SUMS 2016 PATIENT DOCTOR THORAX AND LUNGS CHEST PAIN

PROB
AP MI PCD DAA TRB PP RE DES CWP ANX

PROCESS
temporary MI secondary to coronary atherosclerosis prolonged MI result to necrosis Irritation of parietal pleura adjacent to pericardium(mechanism unclear) splitting in layers of aortic wall; allow blood pass to dissect channel Inflammation of trachea and large bronchi Infla of parietal pleura (pleurisy, pneumonia, p infarction, neoplasm) Inflammation of the esophageal mucosa by reflux of gastric acid motor dysfunction of the esophageal muscle variable, often unclear unclear

LOCATION
retrosternal to shoulder, arm, neck retrosternal to shoulder, arm, neck precordial-shoulder (retrosternal) ant chest to neck, back, abdomen upper sternal side of sternum chestwall overlying the process retrosternal to back retrosternal to back arm jaw below L breast; w/ costal cartilage below L breast; across ant chest

QUALITY
squeezing burning squeezing burning Knifelike (crushing) ripping, tearing burnig sharp knifelike burning squeezing squeezing usually stabbing sticking stabbing dull

SEVERITY
mild to mod (discomfort) often not always often sever very severe mold to moderate often severe mild to severe mild to severe variable variable

TIMING
1-3 to10 mn (20 mn) 20 min to hr persistent abrupt variable persistent variable variable fleeting- hr fleeting-hr

AGGRAVATE
exertion, cold, emotional stress breath, cough, swallow, lying hypertension coughing breath & cough large meal, bend, lying cold drink, emotional stress move chest arm trunk may follow affort, emotional stress

RELIEVE
rest, nitroglycerin

ASSOC
dyspnea, nausea, sweat nausea, vom, sweat underlying illness

sitting forward

lying on involve side anatacid nitroglycerine sometimes

underlying illness regurgitation, dysphagia dysphagia local tenderness breathless, palp,weak,anx

DYSPNEA PROB
LSHF CB COPD BA DALD PNEU SP APE ANX HPV

PROCESS

TIMING

AGGREVATE

RELIEVE
rest, sitting up, expectoration; rest, rest, separation from aggravating fac rest

ASSOC
cough, orthopnea, pnd,wheezing chro prod cough res inf, wheezing Cough, with scant mucoid sputum Wheezing, cough, tightness chest weak, fatigue, cough less comn Pleuritic pain, cough, sputum, Pleuritic pain, cough None: oppressive pain if massive. sigh lighthead numb, palp, c pain

SETTING
histort heart disease w/ predisposing fac History of smoking, air pollutants, res inf smoking, air pollute 1-antitrypsin def Environmental and emotional conditions Varied Varied Often a previously healthy young adult postop; rest; chr lung dse & hip frac; dvt other manifestation of anxiety

pulmonary capillay pressure; uid to IS & progress slow; sudden Exertion, lying alveoli, compliance ( stiff), breathing work pulmo edema down mucus production in bronchi, chronic chronic productive Exertion, inhaled obstruction ofairways cough; slow prog irritants, respi inf air spaces overdistend distal term bronc, dest slow prog; relatively exertion of alveolar septa & chronic airways obstruct mild cough later bronchial hyperresponsiveness (rel of chem acute epi; nocturnal allergens, irritants, mediators, airway sec, bronchoconstriction) epi are common. resp inf, exc & emo Abnormal inltration of cells, uid, and collagen prog dys,vary in rate of exertion into IS between alveoli. Many causes dev w cause Inammation of lung parenchyma from acute illness, timing the respiratory bronchioles to the alveoli varies w/ ca Leakage of air to pleural space through blebs Sudden onset of on visceral pleura, result to collapse of the lung dyspnea Sudden occlusion of pulmonary arterial tree by Sudden onset of blood clot from deep veins of legs or pelvis dyspnea overbreathing, resulting to respiratory alkalosis Episodic, often occur in resting and fall in partial pressure of CO2 in blood recurrent

breathing in or plastic bag

COUGH AND HEMOPTYSIS PROB

Laryngitis Tracheobronchitis Mycoplasma or Viral Pneumonia Bactrerial Pneumonia Postnasal Drip Chronic Bronchitis Bronchiectasis Pulmonary Tuberculosis Lung Abscess Asthma Gastroesophageal Reflux Lung Cancer Left Vantricular Failure or Mitral Stenosis Pulmonary Embolism Irritating Particles

