[03.01] CMD - Approach to Adult Patients with Respiratory Symptoms V2.1.pdf

Asthma, COPD, Bronchiectasis

What are examples of obstructive airway disease?

Idiopathic pulmonary fibrosis IPF, Asbestosis, Sarcoidosis, Pulmonary edema

What are examples of restrictive parenchymal disease?

Amyotrophic Lateral Sclerosis ALS, Guillain-Barre syndrome GBS, Myasthenia Gravis MG

What are examples of restrictive neuromuscular weakness respiratory disease?

Kyphoscoliosis, Ankylosing spondylitis, Pleural effusion, Pneumothorax, Obesity

What are examples of restrictive chest wall or pleural disease?

Pulmonary embolism, Vasculitis, Pulmonary arterial hypertension PAH, Pulmonary veno-occlusive disease PVD

What are examples of pulmonary vascular disease?

Bronchogenic carcinoma, Metastatic disease

What are examples of respiratory malignancy?

Pneumonia, Tuberculosis, Bronchitis

What are examples of respiratory infectious diseases?

Malignancy and infectious diseases

Which respiratory disease categories can present with either an obstructive or restrictive physiology?

Hypoxemic and hypercarbic

What are the two major categories of respiratory diseases based on gas exchange dysfunctions?

Altitude reduced PiO2

What is an example and mechanism of hypoxemia caused by decreased inspired O2 concentration?

COPD, Obesity hypoventilation

What are examples of hypoxemia caused by alveolar hypoventilation?

Interstitial pneumonitis

What is an example of hypoxemia caused by a diffusion defect?

Pulmonary embolism, COPD, ARDS

What are examples of hypoxemia caused by ventilation-perfusion mismatch?

Atelectasis, ASD with right-to-left shunt

What are examples of hypoxemia caused by shunt?

Drug overdose, brainstem injury, severe hypothyroidism, sleep-disordered breathing

What are central nervous system causes of hypercarbic gas exchange dysfunction?

Impaired neuromuscular transmission, respiratory muscle weakness

What are neuromuscular dysfunction categories that lead to hypercarbic gas exchange dysfunction?

Myasthenia Gravis, Guillain-Barre Syndrome, Amyotrophic Lateral Sclerosis

What are examples of impaired neuromuscular transmission causing hypercapnia?

Myopathy, electrolyte derangements

What are examples of respiratory muscle weakness causing hypercapnia?

Resistive loads

What is the mechanism of increased airway load during bronchospasm?

Alveolar edema, atelectasis

What are examples of reduced lung compliance causing increased load?

Pneumothorax, pleural effusion, abdominal distention

What are examples of reduced chest wall compliance causing increased load?

Pulmonary embolus

What can cause increased minute ventilation requirements leading to increased airway load?

They can co-exist or happen at the same time

Are the causes of hypoxemia independent or can they co-exist?

Diagnose the underlying cause of hypoxemia

What is required to address hypoxemia efficiently?

History, Physical Exam, Diagnostic Examinations

What are the three main components of the approach to a patient presenting with respiratory symptoms?

Dyspnea, Cough, Hemoptysis, Chest pain

What are the four common presenting symptoms or complaints of respiratory patients?

Allergy, tuberculosis, asthma, COPD, heart disease

Which prior and current medical problems are particularly important to elicit during history taking?

Higher predilection to developing an asthma exacerbation in adulthood

What is the clinical significance of a history of childhood allergies or asthma?

They may have lung lesions or fibrosis that could develop bronchiectasis and result with exacerbation later

What is the long-term respiratory consequence of a past tuberculosis infection?

Metastasize to the lungs

What is the significance of a non-lung malignancy such as breast or colon carcinoma in a respiratory patient?

Pancreatic carcinoma

Which non-lung malignancy increases the risk for venous thromboembolism VTE and pulmonary embolism PE?

Interstitial lung disease, aspiration pneumonia from esophageal involvement, or pulmonary vascular disease

What respiratory complications are associated with connective tissue diseases like systemic sclerosis or scleroderma?

Pulmonary complications

What often serves as the initial presentation of AIDS in patients with HIV?

Autoimmune diseases on chronic steroids or immunomodulating drugs, hematologic malignancy, prior chemotherapy

What are causes of immunodeficiency other than HIV that increase likelihood of infectious respiratory symptoms?

Beta blockers and ACE inhibitors

Which medications in the patient history may cause cough or bronchospasms?

Prior chest imaging such as X-ray, CT scan, ultrasound

What should always be asked for in outpatient clinics to serve as a point of comparison?

Help determine if there is progression or improvement in patient symptoms

What is the purpose of comparing current chest imaging with previous scans?

Cigarette smoking

What is the number one modifiable risk factor for a lot of lung diseases?

Pack years equals number of packs in a day times number of years of smoking

What is the equation used to compute smoking pack-years?

Silicosis or asbestosis

What occupational lung diseases can develop from working in mines or factories with toxic inhalants?

Sexual history

What should be asked in patients with high-risk behavior to check for infections or immunodeficiencies?

Cystic fibrosis, A1 antitrypsin deficiency, asthma, lung cancer, COPD

What are heritable diseases of the lungs that should be noted in family history?

Pulmonary Tuberculosis and pneumonia

What infections should be asked about regarding exposure in family history?

General survey, Vital signs, Inspection, Palpation, Percussion, Auscultation

What are the six sequential parts of a thorough respiratory physical examination?

Rate, rhythm, depth, and effort of breathing

What elements of breathing are evaluated during inspection?

