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78 Cards in this Set

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Role of Medical Interview
Gather data

Develop Rapport

Respond to concerns

Educate the patient
Dyspnea
- Shortness of breath

- Abnormally uncomfortable

- Awareness of breathing disproportionate to stimulus (for that individual)
How do patients describe dyspnea?
Breathlessness
Tightness
Choking
Inability to take deep breath
Suffocating
Can’t get enough air
How do you quantify the degree of dyspnea?
Threshold discrimination (e.g. walking on flat surface or incline, etc)

Scaling techniques (e.g. Borg Scale: 0-10 grading of breathing difficulty during exercise)

Validated questionnaires (British Medical Research Council Questionnaire; Pulmonary Functional Status and Dyspnea Questionnaire)
What systems cause dyspnea?
- Respiratory
- Cardiac
- Hematologic
- Metabolic
- Psychogenic
Characteristics of Dyspnea
Sudden onset (e.g. pulmonary embolism, pneumothorax, myocardial ischemia, etc)

Gradual onset (e.g. pulmonary fibrosis, lung cancer, etc.)

Rapid onset (e.g. asthma, etc.)
Paroxsymal Nocturnal Dyspnea
Wakes patient from sleep

Congestive heart failure

Chronic pulmonary disease- secondary to secretions

Respiratory sleep disorders
Orthopnea
Dyspnea on supine position

Heart failure

Chronic pulmonary disease

Diaphragm paralysis
Orthodeoxia
Fall in arterial blood oxygen on assuming the upright posture. Usually caused by right-to-left cardiac or vascular shunting with a posturally induced fall in left-sided pressure permitting a corresponding gradient across the shunt.
Trepopnea
Dyspnea on either right or left decubitus positions

Causes:
- Pleural effusion
- Airway obstruction
Platypnea
Dyspnea in the upright position

Causes:
Liver disease- may be associate with orthodeoxia
What is the most common complaint for seeking medical attention?
cough
What is the second most common reason for a general medical examination?
cough
Cough
Essential defense mechanism to protect airways from inhaled noxious substances and clear secretions
What is important to consider in a patient interview when a patient has cough?
1. Acute vs. Chronic
2. Productive vs. non-productive
3. Character
4. Time relationship
5. Type and quantity of sputum production
6. Associated features
Acute Causes of Cough
- Infectious- viral, bacterial
- Allergic or irritation to inhalant
Chronic Causes of Cough
Recurring or persistent for 3 weeks or longer

- Postnasal drip- 41%
- Asthma- 24%
- GERD- 21%
- Chronic Bronchitis- 5%
- Bronchiectasis- 4%
- Eosinophilic bronchitis
- Drugs- Angiotensin Converting Enzyme (ACE) inhibitors
- Bronchogenic Carcinoma
- Tuberculosis
Causes of Productive Cough
Inflammatory or infectious

Airway (e.g. chronic bronchitis), Nasal (sinus drainage)
Causes of Non-Productive Cough
Mechanical (e.g. pulmonary fibrosis)

Irritative stimulus (e.g. smoke inhalation, ACEI, etc)
What do you suspect if the cough is nocturnal?
asthma

GERD

Heart Failure

Bronchiectasis

Secretions
What do you suspect if the cough is related to meals?
aspiration
What do you suspect if the cough is related to exercise?
asthma
Cause of Whooping Cough
Pertussis (whooping cough)
Cause of Brassy Cough
major upper airways
Cause of Croupy Cough
laryngeal
Cause of Barking Cough
laryngeal
Foul smelling secretions suggest
anaerobic infections
abscess
Frothy secretions suggest
broncheoalveolar carcinoma
Pink foamy secretions suggest
CHF
Rust or prune-juice colored secretions suggest
Pneumococcal Pneumonia
What quantifies massive hemoptysis?
>200 ml per 24 hours
What is the etiology of hemoptysis?
Chronic bronchitis/bronchiectasis

Carcinoma

Tuberculosis
What information is important to obtain for Chest Pain?
Location

Pattern of onset (at rest, activity, etc.)

