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Pulmonology > Phys Di - Chest & Lungs > Flashcards

Phys Di - Chest & Lungs Flashcards

1
Q

What common complaints might a pulm pt have?

A
  • Cough w/ mucous
  • Dry cough
  • Can’t breath
  • Coughing up blood
  • Chest pain
  • Wheezing
  • Chest congestion
  • My child is in distress
  • Fever and lethargy
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2
Q

Pertinent past med hx for pulm diseases

A
  • Chronic Bronchitis
  • Emphysema
  • TB
  • Asthma
  • Cystic fibrosis
  • H/o bronchiectasis
  • Pulmonary fibrosis
  • Sleep apnea
  • Pneumothorax
  • HOSPITALIZATIONS related to above
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3
Q

Other pertinent diseases

A 
Cancer
Cardiac disease:
--heart failure
--CAD
Blood clotting disorders 
--hypercoaguability
--history of pulmonary emboli
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4
Q

What supportive devices would you ask about?

A
  • Oxygen use? How many liters? 24⁰ or PRN?

- Ventilation-assisting devices? CPAP? BiPAP?

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5
Q

What vaccinations would you ask about?

A

Pneumonia Vaccine

Influenza Vaccine

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6
Q

What prior testing is pertinent?

A
  • Last pulmonary function testing
  • Allergy testing in the past?
  • Last Chest X-Ray? Abnormal?
  • Last CT scan?
  • Last TB tuberculin skin test or quantiferon gold
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7
Q

Pertinent surgical history

A
  • Thoracic surgeries
  • -CABG, Deformity, Embolus, Valve?
  • Lobectomy … For what?
  • Pharyngotracheal surgeries
  • Inferior Vena Cava Filter, Greenfield Filter
  • Ever had a chest tube …. For what?
  • Any lung biopsies? Findings?
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8
Q

Pertinent family history

A
  • Cystic fibrosis
  • Tuberculosis (genetic susceptibility)
  • Emphysema
  • Allergies, asthma, atopic dermatitis
  • Lung Cancer
  • Clotting disorders
  • Pulmonary Fibrosis
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9
Q

Pertinent social history (4)

A

Occupation (work, irritants, animals, carcinogens, etc.), home environment (secondhand smoke, allergens, etc.), exercise, and hobbies.

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10
Q

What should you ask about tobacco use?

A

(1. ) Type: cigarettes, cigars, pipe, smokeless
(2. ) Duration: total years smoked, age started
(3. ) Amount: PPD or Pack Year History = years smoked x PPD
(4. )Ever tried to quit?

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11
Q

What should you ask about marijuana use?

A

(1. ) Route: cigarette, bong
(2. ) Purchase History: How often do you buy it? How much do you buy at a time?
(3. ) Amount: How many bowls smoked per ingestion? How many times do you smoke between purchases?

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12
Q

If a pt traveled to SE and MW United States, what could they have been exposed to?

A

Histoplasmosis

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13
Q

If a pt traveled to SW Asia/Africa/Caribbean, what could they have been exposed to?

A

Schistosomiasis

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14
Q

What are the special populations/what do you ask?

A

Children/infants:

  • Any respiratory issues at birth: prematurity? transient tachypnea of the newborn?
  • History of intubation or respiratory distress syndrome?
  • Aspiration of small object, toy, or food

Pregnancy:

  • Uterus displaces the diaphragm upward
  • Hypercoaguability
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15
Q

Respiratory ROS

A

-Cough
-Sputum production
-Hemoptysis
-Wheezing
-Shortness of Breath (SOB)
-Dyspnea on Exertion (DOE)
-Pleuritic Chest Pain (sharp pain on their side when they breath deeply)
-H/o: Asthma, Bronchitis, Emphysema,
Pneumonia, Tuberculosis
-Last chest x-ray

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16
Q

Physical Exam: Inspect

A
  • Breathing (pattern, rate, effort)

