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respiratory pt 1 Flashcards

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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
What will cause abnormalities in voice transmission tests?
Consolidation
26
What are the three types of vocal transmission test?
- vocal fremitis: pt says '99' or 'E' and it sounds muffled - whispered pectoriloquy - '99' transmits well - egophony - most sensitive; 'E' transmits as 'A'
27
What lab tests might be employed with respiratory issues?
``` CBC CMP Blood arterial gases Sputum culture TB testing ```
28
What are two useful in-office tests?
- 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%)
29
What can be ascertained by a pulmonologist running PFTs?
- 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
30
What is COPD?
Condition of reduced expiration flow; forced emptying of the lungs. Lungs are hyperinflated, hyperreflexive. And the condition is only minimally reversible with bronchodilators.
31
What is the #1 cause of COPD?
Cigarettes - up to 90% of deaths
32
What is missing with inheritable COPD?
alpha-1-antitrypsin
33
What are the s/sx of general COPD?
- dyspnea (worse on ecxertion) - chronic, productive cough - wheezing - cyanosis - clubbing - barrel chest
34
Which lung conditions have a productive cough
- chronic bronchitis - bronchiectasis - CF
35
What are the most important work-up considerations with COPD?
- PFT - CXR - pulse ox
36
What are the two forms of COPD?
emphysema and chronic bronchitis (many patients have both)
37
During which age ranges are the presentations likely for emphysema, AAT deficiency, chronic bronchitis, and asthma?
- emphysema: 50+ - AAT: 32-41 - chronic bronchitis: late 30s and 40s - asthma: 2-20 or over 40
38
What is emphysema?
permanent enlargement of alveolar ducts and sacs distal to terminal bronchioles with fibrosis and lack of recoil. it is a gradual progression.
39
Why might patients with AAT deficiency not complain of SOB?
They will have decreased their activity level so as not to induce it.
40
What is the classical presentation of someone with emphysema?
- pink puffer: dyspnea on mild exertion, cyanosis at rest - finger clubbing - cough is RARE - mucus is scant and clear
41
What would you expect to find on PE of someone with emphysema?
- 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
What are the lab results expected with emphysema?
normal Hgb, normal to reduced Pa02 and PaCO2
43
How will either form of COPD present on a PFT?
reduced FEV1
44
What is chronic bronchitis?
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
What is the classical presentation of someone with chronic bronchitis?
- blue bloater: cyanosis and edema. - chronic productive cough (worse in AM) - frequent infections - mild dyspnea - mucopurulent sputum
46
What would you expect to find on PE of someone with chronic bronchitis?
- 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
How does chronic bronchitis progress?
- shorter intervals between acute exacerbations - cor pulmonale - respiratory failure
48
What are some ddx for COPD?
``` central airway stenosis bronchiectasis heart failure CF bronchiolitis ```
49
What is asthma and what separates it from COPD?
episodes of wide-spread broncho-constriction and dyspnea with underlying inflammation. difference is that it's much more reversible with bronchodilators
50
What are the three main features of asthma?
- airway obstruction (episodic and reversible): tightened airways cause wheezing - inflammation: red, swollen bronchial tubes - airway irritability: overreaction to triggers
51
What are common asthamtic triggers?
- 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
What are the two classifications of asthma?
extrinsic (allergic): inhaled allergens, meds, foods, animals intrinsic (non-allergic): URI, LRI, emotion, exercise, cold weather
53
How would a pt present upon PE during an asthma attack?
- respiratory distress - anxiousness - can't speak in full sentences
54
What is pulsus paradoxus?
Pulse rate slowing during inspiration. There's a decreased cardiac return b/c of hyperinflation
55
Why check the skin of an asthmatic?
looking for manifestations of allergic skin conditions. will not find fingernail clubbing
56
What will be the findings of lung auscultation on an asthmatic?
prolonged expiration with wheezing (high pitched and polyphonic due to a number of different sized airways being obstructed)
57
What might you look for with inspiratory wheezing or stridor?
upper airway obstruction - thyroid enlargement, tumor, vocal cord issues
58
What are the ominous clinical signs during an asthma attack?
- change in affect - inability to speak or drink - dorwsiness/confusion - cyanosis
59
What is status asthmaticus?
prolonged attack unresponsive to bronchodilator tx. could be fatal.
60
What are some ddx for asthma?
COPD, bronchiectasis, CF, eosinophilic pneumonia, vocal cord paralysis
61
Why clarify when asthma attacks occur?
Narrow down the irritant. Could be occupational.
62
What is bronchiectasis?
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
How is bronchiectasis commonly mis-diagnosed?
asthma or pneumnia
64
What are possible etiologies of bronchiectasis?
``` congenital bronchial obstruction immunodeficiency (IgG, IgA, HIV) various infxs (H. flu, pseudomonas) ```
65
What other conditions are associated with bronchiectasis?
smoking, toxic inhalation, rheumatic dz (RA, sjogren's), IBD, AAT deficiency
66
What are the common s/sxs of bronchiectasis?
- chronic, productive daily cough - dyspnea - wheezing - sputum mucopurulent and tenacious - chronic fatigue - rhinosinusitis - hemoptysis
67
What might you find on PE of a pt with bronchiectasis?
non-specific findings: | fever w/ acute infx, weight loss, crackles, wheezes, rhonchi, cyanosis, nasal polyps
68
How do yo really differentiate bronchiectasis from COPD?
Imaging...chest HRCT will reveal the bronchial wall thickening and luminal dilation.
69
What is cystic fibrosis?
chronic progressive d/o of excessively thick mucus production due to CTFR gene defect (problem with Cl, Na transport)
70
What conditions may develop with CF progression?
chronic bronchitis with or without bronchiectasis
71
What are the multi-system findings with CF?
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
What is the standard dx test for CF?
sweat test (checking chloride levels) can also do genetic test for CTFR
73
What might PE reveal in pts with CF (multi-system)?
nose: polyps pulmonary: tachypnea, wheezes/crackles, cough, barrel chest GI: abdominal distention, hepatosplenomegaly other: dry skin, cheilosis, kyphosis, scoliosis

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