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6011 Test 1 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Most Common Chief Complaints

A

Cough - cold, COPD, pneumonia, asthma allergies, GERD
SOB
Chest Pain

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2
Q

Social Determinants of Health

A 
What to do? --> Use resources!
NHLBI
American Thoracic Society
AAFP
IDSA
CDC
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3
Q

Maximizing Resilience

A

Vaccines / Infection Control / Nutrition & exercise / Management of ambient temp (ex. apartments with no AC) / Avoidance of stressors, Air quality info

Other (social order) things that help: rich community life, neighborliness, competence, self-reliance, human scale, ecological durability

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4
Q

Air Quality Numbers

A

1 - 3 Low Risk (at risk, enjoy / general, ideal)
4 - 6 Moderate Risk (at risk, consider rescheduling)
7 - 10 High Risk (at risk, reduce or reschedule / general, consider reducing or rescheduling)
10+ Very High Risk (at risk, avoid / general, reduce or reschedule)

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5
Q

Key Preventive Care Points

A
  1. Smoking: Cessation and Avoidance
  2. Exposures (past and present) to pollution, local environment, respiratory pathogens
  3. Vaccines: Influenza, Pneumovax, TB skin tests, childhood immunizations
  4. Optimal management of chronic diseases
  5. Screenings: CXR / CT in smokers / PPDs
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6
Q

When to consider a CT scan?

A

Patients 55 - 80 yo and have smoked at least a pack a day for 30 years

Smoked 2 PPD for 15 years, and are still smoking or have quit less than 15 years ago

In high risk smokers, the benefits of CT scans may be greater than the risks.

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7
Q

Pneumovax

A

65+

Smokers 19+

Cochlear implants (for damaged inner ear)

Immunocompromised adults > 2 (asplenia, sickle cell, HIV, leukemia, Hodgkin’s, Immunosuppressive therapy, renal failure, organ transplant)

2 - 64 with chronic illness, including alcoholism, chronic liver disease, cirrhosis, chronic CVD excluding HTN, chronic pulmonary disease (including asthma for those over 19), diabetes

*Chronic Illness (minus HTN)

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8
Q

Flu Vaccine

A
  • Adults with chronic pulmonary and medical conditions, immunosuppressed or morbidly obese
  • pregnant women (SHOULD get it)
  • residents of nursing homes and LT care
  • American Indian and Alaskan Natives
  • Health care workers
  • Household contacts and caregivers of kids under 5, or 50+ with medical risk for complications
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9
Q

High Risk for TB

A

Migrant works
Homeless
Nursing homes, prisons (ppl in institutions)
Nurses

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10
Q

Anxious + Chest Pain

A

PE

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11
Q

Inspiration vs. Expiration

A

1:2 1:3
Inspiration increases with fibrotic lung diseases
Expiration increases with obstruction

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12
Q

Barrel chest

A

Sign of COPD

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13
Q

Pectus Excavatum

A

Sunken appearance of chest

Usually congenital

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14
Q

Pectus Carinatum

A

Protrusion of sternum and ribs

Congenital, or after open heart surgery

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15
Q

Palpation

A

Look for unilateral changes in expansion

Focus on tenderness, expansion, fremitus, masses or lesions

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16
Q

Thoracic Expansion

A

Place hands on either side of chest at 10th rub
Looking for symmetrical movement of hands
Normal is 1 - 3 cm

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17
Q

Rib Excursion Findings

A

Symmetrically decreased (more than the normal 1-3cm) think obstructive lung diseases.

Asymmetrically decreased: pneumonia, pleural effusion, obstruction, pnemothorax (fracture)

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18
Q

Tactile Fremitus

A

Feel for lateral symmetry
Looking for increased vibration.

Increased vibration: consolidation = pneumonia

Decreased vibration: pleural effusion or pneumothorax (air outside lung prevents expansion) / COPD

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19
Q

Flatness - high pitched

A

Represents: water, fatty tissue or dense bone

Practice on thigh

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20
Q

Dullness - soft bass

A 
Fluid filled (consolidation)
Liver - 1 inch above RCM
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21
Q

Resonance - longer, louder bass

A

Air filled lung tissue

2nd right interspace

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22
Q

Tympany - musical, light

A

Air filled chamber

Puffed out cheek

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23
Q

Hyperresonance - booming bass

A

Hyperinflated lung (COPD)

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24
Q

Percussion Notes

A

Can help determine air vs. water… where pneumonia is potentially

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25
Q

Auscultation

A

Instruct patient to breath in and out of MOUTH

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26
Q

Normal Breath Sounds by location

A

Bronchial - up at neck
Vesicular - over lung area
Bronchovesicular - by sternum

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27
Q

Rhonchi

A

Snore-like, low

Bronchitus

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28
Q

Wheeze

A

Musical, high-pitched, whistling

Asthma, COPD

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29
Q

Crackles (rales) - med, fine, course

A

High to low pitched, popping
Popping open of collapsed alveoli
When you first wake up