- Thorax

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17
Q

Physical Exam: Palpate

A
  • Tenderness
  • Respiratory Excursion
  • Tactile Fremitus
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18
Q

Physical Exam: Percuss

A
  • Posterior (2 bilateral)
  • Anterior (2 bilateral)
  • Lateral (1 bilateral)
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19
Q

Physical Exam: Auscultate

A
  • Posterior (2 bilateral)
  • Anterior (2 bilateral)
  • Lateral (1 bilateral)

3 Special tests:

  • -Bronchophony
  • -Egophony
  • -Whispered Pectoriloquy
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20
Q

What anatomy is pertinent?

A
  • Manubrium
  • Angle of Louis
  • Suprasternal notch
  • Costo-cartilage joints
  • Xiphoid process
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21
Q

Posterior landmark

A

the 8th rib is right at the inferior scapular angle

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22
Q

Inspection of skin/nails

A

Pallor
Cyanosis
Clubbing of Nails

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23
Q

Inspection of thorax

A

Shape, deformity present?
Symmetry
AP diameter < transverse diameter
Trachea is midline

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24
Q

Inspection of breathing

A 
Rate (12-20/min is normal)
--Respiration:heartbeat 1:4
Pattern
Effort/Retractions
Symmetry of expansion with breaths
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25
Q

Kyphosis

A

Spinal deformity –> posterior curvature –> abnormal AP diameter –> can restrict chest expansion

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26
Q

Pectus Excavatum

A
  • Congenital condition
  • Sternum is abnormally depressed
  • If severe, can cause restrictive lung problem
  • Can compress heart/great vessels –> murmurs
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27
Q

Pectus Carinatum (Pigeon Chest)

A
  • Anterior protrusion of the sternum
  • AP diameter increased
  • Does NOT compromise ventilation
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28
Q

Is trachea midline?

A
  • Trachea deviates toward atelectasis and fibrosis

- Trachea deviates away from pleural effusion and tension pneumothorax

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29
Q

Tachypnea

A

Increased respirations - can be a normal response
> 20 breaths/min (rapid rate and normal depth)
-associated: pain, broken rib, pleurisy, ascites

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30
Q

Bradypnea

A

Decreased respirations
< 8 breaths/min
-associated: meds, intoxication, neurologic disease, electrolyte disturbance

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31
Q

Hyperpnea

A

AKA hyperventilation, pathologic
> 20 breaths/min (rapid and deep, laborious)
-associated: anxiety, heavy exercise, CNS disease, metabolic acidosis (“Kussmaul’s”)

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32
Q

Hypopnea

A 
Normal rate (12-20), but shallow
-associated: pleuritic pain, pleurisy, s/p surgery
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33
Q

Respiratory Alternans, Abdominal Paradox

A

Abnormal pattern, asynchronous

-associated: diaphragmatic fatigue/dysfunction or paralysis

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34
Q

Air trapping

A

inefficient expiratory effort; as rate increases, depth becomes more shallow

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35
Q

Biot/Ataxic

A

Irregular respirations, depth varies, intervals of apnea (NO pattern)

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36
Q

Causes of Biot/Ataxic

A
  • Severe increased intracranial pressure
  • Drug Toxicity
  • Brain damage at level of medulla
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37
Q

Cheyne-Stokes

A

Cyclical pattern of crescendo/decrescendo hyperpnea with alternating intervals of apnea

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38
Q

Causes of Cheyne-Stokes

A
  • Neurogenic loss of control over respiration (cerebral brain injury)
  • Drug-induced respiratory depression
  • 90% cardiogenic by prolongation of circulation time (CHF)
  • Can be normal in children or elderly when sleeping
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39
Q

Manifestations of increased respiratory effort

A
  • Dyspnea: difficult and labored breathing with SOB
  • Nasal flaring: air hunger, suggest alveoli involvement
  • Pursing of Lips: increased expiratory effort
  • Chest retractions: obstruction to inspiration
  • Accessory Muscle Use
  • Posture
  • Stridor: high pitched whistling or crowing sound; suggests obstruction is high, heard on inspiration
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40
Q