COUGH AND SPUTUM

Dry cough (without sputum), may become productive of variable amounts of sputum

ASSOCIATED SYMPTOM AND SETTING

An acute, fairly minor illness with hoarseness. Often associated with viral nasopharyngitis An acute, often viral illness, with burning retrosternal discomfort An acute febrile illness, often with malaise, headache, and possibly dyspnea An acute illness with chills, high fever, dyspnea, and chest pain. Often is preceded by acute upper respiratory infection. Typically occurs in older alcoholic men Repeated attempts to clear the throat. Postnasal discharge may be sensed by patient or seen in posterior pharynx. Associated with chronic rhinitis, with or without sinusitis Often longstanding cigarette smoking. Recurrent superimposed infections. Wheezing and dyspnea may develop. Recurrent bronchopulmonary infections common; sinusitis may coexist Early, no symptoms. Later, anorexia, weight loss, fatigue, fever, and night sweats A febrile illness. Often poor dental hygiene and a prior episode of impaired consciousness Episodic wheezing and dyspnea, but cough may occur alone. Often a history of allergy Wheezing, especially at night (often mistaken for asthma), early morning hoarseness, and repeated attempts to clear the throat. Often a history of heartburn and regurgitation Usually a long history of cigarette smoking Associated manifestations are numerous. Dyspnea, orthopnea, paroxysmal nocturnal dyspnea Dyspnea, anxiety, chest pain, fever; factors that predispose to deep venous thrombosis Exposure to irritants. Eyes, nose, and throat may be affected.

Dry cough, may become productive (as above) Dry hacking cough, often becoming productive of mucoid sputum Pneumococcal: sputum mucoid or purulent; blood-streaked, pinkish, or rusty Klebsiella: similar; or sticky, red, and jellylike Chronic cough; sputum mucoid or mucopurulent Chronic cough; sputum mucoid to purulent, may be bloodstreaked or even bloody Chronic cough; sputum purulent, often copious and foulsmelling; may be blood streaked or bloody Cough dry or sputum that is mucoid or purulent; may be bloodstreaked or bloody Sputum purulent and foul-smelling; may be bloody Cough, with thick mucoid sputum, especially near end of an attack Chronic cough, especially at night or early in the morning Cough dry to productive; sputum may be blood-streaked or bloody Often dry, especially on exertion or at night; may progress to the pink frothy sputum of pulmonary edema or to frank hemoptysis Dry to productive; may be dark, bright red, or mixed with blood Variable. There may be a latent period between exposure and symptoms.

NORMAL AND ALTERED BREATH AND VOICE SOUND PARAMETER NON AIRFILLED Breath Sounds Predominantly vesicular Transmitted Voice Sounds Tactile Fremitus Spoken words mufed and indistinct Spoken ee heard as ee Whispered words faint and indistinct, if heard at al Normal

AIRLESS IN LOBAR PNEUMONIA Bronchial or bronchovesicular over the involved area Spoken words louder, clearer (bronchophony) Spoken ee heard as ay (egophony) Whispered words louder, clearer (whispered pectoriloquy) Increased

