Pulmonary Signs and Symptoms Flashcards
1
Q
Dyspnea
Definition
A
A subjective sensation of breathlessness, air hunger, or shortness of breath.
Not a physical exam finding.
2
Q
Dyspnea
Associated Findings
A
- Tachypnea
- Labored breathing
- High minute ventilation
- No physical signs
3
Q
Dyspnea
Physiological Causes
A
-
↑ Ventilatory requirement
- Exercise, hypoxia, metabolic acidosis
-
↑ Airway resistance
- COPD, asthma, upper airway obstruction
-
↓ Lung compliance
- Interstitial lung disease, pulmonary fibrosis
-
↓ Chest wall compliance
- Kyphoscoliosis
-
Psychogenic dyspnea
- “Hyperventilation syndrome”
- Low CO2 causes sensation that you need to breathe faster
- “Hyperventilation syndrome”
4
Q
Dyspnea
History
A
-
Duration of sx
- Chronic vs acute
-
Rate of onset
- Acute (mins-hrs), subacute (days-weeks), chronic (months-yrs)
-
Exposures
- Smoking, occupational, environmental
- Organic dust ⇒ allergic alveolitis
- Inorganic dust ⇒ pulmonary fibrosis
- Smoking, occupational, environmental
5
Q
Acute Dyspnea
Causes
A
6
Q
Subacute Dyspnea
Causes
A
7
Q
Chronic Dyspnea
Causes
A
8
Q
Exertional Dyspnea
Causes
A
-
Obstructive lung disease
- Exertion → ↑ RR → ↓ expiratory time
- Obstruction → ↓ expiratory flow
- Trapped air exerts pressure on lungs
-
Interstitial lung disease
- Exertion → ↑ HR
- ↓ Time for O2 to diffuse across diseased alveolar-capillary membrane
- Exercise-induced asthma
- CHF
-
Peripheral vascular disease
- Anaerobic threshold sooner → ↑ CO2 → dyspnea
9
Q
Exertional Dyspnea
History
A
- Quantify amount of exertion → distance
- Rate of decline
- Severity
-
Timing/duration of sx
- During or after exercise
-
Associated symptoms
- CP, cough, edema
- Effect of position change
10
Q
Orthopnea
Definition
A
Dyspnea in a recumbent position which is relieved by sitting up.
11
Q
Orthopnea
Causes
A
-
CHF
- More fluid into the lungs
-
COPD
- Diaphragm works better when sitting up
- Diaphragm weakness
12
Q
Paroxysmal Nocturnal Dyspnea
Definition
A
Episodic dyspnea that awakens patient from sleep.
13
Q
PND
Causes
A
-
CHF
- Shift of fluid from BLE ⇒ ↑ venous return to the heart ⇒ ↑ fluid in lungs
-
COPD
- Diaphragm works better upright
14
Q
Platypnea
Definition
A
Dyspnea in the upright position which is relieved in a recumbent position.
15
Q
Orthodeoxyplatypnea
A
Platypnea associated with positional hypoxia.
16
Q
Platypnea
Causes
A
-
Right-to-left shunt
- Usually at the lung base
- Sitting up pulls more blood into the lower lung
- Liver disease
17
Q
Trepopnea
Definition
A
Dyspnea in one lateral position but not the other.
18
Q
Trepopnea
Causes
A
Seen in unilateral lung disease.
Ex. PNA
Good lung down ⇒ gravity improves ventilation and perfusion
19
Q
Cough
Definition
A
Reflex initiated by stimulation of irritant airway receptors to expel secretions and irritants.
20
Q
Cough
Mechanism
A
- Initial inspiration
- Occlude glottis with vocal cord closure
- Contraction of expiratory muscles against a closed glottis
- Rapid opening of glottis with release of air under pressure
21
Q
Cough
History
A
- Smoking hx
-
Duration/onset of cough
- Acute ⇒ < 3 weeks
- Subacute ⇒ 3-8 weeks
- Chronic ⇒ > 8 weeks
-
Position/time of day
- Recumbent cough ⇒ post-nasal drip, CHF, GERD
- Presence/quality of sputum
22
Q
Sputum
Qualifications
A
-
Dry cough
- Viral URI, asthma, GERD, post-nasal drip
- Clear frothy sputum ⇒ normal saliva
- Pink frothy sputum ⇒ pulmonary edema
-
Mucoid sputum
- Lower airway secretions, chronic bronchitis, asthma
-
Purulent sputum
- Infection ⇒ PNA, bronchitis, bronchiectasis
23
Q
Acute Cough
Causes
A
24
Q
Subacute Cough
Causes
A
25
Chronic Cough
Causes
26
Chronic Cough
Management
**CXR** ⇒ r/o serious pathology
_History and physical may guide approach:_
* **Smoker**
* CXR, PFT, smoking cessation
* **Post-nasal drip**
* Trial antihistamine/decongestant, allergy testing, sinus CT
* **Reflux or cough worse with meals/recumbency**
* Trial H2 blocker or PPI, 24 hour pH probe
* **Wheezy dry cough precipitated by asthma triggers**
* PFT, bronchodilator trial, methacholine challenge
* **Prolonged cough following URI**
* Trial bronchodilator ± inhaled steroid
* **History of ACEi or β-blocker**
* Trial of drug cessation
27
Hemoptysis
Definition
Expectoration of blood.