Stridor

A
  • Indicates upper airway is narrowed or obstructed

- Can signal impending airway closure and asphyxiation

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41
Q

Stridor causes

A

Epiglottitis, neoplasm, croup, abscess, foreign body

42
Q

Assessing Retractions

A
  • Working hard to get air in
  • Obstruction to INSPIRATION
  • Sign of distress and increased effort
43
Q

Descriptors of respiratory difficulty

A
  • Dyspnea
  • Orthopnea = SOB that begins/increases when laying down (CHF, obesity, ascites)
  • Paroxysmal Nocturnal Dyspnea = sudden onset of SOB during sleep (CHF)
  • Platypnea = dyspnea increases when upright (hepatopulmonary syndrome)
44
Q

Flail chest

A

Chest wall moves inward during inspiration, outward during expiration
-Seen with multiple rib fractures

45
Q

Palpation

A 
1. For musculoskeletal tenderness:
	Anterior Ribs - at least 2 points
	Lateral Ribs - at least one point
	Posterior Ribs - at least two points
2. For crepitus of the chest wall
3. For Symmetry of Respiratory Excursion
4. For Tactile Fremitus – posterior, 2 locations
46
Q

Palpation for musculoskeletal tenderness

A

-Pulsations
-Tenderness
“chest pain” is often musculoskeletal in origin
-Palpate anterior/posterior and at same time
-Palpate costochondral joints at sternum

47
Q

Palpation for crepitus

A
  • Crackly, bubbly feeling
  • Can be palpated and heard
  • Indicates air in subcutaneous tissue from
  • -Rupture in respiratory system
  • -Infection with gas-producing organism (Pseudomonas)
  • ALWAYS REQUIRES ATTENTION, NEVER NORMAL!
48
Q

Respiratory Excursion Technique

A

FOR SYMMETRY Of THORACIC EXPANSION

  • Posterior position
  • Thumbs along spinal processes
  • Level of 10th rib,
  • Palms lightly in contact with skin
  • Watch your thumbs diverge during breathing
  • Loss of symmetry = pulmonary disease
49
Q

Tactile Fremitus Technique

A
  • Patient says a word (e.g.“moon”) while examiner firmly palpates the chest with hand (ulnar or palmar)
  • Palpate for vibration, both sides simultaneously and symmetrically
50
Q

Decreased/Increased Tactile Fremitus

A

Decreased fremitus: due to sound screens in pleural space,
e.g. pleural effusion, pneumothorax

Increased fremitus: due to consolidation, pneumonia, tumor

51
Q

Percussion

A
  • Tapping on a surface to determine the underlying structure (4-6 cm deep)
  • Percuss at 4 to 5 cm intervals over the intercostal spaces
  • Start at top and work your way down
  • Also move medial to lateral
  • To “map” the lung borders
  • Lung tissue = resonant
52
Q

Percussion locations

A

Anterior Fields: 2 locations bilateral
Lateral Fields: 1 location bilateral
Posterior Fields: 2 locations bilateral

53
Q

Auscultate for…

A
  1. Air movement
  2. Lung sounds
  3. Special tests
54
Q

Auscultate - locations

A

Anterior: 2 locations bilateral
Lateral: 1 location bilateral
Posterior: 2 locations bilateral

55
Q

Auscultation Breath Sounds (4)

A
  1. Vesicular
  2. Bronchovesicular
  3. Bronchial
  4. Tracheal
56
Q

Vesicular breath sounds

A

Normal, soft, low-pitched sounds heard in healthy lung tissue, Inspiration > expiration

57
Q

Bronchovesicular breath sounds

A

Pathologic, inspiration = expiration, sign of early consolidation or compression, (normal in the 1st and 2nd interspaces anteriorly the interscapular region)

58
Q

Bronchial breath sounds

A

Pathologic, loud, high-pitched sound, expiration > inspiration, sign of lung consolidation

59
Q

Tracheal breath sounds

A

Harsh and hollow, heard over suprasternal notch and over 6th and 7th cervical spines

60
Q

What are the abnormal breath sounds?

