PE SUMMARY

Uncomfortable awareness of breathing that is inappropriate to the level of exertion

What is the definition of Dyspnea?

Non-painful

What is a characteristic quality of the awareness of breathing in Dyspnea?

Cardiac or pulmonary disease

Dyspnea commonly results from which two major disease categories?

Abnormalities of gas exchange or increased work of breathing

What are the two general responses that increase ventilation and commonly result in Dyspnea?

Decreased oxygenation, hypoventilation, hyperventilation

What are three types of abnormalities of gas exchange that increase ventilation?

Changes in respiratory mechanics and/or anxiety

What causes increased work of breathing leading to Dyspnea?

Paresthesias, or sensations of tingling or “pins and needles” around the lips or extremities

What accompanying sensations may anxious patients describe with difficulty taking a deep enough breath?

Rapid, shallow breathing

What type of breathing may anxious patients with Dyspnea present with?

Effèrent (motor output from the brain to the ventilatory muscles) and Afferent (sensory input from receptors throughout the body) signals

Dyspnea is a consequence of interactions between which two types of signals?

Feed-forward

What is the term for the motor output from the brain to the ventilatory muscles?

Feedback

What is the term for the sensory input from receptors throughout the body?

Sensory cortex

Afferent information projects directly to this brain area to contribute to primary qualitative sensory experiences and provide feedback on the action of the ventilatory pump?

Corollary discharge

What is the output signal sent from the motor cortex to the sensory cortex simultaneously with the instruction sent to the ventilatory muscles?

Error signal

What is generated when the feed-forward and feedback messages do not match, causing the intensity of dyspnea to increase?

Vagal irritants/receptors

What generates the feeling of chest tightness transmitted directly to the brainstem and sensory cortex?

Decreased FiO
2
​
(Fraction of inspired oxygen)

What mechanism of Dyspnea involves a reduced concentration of oxygen in inspired air, such as at high altitude?

Larynx and Trachea

Where might airway obstruction occur due to infections, angioedema, trauma, or foreign body aspiration?

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

What are examples of airway obstruction involving the Bronchi and Bronchioles?

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

What types of alveolar filling (blood, pus, or fluid) can lead to Dyspnea?

Atelectasis, pneumothorax, hydrothorax

What conditions involve mechanically compressed alveoli leading to Dyspnea?

Fibrosis

What alveolar abnormality causes alveolar distraction leading to Dyspnea?

Paralysis of respiratory muscles, thoracic deformities (kyphoscoliosis), scleroderma of the thoracic wall, pulmonary fibrosis

What are examples of restrictive chest and lung diseases causing Dyspnea?

Pulmonary thromboemboli and infarction, pericardial tamponade, pulmonary artery stenosis, arteriovenous shunts, arteriolar stenosis

What conditions involving the blood vessels cause Dyspnea due to abnormal pulmonary circulation?

Anemia, carbon monoxide poisoning (Carboxyhemoglobinemia), Methemeglobineamia, Cyanide

What conditions are associated with Oxyhemoglobin deficiency leading to Dyspnea?

Pain from respiratory movements, hyperventilation syndrome (panic attack), increased intracranial pressure, metabolic acidosis

What are examples of abnormal respiratory stimuli causing Dyspnea?

Sudden paroxysms of breathlessness

What is the definition of Paroxysmal Dyspnea?

Transient increase in pulmonary capillary pressure, or ischemia-induced transient decreases in left ventricular performance

What are two associated causes of Paroxysmal Dyspnea?

Paroxysmal nocturnal dyspnea (PND)

What subtype of dyspnea occurs at night, is severe enough to cause suffocation, and resolves when the patient sits up?

Bronchodilators

PND does not respond to which type of medication, differentiating it from Nocturnal Asthma?

Orthopnea

What subtype of dyspnea is associated with persistent recumbency, leading the patient to elevate their head and chest?

Redistribution of extracellular fluid from the periphery to the lungs, or elevation of the diaphragm (from obesity or ascites)

What are two similar pathophysiological causes of Orthopnea and Paroxysmal Dyspnea?

Number of pillows used to elevate the head

How is the degree of Orthopnea elicited from the patient?

Breathlessness felt for the entire duration

Orthopnea is characterized by this, contrasting it with the transient nature of PND.

Sudden, forceful, noisy expulsion of the air from the lungs

What is the definition of a Cough?

Preliminary inspiration, glottal closure and contraction of respiratory muscles, sudden glottal opening

What are the three stages of coughing?

Larynx, supralaryngeal area, trachea and bronchi, ear canals and eardrums, pleura, pericardium and diaphragm, esophagus and stomach

What are the locations of cough receptors?

Vagus

Which nerve transmits sensory signals from the pharynx, larynx, airways, pleura, and ear canals to the cough center?

Medulla, nucleus tractus solitarius

Where is the cough center located in the brainstem (the cough center)?

CNS cortical modulation

What allows for voluntary coughing even without activation by irritation?

Spinal motor nerve

Which nerve carries efferent signals from the cough center to the expiratory muscles and pelvic sphincters?

Phrenic nerve

Which nerve carries efferent signals from the cough center to the diaphragm?

Expiratory muscles and pelvic sphincters

What two structures receive efferent signals via the spinal motor nerve, explaining why patients may accidentally urinate while coughing?

Vagus nerve

Which nerve carries efferent signals to the larynx, trachea, and bronchi, leading to their contraction during cough?

Exudates in the pharynx or bronchial tree, irritation of foreign bodies, and inflammation

What are examples of stimuli that initiate the cough reflex?

< 3 weeks

What is the duration defining an Acute Cough?

3 to 8 weeks

What is the duration defining a Subacute Cough?

