05.31-Lung-History-and-Physical-Examination.pdf

Dyspnea, Cough, Hemoptysis, Chest Pain

Name two clinical manifestations of respiratory disorders discussed.

General Considerations, Inspection, Palpation, Percussion, Auscultation

Name two components of the Physical Examination section.

Uncomfortable awareness of breathing

What is the non-painful description of dyspnea?

Inappropriate to the level of exertion

What condition must be met for an uncomfortable awareness of breathing to be classified as dyspnea?

Expected physiological response

What is running for several kilometers and feeling difficulty of breathing classified as, distinguishing it from dyspnea?

Cardiac or pulmonary disease

Dyspnea commonly results from which two types of disease?

Symptom

How is dyspnea classified when perceived by the patient?

Sign

How is dyspnea classified when observed by the physician?

Abnormalities of gas exchange and Increased work of breathing

What are the two general physiological responses that increase ventilation and cause dyspnea?

Decreased oxygenation, hypoventilation, hyperventilation

Name two abnormalities of gas exchange that cause dyspnea.

Anxiety

Besides changes in respiratory mechanics, what other factor increases the work of breathing, leading to dyspnea?

Paresthesias

What sensation (tingling or "pins and needles") may anxious patients present with around the lips or extremities due to dyspnea?

Efferent (outgoing) and Afferent (incoming)

What two signal types interact in the pathophysiology of dyspnea?

Motor output from the brain to the ventilatory muscles

What defines the efferent signal (feed-forward) in dyspnea pathophysiology?

Sensory input from receptors throughout the body

What defines the afferent signal (feedback) in dyspnea pathophysiology?

Sensory cortex

Afferent information from respiratory receptors projects directly to which part of the brain to contribute to primary qualitative sensory experiences?

Corollary discharge

What signal does the motor cortex send to the sensory cortex (feed-forward) alongside the neural messages to the ventilatory muscles?

Error signal

What is generated if the feed-forward and feedback messages do not match, increasing the intensity of dyspnea?

Brainstem and sensory cortex

To what two areas are signals of chest tightness, generated by vagal irritants/receptors, transmitted?

Decreased FiO2(Hypoxemia)

What mechanism involves decreased oxygen concentration in inspired air?

Airway obstruction

What mechanism involves part of the airway being blocked?

Larynx and Trachea

What two upper airway structures, when obstructed, can cause dyspnea?

Infections, angioedema, trauma, foreign body, tumors of the neck

Name two causes of airway obstruction in the Larynx and Trachea.

Bronchi and Bronchioles

What two lower airway structures, when obstructed, can cause dyspnea?

Bronchitis, asthma, extensive bronchiectasis, bronchial stenosis, retrosternal goiter, aspirated foreign body

Name two causes of airway obstruction in the Bronchi and Bronchioles.

Alveolar filling, Mechanically compressed, Alveolar distraction

What are the three categories of abnormal alveoli that cause dyspnea?

Blood, pus, or fluid

What substances can fill the alveolar sac causing dyspnea?

Pulmonary edema, pulmonary infiltrations (pneumonia, carcinoma), pulmonary hemorrhage

Name two causes of alveolar filling.

Atelectasis, pneumothorax, hydrothorax

Name two conditions that cause dyspnea by mechanically compressing the alveoli.

Fibrosis

What condition causes dyspnea by alveolar distraction?

Restrictive chest and lung disease

What dyspnea mechanism involves paralysis of respiratory muscles or thoracic deformities?

Kyphoscoliosis

What thoracic deformity can cause dyspnea via restrictive chest and lung disease?

Scleroderma of the thoracic wall

What skin/tissue condition can cause dyspnea via restrictive chest and lung disease?

Abnormal pulmonary circulation

What dyspnea mechanism is associated with problems with blood vessels?

Pulmonary thromboemboli and infarction

What circulatory problem can cause dyspnea?

Anemia

What condition associated with oxyhemoglobin deficiency can cause dyspnea?

Carbon monoxide poisoning (Carboxyhemoglobinemia)

What poisoning causes dyspnea via oxyhemoglobin deficiency?

Methemeglobineamia

What blood condition causes dyspnea via oxyhemoglobin deficiency?

Hyperventilation syndrome

What abnormal respiratory stimulus associated with panic attacks can cause dyspnea?

Increased intracranial pressure, metabolic acidosis

What two conditions can lead to secondary respiratory alkalosis, causing dyspnea via abnormal respiratory stimuli?

Sudden paroxysms of breathlessness

What defines Paroxysmal Dyspnea?

Transient increase in pulmonary capillary pressure

What physiological event is associated with Paroxysmal Dyspnea?

Redistribution of fluid from edematous extremities to the lungs with recumbency

What fluid change contributes to Paroxysmal Dyspnea?

Paroxysmal nocturnal dyspnea (PND)

What subtype of dyspnea occurs at night, interrupting sleep and inducing suffocation?

Bronchodilators

PND is resolved when the patient sits up but does not respond to which class of drugs?

Nocturnal Asthma

What condition responds to bronchodilators but is not affected by any change in position, distinguishing it from PND?

Orthopnea

What subtype of dyspnea occurs when lying flat, leading the patient to elevate their head and chest?

