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Clinical Physical Diagnosis > Respiratory Exams/Tests/Hx > Flashcards

Respiratory Exams/Tests/Hx Flashcards

1
Q

Hx - what systems could be the source of respiratory symptoms?

How do we determine this?

A 
Respiratory
GI (GERD, esophagus)
Renal (CRF)
Musculoskeletal
Cardiovascular (CHF) 
CNS (anxiety)
Endocrine (DM)

Ask about concomitant symptoms, environmental exposures, and Family Hx!

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2
Q

Common Causes of Cough

A 
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
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3
Q

Durations of Cough

A

Acute: less than 3 wks, infection or exacerbation of a lung dz

Subacute: 3-8 wks, often post-infection

Chronic: over 8 wks

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4
Q

Cough with postural changes suggests..?

A
  • Chronic lung abscess
  • TB
  • Bronchiectasis
  • Tumor
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5
Q

Cough during eating suggests…?

A

Problems with swallowing mechanism

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6
Q

Cough with cold air or exercise suggests…?

A

Asthma

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7
Q

Cough in the morning that persists until sputum is produce is characteristic of…?

A

Bronchitis

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8
Q

Cough in AM may suggest…?

A

Allergy to something in sleeping quarters

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9
Q

Clear sputum is associated with…?

A
  • Allergies

- COPD

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10
Q

Yellow sputum is associated with…?

A

Infection -> live neutrophils.

acute bronchitis, acute pneumonia

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11
Q

Green sputum is associated with…?

A

Chronic infection -> neutrophil breakdown

chronic bronchitis, pneumonia, bronchiectasis, CF

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12
Q

Brown/black/rust colored sputum is associated with..?

A

“Old blood”

chronic pneumonia, TB, lung cancer

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13
Q

What things do you want to know about sputum?

A

Color, Timing, Quantity (scant/profuse), and quality (thin, stringy, thick, etc.)

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14
Q

Hemoptysis

A
  • 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.
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15
Q

Dyspnea

A
  • 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)

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16
Q

Signs of SOB from cardiac origin

A
  • 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)
17
Q

Chest Pain as a sx

A

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)
18
Q

Physical Exam

A
  • 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,
19
Q

Palpation during PE

A

Assess area, chest expansion, tactile fremitis. Press on it & see if it hurts…

20
Q

Percussion during PE

A
  • 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..?
21
Q

Auscultation during PE - Changes in breath sounds

A
  • 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…)
22
Q

Auscultation during PE - Adventitious Lung Sounds

A
  • 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)
23
Q

Voice Transmission Tests during PE

A

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.
24
Q

Lab Tests to perform

A
  • 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
25
Q

Special Tests: Lungs

A
  • 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.

26
Q

PFT - Obstructive

A

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.

27
Q

PFT - Restrictive

A

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)
28
Q

Imaging for Lungs

A
  • 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)

Clinical Physical Diagnosis (5 decks)

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