Approach to the Pulmonary Patient - PDF

APPROACH 2/5/25 TO THE Randi Beth Cooperman PULMONARY PATIENT DHSc, MCMSc, PA-C LEARNING OUTCOMES The student will be able to: Obtain a thorough patient history specifically regarding complaints of chest pain, shortness of breath, wheezing, cough, and hemoptysis Gather su...

APPROACH 2/5/25 TO THE Randi Beth Cooperman PULMONARY PATIENT DHSc, MCMSc, PA-C LEARNING OUTCOMES The student will be able to: Obtain a thorough patient history specifically regarding complaints of chest pain, shortness of breath, wheezing, cough, and hemoptysis Gather subjective and objective data for a problem-oriented case Provide health maintenance strategies for smoking cessation and proper adult immunizations against influenza and pneumonia Identify abnormal disease pattern characteristics during the examination of the thorax and lungs Utilize the problem list to generate a working differential diagnosis for common pulmonary complaints. PULMONARY ANATOMY ANATOMY OF THE CHEST WALL ANATOMY, CONTINUED Locating findings on the chest Describe abnormalities in two dimensions  Vertical axis  Circumference of the chest  To make vertical locations, count the ribs and interspaces; sternal angle is the best guide ANATOMY, CONTINUED To locate findings around the circumference of the chest, imagine a series of vertical lines ANATOMY, CONTINUED Lungs, fissures, and lobes  Each lung is divided roughly in half by an oblique (major) fissure  The right lung is further divided by the horizontal (minor) fissure  These fissures divide the lungs into lobes  The right lung is divided into upper, middle, and lower lobes  The left lung is divided into upper and lower lobes ANATOMY, CONTINUED The trachea and major bronchi  The trachea bifurcates into its main stem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly The pleurae  The pleurae are serous membranes that cover the outer surface of each lung (visceral pleura), and also the inner rib cage and upper surface of the diaphragm (parietal pleura) ANATOMY, CONTINUED Topographic markers  Nipples  Manubriosternal junction (angle of Louis)  Suprasternal notch  Costal angles  Vertebra prominens (C-7 spinous process)  Clavicles ANATOMY, CONTINUED Supraclavicular—above the clavicles Infraclavicular—below the clavicles Interscapular—between the scapulae Infrascapular—below the scapulae Apices of the lungs—the uppermost portions Bases of the lungs—the lowermost portions Upper, middle, and lower lung fields  ANATOMY PEARLS Anatomy is always relevant! 2nd intercostal space for needle insertion for tension pneumothorax. 4th intercostal space for chest tube insertion. T4 for the lower margin of an endotracheal tube on a chest x-ray. Neurovascular structures run along the inferior margin of each rib, so needles and tubes should be placed just at the superior rib margins. COMMON PULMONARY CHIEF COMPLAINTS Chest Pain Dyspnea Cough Wheezing Hemoptysis CHEST PAIN Differential Diagnosis? HPI - CHEST PAIN  Initial questions should be as broad as possible, such as, “Do you have any discomfort or unpleasant feelings in your chest?”  Ask the patient to point to the location of the pain  Aside from lung conditions, chest pain may arise from cardiac, vascular, gastrointestinal, musculoskeletal, or skin pathology; it is also commonly associated with anxiety  HPI-CHEST PAIN Attempt to elicit all attributes of the patient’s symptom (PQRST or OLD CARTS) Table 15.3 Single location aggravated with inspiration usually sharp or stabbing Pleuritic pain, costochondritis Anterior chest radiating to shoulder, pressure or squeezing pain Angina pectoris or myocardial infarction Sharp pain with inspiration that is relieved with siting up and leaning forward Pericarditis Severe chest pain described as ripping or tearing Dissecting aortic aneurysm Retrosternal pain, described as burning after meals Gastrointestinal Reflux Disease DYSPNEA Differential diagnosis? HPI-DYSPNEA  Dyspnea is a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion  Begin assessment with a broad question, such as, “Have you had any difficulty breathing?”  