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Thread: Pulmonary Disorders [History Taking & Examination]

  1. #1
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    Arrow Pulmonary Disorders [History Taking & Examination]

    Pulmonary Disorders


    Hemoptysis

    Chief Compliant:

    The patient is a 50 year old white male with
    hypertension who has been coughing up blood for one day.

    History of the Present Illness:

    Quantify the amount of blood, acuteness of onset, color (bright red, dark), character (coffee grounds, clots); dyspnea, chest pain (left or right), fever, chills; past bronchoscopies, exposure to tuberculosis; hematuria, weight loss,
    anorexia, hoarseness, Farm exposure, homelessness, residence in a
    nursing,home, immigration from a foreign country. Smoking, leg pain or swelling (pulmonary embolism), bronchitis, aspiration of food or foreign body.

    Past Medical History:

    COPD, heart failure, HIV risk factors
    (pulmonary Kaposiís sarcoma). Prior chest X-rays, CT scans,
    tuberculin testing (PPD).

    Medications:

    Anticoagulants, aspirin, NSAIDs.


    Physical Examination

    General Appearance:

    Dyspnea, respiratory distress. Anxiety, diaphoresis, pallor. Note whether the patient appears ill or well.

    Vital Signs: Temperature, respiratory rate (tachypnea), pulse
    (tachycardia), BP (hypotension); assess hemodynamic status.

    Skin: Petechiae, ecchymoses (coagulopathy); cyanosis, purple
    plaques (Kaposi's sarcoma); rashes (paraneoplastic syndromes).

    HEENT: Nasal or oropharyngeal lesions, tongue lacerations;
    Telangectasias on buccal mucosa (Rendu-Osler-Weber disease);
    ulcerations of nasal septum (Wegener's granulomatosus),
    jugulovenous distention, gingival disease (aspiration).

    Lymph Nodes: Cervical, scalene or supraclavicular adenopathy
    (Virchow's nodes, intrathoracic malignancy).

    Chest:

    Stridor, tenderness of chest wall; rhonchi, apical crackles
    (tuberculosis); localized wheezing (foreign body, malignancy),
    basilar crackles (pulmonary edema), leural friction rub, breast
    masses (metastasis).

    Heart:

    Mitral stenosis murmur (diastolic rumble), right ventricular
    gallop; accentuated second heart sound (pulmonary embolism).

    Abdomen:

    Masses, liver nodules (metastases), tenderness.

    Extremities:

    Calf tenderness, calf swelling (pulmonary embolism);
    clubbing (pulmonary disease), edema, bone pain (metastasis).

    Rectal: Occult blood.

    Labs:

    Sputum Gram stain, cytology, acid fast bacteria stain; CBC,
    platelets, ABG; pH of expectorated blood (alkaline=pulmonary; acidic=GI); UA
    (hematuria); INR/PTT, bleeding time; creatinine, sputum fungal culture;
    anti-glomerular basement membrane antibody, antinuclear antibody;
    PPD, cryptococcus antigen. ECG, chest X-ray, CT scan, bronchoscopy, ventilation/perfusion scan.

    Differential Diagnosis

    Infection:

    Bronchitis, pneumonia, lung abscess, tuberculosis, fungal
    infection, bronchiectasis, broncholithiasis.

    Neoplasms:

    Bronchogenic carcinoma, metastatic cancer, Kaposiís
    sarcoma.

    Vascular:

    Pulmonary embolism, mitral stenosis, pulmonary edema.

    Miscellaneous:

    Trauma, foreign body, aspiration, coagulopathy,
    epistaxis, oropharyngeal bleeding, vasculitis, Goodpasture's
    syndrome, lupus, hemosiderosis, Wegener's granulomatosus.


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  2. #2
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    Default Wheezing and Asthma

    Wheezing and Asthma



    Chief Compliant:

    The patient is a 50 year old white male with hypertension who complains of wheezing for one day.

    History of the Present Illness:

    Onset, duration, and progression of wheezing; severity of attack compared to previous episodes; cough, fever, chills, purulent sputum; current and baseline peak flow rate.