ADVENTITIOUS (ADDED) LUNG SOUNDS Crackle 2 leading explaination. (1) tiny explosions when small airways, deated during expiration, pop open during inspiration. (2) air bubbles owing through secretions or lightly closed airways during respiration. Late inspiratory crackles: begin in rst half of inspiration but must cont to late inspiration; usually ne & fairly profuse, & persistent; appear rst at bases of lungs, spread upward as condition worsens, and shift to dependent regions w/ changes in posture; causes: interrstitial lung disease (brosis) and early CHF Early inspiratory crackles: appear soon after start of inspiration; not continue to late inspiration; often but not always coarse are relatively few in #. Expiratory crackles are sometimes assoc; causes CB & BA Midinspiratory &expiratory crackles: in bronchiectasis; not specic for dx Wheezes & rhonchi are associated. Wheeze & Wheezes: air ows rapidly through bronchi that are narrowed nearly to the point of closure.; often audible at the Ronchi mouth & chest wall; causes asthma, chronic bronchitis, COPD, and CHF (cardiac asthma); wheezes may be heard only in expiration or in both phase. Rhonchi suggest secretions in larger airways. In chronic bronchitis, wheezes and rhonchi often clear with coughing. Occasionally in severe obstructive pulmonary disease, the patient is no longer able to force enough air; resulting to silent chest should raise immediate concern; persistent localized wheeze suggests a partial obstruction of a bronchus (tumor or foreign body. Stridor A wheeze that is entirely or predominantly inspiratory is called stridor. It is often louder in the neck than over the chest wall. It indicates a partial obstruction of the larynx or trachea, and demands immediate attention. Pleural Rub Inamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction. These movements produce creaking sounds known as a pleural rub (or pleural friction rub). Pleural rubs resemble crackles acoustically, although they are produced by different pathologic processes. The sounds may be discrete, but sometimes are so numerous that they merge into a seemingly continuous sound. A rub is usually conned to a relatively small area of the chest wall, and typically is heard in both phases of respiration. When inamed pleural surfaces are separated by uid, the rub often disappears. Mediastinal Crunch A mediastinal crunch is a series of precordial crackles synchronous with the heart beat, not with respiration. Best (Hommans Sign) heard in the left lateral position, it is due to mediastinal emphysema (pneumomediastinum).

PHYSICAL FINDINGS IN SELECTED CHEST DISORDER CONDITION PERCUSSION TRACHEA Normal tracheobronchial tree and alveoli are clear; pleurae are thin and close mobility of the chest wall is unimpaired. Chronic Bronchitis bronchi are chronic inamed; productive cough present. Airway obstruction develop LSHF (Early) pressure in veins causes congestion & interstitial edema (around the alveoli); results to edeme of bronchial mucosa Consolidation Alveoli ll uid or blood cells (pneumonia pulmonary edema, pulmonary hemorr) Atelectasis (Lobar Obstruction) a plug in bronchus (from mucus or FO) obstructs air ow, affected lung collap to airless state. Pleural Effusion Fluid accumulates in the pleural space, separates air lled lung from the chest wall, blocking the transm of sound. Pneumothorax air leaks to pleural space, unilaterally, the lung recoils from chest wall; air blocks sound trans COPD slow prog dso in distal air spaces enlarge & lungs hyperinated. Chronic bronchitis is often associated. Asthma narrowing of tracheobronchial tree diminishes airow to a uctuating degree. During attacks, airow decreases further & lungs hyperinate.

BREATHING Vesicular, except bronchovesicular & bronchial sounds over the large bronchi & trachea

ADVENTITIOUS

TACTILE FREMITUS

Resonant

Midline

None, except few transient inspiratory crackles at bases of the lungs None; or scattered coarse crackles in early inspiration & expiration; or wheezes or rhonchi Late inspiratory crackles in the dependent portions of the lungs; possibly wheezes

Normal

Resonant

Midline

Vesicular

Normal

Resonant

Midline

Vesicular

Normal

Dull in airless area Dull over the airless area

Midline

Bronchial over the involved area Usually absent when bronchial plug persists. except right upper lobe atelectasis,where adjacent tracheal sounds trans Decreased to absent, but bronchial breath sounds may be heard near top of large effusion. Decreased to absent over the pleural air

Late inspiratory crackles over the involved area None

in area with bronchophony, egophony & whispered pectoriloquy Usually absent when the bronchial plug persists. In exceptions, e.g., right upper lobe atelectasis, may be increased Decreased to absent, but may be increased toward the top of a large effusion Decreased to absent over the pleural air

May be shifted toward involved side

Dull to at over the uid

Shifted toward opposite side in a large effusion

None, except a possible pleural rub

Hyperresonant or tympanitic over the pleural air Diffusely hyperresonant

Shifted toward opposite side if much air

None, except a possible pleural rub

Midline

Decreased to absent

None, or the crackles, wheezes, and rhonchi of associated chronic bronchitis Wheezes, possibly crackles

Decreased

Resonant to diffusely hyperresonant

Midline

Often obscured by wheezes

Decreased