Clinical Approach to Respiratory Diseases

Question 1

What is the critical first step in order to arrive at the correct diagnosis?

Answer 1

Obtaining a good history

(if you listen long enough the patient will tell you what is wrong with them)

Question 2

What are the most common complaints for patients with pulmonary disorders (5)?

Answer 2

1. Dyspnea (aka SOB)
2. Cough with or without sputum
3. Fatigue
4. Exercise intolerance
5. Chest tightness/pain

Question 3

While dyspnea and cough are common to pulmonary disorders, what are other common causes of these symptoms?

Answer 3

1. positional dyspnea: CHF
2. cough: GERD

Question 4

What follow-up questions would you ask for the complaint of dyspnea (4)?

Answer 4

1. Impairment?
2. Triggers?
3. Cough? Wheezing?
4. Chest pain?

Question 5

Differential diagnosis for dyspnea with chest pain and sudden onset (5)

Answer 5

1. MI
2. PE
3. Pulmonary edema
4. Pneumothorax
5. Pericardial tamponade

(these are ALL life-threatening, must rule them out)

Question 6

Episodic dyspnea associated with exertion often suggests _______ (2).

Answer 6

1. lung disease
2. cardiac dysfunction

Question 7

Dyspnea that is seasonal or triggered by environmental exposure suggests _______(2).

Answer 7

1. asthma
2. hypersensitivity pneumonitis

Question 8

Positional dyspnea commonly occur in patients with _______ (3).

Answer 8

1. CHF
2. severe obstructive lung disease
3. neuromuscular weakness

Question 9

Orthopnea

Answer 9

Dyspnea that occurs in the Supine position

Question 10

Orthopnea most commonly occurs in _______.

Answer 10

CHF

(also common in asthma & COPD)

Question 11

Paroxysmal nocturnal dyspnea

Answer 11

Dyspnea that occurs several hours after lying down

Question 12

Paroxysmal nocturnal dyspnea is often associated with _______ & is due to ______.

(TQ!!)

Answer 12

• CHF
• ⇡ venous return to heart → interstitial edema

(assoc. w/asthma also)

Question 13

Most common cause of wheezing

Answer 13

asthma

(though not the only cause)

Question 14

Causes of wheezing, other than asthma (4)

Answer 14

1. CHF
2. COPD
3. bronchial obstruction (tumor, FB)
4. acute bronchitis (asthmatic bronchitis)

(asthmatic bronchitis = bronchitis with wheezing)

Question 15

Cough may be dry or productive (mucous) and commonly accompanies _____.

Answer 15

bronchitis

(may be severe enough to induce emesis or syncope)

Question 16

Common cause of cough (3)

Answer 16

1. Mild infection (i.e. bronchitis, common cold)
2. croup
3. pneumonia

(whooping cough/bordetella pertussis on the rise)

Question 17

________ may cause a dry cough months after initiation.

Answer 17

ACE inhibitors

Question 18

Define cough variant asthma

Answer 18

Cough is the only symptom of asthma

Question 19

What are the most common causes of chronic cough (4)?

Answer 19

1. Post nasal drip
2. Asthma
3. GERD
4. Smoking

Question 20

Define chronic bronchitis

Answer 20

persistent productive cough for 3 months out of the year, over 2 years

(can be due to asthma)

Question 21

How do you clinically characterize sputum (4)?

Answer 21

1. quantity?
2. color?
3. blood?
4. timing/frequency?

Question 22

colored sputum usually indicates _____; clear frothy sputum usually indicates _______.

Answer 22

• bacterial infection
• CHF

Question 23

Clear sputum usually indicates _____ (2); clear and frothy usually indicates _______.

Answer 23

1. allergic condition
2. viral illness

• CHF

Question 24

Hemoptysis is usually due to _____.

Answer 24

persistent or forceful cough (bronchitis) → irritation of bronchial lining.

(most common = infection; less common = pneumonia)

Question 25

What is an important question to ask a patient who has hemoptysis?

Answer 25

How much blood are you producing? (large amounts (500cc in 24 hours) could be cancer or TB)

Question 26

MC causes of massive hemoptysis (4)

Answer 26

1. lung CA 2. pulmonary hemorrhage 3. AV malformations 4. bronchiectasis

Question 27

Define Pleurisy

Answer 27

pleuritic chest pain during deep inspiration “sharp or stabbing pain" (due to inflammation of pleura, lung does NOT have pain receptors)

Question 28

Chest pain due to pulmonary emboli, infection and pneumothorax are usually ______ (type of pain)

Answer 28

pleuritic (Pulmonary HTN usually dull & unrelated to respiration)

Question 29

How can you distinguish benign chest pain?