Relationship (breathing, movement, etc.)

Intensity

Radiation
Acute causes of Pleurisy
pneumothorax

pulmonary embolism

pneumococcal pneumonia
Gradual causes of Pleurisy
Tuberculosis

Carcinoma
What is pleurisy?
(location?)
(feeling?)
(exacerbators?)
Acute inflammation of the pleural surface

Localized but may radiate (e.g. diaphragm pleurisy radiating to ipsilateral shoulder or neck)

Sharp, catch, burning

Worsened with deep breath or cough or sneeze or position changes
Neuritis
(a.k.a. Radiculitis)

Inflammation of the intercostal nerves

Feels knifelike; like electric shock

Worse with deep breathing, cough, sneeze, straining

Herpes zoster (Shingles)... usually precedes rash formation
Angina Pectoris
- Ischemia of heart muscles

- Substernal pressure, constriction or squeezing
- Radiation to jaw or arm

- May have shortness of breath (pulmonary edema)

- Not related to breathing or movement
Costochondritis
Inflammation of rib joints, cartilages

Tietze’s syndrome- redness, swelling and soreness of costochondral junction

Point tenderness on palpation
Why is family history important in pulmonary patients?
Inheritable diseases (e.g. Cystic Fibrosis, alpha-1- antitrypsin deficiency, immotile cilia syndrome, immunodeficiency syndromes, etc.)

- Asthma
- Idiopathic familial pulmonary fibrosis

- Exposure to infections
If patient quit smoking 5 years ago, then...
risk of lung function decline is equal to someone who did not smoke
If patient quit smoking 10 years ago, then...
cancer risk is equal to someone who did not smoke
Social History in Pulmonary Patients
Smoking history- number of pack years cigarettes

Current smoking or quit (if so, how many years)

Smoking of recreational drugs (e.g. marijuana, crack cocaine, etc.)

Alcohol use

HIV risk factors (sexual practices, IVDA)

Exposures and allergic reactions to drugs, herbal medicine, etc.
How do you calculate pack years?
= (packs/day) * number of years
What do you worry about if patient recently traveled to SOUTHEAST?
Blastomycosis
What do you worry about if patient recently traveled to SOUTHWEST?
Coccidiomycosis
What do you worry about if patient recently traveled to OHIO RIVER BASIN?
Histoplasmosis
Occupational/ Environmental History in Pulmonary Patients
Exposure to substances at work

Symptoms related to work (e.g. occupational asthma)

Other workers involved or affected

Travel history

Hobbies (e.g. cave exploring, pet birds, etc.)
What past history is important in pulmonary patients?
Previous illness that may reactivate (e.g. TB)

Previous radiographs- very helpful for lung nodules
In a pulmonary exam inspection, what do you look for?
Overall well-being (e.g. cachexia, obesity, etc.)

Nicotine stains- clothes, fingernails

Cyanosis, pallor, jaundice

Smell- nicotine, lung abscess, gingivitis

Chest -kyphoscoliosis, pectus carinatum, pectus excavatum, ankylosing spondylitis, surgical scars
pectus carinatum
lattening of the chest on either side with forward projection of the sternum resembling the keel of a boat.

Syn: chicken breast, keeled chest, pigeon breast, pigeon chest
pectus excavatum
A hollow at the lower part of the chest caused by a backward displacement of the xiphoid cartilage.

