Respiratory Exams/Tests/Hx Flashcards
Hx - what systems could be the source of respiratory symptoms?
How do we determine this?
Respiratory GI (GERD, esophagus) Renal (CRF) Musculoskeletal Cardiovascular (CHF) CNS (anxiety) Endocrine (DM)
Ask about concomitant symptoms, environmental exposures, and Family Hx!
Common Causes of Cough
URI Lung infection Rhinosinusitis -> post nasal drip GERD Air pollution & smoking CHG (productive cough at night) Asthma COPD Lung disease ACE inhibitors Anxiety - nervous cough
Durations of Cough
Acute: less than 3 wks, infection or exacerbation of a lung dz
Subacute: 3-8 wks, often post-infection
Chronic: over 8 wks
Cough with postural changes suggests..?
- Chronic lung abscess
- TB
- Bronchiectasis
- Tumor
Cough during eating suggests…?
Problems with swallowing mechanism
Cough with cold air or exercise suggests…?
Asthma
Cough in the morning that persists until sputum is produce is characteristic of…?
Bronchitis
Cough in AM may suggest…?
Allergy to something in sleeping quarters
Clear sputum is associated with…?
- Allergies
- COPD
Yellow sputum is associated with…?
Infection -> live neutrophils.
acute bronchitis, acute pneumonia
Green sputum is associated with…?
Chronic infection -> neutrophil breakdown
chronic bronchitis, pneumonia, bronchiectasis, CF
Brown/black/rust colored sputum is associated with..?
“Old blood”
chronic pneumonia, TB, lung cancer
What things do you want to know about sputum?
Color, Timing, Quantity (scant/profuse), and quality (thin, stringy, thick, etc.)
Hemoptysis
- Can be blood-streaked to gross-blood expectorated
- Massive hemoptysis = life threatening (loss of >600ml in 24 hrs)
- Clarify the source: is it upper GI? Upper/lower respiratory?
Causes: Airway inflammation, Foreign body, Coagulopathy, Lung parenchymal infection (TB = streaks of blood, pneumonia, abscesses), Pulmonary embolism (bright red), Bronchiogenic carcinoma (may be frothy), Airway trauma, Esophageal varices.
Dyspnea
- Difficulty breathing (sensation)
- Often accompanies exertion
Origins can be:
Physiologic (high altitude),
Pulmonary (restrictive, obstructive, infectious, or non-infectious),
Cardiac,
Chemical (acidosis),
Neuromuscular (MS, ALS),
Psychological conditions (anxiety/panic attack)
Signs of SOB from cardiac origin
- Cheyne-Stokes respirations: alternating periods of apnea and hyperpnea
- Orthopnea: respiratory problems while supine (L ventricular failure)
- Paroxysmal Nocturnal Dyspnea (PND): pt wakes gasping for breath and must sit or stand (mitral stenosis, aortic insufficiency, HTN)
Chest Pain as a sx
May be cardiac, pulmonary, GI, musculoskeletal, skin or CNS (anxiety). ALERT EMS
- Cardiac: crushing, pressing or squeezing. Generally aggravated by exertion. May radiate to neck, jaw, or arm. (angina, MI) Nausea & diaphoresis are classic concomitants to MI.
- Pulmonary: localized, sharp/knifelike. Worse breathing or coughing (pleural pain). (pleurisy, pneumonia, pneumothorax)
- GI: Sharp, burning, squeezing, or heavy. Affected by swallowing (spasm)
- Musculoskeletal/skin: Hx of fall (fractured rib - pain elicited on palpation, costochrondritis - rib cartilage inflammation, herpes zoster)
- CNS: pain may simulate MI (anxiety, panic attack)
Physical Exam
- Abnormal findings are reported in terms of location (ribs/anatomic lines on chest [mid clavicular, sternal, etc.])
- *All exams performed on anterior AND posterior thorax!