Retractions and use of accessory muscles

What physical signs of increased breathing effort are checked during inspection?

Asymmetry and whether the trachea is midline

What chest and neck alignments are assessed during inspection?

Cyanosis, clubbing, edema

What should extremities be checked for during inspection of patients with chronic respiratory symptoms?

Areas of tenderness, deformity, palpable lymph nodes

What structures and signs are assessed during palpation of the chest?

Chest lag

What term describes the expansion and asymmetry of chest wall movement during palpation?

Tactile fremitus

What term describes the palpable vibrations transmitted through the bronchopulmonary system when the patient speaks?

Normal, dull, hyper-resonant

What are the three possible percussion notes of the lung?

Diaphragmatic excursion

What is the term for the movement of the thoracic diaphragm during breathing as measured by percussion?

3 to 5 cm

What is the normal value NV range for diaphragmatic excursion?

Vesicular, bronchovesicular, bronchial, tracheal

What are the four normal breath sounds heard on auscultation?

Vocal fremiti, bronchophony, whispered pectoriloquy, egophony

What are the transmitted voice sounds evaluated during auscultation?

Tachypnea

What is the term for an elevated respiratory rate greater than 20 breaths per minute?

Greater than 20

What respiratory rate defines tachypnea?

Bradypnea

What is the term for a decreased respiratory rate less than 12 breaths per minute?

Less than 12

What respiratory rate defines bradypnea?

Apnea

What is the term for the temporary cessation of breathing?

Hypopnea

What is the term for depressed or shallow breathing?

Hyperpnea

What is the term for deep breathing?

Clear and nothing obstructing the patient breathing

What are the auscultation characteristics of normal bronchovesicular breath sounds?

Wheezing

What abnormal breath sound is musical and high-pitched?

Crackles

What abnormal breath sound is described as sounding like popcorn or crumpling paper?

Discontinuous, intermittent, non-musical popping sounds

What are crackles?

Air is forced through respiratory passages narrowed by fluid, mucus, or pus

How are crackles created?

On inspiration or expiration

When during the respiratory cycle can crackles be heard?

High-pitched whistling sounds with musical quality

What is the description of wheezing?

Continuous

Are wheezes continuous or discontinuous compared to crackles?

COPD and asthma

What are two common airway narrowing conditions that cause wheezing?

Continuous sounds lower in pitch than wheezes with a snoring quality

What are rhonchi?

Airway secretions and airway narrowing in medium-sized airways

What causes rhonchi?

Clears after coughing or tapping the back

What is a key distinguishing behavior of rhonchi that signifies their location in medium-sized airways?

Wheeze-like sound heard when a person inhales, audible without a stethoscope

What is stridor?

Over the neck

Where is stridor usually heard?

Blockage of airflow in the trachea or back of the throat larger airways

What is the usual cause of stridor?

Respiratory distress requiring immediate attention or emergency

What does the presence of stridor signify?

Normal lung findings

Which respiratory pathology has no lesions on inspection, normal fremitus, resonant percussion, and vesicular breath sounds?

Bronchial Asthma or COPD

Which respiratory pathology presents with chest hyperinflation, accessory muscle use, impaired excursion, low diaphragm, hyperresonance, prolonged expiration, and wheezing?

Hyperinflation barrel-chested

What is the classic inspection finding in bronchial asthma or COPD?

Impaired excursion due to hyperaeration and difficulty to exhale

What is the classic palpation finding in bronchial asthma or COPD?

Normal to decreased fremitus

What is the tactile fremitus finding in bronchial asthma or COPD?

Hyperresonance and low diaphragm

What are the percussion findings in bronchial asthma or COPD?

Prolonged expiration and wheezing

What are the auscultatory findings in bronchial asthma or COPD?

Pneumothorax findings

Which pathology presents with chest lag on the affected side, increased size of hemithorax, absent fremitus, hyperresonant or tympanitic percussion, and absent breath sounds?

Absent fremitus on the affected side

What is the palpation finding in a pneumothorax?

Hyperresonant or tympanitic

What is the percussion finding in a pneumothorax?

Absent breath sounds

What is the auscultation finding in a pneumothorax?

Pleural Effusion findings

Which pathology presents with lag on the affected side, increased size of hemithorax, decreased fremitus, mediastinal shift away from the pathology, dullness/flatness, and absent breath sounds?

Decreased fremitus and mediastinal shift away from pathology

What are the palpation findings in a pleural effusion?

Dullness or flatness

What percussion finding differentiates a pleural effusion from a pneumothorax?

Absent breath sounds

What is the auscultation finding in a pleural effusion?

Consolidation or Atelectasis with blocked airway

Which respiratory pathology presents with lag on the affected side, decreased fremitus, mediastinal shift towards the pathology, dullness/flatness, and absent breath sounds?

Decreased fremitus and mediastinal shift towards the pathology

What are the palpation findings in consolidation or atelectasis with a blocked airway?

Consolidation or Atelectasis with patent airway

Which respiratory pathology presents with possible lag or splinting, increased fremitus on the affected side, dullness, bronchial breath sounds, bronchophony, egophony, pectoriloquy, and crackles?

Increased fremitus on the affected side

What is the palpation finding in consolidation or atelectasis with a patent airway?

Bronchial breath sounds, bronchophony, egophony, pectoriloquy, crackles

What are the auscultation findings in consolidation or atelectasis with a patent airway?

Systemic diseases

What are interstitial lung diseases usually associated with?