Entire duration

How long is breathlessness felt in Orthopnea, distinguishing it from the transient attacks of PND?

Obesity or ascites

What two conditions can lead to elevation of the diaphragm, contributing to Orthopnea?

Pillows

What item is counted when eliciting the degree of Orthopnea from a patient?

“3-4 pillow orthopnea”

How is the assessment reported if the patient uses 3-4 pillows while sleeping?

COPD – Emphysema

What is the impression for a 52/M smoker with progressive dyspnea and CXR showing hyperinflated lungs and a downward diaphragm?

Hyperlucency

What X-ray feature is observed in COPD-Emphysema due to hyperinflation?

Pneumothorax

What is the impression for a 19/M with sudden dyspnea after lifting weights, and CXR showing a collapsed right lung?

Lesser area for oxygenation

What causes the dyspnea in the case of Pneumothorax?

Pulmonary congestion with acute MI

What is the impression for a 52/M, hypertensive, diabetic, with sudden dyspnea, chest pain, and orthopnea, and CXR showing hazy infiltrates?

White, bilateral, fluffy, perihilar congestion

What are the clues on CXR for Pulmonary congestion with acute MI?

Pleural Effusion

What is the impression for a 45/M with progressive dyspnea, weight loss, and afternoon fever, and CXR showing a white pointed portion?

Meniscus sign

What is the name of the white pointed portion observed on the CXR of a pleural effusion?

TB

What is the likely etiology of the fluid in a Pleural Effusion associated with weight loss and afternoon fever?

Reflex response

What classification is given to cough?

Larynx, trachea, or large bronchi

What receptors, when irritated, initiate the cough reflex?

Preliminary inspiration, Glottal closure and contraction of respiratory muscles, Sudden glottal opening

What are the three stages of coughing?

Vagus

What nerve transmits sensory signals from the larynx, trachea, pleura, and stomach to the cough center?

Nucleus tractus solitarius

What region of the brainstem contains the “cough center” in the medulla?

CNS cortical modulation

What allows for voluntary coughing even without activation by irritation?

Spinal motor nerve

What nerve transmits efferent signals from the cough center to the expiratory muscles and pelvic sphincters?

Phrenic nerve

What nerve transmits efferent signals from the cough center to the diaphragm?

Accidentally urinate

What consequence results from efferent signals traveling to the pelvic sphincters via the spinal motor nerve during coughing?

< 3 weeks

What is the duration for Acute Cough?

Acute RTI, Acute exacerbation of COPD, pneumonia, and pulmonary embolism

Name two most common causes of Acute Cough.

3 to 8 weeks

What is the duration for Subacute Cough?

Post-infectious cough, bacterial sinusitis, asthma

Name two possible causes of Subacute Cough.

8 weeks

What is the duration for Chronic Cough?

Tuberculosis (TB)

What is possibly the #1 cause of Chronic Cough in the Philippines?

Upper airway cough syndrome (UACS), Asthma, Gastroesophageal reflux cough (GERC)

Name two other causes of Chronic Cough besides TB.

Infectious, Neoplastic, Inflammatory/Immune, Vascular, Mechanical/Trauma, Congenital, Endocrine, Metabolic/Toxic, Neurologic

Name two categories of cough etiology.

Lung cancer, laryngeal cancer

Name two neoplastic causes of cough.

Inhaled allergens, asthma, chronic bronchitis, vasculitis

Name two inflammatory/immune causes of cough.

CHF, pulmonary embolism, and infarction

Name two vascular causes of cough.

Tobacco smoking, ACE inhibitors

Name two metabolic/toxic causes of cough.

Lung Cancer

What is the impression for a 42/M smoker with dry cough for 3 months, and weight loss, and CXR showing a pulmonary mass?

Bacterial Pneumonia

What is the impression for a 32/F with one week of cough, productive of yellowish phlegm, and fever?

Coughing up of blood from the lungs

What is the definition of Hemoptysis?

Blood-streaked phlegm to frank blood

What is the range of blood volume coughed up in hemoptysis?

Absence of nausea and vomiting

What is the history characteristic of Hemoptysis, distinguishing it from Hematemesis?

Presence of nausea and vomiting

What is the history characteristic of Hematemesis, distinguishing it from Hemoptysis?

Frothy

What is the sputum characteristic of Hemoptysis?

Coffee ground appearance

What is the appearance of blood in Hematemesis?

Alkaline pH

What is the laboratory characteristic of Hemoptysis sputum?

Acidic pH

What is the laboratory characteristic of Hematemesis sputum?

Bronchial Circulation

What high-pressure circuit supplies structural elements of the lung?

Systemic circulation

What circulation is the bronchial circulation circuit part of?

90%

What percentage of massive hemoptysis cases originates from the bronchial circulation?

Chronic hypoxemia and/or chronic inflammation

What two conditions cause bronchial arteries to proliferate and enlarge?

TB, bronchiectasis, and tumor/carcinoma

What are the top three causes of Massive Hemoptysis?

BATTLE CAMP

What mnemonic is used for the causes of Massive Hemoptysis?

Bronchitis, Bronchiectasis

What two conditions start the B in BATTLE CAMP?

Aspergilloma

What condition starts the A in BATTLE CAMP?

Tumor

What condition starts the T in BATTLE CAMP?