Clinical Medicine V
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| 3 classic symptoms of lung disease, and major causes of each | shortness of breath (anxiety, asthma, COPD); hemoptysis (bronchitis, lung abscess, bronchiectasis, pneumonia, TB, lung cancer); cough (post-nasal drip - i.e. allergy, GERD; also bronchitis, pneumonia, TB, ACE-I, asthma, lung cancer)
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| differential for cough mostly at night | GERD, allergies, airway disease (asthma, COPD, foreign body, OSA)
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| differential for productive cough with large amounts of sputum | infection/inflammation
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| differential for acute vs chronic onset of coughing | ACUTE: pneumococcal pneumonia; CHRONIC: bronchitis, TB
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| differential for cough associated with fever/chills | TB, pneumonia
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| differential for seasonal cough | post-nasal drip from allergic rhinitis
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| causes of cough with normal CXR | GERD, post-nasal drip (allergies), bronchitis, asthma, ACE-I usage
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| causes of cough with abnormal CXR | pneumonia, TB, lung cancer, foreign bodies
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| differentiate between hemoptysis and hematemesis | HEMOPTYSIS (from resp. tract): associated with cough, BRIGHT red sputum with hemosiderin-laden macrophages, high pH; HEMATEMESIS (blood coming from GI): associated with nausea, abdominal pain, vomiting, DARK red blood with low pH (ie stomach contents)
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| differential for hemoptysis associated with fever, chills, weight loss | TB, lung cancer
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| differential for hemoptysis associated with pleuritic chest pain | infarct (PE), vasculitis, pneumonia
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| differential for blood-streaked sputum (rather than frank blood) | bronchitis
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| differential for massive (100 - 600 mL) hemoptysis | pulmonary hemorrhage, bleeding disorder, excessive anticoagulant drug administration
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| differential for SOB | airway obstruction (obstructive diseases), decreased lung compliance (restrictive), V/Q mismatch, interstitial lung disease
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| differential for dyspnea with lying down | ie orthopnea: CHF
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| differential for DOE | CHF, valvular heart disease, anemia (high-output heart failure)
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| differential for dyspnea with fever | infection
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| differential for dyspnea with wheezing | asthma, COPD
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| differential for dyspnea with pleuritic chest pain | pulmonary embolism
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| differential for PND | CHF (left heart)
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| classic association of barrel chest | COPD: air trapped inside lungs due to airway obstruction
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| explain respiratory paradox, and implications | overworked diaphragm (e.g. from COPD) > intercostal muscles take over; now instead of diaphragm contracting during inspiration (pushing abdomen out), moves up: abdomen moves IN during INspiration - sign of respiratory failure, needs mechanical ventilation
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| key components of pulmonary physical exam | INSPECTION (chest wall deformities, accessory muscle use, tracheal deviation, splinting, clubbing, cyanosis); PALPATION (fremitus); PERCUSSION (dullness/hyperresonance); AUSCULTATION (intensity, types of breath sounds, adventitious sounds)
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| causes of generalized cyanosis | accumulation of deoxyhemoglobin in the cutaneous vessels, or congenital heart disease leading to Eisenmenger's physiology (R > L shunting)
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| causes of peripheral cyanosis | normal Hb concentration, but decreased cutaneous blood flow > increased O2 extraction by tissues from anxiety, cold environment, or hypoperfusion from sepsis, etc.