A

Wheezes, asthmatic/obstructive, crackles, rhonchi, amphoric

61
Q

What are the abnormal breath sounds?

A

Wheezes, asthmatic/obstructive, crackles, rhonchi, amphoric

62
Q

PLEURAL FRICTION RUB Characteristics (5)

A
  • Outside the respiratory tree
  • Grating sound, like dry leather rubbing together
  • Best heard at the end of inspiration/beginning of expiration
  • Dry, inflamed pleural surfaces rubbing together = pleurisy
  • Over the pericardium, suggests pericarditis
63
Q
  1. WHISPERED PECTORILOQUY (special tests)
A

Whispered word is clearly and distinctly heard through abnormal lung consolidation
(e.g. early pneumonia, atelectasis, infarction)

64
Q
  1. Bronchophony (special tests)
A

Spoken word is clearly heard through abnormal lung consolidation
(e.g. pneumonia, atelectasis)

65
Q
  1. Egophony (special tests)
A

Spoken “e“ sounds like “aay”
if heard through abnormal lung
(e.g. effusion, pneumonia)

66
Q

CC: Cough

A
  • Cough = Coordinated, sudden, forced expiration

- Cough reflex = normal defense mechanism of the lungs to protect them from foreign bodies and excessive secretions

67
Q

Big 8 for cough (part 1)

A

ONSET: sudden vs. gradual
DURATION: chronic vs. acute
If chronic think about asthma, GERD, or post-nasal drip
QUALITY: Dry vs. productive, barking, whooping
PATTERN: occasional, regular, paroxysmal (symptoms occur suddenly), nocturnal, related to time of day, weather, activities (exercise), taking deep breaths

68
Q

Big 8 for cough (part 2)

A

SEVERITY: Does it disrupt your sleep, conversation or breathing? Does it “choke” you?
ASSOC SX: SOB, pleuritic chest pain, chest tightness, wheezing, fever, coryza (rhinitis), nasal congestion, hoarseness, gagging, choking, vomiting, clearing throat, lump in throat
EFFORTS TO TREAT: Prescription or nonprescription meds – did they work?
*Ask about an ACE Inhibitor?
Cause chronic, dry cough

69
Q

What is dry, hacking cough suggestive of?

A

Viral infections, tumor, allergies, anxiety

70
Q

What is productive cough suggestive of?

A

Chronic bronchitis, abscess, pneumonia, tuberculosis

71
Q

What is wheezing cough suggestive of?

A

Bronchospasm, asthma, allergies, congestive heart failure

72
Q

What is barking cough suggestive of?

A

Epiglottal disease (croup)

73
Q

What is stridor cough suggestive of?

A

Tracheal obstruction (foreign body)

74
Q

What is morning cough suggestive of?

A

Smoking

75
Q

What is nocturnal cough suggestive of?

A

Postnasal drip, CHF, reflux

76
Q

What is paroxysmal cough suggestive of?

A

Pertussis or whooping cough/ asthma/ TB/ bronchiectasis

77
Q

What is cough associated with eating/drinking suggestive of?

A

Dysphagia, disorder of swallowing, reflux

78
Q

CC: sputum

A
  • Substance expelled by coughing or clearing the throat
  • Note Character: volume, color, viscosity, odor, blood
  • Note any bronchial casts
79
Q

Infected vs. uninfected sputum

A

Infected sputum: pus-filled, purulent, mucopurulent, yellow, green, or red

Uninfected sputum: mucous is odorless, mucoid, transparent, whitish gray

80
Q

What is mucoid sputum suggestive of?

