Phys Di - Chest & Lungs Flashcards
What common complaints might a pulm pt have?
- Cough w/ mucous
- Dry cough
- Can’t breath
- Coughing up blood
- Chest pain
- Wheezing
- Chest congestion
- My child is in distress
- Fever and lethargy
Pertinent past med hx for pulm diseases
- Chronic Bronchitis
- Emphysema
- TB
- Asthma
- Cystic fibrosis
- H/o bronchiectasis
- Pulmonary fibrosis
- Sleep apnea
- Pneumothorax
- HOSPITALIZATIONS related to above
Other pertinent diseases
Cancer Cardiac disease: --heart failure --CAD Blood clotting disorders --hypercoaguability --history of pulmonary emboli
What supportive devices would you ask about?
- Oxygen use? How many liters? 24⁰ or PRN?
- Ventilation-assisting devices? CPAP? BiPAP?
What vaccinations would you ask about?
Pneumonia Vaccine
Influenza Vaccine
What prior testing is pertinent?
- 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
Pertinent surgical history
- 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?
Pertinent family history
- Cystic fibrosis
- Tuberculosis (genetic susceptibility)
- Emphysema
- Allergies, asthma, atopic dermatitis
- Lung Cancer
- Clotting disorders
- Pulmonary Fibrosis
Pertinent social history (4)
Occupation (work, irritants, animals, carcinogens, etc.), home environment (secondhand smoke, allergens, etc.), exercise, and hobbies.
What should you ask about tobacco use?
(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?
What should you ask about marijuana use?
(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?
If a pt traveled to SE and MW United States, what could they have been exposed to?
Histoplasmosis
If a pt traveled to SW Asia/Africa/Caribbean, what could they have been exposed to?
Schistosomiasis
What are the special populations/what do you ask?
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
Respiratory ROS
-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
Physical Exam: Inspect
- Breathing (pattern, rate, effort)
- Thorax
Physical Exam: Palpate
- Tenderness
- Respiratory Excursion
- Tactile Fremitus
Physical Exam: Percuss
- Posterior (2 bilateral)
- Anterior (2 bilateral)
- Lateral (1 bilateral)
Physical Exam: Auscultate
- Posterior (2 bilateral)
- Anterior (2 bilateral)
- Lateral (1 bilateral)
3 Special tests:
- -Bronchophony
- -Egophony
- -Whispered Pectoriloquy
What anatomy is pertinent?
- Manubrium
- Angle of Louis
- Suprasternal notch
- Costo-cartilage joints
- Xiphoid process
Posterior landmark
the 8th rib is right at the inferior scapular angle
Inspection of skin/nails
Pallor
Cyanosis
Clubbing of Nails
Inspection of thorax
Shape, deformity present?
Symmetry
AP diameter < transverse diameter
Trachea is midline
Inspection of breathing
Rate (12-20/min is normal) --Respiration:heartbeat 1:4 Pattern Effort/Retractions Symmetry of expansion with breaths
Kyphosis
Spinal deformity –> posterior curvature –> abnormal AP diameter –> can restrict chest expansion
Pectus Excavatum
- Congenital condition
- Sternum is abnormally depressed
- If severe, can cause restrictive lung problem
- Can compress heart/great vessels –> murmurs
Pectus Carinatum (Pigeon Chest)
- Anterior protrusion of the sternum
- AP diameter increased
- Does NOT compromise ventilation
Is trachea midline?
- Trachea deviates toward atelectasis and fibrosis
- Trachea deviates away from pleural effusion and tension pneumothorax
Tachypnea
Increased respirations - can be a normal response
> 20 breaths/min (rapid rate and normal depth)
-associated: pain, broken rib, pleurisy, ascites
Bradypnea
Decreased respirations
< 8 breaths/min
-associated: meds, intoxication, neurologic disease, electrolyte disturbance
Hyperpnea
AKA hyperventilation, pathologic
> 20 breaths/min (rapid and deep, laborious)
-associated: anxiety, heavy exercise, CNS disease, metabolic acidosis (“Kussmaul’s”)
Hypopnea
Normal rate (12-20), but shallow -associated: pleuritic pain, pleurisy, s/p surgery
Respiratory Alternans, Abdominal Paradox
Abnormal pattern, asynchronous
-associated: diaphragmatic fatigue/dysfunction or paralysis
Air trapping
inefficient expiratory effort; as rate increases, depth becomes more shallow
Biot/Ataxic
Irregular respirations, depth varies, intervals of apnea (NO pattern)
Causes of Biot/Ataxic
- Severe increased intracranial pressure
- Drug Toxicity
- Brain damage at level of medulla
Cheyne-Stokes
Cyclical pattern of crescendo/decrescendo hyperpnea with alternating intervals of apnea
Causes of Cheyne-Stokes
- 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
Manifestations of increased respiratory effort
- 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
Stridor
- Indicates upper airway is narrowed or obstructed
- Can signal impending airway closure and asphyxiation
Stridor causes
Epiglottitis, neoplasm, croup, abscess, foreign body
Assessing Retractions
- Working hard to get air in
- Obstruction to INSPIRATION
- Sign of distress and increased effort
Descriptors of respiratory difficulty
- 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)
Flail chest
Chest wall moves inward during inspiration, outward during expiration
-Seen with multiple rib fractures
Palpation
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
Palpation for musculoskeletal tenderness
-Pulsations
-Tenderness
“chest pain” is often musculoskeletal in origin
-Palpate anterior/posterior and at same time
-Palpate costochondral joints at sternum
Palpation for crepitus
- 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!