8 weeks

What is the duration defining a Chronic Cough?

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

What are common causes of Acute Cough?

Post-infectious cough, bacterial sinusitis, asthma

What are possible causes of Subacute Cough?

Tuberculosis, upper airway cough syndrome, asthma, gastroesophageal reflux cough

What are common causes of Chronic Cough in the Philippines context?

Coughing up of blood from the lungs

What is the definition of Hemoptysis?

Bronchial Circulation

Which high-pressure vascular circuit supplies structural elements of the lung and is the source of massive hemoptysis in 90% of cases?

Erosion by a bacterial agent or elevated regional blood pressure

What two factors may cause enlarged bronchial vessels to rupture and result in massive hemoptysis?

TB, bronchiectasis, and tumor/carcinoma

What are the top three causes of Massive Hemoptysis?

Absence of nausea and vomiting

What feature of the history differentiates Hemoptysis from Hematemesis?

Lung disease

What associated disease is typical in Hemoptysis?

Asphyxia possible

What severe potential complication is possible in Hemoptysis?

Frothy

What is the appearance of sputum in Hemoptysis?

Bright red or pink

What is the color of blood/sputum in Hemoptysis?

Alkaline pH

What is the expected pH of the sputum in Hemoptysis?

Mixed with macrophages and neutrophils

What cellular components are typically found in the laboratory examination of Hemoptysis sputum?

Coffee ground appearance

What is the typical appearance of blood in Hematemesis?

Acidic pH

What is the expected pH of the blood in Hematemesis?

Irritation of nerve endings of pain fibers in the costal pleura

What is the cause of Pleuritic Chest Pain?

Pneumothorax, Pleuritis/serositis, Pleural effusion

What are examples of etiologies causing Pleuritic Chest Pain?

Visceral pleura

Which layer of the pleura is anesthetic (lacks pain fibers)?

Parietal pleura

Which layer of the pleura contains many sensory fibers that join the trunks of adjacent intercostal nerves?

Stretching of the inflamed parietal pleura or separation of fibrous adhesions

What are the specific causes of Pleural pain?

Knife-like or shooting pains in the skin of the adjacent thoracic wall

How is the pain from inflammation of the pleura (pleuritis) described?

Breathing, coughing, and laughing

What intensifies pleural pain?

Properly undressed and gowned, seated on the end of an exam table

What is the required preparation for the patient during the PE?

Quiet

What is the required environment for adequate percussion and auscultation?

Finger clubbing, cyanosis, air hunger/gasping

What general signs of respiratory disease should be observed?

Right upper lobe (RUL), Right middle lobe (RML), Right lower lobe (RLL)

What are the lobes of the Right lung?

Left upper lobe (LUL), Left lower lobe (LLL)

What are the lobes of the Left lung?

Horizontal fissure

Which fissure divides the RUL and RML?

Oblique fissure

Which fissure divides each lung into an upper and lower lobe?

Junction of the manubrium and the body of the sternum, level of T4-T5 IV disc, level of the 2nd pair of costal cartilages, level of the bifurcation of the trachea

What four anatomical landmarks does the Sternal Angle of Louis mark?

2 cm to 4 cm above the inner third of the clavicle

Where is the apex of the lung located relative to the clavicle?

6th rib at the midclavicular line and the 8th rib at the midaxillary line

Anteriorly, the lower border of the lung crosses which ribs/lines?

T10 spinous process

Posteriorly, the lower border of the lung lies at about the level of which anatomical structure (on expiration)?

Spine of T3 posteriorly to 6th rib anteriorly

What are the boundaries of the Oblique fissure?

4th rib/costal cartilage anteriorly to 5th rib in mid axillary line

What are the boundaries of the Horizontal fissure?

Apical, Posterior, Anterior

What are the three bronchopulmonary segments of the RUL?

Medial, Lateral

What are the two bronchopulmonary segments of the RML?

Posterior basal, anterior basal, lateral basal, medial basal, superior

What are five bronchopulmonary segments of the RLL?

Apico-posterior, Superior lingular, Inferior lingular, Anterior

What are four bronchopulmonary segments of the LUL?

Anteromedial basal, Lateral basal, Posterior basal, Superior

What are four bronchopulmonary segments of the LLL?

Rate, rhythm, depth and effort of breathing, whether the expiratory phase is prolonged

What aspects of breathing should be noted during Inspection?

COPD

A prolonged expiratory phase can be caused by what common condition?

Withdrawn muscles and skin due to severe dyspnea

How are Retractions defined?

Sternocleidomastoid and abdominals

What accessory muscles should be noted if used during breathing?

Pectus excavatum (Funnel chest), Pectus carinatum (Pigeon Chest), Barrel-chest deformity, Kyphoscoliosis

What are examples of chest deformities noted during Inspection?

Increased antero-posterior (AP) diameter of the chest

What characterizes a Barrel-chest deformity, often secondary to COPD?

Pneumothorax, atelectasis, pleural effusion

What conditions can cause lateral displacement of the trachea?

"Regular rate and rhythm. No retractions or use of accessory muscles. Chest is symmetrical, no deformities. Trachea is in midline."

What is the Normal Report for Inspection?

Tenderness or deformity (ribs and sternum), Chest lag/expansion, Tactile fremitus

What are the three main components of Palpation of the thorax/lungs?

Local lag or impairment in respiratory movement

What finding indicates an underlying disease of the lung or pleura when checking Chest Lag/Expansion?

Atelectasis (collapsed lung)

What condition causes Ipsilateral tracheal deviation and chest lag?

Massive Pleural Effusion

What condition causes Contralateral tracheal deviation and chest lag?