Clinical Assessment and Cardiopulmonary Interviewing (Video Notes)

VOCABULARY flashcards covering key terms and concepts from the notes.

Clinical assessment

Process used by clinicians to gather information and interpret data to guide therapy decisions.

Bedside assessment

Interviewing and examining a patient at the bedside to identify signs and symptoms of disease.

Sign

An objective manifestation of illness observed by the clinician.

Medical history

Past illnesses, medications, allergies, and other information used to assess the current condition.

Physical examination

Systematic evaluation of the patient to identify signs of disease.

Differential diagnosis

Process of distinguishing among diseases with similar signs and symptoms.

Diagnosis

Identification of the nature and cause of a patient’s illness.

Interview

Structured process of obtaining essential information for diagnosis and monitoring.

Rapport

Positive, trusting relationship between clinician and patient facilitating communication.

Verbal communication

Information conveyed through spoken language during the interview.

Nonverbal communication

Information conveyed through body language, facial expressions, and tone.

Social space

The distant interviewing space (~4–12 feet) used at first contact.

Personal space

Closer interview space (~2–4 feet) used for conversation.

Neutral questions

Questions designed to avoid leading the patient to a particular answer.

Onset

The time at which a symptom first began.

Severity

Intensity or degree of a symptom, often rated 1–10.

Localization

The specific body area where a symptom is felt.

Aggravating factors

Factors that worsen a symptom.

Alleviating factors

Factors that ease or relieve a symptom.

Prior episodes

Whether the symptom has occurred before and its typical duration.

Dyspnea

The subjective sensation of breathing discomfort.

Breathlessness

Sensation of an unpleasant urge to breathe.

Borg scale

A numerical scale (0–10) used to rate dyspnea severity.

Orthopnea

Dyspnea that occurs when lying flat, often in heart failure.

Platypnea

Dyspnea that occurs when moving to an upright position.

Orthodeoxia

Oxygen desaturation that accompanies upright posture.

Trepopnea

Dyspnea relieved by lying on one side; often with CHF or effusion.

Chest tightness

Sensation commonly described by asthma and other airway diseases.

Work of breathing (won)

The effort required to breathe; reflects respiratory load.

Psychogenic dyspnea

Dyspnea arising from anxiety or panic with otherwise normal function.

Panic disorder

Anxiety disorder with recurrent panic attacks.

Hyperventilation syndrome

Hyperventilation with dyspnea, often with normal cardiopulmonary function.

Cough

Reflex to clear airways due to irritation or inflammation.

Upper airway cough syndrome

Chronic cough due to postnasal drip from the upper airway.

ACE-inhibitor cough

Cough caused by ACE inhibitors.

Sputum

Mucus from lower airways expelled through the mouth.

Phlegm

Mucus from the respiratory tract not contaminated by oral secretions.

Purulent sputum

Sputum containing pus cells.

Fetid sputum

Foul-smelling sputum.

Pleuritic chest pain

Sharp chest pain that worsens with deep breathing; often with pneumonia or PE.

Nonpleuritic chest pain

Chest pain centered in the chest not affected by breathing; may be angina or GERD.

Level of consciousness

Overall mental status; awareness and responsiveness.

Confused

Disoriented or unclear thinking and awareness.

Delirious

Acute, fluctuating confusion and altered consciousness.

Lethargic

Drowsy or sluggish with reduced alertness.

Obtunded

Diminished alertness; difficult to arouse.

Stuporous

Semi-conscious, difficult to awaken.

Comatose

Unresponsive to stimuli; unconscious.

Vital signs

Four main measurements to assess health: temperature, pulse, respirations, and blood pressure.

Temperature

Body temperature; normal ~98.6°F (37°C); can be hyperthermic or hypothermic.

Hyperthermia

Elevated body temperature (fever or heat illness).

Hypothermia

Abnormally low body temperature.

Tachycardia

Heart rate greater than 100 beats per minute.

Bradycardia

Heart rate less than 60 beats per minute.

Pulsus paradoxus

Drop in systolic BP >10 mm Hg during inspiration; seen in severe asthma.

Pulsus alternans

Alternating strong and weak pulses; indicates left-sided heart failure.

Respiratory rate

Number of breaths per minute; normal ~12–20.

Tachypnea

Rapid breathing.

Bradypnea

Slow breathing.

Blood pressure

Systolic pressure during heart contraction and diastolic pressure during relaxation.

Systolic

Peak arterial pressure during ventricular contraction.

Diastolic

Arterial pressure during ventricular relaxation.

Pulse pressure

Difference between systolic and diastolic pressures; normal ~30–40 mmHg.

Hypertension

Persistently elevated blood pressure (BP >140/90).

Hypotension

Low blood pressure (systolic <90 mmHg or MAP <65 mmHg).

Shock

Inadequate delivery of O2 and nutrients to vital organs; require fluids, blood products, or vasoactive drugs.

Cardiogenic shock

Shock due to failure of the heart to pump effectively.

Hypovolemic shock

Shock due to a large loss of blood or fluids.

Septic shock

Shock due to severe infection causing systemic inflammation and hypotension.

Anaphylaxis

Severe, life-threatening allergic reaction leading to shock and airway compromise.

Postural hypotension

Orthostatic drop in blood pressure on standing.

Syncope

Transient loss of consciousness due to temporary cerebral hypoperfusion.

Apnea

No breathing.

Apneustic breathing

Deep, gasping inspiration with brief expiration; brainstem involvement.

Ataxic breathing

Completely irregular breathing with variable pauses.

Asthmatic breathing

Prolonged exhalation with abdominal recruitment.

Biot respiration

Clustered rapid breaths with periods of apnea; brain injury.

Cheyne-Stokes respiration

Oscillating breathing pattern with gradual rise/fall and apnea; often with brain injury or CHF.

Kussmaul breathing

Deep, rapid breathing due to metabolic acidosis.

Paradoxical breathing

Abdominal or chest wall movements opposite to normal during respiration.

Period periodic breathing

Oscillation between rapid/deep and slow/shallow breathing without apnea.

Tracheal breath sounds

Loud sounds heard over the trachea with prominent expiratory component.

Bronchovesicular breath sounds

Medium-pitched sounds heard near the sternum; between vesicular and bronchial.

Vesicular breath sounds

Soft, low-pitched sounds heard over healthy lung parenchyma.

Adventitious breath sounds

Abnormal lung sounds, including crackles and wheezes.

Crackles

Intermittent, discontinuous lung sounds; may be fine or coarse.

Fine crackles

Rales heard with opening of small airways; seen in fibrosis and atelectasis.

Coarse crackles

Rales due to movement of secretions; often cleared by coughing.

Wheezes

Continuous high-pitched sounds indicating airway obstruction.

Monophonic wheeze

Wheeze from a single obstructed airway.

Polyphonic wheeze

Wheezes from multiple airways involved.

Auscultation

Listening to lung sounds to assess the condition of the airways and lungs.

Normal breath sounds

Vesicular sounds typical of healthy lungs.