Determine the severity of dyspnea based on the patient’s daily activities HPI-DYSPNEA Attempt to elicit all attributes of the patient’s symptom (PQRST or OLD CARTS) Table 15.1 Slow progression of SOB, worse when lying down Heart Failure Acute illness, often productive cough Pneumonia Sudden onset, pleuritic pain, often young healthy adult Pneumothorax Sudden onset, pleuritic pain, risk factors! Pulmonary embolism COUGH, WHEEZE, HEMOPTYSIS Differential Diagnosis? HPI – COUGH & WHEEZE  Ask whether the cough is dry or produces sputum, or phlegm  Ask the patient to describe the volume of any sputum and its color, odor, and consistency  “How much do you think you cough up in 24 hours: a teaspoon, tablespoon, quarter cup, half cup, cupful?”  If possible, ask the patient to cough into a tissue; inspect the phlegm, and note its characteristics.  Try to confirm the source of the bleeding by history and examination before using the term “hemoptysis”; blood may also originate from the mouth, pharynx, or gastrointestinal tract HPI-COUGH & HEMOPTYSIS Attempt to elicit all attributes of the patient’s symptom (PQRST or OLD CARTS) Table 15.2 Episodic cough or wheeze, not always related to illness Asthma Cough, hemoptysis, fever, night sweats Tuberculosis Cough, hemoptysis, weight loss, tobacco use Lung cancer PAST MEDICAL HISTORY Thoracic trauma or surgery, dates of hospitalization for pulmonary disorders Use of O2/ventilation-assisting devices Chronic pulmonary diseases Chronic disorders (cardiac, CA, clotting) Childhood illness (asthma) Testing Immunizations (flu, pneumonia) FAMILY HISTORY TB Cystic fibrosis Emphysema Allergy Asthma Malignancy Clotting disorders PERSONAL/SOCIAL HISTORY Employment Home environment Tobacco use Exposure to respiratory infections, flu, TB Nutritional status Regional/travel exposures Hobbies (pigeons) Use of alcohol/drugs Exercise tolerance HIV risk factors PHYSICAL EXAMINATION IDENTIFY RESPIRATORY DISTRESS IDENTIFY RESPIRATORY DISTRESS Tachypnea Cyanosis Pallor Diaphoresis Accessory muscle use Breathing TYPES OF BREATHING PATTERNS  Pursed lip breathing  Obstructive lung disease  With lips pursed patient controls expiration slowly  No abdominal component  Acute abdomen  No thoracic component  Pleurisy  Chest wall pain USE OF ACCESSORY MUSCLES Intercostal  Used by patients with COPD  Signs of use include “Deeper” breathing & intercostal retractions Scalene  Used continuously in advanced COPD  Unable to see; use fingers to palpate Sternocleidomastoid (SCM)  Signs: SCM retractions  Last to be recruited & patients tire quickly  Sign that patient will soon need to be intubated USE OF ACCESSORY MUSCLES INSPECTION Chest Shape/symmetry of chest Chest wall movement Superficial venous patterns Prominence of ribs AP vs. transverse diameter Sternal protrusion Spinal deviation INSPECTION OF THORACIC INTEGRITY AP Diameter Thorax of healthy adult with AP diameter < transverse diameter Increased AP diameter in COPD (barrel chest) BARREL CHEST INSPECTION OF THORACIC INTEGRITY Deformity Pectus carinatum Pectus excavatum Kyphosis PECTUS CARINATUM Pectus Carinatum: sternum & costal cartilages project outwards. It can occur secondary to childhood asthma. PECTUS EXCAVATUM Hollow at lower part of chest Caused by backward displacement of xiphoid cartilage Funnel breast, funnel chest Poor posture, pot belly, & sunken chest PECTUS EXCAVATUM Congenital posterior displacement of lower aspect of sternum. This gives the chest a somewhat "hollowed-out" appearance.. Usually benign, requires no treatment PECTUS EXCAVATUM KYPHOSIS Increased curvature of thoracic spine causes patient to be bent forward THORACIC/CHEST EXPANSION  Normal Findings  Symmetrical  Asymmetric chest expansion  Always abnormal  Abnormal side expands less & lags behind normal side  Implies that air cannot enter affected side  Bilateral reduction: difficult to detect clinically TACTILE FREMITUS  Consolidation  Lobar pneumonia  Heavy bronchial secretions  Segmental atelectasis  Pleural effusion, fibrosis or thickening  Massive pulmonary edema  Hemothorax ABNORMALITIES OF VOCAL RESONANCE Increased Decreased Bronchophony Bronchophony  Consolidation  Hyperinflation  Segmental  Pneumothorax atelectasis  COPD  Pleural Effusion  Asthma REDUCED DIAPHRAGMATIC EXCURSION  Present in conditions which limit its descent  Pulmonary (COPD)  Abdominal (Massive ascites, tumor)  Superficial pain (Fractured rib)  Tenderness, step off  Diaphragm paralysis PERCUSSION Identify boundary between resonant lung tissue and dull structures (below diaphragm) Pathologic examples Large pleural effusion Lobar pneumonia COPD Large pneumothorax ADVENTITIOUS BREATH SOUNDS  Snoring/ gurgling  Arise from disorders in nasopharynx  Hypertrophied tonsils (palatine)/ hypertrophied adenoids (pharyngeal tonsils)  Nasal polyps  Foreign body  Rhinitis  Pleural Friction Rub  Inspiratory or expiratory, disappears when holding breath  Raspy, dry, scratchy sound  Pleural irritation and inflammation ADVENTITIOUS BREATH SOUNDS  Wheeze  FB  Bronchitis  Bronchiolitis  Asthma/COPD/Emphysema  Stridor  Epiglottitis  Laryngitis  Retropharyngeal abscess  FB ADVENTITIOUS BREATH SOUNDS Rales:  Inspiratory, doesn’t clear with cough  Etiology  Fibrosis  Atelectasis  Pneumonia  Fluid (CHF) Rhonchi:  Continuous, more pronounced during expiration  Can clear with cough BREATH SOUNDS: ILL VS. WELL PATIENT HEALTH PROMOTION AND COUNSELING Tobacco Cessation Lung Cancer Immunizations (RSV, influenza, strep pneumonia, COVID-19) TOBACCO CESSATION 19% of US adults smoke #1 preventable cause of premature death (1/5 deaths a year) Quitting smoking significantly reduces disease risk of lung cancer and other. The facts below can be motivating when counseling smokers. Quitting tobacco reduces the cardiovascular risk of heart attack and death from coronary heart disease by half after just 1 year. Stroke risk is reduced within 2 to 5 years to the same level as a nonsmoker. Lung cancer risk is cut in half after 10 years. TOBACCO CESSATION HEALTH PROMOTION AND COUNSELING  Focus on prevention and cessation IMMUNIZATIONS Patient education, promote vaccination CDC Adult Immunization schedule, 2024: RSV COVID-19 Pneumococcal Vaccine Influenza COVID-19 VACCINATION Unvaccinated:  1 dose of updated (2024–2025 Formula) Moderna or Pfizer-BioNTech vaccine  2-dose series of updated (2024–2025 Formula) Novavax at 0, 3–8 weeks Previously vaccinated* with 1 or more doses of any COVID-19 vaccine: 1 dose of any updated (2024–2025 Formula) COVID-19 vaccine administered at least 8 weeks after the most recent COVID- 19 vaccine dose. COVID-19 VACCINATION RESPIRATORY SYNCYTIAL VIRUS (RSV) VACCINATION Pregnant at 32-36 weeks gestation from September through January in most of the continental United States*: 1 dose RSV vaccine (Abrysvo™). Administer RSV vaccine regardless of previous RSV infection. All other pregnant persons: RSV vaccine not recommended Age 60 years or older: Based on shared clinical decision-making, 1 dose RSV vaccine (Arexvy® or Abrysvo™). Persons most likely to benefit from vaccination are those considered to be at increased risk for severe RSV disease.** Age >75 years PNEUMOCOCCAL VACCINE RECOMMENDATIONS INFLUENZA RECOMMENDATIONS PRACTICE A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe? A. Spontaneous Pneumothorax B. Chronic Obstructive Pulmonary Disease (COPD) C. Asthma D. Pneumonia E. Common Cold A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Percussion notes are diffusely hyperresonant. What thorax or lung disorder is most likely causing his symptoms? A. Spontaneous Pneumothorax B. Chronic Obstructive Pulmonary Disease (COPD) C. Asthma D. Pneumonia E. Lung Cancer A 47-year-old vet-tech comes to your office, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated, at 101.1 F. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation she has left sided decreased air movement, and coarse crackles are heard over the left lower lobe. There is left lower dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? A. Spontaneous Pneumothorax B. Chronic Obstructive Pulmonary Disease (COPD) C. Asthma D. Pneumonia E. Upper respiratory infection A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has decreased to absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? A. Spontaneous Pneumothorax B. Chronic Obstructive Pulmonary Disease (COPD) C. Asthma D. Pneumonia E. Common Cold LEARNING OUTCOMES-DID YOU LEARN TO: Obtain a through patient history specifically regarding complaints of chest pain, shortness of breath, wheezing, cough, and hemoptysis Gather subjective and objective data for a problem-oriented case and develop a problem list. Provide health maintenance strategies for smoking cessation and proper adult immunizations against influenza and pneumonia Identify abnormal disease pattern characteristics during the examination of the thorax and lungs Utilize the problem list to generate a working differential diagnosis for common pulmonary complaints. REFERENCES https://www.cdc.gov/vaccines/hcp/imz-schedules/index.html Bickley LS, Szilagyi PS, Bates B. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA. Lippincott Williams & Wilkins. 2020