatic fatigue

**What to do: **

Give oxygen

Anticipate need for airway control and mechanical ventilation

60
Q

Hemoptysis Hx

A

Amount of hemoptysis

Associated sxs

Recent illnesses

PMH

Meds and Drugs

Smoking

Travel

Occupational exposure

61
Q

Hemoptysis DDx

A

Infectious – bronchitis, pneumonia, TB

Neoplastic – lung CA

CV – PE, CHF, pulmonary HTN

Hematologic - ↓ platelets, anticoagulant Rx

Traumatic – foreign body, ruptured bronchus

Iatrogenic – lung bx., bronchoscopy

Inflammatory – bronchiectasis, cystic fibrosis

GI- esophageal varicies

ENT- following nasal trauma

62
Q

Alarming Sxs of Hemoptysis

A

Massive or severe hemoptysis is considered life threatening

Chest imaging indicated

Massive hemoptysis carries a mortality rate of 13-58%

63
Q

Wheezing History

A

Timing and details of onset

Any previous attacks?

Risk factors and associated disease

  • Occupational exposure
  • Immobility
  • PMH, asthma, CHF, smoking
  • FHx-atopy
  • Allergies
  • Medication

Compare severity to baseline

Modifying factors

Associated sxs

64
Q

DDx of Wheezing

A

Asthma

COPD, especially emphysema

PE

Anaphylaxis

Infection: viral or bacterial

Tumors

Aspiration

Mitral valve disease

CHF

65
Q

Initial questions for pts with CP

A

PQRSTA

Rule out the bad stuff:

  • MI
  • PE
  • TAA
  • Pneumothorax
66
Q

Chest pain alarming sxs

A

Diaphoresis

Dyspnea with hemotysis, fever, syncope, or paplpitations

Tearing or ripping sensation radiating to the back

CP with N/V

Radiating to arms, shoulders, or jaw

Sudden onset

Sense of impending doom

67
Q

Chest Pain DDx

A

Heart disease

Structures of the thorax

Lungs: PE, pneumothorax, pneumonia, pleuritis

GI causes

Musculoskeletal causes

68
Q
A
69
Q
A
70
Q
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Pulmonology (17 decks)

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