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30
Q

Rubs

A

Walking in snow

Inflammation of pleura

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31
Q

Transmitted voice sounds

A

When you suspect consolidation (pneumonia, pleural effusion)

Have patient say “e” and what you hear is “a” over areas of consolidation

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32
Q

Egophony

A

Patient says “e” and you hear “a” over consolidation

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33
Q

Whispered Pectoriloquy

A

Patient whispers “1,2,3” - whispered voice is heard more clearly over areas of consolidation

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34
Q

Bronchophony

A

Have patient say “99” - sounds louder and clearer over areas of consolidation

35
Q

Consolidation

A

Fluid filled

36
Q

Additional tests used in primary care

A 
Pulse Oximetry - 02 sats
Spirometry and Peak Flow Meters
CXR
EKG/Echo - dyspnea
CBC - white cell count, anemia (women child bearing age) as a cause of dyspnea
Physical Exam Tests...
37
Q

Chest X-ray

A

Only do chest x-ray when it will change the results of what you do

Need signoff from radiologist

38
Q

How do you determine what tests to do on people

A

(1) Only if it will change management

(2) CT scan - if you suspect cancer

39
Q

Peak Flow Meters

A

Used most commonly in asthma
Not as sensitive as spirometers
Use in asthma at regular intervals
Measures peak flow: highest speed blowing air out of lungs
Not diagnostic!! Need PFts or spirometry to diagnose COPD

40
Q

Use Peak Flow Meters (PFM)

A

To regularly monitor lung function and response to treatment over the short and long term

To determine the severity of an asthma attack

To assess response to treatment during an attack

*Measure peak flow before/after albeuterol treatment

41
Q

Spirometry

A

Done and interpreted by pulmonologists

42
Q

Risk Factors for COPD

A

Cigarette smoke
Occupational dust / chemicals
Environmental tobacco smoke
Indoor and Outdoor air pollution

43
Q

HPI in Chronic Diseases

A

Status of illness/control. Exacerbations, use of albeuterol, hospitalizations, trips of ED

44
Q

COPD vs. Asthma

A

COPD

(1) onset in mid-life
(2) symptoms slowly progressive
(3) long smoking history

45
Q

COPD vs. Asthma

A

COPD

(1) onset in mid-life
(2) symptoms slowly progressive
(3) long smoking history

ASTHMA

(1) onset early in life
(2) symptoms vary from day to day
(3) symptoms worse at night/early morning
(4) allergy, rhinitis, and/or eczema also present
(5) family history of asthma

46
Q

Asthma

A

Patient will present with wheezing, night-time cough, exercise induced asthma, pts who recently started swimming (chlorine), roaches, smoke, pets

47
Q

Asthma - S&S

A

Intermittent breathlessness
Chest tightness
Nonproductive cough

On exam: expiratory wheezes, may have increased expiration time, accessory muscles used in breathing, increased resp rate, cyanosis, pulse ox

Airway obstruction (may be reversible)
Airway inflammation
Airway hyper-responsive to stimuli
Recurrent inflammation induces bronchospasm

48
Q

Asthma - Acute management guidelines

A 
Increased risk for mortality
3+ ED visits last year for asthma
2+ canisters of SABA per month
Recent cessation of oral steroids
Large fluctuations in peak flow
Low socioeconomic status
Mental disorder or substance abuse
SEND TO ER!!
Peak flow less than 40% predicted normal
No improvement with B2 agonist
Severe wheeze or cough
Extreme anxiety due to breathlessness
Gasping, sweaty, cyanotic
Retractions, Nasal flaring, Tripod
49
Q

COPD

A

Cough with clear sputum
Dyspnea on exertion
Worsening dyspnea

On exam: scattered inspiratory and expiratory wheezes and crackles, cyanosis, signs of right sided heart failure, I:E is 1:4 or greater

50
Q

Chronic Bronchitis

A

Productive cough

Inflammation and excess mucus

51
Q

Emphysema

A

Reduction of in expiratory airflow due to tissue destruction
Alveolar membranes break down

To make a diagnosis, you need to have spirometry

52
Q

Assessing COPD Patients

A

How well do you feel you are being treated?

Current level of patient’s symptoms
Severity of the spirometric abnormality
Frequency of exacerbations
Presence of comorbidities

53
Q

Diagnosis of COPD

A

Symptoms: shortness of breath, chronic cough, sputum

Exposure to Risk Factors: tobacco, occupation, pollution

SPIROMETRY: Required to establish diagnosis

54
Q

GOLD Guidelines

A

Used for treatment

Big change: used to rely on this - now relying on how limited is their airflow (FEV) as well as exaccerbation history, and assessment of risk factors.

