Pulmonary H&P Flashcards
What are the different kinds of productive cough and what does each indicate?
Green does not mean bacterial
Productive can be infectious or inflammatory
Dry tends to indicate something other than inf
Large amounts tend to indicate inflammatory or inf
What are the three most common pulmonary symptoms?
Cough
Hemoptysis
Shortness of breath (SOB)
What can a nighttime cough be indicative of?
Reactive airway disease
Allergies
GERD
What is the ddx of a cough with an abnormal CXR?
Tb Pneumonia Lung cancer Foreign bodies Bronchiectasis Interstitial lung disease
What is the Ddx of a cough with a normal CXR?
Upper respiratory inf - bronchitis Allergic rhinitis (postnatal drip) GERD Atypical pneumonia Bronchial asthma Vocal cord polyps Drugs (ACEIs)
What is the difference between hemoptysis and hematemesis?
Hemoptysis - blood is from respiratory tract - bright red frothy sputum, hemosiderin laden macrophages, alkaline ph
Hematemesis - blood is from GI tract - associated with nausea, abdominal pain, vomiting, dark red blood, acid ph
What is massive hemoptysis?
100-600 ml of blood over 24 hrs
Can cause aspiration and asphyxiation
Usually indicates arterial source
What is the Ddx of hemoptysis?
Bronchitis Lung abscess Bronchiectasis Pneumonia Tb Lung carcinoma Pulm infarct Cf CHF Fungal disease Vasculitis
What is the most specific pulmonary symptom for CHF?
PND
What is the Ddx of SOB?
Asthma COPD Interstitial lung disease Pneumonia Tb Pulmonary embolism Pneumothorax Mitral or aortic stenosis Hyperthyroidism MI CHF Anemia Anxiety
What accessory muscles are used in certain respiratory abnormalities?
First scalenes but can’t see them
SCM - indicates FEV1 has decreased to ~30% normal
Intercostal muscles and spaces
Abdominal wall muscles
What abnormalities are seen when the intercostal muscles kick in during respiration?
Decreased inward retraction indicates increased expansion of lungs - consolidation, tension pneumothorax, pleural effusion
Exaggerated outward bulging - increased intrapleural pressure or lungs unable to empty - emphysema, acute asthma exacerbation, tension pneumothorax, flail chest
Constant bulging of spaces - massive pleural effusion
What is the respiratory paradox?
Diaphragm is weak or overloaded
Moves up during inspiration and abdominal wall moves in
Sign of respiratory failure and usually indicates patient needs mechanical ventilation
What is the significance of tracheal deviation?
Toward hemithorax with lower pressure - atelectasis, consolidation with closed bronchus
Away from hemithorax with higher pressure - pleural effusion, pneumothorax
What is the significance of splinting?
Asymmetric expansion of chest
Causes include unilateral diaphragmatic paralysis, pneumothorax, bronchial obstruction, massive pleural effusion
What is the significance of clubbing?
Rounding of distal phalanx of each finger
Seen in chronic hypoxia, congenital heart disease, endocarditis, chronic renal insufficiency, or congenital
Shunts allow megakaryocytes fragments to bypass lungs and deposit in capillaries
What are causes of generalized cyanosis? Peripheral?
Methemoglobinemia
Sulfhemoglobinema
Deoxyhemoglobinemia - only if patients hemoglobin >5
Peripheral from tissue hypoperfusion - hemoglobin normal
How is the I/E ratio used in the pulm exam?
Normal is 1:2
Increased (1:3 or higher) means patient trying to get air out - asthma or COPD
When is decreased fremitus seen?
Atelectasis Consolidation with closed bronchus Pneumothorax Diaphragmatic paralysis Pleural effusion
When is increased fremitus seen?
Fluid in alveoli -
Consolidation with open bronchus
Pneumonia
Heart failure
When is dullness to percussion seen?
Consolidation of lung - open or closed bronchus
Pleural effusion
When is hyper resonance to percussion seen?
Pneumothorax - unilateral
COPD or asthma - bilateral
What is diaphragmatic excursion?
Elevation of left hemidiaphragm always abnormal
Could be due to diaphragmatic paralysis, LUQ mass, pleural effusion, occasionally left lower lobe lesion
What does it mean if breath sounds are decreased in one area of the chest (focal)?
Disease either in the bronchi or alveoli of that region
What does generalized decrease in breath sounds indicate?
Restrictive lung disease
Expanded lungs with obstruction (COPD)
Obstructive lung disease
What is bronchophony?
Tracheal breath sounds in lung from consolidation with open bronchus
What are the different normal breath sounds?
Vesicular - normal or alveolar, present longer during inspiration that expiration
Bronchial - louder and higher frequency, heard best at manubrium, hard to hear normally, longer in expiration that inspiration
Tracheal - equal in inspiration and expiration, louder
What are the possible adventitious breath sounds?
Stridor Rhonchi Wheezes Crackles (rales) Pleural rub
What is stridor?
Hissing noise in inspiration that indicates upper airway obstruction
Inspiratory = hot potato voice - obstruction near trachea, larynx, of epiglottis, emergency
Expiratory - obstruction in lower airways
What are rhonchi?
Continuous sound produced in larger airways caused by fluid rupture or airway wall vibrations
Low pitched snoring sounds
Indicate secretions in large airways or collapsible large airways
What are wheezes?
Continuous sounds indicating airway obstruction
Air in trachea trachea through narrowed bronchi or bronchioles to point of closure
Musical high frequency noise
What are crackles (rales)?
Discontinuous sounds caused by explosive opening of small airways and alveoli creating a crackle noise Wet rales (course crackles) heard in mid-late inspiration - heard in bronchiectasis, pneumonia, CHF - sound like hair Fine (dry crackles) - late inspiration - interstitial lung disease, sound like Velcro
What is the Ddx of FINE crackles?
S arcoid H eart failure, hemorrhage I nfection, idiopathic pulm fibrosis, inhalation T rauma, toxins F ungal, familial A spiration, allergic, alveolar proteinosis C ancer, collagen vascular disease E osinophilic syndromes D rugs, dusts
How can a pleural rub be differentiated form rhonchi?
Rhonchi heard with same intensity in inspiration and expiration and can change with deep breathing
Rubs are localized and louder during inspiration
What are sound changes seen in consolidation?
Egophony - e to a change
Bronchophony - can understand 99 when patient says it
Pectoriloquy - you can actually hear 66 with the stethoscope when the patient whispers it