    Frequency of bronchodilator use, relief of symptoms by bronchodilators. Frequency of exacerbations and hospitalizations or emergency department visits; duration of past exacer-bations, steroid dependency, history of intubation, home oxygen or nebulizer use. Pecipitating factors, exposure to allergens (foods, pollen, animals, drugs); seasons that provoke symptoms; exacerbation by exercise, aspirin, beta- blockers, recent upper respiratory infection; chest pain, foreign body aspiration. Worsening at night or with infection.

    Treatment given in emergency room and response.

    Past Medical History:

    Previous episodes of asthma, COPD,pneumonia. Baseline arterial blood gas resultspast pulmonary function testing.

    Family History:
    Family history of asthma, allergies, hay-fever,atopic dermatitis.

    Social History:
    Smoking, alcohol.

    Physical Examination


    General Appearance: Dyspnea, respiratory distress, diaphoresis,
    somnolence. Anxiety, diaphoresis, pallor. Note whether the patient
    appears cachectic, well, or in distress.

    Vital Signs:
    Temperature, respiratory rate (tachypnea >28
    breaths/min), pulse (tachycardia), BP (widened pulse pressure,
    hypotension), pulsus paradoxus (inspiratory drop in systolic blood
    pressure >10 mmHg = severe attack).

    HEENT:
    Nasal flaring, pharyngeal erythema, cyanosis,
    jugulovenous distention, grunting.

    Chest:
    Expiratory wheeze, rhonchi, decreased intensity of breath
    sounds (emphysema); sternocleidomastoid muscle contractions,
    barrel chest, increased anteroposterior diameter (hyperinflation);
    intracostal and supraclavicular retractions.

    Heart:
    Decreased cardiac dullness to percussion (hyperinflation); distant heart sounds, third heart sound gallop (S3, cor pulmonale); increased intensity of pulmonic component of second heart sound (pulmonary hypertension).

    Abdomen:
    Retractions, tenderness.

    Extremities:
    Cyanosis, clubbing, edema.

    Skin:
    Rash, urticaria.

    Neuro:
    Decreased mental status, confusion.

    Labs:

    Chest X-ray: hyperinflation, bullae, flattening of diaphragms;
    small, elongated heart.

    ABG: Respiratory alkalosis, hypoxia. Sputum gram stain; CBC,
    electrolytes, theophylline level.

    ECG:
    Sinus tachycardia, right axis deviation, right ventricular
    hypertrophy. Pulmonary function tests, peak flow rate.

    Differential Diagnosis:
    Asthma, bronchitis, COPD, pneumonia,
    congestive heart failure, anaphylaxis, upper airway obstruction,
    endobronchial tumors, carcinoid.

  3. #3
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    Default Chronic Obstructive Pulmonary Disease

    Chronic Obstructive Pulmonary Disease


    Chief Compliant:

    50 year old white male with chronic obstructive pulmonary disease who complains of wheezing for one day.

    History of the Present Illness:


    Duration of wheezing, dyspnea, cough, fever, chills; increased sputum production; sputum quantity, consistency, color; smoking (pack-years); severity of attack compared to previous episodes; chest pain, pleurisy. Current and baseline peak flow rate.

    Frequency of bronchodilator use, relief of symptoms by bronchodilators. Frequency of exacerbations and hospitalizations or emergency department visits; duration of past exacerbations, steroid dependency, history of intubation, home oxygen or nebulizer use. Chest trauma, noncompliance with
    medications. Baseline blood gases.

    Treatment given in emergency room and response. Precipitating factors, exposure to allergens (foods, pollen, animals, drugs); seasons that provoke symptoms; exacerbation by exercise, aspirin, beta- blockers, recent upper
    respiratory infection. Worsening at night or with infection.

    Past Medical History:

    Frequency of exacerbations, home oxygen use, steroid dependency, history of intubation, nebulizer use; pneumonia, past pulmonary function tests. Diabetes, heart failure.

    Medications:
    Bronchodilators, prednisone, ipratropium.

    Family History:
    Emphysema.

    Social History:
    smoking, alcohol abuse.

    Physical Examination


    General Appearance:

    Diaphoresis, respiratory distress; speech interrupted by breaths. Anxiety, dyspnea, pallor. Note whether the patient appears ďcachectic,Ē in severe distress, or well.