Respiratory Excursion Technique
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
Tactile Fremitus Technique
- 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
Decreased/Increased Tactile Fremitus
Decreased fremitus: due to sound screens in pleural space,
e.g. pleural effusion, pneumothorax
Increased fremitus: due to consolidation, pneumonia, tumor
Percussion
- 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
Percussion locations
Anterior Fields: 2 locations bilateral
Lateral Fields: 1 location bilateral
Posterior Fields: 2 locations bilateral
Auscultate for…
- Air movement
- Lung sounds
- Special tests
Auscultate - locations
Anterior: 2 locations bilateral
Lateral: 1 location bilateral
Posterior: 2 locations bilateral
Auscultation Breath Sounds (4)
- Vesicular
- Bronchovesicular
- Bronchial
- Tracheal
Vesicular breath sounds
Normal, soft, low-pitched sounds heard in healthy lung tissue, Inspiration > expiration
Bronchovesicular breath sounds
Pathologic, inspiration = expiration, sign of early consolidation or compression, (normal in the 1st and 2nd interspaces anteriorly the interscapular region)
Bronchial breath sounds
Pathologic, loud, high-pitched sound, expiration > inspiration, sign of lung consolidation
Tracheal breath sounds
Harsh and hollow, heard over suprasternal notch and over 6th and 7th cervical spines
What are the abnormal breath sounds?
Wheezes, asthmatic/obstructive, crackles, rhonchi, amphoric
What are the abnormal breath sounds?
Wheezes, asthmatic/obstructive, crackles, rhonchi, amphoric
PLEURAL FRICTION RUB Characteristics (5)
- 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
- WHISPERED PECTORILOQUY (special tests)
Whispered word is clearly and distinctly heard through abnormal lung consolidation
(e.g. early pneumonia, atelectasis, infarction)
- Bronchophony (special tests)
Spoken word is clearly heard through abnormal lung consolidation
(e.g. pneumonia, atelectasis)
- Egophony (special tests)
Spoken “e“ sounds like “aay”
if heard through abnormal lung
(e.g. effusion, pneumonia)
CC: Cough
- Cough = Coordinated, sudden, forced expiration
- Cough reflex = normal defense mechanism of the lungs to protect them from foreign bodies and excessive secretions
Big 8 for cough (part 1)
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
Big 8 for cough (part 2)
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
What is dry, hacking cough suggestive of?
Viral infections, tumor, allergies, anxiety
What is productive cough suggestive of?
Chronic bronchitis, abscess, pneumonia, tuberculosis
What is wheezing cough suggestive of?
Bronchospasm, asthma, allergies, congestive heart failure
What is barking cough suggestive of?
Epiglottal disease (croup)
What is stridor cough suggestive of?
Tracheal obstruction (foreign body)
What is morning cough suggestive of?
Smoking
What is nocturnal cough suggestive of?
Postnasal drip, CHF, reflux
What is paroxysmal cough suggestive of?
Pertussis or whooping cough/ asthma/ TB/ bronchiectasis
What is cough associated with eating/drinking suggestive of?
Dysphagia, disorder of swallowing, reflux
CC: sputum
- Substance expelled by coughing or clearing the throat
- Note Character: volume, color, viscosity, odor, blood
- Note any bronchial casts
Infected vs. uninfected sputum
Infected sputum: pus-filled, purulent, mucopurulent, yellow, green, or red
Uninfected sputum: mucous is odorless, mucoid, transparent, whitish gray
What is mucoid sputum suggestive of?
Asthma, COPD, or early stages of infection
What is mucopurulent sputum suggestive of?
Infectious process
What is yellow-green purulent sputum suggestive of?
Bronchitis, Pneumonia, COPD exacerbation
What is rust-colored purulent sputum suggestive of?
Pneumococcal pneumonia
What is red currant jelly sputum suggestive of?
Klebsiella pneumoniae
What is foul odor sputum suggestive of?
Lung abscess, empyema
What is pink, blood tinged sputum suggestive of?
Strep or Staph pneumonia
What is pink, frothy sputum suggestive of?
Pulmonary edema
What is blood sputum suggestive of?
Pulmonary emboli, abscess, tuberculosis, tumor, cardiac disease, bleeding disorders
CC: Hemoptysis
- 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
Blood-tinged vs. mostly blood hemoptysis
Blood-tinged: Smoking, minor infections, tumors
Mostly blood: (or clots) Lung cancer, cardiac disease, or pulmonary embolism, clotting disorder
Hemoptysis vs. Hematemesis
- Prodrome: Coughing vs. Nausea, vomiting
- Past History: Cardiopulmonary disease vs. Gastrointestinal disorder
- Appearance: Frothy vs. Not frothy
- Color: Bright red vs. Dark red, brown or “coffee grounds”
- Manifestation: Mixed with pus/mucous vs. Mixed with food
- Assoc. Symptoms: Dyspnea vs. Nausea
SOB vs. Dyspnea
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
THE “–PNEAS”
- Dyspnea = difficulty breathing
- Orthopnea = shortness of breath when laying down
- Paroxysmal Nocturnal Dyspnea = waking from sleep severely short of breath
- Platypnea = breathing becomes difficult with standing
- Apnea = cessation of breathing
Dyspnea on Exertion (DOE)
- 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
What should you ask about DOE?
- 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.
CC: Chest Pain Big 8
onset, duration, setting, describe the pain, radiation, alleviation/aggravating, associated symptoms, treatments
CC: Chest Pain H/O
trauma, coughing, respiratory infection
Worse with exertion or present at rest??
CC: Chest Pain Associated Symptoms
shallow breathing, SOB, fever, cough, anxiety about getting air, lightheadedness, N/V, diaphoresis
CC: Chest Pain Radiation
to neck or left arm, jaw
Non-Cardiac Chest Pain
- 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*
