Pulmonary 1 Flashcards
What systems could potentially be source of lung pathology?
respiratory cardiovascular (e.g. CHF) gastrointestinal (GERD) CNS (eg. anxiety) renal (eg. CRF) endocrine (eg. DM) musculoskeletal (herpes zoster, costochrondritis)
What are some environmental exposures that should be assessed in taking history?
Occupation, household chemicals, recent travel, areas of pollution, smoking, pets, hobbies (eg. ceramics, carpentry), Sleep environment, type of pillows, bedding, use of humidifier, Heating system- gas exacerbates allergies, wood exacerbates mold, electric cleanest
What are some common causes of a cough?
Upper respiratory tract infections Asthma Lung infx (pneumonia, acute bronchitis) COPD (emphysema, chronic bronchitis) Rhinosinusitis leading to postnasal drip Lung dz: bronchiectasis, interstitial, tumor Gastroesophageal reflux disease (GERD) Cigarette smoking Second-hand smoke exposure Air pollution exposure ACE inhibitors Aspiration Cystic fibrosis- young individual CHF—unproductive cough at night Anxiety—nervous cough Chronic idiopathic cough
What questions should be asked when taking history to investigate cough?
Duration, sudden or gradual, any recent change in cough?
- Acute cough: < 3 week duration—most likely from infection, exacerbation of underlying lung disease
- Subacute cough: 3-8 wks—often post-infectious
- Chronic cough: >8 wks—often from upper airway cough syndrome (i.e post-nasal drip from allergies, rhinitis, rhinosinusitis), asthma or GERD
What factors affect it? (cold air, talking, eating, posture, drinking, exercise)
Sputum production: amount, quality, color
Any concomitant symptoms? Ie. chest pain, dyspnea, hoarseness, dizziness
Patterns of the cough -
- with posture change suggests chronic lung abscess, TB, bronchiectasis, tumor
- during eating suggests problem with swallowing mechanism
- with cold air or exercise suggests asthma
- in am, that persists until sputum is produced is characteristic of chronic bronchitis
- in am may suggest allergy to something in sleeping quarters
What are some common colors of sputum and corresponding conditions?
- clear: allergy, COPD
- yellow: infection (acute bronchitis, acute pneumonia) (live neutrophils)
- green: chronic infection (chronic bronchitis, pneumonia, bronchiectasis, CF- neutrophil breakdown)
- brown/black/rust: “old blood” eg. chronic bronchitis, chronic pneumonia, TB, lung cancer
- Quantity (scant, profuse) and quality (thin, stringy, thick, etc)
What are some causes of hemoptysis
Airway inflammation
Bronchogenic carcinoma (may be frothy)
Foreign body
Airway trauma
Autoimmune disease
Coagulopathy
Lung parenchymal infection (TB {streaks of blood}, pneumonia, abscess)
Cocaine-induced pulmonary hemorrhage
Pulmonary embolism (bright red)
Esophageal varicesWhat are some causes of physiologic dyspnea?
most common
exertion
high altitude
What are 4 types of pulmonary dyspnea with examples of conditions?
i) restrictive: low compliance of the lungs, usually OK at rest, worse with exertion
- pulmonary fibrosis
- chest deformities: eg pectus excavatum, scoliosis
- broken ribs
- obesity
ii) obstructive: increased resistance to airflow, esp. with expiration
- asthma
- upper airway edema due to allergies, infection
- cystic fibrosis
- COPD (emphesema, chronic bronchitis)
iii) infectious
- pneumonia
- severe acute respiratory syndrome (SARS)
iv) non-infectious
- lung cancer
- sarcoidosis
- pleural effusion
- pneumothorax
- pneumoconiosis
- atelectasis
What are some conditions associated with dyspnea with cardiac origin?
congestive heart failure cardiogenic pulmonary edema valvular heart disease dissecting aortic aneurysm ischemic heart disease cardiomyopathy pericardial effusion malignant hypertension cardiac asthma: acute resp. insufficiency caused by L ventricular failure with bronchospasm, wheezing and hyperventilation
What signs would indicate dyspnea of cardiac origin?
a. Cheyne-Stokes respiration: alternating periods of apnea and hyperpnea (gradually increasing depth and frequency of respiration)
b. Orthopnea: respiratory problems while supine (Left ventricular failure)
c. Paroxysmal Nocturnal Dyspnea (PND): pt awakens gasping for breath and must sit or stand up (eg mitral stenosis, aortic insufficiency, HTN)
Besides physiologic, pulmonary, and cardiac, what are 3 other potential sources of dyspnea?
chemical (acidosis may result in slow, very deep gasping respirations (ie “Kussmaul breathing” - trying to blow off CO2 to compensate for acidosis) - May be seen in diabetes (DKA), chronic anemia, pregnancy, renal failure) neuromuscular (multiple sclerosis, ALS, myasthenia gravis, Guillain Barré Syndrome) Psychological conditions (anxiety, panic attacks)
What are the potential sources of chest pain?
cardiac pulmonary GI musculoskeletal/skin CNS (anxiety)
What are the qualities of cardiac chest pain?
usually crushing, pressing or squeezing, generally aggravated by exertion, cold weather, stress, and after meals. May radiate to neck, jaw or arm
What are the qualities of pulmonary chest pain?
localized, sharp and knifelike; worse breathing or coughing (pleural pain); e.g. - pleurisy, pneumonia, TB, cancer, atelectasis, thromboembolism, pleural effusion, histoplasmosis, pneumothorax
What are the qualities of GI chest pain?
may be sharp, burning, squeezing, or heavy; affected by swallowing (spasm), large meals, certain foods, body position, GERD
What are examples and qualities of musculoskeletal/skin chest pain?
costochrondritis fractured rib (history of fall - pain will be elicited by palpation exam) herpes zoster (prodromal sx, then vesicles erupt along dermatome)
What are the 4 important things to do in lung PE?
Inspection (resp rate, signs of respiratory distress, chest configuration, coloration, etc)
Palpation (assess area of pain, chest expansion, tactile fremitis)
Percussion
Auscultation
What are the notes associated with lung percussion?
Flat: soft, high pitch, short duration – eg. sounds like percussion over thigh muscle
Dull: medium intensity, pitch and duration – eg, sounds like percussion over liver suggests pleural thickening, atelectasis, consolidation, pleural effusion
Hyperresonant: very loud, low pitch, long duration– suggests trapped air as in pneumothorax, severe emphysema
Tympanic: musical quality, e.g., over stomach or puffed cheek
What is diaphragmatic excursion?
Percussion on back between ribs 10-12
During inhalation, lungs should fill to rib 12
During exhalation, lungs should rise to rib 10
What are the normal sounds of lung auscultation?
Vesicular - soft, low pitch, normal over most lungs fields; inspiration lasts longer than expiration I>E
Bronchial – loud, moderately high pitched. Heard over central bronchus. I=E
Bronchovesicular - medium intensity and pitch, normal over main-stem bronchi
Tracheal - loud, high in pitch, normally heard over trachea, E>I (not performed)
When would you hear absence of breath sounds?
Collapsed lung
When would you hear decreased breath sounds?
when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion) Increased distance between lung and chest wall
When would you hear bronchial breathing?
consolidation in lower lobes changes sounds from vesicular to bronchial (blockage of passage of air through area of consolidation, prevents vesicular sounds and makes bronchial sounds dominant).
What are crackles?
(prev term “rales”)
popping sounds, usually heard during inspiration, do not clear with cough produced by the passage of air through bronchi that:
1) contain secretions (early inspiratory crackles)
OR
2) are constricted by spasm or thickened walls (pan- or late insp)