Syn: foveated chest, funnel chest, funnel breast, koilosternia, pectus recurvatum, trichterbrust
Tachypnea
rapid shallow breathing
Kussmaul's
rapid deep breathing (air hunger)
Cheyne-Stokes
rhythmic crescendo-decrescendo with periods of apnea

- typical of patients with CHF and cardiomyopathies... deals with stretch receptors and neural signals
Biots
irregular breaths with periods of apnea
What do you look for with breathing patterns?
1. Tachypnea
2. Kussmaul’s
3. Cheyne-Stokes
4. Biot’s
5. Snoring with paradoxic movements of chest wall
6. Accessory muscle use
Palpation in Pulmonary Exam
Trachea- midline deviation

Thyroid and neck mass

Chest wall lag- diaphragm paralysis, pleural effusion

Fremitus- increase (consolidation) vs. decrease (pleural fluid)
Percussion in Pulmonary Exam
Dullness- fluid, consolidation

Hyper-resonant- hyperinflation (asthma, emphysema, pneumothorax)

Help determine fluid level for thoracentesis
Crackles
(a.k.a. rales)
Opening of small airways

Fine (fibrosis, scar)

Coarse (fluid, secretions)
Egophony
High pitch secondary to consolidation

Bronchophony

Pectriloquy
Wheezing
Continuous, high pitch

Fluttering of narrow airway walls
Rhonchus
Continuous Snoring sound

Low-pitched
Normal Breath Sounds
Peripheral small airways

Prominent inspiration
Bronchial Breath Sounds
Proximal larger airways

Loud, high pitch, tubular

Consolidation if heard peripherally in airways

Expiration louder or as loud as inspiration
Stridor
Upper airway narrowing

Inflammatory (laryngeal edema)

Fixed (tracheal stenosis)
Pleural Friction Rub
Pleura rubbing caused by thickened pleura

Inflammatory, malignancy

Leathery, creaking quality

Both inspiration and expiration

Possible even with pleural effusion
Mediastinal crunch
Pulmonary Auscultation

Pneumo-mediastinum

Synchronous with cardiac cycle (instead of respiratory cycle)
Acute Bronchial Asthma Attack
(Inspection, Palpation, Percussion, Auscultation)
Inspection: Hyperinflation; use of accessory muscles

Palpation: Impaired expansion; decreased fremitus

Percussion: Hyperresonance; low diaphargm

Auscultation: Prolonged expiration; inspiratory and expiratory wheezes
Complete Pneumothorax
(Inspection, Palpation, Percussion, Auscultation)
Inspection: Lag on affected side

Palpation: Absent fremitus

Percussion: Hyperresonant or tympanitic

Auscultation: Absent breath sounds
Large Pleural Effusion
(Inspection, Palpation, Percussion, Auscultation)
Inspection: Lag on affected side

Palpation: Decreased fremitus; trachea and heart shifted away from affected side

Percussion: Dullness or flatness

Auscultation: Absent breath sounds
Atelectasis... Lobar Obstruction
(Inspection, Palpation, Percussion, Auscultation)
Inspection: Lag on affected side

Palpation: Decreased fremitus; trachea and heart shifted away from affected side

Percussion: Dullness or flatness

Auscultation: Absent breath sounds
Consolidation... Pneumonia
(Inspection, Palpation, Percussion, Auscultation)
Inspection: Possible lag or splinting on affected side

Palpation: Increased fremitus

Percussion: Dullness

Auscultation: Bronchial breath sounds, bronchophony, pectoriloquy, crackles
Clubbing
Softening and erythema of periungal nail beds (floating)

Decrease of normal 15 degree angle of nail with cuticle

Enlargement of distal phalanx

Curvature of nails

May be associated with hypertrophic osteoarthropathy

Bronchogenic CA, chronic hypoxemia, chronic bronchiectasis (Cystic Fibrosis)
hypertrophic pulmonary osteoarthropathy
expansion of the distal ends, or the entire shafts, of the long bones, sometimes with erosions of the articular cartilages and thickening and villous proliferation of the synovial membranes, and frequently clubbing of fingers; the disorder occurs in some chronic pulmonary diseases, in heart disease (most often congenital), and occasionally in other acute and chronic disorders
exophthalmos seen with lung disease
Wegner's granulomatosis
uveitis seen with lung disease
sarcoidosis

ankylosing spondylitis
keratoconjunctivitis sicca seen with lung disease
sjogren's syndrome