Pulmonary 1 Overview Flashcards
History - Which system could be the source of the symptoms?
Respiratory gastrointestinal (GERD) renal (CRF) musculoskeletal (chest pain) cardiovascular (CHF) CNS (anxiety) endocrine (DM)
What are concomitants?
They are crucial! GI: inter-abd. pressure, decrease in lower esophageal sphincter tone. Renal: uremia MS: reproducible pain Heart: CHF
What are some possible exposures that could lead to sxs?
Occupation, travel hx, pollutants, home location, bedroom, heating system.
Family hx: hereditary conditions, shared exposures
Cough
Functions to clear secretions and foreign bodies
Is it Acute or chronic?
MANY common causes: URI, infx, GERD, pollution, CHF, Asthma, COPD, lung dz, cigarette smoking, ACE inhibitors
History taking with COUGH
Duration, sudden or gradual, changes?
Acute cough: 8 weeks (asthma, chronic bronchitis, obstructive diseases)
Patterns: positional, eating, cold air, exercise, morning
Concomitants: chest pain, dyspnea, hoarseness, dizziness
Sputum
Colors: clear, yellow, green, brown
Clear: allergy, COPD
Yellow: infx, bronchitis, pneumonia
Green: chronic infx, bacterial, pneumonia, CF
brown: old blood, chronic pneumonia, TB, lung cancer
Quantity: Scant, copius, “productive cough”
Quality: Thin, stringy
Hemoptysis
Blood streaked sputum to gross blood expectoration
Source: lung, upper resp., upper GI?
Frothy pink: pulmonary edema, CHF
Massive hemoptysis: life threatening, loss of >600ml in 24 hours
Causes: TB, bronchogenic carcinoma, pulmonary embolism, esophageal varices
Dyspnea
Sensation of difficulty breathing; SOB shortness of breath. Very common finding with many causes.
Types:
Physiologic: altitude
Pulmonary: restrictive, obstructive, infectious, non-infectious
Cardiac: CHF, cardiac asthma
Chemical: acidosis, very deep gasping respirations, CO2 blow off, may see in DM, pregnancy, renal failure
Neuromuscular: MS, myasthenia gravis, ALS, Guillain Barre Syndrome
Psychological conditions: anxiety, panic attack
Chest pain
may be due to cardiac, pulmonary, GI, MS, skin or CNS(anxiety). ALERT EMS
Cardiac: angina, MI - crushing, pressing, squeezing. may radiate to neck, jaw, arm.
FYI: Nausea and sweating are common classic concomitants to MI.
Pulmonary pain: localized, sharp and knifelike. Worse breathing or coughing (pleural pain)
GI pain: sharp, burning, squeezing, heavy. affected by swallowing.
MS: press on place that hurts. fractured rib, costochondritis
CNS: anxiety, panic attack - may look like MI
Physical Exam components
Report findings in terms of location, referring to ribs and anatomic lines on chest. All exams performed on ANTERIOR and POSTERIOR
- Inspection
- Palpation: assess area of pain, chest expansion, tactile fremitis.
- Percussion
- Auscultation
Landmarks
Front: suprasternal notch, sternomanubrial angle
Side: LU fields at 8th rib on side.
Back: Lower lobes to 10th rib on expiration; lower lobes to 12th rib on inspiration
PE: Inspection
Effort of breathing - accessory muscles, tripod position Respiratory rate Asymmetry of chest Splinting Trachea midline? Skin coloration Nail/toes for presence of clubbing
PE: Palpation
If complaint of chest pain: palpate the location reported by patient.
Chest expansion (ant and post thorax)
Tactile fremitus (ant and post thorax)
-Increased vibration: lung consolidation
-Decreased vibration: fluid, air, solid tissue
PE: Percussion
Anterior and posterior thorax
Posterior: follow pattern, diaphragmatic excursion
Anterior: follow pattern
Normal note over lung filed is resonant
Resonant: loud, low pitch, long duration - air filled
Flat: soft, high pitch, short duration - over thigh
Dull: solid, medium intensity, pitch and duration - over liver - suggests plural thickening, consolidation
Hyper-resonant: very loud, low pitch long duration - suggests trapped air as in pneumothorax, severe emphysema
Tympanic: musical quality - over stomach or puffed cheek
PE: Auscultation
Posterior thorax Anterior thorax Top to bottom Compare side to side Use diaphragm on stethoscope
Abnormal Auscultation
Absent: collapsed lung
Decreased breath sounds: when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion)
Bronchial breathing: loud; consolidation in lower lobes changes sounds from vesicular to bronchial
Adventitious Lung sounds
Crackles: “rales” popping sounds, usually heard during inspiration, do not clear with cough.
Rhonchii: rumbling sounds during expiration. low pitch, clear with coughing.
Wheezes: high pitched with expiration, whistling usually seen with asthma, bronchitis, COPD. Partially obstruction airway
Stridor: inspiratory wheeze associated with upper airway obstruction (croup)
Pleural sounds: pleural friction rub, loud creak or grating sound. Often concurrent with pleurisy.
Voice transmission tests
Bronchophony: Stethoscope over area of concern and patient says “99”. If there is consolidation you will hear it loud and clear whereas normal is a muffled sound.
Whispered pectoriloquy: Listen over area of concern and pt. whispers. Normal - can’t make out sounds. Consolidation - you’ll hear the whispered words.
Egophony- Patients says E repeatedly. Normal - hear E. Consolidation - changes to A
Laboratory work-up
CBC - for infx, allergies
CMP - electrolytes, glucose, lipids, liver enzymes. Check serum LDH to compare with pleural fluid from thoracentesis.
Sputum cultures
Arterial blood gases (pH, PaO2, PaCO2, HCO3
TB testing - Quantiferon Gold
Special Tests
- Peak flow meter (in office)
monitors pulmonary function in patients with asthma. Roughly correlates with FEV1. Based on age, gender compared to expected values. - Pulse Oximeter (in office)
95-99% is normal - oxygen saturation in arterial blood. Sensor uses photodiode. - Pulmonary function tests (spirometry) - order to determine presence of obstructive or restrictive diseases.
Obstruction (of airways, not normal air flow).
Restrictive (some change in the amount of functioning lung, ex: scar tissue, cancer).
Imaging
CXR CT for bronchogenic carcinoma PET 90% accuracy for tumors Chest ultrasound - opacity in pleura, fluid or mass Bronchoscopy -