    Vital Signs:

    Temperature, respiratory rate (tachypnea, >28
    breaths/min), pulse (tachycardia), BP.

    HEENT: Pursed-lip breathing, jugulovenous distention. Mucous
    membrane cyanosis, perioral cyanosis.

    Chest: Barrel chest, retractions, sternocleidomastoid muscle
    contractions, supraclavicular retractions, ntercostal retractions,
    expiratory wheezing, rhonchi. Decreased air movement, hyperinflation.

    Heart:
    Right ventricular heave, distant heart sounds, S3 gallop (corpulmonale).

    Extremities:
    Cyanosis, clubbing, edema.

    Neuro:
    Decreased mental status, somnolence, confusion.

    Labs:


    Chest X-ray:
    Diaphragmatic flattening, bullae, hyperaeration.

    ABG:
    Respiratory alkalosis (early), acidosis (late), hypoxia. Sputum gram stain, culture, CBC, electrolytes.

    ECG:
    Sinus tachycardia, right axis deviation, right ventricular
    hypertrophy, PVCs.

    Differential Diagnosis:
    COPD, chronic bronchitis, asthma, pneumonia, heart failure, alpha-1-antitrypsin deficiency, cystic fibrosis.

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    Default Pulmonary Embolism

    Pulmonary Embolism


    Chief Compliant:


    The patient is a 50 year old white male with hypertension who complains of shortness of breath for 4 hours.

    History of the Present Illness:

    Sudden onset of pleuritic chest pain and dyspnea. Unilateral leg pain, swelling; fever, cough, hemoptysis, diaphoresis, syncope. History of deep venous thrombosis.

    Virchow'sTriad: Immobility, trauma, hypercoagulability; malignancy
    (pancreas, lung, genitourinary, stomach, breast, pelvic, bone); estrogens (oral contraceptives), history of heart failure, surgery, pregnancy.

    Physical Examination


    General Appearance:

    Dyspnea, apprehension, diaphoresis. Note whether the patient appears in respiratory distress, well, or malnourished.

    Vitals:

    Temperature (fever), respiratory rate (tachypnea, >28 breaths/min), pulse (tachycardia >100/min), BP (hypotension).

    HEENT: Jugulovenous distention, prominent jugular A-waves.

    Chest:

    Crackles; tenderness or splinting of chest wall, pleural friction
    rub; breast mass (malignancy).

    Heart:
    Right ventricular gallop; accentuated, loud, pulmonic
    component of second heart sound (S2); S3 or S4
    gallop; murmurs.

    Extremities:
    Cyanosis, edema, calf redness or tenderness; Homan's sign (pain with dorsiflexion of foot); calf swelling, increased calf circumference (>2 cm difference), dilated superficial veins.

    Rectal:
    Occult blood.

    Genitourinary:
    Testicular or pelvic masses.

    Neuro:
    Altered mental status.

    Labs:

    ABG: Hypoxemia, hypocapnia, respiratory alkalosis.

    Lung Scan:
    Ventilation/perfusion mismatch. Duplex ultrasound of
    lower extremities.

    Pulmonary Angiogram:
    Arterial filling defects.

    Chest X-ray:

    Elevated hemidiaphragm, wedge shaped infiltrate; localized oligemia; effusion, segmental atelectasis.

    ECG: Sinus tachycardia, nonspecific ST-T wave changes, QRS
    changes (acute right shift, S1Q3 pattern); right heart strain pattern (Ppulmonale, right bundle branch block, right axis deviation).

    Differential Diagnosis:


    Heart failure, myocardial infarction, pneumonia, pulmonary edema, chronic obstructive pulmonary disease, asthma, aspiration of foreign body
    or gastric contents, pleuritis.

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    Default

    Thanx Alot Really Is A Great Topic

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    Default

    some little quests I heard 2d:
    Someone presenting wiz orthopnea...hw will u find out whether to hv a cvs or RS approach?
    Someone hving dyspnea on rest, bt feels well at work. What can that be? (He's a construction worker!!!)
    Can u get palpitation when u r having bradycardia?

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