Pulm #5: Pulmonary Signs & Symptoms

Front 1

Signs vs. Symptoms

Back 1

Symptoms= what patient reports (cannot tell if they are reputable). Ex: dyspnea, SOB, cough, pleuritic chest pain

Signs= what you determine on physical exam. Ex: crackles, wheezes, friction rub, cyanosis, clubbing.

Front 2

Dyspnea- Causes

Back 2

1. Increased ventilatory drive (hypoxia, pain, fever, anxiety, etc.)

2. Increased work of breathing (i.e. more difficulty in breathing --> chest wall deformity, pneumonia, obstruction, fibrosis post surgery, scleroderma)

3. Increased work needed to PERFORM breathing (neuromuscular problem, muscle deconditioning, hyperinflation or pregnancy)

Front 3

Dyspnea- What mediates it?

Back 3

1. Mechanoreceptors (stretch, irritants, etc.)
2. Chemoreceptor (medulla, carotid, aortic body)
3. Sensors in chest wall skeletal m. (muscle spindles, golgi tendons, etc.)

Front 4

Cough- purpose and process

Back 4

Purpose: protect and clear airway

Process:
-inhale to TLC
-close glottis
- contract expiratory muscles (internal intercostals)
-open glottis
-high pressure & turbulent flow shears off mucous secretion (it is expelled)

Front 5

What triggers cough?

Back 5

Irritants receptor mainly (and some others).

Coordinated by "cough center" in Medulla.

Front 6

What conditions might lead to impaired cough?

How does an endotracheal tube impair cough?

Back 6

- cord lesions (either brainstem, cervical, or even lower spinal cord)
- chest wall disorders (scoliosis, flail chest, etc.)
- vocal cord paralysis
- phrenic nerve palsy

Tracheostomy tube- doesn't allow you to generate positive pressure (can't close the glottis)

Front 7

What is hemoptysis?

What are we worried about with massive hemoptysis?

Back 7

Coughing up blood from airways (careful: could be aspirated epistaxis, oral ,and gastric sources).

Massive hemoptysis can cause stasis and clotting of blood in airways --> asphyxiation

Front 8

Pleuritic chest pain

Why do people with gallbladder problems present with chest or shoulder pain?

Back 8

Chest pain that WORSENS with INSPIRATION (arise from parietal pleura which has pain fibers).

Gallbladder inflammation puts pressure on diaphragm. Sensory signals travel up phrenic (C3,4,5) and can go to shoulder or back.

Front 9

Term for normal breath sounds?

What does a Crackle sound like?

Back 9

Normal= vesicular breath sounds

Crackle aka. Rales = velcro opening, heard over area of pathology

Front 10

What does it mean when you hear an inspiratory or expiratory crackle?

Back 10

Inspiratory = small airways snapping open

Expiratory = small airways snapping shut

Front 11

Transudative vs. Exudative fluid?

How will it sound on auscultation?

Back 11

Like fine crackles!

Transudative- low protein fluid, seen in heart failure (pulm edema). Compresses small airways.

Exudative- high protein fluid, seen in infection (pneumonia, etc.). Compresses small airways.

Front 12

What is the "spine sign" and what does it typically indicate?

Back 12

Increase in radiodensity as you go down spine (typically you should see more radiolucency as you travel down). Best seen in lateral views.

Indicates pneumonia or some sort of consolidation in lower lobe.

Front 13

What is a sign of idiopathic pulmonary fibrosis that can be picked up on CT?

Back 13

Honeycoming (scarring creating lots of cystic spaces representing thickened bronchial walls).

You can also make out network of fine white lines = fibrosis of the interstitum

Front 14

What's another word for coarse crackles? What kinds of disorders is it associated with?

Back 14

Coarse crackle = Rhonchi or lower pitched crackel.

Seen in any disease that has increased mucus (or in people whose cilia are impaired). Ex: bronchiectasis, CB, etc.

Front 15

What is a death rattle?

Why does a wheeze sound the way it does?

Back 15

Death rattle- heard in terminal patients (rhonchi that can be heared without stethoscope).

Wheeze (muscial, continuous sound- due to turbulent air flowing through narrow airway). Heard with any obstructive lung disease.

Front 16

What is stridor and when can you hear it?

Back 16

- Continuous wheeze-like sound during inspiration

- Comes from upper airway obstruction (epiglottitis, airway tumor, foreign body, angioedema, etc.)

Front 17

How can you tell the difference between a pericardial and a pleural friction rub?

Back 17

Pleural friction rub will be in time with breathing (pericardial- in time with heart beat).

Occurs when roughened/inflammed pleura scrape against each other

Front 18

What are 4 physical exam signs that can indicate consolidation?

Back 18

1. Bronchial (tubular) Breath sounds, sound hollow. Consolidated lung transmits sounds to chest surface.

2. Whispered Pectriloquy: whispering is more audble because of transmission through consolidated lung.

3. Egophony (when patient says "E" you hear "A")

4. Tactile Fremitus: vibration transmitted to chest wall (increased with consolidation, decreased with pleural effusion)

Front 19

What is clubbing?

What is Hypertrophic Pulm Osteoarthropathy?

Back 19

Clubbing: increased CT in distal phalanges (normal angle between nail and skin is lost)

HPO: proliferation of osseus tissue at end of long bone (pulmonary disease allows escape of macrophages that can reach distal phalanges and release growth factors). manifests as clubbing and painful, swollen joints.

Front 20

If you see clubbing AND HPO, what should you consider?

If you see clubbing only (in absence of HPO), what should be considering?

Back 20

Clubbing + HPO: Lung cancer, mesothelioma

Clubbing only: chronic pulmonary infection (bronchiectasis, lung abscess), interstitial lung disease

Front 21

Are you more likely to see cyanosis in a baby with polycythemia or anemia?

Back 21

More likely to see in polycythemic patients (since it has to do with insufficient amounts of deox/unsaturated hemoglobin).

More difficult to detect in anemic patients who have less RBC or less Hg to begin with.

Front 22

How can you tell the difference between EFFUSION and CONSOLIDATION on the physical exam?

Back 22

Consolidation: dull to percusion, with crackels, egophony, whispered pectriloqy and INCREASED tactile fremitus (enhanced sound transmission)

Effusion: also dull, but thin crackles, DECREASED tactile fremitus (decreased sound transmission)