Answer 29

benign is usually reproducible w/movement or palpation (must r/o other serious causes including compression fx)

Question 30

Define atelactasis

Answer 30

lungs not expanding fully leading to a space under lung (one of the MC respiratory complications following surgery)

Question 31

Risk of lung disease from smoking is directly related to which 2 risk factors?

Answer 31

1. genetics 2. pack/years of exposure

Question 32

Histoplasmosis is endemic to ______ (2).

Answer 32

1. Ohio 2. Mississippi River valleys (ask about travel hx)

Question 33

Tuberculosis is endemic to _______.

Answer 33

developing countries | (ask about travel hx)

Question 34

deviation of trachea may suggest _____ (2).

Answer 34

1. lung collapse 2. mass

Question 35

Define fremitus

Answer 35

faint vibration felt when patient says “99”

Question 36

Tactile fremitus is *increased* in areas with _______ and *decreased* in areas with _______ (3).

Answer 36

* lung consolidation (pneumonia) * obstruction, pneumothorax, emphysema (fluid = increase; air = decrease)

Question 37

Hyperresonance on percussion of the chest usually indicates ________ (2).

Answer 37

pneumothorax or hyperinflation (air **increases** resonance & **decreases** fremitus)

Question 38

Which 2 breath sounds are described as loud & high pitched? Describe a tracheal breath sounds

Answer 38

1. tracheal 2. bronchial (wheezing is also high pitched, but with a hissing)

Question 39

Describe vesicular breath sounds (2).

Answer 39

1. major normal breath sound 2. soft & low pitch (heard over most of lungs)

Question 40

3 common auscultation errors to avoid

Answer 40

1. listening over clothes 2. misinterpreting hair or tubing that rubs against clothes or rails as adventitious 3. patient breathing w/mouth closed

Question 41

Describe crackles aka rales (on auscultation)

Answer 41

* velcro-like (coarse or fine)

Question 42

Crackles aka rales produce sounds due to _______.

Answer 42

mucous in the airways or openings (coarse in medium or large airways, fine in alveoli)

Question 43

Crackles aka rales are commonly heard in _______ (2 conditions).

Answer 43

1. edema 2. pneumonia

Question 44

Describe wheezing sounds on lung auscultation (2).

Answer 44

1. high pitched 2. hissing

Question 45

Wheezing is commonly heard in _____ (4).

Answer 45

1. anaphylaxis 2. Obstruction (COPD, tumor, FB) 3. CHF 4. PE

Question 46

Describe rub sounds on lung auscultation.

Answer 46

pieces of leather rubbing against each other (heard in pneumonia, PE or pleurisy)

Question 47

When is a “crunching sound” heard? **Dx**? | ("Hamman's Crunch)

Answer 47

1. timed with the cardiac cycle and not with the respirations 2. pneumomediastinum

Question 48

4 Causes of absent breath sounds

Answer 48

1. pneumothorax 2. hydrothorax 3. hemothorax 4. obstruction (main stem)

Question 49

Chest x-rays provide information about _______ (5).

Answer 49

1. thoracic bones 2. pleura 3. lung parenchyma 4. mediastinum 5. cardiac silhouette

Question 50

Arterial blood gas gives direct measurements of _______ (3).

Answer 50

1. arterial oxygen 2. CO₂ 3. pH

Question 51

\_\_\_\_\_\_\_ is essential for the assessment of interstitial lung diseases & masses.

Answer 51

CT (with contrast is excellent for pulmonary vasculature)

Question 52

Bronchoscopy allows for ______ (2)

Answer 52

1. direct visualization of airways 2. biopsy

Question 53

For respiratory c/c, ask about which conditions that run in the family (5)?

Answer 53

1. Cystic fibrosis 2. alpha 1-antitrypsin deficiency 3. asthma 4. emphysema 5. lung CA

Question 54

On physical exam, check the skin for which 2 conditions?

Answer 54

1. cyanosis 2. fingernail clubbing

Question 55

what do blood chemistries tell you about respiratory disease?

Answer 55

1. hb 2. electrolytes

Question 56

When do you send them to the ICU?

Answer 56

they have a condition that may deteriorate rapidly leading to death