A

Asthma, COPD, or early stages of infection

81
Q

What is mucopurulent sputum suggestive of?

A

Infectious process

82
Q

What is yellow-green purulent sputum suggestive of?

A

Bronchitis, Pneumonia, COPD exacerbation

83
Q

What is rust-colored purulent sputum suggestive of?

A

Pneumococcal pneumonia

84
Q

What is red currant jelly sputum suggestive of?

A

Klebsiella pneumoniae

85
Q

What is foul odor sputum suggestive of?

A

Lung abscess, empyema

86
Q

What is pink, blood tinged sputum suggestive of?

A

Strep or Staph pneumonia

87
Q

What is pink, frothy sputum suggestive of?

A

Pulmonary edema

88
Q

What is blood sputum suggestive of?

A

Pulmonary emboli, abscess, tuberculosis, tumor, cardiac disease, bleeding disorders

89
Q

CC: Hemoptysis

A
  • Expectoration of blood (upper) or coughing up blood (bronchial tree)
  • Can arise from nose, oral cavity, larynx, trachea, bronchi, or lungs
  • Can be frothy, bright red blood, dark brown blood, or clots
90
Q

Blood-tinged vs. mostly blood hemoptysis

A

Blood-tinged: Smoking, minor infections, tumors

Mostly blood: (or clots) Lung cancer, cardiac disease, or pulmonary embolism, clotting disorder

91
Q

Hemoptysis vs. Hematemesis

A
  1. Prodrome: Coughing vs. Nausea, vomiting
  2. Past History: Cardiopulmonary disease vs. Gastrointestinal disorder
  3. Appearance: Frothy vs. Not frothy
  4. Color: Bright red vs. Dark red, brown or “coffee grounds”
  5. Manifestation: Mixed with pus/mucous vs. Mixed with food
  6. Assoc. Symptoms: Dyspnea vs. Nausea
92
Q

SOB vs. Dyspnea

A 
SHORTNESS OF BREATH:
Subjective symptom
Complaint is usually SOB
“run out of breath”
“can’t take deep breath"

DYSPNEA:
Objective sign or symptom = Difficulty breathing

93
Q

THE “–PNEAS”

A
  1. Dyspnea = difficulty breathing
  2. Orthopnea = shortness of breath when laying down
  3. Paroxysmal Nocturnal Dyspnea = waking from sleep severely short of breath
  4. Platypnea = breathing becomes difficult with standing
  5. Apnea = cessation of breathing
94
Q

Dyspnea on Exertion (DOE)

A
  • difficulty breathing with minimal exercise or with normal daily activities
  • -Normal with vigorous work or exercise
  • -Can be caused by deconditioning and/or obesity
  • -Related to cardiac and/or pulmonary disorders
95
Q

What should you ask about DOE?

A
  • How much walking causes DOE? Mailbox?
  • Is it necessary to stop and rest when climbing stairs?
  • With what other activities of daily life does dyspnea begin? With what level of physical demand?
  • Well-conditioned patients may only note change in exercise tolerance.
96
Q

CC: Chest Pain Big 8

A

onset, duration, setting, describe the pain, radiation, alleviation/aggravating, associated symptoms, treatments

97
Q

CC: Chest Pain H/O

A

trauma, coughing, respiratory infection

Worse with exertion or present at rest??

98
Q

CC: Chest Pain Associated Symptoms

A

shallow breathing, SOB, fever, cough, anxiety about getting air, lightheadedness, N/V, diaphoresis

99
Q

CC: Chest Pain Radiation

A

to neck or left arm, jaw

100
Q

Non-Cardiac Chest Pain

A
  • is constant achiness that lasts all day
  • is NOT exertional
  • DOES NOT radiate
  • can be reproduced with palpation
  • can be fleeting and sharp
  • can be posterior, between the shoulder blades
  • Always rule out cardiac cause, but remember the differential diagnosis is broad for chest pain*

Pulmonology (11 decks)

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