Includes: Inspection, Palpation, Percussion, Auscultation,
Palpation during PE
Assess area, chest expansion, tactile fremitis. Press on it & see if it hurts…
Percussion during PE
- Listen & feel for intensity, pitch & duration of sounds. 5 notes possible…
- Resonant: loud, low-pitch, long duration. Dominant note over normal lungs
- Flat: soft, high pitch, short duration. Sounds like percussion over thigh muscle
- Dull: medium intensity, pitch, & duration. Sounds like percussion over liver. (pleural thickening, atelectasis, consolidation, pleural effusion)
- Hyperresonant: very loud, low pitch, long duration. (Air trapped [pneumothorax], severe emphysema)
- Tympanic: musical quality. Like percussion over stomach or puffed cheek.
- Percuss diaphragmatic excursion -> change in lung expansion. T-10 on expiration, T-12 on inspiration is normal..?
Auscultation during PE - Changes in breath sounds
- Absent: collapsed lung
- Decreased: normal lung replaced by air (emphysema/pneumothorax), or fluid (pleural effusion), or increased distance between lung & chest wall.
- Bronchial breathing: consolidation in lower loves changes from vesicular to bronchial (I don’t know what that means…)
Auscultation during PE - Adventitious Lung Sounds
- Crackles: aka rales. Popping sounds, usu. during inspiration, don’t clear w/cough. Happen when air passes through bronchi that contain secretions or are constricted by spasms or thickened walls
- Rhonchi: low pitched wheezes originating in upper airways. Snoring, gurgling, rumbling quality. Caused by secretions obstructing large bronchi. Prominent on expiration, clear with coughing.
- Wheezes: classic asthma on exhale, esp. forced expiration. High pitched musical/whistling sound caused by narrowing/obstruction of small bronchi/bronchioles. (asthma, bronchitis, COPD). (If localized - obstruction: tumor, secretions, foreign body)
- Stridor: Inspiratory wheeze -> upper airway obstruction (croup)
Voice Transmission Tests during PE
All these tests become abnormal with lung consolidation (indurated [mass/scarring] or filled with liquid).
- Bronchophony (vocal fremitus): Pt says “99” as you auscultate lungs. Normal = indistinct, abnormal = sounds heard clearly.
- Whispered Pectoriloquy: the patient whispers words as you listen with a stethoscope. Normally the words would be faint, abnormally they will be heard clearly.
- Egophony (most sensitive. E changes to A): Normal = “ee” as in “beet” is heard. Abnormal = “a” as in “say” is heard.
Lab Tests to perform
- CBC: infection, allergies
- Comprehensive Metabolic Panel (CMP): electrolytes, glucose, lipids; liver enzymes
- Sputum culture
- Arterial Blood Gases (pH, O2, CO2, HCO3-)
- TB test: Quantiferon Gold
Special Tests: Lungs
- Peak Flow Meter: Hand-held, in-office test that roughly correlates to FEV1. Compared to expected values based on age/gender. Useful in asthma.
- Pulse Oximetry: Portable fintertip sensor uses photodiode in office. Normal = 95-99%
Pulmonary function tests (spirometry): Determines obstructive/restrictive dz, refer to pulmonologist. Assesses air volume moving in & out of lung, how fast it moves, lung/chest-wall compliance, and response to physical therapy or bronchiodilators.
PFT - Obstructive
Reduced FEV1 (forced expiratory vol. for 1 sec)
Causes: Narrowing airway
- smooth m. contraction (asthma)
- inflammation/swelling of bronchial mucosa (bronchitis)
- material inside passages (mucus plug, foreign body, tumor)
- external compression of airway (tumor, trauma)
Can do a makeshift version in office -> if it takes them more than six seconds to expire fully after a deep breath they’re obstructed.
PFT - Restrictive
Decreased lung volume or TLC = FVC (forced vital capacity) + RV (residual volume)
Causes:
- intrinsic disorders (sarcoidosis, TB, pneumonia)
- extrinsic (scoliosis, pleural effusion, tumors)
- Neuromuscular (myasthenia gravis, paralysis of diaphragm, muscular dystrophy, ALS)
Imaging for Lungs
- CXR
- CT (for cancer)
- PET (positron emission tomography, 90% accurate for tumors)
- Chest U/S (opacities in pleura, fluid or solid mass)
- Flexible Bronchoscopy (evaluate inside bronchus, bronchioles, sample secretions)
