Signs and Symptoms of Lung Disease

Question 1

physical exam: inspection - normal effort

Answer 1

*unlabored breathing
*mouth closed
*allows for normal speech
*diaphragm alone involved
*trachea is midline

Question 2

physical exam: inspection - abnormal effort

Answer 2

*visually labored
*mouth open
*cannot speak normally
*diaphragm not alone (SCM hypertrophy, intercostal retractions, abdominal muscle contractions, “tripod” arm support)
*hyperinflation may be seen (“barrel-chest”)
*tracheal deviation may indicate shift of the mediastinum

Question 3

physical exam: auscultation - normal sounds

Answer 3

*sounds over the lung lobes - “vesicular” sounds
*sounds over the trachea - “bronchial” sounds

note - bronchial sounds are abnormal if heard over the lobes

Question 4

physical exam: auscultation - abnormal sounds

Answer 4

*continuous: wheezes, rhonchi
*discontinuous: fine crackles (rales), coarse crackles (rales)

Question 5

abnormal breath sounds - wheezes

Answer 5

*high pitched (>400 Hz), longer than 250 msec
*produced by fluttering of airway walls
*a “continuous” sound
*ddx: classically present in asthma; less often in pulmonary edema, VCD, foreign body

Question 6

abnormal breath sounds - rhonchi

Answer 6

*low pitched (<200) Hz, longer than 250 msec
*produced by flutter or rupture of fluid films
*a “continuous” sound
*ddx: pneumonia, chronic bronchitis, poor pulmonary toilet; often clear with cough or suctioning

Question 7

abnormal breath sounds - crackles/rales

Answer 7

*crackles are discontinuous, fine sounds; sound like velcro

*early-inspiratory (begin right away during inspiration; do not require much force to generate the crackles)
-ddx for early-inspiratory: heart failure, pulmonary edema

*late-inspiratory (do not begin immediately on inspiration)
-ddx for late-inspiratory: pulmonary fibrosis

Question 8

physical exam: auscultation - stridor

Answer 8

*an important extra-thoracic sound
*differs from wheezing (stridor is predominantly inspiratory)
*caused by turbulent flow in extra-thoracic airway
*most commonly due to vocal cord dysfunction, tracheal stenosis, or foreign body
*may be a medical emergency

Question 9

physical exam: percussion - technique

Answer 9

*coordinated tapping on a finger held against the patient’s chest
*the percussion “note” is heard, but predominantly it is FELT

Question 10

physical exam: percussion - normal lung findings

Answer 10

resonant

Question 11

physical exam: percussion - abnormal lung findings

Answer 11

*dull: pleural effusion, consolidation
*flat: massive effusion
*tympanic: tension pneumo
*hyperresonant: pneumothorax

Question 12

physical exam: fremitus - technique

Answer 12

*bilateral comparison
*place hands on patient’s back and have them give any low frequency phrase (ex. blue balloon)
*this is sound transmission - travels best through solids and poorly through liquid and air

Question 13

physical exam: fremitus - abnormal findings

Answer 13

*increased fremitus: consolidated lung (lobar pneumonia)
*decreased fremitus: pleural space filling (effusion or pneumothorax)

Question 14

dyspnea - overview

Answer 14

*perception of difficult or painful breathing; shortness of breath; difficulty breathing
*triggered by receptors in chest wall, respiratory muscles, lung parenchyma, carotid body, and brainstem
*adaptation can occur!
*not always coupled to oxygen saturation
*not always coupled to respiratory effort

Question 15

respiratory ddx for dyspnea

Answer 15

*pneumothorax
*pulmonary embolism
*pneumonia
*asthma
*COPD
*pulmonary arteriovenous malformations (AVMs)
*interstitial lung disease
*lung cancer

Question 16

cough - overview

Answer 16

*occurs in healthy individuals
*a normal protective mechanism
*unimportant vs. heralding severe disease
*phases:
-Inhalation
-Glottis closure, compression
-Expulsion

Question 17

respiratory ddx for cough

Answer 17

*irritant inhalation or foreign body aspiration
*upper respiratory infection
*upper airway cough syndrome
*ACE inhibitors
*gastroesophageal reflux disease
*asthma
*chronic bronchitis
*lung cancer

Question 18

hemoptysis

Answer 18

*coughing of blood
*most common cause: BRONCHITIS
*other causes: TUBERCULOSIS, LUNG CANCER, hematemesis, epistaxis

Question 19

digital clubbing

Answer 19

*an important but uncommon manifestation in some pulmonary diseases
*NOT present in COPD
*may be present in lung cancer, pulmonary fibrosis, bronchiectasis, cystic fibrosis, congenital cyanotic heart disease

Question 20

cyanosis

Answer 20

*bluish discoloration of lips, nose, ears, fingers, toes, etc
*reflects an increased amount of deoxyhemoglobin ( > 5 grams)
*ddx:
-central cyanosis: anatomic shunts, hemoglobinopathies
-peripheral cyanosis: low cardiac output states, arterial or venous occlusion, cold environmental exposure