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respiratory pt 1 Flashcards

1
Q

Four points in approach to patient

A
  • Hx :which system is responsible for sxs
  • concomitants
  • exposures
  • FHx
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2
Q

What are some systems (and conditions) outside the respiratory system that can respiratory issues

A
  • GI: GERD
  • kidney: CRF
  • endocrine: DM
  • musculoskeletal: HZV
  • heart: CHF
  • CNS: anxiety
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3
Q

Common causes of cough from within the respiratory system

A 
lung dz (bronchiectasis)
asthma
COPD
lung infx (pneu, bronchitis)
URI
rhinosinusitis (post-nasal drip)
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4
Q

Common causes of cough from outside the respiratory system

A

anxiety (CNS)
GERD (GI)
CHF (heart)
cigarettes, air pollution, ACE inhibitors (environmental)

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5
Q

What are two key features to ascertain about a cough from Hx?

A

duration

patterns

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6
Q

What are the three categories of cough duration (and associated causes)

A

acute: less than 6 wks - infx, exacerbation of lung dz
sub-acute: 6-8 wks - post-infx
chronic: more than8 wks - post-nasal drip, GERD, asthma

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7
Q

What are three cough patterns (and associated causes)

A

w/posture change - chronic lung abscess, TB, tumor, bronchiectasis
w/ cold air or exercise - asthma
in AM until productive - chronic bronchitis, allergen in bedroom

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8
Q

Though not always accurate, what are the associations w/ clear, green, yellow, and dark sputum?

A

clear - allergy, COPD
yellow - infx (acute bronchitis or pneumonia); live PMNs
green - chronic infx; PMN breakdown
brown/black - old blood: lung CA, TB, chronic pneu.

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9
Q

What needs to be clarified with hemoptysis?

A

The source: uppler/lower respiratory, upper GI?

Concomitants will help

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10
Q

What are some causes of hemoptysis?

A 
airway inflamx
foreign body
pulmonary embolism
bronchogenic carcinoma
esophageal varices
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11
Q

What are the different clinical types of dyspnea?

A
  • physiologic : exertion at altitude
  • pulmonary: restrictive/obstructive/infx/non-infx
  • cardiac: CHF, cardiogenic pulmonary edema
  • chemical: DKA from DM, renal faiure
  • neuromuscular: MS, ALS
  • psychological: anxiety, panic
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12
Q

What are some signs that dyspnea has a cardiac origin?

A
  • cheyne-stokes respiration: alt. periods of rapid breathing and not breathing
  • orthopnea: resp. problems while supine (LV failure)
  • paroxysmal nocturnal dyspnea (PND): pt awakens gasping for breath and must sit up (HTN, aortic insufficiency)
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13
Q

What are the five systems that can generate chest pain?

A
  • cardiac: MI, angina
  • pulmonary: pleurisy, pneumonia, pneumothorax
  • GI
  • musculoskeletal: fractured rib, HZV
  • CNS: anxiety, panic attack
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14
Q

What kinds of chest pain are specific to each system?

A
  • cardiac: crushing, pressing or squeezing quality, generally aggravated by exertion.May radiate to neck, jaw or arm.
  • pulmonary: localized, sharp and knife-like; worse breathing or coughing (pleural pain)
  • GI: may be sharp, burning, squeezing, or heavy; affected by swallowing (spasm)
  • musculoskeletal: elicited by palpation
  • CNS: akin to MI
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15
Q

On PE, abnormal findings are reported in terms of ______.

A

Location - w/reference to ribs and anatomic lines (sternal, mid-clavicular, mid-axillary, mid-scapular lines)

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16
Q

What are the three aspects of PE and where are they performed?

A

Anterior and posterior thorax (anterior - upper lobes; posterior - lower lobes)

  • inspection
  • palpation
  • percussion
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17
Q

What might you note on inspection?

A

labored breathing
sitting in tripod position
cyanosis
depth and symmetry of breath

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18
Q

What might you note on palpation?

A

areas of pain (press where it hurts)
chest expansion (feel for symmetry)
tactile fremitis

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19
Q

What notes would you find on percussion and what might they represent?

A

resonant: long, low, loud, hollow - normal lung sound
dull: med intensity, pitch, duration - pleural thickening/effusion, atelectasis, consolodation
hyperresonant: very loud, low pitch, and long duration - trapped air..pneumothorax, emphysema

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20
Q

What two types of findings might you have with auscultation?

A

changes in breath sounds

adventitious lung sounds

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21
Q

What are the three changes in breath sound and what might they represent?

A
  • absence: collapsed lung
  • decreased: normal lung displaced by air (emphysema/pneumothorax) or fluid (pleural effusion)
  • bronchial breathing: consolidation in lower lungs
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22
Q

What are the four types of adventitious lung sounds? And during which portion of the breath are they heard?