28
Hemoptysis
Look Alikes
* **Epistaxis** ⇒ blood in nares and/or nasopharynx
* Blood may be inhaled then expectorated
* **Hematemesis** ⇒ vomiting blood
* Acidic pH
* Food particles
* Dark blood
* Epigastric complaints
29
Hemoptysis
History
* Bright red and frothy sputum
* Associated cough
* Alkaline pH
* Contains alveolar macrophages
* Pt can often ID source and location
30
Hemoptysis
Causes
* _Common_
* **Infectious**
* TB, PNA, bronchitis, abscess
* **Bronchogenic cancer**
* **PE with infarction**
* **Bronchiectasis**
* _Unusual_
* **Occupational exposures**
* Trimellite anhydride ⇒ heated metal surfaces sprayed with epoxy paints
* Isocyanates
* **Catamenial hemoptysis** ⇒ pulmonary endometriosis
* Pieces of endometrium ends up in the lungs
* Undergoes cyclical bleeding similar to uterus
* **Free base cocaine**
* **Vasculitis**
* **Trauma**
31
Bronchiectasis
Definition
Abnormal dilation of bronchi with destruction of elastic/muscular components of the bronchial wall.
32
Hemoptysis
Management
* **Quantify hemoptysis**
* _Massive hemoptysis_: \> 600 ml/24 hrs
* Position bleeding side down
* May worsen bleeding but protects good lung
* **CBC, platelets, PT/PTT**
* **Urinalysis** ⇒ check for RBC/casts
* **Start codeine 15-30 mg q4h** ⇒ suppress cough
* **CXR**
* **Sputum culture and sensitivity**
* AFB (Acid fast bacillus) ⇒ check for TB
* Isolation if suspected
* **Start broad spectrum abx**
* Avoid chest percussion
33
Hemoptysis
Evaluation
* Acute management
* **Bronchoscopy** ⇒ localize bleeding
* Vasculitis work-up if suspected
* Collagen vascular panel
* ANCA (Anti-neutrophil cytoplasmic autoantibody)
34
Pleuritic Chest Pain
Definition
Sharp knife-like chest pain associated with coughing or breathing.
35
Pleuritic CP
Mechanism
* **Stimulation of pain fibers in parietal pleura**
* Visceral pleura and lungs have no pain fibers
* **Caused by inflammation or trauma involving any thoracic structure affected by respiratory movement**
* Ribs, cartilage, muscles, nerves, pleura, pericardium
36
Pleuritic CP
History
* Duration and onset
* Severity
* Location
* Associated sx
* Fever, SOB, hemoptysis
* Smoking hx
37
Pleuritic CP
Causes
* **Infection**
* Associated w/ fever, cough, purulent sputum
* **Pulmonary infarction**
* Acute-onset, dyspnea, hemoptysis
* **Pleurisy** ⇒ viral infection of the pleura
* Acute-onset, often with other viral sx
* **Malignancy**
* Usually subacute or chronic
* **Pleuritis** ⇒ associated with collagen vascular disease
* **Pneumothorax** ⇒ collapse of lung d/t air in the pleural space
* Acute-onset, dyspnea, ↓ breath sounds with hyperinflation of affected side
* **MSK pain**
* Mostly acute-onset
* Rib fx, costochondritis, myositis, nerve pain
38
Pleuritic CP
Evaluation
* CXR / rib films
* Cultures and viral serologic studies
* Collagen vascular disease work-up
* Possible work-up for PE
39
Wheezing
Definition
**Continuous adventitous breath sounds.**
* Vibration of air through narrowed airways
* Most prominent during expiration
40
Wheezing
Characteristics
* **Pitch**
* High pitch ⇒ stiff, narrow obstruction
* Low pitch ⇒ large, floppy airways
* **Complexity** ⇒ monophonic vs polyphonic
* **Duration** ⇒ short vs long
* **Timing** ⇒ inspiratory vs expiratory
41
Wheezing
History
* Smoking hx
* Duration and onset
* Triggers / exposures
* Severity
* Location
* Focal or diffuse
* Upper airway
42
Wheezing
Causes
* **Asthma**
* **COPD**
* **Fixed airway obstruction**
* FB aspiration
* Upper airway obstruction or tumor
* **CHF**
* "Cardiac asthma" ⇒ caused by edema of the airways
* **Acute inhalation of irritant gas**
* **"Laryngeal asthma" ⇒** paradoxical motion of the vocal cords
43
Wheezing
Evaluation
* Complete hx
* CXR
* PFTs
* Evaluation for CHF
44
Stridor
Definition
**Loud continuous inspiratory breath sounds.**
* Often heard without a stethoscope
* Usually loudest in the neck
45
Stridor
Causes
**Usually a sign of an extra-thoracic upper airway obstruction:**
* Goiter
* Vocal cord polyp
* Upper airway tumor
* Croup
46
Clubbing
Definition
Painless bulbous enlargement of the distal fingers ± toes, with softening of the nail bed.
47
Clubbing
Diagnosis
* **Check nail bed for sponginess**
* Occurs before loss of angle
* **Evaluate angle between nail and adjacent dorsal surface of the distal phalynx**
* Normal angle ⇒ diamond space between thumbs
48
Clubbing
Pulmonary Etiologies
* Lung cancer
* Chronic infection
* TB, bronchiectasis, lung abscess
* Idiopathic pulmonary fibrosis
* Cystic fibrosis
* Alveolar proteinosis
\*\*\***COPD does not cause clubbing, must look for other causes in a smoker.**