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| implications of tracheal deviation | moving toward side of lower lung volume (e.g. alectasis, consolidation with obstruction); moving away from side of massive pleural effusion or tension pneumothorax
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| use of accessory muscles: general implication | tired diaphragm, with FEV1 < 30% of the normal value
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| implication of decreased inward retraction of intercostal muscles during expiration | intrapleural pressure more positive than usual during expiration (due to tension pneumothorax, pleural effusion) or due to slightly increased lung volume from fluid/inflammation (consolidation)
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| implication of increased outward bulging of intercostal muscles | either lungs are unable to empty (emphysema, asthma attack) or increased intrapleural pressure (tension pneumothorax, flail chest)
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| implication of constant bulging of intercostal spaces | massive pleural effusion (pushes on lungs from outside, preventing lungs from filling)
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| clubbing: appearance and implications | rounding of distal phalanx, nail floating on finger: chronic hypoxia, due to shunts (congenital heart disease), liver disease, endocarditis, chonic renal insufficiency, etc. that causes distal deposition of megakaryote fragments usually filtered by lung
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| splinting: definition, implications | asymmetric expansion of one side of chest wall during inspiration; due to unilateral diaphragmatic paralysis, pneumothorax, bronchial obstruction
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| implications of asymmetric decreased fremitus | obstruction in bronchi (blocks sound - e.g. atelectasis from mucous plugging, consolidation w/CLOSED bronchus), displacement of lung away from chest wall (pneumothorax, massive pleural effusion) or diaphragmatic paralysis (no air entering that lung field)
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| implications of asymmetric increased fremitus | sound travels better through liquid, so consolidation with OPEN bronchus (e.g. pneumonia: air-bronchograms, heart failure) causes stronger vibration
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| causes of dullness to percussion | ie sound traveling through fluid, not air: pleural effusion, consolidation
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| causes of hyperresonance on percussion | ie air between chest wall and lung - pneumothorax
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| implications of impaired diaphragmatic excursion | ie left hemidiaphragm no longer lower than the right hemidiaphragm, due to diaphragmatic paralysis (L doesn't move down with inspiration, so higher than right on CXR), LUQ mass, pleural effusion, or rarely left lower lobe lesion
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| manifestations of lung consolidation with closed bronchus | dullness to percussion (= consolidation) with DECREASED fremitus; trachea shifted towards consolidation (less V in that area)
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| manifestations of lung consolidation with open bronchus | dullness to percussion (= consolidation) with INCREASED fremitus, positive egophony (EE > ah sound = solid in lung, but open transmission) and whispered pectoriloquy (solid connection: sound travels to chest wall)
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| manifestations of pneumothorax | hyperresonance to percussion
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| manifestations of pleural effusion | decreased inward retraction/bulging intercostal muscles during expirat. (more positive P on lungs from pleural fluid), contralateral tracheal deviation, splinting, decreased fremitus, dullness to percussion, focally decreased breath sounds +/- pleural rub
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| bronchophony: definition, pathophysiology | tracheal breath sounds (usually at neck, = during inspiration and expiration) now heard in periphery: consolidation with open bronchus: alveoli have been filled with solid (consolidation), creating solid connection between lung tissue and trachea
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| present and absent breath sounds in diseased lung | PRESENT: ABSENT: vesicular sounds
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| differential for localized decrease in breath sounds, and why | COPD, asthma, foreign body, consolidation, pneumothorax, pleural effusion; all interrupt sound impulse traveling through bronchi and alveoli to chest wall due to bronchial/alveolar disease process
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| differential for generalized decrease in breath sounds | (besides obesity) COPD, diffuse restrictive/obstructive lung diseases = generalized lung disease interrupting sound impulse traveling through bronchi and alveoli
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| describe stridor, and pathophysiology | loud inspiration = upper airway inspiration, causing "hot potato" voice, or loud expiration: obstruction in lower airways from foreign body
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| describe rhonchi, and pathophysiology | low-pitched snoring sounds in inspiration/expiration = large airway secretions
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| describe wheezing, and pathophysiology | continuous high frequency noise in both inspiration and expiration; caused by COPD, asthma, foreign body with obstruction, hypersensitivity pneumonitis, external airway compression
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| describe crackles (rales), and pathophysiology | discontinuous crackling from explosive opening of small airways/alveoli; COARSE (wet) = inspiration, due to CHF, pneumonia, bronchiectasis; FINE (dry) = late inspiration, sounds like lifting a velcro tab; due to interstitial lung disease/lower airway dz.
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| differential for fine crackles | Sarcoid, Heart failure, Infection, Trauma, Fungal, Aspiration, Cancer, Eosinophilic syndrome, Drugs/dust
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| patients that may think they have crackles, but don't | COPD (or normal) patients waking up from sleep - secretions in airways cause "crackles" that CLEAR with cough > not pathologic (bronchial obstruction from COPD wouldn't cause true crackles because air doesn't reach alveoli to produce the sound)
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| describe pleural rub, and pathophysiology | creaky sound heard throughout respiration, caused by pleural inflammation - LOUDER during inspiration (unlike rhonchi, all over lungs and = during inspiration and expiration); etiologies include pleural effusion, TB, cancer
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| differential for "rust-colored" sputum | pneumonia
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