A

inspiration:
-crackles: popping sounds

expiration

  • rhonchi: low pitched wheezes/gurgles/rumbling from upper airways
  • wheezes: high-pitched whistling from small bronchi or bronchioles

both
-pleural sounds: loud grating due to lack of pleural fluid (friction rub) – concurrent with pleurisy - sharp, knife-like pain

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23
Q

What are two characteristics of bronchi that can cause crackles?

A

contain secretions - early inspiratory crackles

constricted (by spasm or thickened walls) - late inspiration crackles

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24
Q

What conditions are associated with diffuse wheezing? Local?

A

Diffuse: asthma, COPD, bronchitis
Local: bronchus obstruction (tumor, foreign body)

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25
Q

What will cause abnormalities in voice transmission tests?

A

Consolidation

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26
Q

What are the three types of vocal transmission test?

A
  • vocal fremitis: pt says ‘99’ or ‘E’ and it sounds muffled
  • whispered pectoriloquy - ‘99’ transmits well
  • egophony - most sensitive; ‘E’ transmits as ‘A’
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27
Q

What lab tests might be employed with respiratory issues?

A 
CBC
CMP
Blood arterial gases
Sputum culture
TB testing
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28
Q

What are two useful in-office tests?

A
  • peak flow meter: good or asthma; correlates with FEV1 (how much can be exhaled)
  • pulse ox: fingertip sensor for oxygen saturation of arterial blood (normally 95-99%)
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29
Q

What can be ascertained by a pulmonologist running PFTs?

A
  • how much air volume can move in and out
  • how fast air moves in and out
  • lung compliance
  • lung response to PT or bronchodilator tx
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30
Q

What is COPD?

A

Condition of reduced expiration flow; forced emptying of the lungs. Lungs are hyperinflated, hyperreflexive. And the condition is only minimally reversible with bronchodilators.

31
Q

What is the #1 cause of COPD?

A

Cigarettes - up to 90% of deaths

32
Q

What is missing with inheritable COPD?

A

alpha-1-antitrypsin

33
Q

What are the s/sx of general COPD?

A
  • dyspnea (worse on ecxertion)
  • chronic, productive cough
  • wheezing
  • cyanosis
  • clubbing
  • barrel chest
34
Q

Which lung conditions have a productive cough

A
  • chronic bronchitis
  • bronchiectasis
  • CF
35
Q

What are the most important work-up considerations with COPD?

A
  • PFT
  • CXR
  • pulse ox
36
Q

What are the two forms of COPD?

A

emphysema and chronic bronchitis (many patients have both)

37
Q

During which age ranges are the presentations likely for emphysema, AAT deficiency, chronic bronchitis, and asthma?

A
  • emphysema: 50+
  • AAT: 32-41
  • chronic bronchitis: late 30s and 40s
  • asthma: 2-20 or over 40
38
Q

What is emphysema?

A

permanent enlargement of alveolar ducts and sacs distal to terminal bronchioles with fibrosis and lack of recoil. it is a gradual progression.

39
Q

Why might patients with AAT deficiency not complain of SOB?

A

They will have decreased their activity level so as not to induce it.

40
Q

What is the classical presentation of someone with emphysema?

A
  • pink puffer: dyspnea on mild exertion, cyanosis at rest
  • finger clubbing
  • cough is RARE
  • mucus is scant and clear
41
Q

What would you expect to find on PE of someone with emphysema?

A
  • barrel chest due to hyperinflated lungs, otherwise cachetic (muscle and fat wasting)
  • purse-lipped breathing
  • hyperresonance on lung percussion
  • decreased diaphragmatic excursion (narrower range of movement)
  • PMI deviated towards sternum
  • Hoover’s sign: ribs pull in on deep inhale due to diaphragm collapsing
42
Q

What are the lab results expected with emphysema?

A

normal Hgb, normal to reduced Pa02 and PaCO2

43
Q

How will either form of COPD present on a PFT?

A

reduced FEV1

44
Q

What is chronic bronchitis?

A

mucus hyper-secretion impairing airflow secondary to hypertrophy of the bronchial mucosa glands.

chronic irritation of the bronchi leads to thickening and scarring.

cough most days of a month, for three months of the year for two consecutive years

45
Q

What is the classical presentation of someone with chronic bronchitis?

A
  • blue bloater: cyanosis and edema.
  • chronic productive cough (worse in AM)
  • frequent infections
  • mild dyspnea
  • mucopurulent sputum
46
Q

What would you expect to find on PE of someone with chronic bronchitis?

A
  • overweight and cyanotic
  • barrel chest from hyperinflation
  • lungs hyperresonant on percussion
  • crackles on early inspiration
  • rhonchi and wheezes and decreased breath sounds during expiration

-late on: elevated jugular venous pulse, peripheral edema

47
Q

How does chronic bronchitis progress?

