Pulmonology - History and physical examination - DONE

Question 1

What questions should be asked of any patient with lung disease?

Answer 1

Think OLD EQQS (onset, location, duration, exacerbation, quality, quantity, associated symptoms)

Question 2

What are the cardinal symptoms of respiratory diseases?

Answer 2

Dyspnea, wheezing, cough, including hemoptysis, and chest pain or discomfort

Question 3

What is hemoptysis?

Answer 3

Coughing up any amount of blood

Question 4

How do we classify hemoptysis?

Answer 4

• Massive hemoptysis—200–600 cc of bleeding in 24 hours

- Minor hemoptysis—anything less than massive

Question 5

What are the main causes of hemoptysis today?

Answer 5

• Bronchitis
• bronchogenic carcinoma
• TB
• pneumonia
• bronchiectasis

Question 6

What parts of the social history are vital?

Answer 6

History of smoking, drug use, sexual activity and other HIV risk factors, travel, work, and animal exposure

Question 7

What findings in someone with obstructive lung disease suggest that a patient’s FEV1 is decreased to 30% or less?

Answer 7

Respiratory rate > 30 breaths/min and the use of accessory muscles of respiration; there may be evidence of CO2 retention on ABG.

Question 8

What does an increased anteroposterior diameter signify?

Answer 8

Pulmonary hyperinflation, as is seen with obstructive diseases such as COPD

Question 9

How do patients with significant emphysema breathe?

Answer 9

They exhale through pursed lips.

Question 10

What does asymmetric chest expansion indicate?

Answer 10

There is volume restriction on the side with reduced expansion such as is seen with pleural effusions, bronchial obstruction, unilateral diaphragm paralysis, and pneumothorax.

Question 11

What does symmetrically impaired chest expansion indicate?

Answer 11

Restrictive pulmonary disease involving the lung, pleura, respiratory muscles, or thoracic cage bilaterally

Question 12

What is paradoxical breathing?

Answer 12

The thorax and abdomen move in opposite directions with the abdomen moving in with inspiration.

Question 13

What is the significance of paradoxical breathing?

Answer 13

It is a sign of diaphragmatic weakness or excessive work of breathing, with accessory muscles assuming the work of breathing.
The patient may require mechanical ventilation if the cause is not fixed promptly.

Question 14

What causes the trachea to deviate toward the side with the chest abnormality?

Answer 14

Lobar atelectasis causes the trachea to deviate toward the side of atelectasis.

Question 15

What causes the trachea to deviate away from the side with the chest abnormality?

Answer 15

Large masses, adenopathy, pulmonary infiltrates, large pleural effusions, and tension pneumothorax

Question 16

How do you interpret an increase in tactile fremitus?

Answer 16

There is a direct solid communication from the bronchus, through the lung, out to the chest wall (i.e., consolidation).

Question 17

How do you interpret a decrease in tactile fremitus?

Answer 17

A process is preventing communication between the bronchus and chest wall including bronchial obstruction or that the lung is displaced from the chest wall by air, fluid, or scar in the pleural space.

Question 18

How do you interpret changes in the volume of breath sounds?

Answer 18

Similarly to changes in tactile fremitus

Question 19

What causes bronchial breath sounds to be heard in the periphery?

Answer 19

Any solid matter—including collapsed lung (atelectasis)—that has replaced the usual acoustic phenomena caused by air- filled alveoli and requires a patent bronchus

Question 20

What causes percussion to be dull?

Answer 20

Consolidation of the underlying lung parenchyma, the fluid in the pleural space, and the pleural thickening

Question 21

What physical signs can be observed with a pleural effusion?

Answer 21

Dullness over the fluid area, decreased expansion of the chest, decreased tactile fremitus, decreased breath sounds and bronchial breathing and egophony above the fluid level (from atelectasis).
With massive effusions, the trachea, the mediastinal structures, and the heart may shift away from the affected side.