55
Q

COPD co-morbidities

A

COPD patients are at increased risk for:
cardiovascular diseases (many are smokers)
Oseoporosis - steroids (often on inhaled steroids)
Respiratory infections
Anxiety and Depression (anxiety because you can’t breath / can’t do what you used to do. Chronic disease0
Diabetes - steroids
Lung cancer - inflammation, smoking, steroids
Bronchiectasis

56
Q

Cancer

A

Big risk factors: unexplained weight loss, family history, cough that doesn’t go away with treatment, night sweats, low back pain

57
Q

Common Complaints

A

Cough, Dyspnea, Chest Pain

58
Q

Cough - Timing

A

Acute < 3 weeks
Subacute 3 - 8 weeks
Chronic > 8 weeks

Red flags include dyspnea, hemoptysis, weight loss, risk for TB/HIV, wheeze, fever / night sweats

59
Q

Pneumonia

A

Consolidation of fluid, fever, tachycardia, HEENT - normal, may see erythemia if coughing a lot, look tired

ROS: General - fever, malayse
Cough, chest pain

Hx of HIV
Green sputum doesn’t tell us anything
“Oftentimes it is people who have a URI and think they are getting better - and then suddenly get worse” Feel terrible.

Tachycardia?
HEENT may be normal
Pt will look tired, terrible

Common cause in elderly is aspiration pneumonia.

60
Q

PE

A

Physical exam: could be totally normal
Searching for clots
Common cause in otherwise healthy person is trauma, casted

Chest pain, anxiety, can be totally asymptomatic

61
Q

Hemotysis

A

Coughing up blood

Most common cause is bronchitis!! (Not TB)

62
Q

Rule out Emergencies

A

Anaphylaxis: wheezing, skin rashes, edema

Acute exacerbations. CHF - chest pain, dyspnea, edema, orthopnea / Asthma - wheezing, retractions

63
Q

Croup

A

Kids have “seal” cough

64
Q

Common Outpatient Differentials: Non Critical

A

Acute - Viral URI
Chronic - smoking.

Also note: most common causes of cough in non-smokers are Post Nasal Drip (PND), Asthma, GERD

For PND look at back of throat

65
Q

Important

A

All patients presenting for a chronic cough (more than 8 weeks), undiagnosed need CXR and spirometry - could be cancer, COPD

66
Q

HPI of cough (10)

A

(1) Improving / Worsening
(2) Onset: gradual vs. sudden
(3) Duration
(4) Dry? If yes, think asthma, CHF, ACE inhibitors, GERD
(5) Productive? volume, color, color of sputum
(6) Quality: horse vs. barking?
(7) Associated symptoms
(8) Triggers / Aggravating factors
(9) Alleviating factors
(10) Impact on activity

67
Q

Acute

A

URI, Sinusitis, Pneumonia, Bronchitis, PND, exacerbation of asthma, COPD, Gerd

68
Q

Sub-acute

A

Post-viral, self limiting cough

69
Q

Chronic

A

CXR. Asthma, COPD, GERD, PND, Bronchitis

70
Q

Cough with Chest Pain…

A

Could be fracture, pneumonia (burning sensation)

71
Q

Allergic Rhinitis

A

Watery eyes, boggy turbinites, itchy eyes, rinorhea

ROS / Hx: itchying, worse when outside (such as smoke)

72
Q

Pneumonia

A

PE: Signs of consolidation. increased tactile fremetis, dullness to percussion, Rhonchi, Rails, Diminish lung sounds

73
Q

Acute Bronchitis

A

PE: < 3 months, history URI, hacking / productive cough. Course, fine crackles or rhonchi on auscultation. Wheeze also possible. Low-grade fever

74
Q

COPD Exacerbation

A

PE: clubbing, cyanosis, barrel chested, rhonci, hyper-resonance, pulse ox low

75
Q

Hemoptysis

A

True = lung

Can also be from GI, nasal, oral

76
Q

pink and frothy

A

Worry about PE!

77
Q

SOB

A

Often present as increased awareness of breathing
Can be lung, cardiac, psychological
Chronic - COPD, CHF, anemia

78
Q

Pneumothorax

A

Hx: trauma

79
Q

Costochondritis

A

Inflammation - 10% of chest pain complaints
Is pain reproducable? YES
Manage it with NSAIDs

80
Q

CT Screen

A

Do not perform CT to evaluate for possible PE in patients with a low clinical probability and negative results of a highly sensitive dimer assay

Do not perform CT screening for lung cancer among patients at low risk of lung cancer

81
Q

Anemia

A 
Menstrual History
Hemoglobin 8 or less
May hear a murmur (turbulant blood flow)
Fast bleeding ulcer
Dyspnea
82
Q

Lupus

A

Butterfly rash, elevated creatine

83
Q

PE

A

Sudden onset, sense of doom (apprehensive)
Risk includes 60+
Pulmonary HTN, CHF, CVD, CA, CVA, Venous statsis, Medications, Recent trauma or immobility, OCPs

6011 Test 1 (6 decks)

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