A
  • shorter intervals between acute exacerbations
  • cor pulmonale
  • respiratory failure
48
Q

What are some ddx for COPD?

A 
central airway stenosis
bronchiectasis
heart failure
CF 
bronchiolitis
49
Q

What is asthma and what separates it from COPD?

A

episodes of wide-spread broncho-constriction and dyspnea with underlying inflammation.

difference is that it’s much more reversible with bronchodilators

50
Q

What are the three main features of asthma?

A
  • airway obstruction (episodic and reversible): tightened airways cause wheezing
  • inflammation: red, swollen bronchial tubes
  • airway irritability: overreaction to triggers
51
Q

What are common asthamtic triggers?

A
  • URI
  • inhaled allergen: pollen, mold, dander
  • meds: aspirin, NSAIDs
  • food: shrimp, dried fruit
  • exercise
  • weather: cold air, humidity change
  • emotion: anxiety
  • GERD
  • irritants: smoke, odors
52
Q

What are the two classifications of asthma?

A

extrinsic (allergic): inhaled allergens, meds, foods, animals

intrinsic (non-allergic): URI, LRI, emotion, exercise, cold weather

53
Q

How would a pt present upon PE during an asthma attack?

A
  • respiratory distress
  • anxiousness
  • can’t speak in full sentences
54
Q

What is pulsus paradoxus?

A

Pulse rate slowing during inspiration. There’s a decreased cardiac return b/c of hyperinflation

55
Q

Why check the skin of an asthmatic?

A

looking for manifestations of allergic skin conditions.

will not find fingernail clubbing

56
Q

What will be the findings of lung auscultation on an asthmatic?

A

prolonged expiration with wheezing (high pitched and polyphonic due to a number of different sized airways being obstructed)

57
Q

What might you look for with inspiratory wheezing or stridor?

A

upper airway obstruction - thyroid enlargement, tumor, vocal cord issues

58
Q

What are the ominous clinical signs during an asthma attack?

A
  • change in affect
  • inability to speak or drink
  • dorwsiness/confusion
  • cyanosis
59
Q

What is status asthmaticus?

A

prolonged attack unresponsive to bronchodilator tx. could be fatal.

60
Q

What are some ddx for asthma?

A

COPD, bronchiectasis, CF, eosinophilic pneumonia, vocal cord paralysis

61
Q

Why clarify when asthma attacks occur?

A

Narrow down the irritant. Could be occupational.

62
Q

What is bronchiectasis?

A

permanent dilation of airways secondary to infx and mucus accumulation. irreversible scarring and deformation allows more bacteria and mucus accumulation resulting in recurrent infxs and progressive injury.

63
Q

How is bronchiectasis commonly mis-diagnosed?

A

asthma or pneumnia

64
Q

What are possible etiologies of bronchiectasis?

A 
congenital bronchial obstruction
immunodeficiency (IgG, IgA, HIV)
various infxs (H. flu, pseudomonas)
65
Q

What other conditions are associated with bronchiectasis?

A

smoking, toxic inhalation, rheumatic dz (RA, sjogren’s), IBD, AAT deficiency

66
Q

What are the common s/sxs of bronchiectasis?

A
  • chronic, productive daily cough
  • dyspnea
  • wheezing
  • sputum mucopurulent and tenacious
  • chronic fatigue
  • rhinosinusitis
  • hemoptysis
67
Q

What might you find on PE of a pt with bronchiectasis?

A

non-specific findings:

fever w/ acute infx, weight loss, crackles, wheezes, rhonchi, cyanosis, nasal polyps

68
Q

How do yo really differentiate bronchiectasis from COPD?

A

Imaging…chest HRCT will reveal the bronchial wall thickening and luminal dilation.

69
Q

What is cystic fibrosis?

A

chronic progressive d/o of excessively thick mucus production due to CTFR gene defect (problem with Cl, Na transport)

70
Q

What conditions may develop with CF progression?

A

chronic bronchitis with or without bronchiectasis

71
Q

What are the multi-system findings with CF?

A

lungs: productive cough w/ sputum
sinuses: chronic nasal polyps
pancreas: insufficient digestive enzyme production leads to steatorrhea
liver: cirrhosis, portal HTN
musculoskeletal: clubbing
skin: salty skin

lung failure leads to multi-system organ failure leads to death

72
Q

What is the standard dx test for CF?

A

sweat test (checking chloride levels)

can also do genetic test for CTFR

73
Q

What might PE reveal in pts with CF (multi-system)?

A

nose: polyps
pulmonary: tachypnea, wheezes/crackles, cough, barrel chest

GI: abdominal distention, hepatosplenomegaly

other: dry skin, cheilosis, kyphosis, scoliosis

CPD (10 decks)

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